Breaking Barriers to Healthy Birth Spacing in Underserved Populations

This series focuses on how states are reaching underserved populations as part of the Collaborative Improvement and Innovation Network to Reduce Infant Mortality.

For women who have recently given birth, waiting at least 18 months before becoming pregnant again is essential as it allows the body much-needed time to recover and heal. Longer intervals between pregnancies also mean better birth outcomes and healthier babies. While there is no consensus on optimal interpregnancy interval, research shows that short intervals of less than 18 months and intervals longer than 60 months are associated with poor health outcomes.

One of the six focus areas of the national Collaborative Improvement and Innovation Network to Reduce Infant Mortality (Infant Mortality CoIIN), pre/interconception care promotes optimal women’s health in part by working to improve birth spacing. Short interpregnancy intervals are associated with low birthweight and preterm birth, which is a leading cause of infant mortality and contributor to long-term health problems such as asthma, learning disorders and vision/hearing loss. Lack of adequate birth spacing can also exacerbate financial hardship, an issue of particular concern for economically disadvantaged populations.

To encourage healthy birth spacing, the New York State (NYS) IM CoIIN team is working to increase access to effective means of contraception during the postpartum period. Based on the 2012 Pregnancy Risk Assessment Monitoring System (PRAMS) report, among live births resulting from an unintended pregnancy in NYS, 45 percent occurred in the state’s Medicaid-covered populations compared to 25 percent for non-Medicaid populations. Given this demonstrated need, the NYS IM CoIIN team has honed its efforts on high-need, Medicaid-eligible women. In addition, the NYS IM CoIIN team has begun reaching out to the state’s undocumented population by joining forces with Public Health Solutions (PHS), a nonprofit public health institute that works closely with recent immigrants (most of whom are referred to PHS by social workers in local hospitals).

“These are women who deal with a host of personal, social and structural barriers—people who lack health insurance or access to health services,” says Meaghan Carroll, Contract Manager for the New York State Department of Health (NYSDOH).

To improve birth intention and promote use of long-acting reversible contraception (LARC) among underserved women, the team expanded its educational strategy enlisting Community Health Workers to educate women on issues like effective contraception and proper birth spacing.

“This approach reinforces what we already have in place for women on Medicaid, and leverages existing resources to obtain even better outcomes,” says Marilyn Kacica, MD, MPH, the Medical Director, Division of Family Health, NYSDOH.

Beginning their efforts in early 2015, Community Health Workers in New York City and Buffalo started helping prepare pregnant women for the postpartum period by offering information on effective contraceptive methods (with an emphasis on intrauterine devices and other forms of LARC).

“We want to provide this information during the prenatal period so that women can go into birth with that knowledge about contraception—or, ideally, having already selected the contraceptive method they want to use during the postpartum period,” says Ms. Carroll. “Then once they’ve given birth, the Community Health Workers can provide them with the support they need to actually obtain that birth control.”

As part of their work within IM CoIIN, the NYS team has also designed their own data collection tool to obtain data for reporting to the national IM CoIIN and for statewide quality improvement. The tool captures information such as the number of women reporting use of birth control in the postpartum period and the number of women reporting a postpartum healthcare visit within 21 to 56 days after giving birth.

“Our pilot sites are committed to this project and are submitting data to us on a very regular basis which is a big success of our project,” notes Dr. Kacica.

Feedback from Community Health Workers has already yielded invaluable insights.

“Through this work we’re able to get a dual focus on systems-level issues and individual-level issues,” says Ms. Carroll. “So when barriers are identified on an individual level, we can come up with strategies to address them within an entire health network.”