RUNNING HEAD: Preconception Health 1

Preconception Health in Women

Linda Ngameduru Brenda Taft-Hall Sybil Williams

Submitted to: Dr Tilghman Dr Warren-Dorsey

!oppin State "ni#ersity $%&%'()*

PRECONCEPTION HEALTH

Introduction Preconception Health Preconception health is a crucial component of health care for +omen during their reproducti#e years Preconception health is defined as health care and practices that are geared to+ards pathophysiological inter#entions, social beha#iors, and ris- factors that affect a +oman.s health before pregnancy /Ba0ter, Berghella, Buchanan, 1 Perireia, '()(2 The identification of health care factors during the preconception period that +ould negati#ely affect a +oman during pregnancy can assist in impro#ing outcomes for pregnant +omen The goal of preconception health is to impro#e the health status and outcome of future pregnancies #ia health promotion, periodic screenings, and inter#entions /!urtis, '()(2 The aim of preconception health is to optimi3e the health of the +omen of childbearing years before conception /!urtis, '()(2 This proacti#e approach impro#es pregnancy outcomes The purpose of this paper is to discuss the social and political issues, trends in care and management, and implications for health care as they relate to preconception health This paper +ill first e0plore the significance and pre#alence of preconception health in adult +omen 4dditionally, the economic cost, pathophysiology, and research supporting preconception health +ill also be e0plored Rationale for Identification of Health Condition Significance. 4ccording to Ba0ter, Berghella, Buchanan 1 Perireia /'()(2, the significance of preconception health is that it aids in decreasing ad#erse maternal and fetal outcomes, such as long-term morbidity and early infant death Lo+ birth +eight, for

PRECONCEPTION HEALTH e0ample, increases the ris- of long-term morbidity +ithin the infant and early infant death Weight at birth is closely associated +ith gestational age, and is an important predictor of infant +ell-being and sur#i#al /5artin, et al , '()'2 Prevalence. 4ccording to the National 6ital Statistics 7eport /'()(2, there are millions of +omen in the "nited States +ho e0perience childbirth annually 8n '()(, an estimated *,999,*$: births occurred and $ ): percent of those births +ere lo+ birth +eight infants; +hereas, )) 99 percent of those births +ere preterm births /5artin, et al , '()'2 8n '(($, '< percent of all infants born +ith #ery lo+ birth +eights died +ithin the first year of life /5artin, et al , '()'2 4 lo+ birth +eight is classified as an infant +eighing less than '&(( grams /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2

Economic cost. The costly effects of ad#erse pregnancy outcomes, such as lo+-birth+eight infants and preterm infants, continue to be a ma?or issue in public health in the "nited States, due to its slo+ decline in the past fe+ years /5artin, et al , '()'2 8n the year '()', it +as estimated that the first year of an infant.s life cost *$,9&* dollars for a preterm birth #ersus a full-term birth of *,9&* " S dollars /5artin, et al , '()'2 This is an estimate of a ten times increase in cost for a preterm birth #ersus a full-term birth @ne of the ma?or medical e0penses that a couple +ill often incur is pregnancy and childbirth; therefore, the importance of the health care pro#iders starting early negotiation regarding childbearing costs, insurance co#erage, and family lea#e policies cannot be o#erly emphasi3ed Pathophysiology Ba0ter, Berghella, Buchanan 1 Perireia /'()(2 states that a thorough health history, +hich includes family and personal history, physical e0amination, blood and laboratory screening, e0ercise, #accinations, #itamin and mineral supplements, +eight management and

PRECONCEPTION HEALTH pre#enti#e measures should be assessed in all men and +omen Pre#enti#e measures such as management of chronic diseases, identification and e0posure to smo-ing, alcohol use, illicit drugs and assessing for teratogens /Ba0ter, Berghella, Buchanan 1 Perireia, '()(2 4d#erse pregnancy outcomes are generally predicated on +omen and men +ho do not practice effecti#e preconception health, such as a#oiding teratogens, maintaining a healthy +eight, refraining from smo-ing cigarettes and drin-ing alcohol and%or effecti#ely

managing their current chronic ailments in#ol#ing hypertension, diabetes, and obesity Health conditions such as hypertension, obesity and diabetes relate to the pathophysiology of preconception health Hypertension is diagnosed +hen the blood pressure is greater than )<(%9( mm Hg during t+o separate occasions /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 Aestational hypertension is diagnosed +hen blood pressure measures greater than )<(%9( mm Hg +ithout proteinuria /protein found in urine2 after '( +ee-s of pregnancy, but has returned to normal after pregnancy /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 Pregnant +omen +ith hypertension face ris- of preeclampsia, eclampsia, and hemolysis ele#ated li#er en3ymes lo+ platelet /HBLLP2 syndrome Women suffering +ith preeclampsia may ha#e symptoms comprising bilateral lo+er e0tremity edema, facial edema, headaches, blurred #ision, heartburn, and abdominal pain /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 Preeclampsia is usually diagnosed during the '(th +ee- of pregnancy +ith such clinical presentations as blood pressure greater than )<(%9( mm Hg, and proteinuria /*(( mg of protein found in a '<-hour urine specimen2 /=oung, Le#ine, 1 Carumanchi, '()(2 8f hypertension is not monitored and treated adeDuately, preeclampsia may lead to eclampsia, sei3ures Preeclampsia may also lead to HBLLP syndrome, as e#idenced by hemolytic anemia, ele#ated li#er en3ymes, and a lo+ platelet count Therefore, the +oman may

PRECONCEPTION HEALTH e0perience symptoms encompassing nausea, epigastric abdominal pain, #omiting, headache, and problems +ith #ision !omplications from HBLLP consist of li#er failure, respiratory failure, renal failure, and also multiple organ failure /=oung, Le#ine, 1 Carumanchi, '()(2 The 4merican !ollege of @bstetrics and Aynecology / '())2 states that as +omen e0perience hypertension during their pregnancy, their fetus recei#e less o0ygen and nutrients, due to less blood flo+ to the placenta; therefore, the fetus may suffer intrauterine gro+th retardation, +hich means the lac- of normal gro+th for the fetus To reduce the ris- of ad#erse pregnancy outcomes such as, sei3ure, stro-e, placental abruption, intrauterine gro+th retardation, prematurity, and stillbirth, +omen must strictly adhere to their physician.s guidelines Eor the past decade, the National High Blood Pressure Bducation Program /NHBPBP2 has recommended antihypertensi#es such as methyldopa, labetalol, hydrala3ine, and Procardia for the treatment of hypertension /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 The 4merican !ollege of @bstetricians and Aynecologists /'())2 recommends intra#enous labetalol and hydrala3ine as first-line therapy for the treatment of se#ere hypertension /blood pressure greater than ):(%))( mm Hg and is persistent for longer than )& minutes2 5agnesium sulfate is gi#en to pregnant +omen +ith a diagnosis of preeclampsia to pre#ent sei3ures or eclampsia /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 @besity is defined as ha#ing a body mass inde0 measuring greater than or eDual to *( -g%m' /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 Women +ho are obese +hile pregnant face #arious ris-s, such as gestational diabetes, preeclampsia, post-operati#e +ound infection, postpartum +eight retention, miscarriage, fetal congenital anomaly, thromboembolism, postpartum hemorrhage, stillbirth, and cesarean section deli#ery /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 @bese pregnant +omen must be monitored

PRECONCEPTION HEALTH closely, due to the aforementioned ris-s Weight gain for obese pregnant +omen should be closely monitored; +hile being sure the +oman understands to gain only bet+een )) to '( pounds during pregnancy Serial blood pressures should be done routinely and glucose testing must be done at the first initial prenatal #isit and again bet+een ': to '$ +ee-s of pregnancy /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2

Pregnant +omen diagnosed +ith diabetes face #arious ris-s such as fetal macrosomia, shoulder dystocia, infant hypoglycemia, spontaneous abortions, congenital birth defects, intrauterine fetal death, and congenital malformations /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 Alucose testing consists of obtaining or ha#ing the +omen ta-e a fasting glucose test, then drin-ing a sugary solution and +aiting an hour to test the results, +hich if greater than )$( mg%dL and if t+o hours later reads greater than )&* mg%dL +ould indicate a diagnosis of gestational diabetes /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 FT+o ele#ated le#els on the *-hour glucose tolerance test are diagnostic of gestational diabetes,G /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*, p &H'2 @nce gestational diabetes has been established, the pregnant clients should be informed of the need to get an eye e0am, due to the ris- of retinopathy Serial abdominopel#ic sonograms should be done to monitor fetal gro+th, because of the ris- of fetal macrosomia; as +ell as fetal echocardiography to monitor the fetus that is at ris- for cardiac lesions /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2 7ecommended treatments for the pregnant +oman +ith gestational diabetes is initially daily *(-minute light physical acti#ity to increase glucose upta-e and diet medication /=oung-in, Da#is, Schade+ald, 1 >u#e, '()*2; ho+e#er, if these self-treatments are ineffecti#e in adeDuately managing glucose

PRECONCEPTION HEALTH le#els, then she must start insulin therapy in con?unction +ith dietary modification and light physical acti#ity Social and Political Issues Political issues in#ol#e constructing policies, +hich +ould allo+ more indi#iduals to gain access to health care The "nited States go#ernment continues to promote the need for preconception care for +omen of child bearing age through the initiation of the Patient Protection and 4ffordable !are 4ct /PP4!42 since 4ugust ), '()'; therefore, ma-ing it easier to effect a discontinuation of a co-payment charge for preconception health or +ell+oman clinic #isits for +omen +ith pri#ate insurance plans /" S Department of Health 1 Human Ser#ices, '())2 The Patient Protection and 4ffordable !are 4ct assists +ith eliminating the disparities of access to health care among minority populations

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Social issues in#ol#e the current disparities among minority populations in regards to their socioeconomic status, age, ethnicity, and gender, +hich prohibit their access to health care The focus of the social aspects of preconception health in#ol#es closing the racial gap in birth outcomes /Lu, et al , '()(2 Blimination of health disparities among different segments of a population is one of the goals of Healthy People '()( +hether #ia socioeconomic status, age, gender, ethnicity, disability, or special health care need, geography, and se0ual orientation /!D!, '()(2 4ccording to 4merican !ollege of @bstetricians and Aynecologists /'(($2, there are higher fetal and infant mortality rates about t+ice among Blac- +omen than !aucasian +omen /)) '& compared to < 9$ per ),((( li#e births and fetal deaths2, and these infant deaths occurs in the first four +ee-s of life /4!@A, '(($2 8rregularity and disproportion of care should be eradicated among minority

PRECONCEPTION HEALTH populations because of the costly outcome of health disparities; it influences a #alue of life, illness, and death /Diggs, '()'2 Trends in Care and Management The "nited States healthcare system functions +ithin a paradigm of reacti#ity !urrently, health care is predominantly a reacti#e system, +hereas preconception health is

proacti#e; therefore, +omen must initiate discussions +ith their health care pro#iders to learn ho+ to optimally care for themsel#es prior to becoming pregnant /!urtis, '()(2 The !D! /'()'2, in order to +or- to+ards changing the current healthcare system.s paradigm, constructed an action plan entitled, F4ction Plan for the National 8nitiati#e on Preconception Health and Health !are /P!HH!2: 4 7eport of the P!HH! Steering !ommittee '()'-'()<G to report goals and ob?ecti#es of preconception health for healthcare practitioners and their clients to follo+ to optimi3e pregnancy outcomes The !enters for Disease !ontrol and Pre#ention /'()'2 in con?unction +ith other professional organi3ations ha#e de#ised four categories of inter#entions encompassing physical assessment, ris- screening, #accinations, and effecting positi#e beha#iors among childbearing-aged men and +omen in terms of pre#ention of human immunodeficiency #irus /H862 and proper folic acid consumption Implications for Health Care Education implications. 4ccording to 5itchell, Le#is, and Prue /'()'2, more education is needed in the areas of educating the general public concerning preconception health, and educating health care practitioners to deli#er proper preconception health, -no+ledge and screening to their clients Implications for health care practice. @rgani3ations such as the 4merican !ollege of @bstetricians and Aynecologists /4!@A2 and !enters for Disease !ontrol and Pre#ention

PRECONCEPTION HEALTH /!D!2 ha#e promoted the need for health care pro#iders to integrate routine preconception care among +omen of child bearing age through their lifespan !ouples that recei#e preconception education and ha#e good -no+ledge of their family health history or genetic conditions ha#e the opportunity to use the information to e0plore their reproducti#e options

/using donor gametes, or adoption, prenatal or pre-implantation diagnosis2 if for instance, the +oman has a genetic disorder /cystic fibrosis or I-lin-ed disorder2 /De Wert, Dondrop, 1 Cnoppers, '()'2 The primary aims of preconception care for genetic ris-s are to increase indi#idual ability to ma-e an informed reproducti#e decision and to pre#ent serious suffering of indi#iduals Bthical issues are currently based on the ob?ecti#es of pro#iding reproducti#e options through preconception genetic counseling or screening, abortions, embryo-selection, eugenics, concerns about medications, and problems arising in the professionalJclient relationship and%or for population screening /De +ert, Donrop, 1 Cnoppers, '()'2 De Wert, Dondorp, and Cnoppers /'()'2 e0plored the use of preconception care genetic rispre#ention counseling as a health care cost reduction for the go#ernment #ersus indi#idual reproducti#e autonomy De Wart et al /'()'2 ad#ised that it is morally acceptable +hen the ob?ecti#e of preconception carrier screening is used for directi#e and pre#ention counseling for indi#iduals +ith high reproduction ris-; other+ise, +hen it is used as a cost reduction for the health care system, reproducti#e choice becomes threatened by economic considerations, +hich may lead to forceful e#ading of pregnancies or fetus%children +ith minor or treatable disorders /De Wert, Dondorp, 1 Cnoppers '()'2 Ceeping clients properly informed creates more trustful relationships +ith their health pro#ider

PRECONCEPTION HEALTH Research implications. Euture research endea#ors should address the current -no+ledge of preconception health among consumers and health care practitioners, so that

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more preconception health programs and policies can be implemented accordingly 5itchell, Le#is, and Prue /'()'2 conducted a research study, using a sample /White :' 9K, 4frican 4merican )< <K, Hispanic )< HK, and others $K2 of childbearing-aged +omen bet+een the ages of )$ to << and men aging )$ to :<, to understand the lac- of -no+ledge and a+areness of preconception care among couples of reproducti#e age The researchers sent out ',H*: post-mail sur#eys as-ing indi#iduals Duestion such as, if preconception health beha#iors +ere important for +omen to practice before becoming pregnant, or if they recei#ed education on preconception health before becoming pregnant The researchers compared the participant le#el of a+areness of preconception health among men and +omen; as +ell as the mode of recei#ed information The result from their study indicated that +omen ac-no+ledged a#oiding alcohol /$: 9K2, cigarettes /9( $K2, folic acid /HH *K2 and illicit drugs /$9 *K2 as preconception health beha#iors +omen should practice /5itchell, Le#is, 1 Prue, '()'2 5itchell, et al /'()'2 used 4ndresen.s beha#ioral theory of health care deli#ery system and health ser#ices utili3ation focusing more on using social mar-eting to ignite beha#ioral change and communication inter#entions among consumers /an indi#idual of reproducti#e age2 There are unmet needs for healthcare of +omen of child bearing age, +hich the primary healthcare pro#iders or organi3ation can aid in ad#ancing the #alue of a person.s lifespan This can be accomplished through pursuing the e0planations on +hy a person and families utili3e, or fail to use preconception +ellness maintenance ser#ices This -no+ledge +ill help practitioners recogni3e ne+ consumers and disco#er reproducti#e goals or concerns of consumers The practitioners +ill use the information to help consumers

PRECONCEPTION HEALTH understand their pregnancy ris-s, e#entually increase consumer satisfaction, and increase a good health outcome Conclusion 8n conclusion, preconception health refers to properly caring for the body prior to planning a pregnancy Prior to planning a pregnancy, +omen must ta-e into consideration their current state of health, +hich should be #alidated by their primary care physician Women of childbearing age must be made a+are if they currently ha#e diabetes, hypertension or obesity, so they may ta-e action by ta-ing the necessary steps to+ards controlling their health by ta-ing their medications properly, eating according to their goals of concei#ing by ta-ing in the daily recommended amounts of folic acid, iron, calcium and other important nutrients to ensure a healthy pregnancy +ith desirable outcomes Women

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li#ing +ith chronic illnesses such as, diabetes, hypertension and obesity must understand the ris-s of ad#erse pregnancy outcomes /!huang, 6elott, 1 Weisman, '((92 4d#erse pregnancy outcomes encompass miscarriages, pregnancy-induced hypertension, gestational diabetes, neural tube defects, thromboembolism, eclampsia, congenital anomalies, spontaneous abortions, renal failure; and fetal ris-s comprising Fpreterm birth, intrauterine gro+th restriction, placental abruption, and stillbirthG /!huang, 6elott, 1 Weisman, '((92 Health care professionals caring for childbearing-aged +omen should educate their patients to pre#ent any potential ad#erse pregnancy outcomes Health care professionals must e0plore the current -no+ledge and beha#iors of their childbearing-aged +omen

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7eferences Centers for Disease Control and Prevention& '2%1%(& Retrie)e* A+,+-t . 2%13. /ro0 Health1 People 2%1%: 2inal Re)ie3: http:44333&c*c&,o)4nch-health1people4hp2%1%5/inal5re)ie3&ht0 American College of Obstetricians and Gynecologists& '2%11(& Retrie)e* 6+l1 22. 2%13. /ro0 Hi,h 7loo* Pre--+re D+rin, Pre,nanc1: http:44333&aco,&or,4840e*ia42or 92%Patient-4/a:%34&p*/;*0c<1=t-<2%13%"22T1#24 %42#1 U.S. Department of Health & H man Services& '2%11(& Retrie)e* A+,+-t . 2%13. /ro0 Pre)enti)e care act en-+re- 3o0en recei)e- pre)enti)e -er)ice- at no a**itional co-t: http:4433&hh-&,o) 'n&*&(& American College of Obstetricians and Gynecologists !"##$%. >a-hin,ton. D&C&: Depart0ent o/ Go)ern0ent A//air-& Retrie)e* /ro0 Health care /or 3o0en. healthcare /or all: A re/or0 a,en*a& 7a?ter. 6& @&. 7er,hella. A&. 7+chanan. E&. = Perireia. L& '2%1%(& Preconception Care& Obstetrical & Gynecological S rvey& '('2(. 11$B131& Ch+an,. C& H&. Aelott. D& L&. = >ei-0an. C& C& '2%%$(& E?plorin, Dno3le*,e an* attit+*erelate* to pre,nanc1 an* preconception health in 3o0en 3ith chronic 0e*ical con*ition-& )aternal Child Health *o rnal& +,' (. "13B"1$& C+rti-. E& G& '2%1%(& Preconception Care: Clinical an* polic1 i0plication- o/ the preconception a,en*a& *o rnal of Clinical O tcomes )anagement& +-'4(. 1!"B1"2& De >ert. G& E&. Don*orp. >& 6&. = @nopper-. 7& E& '2%12(& Preconception care an* ,enetic ri-D: Ethical i--+e& *o rnal of Comm nity Genetics& .'3(. 221B22#&

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Di,,-. C& N& '2%12(& Health *i-paritie- an* health care /inancin,: Re-tr+ct+rin, the A0erican health care -1-te0& *o rnal of Health Care /inance& .$'4(. "!B$%& Go*/re1. 6& R&. = Nachti,all. E& 6& '2%%$(& Con)er-ation 3ith the e?pert- to3ar* opti0al health: An +p*ate on preconception care& *o rnal of 0omen1s Health& +$'!(. ""$B"#3& 6ohn-on. @& A&. 2lo1*. R& L&. H+0phre1. 6& R&. 7ier0ann. 6&. Eoo-. E&. Dr+00on*-. E&. & & & >oo*. C& '2%12(& Action Plan for the 2ational 3nitiative on Preconception Health and Health Care !PCHHC%4 A 5eport of the PCHHC Steering Commitee "#+"6"#+,& Retrie)e* /ro0 Center- /or Di-ea-e Control an* Pre)ention: http:44333&c*c&,o)4preconception4*oc+0ent-4actionplannationalinitiati)epchhc2%12B 2%14&p*/ L+. E& C&. @otelch+cD. E&. Ho,an. A&. 6one-. L&. >ri,ht. @&. = Hal/on. N& '2%1%(& Clo-in, the FlacDB3hite ,ap in Firth o+tco0e-: A li/eBco+r-e approach& 7thnicity & Disease& "#'2(. !2B"!& Eartin. 6&. Ha0ilton.. 7&. Aent+ra.. E&. O-ter0an.. E&. >il-on.. E&. = Eathe3-.. T& '2%12(& 7irth- : 2inal Data /or 2%1%& 2ational 8ital Statistics 5eport. 1B"2& Eitchell. E& >&. Le)i-. D& E&. = Pr+e. C& E& '2%12(& Preconception health: A3arene--. plannin,. an* co00+nication a0on, a -a0ple o/ U&C& 0en an* 3o0en& )aternal and Child *o rnal Health& +''1(. 31B3$& Eo-ta/a. T& '2%1%(& Ci,arette -0oDin, an* 0ale in/ertilit1& *o rnal of Advanced 5esearch& +'3(. 1"$B1#!& >ei-0an. C& C&. Hille0eier. E& E&. Do3n-. E& E&. Ch+an,. D& C&. Ca0acho. 2& T&. = D1er. A& '2%11(& Preconception pre*ictor- o/ Firth o+tco0e-: Pro-pecti)e /in*in,- /ro0 the

PRECONCEPTION HEALTH Central Penn-1l)ania 3o0enG- health -t+*1& )aternal and Child Health *o rnal& +('"(. #2$B#3 & Ho+n,. 7& C&. Le)ine. R& 6&. = @ar+0anchi. C& A& '2%1%(& Patho,ene-i- o/ Preecla0p-ia& Ann al 5evie9 of Pathological )echanical Disease& (. 1"3B1$2& Ho+n,Din. E& I&. Da)i-. E& C&. Ccha*e3al*. D& E&. = 6+)e. C& '2%13(& 0omen1s Health4 A

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Primary Care Clinical G ide '4th e*&(& Upper Ca**le Ri)er: Pear-on E*+cation. Inc&