Background:
Florida is the nation's fourth largest state in the nation and recorded a total of 226,219 live births in 2005. Prenatal care is traditionally the cornerstone for assuring positive birth outcomes. To this end, Florida has a statewide system of Healthy Start Coalitions that work to assure that prenatal care systems are available to all pregnant women. Additionally, we have a legislatively mandated universal Healthy Start Prenatal Risk Screening process which is to be offered to every pregnant woman at no cost to her during her first prenatal visit and which helps to identify women at risk for poor birth outcomes in order to connect them to services. Despite these extensive and coordinated efforts, Florida's Infant Mortality Rate has hovered between 7.0 and 7.5 for the past 10 years. Perinatal Periods of Risk analysis (PPOR) has enabled Florida to examine feto-infant mortality more closely at the state and local levels, and consistently shows that almost half of excess fetal deaths can be attributed to maternal health. Florida initiated a Pregnancy Associated Mortality Review (PAMR) process in 1996. The process is based on the National Fetal Infant Mortality review model and analyses gaps in maternal health systems and care that may contribute to maternal mortality. Our PAMR data shows that 71.8% of women with pregnancy related deaths had a history of chronic disease or condition; many have multiple chronic illnesses with the most common being obesity (22%) and hypertension (14.9%). Twelve Fetal Infant Mortality Review (FIMR) teams covering 30 of Florida's 67 counties have highlighted the strong association between a mother's health both before and during pregnancy and her subsequent birth outcome.

Objectives:
By the end of the presentation participants will be able to: • Discuss data that supports the need to improve systems supporting preconception health for women in Florida. • Identify opportunities to integrate preconception health screening, evaluation, treatment and education in a variety of existing public health programs. • Identify local and statewide initiatives implemented within Florida to address the preconception health of reproductive age women.

Methods:
Methods and strategies for program implementation vary depending on the setting in which women are being served. In the fall of 2004, Healthy Start initiated a campaign to address infant mortality and improve pregnancy outcomes through education and counseling aimed at improving a women's health status before she becomes pregnant. Healthy Start services offering Interconception Care and Counseling were initiated through collaboration with Healthy Start Coalitions and providers, and subsequently, integrated into existing Healthy Start programs without additional funding. Minimum standards were developed to ensure interconception education is provided by qualified individuals in a culturally sensitive manner that is applicable to the participant and their assessed risk factors. Technical assistance guidelines were also developed for use in Florida's 67 county health departments as a guide for programs like Family Planning and prenatal care clinics to provide preconception care to women of child bearing age. Educational components of both these initiatives include access to health care; management of maternal infections and chronic health conditions; weight, physical activity and nutritional counseling; appropriate baby spacing; substance abuse and smoking; mental health issues; and environmental risk factors. Training has been provided to school health and family planning programs and providers who encounter women of reproductive age in prenatal, primary care, pediatric, and social service settings.
The Florida Department of Health in conjunction with the Agency for Health Care Administration has implemented a Medicaid Waiver program that provides family planning services for up to two years to any women who looses Medicaid services.
A statewide program implemented through a very successful collaboration between the Florida Department of Health and the Florida March of Dimes allowed for the distribution of over 450,000 bottles of multivitamins containing 400 mcg of folic acid to nonpregnant women of reproductive age with accompanying literature about the importance of preconception health.
Most recently, the Department of Health funded 2.7 million dollars in one time grants administered through the 32 Healthy Start coalitions and covering 66 counties to support a wide variety of pilot projects intended to promote preconception health. The project proposals were based on community needs assessments and resources and required interventions which were based on the CDC's Ten Preconception Health Recommendations. Local projects included social marketing campaigns addressing a variety of preconception health topics; the development of interactive kiosks which provide screening and education; curriculum development for socially high risk, teen and other specific populations; provider education and conferences; development of faith based health educators; creation of a teen oriented ethnography; strategic planning; and direct services including, preconception health physicals, preventive dental visits, outreach to women with previous poor birth outcomes, education in Family Planning clinics, nutrition and dietary counseling, services to teens in juvenile detention centers, and assistance with reproductive life planning.

Results:
Programmatic services data will be related during the presentation. The local project grants are ongoing and data collection continues. Outcome data in the form of state maternal and child health indicators are monitored on an ongoing basis.

Conclusion and implications for practice:
Florida has recognized the need to promote healthy behaviors and lifestyles in women as a strategy to improve birth outcomes, infant health and developmental outcomes, and women's health across the lifespan. Our state's strong public health system combined with a unique Healthy Start system affords significant opportunities to offer programs to improve preconception health based on in-depth community assessments of needs and resources. We continue to actively investigate evidenced based opportunities for building a system of care for women which offers varied, innovative, and accessible strategies to address health risks and behaviors that impact health prior to conception in order to positively impact birth outcomes. The excitement surrounding the promotion of preconception health is gaining significant momentum throughout Florida. We plan to continue efforts in the public sector and expand our collaboration with the private sector to increase and sustain this momentum. Through continued focus and practice we anticipate a positive impact on birth and health outcomes for Florida's women and infants.