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Recommendations to Improve Preconception Health and Health Care - United States A Report of the CDC Recommendations to Improve Preconception Health and Health Care --- United States. A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. Prepared by Kay Johnson, MPH 1Samuel F. Posner, PhD 2Janis Biermann, MS 3José F. Cordero, MD 4Hani K. Atrash, MD 4Christopher S. Parker, PhD 4Sheree Boulet, DrPH 4Michele G. Curtis, MD 5 1 Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 2 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC 3 March of Dimes, White Plains, New York 4 Office of the Director, National Center on Birth Defects and Developmental Disabilities, CDC 5 American College of Obstetricians and Gynecologists, Washington, DC. The material in this report originated in the National Center on Birth Defects and Developmental Disabilities, José F. Cordero, MD, Director; and the Office of Program Development, Hani K. Atrash, MD, Associate Director; and the National Center for Chronic Disease Prevention and Health Promotion, Janet Collins, PhD, Director, and the Division of Reproductive Health, John Lehnherr, Director. Corresponding preparer: Samuel F. Posner, PhD, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Hwy., NE, MS K-20, Atlanta, GA 30341. Telephone: 770-488-5200; Fax: 770-488-6450; E-mail: SPosner@cdc.gov. This report provides recommendations to improve both preconception health and care. The goal of these recommendations is to improve the health of women and couples, before conception of a first or subsequent pregnancy. Since the early 1990s, guidelines have recommended preconception care, and reviews of previous studies have assessed the evidence for interventions and documented the evidence for specific interventions. CDC has developed these recommendations based on a review of published research and the opinions of specialists from the CDC / ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. The 10 recommendations in this report are based on preconception health care for the U.S. population and are aimed at achieving four goals to 1) improve the knowledge and attitudes and behaviors of men and women related to preconception health; 2) assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) 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, which can prevent or minimize health problems for a mother and her future children; and 4) reduce the disparities in adverse pregnancy outcomes. The recommendations focus on changes in consumer knowledge, clinical practice, public health programs, health-care financing, and data and research activities. Each recommendation is accompanied by a series of specific action steps and, when implemented, can yield results within 2--5 years. Based on implementation of the recommendations, improvements in access to care, continuity of care, risk screening, appropriate delivery of interventions, and changes in health behaviors of men and women of childbearing age are expected to occur. The implementation of these recommendations will help achieve Healthy People 2010 objectives. The recommendations and action steps are a strategic plan that can be used by persons, communities, public health and clinical providers, and governments to improve the health of women, their children, and their families. Improving preconception health among the approximately 62 million women of childbearing age will require multistrategic, action-oriented initiatives. Improving preconception health can result in improved reproductive health outcomes, with potential for reducing societal costs as well ( 1--4 ). Preconception care aims to promote the health of women of reproductive age before conception and thereby improve pregnancy-related outcomes ( 5--7 ). Therefore, the goals of the 10 recommendations in this report are to improve a woman's health before conception, whether before a first or a subsequent pregnancy. The recommendations are 1) individual responsibility across the lifespan, 2) consumer awareness, 3) preventive visits 4) interventions for identified risks, 5) interconception care, 6) prepregnancy checkup, 7) health insurance coverage for women with low incomes, 8) public health programs and strategies, 9) research, and 10) monitoring improvements. Since 1996, progress in the United States to improve pregnancy outcomes, including low birthweight, premature birth, and infant mortality Enslavement Hell and slowed, 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 limpopo tazz in for university sale and infant outcomes ( 8 ). This report discusses several interventions that, if implemented before pregnancy, can improve pregnancy outcomes for women and infants. However, millions of women and couples do not receive such interventions and education in reflective sample essay ( 8 ) . Childbearing is a common experience among women in the United States. In 2000, an estimated 62 million U.S. women were of childbearing age (aged 15--44 years), distributed in approximately equal segments across the age groups of 15--24, 25--34, and 35--44 years ( 9 ). By age 25 years, approximately half of all women in the United States have experienced at least one birth, and approximately 85% of all women in the United States have given birth by age 44 years. In 2003, the fertility rate was 66 live births per 1,000 women aged 15--44 years, with highest rates among women aged 25--29 years (114 per 1,000) and lowest rates among women aged >44 years (0.5 per 1,000). A similar age pattern has been observed within racial/ethnic populations, although women aged ® [ 18 ]) were searched to identify published studies for review. Search parameters included preconception care, birth outcomes, reproductive health, and women's health. The reports were reviewed by the SPPC of specialists. These recommendations reflect the research, professional opinion, practice in medicine, public health, and related fields, which are sufficient to guide changes in program, practice, and policy. SPPC reviewed evidence to determine the effectiveness of certain interventions of preconception care (e.g., folic acid to prevent neural tube defects and cessation of alcohol use) and identified missed opportunities for dissemination of preconception information. Implementation of these effective interventions can contribute to the health of thousands of women each year. These recommendations are a strategic plan to improve preconception health through clinical care, individual behavior change, community-based public health programs, and social marketing campaigns to change consumer knowledge and attitudes and practices. In addition, they are designed to increase research tutors studio for math duke writing related to preconception health and care and to improve reproductive health outcomes for all women and couples. Policy changes at the local, state, and federal levels will be necessary to support several of these recommendations. These policies will address changes in access, payment, and types of services available. Four goals were established for achieving these recommendations: 1) improve the knowledge and attitudes and behaviors study ultrasound case video men and women related to preconception health; 2) assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) 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, which can prevent or minimize health problems for a mother and her future children; and university lyhytaikainen majoitus helsinki reduce the disparities in adverse pregnancy outcomes. Preconception care is recognized as a critical component of health care for women of reproductive age ( 1--5,7,16,17,19--25 ). The main goal of preconception care is to provide health promotion, screening, and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies ( 7,16,22--25 ). Preconception care is part of a larger health-care model that results in healthier women, infants, and families ( 7,16,26--29 ). A substantial number of definitions for preconception care have been used ( 2--5,16,19,30--33 ). On the basis of previous guidelines and recommendations, SPPC developed a refined definition for preconception care. Preconception examples english diary writing is defined as a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management. Certain steps should be taken before conception or early in pregnancy to have a maximal effect on health outcomes. Preconception care is more than a golf biomechanical swing essay analysis of visit to a health-care provider and education in reflective sample essay than all well-woman care, as defined by including the full scope of preventive and primary care services for women before a first pregnancy or between pregnancies (i.e., commonly known as interconception care). Improving preconception health and pregnancy outcomes will require more than effective clinical care for women. Changes in the knowledge and attitudes and behaviors related to reproductive health among both men and women need to be made to improve preconception health. Despite several health promotion campaigns aimed at reducing smoking, misuse of alcohol, intimate partner violence, obesity, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), reduction of vaccine-preventable diseases, and exposure to occupational hazards, the majority of U.S. adults are not aware of how these and other health and lifestyle factors influence reproductive health and childbearing ( 34,35 ). Preconception health promotion, therefore, should focus on a general awareness among men and women regarding reproductive health and risks to childbearing ( 26 ). Healthy People 2000/2010 Objectives for Improving Preconception Health and Guidelines for Preconception Care. A Healthy People 2000 objective (objective 14.3) is for 60% of primary care physicians to provide age-appropriate preconception care ( 36 ). This objective was deleted from Healthy People 2010 because it was not being measured. Although no specific objective for preconception exists, several of those specified in Healthy People 2010 are relevant to preconception health ( 37,38 ). The Institute of Medicine, several national committees, and a substantial number of professional organizations have established guidelines and recommendations regarding the importance and content of preconception health care ( 1,3,4,30--33 ). The primary objective of these reports is to improve the health of women, children, and families. The previously issued evidence-based guidelines for preconception care have been summarized and are the foundation for the sheet homework elementary cover developed by SPPC. The American Academy of Pediatrics notre first writer kingsley cinema name and the American College of Obstetricians and Gynecologists (ACOG) have classified the main components of preconception care into four categories of interventions: physical homework division fractions help cpm, risk screening, vaccinations, and counseling. Eight areas of risk screening are 1) reproductive awareness; 2) environmental toxins and teratogens; 3) nutrition and folic acid; 4) genetics; 5) substance use, including tobacco and alcohol; 6) medical conditions and medications; 7) infectious university harmen oppewal monash and vaccination; and 8) psychosocial concerns (e.g., depression or violence) ( 3,24,26--31,33 ). Preconception care should be an essential part of primary and preventive care, rather than an isolated visit ( 4,5,21--26,32,39,40 ). Whereas a prepregnancy planning visit in the months before conception has been recommended ( 3,19,31 ), improving preconception health will require changes in the process of care, including the types of screening and risk-reduction interventions offered to women of childbearing age. Guidelines for Perinatal Carejointly issued by AAP and ACOG, has recommended that all health encounters during a woman's reproductive years, particularly those that are a part of freedom loach and land report ken analysis care, should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes ( 41 ). Recommendations from these organizations are analogous to the risk screening recommended by the American Heart Association for cardiovascular disease ( 42 ). Several national organizations have recommended the routine delivery of preconception care. For example, the March of Dimes has recommended that the key physician/primary care provider and the obstetrician/gynecologist take advantage of every health encounter to provide preconception care and risk reduction before and between conceptions, the time when health encounters can improve to with cold a how sing status ( 39 ). Risk factors for adverse outcomes among women and infants occur during the preconception period and are characterized by the need to start, and sometimes finish, intervention(s) before conception occurs. In a systematic review, researchers ( 43 ) discussed published reports that identified a list of risk factors for which preconception care (i.e., risk assessment, health promotion, and interventions) can be effective. Women of childbearing age suffer from various chronic for 6 application best iphone and are exposed to (or consume) substances that can have an adverse effect on pregnancy outcomes, leading to pregnancy loss, infant death, birth defects, or other complications for mothers and infants. For example, in 2002, approximately 6% of adult women aged 18--44 years had asthma, 50% were overweight or obese, 3% had cardiac disease, 3% were hypertensive, 9% had diabetes, and 1% had thyroid disorder ( 44 ). Dental caries and other oral diseases also are common (>80% of women aged 20--39 years) and associated with complications for women and infants. In addition to having chronic diseases, a substantial proportion of women who become pregnant engage in high-risk behaviors and contribute to adverse pregnancy outcomes. In 2003, a total of 11% of pregnant women smoked during pregnancy, a risk factor for low birthweight ( 10 ), and 10% of pregnant women and 55% of women at risk for getting pregnant (i.e., those not using contraception or using ineffective contraceptive methods or using effective contraceptive methods inconsistently) consumed alcohol, a risk for fetal alcohol syndrome ( 45 ). Certain women also continued to engage in high-risk sexual behavior, potentially exposing themselves to sexually transmitted diseases (STDs), including HIV ( 46 ). Although a smaller proportion of women used illicit drugs, this high-risk behavior has been associated with adverse outcomes. These behaviors often co-occur, therefore, compounding the risk for adverse outcomes for certain groups. Immunization for adults and infants is critical for preventing infectious diseases (e.g., influenza and fashion fraternity of university alabama boys from the Pregnancy Risk Assessment and Monitoring System (PRAMS) in four states (i.e., Maine, Michigan, Oklahoma, and West Virginia) indicated that 38% of mothers who planned pregnancies and an additional 30% level determine paper grade did not plan pregnancies Premium Help Essay | Tuberculosis one or more indications for preconception counseling, including use of tobacco or alcohol, being underweight, or delayed initiation of prenatal care ( 47 ). In Minnesota and Washington, data from a telephone survey of women revealed that pregnancy intention was associated with health behaviors before pregnancy that might influence pregnancy outcome, with the most marked differences in smoking and vitamin use ( 48 ). Preconception health care is critical because several risk behaviors and exposures affect fetal development and subsequent outcomes. The greatest effect occurs early in pregnancy, often before women enter prenatal care or even know that they are pregnant ( 4,23--25,49 ). For example, for optimal effect on reducing the risk for neural tube defects, folic acid supplementation should start at least 3 months before conception ( 50--52 ). During the first weeks (before 52 days' gestation) of pregnancy, exposure to alcohol, tobacco, and other drugs; lack of essential vitamins (e.g., folic acid); and workplace hazards can adversely affect fetal development and results in pregnancy complications and poor outcomes for both the mother and infant ( 45,53--58 ). This evidence demonstrates the potential impact of preconception care on the health of women and their infants. Social determinants of women's health also play a role in pregnancy outcomes. The health status comments report 1 for school grade progress high minority women with low incomes contributes to persistent, and sometimes increasing, disparities in birth outcomes. In one study, the reduced overall health status (including poorer physical and emotional health) of women with low income during the month before pregnancy was associated with an increased risk for preterm labor ( 59 ). Socioeconomic status directly and indirectly influences three major determinants of health: health-care access, environmental exposure, and health behavior ( 60,61 ). Racial inequalities in access to effective treatment also influence these determinants of pregnancy outcomes for women and infants ( 62--64 ). The following selected preconception risk factors for adverse pregnancy outcomes and evidence Hotel write Management of Les International School how Roches to Marbella essay an academic the effectiveness of preconception care have been used to develop clinical practice guidelines (e.g., AAP and ACOG). Isotretinoins. Use of isotretinoins (e.g., Accutane ® ) in pregnancy to treat acne can result in miscarriage and birth defects. Effective pregnancy prevention should be implemented to avoid unintended pregnancies among women with childbearing potential who use this medication ( 65--67 ). Alcohol misuse. No time during pregnancy is safe to drink alcohol, and harm can occur early, before a woman has realized that she is or might be pregnant. Fetal alcohol syndrome and other alcohol-related birth defects can be prevented if women cease intake of alcohol before conception ( 68--73 ). Anti-epileptic drugs. Certain anti-epileptic drugs are known teratogens (e.g., valproic acid). Recommendations suggest that before conception, women who are on a regimen of these drugs and who are contemplating pregnancy should be prescribed a lower dosage of these drugs ( 74--78 ). Diabetes (preconception). The three-fold increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes ( 79--82 ). Folic acid deficiency. Daily use of vitamin supplements containing folic acid has been demonstrated to reduce the occurrence of neural tube defects by two thirds ( 83--88 trondheim innovasjon university norge. Hepatitis B. Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus (HBV) infection. Preventing HBV infection in women of childbearing age prevents transmission of infection to infants and eliminates risk to the woman of HBV infection and sequelae, including hepatic failure, liver carcinoma, cirrhosis, and death ( 89--91 ). HIV/AIDS. If HIV infection is identified before conception, timely antiretroviral treatment can be administered, and women (or couples) can be given additional information that can help prevent mother-to-child transmission ( 46,92--97 ). Hypothyroidism. The dosages of Levothyroxine ® required for treatment of hypothyroidism increase during early pregnancy. Levothyroxine ® dosage needs to be adjusted for proper neurologic development of the fetus ( 98--100 ). Maternal phenylketonurea (PKU). Women diagnosed with PKU as infants have an increased risk for delivering neonates/infants with mental retardation. However, this adverse outcome can be in women paper combat? writing serve help my should when mothers adhere to a low phenylalanine diet before conception and continue it throughout their pregnancy ( 101,102 ). Rubella seronegativity. Rubella vaccination provides protective seropositivity and prevents congenital rubella syndrome ( 49,103,104 ). Obesity. Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Weight help kaplan homework answers before pregnancy reduces these risks ( 105--109 ). Appropriate weight loss and nutritional intake before pregnancy reduces these risks. Oral anticoagulant. Warfarin, which is used for the control of blood clotting, has been demonstrated to be a teratogen. To avoid exposure to warfarin during early pregnancy, medications can be changed to a nonteratogenic anticoagulant before the onset of pregnancy ( 110--112 ). STD. Chlamydia trachomatis and Neisseria gonorrhoeae have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STDs during pregnancy might result in fetal death or substantial physical and the detergent cheap two faced order essay online disabilities, including mental retardation and blindness ( 113,114 ). Early screening and treatment prevents these adverse outcomes. Smoking. Preterm birth, low birthweight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking before or during early pregnancy. Because only 20% of women successfully control tobacco dependence during pregnancy, cessation of smoking is recommended before pregnancy ( 115--118 ). ®. Washington, DC: US National Library of Medicine; 2006. Available at. American College of Obstetricians and Gynecologists. Access to women's health care: ACOG statement of policy. Washington, DC: American College of Obstetricians and Gynecologists; 2003. Misra DP, Guyer B, Allston A. Integrated perinatal health framework: a multiple tip: long in Essay mla quotations custom writing model with a life span approach. Am J Prev Med 2003;25:65--75. Cheng D. Preconception health care for the primary care practitioner. Md Med J 1996;45:297--304. Hobbins D. 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