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Preconception Care: Policy, Challenges, Opportunities

Hani K. Atrash MD, MPH

Associate Director for Program Development

National Center on Birth defects and Developmental Disabilities

Centers for Disease Control and Prevention

http://www.cdc.gov/ncbddd

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We Have A Problem

Preconception care is not being delivered

• Providers don’t provide it• Insurers don’t pay for it• Consumers don’t ask for it

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Why Should We Care?

Because it is the right thing to do

Because we have moral, ethical and LEGAL obligations to do

“The Right Thing”

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Why Don’t We?

Do we have the Science, Policy, Tools, Programs?

What are the barriers and challenges:• Knowledge, Attitudes, Practices of:

Consumers Providers Insurers

• Practical Guidelines and Tools for implementation:

Who does it, who gets it, how much, what is it, why do it, how to do it, where to do it, when to do it, etc?

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Do We Have The Science?

Yes, but may not be enough for today’s climate:

• Strong evidence for some components• Some evidence for others• Non-existent for others

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Do We Have The Science?

Today’s climate:

Scientific evidence

+ Business Case

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Do We Have The Policy?

We have recommendations from professional organizations

We have no national policy

•No “legal obligations”•No accountability

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Current “Policy”

There is consensus that preconception care should be provided to all women

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Current “Policy”

HP Objectives 5.10 and 14.12

Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception care and counseling.

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Current “Policy”

ACOG/AAP All health encounters during a

woman’s reproductive years, particularly those that are a part of preconceptional care should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes.

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“Current Policy”

U.S. Public Health Service Expert Panel

Preconception care is a critical component of prenatal care

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Are We Asking For Too Much????ACOG/AAP PCC Components: Maternal assessment

• Family planning and pregnancy spacing

• Family history• Genetic history (maternal

and paternal)• Medical, surgical,

pulmonary and neurologic history

• Current medications (prescription and OTC)

• Substance use, including alcohol, tobacco and illicit drugs

• Nutrition

• Domestic abuse and violence

• Environmental and occupational exposures

• Immunity and immunization status

• Risk factors for STDs• Obstetric history• Gynecologic history• General physical exam• Assessment of

Socioeconomic, educational, and cultural context

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Are We Asking For Too Much???? ACOG/AAP PCC Components: Vaccinations

Vaccinations should be offered to women found to be at risk for or susceptible to:

• Rubella• Varicella• Hepatitis B

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Are We Asking For Too Much???? ACOG/AAP PCC Components: Screening Tests

Screening for HIV should be strongly recommended

A number of tests can be performed for specific indications:

• Screening for STDs• Testing for specific diseases based on medical or

reproductive history• Mantoux skin test for TB• Screening for genetic disorders based on racial/ethnic

background• Screening for other genetic disorders based on family

history

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Are We Asking For Too Much???? ACOG/AAP PCC Components: Screening Tests

Screening for genetic disorders based on racial/ethnic background:

• Β-Thalassemia (Mediterraneans, SE Asia, AA/B)• α-Thalassemia (AA/B and Asians)• Tay Sachs disease (Ashkhenazi Jews, French Canadians,

Cajuns)• Gaucher’s, Canavan, and Nieman-Pick Disease (Ashkenazi

Jews)• Cystic Fibrosis (Caucasians and Ashkenazi Jews)

Screening for other genetic disorders based on family history: CF, Fragile X, mental retardation, Duchene muscular dystrophy.

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Are We Asking For Too Much???? ACOG/AAP PCC Components: Counseling

Patients should be counseled regarding the benefits of the following activities:

• Exercising• Reducing weight before pregnancy, if overweight• Increasing weight before pregnancy, if underweight• Avoiding food additives• Preventing HIV infection• Determining the time of conception by an accurate menstrual

history• Abstaining from tobacco, alcohol, and illicit drug use before

and during pregnancy• Consuming Folic Acid• Maintaining good control of any pre-existing medical

conditions

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Do We Have Tools And Programs?

Yes, no, maybe! but:• Mostly individual efforts• Not standard or homogenous• No impact evaluation• No clear / practical guidelines• No tools

NO WE DO NOT HAVE PROGRAMS!!!

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Common Excuses: Challenges, Barriers

Unplanned pregnancies Better definition of components Timing Target population Training and education:

• Providers• Policy makers• Consumers

Policy development and implementation

$$$ Reimbursement $$$

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Before We Proceed, Simple Questions

What is it? Who should provide it? Who should get it? Where do we provide it? When do we provide it? Who pays for it?

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What Is It?

What are the components of PCC that work?

Do we have scientific basis for All the recommended components of PCC?

Is the benefit of the sum equal to or greater than the benefit of each component?

Is it cost-effective?

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Who Should Provide It?

Or, Who should provide what? Obstetricians/Gynecologists Other physicians Nurses Social workers Health educators The media Schools Others

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Who Should Get It?

Women/Couples planning pregnancies? All women at risk of getting pregnant? Women with poor prior pregnancy

outcome? All women of reproductive age? Young women at schools before they are

sexually active? Men and women Others?

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Where Do We Provide It?

Ob/Gyn clinics Clinics where “at risk of

pregnancy” women get services? Every health care provision

setting? Schools and community settings? Other?

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When Do We Provide It?

Between pregnancies? Few months before

pregnancy? A year before pregnancy? At every encounter with the

health care system?

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Who Pays For It?

And what do they pay for?

• Should it be part of the “pregnancy package”?

• Do we expect them to pay every time for all recommended services?

• Should they pay for selected services at selected times?

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What To Do?The CDC PCC Initiative

Try to answer the simple, practical questions Make the scientific case; Solidify the scientific

evidence Make the business case Develop consensus Develop recommendations and national policy Develop the knowledge and skills of providers Educate consumers Develop guidelines and tools for implementation Implement recommendations

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Making the Scientific and Business Cases, Assessing PCC Components

Qualitative assessment of the strength of evidence supporting the guidelines recommending care

Quantitative estimation of women (or couples) who potentially could benefit from improved access

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Making the Scientific CaseQualitative Assessment of Components

Evidence is strong that: • Interventions are effective • Interventions must be begun before

conception

There are clinical practice guidelines to inform health care delivery

There are surveillance systems to measure risk factor prevalence

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Making the Scientific CaseQualitative Assessment, Selected Components

Universal:• Folic Acid

Supplements• Rubella Sero-

Negativity• HIV/AIDS• Maternal PKU• Diet (Obesity)

Targeted:• Oral

Anticoagulant use

• Anti-Epileptic Drugs (AEDs)

• Accutane Use• Smoking • Alcohol Misuse• Diabetes• Hypothyroidism

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Making the Business CaseQuantitative Assessment of Components

Table 4: Estimation of the Potential to Lower Risk among Planned Pregnancies (PLRPP)

Risk Factor Prevalence Component of

Preconception Care

Among Women [18-44 yrs]

Among Women [18-44 yrs]

having Births

PLRPP- (Number of Pregnancies

per Component)

Targeted percent of PLRPP per Component

(To Be Estimated From Best Evidence)

Folic Acid Supplements

721/1000 (40.2 million)

Gallup Poll 2001

2,837,908 (Modeled)

1,999,267

Rubella Sero-Negativity

276,082 (7.1%)

Surveillance

196,287

Diabetes (Preconceptional)

38/1000 (2.1 million) BRFSS 2001

113,132 (Modeled)

66,442

Hypothyroidism 412/1000 (2,3 M) NAMC

2001-2002

160,199 (Modeled)

90,987

HIV/AIDS CDC HIV/AIDS

Maternal PKU 0.09/1000 (5,000)

Modeled

349 (Modeled)

250

Also Maternal PKU, oral anticoagulant use, Anti-epileptic drugs, accutane use, smoking, alcohol, obesity

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Making The Business CaseTarget Population: 2000 Statistics

2,069,995 Intended Births

1,988,819 Unintended Births

77,519 Very Preterm 57,967 Very Low Birthweight467,201 Preterm307,030 Low Birthweight857,475 Induced abortions

80,759,000 Women 15-44 years

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Activities to Date

Literature Review: Qualitative and Quantitative assessments

CDC PCC Workgroup, internal discussions

Partnerships and discussions with national partners: MOD, ACOG, AAP, CityMatCH, MCHEP, CSTE, NACCHO, ASTHO, others

Discussions at conferences

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Next Steps Assessment of Ob/Gyn’s Knowledge, Attitudes and

Practices:• Identify knowledge gaps• Develop training materials

Assessment of Health Plans practices Exploring best practices:

• Telephone support• Chronic care model• Self assessment tools

Workshop to develop a Workplan and Recommendations Implementation

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