Definition and Goals of Care

National and international societies have recognized the importance of the continuum of preconception, prenatal, and interconception care as a comprehensive public health priority across the life span, beginning as early as adolescence, for multiple reasons. The aim of preconception care is to promote the health of women before conception in order to reduce preventable adverse pregnancy outcomes by facilitating risk screening, health promotion, and effective interventions as part of routine health care. As defined by the Centers for Disease Control and Prevention (CDC), it includes “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.” Interconception care is defined as care provided between delivery and the beginning of the woman’s next pregnancy. The term interconception health has limited familiarity among many medical providers, with preconception care being the term used more often in medical circles to refer to care that can maximize parental health before pregnancy. The term interconception health was coined by the CDC as a strategy to optimize parental health between pregnancies by addressing disease processes, health behaviors, and environmental hazards causally associated with infant mortality and other adverse pregnancy outcomes. During the interconception period, intensive interventions are provided to women who have had a previous pregnancy that ended in an adverse outcome (i.e., fetal loss, preterm birth [PTB], low birth­weight [LBW], birth defects, or infant death). Many medical conditions among reproductive-age women frequently become apparent during pregnancy and may contribute to negative birth outcomes in the infant. Hence, interconception care typically refers to enhanced interventions after an adverse pregnancy outcome. However, for purposes of this discussion, preconception and interconception care are essentially interchangeable.

Evidence and Rationale for Paradigm Shift

The evidence and rationale for providing these services are multiple. First, increasing evidence suggests that human health status in adulthood is dictated by microenvironmental and macroenvironmental conditions around the time of conception (fetal programing of adult disease; see Chapter 5 ). Hence, the first prenatal visit may be too late to address modifiable behaviors that could optimize not only pregnancy outcome but the health of the child and future adult. A second significant contribution to adverse pregnancy outcome is related to congenital anomalies, PTB, and LBW. Children born with these conditions contribute significantly to neonatal and infant mortality as well as to family and society health care costs. Patients who present at their first prenatal visit, even as early as the first trimester, are often too late to initiate behaviors or therapeutic interventions to prevent developmental abnormalities or mitigate risk for LBW and potential preterm delivery. Third, almost half of pregnancies are mistimed, unplanned, or unwanted such that women may not be at optimal health or practicing ideal health behaviors at the time of conception, and this is particularly true for adolescents and/or low-income women. Fourth, the proportion of women who delay childbearing or get pregnant with significant medical conditions is increasing, and specific opportunities exist to optimize fertility and pregnancy outcomes as it relates to medication management for those planning pregnancy. Specifically, for those planning pregnancy, preconception/interconception visits provide an opportunity for teachable moments, and data suggest couples planning pregnancy are more likely to change behaviors. Hence, although the functional set of services provided during preconception care, prenatal care, and interconception care are distinct and should be individualized for the patient, operationally—and perhaps politically—these clinical visits should be viewed as a continuum of comprehensive women’s health services provided across a woman’s life span, from menarche to menopause or sterilization. Finally, national surveys reveal that 84% of reproductive-age women (18 to 44 years) have had a health care visit within the past year, which suggests significant opportunity to provide preconception counseling, yet data indicate this is not being done. Although primary care settings and the well-woman visit are an ideal time to provide these services, all health care practitioners—including but not limited to nutritionists, pharmacists, nurses, midwives, physicians in family practice, obstetrician-gynecologists, and medical subspecialists—should approach every health care encounter with a reproductive-age woman as an opportunity to maximize her health and that of her future offspring by asking two simple questions: 1) Are you pregnant or planning to become pregnant? 2) If not, what are you doing to keep from becoming pregnant?

Collectively, these questions are a great segue to the ultimate question: What is your reproductive life plan? The answers to these questions will guide the subsequent health care interaction and appropriate preconception or interconception counseling and any intervention.

Components of Preconception Care and Well-Woman Visits

A pregnancy or the desire to become pregnant is the sentinel event in differentiating preconception, interconception, and well-woman care ( Fig. 6-1 ). Preconception care is included as a preventive health service in well-woman visits covered by the Patient Protection and Affordable Care Act. Barriers to more widespread utilization of preconception care include lack of provider knowledge and training about essential components of preconception care across all specialties. Although multiple checklists and online assessments exist, a detailed description provided by the Select Panel on Preconception Care as part of the CDC work groups and the corresponding rationale and evidence rating scale has been published, along with a recent update of published validated tools. The strategy is similar to most health care interactions: the provider asks screening questions in regard to personal and family history and exposures, undertakes health promotion (counseling for risk reduction), and provides treatment and/or intervention if specific conditions are identified. Table 6-1 lists representative examples of potential topic areas pertinent for a preconception care visit, and it gives examples of medical conditions that could be optimized prior to conception, assuming pregnancy is planned. Ideally, a checklist or questionnaire should be completed prior to seeing the clinician, and the patient would raise questions or ask for clarification as required. Online and interactive modules are also available, and inclusion in electronic medical records (EMRs) and sharing across clinical sites should be encouraged. Perhaps the most essential component of the preconception or well-woman visit that needs more consistent and widespread implementation and dissemination is the development and documentation of an individual’s reproductive life plan.

The fluid interconnections among preconception care, postpartum/interconception care, and well-woman care.

Reproductive Life Plan: Definition

Files and associates have defined a reproductive life plan as a “set of personal goals regarding the conscious decision about whether or not to bear children” and ideally, such a plan outlines a strategy to achieve those goals. Certain key elements should be considered when developing or discussing a reproductive life plan. These include 1) the desire or lack of desire to have children; 2) parental ages; 3) maternal health and coexisting medical conditions; 4) the desired number of children and anticipated spacing of children, taking into consideration ideal birth-spacing intervals, maternal age, and likelihood of fertility; 5) risk tolerance, such as for genetic or medical/obstetric complications; 6) family history; and 7) life context (age, school, career, partner, readiness for childbearing). Importantly, reproductive life plans should be individualized, iterative, and addressed initially at menarche, confirmed or modified at subsequent health encounters by all care providers, and retired with menopause or sterilization. Files and colleagues have provided an algorithm and guidelines for developing a reproductive life plan, and convenient online tools have been designed for women contemplating pregnancy. Unfortunately, studies indicate that even when women have achieved the pregnancy intention stage of readiness, many are still practicing preconception behaviors associated with poor pregnancy outcomes, such as poor diet (overweight or underweight), smoking, and binge drinking; this suggests a greater need for both one-on-one provider-patient interactions and more pervasive social media messages. Research has demonstrated that patients want to be told this information from their providers, and many will respond favorably. Further, sharing this information in groups, community settings, and in the presence of the partner has been shown to increase effectiveness. Importantly, reproductive life plans should not be limited to reproductive-age women—the concept is pertinent for adolescent boys and men as well. If conception is not anticipated within the year, an obvious discussion/intervention includes effective contraception options.

When specific conditions are detected and pregnancy is not recommended or intended, reliable contraception should be prescribed, and the importance of compliance should be strongly reinforced. Data suggest that many women with complex medical problems who are advised against pregnancy conceive unintentionally and/or do not use contraception because of low perceived risk of conceiving. If pregnancy is desired, in addition to screening and encouraging healthy behaviors, interventions to optimize the medical condition and adjust medications to profiles favorable for pregnancy should occur (see Table 6-1 for medical conditions and interventions common for preconception care and pregnancy).

Maternal Age

The average maternal age at first birth has increased steadily over the last three decades in developed countries. In 1970, the average age of first childbirth was 24.3, compared with 27.8 in 2009, the most recent year for which comparable international data are available. The United States has one of the lowest average maternal ages at first birth (25 years), whereas British and German women are delaying motherhood longer than anywhere else in the world (30 years). Advanced maternal age (AMA) is a contributing factor to maternal mortality. Maternal mortality is defined and the causes are described in Chapter 57 .

Body Mass Index

Abnormal maternal weight is an increasingly common complication in developed and developing countries and affects an increasing number of women of reproductive age. Maternal obesity has become a global issue associated with obstetric, surgical, and anesthetic risks and increased risk for acute and chronic diseases, both in the mother and in the child; it also affects the economic productivity of individuals in the society and creates an additional cost burden on the health care system (see Chapter 41 ). Anorexia and bulimia nervosa, once thought to be rare eating disorders, have also been increasing because of cultural pressure on the drive for thinness in developed countries in contrast to longstanding food deprivation in developing countries.

Infections and Immunizations

Primary care, preventative health, and well-women visits are ideal settings in which to screen and counsel women about sexually transmitted infections (STIs) such as syphilis, gonorrhea, chlamydia, and human immunodeficiency virus (HIV) in addition to toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes (TORCH) infections. It is also an ideal time to confirm and update immunization status (see Chapters 52 , 53 , and 54 ). Patients who are sexually active should be counseled about the importance of condoms to prevent STIs (irrespective of other contraceptive methods), and they should be screened for STIs based on age and geographic prevalence as per national guidelines.

Toxoplasmosis screening based on risk factors may be indicated at this time because approximately one fourth of the U.S. population is infected. Patients who have negative screens are at risk for congenital toxoplasmosis and should be counseled to avoid risks such as contact with infected cats and ingestion of raw or undercooked meat. Immunocompetent patients who screen positive can be reassured of low risk with regard to fetal loss or stillbirth; although rare, reports of congenital infection after previous infection have been described. A prospective analysis of the population risks and benefits to substantiate routine screening for and education about toxoplasmosis has not been done in the United States. However, proponents argue a theoretic benefit based on treatment availability, extrapolated epidemiologic data from some European countries (France, Belgium, Austria) where screening is widespread, and the prevalence of congenital infection comparable to other congenital diseases that are currently screened for by mandate, such as phenylketonuria and congenital hypothyroidism. The screening for toxoplasmosis could be performed once at the beginning of pregnancy to provide patients with the information on measures to prevent acquiring the infection during pregnancy, such as avoiding raw vegetables and meat or freezing meat before consumption.

Approximately 50% to 80% of reproductive-age women have evidence of prior cytomegalovirus (CMV) infection, and susceptible women (e.g., child care workers and women with small children in day care) should be counseled about the importance of hand hygiene after contact with toys, saliva, and urine as a preventive measure. Risk of vertical transmission is more likely after primary infection, and current treatment options are limited. Routinely screening for CMV to enhance awareness and encourage prevention practices in at-risk mothers is performed in a few European countries (France, Belgium) but is currently not endorsed in the United States. Likewise, women with primary or recurrent herpes should be informed about the benefits of prophylactic antiviral suppression in the third trimester to decrease risk of vertical transmission and the need for cesarean delivery.

All reproductive-age women should be current with immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and the CDC. This is the time to draw and document protective titers for rubella, varicella, and hepatitis B and to immunize the susceptible patient. Patients should use contraception for up to 3 months following immunizations with live vaccines. If the woman conceives and is expected to deliver during flu season, she should be counseled to receive the influenza vaccine to decrease disease severity for her. She should be given the tetanus, diphtheria, and pertussis (Tdap) vaccine in late pregnancy (27 to 36 weeks) to provide passive immunity for the newborn.

Genetic and Family History

The time to screen appropriate populations for genetic disease-carrier status and multifactorial congenital malformations or familial diseases with major genetic components is before pregnancy. If patients screen positive, referral for genetic counseling is indicated, and consideration of additional preconception options may be warranted including donor egg or sperm, ART after preimplantation selection, prenatal genetic testing after conception, or adoption (see Chapter 10 ). Certain diseases may be related to race/ethnicity or geographic origin. Patients of African, Asian, or Mediterranean descent should be screened for the various heritable hemoglobinopathies (sickle cell disease, α- and β-thalassemia). Patients of Jewish and French-Canadian heritage should be screened for Tay-Sachs disease, Canavan disease, and cystic fibrosis. In the United States, it has been suggested that cystic fibrosis screening be offered to all couples planning a pregnancy or seeking prenatal testing. Resolution of these issues during the preconception period is much easier and less hurried without the time limits placed by an advancing pregnancy. The age of the father is also important because genetic, structural, behavioral, or cognitive risks to the child may exist when the father is older; this emphasizes the importance of a reproductive life plan for men as well as women.

Substance Abuse and Other Hazards

In the general population, fetal and neonatal exposures to drugs and other toxins are often the consequence of the lifestyle choices of the parents, with exposure to tobacco smoke and alcohol among the most pervasive and easily documented. Smoking and use of alcohol and drugs by pregnant women are all harmful to the developing fetus, but because these substances are often used in combination, teasing apart the specific contributions of each substance to adverse child outcomes can prove difficult when analyzing epidemiologic data (see Chapter 8 ). Overall, the risks to the neonate include IUGR, birth defects, altered neuropsychological behavior, and, for some drugs, withdrawal symptoms. Subsequent behavior, development, and neurologic function may also be impaired by behaviors that occurred during the preconception period. Consideration of socioeconomic inequalities in unplanned pregnancy is important in assessing the impact of a specific toxic substance on the developing fetus, because exposure may precede pregnancy recognition. A U.S. study of reproductive-age nonpregnant women looked at the prevalence of behavioral risk factors individually and in combination. One third of the women had at least one risk factor, and 19% had two or more risk factors, which confirms the opportunity for preconception care to mitigate outcomes.

Screening for Chronic Disease, Optimizing Care, and Managing Medication Exposure

Clear evidence shows that for some conditions—such as diabetes mellitus, phenylketonuria, and inflammatory bowel disease—medical disease management before conception can positively influence pregnancy outcome. Medical management to normalize the intrauterine biochemical environment should be discussed with the patient, and appropriate management plans should be outlined before conception; advice can also be given about avoiding specific medications in the first trimester (e.g., isotretinoin). Table 6-1 gives examples of general health and medical conditions by organ system that can be optimized by preventing pregnancy until it can be planned and then adjusting medication type or dose to minimize teratogenicity or impact on neonatal development.

Components of Prenatal Care

Recent guidelines to address the content and efficacy of prenatal care have focused on the medical, psychosocial, and educational aspects of the prenatal care system. Prenatal care satisfies the definition of primary care from the Institute of Medicine as “integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Prenatal care satisfies other criteria for primary care in that it is comprehensive and continuous and offers coordinated health care. Hence, prenatal care provides additional opportunities to advance wellness and prevention. It is another opportunity to introduce and reinforce habits, knowledge, and life-long skills in self-care, health education, and wellness to inculcate principles of routine screening, immunization, and regular assessment for psychological, behavioral, and medical risk factors. Phelan argues that clinicians are not taking advantage of pregnancy as a “teachable moment”—a naturally occurring life transition that motivates people to spontaneously adopt risk-reducing behaviors. If health and habits are not optimized during the preconception period, pregnancy qualifies as a teachable moment because it meets the following criteria proposed by McBride and colleagues:

• •
  

  Perception of personal risk and outcome expectancies is increased.

  
  
• •
  

  The perceptions are associated with strong affective or emotional responses.

  
  
• •
  

  The event is associated with a redefinition of self-concept or social role.

Education about pregnancy, childbearing, and childrearing is an important part of prenatal care, as are detection and treatment of abnormalities. However, more recently, contemporary models of prenatal and childbirth education have been criticized because research has not shown a strong association between class attendance and childbirth experiences or parenting expectations. In fact, among first-time mothers, a decline in childbirth class attendance has been observed, from 70% in 2002 to 56% in 2005.

High-Tech Versus Low-Tech Care

Historically, the primary goal of prenatal care was to minimize maternal and neonatal mortality. However, new technology has been introduced to assess the fetus antepartum that includes electronic fetal monitoring, sonography, prenatal diagnosis, and other in utero interventions with the fetus emerging as a patient in utero. Prevention of morbidity and mortality is now the goal . This has made the task of prenatal care more complex because mother and fetus now require an increasingly sophisticated level of care. At the same time, pregnancy is basically a physiologic process, and the healthy pregnant patient may not benefit from application of advanced technology; that is, she may receive poor quality care as a result of misuse or overutilization of the health care system.

Prenatal care can be provided at a variety of sites that range from the patient’s home to the physician or midwife’s private office to a public health or hospital clinic. Obstetricians must optimize their efforts by resourceful use of other professionals and support groups that include nutritionists, childbirth educators, public health nurses, nurse practitioners, family physicians, nurse midwives, and specialty medical consultants. Most pregnant women who are healthy and have normal pregnancies can be followed by an obstetric team that includes nurses, nurse practitioners, and nurse-midwives in addition to the obstetrician. These women should be cared for by practitioners who have adequate time to spend on patient education and parenting preparation, while physicians can appropriately concentrate on complicated problems that require their medical skills. This also provides for improved continuity of care, which is recognized as extremely important for patient satisfaction.

No prospective controlled trials have demonstrated the efficacy of prenatal care overall. Two documents that have addressed the content and efficacy of prenatal care have suggested changes in the current prenatal care system. Since publication of these recommendations, several well-designed randomized clinical trials and cost-benefit analyses have been reported using alternative visit schedules. No difference was evident in outcomes for patients who underwent a reduced frequency of visits as measured by rates of PTB and LBW, and the reduced frequency model was shown to be cost effective. Although fewer visits were associated with decreased maternal satisfaction with care, as well as increased maternal anxiety, studies support the concept of reduced antenatal visits for selected women.

Efficacy of prenatal care also depends on the quality of care provided by the caretaker. If a blood pressure is recorded as “elevated,” and no therapeutic maneuvers are recommended, the outcome will remain unchanged. Recommendations must be made and must be carried out by the patient, whose compliance is essential to alter outcome. Using national survey data, Kogan and colleagues reported that women received only 56% of the procedures and 32% of the advice recommended as part of prenatal care content, whereas poor women and black women received even fewer of the recommended interventions. Site of care was also an important determinant, suggesting that infrastructure must be geared to address population-specific needs.

Risk Assessment

The concept of risk in obstetrics can be examined at many levels. All the problems that arise in pregnancy, whether common complaints or more hazardous diseases, convey some risk to the pregnancy depending on how they are managed by the patient and her care provider. Risk assessment has received detailed attention in the past. It has been shown that most women and infants who suffer morbidity and mortality will come from a small segment of those with high-risk factors; by reassessing risk factors before pregnancy, during pregnancy, and again in labor, the ability to identify those at highest risk increases. Most of the emphasis for screening, risk assessment, and associated trials for therapeutic interventions have focused primarily on preeclampsia and PTB prevention. Table 6-2 lists representative examples of other clinical conditions that have been proposed to be included as part of routine screening and risk assessment during the antepartum period since 1989. Although commonly included as part of current routine screening programs, few of these screening programs were implemented as a result of evidence-based criteria, such as those proposed by the U.S. Preventive Services Task Force (USPSTF). Most have been utilized as a result of expert or consensus opinion, cost-benefit, or risk-management decisions.

TABLE 6-2

COMPARISON OF DIFFERENT RECOMMENDATIONS REGARDING VISIT FREQUENCY AND PROPOSED CLINICAL INTERVENTIONS FOR PRENATAL CARE FOR LOW-RISK WOMEN

WEEK OF GESTATION	ACOG 1997	EXPERT PANEL NP WOMAN	EXPERT PANEL MP WOMAN	CLINICAL INTERVENTION
1-4		X	X	Preconception counseling, dating
5-8	X	X	X	Dating
9-12	X	X		Dating; nuchal translucency; serum marker screening for aneuploidy
13-16	X	X	X
17-20	X			AFP/multiple marker screening; ultrasound
21-24	X
25-28	X	X	X	Glucose tolerance test
31-32	X	X	X	Childbirth education, risk assessment
35-36	X	X	X	GBS growth
37	X	X		Risk assessment
38	X	X		Risk assessment
39	X
40	X	X		Risk assessment
41	X	X	X	Postterm evaluation

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