1. Connecting the Dots: The Evidence and Significance of Preventive Care for All Women Merry-K. Moos Professor (retired) Department of Obstetrics and Gynecology University of North Carolina mkmoos@med.unc.edu

2. Rationale The major contributors to women’s morbidity and mortality are also major contributors to poor pregnancy outcomes (e.g. nutritional/weight status, tobacco/alcohol exposures; poorly controlled chronic diseases, immunization status, etc.) By emphasizing the promotion of women’s wellness at every visit, we have the potential to impact the health and well-being of women themselves...and achieve higher levels of wellness for women who become pregnant [which will result] in a better pregnancy outcome for women and their infants.

3. Differs from Other Articles Emphasis on health promotion (rather than disease prevention) Rather than providing “burden of suffering” this article provides “burden of risk”. Determination of risk generally relies on patient disclosure (rather than laboratory testing or physical assessment findings)

4. Topics Reviewed Reproductive life plan Physical activity Nutritional status Weight status Specific nutrient intake Immunizations Substance use Tobacco Alcohol STIs

5. Family planning and reproductive life plan Routine health promotion activities for all women of reproductive age should begin with screening women for their intentions to become or not become pregnant in the short and long term and their risk of conceiving (whether intended or not). Providers should encourage patients (women, men and couples) to consider a reproductive life plan and educate patients about how their plan impacts contraceptive and medical decision making. Every woman of reproductive age should receive information and counseling about all forms of contraception and the use of emergency contraception that is consistent with their reproductive life plan and risk of pregnancy. Strength of evidence: A Quality of evidence: III

6. Weight status All women should have their body mass index (BMI) calculated at least annually. All women with BMIs > 26kg/m 2 should be counseled about the risks to their own health, the risks for exceeding the overweight category, and the risks to future pregnancies, including infertility. These women should be offered specific behavioral strategies to decrease caloric intake and increase physical activity and be encouraged to consider enrolling in structured weight loss programs. All women with a BMI < 19.8kg/m 2 should be counseled about the short- and long-term risks to their own health and the risks to future pregnancies, including infertility. All women with a low BMI should be assessed for eating disorders and distortions of body image. Women unwilling to consider and achieve weight gain may require referral for further evaluation of eating disorders. Strength of evidence: A Quality of evidence: III Next

7. Nutrient Intake All women of reproductive age should be assessed for nutritional adequacy and receive a recommendation to take a multivitamin supplement if any question of ability to meet the recommended daily allowance through food sources is uncovered. Care must be taken to counsel against ingesting supplements in excess of the recommended daily allowance. Strength of evidence: A Quality of evidence: III Next

8. Folate and Folic Acid Intake All women of reproductive age should be advised to ingest 0.4mg(400µg) of synthetic folic acid daily from fortified foods and/or supplements and to consume a balanced, healthy diet of folate-rich food. Strength of evidence: A Quality of evidence: I-a

9. Immunizations All women of reproductive age should have their immunization status for tetanus-diphtheria toxoid and diphtheria-tetanus-pertussis; measles, mumps, and rubella; and annually for health, lifestyle, and occupational risks for other infections and be offered indicated immunizations Strength of evidence: A Quality of evidence: III

10. Human Papillomavirus (HPV): Women should be screened routinely for HPV-associated abnormalities of the cervix with cytologic (Papanicolaou) screening. Recommended subgroups should receive the HPV vaccine for the purpose of decreasing the incidence of cervical abnormalities and cancer. By avoiding procedures of the cervix because of abnormalities caused by HPV, the vaccine could help maintain cervical competency during pregnancy. Strength of evidence: B Quality of evidence: II-2

11. Substance use All women should be assessed for use of tobacco at each encounter with the healthcare system; women who smoke should be counseled to limit exposure. All women should be assessed at least annually for alcohol use patterns and risky drinking behavior and be provided with appropriate counseling; all women should be advised of the risks to the embryo/fetus of alcohol exposure in pregnancy and that no safe level of consumption has been established. Strength of evidence: A Quality of evidence: II-2 (tobacco) Quality of evidence: III (alcohol)

12. Summary The logic of identifying areas for health promotion counseling in order to reduce health risks to women, pregnancies and offspring is difficult to refute. The strength of the health promotion recommendations relative to preconception care were consistently “A” However, science lags behind logic and the quality of the evidence was seldom better than “III” (opinions gathered from expert authorities, descriptive studies, case reports or reports of expert committees.

13. Where to from Here? Need research that moves the quality of the evidence around health promotion recommendations from “III” to a higher level. Patient behavior choices are influenced by so many inputs it will be difficult to determine: If provider inputs are critical in determining behavioral choices The impact of ideal vs realistic frequency and dose of provider inputs The impact of provider inputs on preconception wellness and pregnancy outcomes

14. A Reality Check Minutes spent with patients declining Expectations of those minutes is expanding One 2009 study of family med physicians found: To meet the preventive, chronic and acute needs of an average family practice panel would require 21.7 hours a day. To meet only preventive guidelines would require 7.4 hours each day.

15. Bottom Line: Need innovations in service delivery Lessons from Southwestern Airlines: Just because it’s always been done one way doesn’t mean it’s the most efficient way to get it done! Need to design and test small, medium and large innovations to determine if they impact process and outcomes

16. A Very Few Ideas Engage women in previsit preparation including consideration of reproductive life plan Have women identify 2-3 health goals for next year prior to visit Utilize computer prompts to guide most important health promotion assessments Use clear algorithms to guide care (e.g Wisconsin model) Personally tailor health promotion and wellness messages with tools like wellness prescriptions Use support staff to promote wellness (office champions, every phone call started with a greeting that includes “have you had your folic acid today?”, etc.) Exploit opportunities of health care homes (Note: use of “health” rather than “medical” as descriptor)

19. Other Ideas Needed...Please apply

20. Resources: Moos, MK. Speeding the progress to improved health and wellness for North Carolina’s women. NC Med J. 2009; 70 (5): 427-431. All of the articles from the AJOG Suppl Preconception Health and Health Care: The Clinical Content of Preconception Care (eds: Jack and Atrash) available at www.beforeandbeyond.orgwww.beforeandbeyond.org