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PCHHC Newsletter
September 2014
Preconception Health: Mind, Body, and Spirit    
SAMHSA's 10 Guiding Principles of Recovery
This month's newsletter shines a spotlight on the topic of women's mental health and substance abuse, and their impact on preconception wellness. According to the April 2014 CDC MMWR Report on Core State Preconception Health Indicators, in 2009, 13.2% of women age 18-44 years reported frequent mental distress during the previous month. In the same year, among women age 18-44 with a recent live birth, the estimated overall prevalence of receiving clinical care for anxiety or depression during the year prior to pregnancy was 11.2%. Further, about 20% of women reported inadequate emotional and social support. Non-Hispanic black women experienced the highest prevalence of mental distress and inadequate support. This report also highlighted that about one in four women with a recent live birth reported pre-pregnancy binge drinking, while one in four reported smoking. The intersection of mental health issues, substance abuse, and violence can present a multifaceted challenge to women and the family and clinicians who care for them. Preconception health promotion programs need to consider the complexity of women's mental and behavioral health needs. The Recovery Model described above provides a comprehensive approach to women's wellness. Other programs in this issue provide models for complete, woman-centered care.

Also in this issue, we are excited to introduce our new section that will feature state preconception health efforts. North Carolina is our highlight for September. Our next issue will focus on preconception health and chronic disease. If you have a program, story or resource to share please let us know!
Innovative Programs Addressing Reproductive Age Women's Mental Health and Substance Abuse   
The New Haven Mental Health Outreach for Mothers (MOMS) Partnership is a community-academic coalition of health, education, and economic support agencies in the City of New Haven, CT, that works to support the well- being of mothers and families living in the city.  In 2010, the MOMS Partnership conducted a year-long needs assessment with over 1000 mothers, and they found that three major factors place women at high risk for poor outcomes for themselves and their children: 1) Lack of basic needs related to parenting, including diapers, sufficient food, childcare, clothing, and stable housing; 2) social isolation; 3) high levels of maternal mental illness or "stress," defined by mothers to include psychiatric symptoms and actual depressive, anxiety and addictive disorders.
In response, the MOMS Partnership has taken a multi-pronged approach to ensure that pregnant and parenting women achieve the highest possible standards of mental health and physical well-being throughout their life course.  The Partnership is in the process of creating 12, neighborhood-based "MOMS Zones" that each consists of a "MOMS Hub" that delivers centralized mental health and family self-sufficiency economic support and a cadre of community ambassadors who will provide outreach to the hardest-to-reach women and their families and help them engage in the neighborhood MOMS Hub services.  See their website or the MOMS Partnership concept paper for more information.

UNC Horizons at the University of North Ca
rolina School of Medicine is comprehensive substance abuse treatment program for pregnant and/or parenting women and their children in North Carolina. UNC Horizons seeks to increase the number of pregnant women and mothers with substance use issues who successfully engage in the recovery process, increase healthy birth outcomes, assure early intervention for children as needed, and improve community response and service collaboration for women with substance use issues.  The program serves women from across the state, with both residential and outpatient programs, and provides evidence-informed interventions for substance abuse, trauma-informed counseling, individual and family therapy, and attachment-based parenting education and support.  UNC Horizons also provides essential wrap-around services to promote women's long term recovery and assist in preventing relapse, including transportation to treatment, on-site childcare, job assistance, and support and assistance with managing finances.  The UNC Horizons staff conduct on-going research and train professionals around the state and US.  See their website for more information. 
Resources and Relevant Research   
Mental Health Among Women of Reproductive Age  In this fact sheet, the CDC Division of Reproductive Health describes its efforts to improve the mental health of 15-44 year old women in the US through surveillance and research.  The report describes the national and state-based surveillance conducted by CDC, particularly of depression and depressive symptoms in women, and provides information on which women are most at risk, who is likely to receive screening and treatment, and the other health outcomes associated with depression and poor mental health in women.

Knowledge Path & Care Resources:  Health and Wellness for Adolescent Girls and Women with Mental and Behavioral Health  Conditions  

The Women's Integrated Systems for Health (WISH) Project at the University of North Carolina at Chapel Hill and the Maternal and Child Health Library (MCH Library) at Georgetown University, both of whom are funded by the Maternal and Child Health Bureau (MCHB), released a new knowledge path, Health and Wellness for Adolescent Girls and Women with Mental and Behavioral Health Conditions. The knowledge path aims to bridge the public health and mental health information needs of professionals with regard to promising, practical intervention approaches to promote optimal health and wellness among women of childbearing age who experience a mental, emotional, or behavioral health condition. The knowledge path covers topics of particular relevance to health promotion and disease prevention for all women, with content specific to those with mental and behavioral health disorders: Reproductive and maternal health, intentional injury, chronic conditions, healthy behaviors, and health disparities. A separate brief presents resources to help adolescent girls and women with mental health and substance use disorders and their families find care, services, and support and learn more about getting healthy and taking care of themselves during recovery. The brief is available here


Preconception Mental Health Studies
Based on the nationally-representative, population-based Medical Expeditures Panel Survey, researchers found that poor preconception mental health is the most significant risk factor for pregnancy complications, a possible risk factor for non-live birth, and a strong risk factor for low birth weight (LBW). Women who reported poor mental health before pregnancy (a global mental health rating of "fair" or "poor") were nearly twice as likely to give birth to a LBW infant, almost 50% more likely to have a non-live birth, and 40% more likely to have any pregnancy complication when controlling for maternal age, race/ethnicity, marital status, education, health insurance status, income, and number of children in the household. The authors state that significant racial/ethnic disparities exist for pregnancy complications and non-live births, but not for LBW.  They conclude that women's preconception mental health is a modifiable risk factor that stands to reduce the incidence of adverse pregnancy complications and birth outcomes. Witt WP, et al. Preconception mental health predicts pregnancy complications and adverse birth outcomes: A national population-based study. Journal of Maternal and Child Health 16: 1525-1541, 2012.   

In a 2013 study, researchers analyzed self-reported data from over 200,000 reproductive age women surveyed by the 2005, 2007, and 2009 Behavioral Risk Factor Surveillance System. Women who reported that their mental health was not good for ≥14 days during the past month were categorized as having frequent mental distress.   The authors measured associations between mental distress and 15 preconception health indicators in separate models, adjusting for demographic characteristics.  They found that the prevalence of good preconception health for each of the 15 indicators was higher among women with infrequent mental distress.  The authors conclude that women with poor mental health may need tailored interventions to improve preconception health indicators such as social support, smoking, weight, and nutrition. Farr SL, Bish CL. Preconception health among women with frequent mental distress: a population-based study. J Womens Health, 2013 Feb;22(2):153-8.  

The responses of a community-based study of women's postpartum health were analyzed to examine the relationship of preconception and prenatal intimate partner violence (IPV) and postpartum metal health.  The researchers found that almost two-thirds (61%) of women reported postpartum mental health symptoms above normal levels, with 47% reporting symptoms at moderate or higher levels. A majority of respondents reported some form of IPV before pregnancy (84%) and during pregnancy (70%). Multivariate analyses showed that the impact of IPV on postpartum mental health was a function of the type and timing of abuse. Psychology aggression during pregnancy was associated with symptoms of stress and PTSD; sexual coercion, both before and during pregnancy, was associated with symptoms of obsessive-compulsive disorder (OCD); and physical assault was associated with depression, OCD, and PTSD when it occurred during pregnancy. Inconsistent with existing research, the study did not find an independent effect of physical assault before pregnancy on postpartum mental health, after accounting for psychological aggression, sexual coercion, participant education, annual income, and relationship status. The researchers conclude that the results of this study provide further evidence that IPV is a risk factor for postpartum mental health problems. They urge the public health community to go beyond screening and to develop and implement IPV intervention and prevention strategies in the perinatal period.   Desmarais SL, et al. Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems. BMC Pregnancy and Childbirth, 2014; 14 (1): 132  
State Update: Advancing Preconception Health
in North Carolina


The North Carolina Preconception Health Coalition leadership team engaged a statewide coalition in 2007 to develop the NC Preconception Health Strategic Plan released in September 2008. The initial priority areas for the NC Preconception Health Strategic Plan were the promotion of intended pregnancies and healthy weight, although the plan also addressed substance abuse, mental health, collaborative research on preconception-focused topics, and policy development and access to care.  Five years later, many of the suggested strategies in the original plan have been implemented and preconception health awareness continues to grow in NC; yet, input from stakeholders identified the need to expand the priority areas and target population and incorporate recent theoretical models recognized as being essential to advancing preconception health.


As a result, the NC Preconception Health Strategic Plan Supplement: 2014-2019 was developed.  The Supplement incorporates the broader influence of social determinants of health, and it recognizes the impact of events during the life course. It also includes goals and strategies for supporting expanded priority areas of life planning, mental wellness, and access to services, and expands the target population to men as well as women.  


The North Carolina Preconception Health Campaign uses innovative  strategies to educate women about the benefits of folic acid, healthy weight, and preconception health. Led by the North Carolina Chapter of the March of Dimes, in partnership with the NC DHHS Division of Public Health Women's Health Branch and many other key stakeholders, the Campaign seeks to reduce infant mortality and morbidity and chronic health conditions in women, while also aiming to increase intended pregnancies in NC. The Campaign works to achieve these goals through programs to improve women's wellness, improve reproductive outcomes, and reduce health disparities. One such program is the Preconception Community Ambassador initiative that trains lay health advisors on folic acid/nutrition. Campaign Coordinators also train health care providers on preconception health topics, including healthy weight, tobacco cessation, reproductive life planning, and women's health expansions through the Affordable Care Act, as well as provide patient education resources and provider tools.   


The Campaign has recently worked with NC's Young Families Connect program to train health care providers and community partners who serve young, expecting and new parents in five high-need counties on the Ready, Set, Plan reproductive life planning curriculum for youth and young adults. Other initiatives include folic acid distribution to reproductive age women; a Spanish-language media campaign and promotora initiative to reach Latinas in NC; and delivery of the Healthy Before Pregnancy preconception curriculum to high school students across the state. To learn more about the campaign, check out their website.


The recently recorded webinar on the New Preconception (PCC) / Interconception (ICC) Health Toolkit for Clinicians can be accessed here. The  toolkit was designed to help primary care providers and their colleagues incorporate PCC and ICC health into the routine care of all women of childbearing age. It includes specific information on mental health and substance use/abuse. 

  MGH Center for Women's Mental Health
The Massachusetts General Hospital Center for Women's Mental Health  provides information for clinicians and patients on perinatal and reproductive mental health for women across the life span, from premenstrual disorders through menopause. Their website provides an on-going discussion of new research findings in women's mental health and how such investigations inform day-to-day clinical practice, including implications for pharmacotherapy during pregnancy and lactation, non- pharmacologic approaches to improving women's mental health, a library of the latest research organized by topic, and a frequently-updated blog geared toward health professionals.

Smoke Free Women and Smoke Free Mom
Tobacco use among reproductive age women remains a concern in the US, and tobacco continues to be the most-used substance during pregnancy, resulting in poor outcomes for women and their families.  The US DHHS has developed two, interlinked websites for women and the providers who serve them: Smoke Free Women and Smoke Free Mom. These sites provide women with information and support, including cessation support via text, and tools for healthcare providers.

CHOICES Now Included in NREPP
CDC is pleased to announce that CHOICES: A Program for Women about Choosing Healthy Behaviors is now included in SAMHSA's National Registry of Evidence-Based Programs and Practices (NREPP). CHOICES is an evidence-based intervention that increases motivation and commitment to reduce or stop drinking and/or use contraception effectively. It includes 2-4 counseling sessions plus a contraceptive counseling session. The program works with women before they become pregnant to reduce their risk for an alcohol-exposed pregnancy. 

Women's Health Chartbook Now Available

 The US DHHS Office of Women's Health has updated the Women's Health and Mortality Chartbook on the Quick Health Data Online website.  The 2014 edition is a statistical resource on women's health in each of the states, the District of Columbia, Guam, Puerto Rico and the US Virgin islands.  Featuring 28 health indicators, the Chartbook was developed to provide users with an easy-to-use collection of current jurisdiction data on critical issues of relevance to women.   

Sign Up for Bi-Weekly Preconception Updates to Your In-Box 

To receive a bi-weekly media and literature update on preconception and interconception health through a listserv, please email Cheryl Robbins.
About the Newsletter  
Thanks for reading!  Is your organization doing exciting work to promote preconception health? We would love to feature you in an upcoming newsletter.  Email us for details, or if you have any questions about the newsletter.       
Do you work on issues related to women's mental health or substance abuse? 
Please email us - we would love to know more about your work and to connect you with the PCHHC Initiative. 
This e-newsletter is archived.  Find back issues of the newsletter and more information about improving preconception health and health care here.