Preconception Care for Improving Perinatal Outcomes: The Time to Act

A healthy baby and a healthy mother are valued hopes and dreams of families of all cultural heritages. National health goals in many countries around the world prioritize infant and maternal mortality and morbidity. In the United States, as in many other industrialized countries, pregnancy outcomes and maternal and infant health indicators have improved dramatically. At the turn of the 20th century, 7.28 women and 96 infants died for every 1,000 babies born alive 1. By the end of the year 2000, the maternal mortality rate had decreased to less than 0.08 and infant mortality had decreased to less than 7 deaths per 1,000 live births 2. These changes were characterized as one of the ten “great public health achievements” of the 20th century 3. Much of this progress can be attributed to changes in social and living conditions as well as the development and implementation of effective medical interventions. Despite this progress, during the last two decades of the 20th century, even in the presence of significant breakthroughs in medical technology and its application, improvements in maternal and infant pregnancy ouctomes slowed down significantly, and in some cases, outcomes deteriorated. For example, from 1960 to 1980, the maternal mortality rate decreased from 32.1 to 9.4 deaths per 100,000 live births, a decrease of 70.7%. From 1980 to 2000, the maternal mortality rate decreased only 12.8%, from 9.4 to 8.2 (Figure 1) 2. At the same time, from 1980 to 2000, the proportion of babies born preterm, very preterm, low birth weight, and very low birth weight increased by 26%, 8.2%, 14.7% and 25.9%, respectively (Figure 2) 4. However, unlike other maternal and infant health indicators, from 1980 to 2000 the infant mortality rate continued to decrease almost at a similar pace as that from 1960 to 1980, dropping by 45.2% from 12.6 to 6.9 infant deaths per 1,000 live births, compared with a drop of 51.5% from 26.0 to 12.6 per 1,000 live births for 1960 to 1980 (Figure 1) 2. Finally, it is estimated that the proportion of babies born in the United States who have a serious or major structural defect that can have adverse effects on their health or development continues to be about 3% 5. Fig. 1 Maternal and infant mortality rates, United States, 1960–2002 Fig. 2 Percent of all live births that are preterm delivery, very preterm delivery, low birth weight, and very low birth weight, United States, 1980–2002 Associated with this slowing rate of improvement (and, in some cases, deterioration) in pregnancy outcomes and maternal and infant health indicators is a shift in the leading causes of infant mortality. In 1960, maternal complications of pregnancy (including complications of placenta, cord, and the membranes) did not appear on the list of the 10 leading causes of infant mortality 1. By 1980, maternal complications of pregnancy became the fifth leading cause of infant mortality, and the third leading cause of infant death in 2002, after congenital anomalies and low birth weight/preterm delivery 6, 7. In 2002, congenital anomalies, low birth weight, preterm delivery, and maternal complications of pregnancy accounted for 46.4% of all infant deaths in the United States (12,996 infant deaths) (Figure 3) 7. Although some of these infant deaths might have been prevented through interventions targeted at improving the health of mothers and modifying behaviors contributing to adverse pregnancy outcomes, poor maternal health, behaviors contributing to adverse pregnancy outcomes, and maternal complications of pregnancy continue to be prevalent. For example, 28.6% of women who gave birth between 1993 and 1997 were reported to have an obstetric complication, 4.1% had a preexisting medical condition, and 43.0% experienced some form of maternal morbidity (i.e., an obstetric complication, a preexisting medical condition, a cesarean section, or any combination of the three types of morbidity) 8. In 2002, 26.1% of all deliveries were performed using cesarean section, presumably because of maternal or infant complications 8. Fig. 3 Leading causes of infant mortality, United States, 1960, 1980, and 2002. *IMR = Infant Mortality Rate Early prenatal care is too late One of the reasons that progress in improving pregnancy outcomes has slowed down, and in some cases reversed direction, is that we have failed to intervene before pregnancy to detect, manage, modify, and control maternal behaviors, health conditions, and risk factors that contribute to adverse maternal and infant outcomes. Although we know many interventions that, if delivered before pregnancy, could improve pregnancy outcomes, we have failed to make those services and interventions available to couples and women in need. Women of childbearing age suffer from a variety of chronic conditions that could potentially contribute to adverse pregnancy outcomes. For example, in 2002, the U.S. Department of Health and Human Services reported that 6.1% of women of reproductive age have asthma, 5% are obese, 3.4% have cardiac disease, 3.0% are hypertensive, 9.3% are diabetic, and 1.4% have thyroid disorder 9. Moreover, a substantial proportion of women continue to enter pregnancy with risks proven to contribute to adverse pregnancy outcomes: in 2002, 11.4% of pregnant women smoked during pregnancy, a risk factor for low birth weight 4; at the same time, 10.1% of pregnant women and 54.9% of women at risk of getting pregnant consumed alcohol, a risk factor for fetal alcohol syndrome 10. Finally, using the Perinatal Periods of Risk approach, researchers in three cities (New York City; Tulsa, Oklahoma; and Kansas City, Missouri) concluded that racial and ethnic disparities in feto-infant mortality were largely related to maternal health, and, interventions to reduce feto-infant mortality should include preconception care and improvements in women's health 11–13. The prenatal care “revolution” of the 1980s resulted in an increase in the proportion of women receiving early prenatal care (defined as prenatal care begun in the first trimester) 2. After decreasing from 76.3% in 1980 to 75.8% in 1990, the proportion of women receiving early prenatal care increased to 83.2% in 2000 2. However, for many women, “early prenatal care is too late” 14. By the time a pregnant woman makes it to her first early prenatal visit, most fetal organs are already been formed, and many interventions to prevent birth defects or adverse maternal and infant outcomes come too late to have any effect. As a result, many national organizations now recommend routine preconception care. For example, the March of Dimes recommends that “as the key physician/primary care provider, the obstetrician/gynecologists must take advantage of every health encounter to provide preconception care and risk reduction before and between conceptions—the time when it really can make a difference” 14. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend that “all health encounters during a woman's reproductive years, particularly those that are a part of preconception care, should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes” 15.