Pregnancy Advice: An Overview

• What is preconception care?
• Why is preconception care important?
  • Optimising health before conception
• Interventions involved in preconception care
  • Addressing medical and reproductive issues
    • Reproductive life plan
    • Reproductive history
    • Current medication use
    • Genetic history
    • Physical examination
    • Substance use
  • Screening
    • Blood type
    • Antibody status
    • Sexually transmitted infections
    • Psychosocial health
    • Genetic conditions
    • Nutritional status
  • Vaccination and supplementation
    • Vaccination
    • Supplementation
  • Lifestyle interventions
    • Nutrition and exercise
    • Psychosocial health
    • Substance use cessation
    • Environmental health
    • Management of chronic health conditions
• Who should receive preconception care?
  • Women
  • Men
• Who provides preconception care?
• Who accesses preconception care?
• Limitations of preconception care

What is preconception care?

Preconception care refers to a set of interventions that aim to optimise a woman’s health before she conceives. The interventions address her current health by assessing medical, behavioural (e.g. smoking), and social (e.g. food access) risks to her health, and how these will affect the health of the foetus she is planning to conceive.
Preconception care typically involves:

• Health promotion (e.g. education and information dissemination);
• Nutritional planning and supplementation; and
• Screening and vaccination for diseases known to affect maternal health and pregnancy outcomes.

Preconception care focuses on strategies that can be implemented to improve maternal health and pregnancy outcomes before you fall pregnant. The health issues or risk factors addressed in preconception care are those that are likely to result in improved health outcomes if identified and managed before conception.
The health conditions and risk factors addressed in preconception care must be detectable in clinical practice (i.e. there must be a screening or diagnostic test that can detect it). They must also be sufficiently common and severe to warrant screening. Some conditions are so common that all women will be screened for them as part of preconception care (e.g. chickenpox). Others are only common in certain groups of women (e.g. young women have a higher risk of chlamydia), and in these cases only women who appear to be at high risk of the condition will be screened.

Why is preconception care important?

Hundreds of thousands of women die each year as a result of pregnancy complications. While such deaths occur most commonly in developing countries, maternal mortality and morbidity remains a significant threat to women’s health in developed countries. Poor outcomes during pregnancy can seriously impact on the lives of women, families and communities. Improving pregnancy outcomes is therefore important for improving the health of you and your family.
Poor pregnancy outcomes include:

• Maternal illness during pregnancy;
• Miscarriage or stillbirth;
• Poor outcomes for newborn babies, such as low birth weight and birth defects; and
• Poor childhood development.

For more information, see Complications of Pregnancy.

In Australia, 6% of babies are born at a low birth weight (weighing less than 2.5 kg). Factors relating to the pregnant woman, including complications of pregnancy, labour and delivery, account for 27% of infant deaths. Maternal factors are the highest single contributor to infant mortality, and many can be addressed through preconception care. Prematurity and low birth weight, which are often associated with maternal health and nutrition, account for a further 7% of infant mortality. Congenital malformations, which would be expected to reduce with improved preconception care, account for some 12% of infant deaths.

Optimising health before conception
While there are many steps you can take during pregnancy to improve the outcome, it is important to be in the best health before you become pregnant. For example, you have a much higher requirement for folate (a vitamin important for cell growth) during pregnancy. Your folate needs increase during the very early stages of pregnancy, before you have missed menstrual bleeding. Therefore you may not be aware that you are pregnant and need more folate.
Inadequate folate can have a severe impact on the developing foetus, and is associated with neural tube defects. Most women will need to increase their folate intake before pregnancy, and so preconception advice regarding folate supplementation is required. Increased folate intake is also required in the early months of the pregnancy. However, only 30% of women living in Victoria are aware of the need for folic acid before pregnancy, meaning that 70% are unlikely to increase their intake unless they receive advice to do so from their doctor.
In the United States, the increased costs associated with caring for a child born with an intellectual disability are estimated to be as much as US$1 million. In Britain, parents of disabled children spend three times more raising their child than parents of non-disabled children, and disabled children are 80% more likely to live in poverty than non-disabled children. Having a child with an intellectual disability may also involve suffering for the parents, family and carers, and create an additional burden for the healthcare system.
In Australia, 52% of women are obese. Without preconception advice, you may not be aware that obesity increases the likelihood of pregnancy complications, and may not make an attempt to control your weight. Smoking is a significant health issue amongst pregnant women in Australia, with 17% of all pregnant women and 42% of pregnant women under 20 saying they smoke during their pregnancy. In addition, 6% of Australian women use illicit drugs while pregnant. Less than half of Australian women who are planning a pregnancy report this to their doctor. These women are therefore unable to receive advice about appropriate medication use during pregnancy.
By dealing with these and other risk factors, preconception care has the potential to reduce pregnancy complications and birth defects.For example, there was a significant reduced number of neural tube defects in Australian babies, from 2% of live births in 1966, to 0.11% of live births in 1999. This was at least partly due to more folate supplementation before pregnancy.

Interventions involved in preconception care

Preconception care encompasses a variety of specific interventions.

Addressing medical and reproductive issues
During a preconception care consultation, your doctor typically makes enquiries to identify any issues that have the potential to complicate pregnancies, such as chronic health conditions.

Reproductive life plan
All women of childbearing age need to inform their doctor about their future reproductive plans, including whether or not they wish to have children, how many children they want to have, and when they plan to have children. Knowing when future pregnancies are planned will help your doctor to provide appropriate advice about related health services, including screening tests, vaccination and contraceptive use, as well as infertility services.

Reproductive history
Your doctor will usually ask about your previous pregnancies, and whether or not these were complicated, to assess the likelihood of complications in future pregnancies. For example, they may enquire about whether you have experienced gestational diabetes or intrauterine growth retardation in previous pregnancies.

Current medication use
Your doctor will ask you about any medication you currently use. Many medications reduce fertility or are potentially toxic to the foetus if taken during pregnancy. It’s important to tell your doctor about all medications used, including over-the-counter medications and herbal remedies, so that your doctor can consider whether or not they may have a negative effect on your pregnancy. Your doctor can recommend alternative treatment approaches, if needed.

Genetic history
Your doctor might ask about your and your partner’s genetic history, such as whether either of you have a family history of chromosomal abnormalities or congenital birth defects. If you have a family history of genetic disorders, you are more likely to conceive a foetus with a genetic abnormality, and your doctor may recommend a test to screen for genetic abnormalities in the foetus.

Physical examination
Your doctor will conduct a physical examination, which usually includes an assessment of body mass index, blood pressure, pap smear and breast examination. This may identify issues such as obesity or metabolic abnormalities that can affect the pregnancy if they are not managed before conception.

Substance use
Your doctor is likely to ask you about the use of non-medicinal drugs which may affect pregnancy outcomes, including tobacco, alcohol, and illegal drugs such as marijuana.All these substances are risky for foetuses if consumed during pregnancy. Your doctor can give you advice about how to quit these dangerous substances.
Excessive caffeine consumption during pregnancy can also have risks for the foetus, so your doctor may enquire about your caffeine consumption.

Screening
You may undergo a range of screening tests as part of your preconception care. These tests aim to identify undiagnosed health conditions which may affect pregnancy outcomes.

Blood type
A blood test will be taken to determine your blood type. Your and your partner’s Rh type will be assessed to determine whether Rhesus disease poses a threat to any pregnancy.

Antibody status
A blood test will also be used to identify antibodies which protect against specific diseases. The focus of these tests is to identify whether or not your blood contains antibodies to vaccine-preventable diseases that present a pregnancy risk, including:

• Varicella zoster virus (chickenpox);
• Rubella;
• Rubeola (measles);
• Mumps;
• Influenza;
• Diphtheria;
• Tetanus (lockjaw);
• Pertussis (whooping cough);
• Pneumococcal; and
• Hepatitis B.

If antibodies for any of these diseases are not present in your blood, you will require vaccination.

Sexually transmitted infections
Before conceiving, you will be screened for asymptomatic sexually transmitted infections (STIs), including syphilis, chlamydia and HIV. Many asymptomatic STIs have severe consequences if left untreated during pregnancy, including the risk of infecting the baby during delivery. Identifying STIs before conception allows most STIs to be treated and cured. There are some STIs which cannot be cured (e.g. HIV). However, identifying these infections will allow you to take steps to reduce the chances your baby will become infected.

For more information, see Screening Tests for Women Planning a Pregnancy.

Psychosocial health
Your doctor may enquire about your emotional wellbeing and whether or not there are any issues negatively impacting on emotional wellbeing. For example, your doctor may ask you about depression or anxiety.

Genetic conditions
Screening tests for genetic conditions such as chromosomal abnormality may or may not be done, depending on your and your partner’s likely risk and family history of genetic conditions. There are a numerous tests that can be conducted, including tests for Down’s syndrome, cystic fibrosis and neural tube defects.

For more information, see Genetic Screening for Hereditary Diseases.

Nutritional status
Doctors usually assess your nutritional status by calculating your body mass index (BMI) and whether or not you are deficient in particular micronutrients, including vitamin D and iron.

Vaccination and supplementation
Vaccination
Vaccines will be administered where necessary, as indicated by antibody screening tests. Be aware that many vaccines are not recommended for use in pregnancy or within 28 days of conception, and you should therefore avoid becoming pregnant immediately after having a vaccination.

Supplementation
You may need a range of nutritional supplements before or during pregnancy. Your doctor will assess your need for supplementation based on your nutritional status.
Folate supplements are provided to all women planning a pregnancy, for a month before conception and for the first three months of gestation.
 

For more information, see Vitamin and Mineral Requirements and Supplements during Pregnancy.

Lifestyle interventions
Lifestyle factors contribute to the development of many health conditions (including obesity and gestational diabetes) that affect pregnancy outcomes. It is therefore important to optimise your lifestyle before falling pregnant. Doctors can assist by providing advice and support if you are having difficulty modifying your lifestyle.

Nutrition and exercise
Doctors may provide you with advice about appropriate nutrition and exercise for optimal weight management, and also of the risks posed by being underweight or overweight during pregnancy. They can also advise you on the components of a healthy pregnancy diet and exercise before and during pregnancy.

For more information, see Importance of Healthy Eating Before and During Pregnancy.

For more information, see Pregnancy and Exercise.

Psychosocial health
Doctors can provide you with support and advice on psychosocial health issues which may complicate pregnancy. Such advice and support may include:

• Referral to psychological specialists if conditions such as depression are suspected;
• Referral to support groups or health professionals who can help in instances where domestic violence or relationship issues have the potential to affect the pregnancy;
• Strategies to help you cope with emotional health issues, such as relaxation techniques.

Substance use cessation
Health practitioners can advise you on using substances, including tobacco, alcohol and illegal drugs, and can provide support for quitting substance use.

Environmental health
The living environment contains many health risks for pregnancy. In particular, food-borne diseases such as listeriosis and toxoplasmosis pose a risk to pregnant women. Strategies for avoiding food-borne pathogens are often discussed during preconception care.

Management of chronic health conditions
Many chronic health conditions pose an additional risk during pregnancy. and it is often necessary to adjust the types and quantities of medication you are using to manage some chronic conditions, including:

• Hypothyroidism: Foetal neurological development may be impaired if your medication is not adjusted in early pregnancy;
• Diabetes: Proper medication management reduces the risk of birth defects three-fold;
• HIV: Medications can be given to reduce the risk of infecting the newborn baby;
• Epilepsy: Medication may need adjustment to reduce the toxic risks for the foetus;
• Hypotension and other disorders of blood pressure: Medications may need adjustment; and
• Phenylketonuria: Without proper management, the baby has an increased risk of mental retardation.

Who should receive preconception care?

Women
The primary target group for preconception care is women of childbearing age. Women who are planning to become pregnant may be aware of their need for preconception care. However, women who are not planning to become pregnant can also benefit from preconception advice. Up to 50% of pregnancies are unplanned, so women who are not planning to become pregnant may benefit from discussing reproductive planning and contraception. For those who are planning a pregnancy, care focuses on optimising health before conception occurs.
Evidence suggests that the majority of women of childbearing age are interested in receiving preconception advice. A preconception advice survey in the Netherlands indicated that 80% of women would be interested in receiving such advice immediately or when they planned to become pregnant.
If you wish to receive preconception advice and the issue is not broached by your doctor, you may want to discuss preconception care during a visit made for other purposes.

Men
Some preconception care strategies are targeted at men or couples. While a man’s health does not usually directly affect a developing foetus, his lifestyle, health and behaviours may affect the health of his pregnant partner. This in turn will affect foetal health. For example, you may be asked to:

• Stop smoking: Smoking in the presence of your pregnant partner can detrimentally affect the health of your partner and her developing foetus. If you choose to smoke while your partner is pregnant, do not to smoke in the house or near your partner;
• Screen for and treat STIs: Some STIs have particularly serious consequences if present during pregnancy. Screening and treating for them is of great importance while your partner is pregnant, as many men with STI do not show symptoms and are unaware of their infection. Despite the lack of symptoms, you can still infect your partner if you have an STI.
• Screen for genetic risk factors: Many genetic risks, including chromosome abnormalities, relate to your sperm;
• Reproductive planning: You play an important role in ensuring a pregnancy is planned and wanted, and should help your partner plan when you would like to reproduce;and
• Health promotion: Improve your knowledge, attitudes and behaviours relevant to pregnancy.

Who provides preconception care?

All health professionals who provide services to women of childbearing age are in a position to provide preconception care. These include:

• General practitioners;
• Nurses;
• Specialist doctors, including obstetricians and gynaecologists;
• Midwives;
• Allied health professionals, including:
  • Dietitians;
  • Educators, such as diabetes educators; and
  • Physiotherapists.

You can also receive preconception advice from a range of other sources, including:

• Community groups;
• Schools (particularly for adolescents); and
• Mass media, including television, internet, newspapers, magazines and radio.

Who accesses preconception care?

There is no information about the proportion of Australian women who access preconception care. Available statistics indicate that only a minority of Australian women are receiving adequate preconception care and many are unaware of the importance of preconception care. For example, statistics from Victoria indicate that only 30% of reproductive-age women (the target group for preconception care) are aware of the need for preconception folate supplementation. Less than half of women planning a pregnancy reported that their doctor was aware of their intention to conceive. It is important to discuss your intentions with your doctor.

Limitations of preconception care

Despite the effectiveness of preconception care in improving outcomes for you and your baby, there are many challenges to its provision that limit effectiveness. These include:

• Lack of time on the part of doctors, who may use the short time for a consultation to deal with immediate problems rather than preconception care;
• Lack of knowledge amongst the general public on the importance of preconception care;
• Preconception healthcare is rarely addressed in public health outreach campaigns; and
• Many pregnancies are unplanned, and thus women do not have the opportunity to access preconception care.

More information

For more information about pregnancy, including preconception advice, stages of pregnancy, investigations, complications, living with pregnancy and birth, see Pregnancy.

 

References

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