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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 ”