Dean V. Coonrod

The clinical content of preconception care: an overview and preparation of this supplement

In June 2005, the Select Panel on Preconception Care established implementation workgroups in 5 areas (clinical, public health, consumer, policy and finance, and research and surveillance) to develop strategies for the implementation of the Centers for Disease Control and Prevention recommendations on preconception health and healthcare. In June 2006, members of the clinical workgroup asked the following questions: what are the clinical components of preconception care? What is the evidence for inclusion of each component in clinical activities? What health promotion package should be delivered as part of preconception care? Over the next 2 years, the 29 members of the clinical workgroup and > 30 expert consultants reviewed in depth > 80 topics that make up the content of the articles that are contained in this supplement. Topics were selected on the basis of the effect of preconception care on the health of the mother and/or infant, prevalence, and detectability. For each topic, the workgroup assigned a score for the strength of the evidence that supported its inclusion in preconception care and assigned a strength of the recommendation. This article summarizes the methods that were used to select and review each topic and provides a summary table of the recommendations.

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.

Nulliparous term singleton vertex cesarean delivery rates : institutional and individual level predictors

OBJECTIVE This study was undertaken to determine individual and institutional level variables predictive of variations in nulliparous term singleton vertex cesarean delivery rates. STUDY DESIGN Retrospective cohort study of 28,863 nulliparous term singleton vertex births at 40 Arizona hospitals. RESULTS The average nulliparous term singleton vertex cesarean delivery rate was 22.0%, the lowest hospital rate was 10.3%, high, 34.2%. The following individual level variables increased the nulliparous term singleton vertex cesarean delivery rate in a multivariable model: increased mothers age, African American race, increased birthweight, labor induction, and the presence of medical conditions such as diabetes and hypertension. Of the institutional variables, after adjustment, the highest level of nursery or a higher percentage of government-paid births was associated with lower risks, whereas delivery at a hospital with the lowest level of care or with an obstetric and gynecology residency was associated with an increased risk of cesarean delivery. CONCLUSION Substantial variations in nulliparous term singleton vertex cesarean delivery rates were seen in this comparative analysis of 40 hospitals.

Interventions for Weight Management in Postpartum Women

OBJECTIVE To report the results of a comprehensive review of published intervention studies to identify the best evidence available for guiding weight management interventions in postpartum women. DATA SOURCES Electronic searches were conducted of three electronic databases: Cumulative Index to Nursing and Allied Health Literature; Medline; and the Science Citation Index, Expanded, in the Web of Science from 1994 to May 2007. Keyword searches were conducted using the terms obesity, obese, overweight, postpartum, pregnancy weight, and weight management in postpartum women. STUDY SELECTION Six studies were selected that met the inclusion criteria of testing interventions and one that reported preintervention planning and targeted a weight management intervention for postpartum women. DATA EXTRACTION All six interventions showed significant impact with diet and exercise or some combination on body composition in the targeted sample of women. DATA SYNTHESIS The strengths of previous studies include an emphasis on precision in outcome measures and experimental conditions; limitations were that the theoretical basis for the interventions was frequently omitted and limited attention given to the cultural, social, and contextual factors established in descriptive research. CONCLUSIONS Interventions need to target women early in their childbearing years to have the most significant long-term impact.

A Randomized Controlled Study of Brief Interventions To Teach Residents about Domestic Violence.

PURPOSE To test an educational intervention regarding domestic violence. METHOD Residents beginning their training in 1995 or 1996 were randomly assigned to attend, at their hospital orientation, either a 20-minute session emphasizing the importance of screening for domestic violence or a session on an unrelated topic. RESULTS Seventy-one percent of the residents in the experimental group diagnosed domestic violence; 52% in the control did so (RR, 1.35; 95% CI, 0.96-1.90; p = .07) in the nine to 12 months following the intervention. Rates of diagnosis differed by specialty (p <.01): 100% family practice, 90% emergency medicine, 80% obstetrics-gynecology, 63% pediatrics, 47% internal medicine, 0% surgery. Change in knowledge was assessed in 1996; significant improvement was noted (p = .002). CONCLUSION An intervention about domestic violence conducted at orientation for residents improved the rate of diagnosis of domestic violence. While the improvement was not statistically significant in this case, the intervention was brief and harmless. Other institutions should consider this kind of brief intervention.

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.

Knowledge and attitudes regarding preconception care in a predominantly low-income Mexican American population

OBJECTIVE The objective of the study was to determine knowledge and attitudes regarding preconception care in a low-income Mexican American population. STUDY DESIGN This was a cross-sectional survey of 305 reproductive-age women at an urban public hospital. RESULTS The sample was mostly Hispanic (88%) and pregnant (68%); 35% had not completed high school. Eighty-nine percent agreed that improving preconception health benefits pregnancy. Seventy-seven percent expressed some interest in preconception health care with the obstetrics gynecology office at the preferred location. The average knowledge of preconception care score was 76% (higher score more favorable). Areas of higher knowledge included the effects on pregnancy of folic acid; alcohol use; substance use; and verbal, physical, and sexual abuse; lower knowledge was found for the effects of cat litter and fish products. CONCLUSION There was interest in preconception education and agreement that preconception health has a positive effect on pregnancy. Fewer respondents agreed that it had a good effect than a suburban sample in the same region (89% vs 98%).

Inhibition of uterine contractility with various tocolytics with and without progesterone: in vitro studies.

OBJECTIVE Various tocolytics are used to suppress uterine contractility in patients in preterm labor. Progesterone (P4) is used in patients at high risk for preterm delivery. In this study, we evaluated the effects of various tocolytics with and without P4 to examine effects on uterine contractility. STUDY DESIGN Uterine tissues (n = 280) from women undergoing cesarean at term were exposed in vitro to various agents (vehicle, magnesium sulfate [MgSO(4)], nifedipine, indomethacin, or pinacidil-all with and without P4). Contractility was measured before and after addition of the various agents. RESULTS P4 alone at 10(-5) mol/L concentration has little effect to inhibit contractility (P ≥ .05). MgSO(4) (2-8 × 10(-3) mol/L) inhibits uterine contractility (P < .05) but there is no change when combined with P4 (P > .05). Nifedipine (10(-8) mol/L) and indomethacin (10(-5) mol/L) inhibit contractions alone (P < .05) and to a greater extent when combined with P4 (P < .05). P4 significantly (P < .05) reduced the effects of pinacidil (10(-6.5) mol/L). CONCLUSION Combinations of P4 with nifedipine or indomethacin, but not MgSO(4), might be used to effectively suppress preterm labor.

Screening for domestic violence: practice patterns, knowledge, and attitudes of physicians in Arizona

Objectives: Victims of domestic violence presenting for health care are frequently referred to medical specialists, but little is known about domestic violence screening among specialists. The aim of this study was to evaluate attitudes and behaviors concerning domestic violence of all physicians in Arizona. Methods: A cross-sectional survey of 2,244 physicians from 13 medical specialties describes domestic violence screening practices, attitudes, and behaviors of practicing physicians in Arizona. Results: Among 976 respondents, 56% reported prior education on domestic violence screening; 50.5% rarely or never screen their female patients for domestic violence; and 52% reported their competence for providing treatment for victims as poor to fair. Physicians from emergency medicine, psychiatry, obstetrics/gynecology, and family practice reported higher rates of domestic violence education, screening, awareness of services, and competence at treating victims. Physical medicine/rehabilitation, anesthesiology/pain control, surgical subspecialty, medicine subspecialty, general surgery, and orthopedic physicians scored lowest on these characteristics. Conclusions: Differences in attitudes and behaviors regarding domestic violence screening were noted among specialty groups. Customizing physician training based on these findings may be beneficial.

The clinical content of preconception care: immunizations as part of preconception care

Many vaccine-preventable diseases have serious consequences for the pregnant mother, the fetus, and the neonate. This article reviews the rationale and impact of including vaccinations as part of preconception care and provides recommendations for clinical care. Vaccinations that are recommended highly in preconception care include the hepatitis B and the measles, mumps, and rubella vaccines. The role of human papillomavirus, varicella, diphtheria, tetanus, and pertussis vaccinations as part of preconception care is also discussed.