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

Promoting REproductive Planning And REadiness in Diabetes (PREPARED) Study protocol: a clinic-randomised controlled trial testing a technology-based strategy to promote preconception care for women with type 2 diabetes

INTRODUCTION

Women with type 2 diabetes (T2DM) are more likely to experience adverse reproductive outcomes, yet preconception care can significantly reduce these risks. For women with T2DM, preconception care includes reproductive planning and patient education on: (1) the importance of achieving glycaemic control before pregnancy, (2) using effective contraception until pregnancy is desired, (3) discontinuing teratogenic medications if pregnancy could occur, (4) taking folic acid, and (5) managing cardiovascular and other risks. Despite its importance, few women with T2DM receive recommended preconception care.

METHODS AND ANALYSIS

We are conducting a two-arm, clinic-randomised trial at 51 primary care practices in Chicago, Illinois to evaluate a technology-based strategy to 'hardwire' preconception care for women of reproductive age with T2DM (the PREPARED (Promoting REproductive Planning And REadiness in Diabetes) strategy) versus usual care. PREPARED leverages electronic health record (EHR) technology before and during primary care visits to: (1) promote medication safety, (2) prompt preconception counselling and reproductive planning, and (3) deliver patient-friendly educational tools to reinforce counselling. Post-visit, text messaging is used to: (4) encourage healthy lifestyle behaviours. English and Spanish-speaking women, aged 18-44 years, with T2DM will be enrolled (N=840; n=420 per arm) and will receive either PREPARED or usual care based on their clinic's assignment. Data will be collected from patient interviews and the EHR. Outcomes include haemoglobin A1c (primary), reproductive knowledge and self-management behaviours. We will use generalised linear mixed-effects models (GLMMs) to evaluate the impact of PREPARED on these outcomes. GLMMs will include a fixed effect for treatment assignment (PREPARED vs usual care) and random clinic effects.

ETHICS AND DISSEMINATION

This study was approved by the Northwestern University Institutional Review Board (STU00214604). Study results will be published in journals with summaries shared online and with participants upon request.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04976881).

Knowledge, attitude and practice of physicians regarding periconceptional folic acid for women at low risk of a neural tube defect affected pregnancy

Canadian expert guidelines recommend low-risk women to consume a daily multivitamin supplement containing 400 µg of folic acid (FA) to prevent neural tube defects. Mandatory food fortification coupled with intake of prenatal vitamin/mineral supplements (PVS), most of which contain ≥ 1000 µg-FA, has resulted in an unprecedented shift in Canadian pregnant women folate status. This study assessed the knowledge, attitude and practice (KAP) of physicians regarding periconceptional FA recommendations, intake and health related outcomes, since they play an essential role in promoting appropriate FA intake. Seventy-seven physicians answered the self-administered KAP survey. Only half of physicians knew the correct dose and duration of FA for low-risk women. Approximately 70% were unsure of, or unfamiliar with the most recent guidelines and 60% of physicians most often recommend a ≥ 1000 µg-FA supplement. Knowledge score 1 (KS1), which related to low-risk women, was associated with physicians' attitude toward believing that most PVS contain the recommended amount of FA (p = 0.004). Significant correlations were also found between KS1 and the total practice score (TPS) (r = 0.45, p < 0.0001) as well as between the total knowledge score and TPS (r = 0.38, p = 0.0007). Our findings show that physicians lacking knowledge regarding periconceptional FA is associated with their attitude and practice. Despite a vast majority of physicians being unsure or uncomfortable recommending PVS that are not in line with recommendations, a lack of knowledge and a widely accessible 400 µg-FA PVS, enables a contradictory practice in reality.

Food and Nutrition-Related Knowledge, Attitudes, and Practices among Reproductive-Age Women in Marginalized Areas in Sri Lanka

Nutrient deficiencies are a public health problem in Sri Lanka. Achieving food security is a major challenge due to unhealthy eating patterns. The nutritional status of a woman and her knowledge is a powerful indicator of the nutritional security of her children and household food security. Nutrition-related knowledge and attitude are necessary for dietary changes towards a healthier dietary pattern. For that reason, food and nutrition-related Knowledge, Attitude and Practice (KAP) is one of the key factors to achieving household food and nutritional security. The main objective of this study is to assess the food and nutrition-related KAP among reproductive-age women and understanding of household food and nutritional security in Sri Lanka as an example for marginalized societies. Thus, a cross-sectional survey was conducted using the KAP model questionnaire administered on 400 reproductive age women (18-49 Years) in marginalized areas in Sri Lanka. Data were collected using a random sampling method. The research results clearly showed that the reproductive age women have a low level of nutritional knowledge in the areas being investigated. Most women have a positive attitude towards receiving nutritional knowledge but have low-level practice about a healthy diet. Furthermore, knowledge, practices, and attitudes of women largely affect their BMI status, as well as household food security. Multiple linear regression analysis was used to analyze the influential factors. There was a highly significant positive correlation between nutritional knowledge, attitude score, and BMI level and a significant difference was found in the area, age, family size, monthly income, educational level, attitudes towards nutrition, food and nutrition practices across the reproductive women (R2:467, p < 0.01). The research results showed that KAP largely determines women's nutrition and household food security. Based on the results of this research, there is a need to enhance nutritional education in reproductive-age women in marginalized areas in Sri Lanka.

The Association Between Preconception Care Receipt and the Timeliness and Adequacy of Prenatal Care: An Examination of Multistate Data from Pregnancy Risk Assessment Monitoring System (PRAMS) 2009-2011

Objectives Prenatal care (PNC) is a critical preventive health service for pregnant women and infants. While timely PNC has been associated with improved birth outcomes, improvements have slowed since the late 1990s. Therefore, focus has shifted to interventions prior to pregnancy. Preconception care is recommended for all women of reproductive age. This study aimed to examine preconception care and its association with timeliness and adequacy of PNC. Methods This retrospective cohort study used data from a large sample of United States first-time mothers (n = 13,509) who participated in the 2009-2011 Pregnancy Risk Assessment Monitoring System in ten states. Timeliness and adequacy of PNC data came from birth certificates, while preconception care receipt was self-reported. Logistic regression provided odds ratios (ORs) and 95% confidence intervals (CIs) to model the association between preconception care receipt and the two PNC outcomes. Results After adjustment, women who received preconception care had statistically significant increased odds of timely (OR 1.30, 95% CI 1.08, 1.57), but not adequate PNC (OR 1.08, 95% CI 0.94, 1.24) as compared to women who did not receive preconception care. Pregnancy intention modified these associations. Associations were strongest among women with intended pregnancies (timely PNC: OR 1.63 and adequate PNC: OR 1.22). Conclusions for Practice Given that untimely PNC is associated with adverse birth outcomes, the observed association warrants increased focus on implementing preconception care. Future studies should investigate how specific components of preconception care are associated with PNC timeliness/adequacy, health behaviors during pregnancy, and birth outcomes.

Models of HIV Preconception Care and Key Elements Influencing These Services: Findings from Healthcare Providers in Seven US Cities

Preconception care can improve maternal and infant outcomes by identifying and modifying health risks before pregnancy and reducing unplanned pregnancies. However, information about how preconception care is provided to persons living with HIV (PLWH) is lacking. This study uses qualitative interviews with HIV care providers to describe current models of preconception care and explore factors influencing services. Single, anonymous, telephone interviews were conducted with 92 purposively selected HIV healthcare providers in Atlanta, Baltimore, Houston, Kansas City, Newark, Philadelphia, and San Francisco in 2013-2014. Content analysis and a grounded theory approach were used to analyze data. Participants included 57% physicians with a median of 10 [interquartile range (IQR) = 5-17] years HIV care experience; the mean proportion of female patients was 45%. Participants described Individual Provider (48.9%), Team-based (43.2%), and Referral-only (7.6%) models of preconception care, with 63% incorporating referrals outside their clinics. Thematic analysis identified five key elements influencing the provision of preconception care within and across models: consistency of delivery, knowledge and attitudes, clinic characteristics, coordination of care, and referral accessibility. Described models of preconception care reflect the complexity of our healthcare system. Qualitative analysis offers insights about how HIV clinicians provide preconception care and how key elements influence services. However, additional research about the models and outcomes of preconception care services are needed. To improve preconception care for PLWH, research and quality improvement initiatives must utilize available strengths and tackle existing barriers, identified by our study and others, to define and implement effective models of preconception care services.

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.

Utilisation of preconception care services and determinants of poor uptake among a cohort of women in Abakaliki Southeast Nigeria

Preconception care (PCC) is a preventive strategy for maternal and perinatal morbidity and mortality. This study aimed to assess the level of awareness and utilisation of PCC services. A descriptive cross-sectional survey was conducted at a teaching hospital. Interviewer-administered questionnaires were used to extract information. A total of 450 participants responded; 44.2% (190/450) were aware, 31.7% (143/450) had good knowledge, while only 10.3% (46/450) received PCC. Health care providers were the main source of information (77.9%). There was statistically significant correlation between awareness and participants' level of education (p < .001) and residence (p < .001), as well as between utilisation and education (p < .001), and information from doctors (p < .001). There was a low level of awareness and poor utilisation of PCC, underpinning the need to scale up health education, establishment of functional PCC clinics and formulation of evidence-based guidelines to improve uptake and pregnancy outcome. Impact statement What is already known on the subject of the paper? PCC has been known in high-income countries as a prevention-based strategy, which aims at improving obstetric outcomes. However, the level of utilisation in low-income countries like Nigeria is either unknown or far too low. What do this study add? This work has provided local data on PCC; clearly indicating that the awareness and utilisation of PCC services in Abakaliki, Nigeria is very low when compared with other regions of the world, and this was influenced by the socio-demographic factors - particularly education and place of residence (for awareness), and level of education and information from health care providers (for utilisation), thus suggesting that enlightenment and improvement in social infrastructures could improve awareness, access and utilisation of PCC. What are the implications for clinical practice and/or further research? The implications of these findings in low resource settings like ours will include introducing interventions to scaling up health education, universal establishment of functional PCC units and formulation of evidence-based guidelines aimed at improving the uptake of PCC and pregnancy outcome. Further research will also be needed in future to assess the impact of such interventions and how to sustain potential benefits.

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.

General practitioners' knowledge, attitudes and views of providing preconception care: a qualitative investigation

BACKGROUND

Preconception health and care aims to reduce parental risk factors before pregnancy through health promotion and intervention. Little is known about the preconception interventions that general practitioners (GPs) provide. The aim of this study was to examine GPs' knowledge, attitudes, and views towards preconception health and care in the general practice setting.

METHODS

As part of a large mixed-methods study to explore preconception care in England, we surveyed 1,173 women attending maternity units and GP services in London and interviewed women and health professionals. Seven GPs were interviewed, and the framework analysis method was used to analyse the data.

FINDINGS

Seven themes emerged from the data: Knowledge of preconception guidelines; Content of preconception advice; Who should deliver preconception care?; Targeting provision of preconception care; Preconception health for men; Barriers to providing preconception care; and Ways of improving preconception care. A lack of knowledge and demand for preconception care was found, and although reaching women before they are pregnant was seen as important it was not a responsibility that could be adequately met by GPs. Specialist preconception services were not provided within GP surgeries, and care was mainly targeted at women with medical conditions. GPs described diverse patient groups with very different health needs.

CONCLUSION

Implementation of preconception policy and guidelines is required to engage women and men and to develop proactive delivery of care with the potential to improve pregnancy and neonatal outcomes. The role of education and of nurses in improving preconception health was acknowledged but remains under-developed.

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.

Preconception healthcare delivery at a population level: construction of public health models of preconception care

A key challenge of preconception healthcare is identifying how it can best be delivered at a population level. To review current strategies of preconception healthcare, explore methods of preconception healthcare delivery, and develop public health models which reflect different preconception healthcare pathways. Preconception care strategies, programmes and evaluations were identified through a review of Medline and Embase databases. Search terms included: preconception, pre-pregnancy, intervention, primary care, healthcare, model, delivery, program, prevention, trial, effectiveness, congenital disorders OR abnormalities, evaluation, assessment, impact. Inclusion criteria for review articles were: (1) English, (2) human subjects, (3) women of childbearing age, (4) 1980–current data, (5) all countries, (6) both high risk and universal approaches, (7) guidelines or recommendations, (8) opinion articles, (9) experimental studies. Exclusion criteria were: (1) non-human subjects, (2) non-English, (3) outside of the specified timeframe, (4) articles on male healthcare. The results of the literature review were synthesised into public health models of care: (1) primary care; (2) hospital-based and inter-conception care; (3) specific preconception care clinics; and, (4) community outreach. Fifteen evaluations of preconception care were identified. Community programmes demonstrated a significant impact on substance use, folic acid supplementation, diabetes optimization, and hyperphenylalaninemia. An ideal preconception visits entail risk screening, education, and intervention if indicated. Subsequently, four public health models were developed synthesizing preconception care delivery at a population level. Heterogeneity of risk factors, health systems and strategies of care reflect the lack of consensus about the best way to deliver preconception care. The proposed models aim to reflect differing aspects of preconception healthcare delivery.

Surveillance of preconception health indicators in behavioral risk factor surveillance system: emerging trends in the 21st century

OBJECTIVES

This article assesses emerging trends in the 21st century, if any, in preconception health indicators among women of reproductive age.

METHODS

This is a secondary analysis of cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS), 2003-2010. Subjects were a sample of noninstitutionalized, 18-44-year-old, nonpregnant, women in the United States (n=547,177) grouped into two categories, 2003-2006 (n=275,630) and 2007-2010 (n=271,547). Overall crude and adjusted prevalence odds ratios were calculated for preconception indicators before 2006 and after 2006.

RESULTS

Significant improvements were found for any and heavy alcohol use, smoking, social and emotional support, moderate/vigorous physical activity, and having had an influenza shot in the last year. In contrast, binge drinking, having a medical condition (i.e., diabetes, high blood pressure, asthma, or obesity), and self-reported health significantly worsened. No change was found for mental distress, HIV testing, and having a routine checkup.

CONCLUSIONS

As the 21st century unfolds, emerging trends suggest that we need to focus on educating women, providers, and public health advocates about improved health before pregnancy, especially for women with chronic conditions and those who binge drink alcohol.

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.

Core state preconception health indicators: a voluntary, multi-state selection process

This report describes the consensus-based selection process undertaken by a voluntary committee of policy/program leaders and epidemiologists from seven states to identify core state indicators to monitor the health of reproductive age women (aged 18-44 years). Domains of preconception health were established based on priority areas within maternal and child health and women's health. Measures (i.e., potential indicators) addressing the domains were identified from population-based, state level data systems. Each indicator was evaluated on five criteria: public health importance, policy/program importance, data availability, data quality, and the complexity of calculating the indicator. Evaluations served as the basis for iterative voting, which was continued until unanimous consent or a super majority to retain or exclude each indicator was achieved. Eleven domains of preconception health were identified: general health status and life satisfaction; social determinants of health; health care; reproductive health and family planning; tobacco, alcohol and substance use; nutrition and physical activity; mental health; emotional and social support; chronic conditions; infections; and genetics/epigenetics. Ninety-six possible indicators were identified from which 45 core indicators were selected. The scope of preconception care and the public health components to address preconception health are still under development. Despite this challenge and other measurement limitations, preconception health and health care indicators are urgently needed. The proposed core indicators are a set of measures that all states can use to evaluate their preconception health efforts. Furthermore, the indicators serve as a basis for improving the surveillance of the health of reproductive age women.

Integrating preconception care for women with diabetes into primary care: a qualitative study

BACKGROUND

National guidelines emphasise the need to deliver preconception care to women of childbearing age. However, uptake of the services among women with diabetes in the UK is low. Questions arising include how best to deliver preconception care and what the respective roles of primary versus secondary caregivers might be.

AIM

To explore the perspective of GPs and secondary care health professionals on the role of GPs in delivering preconception care to women with diabetes.

DESIGN OF STUDY

Qualitative, cross-sectional study.

SETTING

A London teaching hospital and GP practices in the hospital catchment area.

METHOD

Semi-structured interviews with GPs and members of the preconception care team in secondary care. Thematic analysis using the framework approach.

RESULTS

GPs and secondary care professionals differ in their perception of the number of women with diabetes requiring preconception care and the extent to which preconception care should be integrated into GPs' roles. Health professionals agreed that GPs have a significant role to play and that delivery of preconception care is best shared between primary and secondary care. However, the lack of clear guidelines and shared protocols detailing the GP's role presents a challenge to implementing 'shared' preconception care.

CONCLUSION

GPs should be more effectively involved in providing preconception care to women with diabetes. Organisational and policy developments are required to support GPs in playing a role in preconception care. This study's findings stress the importance of providing an integrated approach to ensure continuity of care and optimal pregnancy preparation for women with diabetes.

Lifestyle factors in people seeking infertility treatment - A review

BACKGROUND

Clinical infertility is a prevalent problem with significant financial and psychosocial costs. Modifiable lifestyle factors exist that may affect a person's time to conception and their chance of having a healthy, live birth. However, no guideline delineates what preconception advice should be offered to people presenting for infertility treatment.

AIM

The aim of this article is to review the literature regarding modifiable lifestyle factors in people seeking infertility treatment.

RESULTS

A person's time to pregnancy and their chance of having a healthy, live birth may be affected by factors such as weight, vitamin and iodine intake, alcohol and caffeine consumption, smoking, substance abuse, stress, environmental pollutants, vaccinations and oxidative stress.

CONCLUSIONS

Advice on modifiable lifestyle factors should be given to people presenting for infertility treatment to help them make positive changes that may improve their chances of pregnancy and delivering a healthy, live baby. Developing a guideline for this would be a prudent step towards helping clinicians to implement this aspect of preconception care.

Preconception lifestyle advice for people with subfertility

BACKGROUND

Infertility is a prevalent problem and has significant consequences for individuals, families and the wider community. People's chance of having a healthy, live birth may be impacted upon by factors such as weight, diet, smoking, other substance abuse, environmental pollutants, infections, medical conditions, medications and family medical history. However, there is no current guideline about what preconception advice should be offered to people presenting for infertility treatment. It is important to determine what preconception advice should be given about these types of factors to such people in order to help them to make positive changes and hopefully improve their chances of conception and delivering a healthy, live baby.

OBJECTIVES

To assess the effects of preconception advice on the chances of a live birth for people who perceive that they may be infertile and are investigating the possibility of medical treatment to address subfertility.

SEARCH STRATEGY

All published and unpublished randomised controlled trials addressing preconception advice to influence lifestyle factors in people who perceived that they may be infertile and investigated the possibility of medical treatment to address subfertility were sought from the Cochrane Menstrual Disorders and Subfertility Review Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, MEDLINE, PubMed, EMBASE, PsycINFO, AMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL), LILACS, trial registers for ongoing and registered trials, citation indexes, ISI Web of Knowledge, Clinical Study Results database, OpenSIGLE database, China National Knowledge Infrastructure (CNKI) Periodical Index and Google (inception to 5 October 2009).

SELECTION CRITERIA

Only randomised controlled trials (RCTs), including cluster-randomised (group-randomised) trials, that considered preconception advice given to individuals who perceived that they may be infertile and were investigating the possibility of medical treatment from subfertility specialist services were eligible for inclusion. The primary outcome was live birth, defined as delivery of a live fetus after 20 completed weeks of gestation.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied eligibility criteria to, extracted data from and assessed the risk of bias in the single included trial.

MAIN RESULTS

One trial assessing smoking cessation advice for 94 infertile women smokers fulfilled the criteria for this review, but the trial did not report on the review's primary outcome of live birth or any other fertility-related outcomes. This trial of women attending a fertility clinic showed that smoking cessation advice tailored to a woman's "stage-of-change" (readiness to stop smoking) did not show significant evidence of a difference in stage (including smoking cessation rates) compared with standard clinical advice.

AUTHORS' CONCLUSIONS

No RCTs were located that assessed the effects of preconception advice on the chance of a live birth or other fertility outcomes in people who perceived that they may be infertile and were investigating the possibility of medical treatment to address subfertility. Given the lack of RCTs evaluating the effectiveness of preconception lifestyle advice for people in the afore-mentioned population, this review cannot provide guidance for clinical practice in this area. However, it does highlight the need for further research into this important subject.

Role of medicaid family planning waivers and Title X in enhancing access to preconception care

PURPOSE

This article identifies the ways in which Medicaid eligibility expansions for family planning services and the Title X network of family planning clinics provide opportunities to introduce preconception care. The introduction of family planning eligibility expansions brought in populations heretofore ineligible for Medicaid. Family planning clinics serve a large number of low-income and young women and would play an important part in introducing preconception care. However, very real barriers to preconception service provision need to be addressed before this goal can be fully realized.

BACKGROUND

When established in 1965, Medicaid, by and large, covered low-income women and their children receiving welfare. A succession of Medicaid eligibility expansions for pregnancy-related care broke the link with welfare. More recently, expansions implemented in 20 states have created an eligibility pathway to Medicaid coverage for women before pregnancy. Today, whether as part of a Medicaid family planning program or independently, many women receive family planning services through the nation's system of publicly funded clinics. As the nation's only dedicated source of funding for family planning services, Title X supports a nationwide network of family planning clinics on which young women rely for affordable and confidential reproductive care.

DISCUSSION

Working preconception care into the existing family planning and pregnancy care programs would create a single, continuous reproductive health care platform. Family planning clinics could introduce preconception health measures to the young women who rely on them for their reproductive health care. Important barriers to rolling out preconception care still exist, however. For family planning providers to integrate the services into their current practices, a definition of the package of services that is realistic to provide in a family planning setting must be crafted. In addition, securing a stable funding stream is a necessary prerequisite to any large-scale integration of preconception care into family planning settings. Finally, attention needs to be given to ways to talk to predominantly young clientele about preparing for a pregnancy at the moment when they are coming in for services precisely to avoid becoming pregnant.

CONCLUSION

Despite the challenges laid out, integrating preconception care into family planning services is achievable. Combining preconception care with family planning and pregnancy care initiatives would be a significant step in moving the country closer to the goal of providing the comprehensive reproductive health care women need.

Women's perceptions of being pregnant and having pregestational diabetes

OBJECTIVE

to explore the experiences of White British and South East Asian women with type 1 and type 2 diabetes, and the perceived impact of diabetes on their reproductive health.

DESIGN

a hermeneutic phenomenological approach was used to explore the perceptions of women with diabetes from two different cultural backgrounds with varied reproductive health experiences. Focus groups and one-to-one interviews were used to elicit women's experiences. An interpretive analytical approach was conducted by two researchers.

SETTING

obstetric and diabetes clinics in three hospital sites in the North West of England.

PARTICIPANTS

a purposive sample of 22 women with type 1 or type 2 diabetes of different parity and ethnicity.

FINDINGS

the main themes were relinquishing personal control, pregnancy overshadowed by diabetes and haphazard preconception care.

KEY CONCLUSIONS

strategies should be developed to ensure that whilst safety is maintained, the pregnancy focus is not lost. Women should be supported to optimise their experience as well as clinical outcomes. The convergence of professional roles needs consideration; individual members of multidisciplinary diabetes teams should provide a unique and complementary contribution to care. Preconception care needs to be accessible and responsive to women; this should include recognition of socio-cultural differences.

Translating policy to practice and back again: implementing a preconception program in Delaware

The state of Delaware is in the unique position of implementing legislatively supported policy on preconception health. The state has allocated funding to translate preconception care policy to practice through a statewide program. The Delaware Division of Public Health has been given the responsibility of defining and implementing the preconception care program targeting a high-risk population. The state partnered with Medicaid, private practitioners, local hospitals, state service centers, and Federally Qualified Health Centers to develop a scope of program services that supplement the current clinical care provided at annual visits for women of childbearing age. Because the program has been in operation for 9 months, the Division of Public Health utilized feedback from the providing agencies to begin efforts for program sustainability and to modify the existing policy. Current efforts include developing outcome measures for the program, measuring program effectiveness through evaluation, and working with Medicaid and Managed Care Organizations to develop a reimbursement system for services.

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.

What obstetrician-gynecologists think of preconception care

Objectives: To describe obstetrician-gynecolog-ists’ opinions of preconception care (PCC) and ascertain patient uptake for this service. Methods: A questionnaire was mailed to 1105 ACOG members in August 2004. Results: There was a 60% response rate. Most physicians think PCC is important (87%) and almost always recommend it to women planning a pregnancy (94%); 54% do so with women who are sexually active. Around a third (34%) thought their patients usually do not plan their pregnancies and 49% said very few pregnant patients came in for PCC. Of those who obtain PCC, they were believed to do so more likely to assure a healthy pregnancy (83%) than because of an elevated risk for birth defects (20%). Of 11 issues presented, cigarette smoking and folic acid supplementation were rated the most important for PCC counseling; exercise and environmental concerns were the least important. Conclusions: Physicians are willing to provide PCC but few patients are accessing such services.