Volume 70, Number 7 OBSTETRICAL AND GYNECOLOGICAL SURVEY Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
CME REVIEW ARTICLE
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA PRA Category 1 Credits™ can be earned in 2015. Instructions for how CME credits can be earned appear on the last page of the Table of Contents.
Interconception Care Opportunities for Mom and Baby Julie Z. DeCesare, MD, FACOG,* Jessica R. Jackson, MD, MSBS,† and Briana Phillips, MD† *Program Director, OBGYN Residency Program, and Associate Professor, Florida State University College of Medicine; and †Resident Physician, OBGYN Residency Program, Florida State University College of Medicine, Pensacola, FL Importance: Interconception care provides an irreplaceable opportunity to address existing chronic disease and correct maladaptive health behaviors. Objective: Utilizing the postpartum visit as an opportunity to improve interconception health and provide education to patients will not only improve the patient’s life, but also impact any future offspring. Evidence Acquisition/Results: Optimization of interconception health has the potential to improve population wellbeing and reduce the societal burden poor birth outcomes. Evidence-based recommendations are described. Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completing the activity, the learner will be better able to assess the scope and importance of interconception care; explain the different recommendations for interconception health in women actively trying get pregnant, those unsure of pregnancy plans, and those who are preventing pregnancy; and to present strategies for utilizing the postpartum visit as an opportunity to promote and improve interconception health.
According to the US Centers for Disease Control (CDC), the United States spends $98 billion annually on prenatal care. The maternal death rate was lowest in 1986, reported at 6.6 per 100,000 live births. It peaked in 2012, at 12.7 death per 100,000 live births. Infant mortality in 2010 in the United States was 6.1 per 1000, which is one of the highest infant mortality rates of all industrialized nations, including Korea, Japan, and most European nations.1,2 Racial disparities are even more alarming, with maternal mortality rates as high as 34.8 deaths per 100,000 in African American women in 2012. Preconception care has been defined as care prior to pregnancy; interconception care is the care between pregnancies. As both of these terms focus on optimization of All authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. Correspondence requests to: Julie Z. DeCesare, MD, FACOG, 5045 Carpenter Creek Dr, Pensacola, FL 32503. E-mail: [email protected].
maternal health prior to pregnancy, they will be used interchangeably throughout this article. Preconception care has been recognized throughout history. Documentations from the Old Testament (Book of Judges) as well as Plutarch, a noted Greek historian (24-120 AD), both include references to maternal health prior to conceiving.3 Modern medicine started to recognize the importance of preconception health in the 1970s and 1980s. During this period, published research demonstrated an association between fetal intrauterine growth restriction and prepregnancy diet. Additional research demonstrated that optimization of maternal glycemic control in diabetic women improves both maternal and fetal outcomes.4–6 Several federal organizations and national working groups have brought attention to need for evidencebased preconception care. In 1985, an Institute of Medicine publication on prevention of low-birth-weight neonates established that optimized maternal health and nutrition could lead to better birth outcomes and fewer low-birth-weight infants.6 The Department of Health and Human Services and the March of Dimes both
www.obgynsurvey.com | 465
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
20
466
Obstetrical and Gynecological Survey
made strong recommendations for improved maternal health to help improve birth outcomes, as well as to provide cost and societal benefits.7,8 Further research elucidated a better understanding of the importance of prenatal care, and a 2005 American Congress of Obstetricians and Gynecologists (ACOG) Committee Opinion9 upheld the importance of preconception health. Recommendations from a 2006 CDC/Agency for Tobacco Substance Disease Registry working group charged women’s health care providers to implement a series of evidence-based recommendations for improved preconception care (Table 1).10 Scope of the Problem Understanding the scope of the problem is an important first step in impacting maternal outcomes and overarching societal benefits. Almost half of all pregnancies in the United States are unplanned. In addition, approximately 9% of reproductive-age women have diabetes, 5% have hypertension, and 50% have obesity.11 These medical conditions have a high prevalence in reproductive-age women. more than half of all women are at risk for a poor pregnancy outcome. Women with obesity, hypertension, or diabetes may experience an improved outcome if their disease state is properly controlled in the interconception period. Data suggest that only half of women with high-risk pregnancy conditions receive any information on preconception care.12 Interconception care is linked not only to good pregnancy outcomes, but also to lifelong good health outcomes for both the patient and her children.13 The “every woman every time” slogan, introduced by former ACOG president Dr Jeanne Conry, reminds the provider to make interconception care and preventive services a part of every patient encounter. Asking 1 simple question, “Are you planning on becoming pregnant over the next year?” will allow the health care provider
TABLE 1 Evidenced Based Recommendations for Improved Preconceptional Care Recommendations From 2006 CDC/Agency for Tobacco Substance Disease Registry Working Group11 1. Individual responsibility across the life-span 2. Consumer awareness 3. Preventive visits 4. Interventions for identified risks 5. Interconception care 6. Prepregnancy checkup 7. Health insurance coverage for women with low income 8. Public health programs and strategies 9. Research 10. Monitering outcomes
to risk assess and provide counseling and interventions based on the patient’s reproductive health plan. The clinician can then implement a series of evidence-based interventions to enhance maternal health and improve perinatal outcomes. Patient Desires Pregnancy or Is Considering Pregnancy If the patient desires pregnancy over the next year, the preventive visit should include the following: nutritional assessment, immunization status, review of chronic medical conditions, review of medications, substance abuse, previous pregnancies, genetics, mental illness, and screening for intimate-partner violence.14 Within the nutritional assessment, review of Institute of Medicine recommendations for healthy weight gain and pregnancy should be reviewed with the patient. Healthy American women at a normal weight for their height (body mass index [BMI] of 18.5–24.9 kg/m2) should gain 25 to 35 lb during pregnancy, underweight women (BMI
CME REVIEW ARTICLE
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA PRA Category 1 Credits™ can be earned in 2015. Instructions for how CME credits can be earned appear on the last page of the Table of Contents.
Interconception Care Opportunities for Mom and Baby Julie Z. DeCesare, MD, FACOG,* Jessica R. Jackson, MD, MSBS,† and Briana Phillips, MD† *Program Director, OBGYN Residency Program, and Associate Professor, Florida State University College of Medicine; and †Resident Physician, OBGYN Residency Program, Florida State University College of Medicine, Pensacola, FL Importance: Interconception care provides an irreplaceable opportunity to address existing chronic disease and correct maladaptive health behaviors. Objective: Utilizing the postpartum visit as an opportunity to improve interconception health and provide education to patients will not only improve the patient’s life, but also impact any future offspring. Evidence Acquisition/Results: Optimization of interconception health has the potential to improve population wellbeing and reduce the societal burden poor birth outcomes. Evidence-based recommendations are described. Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completing the activity, the learner will be better able to assess the scope and importance of interconception care; explain the different recommendations for interconception health in women actively trying get pregnant, those unsure of pregnancy plans, and those who are preventing pregnancy; and to present strategies for utilizing the postpartum visit as an opportunity to promote and improve interconception health.
According to the US Centers for Disease Control (CDC), the United States spends $98 billion annually on prenatal care. The maternal death rate was lowest in 1986, reported at 6.6 per 100,000 live births. It peaked in 2012, at 12.7 death per 100,000 live births. Infant mortality in 2010 in the United States was 6.1 per 1000, which is one of the highest infant mortality rates of all industrialized nations, including Korea, Japan, and most European nations.1,2 Racial disparities are even more alarming, with maternal mortality rates as high as 34.8 deaths per 100,000 in African American women in 2012. Preconception care has been defined as care prior to pregnancy; interconception care is the care between pregnancies. As both of these terms focus on optimization of All authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. Correspondence requests to: Julie Z. DeCesare, MD, FACOG, 5045 Carpenter Creek Dr, Pensacola, FL 32503. E-mail: [email protected].
maternal health prior to pregnancy, they will be used interchangeably throughout this article. Preconception care has been recognized throughout history. Documentations from the Old Testament (Book of Judges) as well as Plutarch, a noted Greek historian (24-120 AD), both include references to maternal health prior to conceiving.3 Modern medicine started to recognize the importance of preconception health in the 1970s and 1980s. During this period, published research demonstrated an association between fetal intrauterine growth restriction and prepregnancy diet. Additional research demonstrated that optimization of maternal glycemic control in diabetic women improves both maternal and fetal outcomes.4–6 Several federal organizations and national working groups have brought attention to need for evidencebased preconception care. In 1985, an Institute of Medicine publication on prevention of low-birth-weight neonates established that optimized maternal health and nutrition could lead to better birth outcomes and fewer low-birth-weight infants.6 The Department of Health and Human Services and the March of Dimes both
www.obgynsurvey.com | 465
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
20
466
Obstetrical and Gynecological Survey
made strong recommendations for improved maternal health to help improve birth outcomes, as well as to provide cost and societal benefits.7,8 Further research elucidated a better understanding of the importance of prenatal care, and a 2005 American Congress of Obstetricians and Gynecologists (ACOG) Committee Opinion9 upheld the importance of preconception health. Recommendations from a 2006 CDC/Agency for Tobacco Substance Disease Registry working group charged women’s health care providers to implement a series of evidence-based recommendations for improved preconception care (Table 1).10 Scope of the Problem Understanding the scope of the problem is an important first step in impacting maternal outcomes and overarching societal benefits. Almost half of all pregnancies in the United States are unplanned. In addition, approximately 9% of reproductive-age women have diabetes, 5% have hypertension, and 50% have obesity.11 These medical conditions have a high prevalence in reproductive-age women. more than half of all women are at risk for a poor pregnancy outcome. Women with obesity, hypertension, or diabetes may experience an improved outcome if their disease state is properly controlled in the interconception period. Data suggest that only half of women with high-risk pregnancy conditions receive any information on preconception care.12 Interconception care is linked not only to good pregnancy outcomes, but also to lifelong good health outcomes for both the patient and her children.13 The “every woman every time” slogan, introduced by former ACOG president Dr Jeanne Conry, reminds the provider to make interconception care and preventive services a part of every patient encounter. Asking 1 simple question, “Are you planning on becoming pregnant over the next year?” will allow the health care provider
TABLE 1 Evidenced Based Recommendations for Improved Preconceptional Care Recommendations From 2006 CDC/Agency for Tobacco Substance Disease Registry Working Group11 1. Individual responsibility across the life-span 2. Consumer awareness 3. Preventive visits 4. Interventions for identified risks 5. Interconception care 6. Prepregnancy checkup 7. Health insurance coverage for women with low income 8. Public health programs and strategies 9. Research 10. Monitering outcomes
to risk assess and provide counseling and interventions based on the patient’s reproductive health plan. The clinician can then implement a series of evidence-based interventions to enhance maternal health and improve perinatal outcomes. Patient Desires Pregnancy or Is Considering Pregnancy If the patient desires pregnancy over the next year, the preventive visit should include the following: nutritional assessment, immunization status, review of chronic medical conditions, review of medications, substance abuse, previous pregnancies, genetics, mental illness, and screening for intimate-partner violence.14 Within the nutritional assessment, review of Institute of Medicine recommendations for healthy weight gain and pregnancy should be reviewed with the patient. Healthy American women at a normal weight for their height (body mass index [BMI] of 18.5–24.9 kg/m2) should gain 25 to 35 lb during pregnancy, underweight women (BMI
