Optimizing Care for Women of Reproductive Age with One Key Question® July 26, 2018 LA County Dept of Public Health, Public Health 1314 The Los Angeles County Department of Public Health recommends that health care providers routinely screen for pregnancy desire in well-woman and primary care visits for women of reproductive age. In LA County, chronic diseases that negatively impact pregnancy, such as diabetes and hypertension, are increasing in this population. In addition, many younger women with chronic diseases are prescribed medications that are teratogenic and contraindicated in pregnancy. To maximize patient safety and improve care for women of reproductive age, internists and family medicine providers need a way to quickly and efficiently address preventive reproductive health with their female patients. This article discusses the pregnancy desire screening tool, One Key Question®, and implementation strategies for a busy clinic or practice. Are you treating hypertension, hyperlipidemia, or diabetes in reproductive-aged women? What are you prescribing? ACE Inhibitors Angiotensin Receptor Blockers Statins should not be prescribed during pregnancy. Be sure to consider women's desire for pregnancy when prescribing any medication. Assessing Pregnancy Desire with One Key Question One Key Question integrates routine, proactive screening for pregnancy desire into the primary health care visit by asking all women of reproductive age who can get pregnant: "Would you like to become pregnant in the next year?" This question was developed by the Oregon Foundation for Reproductive Health to more accurately identify the preventive reproductive health services needed by women of childbearing age. Based upon the woman's answers (i.e., "yes," "no," "I'm okay either way"/"I'm not sure"), clinicians and their teams can take steps to meet those needs (see figure below). Here, we outline the recommended action steps and suggest clinical and patient resources based on patient response. While some action steps can be deferred to a subsequent appointment or referral to a specialist, there are key steps that should be addressed at the point of screening; those are marked with an asterisk. Clinics and offices are encouraged to develop site-specific protocols based on patient response to One Key Question that minimize barriers to follow-up for both the clinician and the patient. One Key Question and Patient Responses Would you like to become pregnant in the next year? 1. YES ACTION: Assess and initiate preconception care. Review medications.* Recommend daily folic acid.* Screen and counsel on tobacco and substance use.* Counsel patients with untreated or poorly controlled medical conditions about the need to optimize their health prior to becoming pregnant (e.g., get blood pressure or diabetes under control, treat anemia). Refer for specialty consultation or care as needed. Screen for conditions that can affect pregnancy. Screen for intimate partner violence. Review immunization history. Provide or refer for contraceptive counseling and care if health and medications are not yet optimized for pregnancy. Refer for a preconception visit and recommend early prenatal care. For women who would like to get pregnant within a year, One Key Question alerts the clinician to consider the impact of patients' medical conditions and medications on pregnancy, and to work with patients to adjust treatment accordingly. One Key Question also provides clinicians an entrée to educate women on the importance of health-related behaviors in the preconception period, including tobacco cessation and folic acid supplementation. At a minimum, for a woman who desires pregnancy, a busy provider should consider alternatives to teratogenic medication and refer her for more comprehensive preconception counseling. Preconception Resources LA County Department of Public Health - Maternal, Child, and Adolescent Health Programs: Preconception Health Resources for Health Care Providers publichealth.lacounty.gov/mch/ReproductiveHealth/PreconceptionHealth/PCH_PreconceptionHealthResources.htm Every Woman California: Preconception Guidelines everywomancalifornia.org/content_display.cfm?categoriesID=97&contentID=360 Centers for Disease Control and Prevention (CDC): Before Pregnancy cdc.gov/preconception/index.html CDC: Treating for Two - Medicine and Pregnancy cdc.gov/pregnancy/meds/treatingfortwo/index.html Iris Cantor - UCLA Women's Health Center: Planning for a Healthy Home, Body, and Baby womenshealth.ucla.edu/phhbb 2. NO ACTION: Determine if patient is at risk for unintended pregnancy (e.g., Is she sexually active with men? Is she able to get pregnant?). If indicated, discuss contraception. Inquire about current contraceptive method use and satisfaction.* For patients not using contraception or not satisfied with their method, offer or refer for the full spectrum of contraceptive options, including long acting reversible contraception (LARC, which includes intrauterine and implantable contraception).* Offer emergency contraception as indicated. For women who do not desire pregnancy within a year (and are at risk for conception), the provider should assure that the patient is adequately protected against unintended pregnancy. At a minimum, it should be determined if the patient is currently using contraception, is satisfied with her choice, and is using it consistently and correctly. Ideally, for women at risk of contraceptive failure or unprotected intercourse, an advance prescription of emergency contraception should be offered at that visit. Use of emergency contraception within 72-120 hours of unprotected vaginal intercourse can prevent pregnancy by inhibiting ovulation. Patients who are at risk for unintended pregnancy who are not using contraception or who are not satisfied with their current method should receive full contraceptive counseling and education. If this cannot occur during the current visit, an appointment or referral should be provided. It is important to ensure the discussion happens in a timely manner while minimizing barriers for patients. Family Planning Resources Reproductive Health Access Project: Contraception reproductiveaccess.org/key-areas/contraception CDC: United States Medical Eligibility Criteria for Contraceptive Use cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html Office of Population Research at Princeton University and Association of Reproductive Health Professionals: Emergency Contraception Website ec.princeton.edu/emergency-contraception.html Power to Decide: Bedsider Providers providers.bedsider.org Bixby Center at the University of California, San Francisco: Beyond the Pill beyondthepill.ucsf.edu Planned Parenthood: Birth Control plannedparenthood.org/learn/birth-control California Department of Health Care Services: Family PACT (Family Planning Access Care Treatment) familypact.org/Home/home-page 3. OKAY EITHER WAY OR UNSURE ACTION: Plan for pregnancy but attend to family planning needs as indicated. Offer a combination of responses from #1 and #2 about contraception and preconception care, depending on individual patient needs and circumstances. Discuss ambivalence and relevant issues, offering support for the patient's reproductive path, or refer to a provider who can explore the patient's reproductive decision-making. An ambivalent response to One Key Question from is not uncommon. Studies demonstrate that 23-36% of young women are conflicted about their desire to have a baby.While these responses are the most challenging for a clinician to address, they provide a critical opportunity to explore patients' reproductive decision making and help them take action to avoid an unintended pregnancy or to plan for a healthy one. In the context of primary and chronic disease care, health care providers can explore with women the steps they need to take to optimize their health for pregnancy, should one occur, or refer them for preconception counseling. Clinicians can also immediately offer contraception or provide a referral to family planning if there are medical, social, or other issues that would make deferral of pregnancy a safer choice. In sum, for women who are ambivalent about pregnancy, One Key Questionopens a discussion that allows for the delivery of preventive reproductive health care. Implementation Successful implementation of One Key Question requires incorporating the question into routine patient assessment. The LA County Department of Public Health recommends including the question in an initial visit, and then, at minimum, annually or whenever a new medication is prescribed. It is important to have a protocol for a given clinical setting to ensure that the question is consistently asked of patients and that the process is straightforward for the clinician, clinic staff, and the patient. The question need not be posed by the clinician but can be asked by a medical assistant, nurse, or other members of the health care team. This could occur while taking a history, checking vital signs, or once the patient is roomed—anywhere that privacy can be assured. The question can be automated and flagged in the electronic health record, so that a member of the team can review the response during the visit and that a qualified health professional provides the necessary follow up. Support for One Key Question The consensus that One Key Question is an important tool is growing. One Key Question has been endorsed by 30 public health and professional organizations including the American College of Obstetrics and Gynecology, the American Public Health Association, Physicians for Reproductive Health, and the National Association of Nurse Practitioners in Women's Health. The American Academy of Family Physicians recommends that a woman's reproductive life plan be discussed at each visit. Conclusion One Key Question provides a straightforward screening tool for engaging patients in a critical conversation about improving health and well-being prior to pregnancy and preventing unintended pregnancies. The Department of Public Health is promoting One Key Question as a strategy to advance women's health. Because One Key Question serves as a means both to promote equity and to empower women of color, it has been incorporated into our multi-pronged approach to reduce African American Infant Mortality by 2023. The implementation of preventive reproductive health care is essential for many women of childbearing age. By taking a nonjudgmental but proactive approach to women's reproductive aims, providers can build trust that is a precondition for effective treatment and for a rewarding doctor-patient relationship. Because primary care providers play a fundamental role in meeting the comprehensive health needs of women with childbearing potential, LA County Department of Public Health hopes providers will implement this approach into their practice.