Jean Amoura, MD, MSc Marvin L.Stancil, MD

 Evaluate how fetal, infant, and childhood development is critical to understanding chronic diseases among the elderly  Review the extended significance of reproductive health care for the health of the community

 Public health approaches deal with the health of an entire community or population  Mostly prevention oriented  Why is there an obesity epidemic?  What factors put women at risk for preterm delivery?  Medical care approaches deal with the individual patient  More often treatment oriented  What can I do to help this patient lose weight?  How can I help this patient avoid preterm delivery, or treat it if it occurs?

 Looks for determinants of a health outcome  Biological (eg, genetic)  Social (eg, ability to access health care)  Behavioral (eg, smoking)  Environmental (eg, lead exposure)  Focus community and patient education on changeable factors  Prioritize policies and funding to community- level factors

 A framework to address health determinants:  Earlier in development  Over the course of lifespan  With emphasis on reproductive years

 Considerations for reproductive health  Disparities in birth outcomes persist despite more advanced and expensive therapies for newborns  Improving health care during nine months of pregnancy is not adequate  Woman’s health before and during pregnancy are critical to lifelong health of offspring  Women spend the majority of their reproductive years in a preconceptional or interconceptional state

 Combines two models  Early programming model Factors present in early life (fetal/neonatal/childhood) have long-range effects  Cumulative pathway model Lifelong stressors create wear and tear on the body’s adaptive systems  Addresses emerging epidemics  Childhood obesity, asthma, diabetes, autism

 Combining the two models allows us to account for risk factors and their timing  Barker hypothesis  Fetal events have lasting physiologic effects  Growth restriction of the fetus indicates relative malnutrition in utero  Preterm delivery is associated with exogenous or endogenous cortisol rise  Both factors can contribute to lasting physiologic changes in fat and carbohydrate metabolism Increased rates of diabetes, obesity, hypertension, and heart disease in adulthood

Copyright restrictions may apply. Ben-Shlomo, Y. et al. Int. J. Epidemiol : ; doi: /ije/ Schematic representation of biological and psychosocial exposures acting across the life course that may influence lung function and/or respiratory disease

 Health before pregnancy  A woman with an unplanned pregnancy is at risk for: Preterm delivery Lack of folic acid supplementation 29% of women report taking folic acid before pregnancy Late presentation to prenatal care Lack of control of underlying medical conditions  These factors contribute to suboptimal pregnancy outcomes

 A woman’s health before and during pregnancy is integral to the lifelong health of her child  Women frequently underestimate their risk for pregnancy and therefore do not adequately plan for pregnancy  50% of pregnancies are unintended

 All women of reproductive age should be counseled to:  Consider their reproductive life plan How many children do they desire? When would they ideally like their first/next pregnancy?  Use effective contraception if they do not desire pregnancy in the immediate future  Understand the impact of their health prior to pregnancy on the health of their children  Take folic acid supplementation

Applications to medical practice  Counseling women about their health in terms of promoting healthy future children can have greater impact  Losing weight if obese  Controlling diabetes  Quitting smoking  Addressing a women’s probable fertility can improve her likelihood of using effective contraception if she doesn’t desire pregnancy now

Applications for medical practice  Use the prenatal and postpartum periods to:  Educate women on factors that will improve future pregnancy outcomes  Emphasize the need for contraception to adequately space pregnancies

 Key points:  Women’s health should maintain a focus on every woman of reproductive age as preconceptional even if she is not planning an immediate pregnancy  Prenatal and postpartum care should have the expanded goal of interceptional care—how to help her improve birth outcomes in her next pregnancy