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Clinical
Volume 53, Issue 11, November 2024

Preconception care

Edwina Dorney    Kirsten Black   
doi: 10.31128/AJGP-08-23-6927   |    Download article
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Background

Preconception care (PCC) entails a comprehensive suite of interventions to improve the health of potential parents, their babies and future generations. PCC is not limited to a first pregnancy, and addressing health and wellbeing is equally important in the interconception period.

Objective

The aims of this paper are to discuss the evidence for and components of PCC, as well as the role of the general practitioner in the delivery of PCC.

Discussion

It is estimated that 90% of women and over 50% of men have preconception health issues to address. Although all people stand to benefit from PCC, certain population groups experience increased risk of adverse outcomes and require more targeted attention. Although most do not present for a dedicated PCC consultation, asking about pregnancy intention can start the conversation. Evidence shows that interventions delivered in primary care can improve preconception health knowledge and reduce preconception risk factors.

ArticleImage

Preconception health, the health of a person before pregnancy, impacts pregnancy outcomes, childhood health and the health of future generations.1,2 Preconception care (PCC) is the assessment, identification and intervention targeting risk factors to improve a person’s health across behavioural, biomedical and social domains.1,3

PCC is not limited to a first pregnancy, and addressing health and wellbeing is equally important in the interconception period.4 Evidence shows increased rates of unintended pregnancies, lower rates of preconception health behaviours and increased prevalence of risk factors with increasing parity.5,6 In this update, the term ‘PCC’ relates to care before both a first and subsequent pregnancies.

Each year approximately one in 10 Australian women become pregnant.7,8 Ninety per cent of women9 and over half of all men have at least one preconception health issue to address to improve reproductive outcomes.10

Recommendations and supporting evidence for PCC

Over 80 clinical content areas have been identified as part of comprehensive PCC.11 A checklist for PCC is provided in Table 1.

Table 1. Preconception care checklist 
Reproductive health
  • Family planning and reproductive life plan
    • Discussion on desired number of children (if any) and timing of pregnancies
    • Discussion about contraception options, including safety, efficacy and timing for intended pregnancies
    • Discussion about options for unintended pregnancies
Healthy eating and active living
Physical activity
  • 150 min exercise per week or 30 min/day
  • Pelvic floor training
Weight assessment
Nutrient intake
  • Supplementation
    • Folate 400 mcg daily or 5 mg if increased riskA
    • Iodine 150 mcg daily
  • Adequate intake of iron, calcium, vitamin D
  • Restricted intakeB
    • Vitamin A (retinol) 800 mcg/day
    • Restricted caffeine intake (200 mg/day from all sources)
    • Mercury-containing fishC
Immunisation
  • Review vaccination history and update for human papillomavirus, hepatitis B, varicella zoster, measles mumps rubella, pertussis, influenza and COVID-19
Infectious diseases and conditions
  • Recommended screening investigations for all potential parents
    • Blood-borne viruses: HIV, hepatitis B, hepatitis C
    • STIs: syphilis
    • Infectious diseases: rubella, varicella zoster
  • Recommended screening investigations determined by individual situation
    • STIsD: chlamydia, gonorrhoea
    • Infectious diseasesE: cytomegalovirus
  • Education
  • Infectious diseases: cytomegalovirus, toxoplasmosis, parvovirus, herpes simplex virus
    • Food borne: listeriosis
    • Travel: malaria, Zika virus
Medical conditions
  • Review and optimisation of pre-existing conditions; referral to specialist as required
  • Diabetes: optimise glycaemic control
Psychosocial assessment
  • Mental health
  • Domestic and intimate partner violence
  • Assessment of financial support and access to care
Parental exposure
  • Alcohol
    • Ask about alcohol use with AUDIT-C tool and advise there is no safe level in pregnancy
    • Provide support for reducing alcohol intake
  • Smoking and e-cigarettes
    • Ask about smoking and e-cigarette use and advise on benefits of quitting
    • Consider cessation support, including referral to Quitline or nicotine replacement therapy
  • Illicit substances
    • Ask about recreational drug use and advise on benefits of quitting
    • Consider cessation support, including assistance from drug and alcohol services
Family and genetic history
  • Detailed genetic history and referral to genetics counsellor for positive family history, known genetic conditions or previous affected pregnancy
  • Carrier screening to be discussed
Environmental exposure
  • Assess for endocrine disrupting chemicals and reproductive toxin exposures
    • Workplace: chemical, metal, gas, radiation and animal exposures
    • Household: personal care products and plastics
Medication
  • Review prescription and over-the-counter medications for safety in pregnancy
    • Cease and prescribe alternative medications as required
Preventive health
  • Cervical screening and breast self-examination
  • Dental review
Obstetric history
  • Review previous pregnancy outcomes: miscarriages, stillbirth, disorders of placentation
AFamily history or previous pregnancy affected, body mass index (BMI) ≥30 kg/m2, diabetes, on anticonvulsant medication, malabsorptive condition.
BFor patient information resources, refer to Food Standards Australia and New Zealand for patient fact sheets (www.foodstandards.gov.au/consumer).
CFish containing high levels of mercury: shark (flake), orange roughy (deep sea perch), marlin, swordfish, catfish, broadbill.
DFor those who request a sexually transmissible infection (STI) screen, have a new sexual partner, previous STI or exposure in the past 12 months, partner from a high-risk population, those who live or travel to areas with high STI prevalence.
EThose with increased risk of exposure, childcare workers, those with a child in nappies attending childcare.
AUDIT-C, alcohol use disorders identification test consumption; HIV, human immunodeficiency virus.
Patient-centred care and reproductive life plan

PCC is underpinned by the principles of patient-centred care and shared decision making, and discussion should focus on the individual’s or couple’s reproductive life plan. Tools to discuss pregnancy intention are outlined in Table 2. A detailed mental health history and review for family and intimate partner violence should also be performed.12

Table 2. Tools to discuss pregnancy intention
Preconception (future pregnancies)
One Key Question®: assesses pregnancy preferences in next 12 months  
Single question: Would you like to become pregnant in the next year? Four possible answers:
Yes
I don’t mind
I’m not sure
No
Desire to avoid pregnancy scale: assesses preference to avoid pregnancy in the next 3 months (higher score = higher desire to avoid pregnancy)
14 questions Answer options
I wouldn’t mind it if I became pregnant in the next 3 months Five possible answers to each question (scored 0–4): strongly agree; agree; neither agree/disagree; disagree; strongly disagree
For negatively worded questions,
4 = strongly agree
For positively worded questions,
4 = strongly agree
It would be a good thing for me if I became pregnant in the next 3 months
Thinking about becoming pregnant in the next 3 months makes me feel unhappy
Thinking about becoming pregnant in the next 3 months makes me feel excited
Becoming pregnant in the next 3 months would bring me closer to my main partner
I want to have a baby within the next year
If I had a baby in the next year, it would be bad for my life
It would be a positive addition to my life to have a baby in the next year
It would be the end of the world for me to have a baby in the next year
Thinking about having a baby within the next year makes me smile
Thinking about having a baby within the next year makes me feel stressed out
I would feel a loss of freedom if I had a baby in the next year
If I had a baby in the next year, it would be hard for me to manage raising the child
I would worry that having a baby in the next year would make it harder for me to achieve other things in my life
Pregnancy and postpartum (current or recent pregnancy)
Single question of pregnancy intention: Is/was this pregnancy planned? Two possible answers:
Yes
No
London measure of unplanned pregnancy  
Six questions: Answer options (scored 0–2)
In the month that I became pregnant
0 – Always used contraception
1 – Sometimes used contraception
2 – Did not use contraception
Three possible answers to each question
Scores 0–9 unintended
Scores 10–12 intended
In terms of becoming a mother
0 – Wrong time
1 – Okay, but not quite the right
2 – Right time
Just before I became pregnant
0 – Did not intend to get pregnant
1 – My intentions kept changing
2 – I intended to get pregnant
Just before I became pregnant
0 – Did not want a baby
1 – Mixed feelings about a baby
2 – Wanted a baby
Before pregnancy, had you and your partner
0 – Never discussed pregnancy
1 – Discussed, but no firm agreement
2 – Agreed to get pregnant
Preparation for pregnancy
0 – No actions
1 – One action
2 – Two or more actions
Folate supplementation

A daily folate supplement of at least 400 mcg has been demonstrated to lower neural tube defects (NTDs) by 72% compared with no supplementation.13 Women with additional risk factors (refer to Table 1) require increased supplementation.14 Data show that women in Australia have suboptimal rates of preconception folate supplementation, particularly younger women and women having their third or more baby.6

There is ongoing research to explore the most effective dose and formulation of folate for women with recurrent miscarriage and gene polymorphisms. Best practice is to ensure those without risk factors do not exceed the maximum daily intake of 1000 mcg, because this can result in elevated levels of unmetabolised folic acid.15

Non-communicable disease

The evidence supporting PCC interventions for non-communicable disease stems from the concept of fetal programming, where periconceptual health impacts health over the life course, also known as the Developmental Origins of Health and Disease (DOHaD).16 In 2021, almost 50% of women in Australia were above a healthy weight as they entered pregnancy.8 Increased weight leads to a greater risk of gestational diabetes, hypertensive disorders and pre-eclampsia.17 For women who gain weight between pregnancies, these risks further increase in a dose-dependent manner, with women whose body mass index increased by ≥3 kg/m2 having the higher risk.18

Empowering women with type 1 and type 2 diabetes, by providing support and tailored education about the benefits of glycaemic control (target HbA1c <6.5%), can reduce the risk of congenital malformations.19,20 Contraception should be considered until blood sugar levels are stabilised.21 Review for micro- and macrovascular comorbidities should be performed. For women with gestational diabetes in a previous pregnancy, testing to ensure normalisation of blood sugars at 6–12 weeks postpartum is required. Women with elevated blood sugar levels require ongoing surveillance and assessment for type 2 diabetes, with management depending on future pregnancy plans.

Smoking, alcohol and other drugs

Smoking remains an important preventable risk factor for preterm birth, low birthweight and perinatal death. Up to 22% of women smoke in the preconception and early pregnancy period, with higher rates among First Nations people, younger people and people living in rural and remote areas.22 The use of e-cigarettes is increasing, with the largest increase in those aged 18–24 years. The effects of vaping in pregnancy remain unknown, but many e-cigarettes contain harmful substances and their use during pregnancy and preconception is not recommended.23,24

Approximately 77% of adults in Australia drink alcohol.25 There is no safe level of alcohol consumption in the preconception period or during pregnancy, and it is recommended that any person planning a pregnancy abstains from alcohol.26 Research shows that almost all women expect their healthcare provider to talk about alcohol when planning a pregnancy.27 The alcohol use disorders identification test consumption (AUDIT-C) tool is a validated tool to assess alcohol intake in the preconception and pregnancy period, and resources are available from the Foundation for Alcohol Research and Education (FARE) to assist clinicians and consumers with this topic.28 Recreational and other illicit drug use also needs to be assessed, because many of these drugs can cross the placenta and impact fetal brain development.29 Education should be provided on the benefits of quitting and strategies to achieve this.

Genetic carrier screening

Inherited conditions affect up to one in 400 people in Australia. A detailed family history must be taken to assess the likelihood of an inherited genetic condition and appropriate testing arranged. If there is a family history, or if a person is from Eastern European (Ashkenazi) Jewish background, referral to a genetic counsellor is recommended. Carrier screening is relevant to all people considering pregnancy and is outlined in Table 3.30 Medicare rebates for cystic fibrosis, spinal muscular atrophy and fragile X screening are available since November 2023. The Royal Australian College of General Practitioners (RACGP) education module Beware the rare provides general practitioners (GPs) with additional education in this area.31

Table 3. Genetic carrier screening
Preconception and pregnancy
All people planning a pregnancy, and pregnant, should be provided with information on genetic carrier screening
Three-gene panel    
Genetic conditions screened: spinal muscular atrophy, cystic fibrosis, fragile X Considerations  
  • 5% of individuals will carry a gene
  • 1 in 240 couples affected
  • Medicare rebate available
Expanded panel    
Genetic conditions screened: >400, >500, >1000 gene options Considerations  
  • 75% of individuals will carry a gene
  • 1 in 20 couples affected
  • Medicare rebate only for spinal muscular atrophy, cystic fibrosis and fragile X testing
Offering the test    
Sequential: one person offered screening; screen partner as indicated Couple screening: both people screened  
Potential pathways for individual or couple with confirmed genes
Preconception
  • Spontaneous conception
  • IVF, own sperm and egg, with pre-implantation genetic diagnosis
  • IVF, donor sperm or egg from non-carriers
  • Decision to not have a pregnancy
Pregnant (antenatal testing)
  • No antenatal testing
  • CVS from 11 weeks
  • Amniocentesis from 15 weeks
Postpartum
  • Postnatal testing on baby (newborn screening)
CVS, chorionic villus sampling; IVF, in vitro fertilisation.
Medical history and medications

A thorough medical history should be taken, and any medical conditions optimised prior to pregnancy. Contraception should be offered where appropriate while stabilising chronic conditions. All medications, both prescription and complementary, should be reviewed, considering the drug indication, dosing, route of administration and alternatives to ensure there is no or least risk to a developing fetus. Teratology information resources are available to assist in decision making, with examples including Reprotox (https://reprotox.org) and the Teratogen Information Service (https://uktis.org). Mothersafe (www.royalwomen.org.au/mothersafe) is an example of a local teratogen information service for consumers and health professionals in New South Wales.

Previous pregnancy outcomes

Previous pregnancy outcomes can inform risk factor modification and interventions in the interconception period. Disorders of placental insufficiency, such as intra-uterine growth restriction, pre-eclampsia or gestational diabetes, might require targeted interpregnancy diet and exercise goals, and education for early antenatal intervention in subsequent pregnancies.

Preventive health and screening, including sexually transmissible infections and infectious diseases

All potential parents should be educated about infectious diseases and have a review of their vaccination history for measles, mumps, rubella, varicella zoster, diphtheria, tetanus and pertussis and hepatitis B undertaken. Serological testing is recommended to confirm immunity to varicella, rubella and hepatitis B. Required vaccinations should be provided, including information to wait 28 days after rubella and varicella vaccinations before conceiving.32,33 Syphilis, human immunodeficiency virus (HIV)  and hepatitis C testing should be routinely performed, with other sexually transmissible infection testing determined on individual risk (Table 1).

Although routine screening for cytomegalovirus (CMV) is not currently listed in preconception care guidelines, CMV education and prevention are priority areas of pregnancy planning.34 CMV can cross the placenta and is the most common congenital infection, affecting up to 2000 babies annually.35 Fewer than one in five women of reproductive age know about CMV, and this improves with provision of CMV education resources.36 Individual risk assessment and screening should be performed for women with a risk of exposure, such as childcare workers and those with young children in childcare. All women should be educated about hygiene measures to reduce their risk of infection.

Preventive health measures such as breast self-examination, the importance of good oral health and cervical screening should be discussed. Recent changes to the National Cervical Screening Program now enable all people to access self-collection as a means for cervical screening.

Role of the GP in PCC

The prepregnancy period can range from a minimum of three months to years to improve behaviours and health.37,38 Given this, the International Federation of Obstetricians and Gynaecologists (FIGO) has called for all healthcare professionals who see people of reproductive age to deliver PCC.39 Australian studies show that both clinicians and consumers believe that GPs are well placed to deliver PCC.40,41

Barriers to delivering PCC include low levels of community awareness, a lack of presentations for a dedicated PCC appointment and high rates of unintended pregnancies.42,43 For clinicians, barriers include a lack of time, other competing preventive health priorities and a lack of available resources to help facilitate the delivery of PCC.40,44

Asking about pregnancy intention can start the conversation about PCC, including contraception options for those who do not intend to become pregnant. A pilot study in Australian GPs found that using the One Key Question® to ask about pregnancy intention was acceptable to women attending for non-preconception consultations.41 GPs found the tool easy to use, with a median consultation extension time of two minutes.41 Other enablers to the delivery of PCC include checklists and high-quality clinical practice guidelines. A recent systematic review of clinical practice guidelines for PCC identified only 11 guidelines internationally, with two from Australia, from the RACGP and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.45 Evidence exploring the effectiveness of PCC interventions delivered in primary care showed impact for brief interventions in improving a person’s preconception health knowledge and reducing their preconception risk factors.46

PCC is a shared responsibility from the population level down to the individual. The Preconception Health Network Australia is a multidisciplinary collaboration established to promote best practice in preconception healthcare and research and to drive policy change. Priorities and enablers identified by the Network are outlined in Table 4. The Network works with GPs to enhance the delivery of PCC for all Australians.

Table 4. Priorities and enablers for preconception care in primary care
For consumers
  • Health promotion activities to increase awareness among consumers
  • Improved equity of access to care for preconception and contraception consultations
For clinicians
  • Health promotion activities to increase awareness among clinicians
  • Available clinical guidelines to support delivery of high-quality, evidence-based care
  • Available resources of appropriate health literacy to support delivery of preconception care
  • Financial support and health service reform including Medicare rebates for primary care, and practice nurses to enable the timely delivery of preconception care
For policy makers
  • Data collection on preconception health and care indicators to allow deidentification and monitoring of policy for preconception health and care
  • Socioecological enablers for positive healthy eating and active living behaviour change, such as sugar taxes and increased access to green spaces

Key points

  • PCC benefits parents, their children and future generations.
  • Challenges to delivering PCC include low levels of community awareness of the importance of preconception health and low numbers of presentations for PCC.
  • GPs are ideally placed to deliver PCC, and this can begin with a discussion on pregnancy intention.
  • PCC is not only for first pregnancies, and previous pregnancy outcomes need to be reviewed.
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
Funding: None.
Correspondence to:
edwina.dorney@sydney.edu.au
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ObstetricsPreconception careWomen's health

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