1. TM 1 Hani K. Atrash, MD, MPH Associate Director for Program Development National Center on Birth Defects and Developmental Disabilities Promoting the health of babies, children, and adults, and enhancing the potential for full, productive living Overview of Preconception Care And the CDC Preconception Care Collaborative State Infant Mortality Collaborative Conference Call January 18, 2006

2. TM 2 Outline Definition and Goals Why Do We Need Preconception Care? Components Scientific Evidence Current Recommendations Current Practice Challenges to Implementation Update of current activities

3. TM 3 “Optimizing a woman’s health before and between pregnancies is an ongoing process that requires full participation of all segments of the health care system.” The Importance of preconception care in the continuum of women’s health care. ACOG Committee Opinion, Number 313, September 2005 Improving Preconception Health

4. TM 4 To minimize risks to the woman and the fetus and improve pregnancy outcome: Preconception care is comprised of biomedical and behavioral interventions that improve pregnancy outcomes. Preconception interventions must be successfully implemented before the start of pregnancy. Preconception Care: Goal

5. TM 5 Combined Definition of PCC identify and modify biomedical, behavioral, and social risks prevention and management 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, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact. CDC’s Select Panel on Preconception Care, June 2005

6. TM 6 Why do we need Preconception Care?

7. TM 7 Maternal Mortality Rates, United States 1960-2000 71% Decrease 13% Decrease

8. TM 8 Low Birthweight, United States 1980-2002 14.7% Increase Very low birthweigh births increased 25.9%

9. TM 9 Preterm Delivery, United States 1980-2002 26% Increase 8.2% Increase in very preterm births

10. TM 10 Infant Mortality Rates, United States 1920-2000 52% Decrease 45% Decrease

11. TM 11 Five Leading Causes of Infant Death, United States, 1960, 1980 and 2002 Congenital Anomalies Asphyxia/Atelactasis Immaturity LBW/PTD RDS Congenital Anomalies SIDS Complications of Pregnancy Congenital Anomalies LBW/PTD Complications of Pregnancy Unintentional Injury 1980 IMR = 12.6 45,526 Infant Deaths 2002 IMR = 7.0 28,034 Infant Deaths 1960 IMR = 26.0 110,873 Infant Deaths Birth injuries Influenza and pneumonia Congenital Anomalies Asphyxia/Atelactasis Immaturity LBW/PTD Congenital Anomalies SIDS

12. TM 12 Incidence of Adverse Pregnancy Outcomes Major birth defects3.3% of births Fetal Alcohol Syndrome0.2-1.5 /1,000 LB Low Birth Weight7.9% of births Preterm Delivery12.3% Complications of pregnancy30.7% C-section27.6% Unintended pregnancies49% Unintended births31%

13. TM 13 Prevalence of Risk Factors Pregnant or gave birth Smoked during pregnancy11.0% Consumed alcohol in pregnancy10.1% Had preexisting medical conditions4.1% Rubella seronegative7.1% HIV/AIDS0.2% Received inadequate prenatal Care15.9% At risk of getting pregnant Diabetic3.8% On teratogenic drugs2.6% Obese30.8% Not taking Folic Acid69.0%

14. TM 14 Critical Periods of Development 4 5 6 7 8 9 10 11 12 Weeks gestation from LMP Central Nervous System Heart Arms Eyes Legs Teeth Palate External genitalia Ear Missed Period Mean Entry into Prenatal Care Most susceptible time for major malformation

15. TM 15

16. TM 16 Early prenatal care is not enough, and in many cases it is too late!

17. TM 17 Components of Preconception Care 1. Screening for risks 2. Providing health education 3. Delivering effective interventions

18. TM 18 Maternal Assessment Vaccinations Screening Counseling Components Of Preconception Care

19. TM 19 Components of Preconception Care Maternal assessment Family planning and pregnancy spacing Family history Genetic history (maternal and paternal) Medical, surgical, pulmonary and neurologic history Current medications (prescription and OTC) Substance use, including alcohol, tobacco and illicit drugs Nutrition Domestic abuse and violence Environmental and occupational exposures Immunity and immunization status Risk factors for STDs Obstetric history Gynecologic history General physical exam Assessment of Socioeconomic, educational, and cultural context

20. TM 20 Components of Preconception Care Vaccinations Vaccinations should be offered to women found to be at risk for or susceptible to: Rubella Varicella Hepatitis B

21. TM 21 Components of Preconception Care Screening Tests Screening for HIV should be strongly recommended A number of tests can be performed for specific indications: Screening for STDs Testing to assess proven etiologies of recurrent pregnancy loss Testing for specific diseases based on medical or reproductive history Mantoux skin test with purified protein derivative for Tuberculosis

22. TM 22 Components of Preconception Care Screening Tests Screening for other genetic disorders based on family history: CF, Fragile X, mental retardation, Duchene muscular dystrophy. Screening for genetic disorders based on racial/ethnic background: Sickel hemoglobinopathies (African Americans) Β-Thalassemia (Mediterraneans, SE Asia, AA/B) α-Thalassemia (AA/B and Asians) Tay Sachs disease (Ashkhenazi Jews, French Canadians, Cajuns) Gaucher’s, Canavan, and Nieman-Pick Disease (Ashkenazi Jews) Cystic Fibrosis (Caucasians and Ashkenazi Jews)

23. TM 23 Components of Preconception Care Counseling Patients should be counseled regarding the benefits of the following activities: Exercising Reducing weight before pregnancy, if overweight Increasing weight before pregnancy, if underweight Avoiding food additives Preventing HIV infection Determining the time of conception by an accurate menstrual history Abstaining from tobacco, alcohol, and illicit drug use before and during pregnancy Consuming Folic Acid Maintaining good control of any pre-existing medical conditions

24. TM 24 Preconception Care Science, Guidelines, Recommendations, Practice

25. TM 25 Scientific Evidence Does preconception care work?

26. TM 26 Science: There is evidence that individual components of Preconception Care work: Rubella vaccination HIV/AIDS screening Management and control of: Diabetes Hypothyroidism PKU Obesity Folic Acid supplements Avoiding teratogens: Smoking Alcohol Oral anticoagulants Accutane

27. TM 27 Clinical practice guidelines for preconception care of specific maternal health conditions have been developed by professional organizations: American Diabetes Association (Diabetes -2004) American Association of Clinical Endocrinologists (Hypothyroidism – 1999) American Academy of Neurology (Anti-epileptic drugs) American Heart Association/American College of Cardiologists (Anti-epileptic drugs - 2003) Clinical Practice Guidelines Exist

28. TM 28 Where do people stand?

29. TM 29 ACOG/AAP (2002) All health encounters during a woman’s reproductive years, particularly those that are a part of preconceptional care should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes. ACOG/AAP Guidelines for perinatal care, 5 th edition, 2002

30. TM 30

31. TM 31 US Public Health Service HP 2000 Objectives 5.10 and 14.12 Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception care and counseling.

32. TM 32 USPHS “Every woman (and, when possible, her partner) contemplating pregnancy within one year should consult a prenatal care provider. Because many pregnancies are not planned, providers should include preconception counseling, when appropriate, in contacts with women and men of reproductive age….Such care should be integrated into primary care services.” USPHS Expert Panel on the Content of Prenatal Care, 1989

33. TM 33 Most providers don’t provide it Most insurers don’t pay for it Most consumers don’t ask for it Preconception care is not being delivered today!

34. TM 34 Percent Eligible Patients Seen for Preconceptional Care by Type of Provider (2002-2003) CNM = Certified Nurse Midwives; OB/GYN = Obstetricians/ Gynecologists; F/GP = Family / General Practitioners;

35. TM 35 We have evidence, consensus, and guidelines. So, why don’t we do it?

36. TM 36 Challenges to Implementation 1.Absence of a national policy 2.Lack of clinical tools 3.Few proven delivery models / programs 4.Inadequate education of providers and consumers

37. TM 37 What has CDC done? Convening Studying Reporting

38. TM 38 The Preconception Care Initiative A Collaborative Effort of over 35 National Organizations

39. TM 39 Purposes of CDC Initiative  Develop national recommendations to improve preconception health  Improve provider knowledge, attitudes, and behaviors  Identify opportunities to integrate PCC programs and policies into federal, state, local health programs  Develop tools and promote guidelines for practice  Evaluate existing programs for feasibility and demonstrated effectiveness

40. TM 40 What Have We Done?  Established CDC (internal) and external work groups (2004)  Convened a meeting of work groups (Nov. 2004)  Held a National Summit on Preconception Care (June 2004)  Convened a Select Panel (June 2004)  Developed recommendations to improve preconception health (June- Nov. 2004, publication Feb. 2005)  Commissioned a supplement to MCH Journal (anticipated March-April 2005)

41. TM 41 Next Steps  Publish and disseminate the recommendations  Increase awareness among public/private providers  Identify opportunities to integrate PCC programs and policies into state, local, and community health programs  Develop tools and guidelines for practice  Evaluate existing programs for feasibility and demonstrated effectiveness

42. TM 42 What results of this process? Through collaboration and consensus: Assessed current scientific knowledge Identified best and promising practices Identified issues needing further attention Refined definition Developed vision and goals Develop recommendations and action steps Produced documents to share across professional fields.

43. TM 43 Preconception Care Framework Action Steps Research – Surveillance – Clinical interventions Financing – Marketing – Education and training Recommendations Individual Responsibility - Service Provision Access – Quality – Information – Quality Assurance Goals Coverage – Risk Reduction Empowerment – Disparity Reduction Vision Improve health and pregnancy outcomes

44. TM 44 Themes / Areas for Action Social marketing and health promotion for consumers Clinical practice Public health and community Public policy and finance Data and research

45. TM 45 A Vision for Improving Preconception Health and Pregnancy Outcomes All women and men of childbearing age have high reproductive awareness (i.e., understand risk and protective factors related to childbearing). All women have a reproductive life plan (e.g., whether or when they wish to have children, how they will maintain their reproductive health). All pregnancies are intended and planned. All women of childbearing age have health coverage. All women of childbearing age are screened prior to pregnancy for risks related to outcomes. Women with a prior pregnancy loss (e.g., infant death, VLBW or preterm birth) have access to intensive interconception care aimed at reducing their risks.

46. TM 46 Goals for Improving Preconception Health Goal 1. To improve the knowledge, attitudes, and behaviors of men and women related to preconception health. Goal 2. To assure that all U.S. women of childbearing age receive preconception care services – screening, health promotion, and interventions -- that will enable them to enter pregnancy in optimal health. Goal 3. To reduce risks indicated by a prior adverse pregnancy outcome through interventions in the interconception (inter-pregnancy) period that can prevent or minimize health problems for a mother and her future children. Goal 4. To reduce the disparities in adverse pregnancies outcomes.

47. TM 47 Recommendations for Improving Preconception Health (1-2) Recommendation 1. Individual responsibility across the life span. Encourage each woman and every couple to have a reproductive life plan. Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and increase individuals’ use of preconception care services using information and tools appropriate across varying age, literacy, health literacy, and cultural/linguistic contexts.

48. TM 48 Recommendations for Improving Preconception Health (3-4) Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and counseling to all women of childbearing age to reduce risks related to the outcomes of pregnancy. Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow up to preconception risk screening, focusing on high priority interventions.

49. TM 49 Recommendations for Improving Preconception Health (5-6) Recommendation 5. Interconception care. Use the interconception period to provide intensive interventions to women who have had a prior pregnancy ending in adverse outcome (e.g., infant death, low birthweight or preterm birth). Recommendation 6. Pre-pregnancy check ups. Offer, as a component of maternity care, one pre-pregnancy visit for couples planning pregnancy.

50. TM 50 Recommendations for Improving Preconception Health (7-8) Recommendation 7. Health coverage for low-income women. Increase Medicaid coverage among low-income women to improve access to preventive women’s health, preconception, and interconception care. Recommendation 8. Public health programs and strategies. Infuse and integrate components of preconception health into existing local public health and related programs, including emphasis on those with prior adverse outcomes.

51. TM 51 Recommendations for Improving Preconception Health (9-10) Recommendation 9. Research. Augment research knowledge related to preconception health. Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health.

52. TM 52 Diffusion of Innovation Theory Evidence Guidelines for best practice Early adopters Opinion leaders Innovators Change in dominant practice Early and late majority Later - laggards Change Agents

53. TM 53 Opportunities for Action Examples of “Low Hanging Fruit” Permit states to use family planning waivers for more interconception care. Permit coverage of more uninsured women using Medicaid and SCHIP. Direct public health agencies to use resources to: Develop programs, test models, fill gaps Evaluate and monitor progress

54. TM 54 Thank You