Preparing Your Patients for Motherhood -- An Update on Preconception Care

An Expert Interview With Peter S. Bernstein, MD, MPH

Katharine M. Hikel, MD

Disclosures

July 08, 2010

Editor's Note:

As an early advocate of the preconception care model in women’s health, Peter S. Bernstein, MD, MPH, has been a longstanding advocate for healthy pregnancy, notably at the Montefiore Medical Center, where he has led efforts in women-centered, community-based care, such as its Centering Pregnancy Program, and the Group Prenatal Care service. Dr. Bernstein also worked with the Centers for Disease Control and Prevention's (CDC) Select Panel on Preconception Care to develop the National Preconception Curriculum and Resources Guide for Clinicians, available at the Before, Between, & Beyond Pregnancy website.

Dr. Bernstein is Professor of Clinical Obstetrics & Gynecology and Women's Health, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, and Director of the Maternal-Fetal Medicine Fellowship Program at the Albert Einstein College of Medicine in Bronx, New York.

Dr. Bernstein -- also a public health specialist -- spoke with Medscape about the importance of preconception care for women, and for society at large.

Medscape: In 2005, you wrote, “’Ask every woman’ should become the mantra of preconception care” -- that is, every woman of reproductive age should be asked whether she intends to become pregnant in the next year.[1] You described the need for a kind of consciousness-raising effort, among both women and healthcare providers, about the importance of preconception health -- in a sense, a revival of humankind’s oldest traditions of respecting every woman as a potential mother. In the 5 years since then, do you think awareness of the importance of preconception health has grown?

Dr. Bernstein: People have been thinking about preconception care since the 1990s, when Merry-K Moos, MPH, RN, FNP, FAAN,[2]and the late Dr. Robert Cefalo published the pioneering "Preconceptional Health Promotion -- A Practical Guide,"[3] which laid much of the groundwork for today's work on preconception care, including the CDC's recommendations.[4] And in 2004, Sharon Rising, MSN, CNM, FACNM,[5] founder of the Centering Healthcare Institute,[6] a patient-centered foundation working to improve healthcare delivery across the United States, described the Centering Pregnancy model, now used at Montefiore and many other US hospitals and clinics.

Since 2005, I think we have made progress in some areas; in others, we've gone backwards. I don't think the public has greatly improved its knowledge of the need for preconception care; that knowledge has increased in the professional communities because of the work of the March of Dimes, and of the CDC's Select Panel on Preconception Care. Healthcare reform has made some strides in the area of preconception care, but the only empirical evidence of which I know comes from the March of Dimes. One of the markers we use for the awareness of preconception care is how many women are aware of the importance of folate supplementation prior to conception, and that every woman who could conceive a pregnancy should be taking a multivitamin that includes folate. The March of Dimes did a big campaign on that in the early 2000s. That's no longer one of their top campaigns. They have been tracking what's been happening about the awareness of the importance of folic acid, and it has been slipping because the message is not being continually promoted.

Medscape: Can you briefly give any specific recommendations for healthy adult women who are planning to become pregnant within the year?

Dr. Bernstein: Fifty percent of pregnancies in the United States are unplanned, which is a shocking number. I don't know the most recent data from Europe, but in Western Europe, that rate has been only about 20%. There is no reason that we can't get to the same level. So the first thing that women should do is plan when they are going to have their pregnancies.

That means promoting the use of effective family planning. That would give healthcare providers the opportunity to maximize a woman's health before she conceives.

Specific recommendations about what to do before becoming pregnant depend on the woman's personal history. Psychosocial things are important, such as considering the impact a child will have on your life. All women who could become pregnant should be taking multivitamins that include folic acid. All women should have routine checkups to address any health issues -- for example, whether they need to be screened for diabetes; and if they are diabetic, to optimize their glycemic control. If women are on medications, we should make sure that they're on medications that are safe during pregnancy. If you're going to prevent a birth defect, you can't wait until after a woman conceives to remove harmful medications from her regimen.

The worst thing a woman can do is conceive, become alarmed about taking a possibly harmful medication, and stop it abruptly, because that may create more problems. So preconception planning should be specific to her regimen, to her own personal history, and to her last pregnancy -- was it a preterm birth? Was there a miscarriage? -- any information that gives the provider the opportunity to give the woman the stamp of approval that everything has been done that could have been done to maximize the chances of a healthy outcome, for the child, the woman, and her family.

Medscape: The average age of puberty is just over 12 years.[3] About 10% of births (more than 400,000) in the United States per year are to teenage mothers.[7] Is preventing too-early conception part of preconception care? Is there an educational (eg, middle-school) component to all of this?

Dr. Bernstein: Part of preconception care is family planning. We could reduce the number of poor pregnancy outcomes in the United States dramatically -- shockingly, we could halve them -- if we focused on preventing unplanned pregnancy.

Half of all pregnancies are unintended; of those, half are terminated, and half are carried to term. That means that about a third of deliveries in the US are unplanned pregnancies. If you simply eliminated that third, you would eliminate one-third of all the poor pregnancy outcomes that we see.

Poor pregnancy outcomes are concentrated among unplanned pregnancies. For example, women who are using alcohol have a higher risk for unplanned pregnancies, and a higher risk for poor pregnancy outcome. Women who smoke and have unplanned pregnancies have a higher risk for poor pregnancy outcome. Women who have medical conditions -- whose healthcare providers haven't had a chance to optimize their care before these women conceive -- and have unplanned pregnancies have a higher risk for poor pregnancy outcomes.

As a public health intervention, by focusing on preventing unplanned pregnancies, we could do a tremendous amount of good for very little money -- compared with caring for a child with a birth defect, or caring for a mother whose condition has worsened as a result of pregnancy.

Medscape: Can you review the risks of too-early conception, and describe the best ways of engaging young women in their earliest reproductive years -- especially when "sex education" is such a charged topic?

Dr. Bernstein: Part of the problem is that as a society, we're afraid to address this topic head-on. Teenagers are having sex, no matter what we do; we can encourage them to abstain, but we also have to know how we're going to take care of them if they don't abstain.

I can tell you specifically about the risks. Adolescents and young women under 20 years of age who conceive have a higher risk for preterm birth and a low birth-weight infant. The younger they are -- under the age of 20 years -- the higher the risk for preterm birth and low birthweight; these women are also at higher risk for being in abusive relationships and for getting inadequate or insufficient care during pregnancy. They also have higher risks for problems such as pre-eclampsia compared with women in the 20- to 30-year age range.

The other side to this is that women over 35 or 40 years have additional risks: having children with aneuploidy, or wrong numbers of chromosomes; they are at higher risk for having conditions such as diabetes and hypertension, which places them at higher risk for poor pregnancy outcomes. Preconception care is not just about preventing pregnancy, but also choosing the optimal time to have a pregnancy. Part of the calculation that a woman should go through is figuring out when is the best time in her life to have a pregnancy -- knowing that she generally has to balance family, career, and responsibilities and that postponing pregnancy for too long increases the risk for poor outcomes. Part of the counseling that goes along with preconception care is about family planning -- when to have a pregnancy, and when not to have a pregnancy.

So the message of mindfulness around planning for pregnancy should include not only women but also providers -- what they know about preconception care. A lot of people think, "Well, that's the Ob/Gyn's job, or the family physician's job, or the midwife's job;" but it's actually not just the maternity care provider's job, and I can throw out a few examples. Emergency department [ED] physicians often take care of women who come into the ED having miscarriages; that's an opportunity for preconception care: someone who is sexually active, not on adequate birth control, and who has lost a pregnancy. I'm not suggesting that they should do a whole workup for why the patient lost the pregnancy, but to discuss family planning options with them on their way out the door, refer them to someone who could offer family planning if they don't desire a pregnancy; and if they do desire a pregnancy, then refer them to someone who can address any risk for a recurrent miscarriage.

Almost every healthcare provider who takes care of a woman of reproductive age has something to contribute to preconception care. A rheumatologist taking care of a woman with lupus should tell her that her best chance for a healthy pregnancy outcome is when the lupus has been in remission for at least 6 months prior to the pregnancy. For a woman considering a conception, the clinician should prescribe medications that are the least teratogenic, because the next time she is seen, she may be pregnant. If you wait for her to say, "I'm planning on getting pregnant," you're going to miss 50% of the pregnancies, given the statistics in this country.

We want healthcare providers to reframe how they're thinking about the future with their patients. A provider must think, "The next time I see you, you could be pregnant”; or, if the woman doesn't want to be pregnant, and the specialist is not comfortable prescribing family planning methods, he or she can make the appropriate referral, so that the woman doesn't have an unintended pregnancy.

Another example is bariatric surgery patients. Women who are morbidly obese are often anovulatory, so they think that they're infertile; but, after having bariatric surgery, and losing a significant amount of weight, they may start ovulating again. We were seeing many women with unintended pregnancies while they were in the weight-loss stage after their bariatric surgery. No one had told them that they ran the risk of conceiving a pregnancy after the surgery, or asked if they were using an appropriate contraceptive.

Medscape: According to a report from the Guttmacher Institute, over the last half of the 1990s, the abortion rate declined, whereas the unintended birth rate increased.[8] Has that picture changed more recently? Do you consider abortion or termination-of-pregnancy counseling part of preconception care?

Dr. Bernstein: Strictly speaking, preconception care happens before the pregnancy. If you are counseling a woman who is pregnant, it's too late. That said, if you are counseling a woman who is undergoing an abortion -- maybe it's because the baby has severe birth defects or something similar -- it is incumbent upon us to talk about preconception care for the next pregnancy. I find it very useful to talk with a woman in that setting, when she's losing a desired pregnancy because of a severe problem. If she should desire to become pregnant again, I talk about what could be done to avoid this poor outcome; and during that mourning period, to try to find some hope for the future.

Medscape: According to the Department of Labor, women comprised about 46% of the labor force in 2008.[9] The concept of preconception care for all women could revolutionize the workplace: limiting exposures to toxins, for example, and assuring that every woman's working environment is optimal for her health and for a potential pregnancy. However, in the United States, we provide very little support for working women who have already given birth: variable (mostly unpaid) parental leave[10]; few provisions for child care[11]; and the marginalization of breast-feeding, so that few women are exclusively breast-feeding 6 months postpartum.[12] Still, more than 70% of mothers are also working women. In this challenging milieu, are you making inroads in your efforts to raise awareness of the importance of preconception health among employers?

Dr. Bernstein: The CDC Select Committee on Preconception Care is divided into different areas; people from public health, focusing on city and state departments of health; another group focused on the insurance industry; a different group focused on consumers. The group I was part of focused on clinicians and developing guidelines for clinical care. So workplace issues are not my area, though I have some thoughts on this problem.

First of all, there's a little bit of a slippery slope here; a case that was argued before the Supreme Court involved a midwestern company where the workers were potentially exposed to lead. It was a discrimination case because the company wouldn't hire women for certain jobs unless they had documentation that they were sterile. The company was sued; the plaintiffs said that although the company should educate workers about potential risks of working around toxins, it was unconstitutional to discriminate in hiring; the decision should remain with the workers.

An important part of preconception care is insurance reform, or healthcare reform. Many states now expand their Medicaid eligibility once a woman conceives a pregnancy. For example, in New York State, women are eligible for Medicaid when they are at 125% of the poverty level; if they conceive a pregnancy, they are eligible at up to 200% of the poverty level. That means that a large chunk of women only have access to health insurance after they've conceived a pregnancy, so they have no opportunity for preconception care, because they have no access to healthcare until they conceive.

The US Public Health Service issued its guidelines for prenatal care in 1989, which said that the most important visit may be the one that happens before a pregnancy. To improve pregnancy outcomes, women must have access to that visit.

Medscape: In restoring our awareness of every fertile woman as a potential mother, you’ve written about the work of the Foundation for Blood Research in screening women with higher risks for having babies with birth defects or genetic problems.[1] Can you give us examples of some specific problems that providers might screen for, in anticipation of future pregnancy?

Dr. Bernstein: Once a woman conceives, healthcare providers do a lot of screening during prenatal care: we screen for sickle cell anemia and cystic fibrosis; we take a family genetic medical history, with the father and the mother, at the first prenatal visit. All of that really should be done prior to conception, because once the pregnancy is conceived, the horse is out of the barn.

These screenings should be done before a woman is pregnant, so that she will know what her risk is of having a child with a genetic condition. We create such anxiety during pregnancy; for example, we'll screen a woman for cystic fibrosis and she will come back positive -- she has the gene; now all of a sudden she's worried that the baby has the problem. A couple of weeks of high anxiety occur while we send out the screening tests on the father of the baby, only to learn that he doesn't have the gene. She could have been armed with that knowledge before she even conceived the pregnancy. Or, had she known that they both carried the gene, she could have had a prenatal diagnosis of the condition; and if the child had it, she would have been able to plan what to do next.

The ultra-Orthodox Jewish community does this very well; in arranged marriages, the matchmakers have access to the genetic information of the clients, and have dropped dramatically the incidence of Tay-Sachs disease, by making sure not to match people who are both carriers of the gene.

There are other examples: we immunize everyone against rubella, as part of routine childhood vaccinations. It's truly a preconception intervention because having German measles during pregnancy increases the risk for birth defects. Now, one of the routine things we do during prenatal care is making sure the woman is immune to rubella. If she's not -- because the vaccine didn't take, or the immunity has worn off -- we can't vaccinate during pregnancy, because the vaccine is a live-virus vaccine. We have to wait until she's no longer pregnant, then vaccinate. Checking immunities before pregnancy, and vaccinating for rubella, varicella, and any of the other conditions that require live-virus vaccines before women ever become pregnant, is another model of preconception care that we should be following.

Medscape: It appears that 2 huge areas make up "preconception" care -- preventing unintended and too-young pregnancies; and preparing the best environment for pregnancies that are to be continued. Primary care providers are having a hard time in general convincing patients to change unhealthy behaviors -- quitting smoking, losing weight, etc. Have you found that consciousness-raising around preconception care is helpful in these efforts? Does thinking about the possible future health status of a child enhance people’s motivation to adopt healthier behaviors?

Dr. Bernstein: One of the 2 huge areas is preventing unintended pregnancies, because if you are not going to be able to maximize your health to improve your chances for a good pregnancy outcome for yourself and your newborn, at least don't get pregnant by mistake.

That said -- and I don't know if research is out there to back me up -- we have a large number of women who say, "I could never quit smoking." But then they conceive a pregnancy. And at the first prenatal visit, they have quit cold turkey for the rest of the pregnancy -- at least that's what they tell me. Pregnancy is a tremendous motivator for behavior change. I don't know whether data [are] out there to show that it has that impact in the preconception period, but it's surely another tool in your armamentarium to use while caring for a patient and convincing her to stop smoking, to cut back on drinking, or to lose weight. The prospect of a pregnancy may be a very strong motivator to bring about those healthy behavior changes.

Medscape: Would preconception counseling help women with chronic conditions, such as diabetes, epilepsy, or hypertension, comply with their treatments?

Dr. Bernstein: I think it does. Each condition has its unique set of issues. In diabetes, the big issue is that poor control of blood sugar is a risk factor for having a child with birth defects. When women who are not compliant or not in optimal control come in for a preconception visit, we say, "You know, it's really not safe for you to get pregnant now; your hemoglobin A1c is high, which gives you a higher chance of having a baby with a birth defect." If they highly desire a pregnancy, they may quickly become compliant with the recommendations.

The recommendations around epilepsy are not to stop your medications when you become pregnant. It's best to get these patients to a neurologist to evaluate their regimen, and make sure it's the simplest regimen that is the most effective at controlling their seizures and that is the least teratogenic.

With hypertension, the recommendation may be losing weight, which is notoriously difficult to do. I don't know in that instance if preconception counseling will be a strong enough motivator to help a woman succeed. I would certainly say that with diabetes, quite a few women become much more compliant in anticipation of a pregnancy.

Medscape: Can you talk about any evidence on outcomes among practitioners who've incorporated preconception care thinking into their practices?

Dr. Bernstein: Not a great deal of evidence is out there; we're still too new into this. I think healthcare providers have a concern that we're adding something else to do as part of patient visits, when they're feeling the pressure to see more and more patients, in less and less time. One of our messages is that we're not trying to give providers and patients something else to do; not a lot in the recommendations is different from what they're already doing. We're asking them to reframe what they're doing. For example, in choosing a medication for a woman with hypertension, you might ask whether she's using birth control, and prescribe a medication that is not teratogenic, if that is appropriate. For a woman with diabetes, in trying to get her glucose under control, you might mention the possibility of conceiving a child with a birth defect, and that might motivate her to do a better job of keeping her glucose in control. You are already encouraging her to lose weight; being obese brings a higher risk for poor pregnancy outcome, cesarean delivery, and birth defects; maybe this little bit of added information will be a motivator for change.

A lot of preconception care is just good care; we're asking providers to reframe their counseling, their medication choices, and their treatment choices, because in the backs of their minds, they're aware that a woman could be pregnant the next time she comes in. Or she may be considering a pregnancy, but hasn't mentioned it. Or she doesn't want a pregnancy, and needs contraception.

I view preconception care as empowering women, to give them control over their pregnancy outcomes: not becoming pregnant if they don't want a pregnancy; if they want a pregnancy, having the best outcomes for their own health, for the health of their children, and for the health of their families. Preconception care means fostering improved outcomes for everybody.

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