Impact of obesity on women's health: Diabetes. Hypertension

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Preconception Care

• Before
• Between
• After Pregnancy

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Credits

• Our thanks for parts of this
• presentation are to
• Albert Einstein College of Medicine
• Centers for Disease Control and Prevention (CDC)
• March of Dimes (MOD)

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What is Preconception Care?

• Education, counseling, and services provided to
  women before and between pregnancies that address
  risk factors that could cause poor infant and
  maternal outcomes in first and subsequent
  pregnancies.
• In addition, these services also support the
  woman in obtaining and maintaining lifelong
  health for herself and her family.

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Related Vocabulary

• Preconception
• Health status and risks before first pregnancy
  and in fact the health status before any
  pregnancy.
• Periconception
• Immediately before conception through
  organogenesis.
• Interconception
• Period between pregnancies.

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Why is Preconception Care Important?

• Approximately 50 of all pregnancies among adult
  women and 95 of pregnancies among teens are
  unplanned.

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Critical Periods of Development
Weeks gestation

4 5 6 7 8 9
10 11 12
from LMP
Most susceptible

Central Nervous System
time for major

malformation
Heart
Arms
Eyes
Legs
Teeth
Palate
External genitalia
Ear
Mean Entry into Prenatal Care
Missed Period
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Nationally

• The U.S. infant mortality rate is higher than
  many other countries.
• Although higher percentages of women receive
  early prenatal care than ever before, preterm
  birth and low birth weight rates are increasing.
• Declines in infant mortality have stalled.

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INTERNATIONAL COMPARISONS OF INFANT MORTALITY
RATES 2004
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Preterm Birth in the U.S.

• In 2004, 1 in 8 babies (12.5 of live births)
  were born preterm in the United States. Preterm
  birth affected approximately 513,875 infants that
  year.
• In 2000, The Healthy People 2010 goal for preterm
  births was set. The goal is to reduce the rate
  of preterm births to no more than 7.6 of all
  live births by 2010.
• Movement is in the wrong direction! 

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Preterm Birth
U.S. 1994-2004
Preterm is less than 37 completed weeks
gestation. Source National Center for Health
Statistics, final natality data. Retrieved July
30, 2007, from www.marchofdimes.com/peristats.
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Low Birth Weight in the U.S.

• In 2004, 1 in 12 babies (8.1 ) were born
  weighing less than 2500 gms. Low birth weight
  affected approximately 332,991 infants.
• In 2000, the Healthy People 2010 goal for low
  birth weight was set. The goal is to reduce the
  rate of low birth weight to 5.0 of live births
  by the end of this decade.
• Between 1994 and 2004, the rate of infants born
  with low birth weight in the United States
  increased 11.

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Low Birth Weight
U.S. 1994-2004
Low birth weight is less than 2500 grams (5 1/2
pounds). Source National Center for Health
Statistics, final natality data. Retrieved July
30, 2007, from www.marchofdimes.com/peristats.
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Infant mortality rates in the U.S.

• In 2004, the infant mortality rate was 6.8
  deaths per 1,000 live births. Approximately
  27,860 babies born that year died before their
  first birthday.
• Between 1994 and 2004, the infant mortality rate
  in the United States declined 15.

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Infant Mortality Rates
U.S. 1994-2004
Deaths to infants less than one year of age.
Source National Center for Health Statistics,
final mortality data, 1990-1994 and period linked
birth/infant death data, 1995-present. Retrieved
April 22, 2008, from www.marchofdimes.com/peristat
s.
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Florida Infant Mortality

• Floridas infant mortality has remained
  essentially the same for the past 10 years.

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Florida Low Birth Weight

• At the same time, Floridas premature and low
  birth weight rates have risen.

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Single-Year Percentage of Live Births
Under 2500 Grams to All Mothers
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Preconception Care is Important

• Recent data, from many different sources,
  indicate that an important time to intervene for
  positive birth outcomes is BEFORE a woman becomes
  pregnant.

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Preconception Care is Important

• The relationship between maternal health and
  birth outcomes has been established by
• Pregnancy-Associated Mortality Review (PAMR)
• Perinatal Periods of Risk (PPOR)
• Fetal and Infant Mortality Reviews (FIMR)
• March of Dimes (MOD)
• American College of Obstetricians and
  Gynecologists (ACOG)

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Floridas Pregnancy-Associated Mortality Review
(PAMR)

• A review of cases where death of a
• woman has occurred, from any cause,
• while she is pregnant or within one
• year of termination of pregnancy,
• regardless of duration and site of the
• pregnancy.
• CDC and ACOG definition of maternal mortality

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Risk Factors

• Women most at risk for pregnancy-related death
• Age 35 and older (RR3.65)
• Black non-Hispanic (RR3.32)
• High school education or less (RR1.72,1.50,
  respectively)
• Received no prenatal care (RR9.95)
• Cesarean Delivery (RR5.09)
• Overweight (OR 2.13)
• Obese Categories 1,2,or 3 (OR3.5, 3.5, 8.0)

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PAMR 1999-2005

• The majority (68) of women with
  pregnancy-related deaths fell into the overweight
  and obese category.
• Hypertensive disorders 15.

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Leading Causes of Death
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PAMR 1999-2005

• Most at-risk
• Black non-Hispanic
• Age 35 and older
• High School education or less
• Received no prenatal care
• Cesarean Delivery
• Overweight
• Obese

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Perinatal Periods of Risk

• The Perinatal Periods of Risk Approach
• was developed by Dr. Brian McCarthy
• from the World Health Organization
• (WHO), Perinatal Collaborative Center
• at CDC, and other WHO colleagues.
• For over a decade, this approach has been
• used to monitor and investigate feto-infant
• mortality problems in developing countries.

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Florida PPOR MAP 1998-2000 Birth
Cohort 596,585 Fetal Deaths and Live Births
5734 Fetal-Infant Deaths
Infant Health 1021
9.6 Fetal-Infant Death Rate
All Death Rates Per 1,000 Births and Fetal Deaths
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Florida Reference Group
5.8 Fetal-Infant Death Rate

• Race White
• Education 13
• Age 20-50
• 212,755 Fetal Deaths and Live Births

1229 Fetal-Infant Deaths
Infant Health 166
All Death Rates Per 1,000 Births and Fetal Deaths
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Florida Non-Reference Group
11.7 Fetal-Infant Death Rate
Race Non-White OR Education lt13 OR Age lt20 or
gt50 383,830 Fetal Deaths and Live Births
4505 Fetal-Infant Deaths
Infant Health 855
All Death Rates Per 1,000 Births and Fetal Deaths
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CDC Definition of Preconception Care

• Preconception care is a set of interventions that
  aim to identify and modify biomedical,
  behavioral, and social risks to a womans health
  or pregnancy outcome through prevention and
  management.
• It is more than a single visit and less than all
  well-woman care.

CDC and Select Panel, 2006
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CDC Preconception Care Framework
Vision Improve health and pregnancy outcomes
Goals Coverage Risk Reduction Empowerment
Disparity Reduction
Recommendations Individual Responsibility -
Service Provision Access Quality Information
Quality Assurance
Action Steps Research Surveillance Clinical
interventions Financing Marketing Education
and training
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What can we do??

• Provide
• Preconception Screening
• Education
• Counseling
• Services to address the identified risks in
  screening

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Preconception Screening

• Every woman coming into a health care setting
  should be screened for possible health needs.

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Preconception Care Topics for Consideration

• Preconception care includes addressing the
• following topic areas
• Access to health care
• Nutrition (including folic acid education)
• Physical activity
• Maternal infections (including periodontal
  disease)
• Chronic health conditions
• Substance abuse
• Smoking
• Mental health
• Baby spacing
• Environmental risk factors
• And any other risks identified on the
  Preconception Screen

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Access to Health Care

• Regular health care is critical to the overall
  health of the woman. Key components of regular
  care should include
• Pap smear
• Breast exam (with teaching on techniques of
  self-breast exam)
• Review of family health history
• Weight, height, blood pressure
• Lab testing for diabetes or thyroid conditions,
  if needed
• Management of chronic health conditions
• Dental services

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Nutrition

• Healthy Eating
• Avoid thinking of foods as good or bad
• Avoid skipping meals
• Focus on eating healthy for life - not dieting
• Eat a variety of foods as represented in the
• Food Pyramid
• Pay attention to serving sizes
• Barriers to Healthy Eating
• Access to healthy food sources (location,
  financial)
• Cultural beliefs

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NUTRITIONAL STATUS Obesity

• Impact of obesity on womens health
• Diabetes
• Hypertension
• Cardiovascular disease
• Disabilities

• Impact of maternal obesity on reproductive
  outcomes
• Glucose intolerance of pregnancy
• Pregnancy-induced hypertension
• Thrombophlebitis
• Infertility
• Neural tube defects (NTD)
• Prematurity

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NUTRITIONAL STATUS Underweight

• Impact of being underweight on womens health
• Risk of osteoporosis in later life
• Fragile health status

• Impact of low pregravid weight on reproductive
  outcomes
• Infertility
• Low birth weight
• Prematurity

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NUTRITIONAL STATUS Specific nutrients

• Impact of low folate levels and womens health
• Increased heart disease evidence accumulating
  about increases in
• Colon cancer
• Breast cancer
• Some forms of dementia

• Impact of inadequate maternal folate levels on
  reproductive outcomes
• Increased incidence of neural tube defects (NTD)
• Increased incidence of other birth defects
• Some anemias mother and infant

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Nutrition Folic Acid

• Ideal levels of folic acid can prevent
• Up to 70 of neural tube defects
• Fifty percent of cleft lip and palate defects
• Forty to fifty percent of congenital heart
  defects
• It has also been demonstrated that folic acid may
  prevent pre-eclampsia and other
  pregnancy-related complications.

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Nutrition Folic Acid

• Hispanic women, particularly those of Mexican
  origin, appear to have greater risk of neural
  tube defects.
• Florida birth defects registry indicates
  Mexican-Hispanic women have a relative risk nine
  times higher than non-Hispanic women born in the
  U.S.

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Nutrition Folic Acid

• Folic acid requirements
• All women of childbearing age, regardless of
  their intentions to become pregnant, should take
  at least 400 micrograms (0.4 milligrams) of folic
  acid daily.
• Past history of a baby with a NTD may require a
  higher, therapeutic dose of folic acid (4.0
  milligrams), available through prescription only.
• Folic acid requirement increases during pregnancy.

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Physical Activity

• Benefits of exercise include
• Lower stress, depression, and anxiety
• Feel better about yourself
• Sleep better
• Better concentration
• Decrease your chance of developing a chronic
  disease
• Improve your blood pressure and decrease your
  cholesterol
• Maintain a healthy weight

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Maternal Infections

• Maternal infections have been consistently linked
  to poor birth outcomes.
• All sexually active women of childbearing age
  should be counseled on the risks of infection to
  their own health and their future pregnancies.
• All women should be offered screening, testing,
  and treatment for sexually-transmitted diseases
  (STDs) including syphilis, gonorrhea, HIV,
  genital herpes, Chlamydia, and HPV.
• Conditions such as bacterial vaginosis should be
  screened for and treated, if necessary.
• Douching should be discouraged.
• Women should be up-to-date with immunizations,
  especially rubella, hepatitis B, and varicella,
  prior to becoming pregnant.
• Women should receive information on the
  recognition and risks of untreated urinary tract
  infections, bacterial vaginosis, and STDs.

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Maternal Infections - Periodontal Disease

• Periodontal disease - A disease of the gingiva,
  gums, and supporting structures of the teeth.
• May lead to prematurity and/or low birth weight.
• Affects between 5-40 of women of childbearing
  age.
• Increases the risk of heart attack and stroke.
• Exacerbates diabetes.
• Contributes to lung disorders such as pneumonia
  and emphysema.

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Chronic Health Conditions

• Management of chronic health conditions prior to
  pregnancy helps reduce risks to mother and baby.
  These conditions include, but are not limited to
• High blood pressure
• Systemic Lupus Erythematosus (SLE)
• Kidney disease
• Diabetes
• Asthma
• Endocrine conditions such as thyroid disease
• Depression

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Chronic Health Conditions

• High Blood Pressure - Chronic high blood pressure
  can increase the risk of pregnancy complications,
  including placental problems and fetal growth
  retardation.
• Systemic Lupus Erythematosus (SLE) can increase
  the risk of miscarriage or preterm labor. If
  symptoms have been inactive for at least six
  months, an affected woman is likely to have a
  healthy pregnancy. Preconception care helps plan
  the safest timing of pregnancy.

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Chronic Health Conditions

• Kidney Disease - Women who have chronic kidney
  disease should consult their doctors prior to
  pregnancy to see if pregnancy is safe for them
  and their baby.
• Diabetes - Women with poorly controlled
  insulin-dependent diabetes are several times more
  likely than non-diabetic women to have a baby
  with a serious birth defect. They are also at
  increased risk of miscarriage and stillbirth.

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Chronic Health Conditions

• Asthma Poorly controlled asthma can increase a
  womans likelihood for complications in
  pregnancy, including compromising the oxygen
  supply to the developing fetus.
• Endocrine Conditions Thyroid conditions, if
  untreated, such as hypothyroidism and
  hyperthyroidism can affect a womans fertility,
  can increase her likelihood for miscarriage and
  other complications, including mental retardation
  in the unborn infant.

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Chronic Health Conditions

• Depression Women with a history of depression
  are more likely to experience depression in
  pregnancy and in the postpartum period.
  Additionally, women receiving treatment for
  depression through medication may need to consult
  with their doctor on a medication that is safe
  for pregnancy or while breastfeeding.

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Substance Use

• There is no known amount of drugs or alcohol that
  is safe in pregnancy. Both drugs and alcohol
  cross the placental barrier to the developing
  fetus in utero.
• Illegal drugs and alcohol can cause fetal loss,
  birth defects, fetal alcohol syndrome, low birth
  weight, and intrauterine growth restriction. Many
  pregnancies are unplanned.
• Women need support and linkages to substance
  abuse treatment for their health today and for
  the health of any children in the future.

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SUBSTANCE USE

• Impact of alcohol abuse on womens health
• Risk for motor vehicle and other accidents
• Risk for unintended pregnancy
• Risk for addiction
• Risk for nutritional depletions and inadequacies

• Impact of alcohol use on reproductive outcomes
• Delayed fertility
• Increased spontaneous abortions (SABs)
• Fetal alcohol spectrum disorders (full fetal
  alcohol syndrome can only occur with fetal
  exposure between days 17-56 of gestation)

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SUBSTANCE USE

• Impact of tobacco use on womens health
• Implicated in most of the leading causes of death
  for women
• Heart disease (1 cause of death)
• Stroke (2)
• Lung cancer (3)
• Lung disease (4)

• Impact of tobacco use on reproductive outcomes
• Leading preventable cause of infant mortality.
• Preventable cause of low birth weight and
  prematurity.
• Associated with placental abnormalities including
  placenta previa and placenta abruptio.

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Smoking

• In 2006, the percent of births under 2500 grams,
  low birth weight (LBW), for mothers who reported
  smoking on the Florida birth certificate was
  13.2.
• Mothers who reported not smoking had a LBW infant
  rate of 8.3.

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Mental Health

• Stress, anxiety, depression, and abuse can have
  serious effects on a womans health and the
  health of her children.

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Mental Health

• All women need to be screened for domestic
  violence and depression.
• Twenty percent of women will experience
  depression at least once during their lifetime.
• One in four women are the victim of abuse.
• About three women die in the U.S. from domestic
  violence every day.

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Mental Health - Stress

• Studies have proven that high levels of stress
  can cause
• Fatigue
• Lowered resistance to infectious disease
• Poor nutrition (no appetite or overeating)
• Headaches Backaches
• High blood pressure
• Heart disease
• Substance abuse

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Mental Health - Stress

• Studies indicate that chronic psychosocial,
  prenatal maternal stress, as opposed to acute or
  episodic stress, has a negative impact on
  pregnancy outcomes and fetal development.
• Both increased anxiety and decreased social
  support are associated with poorer pregnancy
  outcomes.

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Environmental Risk Factors

• Women may be exposed to harmful substances at
  work, at home, or outside, without even knowing
  it.
• Awareness and education of possible environmental
  toxins may reduce exposures and possible poor
  birth outcomes.

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Environmental Risk Factors

• Lead
• Found in paint, dust, soil, pottery, glass,
  cooking utensils, and other places, can damage
  the brain and nervous system causing behavior,
  learning, hearing problems, headaches, and
  delayed growth.
• Some herbal remedies such as Azarcon and Greta
  may contain high levels of lead.
• Previous maternal exposure to lead can affect the
  developing fetus.

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Environmental Risk Factors

• Mercury
• A poisonous metal that occurs naturally in the
  environment. It is released into the air then
  falls directly into the water. Upon reaching the
  water it turns into a very toxic form
  (methyl-mercury).
• In 2004, the Food and Drug Administration
  (FDA)/Environmental Protection Agency (EPA)
  Consumer AdvisoryWhat You Need to Know about
  Mercury in Fish and Shellfish was released.
• For more information, call the FDA Food
  Information Hotline toll-free at 1-888-SAFEFOOD
  or visit the FDAs Food Safety Website at
  www.cfsan.fda.gov/seafodd1.html.

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Environmental Risk Factors

• Pesticides
• Includes bug sprays, fertilizers, and wood
  treatment.
• Migrant farm workers may be more heavily exposed
  to these toxins.

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Environmental Risk Factors

• Gases
• Carbon Monoxide is given off by cars, gas
  furnaces, kerosene heaters and cigarette smoke.
  It can not be seen nor smelled. Side effects of
  exposure include
• Low birth weight
• Stillbirth
• Headaches
• Death

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Environmental Risk Factors

• Food-borne risks
• Undercooked foods (raw fish, oysters, underheated
  deli meats)
• Unpasteurized milk or juice
• Soft cheeses
• Some herbal teas
• Homeopathic remedies
• Toxoplasmosis
• cat litter
• soil

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Baby Spacing

• Research shows that waiting at least two years
  between pregnancies is optimal for both the
  mother and infants health.
• A short pregnancy interval may be associated
  with
• Birth of a small (for gestational age) infant in
  a subsequent pregnancy.
• Preterm birth in a subsequent pregnancy.
• Low birth weight.
• Stillbirth.
• Death within the first year of life.

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Baby Spacing

• Having babies too close together can deplete the
  mothers nutrients, energy, and finances.
• Family Planning and Primary Care clinics can
  assist women with their contraceptive needs.
• There is a special Medicaid program for women
  aged 1455, who lose full Medicaid benefits,
  including pregnancy-related benefits. This
  program provides coverage for family planning
  services for up to two years.

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How Should Services be Provided?

• Every Woman, Every Time
• In a culturally-sensitive manner

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Preconception Care and Cultural Competency

• Counseling, education, and services must be
  provided with consideration to the cultural,
  language, education/literacy, and accessibility
  needs of the participant. This includes
  understanding of the
• Beliefs, values, traditions, and practices of a
  culture.
• Culturally-defined, health-related needs of
  individuals, families, and communities.
• Culturally-based belief systems of the etiology
  of illness and disease and those related to
  health and healing.
• Attitudes toward seeking help from the health
  care providers.
• For more information, contact the National
  Center for Cultural Competence at the Georgetown
  University Center for Child and Human Development
  at 1-800-788-2066 or http//gucdc.georgetown.edu/n
  cc

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Preconception Care and Cultural Competency

• Examples of varying cultural beliefs or practices
  among groups
• Mexicans douching a common practice.
• Mormons procreation as a sacred duty.
• Native Americans children should be spaced
  three to four years apart.
• African Americans prenatal care may not be
  readily sought because of negative experiences
  with health care system.
• Cubans male contraception is not acceptable due
  to machismo.

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First The Specific Goals of the CDC
Preconception Initiative are to

• Improve the knowledge, attitudes and behaviors of
  men and women related to preconceptional health.
• Assure that all women of childbearing age in the
  United States receive care services that will
  enable them to enter pregnancy in optimal health.

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CDCs 10 Recommendations to Improve Preconception
Health
April 21, 2006
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CDC Recommendation 1

• Each woman, man, and couple should be encouraged
  to have a reproductive life plan.

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CDC Recommendation 2

• Increase public awareness of the importance of
  preconception health behaviors and preconception
  care services by using information and tools
  appropriate across various ages literacy,
  including health literacy and cultural/linguistic
  contexts.

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CDC Recommendation 3

• As a part of primary care visits, provide risk
  assessment and educational and health promotion
  counseling to all women of childbearing age to
  reduce reproductive risks and improve pregnancy
  outcomes.

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CDC Recommendation 4

• Increase the proportion of women who receive
  interventions as follow-up to preconception risk
  screening, focusing on high priority
  interventions.

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CDC Recommendation 5

• Use the interconception period to provide
  additional intensive interventions to women who
  have had a previous pregnancy that ended in an
  adverse outcome (e.g. infant death, fetal loss,
  birth defects, low birth weight, preterm birth,
  significant maternal morbidity).

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CDC Recommendation 6

• Offer, as a component of maternity care, one
  prepregnancy visit for couples and persons
  planning a pregnancy.

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CDC Recommendation 7

• Increase public and private health insurance
  coverage for women with low incomes to improve
  access to preventive womens health and
  preconception and interconception care.

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CDC Recommendation 8

• Integrate components of preconception health into
  existing local public health and related
  programs, including emphasis on interconception
  interventions for women with previous adverse
  outcomes.

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CDC Recommendation 9

• Increase the evidence base and promote the use of
  the evidence to improve preconception health.

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CDC Recommendation 10

• Maximize public health surveillance and related
  research mechanisms to monitor preconception
  health.

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Healthy Start Standards and Guidelines

• Chapter 21 Healthy Start Services
• Interconception Education and Counseling

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Standards and Guidelines Overview

• Services are determined based on the coalition
  service delivery plan and local resources.
• Services are above and beyond health information
  provided during care coordination.
• Coalition-approved curriculum.
• Services are provided to women determined to be
  at risk for a poor birth outcome in a subsequent
  pregnancy.
• May use screening tools to help determine risks.

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Interconceptional Education and Counseling
Curriculum Topics

• Access to care
• Baby spacing
• Nutrition
• Physical activity
• Maternal infections

• Chronic health problems
• Substance abuse
• Smoking
• Mental health
• Environmental risks

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Interconceptional Education and Counseling
Service Components

• Plan of Care
• Presentation
• Demonstration activity
• Follow-up
• Feedback
• Evaluation

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Interconceptional Education and Counseling
Services

• Provided one-on-one with participant in
  face-to-face visit.
• Provided in a support group setting.
• Provided in a classroom setting in a set series
  of classes.

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Interconceptional Education and Counseling
Services

• Trained providers with up-to-date knowledge of
  interconceptional health.
• Written follow-up provided to the Healthy Start
  care coordinator within 30 days.
• Service provider communicates any additional
  needs identified to the care coordinator.

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Interconceptional Education and Counseling
Services

• Documented in the record of the person receiving
  the service.
• Follow-up on referral documented in participants
  record.
• Consent for release of information between
  provider and care coordinator.
• Certification of completion provided to care
  coordinator for participants record.
• Quarterly Quality Assurance (QA)/Quality
  Improvement (QI) by provider.

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Interconceptional Education and Counseling
Services Coding

• Activities that educate and inform the Healthy
  Start woman about health behaviors that will help
  to reduce risk and improve subsequent birth
  outcomes.
• Code 8013 is open to program components 26, 27,
  30, and 31.

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Interconceptional Education and Counseling
Services Coding

• Who can be provided this Healthy Start service?
• Any Healthy Start woman determined at risk for a
  poor outcome of a subsequent pregnancy.
• May be provided prenatally or postnatally.
• May be provided to the Healthy Start participant,
  or to the mother of a Healthy Start participant
  on behalf of the participant.

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Interconceptional Education and Counseling
Services Coding

• Who can provide and code this Healthy Start
  service?
• Trained and qualified Healthy Start providers.
• May be provided individually, in support groups,
  or formal classes.
• One unit of service equals 15 minutes.

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Interconceptional Education and Counseling
Services Coding

• What is required for the service?
• Healthy Start coalition-approved curriculum with
  components covering access to health care baby
  spacing nutrition physical activity maternal
  infections chronic health problems substance
  abuse smoking mental health and environmental
  risk factors.
• Learning objectives for the curriculum.

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Interconceptional Education and Counseling
Services Coding

• What if my staff is not trained to provide this
  special service?
• Healthy Start care coordinators who do not
  receive special interconceptional education and
  counseling training may still provide their
  participants with the appropriate health
  education to reduce risks as part of their care
  coordination activities and code to 3320 or 3321.

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Preconception Care presents a Golden Opportunity

• We recognize that powerful influences on outcome
  occur long before pregnancy begins. Pregnancy is
  shaped by
• Social
• Psychological
• Behavioral
• Environmental
• Biological forces
• Improving pregnancy outcomes necessitates the
  linkage of an even broader array of health care
  providers embracing a life course perspective
  with regard to perinatal health.
• Dawn Misra, Womens and Childrens Health Policy
  Center, Bloomberg School
• of Public Health, Johns Hopkins University.

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Golden Opportunity

• Any health care provider who comes into contact
  with a woman of reproductive age has the
  potential to protect the health of that woman and
  her future offspring.