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Title: Preconception%20Care:%20%20Why%20Should%20We%20Care?


1
Preconception Health and Health Care
Recommendations and PPOR
July 11, 2006Magda Peck, ScD CEO/Founder,
CityMatCH Co-Chair of Public Health Workgroup,
CDC/ATSDR Workgroup on Preconception
CareAnd,Hani K. Atrash, MD, MPH Associate
Director for Program Development National
Center on Birth Defects and Developmental
Disabilities The CDC/ATSDR Workgroup on
Preconception CareThe CDC Select Panel on
Preconception care
Promoting the health of babies, children, and
adults, and enhancingthe potential for full,
productive living
2
Preconception Health and Health Care and PPOR
(Published) Perinatal Periods of Risk analysis in
New York City, Tulsa, and Kansas City concluded
that racial and ethnic disparities in fetoinfant
mortality were largely related to maternal
health, and, interventions to reduce feto-infant
mortality should include preconception care and
improvements in womens health
  • Besculides M, Laraque F. Racial and ethnic
    disparities in perinatal mortality applying the
    perinatal periods of risk model to identify areas
    for intervention. JAMA 200597112832.
  • Cai J, Hoff GL, Dew PC, Guillory VJ, Manning J.
    Perinatal periods of risk analysis of
    fetal-infant mortality rates in Kansas City,
    Missouri. Matern Child Health J 20059199205.
  • Burns PG. Reducing infant mortality rates using
    the perinatal periods of risk model. Public
    Health Nurs 20052227.

3
Early prenatal care is not enough, and in many
cases it is too late!
4
Time For a Paradigm Shift!
  • Healthy Mothers
  • Healthy Babies

From
5
Time For a Paradigm Shift!
To
  • Healthy Women
  • Healthy Mothers
  • Healthy Babies

6
Improving Preconception Health and Health
careSummary - Bottomline
  • Poor pregnancy outcomes continue to be at an
    un-acceptable level
  • A good proportion of women enter pregnancy
    at-risk for adverse pregnancy outcomes
  • There is evidence that intervening before
    pregnancy will help
  • There is widespread consensus that we must act
    before pregnancy
  • CDC and its partners are working to provide
    guidance on how to make it happen

7
Preconception Care - Goal
To promote the health of women of reproductive
age before conception and thereby improve
pregnancy-related outcomes
8
Definition of PCC
  • A set of interventions that aim to identify and
    modify biomedical, behavioral, and social risks
    to a womans health or pregnancy outcome through
    prevention and management, emphasizing those
    factors which must be acted on before conception
    or early in pregnancy to have maximal impact.
  • CDCs Select Panel on Preconception
    Care, June 2005

9
Why do we need Preconception Care?
10
Adverse Pregnancy Outcomes Continue to be Higher
Than Acceptable
Major birth defects 3.3 of births
Fetal Alcohol Syndrome 0.2-1.5 /1,000 LB
Low Birth Weight 7.9 of births
Preterm Delivery 12.3
Complications of pregnancy 30.7
C-section 27.6
Unintended pregnancies 49
Unintended births 31
11
Improvement in Maternal Mortality Rates Slowed
Down
71 Decrease
13 Decrease
1980-2003 29 Increase
12
Low Birthweight Births Are Increasing
14.7 Increase
Very low birthweigh births increased 25.9
13
Preterm Deliveries Are Increasing
26 Increase
Very preterm births increased 8.2
14
Infant Mortality Rates Improved But Continue to
be Very High
52 Decrease
45 Decrease
15
Infant Mortality Rankings (Ascending)
1960-2002 Selected Countries (Health United
States 2005)
1960 1970 1980 1990 2000 2002
1 Sweden Sweden Sweden Japan Singapore Hong Kong
2 Netherlands Netherlands Japan Finland Hong Kong Sweden
3 Norway Norway Finland Sweden Japan Singapore
4 Czech Rep. Japan Norway Hong Kong Sweden Japan
5 Australia Finland Denmark Singapore Finland Finland
6 Finland Denmark Netherlands Switzerland Norway Spain
7 Switzerland Switzerland Switzerland Canada Spain Norway
8 Denmark New Zealand France Norway Czech Rep. France
9 Eng. Wales Australia Canada Germany Germany Austria
10 New Zealand France Australia Netherlands Italy Czech Republic
11 United States Engl. Wales Ireland France France Germany
12 Scotland Canada Hong Kong Denmark Austria Denmark
13 N. Ireland Israel Singapore N. Ireland Belgium Switzerland
14 Canada Hong Kong Engl. Wales Spain Switzerland Italy
15 France Ireland Scotland Scotland Netherlands N. Ireland
16 Slovakia Scotland Belgium Austria N. Ireland Belgium
17 Ireland United States Spain Engl. Wales Australia Netherlands
18 Japan Czech Rep. Germany Belgium Canada Australia
19 Israel Belgium United States Australia Denmark Portugal
20 Belgium Singapore New Zealand Ireland Israel Ireland
21 Singapore Germany N. Ireland Italy Portugal Engl. Wales
22 Germany N. Ireland Austria New Zealand Engl. Wales Scotland
23 Cuba Slovakia Italy United States Scotland Canada
24 Austria Austria Israel Greece Greece Israel
25 Greece Bulgaria Czech Rep. Israel Ireland Greece
26 Hong Kong Puerto Rico Greece Cuba New Zealand New Zealand
27 Puerto Rico Spain Puerto Rico Czech Republic United States Cuba
28 Spain Greece Cuba Portugal Cuba United States
29 Italy Italy Bulgaria Slovakia Poland Hungary
30 Bulgaria Hungary Costa Rica Puerto Rico Slovakia Poland
31 Hungary Poland Slovakia Bulgaria Hungary Slovakia
32 Poland Cuba Russian Fed. Hungary Puerto Rico Chile
33 Costa Rica Romania Hungary Costa Rica Costa Rica Puerto Rico
34 Romania Portugal Portugal Chile Chile Costa Rica
35 Portugal Costa Rica Poland Russian Fed. Bulgaria Russian Fed.
16
Leading causes of Infant Death Have Changed
Maternal Complications Are Now Third Leading
Cause of Infant Death
17
Risk Factors Are Prevalent Among Pregnant Women
and Women Likely to Become Pregnant
Pregnant or gave birth Smoked during pregnancy 11.0
Pregnant or gave birth Consumed alcohol in pregnancy (55 at risk of pregnancy) 10.1
Pregnant or gave birth Had preexisting medical conditions 4.1
Pregnant or gave birth Rubella seronegative 7.1
Pregnant or gave birth HIV/AIDS 0.2
Pregnant or gave birth Received inadequate prenatal Care 15.9
At risk of getting pregnant Cardiac Disease 3
At risk of getting pregnant Hypertension 3
At risk of getting pregnant Asthma 6
At risk of getting pregnant Dental caries or oral disease (women 20-39) gt80
At risk of getting pregnant Diabetic 9
At risk of getting pregnant On teratogenic drugs 2.6
At risk of getting pregnant Overweight or Obese 50
At risk of getting pregnant Not taking Folic Acid 69.0
18
We Currently Intervene Too Late
Critical Periods of Development

Weeks gestation
4 5 6 7 8 9
10 11 12
from LMP
Most susceptible

Central Nervous System
Central Nervous System
time for major

malformation
Heart
Heart
Arms
Arms
Eyes
Eyes
Legs
Legs
Teeth
Teeth
Palate
Palate
External genitalia
External genitalia
Ear
Ear
Mean Entry into Prenatal Care
Missed Period
19
Components of Preconception Care
  • Screening, health education, effective
    interventions
  • ACOG/AAP
  • Maternal Assessment
  • Vaccinations
  • Screening
  • Counseling

20
Components of Preconception CareMaternal
assessment
  • Domestic abuse and violence
  • Environmental and occupational exposures
  • Immunity and immunization status
  • Risk factors for STDs
  • Obstetric history
  • Gynecologic history
  • General physical exam
  • Assessment of Socioeconomic, educational, and
    cultural context
  • Family planning and pregnancy spacing
  • Family history
  • Genetic history (maternal and paternal)
  • Medical, surgical, pulmonary and neurologic
    history
  • Current medications (prescription and OTC)
  • Substance use, including alcohol, tobacco and
    illicit drugs
  • Nutrition

21
Components of Preconception CareVaccinations
  • Vaccinations should be
  • offered to women found to be
  • at risk for or susceptible to
  • Rubella
  • Varicella
  • Hepatitis B

22
Components of Preconception CareScreening Tests
  • Screening for HIV should be strongly recommended
  • A number of tests can be performed for specific
    indications
  • Screening for STDs
  • Testing to assess proven etiologies of recurrent
    pregnancy loss
  • Testing for specific diseases based on medical or
    reproductive history
  • Mantoux skin test with purified protein
    derivative for Tuberculosis

23
Components of Preconception CareScreening Tests
  • Screening for other genetic disorders based on
    family history CF, Fragile X, mental
    retardation, Duchene muscular dystrophy.
  • Screening for genetic disorders based on
    racial/ethnic background
  • Sickel hemoglobinopathies (African Americans)
  • ?-Thalassemia (Mediterraneans, SE Asia, AA/B)
  • a-Thalassemia (AA/B and Asians)
  • Tay Sachs disease (Ashkhenazi Jews, French
    Canadians, Cajuns)
  • Gauchers, Canavan, and Nieman-Pick Disease
    (Ashkenazi Jews)
  • Cystic Fibrosis (Caucasians and Ashkenazi Jews)

24
Components of Preconception CareCounseling
  • Patients should be counseled regarding the
    benefits of the following activities
  • Exercising
  • Reducing weight before pregnancy, if overweight
  • Increasing weight before pregnancy, if
    underweight
  • Avoiding food additives
  • Preventing HIV infection
  • Determining the time of conception by an accurate
    menstrual history
  • Abstaining from tobacco, alcohol, and illicit
    drug use before and during pregnancy
  • Consuming Folic Acid
  • Maintaining good control of any pre-existing
    medical conditions

25
Some Common Conditions Amenable to Preconception
Care
  • STDs
  • Repetitive pregnancy losses
  • Eating disorders
  • Alcohol, tobacco and other drug use
  • Domestic violence
  • Poor nutrition
  • Diabetes
  • Hypertension
  • Seizure disorder
  • Thyroid disorders
  • Thrombo-embolic disease
  • Hemoglobin disorders

26
Preconception Issues for Well Women
  • Family planning
  • Genetic risks familial, ethnic, racial
  • Nutrition and weight
  • Tobacco, alcohol, OTC medications, illicit drugs
  • Occupational and environmental hazards
  • Domestic violence
  • Infections and immunization
  • Screening for unapparent medical disease

27
Preconception Care
28
Preconception Interventions Give
protection
  • Folic Acid Supplements Reduce the occurrence of
    neural tube defects by two thirds
  • Rubella Sero-negativity Rubella immunization
    provides protective sero-positivity and prevents
    the occurrence of congenital rubella syndrome
  • HIV/AIDS timely antiretroviral treatment can be
    administered, pregnancies can be better planned
  • Hepatitis B Vaccination is recommended for men
    and women who are at risk for acquiring hepatitis
    B virus (HBV) infection.

29
Preconception Interventions Manage
conditions
  • Diabetes 3-fold increase in birth defects among
    infants of women with type 1 and type 2 diabetes,
    without management
  • Hypothyroidism Dosage of Levothyroxine should be
    adjusted in early pregnancy to maintain levels
    needed for neurological development
  • Maternal PKU Low phenylalanine diet before
    conception and throughout pregnancy prevents
    mental retardation in infants born to mothers
    with PKU
  • Obesity Associated adverse outcomes include
    neural tube defects, preterm birth, c-section,
    hypertensive and thromboembolic disease.
  • STDs have been strongly associated with ectopic
    pregnancy, infertility, and chronic pelvic pain.

30
Preconception Interventions Avoid
Teratogens
  • Alcohol use Fetal alcohol syndrome (FAS) and
    other alcohol-related birth defects can be
    prevented.
  • Anti-epileptic drugs Some anti-epileptic drugs
    are known teratogens
  • Accutane use Use of Accutane in pregnancy
    results in miscarriage and birth defects
  • Oral anticoagulants Warfarin is a teratogen
    medications can be switched before the onset of
    pregnancy
  • Smoking Associated adverse outcomes include
    preterm birth, low birth weight.

31
QUESTIONS?????
32
Preconception Care
  • Current Guidelines, Recommendations, Practice,
  • The CDC Initiative and Recommendations

33
Clinical Practice Guidelines Exist
  • Clinical practice guidelines for preconception
    care of specific maternal health conditions have
    been developed by professional organizations
  • American Diabetes Association (Diabetes -2004)
  • American Association of Clinical Endocrinologists
    (Hypothyroidism 1999)
  • American Academy of Neurology (Anti-epileptic
    drugs)
  • American Heart Association/American College of
    Cardiologists (Anti-epileptic drugs - 2003)

34
March of Dimes
  • The key physician/primary care provider and the
    obstetrician/ gynecologist should take advantage
    of every health encounter to provide
    preconception care and risk reduction before and
    between conceptions, the time when health
    encounters can improve health status

35
US Public Health Service
  • HP 2000 Objectives 5.10 and 14.12
  • Increase to at least 60 percent the proportion
    of primary care providers who provide
    age-appropriate preconception care and counseling.

36
USPHS
  • Every woman (and, when possible, her partner)
    contemplating pregnancy within one year should
    consult a prenatal care provider. Because many
    pregnancies are not planned, providers should
  • include preconception counseling,
  • when appropriate, in contacts
  • with women and men of
  • reproductive age.Such care
  • should be integrated into primary
  • care services.
  • USPHS Expert Panel on the
  • Content of Prenatal Care, 1989

37
ACOG/AAP (2002)
  • All health encounters during a womans
    reproductive years, particularly those that are a
    part of preconceptional care should include
    counseling on appropriate medical care and
    behavior to optimize pregnancy outcomes.
  • ACOG/AAP Guidelines for perinatal care, 5th
    edition, 2002

38
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39
  • Where do people stand?

40
Preconception care is not being delivered today!
  • Most providers dont provide it
  • Most insurers dont pay for it
  • Most consumers dont ask for it

41
Percent Eligible Patients Seen for
Preconceptional Care by Type of Provider
(2002-2003)
CNM Certified Nurse Midwives OB/GYN
Obstetricians/ Gynecologists F/GP Family /
General Practitioners
42
The CDC PCC Initiative A Collaborative Effort of
22 CDC programs and over 35 National Organizations
43
Purposes of CDC Initiative
  • Develop national recommendations to improve
    preconception health
  • Improve provider knowledge, attitudes, and
    behaviors
  • Identify opportunities to integrate PCC programs
    and policies into federal, state, local health
    programs
  • Develop tools and promote guidelines for practice
  • Evaluate existing programs for feasibility and
    demonstrated effectiveness

44
The National Summit on Preconception care
The National Summit on Preconception care
                            
45
The Select Panel on Preconception care
46
Recommendations to Improve Preconception Health
and Health Care
47
MCH Journal Supplement on Preconception Care
48
Recommendations Guiding Principals
  • Specific to improving womens
  • health throughout the lifespan
  • Emphasize individual behavior
  • and responsibility
  • PCC is NOT a single visit but a
  • process of care
  • Focus on changes in
  • consumer knowledge
  • clinical practice
  • public health programs
  • health-care financing, and
  • data and research activities

49
A Vision for Improving Preconception Health and
Pregnancy Outcomes
  • All women and men of childbearing age have high
    reproductive awareness
  • All women have a reproductive life plan
  • All pregnancies are intended and planned.
  • All women of childbearing age have health
    coverage.
  • All women of childbearing age are screened prior
    to pregnancy for risks related to outcomes.
  • Women with a prior pregnancy loss have access to
    intensive interconception care aimed at reducing
    their risks.

50
Goals for Improving Preconception Health
  • Goal 1. Improve the knowledge and attitudes and
    behaviors of men and women related to
    preconception health
  • Goal 2. Assure that all women of childbearing age
    in the United States receive preconception care
    services (i.e., evidence-based risk screening,
    health promotion, and interventions) that will
    enable them to enter pregnancy in optimal health
  • Goal 3. Reduce risks indicated by a previous
    adverse pregnancy outcome through interventions
    during the interconception period, which can
    prevent or minimize health problems for a mother
    and her future children, and
  • Goal 4. Reduce the disparities in adverse
    pregnancy outcomes

51
Framework for Developing the Recommendations
Vision Improve health and pregnancy outcomes
Goals Coverage Risk Reduction Empowerment
Disparity Reduction
Recommendations Individual Responsibility -
Service Provision Access Quality Information
Quality Assurance
Action Steps Research Surveillance Clinical
interventions Financing Marketing Education
and training
52
Themes / Areas for Action
  • Social marketing and health promotion for
    consumers
  • Clinical practice
  • Public health and community
  • Public policy and finance
  • Data and research

53
Recommendations for Improving Preconception
Health 12 Individual Responsibility
  • Recommendation 1. Individual responsibility
    across the life span. Encourage each woman and
    every couple to have a reproductive life plan.
  • Recommendation 2. Consumer awareness. Increase
    public awareness of the importance of
    preconception health behaviors and increase
    individuals use of preconception care services
    using information and tools appropriate across
    varying age, literacy, health literacy, and
    cultural/linguistic contexts.

54
Recommendations for Improving Preconception
Health 34 Prevention Interventions
  • Recommendation 3. Preventive visits. As a part of
    primary care visits, provide risk assessment and
    counseling to all women of childbearing age to
    reduce risks related to the outcomes of
    pregnancy.
  • Recommendation 4. Interventions for identified
    risks. Increase the proportion of women who
    receive interventions as follow up to
    preconception risk screening, focusing on high
    priority interventions.

55
Recommendations for Improving Preconception
Health 56 Interconception Pre-pregnancy
  • Recommendation 5. Interconception care. Use the
    interconception period to provide intensive
    interventions to women who have had a prior
    pregnancy ending in adverse outcome (e.g., infant
    death, low birthweight or preterm birth).
  • Recommendation 6. Pre-pregnancy check ups. Offer,
    as a component of maternity care, one
    pre-pregnancy visit for couples planning
    pregnancy.

56
Recommendations for Improving Preconception
Health 78 Public Programs
  • Recommendation 7. Health coverage for low-income
    women. Increase Medicaid coverage among
    low-income women to improve access to preventive
    womens health, preconception, and
    interconception care.
  • Recommendation 8. Public health programs and
    strategies. Infuse and integrate components of
    preconception health into existing local public
    health and related programs, including emphasis
    on those with prior adverse outcomes.

57
Recommendations for Improving Preconception
Health 910 Research and Evaluation
  • Recommendation 9. Research. Augment research
    knowledge related to preconception health.
  • Recommendation 10. Monitoring improvements.
    Maximize public health surveillance and related
    research mechanisms to monitor preconception
    health.

58
Diffusion of Innovation Theory
Innovators
Change Agents
Evidence
Guidelines for best practice
Opinion leaders
Early adopters
Change in dominant practice Early and late
majority
Later - laggards
59
Steering Committee Meeting White Plains, NY -
January 12-13 Priority Action Steps
  • Convening working groups to
  • Define contents of preconception care (3 and 4)
  • Integrate existing clinical guidelines (3, 4, 5b,
    and 6b)
  • Information dissemination
  • Develop key messages (1, 3, and 4)
  • Create an information portals on the web (1)
  • Catalogue existing materials (2c)
  • Demonstrate the effectiveness
  • Evaluate existing models (5b and 8c)
  • Conduct demonstration projects (3a, 4a, 5b, 5d,
    5e, 8a, 8d, 9c, and 9e)
  • Explore means for financing
  • Explore options for augmenting Medicaid waivers
    (7a)
  • Conduct health plan demonstration projects (3h,
    4f, and 6a)
  • Augment CDC and other surveillance to monitor
    practice (10b, 10d, and 10f)
  • Analyze existing data to further study
    association between womens
  • health and pregnancy outcomes (10)
  • Complete a systematic review and a cost study
    (9a, 9c, and 9d)

60
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