the importance of reproductive life planning ......jul 31, 2013  · widespread adoption of...

The Importance of Reproductive Life Planning & Preconception Care

Michael C Lu, MD, MPH Associate Administrator

Maternal and Child Health Bureau Health Resources and Services Administration

Department of Health and Human Services

Title X National Grantee Meeting

Seattle, WA

July 31, 2013

Maternal & Child Health Bureau

HHS

HRSA

MCHB

NIH AHRQ CDC FDA

CMS ACF ATSDR IHS SAMHSA ACL

Mission

• Improve the health of all women, children, and families in our nation

MCHB

• Annual budget of $1.2 billion • Title V MCH Services Block Grant

• Maternal, Infant, and Early Childhood Home Visiting Program

• Other Categorical Programs • Autism and other developmental disabilities

• Traumatic brain injury

• Sickle cell service demonstration

• Universal newborn hearing screening

• Heritable disorders

• Emergency medical services for children

• Family-to-Family information centers

• Healthy Start

MCHB

• Title V MCH Services Block Grant • State Block Grant

• Special Projects of Regional & National Significance (SPRANS)

MCHB

• Maternal, Infant, and Early Childhood Home Visiting Program

MCHB

• Other Categorical Programs • Autism and other developmental disabilities

• Traumatic brain injury

• Sickle cell service demonstration

• Universal newborn hearing screening

• Heritable disorders

• Emergency medical services for children

• Family-to-Family information centers

• Healthy Start

Preconception • any time that a woman of reproductive

potential is not pregnant but at risk for becoming pregnant, or when a man is at risk for getting someone pregnant.

CDC. Recommendations to improve preconception health and health care – United States. In:

Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.

Preconception Care • A set of interventions that aim to identify

and modify biomedical, behavioral and social risks to the woman's health or pregnancy outcome through prevention and management

CDC. Recommendations to improve preconception health and health care – United States. In:

Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.

Preconception Care • Reproductive life plan

• Medical history

• Sexual health assessment

• Intimate partner and sexual violence

• Alcohol and other drug use

• Tobacco use

• Immunizations

• Depression

• Height, weight and BMI

• Blood pressure

• Chlamydia, gonorrhea, syphilis and HIV/AIDS

• Diabetes.

CDC. Recommendations to improve preconception health and health care – United States. In:

Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.

Preconception Care & Family Planning

Family planning services are necessary for the widespread adoption of preconception care for two reasons. First, preconception care is more likely if pregnancies are planned, and family planning services encourage pregnancy planning. Second, family planning services usually include counseling, and counseling provides an opportunity to discuss the advantages of preconception care.

Klerman LV. Family Planning Services: An Essential Component of Preconception Care. Matern Child Health J. 2006

Reproductive Life Plan • A set of personal goals about having (or not

having) children based on personal values and resources, and a plan to achieve those goals.

CDC. Recommendations to improve preconception health and health care – United States. In:

Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.

Reproductive Life Plan • Do you have any children now?

• Do you want to have (more) children?

• How many (more) children would you like to have and when?

CDC. Recommendations to improve preconception health and health care – United States. In:

Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.

Importance of Preconception Care • Prenatal care may be too late

Importance of Preconception Care • Prenatal care may be too late

• To prevent some birth defects

Early Prenatal Care Is Too Late to prevent some birth defects

• The heart begins to beat at 22 days after conception

• The neural tube closes by 28 days after conception

• The palate fuses at 56 days after conception

• Critical period of teratogenesis – Day 17 to Day 56

Importance of Preconception Care • Even early prenatal care may be too late

• To prevent some birth defects

• To prevent implantation errors

Early Prenatal Care Is Too Late to prevent some birth defects

Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400-8.

Importance of Preconception Care • Even early prenatal care may be too late

• To prevent some birth defects

• To prevent implantation errors

• To restore allostasis

Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/

Allostasis: Maintain Stability through Change

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

Allostastic Load: Wear & Tear from Chronic Stress

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

Stressed vs. Stressed Out • Stressed

• Increased cardiac output • Increased available glucose

• Enhanced immune functions • Growth of neurons in

hippocampus & prefrontal cortex

• Stressed Out

• Hypertension & cardiovascular diseases

• Glucose intolerance & insulin

resistance • Infection & inflammation • Atrophy & death of neurons in

hippocampus & prefrontal cortex

Allostasis & Allostatic Load

McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002

Rethinking Preterm Birth

Racial & Ethnic Disparities Preterm Births < 37 Weeks

17.9

11.5

0

2

4

6

8

10

12

14

16

18

African American White

Percent of Live Births

NCHS 2006

Year 2010 Goal

Preterm Birth & Infant Mortality, US, 2007

Source: NCHS, linked birth/infant death data set

Racial & Ethnic Disparities Preterm Births < 37 weeks

Percent of Live Births

Year 2010 Goal

NCHS 2010

Racial & Ethnic Disparities Very Preterm Births < 32 Weeks

Percent of Live Singleton Births

Year 2010 Goal

NHS 2010

Racial & Ethnic Disparities Infant Mortality

Deaths Per 1,000 Live Births

NCHS 2010

Year 2010 Goal

Rethinking Preterm Birth

Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course (early programming & cumulative allostatic load)

Preterm Birth & Maternal Ischemic Heart Disease

Kaplan-Meier plots of cumulative probability of survival without admission or death from ischemic heart disease after first pregnancy in relation to preterm birth

Smith et al Lancet 2001;357:2002-06

Take Home Message #1 • Even early prenatal care may be too late

• To prevent some birth defects

• To prevent implantation errors

• To restore allostasis

Take Home Message #2 • An important objective of preconception care

is to restore allostasis and optimize women’s health

Take Home Message #3 • If we want to improve maternal and child

health, we start by improving women’s health

Preconception Care for Men • Xenobiotics

• Pesticides, insecticides, fumigants

• Nonylphenol (super detergents)

• Polycyclic aromatic hydrocarbons (PAHs) (smoking)

• Polychlorinated biphenyls (fishing, old appliances)

• Dioxins (animal fat)

• Phthlates (plastics)

• Acrylamide (overcooking)

• Heavy metals (lead, cadmium, etc)

• Infection/inflammation

• Hyperthermia

• Radiation

Preconception Care for Men • Reproductive life plan

• Medical history

• Sexual health assessment

• Screening for alcohol and other drug use

• Tobacco use

• Depression screening

• height, weight and BMI

• STDs (chlamydia, gonorrhea, syphilis and HIV/AIDS)

• Diabetes

Frey KA NS, Kotelchuck M, Lu M The clinical content of preconception care: preconception care for men. . AJOG. 2008;December:S389-95.

Interconception Care

The definition of insanity is doing the same thing over and over and expecting different results.

Benjamin Franklin

We must become the change we want to see.

Mohandas Gandhi

Contact Information

Michael C. Lu, MD, MPH

Associate Administrator

Maternal and Child Health Bureau

Health Resources & Services Administration

mlu@hrsa.gov