Pregnant People - Key Activity 8

KEY ACTIVITY #8:

Provide Prepregnancy Healthcare

 

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; pre-visit planning and care gap reduction.

 

Overview

This activity provides guidance on delivering effective prepregnancy healthcare. The CDC and U.S. Office of Population Affairs describe preconception as any time that a person of reproductive potential is not pregnant but at risk of becoming pregnant, or when a man is at risk for impregnating his female partner.[1] While many organizations and agencies still utilize the term “preconception,” there is increasing adoption of “prepregnancy care” as alternative language.[2] Prepregnancy health services aim to identify and modify biomedical, behavioral and social risks to an individual’s health or future pregnancy outcomes through prevention and management. Individuals of reproductive age should receive services tailored to their unique needs before getting pregnant (prepregnancy health services) or between births (interconception health services).[3] Based on the unique needs identified, healthcare providers should suggest a treatment plan or follow-up care as needed.[4]

Prepregnancy health services are beneficial because of their role in improving the health of individuals of reproductive age across their lifespan, regardless of whether they are planning a pregnancy and because of their effect on pregnancy and birth outcomes, especially for people with preexisting health conditions. These services help to reduce pregnancy-related adverse outcomes, such as maternal morbidity and mortality, low birth weight, preterm birth, and infant mortality. Prepregnancy health services are particularly important given that, according to the Centers for Disease Control and Prevention (CDC), almost half of all pregnancies in the United States are unintended.[5] Since many people do not actively plan a pregnancy, focusing on overall prepregnancy health and well-being allows individuals to be prepared for a healthy pregnancy if it does happen. CDC recommends that prepregnancy health services be integrated into primary care visits for all individuals of reproductive age.

In 2021, the maternal mortality rate for non-Hispanic Black women was 69.9 deaths per 100,000 live births, 2.6 times the rate for non-Hispanic white women (26.6). Rates for Black women were significantly higher than rates for white and Hispanic women. These disparities identify an opportunity for significant improvement, as per the CDC. Research indicates that contraceptive services in the year before conception and routine exams for women with chronic disease are associated with decreased odds of severe maternal morbidity or death for Medicaid enrollees.[6] Prepregnancy care, in addition to quality prenatal and postpartum care, helps to ensure good health outcomes for birthing people and infants. Prepregnancy services present a critical opportunity to address modifiable risk factors that contribute to poor birth outcomes for birthing people and infants, both before pregnancy as well as between pregnancies.[7]

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) identified four categories of interventions and eight areas of screening for preconception health services. Two of these areas present opportunities to attend to the social needs of patients, including psychosocial concerns such as depression or violence.[8] The four categories of interventions are physical assessment, 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 diseases and vaccination; and 8) psychosocial concerns (e.g., depression or violence).

This activity entails the promotion of education, screening and appropriate care to people of childbearing age, and therefore should entail support through all relevant care activities.

Relevant health information technology (HIT) capabilities to support this activity include documentation of medical and surgical histories; routine women’s health, prepregnancy and prenatal care guidelines; care gap reports; SOGI; social needs and SDOH assessments provide information necessary to support comprehensive preconceptual healthcare for individual patients. Data can be available in the EHR or can be collected and integrated into the patient record. Ideally, clinical decision support can inform many care and screening needs, when available (EHR capture is il). Standing orders can be created to support pregnancy care requirements.

Action steps and roles

1. Assess current preconception health services to identify gaps between current and recommended practices.

Suggested team member(s) responsible: Population health staff, care managers, data analysts, all care team members.

Review current preconception health evidence-based guidelines and recommendations. Determine if the recommended eight areas of risk screening for preconception health services are in place. Based on assessment findings, develop and implement a quality improvement plan over time. Your practice might want to start with a focus on one specific process change to support prepregnancy health that might be most impactful in your patient population.
 

2. Ensure prepregnancy health assessments incorporate social health.

Suggested team member(s) responsible: All care team members.

Incorporate life course theory into preconception health assessments. Life course theory describes how contextual and environmental factors inform individuals’ health across their lifetimes and shape health and disease patterns across populations and communities. Before counseling a client about healthy behaviors, providers should routinely assess the client’s context and environment.

Balanced information on risks and benefits should be presented:

See Key Activity 7: Use Social Needs Screening to Inform Patient Treatment Plans.
 

3. Routinely assess all patients’ reproductive goals.

Suggested team member(s) responsible: All care team members and patients.

A standardized and systematic approach is recommended to assess patients’ reproductive goals.5 A standardized approach can decrease bias and inequity in screening and service provision.

PATH (Parenting/Pregnancy Attitudes, Timing, How Important) questions are one client-centered approach to assess parenthood and pregnancy attitude, timing, and pregnancy prevention.

PA: Do you think you might like to have (more) children at some point?
T: When do you think that might be?
H: How important is it to you to prevent pregnancy (until then)?

PATH can be used with clients of any gender, sexual orientation or age. PATH is designed to facilitate listening and efficient client-centered conversations about preconception care, contraception and fertility, as appropriate.

To adapt for EHR, a screening question can be, “Do you think you might like to have (more) children any time soon?”

Another option is One Key Question®. One Key Question® (“Would you like to become pregnant in the next year?”) can be used by healthcare providers, community health workers and home visiting nurses to guide a conversation with patients on a routine basis about pregnancy desires and goals and offer personalized counseling and care based on their response.[9] The One Key Question® is person-centered as it guides a conversation, supporting those who want to get pregnant, those who do not and those who are uncertain.7 One Key Question® (“Would you like to become pregnant in the next year?”) has four possible answers (there is no right or wrong answer): “Yes,” “no,” “unsure,” or “OK either way.”5 The benefits are its simplicity and ability to easily incorporate into routine intake questions and EHR workflows. The question of, “How important is preventing a pregnancy to you?” should also be explored.5

The importance of standardizing: All patients benefit from prepregnancy health services. Following a standardized and systematic approach to assessing patients’ reproductive goals can decrease bias and inequity in screening and service provision.5 Establishing effective referrals systems and making referrals based on identified needs ensures promotion of whole-person care.
 

4. Assess risk factors for adverse health and adverse pregnancy outcomes before conception.

Suggested team member(s) responsible: All care team members.

The goal of preconception (or prepregnancy) care is to optimize health outcomes by providing education and addressing modifiable risk factors.2 Any visit with a client who has reproductive potential is an opportunity for prepregnancy counseling. After a discussion of the client’s reproductive desires, a prepregnancy counseling conversation can be introduced, if relevant, with: “Since you said ______, would you like to talk about ways to be prepared
for a healthy pregnancy?” For example, the Preconception Counseling Checklist.
 

5. Make appropriate referrals based on the prepregnancy counseling conversation and assessment.[10]

Suggested team member(s) responsible: All care team members.

Referral and communication pathways between healthcare providers, community-based organizations, and state and public health agencies can enhance access to, and utilization of, services and supports for patients.

Making referrals encompasses a spectrum of potential information-giving and supportive behaviors ranging from providing information on specific services to follow-up on service utilization and outcomes and assessment of the quality of referrals. “Cold” and “warm” are often used to describe referral behaviors at two points along this spectrum. A cold referral means providing information to the client about another agency or service, and it is then the client’s responsibility to contact the agency or service. A warm referral involves contacting another agency or service provider on the client’s behalf. This entails calling and making an appointment for the client, viding support to overcome barriers to care, and following up to determine if the appointment has been kept.
 

6. Strengthen the quality and responsiveness of prepregnancy health services.

Suggested team member(s) responsible: All care team members.

Unique factors affect each client’s health. Health centers should provide prepregnancy health education, counseling, care and referrals that align with evidence-based guidelines and take into account the goals, risks, social needs, and contextual and environmental factors gathered during a client’s prepregnancy health assessment.
 

7. Collaborate with community partners to improve preconception health.

Suggested team member(s) responsible: All care team members, community health workers, outreach workers and navigators, community partners, and patients.

Although improving the quality of prepregnancy health services in the clinical setting is important, it is insufficient for reducing maternal morbidity and mortality at scale. Local and national agencies and local birth-centering programs must work together to address social needs, which drive health inequities within communities of color and increase their burden of poor health outcomes. Engaging in diverse collaborative community partnerships can help family planning agencies identify additional opportunities for improving maternal health outcomes.

For going deeper in this area, please see Key Activity 18: Strengthen Community Partnerships.

Endnotes

  1. Gavin, L.. Moskosky,S., Carter, M., et al. Providing Quality Family Planning Services Recommendations of CDC and the U.S. Office of Population Affairs. MMWR 2014;63(No.4) https://opa.hhs.gov/sites/default/files/2020-10/providing-quality-family-planning-services-2014_1.pdf&sa=D&source=docs&ust=1698619531900258&usg=AOvVaw3-09xEm3H3GcRyj-bnBDQq 
  2. Dehlendorf, Christine MD, MAS; Akers, Aletha Y. MD, MPH; Borrero, Sonya MD, MS; Callegari, Lisa S. MD, MPH; Cadena, Denicia BA; Gomez, Anu Manchikanti PhD; Hart, Jamie PhD; Jimenez, Laura; Kuppermann, Miriam PhD, MPH; Levy, Barbara MD; Lu, Michael C. MD, MS; Malin, Kiko MPH, MSW; Simpson, Monica; Verbiest, Sarah DrPH; Yeung, Miriam MPA; Crear-Perry, Joia MD. Evolving the Preconception Health Framework: A Call for Reproductive and Sexual Health Equity. Obstetrics & Gynecology 137(2):p 234-239, February 2021. | DOI: 10.1097/AOG.0000000000004255 
  3. Reproductive Health National Training Center. Preconception Health Toolkit. https://rhntc.org/resources/preconception-health-toolkit%23assessprog&sa=D&source=docs&ust=1698619531896866&usg=AOvVaw0TZiLyyoM-vB2qZHrI610Z 
  4. Centers for Disease Control and Prevention. Preconception Health and Health Care Is Important For All https://cdc.gov/preconception/overview.html 
  5. Healthy People 2030. Family Planning. https://health.gov/healthypeople/objectives-and-data/browse-objectives/family-planning&sa=D&source=docs&ust=1698619531898600&usg=AOvVaw1957CRBeIDezLf90-94IsE 
  6. Dude AM, Schueler K, Schumm LP, Murugesan M, Stulberg DB. Preconception care and severe maternal morbidity in the United States. American Journal of Obstetrics & Gynecology MFM [Internet]. 2022 Mar 1 [cited 2022 Nov 11];4(2). Available from: https://www.ajogmfm.org/article/S2589-9333(21)00245-7/fulltext 
  7. Verbiest, S., Frayne, D., McClain, E., Woodward, S. Preconception Health and Health Care Initiative. Women’s Health Practice Bulletin 2020 https://beforeandbeyond.org/wp-content/uploads/2021/02/phc-bulletin-0223211.pdf&sa=D&source=docs&ust=1698619531907693&usg=AOvVaw2KbKsCEHuY37mrI15cbFUq 
  8. Johnson, K.,, Posner,SF., Biermann, J., et al. 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. MMWR 2006. 55(RR06);1-23 https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm 
  9. Power to Decide. One Key Question 
  10. Reproductive Health National Training Center. Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers.