Preconception Care (Position Paper)

Introduction

Family physicians provide preventive health and chronic disease care for patients across the gender spectrum and throughout their reproductive years. As such, they are well-positioned to proactively counsel and care for patients and their families before, during, and after pregnancy.

Preconception care is individualized care for people considering pregnancy. It focuses on reducing morbidity and mortality for the patient and the fetus, increasing the chances of conception when pregnancy is desired, and providing contraceptive counseling to help prevent unintended pregnancies.

Interconception care refers to the care provided between pregnancies. Details about previous pregnancies, patient health history, and pregnancy risk factors are integral to interconception care. Since preconception care and interconception care address the same risk factors, preconception care is used throughout this position paper to include issues related to interconception care unless a distinction is required.

National attention to preconception care interventions dates to 1980 and continues today, with the Healthy People 2030 initiative focusing on reducing unintended pregnancies.¹ The health objectives outlined in the initiative are designed to reduce unintended pregnancy by increasing the use of birth control and family planning services and addressing disparities in unintended pregnancy rates related to age and racial/ethnic group.² These disparities were often associated with patient risk factors and subsequent adverse reproductive outcomes.^3,4,5,6

Preconception care and improving health before, during, and after pregnancy remains a strategic objective of Healthy People 2030.⁷ Despite decreases in pregnancy-related deaths globally, pregnancy-related deaths in the United States have increased.⁸ Birth outcomes in the United States are comparatively worse than in many other countries, including high- and low-income countries.^9,10 Disproportionate racial and ethnic disparities also persist for pregnancy-related morbidity and mortality.¹¹

In 2006, the Centers for Disease Control and Prevention (CDC) released a report to improve reproductive health outcomes in several key areas.¹² Despite efforts to improve outcomes and reduce infant and maternal mortality and morbidity, significant disparities still exist between the United States and European counties¹³ and among racial and ethnic groups in the United States.¹¹ Incorporating preconception counseling into routine primary care continues to be an effective strategy to reduce these disparities.¹²

To deliver comprehensive care to all patients, family physicians must possess the knowledge and skills necessary to provide high-quality, patient-centered preconception care to individuals planning a family. This position paper discusses family physicians’ critical role in preconception care and offers evidence-based recommendations to address reproductive care, an essential element to healthy family planning.

Language Disclaimer

The American Academy of Family Physicians (AAFP) recognizes that not every individual who becomes pregnant identifies as a woman. However, current research and data collection on preconception care have been primarily focused on individuals who identify as women. The AAFP encourages additional research and improved data collection methods that better reflect the diversity of individuals and families that may seek preconception care. Wherever possible, this paper will strive to remain gender-neutral in its considerations and recommendations. When citing specific literature, gendered language, such as woman or women, may be used to represent research findings accurately.

Benefits of Preconception Care

Infant mortality is often a critical indicator of the overall health of a nation. Although the U.S. infant mortality rate has declined,^14,15 it continues to be higher than many other high-income countries¹³ and higher among racial and ethnic minority groups in the United States.¹¹ Congenital malformations and prematurity account for most infant deaths in the United States,¹⁴ with interventions to improve prenatal care not substantially improving these outcomes. The mortality rate for individuals who are pregnant is also high in the United States. An individual who is pregnant is more than twice as likely to die from childbirth-related complications in the United States than in most other high-income countries such as France, Canada, and the United Kingdom,¹⁶ with significant and persistent disparities among racial and ethnic minority groups in the United States.¹¹ The incidence and prevalence of obesity, hypertension, diabetes, and other chronic conditions are increasing in the United States. These conditions negatively impact pregnancy-related and infant mortality, with their impact exacerbated among racial and ethnic minority groups.¹⁷

Preconception care offers family physicians and their patients an opportunity to discuss these risk factors to minimize them before pregnancy. Clinical practice guidelines for interventions based on sound, quality evidence improves outcomes.¹⁸ These outcomes strengthen the case for more robust delivery of preconception services in routine primary care. Yet, the delivery of preconception care has been less than satisfactory due to numerous barriers.

Barriers to Delivery of Preconception Care

Traditionally, preconception care has focused on patients planning a pregnancy and has primarily been delivered at the wellness/preventive care visit. However, since 45% of U.S. pregnancies are currently reported as unintended at the time of conception, the timing of addressing preconception risks poses a challenge.² Additionally, until they are pregnant, some individuals of childbearing age do not seek care for themselves or may have limited or no access to care.¹⁹

There are also barriers to achieving the goals of interconception care. They include educating individuals of childbearing age about avoiding unintended, rapid repeat pregnancy, following up on health risks identified during pregnancy, and transitioning into appropriate primary care.

The postpartum visit provides one opportunity for interconception care. However, patient attendance is not guaranteed. Evidence suggests that as many as one-third of those who received prenatal and intrapartum care do not show up for their initial postpartum visit.²⁰ Some individuals may lose insurance coverage in the early postpartum period, making it difficult for them to get access to appropriate follow-up care.¹⁹

Researchers have identified perceptions and barriers to preconception care, including²¹:

•  Individuals most in need of preconception care are the least likely to receive counseling
• Fragmented health care delivery system
• Lack of treatment for high-risk behaviors
• Inadequate physician reimbursement for providing counseling services
• Lack of efficacy of the counseling supplied to patients and the people who support them
• Limited number of conditions with evidence-based preconception interventions
• Lack of emphasis on risk assessment/health promotion in training programs

Unfortunately, most of these perceptions and barriers still exist. One study surveyed individuals presenting for an annual well-woman exam. More than 98% of women recognized the need to achieve optimal health before conception and the benefit of receiving information before conception.²² However, nearly four in ten did not recall receiving any preconception counseling from their physician.²² While most preconception counseling is essential, many providers neither provide nor recommend routine counseling for their patients of childbearing age. Another study showed that just 14% of individuals receive preconception care services during ambulatory care visits (i.e., obstetrician-gynecologist visits, family physician visits).²³

Changes in the current health care landscape are removing some of these barriers through expanded health insurance coverage, improved reimbursement for preventive services, and public health initiatives.^19,21 In addition, clinical practice guidelines based on evidence-based research for preconception interventions improve pregnancy-related and fetal outcomes.²⁴ With these interventions, family physicians have a unique opportunity to improve pregnancy-related and fetal outcomes in the United States.

Health Disparities and Achieving Health Equity in Reproductive Outcomes

There are significant racial and ethnic disparities in pregnancy-related and fetal/infant morbidity and mortality.^10,11 Black individuals who become pregnant have the highest pregnancy-related mortality ratios of any racial/ethnic group.¹¹ People of color who become pregnant are more likely to have health conditions such as hypertension, diabetes, and asthma which can worsen during pregnancy and cause morbidity.⁵ People of color are also more likely to be uninsured or underinsured, which can delay access to care before, during, and after pregnancy.¹⁹ In the United States, Black fetal and infant death rates are higher than any other racial or ethnic identity.⁵

Institutional racism, implicit bias, and social determinants of health (SDoH) are key contributors to reproductive health disparities.²⁵ The AAFP position paper, Striving for Birth Equity: Family Medicine's Role in Overcoming Disparities in Maternal Morbidity and Mortality, further outlines these significant disparities in pregnancy-related mortality and morbidity.²⁶ The AAFP has adopted policy statements against discrimination²⁷ and institutional racism in health care.²⁸ The AAFP EveryONE Project supports members by providing resources and training to minimize implicit bias when caring for patients and address SDoH in communities.²⁹

Call to Action: Why Family Medicine Should Lead this Process

Family physicians are ideally suited to lead health care system change related to preconception care. They provide the most ambulatory primary care services to patients and their families across the reproductive life cycle.³⁰ Family physicians have an outstanding opportunity to address health issues (e.g., preconception risk reduction, chronic disease management) with patients in multiple settings. For example, if a parent missed their postpartum care visit, the family physician would likely have an opportunity to address their health risks during their child’s routine health care visit.

Key Concept

Providing quality preconception care is the responsibility of all primary care clinicians, not just those who provide prenatal or reproductive health care. Innovative strategies that incorporate preconception care into routine primary care visits are needed. Transforming the way preconception care is delivered is critical. To successfully provide preconception care, family physicians must understand the risk factors for, and the realities of, unintended pregnancy; recognize the value of reproductive planning in reducing risks; and assess preconception risks during chronic and acute care visits that are not specifically focused on reproductive or perinatal health.

Preconception care is primary care, and it should be a priority for primary care clinicians in all settings. The majority of preconception health topics are important whether an individual desires a future pregnancy or not, so providing quality preconception care is essentially providing quality reproductive health care. The AAFP outlines the following evidence-based recommendations for preconception care provided by family physicians.

Preconception Interventions for Individuals who Have a Uterus

During routine care, family physicians should identify patients’ childbearing goals, screen for risk factors that can impact future pregnancies, and provide interventions to help patients enter pregnancy in optimal health. The following are key interventions addressing contraceptive needs and preconception risk factors.

An individual’s childbearing goals (i.e., reproductive plan) should be considered for discussion at each visit, regardless of their reason for the visit, because their plans may change based on life circumstances. Reproductive plan discussions with individuals who want to become pregnant or may become pregnant should include assessing risks due to age, health conditions, obstetric history, and family history.³¹

Comprehensive contraceptive services should be offered if an individual is sexually active, has penis-in-vagina sex, and wants to prevent or delay pregnancy. All individuals who wish to delay or prevent pregnancy should be provided the following:

• A full range of U.S. Food and Drug Administration (FDA)-approved contraceptive methods³¹
• A health assessment to identify safe method options using the U.S. Medical Eligibility Criteria^31,32
• Counseling to help choose a contraceptive method that will work best for them³¹
• Prompt provision of the contraceptive method selected by the patient (preferably on-site by referral, if necessary)³³

Family physicians should use shared decision-making and tailor contraceptive methods to focus on patients’ preferences. For some patients, efficacy may not be the highest priority.³⁴ Counseling should include an explanation that long-acting reversible contraception (LARC) is safe and effective for most individuals, including adolescents and people who have never given birth.^31,32 Routine counseling about emergency contraceptive methods and provision of emergency contraception when needed should also be components of comprehensive family planning services.

Due to the association of short interpregnancy levels with an increased risk of adverse perinatal outcomes, birth spacing should be discussed with patients during prenatal and postpartum care.³⁵ A meta-analysis on birth spacing and perinatal outcomes found that an interpregnancy interval of 18-24 months was associated with lower risks of poor outcomes than intervals shorter than six months. Interestingly, longer interpregnancy intervals (more than 59 months) were also associated with poor outcomes.³⁵ A gap of at least 24 months is consistent with the WHO’s birth interval recommendation³⁶ and the United Nations Children Fund (UNICEF) recommendation that breast/chestfeeding for two years or more is optimal.³⁷ Counseling on birth spacing should be individualized based on an individual's reproductive plan. Family physicians should consider the health risks and benefits of the timing for subsequent pregnancies and discuss effective contraceptive options.³⁶

All individuals of reproductive age considering pregnancy should be advised to take a daily supplement (prenatal or multivitamin) of 400-800 micrograms (mcg) of folic acid and consume a balanced, healthy diet of folate-rich foods.³⁸ Folic acid supplementation starting before conception and continuing through 12 weeks of pregnancy reduces the risk of neural tube defects (NTDs), such as anencephaly, spina bifida, and encephalocele.³⁹ A higher dose of preconception folic acid (4 milligrams [mg] starting one month before attempting pregnancy and continuing through the first three months of pregnancy) is recommended for people at high risk for a pregnancy complicated by an NTD. This includes patients who had a prior pregnancy complicated by an NTD, have a personal or family history of NTD, have insulin-dependent diabetes, or have a seizure disorder (especially if it is treated with valproic acid or carbamazepine).^40,41

Partnering for a Healthy Pregnancy: Chronic Health Conditions and Higher BMI

Managing overall health and chronic conditions is crucial for proper preconception care. Nearly 38% of U.S. adults 20 years and older are considered obese (body mass index [BMI] greater than or equal to 30 kg/m² [kilograms divided by height in meters squared]) or extremely obese (BMI greater than or equal to 40 kg/m²).⁴² It is essential to counsel patients on achieving a healthy weight and preventing excess gestational weight gain in pregnancy.⁴³ Although a healthy pregnancy is possible at any size and many people with a higher BMI have healthy pregnancies, individuals who are obese encounter increased risks of pregnancy complications. Complications include gestational diabetes, hypertension, macrosomia (larger than average size baby), birth trauma, cesarean section, and an increased risk of induced and spontaneous preterm birth.^44,45 Individuals who are obese also have a higher likelihood of pregnancies affected by congenital anomalies, including NTDs, cardiovascular abnormalities, and cleft palate.⁴⁶

Conversely, individuals with a BMI less than 18.5 kg/m² are at increased risk for infertility, first-trimester miscarriage, and preterm birth, and they are more likely to have an infant with low birth weight.^47,48,49 All individuals who have a BMI greater than 26 kg/m² or less than 18.5 kg/m² should be counseled about the risks their weight poses to their health and future pregnancies.⁴⁷ Patients should be offered specific strategies to improve the balance and quality of their diet and physical activity level.⁴⁷

Chronic hypertension can also increase pregnancy-related and fetal morbidity and mortality.⁵⁰ All individuals of reproductive age should have their blood pressure checked during routine care. Family physicians should provide counseling on lifestyle changes and appropriate medication adjustments for people diagnosed with hypertension.⁴⁴ Individuals with chronic hypertension considering pregnancy should be counseled about preeclampsia and undergo a preconception assessment for ventricular hypertrophy, retinopathy, and renal disease to prevent end-organ damage.⁴⁴ Individuals who could become pregnant while taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers should be counseled about the adverse fetal effects of these medications and offered contraception. People taking these medications who are planning a pregnancy or are not using an effective contraceptive method should strongly consider switching to a medication compatible with a healthy pregnancy.⁴⁴

From 2014-2015, data show the prevalence of diabetes was 3.1% in nonpregnant women.⁵¹ Poor glycemic control in the first trimester – before some people know they are pregnant – is associated with an increased risk of spontaneous abortion⁵² and congenital malformations.⁴⁴ Other risks related to poor glycemic control include fetal macrosomia and associated birth trauma, stillbirth, and newborn hypoglycemia.⁴⁴ If blood glucose remains uncontrolled during pregnancy, individuals with diabetes may have progression of any underlying retinopathy and/or nephropathy.^53,54,55 People with diabetes also have an increased risk of high blood pressure and/or preeclampsia during pregnancy.⁵⁴ Optimal glycemic control can reduce but not eliminate risks.

All individuals of childbearing age with diabetes should be counseled about the importance of glycemic control before pregnancy. Those with suboptimal diabetes control should be encouraged to use an effective contraceptive method.⁴⁴ Assisting individuals with diabetes and other chronic conditions in reproductive planning and optimal timing of pregnancy is an essential component of quality preconception care.

Importance of Oral Health for Healthy Pregnancy

Numerous national professional organizations concur about the importance of addressing an individual’s oral health throughout the life cycle.^56,57 It has been established that preventive, diagnostic, and restorative dental treatment is safe throughout pregnancy and effectively improves and maintains oral health.⁵⁶ Evidence shows an association between periodontitis and risk for adverse outcomes (e.g., preeclampsia, preterm birth, low birth weight).^58,59,60 In addition, oral health in individuals who are pregnant has implications for infant oral health.⁶¹ For example, primary and permanent teeth begin to form in utero, and bacteria that cause tooth decay primarily pass from parent to child postpartum.^56,62

Oral health interventions targeting individuals before, during, and after pregnancy can help prevent or reduce the risk of tooth decay in children. To promote optimal oral health for individuals considering pregnancy and their children, family physicians can screen people for periodontitis and dental caries using a risk assessment, oral exam, counseling on good oral hygiene practices, and referrals to oral health professionals for prevention and management.⁵⁶

Immunizations and Medication Use

Counseling on medication usage is an integral part of preconception care.³¹ Approximately 10-15% of congenital anomalies in the United States are attributed to the adverse effect of environmental factors during pregnancy. These include prescription medications, drugs, chemical exposure, and maternal conditions or diseases.⁶³ Since the late 1970s, the use of prescription medications in the first trimester of pregnancy increased by more than 60%, with half of the individuals who are pregnant reporting taking at least one medication by 2008.⁶⁴ One study found that between 2006-08, more than 80% of individuals who are pregnant reported taking at least one prescription or over-the-counter (OTC) medication in the first trimester.⁶⁵

Many commonly prescribed medications are considered unsafe in pregnancy. Examples include ACE inhibitors, angiotensin receptor blockers (ARBs), warfarin, valproic acid, lithium, statins, and methotrexate.^66,67,68,69 When reviewing medications or prescribing new medications, it’s important to consider the impact of potentially teratogenic medications and target counseling about the potential effects of medications for chronic conditions on pregnancy and fetal outcomes depending on the reproductive plan for the patient. For individuals considering pregnancy now or soon, known teratogenic medications should be switched to safer medications before conception.⁴⁴ For those with a chronic condition that poses a risk of severe morbidity to them and the infant if untreated, focus counseling on the minimum number and the lowest doses of medications essential to control the condition. A plan for effective contraception should be discussed and initiated for individuals who do not desire pregnancy. 

Preconception care should also include counseling on immunizations. All individuals of reproductive age should have their immunization for tetanus-diphtheria-pertussis (Tdap), measles-mumps-rubella (MMR), and varicella reviewed annually and updated as indicated.⁷⁰ In addition, all individuals considering pregnancy should be assessed annually to determine the need for vaccines recommended for those who have medical, occupational, or lifestyle risk factors for other infections.⁴⁷

Addressing Mental and Behavioral Health in Preconception Care

Mental health assessment should be included in preconception care and should be a routine part of wellness screening.⁷¹ Mood and anxiety disorders are prevalent among people of reproductive age, and there is a high prevalence of new psychiatric illness or a relapse of a pre-existing disease during pregnancy.⁷¹ Controlling depression and anxiety disorders before pregnancy may help prevent adverse outcomes during the intrapartum or postpartum period.⁷¹

If a patient who has depression or an anxiety disorder could become pregnant or is planning a pregnancy, their family physician should inform them about the potential risk of untreated or undertreated illness during pregnancy. Patients should also be informed about the risks and benefits of treatment options for depression and anxiety disorders during pregnancy. If necessary, medications should be adjusted before conception. Proper timing of medication adjustments decreases the exposure of the fetus to multiple medications and allows the medication dose to be tapered to minimize the risk of withdrawal symptoms.⁷¹ Treatment for depression and anxiety disorders during pregnancy should be individualized.

It’s also important to address behavioral health and lifestyle risks – including alcohol, tobacco, and substance use – and provide resources and support for lifestyle modifications as part of routine preconception care. Alcohol use in pregnancy is the cause of fetal alcohol spectrum disorders (FASDs), a range of effects that include physical problems and behavioral and intellectual disabilities that can have lifelong implications.⁷² All people of childbearing age should be screened for unhealthy alcohol consumption. Family physicians should provide brief interventions that include describing the effects of drinking during pregnancy and warning that there are no safe levels of alcohol consumption during pregnancy.⁷³

Tobacco smoking in pregnancy is also associated with numerous pregnancy complications, including spontaneous abortion, stillbirth, low birth weight, preterm birth, placenta previa, placental abruption, cleft lip/palate, and an increased risk of sudden infant death syndrome (SIDS).^74,75,76 Family physicians should screen all people of childbearing age for tobacco use.⁷³ Patients who use tobacco should be provided with brief interventions that focus on the importance of reducing smoking – and ideally, completely stopping smoking – before pregnancy. Interventions should include discussing tobacco cessation medications and referring patients for intensive services.^73,77

The U.S. Preventive Services Task Force (USPSTF) recommends screening for unhealthy drug use in adults 18 years or older. Screening in this setting includes asking patients who are asymptomatic about their unhealthy use of illegal drugs and the nonmedical use of prescription psychoactive medications.⁷⁸ The AAFP disagrees with this USPSTF screening recommendation and has concluded that the evidence is insufficient to assess the benefits and harms of screening adults for unhealthy drug use.⁷⁹ Both the USPSTF and the AAFP have concluded that the evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents.^78,79 The AAFP has also issued a separate recommendation for clinicians to selectively screen and refer adults 18 years and older to treatment for opioid use disorder (OUD) after carefully considering the benefits and harms to the patient, including health, social, and legal outcomes.⁸⁰ Selective screening and referral should only be implemented if services for accurate diagnosis, effective treatment, and psychosocial supports can be offered or referred.⁸⁰

The AAFP recognizes that the literature does not support any lower limit of substance use at which potential fetal harm is reduced and supports public and individual education about the risks of any substance use during pregnancy.⁸¹ For patients with an OUD who desire pregnancy, medication for opioid use disorder (MOUD) treatment should be started – ideally before pregnancy and should continue throughout pregnancy.⁸² The AAFP opposes imprisonment or other criminal sanctions for substance use during pregnancy and encourages facilitated access to established drug and alcohol rehabilitation programs for persons who are pregnant struggling with substance use.⁸¹

Other lifestyle or occupational risks include occupational hazards and/or exposures, sexually transmitted infections (STIs), and physical and emotional abuse. Family physicians should regularly assess STI risks, provide counseling and immunizations to prevent contracting STIs, and provide indicated STI testing and treatment.^73,83 Expedited treatment of patients and their sexual contacts significantly reduces the risk of persistent infection.⁸⁴ All individuals of reproductive age should be asked whether physical, sexual, or emotional violence from any source is happening currently or has happened in the recent past or during childhood.⁷³ If an individual is being abused or has been abused in the recent past, the family physician should express concern and willingness to assist by giving support and referring the patient to appropriate organizations for help. Appropriate evaluation, counseling, and treatment for physical injuries, STIs, unintended pregnancy, and psychological trauma should be offered –  including emergency contraception, if appropriate. Individuals should be provided information about community agencies specializing in abuse, including counseling, legal advice, and other services.

Preconception Interventions for Individuals who do not Have a Uterus

Most family planning and preconception care programs, research, and clinical practice guidelines have focused almost exclusively on people with a uterus. Survey data have shown that many individuals without a uterus need family planning and/or preconception care.^85,86 Despite this need, an individual’s reproductive health before pregnancy and the effect of their health status on conception and pregnancy outcomes generally receive little attention unless fertility issues arise.

The goals of these individuals’ preconception health are similar in many ways to those with a uterus. The overall objective is to ensure optimal and positive outcomes of their reproductive and sexual behaviors while minimizing the potential negative consequences of unhealthy lifestyle choices and unprotected sex. In addition, preconception care for an individual without a uterus should include counseling on enhancing overall health, the planning and timing of pregnancy, genetic and biologic contributions to the pregnancy, improving the partner’s reproductive health and postpartum outcomes, and improving parenting skills.^87,88

Effects on Fertility and Conception

Researchers have studied various substances, anatomical variations, behaviors, and environmental issues that may affect an individual’s ability to contribute to a successful conception. Factors affecting sperm quality, quantity, concentration, and motility include the following:

• Health conditions such as diabetes, varicoceles, and epididymitis may affect fertility if left untreated.⁸⁷
• Numerous medications (e.g., nifedipine, steroids, testosterone, colchicine, selective serotonin reuptake inhibitors [SSRIs], cimetidine, tetracyclines, allopurinol, opiates, ketoconazole) may alter the hypothalamic-pituitary-gonadal axis and reduce libido, contribute to erectile dysfunction, and have toxic effects on sperm.⁸⁹
• Tobacco, alcohol, and certain drugs (e.g., marijuana, cocaine) can affect spermatogenesis.⁸⁸
• Exposure to environmental hazards, including ionizing radiation, radiant heat, pollutants in the diet, lead, mercury, and other occupational chemicals, have been shown to affect sperm quality.⁸⁸
• Chemicals associated with woodworking, painting, pottery, stained glass, and gun cleaning may affect sperm production.⁸⁸
• Stress has been shown to negatively impact sperm morphology and concentration.⁸⁸
• High BMI may reduce fertility, with overweight men having a greater risk of erectile dysfunction.⁹⁰
• Genetic disorders (e.g., cystic fibrosis, Klinefelter syndrome, Kartagener syndrome, polycystic kidney disease) may affect sperm quality.⁸⁷

Effects on Pregnancy Outcomes

An individual’s lifestyle factors can directly impact a partner’s pregnancy. These factors include tobacco smoking, which exposes the expectant individual to secondhand smoke and potentially leads to negative effects such as low birth weight,^91,92,93 intrauterine growth restriction (IUGR),⁹⁴ preterm birth,^91,92 and an increased risk of sudden infant death syndrome (SIDS).^91,92 An individual with an untreated or uncontrolled STI, including HIV, could put their pregnancy partner and the fetus at risk for pregnancy complications and further morbidity.⁹⁵

Research also suggests that an individual’s involvement during their partner’s pregnancy and delivery can positively affect health outcomes for the family and themselves.⁹⁶ During wellness visits, family physicians should consider discussing intimate partner violence and coercive relationships and promote respectful and consensual sexual relationships.⁹⁷

Factors including genetics and age have been shown to affect fetal outcomes. Screening for genetic conditions should be discussed and offered when appropriate.^87,88 Recent studies have pointed to a relationship between advanced age and conditions such as autism,^98,99 schizophrenia,⁹⁹ bipolar disorder,⁹⁹ and other mental health disorders.¹⁰⁰ For example, a child conceived with sperm from an individual older than 45 years was more likely when compared to younger individuals to be affected by disorders, such as schizophrenia, bipolar disorder, mental retardation, and other disorders.¹⁰⁰ Likewise, a diagnosis of autism in a child is more likely in a child conceived with sperm from an individual who was older than 40 years of age.⁹⁸

Table 1 - General Recommendations for Preconception Interventions for Women

Considerations for Gender Diverse Patients

There is limited literature surrounding pregnancy and prepregnancy-related care for individuals who are transgender, gender diverse, and non-binary (TGNB). Nevertheless, many individuals who are TGNB were assigned female sex at birth and may want to conceive, carry a pregnancy, and parent a child. While the general approach to reproductive life planning remains the same, there are some unique considerations relevant to preconception care for patients who are TGNB, including management of perinatal testosterone use, considerations for chest/breastfeeding, and discussion about gender dysphoria as it may relate to clinical environments that do not always recognize the gender diversity of pregnancy.¹⁰¹

Individuals using exogenous testosterone still need to be counseled about the need for contraception if they are having penis-in-vagina sex and do not want to become pregnant. While exogenous testosterone will thin the endometrial lining, often eventually causing amenorrhea, a small study of transgender men still indicated that 20% of pregnancies occurred despite amenorrhea.¹⁰²

It is essential for individuals who are TGNB, on testosterone, and considering pregnancy to discuss the possibility of infertility and the potential need for fertility treatment. While data are limited, testosterone can lead to permanent changes in ovarian structure. Nevertheless, transgender men on testosterone have also successfully conceived and carried pregnancies to term. The decision to stop testosterone while attempting to conceive or during pregnancy will need to be highly individualized, weighing the risks and benefits to both the patient and the developing fetus.¹⁰¹ However, data are limited in this area. There may be some theoretical benefits to stopping testosterone for the developing fetus. Excessive testosterone exposure may contribute to virilization of the fetus, possible intrauterine growth restriction,¹⁰³ or another pregnancy-related morbidity, such as preterm labor, placental abruption, or pregnancy-induced hypertension.¹⁰² At the same time, stopping testosterone may negatively affect the individual who is pregnant. There are known mental health benefits and improved quality of life from gender-affirming hormone therapy, and suppressing hormones may have psychological effects that need to be considered.

The decision to chest/breastfeed an infant may be affected by surgical history. Chest surgery is the most common gender-affirming surgery by individuals who are TGNB and were assigned female at birth.¹⁰⁴ Anticipatory guidance regarding chest/breastfeeding should be provided regardless of surgical status, understanding that some lactation may still be possible after surgery. One prepregnancy counseling and anticipatory guidance states that, “while the desire and ability to chestfeed likely varies among TGNB patients as it does for cisgender women, we recommend discussing it with each person, regardless of surgical history and providing personalized support towards meeting infant feeding goals.”¹⁰¹

Finally, it is essential to understand the patient’s personal experience with gender dysphoria. While pregnancy and postpartum have some known associated mental health considerations for cisgender women, this is also true for individuals who are TGNB with the added possibility of worsening gender dysphoria or distress. At the same time, many individuals who are TGNB did not experience dysphoria before their transition,¹⁰⁵ and some TGNB people may feel empowered by pregnancy and birth.^105,106

External sources of distress should also be addressed, including being misgendered due to body changes during pregnancy, the effects of typically gendered language by clinic and/or birth center staff and providers, and exposure to signage and art that typically focuses on cisgender women and heteronormative relationships. Creating a more welcoming clinical environment for people across the gender spectrum can help, including providing signage that celebrates the diversity of gender and relationship types, using inclusive intake forms and health records, providing access to all-gender bathrooms, and encouraging system changes that reduce cisnormative and heteronormative language in policies and processes.¹⁰¹

Summary

Preconception care is primary care, and providing quality preconception care is the responsibility of all primary care providers. Successful implementation requires transforming care delivery and providing preconception care based on the best available evidence.

The AAFP encourages members to follow these evidence-based recommendations to incorporate preconception care into all routine primary care visits and supports members’ efforts to improve pregnancy-related and fetal outcomes.

References

1. U.S. Department of Health and Human Services. Family planning. Healthy People 2030. Office of Disease Prevention and Health Promotion. Accessed December 20, 2021. https://health.gov/healthypeople/objectives-and-data/browse-objectives/family-planning  
2. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med. 2016;374(9):843-52.
3. D’Angelo D, Williams L, Morrow B, et al. Preconception and interconception health status of women who recently gave birth to a live-born infant–Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR Surveill Summ. 2007;56(10):1-35.
4. Phares TM, Morrow B, Lansky A, et al. Surveillance for disparities in maternal health-related behaviors–selected states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2001. MMWR Surveill Summ. 2004;53(4):1-13.
5. Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol. 2010;202(4):335-343.
6. Rowland Hogue CJ, Silver RM. Racial and ethnic disparities in United States: stillbirth rates: trends, risk factors, and research needs. Semin Perinatol. 2011;35(4):221-233.
7. U.S. Department of Health and Human Services. Pregnancy and childbirth. Healthy People 2030. Office of Disease Prevention and Health Promotion. Accessed December 20, 2021. https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth
8. MacDorman MF, Declercq E, Cabral H, Morton C. Recent increases in the U.S. maternal mortality rate: disentangling trends from measurement issues. Obstet Gynecol. 2016;128(3):447-455.
9. Ozimek JA, Kilpatrick SJ. Maternal mortality in the twenty-first century. Obstet Gynecol Clin North Am. 2018;45(2):175-186.
10. Hirshberg A, Srinivas SK. Epidemiology of maternal morbidity and mortality. Semin Perinatol. 2017;41(6):332-337.
11. Hoyert DL, Miniño AM. Maternal mortality in the United States: changes in coding, publication, and data release, 2018. Natl Vital Stat Rep. 2020;69(2):1-18.
12. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care – United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR. 2006;55(RR06):1-23.
13. MacDorman MF, Matthews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. Natl Vital Stat Rep. 2014;63(5):1-6.
14. Mathews TJ, Driscoll AK. Trends in infant mortality in the United States, 2005-2014. NCHS Data Brief. 2017;(279):1-8.
15. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2008 period linked birth/infant death data set. Natl Vital Stat Rep. 2012;60(5):1-27.
16. The Commonwealth Fund. Maternal mortality and maternity care in the United States compared to 10 other developed countries. Accessed December 20, 2021. www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries
17. Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol. 2018;61(2):387-399.
18. American Academy of Family Physicians. Maternity care clinical recommendations & guidelines. Accessed December 20, 2021. www.aafp.org/family-physician/patient-care/clinical-recommendations/recommendations-by-topic/maternity-care-clinical-recommendations-guidelines.html
19. Kaiser Family Foundation. Women’s coverage, access, and affordability: key findings from the 2017 Kaiser Women’s Health Survey. Accessed December 20, 2021. www.kff.org/womens-health-policy/issue-brief/womens-coverage-access-and-affordability-key-findings-from-the-2017-kaiser-womens-health-survey/
20. Wilcox A, Levi EE, Garrett JM. Predictors of non-attendance to the postpartum follow-up visit. Matern Child Health J. 2016;20(Suppl 1):22-27.
21. Jack BW, Culpepper L. Preconception care. Risk reduction and health promotion in preparation for pregnancy. JAMA. 1990;264(9):1147-1149.
22. Frey KA, Files JA. Preconception healthcare: what women know and believe. Matern Child Health J. 2006;10(Suppl 1):73-77.
23. Bello JK, Rao G, Stulberg DB. Trends in contraceptive and preconception care in United States ambulatory practices. Fam Med. 2015;47(4):264-271.
24. Atrash HK, Johnson K, Adams M, Cordero JF, Howse J. Preconception care for improving perinatal outcomes: the time to act. Matern Child Health J. 2006;10(5 Suppl):S3-11.
25. Gadson A, Akpovi E, Mehta PK. Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Semin Perinatol. 2017;41(5):308-317.
26. American Academy of Family Physicians. Striving for birth equity: family medicine’s role in overcoming disparities in maternal morbidity and mortality. Accessed December 21, 2021. www.aafp.org/about/policies/all/birth-equity-pos-paper.html
27. American Academy of Family Physicians. Discrimination, patient. Accessed December 21, 2021. www.aafp.org/about/policies/all/discrimination-patient.html
28. American Academy of Family Physicians. Institutional racism in the health care system. Accessed December 21, 2021. www.aafp.org/about/policies/all/institutional-racism.html
29. American Academy of Family Physicians. The EveryONE Project™. Accessed December 21, 2021. www.aafp.org/family-physician/patient-care/the-everyone-project.html
30. National Ambulatory Medical Care Survey: 2016 National Summary Tables. Accessed December 21, 2021. www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf
31. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016;65 (No. RR-3):1-104.
32. Tepper NK, Curtis KM, Cox S, Whiteman MK. Update to U.S. Medical Eligibility Criteria for contraceptive use, 2016: updated recommendations for the use of contraception among women at high risk for HIV infection. MMWR Morb Mortal Wkly Rep. 2020;69:405-410.
33. Gavin L, Moskosky S, Cater M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep. 2014;63(RR-04):1-54.
34. Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use. Clin Obstet Gynecol. 2014;57(4):659-673.
35. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295(15):1809-1823.
36. World Health Organization. Birth spacing: report from a WHO technical consultation. Accessed December 21, 2021. https://apps.who.int/iris/bitstream/handle/10665/73710/RHR_policybrief_birthspacing_eng.pdf?sequence=1&isAllowed=y
37. United Nations Children’s Fund. Infant and young child feeding. Accessed December 21, 2021. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/
38. U.S. Preventive Services Task Force. Folic acid for the prevention of neural tube defects: preventive medication. Accessed December 21, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication
39. De-Regil LM, Fernandez-Gaxiola AC, Dowswell T, Pena-Rosas JP. Effects and safety of periconceptional folate supplementation for preventing birth defects. Cochrane Database Syst Rev. 2010(10):CD007950.
40. Centers for Disease Control and Prevention. Recommendations: women and folic acid. Accessed December 21, 2021. www.cdc.gov/ncbddd/folicacid/recommendations.html
41. Kennedy D, Koren G. Identifying women who might benefit from higher doses of folic acid in pregnancy. Can Fam Physician. 2012;58(4):394-397.
42. Fryar CD, Carroll MD, Ogden CL. Prevalence of overweight, obesity, and extreme obesity among adults aged 20 and over: United States, 1960-1962 through 2011-2012. National Center for Health Statistics. Health E-Stat. Accessed December 22, 2021. www.cdc.gov/nchs/data/hestat/obesity_adult_13_14/obesity_adult_13_14.pdf
43. U.S. Preventive Services Task Force. Healthy weight and weight gain in pregnancy: behavioral counseling interventions. Accessed December 22, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/healthy-weight-and-weight-gain-during-pregnancy-behavioral-counseling-interventions  
44. Dunlop AL, Jack BW, Bottalico JN, Geero WG, Menard MK, Prasad MR. The clinical content of preconception care: women with chronic medical conditions. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S310-327.
45. McDonald SD, Han Z, Mulla S, Beyene J. Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and meta-analyses. BMJ. 2010;341:c3428.
46. Stothard KJ, Tennant PWG, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA. 2009;301(6):636-650.
47. Jack BW, Atrash H, Coonrod DV, et al. The clinical content of preconception care: an overview and preparation of this supplement. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S266-279.
48. Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage – results from a UK-population-based case – control study. BJOG. 2007;114(2):170-186.
49. Han Z, Mulla S, Beyene J, Liao G, McDonald SD. Maternal underweight and the risk of preterm birth and low birth weight: a systematic review and meta-analyses. Int J Epidemiol. 2011;40(1):65-101.
50. Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ. 2014;348:g2301.
51. Robbins CL, Boulet SL, Morgan I, et al. Disparities in preconception health indicators – Behavioral Risk Factor Surveillance System, 2013-2015, and Pregnancy Risk Assessment Monitoring System, 2013-2014. MMWR Surveill Summ. 2018;67(01):1-16.
52. Mills JL, Simpson JL, Driscoll SG, et al. Incidence of spontaneous abortion among normal women and insulin-dependent diabetic women whose pregnancies were identified within 21 days of conception. N Engl J Med. 1988;319(25):1617-1623.
53. Hawthorne G. Maternal complications in diabetic pregnancy. Best Pract Res Clin Obstet Gynaecol. 2011;25(1):77-90.
54. Ornoy A, Becker M, Weinstein-Fudim L, Ergaz Z. Diabetes during pregnancy: a maternal disease complicating the course of pregnancy with long-term deleterious effects on the offspring. A clinical review. Int J Mol Sci. 2021;22(6):2965.
55. Gordin D, Forsblom C, Groop PH, Teramo K, Kaaja R. Risk factors of hypertensive pregnancies in women with diabetes and the influence on their future life. Ann Med. 2014;46(7):498-502.
56. Oral health care during pregnancy and through the lifespan. Committee Opinion. Number 569. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2013;122(2 Pt 1):417-422.
57. National Maternal and Child Oral Health Resource Center. Oral health during pregnancy: a national consensus statement. Accessed December 23, 2021. www.mchoralhealth.org/materials/consensus_statement.php  
58. Corbella S, Taschieri S, Del Fabbro M, Francetti L, Weinstein R, Ferrazzi E. Adverse pregnancy outcomes and periodontitis: a systematic review and meta-analysis exploring potential association. Quintessence Int. 2016;47(3):193-204.
59. Daalderop LA, Wieland BV, Tomsin K, et al. Periodontal disease and pregnancy outcomes: overview of systematic reviews. JDR Clin Trans Res. 2017;3(1):10-27.
60. Matevosyan NR. Periodontal disease and perinatal outcomes. Arch Gynecol Obstet. 2011;283(4):675-678.
61. Kloetzel MK, Huebner CE, Milgrom PM. Referrals for dental care during pregnancy. J Midwifery Womens Health. 2011;56(2):110-117.
62. Da Silva Bastos Vde A, Freitas-Fernandes LB, Fidalgo TK, et al. Mother-to-child transmission of Streptococcus mutans: a systematic review and meta-analysis. J Dent. 2015;43(2):181-191.
63. Gilbert-Barnes E. Teratogenic causes of malformations. Ann Clin Lab Sci. 2010;40(2):99-114.
64. Mitchell AA, Gilboa SM, Werler MM, et al. Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008. Am J Obstet Gynecol. 2011;205(1):51.e51-58.
65. Thorpe PG, et al. Medications in the first trimester of pregnancy: most common exposures and critical gaps in understanding fetal risk. Pharmacoepidemiol Drug Saf. 2013;22(9):1013-1018.
66. Daller JA. Pregnancy – dangerous drugs for baby. OnHealth. Accessed December 24, 2021. www.onhealth.com/content/1/pregnancy_-_dangerous_drugs_for_baby
67. Wei Q, Duan M-F, Wang Y-M, Huang N, Song C-R. Use of angiotensin II receptor blocker during pregnancy: a case report. Medicine (Baltimore). 2021;100(3):e24304.
68. U.S. Food and Drug Administration. FDA requests removal of strongest warning against using cholesterol-lowering statins during pregnancy; still advises most pregnant patients should stop taking statins. Accessed December 24, 2021. www.fda.gov/drugs/drug-safety-and-availability/fda-requests-removal-strongest-warning-against-using-cholesterol-lowering-statins-during-pregnancy#:~:text=FDA%20is%20requesting%20that%20manufacturers,they%20learn%20they%20are%20pregnant
69. Medscape. Is methotrexate (MTX) safe for pregnant women with rheumatoid arthritis? Accessed December 24, 2021. www.medscape.com/answers/335186-187626/is-methotrexate-mtx-safe-for-pregnant-women-with-rheumatoid-arthritis-ra#:~:text=Methotrexate%20(MTX)%2C%20a%20folic,hydrocephaly%2C%20and%20meningomyelopathy%2C%20especially%20with
70. Centers for Disease Control and Prevention. Table 1. Recommended adult immunization schedule for ages 19 years or older, United States, 2021. Accessed December 24, 2021. www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
71. Frieder A, Dunlop AL, Culpepper L, Bernstein PS. The clinical content of preconception care: women with psychiatric conditions. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S328-332.
72. Centers for Disease Control and Prevention. Alcohol use during pregnancy. Accessed December 24, 2021. www.cdc.gov/ncbddd/fasd/alcohol-use.html
73. Jack BW, Atrash H, Coonrod DV, et al. The clinical content of preconception care: an overview and preparation of this supplement. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S266-279.
74. Chamberlain C, O’Mara-Eves, Oliver S, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2013;10:Cd001055.
75. U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress. A report of the Surgeon General. Accessed December 24, 2021. www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf  
76. Andres RL, MC Day. Perinatal complications associated with maternal tobacco use. Semin Neonatol. 2000;5(3):231-241.
77. U.S. Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons. Accessed December 24, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions
78. U.S. Preventive Services Task Force. Unhealthy drug use: screening. Accessed December 24, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening
79. American Academy of Family Physicians. Unhealthy drug use: screening. Accessed December 24, 2021. www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/unhealthy-drug-use.html
80. American Academy of Family Physicians. Opioid use disorder (OUD): screening. Accessed December 24, 2021. www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/oud.html
81. American Academy of Family Physicians. Substance use disorders. Accessed December 24, 2021. www.aafp.org/about/policies/all/substance-use-disorders.html#pregnant
82. Substance Abuse and Mental Health Services Administration (SAMHSA). Buprenorphine. Accessed December 24, 2021. www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine
83. American Academy of Family Physicians. Screening for sexually transmitted infections. Accessed December 24, 2021. www.aafp.org/dam/AAFP/documents/patient_care/sti/hops19-sti-manual.pdf
84. Centers for Disease Control and Prevention, Expedited partner therapy in the management of sexually transmitted diseases. Review and guidance. Accessed December 24, 2021. www.cdc.gov/std/treatment/eptfinalreport2006.pdf
85. Casey FE, Sonenstein FL, Astone NM, et al. Family planning and preconception health among men in their mid-30s: developing indicators and describing need. Am J Mens Health. 2014;10(1):59-67.
86. Choiriyyah I, Sonenstein FL, Astone NM, et al. Men aged 15-44 in need of preconception care. Matern Child Health J. 2015;19(11):2358-2365.
87. Frey KA, Navarro SM, Kotelchuck M, Lu MC. The clinical content of preconception care: preconception care for men. Am J Obstet Gynecol. 2008;199(6, Suppl B):S389-S395.
88. Warner JN, KA Frey. The well-man visit: addressing a man's health to optimize pregnancy outcomes. J Am Board Fam Med. 2013;26(2):196-202.
89. Nudell DM, Monoski MM, Lipshultz LI. Common medications and drugs: how they affect male fertility. Urol Clin North Am. 2002;29(4):965-973.
90. Sallmen M, Sandler DP, Hoppin JA, Blair A, Baird DD. Reduced fertility among overweight and obese men. Epidemiology. 2006;17(5):520-523.
91. Stotts AL, Northrup TF, Hutchinson MS, Pedroza C, Blackwell SC. Families at risk: home and car smoking among pregnant women attending a low-income, urban prenatal clinic. Nicotine Tob Res. 2014;16(7):1020-1025.
92. World Health Organization. WHO recommendations for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy. Accessed December 28, 2021. https://apps.who.int/iris/bitstream/handle/10665/94555/9789241506076_eng.pdf;jsessioni
93. Tong VT, Dietz PM, Rolle IV, et al. Clinical interventions to reduce secondhand smoke exposure among pregnant women: a systematic review. Tob Control. 2015;24(3):217-223.
94. Niu Z, Xie C, Wen Z, et al. Potential pathways by which maternal second-hand smoke exposure during pregnancy causes full-term low birth weight. Sci Rep. 2016;6:24987.
95. Centers for Disease Control and Prevention. STDs during pregnancy – CDC fact sheet (detailed). Accessed December 28, 2021. www.cdc.gov/std/pregnancy/stdfact-pregnancy-detailed.htm
96. Plantin L, Olukoya AA, Ny P. Positive health outcomes of fathers' involvement in pregnancy and childbirth paternal support: a scope study literature review. Fathering. 2011;9(1):87-102.
97. Carlson J, Casey E, Edleson JL, et al. Strategies to engage men and boys in violence prevention: a global organizational perspective. Violence Against Women. 2015;21(11):1406-1425. 
98. Sandin S, Schendel D, Magnusson P, et al. Autism risk associated with parental age and with increasing difference in age between the parents. Mol Psychiatry. 2016;21(5):693-700.
99. Malaspina D, Gilman C, Kranz TM. Paternal age and mental health of offspring. Fertil Steril. 2015;103(6):1392-1396.
100. McGrath JJ, Petersen L, Agerbo E, et al. A comprehensive assessment of parental age and psychiatric disorders. JAMA Psychiatry. 2014;71(3):301-309.
101. Martinez E, Klein A, Obedin-Maliver J. Prepregnancy counseling for people of all genders: enhancing safe and accessible family building for transgender, gender diverse, and non-binary individuals. Curr Obstet Gynecol Rep. 2020;9:159-165.
102. Light AD, Obedin-Maliver J, Seelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127.
103. Carlsen SM, Jacobsen G, Romundstad P. Maternal testosterone levels during pregnancy are associated with offspring size at birth. Eur J Endocrinol. 2006;155(2):365-370.
104. James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. Accessed January 3, 2022. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
105. Hoffkling A, Obedin-Maliver J, Sevelius J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth. 2017:17(Suppl 2):332.
106. Ellis SA, Wojnar DM, Pettinato M. Conception, pregnancy, and birth experiences of male and gender variant gestational parents: it's how we could have a family. J Midwifery Women's Health. 2015;60(1):62-69.