Preconception Care Clinical Toolkit: Efficient and Evidence-Based Care for Women

1. The National Preconception Care Clinical Toolkit (“PCC Toolkit”) An Orientation: What It Offers and How to Use It

2. What Is the Purpose of this Toolkit? • This toolkit is designed to assist primary care clinicians incorporate efficient, evidence-based preconception messages and services into their routine preventive care. This will help women achieve: • Better health, irrespective of pregnancy desires; • Increased likelihood that any future pregnancies are desired and planned; • The lowest likelihood of pregnancy problems should pregnancy occur.

3. Why Create a Toolkit? • As the preconception health initiative has gained momentum, primary care providers have repeatedly said they wanted to help make a difference but are unsure of what to do. . . • This toolkit was created to help clinicians realize that it won’t take many changes to their current care to meet the preconception needs of the women in their practiceswho are of childbearing age and might become pregnant at some point in their futures.

4. Who is This Toolkit For? Anyone involved in providing primary health care such as: • Family practice clinicians • Gynecologists • Internists • Nurse practitioners • CNMs • Physician assistants • Registered nurses • Office and clinical support staff The toolkit is not designed to meet the needs of specialists dealing with complex preconception care needs.

5. Who Created This Toolkit? • The National Preconception Health and Health Care (“PCHHC”) initiative is a public-private partnership to advance preconception health through consumer, clinical, public policy and other avenues. • The PCHHC initiative includes a Clinical Work Group of experts in preconception care; they compiled “The Clinical Content of Preconception Care”, the foundation for much of the toolkit (Jack, B & Atrash HK (ed). AJOG, 2008; 199(6B): S3A-S395). • In response to many requests, the Clinical Work Group, comprised of Ob/GYN and FM physicians, nurse practitioners, nurse midwives and representatives of major professional organizations engaged in the clinical care of women of childbearing age, undertook creation of this toolkit. • While much of the effort to create this tool was voluntary, the PCHHC and the Clinical Work Group are grateful to the W.K. Kellogg Foundation for its support of this work.

6. Why Has Preconception Health Become a Prevention Focus for Primary Care? • Prenatal care starts too late to prevent many poor outcomes including: • Birth defects; • Some causes of miscarriage, low birth weight, prematurity, stillbirths and infant death; • Some serious, even life-threatening, maternal complications. • By “tweaking” routine primary care services slightly, more women will receive the information they need to make informed decisions about their own health and the health of any future pregnancies.

7. Why Don’t Women Just Go See Their Chosen Obstetrical Provider before They Get Pregnant? • At least 50% of the pregnancies in this country occur by chance rather than plan. • In addition, the majority of women are unaware of the benefits to themselves and their future children of addressing specific risks before becoming pregnant. • Most women who become pregnant already see a primary care provider for routine care—those visits offer the opportunity to provide important prevention messages for the woman’s own health and the health of any children in her future.

8. I Want to Learn More About the Link Between Primary Care and Reproductive Outcomes • To learn more about the rationale and opportunities of preconception care, take the free CME course on this site, “Preconception Care: What It Is and What It Isn’t” (www.beforeandbeyond.org CE Modules). • To learn more about how the prevention emphases within primary care naturally intersect with preconception health promotion, take the free CME course on this site, “Every Woman, Every Time: Integrating Preconception Health Promotion into Primary Care” (www.beforeandbeyond.org CE Modules)

9. How Is this Toolkit Going to Help Me? • The toolkit is designed to help the busy clinician and practice personnel: • Focus on the general preventive care needs of every woman who presents for routine care. • Save time by tailoring preventive care based on a woman’s (couple’s) specific desires regarding pregnancy in the next year. • Provide “at-your-fingertip” guidance with the option of exploring more in-depth information and references. • Connect quickly with relevant clinical tools and patient education resources.

10. The PCC Toolkit Provides Guidance and Resources to Enrich these Components of Routine Care • Family Planning and Contraception • Nutrition • Infectious Disease and Immunizations • Chronic Diseases • Medication Use • Substance Use • Previous Pregnancy Outcomes • Genetic History • Mental Health History • Interpersonal Violence

11. The topics in the PCC Toolkit are already covered in my routine well woman care—what’s the difference? Comprehensive well woman care is preconception care for women who may become pregnant. . . with a few extra emphases.

12. PCC Toolkit Unique Features • Designed to complement (not replace) the content of routine primary care preventive services. • Provides guidance based on a woman’s reproductive life plan and desires for conception in the next year. • Includes “At-Your-Fingertips” summaries to help the provider incorporate important emphases based on a woman’s plans and desires. • For each of the 10 clinical topics the clinician can explore: • Background information (overview of the topic) • Clinical guidance (specific guidance—in many instances such as infectious disease and chronic diseases the guidance is provided by specific condition) • Clinical tools ( a sampling of tools to help provide recommendations) • Patient resources (a sampling of web resources to direct patients to) • References (bibliography)

13. The Keyto These Efforts : Encourage everyone of childbearing potential to develop a Reproductive Life Plan

14. What Is a Reproductive Life Plan? • The Reproductive Life Plan (RLP) asks women and their partners to consider if they want to have any (more) children and how many they hope to have. • These decisions evolve over time and are best considered outside the examining room but they can be reported via questionnaires (pre-visit or in the waiting room) or during a face-to-face interaction. • A woman’s (couple’s) RLP should be assessed at least annually. • The RLP plan for the coming year is an efficient way to determine what preconception recommendations and education should be integrated into the visit. This can be assessed by asking EVERY woman capable of becoming pregnant, “Do you hope to become pregnant in the next year?”

15. Is There Guidance Available on Developing and Assessing RLPs? • A set of questions to help the provider individualize care for women who do not want to become pregnant in the next year or who are ambivalent or at risk for an unintended pregnancies is available at http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf. • A handout to help women consider their reproductive plans in the context of their life goals is provided at http://www.cdc.gov/preconception/documents/reproductivelifeplan-worksheet.pdf. • Thetab titled “Reproductive Life Planning Assessment” on the left hand menu bar provides additional information.

16. What Are the Possible Responses to Assessing a Woman’s RLP • Woman (couple) desires pregnancy within the next year. • Woman (couple) ambivalent about pregnancy in next year or engaging in contraceptive practices that place them at risk for an unintended pregnancy • Woman (couple) do not want pregnancy in the next year.

17. The Toolkit is Organized to Help the Provider Offer Care Specific To Pregnancy Desires and Needs

18. Woman/Couple Desires Pregnancy If a woman (couple) desires pregnancy in the next year, she is likely to need • Extra emphasis on preconception content in her routine preventive visit. The green(radio) button on the left side of the page takes the clinician and support staff to information especially appropriate to the preventive care of this woman.

19. Woman/Couple At Risk For Unintended Pregnancy If a woman (couple) is at risk for an unintended or unplanned pregnancy in the next year, she is likely to need: • Some preconception content (she is at high risk for an unintended pregnancy). • Extra emphasis on family planning and encouragement to deliberately consider her short and long term pregnancy desires. The yellow(radio) button on the left side of the page takes the clinician and support staff to information especially appropriate to the preventive care of this woman.

20. Woman/Couple Do NOT Desire Pregnancy If a woman (couple) does not desire pregnancy in the next year, she is likely to need • Routine preventive care and encouragement to seek additional care if her plans about becoming pregnant change. The red(radio)button on the left side of the page takes the clinician and support staff to information appropriate to the care of this woman.

21. How Will the Green, Yellow and Red Buttons Help Me Individualize Care to the Woman’s Preconception Needs? Under each button you can choose to… • Review all of the content available to guide the clinician, the practice and the patient in achieving their goals: • background information, clinical guidance, clinical tools, patient resources and references for all 10 clinical components of the toolkit. • Read only the Clinical Guidance section for one or more specific components of care (e.g. nutrition, chronic diseases, family planning) to get detailed guidance for addressing a woman’s specific needs and risks. • Utilize the “At-Your-Fingertips” document which provides a summary of all the general guidance recommended for a woman based on her desires and risks for pregnancy in the next year. This document can be downloaded as a pdf and printed.

22. Clicking on the Radio Button that Corresponds with the Woman’s Desires and Likelihood of Pregnancy Provides Access to Relevant Patient Care Guidance

23. Each of the 10 clinical topics is organized so you can dig as deep as you want—simply by choosing the desired tab(s) and clicking on the radio buttons.

24. When Specific Diseases Are of Interest the Clinical Guidance Buttons Organize Content Alphabetically(e.g. chronicand infectious diseases)

25. The Toolkit is Designed So You Can Easily Determine Where You Are: In this example, you are exploring the preconception significance of nutrition for a woman at risk of an unintended pregnancy

26. A Summary Document that Covers All the General Recommendations for a Woman Based on Her Pregnancy Desires and Risks is Available Under “At-Your-Fingertips”– a printable document

27. How to Maximize Benefit of theToolkit to Your Practice • To appreciate all the toolkit has to offer explore the various buttons and links—there is much to discover BUT YOU ARE BUSY so. . . • Don’t think you need to search the site every time you see a patient—once you are familiar with the general recommendations you will only need to come back when you desire additional information or resources.

28. The PCC Toolkit Is Dynamic and Will Change as New Evidence/Approaches Become Available. . . . . .Be sure to bookmark this site and refer to it often. Encourage colleagues and staff to become familiar with the resource, too.

29. There are many ways to advance prevention in your practice that are not clinician-dependent For instance, nurses and other support staff might be empowered to do much of the screening and education recommended in this toolkit. Let us know of innovations in your practice aimed at achieving higher levels of women’s health, healthier intended pregnancies for those desiring childbearing in their futures and healthier maternal and infant outcomes. mkmoos@med.unc.edu