Prenatal care seems to get all of the attention in maternal health. But preconception health may be even more important.
Prenatal care undoubtedly is an important component of ensuring a healthy pregnancy. However, such care is often too late because it cannot undo years of damage to health. The first few weeks after conception are the most critical for fetal development. Most women are not aware that they are pregnant until after this critical period.
This lack of awareness contributes to adverse pregnancy outcomes such as low birth weight and premature births, which are higher in the U.S. compared to other industrialized nations. The U.S. lags despite important advances in medicine and prenatal health in recent years.
Much of preconception health can be addressed simply by ensuring women get healthy –and stay healthy—throughout their lives.
Texas tracks preconception health through its Pregnancy Risk Assessment Monitoring System (PRAMS). The ongoing survey collects data on maternal health behaviors, experiences and health before, during and after pregnancy.
Among the women it surveyed from 2002 to 2010:
• Nearly half had no health-insurance coverage before pregnancy.
• Nearly 2 out of 3 Hispanic women, who account for half of Texas births, lacked insurance.
• Three out of four did not take daily multivitamins the month before pregnancy.
• Nearly half said their pregnancies were unintended.
• Nearly half said they consumed alcohol during the three months before pregnancy, including 18 percent who reported they were binge drinking.
Experts encourage women who plan to become pregnant to take 400-800 micrograms of folic acid; stop smoking and drinking alcohol; ensure vaccinations are up to date; control medical conditions such as diabetes, obesity, asthma and epilepsy; discuss prescription and over-the-counter medications with their physicians, and avoid toxic substances at home or at work.
During the study’s eight years, there was a statistically significant increase in obesity and binge drinking among Texas women.
A group of University of North Texas Health Science Center researchers in 2007 surveyed 400 women of child-bearing age in four Fort Worth zip codes that were among the nation’s worst 25 in infant deaths. About 58 percent were black and 33 percent were Hispanic.
What they found:
• Nearly 36 percent had less than a high school education.
• About 71 percent were not married.
• More than 69 percent were overweight or obese, about 25 percent reported feeling depressed or hopeless nearly every day, and more than 8 percent had been physically abused in the past year.
• An astounding 82 percent were uninsured, compared to about 37 percent of women 18-44 in Texas and about 21 percent nationally.
• Few took advantage of safety net programs. Although most U.S.-born women were eligible for the JPS Health Network, only about 9 percent were enrolled. About 22 percent said they had no pregnancy-health coverage despite the fact that county and state programs cover all pregnant women in Fort Worth.
They found frequent negative health behavior such as smoking, binge drinking and illegal drug use regardless of whether the women intended to become pregnant. Symptoms of depression ranged from about half of women who did not plan to become pregnant to more than 88 percent among those who intended to become pregnant within two years.
One of the researchers was Amy Raines-Milenkov, assistant professor of obstetrics and gynecology, and member of UNT’s FOR HER Institute, which seeks to improve women’s lifelong health.
She said preconception health “shifts the conversation away from the time of pregnancy, which is more tangible and appealing.”
Key Barrier: Lack of Access
Raines-Milenkov said the key barrier to preconception health is lack of access to healthcare. Medicaid pays for 59 percent of Texas births. However, it does not cover women prior–or in between –pregnancies.
She said the Affordable Care Act is consistent with the goals of preconception health because it offers the opportunity for continuous insurance coverage. As of Aug. 1, preventive services for woman that have no cost sharing include contraception, domestic violence screening and counseling, folic acid supplements, tobacco use screening, and counseling for sexually transmitted infections.
Raines-Milenkov said insurance is part of preconception health, but ultimately it depends on personal responsibility.
“It’s about preparing and planning to become pregnant and taking steps not to get pregnant, especially if your health conditions are not managed yet,” she said.
Mary Lou Wilson, director of women’s services leader at Texas Health Harris Methodist Hurst-Euless-Bedford, said her hospital plans to work with local school districts this fall to encourage students to maintain life-long health.
“That is how you get preconception health. We don’t start early enough,” she said.
Julia Flowers, M.D., said Baylor also does not have a formal preconception program. The Baylor Grapevine-based gynecologist and obstetrician said she routinely does preconception counseling with her patients during annual exams. Patients in the hospital’s affluent suburban service area proactively seek her out to do preconception counseling.
“We wish they would seek us out even more,” she said.
Texas is one of seven states that attempted to propose measureable preconception health indicators at the state level. In 2011, the Texas legislature appropriated $4.1 million for the Health Texas Babies initiative to decrease infant mortality by using evidence-based interventions. The goal is to reduce pre-term births by 8 percent and save $7.2 million in Medicaid costs.
Steve Jacob is editor of D Healthcare Daily and author of the new book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at [email protected]