PRECONCEPTION COUNSELING A BEST BUT UNCOMMON PRACTICE INTENDEDNESS

PRECONCEPTION COUNSELING A “BEST” BUT UNCOMMON PRACTICE

INTENDEDNESS n n 2002 DATA: 30. 8% ALL WOMEN AGE 15 -44 HAVE EXPERIENCED AN UNINTENDED BIRTH ESTIMATE THAT 49. 2% ALL PREGNANCIES UNININTENDE (nsfg)

ORGANOGENSIS n DAYS 17 -56 POST CONCEPTION n n n FIRST DAY OF “MISSED” PERIOD IS DAY 14 POST-CONCEPTION DAY 56 IS ABOUT 6 WEEKS ALL ORGANS FORMED BY WEEK 9

Prevention, in order to be truly preventive, must be antenatal J. W. Ballantyne in 1902

1960: Maternal complications of pregnancy not on top 10 list of leading causes of infant mortality 1980: Number 5 2001: Number 3 2002: 46% of infant mortality related to congenital anomalies, LBW, Preterm Delivery and Maternal complications

2004 Behavioral Risk Factor Surveillance System n n Phone survey of Americans > 18 years of age Median response rate >52% Content varies by state Defined as preconceptional if: n Wanted a baby in next 12 months, not using contraception, not sterile and not already pregnant

BRFSS 2004

Amongst reproductive aged women 6. 1% asthma 11. 4% smoke 5% obese 54. 9% consume alcohol 3. 4% cardiac dz 3% hypertension 80% dental caries &other oral diseases PRENATAL CARE IS TOO 9. 3% diabetes LATE 1. 4% thyroid disease Maternal-Child Health J 2006 10: s 3 -s 11

Spartan Preconception Recommendations a la Plutarch n “ordered the maidens to exercise themselves with wrestling, running, throwing the quoit and casting the dart, to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth”

Preventing Low Birthweight Institute of Medicine 1985 n “…one of the best protections available against low birth weight and other poor pregnancy outcomes is to have a woman actively plan for pregnancy, enter pregnancy in good health with as few risk factors as possible, and be fully informed about her reproductive and general health”

IOM-1985 n n n Family planning services essential to preconception initiatives Reproductive health/family planning must introduce concept of prepregnancy wellness Developed concept of preconception consultation

Expert Panel on the Content of Prenatal Care: 1989 “Rosen Report” n n Preconception visit may be the single most important health care visit with respect to impact on pregnancy outcome Preconception counseling most likely to be effective when provided in context of general preventive care OR primary care visits n Concept of “Opportunistic Care”

ROSEN REPORT n n Risk Assessment Health Promotion Intervention Follow up

Healthy People 2000 n n Increase to at least 60% the proportion of primary care providers who provide age-appropriate preconception care and counseling Deleted in 2010 Healthy People as not measurable

Toward Improving Outcome of Pregnancy: The 90’s and Beyond MOD 1993 n n Concept of “reproductive awareness” Called for a new strategy to reach woman of child-bearing age with reproductive awareness messages at every health encounter

ACOG 1995: First technical bulletin on Preconception Care n n n Thorough & Systematic ID of risks Provision of education individualized to patient needs Initiation of desired interventions

2002: Guidelines for Perinatal Care AAP/ACOG n n Emphasized integration of preconceptional health into ALL health encounters in reproductive age women Average woman of childbearing has 6. 4 visits to MD’s per year

Healthy People 2010 n n No global comment “Increase the proportion of pregnancies begun with an optimum folate level” (target 80%)

HALLMARKS OF PRECONCEPTION CARE REYNOLDS n n PROVIDES WOMEN & FAMILIES INFORMATION AND OPPORTUNITIES TO MODIFY UNHEALTHY BEHAVIORS AND THUS POTENTIALLY IMPROVE THE QUALITY OF THEIR LIVES INCREASE REPRODUCTIVE CHOICES, POSSIBLY DECREASED UNINTENDED & UNWANTED PREGNANCIES

HALLMARKS, cont’d n n IMPROVE PREGNANCY OUTCOME BY DECREASING INFANT MORTALITY & MORBIDITY REDUCES THE PROBABILITY OF DAMAGE DURING ORGANOGENESIS

Which women most likely to get preconception care? n n n n Older Married or stable relationship Non Hispanic White Income >$20, 000/year Non-smokers Private medical insurance Positive bond with pre-pregnancy health care provider

NEGATIVE PREGNANCY TEST n n n POPULATION OF ABOUT 100 WOMEN AT FAMILY PLANNING CLINIC WITH NEG. PREGNANCY TEST ALL HAD ASSESSMENTS DONE USING PRECONCEPTION RISK SURVEY INSTRUMENT ½ HAD RESULTS REPORTED TO DOC

NEGATIVE PREGNANCY TEST n n n AVERAGE WOMAN HAD 9 IDENTIFIED ISSUES 21% PSYCHIATRIC/BEHAVIORAL 12% FETAL EXPOSURE 7 – 10%: FAMILY PLANNING, NUTRITION, GENETIC, MEDICAL, BARRIERS TO CARE, DV, SEXUAL VIOLENCE 2 -6%: REPRODUCTIVE HISTORY, STD’S

Best Evidence n n Focus on a single intervention Not in the context of improving pregnancy outcomes

PROMOTION OF LIFELONG WELLNESS PROMOTION OF HEALTHY AND DESIRED PREGNANCIES PROMOTION OF HEALTHY FUTURE INFANTS

PREGNANCY FAMILY PLANNING/ PRECONCEPTIONAL CHILDBIRTH MENARCHE FAMILY PLANNING INTERCONCEPTIONAL MENOPAUSE

PREVENTING PREMATURITY n n SPACING OF PREGNANCIES n LOWEST RATE VERY/MODERATELY PREMATURE INFANTS n 18 to 59 MONTHS BETWEEN PREGNANCIES DISCONTINUE SMOKING PRECONCEPTIONALLY

What We Know: Tobacco Use n Tobacco And Women’s Health: n Implicated the leading causes of death for women: n Heart disease (1) n Stroke (2) n Lung cancer (3) n Lung disease (4) n Tobacco and Reproductive Outcomes: n Leading preventable cause of infant mortality n Preventable cause of low birth weight and prematurity n Associated with placental abnormalities

SMOKING n n n ECTOPIC PREGNANCY PLACENTA PREVIA UNDER-DEVELOPMENT OF PLACENTA n MAY INCREASE RISK OF PREMATURITY AND BABIES TOO SMALL

15% and 29% of pregnant women smoke during pregnancy n If smoking during pregnancy eliminated, estimated: n 10% reduction in perinatal mortality n 11% reduction in the incidence of low birth weight n

SMOKING: Evidence based counseling n n Ask every patient about tobacco use Advise them to quit Assess willingness to quit Assist them in quitting n n n Pharmocotherapies and additional counseling each DOUBLE quit rate Arrange follow up 305. 10 ICD-10 Code for tobacco dependence

Effectiveness of smoking cessation programs n n 25 -30% quit rates in general population Many women spontaneously quit when pregnancy n n 11 -28% publically insured 40 -65% privately insured

ACOG COMMITTEE OPINION October 2006 # 316 n Smoking is one of the most important modifiable causes of poor pregnancy outcomes in the United States. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment has been proved to increase quit rates. For pregnant women who are light to moderate smokers, a short counseling session with pregnancy-specific educational materials often is an effective intervention for smoking cessation. The 5 A's is an office-based intervention developed for use by trained practitioners. Techniques for smoking reduction, pharmacotherapy, and health care support systems can help smokers quit.

What We Know: Alcohol Use n Alcohol and Women’s Health n Risk for MV and other accidents n Risk for unintended pregnancy n Risk for addiction n Risk for nutritional depletions and inadequacies n Alcohol and Reproductive Outcomes n Delayed fertility n Increased SABs n FAS and FAE

ALCOHOL n n n 2002: 8% of American women 18 -44 years of age were sexually active, fertile, not contracepting. Women age 18 -24: 20% binge drink FAS 0. 3 -2 per 1000 live births

Project CHOICES n n CDC sponsored trial Population at high risk of alcoholexposed pregnancy (12% binge) Focused on reducing risk drinking AND postponing pregnancy 4 brief motivational visits and Family Planning provider visit n 68% at reduced risk at 6 months

What We Know: Obesity n Obesity and Women’s n Obesity and Pregnancy: Health: n Glucose intolerance of pregnancy n Diabetes n Hypertension n Pregnancy induced hypertension n Cardiovascular disease n Thrombophlebitis n Disabilities n Neural tube defects n Prematurity n Higher rates of difficult births

OBESITY n n Increased rates of: infertility, gestational diabetes, pre-existing diabetes, hypertension, preeclampsia, stillbirth, birth defects, LGA, cesarean sections, long dysfunctional labors, CPD, post partum anemia Fat is not inert

What can we do about it? n Weight loss programs n Tsai and Wadden: , 2005 n n Weight Watcher least costly, maintenance of 3. 2% of initial weight at 2 years Very Low Calorie Commercial Diet: n n Greatest initial weight loss; high costs; high attrition Internet based and organized self-help: minimal weight loss Low income obese women receiving 5 email messages in pregnancy around maintaining normal weight gain less likely to gain excessive weight Interconception period important if woman retained a lot of pregnancy weight

What we know: FOLATE n n n Peri conceptional supplementation with 400 micrograms of folate (folic acid) from 3 months preconceptionally to 8 weeks postconceptionally Decreases rate of spina bifida by 50 -70% Decreases rate of cleft lip Decreases rate of heart disease Generally good health habit for adult cardiovascular health Probably decreases placental problems

EPILEPSY n MEDICATIONS n n ASSOCIATION WITH SOME MEDICATIONS WITH SOME BIRTH DEFECTS SOME WOMEN ON ANTI-SEIZURE MEDICATIONS FOR YEARS AFTER A SEIZURE AND MIGHT BE ABLE TO DISCONTINUE LOWEST POSSIBLE EFFECTIVE DOSE SINGLE DRUG VERSUS MULTIPLE DRUGS

DIABETES n GENERAL POPULATION n n 2 -3% RISK OF SEVERE BIRTH DEFECTS DIABETICS PRIOR TO PREGNANCY n POORLY CONTROLLED [Hgb A 1 c>7] RISK INCREASES TO 6 -9% HEART DISEASE, SPINA BIFIDA, OTHER n WELL CONTROLLED PRECONCEPTIONALLY n n n BACK TO BASELINE RATE IN THE GENERAL POPULATION!

INFECTIONS n HEPATITIS B n n 90% CHRONIC CARRIERS ARE WITHOUT SYMPTOMS PREGNANCY DOESN’T ALTER COURSE OF DISEASE IDENTIFY NEONATES FOR FULL VACCINATION AND PROPHYLAXIS HIGH RISK WOMEN WHO ARE HEP. NEG CAN BE VACCINATED

HIV n n n HELPS INFECTED WOMEN MAKE INFORMED REPRODUCTIVE DECISIONS BEGIN MATERNAL CARE PROGRAM HIGH RISK WOMEN CAN BE COUNSELED RE: RISK REDUCTION

TOXOPLASMOSIS n n n 85% US WOMEN NON-IMMUNE (NHANES) 400 -4000 CASES OF CONGENITAL TOXO/YR IN US PRENATAL TESTING VERY DIFFICULT TREATMENT IF KNOWN PRENATAL SEROCONVERSION PRECONCEPTION TESTING CAN ALTER BEHAVIOR n n AVOID FECES IN LITTERBOX/GARDEN AVOID RAW OR UNDERCOOKED MEAT DISPOSE OF CAT LITTER DAILY AND DISINFECT BOX; USE GLOVES PEEL OR WASH FRUITS AND VEGETABLES

CMV n n n 0. 6 -1. 5% ALL BIRTHS IN US ADULTS USUALLY ASYMPTOMATIC, MONO LIKE ILLNESS LATENT STATE AFTER INFECTION MOST COMMON SOURCE OF PRIMARY INFECTION: TODDLERS MOST EFFECTIVE PREVENTION: HAND WASHING (URINE, SALIVA)

OTHER INFECTIONS n STD’S n n n APPROPRIATE TREATMENT DEAL WITH MONOGAMY ISSUES VARICELLA AND RUBELLA: n n IF NEGATIVE ANTIBODY, CAN IMMUNIZE WAIT THREE MONTHS PRIOR TO CONCEPTION

WWW. IHEALTHRECORD. ORG CDC, other federal agencies, and medical societies have developed emailbased education programs that are offered through the Interactive Health Record (i. Health. Record n n Learn what you need to know to have a safe pregnancy and healthy baby. CDC has a new online education program available for women who are planning to get pregnant. Health information via email every other week for 3 months as you prepare for pregnancy. You can sign up for CDC’s pregnancy-planning education program by 1. Logging onto WWW. IHEALTHRECORD. ORG 2. Signing up for a free i. Health. Record. 3. Going to the "Education Programs" page. 4. Checking the box next to “Pregnancy Planning: What To Know About Your Health Before You Get Pregnant”.

AAP/ACOG: Components of PCC n n Physical assessment Risk Screening n n n n n Reproductive awareness Environmental toxins/teratogens Nutrition/folate Genetics Substance use Medical conditions/medications Infections/vaccinations Psychosocial concerns Vaccinations Counseling

Preconception Risk Factors with Developed Clinical Practice Guidelines n n n n Folic Acid Rubella seronegativity Diabetes Hypothyroidism HIV/AIDS PKU Oral Anticoagulant n n n n Anti-epileptic drugs Isotretinoins Smoking Alcohol misuse Obesity STD Hepatitis B MMWR: April 21, 2006 Recommendations to Improve Preconception Health and Health Care-US

Summary n Preconception care n n n “Opportunistic” Rolled into routine health encounters for reproductive aged women Needs to be proactive Clinical practice guidelines are available MMWR April 12, 2006