Associations Between Preconception Counseling and Maternal Behaviors Before and During Pregnancy

1. Associations Between Preconception Counseling and Maternal Behaviors Before and During Pregnancy Lauren B. Zapata, PhD , MSPH Letitia Williams, MPH, Denise D’Angelo, MPH & Leslie Harrison, MPH, Brian Morrow, MA, Division of Reproductive Health, CDC

2. Preconception Health • Key public health strategy to decrease morbidity & mortality associated with negative birth outcomes • Improving health BEFORE pregnancy • Awareness • Behavior change • Health care utilization Increases likelihood of healthy pregnancy and infant

3. Preconception Health

4. Preconception Health • 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 risks and improve pregnancy outcomes.” To integrate preconception health counseling into EVERY primary care visit for ALL women of reproductive age.

5. Preconception Counseling (PCC) • Educate and recommend strategies to improve health and birth outcomes • Evidence supports specific interventions • Folic acid supplementation • Smoking cessation • Obesity control • Less evidence on effectiveness of PCC, in general

6. Purpose • To assess the associations between receipt of PCC and positive maternal behaviors before and during pregnancy • Pre-pregnancy daily multivitamin (MV) consumption • 1st trimester entry into prenatal care (PNC) • Smoking cessation before pregnancy* • Drinking cessation before pregnancy* *Among those who smoked/drank in the past two years.

7. Purpose • To determine if the effect of PCC on positive maternal behaviors was modified by pregnancy intention or type of insurance. • To identify characteristics of women reporting the lowest levels of PCC.

8. Data Source • Pregnancy Risk Assessment Monitoring System (2004-2008): ME, NJ, UT, VT (n=30,481) • Overview of PRAMS • State and population-based surveillance system • Monitors self-reported behaviors and experiences around time of pregnancy among women with a recent live birth • Annual weighted response rates ranged from 72% - 89%.

9. Main Exposure • Receipt of preconception counseling • BEFORE you got pregnant with your new baby, did you talk with a doctor, nurse, or other health care worker to prepare for a healthy pregnancy and baby? [Yes or No]

10. Outcome Variables • Pre-pregnancy daily MV consumption • During the month before you got pregnant with your new baby, how many times a week did you take a multivitamin or a prenatal vitamin? [Daily versus not daily]

11. Outcome Variables • First trimester prenatal care • How many weeks or months pregnant were you when you had your first visit for prenatal care? [1st trimester versus all others]

12. Outcome Variables • Among smokers in past 2 years (n=7,650): • Smoking cessation before pregnancy • During the 3 months before you got pregnant, how many cigarettes did you smoke on an average day? [None versus some smoking] • Among drinkers in past 2 years (n=17,585): • Drinking cessation before pregnancy • During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week? [None versus some drinking]

13. Age Race/Ethnicity Education Marital status* Type of insurance* BMI* Pregnancy intention Diabetes* Previous live birth Previous LBW infant Previous preterm infant State Year of survey Covariates *Before pregnancy

14. Data Analysis • % of women reporting receipt of PCC • Overall & stratified by maternal characteristics • Logistic regression – ORs, AORs, and 95% CIs • Factors associated with receipt of PCC • Associations between receipt of PCC and each of outcome variable • Effect modification by pregnancy intention and type of insurance before pregnancy • Weighted data using SUDAAN

15. Results

16. Sample Characteristics • Majority of women were: • Aged 20-34 years 76.4% • Self identified as white, non-Hispanic 62.5% • Completed >12 years of education 57.5% • Married before pregnancy 70.0% • Private insurance before pregnancy 67.8%

17. Sample Characteristics • Additional characteristics: • Overweight or obese 32.0% • Pre-pregnancy diabetes 1.8% • Previous live birth 59.5% • Previous LBW infant 5.8% • Previous preterm infant 6.8% • Intended pregnancy 64.8%

18. Receipt of PCC • Overall: 32.4% • Significant differences between subgroups of women

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22. Receipt of PCC

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29. Pre-pregnancy Daily MV Consumption *Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

30. Pre-pregnancy Daily MV Consumption *Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

31. First Trimester Prenatal Care *Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

32. First Trimester Prenatal Care *Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

33. First Trimester Prenatal Care *Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

34. Smoking Cessation Before Pregnancy* *Among those who smoked in the past 2 years. **Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

35. Smoking Cessation Before Pregnancy* *Among those who smoked in the past 2 years. **Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

36. Smoking Cessation Before Pregnancy* *Among those who smoked in the past 2 years. **Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

37. Drinking Cessation Before Pregnancy* *Among those who drank in the past 2 years. **Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

38. Drinking Cessation Before Pregnancy* *Among those who drank in the past 2 years. **Adjusted for age, race/ethnicity, marital status, education, type of insurance at conception, pregnancy intention, pre-pregnancy diabetes, previous live birth, previous LBW infant, previous preterm infant, state and year.

39. Summary • Overall prevalence of PCC low (31%) • Absolute lowest levels for women: • Unintended pregnancy 13.5% • No insurance 13.7% • Unmarried 18.4% • Aged <20 years 19.2% • <12 years of education 19.2%

40. Summary • Receipt of PCC was associated with: • Pre-pregnancy MV consumption • 1st trimester PNC for those with IP • Drinking cessation before pregnancy • PCC is important for all women of reproductive age despite pregnancy desire

41. Limitations • Question used to measure PCC was broad • Cross-sectional data • Data are self-reported after delivery • Results may not be generalizable

42. Conclusions • PCC is a successful tool in the promotion of positive maternal behaviors • Efforts should be taken to increase rates of PCC for all women as part of primary care • Special attention for subpopulations reporting particularly low levels

43. THANK YOU! • Contact Information: lzapata@cdc.gov • CDC Disclaimer: The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.