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Preconception Counseling: Delivering the Promise of Healthy Mothers and Babies
Evidence of benefit is clear, but preconception care has yet to become routine.
Each year, 3% of U.S. births — more than 120,000 infants — are affected by birth defects (MMWR Morb Mortal Wkly Rep 2008; 57:1). To limit the number of families affected by such congenital anomalies, the CDC has published recommendations for improving the health of women before and during early pregnancy (MMWR Morb Mortal Wkly Rep 2006; 55:1), and the Institute of Medicine has recently identified preconception care as a core component of preventive healthcare for women (IOM. 2011. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press). Nonetheless, receipt of prepregnancy health counseling is reported by less than one third of U.S. women who give birth (MMWR Surveill Summ 2007; 56:1), and substantial racial and ethnic disparities in receipt of such guidance remain an issue (MMWR Surveill Summ 2004; 53:1).
CONTRACEPTION
Helping women prepare for pregnancy is challenging, because nearly half of U.S. pregnancies are unintended (JW Womens Health Apr 19 2007). Therefore, facilitating use of effective, easy-to-use contraception until a woman is ready for pregnancy is an integral part of preconception care. Intrauterine or implantable contraceptives are the most effective options. These methods have high rates of user satisfaction (JW Womens Health May 12 2011) yet are chosen by less than 6% of contraceptive users (JW Womens Health Jun 23 2011), many of whom have never heard of them. Clinician counseling can play an important role in encouraging women to use highly effective reversible contraception while preparing for pregnancy. In addition, clinicians can help prevent unintended pregnancy by providing patients who opt for combined hormonal contraception with 12-month supplies (JW Womens Health Apr 7 2011).
FERTILITY PRESERVATION AND AWARENESS
Routine screening for chlamydia and prompt treatment of infection can help prevent pelvic adhesive disease that can cause infertility. In addition, couples should be aware of when during a woman's cycle she is most fertile and should know that, as women approach age 35, fertility wanes and risk for pregnancy complications rises.
FOLATE SUPPLEMENTATION
Neural tube defects can be prevented by adequate maternal consumption of folate around the time of conception (JW Womens Health May 28 2009); thus, all women of reproductive age (especially those who are not using effective contraception) should take daily folate supplements or multivitamins. Although these supplements are inexpensive, safe, and available over the counter, preventable neural tube defects continue to affect more than 3000 U.S. pregnancies annually, in part because many women remain unaware that folate supplements should be taken before pregnancy (MMWR Morb Mortal Wkly Rep 2008; 57:5). Accordingly, counseling about the benefits of daily folate supplementation is a key component of preconception care.
VACCINES
Before becoming pregnant, women should be up-to-date on all recommended adult immunizations, particularly those against rubella and varicella. In addition, women who become pregnant during flu season should receive inactivated flu vaccine, because pregnant women who contract influenza face serious complications (JW Womens Health Sep 30 2010). Maternal influenza immunization can lower the likelihood of prematurity and small-for-gestational-age infants.1 Nonetheless, in 2009, only one third of pregnant women in the U.S. were vaccinated against influenza.2
OPTIMIZING MATERNAL HEALTH
Maternal obesity raises risk for cesarean delivery, preeclampsia, preterm delivery, stillbirth, and obesity-related disorders in offspring.3,4 Women who are overweight (body-mass index [BMI] 25.0 kg/m2) or obese (BMI 30.0) should be encouraged to lower their risk for adverse pregnancy outcomes by endeavoring to reach a healthy weight before becoming pregnant. This is a substantial public health challenge, as obesity during reproductive age now affects more than 35% of U.S. women overall5 and more than half of black women (MMWR Morb Mortal Wkly Rep 2009; 58:740).
Health-related behaviors other than diet and exercise also are relevant as women prepare for pregnancy. Maternal smoking raises risk for stillbirth (JW Womens Health May 12 2011), and alcohol intake adversely affects fetal development.6 Although quitting smoking, drinking, and recreational drug use before conceiving is ideal, women who do not manage to do so should be encouraged to strive for abstinence throughout their pregnancies.7
Birth defects occur in 5% to 8% of offspring of women with diabetes,8 more than twice the rate in the general population. With tight glycemic control before and during pregnancy, rates of congenital malformations and birth trauma can be minimized.9 In addition, hypothyroidism must be well controlled prior to pregnancy.10
USE OF POTENTIALLY TERATOGENIC MEDICATIONS
Each year, reproductive-age women in the U.S. receive 12 million prescriptions for potentially teratogenic medications (table).11 Although many women depend on their clinicians to inform them about which medications pose risks to pregnancy,12 <20% of women who are prescribed potentially teratogenic medications in ambulatory care settings receive contraceptive counseling.11 As a result, approximately 6% of pregnancies are exposed to potentially teratogenic medications (JW Gen Med Oct 19 2004).
GENETIC SCREENING
Some families might benefit from screening for and counseling about certain genetic conditions (e.g., sickle cell anemia, thalassemia, Tay-Sachs disease, cystic fibrosis).
INTIMATE PARTNER VIOLENCE
Women and their clinicians should be aware that intimate partner violence can be exacerbated by pregnancy (JW Womens Health Oct 2 2008).
SYSTEM-BASED APPROACHES TO PRECONCEPTION COUNSELING
To facilitate provision of effective preconception and early-pregnancy care, clinicians must engage women and their partners in planning for pregnancy. Practice-based registries and electronic health records that include reminders to provide preconception counseling on an annual basis can be useful tools, but, in many cases, the first step is to ask, "When, if ever, do you hope to become pregnant?"
— Eleanor Bimla Schwarz, MD, MS
Published in Journal Watch Women's Health August 18, 2011
Citation(s):
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Medline abstract (Free)
2. Ding H et al. Influenza vaccination coverage among pregnant women — National 2009 H1N1 Flu Survey (NHFS). Am J Obstet Gynecol 2011 Jun; 204:Suppl 1:S96. ([
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Medline abstract (Free)
3. Catalano PM and Ehrenberg HM. The short- and long-term implications of maternal obesity on the mother and her offspring. BJOG 2006 Oct; 113:1126. ([
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5. Ogden CL et al. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006 Apr 5; 295:1549.
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6. Carson G et al. Alcohol use and pregnancy consensus clinical guidelines. J Obstet Gynaecol Can 2010 Aug; 32
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8. Weintrob N et al. Short- and long-range complications in offspring of diabetic mothers. J Diabetes Complications 1996 Sep/Oct; 10:294.
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9. Willhoite MB et al. The impact of preconception counseling on pregnancy outcomes: The experience of the Maine Diabetes in Pregnancy Program. Diabetes Care 1993 Feb; 16:450.
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10. Reid SM et al. Interventions for clinical and subclinical hypothyroidism in pregnancy. Cochrane Database Syst Rev 2010 Jul 7; 7:CD007752. ([
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Medline abstract (Free)
11. Schwarz EB et al. Prescription of teratogenic medications in United States ambulatory practices. Am J Med 2005 Nov; 118:1240. ([
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Medline abstract (Free)
12. Santucci AK et al. Women's perspectives on counseling about risks for medication-induced birth defects. Birth Defects Res A Clin Mol Teratol 2010 Jan; 88:64. ([
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