Merry-K Moos

Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda

Unintended pregnancies account for about half of all pregnancies in the United States and, in 1995, numbered nearly 3 million pregnancies. They pose appreciable medical, emotional, social and financial costs on women, their families and society. The US is not attaining national goals to decrease unintended pregnancies, and little is known about effective means for reducing unintended pregnancy rates in adults or adolescents.To examine the evidence about the effectiveness, benefits and harms of counseling in a clinical setting to prevent unintended pregnancy in adults and adolescents and to use the evidence to propose a research agenda.We identified English-language articles from comprehensive searches of the MEDLINE, CINAHL, PsychLit and other databases from 1985 through May 2000; the main clinical search terms included pregnancy (mistimed, unintended, unplanned, unwanted), family planning, contraceptive behavior, counseling, sex counseling, and knowledge, attitudes and behavior. We also used published systematic reviews, hand searching of relevant articles, the second Guide to Clinical Preventive Services and extensive peer review to identify important articles not otherwise found and to assure completeness. Of 673 abstracts examined, we retained 354 for full article review; of these, we used 74 for the systematic evidence review and abstracted data from 13 articles for evidence tables. Four studies addressed the effectiveness of counseling in a clinical setting in changing knowledge, skills and attitudes about contraception and pregnancy; all had poor internal validity and generalizability and collectively did not provide definitive guidance about effective counseling strategies. Nine studies (three in teenage populations) addressed the relationship of knowledge on contraceptive use and adherence. Knowledge of correct contraceptive methods may be positively associated with appropriate use, but reservations about the method itself, partner support of the method, and womens beliefs about their own fertility are important determinants of method adherence that may attenuate the knowledge effect. Many factors influence contraceptive use and adherence; among them are age, marital status, ambivalence about becoming pregnant, attitudes of partner, side effects, satisfaction with provider and costs; however, the impact of such factors may not be consistent across populations defined by cultural, age or other factors. The studies themselves differed materially in outcome variables, populations and methodologies and did not yield a body of work that can reliably identify specific influences on contraceptive use and adherence. No literature reports on harms of counseling or on the costs or cost-effectiveness of different approaches to counseling about unintended conceptions in the primary care setting. Virtually no experimental or observational literature reliably answers questions about the effectiveness of counseling in the clinical setting to reduce rates of unintended (unwanted, mistimed) pregnancies in this country. Existing studies suffer from appreciable threats to internal validity and loss to follow-up and are extremely heterogeneous in terms of populations studied and outcomes measured. The quality of the existing research does not provide strong guidance for recommendations about clinical practice but does suggest directions for future investigations. Numerous issues warrant rigorous investigation.

Complementary and alternative medicine in pregnancy: a survey of North Carolina certified nurse-midwives

Objective To determine the prevalence and types of complementary and alternative medicine therapies used by certified nurse-midwives in North Carolina. Methods Surveys were sent to all 120 licensed certified nurse-midwives in North Carolina requesting information concerning their recommendations for use of complementary and alternative medicine for their pregnant or postpartum patients. Results Eighty-two responses were received (68.3%). Seventy-seven (93.9%) reported recommending complementary and alternative medicine to their pregnant patients in the past year. Forty-seven (57.3%) reported recommending complementary and alternative medicine to more than 10% of patients. The percentage of nurse-midwives who recommended each type of complementary and alternative medicine was as follows: herbal therapy (73.2%), massage therapy (67.1%), chiropractic (57.3%), acupressure (52.4%), mind-body interventions (48.8%), aromatherapy (32.9%), homeopathy (30.5%), spiritual healing (23.2%), acupuncture (19.5%), and bioelectric or magnetic applications (14.6%). The 60 respondents who reported prescribing herbal therapies gave them for the following indications: nausea and vomiting, labor stimulation, perineal discomfort, lactation disorders, postpartum depression, preterm labor, postpartum hemorrhage, labor analgesia, and malpresentation. Conclusion Complementary and alternative medicine, especially herbal therapy, is commonly prescribed to pregnant women by nurse-midwives in North Carolina.

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.

Defining and Measuring Unintended Pregnancy: Issues and Concerns

This article of the past and current measures of unintendedness of pregnancy has been offered in the hope that investigation into this area can be expanded. Current information available from available national surveys is not comparable due to different survey questions, inclusion criteria, and timing of interviews. What are often reported as rates of unintendedness may be rates of unwantedness--a completely different concept. Many studies fail to delineate the distinction between those unintended pregnancies that are indeed unintended versus those that were mistimed. Potentially, these existing data sets could be reanalyzed by using specific inclusion criteria for unintendedness, maternal age, and marital status. This information might be helpful in improving the comparability between the surveys and in assessing trends in unintendedness. In the future, to accurately measure unintendedness of pregnancy, we must use a consistent definition that takes into account the complexities of the issue. Valid and reliable scales that reflect the value of unintendedness from the mothers perspective need to be developed to reflect the potential change in intendedness over time. The adequate measurement of unintendedness of pregnancy is the first step in addressing the Healthy People 2000 goal and measuring progress in addressing the nations reportedly high rate in the long-term goal of addressing the risk factors of unintended pregnancy.

The History of Preconception Care: Evolving Guidelines and Standards

This article explores the history of the preconception movement in the United States and the current status of professional practice guidelines and standards. Professionals with varying backgrounds (nurses, nurse practitioners, family practice physicians, pediatricians, nurse midwives, obstetricians/gynecologists) are in a position to provide preconception health services; standards and guidelines for numerous professional organizations, therefore, are explored. The professional nursing organization with the most highly developed preconception health standards is the American Academy of Nurse Midwives (ACNM); for physicians, it is the American College of Obstetricians and Gynecologists (ACOG). These guidelines and standards are discussed in detail.

Preconceptional Wellness as a Routine Objective for Women's Health Care: An Integrative Strategy

Preconceptional health promotion should not be approached as an isolated activity. Instead, a new approach to womens wellness is needed. Rather than targeting care to women based on their pregnancy status or desires, health promotion and disease prevention should be integrated into a continuum of care throughout the life cycle. When care for women is viewed as an integrated continuum approach to health, rather than as a series of episodic events, higher levels of womens wellness will be achieved. This approach is likely to result in healthier women, pregnancies, and offspring. These outcomes are consistent with the goals of preconceptional health promotion. Using several case illustrations, this article highlights the benefits of integrating care into a continuum model.

Preconceptional Health Promotion

Efforts to prevent perinatal mortality and morbidity are traditionally directed at the pregnant woman. It is during the prenatal period that the mothers health status is closely monitored; her exposure to substances known to be harmful to the fetus is assessed, and intensive patient education on behaviors likely to benefit the unborn child is offered. Unfortunately, the initiation of prenatal care may already be too late to prevent spontaneous abortions, congenital anomalies, and some causes of low birthweight. Until routine prepregnancy care is available to all women of childbearing age, many opportunities for the primary prevention of poor reproductive outcomes will be lost. This paper describes the rationale for prepregnancy or preconceptional counseling and the specific purposes it should serve. A model program providing such services is described, and findings for a low socioeconomic population involved in the model program are given.

Editorial: Preconceptional Health Promotion: Opportunities Abound

Following this call to reconsider the usual paradigm for preventive services for maternal and neonatal health, Healthy People 2000 put forth a target to increase to at least 60% the proportion of primary care clinicians who provide age-appropriate preconception care and counseling. This objective appeared in both the family planning and the maternal and infant health chapters. Interestingly, the objective targeted providers rather than women. Subsequently, professional organizations including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics endorsed preconceptional care. Unfortunately, as noted in Healthy People 2010, progress in meeting the target for preconception care and counseling is unknown; indeed, it may be limited. It is difficult to determine the proportion or providers who are actually providing “age appropriate preconception care and counseling” or, more importantly, the percentage of women reached with preconception information through their clinical encounters. There is no objective or systematic evidence to suggest that preconceptional health promotion has become routine in health care for women of reproductive age. In fact, despite a myriad of papers advocating preconceptional health and related CME offerings, there is nothing to suggest that the prevention shift called for in the 1985 Institute of Medicine report has been realized. What, exactly, is the problem? As documented by Korenbrot et al. in their paper, Preconception Care: A Systematic Review, except for few exceptions, preconceptional health promotion has not been proven beneficial. Exceptions exist for women with insulindependent diabetes and hyperphenylalanemia, and for preconceptional folic acid intake. Even when the evidence is overwhelming, successes in changing knowledge, attitudes, and behaviors of health care providers has been very slow. A decade ago, the U.S. Public Health Service issued its landmark recommendation that all women of childbearing age consume 0.4 mg of folic acid per day to reduce the risk of neural tube defects; in 1998, the Institute of Medicine reaffirmed the recommendation and added that women of childbearing years should ingest 400 μg of synthetic folic acid daily, in combination with a balanced, healthy diet of folate-rich foods (2). A study undertaken by the March of Dimes in 1999 used a convenience sample of OB/GYN providers from around the country to obtain a snapshot of provider practices. The study found that only 28.7% of the physicians self-reported that they recommended folic acid to the target population “always,” 26.8% reported “most times,” 24% reported “sometimes,” and nearly 12.1% of respondents identified that they rarely made this recommendation to women of childbearing age. Less than 70% could identify the USPHS recommendation. The March of Dimes undertook a similar survey of registrants at a 1999 national convention of nurses specializing in women’s health and neonatal health and found only 51.7% could identify the correct recommendation (March of Dimes, personal communication, Karla Damus, 2002). These results represent a stunning lack of regard and knowledge regarding a powerful prevention opportunity. Despite the relative paucity of carefully designed studies to prove the value of general preconceptional health promotion activities, such an emphasis in care should not be discounted: It has the potential to empower women to make informed decisions about future childbearing, and such decisions may result in higher rates of pregnancy intendedness in the United States, and in earlier initiation of prenatal care,

1 Preconception care: a means of prevention

Preconceptional health promotion should provide a prevention framework for interactions with all women of childbearing potential. Preconceptional counselling is properly directed by specialists in the field of obstetrics and gynaecology, but a multispecialty effort may be needed to achieve adequate information for decision-making. Preconceptional health care offers an important opportunity for physicians involved in womens health to expand a primary care and a primary prevention focus. The obstetrician or gynaecologist is not only involved in acute diagnosis and treatment plans but also in disease prevention, risk and behaviour modification and counselling, which are integral parts of primary prevention and co-ordinated womens health care.

The pharmacist's role in promoting preconception health.

OBJECTIVE To review the pharmacists role in preconception health. DATA SOURCES PubMed search using the terms preconception, immunizations, epilepsy, diabetes, depression, tobacco, asthma, hypertension, anticoagulation, pharmacist, pregnancy, and current national guidelines. DATA SYNTHESIS Preconception health has become recognized as an important public health focus to improve pregnancy outcomes. Pharmacists have a unique role as accessible health care providers to optimize preconception health by screening women for tobacco use, appropriate immunizations, and current medication use. Counseling patients on preconception risk factors and adequate folic acid supplementation as well as providing recommendations for safe and effective management of chronic conditions are also critical and within the scope of practice for pharmacists. CONCLUSION Pharmacists play an important role in medication screening, chronic disease state management, and preconception planning to aid women in preparing for healthy pregnancies.