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The Preconception Visit

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)?

As I created these posts on preconception and pregnancy care, I made a series of checklists for your pregnancy visit. These checklists are a tool to use through each month of your pregnancy.

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.

You can get your FREE checklist for preconception care on the TOOLS & HANDOUTS page.

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:

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).


Immunization 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).

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).

Infectious diseases

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.

Periodontal disease

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

Medical conditions

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).


Reproductive history

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):

Psychiatric conditions

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):


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).

Substance abuse

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).

Environmental exposures

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):

Psychosocial risks

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:


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…

If you’re a practicing midwife…these are the questions I pondered as I was researching and writing the post!


1 year ago on the blog…What are the hallmarks of midwifery?

Overwhelmed by all the information about pregnancy? Looking for a checklist to guide to each pregnancy visit? Don’t expect your OB provider to do all the work – take control of your care and get these templates to guide every aspect of your pregnancy visits.

Make the investment in you and your baby here!


American Academy of Family Physicians. (2015). Preconception care (position paper).

American College of Obstetricians & Gynecologists. (2018). ACOG committee opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology, 131(5), e140-e150.

American College of Obstetricians and Gynecologists, & American Society for Reproductive Medicine. (2020). Prepregnancy counseling. Committee Opinion: Number 762.

Centers for Disease Control and Prevention. (2020). Preconception health.

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.

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.

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