PROFESSIONALS

1. What are the new recommendations for improving preconception health?
2. How should I, as a provider, address the issue of reproductive planning with my patients?
3. What source for information and resources are available to help me incorporate preconception care into my practice?
4. What specific preconception interventions have proven to be effective in improving pregnancy outcomes?

1. What are the new recommendations for improving preconception health?

The CDC and its partners have released a set of 10 Recommendations for Preconception Health. These recommendations reflect the best of scientific evidence and programmatic experience in the field, and are designed to guarantee optimal reproductive health outcomes for all women and couples. There are four explicit goals for the Recommendations:

• Goal 1. Improve the knowledge and attitudes and behaviors of men and women related to preconception health.

• Goal 2. Assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health.

• Goal 3. Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children.

• Goal 4. Reduce the disparities in adverse pregnancy outcomes

Each of the Recommendations has an associated detailed action plan. Below are the Recommendations:

• Recommendation 1. Individual responsibility across the life span. Each woman, man, and couple should be encouraged to have a reproductive life plan.

• Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts.

• Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risk and improve pregnancy outcomes.

• Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow up to preconception risk screening, focusing on high priority interventions (i.e., those with evidence of effectiveness and greatest potential impact).

• Recommendation 5. Interconception care. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (e.g., infant death, fetal loss, birth defects, low birthweight or preterm birth).

• Recommendation 6. Pre-Pregnancy Check Ups. Offer, as a component of maternity care, one pre-pregnancy visit for couples and persons planning pregnancy.

• Recommendation 7. Health Insurance Coverage Women with Low Incomes. Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care.

• Recommendation 8. Public Health Programs and Strategies. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.

• Recommendation 9. Research. Increase the evidence base and promote the use of evidence to improve preconception health.

• Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health.

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2. How should I, as a provider, address the issue of reproductive planning with my patients?

Reproductive health planning is about being intentional around preparing for and starting pregnancies. It includes making decisions about when to have children, how many to have, how to time pregnancies, and how to ensure the healthiest pregnancies and families. It sometimes involves contraception, sometimes fertility promoting actions, sometimes other behavior changes. Providers can start by asking women when they want their next (or first) pregnancy, if ever. Providers can then ask about current sexual activity, contraceptive use, and health status to determine whether a woman is doing everything possible to realize her goals for pregnancy. Reproductive planning should be addressed with everyone of reproductive age. Because different people have different cultural and personal concepts of sexuality, fertility, health, and control over pregnancy, cultural competence is of critical importance in communicating about reproductive planning. For example, “planning to get pregnant”, “wanting to get pregnant”, “trying to get pregnant”, and the opposites of each of these might take on different meanings depending on the woman.

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3. What source for information and resources are available to help me incorporate preconception care into my practice?

There have been numerous publications related to preconception care, and there currently are many sets of recommendations. To simplify matters, ACOG and AAP have grouped the main components of preconception care under four categories of interventions: maternal assessment (e.g., family history, behaviors, obstetric history, general physical exam); vaccinations (e.g., rubella, varicella and hepatitis B); screening (e.g., HIV, STD, genetic disorders); and counseling (e.g., folic acid consumption, smoking and alcohol cessation, weight management). Many of these interventions are currently available to women and, when indicated, to couples; however, they are not systematically delivered. Moreover, many national professional organizations have developed and published clinical practice guidelines (CPGs) for specific components of preconception care. For example, the American Diabetes Association developed CPGs to be started before pregnancy for women with preconception diabetes. The American Association of Clinical Endocrinologists has developed preconception CPGs for women with hypothyroidism. CPGs have also been developed for women being treated with teratogenic medications to guide the transition to safer medications. CPGs for women using antiepileptic drugs or oral anticoagulants have been developed by the American Academy of Neurology and, the American Heart Association/American College of Cardiologists, respectively. Guidelines, recommendations, and strategies for reducing alcohol misuse and prevention of fetal alcohol syndrome have been developed and published by the U.S. Public Health Service, U.S. Preventive Service Taskforce, ACOG, and the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect.

CDC, in collaboration with national partner organizations, will be convening workgroups in June 2006, to review current knowledge and practices and define and develop the content of preconception care for clinical care providers, public health workers, and for consumers. The deliberations of the workgroup are expected to result in practice tools which will be disseminated to the public in early 2007.

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4. What specific preconception interventions have proven to be effective in improving pregnancy outcomes?

A comprehensive review of the literature identified a long list of risk factors suggested to be included in comprehensive preconception care. The strength of evidence supporting the efficacy of the various components of preconception care varies greatly. Clinical practice guidelines (CPGs) have been developed for reducing the risk related to some of these factors. The Select Panel on Preconception care identified 14 conditions for which CPGs exist and for which there is scientific evidence demonstrating effectiveness in improving pregnancy outcomes:

• Folic acid. Daily use of vitamin supplements containing folic acid has been demonstrated to reduce the occurrence of neural tube defects by at least 50%.

• Rubella seronegativity. Rubella vaccination provides protective seropositivity and prevents the occurrence of congenital rubella syndrome.

• Diabetes (preconception). The three-fold increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes.

• Hypothyroidism. The dosages of Levothyroxine® required for treatment of hypothyroidism increases in early pregnancy. Levothyroxine® dosage needs to be adjusted for proper neurologic development.

• HIV/AIDS. If HIV infection is identified before conception, timely treatment can be administered and women (or couples) can be given additional information that can influence the timing of the onset of pregnancy.

• Maternal phenylketonurea (PKU). Women diagnosed with PKU as infants may have infants with mental retardation. However, this adverse outcome can be prevented when mothers adhere to a low phenylalanine diet before conception and continue it throughout their pregnancy.

• Oral anticoagulant. Warfarin, which is used for the control of blood clotting, has been demonstrated to be a teratogen. To avoid exposure to warfarin during early pregnancy, medications can be changed to a nonteratogenic anticoagulant before the onset of pregnancy.

• Anti-epileptic drugs. Certain anti-epileptic drugs are known as teratogens. Before conception, women who are on a regimen of these drugs and who are contemplating pregnancy should be prescribed a lower dosage of these drugs.

• Isotretinoins (Accutane®): Use of isotretinoins in pregnancy to treat acne results in miscarriage and birth defects. Effective pregnancy prevention should be implemented to avoid unintended pregnancies among women with childbearing potential who use this medication.

• Smoking. Preterm birth, low birthweight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking during early pregnancy. Because only 20% of women successfully control tobacco dependence during pregnancy, cessation of smoking is recommended before pregnancy.

• Alcohol or other recreational drug misuse. No time during pregnancy is safe to drink alcohol or other recreational drugs, and harm can occur early, before a woman has realized that she is or might be pregnant. Fetal alcohol syndrome and other drug-related birth defects can be prevented if women cease intake of alcohol and use of other drugs before conception.

• Obesity. Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Weight loss before pregnancy reduces these risks.

• STDs. Chlamydia trachomatis and Neisseria gonorrhea have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STDs during pregnancy might result in fetal death or substantial physical and developmental disabilities, including mental retardation and blindness.

• Hepatitis B. Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus (HBV) infection through sexual transmission or through percutaneous or mucosal exposure to blood.. Preventing HBV infection in women of childbearing age prevents transmission of infection to infants and eliminates risk for to women of sequelae of HBV infection, including hepatic failure, liver carcinoma, cirrhosis, and death.
  
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Date: April 12, 2006
Content source: National Center on Birth Defects and Developmental Disabilities