Ask Every Woman: Focusing on Preconception Care

Peter S. Bernstein, MD, MPH

Disclosures

July 21, 2005

"Ask every woman" may become the new mantra of preconception care. Ask every woman of reproductive age whether she intends to become pregnant in the next year. This was one of the suggestions of the participants at the Centers for Disease Control and Prevention's (CDC) National Summit on Preconception Care that was held in Atlanta, Georgia, June 21-23. Present at the meeting were representatives of health provider organizations; businesses; local, state and federal agencies; nonprofit organizations; and others with an interest in improving the access to and the quality of preconception care.

A woman's health before her pregnancy is a significant determinant of the outcome of her pregnancy, not just for her newborn, but also for herself and her family. This was recognized in 1989 by the US Public Health Service Expert Panel on the Content of Prenatal Care when they suggested that the most important prenatal visit may be the preconception visit.[1] Today, this is becoming more and more clear as evidence accumulates regarding the impact on pregnancy outcomes of genetics and environment at the time of conception. We are even beginning to understand how the early intrauterine environment affects an offspring's development of adult diseases (such as obesity, diabetes, and hypertension). And yet many barriers remain in the way of achieving the goal to provide appropriate preconception care to all women.

The barriers that were highlighted at the conference were categorized into those presented by providers, patients, and payors.

Fifty percent of pregnancies in the United States are unplanned[2] and therefore are not amenable to a defined preconception visit with a provider. Add to this the fact that the public does not realize the value of preconception care.

Providers present a barrier when they consider the concept of preconception care only in terms of care sought at a defined visit by a patient who declares her intention to conceive a pregnancy. And yet, preconception care should happen at almost all visits with women of reproductive age. This includes visits with primary care providers and specialists. For example, preconception care should be considered by the neurologist choosing a medication for a woman with epilepsy, by an emergency room physician performing a pregnancy test for a woman being seen for any number of reasons, by a dietician counseling a woman with diabetes about how to improve her glycemic control, and by a social worker caring for a woman who is a victim of domestic violence.

In particular, primary care providers need to understand that most of the care that they provide to fertile women is a part of preconception care -- not something extra that they are being asked to do. They need to reframe some of their thinking and counseling to recognize that the patient they are caring for might be pregnant the next time she presents for care. Seen in this light, counseling a patient about smoking cessation or choosing a medication for the management of hypertension takes on a different significance. (More information about how primary care providers can incorporate preconception care into their practice can be found on the March of Dimes Web site at https://www.marchofdimes.com/professionals/681_4182.asp ). Interested healthcare providers can download an educational curriculum on the topic ( www.marchofdimes.com/professionals/14429_1483.asp ). Payors need to buy into the concept as well. They need to reimburse for preconception care -- and to demand it as a part of their quality improvement initiatives. An investment in preconception care may save them a greater expense later on.

A number of programs were presented at the meeting that focused on improving the quality and delivery of preconception care. These included provider education programs such as the one mentioned above that is available from the March of Dimes Web site. Other interventions include chart inserts[3] and questionnaires to be completed by the patient (also available from the March of Dimes Web site https://www.marchofdimes.com/files/preconception_tool_ed.pdf ) to prompt providers about issues that need to be addressed as a part of preconception care. Other presenters advocated for innovative models of care, such as the sort of group care advocated by the Centering Pregnancy and Parenting Association ( https://www.centeringpregnancy.com ). Models such as this could be adapted to provide interconception care to women with a history of a poor pregnancy outcome.

The Foundation for Blood Research presented a program to improve screening for women at risk of having a child with a birth defect or genetic condition. They recognized that many primary care providers feel intimidated by the explosion of knowledge in genetics, and this organization has developed a patient questionnaire that helps to identify women at risk for these outcomes. The program goes even further by supplying providers with a manual that educates them about each of the conditions screened for in the questionnaire, educational materials for the patient, and details about local resources where providers can refer the patients for additional testing and counseling.

Several other presentations championed the Perinatal Periods of Risk (PPOR) model developed by the CDC to target interventions to improve pregnancy outcomes. This system entails a careful local review of fetal, neonatal, and infant deaths for a community or region. These cases are then categorized on the basis of the contribution of birth weight and type of care that might have affected the outcome (maternal care, newborn care, or infant care). Thus a baby who dies of sudden infant death syndrome (SIDS) suggests a different set of interventions to avert that outcome than the fetal demise of a growth-restricted pregnancy in a woman with diabetes. Once the poor outcomes are classified and compared with data from other referent populations (such as statewide data or data from racial/ethnic groups with better outcomes), excess mortalities can be identified in the different categories and programs developed and instituted to attempt to reduce the rates of these excess deaths. Interventions derived from these systematic assessments were presented by various groups from around the country, including the Florida Department of Health's Infant, Maternal, and Reproductive Health Unit and CityMatCH, a program based at the University of Nebraska Medical Center. The CityMatCH program used its Practice Collaborative model to facilitate the adoption of the PPOR model in 14 urban communities in the United States. In all of these communities, they found that the largest number of excess poor outcomes was in the category of deaths of very-low-birth weight fetuses/infants related to maternal health/prematurity. Thus, interventions in these communities were directed to averting these sorts of deaths. Many of these interventions were related to preconception care.

Given that preconception care has the potential to have such a big impact on health outcomes, clearly more attention needs to be focused on it. Asking every woman about her reproductive intentions at all her healthcare visits would sensitize her to the issue of unintended pregnancy and remind providers about the importance of preconception care -- both for the woman who declares that she does not intend to conceive (and therefore the provider could make sure the woman is using appropriate contraception if she is sexually active) and, clearly, for the patient who desires to become pregnant.

Too often in the United States, pregnancy is viewed as a discrete period of time in a woman's life. Thus, programs are developed to address her health only while she is pregnant as part of an effort to ensure the birth of a healthy baby. This is flawed logic for a number of reasons, and not just from the perspective of the mother. To maximize the health of the newborn, a woman must enter her pregnancy in the best of health. Her health before, during, and after her pregnancy is relevant not only to her well-being, but also to the health of her newborn and her family during the years that follow her pregnancy.

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