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PRECONCEPTION CARE
Ensuring healthier pregnancies

WHO SHOULD READ THIS?

Any physician assistant who provides care for women of childbearing age.

WHAT IS PRECONCEPTION CARE?

Preconception care stresses risk assessment and health promotion and education in preparation for childbearing. Emphasis is placed on identifying and modifying medical, behavioral, and social risk factors as well as preventing and managing health problems that require action before pregnancy.^1,2 Examples of effective interventions include smoking cessation, obesity control, folic acid supplementation, and eliminating alcohol and recreational drug use before the woman becomes pregnant. Another important intervention is the review and/or modification of prescription and nonprescription medications in order to prevent teratogenic and other adverse effects.

WHY IS PRECONCEPTION CARE IMPORTANT?

Adverse birth outcomes such as prematurity (12%), low birth weight (8%), major birth defects (3%), and, in particular, maternal pregnancy complications (31%) have remained a persistent problem even though providing prenatal care became standard in the 1980s.^1-3 To improve our national health status, we must change our approach to ensuring healthy birth outcomes. The first step is to incorporate preconception care into primary care as a routine practice. Prenatal care and neonatal care often come too late to prevent many serious maternal and child health problems. Smoking, alcohol/drug use, and pre-existing medical conditions such as hypertension, diabetes, and obesity alter pregnancy outcomes. However, early and appropriate evaluation and intervention can reduce risks, resulting in healthier birth outcomes.²

WHO ARE CANDIDATES FOR PRECONCEPTION CARE?

All women with reproductive potential who present to the primary care setting are considered candidates for preconception care.^1,2 Every woman of reproductive age should be asked whether she intends to become pregnant within the next year; this question promotes the idea that pregnancy should be intended and planned and enables appropriate preconception care to be provided. Women should be informed about how any medical conditions they have or medications they take might affect the outcome of pregnancy; they should also be educated about how pregnancy itself can affect their health.^1,2

WHAT’S NEW?

In 2003, a CDC work group conducted a review of published studies about maternal and child health and preconception care. The work group also held discussions with national organizations. By November 2004, the CDC work group and representatives of 16 external organizations were in place, and in 2005, a national summit was held to review various practice models. The Select Panel on Preconception Care identified preconception health promotion and care as a critical public health issue. Through collaborative efforts, the CDC has now published new national recommendations for improvement of pregnancy outcomes.^1,4,5 These guidelines provide evidence-based support for improving pregnancy outcomes through health promotion and changing patient attitudes and behaviors.¹

Implementing the recommendations in the guidelines is expected to improve access to care and raise standards of care. Some of the CDC work group’s conclusions are detailed in Table 1, which provides 10 key recommendations for incorporating preconception care into practice, and Table 2, which provides specific health care counseling targets. Clinicians should focus on these recommendations as part of preconception care in order to improve pregnancy outcomes.

WHAT ELSE IS IMPORTANT TO KNOW?

Recognized barriers to providing preconception care include lack of provider knowledge, lack of patient knowledge or demand for services, lack of provider time, and lack of insurance coverage. Only one in four providers currently offers age-appropriate preconception care for the majority of patients.¹ A number of the recommendations outlined in Table 1 address these barriers.^1,3,5

Recommendations 1, 2, and 8 address public health outreach strategies and consumer education programs. Recommendation 7 is aimed at improving access and care through Medicaid coverage for low-income women. Numbers 9 and 10 address research and surveillance for preconception health. Recommendations 3 to 6 address preventive care visits, risk assessment, defining interconception care, and prepregnancy checkups. JAAPA

REFERENCES

	1.	Centers for Disease Control and Prevention. Preconception care home page. http://www.cdc.gov/ncbddd/preconception/default.htm. Accessed August 8, 2008.
	2.	Dunlop AL, Jack B, Frey K. National recommendations for preconception care: the essential role of the family physician. J Am Board Fam Med. 2007;20(1):81-84.
	3.	Swan LL, Apgar BS. Preconceptual obstetric risk assessment and health promotion. Am Fam Physician. 1995;51(8): 1875-1885, 1888-1890.
	4.	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. National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9194&nbr=4952%20-%2050k. Accessed August 6, 2008.
	5.	Proceedings of the preconception health and health care clinical, public health, and consumer workgroup meetings. June 27-28, 2006. Atlanta, Georgia. http://www.cdc.gov/ncbddd/preconception/documents/Workgroup%20Proceedings%20June06.pdf. Accessed August 6, 2008.

This article was written by Eileen M. Van Dyke, MPS, PA-C. Contributors included the other members and staff of CSAC 2008-2009: Daniel L. O’Donoghue, PhD, PA-C, Chair; Gilbert A. Boissonneault, PhD, PA-C; Anthony E. Brenneman, MPAS, PA-C; Alison C. Essary, MHPE, PA-C; Michelle Lynn Heinan, EdD, PA-C; Marie-Michèle Léger, MPH, PA-C; and Robert McNellis, MPH, PA. The manuscript was edited by Sarah Zarbock, PA-C.

PRECONCEPTION CARE Ensuring healthier pregnancies