cial assistance, and counseling about pregnancy planning and contraception. ;, .... spite of the dearth of treatment options for severely affected women ...
Reprlnteo from JAMAr,., The Journal of the American Medical AssociatIOn
SeptemDer 5, 7990, Volume 264
Copyright 7990. American Medical AssociatIOn
Commentary
Preconception Care Risk Reduction and Health Promotion in Preparation for Pregnancy THE BIRTH of a healthy baby to a healthy woman and family depends, in part, on a \\Toman's general health and well-being before conception as well as on the amount and quality of prenatal care. Health care before pregnancy can ameliorate disease, improve risk status, and help prepare a family for childbearing. Some interventions that are available prior to conception are not possible once a woman conceives. The trend among women who are in middle- and upper-income levels to delay pregnancy until they are 30 years of age or older has led to increased consumer demand for assistance in preparation for pregnancy. In recent years, the idea has emerged of an organized, comprehensive program that iden tifies and reduces women's reproductive risks before concep tion. This concept has been called "preconception care. "1 Development of this concept has been identified as a priori ty for the 1990s. 2 The Institute of Medicine's Preventing Lou' Birthweight;' found the reduction of medical and psychosocial risks of pregnancy to be worthwhile and suggested that it begin before pregnancy. As a follow-up to this report, the CS Public Health Service Expert Panel on the Content of Prena tal Carel recommended that health care to help women pre pare for pregnancy be an important part of prenatal care, and that this care should be made available to all women and their partners as an integrated part of primary care services. Components of Preconception Care
The components of preconception care are listed in the Table. They include risk assessment, health promotion, and interventions to reduce risk. Risks identifiable prior to con ception may involve medical, social, psychological, or life style conditions. Risk assessment provides opportunity to identify social factors related to poor obstetric outcome, in cluding inadequate housing, low income, having less than a high school education, and problems related to to being a single parent. Psychological risks that can be identified by a sensitive intervie\v include inadequate personal support, de ficient coping skills, living in an abusive situation, higp stress and anxiety, and psychiatric conditions. High-risk be~aviors such as smoking, alcohol, or substance abuse can be discov ered. Real or perceived barriers to family planning or early prenatal care enrollment can be identified. Once risks are known, some women may benefit from counseling and refer ral to social, mental health, and substance abuse treatment programs or for vocational training, which can be presented as an alternative to pregnancy. Other interventions available include home visitation,.) provision of social services and finanFrom the Department of Family MediCine Brown University Memorial HosPital of Island PawtucKet Reprint requests to Department of Family Medicine Brown UniverSity Memorial of Rhode Island 111 Brewster St, PawtucKet R! 02860 (Dr JaCK)
JAMA, September 5, 1990-VoI264, No 9
cial assistance, and counseling about pregnancy planning and contraception. ;, Preconception assessment of nutritional status should iden tify those individuals who are underweight or overweight; conditions such as bulemia, anorexia, pica, or hypervitamin osis; and special dietary habits such as vegetarianism. Once identified, nutritional counseling, and in some cases treat ment of underlying emotional conditions, can be initiated. Multivitamins, particularly folic acid, taken during the peri conception period have been associated \vith a reduced inci dence of neural tube defects. If these data are confirmed, preconception care should include vitamin supplementation. Preconception care of women with a known medical disease may prevent anomalies or illnesses in the newborn. Medical management before conception that normalizes the blood glucose level in women with diabetes mellitus 7 or reduces the blood phenylalanine level in women with phenylketonuriaI' can positively influence pregnancy outcome. Preconception modification of therapeutic regimens, including elimination of known teratogenic drugs such as gold, lithium, isotretinoin, folic acid antagonists, valproic acid, and warfarin can reduce anomalies in the newborn. Alternatively, preconception counseling of women for \vhom such drugs are essential may lead to postponement or avoidance of pregnancy. Certain preventive services can be included as part of a preconception visit. Since the perinatal acquisition of the human immunodeficiency virus causes significant morbidity and mortality, 9 all women of childbearing age should be coun seled about the risks of infection and screened as appropri ate. 111 Women at ongoing risk for hepatitis B, or who are not immunized against rubella, can be vaccinated. Determination of the hemoglobin level or hematocrit, a Papanicolaou smear, and testing for tuberculosis, gonorrhea, syphilis, and chlamy dial infection can be done so that abnormalities can be treated before conception. Testing women for toxoplasmosis before pregnancy identi fies those at risk for primary infection during pregnancy. Women who are not immune can be counseled before preg nancy about ways to prevent infection during pregnancy_ If a woman who is known to be seronegative before pregnancy seroconverts during pregnancy, a prompt and definite diag nosis and treatment decisions can be made. 11 If a woman's serological status is not known before pregnancy, differenti ating a recent infection from a previous infection is often problematic. 12 The ideal time for genetic counseling and investigation is before a couple attempts to conceive. For patients with a specific indication, such as advanced maternal age, a family history of genetic disease, a previously affected pregnancy, or f
Commentary
1147
Components of Preconception Care as Part of Pnmary Care Services
Risk Assessment Individual and social conditions (age. diet. education, housing, and economic status) Adverse health behaviors (tobacco, alcohol, and illicit drug abuse) Medical conditions (immune status. medications, genetic illness, illnesses including infection, and prior obstetric history) Psychological conditions (personal and family readiness for pregnancy. stress. anxiety, and depression) Environmental conditions (workplace hazards, toxic chemicals, and radiation contamination) Barriers to family planning, prenatal care. and primary health care Health Promotion Promotion of healthy behaviors (proper nutrition, avoidance of smoking.
alcohol, teratogens. and practice of "safe sex")
Counseling about the availability of social, financial, and vocational
assistance programs Advice on family planning, pregnancy spacing. and contraception Counseling about the importance of early registration and compliance with prenatal care, including high-risk programs if warranted
Identification of barriers to care and assistance in overcoming them
Arrangements for ongoing care
Interventions Treatment of medical conditions, including changes in medications, if
appropriate, and referral to high-risk pregnancy programs
Referral for treatment of adverse health behaviors (tobacco, alcohol.
and illicit drug abuse)
Rubella and hepatitis immunization
Reduction of psychosocial risks that may involve counseling or referral
to home health agencies, community mental health centers, safe shelters, enrollment in medical assistance, or assistance with housing Nutrition counseling, supplementation or referral to improve adequacy of diet Home visits to further assess and intervene in the home environment Provision of family planning services
a significant occupational exposure, preconception genetic counseling can be offered. Common disorders for \vhich ge netic screening may be recommended include Tay-Sachs dis ease for Ashkenazic Jews, ~-thalassemiafor Greeks and Ital ians, a-thalassemia for Southeast Asians and Philippinos, sickle cell anemia for blacks, and cystic fibrosis for those individuals who have affected relatives. Such counseling al lows the couple to understand their risk and, if necessary, to arrange for diagnostic tests such as chorionic villus sampling or amniocentesis early in the preganancy. It also may influ ence a couple~s decision to conceive or adopt and could alter the clinical management of the pregnancy and ne\vborn.13.1~ Preconception care programs may be designed to encour age men to seek counseling and educational information about responsible fatherhood and sexuality. Such services may be designed to prepare for fatherhood (financial and family plan ning), evaluate genetic risks (genetic counseling and testing), assess for risks of child abuse or neglect (drug or alcohol use), or enlist support in an attempt to lower a woman's reproduc tive risk (weight loss or smoking cessation). Provision of Preconception Care
The components of preconception care have been incorpo rated into "preconception clinics," family planning clinics, or ongoing primary care. Prepregnancy clinics attract patients with a history of a complicated pregnancy or a pptentially complicating medical condition. 15.16 Once identified bS primary care physicians, referral of women with these conditions to such clinics may be of substantial benefit. However, only a small reduction in overall perinatal mortality and morbidity can be achieved by targeting this small group of women. Visits to family planning clinics offer an opportunity to provide preconception care to women \vith no previously known risks. Regularly scheduled visits to family planning clinics include screening for sexually transmitted diseases, anemia, and cervical dysplasia. They also offer an opportunity to provide reproductive education and counseling about preg nancy planning and the means to defer pregnancy. These 1148
JAMA, September 5, 1990- Vol 264, No, 9
routine actiyitie~ have been extended to include a eon1prehen si ve preconception assessment using a self-administered questionnaire, \vhich identifies risks and gives individualized recomn1endations to alter the effects of health and life-style risks on pregnancy outcomes. The appraisal serves to remind the \\Toman of actions to take \vhen she stops using birth control. Preconception care can be provided most effectively as part of ongoing primary care. It can be initiated during visits for routine health maintenance, during examinations for school or work, at premarital or family planning examinations, after a negative pregnancy test, or during well-child care for anoth er family men1ber. These visits provide an opportunity to help women participate in ongoing medical care, including early entry to prenatal care, to practice effective birth control, to stop smoking, and to lose or gain weight and to help families clarify choices about life-style, education, and occupation that may affect their decision about pregnancy. 1";'
j
Barriers to Implementation
There are many social and economic obstacles that must be overcon1e for preconception care to be effectively integrated into ongoing medical care. Those Most in Need of Services Are Those Least Likely to Receive Them. - Women at social risk often encounter barriers in obtaining health services, including counseling and care before conception. These patients also are at in creased risk of poor pregnancy outcome. 1 Thus, women most likely to benefit from preconception care include those least likely to have access to it. Introduction of such care into settings that serve women \vith limited access to health care (such as women's shelters, halfway houses, detention cen ters, sexually transmitted disease clinics, and substance abuse treatment centers) and improving access to primary care in such settings as neighborhood health centers and family planning clinics will increase the availability of these services. Provision of Services Is Often Badly Fragmented. - Co ordination of medical and community services such as visiting nurses, social workers, mental health counselors, and nutri tionists is needed to provide continuous, comprehensive, and coordinated care of women at medical and psychosocial risk. 1 Interventions to reduce risks include activities that may be completed at the risk assessment visit (vaccination for rubel la), ongoing primary care (tailoring of therapeutic regimens), referral services (genetic counseling), and behavior change, possibly with the support of an organized program (diet modi fication or smoking cessation). A complete program of precon ception care will need to include follow-up of all of these interventional services. However, in many communities, and especially for patients with lo\v incomes, only the basic risk assessment, basic educational, and primary care level ser vices are now feasible. There Is a Lack of Available Treatment Services for High-Risk Behaviors. - The ability of preconception activi ties to improve obstetric outcome depends on the availability of effective interventions acceptable to women. Few commu nities have adequate capacity to provide many preconception services such as nutritional counseling or treatment for sub stance abuse, particularly for women with low incomes. In spite of the dearth of treatment options for severely affected women, educating women about the risk of drinking alcohol /
