Anne L. Dunlop

Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age

By addressing the reproductive intentions and contraceptive practices and needs of every patient, providers may be able to decrease womens chances of experiencing unintended pregnancies and support women in achieving planned and well-timed pregnancies. By addressing the health promotion needs of every patient and examining and addressing her health profile for reproductive risks, irrespective of her desires for pregnancy, it is likely that more women will enter pregnancy with high levels of preconception wellness and that healthier women and healthier pregnancies and infants will result. The importance of the integration of reproductive planning and health promotion into womens routine healthcare is further emphasized when the potentially far-reaching effects of reproductive outcomes (such as unintended pregnancies, adverse pregnancy outcomes, pregnancy complications, and sexually transmitted infections) on womens health, well-being, and life circumstances are considered.

The clinical content of preconception care: nutrition and dietary supplements.

Women of child-bearing age should achieve and maintain good nutritional status prior to conception to help minimize health risks to both mothers and infants. Many women may not be aware of the importance of preconception nutrition and supplementation or have access to nutrition information. Health care providers should be knowledgeable about preconception/pregnancy-related nutrition and take the initiative to discuss this information during preconception counseling. Women of reproductive age should be counseled to consume a well-balanced diet including fruits and vegetables, iron and calcium-rich foods, and protein-containing foods as well as 400 microg of folic acid daily. More research is critically needed on the efficacy and safety of dietary supplements and the role of obesity in birth outcomes. Preconception counseling is the perfect opportunity for the health care provider to discuss a healthy eating guideline, dietary supplement intake, and maintaining a healthy weight status.

The clinical content of preconception care: women with chronic medical conditions.

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

Promising Practices in Preconception Care for Women at Risk for Poor Health and Pregnancy Outcomes

Objectives: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. Methods: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of recurrent very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. Results: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for the babies born to women managed in the Magnolia Project compared to the same ration for the United States. Conclusions: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the womans health and subsequent reproductive health outcomes.

Air pollution and very low birth weight infants : A target population?

OBJECTIVE. The goal was to examine systematically the association between maternal exposure to particulate matter of <10 μm and very low birth weight (<1500 g) delivery for evidence of an effect on duration of gestation and/or intrauterine growth restriction. METHODS. This case-control study took place between April 1, 1986, and March 30, 1988, in Georgia Health Care District 9 and included 128 mothers of very low birth weight infants, all of whom were preterm and were classified as either small for gestational age or appropriate for gestational age, and 197 mothers of term, appropriate-for-gestational-age infants weighing ≥2500 g. Maternal exposure to particulate matter of <10 μm was estimated with 2 exposure measures, namely, a county-level measure based on residence in a county with an industrial point source and an environmental transport model based on the geographic location of the birth home. RESULTS. Considering preterm/appropriate-for-gestational-age infants as cases and term/appropriate-for-gestational-age infants as controls, adjusted odds ratios for maternal exposure to particulate matter of <10 μm were statistically significant (adjusted odds ratio for county-level model: 4.31; adjusted odds ratio for environmental transport model: 3.68). Although elevated, no statistically significant association was found between maternal exposure and preterm/appropriate-for-gestational-age delivery when compared to preterm/small-for-gestational-age delivery. CONCLUSIONS. There are increased odds of maternal exposure to ambient particulate matter of <10 μm for very low birth weight preterm/appropriate-for-gestational-age delivery, compared with term/appropriate-for-gestational-age delivery, which suggests that the observed association between maternal exposure to air pollution and low infant birth weight (particularly <1500 g) is at least partially attributable to an effect on duration of gestation.

Preconceptional stress and racial disparities in preterm birth: an overview

Objective. We reviewed the evidence for three theories of how preconceptional psychosocial stress could act as a contributing determinant of excess preterm birth risk among African American women: early life developmental plasticity and epigenetic programming of adult neuroendocrine systems; blunting, weathering, or dysfunction of neuroendocrine and immune function in response to chronic stress activation through the life course; individuals’ adoption of risky behaviors such as smoking as a response to stressful stimuli. Methods. Basic science, clinical, and epidemiologic studies indexed in MEDLINE and Web of Science databases on preconceptional psychosocial stress, preterm birth and race were reviewed. Results. Mixed evidence leans towards modest associations between preconceptional chronic stress and preterm birth (for example common odds ratios of 1.2–1.4), particularly in African American women, but it is unclear whether this association is causal or explains a substantial portion of the Black–White racial disparity in preterm birth. The stress‐preterm birth association may be mediated by hypothalamic‐pituitary‐adrenal axis dysfunction and susceptibility to bacterial vaginosis, although these mechanisms are incompletely understood. Evidence for the role of epigenetic or early life programming as a determinant of racial disparities in preterm birth risk is more circumstantial. Conclusions. Preconceptional stress, directly or in interaction with host genetic susceptibility or infection, remains an important hypothesized risk factor for understanding and reducing racial disparities in preterm birth. Future studies that integrate adequately sized epidemiologic samples with measures of stress, infection, and gene expression, will advance our knowledge and allow development of targeted interventions.

An overview of racial disparities in preterm birth rates: caused by infection or inflammatory response?

Infection has been hypothesized to be one of the factors associated with spontaneous preterm birth (PTB) and with the racial disparity in rates of PTB between African American and Caucasian women. However, recent findings refute the generalizability of the role of infection and inflammation. African Americans have an increased incidence of PTB in the setting of intraamniotic infection, periodontal disease, and bacterial vaginosis compared to Caucasians. Herein we report variability in infection‐ and inflammation‐related factors based on race/ethnicity. For African American women, an imbalance in the host proinflammatory response seems to contribute to infection‐associated PTB, as evidenced by a greater presence of inflammatory mediators with limited or reduced presence of immune balancing factors. This may be attributed to differences in the genetic variants associated with PTB between African Americans and Caucasians. We argue that infection may not be a cause of racial disparity but in association with other risk factors such as stress, nutritional deficiency, and differences in genetic variations in PTB, pathways and their complex interactions may produce differential inflammatory responses that may contribute to racial disparity.

Perinatal Origins of First-Grade Academic Failure: Role of Prematurity and Maternal Factors

OBJECTIVE: We examined the relationships among gestational age at birth, maternal characteristics, and standardized test performance in Georgia first-grade students. METHODS: Live births to Georgia-resident mothers aged 11 to 53 years from 1998 through 2003 were deterministically linked with standardized test results for first-grade attendees of Georgia public schools from 2005 through 2009. Logistic models were used to estimate the odds of failure of the 3 components of the first-grade Criterion-Referenced Competency Test (CRCT). RESULTS: The strongest risk factor for failure of each of the 3 components of the first-grade CRCT was level of maternal education. Child race/ethnicity and maternal age at birth were also associated with first-grade CRCT failure irrespective of the severity of preterm birth, but these factors were more important among children born moderately preterm than for those born on the margins of the prematurity distribution. Adjusting for maternal and child characteristics, there was an increased odds of failure of each component of the CRCT for children born late preterm versus term, including for math (adjusted odds ratio [aOR]: 1.17, 95% confidence interval [CI]: 1.13–1.22), reading (aOR: 1.13, 95% CI: 1.08–1.18), and English/language arts, for which there was an important interaction with being born small for gestational age (aOR: 1.17, 95% CI: 1.07–1.29). CONCLUSIONS: Preterm birth and low maternal education increase children’s risk of failure of first-grade standardized tests. Promoting women’s academic achievement and reduce rates of preterm birth may be important to achieving gains in elementary school performance.

National Recommendations for Preconception Care: The Essential Role of the Family Physician

The Centers for Disease Control and Prevention have published national recommendations for improving preconception health and health care in response to unfavorable aspects of the health status of women and children in the United States. The publication explains that the national recommendations are part of a strategic plan for improving preconception health through the provision of clinical care as well as the promotion of changes in individual behaviors, health policy, and public health strategies. The concept of preconception care has been articulated for well over a decade but has not become part of the routine practice of family medicine. Because all women of reproductive age presenting to the primary care setting are candidates for preconception care, the essential and critical role of family physicians in the provision of preconception care is apparent. As a specialty, we are now challenged to devise ways to effectively translate the concept of preconception care into clinical reality.

The clinical content of preconception care: infectious diseases in preconception care.

A number of infectious diseases should be considered for inclusion as part of clinical preconception care. Those infections strongly recommended for health promotion messages and risk assessment or for the initiation of interventions include Chlamydia infection, syphilis, and HIV. For selected populations, the inclusion of interventions for tuberculosis, gonorrheal infection, and herpes simplex virus are recommended. No clear evidence exists for the specific inclusion in preconception care of hepatitis C, toxoplasmosis, cytomegalovirus, listeriosis, malaria, periodontal disease, and bacterial vaginosis (in those with a previous preterm birth). Some infections that have important consequences during pregnancy, such as bacterial vaginosis (in those with no history of preterm birth), asymptomatic bacteriuria, parvovirus, and group B streptococcus infection, most likely would not be improved through intervention in the preconception time frame.