1. PRECONCEPTION CARE CityMatCH Conference September 13, 2004 Janis Biermann, M.S. jbiermann@marchofdimes.com

2. Preconception Care Greater New York Chapter of the March of Dimes Preconception Care Curriculum Working Group Albert Einstein College of Medicine/Montefiore Medical Center www.marchofdimes.com/prematurity/5195_5785.asp

3. The Continuum of Reproductive Health 4 Improving infant health requires focus on the entire spectrum of reproductive health u Beginning before conception u Continuing through the first year of life u Extending throughout the woman’s childbearing years

4. Preconception Care  Identifies reducible or reversible risks  Maximizes maternal health  Intervenes to achieve outcomes

5. Preconception Care  Reframes issues  Adds an anticipatory element  Focuses on the impact of pregnancy

6. Elements of Preconception Care  Focus on elements which must be accomplished prior to conception or within weeks thereafter to be effective u Risk assessment u Education & Health Promotion u Medical and psychosocial interventions

7. Components of Preconception Care  Medical history  Psychosocial issues  Physical exam  Laboratory tests  Family/genetic history  Nutrition assessment  Occupational/environmental risk assessment

8. Risk Assessment  STD Prevention  Genetic issues  Domestic violence  Substance abuse u Alcohol u Tobacco u Illicit drugs

9. Environmental Teratogens  Exposures u Home, workplace, environment  Physical/chemical hazards u ionizing radiation, lead, mercury, hyperthermia, herbicides, pesticides

10. Health Education & Promotion ! Smoking Cessation counseling: 5A’s ! Folic Acid ! Genetic Counseling ! Dietary and Nutritional Advice

11. Conditions that Need Time to Correct Prior to Conception  Optimal weight  Optimizing choice and use of medications  Substance use/abuse u alcohol u tobacco

12. Some Medical Conditions Amenable to Preconception Care  Diabetes Mellitus  Hypertensive Disorders  Cardiac Disease  Thyroid Disorders  Epilepsy  Asthma  HIV Infection  Systemic Lupus  Thromboembolic Disease  Renal Disease  Hemoglobinopathies  Cancers

13. Intervention Usually Not Undertaken During Pregnancy ! Rubella & varicella immunization ! Narcotic detoxification ! Certain radiological procedures ! Thyroid ablation with radioactive iodine

14. Interventions considered because pregnancy is planned  Correction of mitral stenosis  Switching from oral hypoglycemics to insulin and achieving “tight” glucose control in patients with diabetes mellitus  Evaluation of anticonvulsant therapy

15. Factors That Could Change Timing Of Or Choice To Conceive A Pregnancy  Domestic violence  Birth spacing  Genetic disease  Diseases with poor prognosis (e.g. AIDS)  Diseases dangerous in pregnancy (e.g. CHF)  Conflicts between needed maternal care and fetal well-being  Recurrent Pregnancy loss

16. Does Preconception Care Work? ! Outcomes Impacted ! Fetal/Infant mortality and morbidity ! Maternal mortality and morbidity

17. Historical Perspectives ! 1979: PHS: Primary Care Effectiveness. An approach to clinical quality assurance in BCHS Programs and Projects ! 1985: IOM: Preventing Low Birth Weight ! 1989: Public Health Service Expert Panel on the content of Prenatal Care ! 1991: USPHHS: Healthy People 2000 - National Health Promotions and Disease Prevention Objectives ! 1993: March of Dimes towards improving the outcome of pregnancy report ! 1993: Alan Guttmacher Institute’s Issues in Brief: The nation will be well-served by making a commitment to advance preconception services to a similar extend as it has prenatal care. ! 1996: Guide to Clinical Preventive Services ! 1997: AAP & ACOG Guidelines for Perinatal Care

18. Prevention of Birth Defects ! Optimal glycemic control ! No alcohol consumption ! Preconception rubella immunization ! Folic Acid supplementation

19. Goals of Preconception Care in Diabetes  To reduce the occurrence of obstetric and diabetic complications  To decrease the incidence of congenital abnormalities  Reduce risk of spontaneous abortions

20. How To Accomplish These Goals?  Education about need to change diabetes medication regimen ie substitute insulin for oral hypoglycemics  Optimal glycemic control achieved by home monitoring, multiple daily injections, adjustment of insulin, close supervision and education  Postpone conception until control is achieved  Reassess modifiable risks before conception by assessing end organ damage, retina, kidney, vasculature, heart, nervous system

21. Alcohol  Leading preventable cause of mental retardation  Most common teratogen to which fetuses are exposed  Effects related to dose  No threshold has been identified for “safe” use in pregnancy  Effects at all stages of pregnancy

22. Rubella Vaccination  Determine rubella immunity prior to conception  Vaccinate susceptible nonpregnant women  Congenital rubella syndrome may result from infection during pregnancy (microcephaly, fetal growth restriction, cardiac malformations, etc)

23. Prevention of Neural Tube Defects  Supplementation for all women of childbearing potential with folic acid u No history of NTD: 0.4 mg. qd u Prior infant with NTD: 4.0 mg. qd u Woman with NTD: 4.0 mg. qd  Nutritional sources often inadequate

24. Barriers to Preconception Care Patient Aspects  High rate of unintended pregnancies  Ignorance about importance of good health habits prior to conception  Limited access to health services in general.

25. Barriers To Preconception Care Provider Aspects  Feeling of having inadequate knowledge  Perception of preconception care being time-consuming  Concern about insurance reimbursement.  Lack of awareness of how to integrate preconception care into ongoing primary care

26. % Eligible Patients Seen for Preconceptional Care: Physicians (2002) vs. Other Providers (2003) Percentages are net of 108 physicians (2002) and 55 non-physician providers (2003) who do not provide prenatal care. Mean % Seen for Preconceptional Visit Providers-2003: 22% MDs-2002: 20%

27. Issues Addressed at Annual Well-Woman Exam: Physicians (2002) vs. Other Providers (2003) “Which issues do you always, usually, occasionally, or never address at an annual well-woman exam with a woman of reproductive age, that is, under age 45?” * Statistically significant difference between physicians and non-physicians in % “always.”

28. Reasons Providers Don’t Always Recommend Folic Acid or Multivitamins: Physicians (2002) vs. Other Providers (2003) Responses were categorized from verbatim comments. * Statistically significant difference between all physicians vs. all non- physician respondents. * * *

29. Other Barriers To Preconception Care  Availability of contraceptives  Health Insurance Coverage  Out of Pocket Expenses.

30. Who Should Get Preconception Care  49% of pregnancies in the US are unintended (unwanted or mistimed) - Henshaw. 1988.  Preconception care should be provided to all reproductive age individuals

31. Preconception Care for Men  Alcohol u may be associated with physical and emotional abuse u may decrease fertility  Genetic Counseling  Occupational exposure u lead  Sexually transmitted diseases u syphilis, herpes, HIV

32. WHO TO PROVIDE  Health Care Providers u OB-GYNs, Pediatricians, Family Medicine, Internists, u Nurses, Nurse Practitioners, Nurse-midwives u Genetic Counselors u Health Educators

33. When Should Preconception Care Be Offered  As part of routine health maintenance care  At a defined preconception visit  For women with chronic illness

34. How Preconception Care can be Integrated into Practice  As part of any routine medical visits  Episodic visit for any common complaints  Negative pregnancy test - an opportunity for preconception care  Family planning encounter  Infertility evaluation  Following a poor pregnancy outcome

35. Preconception Care  Primary Prevention  Essential to March of Dimes Mission to prevent birth defects and infant mortality

36. March of Dimes Products/Resources  Consumers u Pregnancy and Newborn Health Education Center u marchofdimes.com u nacersano.org u e-preconception newsletter (Spanish) u comenzando bien u Are You Ready? u Think Ahead for a Healthy Baby u Folic Acid brochures u Pre-Pregnancy Planning Fact Sheet

37. March of Dimes Products/Resources  Providers u marchofdimes.com u Preconception Health Promotion: A Focus for Women’s Wellness nursing module u Upper Hudson Prenatal Services u Preconception Screening and Counseling Tool u Chapter grants

38. “Preconception health promotion is the cornerstone of healthy infants, children, families and communities ”