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Social marketing: planning before conceiving preconception care.

Social marketing approaches can help to shape the formation of and to create demand for preconception care services. This article describes four components of social marketing, often referred to as the 4 P's, that should be carefully researched and set in place before a national effort to launch and sustain preconception care services is pursued. First, the product or package of services must be defined and adapted using the latest in scientific and health care standards and must be based on consumer needs and desires. Second, the pricing of the services in financial or opportunity costs must be acceptable to the consumer, insurers, and health care service providers. Third, the promotion of benefits must be carefully crafted to reach and appeal to both consumers and providers. Fourth, the placement and availability of services in the marketplace must be researched and planned. With the application of market research practices that incorporate health behavior theories in their exploration of each component, consumer demand for preconception care can be generated, and providers can take preconception care to the market with confidence.

Family Planning Services↗

Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis.

Offspring of women with pregestational diabetes mellitus are at increased risk for congenital malformations, largely attributable to poor periconceptional glycaemic control. We assessed the effect of preconception care in reducing congenital malformations, in a meta-analysis of published studies of preconception care in women with diabetes mellitus. Articles were retrieved from Medline (1970 to June 2000) and Embase (1980 to June 2000), and data abstracted by two independent reviewers. The rates and relative risks (RR) for major and minor congenital malformations were pooled from all eligible studies using a random effects model, as were early first-trimester glycosylated haemoglobin values. In 14 cohort studies, major congenital malformations were assessed among 1192 offspring of mothers who had received preconception care, and 1459 offspring of women who had not. The pooled rate of major anomalies was lower among preconception care recipients (2.1%) than non-recipients (6.5%) (RR 0.36, 95%CI 0.22-0.59). In nine studies, the risk for major and minor anomalies was also lower among women who received preconception care (RR 0.32, 95%CI 0.17-0.59), as were the early first-trimester mean glycosylated haemoglobin values (pooled mean difference: 2.3%, 95%CI 2.1-2.4). Women who received preconception care were, on average, 1.8 years older than non-recipients, and fewer smoked (19.6% vs. 30.2%). Only one study described the routine use of periconception folic acid. Out-patient preconception care probably reduces the risk of major congenital anomalies among the offspring of women with pregestational diabetes mellitus. Because many women with diabetes neither plan their pregnancy nor achieve adequate glycaemic control before conception, strategies are needed to improve access to these programs, and to maximize those interventions associated with improved pregnancy outcome, such as smoking cessation and folic acid use.

Adult↗

Models of preconception care implementation in selected countries.

Globally, maternal and child health faces diverse challenges depending on the status of the development of the country. Some countries have introduced or explored preconception care for various reasons. Falling birth rates and increasing knowledge about risk factors for adverse pregnancy outcomes led to the introduction of preconception care in Hong Kong in 1998, and South Korea in 2004. In Hong Kong, comprehensive preconception care including laboratory tests are provided to over 4000 women each year at a cost of $75 per person. In Korea, about 60% of the women served have known medical risk history, and the challenge is to expand the program capacity to all women who plan pregnancy, and conducting social marketing. Belgium has established an ad hoc-committee to develop a comprehensive social marketing and professional training strategy for pilot testing preconception care models in the French speaking part of Belgium, an area that represents 5 million people and 50,000 births per year using prenatal care and pediatric clinics, gynecological departments, and the genetic centers. In China, Guangxi province piloted preconceptional HIV testing and counseling among couples who sought the then mandatory premarital medical examination as a component of the three-pronged approach to reduce mother to child transmission of HIV. HIV testing rates among couples increased from 38% to 62% over one year period. In October 2003, China changed the legal requirement of premarital medical examination from mandatory to "voluntary." This change was interpreted by most women that the premarital health examination was "unnecessary" and overall premarital health examination rates dropped. Social marketing efforts piloted in 2004 indicated that 95% of women were willing to pay up to RMB 100 (US$12) for preconception health care services. These case studies illustrate programmatic feasibility of preconception care services to address maternal and child health and other public health challenges in developed and emerging economies.

Belgium↗

Efficacy of preconception care of diabetic women in a community setting.

OBJECTIVE: To determine the impact of informal preconception care of diabetic women on first-trimester glycemia control in a community setting. STUDY DESIGN: Forty-five women with pregestational diabetes underwent a standardized interview regarding their preconception care prior to the index pregnancy. Patients under 14 weeks' gestation had their glycosylated hemoglobin measured; it was used as an index of first-trimester glycemic control. Variables related to glycemic control were analyzed with reference to glycosylated hemoglobin results. RESULTS: Despite a high incidence of counseling and frequent preconception visits, the mean first-trimester glycosylated hemoglobin (+/- SD) was high (10.7 +/- 2.0), and the majority of pregnancies were unplanned. CONCLUSION: Informal and noncentralized preconception care was not effective in preventing first-trimester hyperglycemia in this group of diabetic women. A high rate of unplanned pregnancy and lack of structured preconception care were prevalent and possibly etiologic.

Adult↗

Knowledge about preconception care in French women with type 1 diabetes.

OBJECTIVE: To assess the knowledge about preconception care among women with type 1 diabetes of childbearing age and to identify factors that may be associated with the absence of preconception care. RESEARCH DESIGN AND METHODS: All women of childbearing age with type 1 diabetes who were seen in 11 Diabetes Centers between December 1 and 12, 2003 were included. An anonymous dual questionnaire was proposed to these women and their consulting diabetologists. RESULTS: One hundred and thirty-eight women were included in the study. The main reported sources of information about pregnancy were the diabetologist (78%) and/or specific leaflets (42%). Although 85% of the women declared having received information about preconception care, 48% were unaware of the risk of congenital malformations and 41% feared for neonatal diabetes. However, 82% of the women thought that a level of HbA1c below 7% was a target to achieve before conception. In multivariate analysis, onset of diabetes before the age of 15 was associated with the knowledge that diabetes may be associated with complications during pregnancy; the use of contraception was associated with knowledge about preconception care; a high educational level was associated with knowledge that complications are avoidable and that good glycemic control is mandatory before conception. CONCLUSIONS: French women with type 1 diabetes, although followed by diabetologists, have major knowledge defects concerning the risks associated with pregnancy. This is the first step towards decreasing the rate of unplanned pregnancies in women with type 1 diabetes.

Adolescent↗

Preconception care--when and what: the attitude of Israeli gynaecologists to preconception counseling.

OBJECTIVES: Preconception care is a form of preventive care and its implementation might improve general women's health as well as improving pregnancy outcome. Our aim was to survey the attitudes of Israeli gynecologists regarding preconception counseling. METHODS: E-mailed questionnaires were sent to gynecologists in an Israeli gynecology network. The questionnaire included two identical sets of questions; one was regarding the care of reproductive aged women who visit their gynecologist for various reasons and the second was regarding the care of women in their first prenatal visit. Answers were scored (from 3-always to 0-never), summed and compared using Chi-square and paired t tests. RESULTS: Mean score for the preconception set was significantly lower than the prenatal set 11.3 (62.7%) versus 16.9 (93.7%) respectively, P < 0.001. Folic acid supplementation and genetic screening tests were recommended to most women in 99 and 94% of first prenatal care visit compared to only 42 and 62% of women who were not pregnant (P < 0.001). CONCLUSIONS: Gynecologists fail to recognize proper opportunities for preconception care. Increased awareness and concrete guidelines concerning timing and content of preconception counseling might be helpful.

Attitude of Health Personnel↗

The negative pregnancy test. An opportunity for preconception care.

OBJECTIVE: To identify women who would likely benefit from preconception care. METHODS: A comprehensive preconception risk survey was administered during a structured interview to 136 women who had a negative pregnancy test visit in a family practice residency ambulatory practice. The survey solicited the presence of self-reported risk variables associated with maternal conditions related to poor obstetric outcome, risk factors for poor obstetric outcome, and risks for developing these conditions. RESULTS: Seventy women (51.5%) reported a medical or reproductive risk that could adversely affect pregnancy. In addition, 68 women (50%) reported a genetic risk; 39 (28.7%) reported a risk for human immunodeficiency virus infection, 35 (25.7%) reported an indication for hepatitis B vaccine, and an equal number reported recent use of illegal substances; 23 (16.9%) reported at least one affirmative answer to the CAGE questionnaire; 79 (58.5%) smoked cigarettes; 74 (54.4%) reported a nutrition risk; 126 (92.6%) reported a psychosocial risk; and 39 (28.7%) reported a perceived barrier to ongoing medical care. Even with the psychosocial risk category excluded, 94% of the women still reported at least one factor requiring further evaluation, counseling, or intervention before pregnancy. CONCLUSIONS: We discovered a significant number of women with obstetric risk factors. A negative pregnancy test visit provides an opportunity for preconception risk assessment and counseling. These results will guide us to further develop practical preconception care protocols.

Female↗

Preconception care: a screening tool for health assessment and risk detection.

BACKGROUND: Identification of risk factors for adverse pregnancy outcome is a main component of preconception care, but requires adequate time and knowledge. This study compares self-administered questionnaires to history taking by a physician to evaluate the reliability of such a screening tool for prepregnancy risk detection. METHODS: One hundred ninety-three women from the outpatient clinic of Obstetrics and Gynecology of the University Medical Center Nijmegen, The Netherlands, were included in a study on preconception care. A Preconceptional Health Assessment form with risk variables pertaining to social, nutritional, medical, infectious disease, medication, reproductive and family history, and two Family History surveys (for the woman and her partner) were completed by 186 couples at home. A physician then orally verified the written answers. Agreement between the written and the oral answers was calculated using kappa statistic. RESULTS: An excellent agreement level was found for all sections of the Preconceptional Health Assessment form (overall kappa = 0.88) except for nutritional history (kappa = 0.70). The Family History surveys also showed a high agreement level (kappa = 0.92 for women and kappa = 0.90 for men). CONCLUSIONS: The questionnaires are an accurate screening tool for preconceptional risk factors. We advocate their implementation in various settings to facilitate the provision of preconception care.

Adult↗

Preconception care for women with type 1 diabetes.

OBJECTIVE: To emphasize preconception care of women with type 1 diabetes and the role of primary care physicians in evaluating and counseling them. QUALITY OF EVIDENCE: Substantial level II evidence indicates that tight glycemic control before conception and early in pregnancy reduces the rate of congenital malformations. Most evidence concerning maternal and fetal risks during pregnancy in patients with type 1 diabetes is level III or IV. Little is published on the role of family physicians in providing preconception counseling or care. MAIN MESSAGE: Preconception care is effective in improving glycemic control early in pregnancy and in reducing the rate of congenital malformations. Preconception evaluation of type 1 diabetic patients involves assessment of prepregnancy glycemic control and diabetic complications. Preconception counseling includes discussing the rate of transmission of diabetes, the effects of pregnancy on maternal and fetal complications, and the use of contraception until optimal glycemic control can be attained. CONCLUSION: Primary care physicians often have frequent and early contact with women of reproductive age; they are ideal candidates for providing type 1 diabetic women with preconception evaluation and counseling.

Adult↗

Preconception care in international settings.

OBJECTIVES: This literature review briefly describes international programs, policies, and activities related to preconception care and resulting pregnancy outcomes. METHODS: Electronic databases were searched and findings supplemented with secondary references cited in the original articles as well as textbook chapters, declarations, reports, and recommendations. RESULTS: Forty-two articles, book chapters, declarations, and other published materials were reviewed. Policies, programs, and recommendations related to preconceptional health promotion exist worldwide and comprise a readily identifiable component of historic and modern initiatives pertaining to women's health, reproductive freedom, and child survival. CONCLUSIONS: The integration of preconception care services within a larger maternal and child health continuum of care is well aligned with a prevention-based approach to enhancing global health.

Child Health Services↗

The national summit on preconception care: a summary of concepts and recommendations.

The Centers for Disease Control and Prevention (CDC) and 35 partner organizations have engaged in developing an agenda for Preconception Health. A summit was held in June 2005 to discuss the current state of knowledge regarding preconception care and convene a select panel to develop recommendations and action steps for improving the health of women, children, and families through advances in clinical care, public health, and community action. A Select Panel on Preconception Care, convened by CDC, deliberated critical related issues and created refined definition of preconception care. The panel also developed a strategic plan with goals, recommendations, and action steps for improving preconception health. The recommendations and action steps are specific to the implementation of health behavior, access, consumer demand, research, and surveillance activities for monitoring and improving the health of women, children and families. The outcome of the deliberations is the CDC publication of detailed recommendations and action steps in the Morbidity and Mortality Weekly Report series, Recommendations and Reports.

Centers for Disease Control and Prevention, U.S.↗

Preconception care by the nonobstetrical provider.

Clinicians who provide health care to women during their childbearing years have the opportunity to affect pregnancy outcomes positively through preconception care. The goal of preconception care is to identify medical and social conditions that may put the mother or fetus at risk. Key elements include screening for certain infectious diseases, obtaining genetic history, updating immunizations, providing specific nutritional advice, and optimizing health status. Some women, and their partners, may require additional care, including a prepregnancy consultation with an obstetrician or maternal-fetal medicine specialist. The clinician can also offer advice that may enhance conception and encourage either early prenatal care when a pregnancy is achieved or early evaluation for infertility.

Congenital Abnormalities↗

Preconception care: a means of prevention.

Preconceptional health promotion should provide a prevention framework for interactions with all women of childbearing potential. Preconceptional counselling is properly directed by specialists in the field of obstetrics and gynaecology, but a multispecialty effort may be needed to achieve adequate information for decision-making. Preconceptional health care offers an important opportunity for physicians involved in women's health to expand a primary care and a primary prevention focus. The obstetrician or gynaecologist is not only involved in acute diagnosis and treatment plans but also in disease prevention, risk and behaviour modification and counselling, which are integral parts of primary prevention and co-ordinated women's health care.

Female↗

What obstetrician-gynecologists think of preconception care.

OBJECTIVES: To describe obstetrician-gynecologists' opinions of preconception care (PCC) and ascertain patient uptake for this service. METHODS: A questionnaire was mailed to 1105 ACOG members in August 2004. RESULTS: There was a 60% response rate. Most physicians think PCC is important (87%) and almost always recommend it to women planning a pregnancy (94%); 54% do so with women who are sexually active. Around a third (34%) thought their patients usually do not plan their pregnancies and 49% 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 (83%) than because of an elevated risk for birth defects (20%). Of 11 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.

Adult↗

Diabetes and pregnancy. Preconception care, pregnancy outcomes, resource utilization and costs.

OBJECTIVE: To describe and compare pregnancy outcomes, resource utilization and costs among women with diabetes who receive and do not receive preconception care. STUDY DESIGN: A multicenter, prospective, observational study of women with type 1 diabetes who received preconception care (PC), became pregnant and delivered (PC women) and women with type 1 diabetes who received prenatal care (PC) only and delivered (PN women). RESULTS: As compared to PN women (n = 74), PC women (n = 24) were seen earlier in gestation and had significantly lower glycosylated hemoglobin levels. The combined number of outpatient visits for PC women was not greater than for PN women. PC women were hospitalized significantly less during pregnancy and tended to have shorter inpatient stays. The mean length of stay after delivery was significantly shorter for PC women. Intensity of care tended to be lower and length of stay shorter for infants of mothers who received PC care. The net cost saving associated with PC care was approximately $34,000 per patient. CONCLUSION: PC achieves its major intended health benefits and is associated with reduced resource utilization and substantially reduced costs. For both health and economic reasons, clinical practice and public policy should embrace PC.

Adult↗

Promising practices in preconception care for women at risk for poor health and pregnancy outcomes.

OBJECTIVES: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. METHODS: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of recurrent very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. RESULTS: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for the babies born to women managed in the Magnolia Project compared to the same ration for the United States. CONCLUSIONS: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the woman's health and subsequent reproductive health outcomes.

Adolescent↗

Preconception care: who needs it, who wants it, and how should it be provided?

BACKGROUND: Preconception care (PC) aims to identify and reduce a number of modifiable factors that can adversely affect pregnancy outcome. AIM: To ascertain both knowledge of the attitudes towards PC among members of primary health care teams (PHCTs) and registered women of childbearing age in a representative sample of general practices in Harrow. METHOD: A questionnaire survey was conducted in a randomly selected group of nine general practices in the London borough of Harrow. Subjects included all relevant health professionals and female patients of childbearing age registered with the practices. RESULTS: A total of 62/88 (70.5%) health professionals and 811 women (1 in 20 of the entire target population) completed the questionnaires. Nurses' knowledge matched that of the doctors, except in the area of genetics. Over 85% of all health professionals believed that PC could be of benefit to both mother and baby. Women were generally well informed; Asian women, those born outside the UK, those who had never been pregnant, and those who had not undertaken education beyond the age of 18 years were significantly less well informed. Health professionals considered PC to be best delivered opportunistically by nurses, and this method appeared to be acceptable to most female patients of childbearing age, although it was significantly less acceptable among Asians. CONCLUSION: Among health professionals and women of childbearing age, there is generally a good level of knowledge of PC, although certain groups are less well informed than others and could benefit from a targeted education approach. Widespread agreement that PC is worthwhile was found among PHCT members, but this view is less strongly held by the female public, with the acceptability of providing PC opportunistically differing significantly between ethnic groups.

Adolescent↗

Preconception care: a systematic review.

OBJECTIVES: To perform a systematic review of published research trials of preconception care services to determine what evidence for effectiveness of care at improving the course of pregnancy or its outcomes has accumulated since the last major review in 1990. METHODS: The review was conducted adapting the systematic methods developed by the Cochrane Collaboration to collect evidence from published clinical research literature with as little bias as possible. The review included literature published after January 1990, and posted on MEDLINE by July 1999. RESULTS: Although more than 40 preconception risk conditions were searched and 470 articles were abstracted, only four problem areas and 19 research trials met the review criteria. New evidence of effectiveness was found for screening women who are seeking family planning for risk conditions; having sexually active women of reproductive age take dietary folate supplements; and providing women affected by certain metabolic conditions (diabetes and hyperphenylalanemia) with nutrition services. CONCLUSIONS: To help improve pregnancy outcomes MCH professionals need to promote the concept of readiness for pregnancy and help see that women are as healthy and appropriately nourished as possible before they become pregnant.

Abortion, Spontaneous↗