Transcript Janis Biermann, MS

PRECONCEPTION CARE
CityMatCH Conference
September 13, 2004
Janis Biermann, M.S.
[email protected]
Preconception Care
Greater New York Chapter of the
March of Dimes
Preconception Care Curriculum Working Group
Albert Einstein College of Medicine/Montefiore Medical Center
www.marchofdimes.com/prematurity/5195_5785.asp
The Continuum of Reproductive
Health
 Improving
infant health requires focus on the entire
spectrum of reproductive health
Beginning before conception
Continuing through the first year of life
Extending throughout the woman’s childbearing
years
Preconception Care



Identifies reducible or reversible risks
Maximizes maternal health
Intervenes to achieve outcomes
Preconception Care



Reframes issues
Adds an anticipatory element
Focuses on the impact of pregnancy
Elements of Preconception Care

Focus on elements which must be accomplished prior to
conception or within weeks thereafter to be effective
 Risk assessment
 Education & Health Promotion
 Medical and psychosocial interventions
Components of Preconception
Care







Medical history
Psychosocial issues
Physical exam
Laboratory tests
Family/genetic history
Nutrition assessment
Occupational/environmental risk
assessment
Risk Assessment
 STD
Prevention
 Genetic issues
 Domestic violence
 Substance abuse
 Alcohol
 Tobacco
 Illicit drugs
Environmental Teratogens

Exposures


Home, workplace, environment
Physical/chemical hazards

ionizing radiation, lead, mercury,
hyperthermia, herbicides, pesticides
Health Education & Promotion




Smoking Cessation counseling: 5A’s
Folic Acid
Genetic Counseling
Dietary and Nutritional Advice
Conditions that Need Time to
Correct Prior to Conception



Optimal weight
Optimizing choice and use of medications
Substance use/abuse
alcohol
 tobacco

Some Medical Conditions
Amenable to Preconception Care







Diabetes Mellitus
Hypertensive Disorders
Cardiac Disease
Thyroid Disorders
Epilepsy
Asthma
HIV Infection





Systemic Lupus
Thromboembolic Disease
Renal Disease
Hemoglobinopathies
Cancers
Intervention Usually Not
Undertaken During Pregnancy
Rubella & varicella immunization
 Narcotic detoxification
 Certain radiological procedures
 Thyroid ablation with radioactive iodine

Interventions considered because
pregnancy is planned



Correction of mitral stenosis
Switching from oral hypoglycemics to insulin and
achieving “tight” glucose control in patients with diabetes
mellitus
Evaluation of anticonvulsant therapy
Factors That Could Change Timing Of
Or Choice To Conceive A Pregnancy

Domestic violence

Birth spacing

Genetic disease

Diseases with poor prognosis (e.g. AIDS)

Diseases dangerous in pregnancy (e.g. CHF)

Conflicts between needed maternal care and
fetal well-being

Recurrent Pregnancy loss
Does Preconception Care Work?
Outcomes Impacted
 Fetal/Infant mortality and morbidity
 Maternal mortality and morbidity

Historical Perspectives

1979: PHS: Primary Care Effectiveness. An approach to clinical quality
assurance in BCHS Programs and Projects
1985: IOM: Preventing Low Birth Weight
1989: Public Health Service Expert Panel on the content of Prenatal
Care
1991: USPHHS: Healthy People 2000 - National Health Promotions and
Disease Prevention Objectives
1993: March of Dimes towards improving the outcome of pregnancy
report
1993: Alan Guttmacher Institute’s Issues in Brief: The nation will be
well-served by making a commitment to advance preconception services
to a similar extend as it has prenatal care.
1996: Guide to Clinical Preventive Services

1997: AAP & ACOG Guidelines for Perinatal Care






Prevention of Birth Defects
Optimal glycemic control
 No alcohol consumption
 Preconception rubella immunization
 Folic Acid supplementation

Goals of Preconception Care
in Diabetes



To reduce the occurrence of obstetric and diabetic
complications
To decrease the incidence of congenital abnormalities
Reduce risk of spontaneous abortions
How To Accomplish These Goals?

Education about need to change diabetes medication
regimen ie substitute insulin for oral hypoglycemics

Optimal glycemic control achieved by home
monitoring, multiple daily injections, adjustment of
insulin, close supervision and education

Postpone conception until control is achieved

Reassess modifiable risks before conception by
assessing end organ damage, retina, kidney,
vasculature, heart, nervous system
Alcohol





Leading preventable cause of mental retardation
Most common teratogen to which fetuses are
exposed
Effects related to dose
No threshold has been identified for “safe” use in
pregnancy
Effects at all stages of pregnancy
Rubella Vaccination



Determine rubella immunity prior to conception
Vaccinate susceptible nonpregnant women
Congenital rubella syndrome may result from
infection during pregnancy (microcephaly, fetal
growth restriction, cardiac malformations, etc)
Prevention of Neural Tube Defects


Supplementation for all women of childbearing
potential with folic acid
 No history of NTD: 0.4 mg. qd
 Prior infant with NTD: 4.0 mg. qd
 Woman with NTD: 4.0 mg. qd
Nutritional sources often inadequate
Barriers to Preconception Care
Patient Aspects



High rate of unintended pregnancies
Ignorance about importance of good health habits
prior to conception
Limited access to health services in general.
Barriers To Preconception Care
Provider Aspects




Feeling of having inadequate knowledge
Perception of preconception care being time-consuming
Concern about insurance reimbursement.
Lack of awareness of how to integrate preconception
care into ongoing primary care
% Eligible Patients Seen for Preconceptional
Care: Physicians (2002) vs. Other Providers
(2003)
30%
27%
26%
27%
25%
Providers-2003
22%
22%
20%
MDs-2002
Mean % Seen for
Preconceptional Visit
Providers-2003: 22%
MDs-2002:
20%
11%
10%
8%
6% 6%
4% 4%
5% 4%
60-79%
80%+
1% 1%
0%
None
1-5%
6-9%
10-19%
20-39%
40-59%
Percentages are net of 108 physicians (2002) and 55 non-physician providers (2003)
who do not provide prenatal care.
Issues Addressed at Annual Well-Woman
Exam: Physicians (2002) vs. Other Providers
(2003)
Always
Usually
Occasionally
Never
2003 2002 2003 2002 2003 2002 2003
2002
MDs NonMD MDs NonMD MDs NonMD MDs NonMD
Annual Pap tests
Breast self-exam
Birth control
Smoking
STD prevention
Mammograms
Alcohol use
Multivitamins
Calcium supplements
Folic acid supplements
Weight control (diet/exercise)
Iron supplements
91%
81%
58%
71%
44%
69%
37%
21%
36%
23%
42%
11%
*
*
*
*
*
*
*
89%
84%
67%
67%
56%
63%
45%
35%
39%
27%
36%
15%
7%
16%
28%
21%
30%
20%
26%
32%
35%
30%
36%
23%
9%
14%
24%
23%
28%
19%
22%
34%
36%
31%
39%
28%
2%
3%
13%
8%
24%
11%
34%
42%
27%
44%
22%
62%
“Which issues do you always, usually, occasionally, or never address at an annual well-woman
exam with a woman of reproductive age, that is, under age 45?” * Statistically significant
difference between physicians and non-physicians in % “always.”
2%
2%
8%
10%
15%
17%
31%
31%
23%
40%
24%
53%
0%
0%
1%
1%
1%
1%
3%
5%
3%
3%
0%
4%
1%
1%
2%
1%
1%
1%
2%
1%
2%
3%
1%
4%
Reasons Providers Don’t Always Recommend
Folic Acid or Multivitamins: Physicians (2002)
vs. Other Providers (2003)
Responses
were
categorized
from verbatim
comments.
* Statistically
significant
difference
between all
physicians vs.
all nonphysician
respondents.
Lack of knowledge about: folic acid,
nutrition, unintended pregnancy
Too busy/not enough time
Don't always remember to mention it
Not relevant for patient
[Not planning to get pregnant; not necessary
for all patients; not reason for visit]
2003 Survey
CNM Other Total
2002
OBG/FP
41% 36% 38%
40%
35% 27% 30%
11% 10% 10%
30%
14%
12% 13% 12%
*
8%
*
No need/there's enough in food supply
Not a high priority
Lack of patient compliance
All others
3%
3%
2%
4%
4%
1%
3%
4%
1%
5%
4%
3%
[Cost, questionable efficacy, not covered by
insurance, not a priority for provider, etc.]
5%
7%
8%
13%
7% 4% 5%
7% 12% 10%
7% 4% 5%
0.2%
5%
4%
No reason
Don't know why
No answer
*
Other Barriers To Preconception
Care



Availability of contraceptives
Health Insurance Coverage
Out of Pocket Expenses.
Who Should Get Preconception
Care

49% of pregnancies in the US are unintended
(unwanted or mistimed) - Henshaw. 1988.

Preconception care should be provided to all
reproductive age individuals
Preconception Care for Men




Alcohol
 may be associated with physical and emotional
abuse
 may decrease fertility
Genetic Counseling
Occupational exposure
 lead
Sexually transmitted diseases
 syphilis, herpes, HIV
WHO TO PROVIDE

Health Care Providers
 OB-GYNs, Pediatricians, Family Medicine, Internists,
 Nurses, Nurse Practitioners, Nurse-midwives
 Genetic Counselors
 Health Educators
When Should Preconception Care
Be Offered



As part of routine health maintenance care
At a defined preconception visit
For women with chronic illness
How Preconception Care can be
Integrated into Practice






As part of any routine medical visits
Episodic visit for any common complaints
Negative pregnancy test - an opportunity for
preconception care
Family planning encounter
Infertility evaluation
Following a poor pregnancy outcome
Preconception Care


Primary Prevention
Essential to March of Dimes Mission to prevent birth
defects and infant mortality
March of Dimes
Products/Resources

Consumers
 Pregnancy and Newborn Health Education Center
 marchofdimes.com
 nacersano.org
 e-preconception newsletter (Spanish)
 comenzando bien
 Are You Ready?
 Think Ahead for a Healthy Baby
 Folic Acid brochures
 Pre-Pregnancy Planning Fact Sheet
March of Dimes
Products/Resources

Providers
 marchofdimes.com
 Preconception Health Promotion: A Focus for
Women’s Wellness nursing module
 Upper Hudson Prenatal Services
 Preconception Screening and Counseling Tool
 Chapter grants
“Preconception health promotion is the
cornerstone of healthy infants, children,
families and communities ”