For years, women have had it drummed into them that prenatal care is the key to having a healthy baby, and that they should see a doctor as soon as they know they are pregnant.
But by then, it may already be too late. Public health officials are now encouraging women to make sure they are in optimal health well in advance of a pregnancy to reduce the risk of preventable birth defects and complications. They have recast the message to emphasize not only prenatal care, as they did in the past, but also what they are calling “preconception care.”
The problem, doctors say, is that by the first prenatal visit, a woman is usually 10 to 12 weeks pregnant. “If a birth defect is going to happen, it’s already happened,” said Dr. Peter S. Bernstein, a maternal fetal medicine specialist at Montefiore Medical Center in New York who helped write new government guidelines on preconception care.
For many women, Dr. Bernstein said, “The most important doctor’s visit may be the one that takes place before a pregnancy is conceived.”
The new guidelines, issued by the Centers for Disease Control and Prevention last spring, include 10 specific health care recommendations and advise prepregnancy checkups that include screening for diabetes, H.I.V. and obesity; managing chronic medical conditions; reviewing medications that may harm a fetus; and making sure vaccinations are up to date.
Much of the advice directed to women is fairly standard: they should abstain from smoking, alcohol and drugs, and should take prenatal vitamins, including folic acid.
For Diane Jackey, a mother of five from Hempstead, N.Y., maintaining preconception health meant continuing prenatal vitamins between pregnancies, snatching exercise whenever she could and maintaining a balanced diet. “I don’t smoke, and I don’t drink at all,” Ms. Jackey said.
What is new and somewhat controversial about the guidelines is the suggestion that they should apply to women throughout their reproductive years, even when they are not planning pregnancies. (Men should be wary of exposures to toxins that cause birth defects and should avoid sexually transmitted diseases, experts say.)
But while the report was criticized in some quarters for treating all women as though they were eternally “prepregnant,” it also discusses the importance of family planning and child spacing and encourages young people to develop a “reproductive life plan.” Half of all pregnancies in the United States are unplanned, experts say, and preparing for a healthy pregnancy can require behavioral changes that may take months. Even daily supplements of folic acid should ideally be taken for three months before conception.
“It’s not like we have an injection we can give someone” to prepare her for pregnancy, said Dr. Hani Atrash, associate director for program development at the National Center on Birth Defects and Developmental Disabilities at the disease centers. “Some of the interventions, like weight management, need time to happen. You cannot quit smoking in one day.”
The issue of preconception health has taken on added urgency in recent years because while infant mortality rates were on the decline from 1980 to 2000, the proportion of small and preterm babies increased significantly. And low birth weight, which has been linked to maternal smoking and multiple births, is a leading cause of death and disability for infants.
In 2002, the infant mortality rate in the United States increased for the first time in more than 40 years, to 7.0 deaths per 1,000 live births in 2002 from 6.8 deaths per 1,000 live births in 2001. The rate dropped back to 6.8 per 1,000 in 2003. Blacks are at the highest risk for preterm birth and low birth weights, and their infant mortality rates are more than double that of whites.
Meanwhile, rising obesity rates and the tendency to postpone motherhood mean far more women are overweight when they become pregnant and thus are more likely to have high blood pressure, diabetes or prediabetes, which complicate pregnancy.
“There is no question the No. 1 issue for women in America is their weight,” said Dr. Gary Hankins, who leads the committee on obstetrics practice of the American College of Obstetricians and Gynecologists.
Pre-existing diabetes significantly increases the risk of birth defects, but the risk is virtually eliminated if the disease is controlled before conception, Dr. Hankins said. Obese women who become pregnant face a higher risk of developing gestational diabetes and of having a large baby and a difficult delivery.
While doctors have been recommending preconception care for many years, it has never really caught on. Only one in six health care providers said they had provided preconception care to patients, one study found, and most health plans do not cover it. Medicaid, the government health plan for the poor, often only covers women after they are pregnant.
Rochelle Carr, 31, a Bronx mother, sought preconception counseling because she worried that her asthma medications might harm a developing fetus. Ms. Carr was also concerned because she had suffered a life-threatening pulmonary embolism, or blood clot to the lung, when she was 29.
Ms. Carr’s doctor referred her to a maternal fetal medicine specialist at Montefiore Medical Center. Dr. Ashlesha Dayal reviewed Ms. Carr’s medications and advised her to stop taking an asthma drug linked to birth defects and to start taking folic acid daily.
Once Ms. Carr became pregnant, Dr. Dayal prescribed an anticoagulant because Ms. Carr was at high risk for developing another blood clot. The doctor also explained the risks of taking the anticoagulant. “She really put my mind at ease,” said Ms. Carr, who delivered a healthy baby, Joshua, on Nov. 29, 2005.
Doctors say that planning pregnancies and using reliable contraception are part and parcel of preconception care, and they are encouraging all health providers — not just obstetricians but emergency room doctors, primary care physicians, cardiologists and endocrinologists — to counsel women of childbearing age about the possibility of pregnancy. “What we’re actually talking about,” Dr. Atrash said, “is women’s health.”
