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The IMPLICIT Network: Promoting Healthy Mothers, Healthy Children and Healthy Communities
By Ron Cichowicz

Some of the best care a mother can provide her child is the care she provides for herself.

That’s the message being shared by the IMPLICIT Network and its Interconception Care Program (IMPLICIT ICC), which encourages primary care providers to screen mothers-to-be who already have children for risk factors during their well-child visits.

“Many complications associated with poor birth outcomes are caused by risk factors for premature birth and low birth weight in infants,” said Lisa Schlar, M.D., Director of Women’s Health at UPMC Shadyside. “These risk factors can be reduced through evidence-based interventions.”

Providing such interventions is the goal of the IMPLICIT Network, which was launched more than a decade ago by a group of passionate family physicians through family residency programs. IMPLICIT (Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques) was started and maintained with the support of the Family Medicine Education Consortium. Today more than 27 members—which includes family physicians, pediatricians, family health centers, federally qualified health centers, and other healthcare facilities—in eight different states.

 “Despite the risks associated with pregnancy for both mother and child, only 18 percent of women get preconception care,” said Dr. Schlar. “Equally disturbing, after the baby’s birth, many women who had been getting regular prenatal care stop doing so. After pregnancy, women often revert to negative behaviors, such as smoking and substance abuse, that put them and their future pregnancies at risk.”

And, while these realities are most harmful for the mother and her child, they should concern everyone. They have negative impacts on society as a whole, beginning with increased healthcare costs and extending to the lost potential of children, some of whom grow into adulthood with developmental challenges or physical or mental limitations as of a result of their poor start in life.

Launched in the early 2000s with seed money from the March of Dimes, today the IMPLICIT Network focuses on a collective strategy to implement evidenced-based prenatal interventions aimed at decreasing the rates of premature and low birth weight babies.

IMPLICIT recognizes that pregnancy outcomes often depend on the health and lifestyle of a woman before the first prenatal visit. Thus, interventions aimed at improving health in the prenatal period alone often fail to significantly reduce low birth weight and premature births. In response, IMPLICIT developed an innovative new model for providing maternal care, called the Interconception Care project. IMPLICIT ICC specifically attempts to reach high risk minority women at the greatest risk for poor birth outcomes.

Knowing that many women don’t seek care for themselves between pregnancies, yet brought their babies to well child visits, IMPLICIT ICC incorporates brief screening and interventions that are feasible to perform within the context of a well child visit and have strong evidence for improving future birth outcomes.

While a number of screenings could be administered, interventions need to be limited due primarily to the amount of time available for them during the well child visit. Currently the IMPLICIT ICC program encourages faculty and residents take a few additional minutes to screen the mother for four modifiable behavioral risks:

  • Smoking: Women who smoke while pregnant are at a higher risk of having a baby born too early and underweight. This can also lead to long-term childhood health issues, such as the child smoking at an early age or developing childhood obesity or Attention-Deficit Hyperactivity Disorder (ADHD).
  • Depression: Early detection and treatment of a mother’s depression lowers the risk of behavioral or mental health problems in children. Symptoms occur in 20 to 40 percent of women during or postpartum and depression has a peripartum recurrence of 40 percent.
  • Contraception Use: The ideal space between pregnancies is 18 months or more. This gives a mother enough time to recover physically and emotionally. ICC intervention focuses on birth spacing and highly effective birth control practices.
  • Multivitamin Intake: Folic acid and multivitamins have been shown to reduce neural tube defects by 66 percent. ICC Intervention provides counseling on the benefits of taking a multivitamin with folic acid daily and will provide a supply to the patient when necessary.

“Mothers screened positive for one or more ICC risk factor at more than 65 percent of well child visits, making this model successful in its ability to identify modifiable maternal risk factors,” said Jessica Brubach, MPA, network manager. “Given high rates of the four risk factors, the Network is currently developing additional strategies to improve maternal behaviors associated with poor pregnancy outcomes with the goal of improving future birth outcomes.”

Brubach added that the Network has distributed copies of the IMPLICIT Interconception Care Toolkit, free of charge, to sites throughout the United States.

“Finally, through its work and data analysis, the Network hopes to demonstrate the ICC program’s cost benefit and its importance in improving delivery of interconception care and associated outcomes,” she said. It also hopes to show its potential for helping to decrease health disparities among various populations.”

The IMPLICIT Network has benefited greatly through various grants and initiatives provided by the National and Pennsylvania March of Dimes. Additionally, individual Network sites have received grants for enhancements to their local initiatives. These include March of Dimes support in New York, North Carolina and Mississippi.

Most recently, Pennsylvania programs have greatly benefited from a grant from the Pennsylvania Department of Health for 2016-2019 to assist with efforts within the Commonwealth.

Additional support has come from the Shadyside Hospital Foundation and St. Margaret Hospital Foundation in Pittsburgh; Duke University Medical Center; Lancaster General Hospital Research Institute and the Pennsylvania American Academy of Pediatrics.

To learn more about the IMPLICIT Network and IMPLICIT ICC, visit http://www.fmec.net/implicitnetwork.html.

 

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