1. TM 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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3. 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

4. TM 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”

5. TM 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?

6. TM 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

7. TM Do We Have The Science? Today’s climate: Scientific evidence + Business Case

8. TM Do We Have The Policy?  We have recommendations from professional organizations  We have no national policy No “legal obligations” No accountability

9. TM Current “Policy” There is consensus that preconception care should be provided to all women

10. TM 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.

11. TM 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.

12. TM “Current Policy” U.S. Public Health Service Expert Panel Preconception care is a critical component of prenatal care

13. TM 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

14. TM 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

15. TM 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

16. TM 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.

17. TM 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

18. TM 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!!!

19. TM Common Excuses: Challenges, Barriers  Unplanned pregnancies  Better definition of components  Timing  Target population  Training and education: Providers Policy makers Consumers  Policy development and implementation $$$ Reimbursement $$$

20. TM 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?

21. TM 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?

22. TM Who Should Provide It? Or, Who should provide what?  Obstetricians/Gynecologists  Other physicians  Nurses  Social workers  Health educators  The media  Schools  Others

23. TM 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?

24. TM 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?

25. TM When Do We Provide It?  Between pregnancies?  Few months before pregnancy?  A year before pregnancy?  At every encounter with the health care system?

26. TM 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?

27. TM 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

28. TM 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

29. TM Making the Scientific Case Qualitative 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

30. TM Making the Scientific Case Qualitative 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

31. TM Making the Business Case Quantitative Assessment of Components Also Maternal PKU, oral anticoagulant use, Anti-epileptic drugs, accutane use, smoking, alcohol, obesity

32. TM Making The Business Case Target Population: 2000 Statistics 2,069,995Intended Births 1,988,819Unintended Births 77,519Very Preterm 57,967Very Low Birthweight 467,201Preterm 307,030Low Birthweight 857,475Induced abortions 80,759,000Women 15-44 years

33. TM 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

34. TM 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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