Non Traditional Approaches to
Preventing Prematurity:
Every Woman. . .Every Time
Merry-K. Moos, BSN, FNP, MPH, FAAN
Professor (retired)
UNC Schools of Medicine, Nursing and Public
Health
&
Lead Nurse Planner
March of Dimes Birth Defects Foundation
[email protected]
• Jenny is a g1 who
entered prenatal care at
11 weeks GA with a
pregravid weight of 98
pounds. Her medical
history was significant for
essential hypertension
treated with an ACE
inhibitor. She smoked
1½ packs per day but
was able to decrease her
tobacco use as the
pregnancy progressed.
• Her daughter was born
following spontaneous
onset of labor at 33
weeks GA; the labor was
complicated by placenta
abruptio and an
emergency c/s. The baby
weighed 1850 grams and
was diagnosed with a
ventricular septal defect
shortly after birth.
• What risk factors did
Jenny have that
predicted this
outcome?
–
–
–
–
Underweight
Tobacco use
Essential hypertension
Use of a known
teratogen during
organogenesis
• LaQuisha entered
prenatal care at 17
weeks quite
despondent because
her son had just
turned 6 months old;
her BMI was 38. Her
previous pregnancy
resulted in a 2150 gm
infant born at 35
weeks GA
• LaQuisha’s baby was
delivered 11 weeks
later weighing 1100
gms.
• What risk factors did
LaQuisha have that
predicted this outcome?
– Late entry PNC
– Obesity
– Short interconceptional
period
– Unintended pregnancy
– Previous premature infant
Objectives
At the conclusion of this presentation, nurses will be
able to:
• Explain the rationale and advantages of targeting
prematurity reduction efforts at women before and
between pregnancies.
• Discuss 5 preconception/interconception risk factors
for prematurity and link to appropriate evidencebased interventions.
• Identify 3 specific actions that a nurse working in well
woman care, antenatal and postpartum care or NICU
and child health care can employ to decrease the
risks for prematurity in future pregnancies.
• Access additional information about preconception
and interconception care.
Disclosure Statement
• I am a paid consultant for the March of Dimes
and Lead Nurse Planner for its Continuing Nurse
Education Provider Unit.
• I am chair of the Centers for Disease Control
Preconception Health and Health Care Clinical
Workgroup, a recent recipient of a grant from the
Kellogg Foundation to create a clinical toolkit to
advance preconception health and an author of
March of Dimes Nursing Modules on
Preconception Health and on Cultural
Competence.
• There will be no off-label discussions of any
drugs or products.
Summary
• There is good rationale for the preconception
health promotion agenda.
• To make a difference we need an Every
woman, Every time focus.
• Promoting high levels of health throughout the
reproductive continuum (before and between
pregnancies) is likely to result in decreased
rates of prematurity and low birth weight for
those who become pregnant.
• It is possible to work smarter not harder to
make a difference for women, pregnancies and
infants
The Underpinnings
Why Have Prematurity
Rates Been So Difficult to
Impact in the Last Decades?
What are some strategies tried to
reduce preterm birth?
Perhaps because we focus on
the pregnancy rather than the
woman. . .
In obstetrics. . .
many poor outcomes are
already present before we
ever meet our pregnant
patients
Important Examples
•
•
•
•
•
•
•
•
Intendedness of conception
Interpregnancy interval
Maternal weight
Maternal age
Abnormal placentation
Chronic disease control
Congenital anomalies
Timing of entry into prenatal care
Importance of
First Trimester
on Pregnancy
Outcomes
Over time, it has come to be recognized
that
Prepregnancy Health Status and
Preconception Health Care
provide pathways to
the Primary Prevention of many poor
pregnancy outcomes beyond that
available through traditional prenatal
care
We Ask Too Much of Prenatal
Care:
“As attractive and relatively inexpensive
as prenatal care is, a medical model
directed at a 6-8 month interval in a
woman’s life cannot erase the
influence of years of social,
economic, [physical] and emotional
distress and hardship.”
Dillard R, NCMJ, 65:3 p147
Current Dominant Perinatal
Prevention Paradigm
Current Dominant Perinatal
Prevention Paradigm
• Relies on patient-medical service interface
• Community services, if available/accessed, often
disconnected from medical services
• Features categorical focus with little integration
with woman’s preexisting care or with her future
health needs
• Initiated at first prenatal visit with
– Risk assessment
– Health promotion and disease prevention education
– Prescription for prenatal vitamins
• Ends with the postpartum visit (if there is one)
Features of Current
Categorical Approach
•
•
•
•
Episodic
Disjointed
Inefficient
Too often ineffective
Where Does this Categorical
Approach to Care Leave Us?
. . .with many missed opportunities such as:
• Woman with T2DM presents to her endocrinologist but
there is no discussion regarding contraception needs
or importance of planning pregnancy
• Same woman presents for contraceptive care but
family planning provider offers no counseling about the
importance of glycemic control before choosing to
become pregnant.
• No one speaks to the woman about weight control and
specific strategies to, perhaps, reverse the diagnosis
of T2DM; no one assesses/addresses
vaccine/immunity history or previous PTB.
Pregnancy/Well
Woman/Family
Planning
Well-Woman/
Family planning/
Preconceptional
menarche
An integrated,
lifecourse
approach
Postpartum/Family
Planning/WellWoman
Childbirth/
Family
Planning/
WellWoman
The Benefits of an Integrated
Approach to Women’s Wellness
• A woman’s own health (defined both narrowly and
broadly) becomes the focus for prevention before,
between and beyond pregnancy.
• It is very likely that we will achieve better pregnancy
outcomes by addressing women’s wellness “every
woman, every time”.
• Higher levels of women’s wellness before pregnancy
will result in healthier pregnancy outcomes
• Higher levels of women’s wellness will result in
healthier women across the lifespan (which, in and of
itself, is an important health outcome for women and
for the nation).
Nursing Assessments of All Women
of Childbearing Potential Should
Consider:
• Risks to the short term and long term health of
the woman
• Risks to the woman should she become
pregnant
• Risks to the fetus/infant should a pregnancy
occur
Thinking about preconception
prevention opportunities for
our two vignettes. . .
. . .Let’s turn our attention to
their prepregnancy risk
factors:
•Pregravid weight
•Tobacco use
•Chronic health conditions
•Exposure teratogens
•Short interconceptional period
•Previous poor pregnancy outcome
Nutritional Status:
Overweight/Obesity
(BMI > 25)
• Obesity and Women’s
Health: (In 2010, 25.1% of
women ages 18-44 had a BMI
> 30 kg/m2)
– Diabetes
– Hypertension
– Cardiovascular disease
– Disabilities
• Maternal Obesity and
pregnancy
complications:
– Glucose intolerance of
pregnancy
– Pregnancy induced
hypertension
– Thrombophlebitis
– Infertility
– Neural tube defects
– Prematurity
Evidence-based Best
Practices
• Calculate a woman’s BMI annually
• Counsel women with BMIs in the overweight
range (BMI > 25) about risks of exceeding
overweight category, risks for their own health
and risks to future pregnancies, including
infertility
• Offer specific behavioral strategies to decrease
caloric intake, increase physical activities;
encourage enrollment in structured weight
management programs
Nutritional Status:
Underweight
(BMI < 18)
• Underweight and
Women’s Health:
– Sign of disordered
eating
– Low bone mass with
risk of osteoporosis in
later life
– Fragile health status
– Nutrient deficiencies
• Underweight and
Reproductive
Outcomes:
– Infertility
– Preterm birth
– Intrauterine growth
restriction
– Birth defects
Evidence-based Best
Practices
• Calculate BMI annually
• Counsel women with BMIs in the underweight
range (BMI < 19.8) about short and long term
risks to their own health and health of future
pregnancies, including infertility.
• Refer women who are unwilling to consider and
achieve weight gain to more intensive evaluation
for eating disorders.
Tobacco Use
• Tobacco use and
women’s health:
– Implicated in most of
the leading causes of
death for women:
•
•
•
•
Heart disease (1)
Stroke (2)
Lung cancer (3)
Lung disease (4)
• Tobacco use and
reproductive Health:
– Leading preventable
cause of infant
mortality
– Preventable cause of
low birth weight and
prematurity
– Associated with
placental
abnormalities
Evidence-based Best
Practices
• Assess all women for tobacco use/exposure at
each encounter
• Counsel women who smoke using proven
strategies (5 A approach: ask, advise, assess,
assist, arrange)
• Be specific regarding recommendation
• Refer to more intensive services (individual,
group or telephone) if woman is ready and
willing to alter her tobacco use
• Help woman prepare for potential postpartum
relapse
Chronic Health Conditions
(
• Rates of chronic
health conditions in
women 18-44
– Diabetes
5%
– Heart disease 2%
– Hypertension 11%
– Thyroid disease12%
– Asthma/etc
14%
– Depression/
23%
anxiety
• In every pregnancy
there are at least 2
patients
• Medical diseases and
treatments can affect
the woman and the
fetus(es) differently.
Evidence-Based Best Practices
• Beyond own specialty area, step back and look at the
total woman’s health profile and needs.
• Provide each woman with education about risks of her
profile to her own health and to the health of any
pregnancies, children she may have (could be provided
through handout, computer guided, group care, etc.).
• Help woman to consider/articulate reproductive life plan
and to use effective contraception in accord with plan.
• Find non-teratogenic treatment choices, whenever
possible.
• Assure that care coordinated between providers
Exposure to Teratogens
• In 2008, 50% of pregnant
women reported taking at
least one prescription
drug in the first trimester;
7.5% reported taking 4 or
more prescriptions in 1st
trimester.
• In last 30 years, use of
prescription drugs in first
trimester has increased
by more than 60% and
use of 4 or more drugs
has more than tripled.
• The most common
teratogenic exposure is to
alcohol:
– 53% of non-pregnant
women ages 15-44 drink
alcohol and 15.4% report
binge drinking (which is
associated with unintended
pregnancies)
– Alcohol use in earliest
weeks of pregnancy (often
before pregnancy is
recognized) is associated
with fetal alcohol spectrum
disorders--especially fetal
alcohol syndrome)
Evidence-based Best Practices
• Avoid prescribing newer drugs in women of childbearing age
because full reproductive effects may not yet be known.
• Know commonly prescribed drugs which have been proven or
suggested to be associated with birth defects (examples: ACE
inhibitors; SSRIs; antipsychotics such as lithium; antiseizure
medications; accutane, etc.), pregnancy complications and
neonatal problems (if delivered through breast milk).
• Thoughtfully assess medication list for potential dangers.
• Educate women about risks and determine safest choicest for
her and future children should she become pregnant.
• Develop systems whereby these drugs are avoided in women at
risk of an intended or unintended conception (routine
assessment of reproductive life plan; EMR alerts; partnerships
with pharmacists, etc.)
• Assess and counsel every woman about alcohol use
Short Interpregnancy Intervals
(< 18 months from end of one pregnancy and conception of the
next)
• Short interpregnancy
intervals are
associated with
– Growth restriction
– Preterm birth
– Low birthweight
• For each month the
IPI was < 18 months,
the likelihood of these
poor outcomes
increased; for each
month, the IPI > 50
months, the likelihood
for same poor
outcomes increased.
Conde-Agudelo, JAMA, 2006.
Evidence-based Best Practices
• Educate women about the importance of
interpregnancy intervals
• Encourage women to have a reproductive life
plan.
–
–
–
–
–
Do you hope to have any (or any more) children?
How many (more) children would you like to have?
How long would you like to wait until you become pregnant (again)
What do you plan to do to prevent getting pregnant until then?
What can I do to help you achieve your plan? (Moos, MCN, 2003)
• Facilitate contraceptive use that is consistent
with each woman’s plan.
Previous Poor Pregnancy
Outcome
• An important predictor • One previous PTB = 15%
recurrence risk
of poor pregnancy
outcome is a previous • Two previous PTBs=
41% recurrence risk
poor outcome.
• Three previous
PTBs=67% recurrence
risk
• A prior fetal death
increases risk of
recurrence by 2-10 fold.
Evidence-based Best Practices
• All women with a preterm birth (or other
poor pregnancy outcome) should be
evaluated for remedial conditions and
provided with appropriate follow-up.
Thinking about interconception
prevention opportunities for
our two vignettes
• Which of Jenny’s risk
factors could be
addressed before she
becomes pregnant
again?
–
–
–
–
Underweight
Tobacco use
Essential hypertension
Use of a known teratogen
during organogenesis
– Previous preterm/lbw infant
– Previous child with congenital
anomaly
– History of placenta abuptio
• Which of LaQuisha’s risk
factors could be
addressed before she
becomes pregnant
again?
– Obesity
– h/o short interconceptional
period
– Unintended pregnancy
– Two previous premature
infants
Can This Information
Make a Difference in the
Care You Provide?
Selected strategies for moving toward an
“every woman, every time” orientation to
help women achieve high levels of health
What is “preconception
care”?
“Any intervention provided to women of
childbearing age, regardless of pregnancy
status or desire, before pregnancy to
improve health outcomes for women,
newborns and children”
Dean, et al. (2012) Care before and between pregnancy. In: Born Too
Soon: the Global Action Report on Preterm Labor. Ed: March of
Dimes, WHO, et. al..
Available at [email protected]
• Every day maternal/child health nurses
encounter women of childbearing age:
• When you care for these women, it’s not a
question of whether you are providing
preconception care but, rather, a question
of what kind of preconception care you are
providing.
J. Stanford and D. Hobbins,2001
A Very Common Illustration of
Missed Opportunities
• WJ is g2 p1 who had a 1500 gm infant 7 months ago.
She is presenting for a new ob visit. During her
previous pregnancy she was noted to be
– Underweight (BMI 17.5)
– Smoker at 1 ppd
– Experiencing an unintended pregnancy
– Diagnosed with gestational diabetes
– Depressed
As you review her record you note that none of
these issues has been revisited since her last
delivery—despite contact with the neonatal care
unit for 6 weeks, a routine postpartum visit and
routine and high risk pediatric care
What are some missed
opportunities that have
surfaced in your work?
What are ideas to work smarter
today to prevent prematurity (and
other poor outcomes) tomorrow?
Opportunities to Advance the Wellness
Agenda
Before, Between and Beyond
Pregnancy
• Prenatal/Postpartum
Outpatient
•
•
•
•
Framing smoking cessation,
weight gain, etc as pregnancy
and women’s health issues
Educate about IPI and
introduce/support reproductive
life planning
Education about importance of
postpartum visit and follow-up
At pp visit, specifically review
profile to identify prevention
needs (e.g. immunizations
follow-up GDM; poor
pregnancy outcome, etc.) and
create and communicate (to
woman, other providers, etc.) a
plan
Opportunities to Advance the Wellness
Agenda
Before, Between and Beyond
Pregnancy
• Intrapartum/postpartum
units
•
•
•
•
Education about risks that
surfaced in pregnancy (e.g.
GIP, PIH, etc) and importance
of follow-up
Help develop strategies to
become/maintain smoke free
environment
Give appropriate
immunizations before
discharge
Educate about IPIs and
introduce/support reproductive
life plan.
Opportunities to Advance the Wellness
Agenda
Before, Between and Beyond
Pregnancy
•
NICU/well child care
•
•
•
•
Encourage appropriate IPIs
Help develop strategies to
become/maintain smoke free
environment
Encourage postpartum visit
and appropriate risk-based
follow-up
Education about risks that
surfaced in pregnancy (e.g.
GIP, PIH, recurrence PTD. etc)
and importance of follow-up for
own health and health of any
future pregnancies.
Summary
• There is good rationale for the preconception
health promotion agenda.
• To make a difference we need an Every
woman, Every time focus.
• Promoting high levels of health throughout the
reproductive continuum (before and between
pregnancies) is likely to result in decreased
rates of prematurity and low birth weight for
those who become pregnant.
• It is possible to work smarter not harder to
make a difference for women, pregnancies and
infants.
Challenge you to move to an
“Every Woman, Every Time”
orientation to prevention:
Before, Between and Beyond
Pregnancy
What are the first three steps you can take?
Additional Resources
• Before, Between and Beyond, the National
Preconception Curriculum and Resources Guide for
Clinicians available at: www.beforeandbeyond.org
• Additional MODs CNE activities available at
www.marchofcimes.com/nursing
• The CDC Clinical Work Group’s Content of
Preconception Care available at:
www.beforeandbeyond.org/?page=key-articles-and-studies
• Interconception care plans and other practice supports
available at: www.beforeandbeyond.org/?page=practice-supports
• Genetics and Your Practice (A March of Dimes Resource)
http://www.marchofdimes.com/gyponline/index.bm2
• Prematurity Prevention Resource Center (a March of
Dimes resource) available at:
www.prematurityprevention.org
• Colorado Guidelines for Preconception and
Interconception Care available at:
http://www.healthteamworks.org/guidelines/preconception.
• The California Interconception Tool Kit available at:
http://www.everywomancalifornia.org/content_display.cfm?contentID=221&c
ategoriesID=18&CFID=1016527&CFTOKEN=80379618
• Links to many preconception activities in the Southeast
U.S. and beyond are available at:
www.everywomansoutheast.org
• The National Preconception Health and Health Care
(PHHC) Resource Center available at
www.cdc.gov/preconception/freematerials.html
• Reproductive Life Planning (for women, men and
providers) available at
www.cdc.gov/preconception/reproductiveplan.html