The US Centers for Disease Control and Prevention (CDC) and a select panel of external partners issued guidelines for preconception care of women, emphasizing the importance of providing this type of care in the primary care setting. The new national recommendations, which are published in the January-February issue of Journal of the American Board of Family Medicine, aim to improve preconception health and healthcare in response to unfavorable aspects of the health status of women and children in the United States.
"The national recommendations are part of a strategic plan for improving preconception health through the provision of clinical care as well as the promotion of changes in individual behaviors, health policy, and public health strategies," write Anne L. Dunlop, MD, MPH, from the Emory University School of Medicine in Atlanta, Georgia, and colleagues. "The concept of preconception care has been articulated for well over a decade but has not become part of the routine practice of family medicine. Because all women of reproductive age presenting to the primary care setting are candidates for preconception care, the essential and critical role of family physicians in the provision of preconception care is apparent."
In the United States, rates of adverse birth outcomes (preterm and low birth weight deliveries, infant deaths, and birth defects), maternal pregnancy complications, and unintended pregnancies are all higher than goals targeted in Healthy People 2010.
Key recommendations issued in these guidelines are as follows:
- Individual responsibility across the life span: Each woman and every couple should be encouraged to formulate a reproductive life plan.
- Consumer awareness: Public awareness of the importance of preconception health behaviors should be increased, as should individuals' use of preconception care services. Information and tools used should be appropriate for varying ages, literacy levels, health literacy levels, and cultural/linguistic contexts.
- Preventive visits: To reduce risks related to pregnancy outcomes, all women of childbearing age should have risk assessment and counseling (education and health promotion) as part of their primary care visits.
- Interventions for identified risks: The proportion of women who receive interventions as follow-up to preconception risk screening should be increased. These interventions should focus on high priority interventions (those with high population impact and sufficient evidence of effectiveness).
- Interconception care: The interconception period should be used for intensive interventions to women who have had adverse outcomes in a previous pregnancy, such as infant death, low birth weight, or preterm birth.
- Prepregnancy check ups: As a component of maternity care, 1 prepregnancy visit should be offered for couples planning pregnancy.
- Health coverage for low-income women: Medicaid coverage should be increased among low-income women to improve access to preventive women's health, preconception, and interconception care.
- Public health programs and strategies: Components of preconception health should be infused and integrated into existing local public health and related programs, including emphasis on those with prior adverse outcomes.
- Research: The research base of knowledge related to preconception health should be expanded.
Monitoring improvements: To monitor preconception health, public health surveillance and related research mechanisms should be maximized.
One barrier to providing preconception care is lack of clinician knowledge of recommended interventions, which the new guidelines address by outlining 14 specific preconception healthcare interventions with clinical practice guidelines and evidence of efficacy. These include folic acid supplementation, rubella vaccination, diabetes management, hypothyroidism management, hepatitis B vaccination for at risk women, HIV/AIDS screening and treatment, sexually transmitted infection screening and treatment, maternal phenylketonuria management, oral anticoagulant use management, antiepileptic drug use management, accutane use management, smoking cessation counseling, eliminating alcohol use, and obesity control.
"As a specialty, we are now challenged to effectively translate the concept of preconception care into clinical reality," the authors conclude. "First, ask every women of reproductive age whether she intends to become pregnant in the next year. Asking every woman about her reproductive intentions promotes the idea that pregnancies should be intended and planned by providing contraception to the woman who does not intend to conceive and promotes the initiation of preconception care strategies for women if and when they do desire to become pregnant. Second, inform women that health conditions and medications can affect pregnancy outcomes and that pregnancy can affect a woman's health."
J Am Board Fam Med. 2007;20:81-84.
Preconception counseling offers an effective and efficient means to reduce complications of pregnancy for both the mother and baby. Primary care clinicians, particularly family physicians and family nurse practitioners, are in a privileged position to deliver preconception care. The current article recommends that family physicians inquire about conception plans annually among all women of childbearing age. Women should be made aware that specific preconception interventions may improve not only the outcomes of pregnancy, but their overall health as well.
The current article summarizes recommendations from the CDC for promoting preconception healthcare as well as specific interventions that have been demonstrated to improve pregnancy outcomes.
Preconception health should be encouraged by public health measures and education, including encouragement of a reproductive life plan for all couples. These efforts should include improved health coverage for low-income women.
Preconception care may begin after a negative pregnancy outcome, but all couples planning a pregnancy should receive a clinician visit for counseling. At these visits, clinicians should focus on the most efficacious interventions for preconception health. Such interventions may include:
- Folic acid supplementation: supplementation with folic acid can reduce the risk for neural tube defects by two thirds.
- Rubella vaccination.
- Diabetes management: improved control of diabetes can reduce the risk for birth defects 3-fold.
- Hypothyroidism management: the requirement for thyroid replacement therapy increases during pregnancy, and early intervention promotes healthy neurologic development of children.
- Hepatitis B vaccination for at risk women.
- HIV screening and treatment.
- Screening for Neisseria gonorrhoea and Chlamydia trachomatis. Elimination of these bacteria can reduce the risk for ectopic pregnancy and infertility as well as mental retardation and blindness of the newborn.
- Maternal phenylalanine management among women with phenylketonuria. Elevated levels of maternal phenylalanine may promote mental retardation in childhood.
- Oral anticoagulant use: warfarin is associated with an increased risk for birth defects and hemorrhage in pregnancy. If at all possible, women should stop treatment with warfarin prior to pregnancy.
- Oral antiepileptic medication management: clinicians should attempt to minimize the teratogenic potential of these medications.
- Cessation of treatment with isotretinoin.
- Smoking cessation counseling: smoking is associated with preterm birth, low birth weight, and other negative perinatal outcomes.
- Elimination of alcohol use.
- Obesity control: a healthy weight prior to pregnancy reduces the risks for neural tube defects, preterm delivery, diabetes, Cesarean delivery, hypertension, and thromboembolic disease.
Pearls for Practice
Clinicians should inquire about plans for pregnancy in the next year among all women of childbearing age. Women should also be informed that preconception care can improve health outcomes for both mother and baby.
During preconception screening visits, clinicians should focus on issues such as folate supplementation, hypothyroidism management, obesity control, hepatitis B vaccination for at risk women, and rubella vaccination among previously unvaccinated women.