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Preconception Care

  • Stephen D. RatcliffeEmail author
  • Stephanie E. Rosener
  • Daniel J. Frayne
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Abstract

Preconception care is defined as a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management (Centers for Disease Control and Prevention, MMWR 55(RR-6):1–23, 2006). Interconception care is care provided to women beginning with childbirth until the birth of a subsequent child. It is a subset of preconception care that addresses the continuity of risk from one pregnancy to the next (Lu et al., Matern Child Health J 10:S107–S112, 2006). Preconception and interconception care has increasingly been recognized as a crucial component of both women’s and infant’s health.

Preconception and Interconception Care Defined

Preconception care is defined as a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management [1]. Interconception care is care provided to women beginning with childbirth until the birth of a subsequent child. It is a subset of preconception care that addresses the continuity of risk from one pregnancy to the next [2]. Preconception and interconception care has increasingly been recognized as a crucial component of both women’s and infant’s health.

Ongoing Problem of Perinatal Morbidity and Mortality

Infant mortality remains a significant problem in the USA. In 2017, the US infant mortality rate was 5.8 per 1000 live births. Despite leading the world in healthcare expenditures, the USA ranks 34th among developed nations in infant mortality [3]. Since 2000, after 40 years of improvement, infant mortality rates continue to be unacceptably high, and maternal morbidity and mortality are increasing [4, 5].

The most important causes linked to infant mortality are preterm birth and birth defects (Fig. 1). Birth defects account for 20.4% of all infant deaths and affect 1 in 33 infants born in the USA. Approximately 36.3% of all infant deaths in the USA are attributable to prematurity [6]. After decades of focus on improving prenatal care interventions, the preterm birth rate in the USA remains unacceptably high. Significant racial and ethnic disparities persist. For example, the perinatal infant mortality rate among non-Hispanic black infants is 2.3 times higher than that of white infants [7].
Fig. 1

1990–2017 country comparison infant mortality (per 1000 live births). (Data extracted 4/19/20 OECD.STAT)

Even more striking is the stark contrast in the maternal mortality rate in the USA compared to other countries in other first world countries (Fig. 2). There is a 350% increase in maternal mortality rates among African American women compared to Anglo and Hispanic women resulting in the development of a number of contemporary initiatives to address these critical public health, access to care, and institutional racism issues [8, 9].
Fig. 2

1990–2017 country comparison maternal mortality (per 100,000 live births). ([5], WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 2000 to 2017. Geneva, World Health Organization, 2019 (Accessed 4/19/20))

Need to Address Risks Prior to Pregnancy

It is now recognized that many of the modifiable risk factors affecting preterm birth, birth defects, maternal morbidity, and both maternal and infant mortality occur prior to pregnancy. Structural organogenesis of the central nervous system and heart begins as early as 3 weeks’ postconception, and the development of the heart, limbs, and reproductive organs is nearly completed by 8–9 weeks’ gestation. As early as the missed menses and by the time a woman enters prenatal care, it is often too late to affect periconception risks [10]. Unfortunately, almost half of all pregnancies in the USA are unintended, thus limiting the ability to “plan” preconception risk reduction [11]. Unintended pregnancy is a risk factor for poor birth outcomes likely through uncontrolled health conditions or maternal behaviors. Additional examples of maternal risk factors that determine birth outcomes are interpregnancy interval, maternal age, exposure to teratogenic medications, exposure to substances, chronic disease control, and preventable congenital anomalies [12] (Table 1).
Table 1

Estimated prevalence of selected preconception health measures reported by the behavioral risk factor surveillance system and the pregnancy risk assessment monitoring system, USA, 2009 [12]

  

Age group (years)

Race/ethnicitya

Preconception measure

 

Total

18–24

25–34

35–44

White

Black

Others

Hispanic

Healthcare

Insurance coverageb

74.9

62

79.8

84.6

81.9

76

82.9

50.3

Preconception counselingc

18.4

18.3

19

16.4

17.6

21

16.2

20.6

Postpartum visitd

88.2

83.7

90.5

90

91.6

86.6

88.3

80.3

Reproductive health and family plan

Prior preterm birthe

14.4

16.8

14.1

12.1

12.6

17.5

13.5

17.1

Recent fetal lossf

14.9

12.8

13.6

21.9

14.6

15.7

21.8

13

Unintended pregnancye

42.9

61.6

35.4

29.2

37.3

65.2

37.9

45.9

Unintended pregnancies not on contraceptione

52.6

54.5

51.1

51.3

54.1

54.5

55.4

45.9

Postpartum contraceptioe

85.1

86.2

85.2

82.4

85.9

83.7

78.7

85.7

Tobacco and alcohol use

Current tobacco useb

18.7

18.7

20.4

17.2

22

15.7

16.9

9.8

Prepregnancy tobacco usee

25.1

35.8

21.7

14.1

30.8

22.7

18.7

12.4

Recent binge drinkingb

15.2

21.2

15.8

11.7

17.9

10.1

11.7

11

Nutrition and physical activity

Overweight (BMI 25.0–29.9)b

26.6

21.6

27.7

28.3

25

28.4

25.6

31.1

Obesity (BMI ≥30)b

24.7

16.6

25.8

28

21.7

39.6

18.2

28.2

Multivitamin usee

29.7

16.1

34.5

42.4

34.2

19.5

33

22.5

Adequate physical activityb

51.6

53.5

52.8

49.7

55.3

41

46.8

47.7

Mental health

Frequent mental distressb

13.2

12.9

13.8

12.9

12.8

15.1

12.9

13.4

Anxiety or depressione

11.2

12.1

10.9

10.4

13.2

9.8

7.9

7.3

Postpartum depressione

11.9

14.7

10.7

10

11.8

14.1

10.2

11.1

Emotional and social support

Recent physical abusee

3.8

6.7

2.6

1.9

3

5.7

3.1

5

Adequate social/emotional supportb

79.9

80.3

80

79.6

85

69.7

74.9

70.5

Adequate social support postpartumf

87

86.6

86.9

89.4

90.6

79.4

87.2

75.5

Chronic conditions

Diabetesb

3

1

2.4

4.5

2.3

5.1

3.3

3.6

Hypertensionb

10.2

4.7

8.5

14.7

9.3

19.2

7.9

8.2

Asthmab

10.7

12.9

10.2

9.8

11.3

12.3

9.8

7.7

aWhite, non-Hispanic white; Black, non-Hispanic black; others, non-Hispanic others

bBRFSS, USA

cPRAMS, 4 reporting

dPRAMS, 16 reporting

ePRAMS, 29 reporting

fPRAMS, 2 reporting

(MMWR/April 25, 2014/Bol. 63/No. 3)

CDC Recommendations on Preconception Health

In 2006, the CDC released “Recommendations to Improve Preconception Health and Healthcare – United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care” [1]. This report included ten recommendations to improve women’s health and address the problem of preterm birth, birth defects, and infant mortality through increased focus on preconception care. 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 outcomes.” The select panel also recommended to (1) encourage each woman and couple to have a reproductive life plan; (2) deliver preconception interventions as follow up to risk screening, focusing on those interventions with high population impact and sufficient evidence of effectiveness; and (3) use the interconception period to provide intensive interventions to women who have had a prior adverse pregnancy outcome (e.g., infant death, low birth weight, preterm birth).

As part of its goal to reduce infant mortality and decrease disparities in reproductive outcomes, the CDC incorporated preconception care into Healthy People 2020 and launched the Preconception Health and Healthcare (PCHHC) initiative focusing on five areas of engagement: clinical, consumer, public health, policy/finance, and surveillance/research [12]. In 2008, the clinical working group of the PCHHC published a systematic review of the evidence in support of the clinical content of preconception care. More than 30 experts reviewed over 80 topics using the strength of recommendation taxonomy approach consistent with USPSTF. This compendium of evidence has informed the distillation of preconception care into ten focused content areas of risk reduction and intervention to improve future birth outcomes: family planning, nutrition, infectious disease/immunizations, chronic disease management, medication and environmental exposures, substance use, previous pregnancy outcomes, genetic history, mental health, and interpersonal violence [13].

Barriers

Unfortunately, there remain significant barriers to successful implementation of quality preconception health. Women often do not seek reproductive healthcare prior to pregnancy, and a large proportion of women of reproductive age do not have insurance coverage until they are already pregnant [14]. When there is an opportunity in a clinical setting, there is often insufficient time to address preconception health [15]. Other health issues often take priority, and preconception care is usually not the reason for visit. When it comes to interconception care, the focus is more often on the child than on the woman’s health [16, 17]. Finally, providers may lack education, guidance, or resources on approaching preconception health issues in the continuum of care [15].

Opportunities in Primary Care

Despite evidence that managing preconception health can help to improve pregnancy outcomes, many women do not receive this care [18]. Nationally, of women aged 18–44, only 46.5% received appropriate contraceptive counseling, 45.3% with risk for infection were tested for chlamydia, 33.2% had preconception counseling. While 80.9% had their blood pressure checked, only 44.9% with obesity were counseled about ways to improve diet, and 55.2% of smokers received counseling to quit [19]. Family physicians and other primary care providers have many opportunities to interact with women of childbearing age and provide this care during well-woman exams, acute care, and chronic disease management visits, as well as when they accompany their children or partners to their visits. “It is not a question of whether you provide preconception care. Rather, it’s a question of what kind of preconception care you are providing” (Stanford and Hobbins) [20]. Making preconception health a part of routine primary care could significantly impact the health of women and future pregnancies as well as the health of infants and children.

History

Past Medical History

A thorough past medical history is the cornerstone of comprehensive primary care and equally so in the provision of preconception care. More than 25% of women of childbearing age have a chronic condition such as chronic hypertension, asthma, major depression, etc. (Table 2). It is essential that these chronic conditions be recognized and treated in the preconception period [23, 24]. For example, poorly controlled or undiagnosed diabetes resulting in hyperglycemia in the first trimester results in a fourfold increase in congenital heart defects and increased risk of pregnancy loss [25].
Table 2

Preconception Care of Common Medical Conditions

Condition

Epidemiology/natural history

Preconception interventions

Contraception strategies

Medication use

Diabetes mellitus (DM) and relationship to gestational diabetes (GDM)

One percent of pregnancies with DM and 7% with GDM. Poorly controlled DM in the first trimester associated with fourfold increase in congenital abnormalities. High rate of recurrence of GDM. Fifty percent GDM develop DM within 5 years

Strict glycemic control of DM in the first trimester reduces the risk of congenital malformation. Lifestyle modification decreases risk of developing DM among women with previous history of GDM

Avoid use of estrogen-containing birth control if patient with DM has concurrent hypertension, renal disease, or thrombophilia

Diabetic medications such as sulfonylureas, metformin, and insulin safe to use in pregnancy

Thyroid conditions

Graves (0.2% prevalence) untreated: poor outcomes

Overt hypothyroid (2.5%)

Untreated: decreased IQ and increased spontaneous AB and preterm delivery

Subclinical hypothyroidism (2–5%) associated with adverse perinatal outcomes

Hypothyroid: levothyroxine should be increased 25% as soon as pregnancy diagnosed

Subclinical hypothyroid: RCT evidence for screening and treatment lacking

Overt hypothyroidism and subclinical hypothyroidism are associated with impaired fertility and increased risk of miscarriage

Graves: avoid methimazole in the first trimester; avoid use of propylthiouracil in the second and third trimester

Hypothyroid: maintain TSH below 2.5 in the first trimester

Epilepsy

One percent of population; 3–5/1000 births; increased congenital anomalies in women who have seizures and who take antiseizure meds (two to threefold increase)

Discontinue antiseizure meds if seizure-free for 2 years; switch to meds that are less teratogenic before pregnancy such as lamotrigine and levetiracetam

Decreased efficacy of OCs when taking meds that induce liver enzymes, i.e., phenytoin and carbamazepine; use progesterone-only contraceptive methods if using these medications

Consider switching to safest alternative medication – experts do not suggest immediate cessation of therapy due to possible increased risk of seizures; use high-dose folic acid (4 mg/day) 4 weeks before and 12 weeks after conception

Chronic kidney disease (CKD)

Patients with mild CKD (creat 0.9–1.4) have good outcomes. Patients with moderate CKD (1.4–2.5) or severe (>2.5) at risk of developing worsening disease. These patients have increased risk of adverse outcomes if they have HTN

Very important to control blood pressure. Try to avoid pregnancy with moderate to severe CKD

Absolute contraindication to use estrogen OCs with CKD if they have cardiovascular disease and history of VTE and are smokers >35 and patients with liver disease. Use progesterone-only or barrier methods

Avoid use of ACEs, ARBs, and spironolactone in pregnancy

Cardiovascular disease (CVD)

Three percent of women have CVD with a 1% incidence in pregnancy. CVD is the cause of 10–25% of maternal mortality. Conditions that result in NYHA class greater than II or cyanosis at baseline prenatal visit are most predictive of increased risk of perinatal and maternal mortality

Use of warfarin in pregnancy should be avoided; instead, heparin or enoxaparin is used. With prosthetic valves, warfarin may be used in the second and third trimester. Structural heart lesions should be repaired prior to pregnancy. Certain cardiac syndromes have genetic etiology

Important to have thorough cardiac assessment/imaging prior to pregnancy to assist in risk stratification of patients at high risk of morbidity and mortality

Avoid COCs for patients with R to L shunts and ischemic disease and for patients with multiple cardiac risk factors. Progestin use is okay

Do not use warfarin in the first trimester. Avoid use of ACE, ARBs, and spironolactone in pregnancy

Hypertension (HTN)

Ten percent of women of childbearing age; women with chronic HTN at increased risk of worsening CKD, preeclampsia, and eclampsia in pregnancy

Preconception treatment of mild-to-moderate HTN results in 250 women needing treatment to prevent one fatal or nonfatal cardiovascular event such as a stroke

Combination OCs may be used in women with mild essential hypertension (140–159/90–99); copper IUD listed as preferred contraception for moderate to severe HTN

ACEs and ARBs are teratogenic and fetotoxic; should be stopped prior to conception

Asthma

Eight percent of pregnant women; 30% of women with asthma have worsening symptoms in pregnancy. Increased maternal and perinatal morbidity and mortality among women with poor control of asthma

Use of systemic steroids in the first trimester associated with threefold increased risk of oral clefts and maternal preeclampsia

Anticholinergic agents are class B and short-acting beta agonists are class C. Budesonide is class B and other inhaled corticosteroids are class C. Maternal smoking cessation is of great importance

Avoid use of systemic steroids in the first trimester. Administer influenza vaccine early in pregnancy

Thrombophilia

Factor V Leiden gene present in 5% of Caucasians; antiphospholipid antibody syndrome most common acquired condition and is more common in blacks

Thrombophilias are associated with increased risk of VTE, arterial thrombosis, and severe preeclampsia

Diagnostic testing available for high-risk populations:

FH of VTE, personal Hx of VTE; Hx of recurrent pregnancy loss, severe preeclampsia, severe IUGR

Consensus expert opinion recommends treatment for many of these conditions in pregnancy; recommend MFM consultation

Genetic counseling and targeted screening indicated for high-risk populations during preconception care

Combined OCs not recommended; progestin-only methods, IUDs, and barrier methods preferred

Use heparin or enoxaparin throughout pregnancy. Avoid use of warfarin, especially in the first trimester

Obesity

More than one third of US women are obese which is associated with increased risk of DM, HTN, CVD, OSA, and cancers (breast, uterine, colon)

Associated adverse perinatal outcomes include NTD, GDM, HTN, PTD, VTE, IUFD

Important to achieve weight loss prior to conception. Counseling alone or combined with medication can result in modest and sustained weight loss (USPSTF). Bariatric surgery prior to pregnancy is another effective intervention. This surgery is associated with increased fertility rates [21]

Clinicians need to assess obese women for comorbid conditions such as DM, HTN, and OSA and hx of VTE that markedly increase risk to women. With many of these conditions, use of combined OCs is relatively contraindicated. Increased risk of impaired fertility and early pregnancy loss

Bariatric surgery associated with decrease incidence of DM, GDM, HTN, and OSA but increased risk of preterm delivery, SGA, and NICU admissions. Increased risk of nutritional deficiencies with GI bypass surgery, less so with gastric banding [22]

Major depression/bipolar

Approximately 12% of women in both the preconception and interconception periods have major depression [11]. Victims of intimate partner abuse have a fivefold increase in major depression. Major depression in pregnancy associated with increase in PTD and low birth weight. Bipolar disease associated with increased incidence of postpartum psychosis

Optimizing depression care with medication and psychotherapy associated with improved pregnancy outcomes [20]

Victims of intimate partner abuse have higher incidence of unplanned pregnancy and high-risk sexual behavior. Consider use of long-acting reversible contraception (LARC) for patients who find it difficult to use other daily methods

Patients receiving valproic acid and carbamazepine should be placed on 4 mg of folic acid/day for 4 months prior to conception. Valproic acid should not be used in pregnancy. Avoid use of paroxetine and lithium in the first trimester. Lithium can be used in the second/third trimester

Previous Obstetrical History

Women who have had three or more spontaneous abortions should undergo additional testing to rule out thrombophilia, thyroid dysfunction, uterine anomalies, and other potential genetic syndromes. Women with a history of a spontaneous preterm delivery are at increased risk of this outcome in the next pregnancy [26]. Women with a prior history of preeclampsia, gestational diabetes, or other poor birth outcomes should have additional evaluation for chronic medical conditions such as diabetes mellitus and essential hypertension and undergo counseling on the importance of preconception and early prenatal care.

Family History

A three-generation family history can identify women who are at increased risk for genetic syndromes such as thrombophilia, coagulopathies, hemoglobinopathies, cystic fibrosis, trisomies, etc. In addition, it is important to obtain ethnicity information about both sides of the family. Genetic counselors may be of assistance for patients with positive three-generation family history screening. The carrier frequency for some of these conditions is also increased in selected ethnicities such as African, European, Ashkenazi Jewish, Mediterranean, and Asian descent [27].

Patients identified at increased risk of having a baby affected by one of these syndromes by virtue of a strongly positive family history or belonging to an ethnic group with a higher incidence of these conditions can undergo preconception expanded carrier screening. When one partner is identified to be a carrier, her partner can then undergo this same carrier screening [28].

“Cascade testing” of close relatives is often utilized to identify other family members affected by these conditions [29]. The following site provides summaries of up-to-date genetic conditions and testing recommendations: https://www.acmg.net/ACMG/Medical-Genetics-Practice-Resources/Medical-Genetics-Practice-Resources.aspx.

Social History

Poverty and the constant stressors associated with housing and food insecurity are the norm in many clinical settings. It is important that women living in poverty are given clear instruction and logistical assistance to access available social service resources. These resources vary from community to community, and the clinical team should be actively involved in linking patients to these resources.

Women who are currently experiencing or have a history of intimate partner violence are at marked increase of physical and emotional injury. A national survey in the late 1990s estimated that approximately 4.8 million partner rapes and physical assaults occur in the USA on an annual basis [30]. It is important to screen for exposure to violence routinely in the office setting. The CDC has extensive resources at https://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf.

Smoking exerts deleterious effects on the current and future health of women and future pregnancies. Although smoking rates have been declining in the USA since 1990, an estimated 18.7% of non-pregnancy reproductive-aged women were smoking in 2009 [31].

Women using illicit drugs have a higher incidence of medical, psychiatric, psychosocial, and infectious comorbidities. Illicit drug use/abuse is common in rural and urban settings, often putting women at increased risk of significant morbidity and mortality. Ten percent of women of reproductive age report illicit drug use in the past month [12].

Approximately 54% of non-pregnant women of childbearing age consume alcohol and approximately 15.2% binge drink [12]. Women with alcoholism are at marked increased risk for adverse future pregnancy outcomes because alcohol is both a teratogen and fetal toxic agent. There is no known safe level of alcohol ingestion in pregnancy.

Medication History

It is important to review all prescribed and over-the-counter medications and to note which ones could exert teratogenic effects on the developing embryo. About 10–15% of congenital birth defects are thought to be caused by teratogenic exposure. Many anticonvulsant agents, most notably valproic acid and carbamazepine, markedly increase the incidence of neural tube defects. A valuable source for identifying prescriptive and OTC medications that pose risks to the developing embryo can be found at https://mothertobaby.org/fact-sheets-parent/.

Environmental History

Women should be assessed for exposure to major environmental agents including mercury, lead, hydrocarbons, bisphenols (organic compounds with estrogenic properties), and nitrates. These exposures may come from the workplace, hobbies, exposure from well water, contact from plastic containers (#7 plastic containers), or dietary sources (ingestion of large game fish). Clinicians and patients both need to be conversant about these common exposures in the environment [32].

Physical Examination

The physical exam, in combination with a thorough history, offers the best opportunity to diagnose chronic medical conditions that can adversely impact a woman’s current or future health.

Nutritional Status

When conducting the preconception physical examination, the clinician should determine the patient’s BMI. Underweight women will have a BMI less than 19.8, while obese women will have a BMI greater than 30. Both of these extremes should trigger more extensive nutritional assessments/screening for eating disorders. Obese women have increased risk of developing hypertension, diabetes, cardiovascular disease, infertility, sleep apnea, and breast/uterine/colon cancer. Health risks of women with low BMIs include nutrient deficiencies, cardiac arrhythmias, osteoporosis, amenorrhea, and infertility [33].

It is important to ask patients about their use of dietary and nutritional supplements. Between 18% and 52% of women of childbearing age consume some kind of OTC dietary supplements. Excessive amounts of the fat-soluble vitamin A (>10,000 IU/day) may be teratogenic and can result in cranial and neural crest defects [21].

The Obesity Epidemic

One third of women are obese. Obesity is associated with an increased risk of type 2 diabetes, hypertension, cardiovascular disease, and other comorbid conditions. Maternal cardiovascular disease is the greatest contributor to maternal mortality. Behavioral, medical, and physical activity therapies aimed at losing 5–10% of total body weight over a 6-month period prior to pregnancy are thought to be realistic.

The provision of long-acting reversible contraception (LARC) to obese women is both safe and effective. The use of emergency contraception and the use of the contraceptive patch are less effective. The use of combined oral contraceptives for obese women is associated with a five- to tenfold increase in venous thromboembolism [22].

Bariatric surgery often leads to greater weight loss. A meta-analysis of 33 studies with 14,880 pregnancies that occurred after bariatric surgery and close to 4 million controls showed an increase for perinatal mortality (OR = 1.38, CI 1/03–1.85), congenital anomalies (1.29, CI 1.04–1.59), preterm birth (OR 1.57, CI 1.38–1.79), and NICU admission (OR 1.41, CI 1.25–1.59). These data suggest the need for specific preconception and prenatal nutritional support and increased fetal surveillance during pregnancies that follow bariatric surgery [34].

Standard Nutritional Recommendations

Women should be counseled on the importance of consuming a healthy, well-balanced diet that is high in fruits and vegetables with a low amount of refined carbohydrates and processed food. Women without a history of a previous pregnancy complicated by a neural tube defect (NTD) should be placed on a multivitamin supplement containing at least 400 mcg of folic acid. This is not only effective in preventing 70% of future neural tube defects but also results in a decreased incidence of limb, cranial facial, and urologic congenital birth defects [35]. Women with a previous history of an infant with a NTD require a much higher amount of daily supplementation with folic acid of 4000 mcg [36].

Vaccine Preventable Infections

Women of reproductive age should be counseled about vaccine preventable infections and offered appropriate immunizations according to the CDC ACIP recommendations [37, 38]. Particularly important for preconception health are hepatitis B, rubella, varicella, annual influenza, and HPV (for those aged 11–26 years).

Sexually Transmitted Infections (STIs)

It is important for the clinician to develop skills in taking a thorough and sensitive history that identifies a patient’s gender identity, sexual orientation, sexual history, and practices. The USPSTF has established screening and counseling recommendations for the following STIs: chlamydia, gonorrhea, hepatitis B, hepatitis C, herpes simplex, syphilis, and HIV. For patients at increased risk of contracting HIV, the use of once-daily treatment with tenofovir/emtricitabine (Truvada) is FDA approved for pre-exposure prophylaxis and is recommended by the USPSTF [39].

Laboratory Evaluation

Women should be screened for diabetes according to current USPSTF guidelines. Screen for anemia for patients with a history of excessive menstrual blood loss, those whose physical exam is suggestive of anemia, or whose family history is positive for hemoglobinopathy.

Strategies for the Prevention of Adverse Birth Outcomes

The traditional approach of addressing maternal risk factors through a single preconception visit has failed to improve birth outcomes. Current recommendations focus on integrating preconception screening, risk reduction, and health promotion into all routine healthcare encounters for women with childbearing potential, regardless of pregnancy intention. Visits for preventive and routine gynecologic care provide natural opportunities for risk reduction, health promotion, and family planning. However, encounters for pregnancy testing, treatment of sexually transmitted infections, and management of chronic medical conditions provide unique opportunities for the delivery of preconception care and counseling. In each setting, advice should be tailored to the needs of patient based on individual attitudes, beliefs, preferences, and stage in the reproductive life span [1].

The Reproductive Life Plan

A key strategy for preconception health promotion is the development a reproductive life plan. Family physicians should encourage all men and women to explore their intention to conceive in the short and long term, taking into consideration their personal values and life goals. Once developed, patients should be educated about how their reproductive life plan impacts their contraceptive and medical decision-making. Because planned pregnancies are associated with improved outcomes for mothers and infants, women should be encouraged to make intentional decisions regarding the number and timing of pregnancies. The CDC has developed resources to assist healthcare providers and patients with developing a reproductive life plan which can be accessed at https://www.cdc.gov/preconception/planning.html.

Reducing Disparities

Family physicians should be aware that women of color are at increased risk for adverse pregnancy outcomes for both mother and baby. The cause appears to be multifactorial, and sociodemographic factors alone do not fully explain racial disparities in birth outcomes [40]. However, a large analysis of 2016 US birth certificate data revealed that the known portion of the disparity in preterm births between non-Hispanic black and white women was driven by sociodemographic and preconception/prenatal health factors [41]. This suggests that preconception interventions targeting these risk factors could potentially reduce racial disparities and improve perinatal outcomes. Other factors likely to contribute to disparities include unequal access to reproductive health services and a lack of comfort among women of color interfacing with the healthcare system. The Black Mamas Matter Alliance (https://blackmamasmatter.org), The National Latina Alliance for Reproductive Health (https://www.latinainstitute.org) and other organizations within the reproductive justice movement advocate at the national level to expand access to contraceptive services, prenatal and pregnancy care, and pregnancy termination services for women of color, work to eliminate systematic bias, and increase the voice of women of color within the healthcare system.

Novel Approaches to Preconception Care

In response to the lack of improvement in birth outcomes at the state and national level, many novel strategies for delivering preconception education, screening, and intervention have been developed including the following examples:
  • The Grady Memorial Hospital Interpregnancy Care Program (Atlanta, Georgia) – In this groundbreaking program, low-income African American women with a history of very low-birth-weight delivery received individualized primary care services, intensive case management, and social support from multidisciplinary teams for 24 months following delivery. A significant reduction in rapid repeat pregnancies and adverse subsequent birth outcomes was achieved with an estimated net cost savings of $2397 per participant. The Grady program has been recognized as a successful model for improving birth outcomes by reducing disparities [42].

  • One Key Question® (Power to Decide) – This initiative, originally developed by the Oregon Foundation for Reproductive Health, encourages all primary care providers to routinely ask women ages 18–50 “Would you like to become pregnant in the next year?” This question facilitates a conversation between providers and patients in which reproductive needs and preferences are explored [43]. Women are then offered essential preventive services based on identified needs (https://powertodecide.org/one-key-question).

  • The North Carolina Statewide Multivitamin Distribution Program – This innovative program provided multivitamins with folic acid to low-income, non-pregnant women of childbearing potential to help prevent birth defects. Reported use doubled over a 10-month period among a sample of women receiving multivitamins through this program [44] (http://everywomannc.org/public-health/multivitamin-program/).

  • The IMPLICIT Network – This collaborative of Eastern US family medicine and pediatric residency programs and community partners has implemented an evidence-based interconception screening and risk reduction intervention for mothers bringing their infants for well-child visits. Quality improvement techniques are used to improve care delivery, and future primary care physicians are trained in best practices (www.fmec.net/implicit.htm). The IMPLICIT ICC Toolkit is accessible at https://www.marchofdimes.org/professionals/implicit-interconception-care-toolkit.aspx.

  • Nurse-Family Partnership – This program partners low-income, first-time mothers with a registered nurse early in pregnancy. Participating women receive ongoing nurse home visits through their child’s second birthday. Nurses help mothers access good preventive and prenatal care, provide parenting support, and encourage self-sufficiency by helping mothers plan future pregnancies, continue their education, and find work (www.nursefamilypartnership.org).

  • Show Your Love” Campaign – This social marketing campaign launched by the CDC Preconception Health and Healthcare Initiative encourages women of childbearing age to maintain good health, reduce health risks, and make intentional decisions about pregnancy (https://showyourlovetoday.com).

Preconception Care and the Family

The health of a woman is interdependent with the health and well-being of her family. A woman’s health is influenced by her family’s medical history, culture, and view of health and illness. Some maternal risks for poor birth outcomes such as poor nutrition, smoking, and depression are associated with adverse effects for family members, especially children. The birth of a premature or critically ill newborn has a significant impact on family members. Parents experience stress related to uncertainty of the outcome, increased time away from work, financial burdens, and little time to spend with one another. Older children often experience anxiety due to separation from their parents, disruption of the family schedule, and a limited understanding of the newborn’s condition. Family physicians should consider family values, beliefs, and influences (both positive and negative) when delivering preconception care emphasizing the goal of improving the health of all family members.

Preconception Issues for Men

Preconception care for men engages them in achieving planned, healthy pregnancies with their partners. Like women, men should be encouraged to develop a reproductive life plan to guide decisions about reproductive health. The CDC recommends that all men have a preventive care visit prior to conception to promote physiologic and emotional wellness, manage chronic health conditions, and educate men about the importance of avoiding sexually transmitted infections, substances, and toxic exposures. Men should be made aware of factors that can lead to decreased fertility and how to avoid them. Family physicians should also counsel men on the importance of supporting their partner in efforts to adopt a healthy lifestyle, follow treatment plans for chronic conditions, and take responsible steps to ensure planned, appropriately spaced pregnancies [45].

Key Preconception Care Partnerships and Resources

Family physicians should become familiar with the resources and partnerships in their community that provide preconception services for women. Examples include the local Health Department, Healthy Start Programs, Planned Parenthood, and WIC. State chapters of the March of Dimes also support programs that improve preconception health. Many national organizations have developed extensive preconception resources for clinicians:
  • Center for Disease Control and Prevention, Preconception Health and Healthcare – Information for Health Professionals – summary of the content of preconception care for women and men, reproductive life planning tools, index of state and local resource, and collection of useful articles (https://www.cdc.gov/preconception).

  • The National Preconception Curriculum and Resource Guide for Clinicians developed by the Preconception Health and Healthcare Initiative – includes the National Preconception/Interconception Care Clinical Toolkit, online continuing education modules, and a point of care mobile app (http://beforeandbeyond.org).

  • National Healthy Start – HRSA-funded, locally administered programs that connect pregnant women and new mothers in at-risk communities with healthcare and support services through the child’s first 2 years of life (www.nationalhealthystart.org).

  • National March of Dimes, Resources for Professionals – includes prematurity prevention resources, genetic risk assessment tools, birth outcome statistics (PeriStats), and patient education resources (https://www.marchofdimes.org/professionals/professionals.aspx).

  • Power to Decide (formerly The National Campaign to Prevent Teen and Unplanned Pregnancy) – information and resources for women, clinicians, and organizations with a goal of reducing unwanted pregnancy. Resources include the One Key Question™ clinician tool, Bedsider digital patient education resource, #Talking is Power Toolkit aiming to spark meaningful conversations between young people and trusted adults, a repository of contraception access data, and resources that support advocacy.

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Copyright information

© Springer International Publisher Switzerland 2020

Authors and Affiliations

  • Stephen D. Ratcliffe
    • 1
    Email author
  • Stephanie E. Rosener
    • 2
  • Daniel J. Frayne
    • 3
  1. 1.Lancaster Health CenterLancasterUSA
  2. 2.United Family Medicine Residency ProgramAllina HealthSaint PaulUSA
  3. 3.MAHEC Family Health Center at BiltmoreMountain Area Health Education CenterAshevilleUSA

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