PRECONCEPTION CARE CityMatCH Conference September 13, 2004 Janis Biermann, M.S.

Preconception Care Greater New York Chapter of the March of Dimes Preconception Care Curriculum Working Group Albert Einstein College of Medicine/Montefiore Medical Center

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 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

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

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

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

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

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)

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

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.

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

% 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%

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.”

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. * * *

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

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

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

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

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

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

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

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

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

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