March of Dimes Introduction by mikeholy

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									PRECONCEPTION CARE
    CityMatCH Conference
      September 13, 2004

          Janis Biermann, M.S.
     jbiermann@marchofdimes.com
         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

 Improvinginfant 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           Systemic Lupus
   Hypertensive Disorders      Thromboembolic Disease
   Cardiac Disease             Renal Disease
   Thyroid Disorders           Hemoglobinopathies
   Epilepsy                    Cancers
   Asthma
   HIV Infection
  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%               Providers-2003           MDs-2002
                      27%
                                              26%
                   25%
                                                              22%               Mean % Seen for
                                                           22%                 Preconceptional Visit
20%                                                                            Providers-2003: 22%
                                                                               MDs-2002:       20%


                                                                          11%
10%
                                                                               8%
       6% 6%
                                                                                                5% 4%
                                                                                       4% 4%
                                  1% 1%
0%

       None          1-5%         6-9%        10-19%        20-39%       40-59%        60-79%   80%+
  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
                                       2002    2003 2002 2003 2002 2003 2002 2003
                                       MDs NonMD MDs NonMD MDs NonMD MDs NonMD
Annual Pap tests                       91%           89%         7%          9%         2%        2%   0%   1%
Breast self-exam                       81%           84%         16%        14%         3%        2%   0%   1%
Birth control                          58%      *    67%         28%        24%         13%       8%   1%   2%
Smoking                                71%           67%         21%        23%         8%       10%   1%   1%
STD prevention                         44%      *    56%         30%        28%         24%      15%   1%   1%
Mammograms                             69%      *    63%         20%        19%         11%      17%   1%   1%
Alcohol use                            37%      *    45%         26%        22%         34%      31%   3%   2%
Multivitamins                          21%      *    35%         32%        34%         42%      31%   5%   1%
Calcium supplements                    36%           39%         35%        36%         27%      23%   3%   2%
Folic acid supplements                 23%           27%         30%        31%         44%      40%   3%   3%
Weight control (diet/exercise)         42%      *    36%         36%        39%         22%      24%   0%   1%
Iron supplements                       11%      *    15%         23%        28%         62%      53%   4%   4%
  “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.”
     Reasons Providers Don’t Always Recommend
     Folic Acid or Multivitamins: Physicians (2002)
               vs. Other Providers (2003)
                                                                    2003 Survey      2002
                                                                  CNM Other Total   OBG/FP
                  Lack of knowledge about: folic acid,
                                                                  41% 36% 38%        40%
                  nutrition, unintended pregnancy
  Responses
     were         Too busy/not enough time                        35% 27% 30%        30%
  categorized
from verbatim
                  Don't always remember to mention it
                  Not relevant for patient
                                                                  11% 10% 10%        14%
                                                                                        *
                                                                  12% 13% 12%        8%
  comments.       [Not planning to get pregnant; not necessary
                  for all patients; not reason for visit]                               *
* Statistically   No need/there's enough in food supply           3%    4%   3%      5%
 significant      Not a high priority                             3%    4%   4%      4%
  difference
 between all
                  Lack of patient compliance
                  All others
                                                                  2%    1%   1%      3%
                                                                                          *
physicians vs.    [Cost, questionable efficacy, not covered by    5%    7%   8%      13%
   all non-       insurance, not a priority for provider, etc.]
  physician       No reason                                       7% 4% 5%           0.2%
respondents.
                  Don't know why                                  7% 12% 10%          5%
                  No answer                                       7% 4% 5%            4%
     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 ”

								
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