There are many associations between exposure to adverse childhood experiences, or ACEs, and negative health outcomes. The relationship between these outcomes and reproductive health affects not only gestational parents but their potential offspring as well. By identifying a gestational parent’s ACEs exposure, they can become informed of the possible negative effects before, during, and after pregnancy along with guidance for reproductive planning. By utilizing the Center for Women and Children in the Duval Central Health Plaza in Duval County, FL this program can help individuals make informed reproductive decisions and use the knowledge gained about ACEs to end intergenerational ACEs cycles.
Keywords: ACEs, gestational parent, pregnancy, reproductive planning, health outcomes.
Statement of Need
Exposure to ACEs can lead to different outcomes for reproductive health. The intention to have children is considered a component of reproductive health. ACEs have many associations with reproductive health and reproductive health risks. Those who have experienced ACEs are at higher risk for an unintended pregnancy which has can lead to maternal mental health problems during their pregnancy and adverse pregnancy outcomes (Young-Wolff et al., 2021). Risk factors associated with unintended pregnancy include unsafe “maternal health behaviors, intimate partner abuse, and lower happiness about the pregnancy” (Young-Wolff et al., 2021). Gestational parents with ACEs exposure also experience an elevated risk for prenatal anxiety and mental illness during both pregnancy and postpartum (Racine et al., 2021).
In the state of Florida, 54.7% of adults ages 18 to 44 have experienced at least one adverse childhood experience (Bright et al). This proposed program aims to address the effects that exposure to ACEs can have on reproductive planning. ACEs can lead to abusive relationships and make individuals vulnerable to reproductive coercion (Flaviano et al.). They can also have an increased desire to have a family with a better life and safer environment than they experienced or decreased desire for pregnancy if childhood neglect is experienced (Flaviano et al.). Women who are victims of childhood neglect are also more susceptible to mistimed or unwanted pregnancies (Young-Wolff et al., 2021). In Duval County, the percentage of new moms with unwanted or mistimed pregnancies is 56.1% compared to the state percent of 46.0% (DOH). This program aims to help gestational parents with an ACEs history avoid unintended pregnancy by planning their reproductive health to help decrease the negative effects ACEs’ have on pregnancy.
Target Audience
This program aims to target women of reproductive age in Duval County, Florida who receive care at the Center for Women and Children in the Duval Central Health Plaza. This center offers various reproductive health services to a diverse community. The program will include 100 patients who are attending a Well Women Care appointment. Patients attending these appointments who choose to receive an ACEs evaluation and receive a score of at least one. The program will include patients of any gender identity who intend to be gestational parents. The program will offer the patients support for reproductive planning and resources. The program aims to benefit not only the patient, but their future children as well by addressing ACEs and identifying possible intergenerational ACE cycles (ACEs Aware, 2021).
Project Activities
The grant will provide ACEs screening during Well Women Care visits. Patients will complete a survey to identify their exposure to ACEs. This survey will be evaluated and scored by their physician. Individuals with an ACEs score of at least one will be admitted into the program. After their ACEs evaluation, the physician and participant will discuss the results and their health implications. Participants will be given information on appropriate resources and schedule a follow-up appointment with their physician. At the follow-up appointment, the patient and physician will discuss the patient's reproductive health goals and the physician can address any concerns they or the patient may have in regards to the patient’s ACEs score. A second follow-up appointment will be scheduled to track patient progress and address any challenges or changes. The goal of this project is to help gestational parents in Duval County who have an ACEs score lessen their exposure risks for pregnancy and reproductive planning. Achievement of this goal will result in better health outcomes for both gestational parents and their potential offspring.
Capacity
This project will be taking place at the Center for Women and Children in the Duval Central Health Plaza in Duval County, FL. This center is qualified to carry out the program because it is a medical clinic that has medical providers trained in reproduction with on-call physician support. The clinic also provides the following reproductive services in addition to Well Women Care visits are breast and cervical cancer screening, family planning and birth control, healthy start referrals, immunizations, maternity/prenatal care, pediatric care, pregnancy testing, std testing, and treatment (for males and females), and WIC (DOH). While the Well Women Care visits at this center are the service provided from which participants will be collected, the other services will serve as an aid to the participants' reproductive planning. The center is qualified to carry out this project because this clinic functions to serve a diverse population which will be beneficial for addressing adverse childhood experiences.
Project Goals
The goal of this project is to help gestational parents in Duval County, FL with an ACEs score lessen their exposure to pregnancy risks and reproductive planning by working to provide both gestational parents and potential offspring with better health outcomes. Exposure to ACEs leads to the possibility of many negative experiences and risks for pregnancy and reproductive health. The program focuses on identifying a participant's exposure level and guiding their reproductive health planning to address the ways their adverse childhood experiences may have an effect. Identifying and addressing these possible effects will allow individuals to make informed reproductive decisions. In doing so, the resulting negative ACEs experiences are to be reduced for both the individual and their future children with the proper planning and resource utilization.
Public Health Framework
The program will utilize the empower action model framework for public health. This framework attempts to “provide tangible steps to prevent childhood adversity by implementing protective factors to build resilience and health equity across multiple levels and the life span” and aims to build resilience to promote health, equity, and well-being (Srivastav et al., 2020). One of the goals of the empower action model framework is to address resilience by building protective factors for resilience over the lifespan at the primary level, which is what this program hopes to achieve for ACEs through reproductive planning. The framework also utilizes a multi-level approach which will help to prevent negative exposure in all aspects of a participant's life. This secondary level will function to prevent further exposure to adverse experiences. The tertiary element of this framework will focus on community-based efforts in preventing and reducing the effects of ACEs exposure as the Duval County center being used for this program functions to serve on a community level (Srivastav et al., 2020).
Level(s) of the Social-Ecological Model
This program’s primary focus will be on the individual and relationship levels of the Centers for Disease Control and Prevention’s social-ecological model framework for prevention. The individual level of this model will address the biological and personal history factors that put the individual at risk for ACEs (CDC, 2022). The services will help participants take on their trauma in a safe space that fosters respect and recovery. This will address any current or potential risks they may face due to their ACEs exposure. Examples of these risks include maternal mental health problems during pregnancy, adverse pregnancy outcomes, and unwanted or untimed pregnancies. The relationship level of this model will address the relationships individuals have with family, friends, and intimate partners and the effect they have on their ACEs exposure. This would include relationships issues such as abusive partners, childhood neglect, and relationships with religion. Addressing these relationships will allow individuals to adjust relationships that may be currently contributing to or find closure for past relationships that may be related to ACEs exposure.
All levels of the social-ecological model are important for this program, however, the individual and relationship levels are best suited to achieve the program's goals since it aims to address the personal health outcomes and reproductive goals of participants. With a focus on these levels, gestational parents will receive the resources necessary to support their reproductive planning. Addressing the negative ACEs exposures on these levels will also help to benefit reproductive planning and intergenerational ACEs cycles for future children.
Trauma-Informed Principles
The goal of this project is to reduce pregnancy risk and help with reproductive planning for gestational parents with an ACEs score. To help reduce the negative effects of trauma individuals may be experiencing, several trauma-informed principles will be utilized by the program. In addition to staff training, there will be an emphasis on understanding a person’s trauma response and connecting them with the proper services to promote healing and resilience. The principles being incorporated are those of safety, trust and transparency, empowerment, voice and choice, and cultural, historical, and gender issues (SAMHSA). Creating a safe and trustworthy space will allow individuals to feel less vulnerable and more comfortable while discussing their ACEs score and reproductive plans. This can be accomplished by ensuring privacy and addressing any concerns participants may have at any time during the program. The principle of empowerment, voice, and choice will allow individuals to recognize their strengths and unique experiences. With this, they can take steps towards recovery and resilience that are personalized for them specifically. Participants can also be connected with resources that will build upon their recognized strengths and experiences in addition to achieving their reproductive goals. Recognition of cultural, historical, and gender issues will also be utilized by this program. Individuals participating in the project will come from many different backgrounds, so physicians and support staff should be prepared to recognize and address any cultural or historical concerns of participants. This will be accomplished through continued staff training throughout the program’s duration. It will also be inclusive of all gender identities in both assessment and practice. Stereotypes and biases of any kind will not be tolerated. By upholding these principles, the project will promote and maintain a trauma-informed environment.
Project Outcomes
Those who participate in this program will receive the necessary resources and information needed to help them address the reproductive risks they face due to their ACEs score. These resources will include but are not limited to, peer-support groups, mental health counseling, and protective services. By addressing and decreasing the negative effects of their ACEs exposure, gestational parents can make plans for their reproductive health and reduce their exposure risks for pregnancy. Participants will have knowledge about trauma effects and adverse childhood experiences and be able to identify risk factors that may exist within their life or community. As a result of this program, there is hope that intergenerational ACEs cycles can be found and addressed by changing behaviors and reducing risk factors for future generations to benefit.
Evaluation Plan
Individuals who wish to participate in the program will receive an ACEs evaluation that will be scored by their physician. After their ACEs score has been identified, the physician will discuss what ACEs are, what the score means, and how could affect their reproductive goals. After this discussion, the participant will meet with the Program Coordinator to be connected with the proper resources the individual may need and schedule a follow-up appointment. At this appointment, the participant will discuss their reproductive plans and goals with their physician and a plan of action and goals can be created. If needed, the individual can meet with the Program Coordinator to evaluate any additional resources that may be needed and schedule a second follow-up appointment. The time frame for this appointment is to take place after six weeks or whenever the participant is next available. At this final appointment, the physician and patient will track progress and address any changes or challenges. At the end of this appointment, the participant will be given a feedback survey to complete. The goal of this survey is to learn of any possible improvements or adjustments that the program may need. This survey will also provide insight into participant satisfaction and progress within the program. A contact card for the Program Coordinator will be given to the participant in addition to the feedback survey. The intention of this is to provide a point of contact for any additional needs or concerns the participant may have in the future.
Staff Qualifications
A full-time position will be created to support this program. This position will require a Bachelor's or Master's degree, be certified in trauma-informed care, and have at least 5 years of professional experience. They will receive additional training on how to liaison with community resources and program participants. This position will oversee participant progress and scheduling. This program will utilize the staff already available at the Center for Women and Children with the possibility of hiring an additional physician. An additional physician may be needed to maintain the clinic’s current rate of seeing patients. All staff involved with this program will receive trauma-informed training. In addition to this training, all personnel will receive training on ACEs, how to administer and score an ACEs test, and information on trauma responses. Physicians in this program will already have reproductive training as required by the Center for Women and Children in the Duval Central Health Plaza. These physicians will have to receive continued education on reproductive health care and the effects of ACEs on reproduction. By utilizing resources already available, this program can have the necessary funds for the salary of a full-time Program Coordinator position, physician, and ongoing staff training.
Sustainability
This program will utilize the Center for Women and Children which is already in place and funded by the Duval County division of the Florida Department of Health. The only additional funding needed would be for staff training, the hiring of one full-time employee to serve as Program Coordinator, and an additional physician. If funding is no longer available for the program, the Program Coordinator can establish a resource database and protocol for referring patients after the position is dissolved. If the clinic has the funding available they may choose to keep the additional physician on staff and/or continue trauma-informed staff training.
Participant feedback surveys distributed after the second follow-up appointment will be used to make improvements to the program and address any issues that may exist. One of the main goals of this program is to address intergenerational ACEs cycles, which will benefit future generations of program participants.
Communication & Social Media
To promote the program informational material such as posters, flyers, and brochures will be created. These materials are to be posted in the Center for Women and Children, other offices in the Duval Central Health Plaza, and throughout the Duval County community. Current Florida Health social media accounts will be utilized to post promotions for the program. A Facebook page and website will be created for the program and managed by the Program Coordinator. To protect the privacy of participants and follow HIPPA, no posts will be made about specific participants or images without their explicit consent and approval. In the future, support groups may be formed if the need is expressed.
Use of Funds
Funds for this program will be used to hire a full-time Program Coordinator, an additional physician for the clinic, and trauma-informed staff training. Funds will also be used to create promotional and informational materials for the program and for costs associated with creating a website and Facebook page. Funds may also be utilized to find and establish relationships with community resources available to participants.
Timeline
This program will take place over eight weeks with each participant. The first two weeks will consist of the participant's initial appointment in which they receive an ACEs evaluation, are connected with resources, and a follow-up visit to discuss ACEs outcomes and reproductive planning. The second follow-up appointment is intended to take place six weeks later or whenever they are next available. The duration of the program overall will depend on the amount and duration of available funding.
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References
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