The future of preconception care:

Article Outline

• Abstract
• National Consensus About the Importance of Preconception Care
• Delivery of Preconception Care
• The Clinical Content of Preconception Care
• Barriers to the Delivery of Clinical Preconception Care
• A Change in the “Business as Usual” Paradigm
  • The patient-centered medical home
  • HIT and preconception care
  • Virtual patient advocates: An example of a HIT system to deliver preconception care
  • Three-tier HIT toolbox
  • The preconception care kiosk
• Final Comment
• References
• Biography
• Copyright

The concepts of preconception care (PCC) have been discussed for over 20 years and the standards for PCC have been recently promulgated by the clinical committee of the Centers for Disease Control and Prevention's Select Panel of Preconception Care. For PCC to be fully realized, however, changes must be made in clinical practice, public health supports, and health coverage. This article discusses 1) the clinical content and delivery of PCC, 2) barriers to why this care does not fit easily into the current clinical paradigm for providing medical care, and 3) how new information technologies within the concept of the medical home might be a promising new way to assist in the diffusion of these concepts.

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National Consensus About the Importance of Preconception Care 

Preconception care (PCC) was first described by Chamberlain as a specialty service for women who had previously had a poor reproductive outcome (Chamberlain, 1980, Chamberlain and Lumley, 1986). It was then described in the United States by the US Public Health Service (PHS) in the landmark publication, Preventing Low Birth Weight (Institute of Medicine, 1985) and later by Moos and Cefalo (1987) at the University of North Carolina. The concept was adopted by the US PHS Expert Panel on the Content of Prenatal Care (Jack & Culpepper, 1990a), which defined the components of PCC and emphasized that it is most effectively delivered as part of primary care services. Development of the concept was identified as a priority in the 1990s by the US PHS, whose report included, among the health promotion and disease prevention objectives for 2000, a recommendation to increase to ≥60% the proportion of primary care providers who offer age-appropriate PCC and counseling (US PHS, 1991, 2000). Healthy People 2010 includes many objectives that address preconception health.

The National Committee on Perinatal Health, led by the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the March of Dimes, made recommendations for action and offered a prototype preconception screening tool. They encouraged all primary care providers to play an active role in promoting prevention before pregnancy. The “Guidelines for Perinatal Care” jointly issued by the AAP and ACOG recommended that “all health encounters during a woman's reproductive years, particularly those that are a part of PCC, should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes” (AAP & ACOG, 2001). Other ACOG publications emphasized the importance of PCC in the continuum of women's health care (ACOG, 1995, 2002; ACOG Preconception Work Group, 2005). In 2002, the March of Dimes Birth Defects Foundation suggested that as the key physician/primary care providers, obstetrician/gynecologists must take advantage of every health encounter to provide PCC and risk reduction before and between conceptions—the time when care really can make a difference (March of Dimes Birth Defects Foundation, 1993, March of Dimes Birth Defects Foundation, 2002). The importance of PCC as a concept was further articulated in family medicine (Gjerdingen and Fontaine, 1991, Frey, 2002, Jack, 1995), nurse-midwifery (Reynolds, 1998), nursing (Moos, 2002, Moos, 2003), and public health (US Public Health Service (PHS), 1991, US Public Health Service (PHS), 2000). The American Diabetes Association (2004), the American Academy of Neurology (Anonymous, 1998), and the American Heart Association/American College of Cardiologists (Hirsh, Fuster, Ansell, & Halperin, 2003) promulgated recommendations on PCC in their specialties. A similar approach has been suggested in Canada (Agrey et al., 2005; Best Start, 2002), The Netherlands (Health Council of the Netherlands, 2007), and elsewhere in Europe (Czeizel, 1999).

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Delivery of Preconception Care 

Despite this broad interest in PCC, there has been only modest progress in implementing these concepts into clinical practice. Health services research and translational research to inform changes in clinical practice have lagged. Existing research indicates that most women realize the importance of optimizing their health before pregnancy, whether or not the pregnancy is planned (Frey & Files, 2006), and that most physicians think PCC is important (Morgan, Hawks, Zinberg, & Schulkin, 2006). However, most providers do not routinely recommend or provide PCC to their patients (Williams et al., 2006). One randomized clinical trial found that, even when given specific training, physicians failed to take action on risks identified at the time of a negative pregnancy test (Jack, Culpepper, Babcock, Kogan, & Wesimiller, 1998). National surveys indicate that 84% of women 18–44 years of age have had a health care visit during the past year, and that most women of reproductive age obtain preventive health services any given year (Salganicoff, Ranji & Wyn, 2005); thus there are many opportunities to deliver PCC. However, about only 1 in 6 obstetricians/gynecologists or family physicians provide PCC to the majority of the women for whom they provide prenatal care (Henderson, Weisman, & Grason, 2002). There is still a great deal that we must learn about why PCC is not more widely practiced.

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The Clinical Content of Preconception Care 

In the introductory article to this supplement, Johnson, Atrash, & Johnson (2008) reviewed the accomplishments of the first 4 years of the Centers for Disease Control and Prevention (CDC)’s Workgroup on Preconception Health and Health Care. A key component of this initiative was the organization of the Select Panel on Preconception Care in June 2005. The panel established implementation workgroups to develop strategies for implementing the PCC recommendations published in the Morbidity and Mortality Weekly Report (CDC, 2006) in 5 areas—clinical, public health, consumer, policy and finance, and research and surveillance. In June 2006, members of the clinical workgroup asked the following questions: What are the clinical components of PCC? What is the evidence for inclusion of each component in clinical activities? Over the next 2 years, the 29 members of the clinical workgroup and >30 expert consultants reviewed in depth >80 topics selected based on the effect of PCC on the health of the mother and/or infant, prevalence, and detectability. A series of topics related to PCC were studied by a member of the clinical committee or by a selected content expert, in a process similar to systematic review. The first author, in concert with the editors, then identified members of the clinical committee with interest and expertise in that content area and asked them to contribute to that manuscript. For each topic, the workgroup assigned a score for the strength of the evidence supporting its inclusion in PCC and assigned strength of the recommendation. The resulting series of 16 manuscripts were published in a supplement to the American Journal of Obstetrics and Gynecology (Jack & Atrash, in press). These topics, organized into 14 separate clinical areas, together define the clinical content of PCC (Table 1). The work describes the content of the health promotion activities that are part of PCC and describes the content of preconception risk assessment activities—immunizations, infectious diseases, medical conditions, psychiatric conditions, parental exposures, genetics and genomics, nutrition, environmental exposures, psychosocial stressors, medications, and reproductive history. Finally the committee discussed PCC for special populations and for fathers. A table providing a summary list of the topics reviewed, the consensus recommendation for each topic, the strength of the recommendation, and the rating of the quality of the evidence is included in the AJOG supplement (Jack & Atrash, in press). As identified in the recent Eunice Shriver Child Health and Human Development's Setting the Research Agenda meeting, translating the CDC “best practices” identified by the CDC's Select Panel into everyday use by clinicians is a major priority.

Table 1. Clinical Content of Preconception Care

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Barriers to the Delivery of Clinical Preconception Care 

The slow growth of PCC results from the many challenges faced in providing this care. In a 1990 commentary in JAMA, Jack and Culpepper (1990b) identified the following 7 barriers to the dissemination of PCC: 1) those most in need of services are those least likely to receive them; 2) provision of services is often badly fragmented; 3) there is a lack of available treatment services for high-risk behaviors; 4) reimbursement for risk assessment and health promotion activities is inadequate; 5) health promotion messages are not effective unless received by a motivated couple; 6) only a few conditions have data supporting intervention before conception rather than intervention early in pregnancy; and 7) many clinical training programs do not emphasize risk assessment and health promotion skills. These barriers to delivering PCC as part of clinical services are as relevant today as they were then.

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A Change in the “Business as Usual” Paradigm 

A diffusion theory of new medical practices has been defined for many different new medical concepts, techniques, and technologies. However, in part because of the barriers outlined, diffusion of PCC practices has not been successful. A fundamental shift is needed that incentivizes health promotion, risk assessment, and counseling within medical practice. A new model of care that emphasizes primary care services, assists with coordination of specialty services, and is linked to new information technologies that allow for such care to be conveniently provided offers the potential to assist the much-needed diffusion of these concepts (Atrash et al., in press). Examples of how we can change business as usual are described below.

The patient-centered medical home 

For PCC to be diffused into routine clinical care, there is a need for new innovations in the way care is provided. Concepts such as the patient-centered medical home—which has been described as a partnership approach between patients and providers to provide primary health care that is accessible, patient-centered, coordinated, comprehensive, continuous, and culturally appropriate (Sia, Tonniges, Osterhus, & Taba, 2004)—strive to invoke fundamental change in the way primary care is structured, delivered, and financed, leading to a more efficient and cost-effective health care system. Some of the key principles for advancement of this concept relating to PCC include: 1) realigning incentives to support patient centered preventive care practices; 2) monitoring outcomes at the practice and population levels; 3) maximizing patient adherence to customized self-care management programs; 4) modifying public and private financing for preventive care (e.g., Medicaid, private insurance, public health financing); 5) empowering clinical and nonclinical staff to navigate patients through the medical system; 6) coordinating care through linkage of clinical electronic medical records of primary care coordinators with centralized electronic medical records; and 7) establishing a system of primary care reimbursement that compensates clinicians for care coordination and technology infrastructure advancements. Within the patient-centered medical home concept, the financial and policy incentives are aligned so that health information technology (HIT) can be fully implemented and can provide a framework for delivery of PCC.

HIT and preconception care 

One of the few areas of consistent bipartisan agreement in congress is support for development of HIT. HIT systems hold great promise for assisting in the delivery of PCC services, especially in their ability to assist clinicians in the delivery of PCC care as part of their clinical practice. HIT is a tool that can help to overcome some of the barriers to providing routine health promotion messages, performing risk assessments, and initiating clinical interventions. Electronic medical records are but the tip of the iceberg of HIT; the medical home of the future must be set up to carry out health promotion and patient education that is easily delivered and acceptable to patients. New, innovative information technologies are inevitable and will help to transform the office visit, allowing a shift toward a more efficient, prevention-centered approach to care. Computer programs, delivered over the web or in the clinic, will allow for risk screening and patient education about prevention while better utilizing provider time. One example of such a system that is being developed to provide PCC within a patient-centered medical home concept is described below.

Virtual patient advocates: An example of a HIT system to deliver preconception care 

Our team has designed and created a unique HIT system—the Virtual Patient Advocate (VPA)—that includes a computerized, animated character designed to integrate best practices from provider–patient communication theory. The VPA emulates the face-to-face conversational behavior of an empathic provider, including nonverbal communicative behavior such as gaze, posture, and hand gestures to deliver patient education messages tailored to individual needs, assess patient comprehension, and record progress (Bickmore et al., 2005, Bickmore et al., 2005, Bickmore and Giorgino, 2006, Bickmore and Pfeifer, 2008). This new HIT tool is ideal for delivering PCC because it addresses problems of fidelity, competency, ease of delivery to large numbers of patients, clinician time constraints, patient acceptability, and high cost—problems that we identified as barriers to translating PCC best practices to clinical care (Jack, 2008).

Several studies have focused specifically on the use of life-like pedagogical agents and animated conversational agents for the enhancement of both adult and patient education (Baylor and Kim, 2003, Baylor et al., 2003, Cassell et al., 1998, Cassell et al., 2001, Graesser et al., 1999, Lester et al., 1999, Lester et al., 1997, McNeill, 1992, Moreno et al., 2000, Person et al., 2001). Such studies have found evidence of improved understanding and learning, and of increased motivation to learn, and interest in subject matter with the use of such systems. These improvements in learning and motivation were greater even than those seen with educational software systems that lacked an animated character (Bickmore & Mauer, 2006). In a study comparing different interaction modalities on the personal data assistant-based system, it was found that users who conducted relational (getting acquainted) interactions with the system rated social bonding with the agent and caring of the agent highest when it was presented as an embodied (animated humanoid) conversational agent, compared with text and static image representations of the agent (Bickmore & Mauer, 2006). Another study investigated methods that a VPA could use to explain health documents to patients, and found that low health literacy patients preferred the VPA over explanation by a human (those with high health literacy rated the VPA and human equally; Bickmore, Pfeifer, & Yin, 2008).

Putting these types of systems to work for PCC could generate interest and enhance knowledge of potential risks and important preventive strategies. Table 2 shows the reasons that HIT such as the VPA could be especially effective in delivering PCC.

Table 2. Why Virtual Patient Advocates Can Effectively Deliver Preconception Care

Three-tier HIT toolbox 

Our team is developing three tools to assist in the VPA-delivered PCC.

First, a PCC curriculum containing multiple levels of information about preconception risks that will be used to educate women about these topics has been developed. The VPA will be programmed to incorporate the risk assessment to gauge the level of teaching necessary for each topic. For example, if a woman reports smoking or having active exposure to secondhand smoke, she will receive the full information about the benefits of quitting smoking and avoiding exposure, whereas a woman who reports no exposure (either first- or secondhand) will receive positive reinforcement as well as brief dialogue about the importance of not smoking and of avoiding secondhand exposure. Thus, the curriculum will be tailored to each woman's unique needs, concentrated in areas where she needs the most attention. The VPA can be designed so that women receive key messages but are able to “drill down” into more detail as they choose. At each level, the information provided is designed for women of all health literacy levels.

Second, an individualized reproductive life plan booklet will be printed and spiral bound for each patient to take home. This booklet contains important information about health, identified preconception risks, resources for support, and services to help make behavior changes. Subjects will be encouraged to share this plan with their medical provider, as well as their partner, if applicable, so that risks can be reviewed. The Reproductive Life Plan will be designed to make reproductive life decision making accessible to women with limited health literacy.

Third, the VPA system will print out a personalized letter to the woman's primary care physician listing the topics that were discussed and the activities that need to be performed in the clinical site (e.g., MMR vaccination, toxoplasmosis titer, among others).

The preconception care kiosk 

The VPA will perform preconception risk assessment, health promotion, and interventions using a computer workstation that is a clinic-based kiosk configuration. The VPA is run on a touch-screen computer with integrated speakers, mounted on a mobile kiosk with an articulated arm that can be used by the patient while lying in bed, or sitting in a chair. Headphones are available for privacy if desired. After a brief training session (lasting <1 minute, based on our experience in pretesting), the patient is left to interact with the VPA on the kiosk to review the PCC health promotion curriculum, undergo risk assessment, and then initiate interventions for specific risks identified. Tests of comprehension can be administered by the VPA and material reviewed as necessary. The Reproductive Life Plan is then finalized, published, and given to the patient. The letter to her primary care provider is printed and the woman is encouraged to review this material with her care provider. At the end of the interaction, the workstation can print a list of remaining issues and patient questions that the VPA was unable to resolve for nurse follow-up. These focused issues can then be addressed by human intervention.

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Final Comment 

For more than 20 years, the concepts of PCC have been discussed; the CDC's initiative in this area has added new impetus to its diffusion, particularly with the publication of the evidence in support of the PCC clinical content in the fall of 2008 (Jack & Atrash, in press). At the same time, many barriers to providing these services remain. A fundamental shift is needed that incentivizes well woman care and preventive visits that include health promotion, risk assessment, and counseling within primary care. A new model of care that emphasizes a primary care medical home that accepts responsibility for delivering such services that is linked to new information technologies that allow for such care to be conveniently and comprehensively provided could offer the potential to assist in the much needed delivery of these services. Although changes in clinical practice are necessary to ensure that women receive PCC, such changes cannot and will not occur without important modifications to public policy, health care financing, and incentivization.

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