What obstetrician-gynecologists think of preconception care

The effect of a locally tailored intervention on the uptake of preconception care in the Netherlands: a stepped-wedge cluster randomized trial (APROPOS-II study)

BACKGROUND

The preconception period provides a window of opportunity for interventions aiming to reduce unhealthy lifestyle behaviours and their negative effect on pregnancy outcomes. This study aimed to assess the effectiveness of a locally tailored preconception care (PCC) intervention in a hybrid-II effectiveness implementation design.

METHODS

A stepped-wedge cluster randomized controlled trial was performed in four Dutch municipalities. The intervention contained a social marketing strategy aiming to improve the uptake (prospective parents) and the provision (healthcare providers) of PCC. Prospective parents participated by administering a questionnaire in early pregnancy recalling their preconceptional behaviours. Experiences of healthcare providers were also evaluated through questionnaires. The composite primary outcome was adherence to at least three out of four preconceptional lifestyle recommendations (early initiation of folic acid supplements, healthy nutrition, no smoking or alcohol use). Secondary outcomes were preconceptional lifestyle behaviour change, (online) reach of the intervention and improved knowledge among healthcare providers.

RESULTS

A total of 850 women and 154 men participated in the control phase and 213 women and 39 men in the intervention phase. The composite primary outcome significantly improved among women participating in the municipality where the reach of the intervention was highest (Relative Risk (RR) 1.57 (95% Confidence Interval (CI) 1.11-2.22). Among women, vegetable intake had significantly improved in the intervention phase (RR 1.82 (95%CI 1.14-2.91)). The aimed online reach- and engagement rate of the intervention was achieved most of the time. Also, after the intervention, more healthcare providers were aware of PCC-risk factors (54.5% vs. 47.7%; p = 0.040) and more healthcare providers considered it easier to start a conversation about PCC (75.0% vs. 47.9%; p = 0.030).

CONCLUSION

The intervention showed some tentative positive effects on lifestyle behaviours among prospective parents. Primarily on vegetable intake and the knowledge and competence of healthcare providers. The results of this study contribute to the evidence regarding successfully implementing PCC-interventions to optimize the health of prospective parents and future generations.

TRIAL REGISTRATION

Dutch Trial Register: NL7784 (Registered 06/06/2019).

Factors Influencing Provider Behavior Around Delivery of Preconception Care

OBJECTIVE

Despite growing consensus about the clinical value of preconception care (PCC), gaps and disparities remain in its delivery. This study aimed to examine the factors influencing behavior of health care providers around PCC in outpatient clinical settings in the United States.

METHODS

Twenty health care providers who serve people of reproductive age were interviewed using semi-structured interviews. Data was coded based on a modified Theoretical Domains Framework and analyzed using deductive content analysis.

RESULTS

We interviewed eight family medicine physicians, four obstetricians/gynecologists, seven nurse practitioners, and one nurse midwife. Overall, we found a wide variety in practices and attitudes towards PCC. Barriers and challenges to delivering PCC were shared across sites. We identified six themes that influenced provider behavior around PCC: (1) lack of knowledge of PCC guidelines, (2) perception of lack of preconception patient contact, (3) pessimism around patient "compliance," (4) opinion about scope of practice, (5) clinical site structure, and (6) reliance on the patient/provider relationship.

CONCLUSIONS FOR PRACTICE

Overall, our findings call for improved provider understanding of PCC and creative incorporation into current health care culture and practice. Given that PCC-specific visits are perceived by some as outside the norm of clinical offerings, providers may need to incorporate PCC into other encounters, as many in this study reported doing. We amplify the call for providers to understand how structural inequities may influence patient behavior and the value of standardized screening, within and beyond PCC, as well as examination of implicit and explicit provider bias.

Health Care Professional's Knowledge of Pregnancy Complications and Women's Cardiovascular Health: An International Study Utilizing Social Media

Background: Despite guidelines recommending the evaluation of adverse pregnancy outcomes (APOs) as a part of the atherosclerotic cardiovascular disease (ASCVD) risk assessment in women, there is limited awareness of this issue in health care professionals. We sought to evaluate the extent of this gap in knowledge. Methods: An online study using a standardized questionnaire was advertised through newsletters and websites of professional organizations. After a low response rate, the link to the survey was announced on Twitter and via personal email invitations. Differences between groups of respondents were evaluated with z-tests of proportion. Results: Out of 446 complete responses, there were 315 cardiologists and 112 obstetricians and gynecologists (OBGyns). There was an >90% awareness of association of adverse maternal outcomes with gestational hypertension and gestational diabetes with ASCVD, but only <60% awareness of association of adverse maternal outcomes with preterm birth. There were significant differences in ASCVD risk assessment and awareness of the association of APOs with adverse outcomes between cardiologists and OBGyns, and between female and male cardiologists. A greater proportion of female cardiologists thought that the guidelines recommended annual follow-up for high-risk women. Conversely, a greater proportion of male cardiologists were unsure of the frequency of follow-up of such women in the relevant guidelines. A higher proportion of U.K. respondents thought that women with high-risk pregnancies should never be screened for cardiovascular disease postpartum compared with U.S. respondents. Conclusions: In a self-selected group of health care professionals interested in women's cardiovascular health, there remains a large gap in knowledge and awareness of the association of APOs with ASCVD risk, in particular, a lack of awareness of the association of ASCVD risk with preterm delivery. Specific target groups for improving knowledge regarding these sex-specific risk enhancers include male cardiologists and health care professionals practicing in the United Kingdom.

Preconception and antenatal knowledge and beliefs about gestational weight gain

BACKGROUND

Prevention of excessive gestational weight gain during pregnancy is difficult; targeting women before pregnancy may be more effective.

AIMS

In order to generate knowledge that may influence the development of effective interventions to promote healthy weight in reproductive-aged women, this study aimed to explore knowledge and belief formation regarding gestational weight gain for preconception and pregnant women.

MATERIALS AND METHODS

Women ≥18 years (preconception n = 265; pregnant women at 16 weeks gestation n = 271) completed questionnaires assessing knowledge and beliefs about gestational weight gain. Responses were categorised according to the 2009 Institute of Medicine gestational weight gain recommendations.

RESULTS

Preconception women exhibited poorer gestational weight gain knowledge than pregnant women, yet only half of pregnant women reported accurate gestational weight gain knowledge within the Institute of Medicine recommendations. Beliefs about gestational weight gain were also inaccurate for both preconception and pregnant women, with 34.1% of pregnant and 44.6% of preconception women expecting to gain less than recommendations. Gestational weight gain knowledge accounted for about half of the variance in gestational weight gain beliefs.

CONCLUSIONS

Overall, the large inaccuracies in gestational weight gain knowledge and beliefs reported by both preconception and pregnant women suggest significant gaps in dissemination of gestational weight gain advice throughout the reproductive life phase. Knowledge is an important part of belief formation that can lead to appropriate weight gain. Hence, health professionals and policy makers should actively pursue opportunities to improve gestational weight gain knowledge in reproductive-aged women.

Barriers and facilitators to the provision of preconception care by healthcare providers: A systematic review

BACKGROUND

Healthcare providers play an important role in providing preconception care to women and men of childbearing age. Yet, the provision of preconception care by healthcare providers remains low.

OBJECTIVES

To provide an overview of barriers and facilitators at multiple levels that influence the provision of preconception care by healthcare providers.

DESIGN

A mixed-methods systematic review.

DATA SOURCES

PubMed, Web of Science, CINAHL, The Cochrane Library, and EMBASE were systematically searched up to April 27, 2017. The search strategy contained MeSH terms and key words related to preconception care and healthcare providers. Reference lists of included studies and systematic reviews on preconception care were screened.

REVIEW METHODS

Publications were eligible if they reported on barriers and facilitators influencing the provision of preconception care by healthcare providers. Data were extracted by two independent reviewers using a data extraction form. Barriers and facilitators were organized based on the social ecological model. The methodological quality of included studies was evaluated using the Critical Appraisal Skills Programme Qualitative checklist for qualitative studies, the Quality Assessment Tool for quantitative studies, and the Mixed Methods Appraisal Tool for mixed methods studies.

RESULTS

Thirty-one articles were included. Barriers were more reported than facilitators. These were situated at provider level (unfavourable attitude and lack of knowledge of preconception care, not working in the field of obstetrics and gynaecology, lack of clarity on the responsibility for providing preconception care) and client level (not contacting a healthcare provider in the preconception stage, negative attitude, and lack of knowledge of preconception care). Limited resources (lack of time, tools, guidelines, and reimbursement) were frequently reported at the organizational and societal level.

CONCLUSIONS

Healthcare providers reported more barriers than facilitators to provide preconception care, which might explain why the provision of preconception care is low. To overcome the different client, provider, organizational, and societal barriers, it is necessary to develop and implement multilevel interventions.

Recall of Prenatal Counselling Among Obese and Overweight Women from a Canadian Population: A Population Based Study

Objective The objective of this study was to evaluate the recall of prenatal counselling received among overweight and obese women in primary care settings. Methods A sample of 1996 women with singleton, term deliveries and pre-pregnancy BMI >18.5 kg/m² were identified from the All Our Babies pregnancy cohort. Information on socio-demographic characteristics and women's experiences with prenatal counselling on nutrition, vitamin and mineral supplements, exercise, weight gain, employment, alcohol and drug use, and smoking during pregnancy were collected through questionnaires administered at <25 weeks and 34-36 weeks gestation. Multivariable logistic regression analyses explored the associations between pre-pregnancy BMI and the domains of prenatal counselling, controlling for confounders. Results Women reported high levels of comfort asking questions and satisfaction with their health care provider. Women reported getting information about nutrition (69.3%), weight gain (67.8%), exercise (64.4%), vitamins and minerals supplementation (86.1%). Obese women (211, 10.6%) were more likely than normal weight women (1313, 65.8%) to be Caucasian (p = 0.004), less educated (p = 0.001), and to have been born or lived in Canada for at least 5 years (p = 0.01). There was no difference in the prenatal advice received on nutrition, weight gain and exercise in pregnancy between obese, overweight, and normal weight women. Conclusions for Practice Pre-pregnancy BMI did not appear to influence the recall of prenatal counselling women receive in community health care centers. Given the importance of nutrition and weight gain during pregnancy, and guidelines for weight gain based on pre-pregnancy BMI, there are missed opportunities in knowledge exchange between women and providers in the prenatal period.

A needs assessment on addressing environmental health issues within reproductive health service provision: Considerations for continuing education and support

BACKGROUND

This needs assessment was initially undertaken to explore the beliefs and knowledge of nurses and physicians about the impact of environmental toxicants on maternal and infant health, as well as to describe current practice and needs related to addressing environmental health issues (EHI).

METHODS

One hundred and thirty-five nurses (n = 99) and physicians (n = 36) working in Saskatchewan completed an online survey. Survey questions were designed to determine how physicians and nurses think about and incorporate environmental health issues into their practice and means of increasing their capacity to do so.

RESULTS

Although participants considered it important to address EHIs with patients, in actual practice they do so with only moderate frequency. Participants reported low levels of knowledge about EHIs' impact on health, and low levels of confidence discussing them with patients. Participants requested additional information on EHIs, especially in the form of online resources.

CONCLUSION

The results suggests that while nurses and physicians consider EHIs important to address with patients, more education, support, and resources would increase their capacity to do so effectively. Based on the findings, considerations and recommendations for continuing education in this area have been provided.

The Power and Pitfalls of Big Data Research in Obstetrics and Gynecology: A Consumer's Guide

IMPORTANCE

Research in obstetrics and gynecology (OB/GYN) increasingly relies on "big data" and observational study designs. There is a gap in practitioner-relevant guides to interpret and critique such research.

OBJECTIVE

This guide is an introduction to interpreting research using observational data and provides explanations and context for related terminology. In addition, it serves as a guide for critiquing OB/GYN studies that use observational data by outlining how to assess common pitfalls of experimental and observational study designs. Lastly, the piece provides a compendium of observational data resources commonly used within OB/GYN research.

EVIDENCE ACQUISITION

Review of literature was conducted for the collection of definitions and examples of terminology related to observational data research. Data resources were collected via Web search and researcher recommendations. Next, each data resource was reviewed and analyzed for content and accessibility. Contents of data resources were organized into summary tables and matched to relevant literature examples.

RESULTS

We identified 26 observational data resources frequently used in secondary analysis for OB/GYN research. Cost, accessibility considerations for software/hardware capabilities, and contents of each data resource varied substantially.

CONCLUSIONS AND RELEVANCE

Observational data sources can provide researchers with a variety of options in tackling their research questions related to OB/GYN practice, patient health outcomes, trends in utilization of medications/procedures, or prevalence estimates of disease states. Insurance claims data resources are useful for population-level prevalence estimates and utilization trends, whereas electronic health record-derived data and patient survey data may be more useful for exploring patient behaviors and trends in practice.

Healthcare providers' views on the delivery of preconception care in a local community setting in the Netherlands

BACKGROUND

The attention for preconception care (PCC) has grown substantially in recent years, yet PCC is far from routine in daily practice. One of the major challenges for the implementation of PCC is to identify how it can best be organized and provided within the primary care setting. The aim of this study was to identify bottlenecks and solutions for the delivery of PCC from a healthcare providers' perspective in a local community setting in the Netherlands.

METHODS

Health professionals within the region of Zeist, the Netherlands, were invited for a meeting on the local implementation of PCC. Five parallel group sessions were held with 30 participants from different disciplines. The sessions were moderated based on the Nominal Group Technique, in which bottlenecks (step 1) and solutions (step 2) for the delivery of PCC were gathered, categorized and prioritized by the participants.

RESULTS

Participants expressed that the provision of PCC is challenging due to lack of awareness, the absence of a costing structure and unclear allocation of responsibilities. The most pragmatic approach considered was to make interdisciplinary arrangements within the local primary care setting. Participants recommended to 1) settle a costing structure by means of third party reimbursement, 2) improve collaboration by means of a local cooperation network and an adequate referral system, 3) invest in education, tools and logistics and 4) increase uptake rates by the routine opportunistic offer of PCC and promotional campaigns.

CONCLUSIONS

From a provider's perspective a tailored approach is advocated in which interdisciplinary arrangements for collaboration and referral are set up within the local primary care setting.

A systematic review of women's and health professional's attitudes and experience of preconception care service delivery

BACKGROUND

The value and importance of preconception care (PCC) have been acknowledged by leading health organizations as a vital element within preventive medicine and health promotion for the wider population. The translation of PCC from position statement to relevant service and programme delivery is essential for the benefits of PCC to be realized and relies on insights from health services research. This article aims to review contemporary health services research literature examining women's and health professionals' perceptions and experiences of PCC services.

METHODS

A systematic review of original research published between 2003 and 2015 was conducted in November 2015. Multiple databases (PubMed, CINAHL, AMED and Maternity and Infant Care) were searched through two distinct searches to capture research literature reporting the perspective of health professionals and women towards PCC service delivery.

RESULTS

The search identified 13 papers (4 reported the perceptions of women, 11 described the views of health professionals [2 papers reported findings from both groups]). The analyses of the contemporary literature revealed five broad areas of focus: women's service needs regarding PCC, PCC training and education requirements, role delineation around PCC, priority and value of PCC and barriers and obstacles to PCC.

CONCLUSIONS

Despite the mounting evidence supporting the value and importance of PCC, there is insufficient research attention given to the clinical reality of PCC service and programme delivery. The transfer of PCC guidelines from broad policy to grass roots practice requires a more detailed consideration of the practicalities of implementing PCC within contemporary women's health care.

Understanding Women's Awareness and Access to Preconception Health Care in a Rural Population: A Cross Sectional Study

Despite evidence of the benefits of preconception health care (PCHC), little is known about awareness and access to PCHC for rural, reproductive-aged women. This study aimed to assess the prevalence of PCHC conversations between rural reproductive-age women and health care providers, PCHC interventions received in the past year, and ascertain predictors of PCHC conversations and interventions. Women (n = 868; 18-45 years) completed a questionnaire including reproductive history, health care services utilization, and interest in PCHC. The prevalence of health care providers' PCHC conversations was 53.9 %, and the mean number of interventions reported was 2.6 ± 2.7 (±SD). Significant predictors of PCHC conversation based on adjusted odds ratios from logistic regression were race (Native American 76 % greater than White), health care provider type (non-physician 63 % greater than physician), visits to a health care provider (3+ times 32 % greater than 1-2 times), and pregnancy planning (considering in next 1-5 years 51 % greater than no plans). Significant predictors of PCHC interventions received in the past 12 months based on adjusted risk ratios from negative binomial regression were race (Native American 22 % greater than White), PCHC conversation with a health care provider (yes 52 % lower than no), reporting PCHC as beneficial (yes 32 % greater than don't know), and visits to a health care provider in the past year (3+ times 90 % greater than 1-2 times). Increasing conversations about PCHC between health care providers and their reproductive-aged patients can improve awareness and increase their likelihood of receiving all of the recommended interventions.

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.

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.

Using community-based participatory mixed methods research to understand preconception health in African American communities of Arizona

The article discusses Arizona's strategic implementation and evaluation of the first time motherhood initiative grant (FTMI) to understand preconception health among African American men and women in Arizona. Longitudinal focus groups assessed whether African American men and women in the targeted areas comprehended and recalled the messages related to preconception health. Matched pre and posttests assessed community members' knowledge of preconception as well as physicians' perceptions on preconception health and care. Focus-group data were transcribed and coded by independent coders to conduct content analyses. Inter-rater reliability and agreement among coders, bivariate and multivariate statistics were conducted for quantitative matched pre and posttests data using SAS v9.2 (SAS Institute, Cary, NC). The social marketing campaign had limited impact in recall and comprehension of the preconception health message among African American men and women. Data from focus groups revealed that African American men and women perceived preconception health to be vital. And results from the pretest and posttests of community-based presentations, further supported this finding. Evidence from Grand Round presentations indicated that practitioners and health care providers had diverging views on preconception health. Use of community-based participatory mixed methods research can facilitate better understanding of the efficacy of strategic interventions such as FTMI and can provide valuable information on preconception health. Cost limitations often prohibit extensive evaluation of social marketing campaigns, hence, evaluators and researchers should assess the feasibility of conducting an efficacy study versus an effectiveness study in evaluating social marketing campaigns.

Effect of aerobic exercise training on maternal weight gain in pregnancy: a meta-analysis of randomized controlled trials

BACKGROUND

Weight gains in pregnancy within the recommended guidelines are associated with healthy fetal and maternal outcomes; higher weight gains are associated with fetal macrosomia. This study was a systemic review of randomized controlled trials on the effect of aerobic training on maternal weight in pregnancy.

METHODS

The study data source was publications through May 2012 in the MEDLINE (PubMed) database. The citation lists of randomized controlled trials on the effect of aerobic training and maternal weight were extracted. Data on participants' characteristics, study quality, population, intervention, treatment outcome (maternal weight gain) were collected and analyzed.

RESULTS

There were 11 randomized controlled studies using body weight (kg) as measure of treatment outcome. A total of 1177 subjects were recruited in the 11 studies. The mean± SD weight gain (kg) for the exercise (11.31± 7.44kg) and control (14.42± 6.60kg) groups; Meta-analysis result indicated significant effect of aerobic training on maternal weight (t= -7.580, p= .000) at p< 0.05.

CONCLUSION

It was concluded that aerobic training is an effective tool in maternal weight gain control in pregnancy. More randomized controlled trials are warranted.

Preconceptional care: a systematic review of the current situation and recommendations for the future



OBJECTIVE

To review the current knowledge and implementation of preconceptional care (PCC) in the Western world, focusing both on health care workers and the general population, and to analyze pathways to disseminate the influence of preconceptional care on pregnancy outcome.

METHODS

A systematic literature study was performed using OvidSP and Pubmed, searching for articles about PCC and its implementation, published between 1966 and October 2012. Only randomized controlled trials and systematic reviews dealing with PCC in the Western world were retained.

RESULTS

Forty-six articles were identified for review. PCC might result in better pregnancy outcomes, including e.g. a reduction of congenital abnormalities. There are no proven disadvantages of PCC. Health care workers are in favor of the implementation of PCC, but claim that they don't have enough knowledge to do so. The general population shows interest in receiving PCC. The implementation of PCC should be improved by e.g. the development of guidelines and checklists.

CONCLUSIONS

As PCC might improve pregnancy outcomes and is considered important by health care workers and the general population, its implementation should be improved, e.g. by the development of guidelines and checklists.

Primary care physicians' perceptions of barriers to preventive reproductive health care in rural communities

CONTEXT

Women residing in rural areas are less likely than urban women to receive preventive reproductive health care, but reasons for this disparity remain largely unexplored.

METHODS

In 2010, semistructured interviews were conducted with 19 rural primary care physicians in central Pennsylvania regarding their experiences in two domains of preventive reproductive health-contraceptive care and preconception care. Major themes were identified using a modified grounded theory approach.

RESULTS

Physicians perceived that they had a greater role in providing contraceptive care than did nonrural physicians and that contraceptives were widely accessible to patients in their communities; however, the scope of contraceptive services they provided varied widely. Participants were aware of the importance of optimal health prior to pregnancy, but most did not routinely initiate preconception counseling. Physicians perceived rural community norms of unintended pregnancies, large families, and indifference toward career and educational goals for young women as the biggest barriers to both contraceptive and preconception care, as these attitudes resulted in a lack of patient interest in family planning. Lack of time and resources were identified as additional barriers to providing preconception care.

CONCLUSIONS

Rural women's low use of contraceptive and preconception care services may reflect that preventive reproductive health care is not a priority in rural communities, rather than that it is inaccessible. Efforts to motivate rural women to engage in reproductive life planning, including more proactive counseling by providers, merit examination as ways to improve use of services.

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.

The reproductive life plan as a strategy to decrease poor birth outcomes

The purpose of this article is to discuss the importance of implementing a life course perspective model that includes a reproductive life plan to improve health outcomes, especially in populations at risk for adverse outcomes. A reproductive life plan is a comprehensive strategy that can be incorporated into nursing practice at all levels to improve birth outcomes. Health care providers, especially nurses, should incorporate reproductive life planning into their daily encounters with patients.

Factors affecting the willingness of counselors to integrate preconception care into sexually transmitted disease clinics

BACKGROUND

The high rate of unintended pregnancy is an immediate barrier to providing preconception care (PCC). Failure to deliver additional PCC messages at sexually transmitted disease (STD) clinics might represent a major missed opportunity to target women at increased risk for unintended pregnancy for behaviors that also put them at risk for adverse pregnancy outcomes.

METHODS

Using a survey questionnaire, we assessed perceptions of PCC and factors influencing the willingness of STD counselors to integrate PCC as an intervention service provided by the STD clinics of 140 STD counselors. We used a cross-sectional design and selected survey participants with a minimum of 2 years' experience in providing HIV pretest and posttest counseling and syphilis interviewing using a nonprobability, purposive sample.

RESULTS

The level of occupational responsibility and the amount of time available seemed to affect counselor perceptions of the importance of PCC and whether it should be integrated as an intervention service provided by STD clinics. Findings suggested that, although most STD counselors reported that PCC was an important issue, there was significant variation in the perception of whether PCC should be delivered at STD clinics.

CONCLUSION

STD counselors perceived PCC to be an important intervention service that can be delivered at STD clinics. Additional study is needed to identify factors that might affect full integration into the STD clinic setting.

Management of prescription and nonprescription drug use during pregnancy

OBJECTIVE

To assess screening and treatment patterns of obstetrician-gynecologists regarding medication use during pregnancy.

METHODS

A questionnaire was mailed to 770 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network.

RESULTS

The response rate was 58%. Most respondents reported always asking pregnant patients about use of over-the-counter (OTC) (86%) and prescription (98%) drugs; 24% reported not always asking about alternative medications. Far fewer reported always asking nonpregnant patients about use of alcohol (67%), illegal drugs (51%) and OTC medications (52%) than pregnant patients. Two-fifths (41%) reported prescribing a medication during pregnancy for which they had insufficient information about potential effects on the fetus; nearly half (47%) reported that there are medical conditions for which they would like to prescribe medications but do not due to insufficient safety information. Physician responses indicate that they are less likely to refer pregnant than nonpregnant patients to a specialist for treatment of certain conditions.

CONCLUSIONS

These results indicate that obstetrician-gynecologists sometimes prescribe medications for pregnant patients under less than optimal conditions and emphasize the importance of generating up-to-date information on effects of medications during pregnancy and having it readily available to health care providers.

Reproductive life plans: initiating the dialogue with women

This article examines the concept of the reproductive life plan and provides information about translating this important idea into practice. The idea of the reproductive life plan was introduced in a report from the , but has thus far received little attention in the nursing literature. Reproductive life plans are important for women and their partners during their childbearing years, for they facilitate discussion about childbearing intentions and choices. Additionally, a dialogue about reproductive life planning may help nurses open a gateway to the utilization of preconception care as an intervention to improve maternal fetal outcomes. Nurses are ideally prepared and situated to assist women and their partners in learning about and developing reproductive life plans.

Knowledge and attitudes regarding preconception care in a predominantly low-income Mexican American population

OBJECTIVE

The objective of the study was to determine knowledge and attitudes regarding preconception care in a low-income Mexican American population.

STUDY DESIGN

This was a cross-sectional survey of 305 reproductive-age women at an urban public hospital.

RESULTS

The sample was mostly Hispanic (88%) and pregnant (68%); 35% had not completed high school. Eighty-nine percent agreed that improving preconception health benefits pregnancy. Seventy-seven percent expressed some interest in preconception health care with the obstetrics gynecology office at the preferred location. The average knowledge of preconception care score was 76% (higher score more favorable). Areas of higher knowledge included the effects on pregnancy of folic acid; alcohol use; substance use; and verbal, physical, and sexual abuse; lower knowledge was found for the effects of cat litter and fish products.

CONCLUSION

There was interest in preconception education and agreement that preconception health has a positive effect on pregnancy. Fewer respondents agreed that it had a good effect than a suburban sample in the same region (89% vs 98%).

Where is the "W"oman in MCH?

Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of "W"omen will improve the health of mothers and children, we must focus on improving the health of "W"omen before pregnancy and put the "W" in Maternal and Child Health.

The Effect of Exercise During Pregnancy on Maternal Outcomes: Practical Implications for Practice

The American College of Obstetricians and Gynecologists recommends that women with low-risk pregnancies participate in moderate-intensity exercise during their pregnancy. Currently, only 15.1% of pregnant women exercise at the recommended levels, which is significantly lower than the general population's 45%. One potential reason is that exercise during pregnancy is perceived as risky. In this article, the authors provide a critical review of the literature examining the effect of exercise on preeclampsia, gestational diabetes, weight gain, labor and birth, and other issues associated with pregnancy. Overall, the evidence indicates that exercise during pregnancy is safe and perhaps even reduces the risk of preeclampsia and gestational diabetes. The evidence for weight gain and labor and birth (rates of cesarean sections, duration of labor) is mixed. Unfortunately, much of the research examining exercise during pregnancy is observational, and the few randomized controlled trials that do exist are small and inadequately powered. Taken together, given the potential benefits of exercise during pregnancy and the lack of evidence for harmful effects on the mother and newborn, practitioners should encourage their healthy pregnant patients to exercise. Practical guidelines for recommending exercise to pregnant women are presented.

Medical issues from preconception through delivery: a roadmap for the internist

The age of the pregnant population and the number of pregnant women with medical issues are increasing. It is widely recognized that internists have the unique opportunity to identify potential pregnancy issues and address them before a problem arises. Therefore, it's important that we become aware of how to approach these issues. In addition to addressing medical issues in a currently pregnant woman, doctors also have the opportunity to identify issues that occurred during a prior pregnancy, such as gestational diabetes, preeclampsia, or pregnancy loss, and to decrease the risk of complications in future pregnancies. The goal of this article is to provide a roadmap to practicing internists so they will incorporate pregnancy planning into their everyday care plans. The approach is similar to that used when performing a preoperative risk assessment: We want to optimize our patients medically for pregnancy.

Obstetrician-gynecologists' screening patterns for anxiety during pregnancy

As obstetrician-gynecologists (ob-gyns) take on a greater role in women's healthcare, it is important that they are aware of the high prevalence of anxiety disorders in their patient population. Anxiety disorders present during pregnancy can have detrimental effects on both mother and child. In this study, we queried 1,193 ob-gyns on their screening rates, practice patterns, training, and knowledge as they relate to anxiety disorders during pregnancy. We achieved a 44% response rate (n=397) after three mailings. Physicians reported a moderate interest in screening for and diagnosing anxiety, but less interest in treatment. Only 20% of respondents (n=79) screen for anxiety during pregnancy, and they typically refer anxiety-disordered patients to mental health professionals. Ob-gyns with comprehensive or adequate training were significantly more likely to screen than those who stated that their training was inadequate. Having a friend who has been diagnosed with an anxiety disorder also significantly increased both the likelihood that these physicians would screen and the reported level of interest in screening of anxiety disorders during pregnancy. At present, the majority of ob-gyns feel that their training in this area was barely adequate to inadequate. Specifically, generalized anxiety disorder may be the least understood. Increased training in this area would allow ob-gyns to overcome what they list as the primary barrier to anxiety screening during pregnancy--that is, inadequate training about anxiety disorders.

Periconception window: advising the pregnancy-planning couple

OBJECTIVE

To discuss the importance of the periconceptional window with regard to being a critical window of exposure. To review the empirical data related to healthy periconceptional behaviors.

DESIGN

Literature review.

CONCLUSION(S)

Human reproduction is a couple-dependent process. Recent literature has highlighted that the periconceptional time period is a critical window of exposure that can impact growth and development. In advising the pregnancy-planning couple, it is of paramount importance that couples have knowledge of the timing of the fertile window to ensure that intercourse occurs on days with the maximum probability of pregnancy. Many women adopt healthier lifestyles while trying to conceive, often quitting smoking, eating healthier or taking vitamins. However, there is a lack of empirical data from prospective studies regarding which environmental exposures or behaviors are or are not safe. Noticeably absent are data regarding the effect of male partners' exposures or behaviors on couple fecundity and fertility. As we improve our ability to pinpoint the timing of conception, we should be able to better advise couples planning pregnancy.

Do we practice what we preach? A review of actual clinical practice with regards to preconception care guidelines

OBJECTIVES

To review what past studies have found with regard to existing clinical practices and approaches to providing preconception care.

METHODS

A literature review between 1966 and September 2005 was performed using Medline. Key words included preconception care, preconception counseling, preconception surveys, practice patterns, pregnancy outcomes, prepregnancy planning, and prepregnancy surveys.

RESULTS

There are no current national recommendations that fully address preconception care; as a result, there is wide variability in what is provided clinically under the rubric of preconception care.

CONCLUSIONS

In 2005, the Centers for Disease Control and Prevention sponsored a national summit regarding preconception care and efforts are underway to develop a uniform set of national recommendations and guidelines for preconception care. Understanding how preconception care is presently incorporated and manifested in current medical practices should help in the development of these national guidelines. Knowing where, how, and why some specific preconception recommendations have been successfully adopted and translated into clinical practice, as well as barriers to implementation of other recommendations or guidelines, is vitally important in developing an overarching set of national guidelines. Ultimately, the success of these recommendations rests on their ability to influence and shape women's health policy.