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Preconceptional Health: Who Cares?

Preconceptional Health: Who Cares?. Karla Damus, RN MSPH PhD Ob/Gyn and Women’s Health, AECOM, Bronx, NY Office of the Medical Director March of Dimes Birth Defects Foundation, White Plains, NY kdamus@marchofdimes.com 914 997 4463. Objectives. State the goals of preconcpetion care

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Preconceptional Health: Who Cares?

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  1. Preconceptional Health:Who Cares? Karla Damus, RN MSPH PhD Ob/Gyn and Women’s Health, AECOM, Bronx, NY Office of the Medical Director March of Dimes Birth Defects Foundation, White Plains, NY kdamus@marchofdimes.com 914 997 4463

  2. Objectives State the goals of preconcpetion care Identify the major elements of preconcpeiton care Understand the limitations of the research and science Describe the benefits and challenges of preconception care Learn about the most current national efforts and guidelines

  3. Healthy PeopleThe Road Map to the Nation’s Health • HP2000- Increase the proportion of women receiving appropriate preconceptional care to 60% • HP2010- Removed- unable to measure and track objective

  4. Major March of Dimes Funded Research Polio vaccine PKU Neonatal Intensive Care Unit (NICU) Fetal Alcohol Syndrome Surfactant therapy for RDS Nitric oxide therapy for PPHN PERI Grants PRI Grants

  5. March of Dimes Birth Defects Foundation Mission: • To improve infant health by preventing infant mortality, birth defects, LBW and PTB The Continuum of Reproductive Health • Improving health of infants requires focusing on the entire spectrum of reproductive health from prior to conception through the first year of an infant’s life and throughout the woman’s childbearing years • Preconceptional health is the cornerstone of healthy infants, children, families and communities

  6. Definition of Preconception Care • Preconception care is comprised of biomedical and behavioral interventions that aim to identify and address reversible risks to a woman’s health or pregnancy outcome, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact. • Thus, it is neither a single visit nor all well-woman care. 8/29 DRAFT SUMMARY OF RECOMMENDATIONS TO IMPROVE PRECONCEPTION HEALTH

  7. Definition of Preconception Care • Preconceptional care is an anticipatory process, often facilitated by a care provider, that encourages individuals and couples to seriously consider their decision to become parents. Through this process they become aware that preconception, conception, pregnancy, birth, and childbearing are a continuum in which earlier events affect the present and the future. • This process helps people examine their desire and readiness for parenthood. • Individuals consider their health, age, emotions, support network, finances and career goals as they decide to become parents, to delay parenthood or not to become parents. Wisconsin Association for Perinatal Care Position Statement on Preconceptional Care

  8. Goal of Preconception Care • To reduce the risk of adverse health effects for the woman, fetus, or neonate by optimizing the woman’s health and knowledge before planning and conceiving a pregnancy. • Because reproductive capacity expands almost four decades for most women, optimizing women’s health before and between pregnancies is an ongoing process that requires access to and the full participation of all segment of the health care system. The Importance of Preconception Care in the Continuum of Women's Health Care ACOG Committee Opinion Number 313, September 2005

  9. What is Preconception Care • Counseling about folic acid and prevention of neural tube defects • Education about risks for diabetes, glycemic control and pregnancy outcome • Education to increase awareness of the importance of diet, weight and fitness • Education about the importance of compliance with treatment in women with chronic conditions and when appropriate, obtaining preconceptional genetic counseling • Identification of and help for victims of domestic violence/abuse • Appropriate screening, prevention and treatment of infectious diseases • Education to increase awareness that during the earliest weeks of pregnancy, no level of alcohol and tobacco ingestion is proven safe California Preconception Care Initiative: Every Woman, Every Time

  10. Pre/Interconception/Internatal Care • Readiness for pregnancy (FP) • Optimal management of any medical conditions (diabetes, HBP, asthma, infections, heart disease, depression, addiction ) • Infections and STIs • Immunizations • Family history, genetic counseling, carrier testing • Substance abuse (smoking, alcohol, other drugs) • Domestic violence (DV/IPV) • Stress reduction • Optimal weight and activity • Good nutrition-- folic acid for men and women • Avoid teratogens (work site, environment) • Review all meds and home remedies with hcp

  11. 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 Mean Entry into Prenatal Care Missed Period

  12. Why Preterm Birth? • #1 obstetric challenge in the U.S. • Leading problem in pediatrics • Common, serious, and costly

  13. Preterm Birth/Prematurity • Single most important cause of perinatal mortality in U.S. (about 75% of these losses) • Leading cause of neonatal mortality (0-27 days) in U.S. since 1999 • Second leading cause of infant mortality in U.S. • Leading cause of black infant mortality in U.S.

  14. Preterm Birth/Prematurity • Major determinant of neonatal and infant illness: • Neurodevelopmental handicaps (CP, mental retardation) • Chronic respiratory problems • Intraventricular hemorrhage • Periventricular leukomalacia • Infection • Retinopathy of prematurity • Necrotizing enterocolitis • Neurosensory deficits (hearing, visual)

  15. Birth Weight and Coronary Heart DiseaseBarker Hypothesis Age Adjusted Relative Risk Birthweight (lbs) Rich-Edwards 1997

  16. Birth Weight and Insulin Resistance Syndrome Barker Hypothesis Odds ratio adjusted for BMI Barker 1993 Birthweight (lbs)

  17. Current Definitions • Gestation Length • Premature (preterm delivery, PTD)- < 37 weeks • Early preterm delivery - < 32 weeks • Birth Weight • Low Birth weight (LBW) - < 2500 grams or 5.5 lbs • Very low birth weight - (VLBW) < 1500 grams or 3.3 lbs • Growth Restriction • < 10th percentile for gestational age • IUGR - intrauterine growth restricted applies to fetuses • SGA - small for gestational age applies to neonates

  18. www.marchofdimes.com/peristats

  19. Preterm Birth RatesUnited States, 1983, 1993, 2003 Percent Percent HP 2010 Objective 28% Increase Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2004

  20. Distribution of Live Births by Gestational Age United States, 1990 and 2001 1990 Live Births n = 4,111,396* 2001 Live Births n = 3,986,102* Not Preterm (89.4%) Not Preterm (88.4%) Moderately Preterm (8.7%) Very Preterm (1.9%) Moderately Preterm (10.0%) Very Preterm (1.9%) Total Preterm = 10.6% Total Preterm = 11.9% * Note: Live births with missing gestational age data were excluded from the analysis. Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2003

  21. Distribution of Preterm Births by Gestational Age, US, 2002 (<32 Weeks) “Near term infants had significantly more medical problems and increased hospital costs compared with contemporaneous full term infants Near term infants may represent an unrecognized at-risk neonatal population.” Wang, et al. Clinical Outcomes of Near-Term Infants, Pediatrics (114) 372-6, 2004. (36 Weeks) (32 Weeks) (33 Weeks) ~60% of PTB 35 - 36 weeks (34 Weeks) (35 Weeks) Source: National Center for Health Statistics, 2002 natality file Prepared by the March of Dimes Perinatal Data Center, 2004

  22. TYPE of Preterm Birth Spontaneous Preterm Labor 50% Spontaneous Premature Rupture of the Membranes 25-30% Preterm Birth 25-30% Iatrogenic (Medical Indication) While this suggests distinct pathways, many of the risk factors for all 3 are similar

  23. PLURALITYPreterm and Low Birthweight Births By Plurality, United States, 2002 Percent Higher Order Higher Order Twins Twins Singleton Singleton Preterm is less than 37 weeks gestation Low birthweight is less than 2500 grams or 5 1/2 pounds Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2002

  24. MATERNAL AGEPreterm Births by Maternal AgeAmong Singletons, US, 1990 and 2001 Percent Source: National Center for Health Statistics Prepared by March of Dimes Perinatal Data Center, 2004

  25. RACE ETHNICITYPreterm Birthsby Race/Ethnicity, US, 1990 and 2001 Percent People of Hispanic ethnicity may be any race; all other categories are non-Hispanic Source: National Center for Health Statistics Prepared by March of Dimes Perinatal Data Center, 2004

  26. Infant MortalityUnited States, 1915-2002 Rate per 1,000 live births Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2002

  27. Unexpected findings- most of increase due to: • non Hispanic white • >30 years • married • >high school • onset PNC first trimester • nonsmoker • private insurance www.cdc.gov/mmwr

  28. Three Leading Causes of Infant MortalityUnited States, 1990and 2002 Rate per 100,000 live births Source: National Center for Health Statistics Prepared by March of Dimes Perinatal Data Center, 2004

  29. Leading Cause-specific IMR and % ChangeUnited States, 2001 and 2002 Rates are per 100,000 live births

  30. Risk Factors for Preterm Labor/Delivery • The best predictors of having a preterm birth are: • current multifetal pregnancy • a history of preterm labor/delivery or prior low birthweight • mid trimester bleeding (repeat) • some uterine, cervical and placental abnormalities • Other risk factors: • low pre-pregnant weight • obesity • infections • bleeding • anemia • major stress • lack of social supports • tobacco use • illicit drug use • alcohol abuse • folic acid deficiency • multifetal pregnancy • maternal age (<17 and >35 yrs) • black race • low SES • unmarried • previous fetal or neonatal death • 3+ spontaneous terminations • uterine abnormalities • incompetent cervix • genetic predisposition

  31. Folic Acid Deficiency • Predisposes to: • NTDs • Other birth defects (cleft lip/palate, cardiac, limb reduction, urinary tract, omphalocele, trisomies) • Early and recurrent pregnancy loss • Low birth weight and prematurity • Gestational hypertension, preeclampsia in Black women • Atherosclerotic vascular disease (stroke, CAD) • Colorectal and cervical cancer • Acute Lymphocytic Leukemia • Alzheimer’s Disease

  32. Folic Acid Recommendations Prevent Recurrence, 1991 • All women with a previous NTD pregnancy should take 4 mg or 4000mcg interconceptionally Prevent Occurrence, USPHS September, 1992 • All women of childbearing potential should consume 0.4 mg (400 micrograms) of folic acid daily Food & Nutrition Board of IOM, 1998 • Men (14 yr & older) 400 µg any source • Women (14 yr & older) 400 µg synthetic + food • Pregnancy 600 µg synthetic + food • Lactation 500 µg any source

  33. Folic Acid Knowledge and Behavior1995 and 2004 Percentage of women ages 18-45

  34. Things Women Reported Might Encourage them to Take a Multivitamin DailyMarch of Dimes Folic Acid Survey, 2003

  35. Perceived Benefits of Folic Acid Q. 14 “Please tell me whether each statement is true or false, or if you are not sure.” Note: Correct responses are outlined.

  36. When Do Physicians Recommend Multivitamins/Folic Acid? Q. 15 “In your practice, do you always, usually, occasionally, or never recommend multivitamins or folic acid supplementation:…?”

  37. Prevention or Well-Woman Care • Only about one-half of the physicians generally bring up folic acid (or multivitamins) during an annual exam • Patients are not likely to bring up the issue of folic acid on their own, and physicians perceive that patients have only moderate compliance levels when advised to take folic acid or multivitamins • Physicians suggest that “some doctors” may not address folic acid with their patients primarily due to lack of knowledge about folic acid, and lack of time during the exam • Survey responses suggest that folic acid is not high on physicians’ priority list, in light of all the other preventive issues they need to address with patients

  38. Perceived Recommended PreconceptionalFolic Acid Dose for NTD Patients Q. 21 “To the best of your knowledge, what is the recommended preconceptional daily dose of folic acid for women who have had a pregnancy affected by NTD?”

  39. Mean serum and red blood cell folate levels, before and after folic acid fortification, NHANES women aged 15-44 years ng/mL ng/mL Serum folate Red blood cell folate 20 350 265.5 300 15 250 12.8 200 163.0 10 150 5.0 100 5 50 0 0 1988-1994 1999-2000 1988-1994 1999-2000 SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys, 1988-94 and 1999-2000

  40. DAILY Take the Good Acids • Folic acid (at least 400 mcg) • Vitamin B9 • Ascorbic acid • Vitamin C • Omega 3 fatty acid

  41. Factors that Contribute to Increasing Rates of Preterm Birth • Increasing rates of births to women 35+ years of age • Independent risk of advanced PATERNAL age • Increasing rates of multiple births • Indicated deliveries • Induction • Enhanced management of maternal and fetal conditions • Patient preference/consumerism (section on demand) • Substance abuse • Tobacco • Alcohol • Illicit drugs • Bacterial and viral infections • Increased stress (catastrophic events, DV, racism)

  42. Multiple Birth Ratios by Maternal RaceUnited States, 1980-2002 Ratio per 1,000 live births Source: NCHS, final natality data, 1980-2001 Prepared by March of Dimes Perinatal Data Center, 2003

  43. Higher-Order Multiple Birth RatiosBy Maternal Race, United States, 1980-2002 Ratio per 100,000 live births Source: NCHS, final natality data, 1980-2002 Prepared by March of Dimes Perinatal Data Center, 2004

  44. Proportion of Preterm Births by PluralityUnited States, 1992 and 2002 Percent of preterm births 40% increase in the proportion of multiple preterm births from 1992 to 2002 % Multiple Births 2.4% 3.3% Source: National Center for Health Statistics. Prepared by March of Dimes Perinatal Data Center, 2004.

  45. Total and Primary Cesarean and VBAC Rates United States, 1989-2002

  46. Singleton Preterm Births by Delivery Method United States, 1990 and 2001 Percent Source: National Center for Health Statistics Prepared by March of Dimes Perinatal Data Center, 2004

  47. Perinatal Impact of Substance Abuse • There are many direct and indirect adverse perinatal outcomes associated with substance abuse • Substance use (smoking, alcohol, illicit drugs and abuse of prescription drugs) is associated with many adverse reproductive and perinatal outcomes including: infertility, unintended pregnancy, STIs, miscarriage, fetal death, birth defects, developmental disabilities, PROM, placental abruption, preterm birth, low birthweight, infant mortality, SIDS

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