Minnesota Title V MCH Needs Assessment Fact Sheets

Pregnant Women, Mothers and Infants

Preconception and Interconception Care

Summer 2004

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Size of the Problem

According to the most recent statistics in 2002, Minnesota has 1,096,832 women of childbearing age (15-44 years) [1]. Because approximately 49% of all pregnancies are unplanned, it is beneficial to assess preconception health during routine checkups with all female patients of childbearing age. It is a way of encouraging healthy habits that can affect pregnancy outcome.

According to the March of Dimes (MOD) [2], all women of childbearing age can take steps even before conception to improve their chances of having a healthy baby. These steps include: taking the B vitamin folic acid daily to prevent birth defects; adopting a healthy lifestyle (i.e. balanced nutrition, adequate rest, avoidance of alcohol, tobacco and other drugs, and moderate physical activity); and getting a pre-pregnancy health checkup. Since many crucial stages in a baby’s development occur before a woman may realize she is pregnant, taking these early steps can minimize harm to the baby from certain infections, illnesses, nutritional deficiencies and environmental hazards.

Seriousness

Prenatal care has been referred to as the “window of opportunity” to improve pregnancy outcomes [3]. However, the Institute of Medicine (IOM) [4] reports that only “casual attention” has been given to the best protections against low birthweight and other poor pregnancy outcomes—having a woman actively plan for pregnancy, enter pregnancy in good health and be fully informed about her reproductive and general health before conception. The U.S. Public Health Service (PHS), in Healthy People 2000, set a target of 60% for the proportion of primary care providers giving age-appropriate preconception care and counseling by the year 2000 (PHS, 1991). Unfortunately, the follow-up publication Healthy People 2010 reports that the progress for meeting this target for age-appropriate preconception care and counseling is unknown and, perhaps, limited [5]. The lack of documented progress in achieving this target relates, in part, to the fact that preconception health is carried out in a variety of ways, with little uniformity and structure, and in many settings, thereby making progress difficult to measure [6].

It is difficult to determine the economic cost/benefit of providing or not providing preconception and interconception care because cost effectiveness of family planning, prenatal care, and genetic counseling services would all need to be considered. While infant mortality provides support to initiate prevention campaigns, other reproductive problems, such as spontaneous abortions, fetal deaths, maternal deaths, and maternal and infant morbidity, remain very costly reminders of lost or impaired human potential.

The U.S. Department of Health and Human Services reports that infant mortality is an important measure of a nation’s health and a world-wide indicator of health status and social well-being. The United States ranks 26th among industrialized nations relative to infant mortality. The leading cause of infant mortality in the U.S. is birth defects, many of which are preventable through appropriate preconception counseling.

Disparities
Even though Minnesota has one of the lowest rates of infant mortality in the U.S., the infant mortality rate shows marked discrepancies for different racial and ethnic backgrounds. The largest disparities are in the rates for Black, White, and American Indian infants. There are also racial and ethnic disparities related to access and adequacy of prenatal care, with women of color and American Indian women being much less likely than white women to receive adequate prenatal care.

Interventions

The first prenatal visit is typically the initial point of education for women and their partners about actions they can take to protect their future child from damage during pregnancy. It is usually at this visit that providers review the health history of the woman and her partner, determine risk status and discuss health promotion and positive behaviors. However, because the critical period or organ development begins on day 17 following conception, outcomes for many pregnancies are determined before a woman enters prenatal care. (MOD)

The goal of preconception and interconception health promotion is to provide women and their partners with information about their reproductive futures. The components include medical and psychosocial history, physical exam, laboratory tests, family history and nutritional assessment. Common conditions that are amenable to preconception care include diabetes, hypertension, seizure disorder, thyroid disorder, STIs/HIV, depression and related mental health disorders, poor nutrition, alcohol, tobacco and other drug use, and domestic violence. Preconception counseling can be provided in conjunction with preventive health check ups, family planning clinic visits, or any visit with a woman of childbearing age.

It is difficult, if not impossible, to determine the number of Minnesota women reached with preconception or interconception information through clinical encounters versus other vehicles for health education. There is no objective evidence that the majority of women receive preconception information in clinical encounters. (MOD)

Best practice interventions include a life span perspective that focuses attention on the preconception and interconception periods as targets for intervention in improving perinatal outcomes [7]. Best practice interventions recognize that (1) powerful influences on outcome occur long before pregnancy begins; (2) pregnancy outcome is shaped by social, psychological, behavioral, environmental and biological forces; and (3) pregnancy has changed dramatically in the last few decades with more women delaying their first birth.

Status

Most pregnant women in Minnesota receive prenatal care initiated in the first or second trimester of pregnancy. Despite great strides in improving prenatal care utilization among Minnesota women, there has not been a concurrent decline in indicators of adverse pregnancy outcome. There is a need for increased community awareness related to the powerful influences on pregnancy outcome and how these influences are related to factors that occur long before pregnancy begins.

Counseling to promote preconception and interconception health should ideally include providing both women and men the opportunity to learn about how to maximize their chances of having a healthy pregnancy and healthy baby. This counseling could be provided in private and publicly funded primary care and family planning clinics, as well as in public health nursing and other home visiting programs designed to provide services to women of childbearing age.

In Minnesota, Local Public Health Grant, MCH Block Grant, Family Planning, and Family Home Visiting funds can be utilized by local public health agencies and tribal governments to provide preconception and interconception care and counseling.

References

1. MDH, Center for Health Statistics, 2002.
2. March of Dimes Birth Defects Foundation. (2002) Preconception Health Promotion: A Focus for Women’s Wellness, White Plains, N.Y.
3. Bernstein. P.S., Sanghvi, T. &Merkatz, I. (2000) Inproving Preconception Care.Journal of Reproductive Medicine, 45, 546-552.
4. Institute of Medicine (IOM). Washington D.C.:National Academy Press.
5. Department of Health and Human Services (2000) Health People 2010. MccLean VA: International Medical Publishing, Inc.
6. Dunkley, J. (2000) Health Promotion in Midwifery, Ney York: Bailliere Tindall.
7. Misra, D.P., Guyer, B. & Allston, A. Integrated Perinatal Health Framework: A Multiple Determinants Model with a Life Span Approach. Am J Prev Med 2003; 25 (1).