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Merry-K. Moos, RN, FNP (retired), MPH, FAAN 3.0 contact hours Preconception Health Promotion : The Foundation for a Healthier Tomorrow Note: To use the.

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1 Merry-K. Moos, RN, FNP (retired), MPH, FAAN 3.0 contact hours Preconception Health Promotion : The Foundation for a Healthier Tomorrow Note: To use the links in this module it must be in Slide Show view. See slide 4 for instructions.

2 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Slide 2 Content s 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 #CEP contact hours are available for this activity through November 1, 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.marchofdimes.com/nursing

3 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Slide 3 Content s 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. Author bio and disclosure 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Slide 4 Content s Navigation and links Open the Slide Show view The module must be in the Slide Show view for the navigation buttons and links to work. Depending on your computer settings and software, there are several ways to do this: Click the small slide show button ( ) next to the zoom slider on the bottom right hand corner of the PowerPoint screen. Press the F5 key. Click Slide Show on the PowerPoint ribbon at the top of the page. Then click View Show or From Beginning. Use the navigations buttons and links Click the purple buttons at the bottom of each slide to move around within the module. Click the links on the Contents page to:Contents See the Guidelines and References Print the module (PDF) Take the continuing education test

5 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Slide 5 Content s Contents Accreditation Author bio and disclosure Navigation and links Module purpose Module objectives Objective 1 Objective 2 Objective 3 Guidelines and references (PDF) Print this module (PDF) Independent study test

6 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Slide 6 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Slide 7 Content s After studying this module, the nurse will be able to: 1. Explain the rationale and history of the preconception health movement 2. Identify preconception influences on womens health and pregnancy outcomes and identify appropriate evidence-based clinical care recommendations 3. Describe a framework for incorporating preconception care into clinical practice Module objectives

8 Slide 8 Content s Objective 1: Explain the rationale and history of the preconception health movement

9 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 9 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 10 Content s Rationale for preconception health promotion Table 1. Influences on pregnancy outcomes that predate conception Pregnancy intendedness Interpregnancy interval Maternal age Use of assisted reproduction Maternal nutritional status General health status Exposures to substances such as tobacco, alcohol, prescription, nonprescription and illicit drugs 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).

11 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 11 Content s 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. o The period of organogenesis (when organs are formed) begins just 3 days after the first missed menstrual period. o Organogenesis is complete around the 56th day after conception: 8 weeks by conception date and 10 weeks by menstrual date. o 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. o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 12 Content s The preconception movement in the United States Table 2. Preconception timeline YearEvent 1983The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), in partnership with the March of Dimes Birth Defects Foundation, introduced the concept of preconception health in its first edition of Guidelines for Perinatal Care (AAP & ACOG, 1983). 1985The Institute of Medicine (IOM) noted that numerous opportunities to reduce the incidence of low birthweight exist before pregnancy, but they are often overlooked in favor of prenatal interventions. The publication Preventing Low Birthweight outlined risk identification, counseling and interventions to address risks and health education as important prepregnancy activities (IOM, 1985). 1990In Healthy People 2000, the U.S. Department of Health and Human Services (U.S. DHHS) delivered national health promotion and disease prevention objectives for the nation, including preconception services as a standard expectation of the health care system (U.S. DHHS, 1990). (Continued on next slide)

13 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 13 Content s The preconception movement in the United States Table 2 (continued). Preconception timeline YearEvent 1993The March of Dimes published Towards Improving the Outcome of Pregnancy that called for annual preconception or interconception risk reduction visits for every woman from menarche to menopause. It also noted that preconception health services should not be limited to women and that innovative strategies to reach men with information on reproductive awareness are needed (March of Dimes, 1993). 1995ACOG published its first technical bulletin on preconception care, calling for the thorough and systematic identification of prepregnancy risks, provision of education individualized to the specific womans needs and initiation of risk reduction interventions. ACOG took the position that rather than ensuring a healthy pregnancy outcome, preconception care allows women(and their partners) to make informed decisions about which, if any, reproductive risks they are willing to accept (ACOG, 1995). 1995ACOG cautioned against targeting preconception care only to women planning a pregnancy, noting that women who experience an unintended pregnancy are as likely to have risk factors as women who plan to become pregnant (ACOG, 1995). (Continued on next slide)

14 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 14 Content s The preconception movement in the United States Table 2 (continued). Preconception timeline YearEvent 1994 & 2003 The March of Dimes published Preconceptional Health Promotion (Moos, 1994) and Preconception Health Promotion: A Focus on Womens Wellness (Moos, 2003). The 2003 publication noted that preconception health promotion is a perfect fit for the nursing profession: The nations emerging interest in preconception health promotion presents an ideal opportunity for nurses to assume leadership roles in a new facet of womens health care. The nursing profession is grounded in helping people achieve the highest level of wellness possible, given their current realities. This is the essence of preconception health promotion. (Moos, 2003, p. 62) 2005 & 2006 The Centers for Disease Control and Prevention (CDC) convened a Select Panel on Preconception Care and Health Care. Its recommendations drew attention to preconception health as a womans health issue and have served as a blueprint for changing the nations perinatal prevention paradigm to one that starts before pregnancy. The Select Panels definition of preconception health states: Preconception care is a set of interventions that aim to identify and modify biomedical, behavioral and social risks to a womans health or pregnancy outcome through prevention and management (CDC, 2006, p. 3).

15 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 15 Content s CDC Select Panel on Preconception Care and Health Care Table 3. CDC Select Panel goals for the preconception initiative 1.Improve knowledge, attitudes and behaviors of men and women related to preconception health 2.Ensure that all women of childbearing age receive preconception care services 3.Reduce risks identified by a previous poor pregnancy outcome 4.Reduce disparities in pregnancy outcomes 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 16 Content s CDC Select Panel on Preconception Care and Health Care Table 4. CDC Select Panel recommendations especially relevant for nurses caring for women of childbearing age Encourage each man, woman and couple to have a reproductive life plan. Provide preconception assessment, education and health promotion counseling to all women of childbearing age as a part of routine primary care visits. Increase public awareness of the importance of preconception health behaviors and services by using information and tools appropriate to various ages, literacy skills and cultural/linguistic contexts. Use the interconception period to identify risk factors for future poor pregnancy outcomes among women who have experienced a poor outcome, and offer services that have the potential to reduce risks for poor outcomes. Integrate components of preconception health into existing local public health and related programs, including an emphasis on interconception interventions for women with previous poor pregnancy outcomes. A complete list of recommendations and action steps is available at under the tab Key Articles and Guidance.

17 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 17 Content s CDC Select Panel on Preconception Care and Health Care Table 6. CWG initiatives Publication of The Clinical Content of Preconception Care by Jack and Atrash in 2008 Development of the National Preconception Curriculum and Resources Guide for Clinicians, Before, Between & Beyond Pregnancy available at Table 5. Workgroups The five workgroups are organized around: Clinical guidelines, tools and recommendations Public health strategies Consumer involvement, input and impact Policy and finance Research, surveillance and data analysis 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 18 Content s Emerging paradigms for preventive health care Something to think about… How early in the life cycle do determinants of poor health and poor pregnancy outcomes begin to exercise their influences? Something to think about… How early in the life cycle do determinants of poor health and poor pregnancy outcomes begin to exercise their influences? Complementing and, in part, stimulated by the national preconception movement, are two emerging paradigms for reframing opportunities for prevention for women and their offspring: 1.Womens preventive health framework 2.The life course framework

19 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 19 Content s Womens preventive health framework: Overview The nations approach to the clinical care of women is fragmented, inefficient, and, too often, incomplete and ineffective. Moos, 2009, p.427 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).

20 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 20 Content s Womens preventive health framework: Overview Table 7. Examples of the connection between womans preconception health risks and pregnancy outcomes Health risk: Tobacco useHealth risk: Obesity The leading cause of death for women. It can lead to: Heart disease Cardiovascular accidents Lung cancer Other lung diseases The leading contributor to disabilities and death in women. It can lead to: Type 2 diabetes mellitus Essential hypertension Cardiovascular disease Joint deterioration In pregnancy, it is associated with: Infant mortality Premature birth Low birthweight Placental abnormalities In pregnancy, it is associated with: Gestational diabetes mellitus Pregnancy-induced hypertension Increased rates of thrombophlebitis Increased rates of neural tube defects Premature birth Conclusion: Smoking cessation has lifelong benefits for a woman and her offspring, regardless of pregnancy or pregnancy intention. Conclusion: Weight control has lifelong benefits for a woman and her offspring, regardless of pregnancy or pregnancy intention. Moos, 2008

21 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 21 Content s Womens preventive health care strategies 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 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 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 o 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). o Californias Every Woman, Every Time campaign (Cullum, 2003) became a model for encouraging opportunistic care in other states.

22 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 22 Content s 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: o 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. o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 1: Rationale and history. Slide 23 Content s 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: 1.Early programming model o 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. o 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. 2.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 Slide 24 Content s Objective 2: Identify preconception influences on womens health and pregnancy outcomes and identify appropriate evidence-based clinical care recommendations

25 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 25 Content s Key preconception influences Something to think about… How can the nurse know what specific information and services to provide? Principles of evidence-based care can help. Something to think about… How can the nurse know what specific information and services to provide? Principles of evidence-based care can help. 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

26 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 26 Content s 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: o Conducting a literature review of more than 200 health topics related to preconception care o Assessing whether or not the composite research related to a topic suggests or proves there are benefits to addressing that topic before pregnancy o Assigning a specific recommendation to each topic based on the likely advantage to pregnancy outcomes if the topic is addressed before pregnancy

27 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 27 Content s Assigning recommendations based on the evidence Table 8. Grading the evidence GradeMeaning A Good evidence that addressing the topic in preconception care is beneficial B Fair evidence that addressing the topic in preconception care is beneficial I Insufficient evidence to determine if addressing the topic is beneficial D Fair evidence that addressing the topic will not be beneficial E Good evidence that addressing the topic will not be beneficial Jack et al., 2008 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 28 Content s Quality of the research Something to think about… Why might it be unethical to conduct a randomized trial involving pregnant women? Something to think about… Why might it be unethical to conduct a randomized trial involving pregnant women? While specific clinical recommendations should be 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).

29 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 29 Content s Quality of the research Table 9. Understanding the quality of the research GradeMeaning I-a Evidence includes at least one properly conducted randomized controlled trial done before pregnancy. I-b Evidence includes at least one properly conducted randomized controlled trial done after conception. II-1 Evidence comes from at least one well-designed controlled trials without randomization. II-2 Evidence comes from at least one well-designed cohort or case-control studies results. II-3 Evidence comes from multiple time series with or without interventions or from uncontrolled experiences with dramatic results. III Opinions gathered from respected authorities based on clinical experience, descriptive studies and case reports or reports of expert committees.

30 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 30 Content s Clinical emphases of preconception care Table 10. Clinical emphases of CWG recommendations Providing protectionAvoiding harmful exposuresManaging conditions Includes: Weight and nutrient management, including folic acid Efforts to avoid unintended pregnancies Efforts to avoid short interconception intervals Immunizations Includes: Identification of and counseling and referral for use of tobacco, alcohol, illicit drugs and prescription medications Avoidance of teratogenic prescription drugs Includes: Identification of chronic diseases Strategies to ensure that disease and therapies are best suited to healthy reproductive outcomes Strategies to ensure that future conceptions are planned in consultation with health care providers 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 31 Content s Opportunities for nurses The next several slides provide illustrations of incorporating selected preconception health topics into nursing care. Each illustration: o Builds upon one of the three clinical emphases o Presents background information on the topics significance to the health of the woman and, should the woman become pregnant, her pregnancy and future offspring o 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: (go to the Key Articles and Guidance tab).www.beforeandbeyond.org

32 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 32 Content s 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] >25) (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). Table 11: BMI BMIWeight status Below 18.5Underweight 18.5 – 24.9Normal 25.0 – 29.9Overweight 30.0 and AboveObese CDC, 2011

33 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 33 Content s Providing protection: Nutrition/Overweight Table 12. Risks associated with obesity Womens health risksPregnancy complications Chronic diseases Some cancers Sleep apnea Gall bladder disease Immobility Osteoarthritis Higher rates of infertility Neural tube defects Preterm birth Fetal death Gestational diabetes mellitus Macrosomia Pregestational and pregnancy induced hypertension Thromboembolic complications of gestation Cesarean births Shoulder dystocias Moos et al., 2008Gardiner et al., 2008

34 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 34 Content s Providing protection: Nutrition/Overweight Grades Strength of evidenceA Quality of evidenceIII 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 >25 about the risks, including infertility, for exceeding the overweight category for their own health and for future pregnancies. Offer women specific behavioral strategies to decrease caloric intake and increase physical activity. Encourage women to consider enrolling in structured weight loss programs.

35 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 35 Content s Providing protection: Nutrition/Underweight Table 13. Risks associated with underweight women Womans health risks Pregnancy complications Nutrient deficiencies Heart irregularities Osteoporosis Amenorrhea Infertility Preterm birth Low birthweight Intrauterine growth restriction Birth defects Gardiner et al, 2008; Moos et al., 2008 Statement of the problem In 2009, 4.5 percent of women who became pregnant were under- weight (BMI <18.5) (Reinhold, 2011). Because this rate is based on pregnancy and excludes all women who developed infertility due to their weight, it does not reflect the 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 36 Content s Providing protection: Nutrition/Underweight Grades Strength of evidenceA Quality of evidenceIII 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 (<18.5) 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 37 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 38 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 39 Content s Providing protection: Folic acid Table 14. Folate-rich foods Orange juice Melon Broccoli Fortified cereals Spinach Asparagus Lentils Peas Grades Strength of evidenceA Quality of evidenceI-a 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). o Supplements can be over-the-counter multivitamins or a supplement of only folic acid. o 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 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 40 Content s Table 15. Folic acid awareness, 2008 Eighty-four percent of women ages 18 to 45 have heard of folic acid. Of these: 39 percent reported taking a vitamin containing folic acid daily 20 percent mentioned that folic acid prevents birth defects 11 percent mentioned that women should take folic acid before pregnancy March of Dimes, 2011b 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). Providing protection: Folic acid 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? 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 41 Content s 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: o Forty-four percent end in birth. o Forty-two percent end in abortion. o 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? 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 42 Content s Providing protection: Preventing unintended pregnancies Table 16. Unintended pregnancy Groups with the highest rates Age 18 to 24 Unmarried, particularly cohabitating Low-income Have not completed high school Members of a minority group Finer & Zolna, 2011 Associated with Increased likelihood of abortion Exposures to potentially harmful substances Poor pre-pregnancy disease control Late entry to prenatal care Increased likelihood of low birth weight offspring Maternal depression Reduced school completion and lower income attainment in unmarried women Brown & Eisenberg, 1995 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 43 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 44 Content s Providing protection: Preventing unintended pregnancies Table 17. Reproductive life plans Use of a reproductive life planning framework can facilitate patient-centered contraceptive care by providing a structure for: Communicating with patients about their reproductive goals Helping patients understand their pregnancy risks Matching contraceptive choices to patients personal goals Developing strategies to help patients effectively access and use their chosen method Providing timely preconception health care Moos, 2002, 2010 Grades Strength of evidenceA Quality of evidenceIII

45 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 45 Content s Providing protection: Avoiding short interpregnancy intervals (IPIs) Table 18. Poor pregnancy outcomes associated with short and long IPIs Growth restriction Preterm birth Low birthweight 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 59 months are significantly associated with poor pregnancy outcomes (Table 18) (Conde- Agudelo, Rosas-Bermudez & Kafury-Goeta, 2006). o The study suggests that IPIs 59 months increase the risk of fetal and early neonatal death. o For each month the IPI is <18 months, the risk for poor outcomes increases; for each month the IPI increases beyond 59 months, risks become greater.

46 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 46 Content s Providing protection: Avoiding short IPIs Statement of the problem (continued) o 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. Grades Interpregnancy intervals were not specifically addressed by the CDC/ Select Panels Clinical Work Group (Jack et al., 2008).

47 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 47 Content s 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: o Protect the fetus from congenital infections (e.g.,varicella) o Prevent perinatal transmission of infection (e.g., hepatitis B) o May prevent premature birth (e.g., vaccines that prevent human papillomavirus [HPV] infections) o Protect against severe neonatal disease (e.g., varicella, pertussis and tetanus) o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 48 Content s Providing protection: Immunizations Table 19. When is it safe for women to get vaccinations? Vaccination Before pregnancy During pregnancy After pregnancy Recommended for all women Flu (once a year) HPV (human papillomavirus) Recommended up to age 26 x MMR (measles, mumps, rubella) x Tdap (tetanus, diphtheria, pertussis) If youre not already vaccinated, you can get this vaccine after 20 weeks of pregnancy. Varicella (chickenpox) x Recommended for women at high risk of getting these infections Hepatitis A x Hepatitis B x Meningococcal x Pneumococcal x March of Dimes, 2011e

49 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 49 Content s Providing protection: Immunizations Something to think about… How do immunizations fit into the life course framework? Something to think about… How do immunizations fit into the life course framework? 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 can prevent 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).

50 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 50 Content s Providing protection: Immunizations Grades Strength of evidenceA Quality of evidenceIII Grades Strength of evidenceB Quality of evidenceII-2 Specific recommendations for providers about immunization status (Coonrod et al., 2008; Moos et al., 2008) Review the immunization status of all women of reproductive age for o Tetanus-diphtheria toxoid/diphtheria-tetanus-pertussis o Measles, mumps and rubella o Varicella Assess all women annually for lifestyle and occupational risks for infection and offer women 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 51 Content s Avoiding harmful exposures: Tobacco use Table 20. Tobacco use and associated increased risks General womens health Womens reproductive health Pregnancy complications Fetal/Neonatal complications Lung, cervical, pancreatic, bladder and kidney cancers Cardiovascular diseases, including stroke Osteoporosis Pulmonary disease, including chronic obstructive pulmonary disease and asthma Infertility Dysmenorrhea Secondary amenorrhea Menstrual irregularities Early menopause Placenta previa Placental abruption Ectopic implantation Spontaneous abortion Vaginal bleeding Stillbirth Intrauterine growth restriction (IUGR) Premature birth Low birthweight Birth defects Sudden infant death syndrome (SIDS) Floyd et al., 2008; Moos et al., 2008ACOG, 2007U.S. DHHS, 2004Floyd et al., 2008; Kearney, 2008 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 52 Content s 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: o Protecting a womans short- and long-term health o Decreasing the likelihood a woman will resume smoking in the postpartum period o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 53 Content s Avoiding harmful exposures: Tobacco use Table 21. The 5As Ask Advise Assess Assist Arrange Grades Strength of evidenceA Quality of evidenceI-a 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: o Counseling that describes the benefits of no tobacco use before, during and after pregnancy. o Discussion of NRT and other medication therapies. o Referral to more intensive services (individual, group, or telephone counseling), if the woman is willing.

54 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 54 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 55 Content s 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). o Estimates of the prevalence of FASD is between 0.3 to 2 cases per 1,000 live births (Floyd et al., 2008). o FASD includes fetal alcohol syndrome (FAS). FAS is characterized by growth restriction, physical anomalies and neurodevelopmental abnormalities, including intellectual disabilities (Kearney, 2008). o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 56 Content s 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. Grades Strength of evidenceA Quality of evidenceIII Something to think about… What are the hazards of obtaining alcohol histories on selected patients? How can these risks be eliminated? Something to think about… What are the hazards of obtaining alcohol histories on selected patients? How can these risks be eliminated?

57 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 57 Content s Avoiding harmful exposures: Illegal drugs Table 22. Fetal and neonatal effects of illegal drug use Cocaine Placental abruption Premature birth Low birthweight Neonatal withdrawal Marijuana Increased startle response Tremors Disturbed sleep patterns Kearney, 2008 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 58 Content s Avoiding harmful substances: Illegal drugs Grades Strength of evidenceC Quality of evidenceIII 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 59 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 60 Content s 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. o 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). o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 61 Content s 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): o Complex considerations that should accompany prescribing med- ication for women of childbearing potential are oversimplified. o Risk is undifferentiated between trimesters of exposure. o Letters in the system suggest a gradation of risk when, in fact, they summarize the level of evidence available. o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 62 Content s Avoiding harmful exposures: Prescription and over-the counter drugs Table 23. FDA risk classification for medication safety in pregnancy AAdequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. BAnimal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well controlled studies in pregnant women; or animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus. CAnimal studies have shown an adverse effect and there are no adequate and well- controlled studies in pregnant women; or no animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women. DAdequate, well-controlled or observational studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. XAdequate, well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. The use of the product is contraindicated in women who are or may become pregnant. Dunlop, Gardiner, Shellhaas, Menard & McDiarmid, 2008

63 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 63 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 64 Content s Avoiding harmful exposures: Prescription and over-the counter drugs Grades Strength of evidenceA Quality of evidenceII-2 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 65 Content s Avoiding harmful exposures: Prescription, over-the-counter and other drugs Grades Strength of evidence C Quality of evidenceIIl Grades Strength of evidenceA Quality of evidenceIII 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 66 Content s 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 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 67 Content s Avoiding harmful exposures: Illicit use of prescription drugs 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? 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? 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. Grades Prescription drug abuse was not included in the Clinical Content of Preconception Care (Jack et al., 2008), so grades on the strength and quality of evidence are not available.

68 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 68 Content s Managing medical conditions: Overview Table 24. Rates of chronic health conditions in women age 18 to 44 Diabetes5 percent Heart disease2 percent Hypertension11 percent Thyroid disease12 percent Asthma and other respiratory diseases 14 percent Depression/anxiety23 percent Ranji & Salganicoff, 2011 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 69 Content s Managing medical conditions: Overview Table 25. Minimizing risks during pregnancy Optimize disease control in preparation for pregnancy. Change a potentially teratogenic treatment to one safer for the fetus. Educate the woman about how pregnancy might affect her short- and long-term health and the health of her offspring. Address routine health promotion and disease prevention activities in chronic disease visits (e.g., counseling about weight, addressing alcohol and tobacco use, recommending folic acid supplementation, assessing immunization status). Encourage postponing pregnancy until chronic disease is in optimal control. o 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). o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 70 Content s Managing medical conditions: Overview Information on these and other conditions reviewed by the CWG is available at under Articles and Guidance.www.beforeandbeyond.org o Asthma o Cardiovascular disease o Diabetes mellitus o Hypertension o Phenylketonuria o Psychiatric conditions o Rheumatoid arthritis o Seizure disorders o Systemic lupus erythematosus (SLE) o Thrombophilia o Thyroid disease The following slides discuss the preconception management of two common chronic conditions: diabetes mellitus (DM) and hypertension (HTN).

71 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 71 Content s 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: o Central nervous system anomalies, such as NTDs and anencephaly o Complex cardiac defects o Skeletal malformations

72 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 72 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 73 Content s Managing medical conditions: DM Grades Strength of evidenceA Quality of evidenceI 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 74 Content s Managing medical conditions: DM Something to think about… What contribution does adding a nurse to the care team provide? Something to think about… What contribution does adding a nurse to the care team provide? 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.

75 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 75 Content s Table 26. Complications of Chronic HTN MaternalFetal Preeclampsia Eclampsia Central nervous system disease Cardiac disease Deterioration of renal function Preterm birth Intrauterine growth restriction Placental abruption Fetal death Dunlop, Jack et al., 2008 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). Managing medical conditions: Hypertension (HTN)

76 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 76 Content s 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 77 Content s Managing medical conditions: HTN Grades Strength of evidenceA Quality of evidenceII-2 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? 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? 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.

78 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 78 Content s Other important nursing considerations in each of the three key areas 1.Providing protection: sexually transmitted infections, psychosocial stressors; against repeat poor pregnancy outcome 2.Avoiding harmful exposures: environmental exposures, psychosocial stressors 3.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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 2: Preconception influences. Slide 79 Content s Additional resources on preconception care valuable for nursing practice: Before, Between and Beyond, the National Curriculum and Resources Guide for Clinicians CDCs Preconception Health and Health Care Topics Initiatives for specific states/regions o Every Woman California o CO Preconception and Interconception Care Guideline o Every Woman Florida o Every Woman Southeast How to learn more about the content of preconception health care? Something to think about… What is your state doing for preconception health promotion? Something to think about… What is your state doing for preconception health promotion?

80 Slide 80 Content s Objective 3: Describe a framework for incorporating preconception care into clinical practice

81 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 3: Framework for care. Slide 81 Content s 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: o It can be expensive in terms of personal and professional resources. o 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 Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 3: Framework for care.. Slide 82 Content s 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 o Emergency rooms o Family planning clinics o Primary care clinics o Chronic disease settings o Worksite health centers o College student health services o Postpartum home and clinic visits o Well baby and pediatric visits o Neonatal intensive care units (NICUs) o School health settings

83 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 3: Framework for care.. Slide 83 Content s Preconception care in nursing practice Table 27. Nursing care to promote healthier women and pregnancy outcomes Assessment Systematically assessing each womans health and medical profile, considering its potential impact on her short- and long-term health status and the health of future pregnancies and offspring Considering the pregnancy-related implications of any drug or diagnostic test before ordering for any woman who may be or may become pregnant Education Educating women about health conditions and exposures that can affect pregnancy outcomes, even before a woman is aware she is pregnant Educating women about how pregnancy can impact long-term health, when relevant (e.g., when a woman has a chronic disease) Educating women about the benefits of folic acid and helping them develop strategies to achieve the recommended intake (Continued on next slide) 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 Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 3: Framework for care.. Slide 84 Content s Preconception care in nursing practice Table 27 (continued). Nursing care to promote healthier women and pregnancy outcomes Counseling Promoting intendedness of pregnancy by encouraging reproductive life planning and helping women (and their partners) develop strategies to achieve their plan Using evidence-based behavior-change strategies to help women address tobacco exposures, optimal BMI, exercise, etc. OutreachSupporting or creating coalitions and initiatives in the community to educate women and providers about the benefits of womens wellness, preconception health promotion and reproductive life planning Coordination of services Engaging other health professionals in promoting womens wellness throughout the reproductive continuum and beyond. The professionals include pharmacists, geneticists, pediatricians, WIC counselors and childbirth educators (Moos, Badura, Posner & Lu, 2010). Developing systems that support communication between providers about womens health risks before, between and beyond pregnancy to achieve an integrated approach to womens health care

85 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Objective 3: Framework for care.. Slide 85 Content s 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): o 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. o Having standardized health and wellness assessments completed by women prior to their clinical visit. o Encouraging women, prior to their annual visit, to set three priority health goals for the next year. o 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). o 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 Preconception Health Promotion: The Foundation for a Healthier Tomorrow © 2013 March of Dimes Foundation Slide 86 Content s The skills and activities needed to impact a womans preconception health status are ideally suited to the professional nurse (Moos, 2003). Through outreach, assessment, education, patient-centered counseling and support, nurses can strengthen the foundations for a healthier tomorrowfor women, for pregnancies, for babies and for families. Indeed, in many ways, the future is in the hands of nurses. Conclusion

87 Slide 87 Content s To see the Guidelines and References for this module, click here. here To print a PDF of this module, click here. here To take the Independent Study Test, click here.here. Preconception Health Promotion: The Foundation for a Healthier Tomorrow


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