Hello hello! I am so excited to dive into this series. If you guys didn’t know, midwives aren’t perfect. I like to think we’re pretty awesome but we definitely forget to tell you something in your clinic visits! The other way I think about it is this: we have so much to tell you there’s just not enough time! Sometimes I even think about the things I forgot to tell someone before going to sleep at night – “Dang it! I forgot to tell Susie about her options for birthing classes.” #truth.
Really, we’re doing our best, BUT…what if we had a tool that could help us to do better.
I did a google search last night for books on pregnancy and was overwhelmed by the options – and I do this for a living! I’ve read about 50% of the books out there and tend to only recommend the ones that actually provide education and empowerment to women. I do not recommend books that incite fear and worry in women. There is never a need for that! But I am always amazed at the differences among the different books and resources. So, we’re going back to the basics of education with this series! Other than listening to the baby and measuring your belly, what else should you expect at your prenatal visit? And after your visit, what resources can recommend (as a provider) or read for more education (as a patient)?
The point of this series is two-fold:
- Provide education from the evidence on the components each prenatal visit.
- Offer a tool to guide the mama/family and provider through all the recommended components of the visit while offering a vehicle for the woman to take home that reviews everything covered at the visit and a list of additional resources for education and information.
My hope is to put as much evidence-based information into the tools. I also anticipate the tools will change depending on the evidence available and I’ll update those accordingly! Another disclaimer is this: prenatal care differs a little bit across practices and the nation – BUT, the components should be the same across the spectrum of your care. And as always, the tools are free for use but please credit the source.
Let’s do preconception! Heads up, it’s a loooonnnggg post. Who knew preconception care was in depth?
Why is preconception care important?
There are two main reasons. First, 50% of pregnancies are unplanned which makes counseling about preconception difficult for a provider. It is unclear when it is the best time to offer preconception counseling. Unplanned pregnancy can prevent a woman from making changes to her lifestyle before she becomes pregnant. Second, there are many factors that affect a woman’s health or a fetus’ health that require awareness or changes in the woman’s lifestyle prior to or in the beginning of pregnancy. Sometimes a consultation with a healthcare provider is recommended before pregnancy depending on the woman’s health conditions (example: the mother has diabetes).
The good news is that many risk factors are modifiable prior to pregnancy. Yet the United States has a long way to go. In 2015, “50% of women [were] overweight or obese, 19% [were] current smokers, 10% [had] hypertension and 3% [had] diabetes” (American Academy of Family Physicians [AAFP], 2015, p.1). And these are only a few of the risk factors that should be addressed in preconception health!
What is preconception health care?
The Centers for Disease Control and Prevention (CDC, 2020) has the best definition of preconception health care that I’ve seen:
Preconception health care is the medical care a woman or man receives from a provider that focuses on the parts of health that have been shown to increase the chance of having a healthy baby.
Who makes preconception care recommendations?
The short answer: a lot of organizations (but this is always an excellent question to ask when reviewing guidelines!). I reviewed a lot of articles offering guidelines. One of the best articles I found was published by the American Journal of Obstetrics & Gynecology in 2008. The summary supplement was the work of a task force that reviewed over 700 articles for evidence on preconception care over four year period. The task force was created by the Centers for Disease and Prevention (CDC) to focus on preconception health and health care (Jack et al, 2008). One of my favorite things the authors noted was this: “there is a relatively short list of core interventions for which there is substantial evidence of efficacy when applied in the preconception period” (Jack et. al, 2008, p.1).
Other excellent sources include:
- Preconception Care (Position Paper from the AAFP, 2015)
- Preconception Care (Policy Brief from the World Health Organization (WHO), 2013)
- Preconception Care to Reduce Maternal and Childhood Mortality and Morbidity (WHO, 2012)
- Pre-pregnancy Counseling (American College of Obstetricians and Gynecologists & American Society for Reproductive Medicine [ACOG & ASRM], 2020)
- Recommendations to Improve Preconception Health and Health Care — United States (Centers for Disease Control and Prevention, 2006)
How many woman get preconception care?
About 14% of women get preconception care according to a 2015 study and a 2006 study found that 95% of women surveyed did not recall receiving any counseling about preconception care (AAFP, 2015). Clearly there is a an opportunity to improve.
ACOG & ASRM recommend ANY PATIENT ENCOUNTER with reproductive potential as an opportunity to provide preconception care (2020). But preconception care isn’t just for obstetric providers – most of preconception care can start in the primary care setting!
The AAFP has recognized the potential of primary care visits – but not just for adults. The AAFP put out a call to action in their 2015 position paper to encourage preconception counseling at infant/toddler well visits. Why? Because guess who is present at 98% of well-child visits from birth to 2 years of age? WOMEN. And, if a woman missed her postpartum period, as 60% of women do, it’s a great time to offer preconception counseling or education (AAFP, 2015).
What should be addressed in preconception counseling?
This is the BIG question! And the answer is a long one. There are so many facets to a woman’s health and each needs a proper review to assess what each woman and family needs for preconception care.
Intention for pregnancy, reproductive life plan and breastfeeding
First and foremost, almost all evidence (AAFP, 2015; Jack et al., 2008) recommends starting preconception counseling with this question: Would you like to become pregnant in the next year? (Read more about the ONE question here if you missed the post). Providers should ask women what their family plan (or reproductive life plan) is and assist the woman and/or her family in making a plan should they not have one. Women that wish to prevent pregnancy should be offered contraception counseling to include methods like natural family planning, lactational amenorrhea method and emergency methods such as Plan B (The American College of Obstetricians and Gynecologists (ACOG) recommend that a discussion about a woman’s reproductive plan begin in pregnancy and continue throughout the postpartum time period – but no specific time period to offer this guidance and counseling has been recommended or studied. The “reproductive life plan discussion” should include the woman’s desire for and timing of pregnancies; a review of all 18 methods of contraception and each method’s risks and benefits (to include methods without hormones such as barrier methods, abstinence, lactational amenorrhea method, natural family planning); possible side effects of the method and strategies to manage possible side effects, and a plan for continuation (AAFP, 2015; ACOG, 2018; Dehlendorf, Krajewski & Borrero, 2014).
Additionally, women should be counseled on their chances of becoming pregnant with or without contraceptive methods (Jack et al., 2008). There is good evidence to support this recommendation as a component of preconception counseling (Jack et al., 2008). Assessment of current and desired breastfeeding is recommended in preconception care because short interval pregnancies are associated with poorer outcomes than pregnancies achieved at 18-24 months after the last pregnancy (AAFP, 2015). Additionally, breastfeeding for two or more years is optimal, and as long as desired by the mother or infant, breastfeeding should be encouraged and supported in preconception care (AAFP, 2015).
Nutrition and daily supplements
Preconception counseling should include the recommendation for women take a daily multivitamin and folate (0.4 milligrams or 400 micrograms) daily if not preventing pregnancy (Jack at al., 2008). This recommendation is supported by randomized controlled trials in the first trimester to prevent neural tube defects while cohort/case studies support the recommendation for a multivitamin during pregnancy (Jack et al., 2008).
Supplementation of Vitamin A, Calcium, iron, essential fatty acids and iodine are also strongly recommended in a preconception screening and evidence is from at least one randomized controlled trial possibly done before pregnancy and cohort/case studies. There is currently inconclusive evidence to include Vitamin D in preconception care (Jack et al., 2008).
Physical activity and achieving a healthy weight
A woman should have her body mass index (BMI) calculated annually and counseled on risks accordingly (Jack at al., 2008). For BMIs in the overweight or obese categories, women should be counseled to decrease their BMI via increased physical activity and decreased caloric intake (Jack at al., 2008). The provider can recommend weight loss programs can be recommended to assist women in achieving normal weight (Jack at al., 2008). Pregnancy risks associated with obesity (BMI > 29.9) or underweight (BMI < 19.9) statures should be reviewed in preconception counseling (Jack at al., 2008). Additionally, women with underweight BMIs should be evaluated for current or history of eating disorders and/or body image concerns. For weight assessment, there is strong evidence to include this component in preconception counseling (Jack at al., 2008).
Regarding physical activity, women should be asked about their current exercise regimens – both cardiovascular and strength components. There is insufficient evidence that this should be a component of preconception counseling but expert recommendation/opinion is to include this component based on some cohort studies (Jack at al., 2008).
- Handout: Planning for Pregnancy: Women with Obesity (Wisconsin Association for Perinatal Care)
- Handout: Women of Size and Pregnancy (ACNM)
- Resource: Being Overweight During Pregnancy (March of Dimes, video/education)
Immunization history should be assessed for vaccination against measles, mumps, rubella and varicella. A review of the woman’s immunization record is recommended annually and additional vaccines recommended as appropriate – especially women at risk for additional exposure due to their health, lifestyle or occupation (Jack at al., 2008). Additionally, the provider should inquire about the last vaccine received for tetanus-diphtheria toxoid or diphtheria-tetanus-pertussis (Jack et al., 2008). There is a strong recommendation from experts/committees to include this component of preconception counseling and only expert opinion and case studies for the level of evidence (Jack et al., 2008).
- DTaP (diphtheria-tetanus-pertussis): There is a moderate recommendation to include a review of DTaP vaccination history in preconception assessments but evidence is based on expert opinion/case studies. The vaccine is recommended for a two-fold reason: one, experts think that the vaccine can protect the baby from neonatal tetanus through passive immunity, and two, when received by the mother postpartum, the vaccines helps to prevent pertussis in the newborn/infant (Jack et al., 2008).
- HPV (human papillomavirus) vaccine: There is a moderate recommendation that the HPV vaccine should be included in preconception assessments and evidence is from at least one randomized controlled trial possibly done before pregnancy. Women should be screened per ASCCP guidelines for cervix abnormalities from the HPV virus. The group proposes that the HPV vaccination could prevent procedures to the cervix during pregnancy that may be indicated from abnormalities caused by the HPV virus (Jack et al., 2008).
- Hepatitis B: There is a strong recommendation that the Hepatitis B vaccine should be included in preconception assessments but evidence is from expert opinion/case studies. The recommendation is for all high risk women to be vaccinated before pregnancy (Jack et al., 2008).
- MMR (measles, mumps, rubella): There is a strong recommendation that the MMR vaccine should be included in preconception assessments and evidence is from time series with or without intervention. The supplement recommends screening all women for rubella immunity and to vaccinate women without immunity prior to becoming pregnant. The group recommends women avoid pregnancy for 3 months after MMR vaccination (Jack et al., 2008).
- Influenza: There is insufficient evidence to include or exclude the recommendation to include the influenza vaccine in preconception assessments and evidence is from expert opinion/case studies. Influenza vaccination is recommended for all pregnant women, especially those considered high risk for influenza complications (Jack et al., 2008).
- Varicella: There is a moderate recommendation that the varicella vaccine be included in preconception assessments and evidence is from expert opinion/case studies. Since the varicella vaccine is contraindicated (not recommended) in pregnancy, screening for varicella immunity or a history of the disease is recommended in a preconception assessment. The recommendation is for all women without evidence of varicella immunity to receive the vaccine prior to becoming pregnant (Jack et al., 2008).
Sexually transmitted diseases (STDs)
Providers should routinely assess for STDs and offer counseling for STD prevention. If a STD is diagnosed, treatment is indicated and may be indicated for the woman’s partner as well. There is strong recommendation to include STD screening and treatment in preconception counseling and evidence is from cohort/case studies to support the recommendation (Jack et al., 2008).
Most women are accustomed to having a lot of blood drawn at their first OB visit. Most practices test: blood type, antibody screen, complete blood count, rubella immunity, varicella immunity, HIV (human immunodeficiency virus) screening, hepatitis B immunity, syphilis screening, gonorrhea/chlamydia screening and a urine culture. However, there are many more diseases that are not included in preconception screening for a myriad of reasons. Below is a brief overview of the evidence to support or forgo the testing and the strength of the recommendation each infectious disease.
- Asymptomatic bacteruria: Asymptomatic bacteruria is a urinary tract infection without symptoms. There is good evidence that this screening should be excluded from preconception care and evidence is based on well designed studies without randomization. The supplement offers these explanations as to why:
- No studies have shown that women with infections that are identified and treated have infants that are lower birth weights
- Women often have repeat infections that require series of antibiotics before the infection is resolved
- Screening at the beginning of pregnancy is recommended for all women
- Bacterial vaginosis:
- For women with a history of preterm delivery: A recommendation to include screening in preconception care is unclear at this time and evidence is based on at least one properly executed randomized controlled trial done prior to pregnancy. Well constructed studies have shown inconsistencies in results. Some studies do support early screening (Jack et al., 2008).
- For women without a history of preterm delivery: Routine screening is not recommended and evidence is based on at least one properly executed randomized controlled trial done prior to pregnancy. The recommendation is based on possible adverse effects from treatment and lack of proven benefit to screening (Jack et al., 2008).
- Chlamydia: There is a strong recommendation to include chlamydia screening in preconception care and evidence is based on at least one properly executed randomized controlled trial done prior to pregnancy. The recommendation is to screen all sexually active women less than 25 years of age in the preconception period and to repeat the screening in early pregnancy or as indicated (Jack et al., 2008).
- Cytomegalovirus: There is insufficient evidence to recommend for or against this screening in preconception counseling and expert opinion recommends exclusion. Women that work with young children or infants are highest risk to contract an infection and should be educated on prevention methods in preconception counseling (outstanding hand hygiene after diaper changes or nasal secretion exposure) (Jack et al., 2008).
- Gonorrhea: There is a moderate recommendation to include gonorrhea screening in preconception care and evidence is based on at least one randomized controlled trial possibly done prior to pregnancy. Infections should be treated. Screening is also recommended in early pregnancy and repeated as appropriate in pregnancy (Jack et al., 2008).
- Group B streptococcus (GBS): There is a strong recommendation to exclude GBS screening in preconception care and evidence is based on cohort/case studies (Jack et al., 2008).
- Hepatitis C: There is insufficient evidence that screening for hepatitis C during preconception periods improves neonatal outcomes and expert opinion agrees to avoid routine screening for this STD. Screening is recommended for high risk women (Jack et al., 2008).
- Herpes simplex virus (HSV): There is a moderate recommendation to include HSV screening in preconception care and evidence is based on at least one randomized controlled trial possibly done prior to pregnancy. Universal HSV screening is not recommended in women unless they have a partner with a history of genital herpes. Preconception care should include transmission of the infection, possible asymptomatic nature, and the risks of vertical transmission to the fetus (Jack et al., 2008).
- HIV (human immunodeficiency virus): There is strong recommendation to include HIV screening in pregnancy and evidence is based on at least one randomized controlled trial, but the trial was not necessarily prior to pregnancy. HIV can be transmitted to the infant, known as vertical transmission (Jack et al., 2008).
- Listeriosis: There is insufficient evidence to recommend for or against this screening in preconception counseling and expert opinion recommends exclusion. Preconception counseling should include education about food sources at risk for the organism (soft cheeses from unpasteurized milk; also to heat deli meats, hot dogs thoroughly before eating) (Jack et al., 2008).
- Malaria: There is insufficient evidence to recommend screening for malaria during preconception periods and evidence is based on expert opinion. Women should be counseled to avoid travel to areas where malaria infection is possible and if travel is indicated, to prevent pregnancy with contraception until traveled in completed (Jack et al., 2008).
- Parvovirus: There is moderate evidence to support excluding this screening from precontraception counseling and expert opinion agrees. Screening for the virus antibody or including counseling about parvovirus does not improve perinatal outcomes at this time (Jack et al., 2008).
- Syphilis: There is a strong recommendation to include syphilis screening in preconception care and evidence is based on at least one randomized controlled trial done possibly done prior to pregnancy. Syphilis screening during pregnancy is recommended by the United States Preventative Services Task Force and the Centers for Disease Control and Prevention. Syphilis screening prior to contraception is recommended (Jack et al., 2008).
- Toxoplasmosis: There is insufficient evidence that screening for this infection will prevent or reduce an infection and expert opinion concurs. If a test is conducted and the woman tests positive for a history of the infection (IgG) she is not at risk for the infection during pregnancy (Jack et al., 2008).
- Tuberculosis: There is moderate evidence that women who are at high risk for tuberculosis be screened and treated prior to preconception. Evidence to support the recommendation is based on cohort or case studies (Jack et al., 2008).
There is insufficient evidence that screening or treatment of periodontal disease will prevent or reduce reproductive outcomes and evidence is based on at least one randomized controlled trial done possibly done prior to pregnancy. There are no studies that have evaluated periodontal disease in the preconception or pregnancy time periods. Routine periodontal disease screening and treatment is not currently recommended at this time because there is no known benefit to the fetus (Jack et al., 2008).
Periodontal disease handouts/resources
- Brushing for Two: How your Oral Health Affects Baby (Healthy Children, AAP)
- Dental Care in Pregnancy (ACNM)
- Dental Health in Pregnancy (March of Dimes)
- Is It Safe to go to the Dentist during Pregnancy? (Mouth Healthy, ADA)
- Oral Health Care during Pregnancy and Through the Lifespan (ACOG)
Many medical conditions in pregnancy require additional counseling during the preconception care. The list below is not all inclusive, but these diseases in particular are all strongly recommend (Jack et al., 2008; Farahi & Zolotor, 2013).
- Bariatric surgery
- Cardiovascular disease
- Diabetes mellitus
- Thyroid disease
- Renal disease
- Rheumatoid arthritis
- Seizure disorders
- Planning for Pregnancy: Women with Asthma
- Planning for Pregnancy: Women with Diabetes
- Planning for Pregnancy: Women with Epilepsy
- Planning for Pregnancy: Women with Hypertension
- Planning for Pregnancy: Women with Obesity
- Planning for Pregnancy: Women with Hepatitis C
- If you are pregnant or considering pregnancy after bariatric surgery
Some women will need additional guidance for subsequent pregnancies based on what happened in a prior pregnancy or because of a structural abnormality in their reproductive tract. This is not an all inclusive list, but these specific obstetric circumstances had strong or moderate recommendations to recommend inclusion in preconception care (Jack et al., 2008):
- Prior preterm birth
- Prior cesarean section
- Prior miscarriage
- Prior stillbirth
- Uterine anomaly
Many psychiatric conditions require additional counseling or care during the preconception period. Screening and management of these disorders are recommended in preconception care and evidence is primarily by expert opinion (Jack et al., 2008):
- Bipolar disease
- Depression or anxiety
Family and genetic histories
A three generation medical history is recommended in preconception care and supported primarily by cohort/case studies or expert opinion. Specifically, screening for known genetic disorders, congenital malformations, mental retardation, and ethnicity are cited as important considerations in preconception screening (Jack et al., 2008). Referrals to genetic counselors should be offered as appropriate (Jack et al., 2008).
Women should be assessed for tobacco use every time they access healthcare. Cessation counseling and resources should be offered to any woman using tobacco. Women should be assessed for alcohol use annually and counseled as appropriate. Education about alcohol consumption in pregnancy should be included in preconception counseling: No safe level of alcohol consumption has been established and there are risks to the embryo/fetus during pregnancy (Jack et al., 2008). There is a strong recommendation to include both tobacco and alcohol screening in preconception care but only evidence from cohort or case-control studies for tobacco use in pregnancy was reviewed; the quality of evidence for alcohol was from expert opinion (Jack et al., 2008). Regarding illicit drug use, there is insufficient evidence to recommend for or against this screening in preconception counseling and expert opinion recommends inclusion. Both the woman and her partner should be screened for drug use and pregnancy should be postponed until all parties are drug free (Jack et al., 2008).
The environment a woman lives in or obtains her food and water sources from can impact her pregnancy. For that reason, these additional assessments for environmental exposure are recommended for preconception care (Jack et al., 2008):
- Mercury: Women should be counseled to avoid large fish in the sea that may contain high levels of mercury: shark, tilefish, king mackeral, and swordfish. There is a moderate recommendation to include this in preconception care and evidence is based on expert opinion (Jack et al., 2008).
- Lead: There is insufficient evidence to recommendation lead screening in women at this time base on cohort/case studies (Jack et al., 2008).
- Soil/water hazards: If women use water from a well, they should be asked if the well water has ever been tested and if there are any concerns about water quality (past/present). This is a moderate recommendation and evidence is from expert opinion/case studies.
- Workplace exposure: An assessment of the woman’s work environment should be included in preconception care. This is a moderate recommendation and evidence is based on expert opinion/case studies.
- Household exposure: An assessment of the woman’s home environment should be included in preconception care. This is a strong recommendation and evidence is based on expert opinion/case studies.
There are other contributing factors that are important to include in preconception care – but there is little evidence to support the recommendations except for expert opinion. Regardless, assessment of these factors are recommended in preconception care at this time and appropriate referrals/recommendations reviewed as indicated:
- Inadequate financial resources
- Access to care
- Current or history of abuse
- Spouse readiness (I love this handout! Planning for Pregnancy: Becoming a Father)
There is a strong recommendation to review a woman’s prescription, over the counter and dietary supplements in preconception care. Evidence ranged from cohort studies to expert opinion. Counseling should include assessment for teratogenic medications and assessment of fewest/lowest dosing for pregnancy (Jack et al., 2008).
I found these tools for preconception care but would love to see if someone has another tool to recommend!
Other helpful preconception resources…
- This guideline is based on the majority of recommendations from Jack et al. (2008) and is a helpful desktop reference for providers!
- Want to improve preconception care in your state? Take a look at initiatives in Colorado, Delaware, Oregon, Louisiana, Georgia, North Carolina, California, and Nebraska!
- Ever wonder what preconception guidelines are in other countries? This review looked at Guidelines in six countries (Belgium, Denmark, Italy, the Netherlands, Sweden and the United Kingdom) and found the guidelines to be a mixed bag of recommendations.
- This preconception tool from Canada is well done – Canada has preconception care recommendations that are a little different from the United States but the form is nicely put together.
- Want to know more about the history of preconception care… check out this link!
- This provider handout by Every Woman California which organizes risk factors and offers guidance for each factor via “Ask,” “Advise,” “Refer,” or “Counsel.” This would be a great resource for the desk! *You do have to download the PDF to view it.*
- The Wisconsin Association for Perinatal Care offers a number of patient handouts on pre and interconception care.
- These other sites were also helpful and informative…
If you’re a practicing midwife…these are the questions I pondered as I was researching and writing the post!
- When do you give preconception care? During the postpartum visit? During the well woman visit? Whenever you can appropriately find time? I found it surprising how many articles focused on preconception care in the primary care setting!
- Do you find insurance type plays a big factor in when women seek preconception care?
- Do you routinely counsel on vaccinations?
- Do you include short interval pregnancy risks in your counseling?
- What other things do you all want to see in preconception care?
- Do you think telehealth is an appropriate platform for preconception visits (I do!)?
A tool to mirror all of this evidence is in the works 🙂
And you have a moment today (less than five minutes!), please consider sending Governor Northam a message about supporting a bill called HB 1817 to pass autonomous practice for CNMs in Virginia! Email the Governor here: https://www.governor.virginia.gov/constituent-services/communicating-with-the-governors-office/
Happy Wednesday! See you next Wednesday for the 1st OB visit!
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American Academy of Family Physicians. (2015). Preconception care (position paper). https://www.aafp.org/about/policies/all/preconception-care.html
American College of Obstetricians & Gynecologists. (2018). ACOG committee opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology, 131(5), e140-e150. https://doi.org/10.1097/AOG.0000000000002633ACOG
American College of Obstetricians and Gynecologists, & American Society for Reproductive Medicine. (2020). Prepregnancy counseling. Committee Opinion: Number 762. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/01/prepregnancy-counseling
Centers for Disease Control and Prevention. (2020). Preconception health. https://www.cdc.gov/preconception/overview.html
Dehlendorf, C., Krajewski, C., & Borrero, S. (2014). Contraceptive counseling: Best practices to ensure quality communication and enable effective contraceptive use. Clinical Obstetrics and Gynecology, 57(4), 659-673. doi:10.1097/GRF.0000000000000059
Farahi, N., & Zolotor, A. (2013). Recommendations for preconception counseling and care. American Family Physician, 88(8), 499.506. https://www.aafp.org/afp/2013/1015/p499.html
Jack, B., Atrash, H., Coonrod, D., Moos, M.K., O’Donnell, J., & Johnson, K. (2008). The clinical content of preconception care: An overview and preparation of this supplement. American Journal of Obstetrics & Gynecology, 199(6), S266-S279. https://www.ajog.org/article/s0002-9378(08)00887-9/fulltext#tbl1