Preconception Healthcare

A young woman’s health and lifestyle choices can affect her future pregnancies as well as her own wellbeing for the rest of her life. Ideally, consideration of health status and potential effects on pregnancy should be a component of every encounter with a woman of childbearing age in the healthcare setting. It is an essential aspect of women’s health that is easily overlooked both by healthcare providers and their patients.

Waiting until a woman is pregnant to address risks may be too late. For example, many birth defects occur in the first weeks of gestation before the woman even knows that she is pregnant. In addition, many behaviors and lifestyle choices affect birth outcomes, such as smoking, high-risk sexual behavior, drug or alcohol use, lack of activity, and inadequate nutrition. Addressing behavior changes before pregnancy allows a woman more time to modify her risk than if she learns about it at a first prenatal care visit. Finally, both chronic and infectious diseases can impact a pregnancy. Establishing good medical control and educating the woman about her condition before pregnancy is likely to be easier and more effective than beginning treatment (perhaps with limited options) after a pregnancy has begun.

Risks related to poor pregnancy outcomes are relatively common. In 2002, 54 percent of women ages 18–44 consumed alcohol in the past month (with 13 percent either daily or binge drinkers), 44.8 percent did not take folic acid or a multivitamin daily, 75 percent consumed fewer than five daily servings of fruits and vegetables. That same year, about 6 percent of women, aged 15–44 years, had asthma; 50 percent were overweight or obese; 3 percent had heart disease; 3 percent were hypertensive; 9 percent had diabetes; and 1 percent had a thyroid disorder. Over the course of the twentieth century, the United States saw a dramatic and steady drop in both maternal and infant mortality, reflecting general public health interventions such as clean water and control of infectious diseases, as well as improvements and technological advances in prenatal care, and particularly in neonatal care. For the past decade, the decline in infant mortality has slowed, and the rate of maternal mortality has increased slightly. The rate of preterm and low-birthweight births has also increased. These trends are generally seen in national, state, and local data. Research suggests that improving women’s health before pregnancy may be key to achieving further reductions in infant mortality. There is clearly room for improvement: The United States ranks 27th in the world in infant mortality.

Recognition that a woman’s health is important before her first pregnancy — and between pregnancies — is not new. In addition to references in Greek writings and in the Old Testament, the professional literature includes references to preconception health as far back as 1978. The Guidelines for Perinatal Care, published in 1983 by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), included an appendix with guidelines for a preconception visit when pregnancy is planned. By the 2002 edition, the topic of preconception had moved from an appendix to the main text, emphasizing integrating preconception health promotion into all health encounters with women of childbearing age.

The fact that about half of all pregnancies in the United States are not planned supports moving the concept of preconception health from a special visit with an OB, when a woman is planning to become pregnant, to the more general inclusion in all health encounters. A woman who is not considering becoming pregnant is unlikely to seek preconception care, and her provider is unlikely to offer it. In 2004, surveys of 1,105 ACOG members and women of childbearing age receiving care in private primary care practices showed that only 34 percent of physicians recommend preconception care to women who are sexually active, and only 39 percent of women could recall their physician ever discussing this topic with them.

In 2005, the Centers for Disease Control and Prevention (CDC) and the March of Dimes convened the first national summit on preconception care, which attracted over 400 healthcare providers, public health practitioners, and researchers. The topic is now receiving serious attention throughout the nation. Following the summit, a collaboration of 35 partner organizations, including several physician groups, is starting to take action toward ten broad recommendations developed by summit participants. This complex issue will require clinical interventions, research, surveillance, community education, action at the individual level, and policy changes, including financing and reimbursement issues.

In the meantime, clinicians can consider ways to integrate attention to women’s health as it affects future pregnancies into every encounter with women of childbearing age. Efforts by family practice, internal medicine, pediatrics, dental providers as well as obstetricians and gynecologists can help impact the long-term health of women and babies. What can you do?

• Make sure women of childbearing age have information about what they can do themselves to reduce risk, such as maintaining adequate physical activity and nutrition, including folic acid; using reliable family planning methods to avoid unintended pregnancies; and maintaining good oral health.
• Identify and manage health risks related to poor pregnancy outcomes.
• Assess and provide counseling and resource information on lifestyle factors.

County Health and Human Services Agency (HHSA), Public Heath Services (PHS) has developed some innovative client education materials about preconception health and resources, which include information about local resources. The Maternal, Children, and Family Health Services Branch (MCFHS) of PHS is working to distribute these materials to healthcare providers and community organizations that serve women of childbearing age. For more information about these materials and integrating preconception health into your practice, contact Shukri Adam, PHN, at (619) 692-8453 or at Shukri.Adam@sdcounty.ca.gov. Information is available online at www.cdc.gov/ncbddd/preconception/QandA_providers.htm and at www.marchofdimes.com/professionals.