Preconception Care: What Can Family Planning Do

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Preconception CareWhat Can Family Planning Do?

• Michael C. Lu, MD, MPH
• Associate Professor
• Department of Obstetrics Gynecology
• Department of Community Health Sciences
• UCLA Schools of Medicine and Public Health

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• The Case for Preconception Care
• The Content of Preconception Care
• What Can Family Planning Do?

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The Case for Preconception Care

• Early prenatal care is too late

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The Case for Preconception Care

• Focus on womens health

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The Case for Preconception Care

• Preconception care works

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Preconception Care Works

• Folic acid
• Rubella seronegativity
• Diabetes (preconception)
• Hypothyroidism
• HIV/AIDS
• Maternal phenylketonurea (PKU)
• Oral anticoagulant
• Antiepiletic drugs
• Isotretinoins (Accutane)
• Smoking
• Alcohol misuse
• Obesity
• STD
• Hepatitis B

Atrash HK, Johnson K, Adams MM, Cordero JF, Howse
J. reconception Care for Improving Perinatal
Outcomes The Time to Act. Matern Child Health J.
2006 Jun 14.
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Content of Preconception Care

• Systematic identification of preconceptional
  risks through assessment of reproductive, family,
  and medical histories nutritional status drug
  exposures and social concerns of all fertile
  women
• Provisions of education based on risks
• Discussion of possible effects of pregnancy on
  existing medical conditions for both the
  prospective mother and the fetus and introduction
  of interventions, if appropriate and desired
• Discussion of genetic concerns and referral, if
  appropriate and desired
• Determination of immunity of rubella and
  immunization, if indicated
• Determination of hepatitis status and
  immunization, if indicated

Modified from Jack B, Culpepper L. Preconception
care. In Merkatz IR, Thompson JE, eds. New
Perspectives on prenatal care. New York
Elsevier, 199084
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Content of Preconception Care

• Laboratory tests, as indicated
• Nutritional counseling on appropriate weight for
  height, sources of folic acid, and avoidance of
  vitamin oversupplemenation referral for in-depth
  counseling, if appropriate and desired
• Discussion of social, financial, and
  psychological issues in preparation for pregnancy
• Discussion regarding desired birth spacing and
  real and perceived barriers to achieving desires,
  including problems with contraceptive use
• Emphasis on importance of early and continuous
  prenatal care and discussion of how care may be
  structured based on the womans risks and
  concerns
• Recommendation to patient to keep menstrual
  calendar

Modified from Jack B, Culpepper L. Preconception
care. In Merkatz IR, Thompson JE, eds. New
Perspectives on prenatal care. New York
Elsevier, 199084
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Content of Preconception Care

• Undiagnosed, untreated, or poorly controlled
  medical conditions
• Immunization history
• Medication and radiation exposure in early
  pregnancy
• Nutritional issues
• Family history and genetic risk
• Tobacco and substance use and other high-risk
  behaviors
• Occupational and environmental exposures
• Social issues
• Mental health issues
• Family planning

American College of Obstetricians and
Gynecologists. The Importance of Preconeption
Care in the Continuum of Womens Health Care.
Committee Opinion No 313. Obstet Gynecol
2005106665-666
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Content of Preconception Care

• Risk Assessment
• Health Promotion
• Medical and Psychosocial Interventions

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Content of Preconception CareRisk Assessment

• Assessment of reproductive history
• Prior pregnancy outcomes, if any
• Future pregnancy plans
• Contraceptive use

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Content of Preconception CareRisk Assessment

• Medical Assessment
• Ongoing medical conditions
• e.g. hypertension, diabetes, cardiac diseases,
  thrombophilia
• Medications
• e.g. Accutane, Warfarin, ACE inhibitors

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Content of Preconception CareRisk Assessment

• Medical Assessment
• Infections
• RTI
• UTI
• STI
• Periodontal disease
• Immunizations
• Diptheria-tetanus toxoids booster
• Hepatitis B
• Measles and mumps
• Rubella
• Varicella
• Influenza
• HPV

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Content of Preconception CareRisk Assessment

• Assessment of family history and genetic risks
• Family history
• Cystic fibrosis
• Special populations
• e.g. Ashkenazi Jewish Panel Gaucher disease
  Type 1, Tay-Sachs, cystic fibrosis, Familial
  dysautonomia (Riley-Day syndrome), Canavan
  disease, Niemann-Pick disease, Fanconi anemia
  group C, Bloom syndromeMucolipidosis IV

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Content of Preconception CareRisk Assessment

• Nutritional Assessment
• Anthropometry
• Biochemical
• Clinical
• Dietary

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Content of Preconception CareRisk Assessment

• Social Assessment
• Behavioral risk factors
• smoking, alcohol misuse, drugs
• Family violence, partner support
• Home, occupational, environmental exposures
• e.g. air quality, water quality, pesticides,
  solvents
• Social, financial, psychological stressors

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Content of Preconception CareRisk Assessment

• Assessment of Mental Health
• Depression
• Anxiety
• Positive mental health (resilience)

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Content of Preconception CareRisk Assessment

• Laboratory tests
• CBC
• Type screen
• Rubella immunity
• Antibodies to Hepatitis B surface antigen
• HIV
• Syphilis
• Urine testing
• Chlamydia gonorrhea
• Cystic fibrosis
• Thyroid stimulating hormone (TSH)
• Glycosylated hemoglobin

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Content of Preconception CareHealth Promotion

• Family Planning
• Formulate a reproductive health plan
• Discuss desire for children or desire not to have
  children
• Discuss number, spacing, timing of children
• Discuss fertility
• Provide contraceptive options

American College of Obstetricians and
Gynecologists. The Importance of Preconeption
Care in the Continuum of Womens Health Care.
Committee Opinion No 313. Obstet Gynecol
2005106665-666
20
Content of Preconception CareHealth Promotion

• Nutrition and exercise
• Multivitamin containing folic acid
• Stress resilience social support
• Healthy environment

American College of Obstetricians and
Gynecologists. The Importance of Preconeption
Care in the Continuum of Womens Health Care.
Committee Opinion No 313. Obstet Gynecol
2005106665-666
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Content of Preconception CareMedical
Interventions

• Height and weight measurements
• every 3-5 years
• Blood pressure
• every 2 years
• Total skin examination
• every 1-3 years
• Papanicolau smear and pelvic examination
• every 1-3 years
• Clinical breast examination
• Every 3 year beginning at age 20
• Screening mammography
• every 1-2 years beginning at age 40

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Content of Preconception CarePsychosocial
Interventions

• Access to social support services
• Public assistance
• Childcare
• Housing
• Literacy programs
• Professional clinical support
• Mental health services
• Services for intimate partner violence
• Marital and sexual counseling
• Parenting support
• Mothers groups
• Parenting classes

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What Can Family Planning Do?

• Family planning services are necessary for the
  widespread adoption of preconception care for two
  reasons. First, preconception care is more likely
  if pregnancies are planned, and family planning
  services encourage pregnancy planning. Second,
  family planning services usually include
  counseling, and counseling provides an
  opportunity to discuss the advantages of
  preconception care.

Klerman LV. Family Planning Services An
Essential Component of Preconception Care. Matern
Child Health J. 2006 Jul 1
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What Can Family Planning Do?

• Risk Assessment
• Reproductive history
• Medical assessment
• Family history genetic risk
• Nutritional assessment
• Social assessment
• Mental health
• Laboratory testing

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What Can Family Planning Do?

• Health Promotion
• Family planning
• Nutrition and exercise
• Multivitamin containing folic acid
• Stress resilience and social support
• Healthy environment

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What Can Family Planning Do?Medical
Psychosocial Interventions

• Access to social support services
• Public assistance
• Childcare
• Housing
• Literacy programs
• Professional clinical support
• Mental health services
• Services for intimate partner violence
• Marital and sexual counseling
• Parenting support
• Mothers groups
• Parenting classes

• Height and weight measurements
• every 3-5 years
• Blood pressure
• every 2 years
• Total skin examination
• every 1-3 years
• Papanicolau smear and pelvic examination
• every 1-3 years
• Clinical breast examination
• Every 3 year beginning at age 20
• Screening mammography
• every 1-2 years beginning at age 40

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What Can Family Planning Do?Challenges

• Services already provided by FP programs
• Budget constraints
• Services not provided by FP programs
• Categorical funding
• Provider training
• Lack of referral services
• Lack of systems integration

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What Can Family Planning Do?

• "We must become the change we want to see.
• - MAHATMA GANDHI