Editorials
Women's health Environmental health
Volume 209 - Issue 9

Pre-conception care: an important yet underutilised preventive care strategy

Authors:  Deborah J Bateson and Kirsten I Black

Med J Aust 2018; 209 (9): 389-391. || doi: 10.5694/mja18.00769
Published online: 5 November 2018
This erratum corrects the following:
Correction

Parental health prior to conception is increasingly recognised as being important for the health of future generations

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Parental health prior to conception is increasingly recognised as being important for the health of future generations

Pre-conception care is the provision of health recommendations to women of reproductive age with the goal of improving short and long term health outcomes for both the mothers and their children. It includes an assessment of medical conditions, vaccination status, and lifestyle factors.1 While pre-conception care will benefit any woman contemplating pregnancy, it is particularly important for women with medical conditions such as diabetes and obesity. Nevertheless, it is often underutilised.2 In this article, we describe strategies for overcoming challenges to providing pre-conception care and provide guidance for time-poor clinicians.

Key challenges in the uptake and delivery of pre-conception care

Each year, an estimated 10% of women of reproductive age in Australia become pregnant. One-third of pregnancies that lead to childbirth are unintended,3 so a significant number of women will not have had the opportunity to consider pre-conception care. Other barriers include a lack of community awareness of the importance of the health of the parents during the period preceding pregnancy and, for some women, social, cultural and financial constraints on accessing health care and presenting for advice before a positive pregnancy test result. There are also challenges for clinicians. Pre-conception care is chiefly undertaken in primary care, and general practitioners in Australia report time pressures caused by competing preventive priorities, and that evidence-based pre-conception care resources are not available.4 Overcoming these challenges with simple, user-friendly approaches is essential.

How to start the conversation?

Although there are no data about the effectiveness of any particular approach to raising the topic of pregnancy intention with women, “One Key Question” is a simple option, endorsed by the American Public Health Association.5 This strategy encourages health care practitioners to opportunistically and routinely ask women of reproductive age during consultations — including those for sexual health checks or cervical screening — “Would you like to become pregnant in the next year?”, with the response guiding subsequent discussion towards pre-conception care or effective contraception options. While yet to be tested in Australia, this approach could provide an opportunity for opening a conversation with women considering a pregnancy in the following 12 months. There are also a number of useful internet resources. Tommy’s charity, based at St Thomas’ Hospital in London, has developed an interactive online “planning for pregnancy” tool that asks a number of health- and lifestyle-related questions, and then generates a list of problems that require particular attention (eg, nutrition, physical activity). Such tools may help expand community awareness of pre-conception care.6

What should clinicians discuss?

Nine key items should be covered during a pre-conception care discussion (Box).1 Rates of obesity are increasing in Australia, and body weight is the single most important modifiable risk factor associated with adverse pregnancy outcomes, including prematurity, stillbirth, congenital anomalies and macrosomia, as well as an increased risk of obesity and metabolic disease later in life for the children of obese mothers.18 A discussion of strategies for weight loss should be prefaced by explaining why weight in the normal body mass index (BMI) range (18.5–24.9 kg/m2) is beneficial for both fertility and pregnancy outcomes.

It is, however, important that clinicians be aware that the evidence base for the effectiveness of many pre-conception recommendations for improving pregnancy outcomes, apart from folate supplementation, is relatively poor. For example, it is well documented that supporting women stop alcohol consumption during pregnancy reduces the risk of fetal alcohol spectrum disorder; however, there is little evidence that alcohol consumption prior to conception adversely affects pregnancy outcomes.16 The possible benefit of pre-conception weight reduction on pregnancy outcomes is largely based on population-based cohort studies rather than clinical trials.9,19 Further studies, particularly clinical trials, are needed to determine which pre-conception interventions are most effective and achieve the largest gains at the individual and population levels.

Conclusion

Parental health prior to conception is increasingly recognised as being important for the health of future generations. The Royal Australian College of General Practitioners has provided useful guidance on specific areas, and incorporating the simple question, “Would you like to become pregnant in the next year?”, into routine consultations with women of reproductive age can create opportunities for providing pre-conception advice. Directing women to online tools that engage them in a conversation about aspects of their health and lifestyle issues will also increase community awareness of the importance of pre-conception health.

Box – Key components of pre-conception care counselling, adapted from the Royal Australian College of General Practitioners (RACGP) guidelines1

Pre-conception care item

Recommendation

Rationale and evidence base

Folate supplementation

Folate supplement: 0.5 mg/day; women at high risk, including those with diabetes, obesity, or a child with or family history of neural tube defects, or using anti-epileptic medication: 5 mg/day. Supplementation should ideally begin at least one month before conception and should continue throughout the first trimester

A 2015 Cochrane review concluded that peri-conception folate supplementation reduces the risk of neural tube defects, including spina bifida and anencephaly, by 70%7

Iodine supplementation

Iodine supplement: 150 μg/day

The RACGP and RANZCOG recommend iodine supplementation to prevent neonatal hypothyroidism (based on NHMRC guidelines), but a 2017 Cochrane review found that data supporting routine supplementation to prevent adverse neurological outcomes in infants were insufficient8

Nutrition and weight management

Optimise maternal body mass index (BMI)

Women should aim to be within the normal BMI range, but a large population-based cohort study found that in obese women even a 10% reduction in pre-pregnancy BMI achieves clinically significant reductions in the risks of pre-eclampsia, gestational diabetes, pre-term delivery, macrosomia, and stillbirth9

Oral health

Ask about dental problems, check oral cavity; advise dental review if needed

Chronic gingival and supporting tooth structure infections have been linked in observational studies with increased risks of pre-term birth, pre-eclampsia, and fetal growth restriction10

Smoking

Advise to stop smoking

Smoking during pregnancy is associated with increased risks of pre-term birth and intra-uterine growth restriction. Ceasing prior to conception is important, as a population-based retrospective cohort study found that first trimester smoking increases the risk of fetal growth restriction11

Alcohol and illicit drug use

For women planning to become pregnant, not drinking optimises fertility and facilitates abstinence during the pregnancy

Evidence that ceasing alcohol and illicit drug use prior to conception has not been reported. Pre-conception counselling, however, significantly reduces alcohol consumption during the first trimester12

Inter-pregnancy interval

Contraceptive advice, to optimise inter-pregnancy interval (from birth to the next conception should ideally be longer than 12 months)

Cross-sectional studies have linked short inter-pregnancy intervals (less than 12 months) with increased risks of adverse perinatal outcomes, including pre-term birth, perinatal death, and low birthweight.13 Studies in which women acted as their own controls found increased risks of low birthweight and gestational diabetes, and increased likelihood of starting the next pregnancy obese if the interval was less than 6 months14

Chronic diseases

Optimise control of chronic diseases (eg, diabetes, hypertension, epilepsy); avoid teratogenic medications (eg, sodium valproate)

Diabetes: Hyperglycaemia has a teratogenic effect and the absolute risk of congenital anomalies rises with peri-conceptional glycosylated haemoglobin (HbA1c) levels;15 pre-conception care reduces the incidence of both congenital malformations and perinatal mortality by about 70%16
Epilepsy: Pre-conception care requires careful consideration of the need for continued anti-epileptic therapy, the selection of suitable drugs and doses, and greater folic acid supplementation (5 mg/day)16

Serological testing and vaccinations

Offer serological testing for rubella, varicella, hepatitis B. Offer vaccination as appropriate and ensure adequate contraceptive cover for 28 days after measles, mumps, rubella, and varicella vaccination

Reviewed in references 1 and 17

HIV = human immunodeficiency virus; NHMRC = National Health and Medical Research Council; RANZCOG = Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

A correction to this article is available at https://www.mja.com.au/journal/2018/209/11/correction-0

Authors

  • Deborah J Bateson1,2
  • Kirsten I Black1,3
  • 1. Family Planning New South Wales, Sydney, NSW
  • 2. University of Sydney, Sydney, NSW
  • 3. Royal Prince Alfred Hospital, Sydney, NSW

Correspondence: deborahb@fpnsw.org.au

Competing interests

No relevant disclosures.

References

Linked content

  • MJA Letter: Pre‐conception care: an important yet underutilised preventive care strategy

  • MJA Letter: In Reply

Provenance: Commissioned; externally peer reviewed.

View this article on Wiley Online Library

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