Authored by IHI Innovation Director Marian Bihrle Johnson and IHI Fellow Lucy Pickard, this article is part of a series highlighting IHI’s work to develop a population approach to maternal health, with a focus on reducing disparities in outcomes and reducing preterm birth for pregnant women receiving Medicaid.
Asking the “One Key Question”
More than half of pregnancies in the United States are unintended, yet just 19 percent of women report having any conversation with a provider about pregnancy intention or contraceptive counseling. The “One Key Question” initiative, developed by the Oregon Foundation for Reproductive Health (OFRH), aims to meet this clear need. One Key Question encourages all providers to ask women of childbearing age, “Would you like to become pregnant in the next year?” Women who answer “yes” receive counseling and screening to ensure optimal health in preparation for a pregnancy. Women who answer “no” or “not sure” have meaningful conversations covering all options for contraception and family planning, to ensure that each woman makes an optimal decision based on her individual circumstances.
OFRH has implemented pilot projects of One Key Question across Oregon and several other states; early results have shown an increased number of women who do not desire pregnancy using effective contraception, and an increased number of women who do desire pregnancy taking the recommended folic acid supplements and receiving prenatal counseling. Programs like One Key Question have the potential to reduce disparities in care and outcomes, especially for groups with higher rates of unintended pregnancy and adverse birth outcomes.
Same Day, Same Visit Access to Effective Contraception Through “Upstream USA”
Another approach to reducing unintended pregnancy focuses on building the capability of health centers to offer the full range of contraceptive options to women without delays in care. Research shows that if health centers offer women all contraceptive options, including intra-uterine devices (IUDs) and implants, the same day they want them with person-centered counseling, many more choose the most effective methods, resulting in lower rates of teen pregnancy and unplanned pregnancy.
Upstream USA offers onsite, comprehensive training, counseling, and coaching so that health centers have the knowledge and streamlined processes to offer all women same-day, same-visit access to the full range of contraception options. Upstream USA training has been completed in clinics in five states and has just begun across Delaware.
The South Carolina Birth Outcomes Initiative
South Carolina had the fourth-highest percentage of babies born prematurely in America, and one in ten babies born in the state were admitted to the NICU. The South Carolina Birth Outcomes Initiative (SCBOI) is a collaborative effort to reduce the number of babies born with low birth weight, reduce NICU stays, and reduce the racial disparities in birth outcomes across the state.
The SCBOI advocated for and achieved a significant policy change to Medicaid within the state, which allowed for women to choose and receive Long Acting Reversible Contraception or LARC (implants or intrauterine devices) in the immediate post-partum period. This policy change, in addition to provider communication, education, and a LARC toolkit for providers, has resulted in a 31 percent increase in women choosing LARC after delivery and a 10 percent increase in women choosing LARC in the outpatient setting.
Overall, the SCBOI has achieved impressive results: infant mortality in South Carolina has dropped from 6.9 to 6.5 per 1000 births, the lowest on record for South Carolina; and the odds of preterm birth among black women receiving “Centering” group prenatal care has dropped by 60 percent. The SCBOI initiative is ongoing and aims to continue to achieve great outcomes and reduced disparities among women and babies.
Colorado Family Planning Initiative (CFPI)
Forty percent of all births in Colorado were unintended, and this figure rose to 61 percent among women 15-24. Unintended pregnancies are known to lead to higher rates of preterm birth and low birth weight. Among women in Colorado receiving Title X-funded family planning services the most effective evidence-based contraceptive options were being used by only 2 percent of women under 20. Despite best practice guidelines from ACOG and AAP, high initial costs of Long-Acting Reversible Contraception (LARC), the time needed for proper counseling, and low levels of user and provider knowledge of these methods were preventing women from having access to the best forms of contraception for their needs.
With funding from a private foundation, CFPI removed the cost of LARC contraceptive methods at the point of delivery at 28 Title X-funded family planning clinics in the state. There was a strong focus on person-centered counseling around contraceptive options, the use of motivational interviewing, and consistent use of interpreter services in each clinic, to allow women to choose the contraceptive method best for them.
CFPI has successfully improved outcomes for women and babies: the initiative has increased the uptake of LARC methods at Title X clinics and reduced the likelihood of having a baby preterm for women statewide. The odds of preterm birth fell by 12 percent across the state, and living in a county with a Title X clinic served by the CFPI was protective for preterm birth.
Editor’s note: IHI is seeking to test a “bundled” set of evidence-based practices deployed as individual or limited interventions. The intent of testing these interventions, individually and collectively, is to build a system where women are given power and agency in their reproductive decisions; are supported in their journeys not just by providers, but by peers as well; and are given the support to overcome barriers to health and well-being in respectful environments.
You may also be interested in:
Designing a Population Approach to Maternal Health and Care
The Maternity Medical Home: The Chassis for a More Holistic Model of Pregnancy Care?
Project Nurture: Two Approaches to Integrating Perinatal Care with Substance Use Treatment