Merry-K. Moos, RN, FNP ( retired), MPH, FAAN 3.0 contact hours

1. Preconception Health Promotion:The Foundation for a Healthier Tomorrow Merry-K. Moos, RN, FNP (retired), MPH, FAAN 3.0 contact hours Note: To use the links in this module it must be in Slide Show view. See slide 4 for instructions.

2. Accreditation March of Dimes Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. The March of Dimes also is approved by the California Board of Registered Nursing, Provider #CEP11444. 3.0 contact hours are available for this activity through November 1, 2014. CNE credit may be extended past this date following content review and/or update. Visit marchofdimes.com/nursingfor up-to-date information on all of our CNE activities.

3. Author bio and disclosure Merry-K. Moos, BSN, MPH, FAAN Until her retirement, Merry-K. Moos was a professor in the Department of Obstetrics and Gynecology, and adjunct professor in both the Schools of Public Health and Nursing at the University of North Carolina at Chapel Hill. She is a researcher, author and clinician who is nationally and internationally recognized for her expertise in preconceptional and interconceptional health and health care. She and her colleague, Robert Cefalo, wrote the first book on preconceptional health in the United States in 1988; it, as well as her other related publications, have served as a platform for change in the delivery of reproductive health care in this country. Ms. Moos remains active in developing and promoting strategies to advance preconception health care in the United States and beyond. Disclosure: Merry-K. Moos is Lead Nurse Planner for the March of Dimes Foundation; She has no financial, professional or personal relationships that could potentially bias the content of this module.

4. Navigation and links Open the Slide Show view The module must be in the Slide Show view for the navigation buttons and links to work. Depending on your computer settings and software, there are several ways to do this: • Click the small slide show button ( ) next to the zoom slider on the bottom right hand corner of the PowerPoint screen. • Press the F5 key. • Click Slide Show on the PowerPoint ribbon at the top of the page. Then click View Show or From Beginning. Use the navigations buttons and links • Click the purple buttons at the bottom of each slide to move around within the module. • Click the links on the Contents page to: • See the Guidelines and References • Print the module (PDF) • Take the continuing education test

5. Contents

6. This module is designed for registered nurses who interact with women of childbearing age before and after pregnancy and between pregnancies. It reviews the rationale for moving away from prenatal care as the principle approach to preventing poor pregnancy outcomes to an approach that encompasses a woman’s health before conception. The module examines the link between a woman’s health habits and risks and how they correspond to known risks for a pregnancy and neonate. The module includes evidence-based strategies for addressing key risks before pregnancy to help nurses provide meaningful preventive care throughout the life course of women and their offspring. Module purpose

7. After studying this module, the nurse will be able to: Explain the rationale and history of the preconception health movement Identify preconception influences on women’s health and pregnancy outcomes and identify appropriate evidence-based clinical care recommendations Describe a framework for incorporating preconception care into clinical practice Module objectives

8. Objective 1: Explain the rationale and history of the preconception health movement

9. Preconception vocabulary • Preconception: A woman’s (or man’s) health status and risks before a first pregnancy and subsequent pregnancies. Often used as a synonym for interconception (Moos, 2006; Moos et al., 2010). • Interconception: The period between the end of one pregnancy and the conception of the next pregnancy. The interconception period must be treated as an open-ended timeframe because it only can be accurately defined after the next conception has occurred (Moos et al., 2010). • Preconception health promotion: Includes, but is not limited to, clinical care, because many influences interact to support or undermine high levels of wellness in individuals of childbearing age. Influences include family and community relationships, environmental exposures in the workplace and public policies (Moos et al., 2010). • Periconception: The maternal health status and risks around the time of conception through the period of organogenesis (Moos, 2006).

10. Rationale for preconception health promotion Historically, prenatal care has been the dominant approach to preventing poor pregnancy outcomes in the United States. Over the last 30 years, limitations of this approach have been identified: • Important influences on pregnancy outcomes predate conception (Table 1). • Prenatal care starts too late to offer primary prevention for many poor outcomes. • Prenatal care often starts too late and offers too little to eliminate risks associated with the life circumstances of socially disadvantaged populations. There is no evidence that a medical model directed at a 6- to 8-month interval in a woman’s life can erase years of social, economicand emotional distress and hardship (Dillard, 2004).

11. Rationale for preconception health promotion • Some poor pregnancy outcomes, including spontaneous abortions and congenital anomalies (birth defects), have already occurred before the first prenatal visit. • The period of organogenesis (when organs are formed) begins just 3 days after the first missed menstrual period. • Organogenesis is complete around the 56th day after conception: 8 weeks by conception date and 10 weeks by menstrual date. • Most women are not aware they are pregnant by 3 days after the first missed menses. Many pregnant women do not start prenatal care until organogenesis is complete. • Birth defects account for 20 percent of all infant deaths in the United States, making them the leading cause of infant mortality (March of Dimes, 2011d). Beyond death, birth defects are a major contributor to lifelong disabilities. Approximately 3 percent of all infants born each year have a birth defect.

12. The preconception movement in the United States

13. The preconception movement in the United States

14. The preconception movement in the United States

15. CDC Select Panel on Preconception Care and Health Care The CDC Select Panel (2006) put forth four goals (Table 3), 10 recommendations and more than 50 action steps for the preconception initiative. It also made recommendations relevant to nurses’ involvement in preconception health services (Table 4).

16. CDC Select Panel on Preconception Care and Health Care A complete list of recommendations and action steps is available at www.beforeandbeyond.com under the tab “Key Articles and Guidance.”

17. CDC Select Panel on Preconception Care and Health Care • Recognizing that multiple pathways are needed to change longstanding but inadequate approaches to prevention, the CDC Select Panel created five multidisciplinary workgroups (Table 5). The workgroups include nurses in leadership and membership roles who represent nursing organizations, including the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), the American College of Nurse Midwives (ACNM) and national organizations committed to the work of nurses, like the March of Dimes. • The Clinical Workgroup (CWG), likely to be of particular interest to nurses, has undertaken several important initiatives (Table 6).

18. Emerging paradigms for preventive health care Complementing and, in part, stimulated by the national preconception movement, are two emerging paradigms for reframing opportunities for prevention for women and their offspring: • Women’s preventive health framework • The life course framework • Something to think about… How early in the life cycle do determinants of poor health and poor pregnancy outcomes begin to exercise their influences?

19. Women’s preventive health framework: Overview • Delivery of women’s health care services in the United States relies on a series of relatively distinct service silos. These silos separate a woman’s pregnancy-related care from her nonperinatal care. The non-perinatal care is further compartmentalized into reproductive and non-reproductive foci (Moos, 2009). • It is common, for example, for the contraception needs of a woman with type 2 diabetes mellitusnot to be acknowledged by her endocrinologist; her glycemic control issues to be overlooked by her family planning provider; and her risks for poor pregnancy outcomes to be ignored until her first and subsequent prenatal visits. • The women’s preventive health framework is built upon appreciation that the major determinants of poor health status in women are important risk factors for poor pregnancy outcomes (Table 7). • “The nation’s approach to the clinical care ofwomen is fragmented, inefficient, and, too often, incomplete and ineffective.”— Moos, 2009, p.427

20. Women’s preventive health framework: Overview

21. Women’s preventive health care strategies • Because healthy women have healthier pregnancies, preventive care has the potential to result in healthier women, healthier pregnancies and healthier pregnancy outcomes (Moos, 2009). • Nurses and others in the health care field must shift their paradigm from a singular focus on the pregnant woman and fetus to a wider frame that encompasses the total health needs of the adolescent, woman and mother (Verbiest & Holliday, 2009). • “Opportunistic” approach to prevention • Impacting a woman’s health status across her life-span benefits from incorporating health promotion and disease prevention strategies into every health care encounter (Moos, 2006; Moos, 2009). • California’s Every Woman, Every Time campaign(Cullum, 2003) became a model for encouraging opportunistic care in other states. • “If we hope to achieve better pregnancy outcomes, we must change the way we provide maternal and child health (MCH) services and add the ‘W’oman into MCH.” • — Atrash et al., 2008, p.S264

22. The life course framework: Overview • Traditionally, birth outcomes and disparities in outcomes have been explained by what happens during pregnancy (e.g., preterm labor, infections); harmful influences during pregnancy (e.g., cigarette smoking, food insecurity); and differing exposures to protective factors (e.g., social support, utilization of prenatal care). • Lu & Halfon (2003) propose the life course framework. This suggests: • Protective and harmful influences across the lifespan are key determinants of an individual’s health status. • Imbalances in these influences across different population groups are critical to understanding and addressing racial, ethnic and socioeconomic disparities. • Influences include, but are not limited to, physical, social, psychological and economic variables. • Protective and harmful exposures are likely to have an intergenerational influence on health status so that the influences experienced by grandparents, for instance, may explain health challenges of the grandchildren.

23. The life course framework: Models Lu and Halfon (2003) summarize two models that explain the impact of the life course on women’s health and pregnancy outcomes: • Early programming model • Early life exposures and experiences during particularly sensitive periods of development (including in utero) encode the functions of organs or organ systems that will influence health status throughout an individual’s lifetime. This is sometimes referred to as the “womb to tomb” model. • David Barker (1990) suggests the relationship between fetal exposures and the lifelong likelihood of developing chronic disease in research on coronary heart disease; his work on fetal and infant origins of adult disease is known as the Barker Hypothesis. • Cumulative pathways model—Chronic accommodation to stress results in wear and tear on the body’s adaptive systems (often called allostatic load), affecting health status over the life course (Lu, 2010).

24. Objective 2: Identify preconception influences on women’s health and pregnancy outcomes and identify appropriate evidence-based clinical care recommendations

25. Key preconception influences ACOG (2005, 2007) identifies the following assessments as a basis for preconception care: • Family planning and pregnancy spacing (interpregnancy intervals [IPIs]) • Family history • Genetic history • Medical, surgical, psychiatric and neurologic histories • Current medication exposures • Substance use • Domestic abuse and violence • Nutrition • Environmental and occupational exposures • Immunity and immunization status • OB/GYN history • Assessment of socioeconomic, educational and cultural status • Something to think about… • How can the nurse know what specific information and services to provide? • Principles of evidence-based care can help.

26. Incorporating evidence-based preconception care into practice • In December 2008, the CWG of the CDC Select Panel released recommendations for theClinical Content of Preconception Care (Jack & Atrash, 2008). • The procedure used by the CWG is similar to the steps used by the U.S. Preventive Services Task Force (USPSTF) (1996) in the development of its prevention recommendations. • The CWG procedure involved: • Conducting a literature review of more than 200 health topics related to preconception care • Assessing whether or not the composite research related to a topic suggests or proves there are benefits to addressing that topic before pregnancy • Assigning a specific recommendation to each topic based on the likely advantage to pregnancy outcomes if the topic is addressed before pregnancy

27. Assigning recommendations based on the evidence Using the framework employed by the USPSTF to rate the evidence around a specific topic, the CWG assigned a letter grade to each of the 200 preconception clinical topics it reviewed. The grade helps providers determine the likely benefits of addressing a specific influence during the preconception period (Table 8).

28. Quality of the research • While specific clinical recommendations shouldbe the result of strong research designs, this is not always possible. For example, the most powerful experimental designs (randomized clinical control trials) often are inappropriate or unethical when determining the impact of an intervention on reproductive outcomes. • Using the USPSTF framework to assess the strength of the sciencebehind specific recommendations, the CWG assigned a grade to the total body of research for each of the 200 preconception influences. These grades helps clinicians appreciate the research foundations for specific recommendations (Table 9). • Something to think about… Why might it be unethical to conduct a randomized trial involving pregnant women?

29. Quality of the research

30. Clinical emphases of preconception care Translating the CWG recommendations into clinical care can be divided into three main clinical emphases (Table 10). Nurses should consider the relevance of each emphasis for every woman at each encounter.

31. Opportunities for nurses • The next several slides provide illustrations of incorporating selected preconception health topics into nursing care. Each illustration: • Builds upon one of the three clinical emphases • Presents background information on the topic’s significance to the health of the woman and, should the woman become pregnant, her pregnancy and future offspring • Includes the strength of the CWG’s recommendation and the quality of the research supporting it • More information on these and additional preconception topics is available at: www.beforeandbeyond.org (go to the “Key Articles and Guidance” tab).

32. Providing protection: Nutrition/Overweight Statement of the problem • In 2009, 52.9 percent of women age 18 to 44 in the United States were identified as overweight (having a body mass index [BMI] >25) (Reinold et al., 2011). Many of these women proceed to obesity during and beyond their reproductive years. • In 2010, 25.1 percent of women age 18 to 44 in the United States had a BMI of at least 30, which is the threshold for defining obesity (March of Dimes, 2011c). • Obesity affects a woman’s health in a myriad of ways, and maternal obesity is associated with numerous pregnancy risks (Table 12).

33. Providing protection: Nutrition/Overweight

34. Providing protection: Nutrition/Overweight Potential benefits of preconception care Weight loss is contraindicated in pregnancy; therefore, risk reduction must occur before conception. Specific recommendations for providers (Gardiner et al., 2008; Moos et al., 2008) • Calculate a woman’s BMI annually. • Counsel women with BMI >25 about the risks, including infertility, for exceeding the overweight category for their own health and for future pregnancies. • Offer women specific behavioral strategiesto decrease caloric intake and increase physical activity. Encourage women to consider enrolling in structured weight loss programs.

35. Providing protection: Nutrition/Underweight Statement of the problem • In 2009, 4.5 percent of women who became pregnant were under-weight (BMI <18.5) (Reinhold, 2011). Because this rate is based on pregnancy and excludes all women who developedinfertility due to their weight, it does not reflectthe magnitude of low BMI on reproductive health. • In a study of adolescent female athletes, 18.2 percent met the criteria for disordered eating: 23.5 percent had menstrual irregularities and 21.8 percent had low bone mass, two known results of low BMI (Nichols et al., 2006). • Low BMI is associated with women’s general health risks and pregnancy complications (Table 13).

36. Providing protection: Nutrition/Underweight Potential benefits of care before pregnancy Infertility, poor pregnancy outcomes and lifelong morbidities can be reduced by addressing low BMI before conception. Specific recommendations for providers (Gardiner et al., 2008; Moos et al., 2008) • Calculate BMI for all women at least annually. • Counsel women who are near the underweight weight status about short- and long-term risks of low BMI, including infertility, to their own health and the health of future pregnancies. • Assess women with a low BMI (<18.5) for eating disorders and distortions of body image. • If needed, refer women who are unwilling to consider and achieve weight gain for further evaluation of eating disorders.

37. Providing protection: Folic acid Statement of the problem • Neural tube defects (NTDs) are serious birth defects of the spine (spina bifida) and brain (anencephaly). They are among the most common birth defects in the United States. Approximately 1 in every 1,000 pregnancies is complicated by an NTD (USPSTF, 2009.) • A clear association exists between maternal folate levels and the occurrence of NTDs. This association provides opportunity for the primary prevention of NTDs (CDC, 1992). • Because the neural tube forms during the first weeks of gestation and before most women have entered into prenatal care, a preconception orientation to prevention is necessary to decrease the incidence of NTDs.

38. Providing protection: Folic acid Potential benefits of care before pregnancy • Daily supplementation of 400 mcg of folic acid prior to conception and throughout the first trimester of pregnancy has been reported to reduce the risk of NTDs by 50 to 80 percent (CDC, 1992). • Randomized trials in settings without grain fortification suggest that a multivitamin with 800 mcg of folic acid reduces the risk of NTDs (USPSTF, 2009). • Possible additional benefits of folic acid supplementation on pregnancy outcomes include a reduction in the risk of spontaneous preterm birth (Bukowski et al., 2009; Czeizel et al., 2010) and oral cleft birth defects (Johnson & Little, 2008). Additional studies are needed. • Some evidence exists that folic acid supplementation positively impacts other areas of women’s health, including risk of stroke, cancer and dementia (Gardiner et al., 2008). Findings are inconsistent. • The likelihood that folic acid supplementation masks the symptoms of pernicious anemia are minimal given the prevalence of this disease in women of reproductive age.

39. Providing protection: Folic acid Specific recommendation (Moos et al., 2008; USPSTF, 2009) • Women planning pregnancy or capable of becoming pregnant should consume 400 to 800 mcg of folic acid daily from fortified foods and/or supplements, and eat a balanced, healthy diet of folate-rich food (Table 14). • Supplements can be over-the-countermultivitamins or a supplement of only folic acid. • In the United States, foods fortified with folic acid include enriched grains (wheat flour and corn meal), cereals and juices. • The recommendation is not new. The CDC released the first national recommendation in 1992. It stated that all women of childbearing age in the United States who are capable of becoming pregnant should consume 400 mcg of folic acid daily to decrease the risk of a pregnancy affected by an NTD (CDC, 1992).

40. Providing protection: Folic acid Follow up Since 1995, the March of Dimes has commissioned Gallup surveys to assess women’s awareness and behavior relative to folic acid. After nearly 20 years, progress in women’s understanding and adoption of the routine use of folic acid has been disappointing (Table 15). • Something to think about… • Why has progress been slow in women adopting the practice of taking a multivitamin containing folic acid? • What can be done to improvethe situation?

41. Providing protection: Preventing unintended pregnancies Statement of the problem • Forty-nine percent of pregnancies in the United States are identified by women as unintended (unwanted or mistimed) (Finer & Henshaw, 2006). Of these pregnancies: • Forty-four percent end in birth. • Forty-two percent end in abortion. • Fourteen percent end in fetal loss. • Everyone who has sexual intercourse is at risk for an unintended pregnancy because there is no perfect contraceptive, including sterilization (Trussell, 2007). • Forty-eight percent of unintended pregnancies occur in a month in which a couple used some method of contraception (Finer & Henshaw, 2006). • Something to think about… • What is a practice-based, a community-based and a policy-based strategy that could decrease unintended pregnancies for the women and families you serve?

42. Providing protection: Preventing unintended pregnancies Statement of the problem (continued) • Although the rate of unintended pregnancy is declining for adolescents (ages 15-17), it is increasing for nearly all other groups (Finer & Zolna, 2011) and is associated with negative consequences (Table 16).

43. Providing protection: Preventing unintended pregnancies Potential benefits of care before pregnancy • Primary prevention of unintended pregnancy can only occur before a pregnancy is conceived. All health care visits before pregnancy offer opportunities to educate women (and men) about the advantages of making deliberate decisions regarding future conceptions (Moos, 2010). Specific recommendations for providers (Moos et al., 2008) • As part of routine health promotion activities, screen women for their short- and long-term pregnancy intentions and their risk of conceiving, whether intended or not. • Encourage all patients to consider areproductive life plan (Table 17) and educate themabout how their plan impacts contraceptive and medical decision-making. The CDC Select Panel (2006) endorses use of reproductive life plans. Reproductive life plans offer women and men the opportunity to consider personal goals and values in context with childbearing.

44. Providing protection: Preventing unintended pregnancies

45. Providing protection: Avoiding short interpregnancy intervals (IPIs) Statement of the problem • IPI is generally defined as the amount of time between the delivery date of a liveborn or stillborn infant and conception of the next pregnancy. • A meta-analysis of 67 articles studying the impact of IPIs determined that intervals <18 months and >59 months are significantly associated with poor pregnancy outcomes (Table 18) (Conde-Agudelo, Rosas-Bermudez & Kafury-Goeta, 2006). • The study suggests that IPIs <6 months and >59 months increase the risk of fetal and early neonatal death. • For each month the IPI is <18 months, the risk for poor outcomes increases; for each month the IPI increases beyond 59 months, risks become greater.

46. Providing protection: Avoiding short IPIs Statement of the problem (continued) • While it is common to suggest that poor outcomes associated with short IPIs are due to influences such as socioeconomic status, inadequate use of health care services, and greater use of tobacco, alcohol and other substances, the study found that controlling for these influences does not significantly alter the findings. Potential benefits of care before pregnancy • Decrease risks for poor pregnancy outcomes • Increase likelihood that women and their partners have the information needed to make informed decisions about the timing of future pregnancies Specific recommendations for providers • Educate women about the importance of appropriate IPI. • Guide women on contraceptive choices. • Encourage women to make reproductive life plans and, when appropriate, to discuss them with sexual partners.

47. Providing protection: Immunizations Statement of the problem (Coonrod et al., 2008) • Many vaccine-preventable diseases have serious consequences for the pregnant woman, the fetus and the neonate. Among these are vaccines that: • Protect the fetus from congenital infections (e.g.,varicella) • Prevent perinatal transmission of infection (e.g., hepatitis B) • May prevent premature birth (e.g., vaccines that prevent human papillomavirus [HPV] infections) • Protect against severe neonatal disease (e.g., varicella, pertussis and tetanus) • Increase the likelihood of life-threatening complications for a woman during pregnancy (e.g., varicella and influenza) • To provide protection, some vaccines (e.g., varicella and rubella) must be administered in the preconception period because they are contraindicated in pregnancy (Table 19).

48. Providing protection: Immunizations

49. Providing protection: Immunizations Potential benefits of care before pregnancy • Assuring that every woman is immune to rubella prior to conception can eliminate congenital rubella syndrome; because the rubella immunization involves a live virus, it cannot safely be administered during pregnancy. • Routine assessment of infections, risks and administration of indicated immunizations canprevent avoidable infections before, during and after pregnancy and can provide protection to the fetus and neonate. • HPV immunization may reduce a woman’s risk of premature birth because procedures used to treat HPV and cervical cancer have been associated with cervical incompetence. These procedures include cone biopsies and loop electrosurgical excision procedures (LEEP) (Coonrod et al., 2008). • Something to think about… • How do immunizations fit into the life course framework?

50. Providing protection: Immunizations Specific recommendations for providersabout immunizationstatus (Coonrod et al., 2008; Moos et al., 2008) • Review the immunization status of all women of reproductive age for • Tetanus-diphtheria toxoid/diphtheria-tetanus-pertussis • Measles, mumps and rubella • Varicella • Assess all women annually for lifestyle and occupational risks for infection and offerwomen indicated immunizations. Specific recommendations for providers about HPV-associated abnormalities • Routinely screen all women for cervical cancer adhering to the latest guidelines (USPSTF, 2012). The CDC (2010, 2011b) recommends that all 11 to 12 year old girls and boys receive three doses of the HPV vaccine. The vaccine can be administered safely and effectively to girls and boys from 13 to 26 who do not receive or complete the series. • The vaccine decreases the incidence of HPV-related cervical abnormalities in women and oropharyngeal and anal cancers in men.