1. Variations In Women’s Knowledge And Attitudes Regarding Preconception Healthcare Peter S. Bernstein, MD, MPH Professor of Clinical Obstetrics & Gynecology and Women’s Health

2. Introduction Women vary in their knowledge of the importance of Preconception Care Frey and Files surveyed 499 women attending an Internal Medicine/Family Medicine private practice in AZ. –98% recognized the importance of improving health prior to conception –Responses to knowledge questions were correct 54-99% of the time –39% recalled their MD speaking about Preconception Health issues Matern Child Health J, 2007

3. Introduction A second study of mostly Mexican-American women (n = 305) of lower socioeconomic status found: –Lower levels of correct responses to knowledge questions (range 30-94%) –But 95% knew it was important to improve health prior to conception –41% reported that an MD had spoken to them about the importance of preconception health Coonrod et al., Am J Obstet Gynecol 2009

4. Knowledge that folic acid should be taken before pregnancy US, 1995-2008 Nationally representative telephone surveys conducted by Gallup, targeting approximately 2000 English-speaking women ages 18-45 each year. Margin of error is +/- 3%. Survey not conducted in 1996 and 1999. Source: March of Dimes Folic Acid Surveys, conducted by Gallup. Retrieved June 2, 2011, from www.marchofdimes.com/peristats.

5. Daily use of folic acid among women 18-45 years US, 1995-2008 Nationally representative telephone surveys conducted by Gallup, targeting approximately 2000 English-speaking women ages 18-45 each year. Margin of error is +/- 3%. Survey not conducted in 1996 and 1999. Source: March of Dimes Folic Acid Surveys, conducted by Gallup. Retrieved June 2, 2011, from www.marchofdimes.com/peristats.

6. Knowledge that folic acid prevents birth defects US, 1995-2008 Nationally representative telephone surveys conducted by Gallup, targeting approximately 2000 English-speaking women ages 18-45 each year. Margin of error is +/- 3%. Survey not conducted in 1996 and 1999. Source: March of Dimes Folic Acid Surveys, conducted by Gallup. Retrieved June 2, 2011, from www.marchofdimes.com/peristats.

7. Objective To survey and compare non-pregnant reproductive age women seeking care at two different OBGYN practices that serve differing populations: –Larchmont Women’s Center primarily serves women with private commercial insurance (PCI) –Comprehensive Family Care Center, a Federally-qualified Community Health Center (CHC) that primarily serves women on public assistance.

8. Methods Self-administered survey of knowledge and attitudes regarding preconception care developed by Frey and colleagues (Matern Child Health J, 2007) –Utilized 5 point Likert scale and multiple choice questions –Available in English and Spanish –Completed while waiting for visit –Classified as “Exempt” by the IRB

9. Methods Primary outcome variable: Awareness of the need for preconception care Sample size calculation: –Assuming the PCI group had a similar belief in the need for preconception care (98%) –100 patients needed in each group to detect a 5% difference in response by the CHC group

10. Results: Demographics CHC (n=105) PCI (n=108) p-value Age (years)*30.0 (7.6)30.8 (7.8)0.003 Race** Black Hispanic Asian Caucasian Other 35 (34%) 41 (40%) 4 (3.9%) 3 (2.9%) 19 (3.7%) 19 (18.3%) 10 (9.6%) 4 (3.8%) 62 (59%) 9 (19%) <0.001 Cohabiting with partner** 49 (48%)59 (55%)0.273 *mean (SD) **n (percent)

11. Results: Demographics CHC (n=105) PCI (n=108) p-value Education <12 th grade High school graduate Some college/technical school College graduate Some graduate education Graduate degree 14 (14%) 22 (22%) 37 (37%) 21 (21%) 4 (4%) 3 (3%) 2 (2%) 6 (5.6%) 29 (27%) 35 (33%) 9 (8.4%) 26 (24%) <0.001 Annual Income < $25,000 $26-50,000 $51-75,000 $76-99,000 > $100,000 48 (52%) 35 (38%) 7 (7.6%) 2 (2.2%) 0 12 (12%) 25 (25%) 21 (21%) 10 (9.8%) 34 (33.6%) <0.001 Note: n (percent)

12. Results: Reproductive Characteristics CharacteristicCHC n (percent) PCI n (percent) p-value Pregnancy Plans No Plans Trying, hope to be pregnant Hope to be pregnant in 1-2 years Hope to be pregnant in 3-5 years Not able to get pregnant 63 (62%) 13 (13%) 6 (5.9%) 15 (15%) 5 (4.9%) 72 (67%) 3 (2.8%) 14 (13.1%) 16 (15%) 2 (1.9%) 0.024 Ever pregnant84 (80%)57 (53%)<0.001 If ever pregnant, prior unplanned pregnancy a 59 (70%)34 (58%)0.119 Currently using contraception b 47 (51%)67 (64%)0.059 a.Respondents: CHC=84; PCI=59 b.Respondents : CHC=93; PCI=105

13. Results: Preconception Health Info. ItemCHC n (percent) PCI n (percent) p-value Has a doctor spoken to you about “preconception health”? 61 (59%)45 (43%)0.015 Interested in receiving preconception health education. (Very interested/ Somewhat interested) 67 (65%)63 (59%)0.329 When would you prefer to receive preconception health education? ** 1. At the time I become pregnant 2. Before I try to get pregnant 3. During pregnancy and until delivery 4. Every time I get an annual exam 5. Unsure 10 (11%) 40 (42%) 5 (5.3%) 22 (23%) 18 (19%) 4 (4.0%) 5 (59%) 2 (2.0%) 21 (21%) 14 (14%) 0.095 **Respondents: CHC=95; PCI=100

14. Results: Selected Knowledge Questions QuestionsCHC n (%) PCI n (%) p-value Review of medications prior to pregnancy93 (89%)103 (97%) 0.024 Talk to doctor about diseases in the family prior to getting pregnant 92 (86%)84 (79%)0.052 Important to be tested for infectious diseases before getting pregnant 91 (89%)104 (97%) 0.021 Important to be tested for infectious diseases before getting pregnant 91 (89%)104 (97%) 0.021 Regular exercise can harm an unborn child69 (68%)88 (82%)0.015 A woman thinking about getting pregnant should avoid some fish products 57 (59%)76 (73%)0.041

15. Results: Selected Patient Attitude Items ItemCHC n (%) PCI n (%) p-value A woman should improve her health if considering getting pregnant 91 (89%)106 (99%) 0.002 A woman has control over her health74 (72%)95 (88%)0.002 A woman needs help of health professionals to improve her health 77 (77%)68 (68%)0.044

16. Discussion Interest in preconception health was high in both groups (approx. 60%) Responses to knowledge tended to be >80% correct though gaps existed Women of lower socioeconomic status tended to do less well on knowledge questions

17. Discussion Providers at CHC were more likely to have raised preconception health as a topic (though low at both sites) Need apparently greater at CHC site –Knowledge deficit greater –Women at CHC felt less in control of their health –More women at CHC site felt that the help of a health provider was needed to improve health

18. Thanks to my co-authors: Shilpi Mehta, MD Yves-Richard Dole, MD Lisa Simmonds, MD Ashlesha Dayal, MD Setul Pardanani, MD