What is preconception health?
Preconception is defined as the period of time before pregnancy. While traditionally preconception was a term reserved for those actively planning for a pregnancy, this approach failed to capture the population groups with the potential of pregnancy and the importance of preconception health across the lifespan (1). Maternal preconception health is becoming increasingly recognised as perhaps the most important factor in determining the health and development of future generations. Many critical developmental stages occur before a women may even realise she is pregnant and therefore making changes prior to pregnancy can help mitigate the risk of various problems which may be too late to address once pregnancy is already established (24). Prenatal exposure to various environmental factors can trigger metabolic and physiological changes in the foetus which lays the foundation for increased susceptibility to various chronic diseases such as heart disease, cancer and diabetes later on in life (22). This is thought to occur primarily through epigenetic changes during early development and is based on the Developmental Origins of Health and Disease Theory (23). This theory broadens the perspective of preconception health outside of pregnancy outcomes to encompass the health of the entire lifespan including childhood, adolescence, adulthood and future generations (23).
The many aspects of preconception care:
Preconception care is broad and encompasses lifestyle, medical and environmental factors, all important considerations for the couple attempting pregnancy. Lifestyle factors include contraception, family planning, diet, weight, exercise, smoking, alcohol, caffeine and illicit drug use (4). Medical factors include previous pregnancy history, genetic screening, any medical conditions such as diabetes or thyroid disorders, mental health disorders, dental health, breast examinations, screening for STI’s and ensuring an up to date immunisation history (4). Environmental factors include work, education, financial stability, relationships, community safety, housing, home life and recreational activities (6). Screening for domestic violence or intimate partner violence plays an important role in preconception care (4). Environmental pollutants such as lead and heavy metals are another important consideration as they can negatively impact pregnancies and may interfere with child development into the future (5). There are many risk factors that could put women and their children at greater risk of harm and adverse health outcomes. While not all factors are controllable, most are modifiable. Therefore the preconception period is an opportune time for mothers to assess their lifestyle and implement positive change.
Preconception benefits for fertility:
An important component of preconception care for couples intending on pregnancy is family planning and education on correct timing of intercourse. According to research in 2013, around 60% of Australian women believe they can correctly identify their fertile window but in reality only a small number of women (13%) were actually able to do so (10). Incorrectly identifying the fertile window may lead to missed opportunities for conception, resulting in prolonged time to pregnancy. Overall, knowledge regarding ovulation, fertility, and conception is limited amongst many reproductive aged women. The preconception period offers an opportunity to improve reproductive knowledge and potentially also improve time to conception. Of similar importance is the use of appropriate and effective birth control in the preconception period until pregnancy is desired. This is especially important for women with known medical conditions that could put them at greater risk of adverse pregnancy outcomes (7). There is little evidence surrounding the effectiveness of preconception care in improving rates to conception for couples with infertility (11) however, reducing risk factors can help provide a more favourable environment for fertilisation and implantation thereby potentially increasing conception rates and improving fertility (24).
Preconception benefits for the mother:
A focus on modifying risk factors such as obesity, insulin resistance and high blood pressure prior to pregnancy may help to prevent and reduce the risk of some of the most common pregnancy complications such as gestational diabetes and pre-eclampsia, although more evidence is needed (14). Thyroid assessment and iodine status are important maternal pre-pregnancy considerations due to the increased risk of developing hypothyroidism in pregnancy and postpartum (21). Risk factors such as smoking, obesity and alcohol use are associated with increased chance of miscarriage, spontaneous abortion and still birth (12). For women with personal and family history of genetic abnormalities, repeat miscarriages, lengthy time to conception, intellectual disability and unexplained still birth or birth defects, genetic screening and testing becomes an important part of pre-conception care. Genetic counselling can help identify any known strategies to lower risk (eg. folic acid, selective IVF ) and also provide education on the consequences of opting for or against pregnancy (7). An important additional consideration in preconception care is the care of women with a pre- existing medical condition that will likely affect pregnancy outcomes. Medical conditions that are known to impact pregnancies include type 1 and type 2 diabetes, pre-existing insulin resistance and PCOS, heart disease, auto-immune conditions, thyroid conditions, epilepsy and inflammatory bowel disease (7). Pre- existing maternal health conditions have the added disadvantage of relying on pharmaceuticals which are not always safe in pregnancy. An important aspect of preconception care involves discontinuing medications that are known teratogens and achieving control through lifestyle interventions and/or pregnancy safe medications (7).
Preconception benefits for the child:
Preconception care benefits not only the mother in pregnancy but also the developing foetus. At present, research indicates that preconception care is important in reducing prematurity and low birth weight (1). Preconception interventions such as smoking cessation support can reduce the risk of low birth weight babies, foetal growth restriction, neonatal intensive care admission (15) and developmental abnormalities such as cleft lip, cleft palate (16) and autism (17). Eliminating alcohol prior to conception and during pregnancy can reduce alcohol associated impaired growth, still birth and foetal alcohol syndrome (18). Perhaps the most well researched preconception intervention pertains to folic acid supplementation for the prevention of neural tube defects, anaemia and congenital abnormalities (19). Of importance is folic acid supplementation at least three months prior to conception. Similarly, iodine supplementation can reduce the risk of congenital and intellectual abnormalities (20). For women with pre-exisiting diabetes, good blood sugar control prior to pregnancy can help reduce the risk of macrosomia, perinatal deaths, congenital abnormalities and preterm birth (25).
Conclusion:
Increasing evidence is suggesting that it is “never to early” to establish healthy behaviours to support future pregnancies (23), however, at minimum, the three months prior to conception is considered a critical time for optimising the uterine environment (24). Adequate implementation of preconception care affects positive behaviour change in women such as smoking cessation, increased uptake of folic acid, increased use of antenatal services and increase breast-feeding rates (13). This in turn helps to reduce the risk of pregnancy complications including placenta abrasions, placenta previa, preeclampsia, obstructed labour and haemorrhage (9). Due to the lifelong implications of the preconception period, preconception care has the potential to lower the overall global burden of disease. As preconception care is only recently gaining interest in medicine, there are many barriers to adequate implementation and delivery of preconception care in Australia. These barriers include lack of knowledge and awareness from both practitioners and the general public, limited research and funding, lack of standardised guidelines and a poorly co-ordinated health care system. Increasing knowledge and awareness can help individuals, health care providers and policy makers move towards more research, more funding and better delivery of preconception care.
References:
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