Am Fam Physician. 2006 Dec 1;74(11):1967-1970.
Guideline source: Centers for Disease Control and Prevention
Literature search described? No
Evidence rating system used? No
Published source: Morbidity and Mortality Weekly Report, August 21, 2006
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm
Improving preconception health care can result in improved reproductive health outcomes and has the potential to reduce societal costs, as well. Preconception care aims to promote the health of women of reproductive age and thereby improve pregnancy-related outcomes. Approximately one third to one half of U.S. women have more than one primary care physician. Therefore, all physicians who routinely treat women have a role in improving preconception health. One study shows that only one out of six physicians provides preconception care for most women to whom he or she provides prenatal care. Preconception care, as defined by the Centers for Disease Control and Prevention’s (CDC’s) Select Panel on Preconception Care, is a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcomes through prevention and management; it is more than a single visit to a health care professional but less than all well-woman care.
The CDC developed recommendations for physicians and public health officials that aim to improve women’s health before conception, which in turn will improve pregnancy outcomes (e.g., low birth weight, infant mortality rates). Recommendations for physicians include helping patients with reproductive planning, increasing patient awareness of the importance of preconception health care, providing preventive care and interventions for patients with identified risks, providing interconception care, and performing prepregnancy checkups.
Women of childbearing age (identified by the CDC as 15 to 44 years of age) can have chronic conditions, be exposed to substances that have adverse effects on pregnancy outcomes, or engage in high-risk behaviors. In 2002, 6 percent of women of childbearing age had asthma, 50 percent were overweight or obese, 3 percent had cardiac disease, 3 percent had hypertension, 9 percent had diabetes, and 1 percent had thyroid disease. In 2003, 10 percent of pregnant women drank alcohol, and 11 percent smoked.
Preconception health care is essential because some risk behaviors and exposures affect the developing fetus, and because the greatest effects occur in early pregnancy (before 52 days’ gestation), when a woman may not know she is pregnant. Alcohol or drug exposure, lack of essential vitamins, and workplace hazards during early pregnancy can result in adverse pregnancy outcomes for the mother and child. Social determinants of women’s health (e.g., low income, minority status) also can have a role in pregnancy outcomes. For example, socioeconomic status can affect health care access, environmental exposures, and health behaviors.
Prevention and Intervention
Risk-specific interventions currently are part of preconception health; however, they are best used to focus on a single risk behavior rather than several. Those that address multiple pregnancy-related risks are less common and have not been systematically evaluated. There also is limited evidence on effective methods of providing prepregnancy care and improving health. One study found that at the time of a negative pregnancy test, women have an average of nine pregnancy risk factors. However, notifying women and their physicians of these risks does not improve intervention rates.
Delivering risk screening, promoting health, and providing effective interventions as part of routine physician visits are the main purposes of preconception care. Care should be tailored to individual patients; certain recommendations may be more relevant to some women at different stages of life and with varying levels of risk. More intense interventions may be required for women with behavioral risk factors, previous pregnancy complications, or chronic diseases. These adaptations can inhibit how interventions should and can be incorporated into routine examinations.
The following recommendations have action steps that can be applied in the next two to five years. The steps include revising professional standards of care, developing health promotion messages, and changing patients’ attitudes and behaviors. They also highlight the role of patient responsibility in improving preconception health, and they identify strategies for modifying attitudes, behaviors, and knowledge.
The use of a reproductive life plan should be encouraged for every man, woman, and couple. The plan should be approached from the perspective of the patient’s entire life span; such an approach may help decrease rates of unintended pregnancy, age-related infertility, and fetal teratogen exposure, and it may improve health and pregnancy outcomes. Physicians should develop, evaluate, and disseminate culturally sensitive reproductive life planning tools for women and men in their childbearing years, respecting variations in age and literacy (including health literacy).
INCREASING PATIENT AWARENESS
Childhood experiences and societal norms, as well as age, life stage, childbearing history, and life priorities, influence patients’ reproductive health knowledge, attitudes, and behaviors. Patients should be more involved in improving preconception care; therefore, the use of age-appropriate tools and information is recommended to help increase public awareness. Improving school health education classes and informing adults about risks and opportunities to improve health are important steps. Reproductive health messages could be integrated into existing health promotion campaigns (e.g., responsible alcohol use, reducing tobacco use, eating a healthy diet) to change the attitudes and behaviors of adults. More research is needed to decide which tools and messages could be valuable in encouraging reproductive life planning.
PREVENTIVE HEALTH CARE
Incorporating preconception components into routine primary care visits can help physicians better serve women at different risk levels. Primary care physicians should integrate routine preconception risk assessment through screening (e.g., folic acid intake, nutrition, environmental hazards), provide reproductive health education and risk counseling, and perform short interventions for women with identified risks (e.g., smoking, alcohol use). Although guidelines can influence clinical practice, additional strategies are needed to promote widespread adoption of professional guidelines. Community health centers can be a good starting point for distributing plans for the improvement of preconception health.
INTERVENTIONS FOR IDENTIFIED RISKS
Well-timed interventions for some conditions can improve maternal health and birth outcomes. However, studies have shown that physicians do not routinely provide interventions for identified preconception risks. The proportion of women who receive interventions after preconception risk screening must be increased. Separating childbearing from chronic disease management puts women, their future pregnancies, and their future children at risk. Additional counseling may be required for some women, including those using teratogenic medications (e.g., anticonvulsants, anticoagulants), those with conditions that increase the risk of maternal and neonatal morbidity and mortality (e.g., diabetes, heart disease), those with risk behaviors associated with health risks for the fetus (e.g., smoking, illicit drug use), and those with a family history of genetic disorders.
Every year, approximately 28,000 infants die during their first year of life. Three percent of infants are born with birth defects, and 12 percent are premature (i.e., born at less than 37 weeks’ gestation). A preterm birth usually is listed on the infant’s birth certificate; however, there are no guidelines that include a follow-up plan or intervention for women with this risk predictor. An adverse outcome in a previous pregnancy is a significant predictor of future reproductive risk, yet many of these women do not receive interventions to reduce future pregnancy risks. The interconception period (particularly postpartum physician visits) should be used to provide additional interventions to women who previously had adverse outcomes.
A prepregnancy visit for persons planning to have children should be offered as part of maternity care; this addition could be an important step toward improving pregnancy outcomes. Implementation of the pre-pregnancy visit as a standard of care could reinforce the significance of planning and preparing for childbearing.
Copyright © 2006 by the American Academy of Family Physicians.
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