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Recommendations to Improve Preconception Health and
Health Care --- United States
A Report of the CDC/ATSDR Preconception Care Work Group and the
Select Panel on Preconception Care
Kay Johnson, MPH1, Samuel F. Posner,
PhD2, Janis Biermann, MS3, José F. Cordero,
Hani K. Atrash, MD4, Christopher S. Parker,
PhD4, Sheree Boulet, DrPH4, Michele G. Curtis,
1Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
2Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
3March of Dimes, White Plains, New York
4Office of the Director, National Center on Birth Defects and Developmental Disabilities, CDC
5American College of Obstetricians and Gynecologists, Washington, DC
The material in this report originated in the National Center on Birth Defects and Developmental Disabilities, José F. Cordero, MD, Director; and
the Office of Program Development, Hani K. Atrash, MD, Associate Director; and the National Center for Chronic Disease Prevention and
Health Promotion, Janet Collins, PhD, Director, and the Division of Reproductive Health, John Lehnherr, Director.
Corresponding preparer: Samuel F. Posner, PhD, Division of Reproductive Health, National Center for Chronic Disease Prevention and
Health Promotion, 4770 Buford Hwy., NE, MS K-20, Atlanta, GA 30341. Telephone: 770-488-5200; Fax: 770-488-6450; E-mail:
This report provides recommendations to improve both preconception health and care. The goal of these recommendations
is to improve the health of women and couples, before conception of a first or subsequent pregnancy. Since the early
1990s, guidelines have recommended preconception care, and reviews of previous studies have assessed the evidence for
interventions and documented the evidence for specific interventions.
CDC has developed these recommendations based on a review of published research and the opinions of specialists from
the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. The 10 recommendations in
this report are based on preconception health care for the U.S. population and are aimed at achieving four goals to 1) improve
the knowledge and attitudes and behaviors of men and women related to preconception health; 2) assure that all women
of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health
promotion, and interventions) that will enable them to enter pregnancy in optimal health; 3) reduce risks indicated by a previous
adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health
problems for a mother and her future children; and 4) reduce the disparities in adverse pregnancy outcomes.
The recommendations focus on changes in consumer knowledge, clinical practice, public health programs,
health-care financing, and data and research activities. Each recommendation is accompanied by a series of specific action steps
and, when implemented, can yield resultswithin 2--5 years. Based on implementation of the recommendations, improvements
in access to care, continuity of care, risk screening, appropriate delivery of interventions, and changes in health behaviors of
men and women of childbearing age are expected to occur. The implementation of these recommendations will help
achieve Healthy People 2010 objectives. The recommendations and action steps are a strategic plan that can be used by
persons, communities, public health and clinical providers, and governments to improve the health of women, their children, and
their families. Improving preconception health among the approximately 62 million women of childbearing age will
require multistrategic, action-oriented initiatives.
Improving preconception health can result in improved reproductive health outcomes, with potential for reducing
societal costs as well (1--4). Preconception care aims to promote the health of women of reproductive age before conception
and thereby improve pregnancy-related outcomes
(5--7). Therefore, the goals of the 10 recommendations in this report are
to improve a woman's health before conception, whether before a first or a subsequent pregnancy. The recommendations are
1) individual responsibility across the lifespan, 2) consumer awareness, 3) preventive visits 4) interventions for identified
5) interconception care, 6) prepregnancy checkup, 7) health insurance coverage for women with low incomes, 8)
public health programs and strategies, 9) research, and 10) monitoring improvements.
Since 1996, progress in the United States to improve pregnancy outcomes, including low birthweight, premature birth,
and infant mortality has slowed, in part, because of inconsistent delivery and implementation of interventions before pregnancy
to detect, treat, and help women modify behaviors, health conditions, and risk factors that contribute to adverse maternal
and infant outcomes (8). This report discusses several interventions that, if implemented before pregnancy, can
improve pregnancy outcomes for women and infants. However, millions of women and couples do not receive such interventions
and services (8).
Childbearing is a common experience among women in the United States. In 2000, an estimated 62 million U.S.
women were of childbearing age (aged 15--44 years), distributed in approximately equal segments across the age groups of
15--24, 25--34, and 35--44 years (9). By age 25 years, approximately half of all women in the United States have experienced at
least one birth, and approximately 85% of all women in the United States have given birth by age 44 years. In 2003, the
fertility rate was 66 live births per 1,000 women aged 15--44 years, with highest rates among women aged 25--29 years (114
per 1,000) and lowest rates among women aged >44 years (0.5 per 1,000). A similar age pattern has been observed within
racial/ethnic populations, although women aged <25 years who are non-Hispanic black and Native American had higher
fertility rates than non-Hispanic whites and Asian/Pacific Islanders. Hispanic women have the highest fertility rates overall and
within each age group (10).
In a 2004 survey of women aged 18--44 years, 84% had a health-care visit during the previous year, and slightly more
than half (55%) of women of reproductive age obtained preventive health services in any given year, which are opportunities
to deliver preconception care (11). Because approximately one third to half of women have more than one primary care
provider (i.e., generally a family physician or internal medicine physician and an
obstetrician/gynecologist) (12), all providers
who routinely treat women for well-woman examinations or other routine visits play an important role in
improving preconception health. However, only approximately one of six obstetrician/gynecologists or family physicians had
provided preconception care to the majority of the women for whom they provided prenatal care
(13). Another study reported that mothers frequently interacted with pediatricians after the birth of one child and before conception of another, which
affords another opportunity to promote preconception health care
(14).Community health centers and other Federally
Qualified Health Centers (FQHC), including primary care and prenatal care, deliver services to approximately 4.5 million women
of childbearing ageeach year (15). These centers can be used to provide preconception care to women with low
incomes (income <200% of the federal poverty level) and with no health insurance.
This report provides recommendations to improve both preconception health and preconception health care. Several of
the medical conditions, personal behaviors, psychosocial risks, and environmental exposures associated with negative
pregnancy outcomes can be identified and modified before conception through clinical interventions. For certain conditions,
opportunities for preventive interventions occur only before conception. Establishing preconception health screening as part of routine care
for women of reproductive age has been discussed in previously published reports
(2,5,6,7,13,14). However better health care
alone will not achieve optimal improvements in women's preconception health and reproductive outcomes. Health
promotion activities to modify personal knowledge and attitudes and
behaviors related to reproductive risk factors and the use of
a reproductive life plan for women and couples also have been proposed
(16,17). A reproductive health plan reflects a
person's intentions regarding the number and timing of pregnancies in the context of their personal values and life goals. This health
plan might increase the number of planned pregnancies and encourage persons to address risk behaviors before conception,
reducing the risk for adverse outcomes for both the mother and the infant.
The recommendations should be used by consumers, clinical care providers, public health professionals, researchers,
policy makers, and others concerned with the health of women, children, and families. Federal, state, and local public
health agencies can play a vital role in translating these recommendations into projects, educational materials, and
programs designed to improve preconception health. Primary care providers serving women of reproductive age, including
obstetrician/gynecologists, family physicians, nurse midwives, nurse practitioners, and others working in various clinical settings, have
an equally critical role to play in implementing these recommendations.
CDC developed these recommendations by 1) reviewing published research; 2) convening the
CDC/ASTDR Preconception Care Work Group, representing 22 programs; 3) evaluating presentations of best and emerging practice
models at the National Summit on Preconception Care in 2005; and 4) convening the Select Panel on Preconception Care
comprised of subject matter specialists on obstetrics and gynecology, nursing, public health, midwifery,
epidemiology, dentistry, family practice, pediatrics, and other disciplines. Various databases (e.g.,
PubMed® ) were searched to
identify published studies for review. Search parameters included preconception care, birth outcomes, reproductive health,
and women's health. The reports were reviewed by the SPPC of specialists. These recommendations
reflectthe research, professional opinion, practice in medicine, public health, and related fields, which are sufficient to guide changes in
program, practice, and policy. SPPC reviewed evidence to determine the effectiveness of certain interventions of preconception
care (e.g., folic acid to prevent neural tube defects and cessation of alcohol use) and identified missed opportunities
for dissemination of preconception information. Implementation of these effective interventions can contribute to the health
of thousands of women each year.
These recommendations are a strategic plan to improve preconception health through clinical care, individual
behavior change, community-based public health programs, and social marketing campaigns to change consumer knowledge
and attitudes and practices. In addition, they are designed to increase research knowledge related to preconception health and
care and to improve reproductive health outcomes for all women and couples. Policy changes at the local, state, and federal
levels will be necessary to support several of these recommendations. These policies will address changes in access, payment,
and types of services available. Four goals were established for achieving these recommendations: 1) improve the knowledge
and attitudes and behaviors of men and women related to preconception health; 2) assure that all women of childbearing age
in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and
interventions) that will enable them to enter pregnancy in optimal health; 3) reduce risks indicated by a previous adverse pregnancy
outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother
and her future children; and 4) reduce the disparities in adverse pregnancy outcomes.
Preconception Health and Care
Preconception care is recognized as a critical component of health care for women of reproductive age
(1--5,7,16,17,19--25). The main goal of preconception care is to provide health promotion, screening, and interventions for women
of reproductive age to reduce risk factors that might affect future pregnancies
(7,16,22--25). Preconception care is part of
a larger health-care model that results in healthier women, infants, and families
A substantial number of definitions for preconception care have been used
(2--5,16,19,30--33). On the basis of
previous guidelines and recommendations, SPPC developed a refined definition for preconception care. Preconception care is
defined as a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health
or pregnancy outcome through prevention and management. Certain steps should be taken before conception or early
in pregnancy to have a maximal effect on health outcomes. Preconception care is more than a single visit to a
health-care provider and less than all well-woman care, as defined by including the full scope of preventive and primary care services
for women before a first pregnancy or between pregnancies (i.e., commonly known as interconception care).
Improving preconception health and pregnancy outcomes will require more than effective clinical care for women.
Changes in the knowledge and attitudes and behaviors related to reproductive health among both men and women need to be made
to improve preconception health. Despite several health promotion campaigns aimed at reducing smoking, misuse of
alcohol, intimate partner violence, obesity, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome
(AIDS), reduction of vaccine-preventable diseases, and exposure to occupational hazards, the majority of U.S. adults are not aware
of how these and other health and lifestyle factors influence reproductive health and childbearing
(34,35). Preconception health promotion, therefore, should focus on a general awareness among men and women regarding reproductive health and risks
to childbearing (26).
Healthy People 2000/2010 Objectives for Improving Preconception Health
and Guidelines for Preconception Care
A Healthy People 2000 objective (objective 14.3) is for 60% of primary care physicians to provide
age-appropriate preconception care (36). This objective was deleted from
Healthy People 2010 because it was not being measured.
no specific objective for preconception exists, several of those specified in
Healthy People 2010 are relevant to
preconception health (37,38).
The Institute of Medicine, several national committees, and a substantial number of professional organizations
have established guidelines and recommendations regarding the importance and content of preconception health care
(1,3,4,30--33). The primary objective of these reports is to improve the health of women, children, and families. The previously
issued evidence-based guidelines for preconception care have been summarized and are the foundation for the
recommendations developed by SPPC.
The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists
(ACOG)have classified the main components of preconception care into four categories of interventions: physical assessment,
risk screening, vaccinations, and counseling. Eight areas of risk screening are 1) reproductive awareness; 2) environmental
toxins and teratogens; 3) nutrition and folic acid; 4) genetics; 5) substance use, including tobacco and alcohol; 6) medical
conditions and medications; 7) infectious diseases and vaccination; and 8) psychosocial concerns (e.g., depression or violence)
Preconception care should be an essential part of primary and preventive care, rather than an isolated visit
(4,5,21--26,32,39,40). Whereas a prepregnancy planning visit in the months before conception has been recommended
(3,19,31), improving preconception health will require changes in the process of care, including the types of screening and
risk-reduction interventions offered to women of childbearing age.
Guidelines for Perinatal Care, jointly issued by AAP
and ACOG, has recommended that all health encounters during a woman's reproductive years, particularly those that are a part
of preconception care, should include counseling on appropriate medical care and behavior to optimize pregnancy
outcomes (41). Recommendations from these organizations are analogous to the risk screening recommended by the American
Heart Association for cardiovascular disease
(42). Several national organizations have recommended the routine delivery
of preconception care. For example, the March of Dimes has recommended that the key physician/primary care provider and
the obstetrician/gynecologist take advantage of every health encounter to provide preconception care and risk reduction
before and between conceptions, the time when health encounters can improve health status
Preconception Risks Associated with Adverse Pregnancy Outcomes
Risk factors for adverse outcomes among women and infants occur during the preconception period and are characterized
by the need to start, and sometimes finish, intervention(s) before conception occurs. In a systematic review, researchers
(43) discussed published reports that identified a list of risk factors for which preconception care (i.e., risk assessment,
health promotion, and interventions) can be effective.
Women of childbearing age suffer from various chronic conditions and are exposed to (or consume) substances that
can have an adverse effect on pregnancy outcomes, leading to pregnancy loss, infant death, birth defects, or other
complications for mothers and infants. For example, in 2002, approximately 6% of adult women aged 18--44 years had asthma, 50%
were overweight or obese, 3% had cardiac disease, 3% were hypertensive, 9% had diabetes, and 1% had thyroid disorder
(44). Dental caries and other oral diseases also are common (>80% of women aged 20--39 years) and associated with
complications for women and infants.
In addition to having chronic diseases, a substantial proportion of women who become pregnant engage in
high-risk behaviors and contribute to adverse pregnancy outcomes. In 2003, a total of 11% of pregnant women smoked
during pregnancy, a risk factor for low birthweight
(10), and 10% of pregnant women and 55% of women at risk for
getting pregnant (i.e., those not using contraception or using ineffective contraceptive methods or using effective
contraceptive methods inconsistently) consumed alcohol, a risk for fetal alcohol syndrome
(45). Certain women also continued to engage
in high-risk sexual behavior, potentially exposing themselves to sexually transmitted diseases (STDs), including HIV
(46). Although a smaller proportion of women used illicit drugs, this high-risk behavior has been associated with adverse
outcomes. These behaviors often co-occur, therefore, compounding the risk for adverse outcomes for certain groups. Immunization
for adults and infants is critical for preventing infectious diseases (e.g., influenza and pertussis).
Data from the Pregnancy Risk Assessment and Monitoring System (PRAMS) in four states (i.e., Maine,
Michigan, Oklahoma, and West Virginia) indicated that 38% of mothers who planned pregnancies and an additional 30% who did
not plan pregnancies had one or more indications for preconception counseling, including use of tobacco or alcohol,
being underweight, or delayed initiation of prenatal care
(47). In Minnesota and Washington, data from a telephone survey
women revealed that pregnancy intention was associated with health behaviors before pregnancy that might
influence pregnancy outcome, with the most marked differences in smoking and vitamin use
Preconception health care is critical because several risk behaviors and exposures affect fetal development and
subsequent outcomes. The greatest effect occurs early in pregnancy, often before women enter prenatal care or even know that they
are pregnant (4,23--25,49). For example, for optimal effect on reducing the risk for neural tube defects, folic
acid supplementation should start at least 3 months before conception
(50--52). During the first weeks (before 52 days'
gestation) of pregnancy, exposure to alcohol, tobacco, and other drugs; lack of essential vitamins (e.g., folic acid); and workplace
hazards can adversely affect fetal development and results in pregnancy complications and poor outcomes for both the mother
and infant (45,53--58). This evidence demonstrates the potential impact of preconception care on the health of women and
Social determinants of women's health also play a role in pregnancy outcomes. The health status of minority women
with low incomes contributes to persistent, and sometimes increasing, disparities in birth outcomes. In one study, the
reduced overall health status (including poorer physical and emotional health) of women with low income during the month
before pregnancy was associated with an increased risk for preterm labor
(59). Socioeconomic status directly and
indirectly influences three major determinants of health: health-care access, environmental exposure, and health behavior
(60,61). Racial inequalities in access to effective treatment also influence these determinants of pregnancy outcomes for women and
The following selected preconception risk factors for adverse pregnancy outcomes and evidence for the effectiveness
of preconception care have been used to develop clinical practice guidelines (e.g., AAP and ACOG).
Isotretinoins. Use of isotretinoins (e.g.,
Accutane®) in pregnancy to treat acne can result in miscarriage and birth
defects. Effective pregnancy prevention should be implemented to avoid unintended pregnancies among women
with childbearing potential who use this medication
Alcohol misuse. No time during pregnancy is safe to drink alcohol, and harm can occur early, before a woman
has realized that she is or might be pregnant. Fetal alcohol syndrome and other alcohol-related birth defects can be
prevented if women cease intake of alcohol before conception
Anti-epileptic drugs. Certain anti-epileptic drugs are known teratogens (e.g., valproic acid).
Recommendations suggest that before conception, women who are on a regimen of these drugs and who are contemplating
pregnancy should be prescribed a lower dosage of these drugs
Diabetes (preconception). The three-fold increase in the prevalence of birth defects among infants of women with
type 1 and type 2 diabetes is substantially reduced through proper management of diabetes
Folic acid deficiency. Daily use of vitamin supplements containing folic acid has been demonstrated to reduce
the occurrence of neural tube defects by two thirds
Hepatitis B. Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus
(HBV) infection. Preventing HBV infection in women of childbearing age prevents transmission of infection to infants
and eliminates risk to the woman of HBV infection and sequelae, including hepatic failure, liver carcinoma, cirrhosis,
and death (89--91).
HIV/AIDS. If HIV infection is identified before conception, timely antiretroviral treatment can be administered,
and women (or couples) can be given additional information that can help prevent mother-to-child transmission
Hypothyroidism. The dosages of Levothyroxine® required for treatment of hypothyroidism increase during
early pregnancy. Levothyroxine® dosage needs to be adjusted for proper neurologic development of the fetus
Maternal phenylketonurea (PKU). Women diagnosed with PKU as infants have an increased risk for
delivering neonates/infants with mental retardation. However, this adverse outcome can be prevented when mothers adhere to a
low phenylalanine diet before conception and continue it throughout their pregnancy
Obesity. Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm
delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Weight loss before pregnancy reduces
these risks (105--109). Appropriate weight loss and nutritional intake before pregnancy reduces these risks.
Oral anticoagulant. Warfarin, which is used for the control of blood clotting, has been demonstrated to be a
teratogen. To avoid exposure to warfarin during early pregnancy, medications can be changed to a nonteratogenic
anticoagulant before the onset of pregnancy
STD. Chlamydia trachomatis and
Neisseria gonorrhoeae have been strongly associated with ectopic pregnancy,
infertility, and chronic pelvic pain. STDs during pregnancy might result in fetal death or substantial physical and
developmental disabilities, including mental retardation and blindness
(113,114). Early screening and treatment prevents these
Smoking. Preterm birth, low birthweight, and other adverse perinatal outcomes associated with maternal smoking
in pregnancy can be prevented if women stop smoking before or during early pregnancy. Because only 20% of
women successfully control tobacco dependence during pregnancy, cessation of smoking is recommended before pregnancy
Severalproviders and maternal and child health researchers have recommended that health risks and behaviors be
addressed during any encounter with the health-care system because approximately half of pregnancies in the United States
are unintended (20,22,27,119,120). One clinical trial has indicated that provision of preconception care can increase
pregnancy planning and intention (121). This finding is vital because studies have consistently demonstrated that planned
pregnancies typically have improved outcomes for both women and infants.
Preconception Prevention and Intervention
Since 1987, several reviews of published reports have assessed the evidence and documented the effectiveness for
specific preconception interventions
(2,5,33,43). A systematic review of 21 research trials published during the 1990s
have strengthened the evidence base for preconception care in particular areas (e.g., folic acid deficiency, maternal PKU, and
oral anticoagulant; 43).
The effectiveness of several interventions that address the risk factors for adverse outcomes
(19,33,43) have been documented, including folic acid supplementation
(51,52,122--125); appropriate management of hyperglycemia
(126--131); rubella, influenza, and hepatitis vaccination; low phenylalanine diet
(132--134); and provision of antiretroviral
medications to reduce the risk for mother-to-child HIV transmission
(97). Interventions for smoking and alcohol cessation
(135--139) have been demonstrated to be effective in certain populations; however, they have been less effective with persons at
highest risk (e.g., injection-drug users and polysubstance
A list of core interventions exist that are part of preconception care services. These interventions are risk-specific;
providers can screen and provide appropriate interventions for persons who need them. However, the best evidence for the
effectiveness of these specific components of preconception care has been documented when the focus of delivery was on a single
risk behavior and accompanying intervention, rather than delivery of multiple interventions.
Because of the direct links between a mother's oral health and her offspring's risk for dental caries, dental interventions
can reduce the risk for prematurity and low birthweight
(140--143). Evidence supporting interventions to reduce
mother-to-child transmission of cariogenic bacteria supports recommendations for the appropriate use of fluorides and dietary control
to reduce maternal salivary reservoirs of cariogenic bacteria, particularly for women who have experienced high rates of
dental caries (140).
Interventions that address multiple pregnancy-related risk behaviors simultaneously have not been systematically
evaluated and are less commonly delivered. The U.S. Preventive Services Task Force (USPSTF) evaluated the effectiveness
of interventions related to smoking, alcohol misuse, and obesity, based on studies of interventions delivered in primary
care settings that were not complicated by the additional delivery of multiple components of preconception care
(69,70,144--147). These effective methods for intervention (e.g., the Five As [Ask, Advise, Assess, Assist, and Arrange]) for
smoking cessation and brief counseling interventions to reduce alcohol misuse, as identified by USPSTF, provide models for
the delivery of multiple interventions that can be adapted and tested
(69,70). One study has reported the effectiveness
of comprehensive preconception care; however, the findings have limited applicability for the implementation of
preconception health-care services in the United States because the study was conducted in Hungary
One priority for preconception care activities is to ensure that evidence-based interventions are implemented to
further improve infant and maternal pregnancy outcomes among women living with chronic conditions. Clinical practice
guidelines (CPGs) for preconception care for specific maternal chronic health conditions have been developed by several national
professional groups (25--28). For example, the American Diabetes Association has developed CPGs that should be
followed before pregnancy for women with diabetes
(81). The American Association of Clinical Endocrinologists has developed
CPGs for women with hypothyroidism who are attempting to conceive
(100). CPGs have also been developed for women
being treated with teratogenic medications to guide the transition to safer medications. CPGs for women considering
pregnancy and who are using anti-epileptic drugs or oral anticoagulants have been developed by the American Academy of
Neurology (77) and the American Heart Association/American College of Cardiologists
Whereas the evidence supporting specific interventions and the importance of intervening before pregnancy are
definitive, limited evidence is available to determine effective methods for delivering preconception care and improving
preconception health. Only a limited number of studies regarding effectiveness of interventions have been tested for
increasing preconception screening, counseling, and intervention in primary care settings
(121,148,149). In one randomized clinical trial, preconception risk factors were identified among women who sought care at a hospital primary care clinic for
a pregnancy test. In this trial, an average of nine risk factors per woman was identified at the time of a negative pregnancy
test. However, notifying women and their clinicians of identified preconception risks did not improve intervention rates
(148). In another study in which didactic lectures and chart cues were used, significant increases occurred in risk screening for
medical risk factors (15%--44%), medications (10%--30%), domestic violence (10%--57%), and nutrition (9%-- 50%)
among nonpregnant women who attended an inner-city hospital gynecologic clinic. However, intervention rates and
provider attitudes toward preconception care did not change substantially
(149). A prospective study of the effect of
preconception health promotion on intendedness of pregnancy revealed that women in a family planning clinic who had received
the intervention (22%) during routine visits were more likely to report intended pregnancies than those patients in the
same clinic who were not exposed to the intervention (15)
A limited number of studies have assessed the best methods for integrating interventions to achieve maximum impact
and optimize the use of limited resources. As with other types of preventive care services, time constraints limit physicians'
ability to deliver health promotion interventions
(144). Preconception care interventions can potentially be integrated into a
limited number of model visits to focus on specific content at different visits, as is done for well-child care
(150). Integrated and coordinated care services might also provide additional support to improve health outcomes. For example, an evaluation
of the quality of care in the National Centers of Excellence in Women's Health indicated that women served in these
centers, compared with community samples, received more clinical preventive services and had higher satisfaction levels
(151). Another approach (e.g., self-management) to integrated service of delivery has been illustrated in CDC's recommendations
in Strategies for Reducing Morbidity and Mortality from Diabetes Through Health-Care System Interventions and Diabetes
Self-Management Education in Community Settings: A Report on Recommendations of the Task Force on Community
Preventive Services (152). HIV intervention efforts also have suggested that integrated interventions address substance use and
reduce sexual risk behaviors simultaneously.
The purpose of preconception care is to deliver risk screening, health promotion, and effective interventions as a part
of routine health care. In the United States, this approach is the standard used to achieve prevention of
vaccine-preventable disease, heart disease, diabetes, and other chronic conditions. This approach is similar to well-child care, prenatal care,
and adult wellness care in which studies have demonstrated the effectiveness of individual components rather than
the effectiveness of combined interventions. However, effectiveness depends on ongoing monitoring of health status
Preconception care should be tailored to meet the needs of the individual woman. Because preconception care needs to
be provided across the lifespan and not during only one visit, certain recommendations will be more relevant to women
at different life stages and with varying levels of risk. Health promotion, risk screening, and interventions are different for
a young woman who has never experienced pregnancy than for a woman aged 35 years who has had three children.
Women with chronic diseases, previous pregnancy complications, or behavioral risk factors might need more intensive
interventions. Such variations also place constraints on how interventions can and should be integrated.
Context and Frame Work for Recommendations
The recommendations are designed to promote optimal health throughout the lifespan for women, children, and
families by using both clinical care and population-focused public health strategies. In this report, the approach to
preconception health is not a single clinical visit but a process of care and interventions designed to address the needs
of women during the different stages of reproductive life. SPPC has encouraged the use of a broad definition of prenatal
care that includes ongoing preconception interventions, the addition of a prepregnancy visit, multiple postpartum visits, and
the currently recommended prenatal care visits. Preconception care offers health services that allow women to maintain
optimal health for themselves, choose the number and spacing of their pregnancies and, when desired, prepare for a healthy
baby. Interventions and health care that occur before and between pregnancies are included in this report. This review
identified areas for which further research is needed
(43). Increasing evidence-based research of clinical and public health
interventions by using both qualitative and quantitative methods is essential to the fulfillment of these recommendations.
Each of the 10 recommendations has specific action steps that can be implemented in the next 2--5 years. Increasing
access to and use of preconception care will not occur immediately; diffusion of innovation theory demonstrates how
slowly concepts and best practices are typically disseminated
(153,154). The action steps recommend revision of
professional standards of care, modification of provider behaviors, development of effective health promotion messages, changes
in consumer behavior, and adjustments to payment mechanisms. In addition, the recommendations emphasize
individual behavior and responsibility for improving preconception health and identify specific evidence-based strategies for
modifying individual knowledge and attitudes and behaviors across the lifespan. The recommendations promote changes in clinical
care, public health programs at the federal, state, and local levels, and other community-based programs. For example,
quality improvement strategies, commonly used today in clinical practice, might be used to modify provider knowledge and
attitudes and behaviors. In addition to participation among traditional partners in public health interventions,
improving preconception health will require increased involvement from partners in various sectors (e.g., education, housing,
urban planning, and environmental health). These partners should be included as part of the comprehensive solution to
improve women's health and the health of families. Approaches to improve surveillance, performance monitoring, and
results accountability have been recommended along with strategies to integrate care, develop complementary approaches,
and reduce duplication of activities among different professional and programmatic stakeholders.
The risk and the burden of disease is unequally distributed, and a small number of women experience the majority of
the pregnancy-related morbidity and mortality, which suggests that a two-step approach to implementing interventions would
be beneficial. The first step would target women at highest risk (whether the risks are biologic or social) to reduce morbidity
and mortality. The second step would aim to improve preconception health for all women of reproductive age, regardless of
risk status. The recommendations emphasize targeting interventions for groups of women with known risks and conditions
(e.g., those with previous poor pregnancy outcomes or chronic conditions).
Culturally and linguistically appropriate systems of care are needed to ensure maximal use and impact of
preconception health-care services. By increasing the acceptability, effectiveness, and impact of the health-care system through these
changes, persons involved in improving preconception health care have the opportunity to address and reduce health disparities.
The recommendations are a starting point to make comprehensive preconception care a standard of care in the
United States and to provide a more universal, comprehensive,
evidence-based model of preconception care. The
recommendations will promote the development and practice of preconception care that will be flexible to meet persons' changing
reproductive care needs and address risks throughout their lifespan.
How the Recommendations were Developed
The recommendations were developed through the collaborative efforts of CDC and external partners to 1) target life
stages in reproductive-aged women; 2) encourage special interest groups to collaborate to achieve common goals; 3)
encourage scientific and public health collaboration; and 4) address health impact, public health systems, efficiency, and effectiveness.
During 2003, a review of studies published regarding maternal and child health and preconception care was conducted
by CDC to assess preconception care. The CDC work group also discussed opportunities for collaboration across programs.
Several CDC programs in the work group had previously identified specific interventions with scientific evidence which,
if delivered before conception, would promote preconception health and improve pregnancy-related outcomes. These
programs recognized the need to integrate these interventions with similar services to improve coverage, effectiveness,
access, efficiency, and ultimately maternal and infant pregnancy outcomes. The need for preconception health promotion and care
identified as a critical public health topic by CDC and partners. As a result, a broader working group of
national organizations involved in preconception health issues were established (Appendix).
In November 2004, the CDC work group and representatives of 16 external organizations discussed the
evidence supporting preconception care to determine the steps that can be taken to develop national recommendations. The
consensus of the participants was that a larger meeting on preconception care and an interdisciplinary panel of specialists should
be convened in 2005. A steering committee and planning committee were established (including representatives from CDC
and external partners) to plan for a national summit and to bring together a group of specialists with experience in data,
practice, and policy issues related to preconception health.
In June 2005, a national summit on preconception care was convened to gather information concerning promising
practice models. The summit agenda was developed based on 68 submitted abstracts and reflected various preconception
project models, finance approaches, and research questions (CDC, unpublished data, 2005).
In conjunction with the summit, CDC convened SPPC, which included various subject matter specialists
and representatives from national organizations concerned about the health of women, infants, and families. A Delphi
technique was used to identify subject matter specialists to serve on SPPC. SPPC discussed recommendations regarding clinical
practice, public health/community programs, research/data, and policy/finance.
Initial recommendations were sent to the CDC work group, panel members, and additional subject matter specialists
from academic and professional backgrounds for comment and review. Reviewers shared their comments in writing or as part of
a series of conference calls convened by the SPPC steering committee.
Recommendations to Improve Preconception Health
Ten recommendations were developed for improving preconception health through changes in consumer
knowledge, clinical practice, public health programs, health-care financing, and data and research activities. Each recommendation
has specific action steps. If each action step is implemented, benefits might be observed within 2--5 years, which would
help achieve the Healthy People 2010 objectives to improve maternal and child health
outcomes.The recommendations are aimed at achieving four goals, based on personal health outcomes.
Goal 1. Improve the knowledge and attitudes and behaviors of men and women related to preconception health.
Goal 2. Assure that all women of childbearing age in the United States receive preconception care services (i.e.,
evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health.
Goal 3. Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children.
Goal 4. Reduce the disparities in adverse pregnancy
The recommendations are a strategic plan for improving the health of women, their children, and their families and
are based on existing knowledge and evidence-based practice. Improving preconception health among the estimated 62
million women of childbearing age (9) will require a multistrategy, action-oriented initiative.
The recommendations, which are not prioritized, should be used by consumers, public health and clinical
providers, researchers, and policy makers. Therefore, the recommendations should be implemented simultaneously. In the action
steps, persons, public health and clinical providers, communities, governments (i.e., local, state, and federal), and
professional organizations all have roles. Finally, these recommendations are designed to reduce disparities in maternal and infant
health by improving the preconception health of women and men.
Recommendation 1.Individual Responsibility Across the
Lifespan. Each woman, man, and couple should be
encouraged to have a reproductive life plan.
The target population for preconception health promotion is women, from menarche to menopause, who are capable
of having children, even if they do not intend to conceive. To reach such a broad group, a lifespan perspective is
needed (3,17,20), which is commonly used in efforts to reduce chronic diseases, particularly cardiovascular disease. For
example, persons are encouraged to consider the role of genetic and dietary factors in determining their risk for high cholesterol and
modify their behaviors according to cumulative individual risks (e.g., changes in diet, exercise, or medications)
(155). Similarly, a lifespan approach can be used to focus individual attention on reproductive health to reduce
unintended pregnancies, age-related infertility, fetal exposures to teratogens, and to improve women's health and pregnancy
Certain researchers, providers, and health-care advocates have suggested developing a reproductive health life plan
for young women and couples as they enter their reproductive years. However, reproductive health life plans have not
been systematically implemented and evaluated
(23,26,29,33). Implementing such a reproductive health life plan will require
a change in provision of health services and health promotion (Box 1).
Recommendation 2. Consumer Awareness. Increase public awareness of the importance of preconception health
behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including
health literacy; and cultural/linguistic contexts.
Consumers should be more involved in improving preconception care services. Knowledge and attitudes and
behaviors related to reproductive health are influenced by childhood experiences and prevailing social norms among adults.
Certain U.S. adults are not aware of the factors that influence reproductive health and childbearing
(34,35). The preconception guidelines from Canada state that preconception care is 1) physical preparation for pregnancy and parenting and 2) the
social, psychological, and spiritual components of pregnancy. The factors that influence attitudes regarding preconception
care include a person's age and life stage, their childbearing history, and their life priorities
Activities specifically designed to improve school general health education are an essential step in improving
reproductive awareness. Efforts to inform adults regarding the risks and opportunities to improve their health are equally
important. Several health promotion campaigns provide opportunities to change adult knowledge and attitudes and behaviors,
including campaigns designed to reduce tobacco use, promote responsible use of alcohol, and encourage healthy diet and
optimal weight. Campaigns can include messages concerning reproductive health and childbearing. Such campaigns typically focus
on the effect of adverse behaviors on children and do not include parallel messages regarding the potential impact
on childbearing. New social marketing and health promotion campaigns that focus on how to prepare for childbearing
and parenting can influence the behavior of men and women. For example, folic acid intake has been promoted among women
of childbearing age (123). Similar to efforts to reduce teenage childbearing or increase use of prenatal care, the media can play
a vital role in promoting reproductive awareness
Success in improving preconception health will require changes in public attitudes and has been achieved in other
areas (e.g., attitudes changed during the previous 10 years regarding tobacco use, infant sleep position, or vaccinations for
infants and toddlers instead of preschoolers)
(158). A critical tool for stimulating these changes is social
marketing, which isdesignedto influence the voluntary behavior of targeted audiences to improve their well-being
Consumer-friendly tools can help women self-assess risks, make plans, and take actions that will improve their health
and that of their children. More consumer-focused research is needed to determine which messages and tools might be effective
to encourage reproductive life planning. The SPPC members have suggested that such research explore which terms the
public best understands, what messages might increase demand for services, and how touch-screen kiosks or other technology
might be used to promote knowledge of preconception health topics (Box 2).
Recommendation 3. Preventive Visits. As a part of primary care visits, provide risk assessment and educational and
health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.
Integration of preconception components into primary care can better serve women across their lifespan and at
various levels of risk. Primary care integrates various health promotion, prevention, and acute care services to address the majority
of personal health-care needs and common health problems in a community setting. Primary care also might include
screening for and ongoing management of chronic conditions in a primary care setting. Elements of preconception care can
be integrated into every primary care visit.
Professional guidelines for clinicians (i.e., obstetrician/gynecologists, family practice physicians, certified nurse
midwives, and nurse practitioners) who provide the majority of primary care to women in the United States should include routine
risk assessment through screening
(14,24,28,29,33). Different guidelines recommend eight to 10 specific areas for
preconception risk assessment, including: 1) reproductive history; 2) environmental hazards and toxins; 3) medications that are
known teratogens; 4) nutrition, folic acid intake, and weight management; 5) genetic conditions and family history; 6) substance
use, including tobacco and alcohol; 7) chronic diseases (e.g., diabetes, hypertension, and oral health); 8) infectious diseases
vaccinations; 9) family planning; and 10) social and mental health concerns (e.g., depression, social support,
domestic violence, and housing)
In addition to risk assessment or screening, professional guidelines include health promotion education and
counseling related to reproductive health risks. Such activities should routinely include promotion of healthy behaviors; discussion
of child spacing, family planning, and unintended pregnancy prevention; counseling concerning healthy diet, folic
acid supplementation, and optimal weight; immunization for infectious disease; information regarding the importance of
early prenatal care; and counseling concerning the availability of social and financial support programs.
For women with identified risks, additional counseling, testing, and brief interventions (e.g., for smoking, alcohol,
or changes in prescription medications) can be conducted in the primary care setting
(68--70,116--118). Certain women will need additional intensive interventions and specialty care. Whereas
evidenceand clinical guidelines exist that support
several preconception care interventions, data are needed to determine the effectiveness of integrating those interventions (e.g.,
a limited number of model visits), as is done for well-child care.
Clinical practice can be influenced by evidence-based guidelines, but additional strategies are needed to
promote widespread adoption of professional guidelines
(25,30--33,151--154). In the recommended action steps (Box 3),
additional activities should be provided to support changes in primary care provider knowledge and attitudes and
practices. Consolidation of existing guidelines, better tools, and use of quality improvement techniques have fostered changes
in knowledge and practices (161--164). For example, the Bright Futures Program has consolidated guidelines for child
health, and the Bright Futures for Women's Health and Wellness offers models and opportunities for links to preconception
Community health centers and other FQHC can be a key point of dissemination for strategies to improve
preconception health. FQHC are a critical source of primary care for millions of women with low incomes and no insurance. Perinatal
care for 332,000 women account for one of every 10 U.S. births
(166). Among FQHC, the Health Disparities
Collaboratives (HDC) Initiative is designed to improve the quality of primary care delivered, and approximately 600 FQHCs
have participated (167). The HDC model relies on partnerships among community clinics, federal agencies, and
national organizations. HDC started with a chronic disease care model for quality improvement, and a primary health-care
model integrated with the perinatal care collaboratives and other efforts has been developed.
Recommendation 4. Interventions for Identified
Risks. Increase the proportion of women who receive interventions
as follow-up to preconception risk screening, focusing on high priority interventions (i.e., those with evidence of
effectiveness and greatest potential impact).
Timely preconception interventions for certain conditions can substantially improve maternal health and birth
outcomes (4,43). Separating childbearing from the management of chronic health problems and infectious diseases places women,
their future pregnancies, and their future children at unnecessary risk
(7,20,24,149). Conditions and risk factors have
been identified for which the following exist 1) evidence of potential harm to mother or baby, 2) high prevalence of
adverse pregnancy outcome or effective interventions for reducing adverse pregnancy outcomes, and 3) one or more
effective interventions that have been evaluated.
Certain women and men need additional counseling and interventions. For example, women who have conditions
treated with medications that are known teratogens (e.g., anticonvulsant or anticoagulant medications and isotretinoins) might
need to change prescriptions. Women with medical conditions associated with increased risks for morbidity and mortality
to mother and fetus (e.g., diabetes, hypertension, heart disease, rubella sero-negativity, thrombophilias, dental disease,
or obesity) need to control these conditions. Women with behaviors associated with increased health risks for the fetus
(e.g., smoking and alcohol and illicit drug use) also need targeted interventions. Another group with specific counseling
needs includes prospective parents with a family history of inherited (i.e., genetic) disorders.
The preparers of this report analyzed the National Ambulatory Medical Care Survey
(168) and demonstrated that diabetes affects approximately 1.85 million (21 per 1,000) women in the United States aged 18--44 years, and that
preconceptional diabetes management has the potential to reduce the risk for pregnancy loss and congenital malformation for
approximately 113,000 births per year.
Anti-epileptic/antiseizure drugs are prescribed for approximately 1 million women (19 per
1,000), potentially affecting an estimated 75,000 pregnancies. Approximately 7 million (125 per 1,000) women of childbearing
age are frequent drinkers, and without preconception interventions, alcohol misuse might affect approximately 577,000
births per year (168). Women with chronic medical conditions and their specialty providers should take advantage of
opportunity to discuss preconception health and risks. These conditions and risk factors affect substantial proportions of
the approximately 4 million pregnancies that occur in the United States each year.
Studies of preconception care have indicated that providers do not routinely provide interventions for
identified preconception risks
(23,147,148,164,169). Dissemination of professional guidelines and evidence-based interventions
are two vital ways to encourage changes in practice. However, quality improvement tools and techniques offer
increased potential, particularly for specific interventions for women with identified conditions
(162,170). Research has increasingly indicated that providers and health-care organizations are more likely to engage in evidence-based or best clinical
practices, after participation in quality improvement projects (e.g., rapid improvement cycles using the plan/do/study/act
approach, collaborative groups, or the model of improvement process that involves an aim/change/measure cycle)
(162,170). Incorporation of preconception care modules into the curricula of medical graduate, postgraduate, and continuing
medical education might be another method of disseminating messages regarding the importance and content of preconception
care for women (Box 4).
Recommendation 5. Interconception Care. Use the interconception period to provide additional intensive interventions
to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects,
low birthweight, or preterm birth).
Experiencing an adverse outcome in a previous pregnancy is an important predictor of future reproductive risk
(171--173). However, many women with adverse pregnancy outcomes do not receive targeted interventions to reduce risks during
future pregnancies. Each year, approximately 28,000 infants die during the first year of life
(171). Approximately 12% of all births are preterm (i.e., <37 weeks' gestation)
(10), and an estimated 3% of infants are born with birth defects
(174). Whereas a preterm birth is identified on birth certificates and a woman's primary care provider typically knows this information,
professional guidelines do not include systematic follow-up and intervention for women with this critical predictor of risk.
Postpartum visits are an opportunity to link women to interventions designed to reduce risks to them and their
future children, and promisingstrategies focus on the postpartum period
(170). The Health Employer Data and Information
Set (HEDIS), used by public and private health plans, has measures for postpartum visits. HEDIS data indicate that 80% of
women with private (i.e., commercial) insurance coverage and 55% of those covered by Medicaid receive postpartum
checkups. However, for the majority of health plans, strategies to encourage compliance or address low rates of return for postpartum
care have not been implemented (44). Measures for monitoring postpartum visits also are used by a limited number of state Title
V Maternal Child Health Block Grant agencies
(175). Data collected during postpartum visits typically have not been used
to guide health-care system planning.
Approaches to interconception care, which are part of preconception care, have been proposed
(176,177), and certain approaches have been tested. For example, in the Interpregnancy Care Program of Grady Memorial Hospital in
Atlanta, Georgia, researchers have been studying the effectiveness of interconception care in improving subsequent
reproductive outcomes for women who have delivered a baby born at very low birthweight (<1,500 grams). This model focuses
on reducing identified medical, dental, and psychosocial
risks and assisting women in developing and achieving
their reproductive goals for the future. During the pilot phase, the program identified and treated various medical conditions
and reported substantial positive impact on the length of birth intervals
(177). The federal Healthy Start program requires that
a grantee follow a woman and her child for 2 years postpartum, providing interconception care. In addition, certain
Healthy Start grantees provide more in-depth interconception services to women at high risk to reduce future adverse
pregnancy outcomes (175). Across the United States, Healthy Start grantees (e.g., the Magnolia Project in northeastern Florida)
are providing intensive postpartum case management for women at high risk for adverse pregnancy outcomes
(178--179). Opportunities are available to identify, refer, and serve women at high risk in the Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC) nutrition sites, family planning clinics, and home visiting programs
(175). Federal and state agencies can support such efforts with funding for demonstration, evaluation, and replication projects (Box 5).
Recommendation 6. Prepregnancy Checkup. Offer, as a component of maternity care, one prepregnancy visit for
couples and persons planning pregnancy.
SPPC encourages the use of a broad definition of maternity care that includes the addition of a prepregnancy visit and
the recommended prenatal and postpartum visits. The addition of this prepregnancy visit is an essential step toward
improving pregnancy outcomes, particularly for those planning pregnancy.
The Institute of Medicine Panel on Preventing Low Birthweight, the U.S. Public Health Service Expert Panel on
the Content of Prenatal Care, and the national Committee on Perinatal Health have recommended that women have
a prepregnancy visit (i.e., sometimes called a preconception visit) in the months before conception
(1,3,4). Such visits would include preconception care content, providing women an opportunity to benefit from risk assessment, health promotion,
and specific interventions related to circumstances when couples are trying to conceive. Adoption of the prepregnancy visit as
a standard of care also can help to reinforce the importance of pregnancy planning and preparedness among women and
men (Box 6).
Recommendation 7. Health Insurance Coverage for Women with Low
Incomes. Increase public and private health insurance coverage for women with low incomes to
improve access to preventive women's health and preconception
and interconception care.
Affordability of care is a major concern for multiple women
(11,180,181), and improved access to preconception care
is needed. Approximately 17 million women do not have health insurance, and they are more likely to postpone or forgo
care (180). During 2003, one third of women with low incomes, half of women with disabilities, and 18% of all nonelderly
(aged <65 years) women did not have health insurance
(180). Younger women aged 18--34 years were more likely than
older women not to have health insurance during 2003. Reflecting their income and employment status patterns (i.e., more
likely to have incomes <200% of poverty level and less likely to be employed in jobs that offer health insurance),
non-Hispanic white, Asian, and non-Hispanic black women were more likely than non-Hispanic white women not to have
health insurance (11,180,181).
Medicaid is the primary mechanism for extending health coverage to women with low incomes and who do not have
health insurance. During 2003, a total of 12% of all women of childbearing age and 37% of women with low incomes in that
age group relied on Medicaid for health-care coverage
(181,182). Medicaid has been demonstrated to be effective in
improving access to health care for women with low incomes
(179). Because nearly two thirds (63%) of women covered by Medicaid
are of childbearing age, the program's performance is related to preconception care access and to the outcomes of
pregnancy (183). Many women with low incomes, however, do not qualify for Medicaid because they do not have children aged
<18 years or do not have documentation of legal residence in the United States. As states seek to expand Medicaid coverage
to persons with low incomes and adults who do not have health insurance, women of childbearing age should receive
priority for qualifying for Medicaid coverage.
Since 1995, a total of 22 states have used their federal waiver authority to expand family planning services to women
who do not otherwise qualify for Medicaid, known as family planning waivers. Certain states offer coverage to women who
lose coverage after the birth of a baby or starting a job, whereas other
states offer family planning coverage based on the
income status of men and women (182). An evaluation of these family planning waiver
projectsprepared for the federal Center
for Medicare and Medicaid Services indicated that the projects resulted in substantial savings to both the federal and
state governments (184). Increased potential savings and prevention, however, can result if states provided coverage for
more comprehensive risk screening, health promotion, and interventions, resulting in higher levels of preconception wellness (Box 7).
Recommendation 8. Public Health Programs and
Strategies. Integrate components of preconception health into
existing local public health and related programs, including emphasis on interconception interventions for women with
previous adverse outcomes.
Public health programs serve millionsof women each year. Preconception interventions can be incorporated into
these programs to target women at highest risk. Title
Xfamily planning programs provide approximately 4.6 million women
with family planning education and contraceptives and pregnancy tests. However, a limited number of programs offer
more comprehensive risk screening, reproductive health promotion, and reproductive life planning
(185). Each year, WIC provides nutrition screening and counseling, supplemental food, and referrals to health services for approximately 8 million
women during pregnancy and the postpartum period
(186). These services provide an opportunity to promote preconception
health and refer women at risk to clinicians. Federal and state public health programs funded by the Title V Maternal and
Child Health Services Block Grant and CDC can give greater priority to preconception health and offer support for
demonstration projects and evaluations of prevention programs. Whereas federally funded Healthy Start projects are required to
have interconception health activities, these projects, located in communities with high infant mortality, provide opportunities
to offer more systematic preconception screening, health promotion, and interventions. Publicly funded programs that
offer screening and related services for STDs and HIV/AIDS also might provide risk assessment and health
interventions. Title X, WIC, Title V, Healthy Start, and other public health programs also provide a setting to test
and evaluate new approaches to improve preconception health
Strategies to promote dialogue and action among community members for a geographically defined community or
a community of professionals can help advance these recommendations and action steps (Box 8). Local task force groups
that involve consumer, community leaders, and health professionals can help implement preconception strategies that are
similar to strategies used previously for other topics (e.g., adolescent pregnancy prevention and childhood vaccinations).
Functioning parallel toclinical practice collaboratives, public health practice collaboratives that link local public health programs
can promote development and dissemination of community-based best practices.
Recommendation 9. Research. Increase the evidence base and promote the use of the evidence to improve
Additional evidence is needed regarding the effectiveness of interventions, the value of better service integration, and
the potential cost benefit of preconception care for the general population and for women at high risk for poor
pregnancy outcomes. Evaluations of preconception health programs and projects can help advance understanding of the
potential impact of selected approaches. For certain clinical interventions (e.g., interventions to address multiple risk
factors simultaneously or single risk factor interventions), randomized clinical trials are warranted, although not all
preconception health interventions can be ethically tested in this manner. Economic studies, particularly of clinical intervention
strategies, can support the case for wider dissemination of preconception care practices
(188; Box 9).
Recommendation 10. Monitoring Improvements. Maximize public health surveillance and related research mechanisms
to monitor preconception health.
Community health data are used systematically to conduct public health surveillance to evaluate and improve health,
health programs, and health policy (187). Surveillance includes monitoring the frequency of conditions, risk factors, services,
and outcomes. CDC and other public health agencies conduct surveillance and maintain data collection and surveillance
systems, and the field of maternal and child health benefits from several of these systems. For example, PRAMS, the Behavioral
Risk Factor Surveillance System, and the National Survey of Family Growth (NSFG) can be modified to provide more
data concerning preconception health
(189--191). At the state and local levels, PRAMS, Perinatal Periods of Risk,
Fetal-Infant Mortality Review, and youth risk behavior surveys provide additional opportunities for the data collection, analysis,
and interpretation that comprise public health surveillance
The Maternal and Child Health Bureau, in cooperation with states, operates the Title V data and information
system, which provides an opportunity to strengthen public health surveillance and performance monitoring. A review of
state-selected performance measures and priority needs for 2006--2010 indicated that a limited number of states are
monitoring trends for access to components of preconception and interconception care, access to primary care for women of
childbearing age, unintended pregnancy, and other related topics
Since 1990, indicators and monitoring systems have been used not only to assess programs at the population level but
also to measure the quality of health-care services. HEDIS is an example of a set of measures commonly used by purchasers
of health-care coverage, including state Medicaid agencies and employers. HEDIS includes indicators on prenatal
and postpartum care and family planning
(195). New HEDIS measures are needed to monitor access to, use of, and outcomes
of preconception care services as well as improved maternal and infant health. The recommendations in this report can be
used as a frame work for developing or modifying existing measures to monitor evidence-based interventions used
in preconception health services (Box 10).
The 10 recommendations for improving preconception care services and the health of women and infants were
developed through a process of consultation with a select panel of specialists from the relevant disciplines. Implementation of
the recommendations will help achieve the SPPC vision of preconception health and pregnancy outcomes in which 1)
women and men of childbearing age have high reproductive awareness (i.e., understand risk factors related to childbearing);
2) women and men have a reproductive life plan (e.g., whether or when they want to have children and how they will
maintain their reproductive health); 3) pregnancies are intended and planned; 4) women and men of childbearing age have
health-care coverage; 5) women of childbearing age are screened before pregnancy for risks related to the outcomes of pregnancy; and
women with a previous adverse pregnancy outcome (e.g., infant death, very low birthweight or preterm birth) have access
to interconception care aimed at reducing their
Improving preconception health will require changes in the knowledge and attitudes and behaviors of persons,
families, communities, and institutions (e.g., government and health-care settings). The purpose of preconception care is to
improve the health of each woman before any pregnancy and thereby affect the future health of the woman, her child, and her
family. The recommendations and specific action steps were developed as a result of SPPC meeting and implementation of
CDC's preconception health programs. The frame work has incorporated both an ecological model and a lifespan perspective
on health and recognized the unique contributions and challenges encountered by women, their families, communities,
and institutions. Improving the health of women can increase the quality of health for families and the community.
Several preconception care interventions have reduced risk and improved health outcomes. By increasing support
for provision of preconception care, policy makers have the opportunity to promote broad-based programs and services aimed
at improving the health of women, children, and families. The recommendations present a conceptual frame
work for innovative service delivery models so that women are
afforded the benefit of risk-appropriate
preconception services during every encounter with the health-care system.
Institute of Medicine. Preventing low birth weight. Washington, DC: National Academy Press; 1985.
Moos MK, Cefalo RC. Preconceptional health promotion: a focus for obstetric care. Am J Perinatol 1987;4:63--7.
Committee on Perinatal Health. Toward improving the outcome of pregnancy: recommendations of the Regional Development of Maternal
and Perinatal Health Service---the 90s and beyond. White Plains, NY: March of Dimes, National Foundation; 1993.
US Department of Health and Human Services. Caring for our future: the content of prenatal care: a report of the Public Health Service
Expert Panel on the Content of Prenatal Care. Washington, DC: US Department of Health and Human Services, Public Health Service; 1989.
Jack BW, Culpepper L. Preconception care: risk reduction and health promotion in preparation for pregnancy. JAMA 1990;264:1147--9.
Jack BW, Culpepper L. Preconception care. J Fam Pract 1991;32:306--15.
Cefalo RC, Moos MK. Preconceptional health promotion. In: Preconceptional health care: a practical guide. 2nd ed. St. Louis, MO: Mosby; 1995.
Atrash HK, Johnson K, Adams M, Cordero JF, Howse J. Time to act on missed opportunities to improve perinatal outcomes: preconception
care. Matern Child Health J. In press 2006.
US Census Bureau Population Division. Table 2: annual estimates of the population by selected age groups and sex for the United States: April
1, 2000, to July 1, 2004. Washington, DC: US Census Bureau, Population Division; 2005. (NC-EST) 2004-02.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2003. Natl Vital Stat Rep 2005;54:1--116.
Weisman CS. Women's use of health care. In: Falik M, Collins K, eds. Women's health: the Commonwealth Fund Survey of Women's
Health. Baltimore, MD: Johns Hopkins University Press; 1996.
Henderson JT, Weisman CS, Grason H. Are two doctors better than one? Women's physician use and appropriate care. Women's Health
Klerman LV, Reynolds DW. Interconception care: a new role for the pediatrician. Pediatrics 1994;93:327--9.
National Association of Community Health Centers. A nation's health at risk II: a front row seat in a changing health care system,
2004. Washington, DC: National Association of Community Health Centers; Special Topics Issues Brief No. 7.
Allaire AD, Cefalo RC. Preconceptional health care model. Eur J Obstet Gynecol Reprod Biol 1998;78:163--8.
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J 2003;7:13--30.
US National Library of Medicine. PubMed®. Washington, DC: US National Library of Medicine; 2006. Available at
American College of Obstetricians and Gynecologists. Access to women's health care: ACOG statement of policy. Washington, DC:
American College of Obstetricians and Gynecologists; 2003.
Misra DP, Guyer B, Allston A. Integrated perinatal health framework: a multiple determinants model with a life span approach. Am J Prev
Cheng D. Preconception health care for the primary care practitioner. Md Med J 1996;45:297--304.
Hobbins D. Prepping for healthy moms & babies: making the case for preconception care & counseling. AWHONN Lifelines 2001;5:49--54.
Frey KA. Preconception care by the nonobstetrical provider. Mayo Clin Proc 2002;77:469--73.
Moos MK. Preconceptional health promotion: opportunities abound. Matern Child Health J 2002;6:71--3.
Moos MK. Preconceptional wellness as a routine objective for women's health care: an integrative strategy. J Obstet Gynecol Neonatal
Moos MK. Preconceptional health promotion: progress in changing a prevention paradigm. J Perinat Neonatal Nurs 2004;18:2--13.
Reynolds HD. Preconception care: an integral part of primary care for women. J Nurse Midwifery 1998;43:445--58.
Weisman CS. Changing definitions of women's health: implications for health care and policy. Matern Child Health J 1997;1:179--89.
Clancy CM, Massion CT. American women's health care: a patchwork quilt with gaps. JAMA 1992;268:1918--20.
American College of Obstetricians and Gynecologists. Guidelines for women's health care. 2nd ed. Washington, DC: American College
of Obstetricians and Gynecologists; 1996.
American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 5th ed. Elk Grove
Village, IL: American Academy of Pediatrics; 2002. Washington, DC: American College of Obstetricians and Gynecologists; 2002.
Hobbins D. Preconception care: maximizing the health of women and their newborns: Association of Women's Health Obstetric and
Neonatal Nurses practice monograph. Washington, DC: Association of Women's Health Obstetric and Neonatal Nurses; 2001.
American College of Obstetricians and Gynecologists Preconception Work Group. The importance of preconception care in the continuum
of women's health care. Obstet Gynecol 2005;106:665--6.
Roth LK, Taylor HS. Risks of smoking to reproductive health: assessment of women's knowledge. Am J Obstet Gynecol 2001;184:934--9.
Kaiser Family Foundation. Summary of findings from a new Public Knowledge and Attitudes Survey on sexually transmitted diseases
(STDs). Washington, DC: Kaiser Family Foundation; 1996. Available at
US Department of Health and Human Services. Healthy People 2000: national health promotion and disease prevention objectives---full
report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service; 1991. (DHHS) 91-502212.
US Department of Health and Human Services. Healthy People 2010. 2nd ed. Vol. I. Washington, DC: US Department of Health and
Human Services; 2000.
US Department of Health and Human Services. Healthy People 2010. 2nd ed. Vol II. Washington, DC: US Department of Health and
Human Services; 2000.
March of Dimes Birth Defects Foundation. March of Dimes updates: is early prenatal care too late? Contemporary Ob/Gyn 2002;12:54--72.
Fowler JR, Jack BW. Preconception care. In: Taylor RB, David AK, Fields SA, Phillips DM, Scherger JE, eds. Family medicine principles
and practice. 6th ed. New York, NY: Springer; 2003:85--94.
Brundage SC. Preconception health care. Am Fam Physician 2002;65:2507--14.
Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: American Heart
Association scientific statement. Arterioscler Thromb Vasc Biol 2004;24:e29--e50.
Korenbrot CC, Steinberg A, Bender C, Newberry S. Preconception care: a systematic review. Matern Child Health J 2002;6:75--88.
US Department of Health and Human Services. Women's health USA. Rockville, MD: US Department of Health and Human Services,
Health Resources and Services Administration; 2005.
US Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse:
recommendation statement. Ann Intern Med 2004;140:554--6.
Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use
by adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2004;140:557--68.
American College of Obstetricians and Gynecologists. Substance abuse in pregnancy. Int J Gynaecol Obstet 1994;47:73--80.
Institute of Medicine, Stratton K, Howe C, Battaglia FC, eds. Committee to Study Fetal Alcohol Syndrome: fetal alcohol
syndrome---diagnosis, epidemiology, prevention and treatment. Washington, DC: National Academy Press; 1996.
Institute of Medicine, Bonnie RJ, O'Connell ME, eds. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking:
reducing underage drinking---a collective responsibility. Washington, DC: National Academy Press; 2004.
American College of Obstetricians and Gynecologists. Seizure disorders in pregnancy. Int J Gynec Obstet 1997;56:279--86.
Barrett C, Richens A. Epilepsy and pregnancy: report of an Epilepsy Research Foundation Workshop. Epilepsy Res 2003;52:147--87.
Crawford P, Appleton R, Betts T, Duncan J, Guthrie E, Morrow J. Best practice guidelines for the management of women with epilepsy:
the Women with Epilepsy Guidelines Development Group. Seizure 1999;8:201--17.
American Academy of Neurology. Practice parameter: management issues for women with epilepsy (summary statement): report of the
Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1998;51:944--8.
Morrell MJ. Guidelines for the care of women with epilepsy. Neurology 1998;51(5 Suppl 4):S21--S27.
American Diabetes Association. Preconceptional care of women with diabetes. Diabetes Care 2004;27(Suppl 1):S76--S78.
Kitzmiller JL, Buchanan TA, Kjos S, Combs CA, Ratner RE. Pre-conception care of diabetes, congenital malformations, and
spontaneous abortions. Diabetes Care 1996;19:514--41.
American College of Obstetricians and Gynecologists. Diabetes and pregnancy [Technical bulletin]. Int J Gynaecol Obstet 1995;48:31--9.
Roland JM, Murphy HR, Ball V, Northcote-Wright J, Temple RC. The pregnancies of women with Type 2 diabetes: poor outcomes
but opportunities for improvement. Diabet Med 2005;22:1774--7.
US Department of Health and Human Services. Screening for neural tube defects. In: Guide to clinical preventive services. 2nd ed.
Washington, DC: US Department of Health and Human Services, US Preventive Services Task Force; 1996:473--6.
American College of Obstetricians and Gynecologists. Clinical management guidelines for obstetrician-gynecologists. Obstet
American College of Obstetricians and Gynecologists. Folic acid for the prevention of recurrent neural tube defects: Committee on
Obstetrics---maternal and fetal medicine. Int J Gynaecol Obstet 1993;42:75--7.
Institute of Medicine Food and Nutrition Board. Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin
B12, pantothenic acid, biotin, and choline. Washington, DC: National Academy Press; 1999.
Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube
defects. Cochrane Database Syst Rev 2001;(3):CD001056.
Helfand M. Screening for subclinical thyroid dysfunction in nonpregnant adults: a summary of the evidence for the US Preventive Services
Task Force. Ann Intern Med 2004;140:128--41.
American College of Obstetricians and Gynecologists. Clinical management guidelines for obstetrician-gynecologists: thyroid disease in
pregnancy. Obstet Gynecol 2002;100:387--96.
American Association of Clinical Endocrinologists. Medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism
and hypothyroidism. Endocr Pract 2002;8:457--69.
National Institutes of Health. Phenylketonuria screening and management. Vol. 17, no. 3. Presented at the National Institutes of
Health Consensus Conference, Bethesda, MD; October 16--18, 2000.
American College of Obstetricians and Gynecologists Committee on Genetics. Maternal phenylketonuria. Int J Gynecol Obstet 2001;72:83--4.
US Department of Health and Human Services. Screening for rubella. In: Guide to clinical preventive services. 2nd ed. Washington, DC:
US Department of Health and Human Services, US Preventive Services Task Force; 1996.
American College of Obstetricians and Gynecologists. Rubella vaccination. Int J Gynaecol Obstet 2003;81:241.
US Department of Health and Human Services. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity
in adults: the evidence report. Bethesda, MD: US Department of Health and Human Services, Public Health Service, National Institutes of
Health, National Heart, Lung, and Blood Institute Obesity Education Initiative; 1998. (NIH) 98-4083.
McTigue KM, Harris R, Hemphill B, et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S.
Preventive Services Task Force. Ann Intern Med 2003;139:933--49.
Kramer MS. Energy/protein restriction for high weight-for-height or weight gain during pregnancy. Cochrane Database Syst
Institute of Medicine. Nutrition during pregnancy: part I: weight gain. Washington, DC: National Academy Press; 1990.
Nawaz H, Katz DL. American College of Preventive Medicine Practice Policy statement. Weight management counseling of overweight adults.
Am J Prev Med 2001;21:73--8.
American College of Obstetricians and Gynecologists Committee on Practice Bulletins. Obstetrics: thrombembolism in pregnancy. Int J
Gynaecol Obstet 2001;75:203--12.
Ressel GW. ACOG practice bulletin on preventing deep venous thrombosis and pulmonary embolism. Am Fam Physician 2001;63:2279--80.
Hirsh J, Fuster V, Ansell J, Halperin JL. American Heart
Association/American College of Cardiology Foundation guide to warfarin therapy. J
Am Coll Cardiol 2003;41:1633--52.
US Department of Health and Human Services. Clinical practice guidelines: treating tobacco use and dependence. Washington, DC:
US Department of Health and Human Services, Public Health Service; 2000.
US Preventive Services Task Force. Counseling to prevent tobacco use and tobacco-caused disease: recommendation statement. Rockville, MD:
US Preventive Services Task Force, Agency for Healthcare Research and Quality; 2003.
Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental
tobacco smoke. Am J Prev Med 2001;20(Suppl 2):16--66.
American College of Obstetricians and Gynecologists. Smoking cessation during pregnancy. Obstet Gynecol 2005;106:883--8.
Institute of Medicine. The best intentions: unintended pregnancy and the well-being of children and infants. Washington, DC: National
Academy Press; 1995.
Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24--9, 46.
Moos MK, Bangdiwala SI, Meibohm AR, Cefalo RC. The impact of a preconceptional health promotion program on intendedness of
pregnancy. Am J Perinatol 1996;13:103--8.
Medical Research Council Vitamin Study Research Group. Prevention of neural tube defects: results of the Medical Research Council
Vitamin Study---MRC Vitamin Study Research Group. Lancet 1991;338:131--7.
Williams LJ, Rasmussen SA, Flores A, Kirby RS, Edmonds LD. Decline in the prevalence of spina bifida and anencephaly by race/ethnicity:
1995--2002. Pediatrics 2005;116:580--6.
Robbins JM, Cleves MA, Collins HB, Andrews N, Smith LN, Hobbs CA. Randomized trial of a physician-based intervention to increase the
use of folic acid supplements among women. Am J Obstet Gynecol 2005;192:126--32.
Wald NJ, Bower C. Folic acid and the prevention of neural tube defects. BMJ 1995;310:1019--20.
McElvy SS, Miodovnik M, Rosenn B, et al. A focused preconceptional and early pregnancy program in women with type 1 diabetes
reduces perinatal mortality and malformation rates to general population levels. J Matern Fetal Med 2000;9:14--20.
Kitzmiller JL, Gavin LA, Gin GD, Jovanovic-Peterson L, Main EK, Zigrang WD. Preconception care of diabetes: glycemic control
prevents congenital anomalies. JAMA 1991;265:731--6.
Jovanovic L, Nakai Y. Successful pregnancy in women with type 1 diabetes: from preconception through postpartum care. Endocrinol Metab
Clin North Am 2006;35:79--97.
Ray JG, O'Brien TE, Chan WS. Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a
meta-analysis. QJM 2001;94:435--44.
Diabetes Control and Complications Trial Research Group. Pregnancy outcomes in the Diabetes Control and Complications Trial. Am J Obstet Gynecol 1996;174:1343--53.
Willhoite MB, Bennert HW Jr, Palomaki GE, et al. The impact of preconception counseling on pregnancy outcomes: the experience of the
Maine Diabetes in Pregnancy Program. Diabetes Care 1993;16:450--5.
Koch R, Wenz E, Bauman C, et al. Treatment outcome of maternal phenylketonuria. Acta Paediatr Jpn 1988;30:410--6.
Brenton DP, Tarn AC, Cabrera-Abreu JC, Lilburn M. Phenylketonuria: treatment in adolescence and adult life. Eur J Pediatr
Cipcic-Schmidt S, Trefz FK, Funders B, Seidlitz G, Ullrich K. German Maternal Phenylketonuria Study. Eur J Pediatr 1996;155(Supl
Lumley J, Oliver SS, Chamberlain C, Oakley L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst
Ma Y, Goins KV, Pbert L, Ockene JK. Predictors of smoking cessation in pregnancy and maintenance postpartum in low-income women.
Matern Child Health J 2005;12:1--10.
Floyd RL, O'Connor MJ, Sokol RJ, Bertrand J, Cordero JF. Recognition and prevention of fetal alcohol syndrome. Obstet
Floyd RL, Ebrahim SH, Boyle CA, Gould DW. Observations from the CDC: preventing alcohol-exposed pregnancies among women
of childbearing age: the necessity of a preconceptional approach. J Womens Health Gend Based Med 1999;8:733--6.
Ingersoll K, Floyd L, Sobell M, Velasquez MM. Reducing the risk of alcohol-exposed pregnancies: a study of a motivational intervention
in community settings. Pediatrics 2003;111:1131--5.
Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease:
a randomized controlled trial. J Periodontol 2002;73:911--24.
Offenbacher S, Jared HL, O'Reilly PG, et al. Potential pathogenic mechanisms of periodontitis: associated pregnancy complications.
Ann Periodontol 1998;3:233--50.
Jarjoura K, Devine PC, Perez-Delboy A, Herrera-Abreu M, D'Alton M, Papapanou PN. Markers of periodontal infection and preterm birth. Am
J Obstet Gynecol 2005;192:513--9.
American Academy of Pediatrics. Guidelines for health supervision, III. Elk Grove Village, IL: American Academy of Pediatrics; 1997.
Anderson RT, Weisman CS, Scholle SH, Henderson JT, Oldendick R, Camacho F. Evaluation of the quality of care in the clinical care centers
of the National Centers of Excellence in Women's Health. Womens Health Issues 2002;12:309--26.
Rogers E. Diffusion of innovations. 3rd ed. New York, NY: Free Press; 1983.
Berwick DM. Disseminating innovations in health care. JAMA 2003;289:1969--75.
National Center for Health Statistics. Health, United States, 2005, with chartbook on trends in the health of Americans. Hyattsville, MD:
US Department of Health and Human Services, CDC, National Center for Health Statistics; 2005.
Agrey N, Crowe K, Levitt C, MacDonald J, MacLean D, Polomeno V. Preconception care. In: Hanvey L, ed. Family-centered maternity
and newborn care. Ottowa, Ontario, Canada: Minister of Public Works and Government Services; 2005:3.1--3.29.
Card JJ. Teen pregnancy prevention: do any programs work? Annu Rev Public Health 1999;20:257--85.
Andreasen A. Marketing and social change: changing behavior to promote health, social development, and the environment. San Francisco,
CA: Josey Bass; 1995.
Andreasen A. Marketing social marketing in the social change marketplace. J Public Policy Marketing 2002;21:3--13.
Rodgers BD, Rodgers DE. Efficacy of preconception care of diabetic women in a community setting. J Reprod Med 1996;41:422--6.
Grol R. Improving the quality of medical care: building bridges among professional pride, payer profit, and patient satisfaction.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775--9.
Ozer EM, Adams SH, Lustig JL, et al. Increasing the screening and counseling of adolescents for risky health behaviors: a primary
care intervention. Pediatrics 2005;115:960--8.
Maternal and Child Health Bureau and American Academy for Pediatrics. Bright Futures. Washington, DC: Maternal and Child Health
Bureau and American Academy for Pediatrics; 2005. Available at
A review of community health centers: issues and opportunities. Hearing before the Committee on Energy and Commerce, Subcommittee
on Oversight and Investigations, 111th Congress (May 25, 2005).
Health Disparities Collaboratives. Health Disparities Collaboratives. Rockville, MD: US Department of Health and Human Services,
Health Resources and Services Administration, Bureau of Primary Health Care; 2005. Available at
Kushner K, Ange E. Women's health: prevention and promotion. Washington, DC: National Institute for Health Care Management
National Committee for Quality Assurance. Checkups after delivery: improving program participation. Washington, DC: National Committee
for Quality Assurance; 2002.
MacDorman MF, Martin JA, Mathews TJ, Hoyert DL, Ventura SJ. Explaining the 2001--02 infant mortality increase: data from the linked
birth/infant death data set. Natl Vital Stat Rep 2005;53:1--22.
Mercer BM, Goldenberg RL, Moawad AH, et al. The preterm prediction study: effect of gestational age and cause of preterm birth on
subsequent obstetric outcome: National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet
Surkan PJ, Stephansson O, Dickman PW, Cnattingius S. Previous preterm and small-for-gestational-age births and the subsequent risk
of stillbirth. N Engl J Med 2004;350:777--85.
Kaiser Family Foundation. Women's health insurance coverage. Washington, DC: Kaiser Family Foundation; 2004.
Kaiser Family Foundation. Medicaid's role for women: issue brief on women's health policy. Washington, DC: Kaiser Family Foundation; 2004.
Kaiser Family Foundation. Medicaid: a critical source of support for family planning in the United States: issue brief on women's health
policy. Washington, DC: Kaiser Family Foundation; 2005.
Ross C, Cox L. Beneath the surface: barriers threaten to slow progress on expanding health coverage of children and families. Washington,
DC: Kaiser Family Foundation, Kaiser Commission on the Future of Medicaid and the Uninsured; 2004.
Gold R. Doing more for less: study says state Medicaid family planning expansions are cost effective. Guttmacher Rep Public Policy 2004;7:1--2.
Frost JJ, Frohwirth L, Purcell A. The availability and use of publicly funded family planning clinics: U.S. trends, 1994--2001. Perspect Sex
Reprod Health 2004;36:206--15.
Bartlett S, Olvera R, Bobronnikov E, et al. WIC participant and program characteristics, 2002, WIC-03-PC. Alexandria, VA: US Department
of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation; 2003.
US Department of Health and Human Services. From data to action: CDC's public health surveillance for women, infants, and
children. Washington, DC: US Department of Health and Human Services, Public Health Service; 1994.
Grosse SD, Sotnikkov SV, Leatherman S, Curtis M. The business case for preconception care: methods and issues. Matern Child Health J. In
Jiles R, Hughes E, Murphy W, et al. Surveillance for certain health behaviors among states and selected local areas---Behavioral Risk
Factor Surveillance System, United States, 2003. MMWR 2005;54:1--116.
Groves RM, Benson G, Mosher WD, et al. Plan and operation of Cycle 6 of the National Survey of Family Growth. Vital Health Stat
Burns PG. Reducing infant mortality rates using the perinatal periods of risk model. Public Health Nurs 2005;22:2--7.
Misra DP, Grason H, Liao M, Strobino DM, McDonnell KA, Allston AA. The nationwide evaluation of fetal and infant mortality review
(FIMR) programs: development and implementation of recommendations and conduct of essential maternal and child health services by FIMR
programs. Matern Child Health J 2004;8:217--29.
National Committee for Quality Assurance. HEDIS 1999: technical specifications. Washington, DC: National Committee for Quality
External Partner Organizations
American Academy of Family Physicians (AAFP)
American Academy of Pediatrics (AAP)
American College of Nurse-Midwives (ACNM)
American College of Obstetricians and Gynecologists(ACOG)
American College of Osteopathic Obstetricians and Gynecologists (ACOOG)
American Osteopathic Association (AOA)
Association of Asian Pacific Community Health Organizations (AAPCHO)
Association of Maternal and Child Health Programs(AMCHP)
Association of State and Territorial Health Officials(ASTHO)
Associations of Women's Health, Obstetric and Neonatal Nurses (AWHONN)
Healthy Start Coalition of Miami-Dade
March of Dimes (MOD)
March of Dimes Advisory Council
Maternity Center Association (MCA)
National Alliance for Hispanic Health
National Association of Community Health Centers(NACHC)
National Association of County and City Health Officials (NACCHO)
National Birth Defects Prevention Network (NBDPN)
National Foundation for Infectious Diseases
National Healthy Mothers, Healthy Babies Coalition
National Healthy Start Association (NHSA)
National Hispanic Medical Association (NHMA)
National Medical Association (NMA)
National Partnership to Help Pregnant Smokers Quit; Smoke-Free Families
National Perinatal Association (NPA)
National Society of Genetic Counselors (NSGC)
Society for Maternal Fetal Medicine (SMFM)
Task Force for Child Survival and Development
The Jacobs Institute for Women's Health (JIWH)
CDC/ATSDR Preconception Care Work Group
Agency for Toxic Substances and Disease
Registry: Robert H. Johnson,MD,Division of Health Education and Promotion.
CDC Office of the Director:
Yvonne Green, MSN, Office of Women's Health.
Coordinating Center for Environmental Health and Injury
Prevention: Elizabeth H. Howze, ScD, Office of the Director.
National Center for Chronic Disease Prevention and Health
Promotion: Carmen Ayala, Division of Adult and Community Health; Linda
Bradley, PhD, Office of Genetics and Disease Prevention; William M. Callaghan, MD, Division of Reproductive Health; Paul Idahosa Eke, PhD, Division of
Oral Health; Carol McGowen, MPH, Division of Nutrition and Physical Activity; Michelle D. Owens, PhD, Division of Diabetes Translation; Samuel
F. Posner, PhD, Division of Reproductive Health; Abby C. Rosenthal, MPH, Office on Smoking and Health; Tishia G. Smith, MPH, Division of
Reproductive Health; Mary Vernon-Smiley, Division of Adolescent and School Health.
National Center for Health Marketing:
MPH,Division of Private and Public Partnerships.
National Center for HIV, STD, and TB
Prevention: John Anderson, PhD, Division of HIV/AIDS Prevention; Margaret A. Lampe, MPH, Division
of HIV/AIDS Prevention; Cathleen M. Walsh, DrPH, Division of STD Prevention. National Center for Infectious Diseases:
Stephanie Schrag, PhD, Division of Bacterial and Mycotic Diseases; Susan A. Wang, MD, Division of
Viral Hepatitis. National Center on Birth Defects and Developmental
Disabilities: Myron Adams, MD, Office of the Director; Hani K. Atrash, MD, Office of
the Director; Michele G. Beckman, MPH, Division of Hereditary Blood Disorders; Adam Brush, MPH, Office of the Director; José F. Cordero, MD,
Office of the Director; Nicole Dowling, PhD, Division of Hereditary Blood Disorders; Shahul Ebrahim, Division of Birth Defects and Developmental
Disabilities; Erika L. Edding, Office of the Director; Elizabeth M. Fassett, MS, Division of Human Development and Disability; R. Louise Floyd, DSN, Division
Birth Defects and Developmental Disabilities; Scott Grosse, PhD, Office of the Director; Namita S. Joshi, MA, Office of the Director; Joe Mulinare,
MD, Division of Human Development and Disability; Christopher S. Parker, PhD, Office of the Director; Christine E. Prue, PhD, Office of the
Director; Danielle S. Ross, PhD, Division of Human Development and Disability; JoAnn M. Thierry, PhD, Division of Human Development and Disability.
National Immunization Program:
Susan Reef, MD, Division of Epidemiology and Surveillance.
U.S. Department of Health and Human Services Partners
Agency for Healthcare Research and Quality:
Susan Meikle, MD, Center for Outcomes and Evidence.
Health Resources and Services
Administration: Lisa R. King, MA, Maternal and Child Health Bureau.
National Institutes for Health:
Catherine Y. Spong, MD, National Institute for Child and Health and Human Development.
Office of Public Health and Science:
Wanda K. Jones, DrPH, Office on Women's Health.
Select Panel on Preconception Care
Hani Atrash, MD, National Center on Birth Defects and Developmental Disabilities, CDC; Greg R. Alexander, ScD, College of Medicine, University of
South Florida, Tampa, Florida; Maribeth Badura, MPH, Maternal and Child Health Bureau, Health Resources and Services Administration, Washington, District
of Columbia; Peter Bernstein, MD, Albert Einstein College of Medicine, Bronx, New York; Janis Biermann, MS, March of Dimes, White Plains, New York; Kim
A. Boggess, MD, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Joseph N. Bottalico, DO, American Osteopathic
Association/American College of Osteopathic Obstetricians and Gynecologists, Fort Worth, Texas; Sheree Boulet, DrPH, National Center on Birth Defects and
Developmental Disabilities, CDC; Carol Brady, MA, Northeast Florida Healthy Start Coalition, Jacksonville, Florida; Al Brann, Jr., MD, Emory University School of
Medicine, Atlanta, Georgia; Magdalena Castro-Lewis, National Alliance for Hispanic Health, Washington, District of Columbia; Robert Cefalo, MD, University of
North Carolina, Chapel Hill, North Carolina; José F. Cordero, MD, National Center on Birth Defects and Developmental Disabilities, CDC; Arlene Cullum,
MPH, Sutter Medical Center, Sacramento, California; Michele Curtis, MD, University of Texas-Houston Health Science Center, Houston, Texas; Susan
Halebsky Dimock, PhD, Jacobs Institute of Women's Health, Washington, District of Columbia; Anne Lang Dunlop, MD, Emory University School of Medicine,
Atlanta, Georgia; Margaret Comerford Freda, EdD, Albert Einstein College of Medicine, Bronx, New York; Keith A. Frey, MD, Mayo Clinic, Scottsdale, Arizona;
David Grainger, MD, University of Kansas School of Medicine, Wichita, Kansas; Holly Grason, MA, John Hopkins Bloomberg School of Public Health,
Baltimore, Maryland; Maxine Hayes, MD, Washington State Department of Health, Olympia, Washington; Jennifer Hoskovec, MS, University of Texas Medical
School Houston, Houston, Texas; Brian Jack, MD, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts; Carole Johnson, MA,
Alliance of Community Health Plans, Washington, District of Columbia; Kay Johnson, MEd, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire;
Wanda K. Jones, DrPH, Office on Women's Health, US Department of Health and Human Services, Washington, District of Columbia; Lois Jovanovic, MD,
Sansum Diabetes Research Institute, Santa Barbara, California; Lorraine Klerman, DrPH, Brandeis University Waltham, Massachusetts; Ann M. Koontz, Maternal
and Child Health Bureau, Health Resources and Services Administration, Washington, District of Columbia; Carol Korenbrot, PhD, University of California,
San Francisco, California; Milton Kotelchuck, PhD, Boston University School of Public Health, Boston, Massachusetts; George Little, MD,
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Charles S. Mahan, MD, University of South Florida, Tampa, Florida; Melissa McDiarmid, MD, University
of Maryland School of Medicine, Baltimore, Maryland; Susan Meikle, MD, Agency for Healthcare Research and Quality, Washington, District of Columbia;
Cathy L. Melvin, PhD, University of North Carolina, Chapel Hill, North Carolina; Merry K. Moos, MPH, University of North Carolina, Chapel Hill, North
Carolina; Anne Marie Murphy, PhD, Illinois Department of Public Aid, Springfield, Illinois; Christopher S. Parker, PhD, National Center on Birth Defects and
Developmental Disabilities, CDC; Magda Peck, ScD, CityMatCH, Omaha, Nebraska; Annette Phelps, Florida Department of Health, Tallahassee, Florida; Albert
Pizzica, National Perinatal Association, Harrisburg, Pennsylvania; Samuel F. Posner, PhD, National Center for Chronic Disease Prevention and Health Promotion,
CDC; Winston Price, MD, National Medical Association, Washington, District of Columbia; Elena Rios, MD, National Hispanic Medical Association,
Washington, District of Columbia; Sara Rosenbaum, JD, George Washington University Medical Center, Washington, District of Columbia; Anne Santa-Donato,
MSN, Association of Women's Health, Obstetric and Neonatal Nurses, Washington, District of Columbia; Catherine Y. Spong, MD, National Institute for Child
and Health and Human Development, National Institutes of Health, Washington, District of Columbia; Ann Weathersby, Kaiser Permanente, Lithonia,
Georgia; Carol S. Weisman, PhD, Pennsylvania State College of Medicine, State College, Pennsylvania; Katharine Wenstrom, MD, University of Alabama at
Birmingham, Birmingham, Alabama; Terri D. Wright, W.K. Kellogg Foundation, Battle Creek, Michigan.
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