Introduction 1 2 3 1 2 2 4 1 2 5 1 6 7 3 7 8 8 Fig. 1 Maternal and infant mortality rates, United States, 1960–2002  Fig. 2 Percent of all live births that are preterm delivery, very preterm delivery, low birth weight, and very low birth weight, United States, 1980–2002  Early prenatal care is too late 9 4 10 11 13 Fig. 3 *  2 2 14 14 15 Preconception interventions work 15 1 16 2 17 74 Table 1 Risk factors (by Category) identified in the literature as needing attention during the preconception period 1 Chronic diseases: 2 Infectious diseases: 3 Reproductive concerns: 4 Genetic/inherited conditions: 5 Medications and medical treatment: 6 Personal behaviors and exposures: Note. Table 2 Selected preconception risk factors for adverse pregnancy outcomes for which clinical practice guidelines have been developed • Folic acid. 17 24 • Rubella seronegativity. 25 27 • Diabetes (preconception). 28 31 • Hypothyroidism. 32 34 • HIV/AIDS. 35 41 • Maternal phenylketonurea (PKU). 42 43 • Oral anticoagulant. 15 44 46 • Anti-epileptic drugs. 15 47 51 • Isotretinoins (Accutan ): 15 52 54 • Smoking. 55 58 • Alcohol misuse. 59 64 • Obesity. 15 65 69 • STD. 70 71 • Hepatitis B. 72 74 56 61 66 75 Priorities for preconception care and preconception health 28 34 50 44 46 55 59 However, moving forward towards more universal preconception care is not without its challenges. There is no national policy, nor do standard tools exist, for the delivery of these services. Some have suggested that challenges could be overcome by promoting preconception health to all women of reproductive age at each and every encounter with the health care system. The generally recommended mechanisms would include risk assessment (screening), health promotion (education and counseling), and intervention or referral. However, the existing recommendations to provide these three essential components have not been translated into practical tools for action and decision-making in the clinical setting. Stated another way, primary care providers do not have the tools they need to implement what is known to work for improving preconception health. Challenges and opportunities 76 77 78 79 16 80 81 82 83 84 83 19 44 85 83 86 87 Finally, special attention should be given to the continuing, and sometimes increasing, racial gap in poor outcomes, especially in terms of access to services, and quality of care. These priorities can potentially complicate decision-making for public health policy. The best evidence of intervention effectiveness is often based on studies of health care systems. However, in developing programs and policies for the delivery of preconception services, one must consider the fact that poor access to health care can be a major determinant of health disparities. Preconception care: the next maternal and child health frontier The significant improvements in infant and maternal pregnancy outcomes during the past 40 years have resulted largely from the intensified focus on family planning in the 1960s and 1970s, on child health in the 1970s and 1980s, and on prenatal care in the 1980s and 1990s. Over the past 40 years, many public health and clinical care providers and their organizations have also recognized that, although it is important to offer family planning services to prevent unplanned pregnancies, it is not enough to worry about a pregnant woman's health only during her pregnancy or a child's health only after its birth, because many of the factors that contribute to the mother's and child's health can be identified and often successfully managed before pregnancy. 88 15 89 90 90 Conclusion There is ample evidence that individual elements of preconception care work. Equally important, however, is the evidence that some interventions work best and others only work if provided before pregnancy. Given these realities, to further improve perinatal outcomes, the United States must commit to improving preconception health and to providing preconception care to all women of reproductive age. Even though sufficient knowledge and evidence is present to take action now, further efforts are needed to identify best practices and the most effective means of delivering integrated preconception services.