Practice Guidelines

CDC Releases Guidelines on Improving Preconception Health Care

LISA GRAHAM

See related editorial on page 1840.

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.

Risks

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.

Recommendations

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.

REPRODUCTIVE PLANNING

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.

INTERCONCEPTION CARE

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.

PREPREGNANCY CHECKUP

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 prepregnancy visit as a standard of care could reinforce the significance of planning and preparing for childbearing.

Practice Guideline Briefs

Meningococcal Vaccine Supply Increased; Deferral Request Lifted

The manufacturer of tetravalent meningococcal conjugate vaccine (MCV4; Menactra) reports that previous limitations in the vaccine supply have resolved. Therefore, the Centers for Disease Control and Prevention (CDC) recommends that physicians resume routine vaccination according to recommendations from the Advisory Committee on Immunization Practices. Groups that should be vaccinated include children 11 to 12 years of age, adolescents entering high school (if not previously vaccinated), and college freshmen living in dormitories. Because of problems with vaccine supply, the CDC recommended in May 2006 that physicians defer vaccination of children 11 to 12 years of age. The CDC now recommends that physicians recall these patients for vaccination, if possible.

CARRIE ARMSTRONG

ACOG Recommends That Physicians Restrict Episiotomy

Although episiotomy is performed in approximately one third of vaginal births in the United States, prophylactic use of the procedure does not result in maternal or fetal benefit and should be restricted, according to a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG). The recommendations were published in the April 2006 issue of Obstetrics & Gynecology.

Historically, the purpose of episiotomy was to facilitate completion of the second stage of labor to improve maternal and neonatal outcomes. Maternal benefits were thought to include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, and sexual dysfunction. Potential benefits to the fetus were thought to include a shortened second stage of labor caused by a more rapid spontaneous delivery or from instrumented vaginal delivery. Despite limited data, this procedure became virtually routine, resulting in an underestimation of the potential adverse consequences, such as extension to a third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia.

The best available evidence does not support liberal or routine use of episiotomy. However, there still is a place for episiotomy for maternal or fetal indications (e.g., avoiding severe maternal lacerations, facilitating or expediting difficult deliveries). A systematic review comparing routine episiotomy with restrictive use reported that 72.7 percent of women in the routine-use group underwent episiotomy compared with 27.6 percent in the restricted-use group. The restricted-use group had significantly lower risks of posterior perineal trauma, suturing, and healing complications but a significant increase in anterior perineal trauma. No statistically significant differences were reported for severe vaginal or perineal trauma, dyspareunia, or urinary incontinence.

In general, two types of episiotomy have been described: the median (or midline or medial) episiotomy and the mediolateral episiotomy. The median episiotomy tends to be a simpler incision to repair and is the more commonly used procedure in the United States. However, median episiotomy is associated with a greater risk of extension to the anal sphincter (third-degree extension) or rectum (fourth-degree extension). Mediolateral episiotomy, an incision at least 45 degrees from the midline, maximizes perineal space for delivery while reducing the likelihood of third- or fourth-degree extension. Reported disadvantages of the mediolateral procedure include difficulty of repair, greater blood loss, and, possibly, more discomfort during the early postpartum period. Although the data are insufficient to determine the superiority of either approach, the procedures seem to have similar outcomes, including pain from the incision and time to resumption of intercourse.

CARRIE ARMSTRONG

Self-study Course in Epidemiology Now Available Through CDC Web Site

The Centers for Disease Control and Prevention's (CDC's) introductory self-study course, Principles of Epidemiology in Public Health Practice, 3rd ed., is now available online. The course is designed for public health professionals at the state and local levels who are or expect to be responsible for outbreak investigations or public health surveillance.

The course provides an introduction to applied epidemiology and biostatistics. Continuing education credits are offered. The course is available at no charge at http://www2a.cdc.gov/phtnonline. A printed copy of the course can be ordered from the Public Health Foundation at http://bookstore.phf.org (telephone: 877-252-1200).

CARRIE ARMSTRONG

Influenza Vaccination for Secondary Prevention in CVD

Influenza-related death is more common in patients with cardiovascular disease (CVD) than in patients with any other chronic condition. However, vaccination coverage levels in this population remain well below national goals and are marked by disparities across different age and ethnic groups. To help reverse this trend, the American Heart Association (AHA) and American College of Cardiology (ACC) recommend annual influenza immunization "with the same enthusiasm as control of cholesterol, blood pressure, and other modifiable risk factors," according to an advisory published in the October 3, 2006, issue of Circulation (available at http://circ.ahajournals.org/cgi/content/full/114/14/1549).

Evidence from cohort studies and a randomized clinical trial indicates that annual vaccination against influenza prevents cardiovascular events and all-cause mortality in patients with cardiovascular conditions. Based on this evidence, the AHA and ACC recommend immunization with inactivated influenza vaccine (administered intramuscularly) as a component of secondary prevention for patients with coronary disease and other atherosclerotic vascular conditions. Live, attenuated vaccine (administered intranasally) is contraindicated for persons with cardiovascular conditions. Influenza vaccine should be administered to all persons with CVD unless they have a contraindication to receiving the vaccine.

One of the barriers to vaccination for patients with CVD is that cardiology practices often do not stock and administer influenza vaccine. Therefore, family physicians and other primary care physicians who treat patients with CVD can help improve influenza vaccination rates by providing and strongly recommending vaccination to their patients before and throughout the influenza season.

CARRIE ARMSTRONG

Answers to This Issue's Clinical Quiz Q1. E Q2. C Q3. B Q4. B Q5. C Q6. B Q7. B Q8. A Q9. A, B Q10. B, C, D Q11. A, B, C Q12. A, B, C, D Q13. A, B Q14. A, C, D

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