The Effect of Preconception Counselling on Lifestyle and Other Behaviour Before and During Pregnancy

Patient Experiences with Pregnancy Planning and Perspectives on Reproductive Care in Community Health Centers: A Qualitative Study of African American Women in Chicago

INTRODUCTION

Given the potential benefits of preventive reproductive health care for both women and children, it is important that clinicians routinely offer preconception and contraceptive counseling in ways that are responsive to patients' wishes. The goal of this study is to gain knowledge about the components of preventive reproductive health care that patients at Federally Qualified Health Centers value, and to elicit patient perspectives on how best to deliver this care.

METHODS

We conducted three focus groups with African American women (n = 21) at two Federally Qualified Health Centers in Chicago. The groups were facilitated using an open-ended, semistructured interview guide. We asked women to reflect on past experiences, advice they would give their teenage daughters, and how to design an ideal clinic. All groups were recorded and transcribed verbatim. Transcripts were coded and analyzed using an inductive approach with ATLAS.ti software.

RESULTS

Although participants wanted comprehensive information about sex and pregnancy, they reported receiving no information at all, or many negative messages. The idea of timing and spacing pregnancies was generally embraced by participants. They described an ideal clinic as having a patient population diverse in income, trusting relationships with providers, comprehensive services, and educational opportunities.

CONCLUSIONS

The women in our study expressed a desire for more information and comprehensive care in the setting of an equitable clinic where they feel respected as individuals. Our findings support the idea behind the patient-centered medical home and challenge prior literature, which suggests the concept of pregnancy planning does not resonate with low-income African American women.

Health insurance, alcohol and tobacco use among pregnant and non-pregnant women of reproductive age

BACKGROUND

Understanding the relationship between health insurance coverage and tobacco and alcohol use among reproductive age women can provide important insight into the role of access to care in preventing tobacco and alcohol use among pregnant women and women planning to become pregnant.

METHODS

We examined the association between health insurance coverage and both past month alcohol use and past month tobacco use in a nationally representative sample of women age 12-44 years old, by pregnancy status. The women (n=97,788) were participants in the National Survey of Drug Use and Health (NSDUH) in 2010-2013. Logistic regression models assessed the association between health insurance (insured versus uninsured), past month tobacco and alcohol use, and whether this was modified by pregnancy status.

RESULTS

Pregnancy status significantly moderated the relationship between health insurance and tobacco use (p-value≤0.01) and alcohol use (p-value≤0.01). Among pregnant women, being insured was associated with lower odds of alcohol use (adjusted odds ratio [AOR]=0.47; 95% confidence interval [CI]=0.27-0.82), but not associated with tobacco use (AOR=1.14; 95% CI=0.73-1.76). Among non-pregnant women, being insured was associated with lower odds of tobacco use (AOR=0.67; 95% CI=0.63-0.72), but higher odds of alcohol use (AOR=1.23; 95% CI=1.15-1.32).

CONCLUSION

Access to health care, via health insurance coverage is a promising method to help reduce alcohol use during pregnancy. However, despite health insurance coverage, tobacco use persists during pregnancy, suggesting missed opportunities for prevention during prenatal visits.

Fetal health locus of control: Scale properties and applications in preconception health programs

Preconception health programs have resulted in improved health behaviors among participants and have shown promise in reducing adverse birth outcomes. However, the role of health beliefs in preconception health program outcomes has been overlooked but warrants attention due to reported positive associations between women's views of control over fetal health and health behavior in pregnancy. Towards an ultimate aim of improving preconception health program reach and effectiveness, we examined properties of a fetal health locus of control (FHLC; Labs & Wurtele, 1986) measure in nulliparous, childbearing aged university women and men. Students (n=1467) completed an online survey that included the FHLC subscales maternal, powerful others', and chance control over fetal health. Factor analyses and correlations with related scales supported the soundness of FHLC constructs in both women and men. All participants rated maternal control in fetal health nearly twice as highly as powerful others' and chance. We therefore recommend that FHLC be integrated into preconception health program evaluation as personal agency in fetal health likely has an important role in women's and men's preconception health behavior and health behavior change.

Association Between Preconception Counseling and Folic Acid Supplementation Before Pregnancy and Reasons for Non-Use

To examine the relationship between folic acid preconception counseling (PCC) and folic acid use and reasons for non-use among women with a recent live birth. We analyzed Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) survey responses from 2009 to 2011 (n = 4,426, response rate = 67%). Multivariable weighted logistic regression models were used to explore associations between folic acid PCC receipt and folic acid use and reasons for non-use. Approximately 30% of women reported daily folic acid use the month before pregnancy, with lower rates among those who were <30, non-white, or unmarried; received WIC during pregnancy; had suffered a stressful event prepregnancy; smoked prepregnancy; had a previous live birth; or had an unintended pregnancy (all p < 0.05). The most common reasons for folic acid non-use were "not planning pregnancy" (61%) and "didn't think needed to take" (41%). Folic acid PCC receipt was reported by 27% of women and was associated with three times the odds of folic acid use (adjusted odds ratio [aOR] 3.15, 95% CI 2.47-4.03) and half the odds of reporting "didn't think needed to take" (aOR 0.47, 95% CI 0.28-0.78) as a reason for non-use. Less than one-third of recent Maryland mothers reported using folic acid daily before pregnancy and only 27% reported receiving folic acid PCC. However, folic acid PCC was associated with increased folic acid use and decreased reporting that women did not think they needed to take folic acid. Our data support initiatives to promote provision of folic acid PCC to all women of childbearing age.

Pregnancy risks associated with obesity

Obesity has increased dramatically in the United States over the last several decades, with approximately 40% of pregnant women now considered overweight or obese. Obesity has been shown to be associated with numerous poor pregnancy outcomes, including increased rates of preeclampsia, gestational diabetes, fetal macrosomia, stillbirth, postterm pregnancy, and increased rates of cesarean delivery. Many of these complications have been found to increase even further with increasing body mass index in a dose-response fashion. In this review, the association of obesity with maternal, fetal, and pregnancy outcomes is discussed as are the recommendations for caring for the obese gravida.

The effects of preconception interventions on improving reproductive health and pregnancy outcomes in primary care: A systematic review

BACKGROUND

Reproductive health and pregnancy outcomes may be improved if the reproductive risk assessment is moved from the antenatal to the preconception period. Primary care has been highlighted as an ideal setting to offer preconception assessment, yet the effectiveness in this setting is still unclear.

OBJECTIVES

To evaluate the effectiveness of preconception interventions on improving reproductive health and pregnancy outcomes in primary care.

METHODS

MEDLINE, CINAHL, EMBASE and PsycINFO databases were searched from July 1999 to the end of July 2015. Only interventional studies with a comparator were included, analysed and appraised systematically, taking into consideration the similarities and differences of the participants, the nature of interventions and settings.

RESULTS

Eight randomized controlled trials were eligible. Preconception interventions involved multifactorial or single reproductive health risk assessment, education and counselling and the intensity ranged from brief, involving a single session within a day to intensive, involving more than one session over several weeks. Five studies recruited women planning a pregnancy. Four studies involved multifactorial risks interventions; two were brief and the others were intensive. Four studies involved single risk intervention, addressing folate or alcohol. There was some evidence that both multifactorial and single risk interventions improved maternal knowledge; self-efficacy and health locus of control; and risk behaviour, irrespective of whether brief or intensive. There was no evidence to support reduced adverse pregnancy outcomes. One study reported no undue anxiety. The quality of the studies was moderate to poor.

CONCLUSION

The evidence from eligible studies is limited to inform future practice in primary care. Nevertheless, this review has highlighted that women who received preconception education and counselling were more likely to have improved knowledge, self-efficacy and health locus of control and risk behaviour. More studies are needed to evaluate the effects on adverse pregnancy outcomes.

Receipt and Timing of Pregnancy-Related Preventive Health Messages Vary by Message Type and Maternal Characteristics

Purpose.

To determine when women receive pregnancy-related preventive health messages and to examine differences in receipt timing by maternal characteristics.

Design.

The cross-sectional secondary analyses used data from the Pregnancy Risk Assessment Monitoring System (PRAMS).

Setting.

The study used PRAMS responses from Maryland, Michigan, New Jersey, Ohio.

Subjects.

Study participants were women with a recent live birth.

Measures.

Health messages included mental health, safe medications, smoking, alcohol, and illegal drugs. The timing of message receipt was categorized as early (preconceptionally and prenatally) or late (prenatally only/never).

Analysis.

Weighted χ2 tests and multivariable logistic regression were used for analysis.

Results.

Among n = 3446, women with unintended pregnancies received all messages, except safe medications, significantly more early vs. late compared with women intending pregnancies (all p < .01). In multivariable analyses, there were no significant associations between timing of receipt and pregnancy intention, parity, preconception insurance status, or adequacy of prenatal care for any of the health messages. Hispanic women had increased odds of receiving the messages early compared with non-Hispanic white women, as did high school graduates vs. women with more education and women with lower household incomes vs. women with higher incomes.

Conclusions.

Women who may be perceived to be at higher risk of adverse pregnancy outcomes and/or engaging in high-risk behavior (minorities, lower education, lower income) appear to be getting messages early more often than do other women; messages are not reaching all women equally.

Healthy Diet and Nutrition Education Program among Women of Reproductive Age: A Necessity of Multilevel Strategies or Community Responsibility

BACKGROUND

Reproductive years represent a major proportion of women‟s life. This review focuses on recommended nutritional considerations, physical activity pattern as well as the effect of nutrition education (NE) on behavior modification and health outcomes of women of reproductive age using either single-level, multiple-level or community-level interventions.

METHODS

For this narrative review, numerous searches were conducted on databases of PubMed, Science Direct and Google Scholar search engine using the keywords women, reproductive age, NE, interventions, community-based.

RESULTS

Even though single intervention is effective, multiple intervention programmes in addition to behavior modification components are even more successful in terms of modified behaviors and health outcomes. Moreover, community based interventions using multilevel strategies are further useful for improved health outcomes and behavior modification.

CONCLUSION

NE programmes have been effective in positive behavior modification measured in terms of eating pattern and health quality. Thus, it is recommended that health professionals use multiple intervention strategies at community level to ensure improved outcomes. Political support is also required to create culturally sensitive methods of delivering nutritional programmes. Finally, as policy is dependent on program cost, nutritional programmes need to combine methods of cost analysis to show cost effectiveness of supplying adequate nutrition for women throughout the lifecycle.

Effects of preconception counseling on maternal health care of migrant women in China: a community-based, cross-sectional survey

Background

Migrants have long been a disadvantaged group in China’s health care system, especially in terms of maternal health care. Many studies have explored the factors associated with a lack of maternal health care and found many determinants, including social, economic, behavioral, and environmental factors. However, studies focusing on factors associated with maternal health care have rarely examined preconception counseling (PCC). This study explored factors related to PCC uptake among migrant women, and investigated the association between PCC and maternal health care in migrant women.

Methods

A community-based cross-sectional study was conducted from July to December 2011, in Nanhai, Guangdong Province, and Pinghu, Zhejiang Province, China. A total of 1,012 migrant women who had their most recent pregnancy within 1 year of the survey answered a standardized interviewer-administered questionnaire about maternal health care. Descriptive statistics and multivariable logistic regression were used to analyze the data.

Results

Only 208 (20.6%, 95% confidence interval [CI]: 18.1–23.1%) of 1,012 migrant women had received PCC. Younger age, having more than one child, lack of knowledge of maternal health care and inter-province migration were predictors of a lack of PCC. PCC was associated with higher consumption of folic acid supplements during the preconception period (adjusted odds ratio [AOR] = 2.65, 95% CI: 1.66–4.23). Among migrants who were resident in Nanhai or Pinghu for less than 5 years, PCC was related to better quality prenatal care (AOR = 3.07, 95% CI: 1.79–5.24).

Conclusions

The prevalence of PCC among migrant women was low (20.6%, 95% CI: 18.1–23.1%). Positive associations were found between the receipt of PCC and preconception folic acid supplements and quality prenatal care. Future studies focusing on maternal health care should pay attention to PCC and explore the effects of PCC on maternal health care through intervention studies. Continued efforts to increase PCC in migrants should target specific age groups (20–24 years), families with more than one child, and women who have migrated between provinces, as well as provide in-depth knowledge of maternal health care.

Provision of specific preconception care messages and associated maternal health behaviors before and during pregnancy

OBJECTIVE

The purpose of this study was to examine the associations between receipt of specific preconception care messages before pregnancy and maternal behaviors before and during pregnancy.

STUDY DESIGN

Data were from the Pregnancy Risk Assessment Monitoring System 2009-2010. Only women who reported receiving general preconception care were asked questions about specific health messages that they received before pregnancy (32.2% of the total sample; N = 10,267). Preconception care messages that were received and corresponding behaviors that were examined included taking vitamins with folic acid before pregnancy, dieting to lose weight or exercising before pregnancy (for women who were overweight or obese before pregnancy), and smoking and drinking alcohol during pregnancy (for women who reported smoking or alcohol use in the past 2 years). Separate weighted multivariable logistic regression models were used to assess the association between receipt of specific preconception care messages and maternal behaviors before and during pregnancy.

RESULTS

Women who reported receiving the message about taking vitamins with folic acid before pregnancy reported taking vitamins more often in the month before pregnancy compared with women who did not receive the message (77% vs 40%; P < .01; adjusted odds ratio [aOR], 2.99; 95% confidence interval [CI], 2.24-4.00). Among overweight and obese women, there was no difference in dieting or exercising between those who received the message about maintaining a healthy weight before pregnancy and those who did not (dieting: 41% vs 39% [P = .58; aOR, 1.06; 95% CI, 0.77-1.47]; exercising: 43% vs 40% [P = .42; aOR, 1.10; 95% CI, 0.81-1.51]). Among smokers, women who received the message regarding smoking during pregnancy smoked more often during the last 3 months of pregnancy than women who did not receive the message (47% vs 27%; P < .01; aOR, 2.22; 95% CI, 1.21-4.09). Among drinkers, the same percentage of women who did and did not receive the message about alcohol use during pregnancy drank in the last 3 months of pregnancy (13% vs 13%; P = .86; aOR, 0.95; 95% CI, 0.65-1.38).

CONCLUSION

Our study found that counseling on folic acid was associated with greater vitamin use, although counseling on dieting, exercising, drinking, and smoking among women who were at high risk was not associated with behaviors before or during pregnancy.

Preconception care: caffeine, smoking, alcohol, drugs and other environmental chemical/radiation exposure

INTRODUCTION

As providing health education, optimizing nutrition, and managing risk factors can be effective for ensuring a healthy outcome for women and her yet un-conceived baby, external influences play a significant role as well. Alcohol, smoking, caffeine use and other similar lifestyle factors, have now become an integral part of the daily life of most men and women, who use/misuse one or more of these harmful substances regularly despite knowledge of their detrimental effects. The adverse health outcomes of these voluntary and involuntary exposures are of even greater concern in women of child bearing age where the exposure has the potential of inflicting harm to two generations. This paper is examining the available literature for the possible effects of caffeine consumption, smoking, alcohol or exposure to chemicals may have on the maternal, newborn and child health (MNCH).

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception usage of caffeine, tobacco, alcohol and other illicit drugs; and exposure to environmental chemicals and radiant on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Heavy maternal preconception caffeine intake of >300 mg/d significantly increase the risk of a subsequent fetal loss by 31% (95% CI: 8-58%). On the other hand, preconception alcohol consumption leads to non-significant 30% increase in spontaneous abortion (RR 1.30; 95% CI: 0.85-1.97). Preconception counselling can lead to a significant decrease in the consumption of alcohol during the first trimester (OR 1.79; 95% CI: 1.08-2.97). Periconception smoking, on the other hand, was found to be associated with an almost 3 times increased risk of congenital heart defects (OR 2.80; 95% CI 1.76-4.47). While the review found limited evidence of preconception environmental exposure on maternal, newborn and child health outcomes, occupational exposure in female radiation workers before conception showed an increased impact in risk of early miscarriages.

CONCLUSION

Identification of substance abuse and environmental history during preconception period provides an opportunity to assist women in reducing major health risks and identify key determinants of healthy pregnancy. Studies have shown that the aversion and prevention of exposure feasibility can play an important role in improving the health of women and their families, however, the results should be interpreted with great caution as there were few studies in each section. Therefore, there is a need for more rigorous studies to test the hypotheses.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

Effects of a simple educational intervention in well-baby clinics on women’s knowledge about and intake of folic acid supplements in the periconceptional period: a controlled trial

Objective

To test the hypothesis that a concise intervention to promote the preconception use of folic acid (FA) supplements among mothers who visit a well-baby clinic (WBC) for the 6-month check-up of their youngest child is effective. Effectiveness was measured as intention to use or actual use of FA supplements before a next pregnancy among women who expected to be pregnant within 0–12 months.

Design

Controlled intervention study with independent samples of intervention and control mothers. The intervention took place at the 6-month visit. A post-intervention measurement was done in the intervention group and a comparable measurement in the control group at the 11-month check-up visit.

Setting

The intervention, verbal and in writing, was implemented in four Dutch WBC and given by the WBC physician to the mothers who visited the WBC.

Subjects

All mothers visiting the WBC were eligible for inclusion, unless they were unable to complete a questionnaire. The intervention group consisted of 198 (68 %) mothers recruited from 291 6-month intervention visits and the control group of 215 (84 %) mothers recruited from 255 11-month normal visits.

Results

In mothers who expected to be pregnant within 0–12 months, the proportion using or intending to use FA was 65 % in the intervention group (n 49) v. 42 % in the control group (n 43; difference 23 %, 95 % CI 4, 43 %, P<0·05).

Conclusions

Health education intervention at the 6-month WBC visit is an effective means to promote the use of FA supplements or the intention to do so.

Folic acid use in planned pregnancy: an Italian survey

It is well known that periconceptional folic acid supplementation decreases the risk of neural tube defects. The aim of this study was to evaluate the attitudes and practices of women with planned pregnancies regarding periconceptional folic acid intake and to identify factors associated with the use of this supplement. During 2 years of observation, we surveyed women with planned pregnancies who called our Teratology Information Service. A total of 500 women were surveyed: 217 (43.4%) took folic acid before becoming pregnant, and 283 (56.6%) did not take it. The women who took folic acid before becoming pregnant had a high education level and received preconception counselling. Our results suggest that less than half of Italian women took folic acid before they became pregnant although they were trying to conceive. Knowledge about the benefits of this vitamin is inadequate also among women who planned the pregnancy and the level of information received from their physicians.

Change in women's knowledge of general and personal preconception health risks following targeted brief counseling in publicly funded primary care settings

PURPOSE

To explore knowledge of general and personal preconception health risks among women in publicly funded clinics and whether brief counseling can improve knowledge.

DESIGN

Interventional cohort study.

SETTING

Five publicly funded primary care clinics.

SUBJECTS

Two cohorts of low-income, nonpregnant African-American and Hispanic women of reproductive age (300 in each cohort).

INTERVENTION

Targeted brief counseling based upon risks identified via preconception health risk assessment.

MEASURES

Correct responses on test of women's knowledge of general and personal preconception health risks pre-encounter vs. 3 to 6 months post-encounter.

ANALYSIS

McNemar's test to compare proportion of women in each cohort who correctly answer questions of preconception health knowledge pre-encounter vs. 3 to 6 months post-encounter.

RESULTS

Women in the intervention cohort experienced a significant increase in knowledge related to preconception health from baseline to 3 to 6 months post-encounter, including recognition of the importance of folic acid supplementation, seeking medical care for chronic conditions, and review of medication in the preconception period that was not observed for the comparison cohort. Among women with chronic medical conditions, those in the intervention cohort significantly increased their knowledge that the condition could lead to problems in pregnancy (+43%) relative to the lesser improvement in knowledge observed for those in the comparison cohort (+4%) (p < .05).

CONCLUSIONS

Women's knowledge of general and personal preconception health risks improved following screening and brief counseling in publicly funded primary care clinics.

Born too soon: care before and between pregnancy to prevent preterm births: from evidence to action

Providing care to adolescent girls and women before and between pregnancies improves their own health and wellbeing, as well as pregnancy and newborn outcomes, and can also reduce the rates of preterm birth. This paper has reviewed the evidence-based interventions and services for preventing preterm births, reported the findings from research priority exercise, and prescribed actions for taking this call further. Certain factors in the preconception period have been shown to increase the risk for prematurity and, therefore, preconception care services for all women of reproductive age should address these risk factors through preventing adolescent pregnancy, preventing unintended pregnancies, promoting optimal birth spacing, optimizing pre-pregnancy weight and nutritional status (including a folic acid-containing multivitamin supplement) and ensuring that all adolescent girls have received complete vaccination. Preconception care must also address risk factors that may be applicable to only some women. These include screening for and management of chronic diseases, especially diabetes; sexually-transmitted infections; tobacco and smoke exposure; mental health disorders, notably depression; and intimate partner violence. The approach to research in preconception care to prevent preterm births should include a cycle of development and delivery research that evaluates how best to scale up coverage of existing evidence-based interventions, epidemiologic research that assesses the impact of implementing these interventions and discovery science that better elucidates the complex causal pathway of preterm birth and helps to develop new screening and intervention tools. In addition to research, policy and financial investment is crucial to increasing opportunities to implement preconception care, and rates of prematurity should be included as a tracking indicator in global and national maternal child health assessments.

Does googling for preconception care result in information consistent with international guidelines: a comparison of information found by Italian women of childbearing age and health professionals

Background

Preconception counseling is effective in reducing the risk of adverse pregnancy outcomes. The Internet is commonly used by women and health professionals to search for health information. We compared the consistency of preconception information found on the Internet with the recommendations published by American Journal of Obstetrics and Gynecology (AJOG) simulating a web search by women of childbearing age and health professionals.

Methods

We reviewed websites resulting from a Google search performed using search strings selected by Italian women of childbearing age and health professionals. We investigated if retrieved information was consistent with AJOG recommendations for preconception care. Logistic regression was used to compare presence of consistent recommendations between women and health professionals.

Results

The highest frequency of correct recommendations was found for folic acid supplementation (39.4% of websites). Consistency of preconception information did not significantly differ between search strategies except for folic acid supplementation. “Communities and blogs” website category provided less frequently correct recommendations compared with “Medical/Public Agency" category (i.e. folic acid supplementation (aOR 0.254; CI 0.098-0.664; p = <0.01). Commercial links, found in 60% of websites, were associated with presence of correct recommendations excepting few items (i.e. physical exercise (aOR 1.127; CI 0.331-3.840; p = 0.848).

Conclusions

Preconception information found is poor and inaccurate regardless of the search is performed by women or health professionals. It is unlikely that information found on the web have any positive impact among women and health professionals in our setting. Strategies to improve preconception information on the web and education of health professionals for web searching of health information should be considered.

Opportunities and challenges for enhancing preconception health in primary care: qualitative study with women from ethnically diverse communities

OBJECTIVE

 There is a growing interest in developing and offering more systematic preconception healthcare. However, it is unclear how this might be regarded by ethnically diverse communities at higher risk of poor maternal and child health outcomes. We sought to explore perceptions about preconception health and care among women from these communities to identify opportunities and challenges for intervention development in primary care.

DESIGN

Qualitative study using focus groups and semistructured interviews.

SETTING

Ethnically diverse and socially disadvantaged community settings of the UK.

PARTICIPANTS

41 women aged 18-45 years, of Pakistani, Indian, Caribbean, African, White and mixed ethnic origin, participating in nine focus groups, half of whom (n=19) had one-to-one follow-up telephone interviews.

RESULTS

Women had modest or poor awareness of preconception health issues. They perceived these could be addressed in primary care, particularly if raised within a range of clinically 'relevant' consultations, such as for contraception, or when opportune for individuals in their social context. However, challenges for engaging women in preconception care more routinely were underlined. These included little prevailing culture of preparing for pregnancy and the realities of their pregnancies often being unplanned; and, for those planning pregnancy, sensitivity and maintaining secrecy when trying to conceive. A preference for female professionals, engaging men, and enhancing access for younger people or women less disposed to general practice, in educational and other settings were highlighted.

CONCLUSIONS

Raising preconception health when this has heightened clinical or social resonance for women may hold promise for initiating more systematic intervention. In primary care this could offer greater potential to directly engage those with low awareness or not considering pregnancy, while enlarging opportunity for others who may be seeking to conceive. Promoting 'preparation for pregnancy' more widely might form part of healthcare and education over the life course. Further intervention development research exploring these possibilities, including their feasibility and acceptability is needed.

Lifelong significance of disempowering experiences in prenatal and maternity care: interviews with elderly Swedish women

In this article I show how the effects of harsh and humiliating treatment, experienced by a number of Swedish women in antenatal care and childbirth in the mid-20th Century, endured for the rest of their lives. This treatment was carried out by medical staff in conformity with a view of expectant mothers as irresponsible and ignorant and with the prevalent idea of "natural birth." These effects were findings in an interview investigation that, with a colleague, I conducted into paid and unpaid work and health of 20 women, seen in a lifetime perspective. Our biomedical way of understanding risks and complications during pregnancy and birthing was confronted with many participants' feelings of distress, guilt, and grief linked to their childbearing experience. I interpret the treatments as "violations of dignity" and as abuse. The consequences are similar to those following traumatic birth experiences described in today's literature.

Determinants of excessive gestational weight gain in urban, low-income women

BACKGROUND

Factors influencing excessive weight gain in pregnancy have not been well-studied among urban, low-income women.

METHODS

This prospective cohort study of 94 prenatal care patients at a large university hospital in Philadelphia examined associations of modifiable midpregnancy behaviors and nonmodifiable or early pregnancy factors with excessive gestational weight gain. Data were collected through questionnaires and medical record abstraction from 2009 to 2011.

FINDINGS

The majority of women were African American (83%) and all (100%) received Medicaid. Nearly two thirds (60%) were overweight or obese in early pregnancy and 41% experienced excessive gain. In multivariable logistic regression analyses, significant predictors of excessive gestational weight gain included high early pregnancy body mass index (odds ratio [OR], 4.20; 95% confidence interval [CI], 1.43-12.34 for overweight/obese vs. normal weight), nulliparity (OR, 3.35; 95% CI, 1.17-9.62 for nulliparity vs. multiparity), and clinician advice discordant with Institute of Medicine guidelines (OR, 5.88; 95% CI, 1.04-33.32 for discordant vs. concordant advice). Watching under 2 hours of television daily (OR, 0.18; 95% CI, 0.03-1.03), and engaging in regular physical activity during pregnancy (OR, 0.35; 95% CI, 0.11-1.09) were suggestive of a reduced risk of excessive gain.

CONCLUSIONS

In this sample of urban, low-income women, high early pregnancy body mass index, nulliparity, and discordant clinician advice were directly associated with excessive gestational weight gain, with a trend toward decreased risk for viewing fewer hours of television and engaging in regular physical activity. Intervening on these targets may optimize gestational weight gain and promote long-term maternal health.

What influences Australian women to not drink alcohol during pregnancy?

There is a strong social norm against consuming alcohol during pregnancy. However, many women do not realise they are pregnant until the sixth week and are not provided with information about the risks of consuming alcohol until they visit a health professional in the second trimester. We conducted semi-structured interviews with 12 midwives and 12 pregnant women from two regions in NSW in 2008-09 to explore attitudes towards alcohol consumption during pregnancy, and the factors that may encourage or inhibit women from following the recommendation to abstain from drinking while pregnant. Both groups noted the social issues around pregnant women consuming alcohol due to perceived social norms and the challenges in not revealing early pregnancy status at social events.

Racial and ethnic disparities in preconception risk factors and preconception care

OBJECTIVE

At-risk drinking, cigarette smoking, obesity, diabetes, and frequent mental distress, as well as their co-occurrence in childbearing aged women, are risk factors for adverse pregnancy outcomes. This study estimated the prevalence of these five risk factors individually and in combination among nonpregnant women aged 18-44 years by demographic and psychosocial characteristics, with a focus on racial and ethnic disparities.

METHODS

Data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) on nonpregnant women aged 18-44 years (n=54,612) were used to estimate the prevalences of five risk factors, pairs of co-occurring risk factors, and multiple risk factors for poor pregnancy outcomes.

RESULTS

The majority of women had at least one risk factor, and 18.7% had two or more risk factors. Having two or more risk factors was highest among women who were American Indian and Alaska Native (34.4%), had less than a high school education (28.7%), were unable to work (50.1%), were unmarried (23.3%), and reported sometimes, rarely, or never receiving sufficient social and emotional support (32.8%). The most prevalent pair of co-occurring risk factors was at-risk drinking and smoking (5.7%).

CONCLUSIONS

The high proportion of women of childbearing age with preconception risk factors highlights the need for preconception care. The common occurrence of multiple risk factors suggests the importance of developing screening tools and interventions that address risk factors that can lead to poor pregnancy outcomes. Increased attention should be given to high-risk subgroups.

Understanding the association of biomedical, psychosocial and behavioral risks with adverse pregnancy outcomes among African-Americans in Washington, DC

This study investigates the relationship between adverse pregnancy outcomes in high-risk African American women in Washington, DC and sociodemographic risk factors, behavioral risk factors, and the most common and interrelated medical conditions occurring during pregnancy: diabetes, hypertension, preeclampsia, and Body Mass Index (BMI). Data are from a randomized controlled trial conducted in 6 prenatal clinics. Women in their 1st or 2nd trimester were screened for behavioral risks (smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) and demographic eligibility. 1,044 were eligible, interviewed and followed through their pregnancies. Classification and Regression Trees (CART) methodology was used to: (1) explore the relationship between medical and behavioral risks (reported at enrollment), sociodemographic factors and pregnancy outcomes; (2) identify the relative importance of various predictors of adverse pregnancy outcomes; and (3) characterize women at the highest risk of poor pregnancy outcomes. The strongest predictors of poor outcomes were prepregnancy BMI, preconceptional diabetes, employment status, intimate partner violence, and depression. In CART analysis, preeclampsia was the first splitter for low birthweight; preconceptional diabetes was the first splitter for preterm birth (PTB) and neonatal intensive care admission; BMI was the first splitter for very PTB, large for gestational age, Cesarean section and perinatal death; employment was the first splitter for miscarriage. Preconceptional factors strongly influence pregnancy outcomes. For many of these women, the high risks they brought into pregnancy were more likely to impact their pregnancy outcomes than events during pregnancy.

Prenatal care: touching the future

The provision of preconception and prenatal care is a critical and time-honored role for family physicians. It could even be termed the first preventive care a human being receives. It has been suggested by some studies that, because of the continuity of care that is considered a cornerstone of family practice, family physicians provide prenatal care that may improve birth outcome. Although prenatal care is acknowledged as important for a healthy pregnancy and delivery, there is debate regarding the true efficacy of prenatal care.

Women's lifestyle behaviors while trying to become pregnant: evidence supporting preconception guidance

OBJECTIVE

We sought to prospectively measure women's daily cigarette, alcohol, and caffeine use, while attempting pregnancy in relation to intentions to change.

STUDY DESIGN

This was a cohort comprising 90 women enrolled upon discontinuing contraception and followed up prospectively until pregnant. Women reported number of daily cigarettes, and alcoholic and caffeinated beverages for 459 menstrual cycles while attempting pregnancy.

RESULTS

A significant mean reduction in daily caffeinated drinks (estimate [EST] = -0.52; 95% confidence interval [CI], -0.70 to -0.33) was observed when compared to baseline usage. Intention to change was associated with a reduction in caffeinated drinks (EST = -0.32; 95% CI, -0.64 to 0.00), and with alcohol and cigarette usage from the first menstrual cycle (EST = -0.15; 95% CI, -0.28 to -0.02 and EST = -1.65; 95% CI, -3.12 to -0.19, respectively).

CONCLUSION

A reduction in daily caffeine intake while attempting pregnancy was observed, but not in alcohol or cigarette use, underscoring the need for preconception guidance.

Developing a reproductive life plan

The purpose of this article is 2-fold: to emphasize the importance of a reproductive life plan and to define its key elements. We review the 2006 recommendations from the Centers for Disease Control and Prevention (CDC) regarding ways to improve the delivery of preconception health care to women in the United States, with particular focus on encouraging individual reproductive responsibility throughout the life span and on encouraging every woman to develop a reproductive life plan. We propose recommendations for the content of a reproductive life plan and explore ways to incorporate the guidelines from the CDC into clinical practice. By encouraging women to consider their plans for childbearing before they become pregnant, clinicians have the opportunity to influence behavior before pregnancy, which may decrease the incidence of unintended pregnancies and adverse pregnancy outcomes.

Patterns of alcohol consumption among pregnant African-American women in Washington, DC, USA

The objective of this paper is to describe the patterns and associated behaviours related to alcohol consumption among a selected sample of pregnant women seeking prenatal care in inner city Washington DC. Women receiving prenatal care at one of nine sites completed an anonymous alcohol-screening questionnaire. Questions concerned the amount, type and pattern of alcohol consumption. Women were categorised as at no, low, moderate or high risk for alcohol consumption during pregnancy. For comparisons of risk levels of drinking, bivariate associations were examined using Fisher's exact test. Odds ratios (ORs) and 95% confidence intervals (CIs) were also computed. Although 31% of current/recent drinkers stated that they continued to drink during pregnancy, responses to quantity/frequency questions revealed that 42% continued to do so. Women who were at high compared with moderate risk acknowledged that others were worried about their consumption [OR=4.0, 95% CI 1.5, 10.6], that they drank upon rising [OR=6.7, 95% CI 1.8, 26.9], had a need to reduce drinking [OR=3.2, 95% CI 1.3, 8.1] and in the past 5 years had had fractures [OR=4.2, 95% CI 1.0, 17.8] or a road traffic injury [OR=3.4, 95% CI 1.0, 12.2]. Women in the high/moderate compared with low-risk group were more likely to have been injured in a fight or assault [OR=2.7, 95% CI 1.3, 5.6]. This study validated the usefulness of our questionnaire in identifying women who were at risk for alcohol consumption during pregnancy across a range of consumption levels. Using our screening tool, women were willing to disclose their drinking habits. This low-cost method identifies women appropriate for targeting of interventions.

A systematic review of factors utilized in preconception health behavior research

This systematic review critically synthesizes the literature focusing on factors related to preconception health behaviors (PCHBs) among childbearing age women in the United States, developed countries, and developing countries. Ovid Medline and CINAHL databases were searched for peer-reviewed articles published between 1998 and 2008 relating to PCHB. Six major categories of factors were identified: frequency of alcohol intake prior and during pregnancy, glycemic control/diabetes management, physical activity before and during pregnancy, pregnancy planning behavior, cystic fibrosis carrier screening, and other risk factors. A critical finding of this review is that knowledge, awareness, and beliefs of preconception care do not lead to preconception health practice. Younger preconceptional women and women with children were less likely to engage in PCHB. However, women with advanced postgraduate education were more likely to practice preconception care. There is an urgent need to educate young preconceptional women regarding the importance and benefits of practicing preconception care.

Scheduling the first prenatal visit: office-based delays

OBJECTIVE

The purpose of this study was to evaluate the office-based component of delayed entry into prenatal care.

STUDY DESIGN

Phone numbers for all obstetrics offices in a single state were obtained from a commercial list. A research assistant who posed as a newly pregnant, fully insured woman asked each clinic when she should come in for her first prenatal visit.

RESULTS

Information was provided by 239 of the 279 (86%) offices. The recommended appointment times ranged from immediately (4 weeks of gestation) to 10.6 weeks, which averaged 6.37 weeks. Twenty-five percent of clinics recommended a first appointment at >/=8 weeks. Scheduling calls were not a source of prenatal advice: <5% of clinics asked about smoking, alcohol, or medical condition; 88% of clinics did not mention vitamins.

CONCLUSION

Office-based delays in scheduling the first prenatal visit occur in a substantial proportion of clinics, even for fully insured women. There is a need for a standard source of advice in early pregnancy.

Innovative Strategies to Reduce Disparities in the Quality of Prenatal Care in Underresourced Settings

This study examined what innovative strategies, including the use of health information technology (health IT), have been or can be used to reduce disparities in prenatal care quality in underresourced settings. Based on literature review and key informant interviews, the authors identified 17 strategies that have been or can be used to (a) increase access to timely prenatal care, (b) improve the content of prenatal care, and (c) enhance the organization and delivery of prenatal care. Health IT can be used to (a) increase consumer awareness about the importance of preconception and early prenatal care, facilitate spatial mapping of access gaps, and improve continuity of patient records; (b) support collaborative quality improvement, facilitate performance measurement, enhance health promotion, assist with care coordination, reduce clinical errors, improve delivery of preventive health services, provide decision support, and encourage completeness of documentation; and (c) support data integration and engineer collaborative innovation.

Women's perspectives on counseling about risks for medication-induced birth defects

PURPOSE

This qualitative study explored women's experiences with counseling about medication-induced birth defects, as well as how and when they would like to receive information on medication-induced birth defects from their health care providers (HCPs).

METHODS

We conducted four focus groups with 36 women of reproductive age (18-45 years old) in Pittsburgh, Pennsylvania. Twenty-one women were using medications to treat a chronic health condition, and two were pregnant. Content analysis was performed by three independent coders using a grounded theory approach. Discrepancies were resolved by consensus.

RESULTS

Women reported depending on their HCPs for information about the risks of teratogenic effects of medications on a pregnancy, but felt the information they had been provided was not always comprehensive. Women want HCPs to initiate discussions about potentially teratogenic medications at the time the medications are prescribed, regardless of whether the woman is sexually active or planning a pregnancy. Women want clear information about all potential outcomes for a fetus. Factors women reported as being critical to effective teratogenic risk counseling included privacy, sufficient time to discuss the topic, and a trusting relationship with their HCP.

CONCLUSIONS

Women of reproductive age think that providing information about the possible teratogenic effects of medications could be improved by routine discussions of teratogenic risks at the time medications are prescribed.

Policy and finance for preconception care opportunities for today and the future

This special supplement of Women's Health Issues offers 2 types of articles related to the policy and finance context for improving preconception health and health care. These articles discuss the impact of finance and policy on preconception health and health care, as well as the strategies that are being used to overcome the challenge of implementing preconception care with limited resources and inadequate health coverage for women. Invited papers from authors with expertise in health policy and finance issues describe how women's health and preconception care fit into the larger debates on health reform and how the paradigm for women's health must change. Other invited papers discuss opportunities and challenges for using programs such as Medicaid, Title X Family Planning, Title V Maternal and Child Health Services Block Grant, Healthy Start, and Community Health Centers in improving preconception health and health care. Contributed articles on health services research in this supplement characterize the types of change occurring across the country. This paper also presents a framework for understanding the role of policy and finance in the larger Centers for Disease Control and Prevention Preconception Health and Health Care Initiative.