State Title V Performance Measures and Priority Needs
The federal MCH Block Grant guidance requires states to report annually on National “Core” Performance Measures and to assess needs and set priorities every 5 years. In addition, each state must develop 7 to 10 additional Performance Measures relevant to its own priority needs and programs. Priority Needs reflect a state’s focus for programmatic efforts throughout the next five years and can be adjusted during interim years in response to variations in needs. Performance Measures describe a specific maternal and child need that, when effectively addressed, can lead to improvements in health. In 2005, states completed the 5-year needs assessments and set out priorities and targets for 2010. A previous analysis of the 2000 priorities and measures found that some states, but not all, included measures for preconception care or visits, as did Healthy People 2000 National Health Promotion and Disease Prevention Objectives
Twenty-three states reported a Priority Need that focused on preconception health and health care (Fig. ). “Preconception” or “preconceptual” health was mentioned by 10 states as a Priority Need in maternal and child health. In other states, Priority Needs indirectly addressed preconception care via broad objectives such as improving the health of women of childbearing age, promoting reproductive health and sexual responsibility, and advancing a holistic care continuum for women’s health.
State Title V priority needs focused on preconception health and health care, U.S. 2005
A total of 42 states and jurisdictions reported at least one Performance Measure related to preconception care, neural tube defects, birth spacing, family planning, unintended pregnancy, and healthy weight/obesity (Table ). Unintended pregnancy and healthy weight or obesity were the measures identified most frequently (43% and 19%, respectively). The majority of the measures pertaining to birth spacing or parity, or both, addressed repeat pregnancies among adolescent populations. A total of thirty states or territories reported measures on tobacco use during pregnancy; however, only one focused on the proportion of women who smoked during 3 months prior to pregnancy. Measures pertaining to smoking rates among women of childbearing age were reported by two states. Four states addressed mental health among women of childbearing age and postpartum depression was identified in three others. Two states included measures pertaining to preventive oral health services among women of childbearing age (data not shown).
States or U.S. jurisdictions reporting Performance Measures related to selected preconception health topics
Table provides examples of selected State Performance Measures and Priority Needs derived from 18 states. Variations in state-selected preconception health indicators are evident, with some states detailing various components of preconception care and others employing a broader focus on reproductive health.
Sample of selected state Performance Measures and Priority Needs related to preconception health
Abstracts from the National Summit on Preconception Care
A total of 59 abstracts accepted for presentation at the National Summit on Preconception Care were reviewed and categorized according to primary area of focus. Approximately 32% addressed preconception health research; 27% described preconception care programs and activities; 22% outlined tools for provider or patient education; 15% detailed clinical practice strategies; and 3% highlighted policy-based strategies for increasing access to preconception care services.
Among the research abstracts, the topics noted most frequently pertained to methods for preconception risk assessment, potential predictors of adverse pregnancy outcomes, and variations in preconception health indicators across high-risk populations. Three abstracts described the use of the Perinatal Periods of Risk (PPOR) model [2
] for assessing risks among various populations. Other issues included folic acid awareness among women and health care providers, maternal nutrition, pregnancy planning and risk behaviors, preconception hepatitis B prevention, and workplace hazards.
The PPOR model facilitates the identification of four contributors to infant mortality: maternal health and prematurity, maternal care, newborn care, and infant health. Excess rates of fetal and infant mortality in any of the four components indicate a need for targeted interventions within that construct [2
]. CityMatCH’s 2000–2002 PPOR Practice Collaborative provided public health workers in 14 U.S. cities with the skills, knowledge, and support to implement the PPOR method in various urban communities [2
]. The PPOR approach is also is being used statewide by Florida and Ohio and in selected areas across the country [2
The Fountain Project in Kansas City, Missouri linked PPOR techniques with the Fetal Infant Mortality Review (FIMR) process in an effort to identify the causes of consistently higher rates of infant mortality among African-American residents compared with their non-Hispanic White counterparts. The findings of the analysis indicated an excess rate of maternal health or prematurity-related deaths among African-American infants. In light of the contributing social factors identified by the FIMR, the development of a Women’s and Children’s Wellness Center was proposed to provide social and clinical services for high-risk families (Cook BE, Guillory VJ, Cai J, Hoff GL, Manning J, unpublished data, 2005).
In an effort to facilitate the analysis of various perinatal health outcomes, a group of nine counties surrounding the San Francisco Bay (California) formed the Maternal, Child and Adolescent Health Bay Area Data Collaborative (BADC). The group used the PPOR model to evaluate recent county and regional fetal-infant mortality rates and reported substantial excess in the proportion of deaths among African-American infants, particularly in the prematurity and maternal health component of the model. Using a national comparison group, these investigators were able to determine that approximately 56% of the excess deaths among African-American infants could be prevented by targeting preconception and interconception risk factors (Stein EJ, Abramowitz A, Brown J, Chabra A, unpublished data, 2005).
Federally funded Healthy Start projects were highly represented among the 16 abstracts detailing preconception care programs and activities presented at the Summit. Of these, seven abstracts described the modification or expansion of existing programs to include direct services or community-based interventions for high-risk postpartum mothers or all women of reproductive age. The Magnolia Project in Jacksonville, Florida is an example of a Healthy Start program in which a comprehensive array of health services was offered in an effort to improve birth outcomes. Services included, but were not limited to, case management, education and risk reduction, and well-woman care. The target population was high-risk African-American women aged 15–44 years who lived in five zip code areas of Jacksonville. The project operates as a collaborative between the Northeast Florida Healthy Start Coalition, the Duval County Health Department, and local community-based organizations. As reported, a 2004 assessment of project services conducted by the Health Resources and Services Administration (HRSA) Office of Performance Review found high rates of success (>70%) in the resolution of key risks (for example, lack of family planning, and rates of repeat sexually transmitted diseases) among the project participants (Brady, CM, unpublished data, 2005).
The Missouri Bootheel Healthy Start project, a provider of referral and education services in a five county area of southeast Missouri, uses community-based education and interventions to improve adverse perinatal outcomes. The project has been one of few in the area that has promoted a family-focused approach to health education through the inclusion of various services directed at men. The curriculum for fathers has addressed a variety of issues, such as communication with the mother, addressing stress in the relationship, and the impact of nutrition on birth outcomes (Dean CG, Campbell T, Frazier V, Washington J, unpublished data, 2005).
Title X family planning clinics were identified as providers of preconception primary care and folic acid awareness interventions in two programs and activities abstracts. The Women Enjoying Life Longer (WELL) Project was initiated by the Maryland Department of Health and Mental Hygiene following a community needs assessment. Comprehensive preventive women’s health services were added to three Title X family planning clinics in Baltimore County, using Title X and Maternal and Child Health funding. Augmented services included nutrition and physical activity counseling, adult immunizations, smoking cessation interventions, and preconception counseling, as well as referrals for problems such as substance abuse, depression, domestic violence, and chronic disease. Early evaluation data indicated that patients and staff have responded positively to new services, patient knowledge of women’s health has improved, and patient volume has increased 37% (Cheng D, unpublished data, 2005).
The Oklahoma Birth Defects Registry developed, implemented, and evaluated a preconception “women’s health appraisal” project. The intervention was comprised of a 3-page health appraisal for women, with follow-up risk counseling, in selected family planning clinics (two rural and one urban). Pre-evaluation results indicated that 84% of nurses found the questionnaire helpful in assessing risk factors, 90% of nurses found it helpful as a guide to counseling and referrals, and 86% of patients increased their understanding of risk factors. Post-evaluation results found that 62% of patients modified one to three risk factors in a three-month period (Feuerborn VR, Pearson K, unpublished data, 2005).
The remaining programs were funded either through grants, private organizations, or state/local health departments and comprised comprehensive health care programs for women with a history of preterm delivery or a low birth weight infant and broad women’s wellness interventions aimed at improving women’s health or folic acid utilization. For example, the Interpregnancy Care Program at Grady Memorial Hospital in Atlanta, Georgia employs a “resource mother” to coordinate the provision of primary health care and dental services, enhanced nurse case management, and other outreach services to African-American women who delivered a very low birth weight infant at the hospital and who qualified for indigent or charity care. For 24 months postpartum, the women were offered health care visits every 1–3 months in order to address risks known to be associated with the delivery of a low birth weight infant such as poorly controlled chronic disease, short intervals between pregnancies, reproductive tract infections, periodontal disease, nutritional deficits, substance abuse, and stress. Preliminary evaluation of the 22 women retained in the pilot program indicated that approximately one-quarter of them were affected by unrecognized or poorly managed chronic health problems and none of the participants wanted to become pregnant during the next 2 years (Dunlop A, unpublished data, 2005).
Thirteen abstracts (22%) described the creation, dissemination, and evaluation of tools for patient or provider education. Of those, eight described marketing campaigns and toolkits for patient education, three specifically referenced provider education, and three assessed the use of women’s health appraisals by health care providers. For example, the California Preconception Care Initiative, Every Woman, Every Time, was created in 1989 through a partnership between Sutter Medical Center in Sacramento and the March of Dimes. The project conducted a metanalysis of the preconception care literature [5
] and used this information in a consensus development process to produce a marketing packet for providers. Key components of the packet included the rationale for providing preconception care, a description of the essential elements of care, patient education materials, and information on billing methods. More than 9,000 packets were distributed statewide. An evaluation found that, among 187 providers responding, 75% indicated the information was very useful, 80% said they would distribute materials to patients, and 72% said they would use the billing codes provided. A further impact evaluation is being considered (Cullum AS, unpublished data, 2005).
A research project conducted at a New York inner-city hospital served by Albert Einstein College of Medicine/Montefiore Medical Center sought to evaluate the knowledge and awareness of providers regarding preconception care. A pre-intervention chart review and a provider survey were conducted to evaluate delivery or preconception care. The two-part intervention included: [1
] a 1-h lecture for all providers, and [2
] a standardized preconception care form inserted into all charts. A post-intervention chart review of a convenience sample and repeated provider survey were then conducted. The result was a significant improvement in documentation of the delivery of preconception care (p
<0.05); however, provider knowledge and attitudes, as measured by the survey, did not change significantly (Bernstein P, unpublished data, 2005).
Clinical practice strategies were discussed in nine abstracts and included topics such as genomics, group care, screening for environmental exposures and maternal depression, smoking cessation, and provider knowledge of current practice guidelines. An example of a promising practice strategy presented at the Summit is the use of a group model of prenatal care to address topics relevant to preconception care. In 2002, the Comprehensive Family Care Center at Montefiore Medical Center implemented the group model of prenatal care developed by the Centering Pregnancy and Parenting Association. Traditional prenatal visits were replaced with group appointments lasting approximately 2 hours and attended by 10 to12 women. Typical clinical care services were provided during the visits and were supplemented with group discussions on pregnancy-related topics. Issues related to preconception health were covered during many of the meetings and included nutrition, substance abuse, contraception, and family planning. Since its inception, the group care model has been employed for 14 patient groups with high levels of patient and provider satisfaction reported, particularly related to enhanced opportunities for patient education (Bernstein P, Rising SS, Dolan S, Pardanani S, Merkatz IR, unpublished data, 2005).
Finally, policy-based strategies for the funding of preconception care were described in a small number of abstracts. One pair of abstracts highlighted Illinois’ efforts to promote preconception health using public policy and funding through Medicaid waivers, Title V, and other resources (Murphy AM, unpublished data, 2005; Saunders SE, unpublished data, 2005). Identified as a priority area, preconception care has been integrated into a number of programs, most notably the Illinois Healthy Women program. This Medicaid waiver program initiative extends coverage for family planning services to women who would otherwise lose their benefits after 60 days postpartum and to all women 19 through 44 years of age who were previously enrolled in Medicaid but who had lost their benefits (Murphy AM, unpublished data, 2005). Additional efforts have been made through the Illinois Family Planning Program. Preconception education is currently provided at all state-funded family planning clinics, with 16 state family planning agencies offering additional counseling and referral for high-risk clients [6
]. Other strategies employed by the Illinois Department of Human Services include statewide genetic counseling programs and folic acid campaigns, screening mothers of children enrolled in the state’s Medicaid program for perinatal depression, and programs aimed at increasing birth spacing and promoting the health of teen parents (Saunders SE, unpublished data, 2005).