Immigrant and Refugee Populations
Given the opportunistic fashion in which preconception care of immigrant and refugee women typically occurs, it is important to consider preconception concerns as part of all health care encounters with such women of reproductive age. Referring immigrant and refugee women to a source of ongoing primary care that is culturally and linguistically competent, and that will accept their insurance coverage or provide care free of charge or on a sliding-scale basis, is important for all such women. It is also important that health care providers identify and understand the needs of immigrant women and their families; understand immigrants' potential for increased medical and social risks and previously undetected medical problems; deliver services and written materials in the preferred language of the population served; ensure that interpretation and translation services comply with all relevant federal, state, and local mandates governing language access; integrate preconception care into refugee screening; work with ethnic community-based organizations to provide preconception care messages in non–health care settings (such as English as a Second Language classes); screen immigrants at high risk for tuberculosis and refer them for treatment as indicated; screen immigrants born in Asia, the Pacific Islands, Africa, and other countries where hepatitis B is highly endemic with the hepatitis B surface antigen test; assess the immunization history, including the rubella status, of immigrant women and administer any needed vaccines, or refer the women for these services; and assess the mental health of immigrant women and refer them for services as needed.
Survivors of Cancer
Women and men newly diagnosed with cancer should be educated about fertility preservation options as soon as feasible and should be referred to reproductive specialists if these options are desired, and if time allows. Survivors of cancer should be counseled about the potential reproductive effects of various cancer treatments on fertility and on pregnancy. Women who have received alkylating chemotherapeutic agents or pelvic or abdominal radiation, or both, should be counseled that they have an increased risk for premature ovarian failure. Women who have had pelvic or abdominal irradiation should be counseled that they are at risk for having a low birthweight infant. When considering pregnancy, survivors of breast cancer who are candidates for selective estrogen receptor modulators should be counseled that these agents generally are avoided during pregnancy because of case reports of animal and human birth defects. A reliable nonhormonal contraceptive method should be used during treatment with a selective estrogen receptor modulator. Genetic counseling and testing should be offered to survivors of cancers that are linked to genetic mutations to inform their decisions about future reproduction. Female survivors of cancer who received anthracycline chemotherapy or radiation to the heart or surrounding tissues, or both, should be evaluated by a cardiologist before conception. Annual breast screening for female survivors of childhood cancer who received chest radiation is recommended beginning at age 25 years.
Women With a Disability
Any woman with a disability should receive counseling about the risks of any medications that she uses and about her options to alter dosage or switch to safer medications before conception. The medical, social, and psychologic issues that are related to pregnancy and the disability should be assessed, and the woman and her family should be counseled about them. Health care providers should offer any woman with a disability contraceptive choices that are practical and appropriate for her medical and personal needs. Issues that involve informed consent and guardianship must be addressed when caring for women with a developmental disability in relation to contraception and pregnancy. Referral for genetic counseling, if appropriate, is indicated for all women before conception; however, it might raise difficult psychosocial issues for women with a disability; therefore, counseling referrals should be handled sensitively.
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