The
American College of Obstetricians and Gynecologists, 2006
states in its policy for Access to Women's Health Care that the time has come to optimize women's health. We at the March of Dimes Foundation could not agree more, and this supplement to the Journal of Women's Health Issues is indeed timely. With each passing year, the costs—personal, societal, and economic—become even greater. Despite our progress on many fronts—emerging science, identification of best practices, improved technical capacity—the US infant mortality again rose slightly in 2005 to 6.9 deaths in the first year of life for every 1,000 live births, from 6.8 per 1,000 in 2004 (National Center for Health Statistics, 2008
). Although statisticians tell us this change is not significant, it is another year without progress. Further, more than half a million babies are born preterm (<37 completed weeks gestation) and the US preterm birth rate has increased by nearly 20% since 1990 (National Center for Health Statistics. (2008). Infant mortality statistics from the 2005 period linked birth/infant death data set, Vol. 57, No. 2, of the National Vital Statistics Report. Available: www.cdc.gov/nchs. Accessed August 11, 2008.
National Center for Health Statistics, 2008
).National Center for Health Statistics. (2008). Infant mortality statistics from the 2005 period linked birth/infant death data set, Vol. 57, No. 2, of the National Vital Statistics Report. Available: www.cdc.gov/nchs. Accessed August 11, 2008.
For decades, women have been urged to seek early and regular prenatal care by seeing a health care provider as soon as they know they are pregnant. Prenatal care continues to be the primary way to identify problems during pregnancy, giving health providers a way to assess and manage risks for preterm labor and other threats to the health of the mother and baby; but as the rates of infant mortality and preterm birth confirm, prenatal care is not good enough. The hope lies in preconception care. The goals of preconception care are to promote the health of women of reproductive age before conception, provide appropriate information and intervention, and thereby improve pregnancy-related outcomes.
Ongoing research is continually refining our understanding of many aspects of preconception care such as the role of psychosocial and social support factors, including stress (
Dole et al., 2003
, Lu et al., 2005
, Misra et al., 2003
), depression (Hobel et al., 2008
), interpersonal violence (Amaro et al., 1990
, Coker et al., 2004
), and racism (Collins et al., 2004
, Lu and Chen, 2004
). In addition, a large number of studies suggest a relationship between adverse birth outcomes and behavioral factors such as smoking, alcohol use, nutrition, and obesity (Behrman and Stith-Butler, 2007
). Other interventions known to be effective include rubella immunization, hepatitis B vaccination, diabetes management, hypothyroidism management, management of maternal phenylketonuria, screening and management for sexually transmitted diseases, HIV/AIDS screening and treatment, and avoiding isotretinoin (Accutane, Hoffman-La Roche, Nutley, NJ), oral anticoagulants, and certain anti-epileptic drugs (Atrash et al., 2006
).The US Centers for Disease Control and Prevention (CDC) Select Panel on Preconception Care identifies ≥14 interventions—supported by scientific evidence and clinical practice guidelines—that could improve birth outcomes if provided before pregnancy (
Johnson et al.,2006
). One of the most important is folic acid supplementation, beginning ≥3 months before conception, to prevent spina bifida and other neural tube defects. The March of Dimes and the CDC led the effort to fortify enriched grain products and initiated an awareness campaign to educate women on the importance of taking folic acid before pregnancy. Since folic acid fortification was made mandatory in 1998, the rate of neural tube defects has decreased by 26%. The March of Dimes also continues to advocate for increased funding of CDC's folic acid education campaign which is currently funded at a $2.2 million. Interestingly enough, however, health professionals are not the main source of women's information about folic acid. Of women aware of folic acid, 54% learned about it from the media, whereas only 33% heard of its importance from their physicians or other health care providers (- Johnson K.
- Posner S.F.
- Biermann J.
- Cordero J.F.
- Atrash H.K.
- Parker C.S.
- et al.
CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care
Recommendations for improving preconception health and health care—United States: A report of the CC/ATSDR Preconception Care Workgroup and the Select Panel on Preconception Care. Centers for Disease Control and Prevention.
Recommendations for improving preconception health and health care—United States: A report of the CC/ATSDR Preconception Care Workgroup and the Select Panel on Preconception Care. Centers for Disease Control and Prevention.
Morbidity and Mortality Weekly Report. 2006; 55: 1-23
March of Dimes, 2007
).Clearly, more needs to be done to support women and men in their efforts to start families with babies in optimal health. In 2006, the CDC defined 4 goals for preconception care:
- 1.Improve the knowledge, attitudes, and behaviors of men and women related to preconception health;
- 2.Ensure that all women of childbearing age in the United States receive preconception care services that will enable them to enter pregnancy in optimal health;
- 3.Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period; and
- 4.Reduce the disparities in adverse pregnancy outcomes (Johnson et al.,2006,
- Johnson K.
- Posner S.F.
- Biermann J.
- Cordero J.F.
- Atrash H.K.
- Parker C.S.
- et al.
CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care
Recommendations for improving preconception health and health care—United States: A report of the CC/ATSDR Preconception Care Workgroup and the Select Panel on Preconception Care. Centers for Disease Control and Prevention.Morbidity and Mortality Weekly Report. 2006; 55: 1-23Posner et al., 2006).
Again, we must ask ourselves whether we are making progress. When it comes to access, the second goal on the list, the answer is no. Lack of access to care, particularly for women without health coverage or in medically underserved areas, is a significant barrier. According to U.S. Census data, compiled exclusively for the March of Dimes, in 2007, 12.2 million women of childbearing age were uninsured. Uninsured women receive fewer prenatal care services than their insured peers and report greater difficulty in obtaining the care that they believe they need (
Institute of Medicine, 2002
). The reality is that the lack of insurance coverage is causing too many lives to be lost, or impaired, because patients cannot obtain proper care (Pear(2005May 29),
).Pear, R. (2005, May 29). Health leaders seek consensus over uninsured. The New York Times. Available: http://www.nytimes.com. Accessed May 29, 2005.
Likewise the answer to the question of whether we are making progress in reducing risks indicated by a previous adverse pregnancy outcome or reducing disparities, goals 3 and 4, is again no. The lack of development and dissemination of more quality standards and inconsistent delivery of clinical services, such as use of screening tools and postpartum visits, are factors that keep women from receiving the benefits of evidence-based practices. Some women just need more information about their risks (
Chuang et al., 2008
, March of Dimes Birth Defects Foundation, 2002
, March of Dimes, 2007
), whereas others need intensive medical and social interventions (Biermann et al., 2006
). Both health care providers and consumers need to understand the role of genetics (Mennuti, 2008
), and the care delivered must be culturally competent (Canady et al., 2008
).Although we have made headway in better understanding the factors that affect pregnancy outcomes, we must continue to accelerate and translate our understanding of evidence-based practices to improve the health of women of childbearing age. But we cannot hope to achieve progress—or the March of Dimes to fulfill its mission to lower rates of infant mortality, preterm birth, and birth defects—if known risk factors continue to be addressed as singular events instead of as part of the life cycle continuum deserving comprehensive preventative interventions. We cannot hope to have a positive influence on a broad spectrum of outcomes including maternal health, preterm birth, birth defects, developmental disabilities, and infant mortality if we do not advance policy initiatives that promote and financially provide for preconception care, both in public and private coverage.
The time to optimize women's health is now, and the March of Dimes is committed to working together to find solutions that will bring us closer to the day when every baby—at home and globally—has a healthy start in life.
References
- Violence during pregnancy and substance use.American Journal of Public Health. 1990; 80: 575-579
- Access to women's health care. Statement of policy.Author, Washington, DC2006
- Preconception care for improving outcomes: The time to act.Maternal and Child Health Journal. 2006; 10: S3-S11
- Behrman R.E. Stith-Butler A. Preterm birth: Causes, consequences, and prevention. National Academy Press, Washington, DC2007
- Promising practices in preconception care for women at risk for poor health and pregnancy outcomes.Maternal and Child Health Journal. 2006; 10: S21-S28
- Preconception care and pregnancy planning: Voices of African American women.MCN The American Journal of Maternal Child Nursing. 2008; 33: 90-97
- Perceived risk of preterm and low-birthweight birth in the Central Pennsylvania Women's Health Study.American Journal of Obstetrics and Gynecology. 2008; 199 (Epub 2008 May 2): 64.e1-64.e7
- Partner violence during pregnancy and risk of adverse pregnancy outcomes.Paediatric and Perinatal Epidemiology. 2004; 18: 260-269
- Very low birthweight in African American infants: The role of maternal exposure to interpersonal racial discrimination.Epidemiology. 2004; 11: 337-339
- Maternal stress and preterm birth.American Journal of Epidemiology. 2003; 157: 14-24
- Psychosocial stress and pregnancy outcome.Clinical Obstetrics and Gynecology. 2008; 51: 333-348
- Health Insurance is a Family Matter.National Academy Press, Washington, DC2002
- Recommendations for improving preconception health and health care—United States: A report of the CC/ATSDR Preconception Care Workgroup and the Select Panel on Preconception Care. Centers for Disease Control and Prevention.Morbidity and Mortality Weekly Report. 2006; 55: 1-23
- Learning from success and failure in psychosocial intervention: An evaluation of low birth weight prevention trials.J Health Psych. 2005; 10: 185-195
- Racial and ethnic disparities in preterm birth: The role of stressful life events.American Journal of Obstetrics and Gynecology. 2004; 191: 691-699
National Center for Health Statistics. (2008). Infant mortality statistics from the 2005 period linked birth/infant death data set, Vol. 57, No. 2, of the National Vital Statistics Report. Available: www.cdc.gov/nchs. Accessed August 11, 2008.
- March of Dimes Updates: Is early prenatal care too late?.Contemporary Ob/Gyn. 2002; 12: 54-72
- Improving preconception health: Women's knowledge and use of folic acid. Conducted by the Gallup Organization.Author, White Plain, NY2007
- Genetic screening in reproductive health care.Clinical Obstetrics and Gynecology. 2008; 51: 3-23
- Integrated perinatal health framework. A multiple determinants model with a life span approach.American Journal of Preventive Medicine. 2003; 25: 65-75
Pear, R. (2005, May 29). Health leaders seek consensus over uninsured. The New York Times. Available: http://www.nytimes.com. Accessed May 29, 2005.
- The national summit on preconception care: A summary of concepts and recommendations.Maternal Child Health Journal. 2006; 10: S197-S205
Article info
Publication history
Accepted:
August 20,
2008
Received:
August 20,
2008
Footnotes
Dr. Howse has served as president of the March of Dimes Foundation since 1990, achieving significant gains for mothers and infants including the successful national folic acid campaign and the launch of a National Prematurity Prevention Campaign. She is an honorary fellow at both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists and serves on the boards of the Salk Institute for Biological Studies, the Kaiser Commission on Medicaid and the Uninsured, and Partnership for Prevention.
The author has no direct financial interests that might pose a conflict of interest in connection with the submitted manuscript.
Identification
Copyright
© 2008 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
