Preconception Health: Has the 2006 Call to Action Been Acted Upon? Pamela K. Xaverius, PhD & Joanne Salas, M.P.H

CDC Fact Sheet: Preventing and Managing Chronic Disease to Improve the Health of Women and Infants

2006 Renewed Called to Action Recommends a reproductive health plan Ongoing clinical assessment of pregnancy intention Risk factor modification for all women of reproductive age.

RESEARCH QUESTION The question addressed in this study is whether there have been any significant changes in health behaviors or clinical assessments before and after this 2006 call to action.

Methods What are the changes in the prevalence of preconception behaviors between two time periods, before 2006 (time 1) and after 2006 (time 2)? Secondary analysis of cross-sectional data from the BRFSS ( ). Subjects were a sample of non-institutionalized, year old, non-pregnant, fertile women (n = 384,687) grouped into two categories: (n = 118,771) and (n = 202,916). Overall crude prevalence odds ratios (cPOR) and adjusted prevalence odds ratios (aPOR) were calculated regarding lifestyle behaviors.

Measures Behaviors Any alcohol use Binge alcohol use Heavy Alcohol Use Smoking Leisure Activity Chronic Condition (i.e., obesity, hypertension, diabetes)Screening Pap testing HIV testing Dental Visits

Demographic Changes Table 1. Demographic characteristics by time period, non-pregnant women, years old, BRFSS (N = 384,687) (n=181,771) (n=202,916) Prevalence % (95% CI) p-value Race /Ethnicity.30 White, non-Hispanic62.4 (61.9, 62.9)62.0 (61.6, 62.5) Non-White37.6 (37.1, 38.1)38.0 (37.5, 38.4) Age < (10.3, 11.0)9.8 (9.5, 10.1) (52.3, 53.3)49.6 (49.2, 50.0) (362, 37.1)40.6 (40.3, 41.0) Marital status <.001 Not married41.2 (40.7, 41.6)38.3 (37.9, 38.7) Married58.8 (58.4, 59.3)61.7 (61.3, 62.1) Education <.001 Less than HS grad10.7 ( )10.3 (9.9, 10.6) HS grad26.3 (25.9, 26.7)24.8 (24.4, 25.2) More than HS63.0 (62.6, 63.5)64.9 (64.5, 65.4) Income <.001 Less than $35k42.1 (41.6, 42.6)37.7 (37.2, 38.1) At least $35k57.9 (57.4, 58.4)62.4 (61.9, 62.8) Employment <.001 Employed63.2 (62.7, 63.7)61.6 (61.2, 62.0) Other36.8 (36.3, 37.3)38.4 (38.0, 38.8) Health Insurance.004 No20.5 (20.1, 20.9)19.7 (19.4, 20.1) Yes79.5 (79.1, 79.9)80.3 (79.9, 80.7)

Behaviors Any Alcohol Use: 8% reduction Binge Alcohol Use: 14% increase Heavy Alcohol Use: 5% reduction Any Medical Condition: 30% increase Smoking: 10% reduction Leisure Activity: 3% reductionScreening No significant changes in pap testing; HIV testing, and Dental Visits Change from to 07-09

Adjusted Odds Ratios Table 3. Adjusted odds ratios (95% CI) for selected behavioral conditions comparing to , non-pregnant women, years, BRFSS, (N = 384,687) a aOR (95% CI) Lifestyle / Behavioral Any alcohol use0.91 (0.88, 0.93) Binge drink1.20 (1.16, 1.25) Heavy drink0.97 (0.91, 1.03) Smoke0.95 (0.92, 0.98) Leisure Activity0.94 (0.91, 0.98) Any medical condition1.31 (1.27, 1.34) Screening/Tests Pap Test0.90 (0.82, 0.99) HIV Test1.13 (1.10, 1.16) Dental Visit in Last Year0.94 (0.89, 0.98) a Adjusted for race, age, marital status, education, income, employment, health insurance Behaviors Any Alcohol Use: 9% reduction Binge Alcohol Use: 20% increase Heavy Alcohol Use: No change Any Medical Condition: 31% increase Smoking: 5% reduction Leisure Activity: 6% reductionScreening Pap testing: 10% reduction HIV testing: 13% increase Dental visits: 6% reduction

Key Findings Overall, the prevalence of health behaviors remained at unacceptable levels during the time period Any alcohol use at 51.1% Binge drinking at 15.0% Heavy drinking at 4.9% Smoking at 19.1% Leisure activity at 76.8% Having a medical condition at 30.2% When odds ratios were adjusted for race, age, marital status, education, income, employment, and health insurance, significant increases remained among binge drinking (20% increase) having any medical condition (30% increase). Overall, the prevalence of health behaviors remained at unacceptable levels during the time period Any alcohol use at 51.1% Binge drinking at 15.0% Heavy drinking at 4.9% Smoking at 19.1% Leisure activity at 76.8% Having a medical condition at 30.2% When odds ratios were adjusted for race, age, marital status, education, income, employment, and health insurance, significant increases remained among binge drinking (20% increase) having any medical condition (30% increase).

Limitations BRFSS is a cross-sectional survey, therefore the cohort surveyed in time 1 may be different than the cohort surveyed in time 2. BRFSS relies on self-reported information from survey data, and as such, this may be subject to errors such as recall bias. Pregnancy intention is not considered in this analysis. Proxies to preconception clinical care, such as pap smear, HIV, or detail visits, are insufficient.

Public Health Implications More work is needed in educating women and providers regarding the importance of improved health before pregnancy. Women with chronic conditions represent a high-risk group that may be growing and draining more resources if this trend is not reversed.

Misra, Guyer, & Allston ( 2003 )

Has the 2006 Call to Action Been Acted Upon? Outcomes? * Improved the knowledge and attitudes and behaviors * Assured that all women of childbearing age in the United States receive preconception care services Action? In Missouri, we have multiple local, county, and state level initiatives addressing preconception …. So yes, I think it is being acted upon… the outcomes just don’t show it yet!