The Importance Of Using Primary Care Providers To Promote Preconception Health

Preconception health (PCH) is an emerging discussion in the health world. It has become apparent that it is important for women of child bearing age (18-44 years) to be thinking about their health and lifestyles well before they are even considering having a child. When looking at the statistics, about 50% of pregnancies are unplanned. Knowing this, and the fact that the first couple of weeks post implantation are a critical period for fetal development, tells us that waiting to think about your health until after you have found out that you are pregnant can be too late.

PCH promotes healthy fertility through risk reductions, promoting healthy lifestyles and increasing readiness for pregnancy, whether you are planning to have a child or not. By providing information on PCH the hope is to educate primary health care providers on the importance of educating their patients as well as raise awareness of a new screening tool brought out by Public Health. To further improve preconception care (PCC), women and men of reproductive age must be educated on the possible risk factors, prevention and management. The primary aim of PCC is to establish a health care routine with regular risk screenings, health promotion and other effective interventions, rather than just a one-time visit. These interventions aim to identify and adjust biomedical, behavioural and social risks. Current evidence suggests multiple prevention and management methods.

A key component of PCH is to engage in a healthy lifestyle. This includes developing a healthy balanced diet to prevent malnutrition and obesity. Proper nutrition provides many health benefits for both mental and physical well-being. Calcium, vitamin D and folic acid are three primary micronutrients that offer the most benefits before and during pregnancy. Vitamin D aids in the absorption of calcium, and both are essential for bone health, neurological and muscular functions. Folic acid is a crucial nutrient for preconception as it is associated with reducing risks of neural tube defects and other crucial birth defects such as cancers and vital organs anomalies. Obesity before pregnancy is associated with an increased risk of infertility, higher chance of miscarriage and other maternal and/or fetal risks. Obesity during pregnancy also results in various maternal and perinatal complications including hypertension, preeclampsia, gestational diabetes mellitus, and congenital anomalies such as neural tube defects. In addition, there is an increased risk of mortality during pregnancy. Being underweight can cause complications as well, such as intrauterine growth restriction.

Engaging in a healthy lifestyle also consists of daily exercise as well as eliminating any harmful substance use. 150 minutes of moderate intensity exercise per week is recommended to maintain physical and cardiorespiratory fitness. Additional benefits include improved mental health and decreased stress. Substance use such as cigarette smoking and alcohol exposure during pregnancy negatively affect both the mother and infant. Therefore, it is important for women to minimize substance use and be aware of the risk factors of smoking and drinking prior to pregnancy. During PCC or pregnancy, cigarette smokers should focus on non-pharmacological therapies for cessation such as behavioural therapy and educating themselves before attempting any other therapies. If unsuccessful, pharmacological aids such as bupropion and nicotine replacement therapies (nicotine gum and patches) have been reported fairly safe. However, most studies that were conducted on nicotine replacement therapies (NRT) were not strong enough to confirm that the use of pharmacological aids is safe. A study done by Wright et al. (1997) consisted of a sample size of only six participants, and a second study conducted by Schroeder et al. (2002) consisted of only 21 participants. With a sample size this small, this information cannot be considered significant. Furthermore, the study done by Wright el al. (1997) was only a 21-hour period, which is not a sufficient amount of time to be able to determine the effects of NRT on maternal or fetal affects. Overall, more significant research needs to be conducted on the safety of these pharmacological aids. Due to this, women of child bearing age should cease cigarette smoking to avoid any difficulties for cessation during pregnancy in the future. Furthermore, failing to cease alcohol consumption will lead to multiple fetal disorders including; prenatal and postnatal growth retardation, facial dysmorphia, microcephaly and behavioural issues.

It is crucial for women to address unhealthy behaviours and seek professional help when planning for pregnancy. Preconception health is vital for women with chronic conditions such as diabetes, thyroid disorder, hypertension, cardiac disease and more. The most prevalent and studied chronic condition is diabetes. Diabetes care must begin before conception to prevent congenital malformations and spontaneous abortions. The American Diabetes Association states four main components for successful preconception diabetic care which include: patient education on the disease, education about self-management skills, physician-directed assessments and laboratory testing, and undergoing counseling with a mental health professional to reduce stress and maintain commitment to diabetes treatment.

The main goal for a diabetes treatment plan is to achieve blood glucose control and obtain the lowest amount of hemoglobin A1C without excessive risk of hypoglycemia in the patient. The aim is to maintain levels less than 1% above the normal range. This is where a female patient with diabetes must develop self-management skills and take action. The American Diabetes Association (2002) and Lassi, Z. S. et al. (2014) both state that women who participated in PCC had lower levels of A1C compared to the women who did not participate in PCC. This decrease in A1C levels lead to noticeable reductions in infant malformations. Overall, promoting regular PCC will optimize a woman’s health and pregnancy outcome while limiting any potential risk factors.

The My Health eSnapshot (MHeS) tool is an online survey program that provides information to the general population (of reproductive age) about their reproductive health. The MHeS tool also works to assess and identify risk factors that are correlated with reproductive or sexual health including “genetics, nutrition, weight, physical activity, oral health, chronic diseases, infections, immunizations, substance use environmental toxins, mental health, stress and more”. In February of 2016 the MHeS study launched by public health in primary care sites in the Wellington-Dufferin-Guelph area as a three-part model, with a sample size of 300 participants between the ages of 15 and 49 years. First the patient completed the survey with their regular physician, saving results into the patient’s electronic medical record. Results were then discussed with the physician. Finally, the patient was provided with a printed copy of their information to reference at home. Each participant was screened for a total of 34 risk factors relating to preconception health yielding an average of 15 present risk factors per participant (ranged 4 to 24). The most common risks present among patients included not following Canada’s food guide, experiencing stress within a year, and consuming unsafe foods (uncooked, high mercury, caffeine).

After all participants had completed the three-stage model two follow up surveys were completed, the first taking place after one week and the second after 2 months. 188 of the 300 participants completed the one-week study and results were positive, outlining that completing the MHeS was a positive, safe and comfortable experience. 144 of the 300 participants completed the two-month survey, claiming that they learned about the importance of PCH, were encouraged to make positive behavior changes based on their personalized MHeS print out and even obtained more information regarding their PCH post study. These results go to show the positive impact of PCH on people of reproductive age. Without the introduction of the MHeS tool they likely would not have made steps towards healthier preconception lifestyles, and likely would not have even considered their current lifestyles impact on their future outcomes with potential pregnancy. This shows that almost 50% of the people in the study had a benefit from the MHeS tool. When interviewed, primary health staff reported that the MHeS tool worked very well in providing patients with information about their preconception health, however outlined some limitations and suggestions.

Primary health care providers were concerned with the time that it takes to complete the survey with limited appointment time, suggesting that the survey be shortened and offered during specific appointment types (PHC, physicals and family planning). Primary health care providers have expressed interest in the use of this tool given that the recommended changes be made to the survey model. According to the statistics 94% of women in Ontario have a regular medical doctor, which illustrates the importance of using primary care providers to promote preconception health and the MHeS tool.