Look before you leap: Preconception care

1. Look before you leap: Preconception care Melanie Chichester, BSN, RNC-OB Christiana Care Health System Newark, Delaware, USA *With grateful acknowledgement to Deborah Ehrenthal, MD, FACP & Michele Savin, MSN, NNP-BC

2. Faculty Disclosure I have done consulting for GE Healthcare.

3. All the notes you need…. AJOG issue on preconception care http://www.ajog.org/issues?issue_key=S0002-9378(08)X0011-0 Google AJOG preconception care 2008

4. The United States has one of the highest infant mortality rates among industrialized nations

5. Prematurity and birth defects are the major drivers of infant mortality #1 Prematurity: • Preterm birth accounted for at least 1/3 of infant deaths in 2002* • 65% of all infants who died in 2002 were born preterm • The vast majority of deaths were among those born < 32 weeks and weighing <1500 g. #2 Congenital anomalies: • Present in 25% of infant deaths in 2002 Based on reanalysis of 2002 NVSS data, Pediatrics, 2006

6. Maternal health is a key risk for both prematurity and congenital anomalies • Health status overall • Nutrition: • Underweight • Overweight and obesity • Inadequate folic acid • Exercise habits • Infection risk (immunizations) • Specific health risks • Chronic medical conditions • Medications • Tobacco, recreational drugs, and alcohol Who takes their vitamin daily?

7. We will have the greatest impact on outcomes if health risks are addressed prior to conception The Challenge: 50% of pregnancies are unplanned

8. We will have the greatest impact on outcomes if health risks are addressed prior to conception The Challenge: 50% of pregnancies are unplanned

9. “The definition of insanity is doing the same thing over and over and expecting a different outcome”

10. What we have been doing… • Waiting until pregnancy established to begin care. • Entry into prenatal care ~8-12 weeks, after organogenesis of major organ systems complete. • We know folic acid reduces neural tube defects • Prenatal care is too late! • Health risks are already present; prenatal care is simply surveillance of women at risk. (MK Moos)

11. Changing course • We need women to be healthy before conception. • Health problems which put pregnant women at risk put women at risk throughout the life span. • ACOG, ACNM, CDC, March of Dimes, all endorse preconception care as integral part of well woman care. • “As part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of reproductive age to reduce reproductive risks and improve pregnancy outcomes.” • Center for Disease Control and Prevention’s (CDC) Select Panel on Preconception Health

12. So what can we do?

13. Teach about Reproductive Life Plan Puberty Conception Childbirth Postpartum Preconception Pregnancy Time Preconception begins again Kroelinger, C, 2007

14. Courtesy of Planned Parenthood of Delaware

15. Life plan perspective • Health promotion and risk reduction • Invest in: • Wellness • Strengthening families • Improving education • Improving the environment • Creating policy that supports maternal/child health

16. Courtesy of Planned Parenthood of Delaware

17. “Every woman, every time.” “Healthy women have a plan.” “What is your life plan?” Life plan perspective

18. Goals of Preconception Care • Identify important risk factors • Risks to a women’s health overall • Risk of poor pregnancy outcome • Emphasize factors which must be acted on before conception or early in pregnancy for maximal impact • Recommend folic acid for everyone • Encourage development of a reproductive plan

19. The CDC says every person should have a reproductive lifeplan: DO YOU??????

20. ASK! • Where are your clients on the continuum?

21. “I’d like to be a father, but I have to finish school and have a job to support a family. Until we’re ready to have a baby, I’ll make sure we use effective contraception every time.”   “I am ready to try to get pregnant. I have diabetes, so I’ll go see my doctor to make sure my body is ready for pregnancy. In the meantime, I’m taking really good care of myself just for me.” “I don’t want to have any children. I need to find a good birth control method.” “I have two kids, but my partner and I want to wait two years before we have another. I’ll talk to my doctor about timing between pregnancies. This time, I’m going to make sure I only get pregnant when I want to. “I want to be a father some day, but my life is too stressful to start a family.  I’ll take care of myself now so that I’m healthy when my partner and I decide to start a family in the future.” “I’m just going to let pregnancy happen whenever it happens.  Since I don’t know when that will be, I’m making sure that I’m in the best health now, just in case!”

22. Life plan goals • Reduce a women’s chance of an unintended pregnancy • Support women in achieving planned pregnancies.

24. Who else?

25. Women with psychiatric disorders

26. Teens

27. Special needs

28. Preconception care is simply excellent primary care with attention to reproductive potential M Moos, A. L. Dunlop, B. W. Jack, L Nelson, D. V. Coonrad, R Long, K Boggess, and P.M. Gardner, Healthier Women, Healhtier Reproductive Outcomes: Recommendations for the Routine Care of All women of Reproductive Age. Amer J Obstet Gynecol, 2008.

29. Who are the women we should we especially target? • Women with prior premature baby or other poor pregnancy outcome • Women with chronic medical conditions • Women with psychosocial and behavioral risks • Women who are underinsured • Women with poor health literacy

30. When should preconception care be addressed?

31. Where should we address preconception care? • Annual exam? • Pre-pregnancy check-up with OBGYN? • Routine visits with PCP? • Pre-pregnancy check-up with PCP? • Chronic disease management with specialist? • Integrated into our routine care of girls and women of childbearing age 50% of all pregnancies are unplanned

32. OB/GYN? • National study of ACOG fellows, 2006 • Most believe preconception care is important • Almost always recommend it to women who are intending a pregnancy • Only half offer counseling to sexually active women who are not seeing them specifically for preconception advice Morgan, M., Hawks, D, Zinberg, S, Schulking J, What Obstetrician-Gynecologists think of preconception care. Maternal Child Health Journal, 2006.

33. OB/GYN? • National study of ACOG fellows, 2006 • Most believe preconception care is important • Almost always recommend it to women who are intending a pregnancy • Only half offer counseling to sexually active women who are not seeing them specifically for preconception advice Morgan, M., Hawks, D, Zinberg, S, Schulking J, What Obstetrician-Gynecologists think of preconception care. Maternal Child Health Journal, 2006.

34. Specialists? • Diabetics in a managed care setting • 52% of women recalled counseling about glycemic control • 37% recalled receiving contraceptive advice • Kim, C., et al., Preconception care in managed care: the translating research into action for diabetes study. Am J Obstet Gynecol, 2005. 192(1): p. 227-32.

35. Specialists? • Diabetics in a managed care setting • 52% of women recalled counseling about glycemic control • 37% recalled receiving contraceptive advice • Kim, C., et al., Preconception care in managed care: the translating research into action for diabetes study. Am J Obstet Gynecol, 2005. 192(1): p. 227-32.

36. Primary care provider? • Women surveyed at their annual exam • Majority of women recognized the importance of optimizing their health prior to conception • Most looked to their primary health care provider for such information. • Deficiencies in their knowledge of risk factors suggested physicians are not routinely providing preconception care A Frey, K.A. and J.A. Files, Preconception Healthcare: What Women Know and Believe. Matern Child Health J, 2006.

37. Primary care provider? • Women surveyed at their annual exam • Majority of women recognized the importance of optimizing their health prior to conception • Most looked to their primary health care provider for such information. • Deficiencies in their knowledge of risk factors suggested physicians are not routinely providing preconception care A Frey, K.A. and J.A. Files, Preconception Healthcare: What Women Know and Believe. Matern Child Health J, 2006.

38. Family practice HCPs are in a key position to provide preconception care: • Internists/family nurse practitioners care for the women who are at highest risk: those with chronic health problems • These health care providers need to know: • OB/Gyns do not routinely provide preconception counseling and may not be aware of recommendations for women with chronic health problems • Specialists do not routinely provide preconception counseling • Women • do not always attend their 6 week post-partum check-up • do not always address contraception post-partum • are not aware of the follow-up needed for pregnancy complications (e.g. Gestational diabetes, HTN)

39. Family practice HCPs are in a key position to provide preconception care: • Internists/family nurse practitioners care for the women who are at highest risk: those with chronic health problems • These health care providers need to know: • OB/Gyns do not routinely provide preconception counseling and may not be aware of recommendations for women with chronic health problems • Specialists do not routinely provide preconception counseling • Women • do not always attend their 6 week post-partum check-up • do not always address contraception post-partum • are not aware of the follow-up needed for pregnancy complications (e.g. Gestational diabetes, HTN)

40. Family practice HCPs are in a key position to provide preconception care: • Internists/family nurse practitioners care for the women who are at highest risk: those with chronic health problems • These health care providers need to know: • OB/Gyns do not routinely provide preconception counseling and may not be aware of recommendations for women with chronic health problems • Specialists do not routinely provide preconception counseling • Women • do not always attend their 6 week post-partum check-up • do not always address contraception post-partum • are not aware of the follow-up needed for pregnancy complications (e.g. Gestational diabetes, HTN)

41. Examples of interventions with evidence for efficacy: • Folic acid use: reduces NTD but must be begun prior to conception • Diabetes: anomalies rates correlate with HgbA1C at the time of conception • Obesity: achieving a healthy weight prior to conception will improve outcomes and decrease maternal risks • Hypertension: ACE Inhibitors and ARBs are teratogenic and must be stopped prior to conception • Seizure disorders: adjustment of medications prior to conception will decrease risk of anomalies • Immunization Rubella and varicella vaccines must be given prior to conception CDC recommendations, 2006

42. Examples of interventions with evidence for efficacy: • Folic acid use: reduces NTD but must be begun prior to conception • Diabetes: anomalies rates correlate with HgbA1C at the time of conception • Obesity: achieving a healthy weight prior to conception will improve outcomes and decrease maternal risks • Hypertension: ACE Inhibitors and ARBs are teratogenic and must be stopped prior to conception • Seizure disorders: adjustment of medications prior to conception will decrease risk of anomalies • Immunization Rubella and varicella vaccines must be given prior to conception CDC recommendations, 2006

43. Examples of interventions with evidence for efficacy: • Folic acid use: reduces NTD but must be begun prior to conception • Diabetes: anomalies rates correlate with HgbA1C at the time of conception • Obesity: achieving a healthy weight prior to conception will improve outcomes and decrease maternal risks • Hypertension: ACE Inhibitors and ARBs are teratogenic and must be stopped prior to conception • Seizure disorders: adjustment of medications prior to conception will decrease risk of anomalies • Immunization Rubella and varicella vaccines must be given prior to conception CDC recommendations, 2006

44. Examples of interventions with evidence for efficacy: • Folic acid use: reduces NTD but must be begun prior to conception • Diabetes: anomalies rates correlate with HgbA1C at the time of conception • Obesity: achieving a healthy weight prior to conception will improve outcomes and decrease maternal risks • Hypertension: ACE Inhibitors and ARBs are teratogenic and must be stopped prior to conception • Seizure disorders: adjustment of medications prior to conception will decrease risk of anomalies • Immunization Rubella and varicella vaccines must be given prior to conception CDC recommendations, 2006

45. Examples of interventions with evidence for efficacy: • Folic acid use: reduces NTD but must be begun prior to conception • Diabetes: anomalies rates correlate with HgbA1C at the time of conception • Obesity: achieving a healthy weight prior to conception will improve outcomes and decrease maternal risks • Hypertension: ACE Inhibitors and ARBs are teratogenic and must be stopped prior to conception • Seizure disorders: adjustment of medications prior to conception will decrease risk of anomalies • Immunization Rubella and varicella vaccines must be given prior to conception CDC recommendations, 2006

46. Examples of interventions with evidence for efficacy: • Folic acid use: reduces NTD but must be begun prior to conception • Diabetes: anomalies rates correlate with HgbA1C at the time of conception • Obesity: achieving a healthy weight prior to conception will improve outcomes and decrease maternal risks • Hypertension: ACE Inhibitors and ARBs are teratogenic and must be stopped prior to conception • Seizure disorders:adjustment of medications prior to conception will decrease risk of anomalies • Immunization Rubella and varicella vaccines must be given prior to conception CDC recommendations, 2006

47. Examples of interventions with evidence for efficacy: • Folic acid use: reduces NTD but must be begun prior to conception • Diabetes: anomalies rates correlate with HgbA1C at the time of conception • Obesity: achieving a healthy weight prior to conception will improve outcomes and decrease maternal risks • Hypertension: ACE Inhibitors and ARBs are teratogenic and must be stopped prior to conception • Seizure disorders:adjustment of medications prior to conception will decrease risk of anomalies • Immunization Rubella and varicella vaccines must be given prior to conception CDC recommendations, 2006

48. Let’s not forget…

49. Military personnel • Unintended pregnancy equally challenging issue for women in the military • Rate equals that of the civilian populations (51%)

50. Your assignments may represent exposure to toxins with reproductive and developmental effects. • Diet and drinking water sources, as well as duties, stress • may also pose a threat to a healthy pregnancy.