Preconception health [Feb. 2006]

Preconception Health
Health care providers should strive to help women achieve optimal health before conception so they may have healthy pregnancies and healthy infants. Currently, much of the health information given to women considering pregnancy is provided during the prenatal period or after delivery. Since most women's reproductive capacity spans many decades, and because nearly half of United States pregnancies are unintended, it is important that health care providers integrate health promotion and disease prevention into a continuum of care throughout the lifecycle (1). Below are the key elements to include as part of a comprehensive package of information that women should receive prior to pregnancy to achieve optimal health.
Create a Non-threatening Medical Environment
Many women may not be aware of the importance of preconception health. To help improve birth outcomes, health care providers can assure that women of child-bearing age achieve and maintain good health status before conception by initiating a dialogue with them regarding their reproductive health plan. If health care providers take the initiative to discuss with all women of child-bearing age the importance of preconception health, it will help create a non-threatening environment in which a woman will feel more comfortable talking about her own health concerns. As a result, health care providers can more easily assess and identify opportunities for improving the woman's overall health status before pregnancy.
Provide Genetic Screening and Counseling
Depending on a woman's ethnic background and family medical history, some women should be screened and counseled for certain genetic conditions before conception. Examples include: sickle cell anemia, thalassaemia, cystic fibrosis, chromosomal abnormalities, and muscular dystrophy (2). Counseling enables couples to become more informed about the potential genetic disorders, the current availability of prenatal and postnatal testing, the accuracy and limitations of such testing, as well as their reproductive options (3).
Review Immunization Records
Though screening for immunizations should be routinely conducted this is not always the case. Encouraging and administering vaccinations prior to pregnancy is preferable (1). Health care professionals should review the last time of administration of a woman's standard adult immunizations including: tetanus, rubella, hepatitis, varicella, and influenza. Susceptible women should receive vaccinations for rubella and varicella at least 28 days before becoming pregnant.
Screen for Sexually Transmitted Infection (STI) and Human Immunodeficiency Virus (HIV)
STIs and HIV can have many of the same consequences for pregnant women as women who are not pregnant, for example: cervical and other cancers, chronic hepatitis, pelvic inflammatory disease, infertility, and other complications. Furthermore, a pregnant woman with an STI or who is HIV-positive may have early onset of labor, premature rupture of the membranes (PROM), and intrauterine infection after delivery. The harmful effects of STIs in babies may include: stillbirth, low birth weight, conjunctivitis, pneumonia, neonatal sepsis, neurological damage, blindness, deafness, acute hepatitis, meningitis, chronic liver disease, and cirrhosis (5).
Because infections passed through sexual contact are harmful during pregnancy and can also infect babies, women should be advised to get tested before pregnancy to improve perinatal outcomes. It should be explained to women that it is better to get tested and treated before pregnancy if they feel there is a chance of having contracted an STI or HIV, even if they have been tested previously. It is important that a women know her STI and HIV status before pregnancy so that if the test if positive, she can make
an informed decision regarding appropriate treatment for herself and prophylaxis for her infant.

Ensure Optimal Management of Preexisting Medical Conditions
Preexisting medical conditions, such as obesity, diabetes, cardiovascular disease, hypertensive disorders, epilepsy, DVT, systemic lupus, thyroid disorders, and depression/anxiety can be affected by pregnancy. Women with these conditions are at a higher risk of serious pregnancy complications and poor birth outcomes. It is important for health care providers to inform women of child-bearing age of the risks associated with these conditions and the need for optimal management before becoming pregnant. Certain medications may need to be managed differently before and during a woman's pregnancy in order to achieve an optimal pregnancy outcome (24). Women will need to be educated on the importance of adherence to medication regimens and disease monitoring during this critical time period, and the risks of not doing so.
Promote Achievement and Maintenance of a Healthy Weight
A woman's weight at conception can influence her pregnancy and delivery as well as the infant's health (6). Body Mass Index (BMI), defined as weight (kg)/height (m2), is one method of determining a woman's weight status.
Overweight In 2002, over half (53%) of women in Georgia were overweight or obese (7). Women who are overweight (BMI >25) or obese (BMI >30) before conception are at increased risk of several adverse pregnancy outcomes including preterm delivery, gestational diabetes, preeclampsia, macrosomia, neonatal death, and fetal death (8, 6, 9, 10). Furthermore, women who are obese before conception, tend to gain and retain more weight during pregnancy than recommended by the Institute of Medicine (11). After delivery, overweight and obese women have more difficulty initiating and maintaining breastfeeding than do women of normal weight (8, 12, 13, 14).
It is not recommended that woman lose weight during pregnancy. Therefore, it is important to identify women who are overweight or obese as early as possible, and refer them to a registered dietitian who can help them lose weight safely before conception.
Underweight Women who are severely underweight (BMI <18.5) are also at increased risk for a number of adverse pregnancy outcomes, including low birth weight, preterm birth, and intrauterine growth retardation (15, 16). Women identified by health care providers as underweight before they become pregnant, should be referred to a registered dietitian to receive guidance on how to increase their weight.
Encourage Optimal Nutrition Intake through a Balanced Diet
Women should consume a balanced diet rich in fruits and vegetables, low-fat dairy products, whole grains and high-protein foods (see 2005 Dietary Guidelines for Americans at www.mypyramid.gov for more information). A balanced diet will ensure that women acquire the recommended daily requirements for vitamins and minerals, and also adequate nutrient stores for pregnancy. Women with a low-income should be referred to the local food bank, and/or other relevant food assistance programs in the community.
Highlight the Importance of Folic Acid
Folic acid is an especially important nutrient for women of child-bearing age. Taking a folic acid supplement before conception as part of a healthy diet reduces the risk of neural-tube defects such as spina bifida. The recommended daily intake for all women of child-bearing age is at least 400 micrograms (mcg), or 0.4 milligrams (mg). Though it is ideal that all women of child-bearing age take folic acid daily, it is essential that women trying to get pregnant begin supplementation immediately. Food sources of folic acid include enriched grain products such as breakfast cereals, bread, pasta, and rice, and natural sources such as dark green leafy greens and legumes. Health care providers may recommend a higher level of folic acid intake for women with a family history of NTD, or women who have had a previous pregnancy affected by a NTD Health care providers may recommend a higher level of folic

Preconception Health

2

February 2006

acid intake for women with a family history of NTD, or women who have had a previous pregnancy affected by a NTD (2, 8).
Raise Awareness of the Significance of Safe Food Preparation
Preparing food safely is as important as eating the right things. Consuming food contaminated with methylmercury or toxoplasma, may cause harm to an unborn baby. To avoid the harmful effects of these food borne illnesses, women should be advised to follow recommendations of the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) before and during pregnancy (http://www.cfsan.fda.gov/pregnancy.html) (17):
Methylmercury: Do not eat Shark, Swordfish, King Mackerel, or Tilefish because they contain high levels of mercury. Eat up to 12 ounces (2 average meals) a week of a variety of fish and shellfish that are lower in mercury. Check local advisories about the safety of fish caught by family and friends in local lakes, rivers, and coastal areas. If no advice is available, eat up to 6 ounces (one average meal) per week of fish you catch from local waters, but don't consume any other fish during that week.
Toxoplasmosis: Wash hands with soap and warm water after touching soil, sand, raw meat, cat litter, or unwashed vegetables. Wash all cutting boards and knives thoroughly with soap and hot water after each use. Thoroughly wash and/or peel all fruits and vegetables before eating them. Separate raw meat from other foods in grocery shopping cart, refrigerator, and while preparing and handling foods at home. Cook meat thoroughly. The internal temperature of the meat should reach 160 F (71 C). Use a food thermometer to check. Don't sample meat until it's cooked. Avoid drinking untreated water, particularly when traveling in less-developed countries.
Be a Breastfeeding Advocate
The American Academy of Family Physicians, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists, recommend that all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first 6 months of life (18,19, 27). As part of preconception counseling, women should receive information on the benefits of breastfeeding for mother and infant. Benefits include: decreased severity or incidence of allergies, reduced risk of overweight and obesity, increased bonding, a decreased postpartum recovery time, and cost and time savings. Discussing breastfeeding information before pregnancy allows women to explore concerns, fears and myths that may inhibit successful breastfeeding (20). Encouragement to breastfeed from a health care provider, as well as from family members will increase the likelihood that a woman will initiate breastfeeding and maintain breastfeeding for a longer period of time (18).
Strategies for Health Care Providers (7) Train staff on the importance of breastfeeding, and its promotion and support Provide education and counseling to mothers before conception and during pregnancy and breastfeeding support after birth Know your area lactation consultants, and inform women of their availability Encourage hospitals to adopt the Baby Friendly Hospital 10-step program Create and maintain breastfeeding friendly clinic areas Encourage staff to receive training in lactation management skills

Preconception Health

3

February 2006

Emphasize the Benefits of an Active Lifestyle
Incorporating physical activity into a daily routine has many benefits such as: contributing to weight management, decreasing stress, improving healthy birth weight outcomes, and reducing risk of chronic diseases. Women planning on becoming pregnant should engage in moderate-intensity physical activity of 30 minutes or more on 5 or more days of the week, beginning at least 3 months before conception. Women should consult their health care provider before starting an exercise program (21).
Incorporate Advice on Good Maternal and Infant Oral Health
Studies have shown a relationship between periodontal disease and preterm, low birth weight babies. Periodontal disease may increase this risk by up to seven times. The American Academy of Periodontology recommends that women considering pregnancy have a periodontal evaluation, and a biannual comprehensive dental examination. Removing plaque and tartar from the roots of the teeth may significantly reduce the risks of having a preterm birth.
Women and their partners should be counseled on:
The importance of how to avoid transmission of the decay causing bacteria, streptococcus mutans, present in the saliva of adults who have had tooth decay, but not present in the saliva of newborns.
To avoid activities that increase the likelihood of sharing saliva, such as sharing food, and eating utensils, as well as placement of the baby's fingers into another's mouth.
The importance of a dental inspection at each "well baby" visit, so that physicians can visually inspect the infant's mouth. Infants identified as at risk for poor oral health should be referred to a Pediatric dentist by one year of age. Establishment of the dental home for both mother and child is an important step to ensure good oral health (28-33).
Assess Exposure to Alcohol, Caffeine, and Other Drugs
Alcohol In Georgia in 2003, 8.7% of women of child-bearing age (18-44 years) reported binge* drinking in the past month (22). Women should be informed that consumption of alcohol for those who may become pregnant should be avoided, as a safe level of alcohol consumption has not been established at any stage during pregnancy. * Binge alcohol use is defined as having five or more drinks on at least one occasion during the past month
Caffeine Some evidence suggests that caffeine consumption may delay conception as well as affect iron and calcium absorption (8). Common sources of caffeine include coffee, colas, chocolate, tea and some prescription or over the counter drugs.
Tobacco In Georgia in 2003, 23.3% of women of child-bearing age (18-44 years) reported smoking (22). Chemicals in tobacco have a cumulative deleterious effect on the health of the smoker but are particularly detrimental during the reproductive period. The toxic substances found in tobacco products adversely affect the reproductive capacity of females and males, as well as have a damaging effects on their offspring. Some of the adverse effects of smoking on reproductive health include:
Reduced length of gestation leading to low birth weight Perinatal mortality, stillbirths, and spontaneous abortions Fetal malformations Male and female infertility

Preconception Health

4

February 2006

o In females, cigarette smoking has been linked with both an early onset of menopause as well as directly with infertility
o In males cigarette smoking has been linked with decreased sperm density, a lower proportion of motile sperm, decreased total sperm count, reduced testosterone secretion and, as previously shown, an increase in abnormal spermatids and spermatozoa, which can be a direct cause of various fetal malformations (23).
Illegal Drugs Women should be informed that use of illegal drugs (such as cocaine, marijuana, and heroin) can affect a pregnancy and the fetus. Illegal drug use before conception is associated with miscarriage, prematurity, growth retardation, congenital defects, intrauterine growth restriction, hyperactivity, and severe neonatal withdrawal syndrome (2).
Discuss Men's Role in Pregnancy Planning
Information should be provided to couples that are planning to get pregnant on the impact that the male's health status can have on conception.
Similar to the health issues of women that affect pregnancy, there are many important male health concerns that may impact conception, pregnancy, and birth outcomes that should also be addressed.
Male fertility: contributes to approximately 50% of all infertility cases (5). It can be difficult to get pregnant if a man has a low sperm count. Some examples of factors that can negatively affect sperm include (4): drinking alcohol smoking cigarettes using anabolic steroids using illegal drugs, such as marijuana, cocaine, or heroin taking certain antibiotics, prescription drugs, or over-the-counter medicine using saunas, whirlpools, or hot tubs at more than 102F unhealthy diet stress, certain bacterial and viral infections, some medical conditions, and exposure to pesticides may also reduce sperm count or the quality of semen.
Genetics and family history Exposures affecting reproduction: occupational, HIV, and STI's.
Take Simple Steps to Provide Preconception Care
There is a comprehensive list of important issues that need to be discussed with women of child-bearing age and their partners, to adequately prepare them for achieving a safe and healthy pregnancy. If integrated into routine visits and the clinic environment, providing preconception care and information will not add an extra burden to a clinician's workload. Simply:
Incorporate preconception health discussions into every visit Administer preconception screening, and plan for appropriate follow-up Stock waiting rooms with posters, and magazines addressing preconception health related issues Distribute pamphlets on preconception care, from reputable sources such as: March of Dimes,
ACOG, AAP, etc. Refer women to a maternal-fetal medicine specialist as necessary Be an advocate for preconception health interventions in the community and schools

Preconception Health

5

February 2006

References
1. Committee Opinion: The Importance of Preconception Care in the Continuum of Women's Health Care. Obstetrics & Gynecology. 2005; 106: 665-666.
2. Burndage, Stephanie C. Preconception Health Care. American Family Physician. 2002; 65: 2507-2514.
3. Driscoll DA, Wenstrom KD, Williams J 3rd; ACOG Committee on Genetics. ACOG Technology Assessment in Obstetrics and Gynecology. Number 1, July 2002. Genetics and molecular diagnostic testing. Obstet Gynecol. 2002;100:193-211
4. Having a Healthy Baby -- Planning Your Pregnancy. Planned Parenthood. Available at: http://www.plannedparenthood.org/pp2/portal/files/portal/medicalinfo/pregnancy/pub-pregnancyplanning.xml. Accessed December 21, 2005.
5. Centers for Disease Control and Prevention. STDs and Pregnancy - CDC Fact Sheet Available at: http://www.cdc.gov/std/STDFact-STDs&Pregnancy.htm. Accessed December 23, 2005.
6. Insel, P. Turner, RE. Ross, D. Nutrition. Jones and Bartlett Publishers, Massachusetts, 2001.
7. Georgia Department of Human Resources, Division of Public Health. Overweight and Obesity in Georgia, 2005. April 2005. Publication Number: DPH05.023HW
8. Position of the American Dietetic Association: Nutrition and lifestyle for a healthy pregnancy outcome. Available at www.eatright.org/cps/rde/xchg/SID-5303FFEA397D907A/ada/hs.xsl/home_adar1002b_ENU_HTML.htm. Accessed October 5, 2005.
9. Rosenberg, TF. Garbers, S. Chavkin, W. Chiasson, MA. Pregnancy Weight and Adverse Perinatal Outcomes in an Ethnically Diverse Population. Obstetrics and Gynecology. 2003; 102: 1022-1027.
10. Kristensen, J. Vestergaard, M. Wisborg, K. Kesmodel, U. Jorgen Secher, N. Pre-pregnancy Weight and the Risk of Stillbirth and Neonatal Death. BJOG: An International Journal of Obstetrics and Gynaecology. 2005; 112: 403-408.
11. Gilberto, K. Bencio, M. Velsquez-Melndez, G. Valente, JG. Struchiner, CJ. Gestational Weight Gain and Prepregnancy Weight Influence Postpartum Weight Retention in a Cohort of Brazilian Women. Journal of Nutrition. 2004; 134:661-666.
12. Rasmussen, KM. Hilson, JA. Kjolhede, CL. Obesity May Impair Lactogenesis II. Journal of Nutrition. 2001; 131: 3009S-3011S.
13. Lovelady, Cheryl A. Brief Critical Review: Is Maternal Obesity a Cause of Poor Lactation Performance? Nutrition Reviews. 2005; 352-355.
14. Rasmussen, KM. Kjolhede, CL. Pregnant Overweight and Obesity Diminish the Prolactin Response to Suckling in the First Week Postpartum. Pediatrics. 2004;113: e465-e471
15. Ronnenberg, GA. Xiaobin, W. Houxun, X. Chanzhong, C. Dafang, C. Wenwei, G. Aiqun, G. Lihua, W. Ryan, L. Xiping, X. Low Preconception Body Mass Index Is Associated with Birth Outcome in a Prospective Cohort of Chinese Women. Journal of Nutrition. 2003; 133: 3449-3455.
16. Neggers, Y. Goldberg, RL. Some Thoughts on Body Mass Index, Micronutrient Intakes, and Pregnancy Outcome. Journal of Nutrition. 2003; 133: 1737S-1740S.
17. Food Safety for Moms to Be - Protecting yourself and your unborn baby just takes following these careful food selection and preparation tips: Before You're Pregnant. Available at: http://www.cfsan.fda.gov/~pregnant/before.html. Accessed December 28, 2005.
18. American Academy of Family Physicians. Breastfeeding (Position Paper). Available at: http://www.aafp.org/x6633.xml. Accessed September 30, 2005.
19. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics. 2005; 115: 496-506.
20. Association of Women's Health, Obstetric, and Neonatal Nurses. Breastfeeding: Clinical Position Statement. Available at: http://www.awhonn.org/awhonn/?pg=875-4730-7240. Accessed October 19, 2005.

Preconception Health

6

February 2006

21. ACOG Committee Opinion. Number 267, January 2002: Exercise during pregnancy and the postpartum period. Obstet Gynecol 2002; 99:171-3.
22. Peristats March of Dimes. Binge alcohol use among women of childbearing age: Georgia and US 2003. Available at: http://www.marchofdimes.com/Peristats/tlanding.aspx?reg=13&top=9&lev=0&slev=4. Accessed October 19, 2005
23. Tuormaa, Tuula, E. The Adverse Effects of Tobacco Smoking on Reproduction: A Review from the Literature by Tuula E. Tuormaa for FORESIGHT, The Association for the Promotion of Preconceptual Care. Available at: http://www.foresight-preconception.org.uk/summaries/frames/smoking-nf.html. Accessed December 20, 2005.
24. Kaunitz, Andrew M. Perlmutter, Johanna F. Westhoff, Carolyn L. Preconception Care and Contraception. Dialogues in Contraception. 2005. 8. Available at:
http://usc.edu/schools/medicine/education/continuing_education/calendar/assets/pdf/misc/DIC/DIC%20Vol8-
8.pdf. Accessed December 21, 2005.
25. Li, R. Jewell, S. Grummer-Strawn, L. Maternal Obesity and Breast-Feeding Practices. American Journal of Clinical Nutrition. 2003; 77:931-936.
26. American Pregnancy Association. Preconception Health for Men. Available at: http://www.americanpregnancy.org/gettingpregnant/menpreconception.htm. Accessed December 6, 2005.
27. Policy Statement: Breastfeeding. American College of Obstetricians and Gynecologists. September 1994 (Amended and Reaffirmed July 2003). Available at: http://www.acog.org/departments/underserved/breastfeedingStatement.pdf. Accessed January 30, 2006.
28. Periodontal Disease and Reproductive Outcomes. Accessed January 30,
2006.http://www.cdc.gov/oralhealth/conferences/periodontal_infections.htm. Accessed January 30, 2006.
29. American Academy of Periodontology. Available at: http://www.perio.org/consumer/pregnancy.htm. Accessed January 30, 2006.
30. Healthy Mothers, Healthy Babies Coalition. Available at: http://216.180.241.234/%7Ehmhb/forfamilies/dental_health/motherhood.htm. Accessed January 30, 2006.
31. American Academy of Pediatrics. Available at: http://www.aap.org/advocacy/archives/maydental.htm. Accessed January 30, 2006.
32. Anticipatory Guidance in Infant Oral Health: Rationale and Recommendations. Available at: http://www.aafp.org/afp/20000101/115.html. Accessed January 30, 2006.
33. March of Dimes. Available at: http://www.marchofdimes.com/pnhec/pnhec.asp. Accessed January 30, 2006.

Georgia Department of Human Resources

7

Family Health Branch, Phone: 404-657-2850

http://health.state.ga.us/programs/family/

DPH06.019HW