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Tier 3:
Protective, long-lasting protection to individuals

Long lasting protective interventions have broad population impact, but do require outreach to individuals.

Tier 3 Recommendations: Protective, long lasting protections to individuals

A.  Support the provision of preconception health care throughout the childbearing years.


B.  Integrate Life Course education into provider training.

Recommendation 3A: Support the provision of preconception health care throughout the childbearing years.


The goal of preconception health care is to promote the health status of women, men, and couples prior to a first conception or subsequent pregnancies.42,43 Preconception health care interventions allow providers to screen, identify, and treat childbearing women and men for biomedical, behavioral, and social risks that could negatively impact the outcomes of a future pregnancy.42


Although preconception care guidelines exist, there is no standardized model for delivering preconception/interconception care and many barriers to implementations still exist.44 Documented barriers include: lack of access to care between pregnancies, loss of insurance coverage postpartum, maternal focus on the infant to the exclusion of her own health care needs, lack of awareness about preconception/interconception health care guidelines among providers, increasingly limited clinician time, and the lack of an established model for delivery of interconception care (ICC).45


In order for preconception/interconception health care to become an integral part of routine care within different health care settings and interactions, new tools, structures, and processes need to be created, disseminated, and institutionally supported. Clinicians belonging to the Coalition have shared the challenges tied to including meaningful screening, education, and counseling opportunities within the limited parameters of medical visits. While payment incentives tied to performance may have the potential of increasing the implementation of preconception health care interventions, providers have indicated that identifying strategies to appropriately modify the visit flow so that it can seamlessly include preconception health care education, counseling, screening, and treatment, may be a more promising way of supporting greater widespread provision of preconception health care in the state of Connecticut.

Recommendation 3A: Emerging and promising examples


Before, Between, and Beyond Pregnancy

Before, Between and Beyond was created as a key component of the national Preconception Health and Healthcare Initiative. It is designed to be a “one stop” resource for clinicians and others who want to learn more about preconception health, its history, the evidence supporting it and strategies for incorporating relevant content into daily clinical practice. It includes CME opportunities,  articles, clinical guidance,  news, and a  clinical toolkit that can be used as a reference or as an educational tool when engaging with women of reproductive age during routine care with the one single assessment question: “Are you hoping to get pregnant in the next year?” Based on the desires and likelihood of pregnancy in the next year, the online toolkit offers specific clinical recommendations for ten components of routine primary care: family planning guidance, nutrition, infectious diseases and immunizations, chronic diseases, medication use, substance use, previous pregnancy outcomes, genetic history, mental health, and intimate partner violence.


The IMPLICIT Network

The  IMPLICIT Network, a family medicine residency collaborative with members in the Northeastern US, including the Family Medicine Residency Program at Middlesex Hospital in Connecticut, tested the impact of an innovative approach to interconception care (ICC) delivered during well child visits by family physicians.46 First created in 2003, the IMPLICIT Network set out to educate family medicine residents and practicing physicians on the primary and secondary prevention of low birth weight and preterm birth, as well as their role in reducing preventable adverse birth outcomes through the delivery of preconception and interconception care. Through a Continuous Quality Improvement (CQI) approach, the nineteen network members, developed a replicable 5-minute model that makes use of maternal contact during well child visits to screen for and address four primary risks for poor outcomes in subsequent pregnancies: smoking, depression, contraception use, and multivitamin intake.45 In addition to documented increases in screening rates, reductions in preterm births have also been observed.47

Recommendation 3B: Integrate life course education into provider training.

The Life Course Perspective suggests that many facets of life contribute to health outcomes across the course of one’s life. It is substantiated by public health and social science research literature highlighting the influence of each stage of life on the next and showing how social, economic, and physical environments interact with the biological domain to have a profound impact on individual and community health.48 Anecdotal evidence from clinicians across Connecticut has shown a need to increase training opportunities for clinical providers about social determinants of health and the life course perspective. Published literature on the topic supports the benefits of integrating life course education into provider training.49,50 For example, after the introduction of a social determinants of health curriculum, pediatric residents reported increased knowledge of key issues and community resources, along with an increased level in self-confidence regarding their ability to integrate social determinants of health assessments into routine care visits with their patients.51,52 The American Association of Family Physicians (AAFP) also supports the recommendation that physicians be trained and skilled in knowing how to identify and address social determinants of health. 53

Recommendation 3B: Promising and emerging examples


The MCH Navigator

An online portal created as a training repository for educational webinars, podcasts, and training modules on Maternal and Child Health concepts and competencies, the  MCH Navigator site also has a section dedicated to the Life Course perspective and Social Determinants of Health.


MCHB Training Programs

A branch of the Health Resources and Services Administration (HRSA), the Maternal and Child Health Bureau (MCHB) invests in lifelong learning, from pipeline programs to encourage high school and college students to enter Maternal and Child Health (MCH) professions to continuing education for practicing MCH professionals and clinicians. In Fiscal Year 2013, the Division of MCH Workforce Development awarded 151 grants, an investment of $47 million. Grants are awarded to develop trainees for leadership roles in the areas of MCH clinical practice, teaching, research, public health administration and policy making, and community-based programs. A complete description of all training programs is available at the MCH Training website.


The MCH Life Course Toolbox

Hosted on the CityMatCH website, the MCH Life Course Toolbox is a repository for training modules, research, policy, and practice-related examples and documents concerning the Life Course perspective. This online resource also includes an interactive teaching tool that can be used as part of any Life Course curriculum: the Life Course Game. As described on the website where anyone can download the game materials, free of charge: “in the Life Course Game, participants are led through an interactive experience, designed to illustrate key concepts of the life course framework. Specifically, participants receive birth certificates at the start of the game that identify socially- and biologically-based historical factors that help determine their course in life. As they work their way through the game board, each person's roll of the dice identifies risk factors and protective factors that either push down or lift up their overall health trajectory and life course.”


Residency Program in Social Medicine

Serving low-income families in the Bronx seeking services at the Montefiore University Hospital, primary care residents enrolled in the Albert Einstein College of Medicine Yeshiva University Residency Program in Social Medicine (RPSM) are specifically trained for practice in underserved communities. The program combines a community-oriented primary care (COPC) curriculum with a biopsychosocial approach, preparing residents to deliver excellent clinical care that encompasses all spheres of their patients’ lives, throughout the life course.

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