Preconception Care and Women with or at Risk for Diabetes : Implications for Community Intervention Introduction Diabetes is a chronic and , often , disabling disease , which has reached epidemic proportions in America and worldwide . When a person has diabetes their body can not produce or properly use insulin -- a hormone needed to convert sugar , starches , and other foods into energy . This leads to high levels of sugar in the bloodstream , which can result in serious complications and premature death , if diabetes is not controlled . There are three main types of diabetes -LSB- 1 -RSB- . In type 1 diabetes , the body does not produce any insulin ; daily injections of insulin are required for survival . Typically beginning in childhood or young adulthood , type 1 accounts for approximately 5 -- 10 % of all cases of diabetes . Autoimmune , genetic , and environmental factors influence type 1 diabetes risk -LSB- 1 -RSB- . In type 2 diabetes , which accounts for 90 -- 95 % of all diagnosed cases , the body 's cells do not secrete or use insulin adequately . Risk factors for type 2 diabetes include obesity , physical inactivity , family history of diabetes , and history of gestational diabetes -LRB- GDM -RRB- . GDM , defined as diabetes that develops or is first recognized during pregnancy , is the third type of diabetes . Risk factors for GDM include obesity , pregnancy weight gain , age , and family history of diabetes -LSB- 1 -- 5 -RSB- . In the weeks after pregnancy , 5 -- 10 % of women who had GDM are diagnosed with type 2 diabetes -LSB- 1 -RSB- . Subsequently , women with a history of GDM have a 20 -- 50 % chance of developing type 2 diabetes five to 10 years after the index pregnancy , with a lifetime risk near 80 % -LSB- 1 , 4 -- 7 -RSB- . Both type 2 diabetes and GDM are diagnosed more frequently in African Americans , Hispanic/Latino Americans , and American Indians compared to non-Hispanic whites -LSB- 1 -RSB- . National Health and Nutrition Examination Survey III data for nonpregnant women aged 20 -- 49 years indicate that during the period 1988 -- 1994 , 27.6 % of Mexican American women and 22.4 % of African American women of childbearing age had diabetes or impaired glucose tolerance , in comparison to 10.1 % of non-Hispanic white women -LSB- 8 -RSB- . Approximately one third of women of childbearing age have undiagnosed diabetes -LSB- 9 -RSB- . Additionally , between 3 and 8 % of pregnant women have gestational diabetes -LRB- GDM -RRB- -LSB- 2 , 3 , 9 , 10 -RSB- . A study of women with pregestational diabetes -LRB- type 1 and type 2 -RRB- found that 60 % of the women had suboptimal glucose control before conception -LSB- 11 -RSB- . Women who had a poor outcome in a previous pregnancy were more likely to enter a subsequent pregnancy with poor glucose control then were women with good outcomes -LSB- 11 -RSB- . Diabetes during pregnancy is associated with increased risk for miscarriages , stillbirth , macrosomia and obstetric complications -LSB- 12 -- 16 -RSB- , intrauterine developmental and growth abnormalities , birth and neonatal complications , and later development of obesity and type 2 diabetes -LSB- 3 , 10 -- 15 , 17 , 18 -RSB- . Treatment to normalize maternal blood glucose prior to conception and throughout pregnancy is necessary to reduce the likelihood of maternal , obstetric , and infant complications -LSB- 12 -- 16 -RSB- . While treatment and monitoring are common practice during prenatal care , many women and their families may not know about the importance or even the existence of preconception care interventions for women of childbearing age who have or are at risk for diabetes . Greater awareness of the potential contribution of preconception care to diabetes prevention and control may help reduce the devastating impact of diabetes and its complications on the lives of women and their families . The objectives of this paper are to : 1 -RRB- review barriers that can impede a woman 's ability to receive preconception care , and 2 -RRB- recommend novel interventions to reach reproductive-aged women with or at risk for diabetes . Prevention trials have demonstrated that type 2 diabetes and its complications can be prevented or at least delayed through healthful dietary practices , regular moderate physical activity , weight loss , and medication use -LSB- 19 , 20 -RSB- . The clinical practice guidelines of the American College of Obstetrics and Gynecologists -LSB- 21 -RSB- and the American Diabetes Association -LSB- 15 -RSB- suggest that preconception care is an ideal primary prevention opportunity during which modifiable risk factors can be identified and reduced . Preconception care may be defined as a window of opportunity for comprehensive health care to : 1 -RRB- identify conditions that may have detrimental effects on the mother or fetus , and 2 -RRB- recommend necessary medical , behavioral , and educational interventions for increasing the likelihood of achieving optimal pregnancy outcomes . A major goal of preconception care for women with diabetes is to reduce the risk of diabetes-related complications by obtaining the lowest possible glycated hemoglobin -LRB- HbA1C -LSB- a measure of glucose control -RSB- -RRB- without significant episodes of hypoglycemia -LSB- 15 -RSB- . Women with diabetes who receive preconception care obtain intensive treatment to assist them with developing diabetes self-management skills , and obtaining nutritional , physical activity , and medical support needed to promote optimal glucose control and health status before becoming pregnant . During interconception periods , diabetes education , postpartum glucose testing , and ongoing support to reduce postpartum weight retention and maintain a healthy weight and glucose control may also help reduce risk factors for subsequent morbidity -LSB- 3 , 19 , 24 -RSB- . Previous studies have found that women with diabetes who received preconception care demonstrated improved glucose control during pregnancy , their offspring had fewer congenital anomalies , and the women 's hospital stays were shorter in comparison with women who did not receive preconception care -LSB- 25 -- 27 -RSB- . Although these findings are very positive and they support the importance of preconception care for women with diabetes , other studies have indicated that many women who could benefit from preconception care are not receiving this intervention -LSB- 25 , 28 -RSB- . Barriers to receiving preconception care At every health care encounter , a woman of childbearing age should be informed about the importance of preconception care and , if she has diabetes , the steps required to maintain appropriate blood glucose control -LSB- 15 , 28 , 29 -RSB- . Unfortunately , however , reaching women who may be in need of preconception care has proven to be difficult , with only a quarter to a third of women with diagnosed diabetes receiving this care -LSB- 25 , 28 -RSB- . There are many barriers to providing and/or receiving preconception care . Among them are : 1 -RRB- Many women with diabetes do not know that they have the illness and , thus , they are undiagnosed -LSB- 1 -RSB- , 2 -RRB- Approximately 50 % of all pregnancies are unintended -LSB- 28 , 30 , 31 -RSB- , 3 -RRB- Even among women planning to become pregnant , lack of health insurance or a regular care primary care or obstetric provider reduces contact with the health care system -LSB- 32 -- 34 -RSB- , 4 -RRB- Many primary care practices do not have or use established guidelines for providing preconception care , or identifying women with risk factors -LSB- 32 , 34 -RSB- , 5 -RRB- Some women and health care providers may not know about about the existence or the importance of preconception care or do not see it as a high priority -LSB- 15 , 32 , 34 , 35 -RSB- , and 6 -RRB- Women with incomplete health care coverage , lack of child care or transportation , geographic isolation , distrust of health care providers or other social and economic challenges have additional barriers to receiving preconception care -LSB- 15 , 32 , 34 -- 36 -RSB- . Women are more likely to receive preconception care if they are married or in a stable relationship , are comparatively older , are nonsmokers , are non-Hispanic whites , are more educated , have annual incomes above $ 20,000 , have private medical insurance , and have a positive bond with their prepregnancy care provider -LSB- 25 , 26 , 28 , 33 , 35 -RSB- . Younger women with diabetes and those who are single , have low income , or are less educated may be particularly vulnerable to unplanned pregnancies , which greatly reduces the chances that they will receive any form of diabetes-related preconception counseling -LSB- 16 , 32 , 36 -RSB- . Interventions to reach women of childbearing age with diabetes Since the establishment of preconception care programs , health care centers have employed numerous marketing approaches geared toward physicians , and for patients in need of preconception care intervention . Janz et al. -LSB- 28 -RSB- identified marketing approaches which were employed in five Michigan medical centers to encourage the use of preconception care programs in treating high-risk women . These included journal advertisements , newsletters , brochures , flyers , posters , and patient education programs . However , the results of these outreach efforts were `` generally disappointing -LSB- 28 -RSB- . '' In a Maine study , a diabetes registry was developed to promote the availability of preconception care programs -LSB- 27 -RSB- . In addition , health care providers formed a network to enhance the care of pregnant women using locally developed patient care guidelines . From 1987 -- 1990 , there were a total of 185 pregnancies in women with diagnosed diabetes . Of the total pregnancies , only 34 % of these women received preconception care . These findings support those of Janz et al. -LSB- 28 -RSB- , which demonstrate that very few women with diabetes are receiving preconception care . Additional innovative strategies are needed to increase awareness of the availability of preconception care . Novel interventions to reach reproductive-aged women with or at risk of diabetes The National Public Health Initiative on Diabetes and Women 's Health -LRB- cosponsored by the American Diabetes Association , the American Public Health Association , the Association of State and Territorial Health Officials , and the Centers for Disease Control and Prevention -RRB- is a partnership devoted to increasing public and provider awareness of the importance of interventions such as preconception care in the prevention and management of diabetes for women -LSB- 37 , 38 -RSB- . Using a life stage approach , the Initiative 's cosponsors and partners developed and disseminated a national action plan , The National Agenda for Public Health Action -LSB- 39 -RSB- , to identify 10 priority action steps to improve the lives of women with or at risk of diabetes , from adolescence to the older years -LRB- see Table 1 -RRB- . The National Agenda serves as a blueprint to guide the nation in implementing strategies related to diabetes and women 's health . Given the devastating effects that diabetes can have on women 's health , the National Agenda recognizes and identifies the need for effective interventions , such as quality health care and programs , public health research and surveillance , and specific policies to address the burden of this chronic illness on the lives of women and their families -LSB- 37 , 38 -RSB- . Table 1The National Agenda 's 10 priority recommendations for action1 . Encourage and support diabetes prevention and control programs in state health departments to develop prevention programs for all women and establish efficient links for women at risk for type 2 diabetes2 . Expand community-based health promotion , education , activities , and incentives for all ages in a wide variety of settings -- schools , workplaces , senior centers , churches , and other locations where women live , learn , work , and play3 . Strengthen advocacy on behalf of women with or at risk for diabetes4 . Fortify community programs for women with sufficient training , tools , and materials5 . Expand population-based surveillance to monitor and understand : a. Variations in the distribution of diagnosed and undiagnosed diabetes b . The factors -- cultural , racial , ethnic , geographic , demographic , socioeconomic , and genetic factors -- that influence the risk for diabetes and complications among women at all life stages6 . Educate community leaders about diabetes and its management and about the value of healthy environments7 . Encourage healthcare providers to promote risk assessment , quality care , and self-management for diabetes and it complications in their practice settings8 . Ensure access to trained healthcare providers who offer quality services consistent with established healthcare guidelines9 . Encourage healthcare coverage and incentives for recommended diabetes prevention management practices by : a. Promoting partnerships between insurers and workplaces or labor communities and encouraging employers and employees to discuss needed diabetes benefits in offered health care packages b. Working with health insurers and policymakers to expand coverage and reimbursement policies to include prevention services for women throughout their lives10 . Conduct public health research to further our knowledge about the epidemiological , socioenvironmental , behavioral , translational , and biomedical factors that influence diabetes and women 's health Several of the National Agenda 's recommendations support the need for preconception care and follow-up care for women with or at risk for diabetes through community intervention efforts and policy development . These recommendations identify the need to : 1 -RRB- expand our outreach to communities where women live , learn , work , and play by offering health promotion , education , activities and other incentives ; 2 -RRB- provide sufficient funding , tools , training , and materials to fortify community programs that focus on women 's health needs ; 3 -RRB- educate community members and leaders about diabetes prevention and control and the roles that they can play in promoting healthy environments ; 4 -RRB- encourage healthcare providers to promote risk assessment and quality care for women , including preconception care ; and 5 -RRB- conduct public health research to better understand multiple factors that influence diabetes and women 's health . Community intervention and the involvement of community health workers One of the community-focused strategies from the National Agenda , is the need to `` identify and develop links with community agencies that interface with women at greatest risk for diabetes , including organizations in the non-health related sectors -LSB- 39 -RSB- . '' Given that preconception care programs have had difficulty reaching high-risk women , nontraditional approaches to outreach and preconception care should be explored -LSB- 32 , 36 -RSB- . Community health organizations and community health workers -LRB- CHWs -RRB- appreciate and understand the social , political , environmental , and cultural factors that affect individuals within their own neighborhoods and have the potential to influence the consumers ' relationship with the health care system -LSB- 33 -RSB- . They serve as `` bridges '' -- connecting community members who have traditionally lacked access to the appropriate services needed -LSB- 40 , 41 -RSB- . The Institute of Medicine -LRB- IOM -RRB- recommends supporting the use of CHWs . The IOM identifies CHWs as an integral component of the health care system that help to address racial and ethnic disparities in access to care -LSB- 41 , 42 -RSB- . Many community-based projects funded by the Centers for Disease Control and Prevention have included CHWs in community-based programs aimed at health intervention for people with diabetes -LSB- 43 -RSB- . Programs employing CHWs have reported that they improve access and health outcomes for persons with chronic diseases , including diabetes , particularly in minority and underserved populations -LSB- 44 -- 48 -RSB- . Although , no empirical studies have been published that assess the effectiveness or impact of CHWs in providing preconception care services for women with diabetes , CHWs have also played an important role in maternal and child health care . Thus , studying the methods for , and outcomes of an expanded role for CHWs with preconception outreach and education for women with , or at risk for diabetes , is recommended . Community health workers could play a vital role in linking women to preconception care services in the following manner : 1 -RRB- increasing women 's awareness about the importance of preconception care programs , 2 -RRB- providing culturally and linguistically appropriate diabetes-related health information and education , 3 -RRB- reminding women about scheduled health provider visits , 4 -RRB- providing a communication bridge linking women and providers in terms of patients ' needs and providers ' recommendations . The prevalence of diabetes among women of childbearing age is rising , particularly in communities with ethnic minorities and low resources -LSB- 4 , 8 -RSB- . There is a strong relationship between these conditions and adverse maternal , child and subsequent adult health outcomes . Assessing the processes and effects of preconception care interventions implemented by providers and CHWs , especially in those communities with varied ethnic and socioeconomic backgrounds , is a critical first step toward identifying and promoting effective preconception care -LSB- 18 , 49 -- 55 -RSB- .

B I O B O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O B O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O B O O O O O O O O O O O O O B O O O O O O O O B O O O O O B O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B I O O B O O O O O O O O O O B O O O O O O O O B I O B O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O B I O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O B I O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O B I O O O O O O O O O O O O O O O O O O B I O B O B O O O O O O O B O O O O B I O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O B I O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O B I O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O B I O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O B O B I O O O O O O O O O O O O O O O O O O B O B O O B I O O O O O O O O O O O O O B I O O O O O O B O O O O O B O O O O O O B O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O B I O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B I O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O B I O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O B O B I O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O


What

Obstetrician-Gynecologists

Think

of

Preconception

Care

Objectives

To

describe

obstetrician-gynecolog-ists

opinions

of

preconception

care

-LRB-

PCC

-RRB-

and

ascertain

patient

uptake

for

this

service

Methods

A

questionnaire

was

mailed

to

ACOG

members

in

August

Results

There

was

a

response

rate

Most

physicians

think

PCC

is

important

-LRB-

-RRB-

and

almost

always

recommend

it

to

women

planning

a

pregnancy

-LRB-

-RRB-

do

so

with

women

who

are

sexually

active

Around

a

third

-LRB-

-RRB-

thought

their

patients

usually

do

not

plan

their

pregnancies

and

said

very

few

pregnant

patients

came

in

for

PCC

Of

those

who

obtain

PCC

they

were

believed

to

do

so

more

likely

to

assure

a

healthy

pregnancy

-LRB-

-RRB-

than

because

of

an

elevated

risk

for

birth

defects

-LRB-

-RRB-

Of

issues

presented

cigarette

smoking

and

folic

acid

supplementation

were

rated

the

most

important

for

PCC

counseling

exercise

and

environmental

concerns

were

the

least

important

Conclusions

Physicians

are

willing

to

provide

PCC

but

few

patients

are

accessing

such

services

Introduction

When

poor

pregnancy

outcomes

occur

they

frequently

have

been

set

in

motion

long

before

the

first

prenatal

visit

Fortunately

many

of

the

factors

contributing

to

less

than

ideal

birth

outcomes

can

be

managed

and

brought

under

control

prior

to

conception

Preconception

care

-LRB-

PCC

-RRB-

consists

of

the

identification

of

those

conditions

that

could

affect

a

future

pregnancy

or

fetus

and

that

may

be

amenable

to

intervention

-LSB-

-RSB-

ACOG

recommends

that

all

health

encounters

during

a

woman

's

reproductive

years

particularly

those

that

are

a

part

of

PCC

should

include

counseling

on

appropriate

medical

care

and

behavior

to

optimize

pregnancy

outcomes

-LSB-

-RSB-

Through

PCC

physicians

can

advise

patients

on

numerous

behavioral

and

lifestyle

changes

ranging

from

exercise

and

weight

control

to

the

use

of

prescribed

medications

and

illicit

drugs

They

may

also

address

carrier

screening

for

heritable

genetic

disorders

and

the

options

available

for

helping

to

avoid

an

affected

birth

For

example

it

is

well

known

that

women

with

a

chronic

disease

such

as

diabetes

have

an

increased

risk

of

congenital

abnormalities

in

their

offspring

and

they

are

known

to

have

improved

birth

outcomes

when

they

plan

their

pregnancies

and

utilize

PCC

-LSB-

-RSB-

Another

prime

example

of

the

success

of

PCC

efforts

is

the

reduction

in

the

number

of

pregnancies

affected

by

neural-tube

defects

following

national

efforts

to

increase

consumption

and

supplementation

of

folic

acid

by

women

of

childbearing

potential

-LSB-

-RSB-

through

education

and

food

fortification

Despite

such

improvements

fewer

than

of

women

are

aware

of

the

benefits

of

taking

folic

acid

supplements

around

the

time

of

conception

-LSB-

-RSB-

the

majority

of

women

with

diabetes

do

not

plan

their

pregnancies

-LSB-

-RSB-

many

women

continue

to

drink

alcohol

regularly

during

pregnancy

-LSB-

-RSB-

and

almost

of

pregnancies

in

the

U.S.

are

unplanned

-LSB-

-RSB-

PCC

has

had

its

successes

but

clearly

more

work

needs

to

be

done

The

importance

of

PCC

in

promoting

maternal

and

fetal

health

has

long

been

recognized

and

national

recommendations

and

guidelines

for

PCC

are

being

developed

-LSB-

-RSB-

One

aspect

of

successful

development

of

PCC

guidelines

involves

knowledge

of

obstetrician-gynecologists

current

practices

and

opinions

regarding

PCC

and

what

they

perceive

to

be

barriers

to

successful

implementation

of

PCC

The

purpose

of

this

study

was

to

assess

the

practices

and

opinions

of

obstetrician-gynecologists

regarding

PCC

and

how

frequently

they

perceive

their

patients

to

avail

themselves

of

such

services

Materials

and

methods

Questionnaires

were

mailed

in

August

to

American

College

of

Obstetricians

and

Gynecologists

-LRB-

ACOG

-RRB-

Fellows

and

Junior

Fellows

in

Practice

Of

these

subjects

were

members

of

the

Collaborative

Ambulatory

Research

Network

-LRB-

CARN

-RRB-

and

were

a

computer-generated

random

sample

of

ACOG

members

who

had

not

received

a

survey

from

ACOG

during

the

previous

two

years

-LRB-

Non-CARN

-RRB-

Members

of

CARN

are

practicing

obstetrician-gynecologists

who

have

volunteered

to

participate

in

survey

studies

on

a

regular

basis

CARN

was

established

to

facilitate

assessment

of

clinical

practice

patterns

and

aid

the

development

of

educational

materials

Two

reminder

mailings

were

sent

to

non-respondents

and

questionnaires

returned

by

December

were

included

in

the

survey

This

protocol

has

typically

resulted

in

a

total

sample

size

of

which

is

sufficient

to

detect

differences

between

groups

of

standard

deviation

with

power

of

and

significance

at

the

level

-LSB-

-RSB-

The

survey

recorded

demographic

details

of

physicians

and

their

patient

population

and

assessed

practices

and

opinions

regarding

PCC

A

questionnaire

concerning

screening

for

aneuploidy

was

included

in

the

same

mailing

both

questionnaires

shared

a

demographics

section

containing

questions

on

one

page

The

PCC

questionnaire

contained

questions

some

multi-part

on

two

pages

Both

questionnaires

were

brief

and

resulted

in

a

final

document

of

double-sided

pages

a

standard

length

for

our

full-length

questionnaires

Seven

of

the

questions

on

PCC

involved

rating

the

frequency

of

an

activity

-LRB-

e.g.

always

usually

occasionally

never

-RRB-

or

degree

of

agreement

with

a

statement

and

three

questions

were

of

a

multiple-choice

format

The

questionnaires

were

developed

in

consultation

with

medical

specialists

and

were

pilot

tested

on

a

sample

of

practicing

obstetrician-gynecologists

prior

to

final

distribution

The

data

were

analyzed

using

a

personal

computer-based

software

package

-LRB-

SPSS

SPSS

Inc.

Chicago

IL

-RRB-

Descriptive

statistics

were

computed

for

the

measures

used

in

the

analyses

which

are

reported

as

mean

SEM

Student

's

t

test

was

used

to

compare

group

means

of

continuous

variables

Factor

Analysis

was

conducted

on

two

sets

of

rating

variables

-LRB-

Agreement

with

statements

regarding

PCC

and

Importance

of

counseling

on

issues

during

PCC

and

during

routine

care

-RRB-

and

factors

with

eigenvalues

greater

than

one

were

treated

with

a

varimax

rotation

Differences

in

ratings

on

the

Importance

scales

were

examined

with

multivariate

analysis

of

variance

Differences

on

categorical

measures

were

assessed

using

χ2

Group

differences

on

ordinal

measures

were

assessed

using

the

Mann-Whitney

U

test

or

Kruskal

Wallis

χ2

Related-sample

differences

on

ordinal

measures

used

the

Wilcoxon

signed

ranks

test

Correlations

including

an

ordinal

measure

used

the

Spearman

's

rho

coefficient

All

analyses

were

tested

for

significance

using

an

alpha

of

Results

Demographics

A

total

of

questionnaires

were

returned

Data

from

respondents

were

judged

invalid

-LRB-

physician

retired

returned

to

sender

-RRB-

resulting

in

a

valid

response

rate

of

-LRB-

-RRB-

from

CARN

members

-LRB-

response

rate

-RRB-

and

from

Non-CARN

-LRB-

response

rate

-RRB-

Physicians

responded

from

every

state

of

the

United

States

except

Maine

as

well

as

the

District

of

Columbia

Puerto

Rico

Canada

and

overseas

military

installations

The

respondents

mean

age

-LRB-

-RRB-

and

the

proportion

of

males

to

females

-LRB-

males

-RRB-

closely

matched

those

of

the

larger

population

to

whom

the

survey

was

sent

-LRB-

males

-RRB-

and

of

ACOG

Fellows

and

Junior

Fellows

in

Practice

as

a

whole

-LRB-

males

-RRB-

The

remaining

analyses

are

limited

to

the

-LRB-

-RRB-

of

respondents

who

indicated

that

their

primary

medical

specialty

was

gynecology

or

general

obstetrics

and

gynecology

This

selection

was

made

to

best

assess

the

practices

of

non-subspecialist

obstetricians

and

gynecologists

rather

than

those

in

maternal

fetal

medicine

reproductive

endocrinology

or

other

subspecialties

to

whom

patients

may

be

referred

after

pregnancy

has

already

been

attempted

Of

these

physicians

-LRB-

-RRB-

practice

obstetrics

-LRB-

ObGyn

-RRB-

and

-LRB-

-RRB-

do

not

-LRB-

GynOnly

-RRB-

the

term

physicians

is

used

when

referring

to

both

ObGyns

and

GynOnlys

See

Table

for

physician

demographics

CARN

and

Non-CARN

differed

on

only

one

non-demographic

item

-LRB-

CARN

were

more

likely

than

Non-CARN

to

discuss

carrier

screening

with

all

patients

who

present

for

PCC

See

results

-RRB-

thus

data

were

collapsed

across

these

two

groups

Table

demographicsTotal

-LRB-

n

-RRB-

Gender

-LRB-

-RRB-

Age

in

years

mean

-LRB-

SEM

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Years

in

practice

mean

-LRB-

SEM

-RRB-

-LRB-

-RRB-

Deliveries

in

mean

-LRB-

SEM

-RRB-

-LRB-

-RRB-

Practice

location

-LRB-

-RRB-

Urban

inner

Urban

non-inner

Mid-sized

Practice

type

-LRB-

-RRB-

Ob/Gyn

Solo

University

full-time

faculty

and

Patient

ethnicity

mean

-LRB-

SEM

-RRB-

of

patients

Non-Hispanic

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Asian/Pacific

-LRB-

-RRB-

Native

-LRB-

-RRB-

P

Males

older

than

females

CARN

older

than

non-CARN

Defining

preconception

care

Physicians

were

asked

whether

they

would

define

PCC

as

specialized

or

routine

care

The

great

majority

-LRB-

-RRB-

defined

it

As

specialized

pre-pregnancy

care

that

focuses

on

issues

not

typically

addressed

during

a

routine

exam

which

are

specific

to

ensuring

an

optimal

pregnancy

outcome

Far

fewer

-LRB-

-RRB-

defined

it

as

The

same

as

routine

well-woman

care

that

occurs

during

the

reproductive

years

prior

to

a

pregnancy

Those

who

defined

PCC

as

routine

tended

to

be

in

practice

longer

than

those

defining

it

as

specialized

-LRB-

yrs

versus

yrs

t

-LRB-

-RRB-

P

-RRB-

independent

of

gender

Recommending

PCC

The

vast

majority

of

physicians

-LRB-

-RRB-

indicated

that

they

provide

PCC

for

their

patients

Physicians

were

asked

how

frequently

they

recommend

PCC

to

different

groups

of

women

of

childbearing

age

-LRB-

see

Table

-RRB-

Three

quarters

-LRB-

-RRB-

always

recommend

PCC

to

patients

planning

a

pregnancy

and

in

-LRB-

-RRB-

always

recommend

it

to

diabetic

patients

planning

a

pregnancy

Physicians

who

defined

PCC

as

routine

were

more

likely

than

those

who

defined

it

as

specialized

to

recommend

PCC

to

women

who

are

sexually

active

-LRB-

always

or

usually

routine

specialized

M-W

U

P

-RRB-

and

to

women

who

are

using

birth

control

-LRB-

always

or

usually

routine

specialized

M-W

U

P

-RRB-

Table

of

physicians

indicating

how

frequently

they

recommend

PCC

to

different

groups

of

womenHow

frequently

do

you

recommend

preconceptioncare

to

the

following

women

of

childbearing

age?AlwaysUsuallyOccasionallyNeverDiabetic

women

planning

a

Women

who

are

planning

a

Obese

women

planning

a

Women

indicating

they

want

children

in

the

Women

who

are

sexually

Women

who

are

using

birth

Opinions

about

PCC

Physicians

were

asked

their

level

of

agreement

with

several

statements

regarding

PCC

-LRB-

see

Table

-RRB-

The

majority

agreed

-LRB-

on

point

scale

-RRB-

that

PCC

is

an

important

issue

-LRB-

-RRB-

and

that

it

has

a

positive

effect

on

pregnancy

outcomes

-LRB-

-RRB-

though

only

agreed

that

it

is

a

high

priority

in

their

workload

Three

quarters

-LRB-

-RRB-

thought

they

have

appropriate

training

to

provide

PCC

Half

agreed

that

there

is

not

enough

time

to

provide

preconception

care

visits

to

all

women

of

childbearing

age

-LRB-

-RRB-

and

that

time

devoted

to

PCC

is

not

reimbursed

-LRB-

-RRB-

Based

on

factor

analysis

the

first

three

items

were

combined

to

produce

a

single

mean

score

for

the

positive

aspects

of

PCC

-LRB-

Factor

I

-RRB-

and

the

second

set

of

three

items

for

the

negative

aspects

of

PCC

-LRB-

Factor

II

-RRB-

There

were

significant

positive

correlations

between

agreement

on

Factor

I

and

frequency

of

recommending

PCC

in

all

groups

of

women

-LRB-

all

P

's

-RRB-

there

were

significant

negative

correlations

between

agreement

on

Factor

II

and

frequency

of

recommending

PCC

in

all

groups

of

women

-LRB-

all

P

's

-RRB-

In

other

words

the

more

strongly

they

agreed

that

PCC

was

important/positive/high

priority

the

more

frequently

they

recommended

PCC

Looking

at

the

individual

components

of

the

two

factors

lack

of

reimbursement

for

PCC

was

the

only

item

that

did

not

correlate

with

frequency

of

recommending

PCC

in

any

group

of

women

Table

of

physicians

indicating

how

strongly

they

agree

with

several

statement

regarding

PCCStronglyStronglyagreedisagreeMean

on

pt

Six

statements

regarding

opinions

about

-LRB-

SEM

-RRB-

Factor

I

positive

aspects

Preconception

care

is

an

important

-LRB-

-RRB-

Preconception

care

has

a

positive

effect

on

pregnancy

-LRB-

-RRB-

Preconception

care

is

a

high

priority

in

my

-LRB-

-RRB-

Factor

II

negative

aspects

Time

devoted

to

preconception

care

is

not

-LRB-

-RRB-

There

is

not

enough

time

to

provide

preconception

care

visits

to

all

women

of

childbearing

-LRB-

-RRB-

I

do

not

have

appropriate

training

to

provide

preconception

-LRB-

-RRB-

Counseling

in

PCC

Almost

a

third

-LRB-

-RRB-

of

physicians

said

they

discuss

screening

for

aneuploidy

with

All

patients

who

present

for

preconception

counseling

Of

those

not

selecting

All

said

they

did

so

with

patients

at

risk

for

aneuploidy

Almost

one-in-ten

-LRB-

-RRB-

said

they

did

not

discuss

aneuploidy

The

majority

-LRB-

-RRB-

of

physicians

said

they

discuss

carrier

screening

for

heritable

genetic

disorders

-LRB-

e.g.

CF

sickle

cell

anemia

-RRB-

with

All

patients

who

present

for

preconception

counseling

and

of

those

not

selecting

All

said

they

did

so

with

patients

who

have

a

family

history

of

heritable

genetic

disorders

or

other

risk

factors

Only

said

they

did

not

discuss

carrier

screening

Physicians

were

presented

with

health-related

issues

-LRB-

e.g.

exercise

nutrition

over

the

counter

drug

use

-RRB-

and

were

asked

to

rate

how

important

counseling

was

for

each

issue

during

a

routine

office

exam

and

during

preconception

care

-LRB-

see

Table

-RRB-

-LRB-

Note

Physicians

were

not

asked

to

rank

order

the

issues

in

terms

of

relative

importance

nor

were

they

asked

to

compare

the

issues

in

terms

of

routine

or

PCC

such

calculations

were

made

based

on

analyzing

the

mean

ratings

for

each

issue

-RRB-

Physicians

rated

all

issues

as

more

important

in

PCC

than

in

routine

care

although

the

difference

for

Exercise

was

marginal

-LRB-

Wilcoxon

signed

ranks

test

Exercise

P

All

other

P

's

-RRB-

All

issues

were

rated

as

very

important

for

PCC

with

cigarette

smoking

and

folic

acid

supplementation

rated

the

most

highly

important

issues

in

PCC

Cigarette

smoking

and

illegal

drug

use

were

rated

the

most

important

issues

for

counseling

in

routine

care

Whereas

folic

acid

supplementation

ranked

second

in

importance

for

PCC

it

ranked

tenth

for

routine

care

Table

of

physicians

indicating

how

important

they

think

counseling

is

on

several

issues

for

patients

who

-LRB-

a

-RRB-

come

in

for

a

routine

office

exam

and

-LRB-

b

-RRB-

those

who

are

planning

a

pregnancy

-LRB-

Rank

of

meanImportanceVery

importantNot

importantMean

-LRB-

SEM

-RRB-

within

a

or

b

-RRB-

Neutral

-LSB-

-RSB-

on

pt

scaleFactor

I

Folic

acid

supplements

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Factor

II

Cigarette

smoking

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Illegal

drug

use

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Alcohol

consumption

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Factor

III

Obesity

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Exercise

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

General

Nutrition

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Factor

IV

Chronic

diseases

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Family

health

history

-LRB-

inherited

disorders

-RRB-

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Over

the

counter

and

prescription

drug

use

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

Environmental

concerns

-LRB-

a

-RRB-

routine

exam

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

b

-RRB-

preconception

care

-LRB-

-RRB-

-LRB-

-RRB-

The

issues

were

grouped

into

factors

for

both

routine

care

and

PCC

-LRB-

see

item

labels

Table

-RRB-

How

physicians

defined

PCC

had

a

significant

effect

on

importance

ratings

overall

controlling

for

years

in

practice

-LSB-

F

-LRB-

-RRB-

P

-RSB-

However

the

only

individual

factor

on

which

ratings

were

distinctly

different

was

folic

acid

supplementation

during

routine

care

physicians

who

defined

PCC

as

routine

were

more

likely

than

those

defining

it

as

specialized

to

rate

it

as

very

important

-LRB-

vs

-RRB-

during

routine

care

-LSB-

t

-LRB-

-RRB-

P

-RSB-

Gender

controlling

for

years

in

practice

also

had

an

overall

effect

on

ratings

-LSB-

F

-LRB-

-RRB-

P

-RSB-

females

tended

to

rate

most

items

as

more

highly

important

than

did

males

Patient

use

of

PCC

Of

the

physicians

who

provide

PCC

a

third

-LRB-

-RRB-

said

that

patients

rarely

present

for

PCC

almost

half

-LRB-

-RRB-

said

they

sometimes

do

and

said

patients

frequently

present

for

PCC

Over

a

third

-LRB-

-RRB-

agreed

that

their

patients

usually

do

not

plan

their

pregnancies

Almost

half

-LRB-

-RRB-

of

ObGyns

said

few

or

of

their

pregnant

patients

came

in

for

PCC

prior

to

the

pregnancy

and

almost

two

thirds

-LRB-

-RRB-

said

most

or

all

of

their

pregnant

patients

initially

made

contact

with

them

once

they

were

already

pregnant

See

Table

The

frequency

with

which

patients

reportedly

present

for

PCC

was

positively

correlated

with

physician

agreement

that

their

patients

plan

their

pregnancies

-LRB-

P

-RRB-

as

well

as

with

how

frequently

physicians

recommend

PCC

to

the

different

patient

groups

listed

in

Table

-LRB-

all

P

's

except

Diabetic

P

-RRB-

Table

use

of

pre-pregnancy

planningPercent

of

physicians

selecting

a

particular

response

to

questionnaire

items

How

frequently

do

you

have

patients

present

for

PCC?Never

or

Women

that

I

see

usually

do

not

plan

their

pregnancies

Agree

-LRB-

-RRB-

Neutral

-LRB-

-RRB-

Disagree

-LRB-

-RRB-

-LRB-

on

a

point

scale

-RRB-

How

many

of

your

pregnant

patients

came

in

for

NoneFewSomeHalf

or

More

preconception

care

before

they

became

pregnant

-LRB-

OB

-RRB-

How

many

of

your

pregnant

patients

initially

made

AllMostManyHalf

or

Fewer

contact

with

you

once

they

were

already

pregnant

-LRB-

OB

-RRB-

Physicians

were

asked

to

indicate

how

many

of

the

patients

who

presented

for

PCC

did

so

for

each

of

three

reasons

-LRB-

point

scale

Few

Some

Half

Many

Most

All

-RRB-

Over

four-fifths

-LRB-

-RRB-

of

physicians

indicated

that

more

than

half

of

the

patients

do

so

to

ensure

a

healthy

pregnancy

-LRB-

mean

on

pt

scale

-RRB-

In

contrast

said

more

than

half

do

so

because

of

difficulties

conceiving

-LRB-

mean

-RRB-

and

said

more

than

half

do

so

because

of

an

elevated

risk

of

a

birth

defect

or

developmental

disorder

-LRB-

mean

-RRB-

Discussion

The

purpose

of

this

study

was

to

examine

obstetrician-gynecologists

opinions

and

beliefs

about

PCC

and

how

frequently

they

perceived

their

patients

to

be

utilizing

PCC

Our

findings

document

that

most

physicians

think

it

is

an

important

issue

that

it

has

a

positive

effect

on

pregnancy

outcomes

and

that

they

are

appropriately

trained

to

provide

it

-LRB-

Table

-RRB-

However

respondents

reported

that

few

of

their

patients

seek

PCC

Explanations

for

this

lack

of

patients

seeking

PCC

likely

include

the

fact

that

almost

of

pregnancies

in

the

U.S.

are

unplanned

-LSB-

-RSB-

the

lack

of

third

party

reimbursement

for

PCC

visits

and

patients

rather

poor

understanding

of

the

potential

benefits

of

PCC

to

the

lifetime

health

of

future

offspring

We

did

find

an

association

between

the

frequency

with

which

physicians

recommend

PCC

and

the

frequency

with

which

patients

present

for

PCC

It

is

also

possible

that

some

women

receiving

routine

health

care

prior

to

a

first

pregnancy

see

an

internist

family

physician

or

nurse

practitioner

for

such

care

and

only

seek

the

care

of

an

obstetrician-gynecologist

once

they

become

pregnant

Thus

it

is

possible

that

our

study

of

obstetrician-gynecologists

does

not

reflect

the

full

extent

to

which

women

may

be

seeking

PCC

However

a

recent

study

of

primary

care

providers

-LRB-

not

obstetrician-gynecologist

-RRB-

also

found

that

few

patients

were

receiving

PCC

-LSB-

-RSB-

Stumbling

blocks

to

increasing

utilization

of

PCC

may

include

physicians

beliefs

that

time

devoted

to

PCC

is

not

reimbursed

and

that

there

is

not

enough

time

to

provide

PCC

to

all

women

of

childbearing

age

Regarding

this

latter

point

opinions

differ

within

the

medical

community

as

to

who

the

target

population

for

PCC

should

be

Three

general

target

groups

include

women

at

high

risk

for

poor

birth

outcome

women

planning

a

pregnancy

and

all

women

of

childbearing

age

-LSB-

-RSB-

In

this

study

the

vast

majority

of

physicians

said

they

frequently

recommend

PCC

to

diabetic

and

obese

women

planning

a

pregnancy

as

well

as

to

women

generally

who

are

planning

a

pregnancy

-LRB-

see

Table

-RRB-

Far

fewer

obstetrician-gynecologists

said

they

frequently

recommend

PCC

to

women

described

simply

as

sexually

active

-LRB-

-RRB-

or

to

those

using

birth

control

-LRB-

-RRB-

This

suggests

that

our

survey

sample

population

views

women

who

have

consciously

decided

to

plan

a

pregnancy

as

the

most

appropriate

target

group

for

PCC

Almost

in

-LRB-

-RRB-

physicians

defined

PCC

as

specialized

pre-pregnancy

care

focusing

on

issues

not

typically

addressed

during

a

routine

exam

and

the

remaining

defined

it

as

routine

well-woman

care

occurring

during

the

reproductive

years

prior

to

a

pregnancy

Those

who

defined

it

as

routine

were

more

likely

to

offer

such

counseling

to

women

who

were

sexually

active

or

using

birth

control

than

were

those

defining

it

as

specialized

care

One

aspect

of

PCC

includes

counseling

women

on

topics

that

encourage

a

healthy

pregnancy

although

many

such

topics

are

clearly

relevant

to

the

general

health

of

any

woman

Physicians

were

asked

to

rate

eleven

topics

in

terms

of

their

importance

for

counseling

during

PCC

and

routine

care

such

as

exercise

nutrition

and

over

the

counter

drug

use

-LRB-

see

Table

-RRB-

All

were

considered

very

important

topics

for

counseling

in

PCC

with

cigarette

smoking

and

folic

acid

supplementation

rated

the

most

highly

important

for

PCC

For

counseling

in

routine

care

folic

acid

supplementation

received

the

second

lowest

score

of

all

with

under

two-fifths

-LRB-

-RRB-

of

physicians

rating

it

as

important

This

points

to

the

need

for

continued

national

attention

to

increase

consumption

and

supplementation

of

folic

acid

Our

study

has

limitations

that

should

be

acknowledged

The

response

rate

was

and

our

findings

are

based

on

the

responses

of

non-subspecialist

obstetricians

and

gynecologists

While

our

study

may

be

subject

to

non-response

bias

we

believe

that

our

findings

are

reliable

The

typical

response

rate

in

these

survey

studies

is

approximately

and

our

response

rate

was

at

the

high

end

of

expected

participation

In

addition

the

responses

were

derived

from

geographically

diverse

locations

and

from

physicians

from

different

practice

types

reflecting

the

influence

of

physician

location

and

practice

type

Whereas

physicians

who

were

more

interested

in

the

topic

of

the

survey

may

have

been

more

likely

to

respond

a

subset

of

our

subject

pool

was

comprised

of

CARN

members

who

respond

to

several

questionnaires

a

year

covering

a

wide

variety

of

topics

it

is

unlikely

that

Preconception

Care

is

a

topic

of

greater

interest

to

this

group

than

to

the

group

of

randomly

selected

ACOG

members

CARN

members

differed

significantly

from

non-CARN

subjects

on

only

one

non-demographic

response

and

the

mean

age

and

male

to

female

ratio

of

respondents

closely

matched

those

of

the

larger

group

to

whom

the

survey

was

sent

and

of

ACOG

Fellows

and

Junior

Fellows

as

a

whole

all

of

which

suggests

that

response

bias

was

minimized

Recent

studies

have

recommended

offering

PCC

opportunistically

incorporating

information

relevant

to

preconception

care

into

routine

well-woman

visits

-LSB-

-RSB-

Most

topics

relevant

to

preventing

congenital

birth

defects

are

also

important

to

the

overall

health

of

women

pointing

out

the

compatibility

of

the

two

counseling

contexts

The

one

exception

to

this

in

our

questionnaire

was

folic

acid

supplementation

and

it

would

need

greater

emphasis

in

routine

care

to

take

advantage

of

opportunistic

counseling

We

found

that

those

physicians

who

defined

PCC

as

the

same

as

routine

well-woman

care

differed

from

those

defining

it

as

specialized

in

several

ways

including

increased

importance

of

counseling

on

folic

acid

supplementation

during

routine

care

A

recent

study

found

that

topics

such

as

vitamin

supplements

and

alcohol

use

were

rarely

discussed

during

routine

care

by

a

high

proportion

of

obstetrician-gynecologists

and

by

an

even

higher

proportion

of

family

practitioners

-LSB-

-RSB-

They

also

found

that

physician

recommendations

influenced

women

's

decisions

to

take

folic

acid

Obstetrician-gynecologists

recognize

the

importance

of

preconception

care

and

provide

this

care

for

their

patients

However

lack

of

third

party

reimbursement

lack

of

time

during

office

visits

due

to

competing

demands

and

lack

of

consumer

awareness

pose

barriers

to

effective

implementation

of

PCC

The

fact

that

almost

half

of

all

pregnancies

in

the

U.S.

are

unplanned

poses

an

even

greater

challenge

Continued

efforts

are

needed

to

raise

awareness

of

the

importance

of

PCC

by

consumers

health

care

providers

third

party

carriers

and

policy

makers

O O O O B I O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O 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preconception care
survey
routine care
folic acid


Toxoplasmosis

Cytomegalovirus

Listeriosis

and

Preconception

Care

Toxoplasma

gondii

-LRB-

T.

gondii

-RRB-

cytomegalovirus

-LRB-

CMV

-RRB-

and

Listeria

monocytogenes

-LRB-

L.

monocytogenes

-RRB-

can

all

negatively

affect

pregnancy

outcomes

Preconception

counseling

about

such

effects

can

reduce

the

risks

posed

by

these

pathogens

Informing

women

of

childbearing

age

about

these

pathogens

and

how

to

prevent

their

negative

effects

can

help

women

make

informed

decisions

about

prevention

This

brief

summarizes

some

basic

information

about

these

infections

and

provides

some

web

sites

and

articles

for

further

information

about

how

to

prevent

them

within

the

context

of

preconception

care

Toxoplasmosis

is

a

disease

caused

by

Toxoplasma

gondii

-LRB-

T.

gondii

-RRB-

a

protozoan

parasite

mainly

transmitted

to

humans

via

three

routes

a

-RRB-

ingestion

of

raw

or

undercooked

contaminated

meat

b

-RRB-

exposure

to

T.

gondii

oocysts

-LRB-

a

form

of

the

organism

passed

in

cat

feces

-RRB-

through

cat

litter

or

soil

-LRB-

e.g.

from

gardening

or

unwashed

fruits

or

vegetables

-RRB-

or

contaminated

water

and

c

-RRB-

congenital

in

which

maternal

infection

is

passed

transplacentally

via

blood

to

the

fetus

-LSB-

-RSB-

Congenital

infection

leads

to

stillbirth

and

severe

neurological

illness

in

some

instances

although

the

majority

of

infected

newborns

are

asymptomatic

at

birth

and

some

develop

sequelae

such

as

mental

retardation

blindness

and

epilepsy

later

in

life

-LSB-

-RSB-

Extrapolation

from

regional

studies

suggests

that

cases

of

congenital

toxoplasmosis

occur

each

year

in

the

United

States

-LSB-

-RSB-

Adults

with

normal

immune

function

who

are

infected

with

T.

gondii

are

usually

asymptomatic

or

have

self-limited

symptoms

-LRB-

e.g.

fever

malaise

and

lymphadenopathy

-RRB-

-LSB-

-RSB-

Once

infected

these

individuals

usually

develop

an

immune

response

against

toxoplasmosis

-LSB-

-RSB-

A

recent

study

based

on

the

National

Health

and

Nutrition

Survey

conducted

from

-LRB-

NHANES

III

-RRB-

reported

that

among

women

aged

years

seroprevalence

of

T.

gondii

antibodies

was

suggesting

that

of

women

of

childbearing

age

are

susceptible

to

T.

gondii

infection

-LSB-

-RSB-

Three

principal

interventions

are

presently

used

to

reduce

morbidity

and

mortality

from

congenital

toxoplasmosis

a

-RRB-

education

about

how

to

prevent

infection

-LRB-

especially

during

pregnancy

-RRB-

b

-RRB-

prenatal

and

newborn

screening

to

identify

and

treat

congenital

infection

and

c

-RRB-

animal

rearing

and

production

methods

designed

to

reduce

T.

gondii

contamination

of

meat

Of

the

three

education

about

how

to

prevent

infection

is

applicable

to

adolescents

and

women

in

the

preconception

period

Education

programs

during

pregnancy

have

been

associated

with

improved

knowledge

and

behavior

and

a

reduction

in

infection

rates

-LSB-

-RSB-

Toxoplasma

infection

can

be

prevented

by

one

or

more

of

the

following

a

-RRB-

cooking

meat

to

a

sufficient

temperature

to

kill

Toxoplasma

b

-RRB-

peeling

or

thoroughly

washing

fruits

and

vegetables

before

eating

c

-RRB-

cleaning

cooking

surfaces

and

utensils

after

they

have

contacted

raw

meat

poultry

or

unwashed

fruits

or

vegetables

d

-RRB-

pregnant

women

avoiding

changing

cat

litter

or

using

gloves

then

washing

hands

thoroughly

and

e

-RRB-

not

feeding

raw

or

undercooked

meat

to

cats

and

keeping

cats

inside

to

prevent

acquisition

of

Toxoplasma

by

eating

infected

prey

-LSB-

-RSB-

Although

prenatal

and

newborn

screening

programs

have

been

evaluated

they

are

controversial

because

of

the

lack

of

proven

efficacy

of

treatment

side

effects

of

treatment

and

potential

complications

of

invasive

procedures

such

as

amniocentesis

to

evaluate

fetal

infection

-LSB-

-RSB-

Animal

rearing

and

production

methods

to

reduce

T.

gondii

contamination

of

meat

are

effective

and

have

been

associated

with

a

reduction

in

the

prevalence

of

T.

gondii

in

important

meat

sources

such

as

pork

-LSB-

-RSB-

however

the

need

for

improvement

in

producers

knowledge

and

production

practices

is

acknowledged

-LSB-

-RSB-

Education

about

toxoplasmosis

is

an

important

component

of

preconception

care

that

can

be

integrated

with

information

about

other

diseases

that

affect

women

Human

cytomegalovirus

-LRB-

CMV

-RRB-

is

the

largest

DNA

virus

belonging

to

the

herpesvirus

family

Humans

are

the

only

reservoirs

for

the

human

herpesviruses

and

they

can

transmit

these

agents

through

direct

contact

with

infected

blood

tissues

bodily

fluids

feces

and

fomites

-LSB-

-RSB-

A

pregnant

woman

infected

with

CMV

can

transmit

this

virus

to

her

unborn

fetus

which

can

cause

damage

to

the

central

nervous

system

hematopoietic

system

kidneys

endocrine

glands

gastrointestinal

tract

lungs

and

liver

Long-term

sequelae

include

cerebral

palsy

mental

retardation

and

hearing

loss

-LSB-

-RSB-

The

birth

prevalence

rate

of

congenital

CMV

infection

varies

between

-LSB-

-RSB-

in

the

United

States

making

it

the

most

commonly

transmitted

virus

in

utero

-LSB-

-RSB-

and

a

major

cause

of

cerebral

palsy

mental

retardation

and

hearing

loss

among

children

-LSB-

-RSB-

CMV

infects

almost

all

humans

at

some

point

in

their

lives

Adults

with

normal

immune

function

infected

with

CMV

are

usually

asymptomatic

or

might

experience

mild

flu-like

symptoms

or

even

mononucleosis

with

symptoms

such

as

malaise

persistent

fever

myalgia

and

cervical

lympadenopathy

-LSB-

-RSB-

Once

a

human

is

infected

the

virus

passes

into

a

latent

state

-LSB-

-RSB-

Although

the

virus

can

be

reactivated

it

is

usually

kept

under

control

because

adults

with

normal

immune

function

usually

retain

lifelong

immunity

against

CMV

Primary

CMV

infection

of

women

during

pregnancy

or

periconceptionally

results

in

transmission

to

the

fetus

transplacentally

in

of

maternal

infections

-LSB-

-RSB-

Preexisting

maternal

immunity

strongly

reduces

the

risk

of

transmission

to

the

fetus

-LSB-

-RSB-

However

approximately

of

newborns

with

congenital

CMV

will

be

symptomatic

and

from

of

those

born

without

symptoms

will

develop

late

sequelae

-LSB-

-RSB-

The

most

common

means

for

women

to

be

infected

with

CMV

is

by

exposure

to

toddlers

who

shed

large

amounts

of

the

virus

in

their

saliva

and

urine

for

many

months

following

their

first

-LRB-

usually

asymptomatic

-RRB-

infection

-LSB-

-RSB-

Daycare

providers

and

pregnant

women

who

have

a

toddler

of

their

own

are

at

high

risk

for

infection

-LSB-

-RSB-

Sexual

transmission

blood

transfusion

and

organ

transplantation

are

other

means

by

which

CMV

is

transmitted

-LSB-

-RSB-

It

is

important

to

counsel

all

women

about

safe

sex

practices

Currently

there

are

no

vaccines

available

for

preventing

CMV

infection

although

some

promising

advances

have

been

made

-LSB-

-RSB-

It

is

therefore

extremely

important

to

provide

women

of

childbearing

age

with

information

about

how

they

can

prevent

CMV

infection

before

conception

The

most

effective

means

for

preventing

CMV

infection

is

handwashing

-LSB-

-RSB-

Education

about

careful

hygiene

and

frequent

handwashing

especially

after

contact

with

the

saliva

and

urine

of

young

children

and

careful

disposal

of

diapers

tissues

and

other

contaminated

items

can

reduce

the

transmission

of

CMV

Avoiding

sharing

drinking

glasses

and

eating

utensils

with

young

children

can

also

prevent

transmission

This

is

especially

true

for

women

who

work

in

daycare

settings

and

for

those

who

are

pregnant

-LSB-

-RSB-

As

some

studies

suggest

that

CMV

infection

prior

to

conception

can

result

in

congenital

CMV

infection

-LSB-

-RSB-

counseling

all

women

of

childbearing

age

about

how

to

prevent

transmission

preconceptionally

could

significantly

reduce

the

incidence

of

congenital

CMV

infection

Listeriosis

is

an

invasive

foodborne

infection

caused

by

the

motile

gram-positive

bacterium

Listeria

monocytogenes

-LRB-

L.

monocytogenes

-RRB-

The

disease

affects

primarily

pregnant

women

newborns

and

adults

with

weakened

immune

systems

-LSB-

-RSB-

Maternal

infection

during

pregnancy

is

usually

a

self-limited

nonspecific

acute

febrile

illness

of

the

third

trimester

In

contrast

to

the

maternal

illness

fetal

and

neonatal

infection

is

severe

and

frequently

fatal

Infection

in

the

fetus

and

newborn

occurs

by

transplacental

transmission

or

possibly

from

exposure

to

L.

monocytogenes

in

the

perinatal

period

The

effects

of

intrauterine

infection

on

the

fetus

and

neonate

include

preterm

labor

amnionitis

spontaneous

abortion

still

birth

and

early-onset

of

the

neonatal

sepsis

syndrome

evident

at

birth

or

shortly

thereafter

Late-onset

neonatal

disease

is

likely

due

to

infection

at

or

around

the

time

of

birth

and

presents

as

meningitis

at

one

to

several

weeks

of

age

-LSB-

-RSB-

Listeriosis

is

a

rare

disease

the

incidence

rate

in

states

participating

in

the

Foodborne

Diseases

Active

Surveillance

Network

-LRB-

FoodNet

-RRB-

was

cases

per

population

in

the

year

-LSB-

-RSB-

However

the

incidence

rate

in

susceptible

subgroups

is

much

higher

The

rate

among

neonates

younger

than

days

of

age

in

FoodNet

sites

was

per

population

in

the

year

-LRB-

CDC

unpublished

data

-RRB-

More

importantly

listeriosis

has

a

very

high

case

fatality

rate

-LRB-

in

neonates

-RRB-

and

is

responsible

for

an

estimated

deaths

each

year

in

the

United

States

-LSB-

-RSB-

The

food

items

implicated

in

outbreaks

of

listeriosis

include

ready-to-eat

meats

such

as

turkey

delicatessen

meat

-LSB-

-RSB-

meat

paté

-LSB-

-RSB-

pork

tongue

in

jelly

-LSB-

-RSB-

hot

dogs

-LSB-

-RSB-

and

dairy

products

made

from

unpasteurized

milk

in

particular

fresh

soft

cheeses

-LSB-

-RSB-

Primary

prevention

for

listeriosis

focuses

on

improvements

in

food

processing

and

on

consumer

education

Substantial

efforts

by

the

food

industry

and

food

regulatory

agencies

have

been

directed

toward

reducing

the

likelihood

that

high

risk

foods

will

be

contaminated

with

L.

monocytogenes

-LSB-

-RSB-

Despite

this

pregnant

women

immunocompromised

persons

and

the

elderly

should

be

advised

to

avoid

paté

fresh

soft

cheeses

made

from

unpasteurized

milk

and

to

cook

ready-to-eat

foods

such

as

hotdogs

delicatessen

meats

and

left

over

foods

until

steaming

-LSB-

-RSB-

Information

regarding

these

foods

at

high

risk

of

contamination

with

Listeria

can

be

incorporated

into

preconception

care

dietary

recommendations

For

more

information

CDC

web

sites

Toxoplasmosis

toxoplasmosis/default.htm

CMV

Listeria

Publications

for

practitioners

Disclaimer

These

references

are

included

for

information

only

CDC

has

no

control

over

the

information

in

these

articles

Views

and

opinions

of

these

organizations

are

not

necessarily

those

of

CDC

the

Department

of

Health

and

Human

Services

-LRB-

HHS

-RRB-

or

the

U.S.

Public

Health

Service

-LRB-

PHS

-RRB-

American

College

of

Obstetricians

and

Gynecologists

Perinatal

viral

and

parasitic

infections

ACOG

Practice

Bulletin

Brundage

SC

Preconception

health

care

American

Family

Physician

June

-LRB-

-RRB-

Hanlin

RB

Congenital

infections

and

preconception

counseling

J

S

C

Med

Assoc.

Oct

-LRB-

-RRB-

B O B O B O O B I O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B I O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B I O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

preconception care
cytomegalovirus
toxoplasmosis
listeria
listeriosis
infection