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Forever Pregnant
Guidelines: Treat Nearly All Women as Pre-Pregnant

By January W. Payne
Washington Post Staff Writer
Tuesday, May 16, 2006

New federal guidelines ask all females capable of conceiving a baby to treat themselves -- and to be treated by the health care system -- as pre-pregnant, regardless of whether they plan to get pregnant anytime soon.

Among other things, this means all women between first menstrual period and menopause should take folic acid supplements, refrain from smoking, maintain a healthy weight and keep chronic conditions such as asthma and diabetes under control.

While most of these recommendations are well known to women who are pregnant or seeking to get pregnant, experts say it's important that women follow this advice throughout their reproductive lives, because about half of pregnancies are unplanned and so much damage can be done to a fetus between conception and the time the pregnancy is confirmed.

The recommendations aim to "increase public awareness of the importance of preconception health" and emphasize the "importance of managing risk factors prior to pregnancy," said Samuel Posner, co-author of the guidelines and associate director for science in the division of reproductive health at the Centers for Disease Control and Prevention (CDC), which issued the report.

Other groups involved include the American College of Obstetricians and Gynecologists, the March of Dimes, Dartmouth Hitchcock Medical Center, the National Center for Chronic Disease Prevention's Division of Reproductive Health and the National Center on Birth Defects and Developmental Disabilities.

The idea of preconception care has been discussed for nearly 20 years, experts said, but it has drawn more attention recently. Progress toward further reducing the rate of unhealthy pregnancy results, including premature birth, low birthweight and infant mortality, has slowed in the United States since 1996 "in part because of inconsistent delivery and implementation of interventions before pregnancy to detect, treat and help women modify behaviors, health conditions and risk factors that contribute to adverse maternal and infant outcomes," according to the report.

Nearly 28,000 U.S. infants died in 2003, according to the National Center for Health Statistics (NCHS). The infant mortality rate increased in 2002 for the first time in more than 40 years to seven deaths per 1,000 live births, but it did not change significantly in 2003. Birth defects, low birthweight and sudden infant death syndrome (SIDS) were the leading causes of infant death in 2003, according to NCHS.

The U.S. infant mortality rate is higher than those of most other industrialized nations -- it's three times that of Japan and 2.5 times those of Norway, Finland and Iceland, according to a report released last week by Save the Children, an advocacy group.

Preconception care should be delivered by any doctor a patient sees -- from her primary care physician to her gynecologist. It involves developing a "reproductive health plan" that details if and when children are planned, said Janis Biermann, a report co-author and vice president for education and health promotion at the March of Dimes.

"The recommendations say we need to be opportunistic," or deliver care and counseling when opportunities arise, said Merry-K. Moos, a professor in the University of North Carolina's maternal fetal medicine division who sat on the CDC advisory panel. "Healthier women have healthier pregnancies."

Women should also make sure all vaccinations are up-to-date and avoid contact with lead-based paints and cat feces, Biermann said.

The report recommends that women stop smoking and discuss with their doctor the danger alcohol poses to a developing fetus.

Research shows that "during the first few weeks (before 52 days' gestation) of pregnancy" -- during which a woman may not yet realize she's pregnant -- "exposure to alcohol, tobacco and other drugs; lack of essential vitamins (e.g., folic acid); and workplace hazards can adversely affect fetal development and result in pregnancy complications and poor outcomes for both the mother and the infant," the report states.

The CDC report also discusses disparities in care, noting that approximately 17 million women lack health insurance and are likely to postpone or forgo care. These disparities are more prominent among minority groups and those of lower socioeconomic status, the report states.

The NCHS data also reflect these disparities. Babies born to black mothers, for example, had the highest rate of infant death -- 13.5 per 1,000 live births. Infants born to white women had a death rate of 5.7 per 1,000.

Obstacles to preconception care include getting insurance companies to pay for visits and putting the concept into regular use by doctors and patients. Experts acknowledge that women with no plans to get pregnant in the near future may resist preconception care.

"We know that women -- unless you're actively planning [a pregnancy], . . . she doesn't want to talk about it," Biermann said. So clinicians must find a "way to do this and not scare women," by promoting preconception care as part of standard women's health care, she said.

Some medical facilities have already found a way to weave preconception care in with regular visits. At Montefiore Medical Center in Bronx, N.Y., a form that's filled out when checking a patient's height, weight and blood pressure prompts nurses to ask women, "Do you smoke, and do you plan to become pregnant in the next year? And if not, what birth control are you using?"

"It's a simple way of getting primary care providers to think about preconception care," said Peter Bernstein, a maternal fetal medicine specialist who sat on the advisory committee that helped produce the report. "It's simple and [it] costs nothing." ยท

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