Women's Preconceptional Health and Use of Health Services: Implications for Preconception Care

Strategies to prevent adverse pregnancy outcomes by improving the health of women before they become pregnant are receiving increased attention for a number of important reasons. Most significantly, rates of preterm and low birthweight births continue to rise in the United States, despite increasing use of prenatal care services (Hoyert et al. 2006). This suggests that interventions after pregnancy occurs do not optimally address risks for adverse pregnancy outcomes that have been shown to be prevalent among women before pregnancy (Anderson et al. 2006; Weisman et al. 2006). In addition, nearly half of all U.S. pregnancies are unintended (Henshaw 1998), suggesting that many women may not realize they are pregnant in time to obtain early prenatal care, initiate preventive measures such as folic acid supplementation, or take steps to address preexisting health problems. In recognition of these issues, professional associations have published guidelines for the health care of women before the first pregnancy and between pregnancies, emphasizing the importance of pregnancy planning and preconceptional health promotion to improve pregnancy outcomes for both mother and baby (American Academy of Pediatrics and American College of Obstetricians and Gynecologists 2002; American Diabetes Association 2002; American College of Obstetricians and Gynecologists 2005; Freda, Moos, and Curtis 2006). Most recently, the Centers for Disease Control and Prevention (CDC) released recommendations to improve preconceptional health and health care (Centers for Disease Control and Prevention 2006). The purpose of this study is to address how pre- and interconceptional women with specific health needs use health services. Little research has addressed this topic. Both the fragmentation of health care delivery and the lack of universal health insurance are impediments to comprehensive coordinated health care for reproductive-age women in the United States. Women access both generalist physicians (internists and family physicians) and obstetrician–gynecologists for primary care services, and these physicians differ in the services they provide (Henderson, Weisman, and Grason 2002; Scholle et al. 2002; Salganicoff, Ranji, and Wyn 2005). Family planning and prenatal care services often are provided in specialized centers including Federally Qualified Health Centers (National Association of Community Health Centers 2004). The responsibility for providing preconceptional care, as it includes assessment of multiple health conditions and risks in the context of reproductive life stages, is ambiguous at best. Accessing such care is problematic not only because it is unclear from whom it may be obtained but also because it may not be covered by health insurance. Medicaid targets women after they have become pregnant up to 60 days postdelivery, unless women qualify for health benefits for other categorical or financial reasons; this means that many poor and low-income women are not likely to have coverage for health care before or between pregnancies. A recent study estimated that 36.5 percent of women who had Medicaid payment for childbirth in 1998–2000 had no prepregnancy Medicaid coverage (Handler et al. 2006). Even among women with private health insurance, the lack of billing codes associated with preconception services presents a barrier for many providers who might otherwise offer these services. The research base on utilization of preconception care is scant, and the information that is available suggests that recommended preconception care is not widely provided. For example, Bernstein, Sanghvi, and Merkatz (2000) found in reviewing patient records that gynecological providers commonly missed opportunities for preconceptional health promotion during routine gynecological visits, as evidenced by failure to document medical histories, prescription drug use, and dietary supplements. Similarly, a survey of reproductive-aged women sponsored by the March of Dimes revealed that elements of preconceptional care such as counseling about folic acid supplementation are often not addressed during preventive visits (March of Dimes Birth Defects Foundation 2004). Only one in four women surveyed reported receiving folic acid information from a health care provider. Among those women not currently taking vitamin supplements on a daily basis, 89 percent said they would be likely to take a multivitamin if advised to do so by their health care provider, suggesting that greater attention to health counseling in the preconception period could facilitate significant health improvement. Finally, a recent survey of 499 patients in primary care practices found that 56 percent were very or somewhat interested in receiving preconceptional health education (Frey and Files 2006). Conceptualizing the possible determinants of the use of health services for preconceptional care is challenging. While preconceptional health care may be viewed as a type of preventive care, in that a goal is to prevent adverse pregnancy outcomes for the woman and for the infant, the preventive aspects may not be apparent to women. The fact that about half of U.S. pregnancies are unplanned suggests that women do not necessarily think of themselves as “preconceptional” even if they are capable of reproduction or are contemplating a pregnancy at some time in the future. The Behavioral Model of Health Services Use (Andersen 1968, 1995) conceptualizes use of ambulatory health services as a function of three types of variables at the individual level: need (such as symptoms, risks to health, and general state of health, which may be perceived by the individual or evaluated by health professionals); predisposing characteristics (such as age, education, and health beliefs, which affect, for example, individuals' awareness of health care availability or effectiveness); and enabling resources (such as income and health insurance or social relationships, which affect individuals' ability to access health care). In this framework, use of preconceptional care would be conceptualized as a function not only of health problems and risks that might affect pregnancy outcomes, but also of predisposing and enabling variables relevant to women at this reproductive life stage. To the extent that health care needs relevant to pregnancy outcomes do not determine use of health care by pre- and interconceptional women, unmet needs for care are likely to exist. This paper uses a unique population-based data set to address the health status and health risks of pre- and interconceptional women, and how these health-related needs are associated with use of health services of various kinds, taking relevant predisposing and enabling variables into account. More specifically, the research investigates whether there is evidence of underutilization of care for specific types of health problems that are known risks for adverse pregnancy outcomes.