PRECONCEPTION COUNSELING

A “BEST” BUT UNCOMMON PRACTICE

INTENDEDNESS 2002 DATA: 30.8% ALL WOMEN

AGE 15-44 HAVE EXPERIENCED AN UNINTENDED BIRTH

ESTIMATE THAT 49.2% ALL PREGNANCIES UNININTENDE (nsfg)

ORGANOGENSIS DAYS 17-56 POST CONCEPTION

FIRST DAY OF “MISSED” PERIOD IS DAY 14 POST-CONCEPTION

DAY 56 IS ABOUT 6 WEEKS ALL ORGANS FORMED BY WEEK 9

Prevention, in order to be truly preventive, must be antenatal

J. W. Ballantyne in 1902

Maternal Mortality per 100,000 live births

0

100

200

300

400

500

600

700

800

1900 1960 1980 2000

Rate Increase from 1980-2000

0%

5%

10%

15%

20%

25%

30%

Preterm Very Preterm LBW VLBW

Infant Deaths per 1000 Live Births

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

1960 1980 2000

1960: Maternal complications of pregnancy not on top 10 list of leading causes of infant mortality1980: Number 52001: Number 3

2002: 46% of infant mortality related to congenital anomalies, LBW, Preterm Delivery and Maternal complications

2004 Behavioral Risk Factor Surveillance System Phone survey of Americans > 18

years of age Median response rate >52% Content varies by state Defined as preconceptional if:

Wanted a baby in next 12 months, not using contraception, not sterile and not already pregnant

BRFSS 2004

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Pregnant Preconceptional

Amongst reproductive aged women

6.1% asthma 11.4% smoke

5% obese 54.9% consume alcohol

3.4% cardiac dz 80% dental caries &other oral diseases

3% hypertension PRENATAL CARE IS TOO

9.3% diabetes LATE

1.4% thyroid diseaseMaternal-Child Health J 2006 10:s3-s11

Spartan Preconception Recommendations a la Plutarch

“ordered the maidens to exercise themselves with wrestling, running, throwing the quoit and casting the dart, to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth”

Preventing Low BirthweightInstitute of Medicine 1985

“…one of the best protections available against low birth weight and other poor pregnancy outcomes is to have a woman actively plan for pregnancy, enter pregnancy in good health with as few risk factors as possible, and be fully informed about her reproductive and general health”

IOM-1985 Family planning services essential

to preconception initiatives Reproductive health/family

planning must introduce concept of pre-pregnancy wellness

Developed concept of preconception consultation

Expert Panel on the Content of Prenatal Care: 1989 “Rosen Report”

Preconception visit may be the single most important health care visit with respect to impact on pregnancy outcome

Preconception counseling most likely to be effective when provided in context of general preventive care OR primary care visits Concept of “Opportunistic Care”

ROSEN REPORT Risk Assessment Health Promotion Intervention Follow up

Healthy People 2000 Increase to at least 60% the

proportion of primary care providers who provide age-appropriate preconception care and counseling

Deleted in 2010 Healthy People as not measurable

Toward Improving Outcome of Pregnancy: The 90’s and BeyondMOD 1993

Concept of “reproductive awareness”

Called for a new strategy to reach each woman of child-bearing age with reproductive awareness messages at every health encounter

ACOG 1995: First technical bulletin on Preconception Care

Thorough & Systematic ID of risks Provision of education

individualized to patient needs Initiation of desired interventions

2002: Guidelines for Perinatal Care AAP/ACOG

Emphasized integration of pre-conceptional health into ALL health encounters in reproductive age women

Average woman of childbearing has 6.4 visits to MD’s per year

Healthy People 2010 No global comment “Increase the proportion of

pregnancies begun with an optimum folate level” (target 80%)

HALLMARKS OF PRECONCEPTION CARE REYNOLDS

PROVIDES WOMEN & FAMILIES INFORMATION AND OPPORTUNITIES TO MODIFY UNHEALTHY BEHAVIORS AND THUS POTENTIALLY IMPROVE THE QUALITY OF THEIR LIVES

INCREASE REPRODUCTIVE CHOICES, POSSIBLY DECREASED UNINTENDED & UNWANTED PREGNANCIES

HALLMARKS, cont’d IMPROVE PREGNANCY OUTCOME

BY DECREASING INFANT MORTALITY & MORBIDITY

REDUCES THE PROBABILITY OF DAMAGE DURING ORGANOGENESIS

Which women most likely to get preconception care?

Older Married or stable relationship Non Hispanic White Income >$20,000/year Non-smokers Private medical insurance Positive bond with pre-pregnancy

health care provider

NEGATIVE PREGNANCY TEST POPULATION OF ABOUT 100 WOMEN

AT FAMILY PLANNING CLINIC WITH NEG. PREGNANCY TEST

ALL HAD ASSESSMENTS DONE USING PRECONCEPTION RISK SURVEY INSTRUMENT

½ HAD RESULTS REPORTED TO DOC

NEGATIVE PREGNANCY TEST AVERAGE WOMAN HAD 9 IDENTIFIED

ISSUES 21% PSYCHIATRIC/BEHAVIORAL 12% FETAL EXPOSURE 7 – 10%: FAMILY PLANNING, NUTRITION,

GENETIC, MEDICAL, BARRIERS TO CARE, DV, SEXUAL VIOLENCE

2-6%:REPRODUCTIVE HISTORY, STD’S

Best Evidence Focus on a single intervention Not in the context of improving

pregnancy outcomes

PROMOTION OFHEALTHY FUTURE

INFANTS

PROMOTION OFLIFELONGWELLNESS

PROMOTION OFHEALTHY AND

DESIRED PREGNANCIES

PREGNANCY

FAMILY PLANNING/PRECONCEPTIONAL

FAMILY PLANNINGINTERCONCEPTIONAL

CHILDBIRTH

MENOPAUSE

MENARCHE

PREVENTING PREMATURITY SPACING OF PREGNANCIES

LOWEST RATE VERY/MODERATELY PREMATURE INFANTS

18 to 59 MONTHS BETWEEN PREGNANCIES

DISCONTINUE SMOKING PRECONCEPTIONALLY

MODERATE EXERCISE

What We Know: Tobacco Use

Tobacco And Women’s Health: Implicated the

leading causes of death for women:

Heart disease (1) Stroke (2) Lung cancer (3) Lung disease (4)

Tobacco and Reproductive Outcomes: Leading preventable

cause of infant mortality

Preventable cause of low birth weight and prematurity

Associated with placental abnormalities

SMOKING ECTOPIC PREGNANCY PLACENTA PREVIA UNDER-DEVELOPMENT OF

PLACENTA MAY INCREASE RISK OF PREMATURITY

AND BABIES TOO SMALL

15% and 29% of pregnant women smoke during pregnancy

If smoking during pregnancy eliminated, estimated: 10% reduction in perinatal mortality

11% reduction in the incidence of low birth weight

SMOKING:Evidence based counseling

Ask every patient about tobacco use Advise them to quit Assess willingness to quit Assist them in quitting

Pharmocotherapies and additional counseling each DOUBLE quit rate

Arrange follow up 305.10 ICD-10 Code for tobacco

dependence

Effectiveness of smoking cessation programs

25-30% quit rates in general population

Many women spontaneously quit when pregnancy 11-28% publically insured 40-65% privately insured

ACOG COMMITTEE OPINIONOctober 2006 # 316

Smoking is one of the most important modifiable causes of poor pregnancy outcomes in the United States. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment has been proved to increase quit rates. For pregnant women who are light to moderate smokers, a short counseling session with pregnancy-specific educational materials often is an effective intervention for smoking cessation. The 5 A's is an office-based intervention developed for use by trained practitioners. Techniques for smoking reduction, pharmacotherapy, and health care support systems can help smokers quit.

What We Know: Alcohol Use

Alcohol and Women’s Health Risk for MV and other

accidents Risk for unintended

pregnancy Risk for addiction Risk for nutritional

depletions and inadequacies

Alcohol and Reproductive Outcomes Delayed fertility Increased SABs FAS and FAE

ALCOHOL 2002: 8% of American women 18-

44 years of age were sexually active, fertile, not contracepting.

Women age 18-24: 20% binge drink

FAS 0.3-2 per 1000 live births

Project CHOICES CDC sponsored trial Population at high risk of alcohol-

exposed pregnancy (12% binge) Focused on reducing risk drinking

AND postponing pregnancy 4 brief motivational visits and

Family Planning provider visit 68% at reduced risk at 6 months

What We Know: Obesity

Obesity and Women’s Health: Diabetes Hypertension Cardiovascular

disease Disabilities

Obesity and Pregnancy: Glucose intolerance of

pregnancy Pregnancy induced

hypertension Thrombophlebitis Neural tube defects Prematurity Higher rates of difficult births Fetal injury from birth difficulty

OBESITY Increased rates of: infertility,

gestational diabetes, pre-existing diabetes, hypertension, preeclampsia, stillbirth, birth defects, LGA, cesarean sections, long dysfunctional labors, CPD, post partum anemia

Fat is not inert

What can we do about it? Weight loss programs

Tsai and Wadden:, 2005 Weight Watcher least costly, maintenance of 3.2% of initial

weight at 2 years Very Low Calorie Commercial Diet:

Greatest initial weight loss; high costs; high attrition Internet based and organized self-help: minimal weight loss

Low income obese women receiving 5 email messages in pregnancy around maintaining normal weight gain less likely to gain excessive weight

Interconception period important if woman retained a lot of pregnancy weight

What we know: FOLATE Peri conceptional supplementation with 400

micrograms of folate (folic acid) from 3 months preconceptionally to 8 weeks postconceptionally

Decreases rate of spina bifida by 50-70% Decreases rate of cleft lip Decreases rate of heart disease Generally good health habit for adult

cardiovascular health Probably decreases placental problems

EPILEPSY MEDICATIONS

ASSOCIATION WITH SOME MEDICATIONS WITH SOME BIRTH DEFECTS

SOME WOMEN ON ANTI-SEIZURE MEDICATIONS FOR YEARS AFTER A SEIZURE AND MIGHT BE ABLE TO DISCONTINUE

LOWEST POSSIBLE EFFECTIVE DOSE SINGLE DRUG VERSUS MULTIPLE DRUGS

DIABETES GENERAL POPULATION

2-3% RISK OF SEVERE BIRTH DEFECTS DIABETICS PRIOR TO PREGNANCY

POORLY CONTROLLED [Hgb A1c>7] RISK INCREASES TO 6-9% HEART DISEASE, SPINA BIFIDA, OTHER

WELL CONTROLLED PRECONCEPTIONALLY BACK TO BASELINE RATE IN THE GENERAL

POPULATION!

INFECTIONS HEPATITIS B

90% CHRONIC CARRIERS ARE WITHOUT SYMPTOMS

PREGNANCY DOESN’T ALTER COURSE OF DISEASE

IDENTIFY NEONATES FOR FULL VACCINATION AND PROPHYLAXIS

HIGH RISK WOMEN WHO ARE HEP. NEG CAN BE VACCINATED

HIV HELPS INFECTED WOMEN MAKE

INFORMED REPRODUCTIVE DECISIONS

BEGIN MATERNAL CARE PROGRAM HIGH RISK WOMEN CAN BE

COUNSELED RE: RISK REDUCTION

TOXOPLASMOSIS 85% US WOMEN NON-IMMUNE (NHANES) 400-4000 CASES OF CONGENITAL TOXO/YR IN US PRENATAL TESTING VERY DIFFICULT TREATMENT IF KNOWN PRENATAL

SEROCONVERSION PRECONCEPTION TESTING CAN ALTER BEHAVIOR

AVOID FECES IN LITTERBOX/GARDEN AVOID RAW OR UNDERCOOKED MEAT DISPOSE OF CAT LITTER DAILY AND DISINFECT BOX;USE

GLOVES PEEL OR WASH FRUITS AND VEGETABLES

CMV 0.6-1.5% ALL BIRTHS IN US ADULTS USUALLY ASYMPTOMATIC,

MONO LIKE ILLNESS LATENT STATE AFTER INFECTION MOST COMMON SOURCE OF

PRIMARY INFECTION: TODDLERS MOST EFFECTIVE PREVENTION:

HAND WASHING (URINE, SALIVA)

OTHER INFECTIONS STD’S

APPROPRIATE TREATMENT DEAL WITH MONOGAMY ISSUES

VARICELLA AND RUBELLA: IF NEGATIVE ANTIBODY, CAN

IMMUNIZE WAIT THREE MONTHS PRIOR TO

CONCEPTION

WWW.IHEALTHRECORD.ORGCDC, other federal agencies, and medical societies have developed email-based education programs that are offered through the Interactive Health Record (iHealthRecord

Learn what you need to know now to have a safe pregnancy and healthy baby.   CDC has a new online education program available for women who are planning to get pregnant.

Health information via email every other week for 3 months as you prepare for pregnancy.  You can sign up for CDC’s pregnancy-planning education program by 1. Logging onto WWW.IHEALTHRECORD.ORG2. Signing up for a free iHealthRecord.3. Going to the "Education Programs" page.4. Checking the box next to “Pregnancy Planning: What To Know About Your Health Before You Get Pregnant”.

AAP/ACOG:Components of PCC Physical assessment Risk Screening

Reproductive awareness Environmental toxins/teratogens Nutrition/folate Genetics Substance use Medical conditions/medications Infections/vaccinations Psychosocial concerns

Vaccinations Counseling

Preconception Risk Factors with Developed Clinical Practice Guidelines

Folic Acid Rubella

seronegativity Diabetes Hypothyroidism HIV/AIDS PKU Oral Anticoagulant

Anti-epileptic drugs

Isotretinoins Smoking Alcohol misuse Obesity STD Hepatitis B

MMWR: April 21, 2006 Recommendations to ImprovePreconception Health and Health Care-US

Summary Preconception care

“Opportunistic” Rolled into routine health encounters

for reproductive aged women Needs to be proactive Clinical practice guidelines are

available MMWR April 12, 2006