The Foundation for a Healthier Tomorrow

1
Preconception Health PromotionThe Foundation
for a Healthier Tomorrow
Merry-K. Moos, RN, FNP (retired), MPH, FAAN 3.0
contact hours
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2
Accreditation

• March of Dimes Foundation is accredited as a
  provider of continuing nursing education by the
  American Nurses Credentialing Center's Commission
  on Accreditation.
• The March of Dimes also is approved by the
  California Board of Registered Nursing, Provider
  CEP11444.
• 3.0 contact hours are available for this activity
  through November 1, 2014. CNE credit may be
  extended past this date following content review
  and/or update.
• Visit marchofdimes.com/nursing for up-to-date
  information on all of our CNE activities.

3
Author bio and disclosure
Merry-K. Moos, BSN, MPH, FAAN Until her
retirement, Merry-K. Moos was a professor in the
Department of Obstetrics and Gynecology, and
adjunct professor in both the Schools of Public
Health and Nursing at the University of North
Carolina at Chapel Hill. She is a researcher,
author and clinician who is nationally and
internationally recognized for her expertise in
preconceptional and interconceptional health and
health care. She and her colleague, Robert
Cefalo, wrote the first book on preconceptional
health in the United States in 1988 it, as well
as her other related publications, have served as
a platform for change in the delivery of
reproductive health care in this country. Ms.
Moos remains active in developing and promoting
strategies to advance preconception health care
in the United States and beyond.
Disclosure Merry-K. Moos is Lead Nurse Planner
for the March of Dimes Foundation She has no
financial, professional or personal relationships
that could potentially bias the content of this
module.
4

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5
Contents
6
Module purpose

• This module is designed for registered nurses who
  interact with women of childbearing age before
  and after pregnancy and between pregnancies. It
  reviews the rationale for moving away from
  prenatal care as the principle approach to
  preventing poor pregnancy outcomes to an approach
  that encompasses a womans health before
  conception. The module examines the link between
  a womans health habits and risks and how they
  correspond to known risks for a pregnancy and
  neonate. The module includes evidence-based
  strategies for addressing key risks before
  pregnancy to help nurses provide meaningful
  preventive care throughout the life course of
  women and their offspring.

7
Module objectives

• After studying this module, the nurse will be
  able to
• Explain the rationale and history of the
  preconception health movement
• Identify preconception influences on womens
  health and pregnancy outcomes and identify
  appropriate evidence-based clinical care
  recommendations
• Describe a framework for incorporating
  preconception care into clinical practice

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Objective 1

• Explain the rationale and history of the
  preconception health movement

9
Preconception vocabulary

• Preconception A womans (or mans) health status
  and risks before a first pregnancy and subsequent
  pregnancies. Often used as a synonym for
  interconception (Moos, 2006 Moos et al., 2010).
• Interconception The period between the end of
  one pregnancy and the conception of the next
  pregnancy. The interconception period must be
  treated as an open-ended timeframe because it
  only can be accurately defined after the next
  conception has occurred (Moos et al., 2010).
• Preconception health promotion Includes, but is
  not limited to, clinical care, because many
  influences interact to support or undermine high
  levels of wellness in individuals of childbearing
  age. Influences include family and community
  relationships, environmental exposures in the
  workplace and public policies (Moos et al.,
  2010).
• Periconception The maternal health status and
  risks around the time of conception through the
  period of organogenesis (Moos, 2006).

10
Rationale for preconception health promotion

• Historically, prenatal care has been the dominant
  approach to preventing poor pregnancy outcomes in
  the United States. Over the last 30 years,
  limitations of this approach have been
  identified
• Important influences on pregnancy outcomes
  predate conception (Table 1).
• Prenatal care starts too late to offer primary
  prevention for many poor outcomes.
• Prenatal care often starts too late and offers
  too little to eliminate risks associated with
  the life circumstances of socially disadvantaged
  populations. There is no evidence that a medical
  model directed at a 6- to 8-month interval in a
  womans life can erase years of social, economic
  and emotional distress and hardship (Dillard,
  2004).

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Rationale for preconception health promotion

• Some poor pregnancy outcomes, including
  spontaneous abortions and congenital anomalies
  (birth defects), have already occurred before the
  first prenatal visit.
• The period of organogenesis (when organs are
  formed) begins just 3 days after the first missed
  menstrual period.
• Organogenesis is complete around the 56th day
  after conception 8 weeks by conception date and
  10 weeks by menstrual date.
• Most women are not aware they are pregnant by 3
  days after the first missed menses. Many pregnant
  women do not start prenatal care until
  organogenesis is complete.
• Birth defects account for 20 percent of all
  infant deaths in the United States, making them
  the leading cause of infant mortality (March of
  Dimes, 2011d). Beyond death, birth defects are a
  major contributor to lifelong disabilities.
  Approximately 3 percent of all infants born each
  year have a birth defect.

12
The preconception movement in the United States
13
The preconception movement in the United States
14
The preconception movement in the United States
15
CDC Select Panel on Preconception Care and Health
Care

• The CDC Select Panel (2006) put forth four goals
  (Table 3), 10 recommendations and more than 50
  action steps for the preconception initiative. It
  also made recommendations relevant to nurses
  involvement in preconception health services
  (Table 4).

16
CDC Select Panel on Preconception Care and Health
Care
A complete list of recommendations and action
steps is available at www.beforeandbeyond.com
under the tab Key Articles and Guidance.
17
CDC Select Panel on Preconception Care and Health
Care

• Recognizing that multiple pathways are needed to
  change longstanding but inadequate approaches to
  prevention, the CDC Select Panel created five
  multidisciplinary workgroups (Table 5). The
  workgroups include nurses in leadership and
  membership roles who represent nursing
  organizations, including the Association of
  Womens Health, Obstetric and Neonatal Nurses
  (AWHONN), the American College of Nurse Midwives
  (ACNM) and national organizations committed to
  the work of nurses, like the March of Dimes.
• The Clinical Workgroup (CWG), likely to be of
  particular interest to nurses, has undertaken
  several important initiatives (Table 6).

18
Emerging paradigms for preventive health care

• Complementing and, in part, stimulated by the
  national preconception movement, are two emerging
  paradigms for reframing opportunities for
  prevention for women and their offspring
• Womens preventive health framework
• The life course framework

• Something to think about
• How early in the life cycle do determinants of
  poor health and poor pregnancy outcomes begin to
  exercise their influences?

19
Womens preventive health framework Overview

• Delivery of womens health care services in the
  United States relies on a series of relatively
  distinct service silos. These silos separate a
  womans pregnancy-related care from her
  nonperinatal care. The non-perinatal care is
  further compartmentalized into reproductive and
  non-reproductive foci (Moos, 2009).
• It is common, for example, for the contraception
  needs of a woman with type 2 diabetes mellitus
  not to be acknowledged by her endocrinologist
  her glycemic control issues to be overlooked by
  her family planning provider and her risks for
  poor pregnancy outcomes to be ignored until her
  first and subsequent prenatal visits.
• The womens preventive health framework is built
  upon appreciation that the major determinants of
  poor health status in women are important risk
  factors for poor pregnancy outcomes (Table 7).

The nations approach to the clinical care
ofwomen is fragmented, inefficient, and, too
often, incomplete and ineffective. Moos, 2009,
p.427
20
Womens preventive health framework Overview
21
Womens preventive health care strategies

• Because healthy women have healthier pregnancies,
  preventive care has the potential to result in
  healthier women, healthier pregnancies and
  healthier pregnancy outcomes (Moos, 2009).
• Nurses and others in the health care field must
  shift their paradigm from a singular focus on the
  pregnant woman and fetus to a wider frame that
  encompasses the total health needs of the
  adolescent, woman and mother (Verbiest
  Holliday, 2009).
• Opportunistic approach to prevention
• Impacting a womans health status across her
  life-span benefits from incorporating health
  promotion and disease prevention strategies into
  every health care encounter (Moos, 2006 Moos,
  2009).
• Californias Every Woman, Every Time campaign
  (Cullum, 2003) became a model for encouraging
  opportunistic care in other states.

If we hope to achieve better pregnancy outcomes,
we must change the way we provide maternal and
child health (MCH) services and add the Woman
into MCH. Atrash et al., 2008,
p.S264
22
The life course framework Overview

• Traditionally, birth outcomes and disparities in
  outcomes have been explained by what happens
  during pregnancy (e.g., preterm labor,
  infections) harmful influences during pregnancy
  (e.g., cigarette smoking, food insecurity) and
  differing exposures to protective factors (e.g.,
  social support, utilization of prenatal care).
• Lu Halfon (2003) propose the life course
  framework. This suggests
• Protective and harmful influences across the
  lifespan are key determinants of an individuals
  health status.
• Imbalances in these influences across different
  population groups are critical to understanding
  and addressing racial, ethnic and socioeconomic
  disparities.
• Influences include, but are not limited to,
  physical, social, psychological and economic
  variables.
• Protective and harmful exposures are likely to
  have an intergenerational influence on health
  status so that the influences experienced by
  grandparents, for instance, may explain health
  challenges of the grandchildren.

23
The life course framework Models

• Lu and Halfon (2003) summarize two models that
  explain the impact of the life course on womens
  health and pregnancy outcomes
• Early programming model
• Early life exposures and experiences during
  particularly sensitive periods of development
  (including in utero) encode the functions of
  organs or organ systems that will influence
  health status throughout an individuals
  lifetime. This is sometimes referred to as the
  womb to tomb model.
• David Barker (1990) suggests the relationship
  between fetal exposures and the lifelong
  likelihood of developing chronic disease in
  research on coronary heart disease his work on
  fetal and infant origins of adult disease is
  known as the Barker Hypothesis.
• Cumulative pathways modelChronic accommodation
  to stress results in wear and tear on the bodys
  adaptive systems (often called allostatic load),
  affecting health status over the life course (Lu,
  2010).

24
Objective 2

• Identify preconception influences on womens
  health and pregnancy outcomes and identify
  appropriate evidence-based clinical care
  recommendations

25
Key preconception influences

• ACOG (2005, 2007) identifies the following
  assessments as a basis for preconception care
• Family planning and pregnancy spacing
  (interpregnancy intervals IPIs)
• Family history
• Genetic history
• Medical, surgical, psychiatric and neurologic
  histories
• Current medication exposures
• Substance use
• Domestic abuse and violence
• Nutrition
• Environmental and occupational exposures
• Immunity and immunization status
• OB/GYN history
• Assessment of socioeconomic, educational and
  cultural status

Something to think about How can the nurse know
what specific information and services to
provide? Principles of evidence-based care can
help.
26
Incorporating evidence-based preconception care
into practice

• In December 2008, the CWG of the CDC Select Panel
  released recommendations for the Clinical Content
  of Preconception Care (Jack Atrash, 2008).
• The procedure used by the CWG is similar to the
  steps used by the U.S. Preventive Services Task
  Force (USPSTF) (1996) in the development of its
  prevention recommendations.
• The CWG procedure involved
• Conducting a literature review of more than 200
  health topics related to preconception care
• Assessing whether or not the composite research
  related to a topic suggests or proves there are
  benefits to addressing that topic before
  pregnancy
• Assigning a specific recommendation to each topic
  based on the likely advantage to pregnancy
  outcomes if the topic is addressed before
  pregnancy

27
Assigning recommendations based on the evidence

• Using the framework employed by the USPSTF to
  rate the evidence around a specific topic, the
  CWG assigned a letter grade to each of the 200
  preconception clinical topics it reviewed. The
  grade helps providers determine the likely
  benefits of addressing a specific influence
  during the preconception period (Table 8).

28
Quality of the research

• While specific clinical recommendations shouldbe
  the result of strong research designs, this is
  not always possible. For example, the most
  powerful experimental designs (randomized
  clinical control trials) often are inappropriate
  or unethical when determining the impact of an
  intervention on reproductive outcomes.
• Using the USPSTF framework to assess the strength
  of the science behind specific recommendations,
  the CWG assigned a grade to the total body of
  research for each of the 200 preconception
  influences. These grades helps clinicians
  appreciate the research foundations for specific
  recommendations (Table 9).

• Something to think about
• Why might it be unethical to conduct a randomized
  trial involving pregnant women?

29
Quality of the research
30
Clinical emphases of preconception care

• Translating the CWG recommendations into clinical
  care can be divided into three main clinical
  emphases (Table 10). Nurses should consider the
  relevance of each emphasis for every woman at
  each encounter.

31
Opportunities for nurses

• The next several slides provide illustrations of
  incorporating selected preconception health
  topics into nursing care. Each illustration
• Builds upon one of the three clinical emphases
• Presents background information on the topics
  significance to the health of the woman and,
  should the woman become pregnant, her pregnancy
  and future offspring
• Includes the strength of the CWGs recommendation
  and the quality of the research supporting it
• More information on these and additional
  preconception topics is available at
  www.beforeandbeyond.org (go to the Key Articles
  and Guidance tab).

32
Providing protection Nutrition/Overweight

• Statement of the problem
• In 2009, 52.9 percent of women age 18 to 44 in
  the United States were identified as overweight
  (having a body mass index BMI gt25) (Reinold et
  al., 2011). Many of these women proceed to
  obesity during and beyond their reproductive
  years.
• In 2010, 25.1 percent of women age 18 to 44 in
  the United States had a BMI of at least 30,
  which is the threshold for defining obesity
  (March of Dimes, 2011c).
• Obesity affects a womans health in a myriad of
  ways, and maternal obesity is associated with
  numerous pregnancy risks (Table 12).

33
Providing protection Nutrition/Overweight
34
Providing protection Nutrition/Overweight

• Potential benefits of preconception care
• Weight loss is contraindicated in pregnancy
  therefore, risk reduction must occur before
  conception.
• Specific recommendations for providers (Gardiner
  et al., 2008 Moos et al., 2008)
• Calculate a womans BMI annually.
• Counsel women with BMI gt25 about the risks,
  including infertility, for exceeding the
  overweight category for their own health and for
  future pregnancies.
• Offer women specific behavioral strategiesto
  decrease caloric intake and increase physical
  activity. Encourage women to consider enrolling
  in structured weight
  loss programs.

35
Providing protection Nutrition/Underweight

• Statement of the problem
• In 2009, 4.5 percent of women who became pregnant
  were under-weight (BMI lt18.5) (Reinhold, 2011).
  Because this rate is based on pregnancy and
  excludes all women who developed infertility due
  to their weight, it does not reflectthe
  magnitude of low BMI on
  reproductive health.
• In a study of adolescent female athletes, 18.2
  percent met the criteria for disordered eating
  23.5 percent had menstrual irregularities and
  21.8 percent had low bone mass, two known
  results of low BMI (Nichols et al., 2006).
• Low BMI is associated with womens general
  health risks and pregnancy complications
  (Table 13).

36
Providing protection Nutrition/Underweight

• Potential benefits of care before pregnancy
• Infertility, poor pregnancy outcomes and lifelong
  morbidities can be reduced by addressing low BMI
  before conception.
• Specific recommendations for providers (Gardiner
  et al., 2008 Moos et al., 2008)
• Calculate BMI for all women at least annually.
• Counsel women who are near the underweight weight
  status about short- and long-term risks of low
  BMI, including infertility, to their own health
  and the health of future pregnancies.
• Assess women with a low BMI (lt18.5) for eating
  disorders and distortions of body image.
• If needed, refer women who are unwilling to
  consider and achieve weight gain for further
  evaluation of eating disorders.

37
Providing protection Folic acid

• Statement of the problem
• Neural tube defects (NTDs) are serious birth
  defects of the spine (spina bifida) and brain
  (anencephaly). They are among the most common
  birth defects in the United States. Approximately
  1 in every 1,000 pregnancies is complicated by an
  NTD (USPSTF, 2009.)
• A clear association exists between maternal
  folate levels and the occurrence of NTDs. This
  association provides opportunity for the primary
  prevention of NTDs (CDC, 1992).
• Because the neural tube forms during the first
  weeks of gestation and before most women have
  entered into prenatal care, a preconception
  orientation to prevention is necessary to
  decrease the incidence of NTDs.

38
Providing protection Folic acid

• Potential benefits of care before pregnancy
• Daily supplementation of 400 mcg of folic acid
  prior to conception and throughout the first
  trimester of pregnancy has been reported to
  reduce the risk of NTDs by 50 to 80 percent (CDC,
  1992).
• Randomized trials in settings without grain
  fortification suggest that a multivitamin with
  800 mcg of folic acid reduces the risk of NTDs
  (USPSTF, 2009).
• Possible additional benefits of folic acid
  supplementation on pregnancy outcomes include a
  reduction in the risk of spontaneous preterm
  birth (Bukowski et al., 2009 Czeizel et al.,
  2010) and oral cleft birth defects (Johnson
  Little, 2008). Additional studies are needed.
• Some evidence exists that folic acid
  supplementation positively impacts other areas of
  womens health, including risk of stroke, cancer
  and dementia (Gardiner et al., 2008). Findings
  are inconsistent.
• The likelihood that folic acid supplementation
  masks the symptoms of pernicious anemia are
  minimal given the prevalence of this disease in
  women of reproductive age.

39
Providing protection Folic acid

• Specific recommendation (Moos et al., 2008
  USPSTF, 2009)
• Women planning pregnancy or capable of becoming
  pregnant should consume 400 to 800 mcg of folic
  acid daily from fortified foods and/or
  supplements, and eat a balanced, healthy diet of
  folate-rich food (Table 14).
• Supplements can be over-the-countermultivitamins
  or a supplement of only folic acid.
• In the United States, foods fortified with folic
  acid include enriched grains (wheat flour and
  corn meal), cereals and juices.
• The recommendation is not new. The CDC released
  the first national recommendation in 1992. It
  stated that all women of childbearing age in the
  United States who are capable of becoming
  pregnant should consume 400 mcg of folic acid
  daily to decrease the risk of a pregnancy
  affected by an NTD (CDC, 1992).

40
Providing protection Folic acid

• Follow up
• Since 1995, the March of Dimes has commissioned
  Gallup surveys to assess womens awareness and
  behavior relative to folic acid. After nearly 20
  years, progress in womens understanding and
  adoption of the routine use of folic acid has
  been disappointing (Table 15).

Something to think about Why has progress been
slow in women adopting the practice of taking a
multivitamin containing folic acid? What can be
done to improve the situation?
41
Providing protection Preventing unintended
pregnancies

• Statement of the problem
• Forty-nine percent of pregnancies in the United
  States are identified by women as unintended
  (unwanted or mistimed) (Finer Henshaw, 2006).
  Of these pregnancies
• Forty-four percent end in birth.
• Forty-two percent end in abortion.
• Fourteen percent end in fetal loss.
• Everyone who has sexual intercourse is at risk
  for an unintended pregnancy because there is no
  perfect contraceptive, including sterilization
  (Trussell, 2007).
• Forty-eight percent of unintended pregnancies
  occur in a month in which a couple used some
  method of contraception (Finer Henshaw, 2006).

Something to think about What is a
practice-based, a community-based and a
policy-based strategy that could decrease
unintended pregnancies for the women and families
you serve?
42
Providing protection Preventing unintended
pregnancies

• Statement of the problem (continued)
• Although the rate of unintended pregnancy is
  declining for adolescents (ages 15-17), it is
  increasing for nearly all other groups (Finer
  Zolna, 2011) and is associated with negative
  consequences (Table 16).

43
Providing protection Preventing unintended
pregnancies

• Potential benefits of care before pregnancy
• Primary prevention of unintended pregnancy can
  only occur before a pregnancy is conceived. All
  health care visits before pregnancy offer
  opportunities to educate women (and men) about
  the advantages of making deliberate decisions
  regarding future conceptions (Moos, 2010).
• Specific recommendations for providers (Moos et
  al., 2008)
• As part of routine health promotion activities,
  screen women for their short- and long-term
  pregnancy intentions and their risk of
  conceiving, whether intended or not.
• Encourage all patients to consider a reproductive
  life plan (Table 17) and educate them about how
  their plan impacts contraceptive and medical
  decision-making. The CDC Select Panel (2006)
  endorses use of reproductive life plans.
  Reproductive life plans offer women and men the
  opportunity to consider personal goals and values
  in context with childbearing.

44
Providing protection Preventing unintended
pregnancies
45
Providing protection Avoiding short
interpregnancy intervals (IPIs)

• Statement of the problem
• IPI is generally defined as the amount of time
  between the delivery date of a liveborn or
  stillborn infant and conception of the next
  pregnancy.
• A meta-analysis of 67 articles studying the
  impact of IPIs determined that intervals lt18
  months and gt59 months are significantly
  associated with poor pregnancy outcomes (Table
  18) (Conde-Agudelo, Rosas-Bermudez
  Kafury-Goeta, 2006).
• The study suggests that IPIs lt6 months and gt59
  months increase the risk of fetal and early
  neonatal death.
• For each month the IPI is lt18 months, the risk
  for poor outcomes increases for each month the
  IPI increases beyond 59 months, risks become
  greater.

46
Providing protection Avoiding short IPIs

• Statement of the problem (continued)
• While it is common to suggest that poor outcomes
  associated with short IPIs are due to influences
  such as socioeconomic status, inadequate use of
  health care services, and greater use of tobacco,
  alcohol and other substances, the study found
  that controlling for these influences does not
  significantly alter the findings.
• Potential benefits of care before pregnancy
• Decrease risks for poor pregnancy outcomes
• Increase likelihood that women and their partners
  have the information needed to make informed
  decisions about the timing of future pregnancies
• Specific recommendations for providers
• Educate women about the importance of
  appropriate IPI.
• Guide women on contraceptive choices.
• Encourage women to make reproductive life plans
  and, when appropriate, to discuss them with
  sexual partners.

47
Providing protection Immunizations

• Statement of the problem (Coonrod et al., 2008)
• Many vaccine-preventable diseases have serious
  consequences for the pregnant woman, the fetus
  and the neonate. Among these are vaccines that
• Protect the fetus from congenital infections
  (e.g.,varicella)
• Prevent perinatal transmission of infection
  (e.g., hepatitis B)
• May prevent premature birth (e.g., vaccines that
  prevent human papillomavirus HPV infections)
• Protect against severe neonatal disease (e.g.,
  varicella, pertussis and tetanus)
• Increase the likelihood of life-threatening
  complications for a woman during pregnancy (e.g.,
  varicella and influenza)
• To provide protection, some vaccines (e.g.,
  varicella and rubella) must be administered in
  the preconception period because they are
  contraindicated in pregnancy (Table 19).

48
Providing protection Immunizations

49
Providing protection Immunizations

• Potential benefits of care before pregnancy
• Assuring that every woman is immune to rubella
  prior to conception can eliminate congenital
  rubella syndrome because the rubella
  immunization involves a live virus, it cannot
  safely be administered during pregnancy.
• Routine assessment of infections, risks and
  administration of indicated immunizations
  canprevent avoidable infections before, during
  and after pregnancy and can provide protection
  to the fetus and neonate.
• HPV immunization may reduce a womans risk of
  premature birth because procedures used to treat
  HPV and cervical cancer have been associated with
  cervical incompetence. These procedures include
  cone biopsies and loop electrosurgical excision
  procedures (LEEP) (Coonrod et al., 2008).

Something to think about How do immunizations
fit into the life course framework?
50
Providing protection Immunizations

• Specific recommendations for providers about
  immunizationstatus (Coonrod et al., 2008 Moos
  et al., 2008)
• Review the immunization status of all women of
  reproductive age for
• Tetanus-diphtheria toxoid/diphtheria-tetanus-pertu
  ssis
• Measles, mumps and rubella
• Varicella
• Assess all women annually for lifestyle and
  occupational risks for infection and offerwomen
  indicated immunizations.
• Specific recommendations for providers about
  HPV-associated abnormalities
• Routinely screen all women for cervical cancer
  adhering to the latest guidelines (USPSTF, 2012).
  The CDC (2010, 2011b) recommends that all 11 to
  12 year old girls and boys receive three doses of
  the HPV vaccine. The vaccine can be administered
  safely and effectively to girls and boys from 13
  to 26 who do not receive or complete the series.
  
• The vaccine decreases the incidence of
  HPV-related cervical abnormalities in women and
  oropharyngeal and anal cancers in men.

51
Avoiding harmful exposures Tobacco use

• Statement of the problem
• Tobacco use before, during and after pregnancy
  leads to adverse health conditions for women,
  their pregnancies and their babies (Table 20).

52
Avoiding harmful exposures Tobacco use

• Potential benefits of care before pregnancy
• Tobacco use is the largest preventable cause of
  premature death and avoidable illness among women
  in the United States (ACOG, 2007). It is
  associated with more than 400,000 annual deaths
  from cancer, respiratory disease and
  cardiovascular disease (USPSTF, 2009).
• Cessation of tobacco use at anytime in pregnancy
  is beneficial however, cessation before
  pregnancy has the added advantages of
• Protecting a womans short- and long-term health
• Decreasing the likelihood a woman will resume
  smoking in the postpartum period
• Preventing some placental abnormalities,
  including placenta previa, associated with
  tobacco use
• Efficacy of nicotine replacement therapy (NRT)
  during pregnancy has not been established, and
  its safety for pregnant women and fetuses has not
  been proven (Forest, 2010).

53
Avoiding harmful exposures Tobacco use

• Specific recommendations for providers (Floyd et
  al., 2008 Moos et al., 2008)
• Assess all women for smoking at each patient
  encounter.
• Counsel women who smoke using the 5As (Table 21)
  (USPSTF, 2009).
• Provide a brief intervention to all smokers that
  includes
• Counseling that describes the benefits of no
  tobacco use before, during and after pregnancy.
• Discussion of NRT and other medication
  therapies.
• Referral to more intensive services (individual,
  group, or telephone counseling), if the woman is
  willing.

54
Avoiding harmful exposures Alcohol use

• Statement of the problem
• Fifty-three percent of nonpregnant women age 15
  to 44 drink alcohol (Substance Abuse and Mental
  Health Services Administration SAMHSA, 2007).
  In 2010, 15.4 percent of nonpregnant women in the
  same age range reported binge drinking (March of
  Dimes, 2011a). Binge drinking is defined as four
  or more drinks on at least one occasion during
  the past month.
• The 2006 National Survey on Drug Use and Health
  (SAMHSA, 2007) found that 11.8 percent of
  pregnant women reported current alcohol use, and
  2.9 percent reported binge drinking.
• Alcohol use is associated with liver disease,
  osteoporosis, neurologic disorders, menstrual
  symptoms, mental health diagnoses, unintended
  pregnancies and motor vehicle and other
  accidents. It can progress from use to abuse to
  addiction (Kearney, 2008 Moos, 2008).
• Prenatal alcohol use is a leading preventable
  cause of birth defects and developmental
  disabilities (CDC, 2009).

55
Avoiding harmful exposures Alcohol use

• Statement of the problem (continued)
• Fetal alcohol exposure is associated with
  miscarriage, IUGR and the continuum of
  disabilities called fetal alcohol spectrum
  disorders (FASD) (Floyd et al., 2008 Kearney,
  2008 Moos et al., 2008).
• Estimates of the prevalence of FASD is between
  0.3 to 2 cases per 1,000 live births (Floyd et
  al., 2008).
• FASD includes fetal alcohol syndrome (FAS). FAS
  is characterized by growth restriction, physical
  anomalies and neurodevelopmental abnormalities,
  including intellectual disabilities (Kearney,
  2008).
• An estimated 11 percent of pregnant women who
  drink 1 to 2 ounces of absolute alcohol a day
  during the first trimester have offspring with
  features consistent with FAS (Warren Blast,
  1988). However, any exposure even one episode
  of binge drinking during a critical period of
  organogenesis can result in FAS.

56
Avoiding harmful exposures Alcohol use

• Potential benefits of care before pregnancy
• Because FAS only can occur if the embryo is
  exposed to alcohol in the earliest weeks of
  pregnancy, the only opportunity to prevent it is
  to reach all women at risk for pregnancy with
  education, screening and appropriate
  interventions to avoid all alcohol.
• Specific recommendations for providers (Floyd et
  al., 2008 Moos et al., 2008)
• Assess all women at least annually for alcohol
  use patterns and risky drinking behaviors, and
  provide appropriate counseling.
• Advise all women of the potential risks of
  alcohol use for their own health and the health
  of any future pregnancies and offspring.
• Counsel women that there is no safe level of
  alcohol consumption at any time in pregnancy.

• Something to think about
• What are the hazards of obtaining alcohol
  histories on selected patients? How can these
  risks be eliminated?

57
Avoiding harmful exposures Illegal drugs

• Statement of the problem
• Women who use illegal drugs have higher rates of
  sexually transmitted infections (STIs), human
  immunodeficiency virus (HIV), hepatitis,
  domestic violence and depression than women not
  exposed to such drugs (Kearney, 2008).
• In 2006, among nonpregnant women age 15 to 44, 10
  percent reported illegal drug use during the
  past month, including marijuana, cocaine,
  inhalants, hallucinogens and heroin (SAMHSA,
  2007).
• Illegal drug use during pregnancy is associated
  with an increased risk of maternal complications
  and poor outcomes for the offspring. Most
  investigations around the effects of illegal
  drugs on pregnancy outcomes involve cocaine and
  marijuana (Floyd et al., 2008) (Table 22).

58
Avoiding harmful substances Illegal drugs

• Potential benefits of care before pregnancy
• Becoming drug-free can be a difficult and lengthy
  process. Because pregnancy risks associated with
  the use of illegal drugs are significant, the
  safest choice for a woman, her pregnancy and
  future offspring is to achieve abstinence prior
  to conception.
• Specific recommendations for providers (Floyd et
  al., 2008)
• Obtain a careful history on all women to identify
  illegal drug use.
• Counsel women of childbearing age about the risks
  of illegal drug use for their own health and for
  the health of any future pregnancies and
  offspring.
• Refer women to appropriate counseling and
  treatment programs that support abstinence and
  rehabilitation.
• Offer women contraception until they are
  drug-free and desire conception.

59
Avoiding harmful exposures Prescription and
over-the counter (OTC) drugs

• Statement of the problem
• Over the last 3 decades, prescription drug use by
  pregnant women in the first trimester increased
  by more than 60 percent, and the use of four or
  more drugs more than tripled in 2008, 50 percent
  of women reported taking at least one
  prescription drug in the first trimester, and 7.5
  percent reported taking four or more in the first
  trimester (Mitchell et al., 2011).
• In two databases, 56.9 percent of women reported
  taking an OTC analgesic before conception and
  59.3 percent reported taking one in the first
  trimester of pregnancy (Werler et al., 2005).
• National surveys estimate that 18 to 52 percent
  of the U.S. popula- tion use dietary supplements,
  including vitamins, herbs, traditional medicines,
  folk remedies and weight-loss and sports
  enhancements (Gardiner et al., 2008). The safety
  and efficacy of many of these products, in
  general and in pregnancy, have not been
  established.

60
Avoiding harmful exposures Prescription and
over-the counter drugs

• Statement of the problem (continued)
• Congenital anomalies are a leading cause of
  infant death and disability.
• Approximately 10 to 15 percent of congenital
  anomalies in the United States are due to
  teratogenic maternal exposures to prescription
  and OTC medications (Dunlop, Gardiner et al.,
  2008).
• Congenital anomalies due to drug use are
  preventable because they are caused by modifiable
  maternal exposures during the earliest weeks of
  pregnancy. Prevention of congenital anomalies and
  other adverse consequences of fetal exposure to
  drugs in the first trimester requires careful
  assessment of all drug exposures, counseling
  about their potential risks during pregnancy and,
  in the case of chronic diseases and acute care,
  prescribing medications with the strongest safety
  profiles.
• A challenge for health care providers is to
  address the balance between effectiveness and
  safety when prescribing drugs for women who could
  become pregnant.

61
Avoiding harmful exposures Prescription and
over-the counter drugs

• Statement of the problem (continued)
• Clinical trials for Food and Drug Administration
  (FDA) approval generally exclude pregnant women.
  The trials require monitoring reproductive
  performance in animals however, safety in these
  trials cannot be extrapolated as safety for
  humans. Many examples exist whereby safety in
  animal models do not equate with safety for human
  fetuses (Dunlop, Gardiner et al., 2008).
• The FDA classification system (Table 23) allows
  clinicians to interpret risks associated with
  medication use during pregnancy. The system has
  come under increasing criticism (Briggs, Freeman
  Yaffe, 2011)
• Complex considerations that should accompany
  prescribing med-ication for women of childbearing
  potential are oversimplified.
• Risk is undifferentiated between trimesters of
  exposure.
• Letters in the system suggest a gradation of risk
  when, in fact, they summarize the level of
  evidence available.
• In response to these and other concerns, the FDA
  is proposing a new approach to summarize the
  risks of specific drugs during pregnancy and
  lactation (Dunlop, Gardiner et al., 2008).

62
Avoiding harmful exposures Prescription and
over-the counter drugs
63
Avoiding harmful exposures Prescription and
over-the counter drugs

• Potential benefits of care before pregnancy
• By assisting women who may become pregnant to
  avoid prescription and OTC drugs known to be
  teratogenic or otherwise harmful in pregnancy,
  the likelihood of birth defects from inadvertent
  exposures can be eliminated.
• Specific recommendations for providers about
  prescription drugs
• (Dunlop, Gardiner et al., 2008)
• Screen all women before pregnancy for use of
  teratogenic medications and drugs with
  questionable safety profiles.
• Counsel women about the potential impact of
  chronic health conditions and related medications
  on pregnancy outcomes for both the woman and the
  fetus.
• Whenever possible, change a womans potentially
  teratogenic medications to safer drug choices
  before conception prescribe the fewest number
  and lowest doses of essential medications.

64
Avoiding harmful exposures Prescription and
over-the counter drugs

• Specific recommendations for providers about
  prescription drugs (continued)
• Choose drugs with long records of safety refrain
  from prescribing a drug that has only recently
  come on the market for a woman who may become
  pregnant.
• Counsel women not to stop taking prescription
  medications without talking to their provider
  first. Independently stopping some medications
  could prove life-threatening. For example,
  stopping seizure medications could lead to
  seizures while driving, putting the woman and
  others at risk.

65
Avoiding harmful exposures Prescription,
over-the-counter and other drugs

• Specific recommendations for providers about OTC
  medications (Dunlop, Gardiner et al., 2008)
• Encourage women of reproductive age to discuss
  their use of OTC medications when planning a
  pregnancy.
• Advise women not to use aspirin if they are
  planning a pregnancy or become pregnant.
• Specific recommendations for providers about
  dietary supplements (Gardiner et al., 2008)
• Encourage women of reproductive age to discuss
  their use of dietary supplements before
  pregnancy. Dietary supplements include all
  vitamins, herbs, weight-loss products and sports
  supplements.
• Caution women about the unknown safety profile
  of many supplements.
• When indicated, encourage use of high quality
  and prescription-quality supplements.

66
Avoiding harmful exposures Illicit use of
prescription drugs

• Statement of the problem
• A growing problem in the United States is the
  abuse of prescription drugs and the resultant
  addictions. CDC (2011a) reveals
• The number of overdose deaths from prescription
  drugs is greater than deaths from heroin and
  cocaine combined.
• In 2010, about 12 million Americans over the age
  of 11 reported using prescription painkillers for
  nonmedically indicated purposes in the past year.
• Prescription painkiller overdoses killed nearly
  15,000 people in the United States in 2008,
  compared to 4,000 in 1999.
• Beyond death from overdosing, prescription drug
  abuse is associated with more motor vehicle
  crashes, self harm and interpersonal violence
  than illegal drug use.
• Prescription drug abuse, specifically opioids, is
  associated with congenital defects, newborn
  withdrawal syndrome and infertility.

67
Avoiding harmful exposures Illicit use of
prescription drugs

• Potential benefits of care before pregnancy
• The specific fetal and neonatal effects of all
  prescription drug exposures are unknown
  however, the psychological, behavioral, social
  and physical toll on women who are addicted to
  prescription drugs is unlikely to benefit
  pregnancy outcomes.
• Specific recommendations for providers about
  illicit use of prescriptions drugs
• Given the emerging epidemic of prescription drug
  abuse, the identification of abuse and
  appropriate treatment are recommended in the
  care of all women.

• Something to think about
• In your practice, how do you assess and address
  the nonmedical use of prescription drugs? What
  are ways the process could be improved?

68
Managing medical conditions Overview

• In every pregnancy there are (at least) two
  patients the woman and the fetus. Medical
  conditions and treatments can affect these
  patients differently. To minimize risk,
  providers must consider the potential impact of
  conditions and treatments on both patients.
• Routine care of all women includes assessing
  risk for acute and chronic diseases and
  providing or modifying the treatment regimen
  based on a womans desire or likelihood for
  pregnancy.
• Chronic health conditions are common in women of
  reproductive age (Table 24).

69
Managing medical conditions Overview

• More than half of all women of reproductive age
  have one or more risk factors for developing a
  chronic disease (Association of Maternal Child
  Health Programs, 2008).
• In general, women of color have a higher
  prevalence of chronic disease (except for
  depression/anxiety and thyroid disease) (Rangi
  Salganicoff, 2011).
• Table 25 includes strategies for minimizing risks
  during pregnancy in women with chronic diseases.

70
Managing medical conditions Overview

• Information on these and other conditions
  reviewed by the CWG is available at
  www.beforeandbeyond.org under Articles and
  Guidance.
• Asthma
• Cardiovascular disease
• Diabetes mellitus
• Hypertension
• Phenylketonuria
• Psychiatric conditions
• Rheumatoid arthritis
• Seizure disorders
• Systemic lupus erythematosus (SLE)
• Thrombophilia
• Thyroid disease
• The following slides discuss the preconception
  management of two common chronic conditions
  diabetes mellitus (DM) and hypertension (HTN).

71
Managing medical conditions Diabetes mellitus
(DM)

• Statement of the problem
• Women with DM that predates conception are at
  increased risk for spontaneous abortion,
  congenital malformations and other pregnancy
  complications (Dunlop, Jack et al., 2008 Mahmud
  Mazza, 2010).
• The risk of pregnancy being complicated by
  congenital malformations in the general
  populations is 2 to 3 percent. It is as much as 3
  times higher for women with type 1 or type 2
  diabetes.
• Poor glucose control in the earliest weeks of
  pregnancy has been identified as the key risk
  factor for these anomalies.
• Common birth defects in offspring of women with
  DM include
• Central nervous system anomalies, such as NTDs
  and anencephaly
• Complex cardiac defects
• Skeletal malformations

72
Managing medical conditions DM

• Potential benefits of care before pregnancy
• Women who achieve strict glycemic control before
  pregnancy and maintain it throughout the period
  of organogenesis (17 to 56 days after conception)
  markedly reduce their risk of having a child with
  congenital malformations (Ray, OBrien Chan,
  2001).
• Waiting until a woman starts prenatal care to
  initiate strategies to prevent malformations is
  waiting too long.
• Pregnancy may advance DM-related complications to
  the womans health. A thorough preconception risk
  assessment and patient education based on the
  findings are necessary so the woman (and her
  partner) can make informed decisions about the
  risks of pregnancy to her health.

73
Managing medical conditions DM

• Specific recommendations for providers (Dunlop,
  Jack et al., 2008)
• Counsel women with DM about the importance of DM
  control before they become pregnant. Discuss
  achieving/maintaining optimal weight and
  maximizing DM control in combination with other
  health promotion topics.
• Help the woman achieve glycosylated hemoglobin
  levels as near to normal as possible in the
  months preceding conception.
• Other recommendations for providers
• (Mahmud Mazza, 2010)
• Counsel all women about the risk of congenital
  malformations related to uncontrolled blood
  sugar.
• Counsel women about the importance of delaying
  conception until diabetes is in optimal control
  support use of contraceptive method.
• Use hemoglobin A1C (HbA1C) levels to monitor
  metabolic control.
• Use insulin to help a woman achieve optimal
  metabolic control.

74
Managing medical conditions DM

• Other recommendations for providers (continued)
• Assess all drugs a woman takes for safety in
  pregnancy and replace with safer choices, if
  needed. These include medications she may take
  for comorbidities, such as hypertension.
• Assess the degree to which target organs, such as
  eyes and kidneys, already have been affected by
  DM.
• Encourage multidisciplinary participation in the
  care team, including the primary care provider,
  obstetrician, endocrinologist, diabetic educator
  and dietician.

Something to think about What contribution does
adding a nurse to the care team provide?
75
Managing medical conditions Hypertension (HTN)

• Statement of the problem
• Chronic HTN is a common condition that affects 11
  percent of women of childbearing age the
  prevalence is higher in women of color and
  increases with advancing age (Ranji
  Salganicoff, 2011).
• Chronic HTN is associated with maternal and fetal
  complications (Table 26).

76
Managing medical conditions HTN

• Statement of the problem (continued)
• The use of ACE inhibitors and angiotensin-receptor
  blockers are contraindicated in pregnancy very
  limited, high-quality data exists on the safety
  of other therapies during the earliest weeks of
  gestation or beyond.
• Potential benefits of care before pregnancy
• Health assessments, education and therapy
  alterations before pregnancy can help minimize
  risks to women and to their fetuses.
• Specific recommendations for providers (Dunlop,
  Jack et al., 2008)
• As part of routine prepregnancy care, advise
  women of childbearing age who have chronic HTN
  about increased risks to themselves and their
  offspring.
• Discuss the advantages of planning pregnancy and
  achieving blood pressure control using the fewest
  and safest medications possible before stopping
  contraception or risking pregnancy.

77
Managing medical conditions HTN

• Specific recommendations for providers
  (continued)
• Explore with the woman her reproductive life plan
  and counsel and support her on the use of safe
  and effective methods of contraception.
• Counsel the woman about weight loss through
  changes in diet and exercise to potentially
  decrease the amount of medication required to
  control her HTN.
• Assess women with severe or longstanding chronic
  HTN for ventricular hypertrophy, retinopathy and
  renal function prior to conception. This
  provides baseline data and a basis for
  individualized counseling regarding the risk of
  pregnancy.

Something to think about The care of women with
chronic diseases often focuses on the specific
disease and overlooks other important preventive
care. What are routine preventive needs that
should be assessed in the care of all women of
childbearing potential?
78
Other important nursing considerations in each of
the three key areas

• Providing protection sexually transmitted
  infections, psychosocial stressors against
  repeat poor pregnancy outcome
• Avoiding harmful exposures environmental
  exposures, psychosocial stressors
• Managing conditions infectious diseases such as
  HIV/AIDS, tuberculosis, hepatitis C, etc.,
  psychiatric conditions, genetic conditions
• Another important area How men fit into the
  preconception health movement (Frey, Navarro,
  Kotelchuck Lu, 2008)

79
How to learn more about the content of
preconception health care?

• Additional resources on preconception care
  valuable for nursing practice
• Before, Between and Beyond, the National
  Curriculum and Resources Guide for Clinicians
  www.beforeandbeyond.org.
• CDCs Preconception Health and Health Care Topics
  www.cdc.gov/preconception
• Initiatives for specific states/regions
• Every Woman California http//www.everywomancalif
  ornia.org
• CO Preconception and Interconception Care
  Guideline http//www.healthteamworks.org/guideline
  s/preconception.html
• Every Woman Florida www.everywomanflorida.com
• Every Woman Southeast www.everywomansoutheast.org

• Something to think about
• What is your state doing for preconception health
  promotion?

80
Objective 3

• Describe a framework for incorporating
  preconception care into clinical practice

81
Preconception care in nursing practice

• Every day maternal/child health nurses encounter
  women of childbearing age. When a nurse sees
  women of reproductive age, it is not a question
  of whether theyre providing preconception care
  but, rather, a question of what kind or
  preconception care they are providing (Stanford
  Hobbins, 2001).
• It may be hard to convince most women to get a
  special preconception checkup
• It can be expensive in terms of personal and
  professional resources.
• It will miss, at minimum, the 49 percent of women
  (Finer Henshaw, 2006) who experience unintended
  pregnancies each year.
• The opportunistic approach to preconception care
  takes advantage of encounters women already have
  with the health care system (Moos et al., 2008).

82
Preconception care in nursing practice

• By adopting the Every Woman, Every Time
  framework, nurses can orient their practice,
  counseling and education strategies toward
  helping every woman achieve high levels of
  wellness for the short- and long-term nurses can
  impact the preconception health status of women
  who subsequently become pregnant (Moos, 2008).
• Common practice venues where nurses can help
  women achieve higher levels of wellness
• Emergency rooms
• Family planning clinics
• Primary care clinics
• Chronic disease settings
• Worksite health centers
• College student health services
• Postpartum home and clinic visits
• Well baby and pediatric visits
• Neonatal intensive care units (NICUs)
• School health settings

83
Preconception care in nursing practice

• The nations energies around preconception health
  promotion present an ideal opportunity for nurses
  to assume leadership roles in advancing womens
  wellness and the preconception agenda (Moos,
  2003). The professional nurse has the necessary
  skill set to impact the life course for
  individual women and their offspring (Table 27).

84
Preconception care in nursing practice
85
Preconception care in nursing practice

• To incorporate new emphases into busy clinical
  practices can seem overwhelming. However, letting
  go of usual practices and testing new approaches
  offer opportunities to work smarter, not harder
  (Moos, 2009)
• Engaging the entire staff in strategies to
  consider prevention opportunities for every
  woman, every time. For example, the person who
  answers a clinics phone can rotate a series of
  health promotion messages in her greeting.
• Having standardized health and wellness
  assessments completed by women prior to their
  clinical visit.
• Encouraging women, prior to their annual visit,
  to set three priority health goals for the next
  year.
• Helping women identify specific steps to work
  toward their priority goals and treat the steps
  seriously wellness prescriptions can be used
  underscore the importance of prevention
  activities (Moos, 2009).
• Using electronic medical records to address
  important prevention activities, such as updating
  immunizations, assessing reproductive life plans,
  counseling around BMI, and assessing and
  addressing tobacco and alcohol use.

86
Conclusion

• The skills and activities needed to impact a
  womans preconception health status are ideally
  suited to the professional nurse (Moos, 2003).