ORIGINAL ARTICLE

 

Preconception care to improve pregnancy outcomes: clinical practice guidelines

 

 

Hani Atrash^I; Brian Jack^II

^IMD, MPH, Adjunct Professor, Department of Epidemiology Emory University, Rollins School of Public Health
^IIMD, Professor and Vice Chair, Department of Family Medicine Boston University School of Medicine / Boston Medical Center

Correspondence

 

 

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ABSTRACT

INTRODUCTION: There is scientific evidence that the health of women before pregnancy contributes to the maternal and infant outcomes of pregnancy. There is also scientific evidence that the health of women of reproductive age may be improved through the provision of Preconception Care (PCC). Preconception care includes interventions to assess, identify, address, and modify a woman's health conditions and risks to ensure that these health conditions and risks do not negatively affect the outcome of her pregnancy. Many of the medical conditions, environmental exposures, personal behaviors, and psychosocial risks associated with negative pregnancy outcomes have been identified and there are recommendations for including these conditions in PCC services
OBJECTIVE: Our purpose is to present a tool for clinical care providers involved in delivering PCC services. We try to answer the following questions: what do providers actually do when a woman of reproductive age arrives at their offices? What questions to ask? What examinations to conduct? What laboratory tests to perform? And, what education and counselling to offer?
METHODS: We reviewed published and un-published literature related to the scientific evidence for the effectiveness of PCC in improving pregnancy outcomes. We searched PubMed for published articles, and we searched the internet for unpublished reports prepared by international organizations such as the World Health Organization and reports from governmental agencies. We summarized the information and presented a comprehensive overview of actions that providers should take to address various risk behaviors, exposures and health conditions
RESULTS: Several scientists, countries, and international organizations have proposed answers to the above questions. However, there has been no consistency and there is not a single publication that includes a comprehensive compilation of the proposed actions. We summarized the recommended actions that clinical care providers should take in addressing various health conditions, risk behaviors, and exposures
CONCLUSION: It is recommended that all providers screen all women for their intentions to become pregnant and to provide them with appropriate services. Women should be referred to specialized care when risk behaviors and medical conditions that go beyond the skills and abilities of the primary care provider are identified

Keywords: preconception care, preconception health, women's health, maternal health, infant health, clinical practice guidelines

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RESUMO

INTRODUÇÃO: Existem evidências científicas de que a saúde das mulheres antes da gravidez contribui para os resultados maternos e infantis da gravidez. Há também evidências científicas de que a saúde das mulheres em idade reprodutiva pode ser melhorada através da prestação de cuidados preconcepção. Os cuidados preconcepção incluem intervenções para avaliar, identificar, abordar e modificar as condições e riscos de saúde de uma mulher para garantir que essas condições e riscos não afetem negativamente o resultado de sua gravidez. Muitas condições médicas, exposições ambientais, comportamentos pessoais e riscos psicossociais associados a resultados negativos da gravidez foram identificados e existem recomendações para a inclusão dessas condições nos serviços de assistência preconcepção
OBJETIVO: O objetivo deste estudo é servir como uma ferramenta para os prestadores de cuidados clínicos envolvidos na prestação de serviços de cuidados preconcepção. Tentamos responder às seguintes perguntas: o que os profissionais realmente fazem quando uma mulher em idade reprodutiva chega a seus escritórios? Que perguntas fazer? Quais exames realizar? Quais exames laboratoriais devem ser realizados? E que educação e aconselhamento oferecer?
MÉTODO: Revisamos a literatura publicada e não publicada relacionada à evidência científica para a eficácia dos cuidados preconcepção na melhoria dos resultados da gravidez. Pesquisamos no PubMed por artigos publicados e pesquisamos na Internet relatórios não publicados preparados por organizações internacionais como a Organização Mundial da Saúde e relatórios de agências governamentais. Resumimos as informações e apresentamos uma visão abrangente das ações que os fornecedores devem adotar para abordar vários comportamentos de risco, exposições e condições de saúde
RESULTADOS: Vários cientistas, países e organizações internacionais propuseram respostas para as perguntas acima. No entanto, não houve consistência e não há uma única publicação que inclua uma compilação abrangente das ações propostas. Resumimos as ações recomendadas que os prestadores de cuidados clínicos devem adotar para lidar com várias condições de saúde, comportamentos de risco e exposições
CONCLUSÃO: Recomenda-se que todos os profissionais examinem todas as mulheres quanto à sua intenção de engravidar e forneçam-lhes os serviços adequados. As mulheres devem ser encaminhadas para atendimento especializado quando forem identificados comportamentos de risco e condições médicas que vão além das habilidades do prestador de cuidados primários

Palavras-chave: cuidados preconcepção, saúde preconcepção, saúde da mulher, saúde materna, saúde infantil, diretrizes de prática clínica.

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Authors summary

Why was this study done?

• There is scientific evidence that improving the health of women before pregnancy (preconception care) will improve maternal and infant pregnancy outcomes. • Over 80 interventions have been recommended to be included in a preconception care package. • Some publications have proposed actions to be taken to address a woman's risk behaviors, exposures and health conditions before pregnancy. • There is no comprehensive compilation of these actions and there is a need for "clinical practice guidelines" for the delivery of preconception care services (a document that presents a comprehensive summary of the proposed actions).

What did the researchers do and find?

• We reviewed published and un-published literature related to the proposed actions to address risk behavior, exposures and health conditions during the preconception period. • We searched PubMed for published articles. • We searched the internet for unpublished reports prepared by international organizations such as the World Health Organization and reports from governmental agencies. • We found several reports that propose actions to be included in preconception care services. • We summarized the proposed actions and developed step by step guidelines for clinical care providers for the delivery of preconception care services.

What do these findings mean?

• There is a need for "clinical practice guidelines" for the delivery of preconception care services. • This article serves as a tool for clinicians and offers a list of proposed actions to manage identified risks during the preconception period.

 

INTRODUCTION

Over the past two decades there has been renewed interest in ensuring the health of women before pregnancy to further improve maternal and infant health outcomes. The health of women of reproductive age may be improved through the provision of Preconception Care (PCC). Preconception care proposes a primary prevention approach that aims to engage women and couples of reproductive age before they become pregnant in a set of educational and management interventions that identify and modify health risks. Risks include physical and behavioral health, exposure to teratogens or environmental conditions, genetic disorders, substance use, smoking, unhealthy diet or weight, domestic abuse or not following evidence-based preventive actions such as taking folic acid. Many of the medical conditions, environmental exposures, personal behaviors, and psychosocial risks associated with negative pregnancy outcomes can be identified and modified or eliminated before conception.

A comprehensive PCC program has the potential to benefit women desiring pregnancy by reducing risks, promoting healthy lifestyles, and increasing readiness for pregnancy. For women not desiring pregnancy, a PCC program can reduce personal health risks and the risk of an unwanted pregnancy. In 2004, the United States Centers for Disease Control and Prevention (CDC) convened experts who developed "Recommendations to Improve Preconception Health and Health Care"¹. Following the publication of the recommendations, state and local health departments within the United States initiated programs to implement the recommendations. Several countries such as Canada, Belgium and the Netherlands have also started to implement PCC programs^2-4. In February 2012, the World Health Organization (WHO) convened a meeting of researchers and partner organizations "to achieve a global consensus on the place of PCC as part of an overall strategy to prevent maternal and childhood mortality and morbidity". The WHO concluded that PCC has a positive impact on maternal and child health outcomes. The WHO also provided a foundation for implementing a package of promotive, preventive and curative health interventions shown to have been effective in improving maternal and child health. According to the WHO a wide range of sectors and stakeholders needs to be engaged to ensure universal access to PCC and guides non-health sectors, foundations and civil society organizations to collaborate with, and support, public health policy-makers to maximize gains for maternal and child health through PCC⁵.

In a previous article we described the components of PCC, the interventions recommended to be included in each component, and the quality of evidence and strength of recommendation in support of these interventions⁶ . The question that remains is: what do providers actually do when a woman of reproductive age arrives at their offices? What questions to ask? What examinations to conduct? What laboratory tests to perform? And, what education and counselling to offer? Another question is: who should be providing these services? The discussion in this article is limited to clinical services provided to individuals; however, a population-based PCC is needed to ensure that patients and providers are educated about PCC and its importance in improving pregnancy outcomes and to also ensure that PCC services are available and accessible to people who need and seek those services. Therefore, the purpose of this publication is to serve as a tool for clinical care providers involved in delivering preconception care services.

 

WHO PROVIDES PRECONCEPTION CARE?

Within the clinical healthcare setup, the main providers of PCC are physicians, including general practitioners, obstetricians/gynecologists, pediatricians, among others (endocrinologists, cardiologists, surgeons, psychiatrists, etc): at every encounter with a woman of reproductive age, physicians should ask the woman about her plans for pregnancy. If planning to get pregnant, physicians should offer or refer her to preconception care counseling and services. If not planning pregnancy, physicians should offer or refer her to family planning services. Other clinical care providers (nurses, midwives, public health workers, social workers, health educators, pharmacists, nutritionists, etc.) also have a role and should enquire about a woman's reproductive life plan at every encounter. Every provider should use every opportunity to educate women, men and the community about the importance of being healthy especially if planning pregnancy, and the importance of effective contraception if not planning pregnancy.

 

WHAT SHOULD PROVIDERS DO?

There have been many reports (published and unpublished) describing recommended services to be provided to women and couples in the context of preconception care. We reviewed the literature and summarized recommended actions in the tables below. The tables and their content align with tables previously prepared and which summarize the recommended components and interventions of PCC⁶. The information in tables 1 to 3 was prepared based on various publications listed in the references at the end of this document describing how to address and implement various recommended interventions^2-14. The recommended interventions were grouped into three categories: assessment (history and medical assessment), counseling and education, and, prevention and management.

I. Assessment

During a preconception encounter, it is important to identify risk factors related to a woman's personal and family history as well as her current behaviors and conditions. Prior personal and family health conditions as well as current personal behavior and health conditions may have an impact on the health of the mother and infant during and after pregnancy. Thus, it is recommended that all women of reproductive age should have a screening history during their encounter with general health care and maternal and child healthcare providers; other health care providers should at least enquire about women's reproductive life planning. In addition, all women in need of PCC services should undergo a thorough physical examination and have specific laboratory tests done to identify potential risks to their pregnancy outcomes. Tables 1-a and 1-b summarize recommended assessment interventions and what to do about them^2-14.

II. Counseling and Education

There is evidence that counseling and education during the preconception period results in changes in risk behaviors which eventually leads to improved maternal and neonatal outcomes. Based on history and medical assessment, if a health condition or a risk is identified, women and couples will have the opportunity to receive treatment or sit down with a specialist to receive counselling on the best course of action. Counselling and education related to chronic health conditions is becoming increasingly important as women are choosing to get pregnant at a more advanced age where chronic conditions (and medications to treat these conditions) are more common. Some of the most common blood pressure medications (ACE inhibitors), high cholesterol medications (statins), blood thinners (Warfarin), and seizure medications have been shown to be teratogenic. Table 2 summarize recommended counselling and education interventions and what to do about them^2-14.

III. Prevention and management

Many women of childbearing age suffer from various chronic conditions and are exposed to (or consume) substances that can have an adverse effect on pregnancy outcomes, leading to pregnancy loss, infant death, birth defects, or other complications for mothers and infants. Conditions like asthma, overweight or obesity, cardiac disease, hypertension, diabetes, thyroid disorder, dental caries and other oral diseases have been found to be associated with complications for mothers and infants⁹. It is essential that these conditions be identified and addressed in the preconception period. Managing chronic conditions during pregnancy is not feasible and often by the time a woman presents for prenatal care, all the fetal organs had been formed and it is too late to prevent maternal and fetal complications related to these conditions. In addition to having chronic diseases, a substantial proportion of women who become pregnant engage in high-risk behaviors that contribute to adverse pregnancy outcomes. These behaviors must be addressed during a PCC encounter. All health conditions should be properly managed and controlled before pregnancy occurs to avoid complications. Consider the need to change treatment regimens when a woman is planning a pregnancy. Refer the woman to a specialist for adjustment or alteration of treatment regimens before conception. Tables 3a and 3b summarize recommended prevention and management interventions and what to do about them^2-14.

 

CONCLUSION

Health care providers are ideally positioned to offer PCC and to serve as advocates for the creation of healthy, supportive communities for women and men throughout the childbearing phase of their lives. Providers involved in PCC enter into a collaborative partnership that enables women and men to examine their own health and its influence on the health of their baby. The role of health care providers is to communicate clear, accurate, and timely information; screen for, and act upon, any potential impediments to a successful outcome; support the decision-making process; and offer and refer patients to relevant services when appropriate. The information provided, and the techniques used to encourage effective discussion and communication will allow women and men to make an informed decision about having a baby. All choices, of course, ultimately rest with the woman and her partner.

The interventions included in a preconception care package are numerous and it is unreasonable to expect every provider to provide all services to all women during all encounters, but much could and should be done at routine exams by primary health care providers. However, it is essential that all providers screen all women for their intentions to become pregnant and to provide (or refer) them with appropriate services. It is also important to keep in mind the "common" conditions that should be screened for. Obviously, there are conditions that are not listed above which affect some women and which have an adverse effect on a pregnancy and its outcome. Thus, the above guidelines are not all-inclusive and include only broad recommendations for action. Specialized care will be needed when risk behaviors and medical conditions are identified.

 

REFERENCES

1.Johnson K, Posner SF, Bierman J, Cordero JF, Atrash HK, Parker CS, et al. Recommendations to Improve Preconception Health and Health Care - United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006;55(RR-6):1-23.         [ Links ]

2.Public Health Agency of Canada. Family-Centered Maternity and Newborn Care: National Guidelines. In: Chapter 2 - Preconception care [internet] 2020. [cited 2020 Jun 09] Available from: https://www.canada.ca/en/public-health/services/maternity-newborn-care-guidelines.html        [ Links ]

3.Sheldon T. Netherlands considers introducing preconception care. BMJ. 2007;335(7622):686-7. DOI: http://doi.org/10.1136/bmj.39353.518067.DB        [ Links ]

4.Ebrahim SH, Lo SST, Zhuo J, Han JY, Delvoye P, Han JY, Zhu L. Models of Preconception Care Implementation in Selected Countries. Matern Child Health J. 200610(Suppl 1):37-42. DOI: http://doi.org/10.1007/s10995-006-0096-9        [ Links ]

5.World Health Organization (WHO). Meeting to Develop a Global Consensus on Preconception Care to Reduce Maternal and Childhood Mortality and Morbidity. Geneva: WHO, 2013        [ Links ]

6.Atrash HK and Jack B. Preconception Care to Improve Pregnancy Outcomes: The Science. J Hum Growth Dev. 2020;30(3):334-341.         [ Links ]

7.Lassi ZS, Dean SV, Mallick D, Bhutta ZA. Preconception care: delivery strategies and packages for care. Reprod Health. 2014;11(Suppl 3):S7. DOI: http://doi.org/10.1186/1742-4755-11-S3-S7        [ Links ]

8.Farahi N, Zolotor A. Recommendations for Preconception Counseling and Care. Am Fam Physician. 2013;88(8):499-506.         [ Links ]

9.Jack BW, Atrash H, Coonrod DV, Moos MK, O'Donnell J, Johnson K. The Clinical Content of Preconception Care: An Overview and Preparation of This Supplement. Am J Obstetr Ginecol. 2008;199(6 Suppl 2): S266-79. DOI: http://doi.org/10.1016/j.ajog.2008.07.067        [ Links ]

10.Jack B, Atrash HK. Preconception Health and Health Care: The Clinical Content of Preconception Care. Am J Obstetr Ginecol. 2008;199(6 Suppl B):S257-396.         [ Links ]

11.Before, Between & Beyond Pregnancy. A preconception resource and training for professionals created by the National Preconception Health & Health Care Initiative [internet] 2020. [cited 2020 Jun 09] Available from: https://beforeandbeyond.org/        [ Links ]

12.South Australian Perinatal Practice Guidelines. Preconception Advice [internet] 2015. [cited 2020 Jun 09] Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/1f11de804eed8cb5afbeaf6a7ac0d6e4/Preconception+Advice_Sept2015.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-1f11de804eed8cb5afbeaf6a7ac0d6e4-n5jkcsW        [ Links ]

13.World health Organization (WHO). Reproductive health and research. Meeting on Promoting Preconception Care in the Eastern Mediterranean Region. [internet] 2020. [cited 2020 Jun 09] Available from: http://www.emro.who.int/images/stories/rhrn/Meeing_report_Preconception_care_Muscat.pdf        [ Links ]

14.World health Organization (WHO). Summary report on the informal working group on promoting preconception care in the Eastern Mediterranean Region, Amman, Jordan 5-7 April 2015 [internet]. [cited 2020 Jun 09] Available from: http://applications.emro.who.int/docs/IC_Meet_Rep_2015_EN_16669.pdf        [ Links ]

 

 

Correspondence:
Hani Atrash
hatrash@emory.edu

Received: May 2020
Revised: May 2020
Accepted: September 2020