Preconception Care: Policy, Challenges, Opportunities

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Preconception Care Policy, Challenges,
Opportunities

• Hani K. Atrash MD, MPH
• Associate Director for Program Development
• National Center on Birth defects and
  Developmental Disabilities
• Centers for Disease Control and Prevention
• http//www.cdc.gov/ncbddd

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We Have A Problem

• Preconception care is not being delivered
• Providers dont provide it
• Insurers dont pay for it
• Consumers dont ask for it

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Why Should We Care?

• Because it is the right thing to do
• Because we have moral, ethical and LEGAL
  obligations to do
• The Right Thing

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Why Dont We?

• Do we have the Science, Policy, Tools, Programs?
• What are the barriers and challenges
• Knowledge, Attitudes, Practices of
• Consumers
• Providers
• Insurers
• Practical Guidelines and Tools for
  implementation
• Who does it, who gets it, how much, what is it,
  why do it, how to do it, where to do it, when to
  do it, etc?

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Do We Have The Science?

• Yes, but may not be enough for todays climate
• Strong evidence for some components
• Some evidence for others
• Non-existent for others

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Do We Have The Science?

• Todays climate
• Scientific evidence
• Business Case

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Do We Have The Policy?

• We have recommendations from professional
  organizations
• We have no national policy
• No legal obligations
• No accountability

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Current Policy

• There is consensus that preconception care
  should be provided to all women

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Current Policy

• HP Objectives 5.10 and 14.12
• Increase to at least 60 percent the proportion
  of primary care providers who provide
  age-appropriate preconception care and counseling.

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Current Policy

• ACOG/AAP
• All health encounters during a womans
  reproductive years, particularly those that are a
  part of preconceptional care should include
  counseling on appropriate medical care and
  behavior to optimize pregnancy outcomes.

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Current Policy

• U.S. Public Health Service Expert Panel
• Preconception care is a critical component of
  prenatal care

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Are We Asking For Too Much????ACOG/AAP PCC
Components Maternal assessment

• Domestic abuse and violence
• Environmental and occupational exposures
• Immunity and immunization status
• Risk factors for STDs
• Obstetric history
• Gynecologic history
• General physical exam
• Assessment of Socioeconomic, educational, and
  cultural context

• Family planning and pregnancy spacing
• Family history
• Genetic history (maternal and paternal)
• Medical, surgical, pulmonary and neurologic
  history
• Current medications (prescription and OTC)
• Substance use, including alcohol, tobacco and
  illicit drugs
• Nutrition

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Are We Asking For Too Much???? ACOG/AAP PCC
Components Vaccinations

• Vaccinations should be offered to women found
  to be at risk for or susceptible to
• Rubella
• Varicella
• Hepatitis B

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Are We Asking For Too Much???? ACOG/AAP PCC
Components Screening Tests

• Screening for HIV should be strongly recommended
• A number of tests can be performed for specific
  indications
• Screening for STDs
• Testing for specific diseases based on medical or
  reproductive history
• Mantoux skin test for TB
• Screening for genetic disorders based on
  racial/ethnic background
• Screening for other genetic disorders based on
  family history

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Are We Asking For Too Much???? ACOG/AAP PCC
Components Screening Tests

• Screening for genetic disorders based on
  racial/ethnic background
• ?-Thalassemia (Mediterraneans, SE Asia, AA/B)
• a-Thalassemia (AA/B and Asians)
• Tay Sachs disease (Ashkhenazi Jews, French
  Canadians, Cajuns)
• Gauchers, Canavan, and Nieman-Pick Disease
  (Ashkenazi Jews)
• Cystic Fibrosis (Caucasians and Ashkenazi Jews)
• Screening for other genetic disorders based on
  family history CF, Fragile X, mental
  retardation, Duchene muscular dystrophy.

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Are We Asking For Too Much???? ACOG/AAP PCC
Components Counseling

• Patients should be counseled regarding the
  benefits of the following activities
• Exercising
• Reducing weight before pregnancy, if overweight
• Increasing weight before pregnancy, if
  underweight
• Avoiding food additives
• Preventing HIV infection
• Determining the time of conception by an accurate
  menstrual history
• Abstaining from tobacco, alcohol, and illicit
  drug use before and during pregnancy
• Consuming Folic Acid
• Maintaining good control of any pre-existing
  medical conditions

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Do We Have Tools And Programs?

• Yes, no, maybe! but
• Mostly individual efforts
• Not standard or homogenous
• No impact evaluation
• No clear / practical guidelines
• No tools
• NO WE DO NOT HAVE PROGRAMS!!!

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Common Excuses Challenges, Barriers

• Unplanned pregnancies
• Better definition of components
• Timing
• Target population
• Training and education
• Providers
• Policy makers
• Consumers
• Policy development and implementation
• Reimbursement

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Before We Proceed, Simple Questions

• What is it?
• Who should provide it?
• Who should get it?
• Where do we provide it?
• When do we provide it?
• Who pays for it?

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What Is It?

• What are the components of PCC that work?
• Do we have scientific basis for All the
  recommended components of PCC?
• Is the benefit of the sum equal to or greater
  than the benefit of each component?
• Is it cost-effective?

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Who Should Provide It?

• Or, Who should provide what?
• Obstetricians/Gynecologists
• Other physicians
• Nurses
• Social workers
• Health educators
• The media
• Schools
• Others

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Who Should Get It?

• Women/Couples planning pregnancies?
• All women at risk of getting pregnant?
• Women with poor prior pregnancy outcome?
• All women of reproductive age?
• Young women at schools before they are sexually
  active?
• Men and women
• Others?

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Where Do We Provide It?

• Ob/Gyn clinics
• Clinics where at risk of pregnancy women get
  services?
• Every health care provision setting?
• Schools and community settings?
• Other?

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When Do We Provide It?

• Between pregnancies?
• Few months before pregnancy?
• A year before pregnancy?
• At every encounter with the health care system?

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Who Pays For It?

• And what do they pay for?
• Should it be part of the pregnancy package?
• Do we expect them to pay every time for all
  recommended services?
• Should they pay for selected services at selected
  times?

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What To Do?The CDC PCC Initiative

• Try to answer the simple, practical questions
• Make the scientific case Solidify the scientific
  evidence
• Make the business case
• Develop consensus
• Develop recommendations and national policy
• Develop the knowledge and skills of providers
• Educate consumers
• Develop guidelines and tools for implementation
• Implement recommendations

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Making the Scientific and Business Cases,
Assessing PCC Components

• Qualitative assessment of the strength of
  evidence supporting the guidelines recommending
  care
• Quantitative estimation of women (or couples) who
  potentially could benefit from improved access

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Making the Scientific CaseQualitative Assessment
of Components

• Evidence is strong that
• Interventions are effective
• Interventions must be begun before conception
• There are clinical practice guidelines to inform
  health care delivery
• There are surveillance systems to measure risk
  factor prevalence

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Making the Scientific CaseQualitative
Assessment, Selected Components

• Universal
• Folic Acid Supplements
• Rubella Sero-Negativity
• HIV/AIDS
• Maternal PKU
• Diet (Obesity)

• Targeted
• Oral Anticoagulant use
• Anti-Epileptic Drugs (AEDs)
• Accutane Use
• Smoking
• Alcohol Misuse
• Diabetes
• Hypothyroidism

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Making the Business CaseQuantitative Assessment
of Components
Also Maternal PKU, oral anticoagulant use,
Anti-epileptic drugs, accutane use, smoking,
alcohol, obesity
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Making The Business CaseTarget Population 2000
Statistics
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Activities to Date

• Literature Review
• Qualitative and Quantitative assessments
• CDC PCC Workgroup, internal discussions
• Partnerships and discussions with national
  partners MOD, ACOG, AAP, CityMatCH, MCHEP, CSTE,
  NACCHO, ASTHO, others
• Discussions at conferences

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Next Steps

• Assessment of Ob/Gyns Knowledge, Attitudes and
  Practices
• Identify knowledge gaps
• Develop training materials
• Assessment of Health Plans practices
• Exploring best practices
• Telephone support
• Chronic care model
• Self assessment tools
• Workshop to develop a Workplan and
  Recommendations
• Implementation

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