Transcript Preconception Care: Why Should We Care?

Overview of Preconception Care
And the CDC Preconception Care Collaborative
State Infant Mortality Collaborative
Conference Call
January 18, 2006
Hani K. Atrash, MD, MPH
Associate Director for Program Development
National Center on Birth Defects and Developmental Disabilities
Promoting the health of babies,
children, and adults, and enhancing
the potential for full, productive living
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Outline
Definition and Goals
Why Do We Need Preconception Care?
Components
Scientific Evidence
Current Recommendations
Current Practice
Challenges to Implementation
Update of current activities
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Improving Preconception Health
“Optimizing a woman’s health
before and between pregnancies is
an ongoing process that requires
full participation of all segments of
the health care system.”
The Importance of preconception care in the continuum of women’s health care.
ACOG Committee Opinion, Number 313, September 2005
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Preconception Care: Goal
To minimize risks to the woman
and the fetus and improve
pregnancy outcome:
Preconception care is comprised of
biomedical and behavioral interventions
that improve pregnancy outcomes.
Preconception interventions must be
successfully implemented before the start
of pregnancy.
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Combined Definition of PCC
A set of interventions that aim to identify
and modify biomedical, behavioral,
and social risks to a woman’s health or
pregnancy outcome through prevention
and management, emphasizing those
factors which must be acted on before
conception or early in pregnancy to have
maximal impact.
CDC’s Select Panel on Preconception Care, June 2005
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Why do we need
Preconception Care?
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Maternal Mortality Rates, United States 1960-2000
Log-Maternal Deaths per 100,000 Live Births
1000
White
Other
AA/B
71% Decrease
100
13% Decrease
10
1
1960
1970
1980
1990
2000
Year
7
Low Birthweight, United States 1980-2002
14
12
10
14.7% Increase
8
6
White
AA/B
Hispanic
4
2
Very low birthweigh births increased 25.9%
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
0
1981
Percent Low Birthweight
16
Year
8
26% Increase
White
AA/B
Year
01
20
99
19
97
19
95
Hispanic
19
93
19
91
19
89
19
87
19
85
19
83
8.2% Increase in very preterm births
19
81
20
18
16
14
12
10
8
6
4
2
0
19
Percent Preterm Births
Preterm Delivery, United States 1980-2002
9
Infant Mortality Rates, United States 1920-2000
Log-Infant Deaths per 1,000 Live Births
100
White
Other
AA/B
52% Decrease
45% Decrease
10
1
1960
1970
1980
1990
2000
Year
10
Five Leading Causes of Infant Death, United States, 1960, 1980 and 2002
Asphyxia/Atelactasis
20.1
1960
Immaturity
IMR = 26.0
110,873 Infant Deaths Congenital Anomalies
20
15.8
Influenza and pneumonia
13.8
Birth injuries
10.5
Congenital Anomalies
0
20.3
SIDS
12.1
11
3.5Complications
0
5
10
15
20
25
1980
IMR = 12.6
45,526 Infant Deaths
RDS
LBW/PTD
8
5
of Pregnancy
10
15
20
25
Congenital Anomalies
20.3
LBW/PTD
12.1
Complications of Pregnancy
2002
IMR = 7.0
28,034 Infant Deaths
11
SIDS
8
Unintentional Injury
3.5
0
5
10
15
20
25
11
Incidence of Adverse Pregnancy Outcomes
Major birth defects
3.3% of births
Fetal Alcohol Syndrome
0.2-1.5 /1,000 LB
Low Birth Weight
7.9% of births
Preterm Delivery
12.3%
Complications of pregnancy
30.7%
C-section
27.6%
Unintended pregnancies
49%
Unintended births
31%
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Prevalence of Risk Factors
Pregnant Smoked during pregnancy
or
Consumed alcohol in pregnancy
gave birth
Had preexisting medical conditions
10.1%
Rubella seronegative
7.1%
HIV/AIDS
0.2%
Received inadequate prenatal Care
11.0%
4.1%
15.9%
At risk of Diabetic
getting
On teratogenic drugs
pregnant Obese
3.8%
30.8%
Not taking Folic Acid
69.0%
2.6%
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Critical
Periods
of Development
Critical Periods
of Development
Weeks gestation
from LMP
Most susceptible
time for major
malformation
4
5
6
7
8
9
10
11
12
Central
Central Nervous
Nervous System
System
Heart
Heart
Arms
Arms
Eyes
Eyes
Legs
Legs
Teeth
Teeth
Palate
Palate
External
External genitalia
genitalia
Ear
Ear
Missed Period
Mean Entry into Prenatal Care
14
15
Early prenatal care
is not enough,
and in many cases
it is too late!
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Components of
Preconception Care
1. Screening for risks
2. Providing health education
3. Delivering effective interventions
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Components Of Preconception Care
Maternal Assessment
Vaccinations
Screening
Counseling
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Components of Preconception Care
Maternal assessment
Family planning and
pregnancy spacing
Family history
Genetic history (maternal and
paternal)
Medical, surgical, pulmonary
and neurologic history
Current medications
(prescription and OTC)
Substance use, including
alcohol, tobacco and illicit
drugs
Nutrition
Domestic abuse and
violence
Environmental and
occupational exposures
Immunity and immunization
status
Risk factors for STDs
Obstetric history
Gynecologic history
General physical exam
Assessment of
Socioeconomic, educational,
and cultural context
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Components of Preconception Care
Vaccinations
Vaccinations should be
offered to women found to be
at risk for or susceptible to:
Rubella
Varicella
Hepatitis B
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Components of Preconception Care
Screening Tests
Screening for HIV should be strongly
recommended
A number of tests can be performed for
specific indications:
Screening for STDs
Testing to assess proven etiologies of recurrent
pregnancy loss
Testing for specific diseases based on medical or
reproductive history
Mantoux skin test with purified protein derivative for
Tuberculosis
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Components of Preconception Care
Screening Tests
Screening for other genetic disorders based
on family history: CF, Fragile X, mental
retardation, Duchene muscular dystrophy.
Screening for genetic disorders based on
racial/ethnic background:
Sickel hemoglobinopathies (African Americans)
Β-Thalassemia (Mediterraneans, SE Asia, AA/B)
α-Thalassemia (AA/B and Asians)
Tay Sachs disease (Ashkhenazi Jews, French
Canadians, Cajuns)
Gaucher’s, Canavan, and Nieman-Pick Disease
(Ashkenazi Jews)
Cystic Fibrosis (Caucasians and Ashkenazi Jews)
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Components of Preconception Care
Counseling
Patients should be counseled regarding the
benefits of the following activities:
Exercising
Reducing weight before pregnancy, if overweight
Increasing weight before pregnancy, if underweight
Avoiding food additives
Preventing HIV infection
Determining the time of conception by an accurate
menstrual history
Abstaining from tobacco, alcohol, and illicit drug use
before and during pregnancy
Consuming Folic Acid
Maintaining good control of any pre-existing medical
conditions
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Preconception Care
Science, Guidelines,
Recommendations, Practice
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Scientific
Evidence
Does preconception care work?
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Science: There is evidence that individual
components of Preconception Care work:
Rubella vaccination
HIV/AIDS screening
Management and
control of:
Diabetes
Hypothyroidism
PKU
Obesity
Folic Acid
supplements
Avoiding teratogens:
Smoking
Alcohol
Oral anticoagulants
Accutane
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Clinical Practice Guidelines Exist
Clinical practice guidelines for
preconception care of specific
maternal health conditions have been
developed by professional
organizations:
American Diabetes Association (Diabetes -2004)
American Association of Clinical Endocrinologists
(Hypothyroidism – 1999)
American Academy of Neurology (Anti-epileptic drugs)
American Heart Association/American College of
Cardiologists (Anti-epileptic drugs - 2003)
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Where do people stand?
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ACOG/AAP (2002)
All health encounters during a
woman’s reproductive years,
particularly those that are a part of
preconceptional care should include
counseling on appropriate medical
care and behavior to optimize
pregnancy outcomes.
ACOG/AAP Guidelines for perinatal care, 5th edition, 2002
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US Public Health Service
HP 2000 Objectives
5.10 and 14.12
Increase to at least 60
percent the proportion
of primary care
providers who provide
age-appropriate
preconception care
and counseling.
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USPHS
“Every woman (and, when possible, her partner)
contemplating pregnancy within one year should
consult a prenatal care provider. Because many
pregnancies are not planned, providers should
include preconception counseling,
when appropriate, in contacts
with women and men of
reproductive age….Such care
should be integrated into primary
care services.”
USPHS Expert Panel on the
Content of Prenatal Care, 1989
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Preconception care is not being
delivered today!
Most providers don’t
provide it
Most insurers don’t
pay for it
Most consumers
don’t ask for it
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Percent Eligible Patients Seen for Preconceptional
Care by Type of Provider (2002-2003)
30
Percent
25
20
15
10
5
0
CNM
OB/GYN
F/GP
Other nonMD
CNM = Certified Nurse Midwives; OB/GYN = Obstetricians/ Gynecologists;
F/GP = Family / General Practitioners;
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We have evidence,
consensus, and
guidelines.
So, why don’t we do it?
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Challenges to Implementation
1. Absence of a national policy
2. Lack of clinical tools
3. Few proven delivery models /
programs
4. Inadequate education of providers
and consumers
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What has CDC
done?
Convening
Studying
Reporting
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The Preconception Care Initiative
A Collaborative Effort of over 35 National Organizations
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Purposes of CDC Initiative
Develop national recommendations to
improve preconception health
Improve provider knowledge, attitudes, and
behaviors
Identify opportunities to integrate PCC
programs and policies into federal, state,
local health programs
Develop tools and promote guidelines for
practice
Evaluate existing programs for feasibility
and demonstrated effectiveness
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What Have We Done?
 Established CDC (internal) and external work
groups (2004)
 Convened a meeting of work groups (Nov. 2004)
 Held a National Summit on Preconception
Care (June 2004)
 Convened a Select Panel (June 2004)
 Developed recommendations to improve
preconception health (June- Nov. 2004, publication Feb. 2005)
 Commissioned a supplement to MCH Journal
(anticipated March-April 2005)
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Next Steps
Publish and disseminate the recommendations
Increase awareness among public/private
providers
Identify opportunities to integrate PCC programs
and policies into state, local, and community
health programs
Develop tools and guidelines for practice
Evaluate existing programs for feasibility and
demonstrated effectiveness
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What results of this process?
Through collaboration and consensus:
• Assessed current scientific knowledge
• Identified best and promising practices
• Identified issues needing further attention
• Refined definition
• Developed vision and goals
• Develop recommendations and action steps
• Produced documents to share across
professional fields.
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Preconception Care Framework
Vision
Improve health
and pregnancy
outcomes
Goals
Coverage – Risk Reduction
Empowerment – Disparity Reduction
Recommendations
Individual Responsibility - Service Provision
Access – Quality – Information – Quality Assurance
Action Steps
Research – Surveillance – Clinical interventions
Financing – Marketing – Education and training
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Themes / Areas for Action
Social marketing and health
promotion for consumers
Clinical practice
Public health and community
Public policy and finance
Data and research
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A Vision for Improving Preconception
Health and Pregnancy Outcomes
All women and men of childbearing age have high
reproductive awareness (i.e., understand risk and
protective 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 coverage.
All women of childbearing age are screened prior to
pregnancy for risks related to outcomes.
Women with a prior pregnancy loss (e.g., infant death,
VLBW or preterm birth) have access to intensive
interconception care aimed at reducing their risks.
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Goals for Improving Preconception Health
Goal 1. To improve the knowledge, attitudes, and
behaviors of men and women related to preconception
health.
Goal 2. To assure that all U.S. women of childbearing age
receive preconception care services – screening, health
promotion, and interventions -- that will enable them to
enter pregnancy in optimal health.
Goal 3. To reduce risks indicated by a prior adverse
pregnancy outcome through interventions in the
interconception (inter-pregnancy) period that can prevent
or minimize health problems for a mother and her future
children.
Goal 4. To reduce the disparities in adverse pregnancies
outcomes.
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Recommendations for Improving
Preconception Health (1-2)
Recommendation 1. Individual responsibility
across the life span. Encourage each woman
and every couple to have a reproductive life plan.
Recommendation 2. Consumer awareness.
Increase public awareness of the importance of
preconception health behaviors and increase
individuals’ use of preconception care services
using information and tools appropriate across
varying age, literacy, health literacy, and
cultural/linguistic contexts.
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Recommendations for Improving
Preconception Health (3-4)
Recommendation 3. Preventive visits. As a
part of primary care visits, provide risk
assessment and counseling to all women of
childbearing age to reduce risks related to the
outcomes of pregnancy.
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.
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Recommendations for Improving
Preconception Health (5-6)
Recommendation 5. Interconception
care. Use the interconception period to provide
intensive interventions to women who have had
a prior pregnancy ending in adverse outcome
(e.g., infant death, low birthweight or preterm
birth).
Recommendation 6. Pre-pregnancy
check ups. Offer, as a component of maternity
care, one pre-pregnancy visit for couples
planning pregnancy.
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Recommendations for Improving
Preconception Health (7-8)
Recommendation 7. Health coverage for
low-income women. Increase Medicaid
coverage among low-income women to improve
access to preventive women’s health,
preconception, and interconception care.
Recommendation 8. Public health
programs and strategies. Infuse and
integrate components of preconception health
into existing local public health and related
programs, including emphasis on those with
prior adverse outcomes.
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Recommendations for Improving
Preconception Health (9-10)
Recommendation 9. Research.
Augment research knowledge related to
preconception health.
Recommendation 10. Monitoring
improvements. Maximize public health
surveillance and related research
mechanisms to monitor preconception
health.
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Diffusion of Innovation Theory
Innovators
Change Agents
Evidence
Guidelines for
Opinion
best practice
Early adopters
Later - laggards
leaders
Change in
dominant practice
Early and late majority
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Opportunities for Action
Examples of “Low Hanging Fruit”
Permit states to use family planning waivers for
more interconception care.
Permit coverage of more uninsured women using
Medicaid and SCHIP.
Direct public health agencies to use resources to:
Develop programs, test models, fill gaps
Evaluate and monitor progress
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Thank You
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