Preconception Care: Why Should We Care? - PowerPoint - PowerPoint by 2Dsm1z

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									Preconception Health and Health Care
Recommendations and PPOR

July 11, 2006
Magda Peck, ScD
 CEO/Founder, CityMatCH
 Co-Chair of Public Health Workgroup,
    CDC/ATSDR Workgroup on Preconception Care


And,
Hani K. Atrash, MD, MPH
 Associate Director for Program Development
 National Center on Birth Defects and Developmental Disabilities
The CDC/ATSDR Workgroup on Preconception Care
The CDC Select Panel on Preconception care
                                        Promoting the health of babies,
                                                  children, and adults, and enhancing
                                                  the potential for full, productive living
                                                                                          1
Preconception Health and Health Care and PPOR


   (Published) Perinatal Periods of Risk analysis in
     New York City, Tulsa, and Kansas City concluded
     that racial and ethnic disparities in fetoinfant
     mortality were largely related to maternal health,
     and, interventions to reduce feto-infant mortality
     should include preconception care and
     improvements in women’s health

• Besculides M, Laraque F. Racial and ethnic disparities in perinatal mortality: applying the perinatal periods
of risk model to identify areas for intervention. JAMA 2005;97:1128–32.
• Cai J, Hoff GL, Dew PC, Guillory VJ, Manning J. Perinatal periods of risk: analysis of fetal-infant mortality
rates in Kansas City, Missouri. Matern Child Health J 2005;9:199–205.
• Burns PG. Reducing infant mortality rates using the perinatal periods of risk model. Public Health Nurs
2005;22:2–7.



                                                                                                                  2
Early prenatal care
  is not enough,
and in many cases
   it is too late!

                      3
Time For a Paradigm Shift!

 From

          Healthy Mothers



           Healthy Babies
                             4
Time For a Paradigm Shift!

To      Healthy Women

          Healthy Mothers


          Healthy Babies
                             5
Improving Preconception Health and Health care
            Summary - Bottomline

   Poor pregnancy outcomes continue to
   be at an un-acceptable level
   A good proportion of women enter
   pregnancy “at-risk” for adverse
   pregnancy outcomes
   There is evidence that intervening
   before pregnancy will help
   There is widespread consensus that we
   must act before pregnancy
   CDC and its partners are working to
   provide guidance on how to make it
   happen

                                                 6
Preconception Care - Goal

To promote the health of
women of reproductive age
before conception and
thereby improve pregnancy-
related outcomes


                             7
Definition of PCC
 A set of interventions that aim to
 identify and modify biomedical,
 behavioral, and social risks to a
 woman’s health or pregnancy outcome
 through prevention and 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

                                                             8
 Why do we need
Preconception Care?



                      9
Adverse Pregnancy Outcomes Continue to
be Higher Than Acceptable

 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%

                                                  10
Improvement in Maternal Mortality Rates Slowed Down


                                               1000
 Log-Maternal Deaths per 100,000 Live Births




                                                                                                      White
                                                                                                      Other
                                                100          71% Decrease                             AA/B



                                                                                   13% Decrease
                                                 10

                                                                                        1980-2003
                                                                                       29% Increase

                                                  1
                                                      1960        1970      1980       1990           2000

                                                                            Year

                                                                                                              11
     Low Birthweight Births Are Increasing


                          16
                          14
Percent Low Birthweight




                          12
                          10
                                                            14.7% Increase
                           8
                           6
                                                                                                                                                             White
                           4
                                                                                                                                                             AA/B
                           2                                                                                                                                 Hispanic
                                  Very low birthweigh births increased 25.9%
                           0
                               1981
                                      1982
                                             1983
                                                    1984
                                                           1985
                                                                  1986
                                                                         1987
                                                                                1988
                                                                                       1989
                                                                                              1990
                                                                                                     1991
                                                                                                            1992
                                                                                                                   1993
                                                                                                                          1994
                                                                                                                                 1995
                                                                                                                                        1996
                                                                                                                                               1997
                                                                                                                                                      1998
                                                                                                                                                             1999
                                                                                                                                                                    2000
                                                                                                                                                                           2001
                                                                                                                                                                                  2002
                                                                                                     Year
                                                                                                                                                                                         12
Preterm Deliveries Are Increasing

                          20
                          18
 Percent Preterm Births




                          16
                          14                       26% Increase

                          12
                          10
                           8
                           6
                                                                                            White
                           4                                                                AA/B
                           2    Very preterm births increased 8.2%                          Hispanic
                           0
                           81


                                  83


                                         85


                                               87


                                                       89


                                                             91


                                                                     93


                                                                           95


                                                                                 97


                                                                                       99


                                                                                               01
                          19


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                                                                   19


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                                                                                      19


                                                                                             20
                                                                  Year
                                                                                                       13
Infant Mortality Rates Improved But Continue to be
Very High

                                           100
                                                        52% Decrease                          White
 Log-Infant Deaths per 1,000 Live Births




                                                                                              Other
                                                                                              AA/B


                                           10                                 45% Decrease




                                            1
                                                 1960      1970        1980      1990        2000
                                                                       Year


                                                                                                      14
     Infant Mortality Rankings (Ascending) – 1960-2002; Selected Countries (Health United States 2005)
                 1960              1970                1980               1990               2000            2002
1      Sweden           Sweden            Sweden              Japan              Singapore          Hong Kong
2      Netherlands      Netherlands       Japan               Finland            Hong Kong          Sweden
3      Norway           Norway            Finland             Sweden             Japan              Singapore
4      Czech Rep.       Japan             Norway              Hong Kong          Sweden             Japan
5      Australia        Finland           Denmark             Singapore          Finland            Finland
6      Finland          Denmark           Netherlands         Switzerland        Norway             Spain
7      Switzerland      Switzerland       Switzerland         Canada             Spain              Norway
8      Denmark          New Zealand       France              Norway             Czech Rep.         France
9      Eng. & Wales     Australia         Canada              Germany            Germany            Austria
10     New Zealand      France            Australia           Netherlands        Italy              Czech Republic
11     United States    Engl. & Wales     Ireland             France             France             Germany
12     Scotland         Canada            Hong Kong           Denmark            Austria            Denmark
13     N. Ireland       Israel            Singapore           N. Ireland         Belgium            Switzerland
14     Canada           Hong Kong         Engl. & Wales       Spain              Switzerland        Italy
15     France           Ireland           Scotland            Scotland           Netherlands        N. Ireland
16
       Slovakia         Scotland          Belgium             Austria            N. Ireland         Belgium
17     Ireland          United States     Spain               Engl. & Wales      Australia          Netherlands
18     Japan            Czech Rep.        Germany             Belgium            Canada             Australia
19     Israel           Belgium           United States       Australia          Denmark            Portugal
20     Belgium          Singapore         New Zealand         Ireland            Israel             Ireland
21     Singapore        Germany           N. Ireland          Italy              Portugal           Engl. & Wales
22     Germany          N. Ireland        Austria             New Zealand        Engl. & Wales      Scotland
23     Cuba             Slovakia          Italy               United States      Scotland           Canada
24     Austria          Austria           Israel              Greece             Greece             Israel
25     Greece           Bulgaria          Czech Rep.          Israel             Ireland            Greece
26     Hong Kong        Puerto Rico       Greece              Cuba               New Zealand        New Zealand
27     Puerto Rico      Spain             Puerto Rico         Czech Republic     United States      Cuba
28     Spain            Greece            Cuba                Portugal           Cuba               United States
29     Italy            Italy             Bulgaria            Slovakia           Poland             Hungary
30     Bulgaria         Hungary           Costa Rica          Puerto Rico        Slovakia           Poland
31     Hungary          Poland            Slovakia            Bulgaria           Hungary            Slovakia
32     Poland           Cuba              Russian Fed.        Hungary            Puerto Rico        Chile
33     Costa Rica       Romania           Hungary             Costa Rica         Costa Rica         Puerto Rico
34     Romania          Portugal          Portugal            Chile              Chile              Costa Rica
35     Portugal         Costa Rica        Poland              Russian Fed.       Bulgaria           Russian Fed.



                                                                                                                     15
Leading causes of Infant Death Have Changed – Maternal Complications Are Now Third Leading Cause of Infant Death


                                                Asphyxia/Atelactasis                                                                             20.1

 1960                           Immaturity                                                                                                       20
 IMR = 26.0
 110,873 Infant Deaths Congenital Anomalies                                                                                       15.8


                                        Influenza and pneumonia                                                          13.8


                                                                Birth injuries                                   10.5



                                                                Congenital Anomalies
                                                                                 0             5            10               15                20            25
                                                         20.3


                                 12.1
                                         SIDS                            1980
                            11          RDS                              IMR = 12.6
                                                                         45,526 Infant Deaths
                   8        LBW/PTD
          3.5Complications              of Pregnancy

  0         5          10                15         20              25

                                         Congenital Anomalies                                                                                 20.3


                                                                LBW/PTD                                          12.1


                   Complications of Pregnancy                                                               11


 2002                                                                SIDS                          8

 IMR = 7.0
                                              Unintentional Injury                   3.5
 28,034 Infant Deaths
                                                                             0             5           10               15               20             25


                                                                                                                                                             16
Risk Factors Are Prevalent Among Pregnant
Women and Women Likely to Become Pregnant
 Pregnant     Smoked during pregnancy                         11.0%

 or           Consumed alcohol in pregnancy (55% at risk of   10.1%
              pregnancy)
 gave birth   Had preexisting medical conditions              4.1%
              Rubella seronegative                            7.1%
              HIV/AIDS                                        0.2%
              Received inadequate prenatal Care               15.9%

 At risk of   Cardiac Disease                                   3%

 getting      Hypertension                                      3%
 pregnant     Asthma                                            6%
              Dental caries or oral disease (women 20-39)     >80%
              Diabetic                                          9%
              On teratogenic drugs                            2.6%
              Overweight or Obese                              50%
              Not taking Folic Acid                           69.0%



                                                                      17
 We Currently Intervene Too Late
                    Critical Periods of Development
Weeks gestation
from LMP            4       5       6         7      8      9        10      11        12
 Most susceptible           Central Nervous System
                            Central Nervous System
 time for major
 malformation                   Heart
                                Heart
                                        Arms
                                        Arms

                                        Eyes
                                        Eyes

                                        Legs
                                        Legs

                                                         Teeth
                                                         Teeth

                                                         Palate
                                                         Palate

                                                                  External genitalia
                                                                  External genitalia

                                        Ear
                                        Ear


                        Missed Period                       Mean Entry into Prenatal Care

                                                                                            18
Components of Preconception Care


   Screening, health education, effective
   interventions

   ACOG/AAP:
     Maternal Assessment
     Vaccinations
     Screening
     Counseling

                                            19
Components of Preconception Care
Maternal assessment

  Family planning and             Domestic abuse and
  pregnancy spacing               violence
  Family history                  Environmental and
  Genetic history (maternal and   occupational exposures
  paternal)                       Immunity and immunization
  Medical, surgical, pulmonary    status
  and neurologic history          Risk factors for STDs
  Current medications             Obstetric history
  (prescription and OTC)          Gynecologic history
  Substance use, including        General physical exam
  alcohol, tobacco and illicit    Assessment of
  drugs                           Socioeconomic, educational,
  Nutrition                       and cultural context


                                                                20
Components of Preconception Care
Vaccinations


    Vaccinations should be
    offered to women found to be
    at risk for or susceptible to:
         Rubella
         Varicella
         Hepatitis B



                                     21
Components of Preconception Care
Screening Tests


     Screening for HIV should be strongly
     recommended
     A number of tests can be performed for
     specific indications:
          Screening for STDs
          Testing to assess proven etiologies of recurrent
          pregnancy loss
          Testing for specific diseases based on medical or
          reproductive history
          Mantoux skin test with purified protein derivative for
          Tuberculosis



                                                                   22
Components of Preconception Care
Screening 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)



                                                            23
Components of Preconception Care
Counseling

     Patients should be counseled regarding the
     benefits of the following activities:
         Exercising
         Reducing weight before pregnancy, if overweight
         Increasing weight before pregnancy, if underweight
         Avoiding food additives
         Preventing HIV infection
         Determining the time of conception by an accurate
         menstrual history
         Abstaining from tobacco, alcohol, and illicit drug use
         before and during pregnancy
         Consuming Folic Acid
         Maintaining good control of any pre-existing medical
         conditions



                                                                  24
Some Common Conditions
Amenable to Preconception Care

  Diabetes            STDs
  Hypertension        Repetitive
  Seizure disorder    pregnancy losses
  Thyroid disorders   Eating disorders
  Thrombo-embolic     Alcohol, tobacco
  disease             and other drug use
  Hemoglobin          Domestic violence
  disorders           Poor nutrition

                                           25
Preconception Issues for Well Women

  Family planning
  Genetic risks: familial, ethnic, racial
  Nutrition and weight
  Tobacco, alcohol, OTC medications, illicit drugs
  Occupational and environmental hazards
  Domestic violence
  Infections and immunization
  Screening for unapparent medical disease


                                                     26
Preconception Care




                     27
Preconception Interventions:
     Give protection

   Folic Acid Supplements: Reduce the occurrence
   of neural tube defects by two thirds

   Rubella Sero-negativity: Rubella immunization
   provides protective sero-positivity and prevents the
   occurrence of congenital rubella syndrome
   HIV/AIDS: timely antiretroviral treatment can be
   administered, pregnancies can be better planned

   Hepatitis B: Vaccination is recommended for men
   and women who are at risk for acquiring hepatitis B virus
   (HBV) infection.

                                                               28
Preconception Interventions:
     Manage conditions
  Diabetes: 3-fold increase in birth defects among infants of women
  with type 1 and type 2 diabetes, without management

  Hypothyroidism: Dosage of Levothyroxine should be adjusted in
  early pregnancy to maintain levels needed for neurological development
  Maternal PKU: Low phenylalanine diet before conception and
  throughout pregnancy prevents mental retardation in infants born to
  mothers with PKU

  Obesity: Associated adverse outcomes include neural tube defects,
  preterm birth, c-section, hypertensive and thromboembolic disease.

  STDs: have been strongly associated with ectopic pregnancy,
  infertility, and chronic pelvic pain.

                                                                           29
Preconception Interventions:
     Avoid Teratogens

    Alcohol use: Fetal alcohol syndrome (FAS) and other
   alcohol-related birth defects can be prevented.
    Anti-epileptic drugs: Some anti-epileptic drugs are
   known teratogens
    Accutane use: Use of Accutane in pregnancy results
   in miscarriage and birth defects
    Oral anticoagulants: Warfarin is a teratogen;
   medications can be switched before the onset of pregnancy
    Smoking: Associated adverse outcomes include
   preterm birth, low birth weight.


                                                               30
QUESTIONS?????



                 31
Preconception Care
       Current Guidelines,
   Recommendations, Practice,
     The CDC Initiative and
       Recommendations


                                32
Clinical Practice Guidelines Exist

 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)

                                                            33
March of Dimes
The key physician/primary care
provider and the obstetrician/
gynecologist should take advantage
of every health encounter to provide
preconception care and risk reduction
before and between conceptions, the
time when health encounters can
improve health status

                                        34
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.
                            35
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

                                                  36
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




                                                             37
38
Where do people stand?




                         39
Preconception care is not being
delivered today!


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




                                  40
Percent Eligible Patients Seen for Preconceptional
Care by Type of Provider (2002-2003)

                30                                             26
                25                               21
                                   20
                20    17
      Percent




                15

                10

                 5

                 0
                     CNM       OB/GYN          F/GP       Other non-
                                                             MD
CNM = Certified Nurse Midwives; OB/GYN = Obstetricians/ Gynecologists;
F/GP = Family / General Practitioners;

                                                                         41
The CDC PCC Initiative: A Collaborative Effort of 22 CDC
     programs and over 35 National Organizations




                                                           42
Purposes of CDC Initiative
  Develop 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
                                                43
The National Summit on Preconception care
The National Summit on Preconception care




                                            44
The Select Panel on Preconception care




                                         45
Recommendations to Improve Preconception Health and Health Care




                                                            46
MCH Journal Supplement on Preconception Care




                                               47
Recommendations Guiding Principals

   Specific to improving women’s
      health throughout the lifespan
   Emphasize individual behavior
      and responsibility
   PCC is NOT a single visit but a
      process of care
   Focus on changes in:
     consumer knowledge
     clinical practice
     public health programs
     health-care financing, and
     data and research activities



                                       48
A Vision for Improving Preconception
Health and Pregnancy Outcomes
  All women and men of childbearing age have high
  reproductive awareness
  All women have a reproductive life plan
  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 have access to
  intensive interconception care aimed at reducing
  their risks.

                                                     49
Goals for Improving Preconception Health

Goal 1. Improve the knowledge and attitudes and behav-iors of
men and women related to preconception health
Goal 2. Assure that all women of childbearing age in the United
States receive preconception care services (i.e., evidence-based risk
screening, health promotion, and inter-ventions) that will enable
them to enter pregnancy in optimal health
Goal 3. Reduce risks indicated by a previous adverse preg-nancy
outcome through interventions during the interconception period,
which can prevent or minimize health problems for a mother and
her future children, and
Goal 4. Reduce the disparities in adverse pregnancy outcomes

                                                                   50
Framework for Developing the Recommendations


                                Vision
                              Improve health
                              and pregnancy
                                outcomes




                             Goals
                      Coverage – Risk Reduction
                 Empowerment – Disparity Reduction


                    Recommendations
              Individual Responsibility - Service Provision
           Access – Quality – Information – Quality Assurance


                    Action Steps
       Research – Surveillance – Clinical interventions
       Financing – Marketing – Education and training

                                                                51
Themes / Areas for Action

   Social marketing and health
   promotion for consumers
   Clinical practice
   Public health and community
   Public policy and finance
   Data and research


                                 52
Recommendations for Improving Preconception
Health: 1&2 = Individual Responsibility

  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.

                                                       53
Recommendations for Improving Preconception
Health: 3&4 = Prevention & Interventions

  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.
                                                    54
Recommendations for Improving Preconception
Health: 5&6 = Interconception & Pre-pregnancy

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.
                                                  55
Recommendations for Improving Preconception
Health: 7&8 = Public Programs

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.

                                                56
Recommendations for Improving Preconception
Health: 9&10 = Research and Evaluation


 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.

                                          57
  Diffusion of Innovation Theory
   Innovators                Change Agents


Evidence


    Guidelines for
                                        Opinion
    best practice
                                        leaders
            Early adopters


                                Change in
                             dominant practice
Later - laggards         Early and late majority
                                                   58
               Steering Committee Meeting
              White Plains, NY - January 12-13
                    Priority Action Steps
1. Convening working groups to:
    •   Define “contents of preconception care” (3 and 4)
    •   Integrate existing clinical guidelines (3, 4, 5b, and 6b)
2. Information dissemination:
    •   Develop key messages (1, 3, and 4)
    •   Create an information portals on the web (1)
    •   Catalogue existing materials (2c)
3. Demonstrate the effectiveness:
    •   Evaluate existing models (5b and 8c)
    •   Conduct demonstration projects (3a, 4a, 5b, 5d, 5e, 8a, 8d, 9c, and 9e)
4. Explore means for financing:
    •   Explore options for augmenting Medicaid waivers (7a)
    •   Conduct health plan demonstration projects (3h, 4f, and 6a)
5. Augment CDC and other surveillance to monitor practice (10b, 10d, and 10f)
6. Analyze existing data to further study association between women’s
    health and pregnancy outcomes (10)
7. Complete a systematic review and a cost study (9a, 9c, and 9d)

                                                                                  59
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