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Impact of obesity on women's health: Diabetes. Hypertension


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Title: Impact of obesity on women's health: Diabetes. Hypertension

Preconception Care
  • Before
  • Between
  • After Pregnancy

  • Our thanks for parts of this
  • presentation are to
  • Albert Einstein College of Medicine
  • Centers for Disease Control and Prevention (CDC)
  • March of Dimes (MOD)

What is Preconception Care?
  • Education, counseling, and services provided to
    women before and between pregnancies that address
    risk factors that could cause poor infant and
    maternal outcomes in first and subsequent
  • In addition, these services also support the
    woman in obtaining and maintaining lifelong
    health for herself and her family.

Related Vocabulary
  • Preconception
  • Health status and risks before first pregnancy
    and in fact the health status before any
  • Periconception
  • Immediately before conception through
  • Interconception
  • Period between pregnancies.

Why is Preconception Care Important?
  • Approximately 50 of all pregnancies among adult
    women and 95 of pregnancies among teens are

Critical Periods of Development
Weeks gestation

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

Central Nervous System
time for major

External genitalia
Mean Entry into Prenatal Care
Missed Period
  • The U.S. infant mortality rate is higher than
    many other countries.
  • Although higher percentages of women receive
    early prenatal care than ever before, preterm
    birth and low birth weight rates are increasing.
  • Declines in infant mortality have stalled.

RATES 2004
Preterm Birth in the U.S.
  • In 2004, 1 in 8 babies (12.5 of live births)
    were born preterm in the United States. Preterm
    birth affected approximately 513,875 infants that
  • In 2000, The Healthy People 2010 goal for preterm
    births was set. The goal is to reduce the rate
    of preterm births to no more than 7.6 of all
    live births by 2010.
  • Movement is in the wrong direction! 

Preterm Birth
U.S. 1994-2004
Preterm is less than 37 completed weeks
gestation. Source National Center for Health
Statistics, final natality data. Retrieved July
30, 2007, from
Low Birth Weight in the U.S.
  • In 2004, 1 in 12 babies (8.1 ) were born
    weighing less than 2500 gms. Low birth weight
    affected approximately 332,991 infants.
  • In 2000, the Healthy People 2010 goal for low
    birth weight was set. The goal is to reduce the
    rate of low birth weight to 5.0 of live births
    by the end of this decade.
  • Between 1994 and 2004, the rate of infants born
    with low birth weight in the United States
    increased 11.

Low Birth Weight
U.S. 1994-2004
Low birth weight is less than 2500 grams (5 1/2
pounds). Source National Center for Health
Statistics, final natality data. Retrieved July
30, 2007, from
Infant mortality rates in the U.S.
  • In 2004, the infant mortality rate was 6.8
    deaths per 1,000 live births. Approximately
    27,860 babies born that year died before their
    first birthday.
  • Between 1994 and 2004, the infant mortality rate
    in the United States declined 15.

Infant Mortality Rates
U.S. 1994-2004
Deaths to infants less than one year of age.
Source National Center for Health Statistics,
final mortality data, 1990-1994 and period linked
birth/infant death data, 1995-present. Retrieved
April 22, 2008, from
Florida Infant Mortality
  • Floridas infant mortality has remained
    essentially the same for the past 10 years.

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Florida Low Birth Weight
  • At the same time, Floridas premature and low
    birth weight rates have risen.

Single-Year Percentage of Live Births
Under 2500 Grams to All Mothers
Preconception Care is Important
  • Recent data, from many different sources,
    indicate that an important time to intervene for
    positive birth outcomes is BEFORE a woman becomes

Preconception Care is Important
  • The relationship between maternal health and
    birth outcomes has been established by
  • Pregnancy-Associated Mortality Review (PAMR)
  • Perinatal Periods of Risk (PPOR)
  • Fetal and Infant Mortality Reviews (FIMR)
  • March of Dimes (MOD)
  • American College of Obstetricians and
    Gynecologists (ACOG)

Floridas Pregnancy-Associated Mortality Review
  • A review of cases where death of a
  • woman has occurred, from any cause,
  • while she is pregnant or within one
  • year of termination of pregnancy,
  • regardless of duration and site of the
  • pregnancy.
  • CDC and ACOG definition of maternal mortality

Risk Factors
  • Women most at risk for pregnancy-related death
  • Age 35 and older (RR3.65)
  • Black non-Hispanic (RR3.32)
  • High school education or less (RR1.72,1.50,
  • Received no prenatal care (RR9.95)
  • Cesarean Delivery (RR5.09)
  • Overweight (OR 2.13)
  • Obese Categories 1,2,or 3 (OR3.5, 3.5, 8.0)

PAMR 1999-2005
  • The majority (68) of women with
    pregnancy-related deaths fell into the overweight
    and obese category.
  • Hypertensive disorders 15.

Leading Causes of Death
PAMR 1999-2005
  • Most at-risk
  • Black non-Hispanic
  • Age 35 and older
  • High School education or less
  • Received no prenatal care
  • Cesarean Delivery
  • Overweight
  • Obese

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Perinatal Periods of Risk
  • The Perinatal Periods of Risk Approach
  • was developed by Dr. Brian McCarthy
  • from the World Health Organization
  • (WHO), Perinatal Collaborative Center
  • at CDC, and other WHO colleagues.
  • For over a decade, this approach has been
  • used to monitor and investigate feto-infant
  • mortality problems in developing countries.

Florida PPOR MAP 1998-2000 Birth
Cohort 596,585 Fetal Deaths and Live Births
5734 Fetal-Infant Deaths
Infant Health 1021
9.6 Fetal-Infant Death Rate
All Death Rates Per 1,000 Births and Fetal Deaths
Florida Reference Group
5.8 Fetal-Infant Death Rate
  • Race White
  • Education 13
  • Age 20-50
  • 212,755 Fetal Deaths and Live Births

1229 Fetal-Infant Deaths
Infant Health 166
All Death Rates Per 1,000 Births and Fetal Deaths
Florida Non-Reference Group
11.7 Fetal-Infant Death Rate
Race Non-White OR Education lt13 OR Age lt20 or
gt50 383,830 Fetal Deaths and Live Births
4505 Fetal-Infant Deaths
Infant Health 855
All Death Rates Per 1,000 Births and Fetal Deaths
CDC Definition of Preconception Care
  • Preconception care is 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
  • It is more than a single visit and less than all
    well-woman care.

CDC and Select Panel, 2006
CDC Preconception Care Framework
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
What can we do??
  • Provide
  • Preconception Screening
  • Education
  • Counseling
  • Services to address the identified risks in

Preconception Screening
  • Every woman coming into a health care setting
    should be screened for possible health needs.

Preconception Care Topics for Consideration
  • Preconception care includes addressing the
  • following topic areas
  • Access to health care
  • Nutrition (including folic acid education)
  • Physical activity
  • Maternal infections (including periodontal
  • Chronic health conditions
  • Substance abuse
  • Smoking
  • Mental health
  • Baby spacing
  • Environmental risk factors
  • And any other risks identified on the
    Preconception Screen

Access to Health Care
  • Regular health care is critical to the overall
    health of the woman. Key components of regular
    care should include
  • Pap smear
  • Breast exam (with teaching on techniques of
    self-breast exam)
  • Review of family health history
  • Weight, height, blood pressure
  • Lab testing for diabetes or thyroid conditions,
    if needed
  • Management of chronic health conditions
  • Dental services

  • Healthy Eating
  • Avoid thinking of foods as good or bad
  • Avoid skipping meals
  • Focus on eating healthy for life - not dieting
  • Eat a variety of foods as represented in the
  • Food Pyramid
  • Pay attention to serving sizes
  • Barriers to Healthy Eating
  • Access to healthy food sources (location,
  • Cultural beliefs

  • Impact of obesity on womens health
  • Diabetes
  • Hypertension
  • Cardiovascular disease
  • Disabilities
  • Impact of maternal obesity on reproductive
  • Glucose intolerance of pregnancy
  • Pregnancy-induced hypertension
  • Thrombophlebitis
  • Infertility
  • Neural tube defects (NTD)
  • Prematurity

  • Impact of being underweight on womens health
  • Risk of osteoporosis in later life
  • Fragile health status
  • Impact of low pregravid weight on reproductive
  • Infertility
  • Low birth weight
  • Prematurity

NUTRITIONAL STATUS Specific nutrients
  • Impact of low folate levels and womens health
  • Increased heart disease evidence accumulating
    about increases in
  • Colon cancer
  • Breast cancer
  • Some forms of dementia
  • Impact of inadequate maternal folate levels on
    reproductive outcomes
  • Increased incidence of neural tube defects (NTD)
  • Increased incidence of other birth defects
  • Some anemias mother and infant

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Nutrition Folic Acid
  • Ideal levels of folic acid can prevent
  • Up to 70 of neural tube defects
  • Fifty percent of cleft lip and palate defects
  • Forty to fifty percent of congenital heart
  • It has also been demonstrated that folic acid may
    prevent pre-eclampsia and other
    pregnancy-related complications.

Nutrition Folic Acid
  • Hispanic women, particularly those of Mexican
    origin, appear to have greater risk of neural
    tube defects.
  • Florida birth defects registry indicates
    Mexican-Hispanic women have a relative risk nine
    times higher than non-Hispanic women born in the

Nutrition Folic Acid
  • Folic acid requirements
  • All women of childbearing age, regardless of
    their intentions to become pregnant, should take
    at least 400 micrograms (0.4 milligrams) of folic
    acid daily.
  • Past history of a baby with a NTD may require a
    higher, therapeutic dose of folic acid (4.0
    milligrams), available through prescription only.
  • Folic acid requirement increases during pregnancy.

Physical Activity
  • Benefits of exercise include
  • Lower stress, depression, and anxiety
  • Feel better about yourself
  • Sleep better
  • Better concentration
  • Decrease your chance of developing a chronic
  • Improve your blood pressure and decrease your
  • Maintain a healthy weight

Maternal Infections
  • Maternal infections have been consistently linked
    to poor birth outcomes.
  • All sexually active women of childbearing age
    should be counseled on the risks of infection to
    their own health and their future pregnancies.
  • All women should be offered screening, testing,
    and treatment for sexually-transmitted diseases
    (STDs) including syphilis, gonorrhea, HIV,
    genital herpes, Chlamydia, and HPV.
  • Conditions such as bacterial vaginosis should be
    screened for and treated, if necessary.
  • Douching should be discouraged.
  • Women should be up-to-date with immunizations,
    especially rubella, hepatitis B, and varicella,
    prior to becoming pregnant.
  • Women should receive information on the
    recognition and risks of untreated urinary tract
    infections, bacterial vaginosis, and STDs.

Maternal Infections - Periodontal Disease
  • Periodontal disease - A disease of the gingiva,
    gums, and supporting structures of the teeth.
  • May lead to prematurity and/or low birth weight.
  • Affects between 5-40 of women of childbearing
  • Increases the risk of heart attack and stroke.
  • Exacerbates diabetes.
  • Contributes to lung disorders such as pneumonia
    and emphysema.

Chronic Health Conditions
  • Management of chronic health conditions prior to
    pregnancy helps reduce risks to mother and baby.
    These conditions include, but are not limited to
  • High blood pressure
  • Systemic Lupus Erythematosus (SLE)
  • Kidney disease
  • Diabetes
  • Asthma
  • Endocrine conditions such as thyroid disease
  • Depression

Chronic Health Conditions
  • High Blood Pressure - Chronic high blood pressure
    can increase the risk of pregnancy complications,
    including placental problems and fetal growth
  • Systemic Lupus Erythematosus (SLE) can increase
    the risk of miscarriage or preterm labor. If
    symptoms have been inactive for at least six
    months, an affected woman is likely to have a
    healthy pregnancy. Preconception care helps plan
    the safest timing of pregnancy.

Chronic Health Conditions
  • Kidney Disease - Women who have chronic kidney
    disease should consult their doctors prior to
    pregnancy to see if pregnancy is safe for them
    and their baby.
  • Diabetes - Women with poorly controlled
    insulin-dependent diabetes are several times more
    likely than non-diabetic women to have a baby
    with a serious birth defect. They are also at
    increased risk of miscarriage and stillbirth.

Chronic Health Conditions
  • Asthma Poorly controlled asthma can increase a
    womans likelihood for complications in
    pregnancy, including compromising the oxygen
    supply to the developing fetus.
  • Endocrine Conditions Thyroid conditions, if
    untreated, such as hypothyroidism and
    hyperthyroidism can affect a womans fertility,
    can increase her likelihood for miscarriage and
    other complications, including mental retardation
    in the unborn infant.

Chronic Health Conditions
  • Depression Women with a history of depression
    are more likely to experience depression in
    pregnancy and in the postpartum period.
    Additionally, women receiving treatment for
    depression through medication may need to consult
    with their doctor on a medication that is safe
    for pregnancy or while breastfeeding.

Substance Use
  • There is no known amount of drugs or alcohol that
    is safe in pregnancy. Both drugs and alcohol
    cross the placental barrier to the developing
    fetus in utero.
  • Illegal drugs and alcohol can cause fetal loss,
    birth defects, fetal alcohol syndrome, low birth
    weight, and intrauterine growth restriction. Many
    pregnancies are unplanned.
  • Women need support and linkages to substance
    abuse treatment for their health today and for
    the health of any children in the future.

  • Impact of alcohol abuse on womens health
  • Risk for motor vehicle and other accidents
  • Risk for unintended pregnancy
  • Risk for addiction
  • Risk for nutritional depletions and inadequacies
  • Impact of alcohol use on reproductive outcomes
  • Delayed fertility
  • Increased spontaneous abortions (SABs)
  • Fetal alcohol spectrum disorders (full fetal
    alcohol syndrome can only occur with fetal
    exposure between days 17-56 of gestation)

  • Impact of tobacco use on womens health
  • Implicated in most of the leading causes of death
    for women
  • Heart disease (1 cause of death)
  • Stroke (2)
  • Lung cancer (3)
  • Lung disease (4)
  • Impact of tobacco use on reproductive outcomes
  • Leading preventable cause of infant mortality.
  • Preventable cause of low birth weight and
  • Associated with placental abnormalities including
    placenta previa and placenta abruptio.

  • In 2006, the percent of births under 2500 grams,
    low birth weight (LBW), for mothers who reported
    smoking on the Florida birth certificate was
  • Mothers who reported not smoking had a LBW infant
    rate of 8.3.

Mental Health
  • Stress, anxiety, depression, and abuse can have
    serious effects on a womans health and the
    health of her children.

Mental Health
  • All women need to be screened for domestic
    violence and depression.
  • Twenty percent of women will experience
    depression at least once during their lifetime.
  • One in four women are the victim of abuse.
  • About three women die in the U.S. from domestic
    violence every day.

Mental Health - Stress
  • Studies have proven that high levels of stress
    can cause
  • Fatigue
  • Lowered resistance to infectious disease
  • Poor nutrition (no appetite or overeating)
  • Headaches Backaches
  • High blood pressure
  • Heart disease
  • Substance abuse

Mental Health - Stress
  • Studies indicate that chronic psychosocial,
    prenatal maternal stress, as opposed to acute or
    episodic stress, has a negative impact on
    pregnancy outcomes and fetal development.
  • Both increased anxiety and decreased social
    support are associated with poorer pregnancy

Environmental Risk Factors
  • Women may be exposed to harmful substances at
    work, at home, or outside, without even knowing
  • Awareness and education of possible environmental
    toxins may reduce exposures and possible poor
    birth outcomes.

Environmental Risk Factors
  • Lead
  • Found in paint, dust, soil, pottery, glass,
    cooking utensils, and other places, can damage
    the brain and nervous system causing behavior,
    learning, hearing problems, headaches, and
    delayed growth.
  • Some herbal remedies such as Azarcon and Greta
    may contain high levels of lead.
  • Previous maternal exposure to lead can affect the
    developing fetus.

Environmental Risk Factors
  • Mercury
  • A poisonous metal that occurs naturally in the
    environment. It is released into the air then
    falls directly into the water. Upon reaching the
    water it turns into a very toxic form
  • In 2004, the Food and Drug Administration
    (FDA)/Environmental Protection Agency (EPA)
    Consumer AdvisoryWhat You Need to Know about
    Mercury in Fish and Shellfish was released.
  • For more information, call the FDA Food
    Information Hotline toll-free at 1-888-SAFEFOOD
    or visit the FDAs Food Safety Website at

Environmental Risk Factors
  • Pesticides
  • Includes bug sprays, fertilizers, and wood
  • Migrant farm workers may be more heavily exposed
    to these toxins.

Environmental Risk Factors
  • Gases
  • Carbon Monoxide is given off by cars, gas
    furnaces, kerosene heaters and cigarette smoke.
    It can not be seen nor smelled. Side effects of
    exposure include
  • Low birth weight
  • Stillbirth
  • Headaches
  • Death

Environmental Risk Factors
  • Food-borne risks
  • Undercooked foods (raw fish, oysters, underheated
    deli meats)
  • Unpasteurized milk or juice
  • Soft cheeses
  • Some herbal teas
  • Homeopathic remedies
  • Toxoplasmosis
  • cat litter
  • soil

Baby Spacing
  • Research shows that waiting at least two years
    between pregnancies is optimal for both the
    mother and infants health.
  • A short pregnancy interval may be associated
  • Birth of a small (for gestational age) infant in
    a subsequent pregnancy.
  • Preterm birth in a subsequent pregnancy.
  • Low birth weight.
  • Stillbirth.
  • Death within the first year of life.

Baby Spacing
  • Having babies too close together can deplete the
    mothers nutrients, energy, and finances.
  • Family Planning and Primary Care clinics can
    assist women with their contraceptive needs.
  • There is a special Medicaid program for women
    aged 1455, who lose full Medicaid benefits,
    including pregnancy-related benefits. This
    program provides coverage for family planning
    services for up to two years.

How Should Services be Provided?
  • Every Woman, Every Time
  • In a culturally-sensitive manner

Preconception Care and Cultural Competency
  • Counseling, education, and services must be
    provided with consideration to the cultural,
    language, education/literacy, and accessibility
    needs of the participant. This includes
    understanding of the
  • Beliefs, values, traditions, and practices of a
  • Culturally-defined, health-related needs of
    individuals, families, and communities.
  • Culturally-based belief systems of the etiology
    of illness and disease and those related to
    health and healing.
  • Attitudes toward seeking help from the health
    care providers.
  • For more information, contact the National
    Center for Cultural Competence at the Georgetown
    University Center for Child and Human Development
    at 1-800-788-2066 or http//

Preconception Care and Cultural Competency
  • Examples of varying cultural beliefs or practices
    among groups
  • Mexicans douching a common practice.
  • Mormons procreation as a sacred duty.
  • Native Americans children should be spaced
    three to four years apart.
  • African Americans prenatal care may not be
    readily sought because of negative experiences
    with health care system.
  • Cubans male contraception is not acceptable due
    to machismo.

First The Specific Goals of the CDC
Preconception Initiative are to
  • Improve the knowledge, attitudes and behaviors of
    men and women related to preconceptional health.
  • Assure that all women of childbearing age in the
    United States receive care services that will
    enable them to enter pregnancy in optimal health.

CDCs 10 Recommendations to Improve Preconception
April 21, 2006
CDC Recommendation 1
  • Each woman, man, and couple should be encouraged
    to have a reproductive life plan.

CDC Recommendation 2
  • Increase public awareness of the importance of
    preconception health behaviors and preconception
    care services by using information and tools
    appropriate across various ages literacy,
    including health literacy and cultural/linguistic

CDC Recommendation 3
  • As a part of primary care visits, provide risk
    assessment and educational and health promotion
    counseling to all women of childbearing age to
    reduce reproductive risks and improve pregnancy

CDC Recommendation 4
  • Increase the proportion of women who receive
    interventions as follow-up to preconception risk
    screening, focusing on high priority

CDC Recommendation 5
  • Use the interconception period to provide
    additional intensive interventions to women who
    have had a previous pregnancy that ended in an
    adverse outcome (e.g. infant death, fetal loss,
    birth defects, low birth weight, preterm birth,
    significant maternal morbidity).

CDC Recommendation 6
  • Offer, as a component of maternity care, one
    prepregnancy visit for couples and persons
    planning a pregnancy.

CDC Recommendation 7
  • Increase public and private health insurance
    coverage for women with low incomes to improve
    access to preventive womens health and
    preconception and interconception care.

CDC Recommendation 8
  • Integrate components of preconception health into
    existing local public health and related
    programs, including emphasis on interconception
    interventions for women with previous adverse

CDC Recommendation 9
  • Increase the evidence base and promote the use of
    the evidence to improve preconception health.

CDC Recommendation 10
  • Maximize public health surveillance and related
    research mechanisms to monitor preconception

Healthy Start Standards and Guidelines
  • Chapter 21 Healthy Start Services
  • Interconception Education and Counseling

Standards and Guidelines Overview
  • Services are determined based on the coalition
    service delivery plan and local resources.
  • Services are above and beyond health information
    provided during care coordination.
  • Coalition-approved curriculum.
  • Services are provided to women determined to be
    at risk for a poor birth outcome in a subsequent
  • May use screening tools to help determine risks.

Interconceptional Education and Counseling
Curriculum Topics
  • Access to care
  • Baby spacing
  • Nutrition
  • Physical activity
  • Maternal infections
  • Chronic health problems
  • Substance abuse
  • Smoking
  • Mental health
  • Environmental risks

Interconceptional Education and Counseling
Service Components
  • Plan of Care
  • Presentation
  • Demonstration activity
  • Follow-up
  • Feedback
  • Evaluation

Interconceptional Education and Counseling
  • Provided one-on-one with participant in
    face-to-face visit.
  • Provided in a support group setting.
  • Provided in a classroom setting in a set series
    of classes.

Interconceptional Education and Counseling
  • Trained providers with up-to-date knowledge of
    interconceptional health.
  • Written follow-up provided to the Healthy Start
    care coordinator within 30 days.
  • Service provider communicates any additional
    needs identified to the care coordinator.

Interconceptional Education and Counseling
  • Documented in the record of the person receiving
    the service.
  • Follow-up on referral documented in participants
  • Consent for release of information between
    provider and care coordinator.
  • Certification of completion provided to care
    coordinator for participants record.
  • Quarterly Quality Assurance (QA)/Quality
    Improvement (QI) by provider.

Interconceptional Education and Counseling
Services Coding
  • Activities that educate and inform the Healthy
    Start woman about health behaviors that will help
    to reduce risk and improve subsequent birth
  • Code 8013 is open to program components 26, 27,
    30, and 31.

Interconceptional Education and Counseling
Services Coding
  • Who can be provided this Healthy Start service?
  • Any Healthy Start woman determined at risk for a
    poor outcome of a subsequent pregnancy.
  • May be provided prenatally or postnatally.
  • May be provided to the Healthy Start participant,
    or to the mother of a Healthy Start participant
    on behalf of the participant.

Interconceptional Education and Counseling
Services Coding
  • Who can provide and code this Healthy Start
  • Trained and qualified Healthy Start providers.
  • May be provided individually, in support groups,
    or formal classes.
  • One unit of service equals 15 minutes.

Interconceptional Education and Counseling
Services Coding
  • What is required for the service?
  • Healthy Start coalition-approved curriculum with
    components covering access to health care baby
    spacing nutrition physical activity maternal
    infections chronic health problems substance
    abuse smoking mental health and environmental
    risk factors.
  • Learning objectives for the curriculum.

Interconceptional Education and Counseling
Services Coding
  • What if my staff is not trained to provide this
    special service?
  • Healthy Start care coordinators who do not
    receive special interconceptional education and
    counseling training may still provide their
    participants with the appropriate health
    education to reduce risks as part of their care
    coordination activities and code to 3320 or 3321.

Preconception Care presents a Golden Opportunity
  • We recognize that powerful influences on outcome
    occur long before pregnancy begins. Pregnancy is
    shaped by
  • Social
  • Psychological
  • Behavioral
  • Environmental
  • Biological forces
  • Improving pregnancy outcomes necessitates the
    linkage of an even broader array of health care
    providers embracing a life course perspective
    with regard to perinatal health.
  • Dawn Misra, Womens and Childrens Health Policy
    Center, Bloomberg School
  • of Public Health, Johns Hopkins University.

Golden Opportunity
  • Any health care provider who comes into contact
    with a woman of reproductive age has the
    potential to protect the health of that woman and
    her future offspring.