Reproductive Life Planning as a Component of Interconception Care_Merry-K Moos_4.23.13

Reproductive Life Planning as a
Component of Interconception
(and Preconception and Preventive)
Care

CORE Group Spring Meeting, 2013

Merry-K. Moos, BSN, (FNP), MPH FAAN
Consultant, Center for Maternal and Infant Health
and Professor (retired) Schools of Medicine, Public
Health, and Nursing
University of North Carolina
mkmoos@med.unc.edu

The Problem
Infant mortality and morbidity remain
high in nations of varying economic
assets (for instance, U.S. ranks 28 in
international comparisons of mortality)
Major contributors to morbidity/mortality
worldwide are prematurity (PTB) and
low birth weight (LBW)

The Problem
Risk factors for PTB and LBW include:
Adolescent childbearing
Unintended pregnancy
Short interpregnancy intervals

Each of these risk factors might be reduced
by reproductive life planning

The Problem
Risk factors for PTB and LBW include:
Adolescent childbearing
Unintended pregnancy
Short interpregnancy intervals

Why and How Interpregnancy
Intervals Matter
IPIs are variably calculated but the standard definition
is that the interval starts with the delivery date of one
infant and ends with the (approximate) conception
date of the next pregnancy.

Both short and long interpregnancy intervals (IPIs)
have been associated with poor pregnancy outcomes
including growth restriction, preterm birth and low
birthweight. (Conde-Aguidelo et al., JAMA, 2006)

Intervals Matter, cont.
cont
Controlling for socioeconomic status, use of health
care services, tobacco, alcohol and other exposures
does not alter the finding that interpregnancy
intervals exercise an independent influence on poor
pregnancy outcomes. (Conde-Aguidelo et al., JAMA, 2006)

Some hypothesize that increased risks for women
with short interconceptional lengths relate to maternal
nutrition depletion and/or inadequate maternal folate
levels.

Intervals Matter, cont
In 2006, a meta-analysis of 67 articles studying the
impact of IPIs determined that intervals < 18 months
and > 59 months are significantly associated with
growth restriction, low birth weight and preterm birth
(Conde-Agudelo et al., JAMA 2006).

The analysis also found some suggestion that IPIs <
6 months and >50 months increase the risk of fetal
and early neonatal deaths.

How and Why Interpregnancy
Intervals Matter, cont.
For each month that For each month that IPI
IPI was shortened extended beyond 59
below 18 months, months,
PTB: increased 1.9% PTB increased 0.6%
LBW increased 3.3% LBW increased 0.9%
SGA increased 1.5% SGA increased 0.8%

The Reproductive Life Plan Is
a Promising Approach for
Impacting Interpregnancy
Intervals [and unintended
pregnancy rates]

Summary of Quantitative and
Qualitative Research
 Marked “disconnect” exists between the recreational and
procreational functions of sex (among individuals and society, at
large)
 Ambivalence about desire for a baby is common (intended vs
unintended is probably not a useful construct)
 Clinical counseling seems to focus on providing contraception
rather than starting with the woman/couples’
goals/realities/concerns—thus, it is not patient-centered and has
limited capacity to affect behaviors
 “If it happens, it happens” is not an effective health
promotion/disease prevention strategy and it certainly flies in the
face of preconception/interconception health initiatives

Evolution of an Idea: The Call
for RLP
Modern contraceptive methods made
choosing if and when to become pregnant
possible—yet in US, 50% of pregnancies
unintended
Nearly half of the unintended pregnancies in
the US occur in a month the woman used
contraception (as everywhere, most of such
conceptions relate to user errors or
misunderstandings NOT method failures)

Need Strategies to Move “if it
happens, it happens” to
Ownership of Choices

If you choose to have sex without
using a method of birth control, you
have made a decision to have a baby.

The Call for Reproductive Life
Planning
Evolution of a Movement

1980s-Hatcher recommends that “young
people” ask themselves a series of 8
questions (e.g. do you want children. . .how
compatible are your reproductive plans and
your religious and moral beliefs)
2005-ACOG indicates that clinicians should
encourage women to formulate a RLP and
provide non-directive counseling

2006- US PCHHC Expert Panel recommends that
“Each woman, man, and couple be encouraged to
have a reproductive life plan”.
2008- PCHHC Clinical Work Group determines that
routine health promotion activities for all women of
reproductive age should begin with screening
women for their intentions to become or not become
pregnant in the short and long term and their risk of
conceiving (whether intended or not).

2009 - Ad hoc committee of PCHHC puts forth that:
” Reproductive life plans are created by
individuals/couples outside the examining room
(although the concept can certainly be introduced,
assessed and reinforced in a clinical visit); they are
ONE approach for helping individuals plan, based on
their own values and resources, a set of personal
goals about whether or when to have children. The are
never right or wrong and they are likely to evolve over
time.
From deliberations of Ad Hoc Committee of PCCHC Select Panel on Reproductive Life
Planning, Washington, DC, November 23, 2009; chaired by MKMoos/J Bermann

* This version reflects continual word-smithing by mkmoos 

. . .but how do we do it?
In the 1990s, I started experimenting with a
series of RLP questions appropriate to clinical
setting. (Moos, MCN, 2003)
Of note, very well received by diverse groups
of patients (who were often amazed at the
questions or that no one had ever asked
before).
Actually, saved time in the encounter
because responses allowed me to focus on
self-determined needs.

My Recommendations for
Assessing an Individual’s RLP
Do you hope to have any (or any more) children?
If no, what are you planning to do to prevent becoming
pregnant (again)
If yes, ask:
How many (more) children do you hope to have?
How long would you like to wait until you become
pregnant (again)?
What do you plan to do to prevent getting
pregnant until then?
What can I do to help you achieve your plan?
Adopted from Moos, MCN, 2003

cdc.gov/preconception/documents/
rlphealthproviders.pdf

Framework
Life Plan
(what do I want to do with my future?)

Reproductive Life Plan
(what do I want to do with my reproductive future?)

Clinical Interactions
Review/Assess Reproductive Plan
Reinforce value
Provide relevant education, c ontraceptive
choices/counseling
Provide contingency planning (if user controlled method)

Overall Life Plan
Other Pieces
in the Life Plan:
Health •Relationships
•Economic status
Education •Spiritual connections,
•Social outlets, etc.

RLP Vocation

Important Attributes of a
Reproductive Plan Assessment
 Starts with no assumptions
 Is patient centered.
 Includes key basic questions and allows
branching.
 Invites goal setting and action steps.
 Has been tested with target population(s).
 Short!

From deliberations of Ad Hoc Committee of PCCHC Select Panel on
Reproductive Life Planning, Washington, DC, November 23, 2009

. . .and, to make a difference, the
process should:
 Encourage individuals (males and females) to find
their own voices about what they want regarding
childbearing.
 Empower individuals to move from “chance” to
“choice” regarding pregnancy risk taking.
 Help providers (whether clinicians, community
outreach workers, etc.) tailor their interactions to
the client’s own desires.
 Be recognized as a process

Applying the Transtheoretical “Stages of
Change” Model to Decisions about Childbearing
Planning
Not ready to consider benefits or possibilities of thinking
about if and when to have (more) children.
(Precontemplation)

Beginning to consider that there could be personal
benefits. (Contemplation)

Accepts that it is possible and beneficial to make
deliberate decisions about if and when to have children.
(Preparation)

Creates a reproductive life plan that has personal
meaning (i.e. not just answering yet more questions
because they are asked). (Action)

Maintains belief that a reproductive life plan is
personally valuable and chooses contraceptive
behaviors in concordance with the plan.
(Maintenance)

Loses interest in planning and takes pregnancy risks.
(Relapse: invites reengagement)
.

Important Considerations,
Irrespective of Tool Used
 Reproductive life plans are NEVER right or wrong.
 Reproductive life plans are fluid--they should never be
considered set in stone because “life happens”.
 Reproductive life planning should be offered to
everyone, irrespective of assumptions or biases about
the woman’s (man’s) circumstances.

*From deliberations of Ad Hoc Committee of PCCHC Select Panel on Reproductive Life Planning,
Washington, DC, November 23, 2009

Assessing the Reproductive Plan Should Help
Direct Clinical and Educational Encounters
• Education on the advantages of spacing pregnancies
for those whose plans includes short interconceptional
periods.
Education when there is a cognitive dissonance
between the plan and the strategies (e.g. I don’t plan to
get pregnant again for 3 years but my partner and I
have decided not to use any contraception; I plan to
use the pill even though I forgot to take my prenatal
vitamin 3 out of every 7 days).
Linkages to affordable methods compatible with plan
Ongoing case management and support to help
achieve reproductive life plan

Reproduc-
tive Life
Planning
Starts
Outside
the
Clinical
Setting
Delaware Created
a Life Plan by and
for
Teens--

Is This RLP Approach the Best
Approach?
 In practice, it successfully initiates conversation
 It engages women (teens, low income and high income
women, white, Latina and black women, etc)
 Women are often surprised by the questions but no one
has ever objected
 It allows the encounter to be more efficient
 It has had limited use with men
 It has not been proven to change behaviors or
outcomes
 It has not been systematically studied to determine
longitudinal impact

Reproductive Life Planning as a Component of Interconception Care_Merry-K Moos_4.23.13

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Editor's Notes