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Preconception CareGreater New York Chapter of the
March of Dimes
Preconception Care Curriculum Working Group
Albert Einstein College of Medicine/Montefiore Medical Center
www.marchofdimes.com/prematurity/5195_5785.asp
The Continuum of Reproductive Health
Improving infant health requires focus on the entire spectrum of reproductive health
Beginning before conceptionContinuing through the first year of lifeExtending throughout the woman’s childbearing years
Preconception Care
Identifies reducible or reversible risks Maximizes maternal health Intervenes to achieve outcomes
Preconception Care
Reframes issues Adds an anticipatory element Focuses on the impact of pregnancy
Elements of Preconception Care
Focus on elements which must be accomplished prior to conception or within weeks thereafter to be effective Risk assessment Education & Health Promotion Medical and psychosocial interventions
Components of Preconception Care
Medical history Psychosocial issues Physical exam Laboratory tests Family/genetic history Nutrition assessment Occupational/environmental risk
assessment
Risk Assessment
STD Prevention Genetic issues Domestic violence Substance abuse
Alcohol Tobacco Illicit drugs
Environmental Teratogens Exposures
Home, workplace, environment Physical/chemical hazards
ionizing radiation, lead, mercury, hyperthermia, herbicides, pesticides
Health Education & Promotion
Smoking Cessation counseling: 5A’s Folic Acid Genetic Counseling Dietary and Nutritional Advice
Conditions that Need Time to Correct Prior to Conception
Optimal weight Optimizing choice and use of medications Substance use/abuse
alcohol tobacco
Some Medical ConditionsAmenable to Preconception Care
Diabetes Mellitus Hypertensive Disorders Cardiac Disease Thyroid Disorders Epilepsy Asthma HIV Infection
Systemic Lupus Thromboembolic Disease Renal Disease Hemoglobinopathies Cancers
Intervention Usually Not Undertaken During Pregnancy
Rubella & varicella immunization Narcotic detoxification Certain radiological procedures Thyroid ablation with radioactive iodine
Interventions considered because pregnancy is planned
Correction of mitral stenosis Switching from oral hypoglycemics to insulin and
achieving “tight” glucose control in patients with diabetes mellitus
Evaluation of anticonvulsant therapy
Factors That Could Change Timing Of Or Choice To Conceive A Pregnancy
Domestic violence Birth spacing Genetic disease Diseases with poor prognosis (e.g. AIDS) Diseases dangerous in pregnancy (e.g. CHF) Conflicts between needed maternal care and
fetal well-being Recurrent Pregnancy loss
Does Preconception Care Work?
Outcomes Impacted Fetal/Infant mortality and morbidity Maternal mortality and morbidity
Historical Perspectives
1979: PHS: Primary Care Effectiveness. An approach to clinical quality assurance in BCHS Programs and Projects
1985: IOM: Preventing Low Birth Weight 1989: Public Health Service Expert Panel on the content of Prenatal Care 1991: USPHHS: Healthy People 2000 - National Health Promotions and
Disease Prevention Objectives 1993: March of Dimes towards improving the outcome of pregnancy report 1993: Alan Guttmacher Institute’s Issues in Brief: The nation will be well-
served by making a commitment to advance preconception services to a similar extend as it has prenatal care.
1996: Guide to Clinical Preventive Services
1997: AAP & ACOG Guidelines for Perinatal Care
Prevention of Birth Defects
Optimal glycemic control No alcohol consumption Preconception rubella immunization Folic Acid supplementation
Goals of Preconception Carein Diabetes
To reduce the occurrence of obstetric and diabetic complications
To decrease the incidence of congenital abnormalities Reduce risk of spontaneous abortions
How To Accomplish These Goals?
Education about need to change diabetes medication regimen ie substitute insulin for oral hypoglycemics
Optimal glycemic control achieved by home monitoring, multiple daily injections, adjustment of insulin, close supervision and education
Postpone conception until control is achieved
Reassess modifiable risks before conception by assessing end organ damage, retina, kidney, vasculature, heart, nervous system
Alcohol
Leading preventable cause of mental retardation Most common teratogen to which fetuses are
exposed Effects related to dose No threshold has been identified for “safe” use in
pregnancy Effects at all stages of pregnancy
Rubella Vaccination
Determine rubella immunity prior to conception Vaccinate susceptible nonpregnant women Congenital rubella syndrome may result from
infection during pregnancy (microcephaly, fetal growth restriction, cardiac malformations, etc)
Prevention of Neural Tube Defects
Supplementation for all women of childbearing potential with folic acid No history of NTD: 0.4 mg. qd Prior infant with NTD: 4.0 mg. qd Woman with NTD: 4.0 mg. qd
Nutritional sources often inadequate
Barriers to Preconception Care
Patient Aspects High rate of unintended pregnancies Ignorance about importance of good health habits
prior to conception Limited access to health services in general.
Barriers To Preconception Care
Provider Aspects Feeling of having inadequate knowledge Perception of preconception care being time-consuming Concern about insurance reimbursement. Lack of awareness of how to integrate preconception
care into ongoing primary care
6%
1%
11%
4%5%
27% 27%
22%22%
26%25%
1%
6%4%4%
8%
0%
10%
20%
30%
None 1-5% 6-9% 10-19% 20-39% 40-59% 60-79% 80%+
Providers-2003 MDs-2002
% Eligible Patients Seen for Preconceptional Care: Physicians (2002) vs. Other Providers
(2003)
Percentages are net of 108 physicians (2002) and 55 non-physician providers (2003) who do not provide prenatal care.
Mean % Seen for Preconceptional VisitProviders-2003: 22%MDs-2002: 20%
Issues Addressed at Annual Well-Woman Exam: Physicians (2002) vs. Other Providers
(2003)
“Which issues do you always, usually, occasionally, or never address at an annual well-woman exam with a woman of reproductive age, that is, under age 45?” * Statistically significant difference between physicians and non-physicians in % “always.”
2002 2003 2002 2003 2002 2003 2002 2003MDs NonMD MDs NonMD MDs NonMD MDs NonMD
Annual Pap tests 91% 89% 7% 9% 2% 2% 0% 1%Breast self-exam 81% 84% 16% 14% 3% 2% 0% 1%Birth control 58% * 67% 28% 24% 13% 8% 1% 2%Smoking 71% 67% 21% 23% 8% 10% 1% 1%STD prevention 44% * 56% 30% 28% 24% 15% 1% 1%Mammograms 69% * 63% 20% 19% 11% 17% 1% 1%Alcohol use 37% * 45% 26% 22% 34% 31% 3% 2%Multivitamins 21% * 35% 32% 34% 42% 31% 5% 1%Calcium supplements 36% 39% 35% 36% 27% 23% 3% 2%Folic acid supplements 23% 27% 30% 31% 44% 40% 3% 3%Weight control (diet/exercise) 42% * 36% 36% 39% 22% 24% 0% 1%Iron supplements 11% * 15% 23% 28% 62% 53% 4% 4%
Always Usually Occasionally Never
Reasons Providers Don’t Always Recommend Folic Acid or Multivitamins: Physicians (2002)
vs. Other Providers (2003)
Responses were
categorized from verbatim
comments.
* Statistically significant difference between all
physicians vs. all non-
physician respondents.
CNM Other Total
41% 36% 38%
Too busy/not enough time 35% 27% 30%
Don't always remember to mention it 11% 10% 10%
Not relevant for patient[Not planning to get pregnant; not necessary for all patients; not reason for visit]
No need/there's enough in food supply 3% 4% 3%
Not a high priority 3% 4% 4%
Lack of patient compliance 2% 1% 1%
All others[Cost, questionable efficacy, not covered by insurance, not a priority for provider, etc.]
No reason 7% 4% 5%
Don't know why 7% 12% 10%
No answer 7% 4% 5%
Lack of knowledge about: folic acid, nutrition, unintended pregnancy
12% 13%
5% 7%
2003 Survey 2002
12%
8%
40%
30%
14%
8%
5%
4%
13%
OBG/FP
4%
3%
0.2%
5%
*
**
Other Barriers To Preconception Care
Availability of contraceptives Health Insurance Coverage Out of Pocket Expenses.
Who Should Get Preconception Care
49% of pregnancies in the US are unintended (unwanted or mistimed) - Henshaw. 1988.
Preconception care should be provided to all reproductive age individuals
Preconception Care for Men Alcohol
may be associated with physical and emotional abuse
may decrease fertility Genetic Counseling Occupational exposure
lead Sexually transmitted diseases
syphilis, herpes, HIV
WHO TO PROVIDE
Health Care Providers OB-GYNs, Pediatricians, Family Medicine, Internists, Nurses, Nurse Practitioners, Nurse-midwives Genetic Counselors Health Educators
When Should Preconception Care Be Offered
As part of routine health maintenance care At a defined preconception visit For women with chronic illness
How Preconception Care can be Integrated into Practice
As part of any routine medical visits Episodic visit for any common complaints Negative pregnancy test - an opportunity for
preconception care Family planning encounter Infertility evaluation Following a poor pregnancy outcome
Preconception Care
Primary Prevention Essential to March of Dimes Mission to prevent birth
defects and infant mortality
March of Dimes Products/Resources
Consumers Pregnancy and Newborn Health Education Center marchofdimes.com nacersano.org e-preconception newsletter (Spanish) comenzando bien Are You Ready? Think Ahead for a Healthy Baby Folic Acid brochures Pre-Pregnancy Planning Fact Sheet
March of Dimes Products/Resources
Providers marchofdimes.com Preconception Health Promotion: A Focus for
Women’s Wellness nursing module Upper Hudson Prenatal Services Preconception Screening and Counseling Tool Chapter grants
“Preconception health promotion is the cornerstone of healthy infants, children,
families and communities ”
