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One of the most important times for prenatal care is when a woman isn't even pregnant.
New recommendations from the Centers for Disease Control and Prevention call this phase in the life of any woman who could conceive -- not just those planning on getting pregnant -- "preconception."
The recommendations, published last month in the CDC's Morbidity and Mortality Weekly Report, emphasize that by the time a woman gets pregnant, it may be too late to ensure that she and her baby are as healthy as possible.
For example, obesity increases the risk of gestational diabetes in the mother and birth defects in her baby. But pregnancy is hardly the time to cut calories. And certain drugs for chronic diseases, such as depression, may have a longer track record in pregnancy, so patients may need to switch prescriptions before conceiving.
About 85% of pregnant women in the USA do receive care after they conceive, a big improvement from 20 years ago, says the CDC's Hani Arrash, co-author of the new recommendations. Yet, the report notes, progress in reducing rates of low-birth-weight babies, premature births and infant mortality has slowed over the past decade, partly because millions of women do not receive preconception care.
Educate 'all providers'
"We really need to educate consumers and (health care) providers -- all providers, not just people dealing with reproductive health," says Arrash, of the National Center on Birth Defects and Developmental Disabilities. Preconception health advice must become a routine part of care for all women who could become pregnant, he says.
The new recommendations, written with representatives of the March of Dimes and the American College of Obstetricians and Gynecologists, are only the beginning, Arrash says. Next, he says, the CDC will convene work groups to better define what constitutes preconception care. "We really want to go beyond the simple, obvious thing," like telling women to stop smoking.
Preconception care is more than just a single doctor's visit by a woman who wants to get pregnant. And, notes obstetrician/gynecologist Peter Bernstein, "preconception care isn't just about the baby. It's also about achieving health for the mother."
Bernstein, a member of the CDC's Select Panel on Preconception Care, sees many patients who also are under the care of other specialists, such as an endocrinologist for diabetes or an internist for high blood pressure. Yet, he says, those doctors often don't consider that their patients could become pregnant before their next visit.
Still, those patients are better off than some, says Bernstein, of New York's Albert Einstein College of Medicine and Montefiore Medical Center. "I'm seeing a lot of patients who do not have insurance until they become pregnant," so chronic health problems go untreated. (Some states have programs that provide insurance to low-income women during pregnancy.)
Lack of coverage isn't the only obstacle, notes Arrash's co-author Janis Biermann, vice president for education and health promotion at the March of Dimes. "Unless a woman is actively planning a pregnancy, she really doesn't want to hear about pregnancy-related health messages," Biermann says.
In 1995 and in 2005, she says, surveys conducted by the March of Dimes found that less than a quarter of women said they had talked with a doctor or nurse about the possibility of getting pregnant before actually conceiving.
Yet, Biermann notes, many health care professionals who provide prenatal care won't see women until they're at least eight weeks pregnant -- too late to begin taking folic acid to prevent neural tube defects such as spina bifida.
The Northeast Florida Healthy Start Coalition recognized in the late 1990s that preconception care represented an overlooked opportunity to lower rates of infant mortality, says executive director Carol Brady. In Jacksonville, blacks' infant mortality rate was about 2 1/2 times higher than whites', Brady says. The gap was widest in five ZIP codes on the city's north side.
That observation gave rise to the coalition's CDC-funded Magnolia Project, a storefront clinic in which a nurse-midwife sees women who live in those areas of the city.
Program can be 'hard sell'
Brady acknowledges that preconception care is a "hard sell" for women who, even if sexually active and not using birth control, don't think they'll ever get pregnant. "We ended up repackaging it as a well-woman health package."
Women with a previous complicated pregnancy also meet regularly for at least a year with members of the Magnolia Project's case management team, made up of a nurse, social worker and community health workers. "If they do get pregnant again, they'll have a better shot of having a good birth outcome," Brady says.
The project's most successful outreach effort has been free pregnancy testing at health fairs, in church parking lots and even at the bus station. "When I was involved in prenatal care, the only pregnancy tests we were interested in were the positive ones," Brady says.
But the Magnolia Project is more interested in the 70% who test negative. "That," she says, "is the perfect intervention moment."
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