RUNNING HEAD: Preconception Health

Preconception Health in Women

Linda Ngameduru Brenda Taft-Hall Sybil Williams

Submitted to: Dr. Tilghman Dr. Warren-Dorsey

Coppin State University 8/5/2013

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Introduction Preconception Health Preconception health is a crucial component of health care for women during their reproductive years. Preconception health is defined as health care and practices that are geared towards pathophysiological interventions, social behaviors, and risk factors that affect a womans health before pregnancy (Baxter, Berghella, Buchanan, & Perireia, 2010) The identification of health care factors during the preconception period that would negatively affect a woman during pregnancy can assist in improving outcomes for pregnant women. The goal of preconception health is to improve the health status and outcome of future pregnancies via health promotion, periodic screenings, and interventions (Curtis, 2010) .The aim of preconception health is to optimize the health of the women of childbearing years before conception (Curtis, 2010). This proactive approach improves pregnancy outcomes. The purpose of this paper is to discuss the social and political issues, trends in care and management, and implications for health care as they relate to preconception health. This paper will first explore the significance and prevalence of preconception health in adult women. Additionally, the economic cost, pathophysiology, and research supporting preconception health will also be explored. Rationale for Identification of Health Condition Significance. According to Baxter, Berghella, Buchanan & Perireia (2010), the significance of preconception health is that it aids in decreasing adverse maternal and fetal outcomes, such as long-term morbidity and early infant death. Low birth weight, for

PRECONCEPTION HEALTH example, increases the risk of long-term morbidity within the infant and early infant death. Weight at birth is closely associated with gestational age, and is an important predictor of infant well-being and survival (Martin, et al., 2012). Prevalence. According to the National Vital Statistics Report (2010), there are millions of women in the United States who experience childbirth annually. In 2010, an estimated 3,999,386 births occurred and 8.16 percent of those births were low birth weight infants; whereas, 11.99 percent of those births were preterm births (Martin, et al., 2012). In 2008, 24 percent of all infants born with very low birth weights died within the first year of life (Martin, et al., 2012). A low birth weight is classified as an infant weighing less than 2500 grams (Youngkin, Davis, Schadewald, & Juve, 2013). Economic cost. The costly effects of adverse pregnancy outcomes, such as low-birthweight infants and preterm infants, continue to be a major issue in public health in the United States, due to its slow decline in the past few years (Martin, et al., 2012). In the year 2012, it was estimated that the first year of an infants life cost 38,953 dollars for a preterm birth versus a full-term birth of 3,953 U.S. dollars (Martin, et al., 2012). This is an estimate of a ten times increase in cost for a preterm birth versus a full-term birth. One of the major medical expenses that a couple will often incur is pregnancy and childbirth; therefore, the importance of the health care providers starting early negotiation regarding childbearing costs, insurance coverage, and family leave policies cannot be overly emphasized. Pathophysiology Baxter, Berghella, Buchanan & Perireia (2010) states that a thorough health history, which includes family and personal history, physical examination, blood and laboratory screening, exercise, vaccinations, vitamin and mineral supplements, weight management and

PRECONCEPTION HEALTH preventive measures should be assessed in all men and women. Preventive measures such as management of chronic diseases, identification and exposure to smoking, alcohol use, illicit drugs and assessing for teratogens (Baxter, Berghella, Buchanan & Perireia, 2010). Adverse pregnancy outcomes are generally predicated on women and men who do not practice effective preconception health, such as avoiding teratogens, maintaining a healthy weight, refraining from smoking cigarettes and drinking alcohol and/or effectively managing their current chronic ailments involving hypertension, diabetes, and obesity. Health conditions such as hypertension, obesity and diabetes relate to the pathophysiology of preconception health. Hypertension is diagnosed when the blood pressure is greater than 140/90 mm Hg during two separate occasions (Youngkin, Davis, Schadewald, & Juve, 2013). Gestational hypertension is diagnosed when blood pressure measures greater than 140/90 mm Hg without proteinuria (protein found in urine) after 20 weeks of pregnancy, but has returned to normal after pregnancy (Youngkin, Davis, Schadewald, & Juve, 2013). Pregnant women with hypertension face risk of preeclampsia, eclampsia, and hemolysis elevated liver enzymes low platelet (HELLP) syndrome. Women suffering with preeclampsia may have symptoms comprising bilateral lower extremity edema, facial edema, headaches, blurred vision, heartburn, and abdominal pain (Youngkin, Davis, Schadewald, & Juve, 2013). Preeclampsia is usually diagnosed during the 20th week of pregnancy with such clinical presentations as blood pressure greater than 140/90 mm Hg, and proteinuria (300 mg of protein found in a 24-hour urine specimen) (Young, Levine, & Karumanchi, 2010). If hypertension is not monitored and treated adequately, preeclampsia may lead to eclampsia, seizures. Preeclampsia may also lead to HELLP syndrome, as evidenced by hemolytic anemia, elevated liver enzymes, and a low platelet count. Therefore, the woman may

PRECONCEPTION HEALTH experience symptoms encompassing nausea, epigastric abdominal pain, vomiting, headache, and problems with vision. Complications from HELLP consist of liver failure, respiratory failure, renal failure, and also multiple organ failure (Young, Levine, & Karumanchi, 2010). The American College of Obstetrics and Gynecology ( 2011) states that as women experience hypertension during their pregnancy, their fetus receive less oxygen and nutrients, due to less blood flow to the placenta; therefore, the fetus may suffer intrauterine growth retardation, which means the lack of normal growth for the fetus. To reduce the risk of adverse pregnancy outcomes such as, seizure, stroke, placental abruption, intrauterine growth retardation, prematurity, and stillbirth, women must strictly adhere to their physicians guidelines. For the past decade, the National High Blood Pressure Education Program (NHBPEP) has recommended antihypertensives such as methyldopa, labetalol, hydralazine, and Procardia for the treatment of hypertension (Youngkin, Davis, Schadewald, & Juve, 2013). The American College of Obstetricians and Gynecologists (2011) recommends intravenous labetalol and hydralazine as first-line therapy for the treatment of severe hypertension (blood pressure greater than 160/110 mm Hg and is persistent for longer than 15 minutes). Magnesium sulfate is given to pregnant women with a diagnosis of preeclampsia to prevent seizures or eclampsia (Youngkin, Davis, Schadewald, & Juve, 2013). Obesity is defined as having a body mass index measuring greater than or equal to 30 kg/m2 (Youngkin, Davis, Schadewald, & Juve, 2013). Women who are obese while pregnant face various risks, such as gestational diabetes, preeclampsia, post-operative wound infection, postpartum weight retention, miscarriage, fetal congenital anomaly, thromboembolism, postpartum hemorrhage, stillbirth, and cesarean section delivery

PRECONCEPTION HEALTH (Youngkin, Davis, Schadewald, & Juve, 2013). Obese pregnant women must be monitored closely, due to the aforementioned risks. Weight gain for obese pregnant women should be closely monitored; while being sure the woman understands to gain only between 11 to 20 pounds during pregnancy. Serial blood pressures should be done routinely and glucose testing must be done at the first initial prenatal visit and again between 26 to 28 weeks of pregnancy (Youngkin, Davis, Schadewald, & Juve, 2013). Pregnant women diagnosed with diabetes face various risks such as fetal macrosomia, shoulder dystocia, infant hypoglycemia, spontaneous abortions, congenital birth defects, intrauterine fetal death, and congenital malformations (Youngkin, Davis, Schadewald, & Juve, 2013). Glucose testing consists of obtaining or having the women take a fasting glucose test, then drinking a sugary solution and waiting an hour to test the results, which if greater than 180 mg/dL and if two hours later reads greater than 153 mg/dL would indicate a diagnosis of gestational diabetes (Youngkin, Davis, Schadewald, & Juve, 2013). Two elevated levels on the 3-hour glucose tolerance test are diagnostic of gestational diabetes, (Youngkin, Davis, Schadewald, & Juve, 2013, p. 572). Once gestational diabetes has been established, the pregnant clients should be informed of the need to get an eye exam, due to the risk of retinopathy. Serial abdominopelvic sonograms should be done to monitor fetal growth, because of the risk of fetal macrosomia; as well as fetal echocardiography to monitor the fetus that is at risk for cardiac lesions (Youngkin, Davis, Schadewald, & Juve, 2013). Recommended treatments for the pregnant woman with gestational diabetes is initially daily 30-minute light physical activity to increase glucose uptake and diet medication (Youngkin, Davis, Schadewald, & Juve, 2013); however, if these self-treatments are ineffective in adequately managing glucose

PRECONCEPTION HEALTH levels, then she must start insulin therapy in conjunction with dietary modification and light physical activity. Social and Political Issues Political issues involve constructing policies, which would allow more individuals to gain access to health care. The United States government continues to promote the need for preconception care for women of child bearing age through the initiation of the Patient Protection and Affordable Care Act (PPACA) since August 1, 2012; therefore, making it easier to effect a discontinuation of a co-payment charge for preconception health or wellwoman clinic visits for women with private insurance plans (U.S Department of Health & Human Services, 2011). The Patient Protection and Affordable Care Act assists with eliminating the disparities of access to health care among minority populations. Social issues involve the current disparities among minority populations in regards to their socioeconomic status, age, ethnicity, and gender, which prohibit their access to health care. The focus of the social aspects of preconception health involves closing the racial gap in birth outcomes (Lu, et al., 2010). Elimination of health disparities among different segments of a population is one of the goals of Healthy People 2010 whether via socioeconomic status, age, gender, ethnicity, disability, or special health care need, geography, and sexual orientation (CDC, 2010). According to American College of Obstetricians and Gynecologists (2008), there are higher fetal and infant mortality rates about twice among Black women than Caucasian women (11.25 compared to 4.98 per 1,000 live births and fetal deaths), and these infant deaths occurs in the first four weeks of life (ACOG, 2008). Irregularity and disproportion of care should be eradicated among minority

PRECONCEPTION HEALTH populations because of the costly outcome of health disparities; it influences a value of life, illness, and death (Diggs, 2012). Trends in Care and Management The United States healthcare system functions within a paradigm of reactivity. Currently, health care is predominantly a reactive system, whereas preconception health is proactive; therefore, women must initiate discussions with their health care providers to learn how to optimally care for themselves prior to becoming pregnant (Curtis, 2010). The CDC (2012), in order to work towards changing the current healthcare systems paradigm, constructed an action plan entitled, Action Plan for the National Initiative on Preconception Health and Health Care (PCHHC): A Report of the PCHHC Steering Committee 2012-2014 to report goals and objectives of preconception health for healthcare practitioners and their clients to follow to optimize pregnancy outcomes. The Centers for Disease Control and Prevention (2012) in conjunction with other professional organizations have devised four categories of interventions encompassing physical assessment, risk screening, vaccinations, and effecting positive behaviors among childbearing-aged men and women in terms of prevention of human immunodeficiency virus (HIV) and proper folic acid consumption. Implications for Health Care Education implications. According to Mitchell, Levis, and Prue (2012), more education is needed in the areas of educating the general public concerning preconception health, and educating health care practitioners to deliver proper preconception health, knowledge and screening to their clients. Implications for health care practice. Organizations such as the American College of Obstetricians and Gynecologists (ACOG) and Centers for Disease Control and Prevention

PRECONCEPTION HEALTH (CDC) have promoted the need for health care providers to integrate routine preconception care among women of child bearing age through their lifespan. Couples that receive preconception education and have good knowledge of their family health history or genetic conditions have the opportunity to use the information to explore their reproductive options (using donor gametes, or adoption, prenatal or pre-implantation diagnosis) if for instance, the woman has a genetic disorder (cystic fibrosis or X-linked disorder) (De Wert, Dondrop, & Knoppers, 2012). The primary aims of preconception care for genetic risks are to increase individual ability to make an informed reproductive decision and to prevent serious suffering of individuals. Ethical issues are currently based on the objectives of providing reproductive options through preconception genetic counseling or screening, abortions, embryo-selection, eugenics, concerns about medications, and problems arising in the professionalclient relationship and/or for population screening (De wert, Donrop, & Knoppers, 2012). De Wert, Dondorp, and Knoppers (2012) explored the use of preconception care genetic risk prevention counseling as a health care cost reduction for the government versus individual reproductive autonomy. De Wart et.al (2012) advised that it is morally acceptable when the objective of preconception carrier screening is used for directive and prevention counseling for individuals with high reproduction risk; otherwise, when it is used as a cost reduction for the health care system, reproductive choice becomes threatened by economic considerations, which may lead to forceful evading of pregnancies or fetus/children with minor or treatable disorders (De Wert, Dondorp, & Knoppers 2012). Keeping clients properly informed creates more trustful relationships with their health provider.

PRECONCEPTION HEALTH Research implications. Future research endeavors should address the current knowledge of preconception health among consumers and health care practitioners, so that more preconception health programs and policies can be implemented accordingly. Mitchell, Levis, and Prue (2012) conducted a research study, using a sample (White 62.9%, African American 14.4%, Hispanic 14.7%, and others 8%) of childbearing-aged women between the ages of 18 to 44 and men aging 18 to 64, to understand the lack of knowledge and awareness of preconception care among couples of reproductive age. The researchers sent out 2,736 post-mail surveys asking individuals question such as, if preconception health behaviors were important for women to practice before becoming pregnant, or if they received education on preconception health before becoming pregnant. The researchers compared the participant level of awareness of preconception health among men and women; as well as the mode of received information. The result from their study indicated that women acknowledged avoiding alcohol (86.9%), cigarettes (90.8%), folic acid (77.3%) and illicit drugs (89.3%) as preconception health behaviors women should practice (Mitchell, Levis, & Prue, 2012). Mitchell, et al (2012) used Andresens behavioral theory of health care delivery system and health services utilization focusing more on using social marketing to ignite behavioral change and communication interventions among consumers (an individual of reproductive age). There are unmet needs for healthcare of women of child bearing age, which the primary healthcare providers or organization can aid in advancing the value of a persons lifespan. This can be accomplished through pursuing the explanations on why a person and families utilize, or fail to use preconception wellness maintenance services. This knowledge will help practitioners recognize new consumers and discover reproductive goals or concerns of consumers. The practitioners will use the information to help consumers

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PRECONCEPTION HEALTH understand their pregnancy risks, eventually increase consumer satisfaction, and increase a good health outcome. Conclusion In conclusion, preconception health refers to properly caring for the body prior to planning a pregnancy. Prior to planning a pregnancy, women must take into consideration their current state of health, which should be validated by their primary care physician. Women of childbearing age must be made aware if they currently have diabetes, hypertension or obesity, so they may take action by taking the necessary steps towards controlling their health by taking their medications properly, eating according to their goals of conceiving by taking in the daily recommended amounts of folic acid, iron, calcium and other important nutrients to ensure a healthy pregnancy with desirable outcomes. Women living with chronic illnesses such as, diabetes, hypertension and obesity must understand the risks of adverse pregnancy outcomes (Chuang, Velott, & Weisman, 2009). Adverse pregnancy outcomes encompass miscarriages, pregnancy-induced hypertension, gestational diabetes, neural tube defects, thromboembolism, eclampsia, congenital anomalies, spontaneous abortions, renal failure; and fetal risks comprising preterm birth, intrauterine growth restriction, placental abruption, and stillbirth (Chuang, Velott, & Weisman, 2009). Health care professionals caring for childbearing-aged women should educate their patients to prevent any potential adverse pregnancy outcomes. Health care professionals must explore the current knowledge and behaviors of their childbearing-aged women.

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References Centers for Disease Control and Prevention. (2010). Retrieved August 5, 2013, from Healthy People 2010: Final Review: http://www.cdc.gov/nchshealthypeople/hp2010_final_review.htm American College of Obstetricians and Gynecologists. (2011). Retrieved July 22, 2013, from High Blood Pressure During Pregnancy: http://www.acog.org/~/media/For%20Patients/faq034.pdf?dmc=1&ts=20130 722T1824504281 U.S. Department of Health & Human Services. (2011). Retrieved August 5, 2013, from Preventive care act ensures women receives preventive services at no additional cost: http://ww.hhs.gov (n.d.). American College of Obstetricians and Gynecologists (2008). Washington, D.C.: Department of Government Affairs. Retrieved from Health care for women, healthcare for all: A reform agenda. Baxter, J. K., Berghella, V., Buchanan, E., & Perireia, L. (2010). Preconception Care. Obstetrical & Gynecological Survey, 65(2), 119-131. Chuang, C. H., Velott, D. L., & Weisman, C. S. (2009). Exploring knowledge and attitudes related to pregnancy and preconception health in women with chronic medical conditions. Maternal Child Health Journal, 14(5), 713-719. Curtis, M. G. (2010). Preconception Care: Clinical and policy implications of the preconception agenda. Journal of Clinical Outcomes Management, 17(4), 167-172.

PRECONCEPTION HEALTH De Wert, G. M., Dondorp, W. J., & Knoppers, B. M. (2012). Preconception care and genetic risk: Ethical issue. Journal of Community Genetics, 3(3), 221-228. Diggs, S. N. (2012). Health disparities and health care financing: Restructuring the American health care system. Journal of Health Care Finance, 38(4), 76-90. Godfrey, J. R., & Nachtigall, M. J. (2009). Conversation with the experts toward optimal health: An update on preconception care. Journal of Women's Health, 18(6), 779783. Johnson, K. A., Floyd, R. L., Humphrey, J. R., Biermann, J., Moos, M., Drummonds, M., . . . Wood, S. (2012). Action Plan for the National Initiative on Preconception Health and Health Care (PCHHC): A Report of the PCHHC Steering Commitee 2012-2014. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/preconception/documents/actionplannationalinitiativepch hc2012-2014.pdf Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the black-white gap in birth outcomes: A life-course approach. Ethnicity & Disease, 20(2), 62-76. Martin, J., Hamilton,, B., Ventura,, M., Osterman,, M., Wilson,, E., & Mathews,, T. (2012). Births : Final Data for 2010. National Vital Statistics Report, 1-72. Mitchell, E. W., Levis, D. M., & Prue, C. E. (2012). Preconception health: Awareness, planning, and communication among a sample of U.S. men and women. Maternal and Child Journal Health, 16(1), 31-39. Mostafa, T. (2010). Cigarette smoking and male infertility. Journal of Advanced Research, 1(3), 179-186.

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PRECONCEPTION HEALTH Weisman, C. S., Hillemeier, M. M., Downs, M. M., Chuang, D. S., Camacho, F. T., & Dyer, A. (2011). Preconception predictors of birth outcomes: Prospective findings from the Central Pennsylvania women's health study. Maternal and Child Health Journal, 15(7), 829-835. Young, B. C., Levine, R. J., & Karumanchi, S. A. (2010). Pathogenesis of Preeclampsia. Annual Review of Pathological Mechanical Disease, 5, 173-192. Youngkin, E. Q., Davis, M. S., Schadewald, D. M., & Juve, C. (2013). Women's Health: A Primary Care Clinical Guide (4th ed.). Upper Saddle River: Pearson Education, Inc.

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