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

Several providers 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 users).

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 (147).

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 health 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 (78), respectively.

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) (121).

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 with interventions.

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 promoting 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 was 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 outcomes.

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.

Recommendations

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 to 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 outcomes (20).

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 (156).

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 (157).

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 is designed to influence the voluntary behavior of targeted audiences to improve their well-being (159,160).

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 and vaccinations; 9) family planning; and 10) social and mental health concerns (e.g., depression, social support, domestic violence, and housing) (5--7,30,31,33,40,41).

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 evidence and 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 care (165).

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 every 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 promising strategies 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 projects prepared 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 millions of women each year. Preconception interventions can be incorporated into these programs to target women at highest risk. Title X family 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 promotion 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 (44,187).

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 to clinical 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 preconception health.

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 (190,192--194).

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 (175).

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).

Conclusion

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 6) 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 risks.

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.

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Appendix

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)

CityMatCH

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: Lisa Koonin, 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 of 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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Date last reviewed: 4/6/2006