1. Child and Adolescent Health
The Promise of Preconception Care in Prevention of Birth Defects and Preterm Births
Footer to be added with mtg name date and WHO logo
Dr Neena Raina
Regional Advisor
Child and Adolescent Health
WHO - SEARO
WHO-SEARO

2. Structure of presentation
What is Pre-conception Care
Do we have evidence based interventions
Why is it important in SEAR
Opportunities for introducing it in SEAR
“Healthy Transitions” for Adolescents
Way forward
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3. 1.What is Pre-conception Care
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4. Pre-pregnancy health status and health behaviors have direct or indirect implications for maternal and neonatal outcomes
Intervening after a woman is pregnant has limited impact:
First few weeks after conception are critical for fetal development
Week 5: brain, spinal cord, heart begin to form
Week 6: Neural tube closes; the heart is pumping
Week 7: Brain and face are rapidly developing
Most women do not seek prenatal advice/care before 12 weeks when it is too late to modify many risks
Intervening during pregnancy is too late for many interventions
Many health risk behaviours are initiated during adolescence
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5. Modifiable risk factors are common to several “congenital conditions”
Malformations
Preterm Birth
IUGR
Developm. disability
Nutrition status X
Insufficient folic acid/vitamin
Smoking
Alcohol use / abuse
Illicit drugs
Obesity
Diabetes - getsational
Infectious diseases
Selected medications
Psycho-social stressors
Environment and working activity
ICBDSR presentation in Regional Meeting 2012
WHO-SEARO

6. Many risk factors are initiated during adolescence
Modifiable risks for birth defects and prematurity that need to be addressed before conception
Undernutrition and anaemia
Folic Acid insufficiency
Obesity
Diabetes
Hypertension
Epilepsy
Alcohol use
Age at pregnancy
Too close and too many pregnancies
Infections: TORCH
Use of medications during early pregnancy
Exposure to toxins
Exposure to tobacco
WHO-SEARO
Many risk factors are initiated during adolescence

7. Pre-Conception Care
Preconception care is the provision of biomedical, behavioral and social health interventions to women and couples before conception occurs.
Aims:
Improving health status and reducing behaviors and individual and environmental factors to improve maternal and child health outcomes.
Boundary: the period before pregnancy may be divided into a proximal and a distal period:
Proximal period immediately preceding pregnancy
Distal adolescence (10-19 years)
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8. Life course – when to intervene?

9. 2.Do we have evidence based interventions
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10. Gathering evidence: Global consultation
Global consultation in WHO Headquarters, Geneva - February 2012
Meeting to develop a global consensus on preconception care to reduce maternal and childhood mortality and morbidity
In 2012, WHO organized a meeting to develop global consensus on preconception care to reduce maternal and childhood mortality and morbidity
The meeting gathered three groups:
Representatives from groups who have led reviews and research within preconception care
Individuals with experience in carrying out preconception care
Organizations looking to move forward the preconception area, including WHO and other UN organizations, Bill and Melinda Gates Foundation, March of Dimes and Preparing for Life Initiative

11. Three questions were answered:
What are the health problems, risk behaviours and risk factors contributing to maternal and childhood mortality and morbidity?
What are the effective interventions to address them?
What are the
effective means
of delivering these
interventions?
Why the health problems/risk behaviours/risk factors were chosen – how they contribute to maternal and childhood mortality and morbidity
Effective interventions to address them
Effective and existing delivery mechanisms to deliver them in middle and low income countries

12. Gathering evidence: Existing reviews
Using existing evidence and reviews from:
The Centers for Disease Control and Prevention
Erasmus University
Aga Khan University
Health Council of the Netherlands

13. Evidence for Pre-Conception Care
Recommendations to Improve Preconception Health – United States by the Centers for Disease Control and Prevention (2006)
Systematic Review of Preconception Evidence by the Aga Khan University in Karachi, Pakistan
(2011)
WHO-SEARO

14. Gathering evidence: WHO departments
Consultation with various relevant WHO departments:
Maternal, Newborn, Child and Adolescent Health
Reproductive Health and Research
Nutrition for Health and Development
HIV
Mental Health and Substance Abuse
Immunization, Vaccine and Biologicals
Public Health and Environment
Tobacco-Free Initiative
Violence and Injury Prevention
Partnership for Maternal, Newborn and Child Health

15. Strength of evidence
There is growing experience in implementing preconception care initiatives:
In high-income countries, such as Italy, the Netherlands and the United States
In low- and middle-income countries, such as Bangladesh, the Philippines and Sri Lanka
There is growing experience in implementing preconception care initiatives both in high, middle and low income countries. Countries with particular experience are Italy, the Netherlands, United States, Bangladesh, the Philippines and Sri Lanka
In the next two presentations…
Weak evidence of how to deliver preconconception care: this is where the focus need to be

16. Preconception care has a positive effect on a range of health outcomes
child mortality
maternal mortality
birth defects
Reduced too early pregnancy
preterm birth
Reduced abortion
congenital and
neonatal infections
Improved mental health
cretinism
Improved mother nutritional status
macrosomia
Preconception care has a positive effect on a range of health outcomes. Among others, preconception care can:
Reduce maternal and child mortality
Prevent unintended pregnancies
Prevent complications during pregnancy and delivery
Prevent stillbirths, preterm birth and low birth weight
Prevent birth defects
Prevent neonatal infections
Prevent underweight and stunting
Prevent vertical transmission of HIV/STIs
Lower the risk of some forms of childhood cancers
Lower the risk of type 2 diabetes and cardiovascular disease later in life
childhood cancers
Low birth weight
vertical transmission
of HIV/STIs
Underweight and stunting
hypothyroidism
diarrhoea

17. Tobacco use and youth health: a potential for Healthy Transitions
5 million deaths in 2005
10 million deaths in 2020
20 y.o.
90% of adult smokers are estimated to have started smoking before age 20 years

18. Exposure to environmental toxins in early life and its long term effect
cigarette smoking during pregnancy
reduced birth weight or increased risk of lower birth weight
offspring obesity
eliminating smoking before
or during pregnancy could
avoid 5–7% of preterm related
deaths and 23–24%
of cases of sudden infant
death syndrome
eliminating smoking before
or during pregnancy could avoid 5–7% of preterm related
deaths and 23–24% of cases of sudden infant death syndrome

19. Areas addressed by preconception care package
However, the report most importantly provides the evidence based 'package of interventions' addressing 13 various areas:
Nutritional conditions; vaccine preventable diseases; genetic conditions; environmental health; infertility/subfertility; female genital mutilation; too early, unwanted and rapid successive pregnancies; sexually transmitted infections; HIV; interpersonal violence; mental health; psychoactive substance abuse; and tobacco use
WHO-SEARO

20. Evidence-based interventions: Selected examples
Area addressed by the preconception care package
Evidence-based interventions
Nutritional conditions
Screening for anemia
Supplementing iron and folic acid
Information, education and counselling
Monitoring nutritional status
Supplementing energy- and nutrient-dense food
Screening for diabetes mellitus
Management of diabetes mellitus
Counselling people with diabetes mellitus
Monitoring blood glucose (also in pregnancy)
Promoting exercise
Salt iodization
I will go through three examples of areas; that is nutritional conditions; genetic conditions; and too early, unwanted and rapid successive pregnancies
"Read the evidence-based interventions"
WHO-SEARO

21. Evidence-based interventions: Selected examples
Areas addressed by the preconception care
package
Evidence-based
interventions
Genetic conditions
Screening for anemia
Taking a thorough family history
Family planning
Genetic counselling
Carrier screening and testing
Appropriate treatment
Providing community-based education
Community-wide or national screening among populations at high risk
Population-wide screening
"Read the evidence-based interventions"
WHO-SEARO

22. Evidence-based interventions: Selected examples
Areas addressed by the preconception care
package
Evidence-based interventions
Keeping girls in school
Influencing cultural norms that support early marriage and coerced sex
Creating visible, high-level support for pregnancy prevention programmes
Educating girls and boys about sexuality, reproductive health and contraceptive use
Building community support for preventing early pregnancy and for contraceptive provision to adolescents
Enabling adolescents to obtain contraceptive services
Empowering girls to resist coerced sex
Engaging men and boys to critically assess norms and practices regarding gender-based violence and coerced sex
Educating women and couples about the dangers to the baby and mother of short birth intervals
Providing contraceptives
Too-early, unwanted
and rapid successive
pregnancy
"Read the evidence-based interventions"
WHO-SEARO

23. 3.Why Preconception care is important in SEAR
WHO-SEARO

24. MDG 5 Indicators-SEAR Countries
MMR (per live births)
SBA (%)
CPR (%)
Unmet Need for family planning (%)
ANC (%)
Births by caesarean section (%)
Post natal within 2 days of child birth (%)
1990
2000
2010
At least 1 visit
Atleast 4 visits
BAN
800
400
240 31 61 12 50 26 17 27
BHU
1000
430
180 58 66 74 77
KRD 97
120 81
100 94 13
IND
600
390
200 55 21 75 8 48
INO
340
220 80 93 82 7 70
MAV
830
190 60 95 35 29 99 85 32 67
MMR
520
300 71 46 83 43
NEP
770
360
170 36 5 45
SRL 68 24
THA 54 3
TLS
610 30 22 84 2 25
Source: World Health Statistics 2013

25. The Region is not likely to reach MDG4
Decline in NMR has been slower
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26. Newborn mortality remains high in SEAR
Responsible for 54% of under-five deaths
Three congenital conditions: Prematurity, Birth Asphyxia and Birth Defects account for 35-55% of under-5 mortality
These causes of mortality share many risk factors
WHO-SEARO

27. Prematurity, Birth Asphyxia and Birth Defects account for 35% (Myanmar) to 55% (Thailand) of under-5 mortality
Source:
World Health Statistics
WHO-SEARO

28. Estimates of Birth Defects in SEAR
March of Dimes Global Report on Birth Defects (2006) 28
WHO-SEARO

29. Birth Defects Situation Analysis: WHO-SEARO and US-CDC

30. Estimates of Pre Term Births Born Too Soon Report: 2012
Very hazy slide. Need to improve or re do it
WHO-SEARO

31. Eleven countries with PT birth >15% by Rank Born Too Soon Report: 2012
Again written material not very clear. Re do it
WHO-SEARO

32. 4.Preconception Care in SEAR
Twin track:
Pre- and Inter-pregnancy care: Maternal Health
Healthy Transitions for adolescents: Adolescent Health
WHO-SEARO

33. Is there a gap in Continuum of Care?
Healthcare provided across the lifecycle through strong public health programs can ensure that all women and babies are healthy
There is a gap in the continuum of care for adolescent girls (and boys) and women before pregnancy.
All babies and children – female and male – have the right to survive and
to grow and develop in good health. Similarly, all women and men have the
right to be healthy physically, psychologically and socially. For this to happen,
strong public health programmes that use a life-course perspective from
infancy through childhood and adolescence to adulthood are needed. The
reality is that such programmes do not exist or are very weak in most low- and
middle-income countries.
Even where strong public health programmes across the life-course are in
place, they do not guarantee that women enter pregnancy in good health. For
this reason, prenatal programmes are needed to promote good health during
pregnancy, to prevent health problems and to respond to those problems that
occur. The reality is that many women in low- and middle-income countries
do not have adequate access to the prenatal care they need.
We need to strengthen public health programmes across the life-course. We
also need to improve access to good-quality prenatal care services. In addition,
there is growing evidence that extending the maternal, newborn and child
health continuum with one step before prenatal care – i.e. before pregnancy
occurs – can increase the well-being of women and couples and improve
subsequent pregnancy and child health outcomes.

34. Strengthening pre-conception care in the RMNCAH Continuum
Clinical
Screening and management of chronic diseases especially diabetes
Genetic counselling
CHILDBIRTH CARE
Emergency obstetric care
Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation
PMTCT
EMERGENCY NEWBORN AND CHILD CARE
- Hospital care of newborn and childhood illness including HIV care
- Extra care of preterm babies including kangaroo mother care
- Emergency care of sick newborns
Post-abortion care
- STI case management
Outreach/outpatient
Multivitamin and folic acid supplementation
Family planning
Youth development programs
Prevention of obesity
ANTENATAL CARE
- 4-visit focused ANC package
- IPTp and bednets for malaria
- PMTCT
POSTNATAL CARE
- Promotion of healthy behaviors
- Early detection of and referral for illness
- Extra care of LBW babies
- PMTCT
Family/community
- Counselling and preparation for newborn care, breastfeeding, birth and emergency preparedness
Healthy home care including:
Newborn care (hygiene, warmth)
Nutrition including exclusive breastfeeding and appropriate complementary feeding
Seeking appropriate preventive care
- Danger sign recognition and careseeking for illness
- Oral rehydration salts for prevention of diarrhoea
- Where referral is not available, consider case management for pneumonia, malaria, neonatal sepsis
- Where skilled care is not available, consider clean delivery and immediate newborn care including hygiene, warmth and early initiation of breastfeeding
Optimising Adolescent and pre-pregnancy nutrition
Health education and counseling on risk factors prevention
INTERSECTORAL Improved living and working conditions – Housing, water and sanitation, and nutrition
education and female empowerment
Pre-pregnancy
Pregnancy
WHO-SEARO
Birth 34

35. Pre-pregnancy care for prevention birth defects Life course Continuum
Infancy U5
Neonatal period
Pregnancy
Birth
10-19
Pre-Pregnancy
CH Immunization
Newborn Care
Ado Health
SBA
PCC
ANC
Interventions to address MH risk factors for BD and PT births
WHO-SEARO

36. Sri Lanka Package for newly married couples Goal: To have improved reproductive health outcomes by improving the health of the newly married couples.
WHO-SEARO

37. Package for newly married couples
RISK SCREENING
CLINICAL ASSESSMENT
IMMUNIZATION
AWARENESS AND COUNSELLING
PROVISION OF OTHER SERVICES
WHO-SEARO

38. TOOLS IN THE PACKAGE INVITATION CARD SCREENING TOOL
GUIDE FOR HEALTH WORKERS
BOOK FOR THE NEW COUPLE
BMI CALCULATOR
WHO-SEARO

39. SCREENING TOOL
Screen for risk factors by using the screening tool by PHM/MOH
Basic investigations
Physical assessment by PHM
Height, weight and BMI
Clinical examination by MOH
Refer for further diagnosis /treatment/ for specialized care
Follow up
WHO-SEARO

40. Book for the New Couple ♣ SEXUALITY AND SEXUAL RELATIONSHIP
♣ SEXUALLY TRANSMITTED DISEASES AND RESPONSIBLE SEXUAL BEHAVIOUR
♣ A PLANNED FAMILY
♣ GOOD NUTRITION
♣ GOOD HEALTH HABITS/ HEALTHY BEHAVIOUR/ HEALTHY LIFE STYLE
♣ GOOD MARITAL RELATIONSHIP AND WELL BEING OF THE FAMILY
♣ BENEFITS OF NON VIOLENCE
♣ BEFORE CONCEPTION
♣ MALE PARTICIPATION AND PARENTHOOD
♣ TOBACCO AND ALCOHOL
WHO-SEARO

41. 5.Many health risk behaviours are initiated during adolescence: Need to catch them young “Healthy Transitions”
WHO-SEARO

42. Large number of adolescents in SEAR with many health problems
Proportion of adolescents (10-19)
Sexual and reproductive health problems
Nutritional problems
Substance use: Tobacco, alcohol
Injuries, accidents and violence
Mental health problems
1.2 billion adolescents (10-19) globally About 350 Millions in SEAR of which 230 million in India
WHO-SEARO
Source: World population prospects: The 2006 Revision Population Database.

43. Health problems start during Adolescent period
Age parameter: years
Confounding factors:
Biological: Early or late onset of puberty
Social-cultural factors
Experiencing rapid growth and development:
Physical: Body image and form
Sexual: Reproductive capacity
Mental: Mind
Emotional-psychological
Social
Formative Phase:
Attitudes
Behaviours
Heterogeneous groups and circumstances with variable needs:
Boys and girls
Urban and rural
In school and out of school
Unmarried and married: Pregnant and mothers
At home and homeless (on streets)
In employment (formal and informal
Age is only one of the parameters to define VYA. There are biological and socio-cultural factors that contribute to the definition
Early adolescence is a very special time between older childhood and full blown adolescence.
Physically, it is the time when puberty occurs and the growth spurt takes off.
Brain continues to develop and evolve until 25 years of age
Psychologically, it is the time when the cognitive changes of adolescence are beginning and when emotional and social competencies are starting to be built. It is a time when the first steps in the development of sense of personal identity and autonomy are being taken.
Socially, it is the time of change – a time when parental influence begins to decline and when the influence of others – including peers and other adults – begins to increase.
Attitudes and beliefs start taking roots and behaviours start getting formed.
Gender roles and socialization set in.

44. Proportion of adolescents who have begun childbearing
Early Marriage and child- bearing
Per cent married by Age 18 among adolescents (15-19 yrs)
Proportion of adolescents who have begun childbearing
Poor women aged are more likely to begin child bearing early
Source: Bangladesh DHS 2007; India NFHS ; Indonesia DHS 2007; Nepal DHS 2006; Sri Lanka DHS ; Timor-Leste DHS 2003
WHO-SEARO

47. Adolescent Pregnancy: Higher Child Mortality
Source: Bangladesh DHS 2011; India NFHS ; Indonesia DHS 2007; Maldives DHS 2009; Myanmar FRHS 2007; Nepal DHS 2011; Sri Lanka DHS ; Timor-Leste DHS
WHO-SEARO

48. Large number are under-nourished and anaemic
WHO-SEARO
Source: Bangladesh DHS 2011; India NFHS ; Nepal DHS 2011; Sri Lanka DHS 2006; Maldives DHS 2009; Timor-Leste DHS

49. Dietary behaviors, Overweight & Obesity (13-15 years)
Source: Latest Global school-based student health survey (GSHS)
WHO-SEARO

50. Early Tobacco use among adolescents (13-15 years)
Source: Latest Global Youth Tobacco Survey (GYTS)
WHO-SEARO

51. Early Alcohol Consumption(13-15 years)
Source: Latest Global school-based student health survey (GSHS)
WHO-SEARO

52. High Unintentional Injuries and Violence(13-15 Years)
Source: Latest Global school-based student health survey (GSHS)
WHO-SEARO

53. Mental Health Problems ( 13-15 Years)
WHO-SEARO
Source: Latest Global school-based student health survey (GSHS)

54. Public Health Issues with Adolescents
Nutrition Issues:
Undernutrition, Anemia, Overnutrition
Sexual And reproductive health:
Early sex: unsafe
Coerced sex
Early marriage and child bearing
STI, HIV
Mental Health: Anxiety, stress, depression, suicide
Tobacco and alcohol use
Injury and accidents
Violence: Victims and perpetrators
Young adolescents experience important public health problems
Health Sector needs to collaborate with other sectors
WHO-SEARO

55. “Home” for adolescents in health services ?
Maternal and
reproductive
health services
Newborn and
child
health services
Disease Treatment for all

57. Progress so far
Regional Strategy and National strategies (9 countries)
Country Fact sheets on AHD and Adolescent pregnancy
National Standards and implementation guidelines on AFHS (9 countries)
Training packages adapted, HWs trained (8 countries)
Quality and coverage assessments (6 countries)
Regional Program management capacity building course
Collaboration with other sectors - education

58. Package of AH services: Range in SEAR Countries
Physical & mental health promotion
Nutrition and micronutrients
STI/RTI: Screen and manage
HIV/AIDS prevention, testing
Contraception, condom promotion
Pregnancy and childbirth care
Substance use prevention
Healthy Lifestyles promotion
Immunization
SEARO is working towards developing “Healthy Transitions” package for comprehensive care of adolescent boys and girls covering all these areas. An age-appropriate package would be offered to age group

59. Coverage assessment: Utilization Received IFA Tabs in Last Six Month
Haryana, India
August 2013
WHO-SEARO

60. Adolescent Health Programme in SEAR
Adolescent Health Programme being scaled up in SEAR Countries
Focus has been on Sexual and Reproductive Health
Opportunity to add elements of Pre-Conception Care Package –
Healthy Transitions Package
SEARO is working towards developing “Healthy Transitions” package for comprehensive care of adolescent boys and girls covering all these areas
August 2013
WHO-SEARO

61. “Healthy Transitions for Adolescents” package
We know that specific interventions are effective and can be delivered to Adolescents
Evidence-based preventive and curative health interventions for adolescents
Existing delivery mechanisms that could be used to deliver interventions at scale
Provide age-appropriate sexual health education
Delay pregnancy
Provide contraceptive services including condoms
Prevent, screen and manage STIs, HIV
Provide Iron folic acid
Immunization
Prevention of Substance use
Prevent NCD risk behaviours
School health program
Nutrition program
Youth programs
AFHS
HIV testing and counselling clinics
NCD programmes
Mental Health programmes
“Healthy Transitions for Adolescents” package
WHO-SEARO

62. ‘Healthy Transitions for adolescents’ Ensuring health across life-course
Healthy adolescence
Healthy reproductive health outcomes
Reduction in prevalence of prematurity, LBW, Birth Defects
Reduction in maternal, foetal, neonatal and child mortality
Healthy adulthood (long term)
NCD prevention
Reduction in Tobacco and harmful use of alcohol related problems and cost
STIs and HIV prevention
WHO-SEARO

63. Existing Opportunities in Public Health Programmes
Where
Service type
Intervention / package
Health Facilities
RH Services
AFHS
Immunization programmes
Add preconception-related interventions
Integrate essential components of Pre-marital counseling and genetic screening
Expanded post-natal care (facility visits)
Healthy Lifestyles: NCD prevention
Schools
School Health Programme
Health Promoting Schools
Integrate essential components of Pre-marital counseling
Nutrition and micronutrient supplementation
Out Reach
Community support groups & delivery platforms
Mass media campaigns/ Social marketing
Information technology, (mHealth)
Expanded post-natal care (home visits)
Pre-marital counseling
Optimizing Adolescent and pre-pregnancy nutrition
WHO-SEARO

64. Existing Opportunities in Public Health Programmes
Where
Service type
Intervention / package
Health Facilities
RH Services
AFHS
Immunization programmes
Add preconception-related interventions
Integrate essential components of Pre-marital counseling and genetic screening
Expanded post-natal care (facility visits)
Healthy Lifestyles: NCD prevention
Schools
School Health Programme
Health Promoting Schools
Integrate essential components of Pre-marital counseling
Nutrition and micronutrient supplementation
Out Reach
Community support groups & delivery platforms
Mass media campaigns/ Social marketing
Information technology, (mHealth)
Expanded post-natal care (home visits)
Pre-marital counseling
Optimizing Adolescent and pre-pregnancy nutrition
Use of modern communication technology for health assessment and prevention/promotion
WHO-SEARO

65. Preconception care in SEAR: 2 Tracks
Infancy U5
Neonatal period
Pregnancy
Birth
10-19
Pre-Pregnancy
CH Immunization
Newborn Care
AFHS
SBA
PCC
ANC
Healthy Transitions for adolescents
Maternal Health
WHO-SEARO

66. 6. Way forward and challenges
WHO-SEARO

67. Regional expert Group Consultation on Pre-Conception Care: Aug 2013 WHO-SEARO and CDC-US
PCC package would address maternal mortality, neonatal morality, pregnancy wastage, birth defects, pre term births and intrauterine growth retardation.
The selected interventions would need to be implemented through integration and convergence within the health system as well as in other sectors.
Optimize on established programmes such as Maternal, Reproductive ,Newborn and Child Health and adolescent health programmes as well as the programmes like Birth Defects prevention and Non Communicable Diseases.
Expanding interventions to adolescent boys and girls would ensure better RH outcomes as well as healthy adulthood in the long term.
WHO-SEARO

68. Opportunities Need for demonstration projects
Global commitments and partnerships for MDG 4 and 5 – Health agenda beyond 2015
Enhanced commitment of national governments for AH programme and earmarking of domestic resources
Better understanding of adolescent brain
Newborn and child health plans, RH plans at Global, regional and national level.
New technology: Information and communication technology (internet,Mobile phones,Social media) to connect with young people and gatekeepers
New initiatives: Newborn health, Preterm births, RH ,Birth defects prevention, Pre-conception, HPV, NCD prevention
Need for demonstration projects
August 2013
WHO-SEARO

69. Every Journey begins with a single step, But you will never finish if you don’t start!

70. miles to go…

71. Regional Meeting on Birth Defects, New Delhi
Thank You
13 Dec 2011
Regional Meeting on Birth Defects, New Delhi