The state of Delaware is in the unique position of implementing legislatively supported policy on preconception health. The state has allocated funding to translate preconception care policy to practice through a statewide program. The Delaware Division of Public Health has been given the responsibility of defining and implementing the preconception care program targeting a high-risk population. The state partnered with Medicaid, private practitioners, local hospitals, state service centers, and Federally Qualified Health Centers to develop a scope of program services that supplement the current clinical care provided at annual visits for women of childbearing age. Because the program has been in operation for 9 months, the Division of Public Health utilized feedback from the providing agencies to begin efforts for program sustainability and to modify the existing policy. Current efforts include developing outcome measures for the program, measuring program effectiveness through evaluation, and working with Medicaid and Managed Care Organizations to develop a reimbursement system for services.
Introduction
In response to an increasing infant mortality rate in Delaware when compared with the national rate (
Delaware Vital Statistics Annual Report 2007
) the Governor of Delaware made reducing infant mortality a state priority. In 2005, she convened an Infant Mortality Task Force (IMTF) to assemble recommendations aimed at reversing the trend (Reducing Infant Mortality in Delaware—The Task Force Report 2005
). The IMTF provided the governor and state legislature with 20 recommendations to reduce infant mortality in Delaware. Several of the recommendations of the IMTF aimed to improve the health of women before pregnancy and called for increased access to preconception health care for Delawarean women, including providing increased access to preconception services for women with a history of poor birth outcomes; requiring that insurers cover services included in standards of care for preconception, prenatal, and interconception care; and improving comprehensive reproductive health services for all uninsured and underinsured Delawareans up to 650% of poverty. During 2005, the state legislature provided $1 million in funding to develop project and policy initiatives designed to impact infant mortality (Table 1).Table 1Description of Priority Recommendations in 2005 and 2006 for the Infant Mortality Initiative in Delaware
| Year | Recommendation | Description |
|---|---|---|
| 2005 | Develop a research center | Specialized researchers to analyze available data sets and determine risk factors associated with infant deaths; provide oversight for the infant mortality initiative |
| Create Delaware Healthy Mother and Infant Consortium (DHMIC) | Entity to provide guidance and oversight to the infant mortality initiative in Delaware; composed of Governor appointed public health professionals, hospital administrators and directors, nonprofit organization directors, state legislators, Delaware Division of Public Health (DPH) staff, and members of the community | |
| Implement a Fetal and Infant Mortality Review (FIMR) | Project to collect information from mothers who experienced either a fetal or infant death | |
| Pilot Pregnancy Risk Assessment Monitoring System (PRAMS) | Survey to collect information on women's behaviors before, during, and after pregnancy; part of National PRAMS | |
| Supplement existing prenatal and postnatal programs with bundled services | Program to supplement clinical care provided during pregnancy and postpartum to eligible women in Delaware | |
| Review policies on neonatal transport and physician capacity | Review to augment existing reports and recommendations to modify policy concerning emergency transport of infants to level 3 facilities and to assess availability of primary health care in rural areas of the state | |
| 2006 | Implement a preconception care program | Program to supplement clinical care provided by agencies throughout Delaware |
In 2006, the core of the preconception care program was developed based on the Centers for Disease Control and Prevention (CDC) published recommendations for preconception health and health care in the United States (
Johnson et al 2006
). The state legislature awarded >$0.5 million to develop a pilot program. The Delaware Division of Public Health (DPH) was tasked with developing the preconception program requirements, estimating program cost, and releasing a Request for Proposals to fund local agencies to implement the defined program and services.- Johnson K.
- Posner S.
- Biermann J.
- Cordero J.
- Atrash H.
- Parker C.
- et al.
Recommendations to improve preconception health and health care—United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
Morbidity and Mortality Weekly Report Surveillance Summaries. 2006; 55: 1-23
Background
Much of the existing literature on preconception health focuses on current evidence for the impact of risk specific interventions on future pregnancy outcomes (
Floyd et al 2007
, Kendrick 2004
, Korenbrot et al 2002
, Moos et al 1996
, Ray et al 2001
). Earlier research describes the barriers to preconception care such as the inability to reach those at greatest risk, fragmentation of services, limited support for treatment of high-risk behaviors, unmotivated women, and a lack of provider skills in and inadequate reimbursement for risk assessment and health promotion (Jack and Culpepper 1990
).Recent research includes survey studies of women to assess their understanding of preconception care and utilization of current surveillance systems to determine risks (
Anderson et al 2006
, D'Angelo et al 2007
, - D'Angelo D.
- Williams L.
- Morrow B.
- Cox S.
- Harris N.
- Harrison L.
- et al.
Preconception and interconception health status of women who recently gave birth to a live-born infant—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.
Morbidity and Mortality Weekly Report Surveillance Summaries. 2007; 56: 1-35
Frey and Files 2006
). Downs et al 2008
outline the design of the Strong Healthy Women Intervention in Pennsylvania in the Central Pennsylvania Women's Health Study (Downs et al 2008
, Hillemeier et al 2008
, Weisman et al 2008
). Further research on this rural cohort indicates that women's perceptions of their influence on a future pregnancy may be associated with their age, education level, marital status, and physical health (Weisman et al 2006
). Additionally, because 49% of pregnancies in the United States are unintended, reaching women during the preconception phase is critical for provision of specific services such as increased contraceptive or folic acid use (Finer and Henshaw 2006
).Current policy work in the preconception care literature focuses on development of national and state standards for care provision, cost and benefit, existing partnerships between federal and state programs, and role of the family physician (
Curtis et al 2006
, Dunlop and Frey 2007
, Freda et al 2006
, Grosse et al 2006
, Johnson 2006
). Additionally, several investigators have made recommendations for the content of preconception health care, focusing on the internatal period and linkage to current health care models through the use of health promotion (Hobbins 2003
, Lu et al 2006
, Moos 2003
, Moos 2004
, Moos 2006
). Prue and Daniel 2006
outline a social marketing strategy to plan, implement, and create demand for preconception care; the strategy outlines service definition, reasonable cost estimation, and service packaging for both providers and consumers (Prue and Daniel 2006
). However, limited publications exist on affecting policy change before and after intervention of a preconception program.The purpose of this article is to describe the role of DPH and other agencies involved in defining and developing policy around preconception care in Delaware (Table 2), implementing pilot programs, modifying policies after program implementation, and envisioning policy and program changes in prospective years of program operation. The Delaware effort offers an example of how national policy recommendations are translated into policy and program at the state level, and how program implementation provides the foundation for modification of state policy.
Table 2CDC Definition of Preconception Care
| The provision of health promotion, screening, and intervention for women of reproductive age to modify biomedical, behavioral, or social risk factors that may impact subsequent pregnancies including updating vaccinations, managing chronic diseases, diagnosing infectious diseases, limiting tobacco and alcohol use, and monitoring diet. |
From
Centers for Disease Control and Prevention 2006
.Centers for Disease Control and Prevention (CDC) (2006). Preconception Health and Care, 2006: State Title V Priority Needs Focused on Preconception Health and Health Care, United States, 2005. (2006). Atlanta: Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities.
Program Development and Implementation: Translating Policy to Practice
Defining the Target Population and Services
In 2006, the DPH began development of the preconception care program by defining the target population and program services. Using available vital statistics data, evidence-based program inclusion criteria for participants were established. DPH staff examined infant death data and zip code of residence to determine high-risk areas throughout the state, enabling targeting of specific regions in Delaware for program implementation. Further analysis of state vital records data indicated that short gestation and fetal malnutrition were the major causes of infant death, and that African-American women experienced the highest proportions of poor birth outcomes (i.e., premature birth, low birth weight at delivery, stillbirth, or fetal or infant death). Resulting inclusion criteria were experience of a previous poor birth outcome with emphasis on African-American women in specific geographic regions. Finally, utilizing the CDC preconception care recommendations, the DPH also targeted for participation women who were uninsured or underinsured, or diagnosed with a chronic disease. The DPH determined that participants needed to meet only 1 of the 5 criteria to enroll in the program to ensure services for a larger majority of women of childbearing age.
After defining the target population, the DPH staff and program managers identified the types of services to be provided under the preconception care program. The federally funded Family Planning program was examined to identify any gaps in services; the program capacity of the Title V Maternal and Child Health block grant was also reviewed. Medicaid was contacted to identify the types of coverage for eligible women, discussions with DPH clinic managers were convened to better understand current services offered by the state, and private gynecologic practices were consulted to determine gaps in services in private practices and at Federally Qualified Health Centers.
The DPH staff found that although services were fragmented between agencies, an annual visit was typically covered by insurers in the state. However, services did not frame preconception care as a concept of care across the reproductive life span, instead addressing a narrower spectrum of health screening and risky behaviors. Thus, coverage did not include intensive nutrition counseling; social service counseling or referral, specifically, coping with chronic diseases and depression diagnosis and treatment; outreach into the community to inform women of preconception care and available services; and case management of all coordinating services including clinical care, education, transportation, scheduling, insurance, payment, and community support. Also, the team elected to promote the CDC concept of comprehensive life-long planning for pregnancy or other reproductive events during women's childbearing years. The resulting DPH preconception care program included funding for awarded clinical care sites to supplement their current care with these added elements (Table 3). DPH staff determined that enhancing the regional and state referral systems for these supplemental services would provide a more comprehensive case-managed system of care compared with bundled services only. Therefore, integration of services across agencies was promoted to build capacity for the program.
Table 3Services Provided Under the Delaware Preconception Care Program for Women of Childbearing Age
| Added services |
| • Comprehensive risk assessment (piloted at 1 site only) |
| • Case management based on participant level of risk |
| • Counseling participants on pregnancy planning to include specifically identifying a reproductive life plan and optimizing the interpregnancy interval |
| • Specialized counseling for participants with chronic diseases or a history of pregnancy-induced complications that may result in future poor birth outcomes |
| • Psychosocial counseling and referral including mental health diagnosis and treatment |
| • Intensive nutrition counseling including basic nutrition, breastfeeding promotion and support, and folic acid education as well as counseling for women with chronic health risks such as diabetes or obesity |
| • Social work services to address individual and family psychosocial needs |
| • Trained community support services personnel to provide street level outreach, reinforce participant education, and assist participants with social service needs |
| Traditional services |
| • Contraceptive education and counseling including access to a broad range of contraceptive methods |
| • Reproductive health services |
| • Screening for chronic diseases |
| • Updating immunizations |
| • Pregnancy diagnosis, counseling, and referral |
| • Testing and treatment for STIs, including gonorrhea, chlamydia, and syphilis |
| • Testing, treatment, and referral for HIV/AIDS |
| • Level 1 infertility counseling |
| • Screening for alcohol, drug, and tobacco use and referral to cessation programs |
| • Oral health education, treatment, and referral |
Piloting the Programs
In calendar year 2007, the state piloted the preconception program with 2 agencies at 7 clinical sites across the state: Christiana Care Health Services and Planned Parenthood of Delaware. These 2 organizations represent different types of clinical care providers and thus developed different implementation strategies for their respective programs. Christiana Care implemented its Healthy Beginnings program within the obstetrics and gynecology, internal medicine, and pediatric outpatient offices of Wilmington Hospital located in Wilmington, Delaware, and the obstetrics and gynecology office in Newark, Delaware. These resident and faculty practice sites were selected owing to their location within multiple zip codes identified as high infant death regions and their role as providers of primary and obstetric care to a large fraction of women living in those areas. Planned Parenthood implemented the program in 5 Title X clinical sites located throughout the state.
Although both programs were required to provide preconception services, the spectrum of services provided differed owing to the nature of their clinical service models. The DPH allowed the 2 funded programs to refer participants to other agencies when specific traditional or added services were not located on-site. However, the DPH encouraged each agency to build the infrastructure necessary to provide a comprehensive package of the additional services.
The Christiana Care program is integrated into a clinical care model and provides services offered by a diverse group of health care providers located in a centralized community setting. The program is linked to a prenatal care program and women transition through each program depending on their reproductive life course. Women are enrolled in the preconception program at the time of an outpatient visit or immediately postpartum. Christiana Care uses a risk assessment screening for preconception care participants that includes psychosocial, economic, and behavioral assessments; identification of medical risks such as sexually transmitted infections, and chronic and psychological diseases; consistency of folic acid use; and adequacy of pregnancy planning throughout the reproductive life course. All participants in the Christiana Care program are screened for risks; no comparison group has been screened during the pilot phase.
The Christiana Care program provides comprehensive clinical care, education, and social services on site allowing for participants to address most needs at 1 location. A nurse or health educator works to engage each participant and to provide guidance and education about pregnancy planning, discuss health and pregnancy risks, and arrange for referral or follow-up visits. The Christiana Care staff includes a dedicated licensed clinical social worker to facilitate access to needed services and provide mental health counseling and referral, as well as a registered dietician. The program provides social services support through community outreach workers who partner with the health care team and local community service agencies. The program additionally provides clinical education to practitioners and community education to participants.
By contrast, the Planned Parenthood program provides traditional clinical services on site, but actively refers participants to partnering agencies for more intensive follow-up on additional services such as community outreach, mental health counseling, specific clinical services, and intensive nutritional counseling. The Planned Parenthood program has implemented a “wellness coaching” referral system for participants. This system includes goal setting, intensive case management, short-term counseling, assistance with filing of Medicaid paperwork, and monitored referrals. Planned Parenthood has uniquely shaped the preconception program to allow for agency-to-agency referral versus placing the responsibility of referral follow-up on the participant. Planned Parenthood partners directly with agencies such as the 24-hour crisis helpline to provide counseling for mental health issues; Planned Parenthood also works with all local dental practices to track periods of availability for new patient enrollment.
Both agencies provided services to a diverse population with Planned Parenthood's participants mirroring the racial and ethnic distribution of the state; Healthy Beginnings focused on specific minorities as recruited in its fixed locations. In the first 9 months of operation, both agencies served 9,196 women between the ages of 14 and 44. For a state with a population of almost 175,000 women between the ages of 14 and 44, these services reached approximately 5% of the eligible population. The women served include both existing and newly recruited participants who entered care based on the community outreach portion of the program. For Christiana Care, its location in a hospital and clinical setting allowed for on-site recruitment into the program, whereas Planned Parenthood recruited many of its new preconception participants through advertising and outreach. Both programs advertised the additional preconception services through brochures, television, radio, and patient intake. All potential participants were offered the additional services at a routine clinical visit during enrollment. The funding for the preconception program allowed for enrollment of additional clients at each site as well as expansion of services currently offered by each agency.
Pilot Program Outcomes
The average age range among participants was 20–24 years, with 61% residing in an identified high-risk region. Among the multiparous participants, 41% were <24 months postpartum at program entry. The majority of participants (63%) were either eligible for public assistance other than Medicaid or paid for services on a sliding fee scale. Finally, the majority of Healthy Beginnings participants were black, whereas Planned Parenthood served primarily white participants (Table 4).
Table 4Racial and Ethnic Distribution of Participants by Contractor for the First 9 Months of the Program
| Agency | Black (%) | White (%) | Other (%) | Total | Hispanic (%) | Non-Hispanic (%) |
|---|---|---|---|---|---|---|
| Christiana Care Healthy Beginnings | 394 (63) | 182 (29) | 51 (8) | 627 (100) | 56 (9) | 571 (91) |
| Planned Parenthood of Delaware | 2,918 (34) | 4,790 (56) | 861 (10) | 8,569 (100) | 523 (6) | 8,046 (94) |
| Total | 3,312 (36) | 4,972 (54) | 912 (10) | 9,196 (100) | 579 (6) | 8,617 (94) |
It is too soon in the evaluation process to provide outcomes; however, preliminary data available for the Healthy Beginnings program provide guidance for further program development. Among women not planning a pregnancy, 48% have elected to use an effective method of contraception. These findings are consistent with the prenatal program indicating that only 21% of women entering prenatal care planned the current pregnancy. Use of folic acid is also low among women in this population (30% of all participants). A history of clinical depression is common (37%) and behavioral risks are highly prevalent, with 30% using tobacco and 90% reporting eating <5 servings of fruits or vegetables daily. A majority of women in the program were offered a follow-up visit with the program nurse to focus on discussion of a pregnancy plan and unhealthy behaviors. Also, 48% of participants were referred to the on-site dietitian, 65% to a community-based weight management program, and 17% for further mental health evaluation.
Translating Practice Back to Policy
The efforts in Delaware followed a social marketing strategy and policy on preconception care was created based on CDC recommendations and current policy research. The state legislature deliberated and obtained consensus on the concept of preconception care, and then established an estimated baseline cost for such services. The DPH followed the policy recommendation, and after implementation, allowed provider feedback to permit modification of policy. This feedback loop was essential in streamlining both the set of preconception care services and the cost of the program.
After the pilot, DPH staff identified barriers for long-term sustainability that required additional modifications to policy. Barriers included maintaining level funding for a statewide program, sustaining political and legislative support, and streamlining the pilot program to best utilize available funding. The modifications to the program concerned funding and reimbursement, program structure for statewide implementation, expansion of additional services, and increasing public awareness of the program. For example, the DPH used pilot demographic, eligibility, and referral data as evidence of high need for the added services supported under the preconception program. These data were critical in providing support for program and staff expansion at existing sites during 2007. The DPH also initiated discussion with the Division of Medicaid and Medical Assistance (DMMA) to negotiate reimbursement for additional services offered by the program. The DMMA recommended that DPH partner with local managed care organizations (MCO) to discuss reimbursement for the additional services. Finally, the DPH piloted a “Pursuing Motherhood: Planning for Pregnancy” guide to local public health practitioners and consumers; feedback obtained from the pilot was used to revise the guide before statewide dissemination.
Next Steps
In subsequent years of the preconception program, the DPH plans to evaluate the effectiveness of the current program, establish outcome measures for the program and data collection protocols for annual visits, complete needs assessments of the pilot sites, begin a dialogue with state insurers to cover and reimburse the additional services, partner with other state agencies for provision of more comprehensive additional services, and expand preconception awareness through a media campaign for targeted populations.
Program evaluation is necessary to ensure that all services are impacting the targeted population to streamline the provided services and to develop outcome measures that indicate program impact. The DPH is currently in the process of evaluating each pilot site and has initiated a needs assessment of the Christiana Care site. In the next year, results from the evaluation will guide identification of the critical services that address health risks for women and modification of the package of preconception services. Using the risk assessment tools tested during the pilot phase, the DPH will approve risk categories for better utilization of case management, annual reassessment of each program participant to determine long-term changes in risk, and tailoring of outcome measures to the service population.
By addressing preconception health risks through medical care, wrap-around services, and community services, collaboration and coordination of care between DPH and other agencies is crucial. To ensure self-sustaining funding over time, the goal of the DPH is to facilitate a transition of program funding to partially or fully reimbursable services. To facilitate this process, the DPH will partner with the DMMA and the 2 primary MCO insuring services in Delaware. All parties agree that, although prenatal services are typically packaged together, the concept of packaging preconception care is new to the insurance industry. Such partnership is anticipated to lead to modification in health care policy throughout the state. Additionally, agencies are examining ways in which to combine current service packages with the preconception care program (e.g., family planning).
The DPH is committed to modifying programs to provide more intensive services to women before pregnancy and during the internatal period. To meet this goal, the DPH will develop a preconception guide for all women of childbearing age in Delaware and revise the “Pursuing Motherhood: Planning for Pregnancy” guide to better inform practitioners of the importance of providing adequate preconception care. Improving reimbursement for preconception care will be helpful in engaging providers in these efforts. The DPH will dedicate funds for a statewide education campaign to raise awareness of healthy lifestyle behaviors before pregnancy through billboards, television, and radio messages.
Conclusion
Although the concept of preconception care was difficult to define, practically apply, integrate into the existing system, and argue for continuous political support, the achievements of the DPH and the state of Delaware provider networks present a promising model of care and illustrate a method for translating policy into action and back again at the state level.
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Biography
Charlan Kroelinger, PhD, is the State Maternal and Child Health Epidemiologist for Delaware and the Director of the Delaware Division of Public Health Center for Excellence in Maternal and Child Health and Epidemiology. She is a Senior Scientist assigned to Delaware by the U.S. Centers for Disease Control and Prevention.
Deborah Ehrenthal, MD, FACP, is Assistant Professor of Medicine at Thomas Jefferson Medical College and Medical Director of Women's Health Programs for the Department of Obstetrics and Gynecology at Christiana Care Health Services. She is the Medical Director of Women First, the Christiana Care Community Center of Excellence in Women's Health, and the Healthy Beginnings Program.
Article info
Publication history
Published online: October 13, 2008
Accepted:
June 30,
2008
Received in revised form:
June 27,
2008
Received:
April 18,
2008
Footnotes
The authors have no direct financial interests that might pose a conflict of interest in connection with the submitted manuscript.
The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.
Identification
Copyright
© 2008 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
