Introduction 1 2 As the modern practice of obstetrics evolved, it became a specialty that separated women’s prepregnancy wellness from prenatal care, but in the last quarter century this has begun to change. The dominant model of prenatal care as the main perinatal prevention strategy has been reexamined, and recognition of the importance of the prepregnancy period has emerged. Today the general public and health care professionals could easily be overwhelmed by the amount of information available which promotes prepregnancy or preconceptional health. A Google search (conducted April 25, 2005) of the term “preconception health” identified 630,000 hits. On the same day a search of the National Library of Medicine’s PubMed found 338 entries for “preconception health” with the earliest published in 1978, and 103 articles for “preconceptional” with the earliest published in 1982; in addition, most of the articles identified through the two search terms were unique. The nation’s approach to women’s health care may well be at the tipping point of redefining the perinatal period to include women’s wellness across the reproductive life span as an appropriate and favored approach to impacting reducing poor pregnancy outcomes. Stimulated by research findings which underscored the limitations of traditional prenatal care on decreasing the incidence of congenital anomalies, leaders in the health community, professional organizations, advocacy groups and federal government began actively encouraging redefinition of the United States’ perinatal prevention paradigm in the early 1980s. Because the usual pathways to impact on perinatal outcomes (prenatal and neonatal care) often start too late to achieve primary prevention, the need to reach women with prevention opportunities before prenatal care was recognized and the concept of preconceptional health promotion emerged. This article explores the history of the preconception movement in the United States and the current status of professional practice guidelines and standards. The decade of the eighties 3 Interconceptional care Prenatal care Perinatal care Child Health care Services for handicapped children Adolescent services Interest in moving away from categorical care to more integrated and comprehensive services has subsequently become a hallmark of current efforts to redefine the perinatal prevention paradigm. Why the list employed the word “interconceptional” rather than preconceptional is not clear. Since 1979, “interconceptional” care has come to represent efforts to address health status between pregnancies, birth spacing and intendedness of subsequent conceptions; “preconceptional” generally refers to the woman’s health status and risks before the first pregnancy and her health status shortly before any conception. “Periconceptional” usually refers to the time immediately before conception through the period of organogenesis. It is important to note that this nomenclature is inconsistently applied and not universally accepted. In England, for instance, “preconceptional” is referred to as “preconceptual.” Preventing Low Birthweight 4 “Much of the literature about preventing low birthweight focuses on the period of pregnancy—how to improve the content of prenatal care, how to motivate women to reduce risky habits while pregnant, how to encourage women to seek out and remain in prenatal care. By contrast, little attention is given to opportunities for prevention before pregnancy. Only casual attention has been given to the proposition that one of the best protections available against low birthweight 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 possibly, and be fully informed about her reproductive and general health.” (p. 119) The IOM Committee advocated that family planning services be positioned as an essential component of effective preconceptional initiatives, thereby supporting the integration of services rather than reinforcing firm boundaries of categorical programs. It also recommended that the content of reproductive health education, particularly in schools and family planning settings, be expanded to introduce concepts of prepregnancy wellness. The third recommendation of the Committee was to develop the notion of preconceptional consultation to identify and reduce risks associated with poor pregnancy outcomes, particularly for women who had already experienced a poor outcome. 5 Specific components of preconception care were identified by the Panel as (1) risk assessment, (2) health promotion and (3) intervention and follow-up. The Panel advocated that the preconception assessment include a holistic range of investigations including: individual and social conditions, adverse health behaviors, medical, psychological and environmental conditions and barriers to family planning and early prenatal care enrollment. Guidelines for Perinatal Care 6 7 8 9 7 10 The decade of the nineties Healthy People 2000 Increase to at least 60% the proportion of primary care providers who provide age-appropriate preconception care and counseling (p. 199) 5 11 Toward Improving the Outcome of Pregnancy: The 90s and Beyond 12 “A woman’s health status in relationship to pregnancy usually is not considered until the first prenatal visit, and prenatal care often is segregated from other health care by provider type and by payment mechanism. Yet women of childbearing age have many encounters with the health care system. These include visits to gynecologists, pediatricians, internists, family physicians, nurse midwives and nurse practitioners, in settings such as public health, school health, women’s health, substance abuse treatment, family planning, and sexually transmitted disease clinics and private offices (p. 13).” TIOP goes on to call for professional standards, structures and financing to be set in place to ensure an annual preconception or interconception risk reduction visit for every woman from menarche to menopause and that a prepregnancy planning visit become a standard component of maternity care, routinely available to all women and integrated into the perinatal care delivery system. TIOP also stressed that reproductive awareness is not sex or gender specific and that the need to reach out to males, especially during the preconception and interconception periods, requires thoughtful and innovative strategies. 13 “Once information is available, the patient can be informed about the certainty or limitations of available information, what the risks of pregnancy may be, and precautions that may be beneficial. After women have been informed of the increased risks pregnancy may pose to their health or the health of a fetus or both, they can accept the increased risks, choose to modify their risks or opt to avoid childbearing (p. 2).” ACOG cautioned against over promising the benefits of preconceptional care to both providers and patients by specifically noting that preconceptional services do not guarantee good pregnancy outcomes. It noted that placing emphasis only on women who are planning their next conception or women who have been identified as high-risk will result in a significant number of missed opportunities for primary prevention. Women who experience an unintended pregnancy are at least as likely to have risk factors for poor pregnancy outcomes as women who consciously plan the timing of their pregnancy. Therefore, ACOG recommended that routine visits by women who may, at some time, become pregnant are important opportunities to emphasize the importance of preconceptional health and habits and the advantages of planned pregnancies. Finally, ACOG called for a coordinated multispecialty effort directed by the obstetrician-gynecologist as a means to provide a comprehensive framework for preconceptional health care for all women of childbearing potential. The current decade Guidelines for Perinatal Care 14 Healthy People 2010 15 Evolving standards and guidelines from professional organizations As the concept of preconception care has evolved in the health care community, several professional organizations have addressed its importance for their members, and some have developed specific guidelines or standards for preconception care. Nursing organizations In nursing, there are several professional organizations whose members care for reproductive age women. The AANP (American Academy of Nurse Practitioners) is the largest national professional organization for nurse practitioners of all specialties, with 15,000 members. While many nurse practitioners might be delivering preconception health services, AANP has not developed specific educational standards specific to this topical area, nor do their generic practice standards include preconception health. According to AANP Executive Director Dr. Judith Dempster (personal communication, April 11, 2005), members with questions about preconception health standards would be referred to specialty organizations such as AWHONN. 16 17 18 19 ( “V. Components of Midwifery Care: The Primary Health Care of Women B. Applies knowledge of midwifery practice in the preconception period that includes, but is not limited to, the following: 1. Assessment of individual and family readiness for pregnancy, including emotional, psychosocial and sexual factors 2. Impact of health, family and genetic history on pregnancy outcomes 3. Influence of environmental and occupational factors, health habits, and behavior on pregnancy planning 4. Health and laboratory screening to evaluate the potential for a healthy pregnancy” (p. 3) 20 In terms of general nursing education, the AACN (The American Association of Colleges of Nursing) does not offer specific guidelines for what is to be taught to student nurses about preconception health, but rather sets standards for overall educational goals. Organizations for all professionals 21 The CDC, the March of Dimes, and the National Council on Folic Acid (NCFA) have organized a national folic acid promotion effort for the prevention of serious birth defects of the brain and spine (neural tube defects or NTDs). The goal of the effort is to teach all women about the importance of getting enough folic acid every day. The effort aims to reach every woman who could possibly become pregnant, as well as teach health care professionals and community advocacy groups about the importance of folic acid. The CDC, the March of Dimes, and NCFA have created messages, materials, websites, and other tools to reach providers and women with the folic acid message. In 2005, the CDC and March of Dimes collaborated to develop a national summit on preconception care in order to bring together all the stakeholders in the subject; this supplement issue of Maternal Child Health is one of the many consequences of these efforts by CDC/MOD. Physician organizations 14 22 23 24 “ II. Antepartum Care—Preconceptional Care 1. Perform a thorough history, assessing historical and ongoing risks that my affect future pregnancy 2. Counsel a patient regarding the impact of pregnancy on maternal medical conditions. 3. Counsel a patient regarding the impact of maternal medical conditions on pregnancy 4. Counsel a patient regarding appropriate lifestyle modification conducive to favorable pregnancy outcome. 5. Counsel a patient regarding appropriate preconception testing. 6. Counsel a patient regarding pregnancy associated risks and conditions, such as advanced age, hypertension, diabetes, genetic disorder, prior aneuploid or anomalous fetus/newborn” (p. 49) 25 26 Components of preconception care—ACOG In examining multiple documents produced by ACOG in recent years, certain components of preconception care can be delineated. Periodic assessments 27 The patient’s history should be reviewed and updated on an annual basis or more often if appropriate. The history should include a review of any medical conditions and medications the patient may be using. It is important to ask about prescription as well as over the counter drugs, herbs, and supplements. Inquiries about occupational and hobby exposures to chemicals, solvents, or heavy metals should be made. In this manner, potentially teratogenic agents may be identified. The patient’s reproductive history may provide important clues about future pregnancy risks. Recurrent miscarriages should raise suspicion of a possible genetic or chromosomal problem. The neonatal outcome of previous pregnancies should be noted but it is equally as important to ask women about the current health of any children they have as some congenital disorders do not become manifest until several months or even years after birth and may not be considered by the family to represent a congenital defect. Genetic disorders and genetic screening 28 29 Carrier screening for Tay-Sachs, Canavan disease, cystic fibrosis, and familial dysautonomia should be offered to Ashkenazi Jewish individuals during preconception screening. These same individuals may be offered or may request screening for Gaucher disease, Niemann-Pick disease type A, Fanconi anemia group C, Bloom syndrome, or mucolipidosis IV as well. Carrier screening should be offered to any individual with a positive family history of one of these disorders; the screening should be for the specific disorder. When only one partner is of Ashkenazi Jewish descent, that individual should be screened first. Except for Tay-Sachs and cystic fibrosis, the carrier frequency and detection rate for the other disorders is unknown. 28 Other screening tests exist for genetic disorders with an increased incidence in specific ethnic groups, e.g., alpha or beta thalassemia screening in Orientals, beta thalassemia screening for those of Mediterranean descent, and sickle cell disease screening for African-Americans. 30 Immunizations and infectious diseases 31 32 32 33 All women should be kept current with age-appropriate vaccines. Reproductive aged women should be asked about previous infection with varicella and offered vaccination if they report no known history of chickenpox. Conception should be delayed until 1 month after the second injection is given. Women who expect to be at least 3 months pregnant during the influenza season (November to April) should be vaccinated. Behavioral/psychosocial factors 34 35 36 Medical history and conditions 37 38 39 40 41 42 Women with quiescent autoimmune disease or a distant history of disease should be carefully evaluated and counseled about maternal and fetal risks. Patients should be counseled that the best time to attempt conception is during periods of inactive disease. 43 44 45 46 47 Women should be asked about any ongoing dermatologic therapy she may be receiving. Isotretinoin (Accutane) is used for a variety of skin conditions and is a known teratogen. Some anti-psoriasis treatments (Acetretin X and methotrexate) are known teratogens, while some antiviral medications (podophyllum) are contraindicated in pregnancy. 1 Table 1 Suggestions for the clinician during routine or periodic health assessments to optimize possible future pregnancy outcomes for all reproductively capable women • Determine if the woman suffers from any undiagnosed or uncontrolled medical problems. If she does, provide recommendations for treatment of these conditions and when it would be best to attempt pregnancy. Make sure the patient is aware of any associations between the medical condition(s) and medications(s) she is taking and their impact on pregnancy outcomes. Ask the woman about her reproductive intentions at every visit, ascertain what her risk of an unplanned pregnancy may be; for women not actively seeking to become pregnant, discuss her current contraceptive method and any concerns or problems she may be having with it. Review the woman’s family history—including new births among family members—annually as things change over time. Discuss any familial conditions that may herald an increased risk of adverse pregnancy outcome for the woman. Discuss the significance that nutrition can have on maternal fetal outcomes,e.g., the impact of 0.4 mg folic acid per day on neural tube defects in women with no family or previous history of a neural tube defect), the need to avoid excessive vitamin usage, especially vitamins A and D, and the additional measures women on restricted diets may need to take to optimize their health and the health of the developing fetus. Review the patient’s social behaviors or lifestyle patterns—such as smoking, alcohol, or other substance use or abuse—that may affect pregnancy adversely and offer treatment options. Ascertain the immunity status of woman to rubella, hepatitis, and varicella. Ensure she is up to date on immunizations. Conclusion 48