Preconception Health & Chronic Disease
Within the past ten years, chronic disease has emerged as one of the most serious public health issues in America. Nearly half of all Americans are living with at least one chronic disease, the treatment of which accounts for more than 75% of the nation's medical care costs. Women of reproductive age face unique challenges when it comes to preventing and treating chronic disease. Half of all women of childbearing age have one or more serious risk factors for developing a chronic disease. Avoiding, delaying, or achieving optimal pregnancy timing is often an important component of preconception care for women with chronic medical conditions. As such, health care providers should explicitly address reproductive life planning and contraceptive options for these women. By educating young women about chronic disease
prevention and management, providing supports for risk reduction, and proactively managing medications that are potential teratogens in a variety of settings, primary care providers, public health professionals, specialists and others can help to reduce pregnancy-related issues associated with chronic disease and improve women's health. Supporting preconception care throughout the lifespan is critical for ensuring optimal health for all women, but it is especially important for those with a chronic health condition.
Gestational Diabetes Collaborative: Better Data, Better Care
With an increase in obesity and maternal age, gestational diabetes (GDM) has increased greatly in the US in the last 20 years, with rates in some populations as high as 14%. GDM puts both the woman and her offspring at higher risk for pregnancy-related and life-long complications, including later development of type 2 diabetes. The American Congress of Obstetricians and Gynecologist (ACOG) defines Gestational Diabetes (GDM) as: "Carbohydrate intolerance leading to hyperglycemia with onset or first recognition during pregnancy." The American Diabetes Association cites "While blood glucose levels usually return to normal after delivery for most women, up to one-third of women with GDM will have type 2 diabetes or impaired glucose intolerance at postpartum testing 5-10 and up to 50% will develop diabetes during their lifetime." In fact, women with a history of gestational diabetes have 7.5 times the risk of developing diabetes compared to women without a history, and recent studies are also documenting an increase in early cardiovascular disease.
What are the Implications for Health Care Practitioners?
Health care practitioners have been good at monitoring for maternal and fetal complications during pregnancy, but not so proficient about making sure all patients have been appropriately diagnosed and counseled about GDM. Postpartum testing for type 2 diabetes has not been well integrated into clinical practice, with only an estimated 50% of women who had GDM during pregnancy receiving a postpartum glucose test.
While most practitioners agree on assessment of the risk for GDM for all pregnant women, they differ on testing procedures, diagnostic criteria, and target blood glucose levels during pregnancy. There continues to be differing opinions on diagnostic screening procedures and diagnostic criteria - that is, the two step versus one step procedure for screening and diagnosing - even though the 2013 NIH Consensus Development Conference: Diagnosing Gestational Diabetes Mellitus continues to support the two-step procedure. These continuing differences can affect the follow-up and management during the postpartum period, as doctors/patients have long considered two common and often concomitant pregnancy complications temporary medical problems: GDM and preeclampsia. But these two conditions should not be taken lightly, as recent studies have found that women with concomitant GDM and preeclampsia are 16-18 times more likely to have diabetes and cardiovascular disease. These conditions have also been linked to heart health problems in the offspring as early as young adulthood.
Gestational Diabetes Collaborative: Better Data, Better Care
The Collaborative, funded 5 years ago by the Centers for Disease Control and Prevention, Division of Diabetes Translation, was developed to address some of the barriers and issues to quality care. This multi-state collaborative with 9 states, academic centers and 4 tribes was charged to: identify, catalogue, and validate routinely-collected data about GDM; identify gaps in the quality of GDM prevalence data; develop interventions, based on validating the gaps, to improve access to care and increase postpartum follow-up; and enhance collaboration among public health programs.
These programs have conducted a variety of interventions for improving surveillance, improving care, and preventing type 2 diabetes. These programs are now disseminating their findings, including: GDM documentation is often inconsistent and missing in medical records, discharge data, and birth certificates; less than 50% of women with GDM receive a postpartum glucose screen; and few women with GDM or history of GDM receive an intervention for weight management or physical activity from their healthcare provider. These lessons learned can assist healthcare providers in deciding where to focus when improving the management of GDM and/or preventing type 2 diabetes.
Providers should consider the following when providing preconception and interconception care: 1) Check for history of GDM as well as pre-pregnancy Diabetes Mellitus. 2) If women of childbearing age have a positive history or high risk, provide counseling about pre-diabetes, the prevention of type 2 diabetes, and the increased risk of GDM if a pregnancy occurs. 3) Provide counseling for pregnant women with elevated screening levels, including information about their risk of developing type 2 diabetes, the potential consequences for their offspring, and the need for postpartum follow-up. 4) Provide appropriate postpartum follow-up for women with GDM, including counseling about weight management. For more information, please see the following resources: CDC's National Diabetes Prevention Program; National Diabetes Education Program - GDM What You Need to Know; American Diabetes Association Professional Resources Online.
*citations available upon request
CDC Resources on Chronic Disease Among Reproductive Age Women
The CDC website provides information on preventing and managing chronic disease to improve women's and infants' health
. Resources available include information on chronic disease prevalence among reproductive age women and the impact of chronic disease on pregnancy and infant outcomes, suggestions for women on reducing their chronic disease risk
including screening for chronic conditions, tobacco cessation
, and adequate exercise, and links to CDC programs and research to address chronic disease risk and management in the reproductive age population.
The Alliance for a Just Society
, a network of 14 racial and economic justice organizations, has released The Promise of Quality, Affordable Health Care for Women: Are States Delivering?
, a 50-state report card that ranks and grades states on a wide range of measures relating to women's health. It assesses states' performance in three subject areas: health coverage for women, women's access to health care, and women's health outcomes. Each section includes a range of data points and incorporates data on race and ethnicity where available.Young Invincibles
is an organization that seeks to ensure adequate representation of the voices of 18-34 year olds in policy debates and decisions that affect this population directly, such as the roll-out of the Affordable Care Act. Young Invincibles
has released a memo detailing the best practices on engaging young adults in health care
, including how to best reach young adults to educate them about new heal
th care coverage options and the core messages important to young adults considering coverage.
Access to health care is clearly a critical component of screening and prevention for many conditions, including chronic diseases.
PCHHC National Preconception Activities Assessment
On September 24, 2014, the PCHHC Initiative launched a nationwide assessment to learn more about current efforts to promote preconception health, determine how professionals have utilized existing campaign materials, and gather input for strategic planning. The electronic survey was distributed through the PCHHC newsletter contact list and a wide variety of partner listservs and networks. At the close of the assessment on October 24, 2014, there were 500 respondents. Thank you to everyone who took the time to participate!!
States with the greatest number of respondents included North Carolina, Florida, California, New York, and Rhode Island. While survey responses were received from every part of the country, overall, Region 4 had the highest proportion of respondents. A majority of these survey respondents (52%) self-identified as health or medical professionals (e.g. nurse, physician, clinician, health educator, social worker, nutritionist, etc.), while 36% of respondents identified as agency or organization managers/administrators. Few respondents identified as teachers or faculty (6%), statisticians or epidemiologists (4%), and students or fellows (2%). Additionally, most respondents reported working in a clinical setting (19%) or local or state health department (18%). Of those reporting their place of employment as "other," the most frequently stated organization types were federally qualified health centers, hospitals, residency programs, state Medicaid agency or department, and non-profit health services clinics. Many respondents also indicated being affiliated with a state or local infant mortality coalition and/or HRSA COIIN initiative. Other affiliations included local maternal, child, and adolescent health programs such as MIECHV, Title V-MCH block grant, and state level Healthy Start programs.
PCHHC Product Usage
Survey questions asked about respondents' usage of different preconception health materials. About 38% of survey respondents indicated that their state or agency had a preconception health website and educational materials. Some of these included Every Woman California, Every Woman North Carolina, Every Woman Wisconsin, the Wisconsin Association for Perinatal Care, and Utah's Power Your Life. Many respondents also listed their state and local health department websites as preconception health sites and materials resources. About a third of the states reported that they had some kind of preconception health strategic plan. Approximately 29% of respondents indicated that they receive the bi-monthly PCHHC newsletter, whereas 19% indicated their receipt of the CDC's bi-weekly emails with preconception health news and research. Twenty-six percent of respondents reported use of CDC's PRAMS data to search for preconception health indicators; 16% indicated that their organization participated in the Show Your Love Campaign; and 13% participated in the Linked by Life webinar series or other preconception health-related webinars in the past year.
Thirty-three percent of respondents indicated that they had visited the Before and Beyond website; 28% indicated that they had viewed the toolkit. The most helpful resources on the website, according to survey respondents, were the toolkit, CME modules/presentations, and the news and articles - for the most part, though, many respondents stated that the entire website is very useful. After the close of the survey, web metrics indicated that there was an increase in the number of people accessing these resources.
Respondents were asked to give feedback in regards to what the workgroups were doing well - here are some quotes: "Show Your Love was a great example of what we can do -- we need to build on our success and take it to the next level," "Keeping the issue alive and supporting us in the field with new tools, materials, etc. is great," and "The energy, drive and commitment of the workgroups is commendable." When asked if they had an interest in being more involved with the initiative - the greatest areas of interest for respondents included public health practice, clinical care and practice, and integration into home visiting and child health services. Interested in getting involved? Email Sarah Verbiest at firstname.lastname@example.org.
Activities in the Field
Partners are now working to reach their traditional MCH target groups, particularly adolescents and new mothers, with new messages such as reproductive life planning. Home visiting programs are expressing an interest in learning more about dyadic care - providing preventive services not only to the baby, but to the mother and the father as well. Some programs such as Peer to Peer Educators are beginning to reach beyond the traditional MCH target audience to serve young women and men who may very much want to stay far beyond our net of services for many years. There is also an increased emphasis on placing more responsibilities on providers and the larger system. There has been a gradual shift away from prenatal as a single focus.
Participants had many ideas for moving preconception health agenda forward. They suggested that health care providers and systems need to invest time in offering comprehensive screening and services to young women and men, with an eye toward supporting their reproductive intentions. They need to see this not only as a critical investment in preventive health services for two generations, but an intervention that offers a strong return on investment. Family planning services, including LARC, must be accessible.
There is a clear desire for significantly increased national visibility for preconception health via an expanded Show Your Love campaign and national website. Respondents thought this visibility would bolster their efforts to get the work out and to gain the attention of policy makers / budget makers. Respondents encouraged the PCHHC to continue to develop tools and resources to support work with adolescents, in communities, with men, and with special populations, as well as additional practice supports, including model policies, expanded consumer information, and clinic tools.
They also stressed that it is important for us to continue to focus on metrics, measures, return on investment calculations, and reimbursement as ways to move change through benchmarking, accreditation, and demonstrated revenue generation. Finally, but most importantly, we need to lead with health equity, using a new narrative to breathe fire into what we've always highlighted in that we need to address the conditions that either inhibit or support health and wellness.
Mark Your Calendars!
Please save the date for a two-part webinar series on preconception health and chronic disease prevention and management:
Wed, 1/14 at 1pm EST
Wed, 2/18 at 1pm EST
has published a series of open-access systematic reviews examining the impact of public health preconception interventions on maternal and child health
in a supplement titled Preconception Interventions
. These articles highlight current understanding regarding how maternal and paternal preconception health and knowledge shapes the long-term health of children, families, communities, and nations.
White House Council on Women and Girls Releases Report
The White House Council on Women and Girls has released Women and Girls of Color: Addressing Challenges and Expanding Opportunity
. The report profiles the status of women and girls of color, providing extensive information on health, including maternal and child health, reproductive health, violence, and health inequities, and the federal programs available to address these issues. Beyond health, the report
also provides information on education, economic security, and criminal and juvenile justice.
2014 Premature Birth Report Cards
March of Dimes has released the 2014 Premature Birth Report Cards
. Assessing prevention strategies and rates among different races and ethnicities, the report cards
provide information for each state, as well as the US as a whole. With 1 in 9 neonates born premature, the US ranks poorly among other Very High Human Development Index countries. The March of Dimes has detailed a new target rate of 5.5% for the US by 2030 in a special article in the Dec 2014 issue of Pediatrics
titled Fighting for the Next Generation: US Prematurity in 2030
Tobacco Cessation Resources Available
There are a variety of resources available for women seeking to quit tobacco use and the health care providers assisting them. The CDC has developed tobacco cessation websites specifically for women
and, also, for pregnancy and motherhood
. CDC has also released updated information on preventing tobacco use during pregnancy
, including information about tobacco use among reproductive age women. Quitlines are free, telephone-based tobacco cessation services that help tobacco users quit. Today, residents in all 50 US states, Puerto Rico, Guam, and DC have access to quitline services. The North American Quitline Consortium Quitline Map can help you find information about your state's quitline and the services they provide.
Sign Up for Bi-Weekly Preconception Updates to Your In-Box
To receive a bi-weekly media and literature update on preconception and interconception health through a listserv, please email Cheryl Robbins
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