TM 1 Hani K. Atrash, MD, MPH Associate Director for Program Development National Center on Birth Defects and Developmental Disabilities Promoting the health

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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 enhancingthe potential for full, productive living

Overview of Preconception CareAnd the CDC Preconception Care Collaborative

State Infant Mortality CollaborativeConference Call

January 18, 2006

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Outline

Definition and GoalsWhy Do We Need Preconception Care?Components Scientific Evidence Current RecommendationsCurrent PracticeChallenges to ImplementationUpdate of current activities

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“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

Improving Preconception Health

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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.

Preconception Care: Goal

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Combined Definition of PCC

A set of interventions that aim to identify identify

and modify biomedical, behavioral, and modify biomedical, behavioral,

and social risksand social risks to a woman’s health or pregnancy outcome through prevention prevention

and managementand 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

1

10

100

1000

1960 1970 1980 1990 2000

Year

Lo

g-M

ate

rna

l De

ath

s p

er

10

0,0

00

Liv

e B

irth

s

White

Other

AA/B71% Decrease

13% Decrease

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Low Birthweight, United States 1980-2002

0

2

4

6

8

10

12

14

16

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

Year

Pe

rce

nt L

ow

Birt

hw

eig

ht

White

AA/B

Hispanic

14.7% Increase

Very low birthweigh births increased 25.9%

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Preterm Delivery, United States 1980-2002

02468

101214161820

Year

Per

cent

Pre

term

Birt

hs

White

AA/B

Hispanic

26% Increase

8.2% Increase in very preterm births

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Infant Mortality Rates, United States 1920-2000

1

10

100

1960 1970 1980 1990 2000

Year

Lo

g-I

nfa

nt

De

ath

s p

er

1,0

00

Liv

e B

irth

s White

Other

AA/B

52% Decrease

45% Decrease

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Five Leading Causes of Infant Death, United States, 1960, 1980 and 2002

3.5

8

11

12.1

20.3

0 5 10 15 20 25

3.5

8

11

12.1

20.3

0 5 10 15 20 25

Congenital Anomalies

Asphyxia/Atelactasis

Immaturity

10.5

13.8

15.8

20

20.1

0 5 10 15 20 25

LBW/PTD

RDS


SIDS

SIDS

Complications of Pregnancy


LBW/PTD

Complications of Pregnancy

Unintentional Injury

1980IMR = 12.645,526 Infant Deaths



Birth injuries

Influenza and pneumonia


Asphyxia/Atelactasis

Immaturity

LBW/PTD


SIDS

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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 orgave birth

Smoked during pregnancy 11.0%Consumed alcohol in pregnancy 10.1%Had preexisting medical conditions 4.1%Rubella seronegative 7.1%HIV/AIDS 0.2%Received inadequate prenatal Care 15.9%

At risk of getting pregnant

Diabetic 3.8%On teratogenic drugs 2.6%Obese 30.8%Not taking Folic Acid 69.0%

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Critical Periods of DevelopmentCritical Periods of Development

4 5 6 7 8 9 10 11 12Weeks gestation from LMP

Central Nervous SystemCentral Nervous System

HeartHeart

ArmsArms

EyesEyes

LegsLegs

TeethTeeth

PalatePalate

External genitaliaExternal genitalia

EarEar

Missed Period Mean Entry into Prenatal Care

Most susceptible time for major malformation

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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 risks2. Providing health education

3. Delivering effective interventions

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Maternal Assessment

Vaccinations

Screening

Counseling

Components Of Preconception Care

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Components of Preconception CareMaternal 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 CareVaccinations

Vaccinations should be offered to women found to be at risk for or susceptible to:

RubellaVaricellaHepatitis B

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Components of Preconception CareScreening Tests

Screening for HIV should be strongly recommendedA number of tests can be performed for specific indications:

Screening for STDsTesting to assess proven etiologies of recurrent pregnancy loss Testing for specific diseases based on medical or reproductive historyMantoux skin test with purified protein derivative for Tuberculosis

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Components of Preconception CareScreening 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 CareCounseling

Patients should be counseled regarding the benefits of the following activities:

ExercisingReducing weight before pregnancy, if overweightIncreasing weight before pregnancy, if underweightAvoiding food additivesPreventing HIV infectionDetermining the time of conception by an accurate menstrual historyAbstaining from tobacco, alcohol, and illicit drug use before and during pregnancyConsuming Folic AcidMaintaining 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 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)

Clinical Practice Guidelines Exist

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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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Most providers don’t provide itMost insurers don’t pay for itMost consumers don’t ask for it

Preconception care is not being delivered today!

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Percent Eligible Patients Seen for Preconceptional Care by Type of Provider (2002-2003)

0

5

10

15

20

25

30P

erce

nt

CNM OB/GYN F/GP Other non-MD

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?

ConveningStudyingReporting

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The Preconception Care InitiativeA Collaborative Effort of over 35 National Organizations

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Purposes of CDC InitiativeDevelop 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

Action StepsResearch – Surveillance – Clinical

interventions

Financing – Marketing – Education and training

RecommendationsIndividual Responsibility - Service Provision

Access – Quality – Information – Quality Assurance

GoalsCoverage – Risk Reduction

Empowerment – Disparity Reduction

Vision Improve health and pregnancy

outcomes

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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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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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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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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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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

Evidence

Guidelines for

best practice

Early adopters

Opinion

leaders

Innovators

Change in dominant practiceEarly and late majorityLater - laggards

Change Agents

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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

Documents

TM 1 Hani K. Atrash, MD, MPH Associate Director for Program Development National Center on Birth Defects and Developmental Disabilities Promoting the health