Introduction In June 2005 the Centers for Disease Control and Prevention (CDC) and the March of Dimes, in collaboration with 35 professional and governmental organizations, convened a 3-day summit to discuss an agenda for preconception care programs, research, and policy. The summit was the result of internal workgroup discussions at CDC and an initial meeting with external stakeholders in November 2004. Prior to the November meeting, subject matter experts in 19 programs from 8 centers throughout CDC conducted a detailed review of the relevant literature. The 3-day summit was divided evenly into two components: a presentation series from preconception care practitioners, followed by a select panel meeting. More than 60 presentations on preconception care research and programs were made and subsequently discussed by the select panel to generate recommendations for improving maternal and child health outcomes through better preconception care. The goals of the select panel discussions were to define current scientific knowledge, to identify best practices, and to highlight key issues needing further attention that could be used as the basis for formulating recommendations and action steps. Deliberations of the select panel A C T One key topic of debate was the potential conflict in characterizing preconception care as preparation for pregnancy, as opposed to the broader promotion of women's health. Some panelists believed strongly that the focus must be on both women and infant health outcomes. In moving forward, the panel was conscientious not to carve preconception care out separately from good routine primary care; however, panel members also asserted that even though the focus should be on preconception care, providers should also recognize that the scope of care should include comprehensive women's health services. As one panel member said, “Preconception care should be happening at every interaction with a woman or man of reproductive age…. It's part of what we’re already doing in primary care. We’re just trying to get providers to reframe their thinking so we’re achieving preconception health.” Some, while agreeing, argued that the ultimate goal was to improve perinatal outcomes, making this a part of, but distinct from, all well-woman's health care. The status of current research emerged as a central issue. Discussions often centered around the concern that insufficient scientific evidence currently exists for many preconception care interventions, for the best methods of integrating them into primary care, and for effectively delivering interventions as a package—or even if they work. Many panelists cited the need for intervention trials. In contrast, other members believed that existing research findings were sufficient, and that moving in the direction of translation and action should be the next step. This theme was captured in one member's comment, “Research is important; there's no doubt about it. But instead of just creating more new knowledge, let's ask ourselves: Why is it that the knowledge we created before isn't getting translated into action?” Ultimately, the panel's recommendations reflected both areas where sufficient evidence exists and those where more research is needed. Many panel members supported recommendations that would advocate provider assistance for a woman and her partner in developing a reproductive life plan and in communicating her/their intentions through the implementation of that plan. As one panel member described it, “[Primary care providers can] develop the ability to help a woman write her reproductive health plan and facilitate her ability to carry this out, including the upgrading of this plan throughout her reproductive years.” Some participants suggested that the recommendations should strongly encourage all providers not only to ask a woman about her reproductive intentions, but to ask in a manner that conveyed to the woman that her decisions should be based on her personal preferences. This would allow the provider to help her choose the best contraceptive for meeting her life goals and to provide appropriate preconception awareness information. Panelists generally agreed that the recommendations should focus on feasible actions that could have the greatest positive impact on health outcomes. This resulted in much discussion of fundamental issues, including 1) who gets preconception care—women at high risk for adverse pregnancy outcomes or all women; 2) what would yield the greatest return on investment (e.g., focus on the preconception period or the interconception period; focus on all women or high-risk women); 3) whether interventions could be packaged and targeted to reach specific populations or address specific needs of women; and 4) how finance case and services, as well as the potential cost effectiveness and cost benefit of the proposed interventions? Defining preconception care 1 6 7 4 Guidelines for Perinatal Care 8 9 Fig. 1 Ecological model  The framework for preconception care recommendations 1 10 Challenges for implementing the proposed frameworks 5 11 13 In the context of clinical care, much can be done by primary care providers, but evidence suggests that many women have two primary care providers—one with expertise in obstetrics and gynecology and one with general medical training. In addition, the U.S. health-care system is fragmented into highly specialized components. Nevertheless, bundling the various preconception interventions has the potential to improve perinatal outcomes and reduce costs associated with adverse outcomes. These recommendations call for more integrated delivery of health promotion and care services for women rather than for greater fragmentation of the health-care system. Integration is critical to moving forward, In consideration of competing priorities and limited resources, integration may achieve health-care economies of scale that produce more efficient delivery of services and more effective results in improving preconception health. For example, primary care providers potentially could routinely and efficiently use the tools available to screen for smoking, alcohol abuse, genetic risks, and occupational hazards; endocrinologists, geneticists, and nutritionists could become an integral part of a preconception care strategy. Moreover, settings such as family planning or sexually transmitted disease clinics must become part of an integrated approach in order to reach many women at high risk for adverse pregnancy outcomes. New models of care and well-designed quality-improvement efforts could foster the integration of preconception interventions. 5 6 11 12 Maternal and Child Health Journal MMWR 7 14 15 16 A strategic plan for improving women's health and pregnancy outcomes 1 Table 1. Panel Recommendations and Actions Recommendation 1. Individual responsibility across the lifespan. Each woman, man and couple should be encouraged to have a reproductive life plan. Action Steps • Develop, evaluate, and disseminate reproductive life planning tools for women and men in their childbearing years, respecting variations in age; literacy, including health literacy; and cultural/linguistic contexts • Conduct research leading to development, dissemination, and evaluation of individual health education materials for women and men regarding preconception risk factors, including materials related to biomedical, behavioral, and social risks known to affect pregnancy outcomes Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts Action Steps • Develop, evaluate, and disseminate age-appropriate educational curricula and modules for use in school health education programs • Integrate reproductive health messages into existing health promotion campaigns (e.g., campaigns to reduce obesity and smoking) • Conduct consumer-focused research necessary to develop messages and terms for promoting preconception health and reproductive awareness • Design and conduct social marketing campaigns necessary to develop messages for promoting preconception health knowledge and attitudes, and behaviors among men and women of childbearing age • Engage media partners to assist in depicting positive role models for lifestyles that promote reproductive health (e.g., delaying initiation of sexual activity, abstaining from unprotected sexual intercourse, and avoiding use of alcohol and drugs) Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes Action Steps • Increase health provider (including primary and specialty care providers) awareness regarding the importance of addressing preconception health among all women of childbearing age • Develop and implement curricula on preconception care for use in clinical education at graduate, postgraduate, and continuing education levels • Consolidate and disseminate existing professional guidelines to develop a recommended screening and health promotion package • Develop, evaluate, and disseminate practical screening tools for primary care settings, with emphasis on the 10 areas for preconception risk assessment (e.g., reproductive history, genetic, environmental risk factors) • Develop, evaluate, and disseminate evidence-based models for integrating components of preconception care to facilitate delivery of and demand for prevention and intervention services • Apply quality improvement techniques (e.g., conduct rapid improvement cycles, establish benchmarks and brief provider training, use practice self-audits, and participate in quality improvement collaborative groups) to improve provider knowledge and attitudes, and practices and to reduce missed opportunities for screening and health promotion • Use the federally funded collaboratives for community health centers and other FQHC to improve the quality of preconception risk assessment, health promotion, and interventions provided through primary care • Develop fiscal incentives for screening and health promotion Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions (i.e., those with evidence of effectiveness and greatest potential impact) Action Steps • Increase health provider (including primary and specialty care providers) awareness concerning the importance of ongoing care for chronic conditions and intervention for identified risk factors • Develop and implement modules on preconception care for specific clinical conditions for use in clinical education at graduate, postgraduate, and continuing education levels • Consolidate and disseminate existing professional guidelines related to evidence-based interventions for conditions and risk factors • Disseminate existing evidence-based interventions that can be used in primary care settings (e.g., brief interventions for alcohol misuse and smoking) • Develop fiscal incentives (e.g., pay for performance) for risk management, particularly in managed care settings • Apply quality improvement techniques and tools (e.g., conduct rapid improvement cycles, establish benchmarks, use practice self-audits, and participate in quality improvement collaborative groups) Recommendation 5. Interconception care. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy which ended in adverse outcome (e.g., infant death, fetal loss, birth defects, low birthweight or preterm birth) Action Steps • Monitor the percentage of women who complete postpartum visits (e.g. using HEDIS measures for managed care plans and Title V Maternal Child Health Block Grant state measures), and use these data to identify communities of women at risk and opportunities to improve provider follow-up • Develop, evaluate, and replicate intensive evidence-based interconception care and care coordination models for women at high social and medical risk • Enhance the content of postpartum visits to promote interconception health • Use existing public health programs serving women in the postpartum period to provide or link to interventions (e.g., family planning, home visiting, and WIC) • Encourage additional states to develop preconception health improvement projects with funds from the Title V Maternal Child Health Block Grant, Prevention Block Grant, and similar public health programs Recommendation 6. Prepregnancy check up. Offer, as a component of maternity care, one prepregnancy visit for couples and individuals planning pregnancy Action Steps • Modify third party payer rules to permit payment for one prepregnancy visit per pregnancy, including development of billing and payment mechanisms • Consolidate existing professional guidelines to develop the recommended content and approach for such a visit • Educate women and couples regarding the value and availability of prepregnancy planning visits Recommendation 7. Health insurance coverage for women with low incomes. Increase public and private health insurance coverage among women with low incomes to improve access to preventive women's health, preconception, and interconception care Action Steps • Improve the design of family planning waivers by permitting states (by federal waiver or by creating a new state option) to offer interconception risk assessment, counseling, and interventions along with family planning services. Such policy developments would create new opportunities to finance interconception care • Increase health coverage among women who have low incomes and are of childbearing age by using federal options and waivers under public and private health insurance systems and the State Children's Health Insurance Program • Increase access to health-care services through policies and reimbursement levels for public and private health insurance systems to include a full range of clinicians who care for women Recommendation 8. Public health programs and strategies. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes Action Steps • Use federal and state agency support to encourage more integrated preconception health practices in clinics and programs • Provide support for CDC programs to develop, evaluate, and disseminate integrated approaches to promote preconception health • Analyze and evaluate the preconception care activities used under the federal Healthy Start program and support replication projects • Convene or use local task forces, coalitions, or committees to discuss opportunities for promotion and prevention in preconception health at the community level • Develop and support public health practice collaborative groups to promote shared learning and dissemination of approaches for increasing preconception health Recommendation 9. Research. Increase the evidence base and promote the use of the evidence to improve to preconception health Action Steps • Prepare an updated evidence-based systematic review of all published reports on science, programs, and policy (e.g., through the Agency for Healthcare Research and Quality) • Encourage and support evaluation of model programs and projects, including integrated service delivery and community health promotion projects • Conduct quantitative and qualitative studies to advance knowledge of preconception risks and clinical and public health interventions, including knowledge of more integrated practice strategies and interconception approaches • Design and conduct analyses of cost-benefit and cost-effectiveness as part of the study of preconception interventions • Conduct health services research to explore barriers to evidence-based and guidelines-based practice • Conduct studies to examine the factors that results in variations in individual use of preconception care (i.e., barriers and motivators that affect health-care use) • Support activities to translate research into clinical practice and public health action Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health Action Steps • Apply public health surveillance strategies to monitor selected preconception health indicators (e.g., folic acid supplementation, smoking cessation, alcohol misuse, diabetes, and obesity) • Expand data systems and surveys (e.g., PRAMS and NSFG) to monitor individual experiences related to preconception care • Use geographic information system techniques to target preconception health programs and interventions to areas where high rates of poor health outcomes exist women of reproductive age and their infants • Use analytic tools (e.g., PPOR) to measure and monitor the proportion of risk attributable to the health of women before pregnancy • Include preconception, including interconception, health measures and population-based performance monitoring systems (e.g., in national and state Title V programs) • Include a preconception measure in the Healthy People 2020 objectives • Develop and implement indicator quality improvement measures for all aspects of preconception care. For example, use HEDIS measures to monitor the percentage of women who complete postpartum visits For each of the 10 recommendations, the panelists identified specific actions. For each action step, those persons primarily responsible for implementation as well as those who had supportive roles were listed. The action steps were designed as feasible and practical activities that could be undertaken in the near future and could result in change in the next 2 to 5 years. 2 Fig. 2 Preconception care pyramid  The recommendations presented here focus on individual health knowledge and behavior, clinical care, public health programs, and health-care policies, improving preconception health will require the involvement of and changes in other sectors, including education, housing, urban planning, and environmental health. Moving forward, these sectors should be included as part of the comprehensive solution to improving women's health and, by extension, the health of families. In all of the action steps, women and their families have a critical role to play in engaging the system and developing the consumer demand and culture to normalize preconception care as part of women's health promotion and routine care. The focus of the recommendations 1 The first two recommendations focus on individual responsibility for preconception health. Under these recommendations, action steps are focused on the development, evaluation, and dissemination of tools to help women and their partners make decisions regarding their reproductive health across the lifespan. The action steps clearly highlight the need to ensure that these tools are age-appropriate and culturally relevant and cover both general health topics and specific risk behaviors. The action steps recognize the importance of being able to integrate preconception health-care messages with existing health promotion activities whenever possible. This is especially important in an environment with limited resources for health promotion activities. Both recommendations 1 and 2 call for action to be taken at both the individual and community level so that societal norms shift toward supporting optimal preconception health behaviors. Recommendations 3, through 6 call for actions to improve health-care services and are particularly focused on changing provider knowledge, attitudes, and behaviors. Because the existing knowledge base has not been widely disseminated, the action steps call for new and continuing education activities to help all providers improve their skills and coverage of preconception care services. The use of quality improvement tools and techniques are suggested as a means of changing professional practices. In the current market-driven environment, it is clear that incentives such as pay for performance and risk management activities also must be developed to help encourage the provision of these services. Recommendations 5 and 6 particularly focus more on improving preconception care and health for specific groups of women. Recommendation 5 focuses on interconception care and the opportunity for the prevention of adverse pregnancy outcomes among those who are at risk for or have previously had pregnancy complications. In addition to action steps aimed at modifying provider practices, others encourage public health programs to do more identification and follow-up of women at risk. Recommendation 6 suggests pre-pregnancy checkups or visits for couples to focus on their health and risks when they are trying to conceive. The action steps include consumer education and consolidated professional guidelines, as well as better third-party health insurance coverage of such visits as a part of prenatal and maternity coverage. Action steps for recommendation 7 call for increased health-care coverage among uninsured, low-income women, specifically through Medicaid. Currently, most low-income women do not qualify for Medicaid unless they are pregnant; unfortunately, this is often too late for some health promotion and therapeutic interventions to have maximum impact on the health of the woman and her child. Recommendation 8 describes a series of action steps that public health and community programs can take to improve preconception health by increasing the access to and use of preconception care services. These steps include using publicly funded women's and children's health programs to promote preconception health, to screen for health risks, and to refer women at risk to appropriate clinicians. For example, preconception health promotion messages are complementary to the purposes of family planning and HIV/STD clinics. However, the use of publicly funded women's and children's health programs for these purposes will require that federal and state public health agencies minimize the categorical restrictions that often prevent true integration at the community level. The second two action steps encourage the adaptation, implementation, and evaluation of community-based programs that provide preconception services. There are model programs currently being implemented that could be modified and used to meet the unique needs of specific populations. A key component of these actions is to engage the community to develop the best methods for development, implementation, and evaluation of local preconception care programs. Without community support and designs that truly represent the needs of the communities, programs will be ineffective. Recommendations 9 and 10 include action steps focused on the continuous quality improvement and planning feedback loop that supports excellence in health-care systems. Research and evaluation are critical to examining progress toward achieving goals. Currently, a need exists for updating the systematic reviews of existing literature on preconception care interventions as well as increasing the knowledge base through qualitative and quantitative research projects. Economic analyses of preconception care interventions are not often conducted, and a great deal of work must be done to understand the impact of interventions. Limitations exist in many of the interventions currently available; and effective interventions have not been developed in some areas. Meeting the need for research and evaluation is a key factor in the ability to continue moving the field forward. In addition to research activities, ongoing monitoring systems—typically managed by public health agencies—are critical to program planning, development, and evaluation. This recommendation includes the use of surveillance systems such as the Pregnancy Risk Assessment and Monitoring System (PRAMS) and the Health Employee Data and Information Set (HEDIS) measures. Conclusion All women and men of childbearing age have high reproductive awareness (e.g., understand risk factors related to childbearing). All women have a reproductive life plan (e.g., whether or when they wish to have children, how they will maintain their reproductive health). All pregnancies are intended and planned. All women of childbearing age have health-care coverage. All women of childbearing age are screened prior to pregnancy for risks related to the outcomes of pregnancy. Women with a prior pregnancy loss (e.g., infant death due to very low birthweight or preterm birth) have access to intensive interconception care aimed at reducing their risks.