PRECONCEPTION CARE

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PRECONCEPTION CARE

• CityMatCH Conference
• September 13, 2004
• Janis Biermann, M.S.
• jbiermann_at_marchofdimes.com

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Preconception Care

• Greater New York Chapter of the
• March of Dimes
• Preconception Care Curriculum Working Group
• Albert Einstein College of Medicine/Montefiore
  Medical Center
• www.marchofdimes.com/prematurity/5195_5785.asp

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The Continuum of Reproductive Health

• Improving infant health requires focus on the
  entire spectrum of reproductive health
• Beginning before conception
• Continuing through the first year of life
• Extending throughout the womans childbearing
  years

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Preconception Care

• Identifies reducible or reversible risks
• Maximizes maternal health
• Intervenes to achieve outcomes

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Preconception Care

• Reframes issues
• Adds an anticipatory element
• Focuses on the impact of pregnancy

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Elements of Preconception Care

• Focus on elements which must be accomplished
  prior to conception or within weeks thereafter to
  be effective
• Risk assessment
• Education Health Promotion
• Medical and psychosocial interventions

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Components of Preconception Care

• Medical history
• Psychosocial issues
• Physical exam
• Laboratory tests
• Family/genetic history
• Nutrition assessment
• Occupational/environmental risk assessment

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Risk Assessment

• STD Prevention
• Genetic issues
• Domestic violence
• Substance abuse
• Alcohol
• Tobacco
• Illicit drugs

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Environmental Teratogens

• Exposures
• Home, workplace, environment
• Physical/chemical hazards
• ionizing radiation, lead, mercury, hyperthermia,
  herbicides, pesticides

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Health Education Promotion

• Smoking Cessation counseling 5As
• Folic Acid
• Genetic Counseling
• Dietary and Nutritional Advice

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Conditions that Need Time to Correct Prior to
Conception

• Optimal weight
• Optimizing choice and use of medications
• Substance use/abuse
• alcohol
• tobacco

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Some Medical ConditionsAmenable to Preconception
Care

• Diabetes Mellitus
• Hypertensive Disorders
• Cardiac Disease
• Thyroid Disorders
• Epilepsy
• Asthma
• HIV Infection

• Systemic Lupus
• Thromboembolic Disease
• Renal Disease
• Hemoglobinopathies
• Cancers

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Intervention Usually Not Undertaken During
Pregnancy

• Rubella varicella immunization
• Narcotic detoxification
• Certain radiological procedures
• Thyroid ablation with radioactive iodine

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Interventions considered because pregnancy is
planned

• Correction of mitral stenosis
• Switching from oral hypoglycemics to insulin and
  achieving tight glucose control in patients
  with diabetes mellitus
• Evaluation of anticonvulsant therapy

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Factors That Could Change Timing Of Or Choice To
Conceive A Pregnancy

• Domestic violence
• Birth spacing
• Genetic disease
• Diseases with poor prognosis (e.g. AIDS)
• Diseases dangerous in pregnancy (e.g. CHF)
• Conflicts between needed maternal care and fetal
  well-being
• Recurrent Pregnancy loss

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Does Preconception Care Work?

• Outcomes Impacted
• Fetal/Infant mortality and morbidity
• Maternal mortality and morbidity

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Historical Perspectives

• 1979 PHS Primary Care Effectiveness. An
  approach to clinical quality assurance in BCHS
  Programs and Projects
• 1985 IOM Preventing Low Birth Weight
• 1989 Public Health Service Expert Panel on the
  content of Prenatal Care
• 1991 USPHHS Healthy People 2000 - National
  Health Promotions and Disease Prevention
  Objectives
• 1993 March of Dimes towards improving the
  outcome of pregnancy report
• 1993 Alan Guttmacher Institutes Issues in
  Brief The nation will be well-served by making a
  commitment to advance preconception services to a
  similar extend as it has prenatal care.
• 1996 Guide to Clinical Preventive Services
• 1997 AAP ACOG Guidelines for Perinatal Care

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Prevention of Birth Defects

• Optimal glycemic control
• No alcohol consumption
• Preconception rubella immunization
• Folic Acid supplementation

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Goals of Preconception Carein Diabetes

• To reduce the occurrence of obstetric and
  diabetic complications
• To decrease the incidence of congenital
  abnormalities
• Reduce risk of spontaneous abortions

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How To Accomplish These Goals?

• Education about need to change diabetes
  medication regimen ie substitute insulin for oral
  hypoglycemics
• Optimal glycemic control achieved by home
  monitoring, multiple daily injections, adjustment
  of insulin, close supervision and education
• Postpone conception until control is achieved
• Reassess modifiable risks before conception by
  assessing end organ damage, retina, kidney,
  vasculature, heart, nervous system

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Alcohol

• Leading preventable cause of mental retardation
• Most common teratogen to which fetuses are
  exposed
• Effects related to dose
• No threshold has been identified for safe use
  in pregnancy
• Effects at all stages of pregnancy

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Rubella Vaccination

• Determine rubella immunity prior to conception
• Vaccinate susceptible nonpregnant women
• Congenital rubella syndrome may result from
  infection during pregnancy (microcephaly, fetal
  growth restriction, cardiac malformations, etc)

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Prevention of Neural Tube Defects

• Supplementation for all women of childbearing
  potential with folic acid
• No history of NTD 0.4 mg. qd
• Prior infant with NTD 4.0 mg. qd
• Woman with NTD 4.0 mg. qd
• Nutritional sources often inadequate

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Barriers to Preconception Care

• Patient Aspects
• High rate of unintended pregnancies
• Ignorance about importance of good health habits
  prior to conception
• Limited access to health services in general.

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Barriers To Preconception Care

• Provider Aspects
• Feeling of having inadequate knowledge
• Perception of preconception care being
  time-consuming
• Concern about insurance reimbursement.
• Lack of awareness of how to integrate
  preconception care into ongoing primary care

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Eligible Patients Seen for Preconceptional
Care Physicians (2002) vs. Other Providers (2003)
Mean Seen for Preconceptional
Visit Providers-2003 22 MDs-2002 20
Percentages are net of 108 physicians (2002) and
55 non-physician providers (2003) who do not
provide prenatal care.
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Issues Addressed at Annual Well-Woman Exam
Physicians (2002) vs. Other Providers (2003)
Which issues do you always, usually,
occasionally, or never address at an annual
well-woman exam with a woman of reproductive
age, that is, under age 45? Statistically
significant difference between physicians and
non-physicians in always.
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Reasons Providers Dont Always Recommend Folic
Acid or Multivitamins Physicians (2002) vs.
Other Providers (2003)
Responses were categorized from verbatim
comments. Statistically significant difference
between all physicians vs. all non-physician
respondents.



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Other Barriers To Preconception Care

• Availability of contraceptives
• Health Insurance Coverage
• Out of Pocket Expenses.

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Who Should Get Preconception Care

• 49 of pregnancies in the US are unintended
  (unwanted or mistimed) - Henshaw. 1988.
• Preconception care should be provided to all
  reproductive age individuals

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Preconception Care for Men

• Alcohol
• may be associated with physical and emotional
  abuse
• may decrease fertility
• Genetic Counseling
• Occupational exposure
• lead
• Sexually transmitted diseases
• syphilis, herpes, HIV

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WHO TO PROVIDE

• Health Care Providers
• OB-GYNs, Pediatricians, Family Medicine,
  Internists,
• Nurses, Nurse Practitioners, Nurse-midwives
• Genetic Counselors
• Health Educators

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When Should Preconception Care Be Offered

• As part of routine health maintenance care
• At a defined preconception visit
• For women with chronic illness

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How Preconception Care can be Integrated into
Practice

• As part of any routine medical visits
• Episodic visit for any common complaints
• Negative pregnancy test - an opportunity for
  preconception care
• Family planning encounter
• Infertility evaluation
• Following a poor pregnancy outcome

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Preconception Care

• Primary Prevention
• Essential to March of Dimes Mission to prevent
  birth defects and infant mortality

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March of Dimes Products/Resources

• Consumers
• Pregnancy and Newborn Health Education Center
• marchofdimes.com
• nacersano.org
• e-preconception newsletter (Spanish)
• comenzando bien
• Are You Ready?
• Think Ahead for a Healthy Baby
• Folic Acid brochures
• Pre-Pregnancy Planning Fact Sheet

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March of Dimes Products/Resources

• Providers
• marchofdimes.com
• Preconception Health Promotion A Focus for
  Womens Wellness nursing module
• Upper Hudson Prenatal Services
• Preconception Screening and Counseling Tool
• Chapter grants

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Preconception health promotion is the
cornerstone of healthy infants, children,
families and communities
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