Preventing Unintended Secondary Pregnancies in Women Receiving Women, Infants and Children (WIC) Services

Summary

Impact Statement:

A local health department noted a high rate of early post-partum unintended pregnancies among women in the Women, Infants and Children (WIC) program, and used QI to identify three interventions to reduce the rate.

Summary:

The Barron County Department of Health and Human Services Public Health Program was awarded a 2012 Strengthening the Community of Practice for Public Health Improvement (COPPHI) Quality Improvement (QI) Award Program Grant through the Robert Wood Johnson Foundation. Through this project, Barron County Public Health (BCPH) sought to increase access to family planning supplies and information for pregnant and postpartum women receiving Women, Infants and Children (WIC) services in an effort to decrease the percentage of women becoming pregnant less than 16 months from their last pregnancy. Data were collected from local medical providers and women receiving WIC services. Data confirmed inconsistencies in the provision of family planning information and services during the third trimester and postpartum period. An educational webinar, hosted by BCPH's medical advisor, was created. The webinar shared the emerging practice of interconception care in reducing unintended secondary pregnancies. Dual protection kits, which contained emergency contraception (EC) in advance of need, condoms, and educational materials were created. Posters were placed in WIC service areas that state "ask me how to get a dual protection kit today" and showed pictures of the components of the dual protection kits. All pregnant and postpartum women receiving WIC services are offered a dual protection kit and a visit with reproductive health staff. It will take time to evaluate the effectiveness of these interventions on reducing the percentage of women becoming pregnant less than 16 months postpartum. The physicians who watched the educational webinar responded positively on the post-webinar survey, and all have stated that they already do the practices listed or responded they are "much more likely" to implement the practice after watching the webinar. In the first month, 12 dual protection kits were distributed to clients.

Organization that conducted the QI initiative:

Barron County Department of Health and Human Services

Citation:

Engen, K. Public Health Quality Improvement Exchange. Preventing Unintended Secondary Pregnancies in Women Receiving Women, Infants and Children (WIC) Services. Thu, 04/16/2015 - 12:50. Available at https://phqix.org/content/preventing-unintended-secondary-pregnancies-women-receiving-women-infants-and-children-wic. Accessed October 5, 2024.

Background and Aim

Aim statement:

By November 30, 2012, the percentage of pregnant/postpartum women enrolled in the WIC program in Barron County, Wisconsin, receiving contraceptive supplies and standardized family planning information in the third trimester of pregnancy or within 2 weeks postpartum will increase from 24% to 40%.

Need For The QI Initiative:

BCPH offers an onsite reproductive health program that operates under the Wisconsin Department of Health guidelines. The high numbers of closely spaced pregnancies in WIC participants were identified as areas of concern. "The health of women before pregnancy or before a subsequent pregnancy has a great impact on birth outcomes. Reproductive health is a key component of women’s health. Family planning services are important to help women achieve their reproductive plan. The Women’s Health Now and Beyond Pregnancy Project integrates interconception care into existing public health services and normalizes family planning as a component of public health programming. The Women’s Health Now and Beyond Pregnancy Project enhances Medicaid Prenatal Care Coordination services to include a focus on interconception care before future pregnancies." (1)

Area for Improvement:

Wisconsin statistics show only 1 in 10 pregnant medical assistance recipients were billed for a contraceptive code during the third trimester of pregnancy or the postpartum period in 2011. The Barron County WIC program saw 160 unduplicated pregnant women in 2011. Of pregnant women enrolled in WIC, 39% conceived less than 16 months postpartum (WIC medical risk factor 332). Pregnancy intervals less than 18 months are associated with adverse maternal and infant outcomes including low birth weight, small size for gestational age, preterm birth, and uterine rupture in women who attempt vaginal birth after a C-section (VBAC). (2) In 2011, 24% of Barron County women receiving WIC services also participate in the Prenatal Care Coordination (PNCC) program. Women enrolled in the PNCC program are offered a dual protection contraceptive kit offered during the third trimester or within 2 weeks of delivery. This kit includes condoms and Plan B and contraceptive information. The 76% of women enrolled in WIC, but not receiving PNCC, do not receive this kit or contraceptive information. WIC participants who are not enrolled in the PNCC program depend on their primary medical providers to discuss child spacing and give contraceptive supplies and information. In Barron County, primary medical providers have historically initiated contraception methods at the 6- to 8-week postpartum visit. PNCC case managers report that many women initiate sexual activity before the 6- to 8-week postpartum medical appointment. References (1) Wisconsin (December 2009, updated June 2011). Women's health now and beyond pregnancy. Association of Maternal & Child Health Programs. Retrieved January 25, 2012 from http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/Womens-Health-Now-and-Beyond.pdf (2) Mayo Clinic Staff (May 27, 2011). Family planning: Get the facts about pregnancy spacing. Mayo Clinic. Retrieved January 25, 2012 from http://www.mayoclinic.com/health/family-planning/MY01691

Root Cause:

Postpartum women did not have family planning supplies on hand in the initial postpartum period. Area physicians have not been prescribing emergency contraceptives in advance of need, were not knowledgeable that Badger Care paid for condoms with a prescription, and have not been discussing pregnancy spacing with their patients.

Planning and Execution Details

QI Implementation:

As part of the COPPHI grant, Barron County had a QI coach who provided guidance throughout the project. 1. Staff brainstormed information for the fishbone analysis. 2. Additional data were collected to support or disprove the suspected root cause of closely spaced pregnancies, including surveying WIC participants (a face-to-face survey with an incentive was offered to WIC participants during a set time period), surveying local medical providers (all area medical providers were sent the electronic survey via e-mail). 3. It is suspected that a lack of knowledge on birth spacing and not having family planning supplies on hand during the immediate postpartum period are contributing to the high number of closely spaced pregnancies among WIC clients. 4. A webinar was created for local medical providers written by public health staff with input from the BCPH medical advisor, who provided voiceover for the production. The webinar detailed the problem of high secondary pregnancy with short birth intervals, the value of birth spacing, postpartum contraception, and EC. The webinar was sent to the same providers who received the previous survey via e-mail. A post-webinar survey was given to local medical providers to determine any planned changes in how they would address family planning with their pregnant and postpartum clients. 5. Dual protection kits were developed for WIC clients with specific contraception information for the postpartum period. Posters in the WIC offices and laboratory advertise the availability of the kits. • Simple tracking and billing forms were created to document kits dispensed through WIC. • Staff were trained in dispensing kits, and new policies and procedures were developed. 6. Dual protection kits along with counseling from reproductive health staff is offered to all pregnant and postpartum WIC participants.

Focus activities

Maternal and Child Health Services:

Family planning

WIC

Data collection, Epidemiology and Surveillance:

Maternal and child health

Population-based Primary Prevention :

Unintended pregnancy

Regulation, inspection and/or licensing :

Local public health agencies

Professional licensure:

Nurses (any level)

Physicians

Other Public Health Services:

Access to care

Administration:

Performance Management

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Fishbone Diagram

Surveys

QI Tool Documentation:

Survey given to WIC clients on birth spacing and family planning

Survey given to all area medical providers before QI implementation

Survey given to all medical providers after watching informational webinar

COPPHI Fishbone Revised 7-2-12.pdf

Initiative Dates:

4/1/12 to 4/1/15

Initiative Duration:

Greater than 24 months

Methods of evaluation:

Measurements will include the following: 1. Self-reported practice changes by area physicians (post-test) 2. Tracking the number of dual protection kits distributed (internal tracking system) 3. The number of women enrolled in WIC who were provided with dual protection kits and contraceptive information in the third trimester of pregnancy or within 2 weeks postpartum (internal tracking system) 4. Data from the Wisconsin WIC program showing new Barron County pregnancy certifications that have conceived equal to or less than 16 months postpartum (WIC record query)

Supplemental Materials:

Storyboard

Supplemental Files:

Attachment	Size
Barron County Birth Spacing in WIC Storyboard.pdf	230.87 KB

Results

Measurable QI Outcomes:

Future measure: Increasing the number of women enrolled in WIC who receive a dual protection kit and contraceptive information in the third trimester of pregnancy or within 2 weeks postpartum. Future measure: Decreasing the percentage of new pregnancy certifications in WIC who have conceived equal to or less than 16 months postpartum. This indicator of success will not be available until 2014. Update on our project: Data showed our WIC secondary pregnancy rate, (WIC risk factor 332, pregnancy spacing <16 months) decreased to 22.3% in 2013. This was down from 31% in 2012. However, 2014 data show our WIC secondary pregnancy rate increased to 25.5% and our dual protection kit distribution fell by 12%.

Other QI Outcomes:

1. Local physicians who watched the educational webinar reported that they either "already do this" or were "much more likely" to do the emerging birth spacing/family planning practices outlined for pregnant and postpartum women. 2. Barron County WIC and reproductive health services initiated a protocol to provide birth spacing/family planning information and supplies to pregnant and postpartum WIC participants. 3. Staff learned about QI with an expert coach's help. QI training included creating a fishbone diagram, identifying root causes, working with area medical providers, and learning the entire QI process.

Lessons Learned, Observations and Insights:

We waited a full year to re-evaluate project outcomes and share this data with staff. We need to re-evaluate and provide feedback to staff more frequently in order to keep this initiative at the forefront of our interventions. We are looking at adding this as a performance measure to ensure quarterly attention.

Future Plans:

Barron County has developed a team of staff members committed to QI. These staff members participate in all QI projects and invite other staff in as the project applies to them. This team monitors the project outcomes and will lead changes as needed. Additionally: • Staff will monitor the rate of women conceiving less than 16 month postpartum using WIC data every 4 months. Results will be discussed in staff meetings and shared with the medical community. • Distribution of kits will continue with modification to the kit or procedure based on client input. • The 2013–2015 BCPH Strategic Plan calls for use of QI processes throughout the program.

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Submission Status:

Completed

Comments

This is a really interesting

This is a really interesting project. I love the idea. I'm wondering how you got Health and Human Service Committe/County Board approval to provide the emergency contraception. Did you experience and road blocks with that?

We manage our family planning

We manage our family planning program based on guidelines provided by the Wisconsin Family Planning and Reporductive Health Program, with approval of our Voluntary Medical Advisor, with support of the program by our board. This dispensing practice falls within those guidelines and clients who receive these services are enrolled as family planning clients.

The webinar we used to

The webinar we used to educate local providers can be viewed on You Tube at: http://youtu.be/mOYTWK6ClLw

This abstract and report have

This abstract and report have been very helpful as the City of Milwaukee Health Department plans to integrate dual protection interventions into their WIC this fall. Thank you Barron County & Nancy Drake for the expert advice and information.

This is a very interesting

This is a very interesting initiative! Have you had an opportunity to collect any data yet on your future measures?

Pregnant women enrolled in

Pregnant women enrolled in our WIC program who had risk factor 332, "Concep 16 mo pp" was at 22.8% for the period of 10/1/12 to 9/30/13, this is down from the 1/1/12 to 12/31/12 time period which showed 30.85% of pregnant women with this risk factor. We started the dual protection kits/birth spacing messaging in November of 2012. We continue to monitor the data. Thanks for your interest!

Any updates on your data?

Any updates on your data?

Laurie Call
Director, Center for Community Capacity Development
Illinois Public Health Institute
Laurie.Call@iphionline.org

Update on our project: Data

Update on our project: Data showed our WIC secondary pregnancy rate, (WIC risk factor 332, pregnancy spacing <16 months) decreased to 22.3% in 2013. This was down from 31% in 2012.

However, 2014 data show our WIC secondary pregnancy rate increased to 25.5% and our dual protection kit distribution fell by 12%.

Lesson's learned: We waited a full year to re-evaluate project outcomes and share this data with staff. We need to re-evaluate and provide feedback to staff more frequently in order to keep this initiative at the forefront of our interventions. We are looking at adding this as a performance measure to ensure quarterly attention.

Thanks for sharing your

Thanks for sharing your experience! Our WIC is also concerned about birth spacing. That's great that you have reproductive health staff and resources. I am going to pass this along to our WIC directors to see if we can think of some possible solutions that could work with the resources we have (such as reaching out to local physicians, etc.)!Also, it

Also, it's tough to keep one initiative at the forefront of your minds and efforts with everything else going on, especially after completing the "project." Keep up the good work! :)

Link to the resource where this submission is also published:

No.

Preventing Unintended Secondary Pregnancies in Women Receiving Women, Infants and Children (WIC) Services

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

This is a really interesting

We manage our family planning

The webinar we used to

This abstract and report have

This is a very interesting

Pregnant women enrolled in

Any updates on your data?

Update on our project: Data

Thanks for sharing your

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Preventing Unintended Secondary Pregnancies in Women Receiving Women, Infants and Children (WIC) Services

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

QI Spotlight