Preconception care

The term preconception care has been used in North America since the 1980s to describe childbearing-related health care for women before they become pregnant. It was first associated with the care provided to women who had already experienced adverse pregnancy outcomes,¹ but soon came to be recommended for all women.² Despite this history, there is no uniform definition or universal recognition of preconception care.³ While a smattering of guidelines and documents has brought the concept to life in several Canadian jurisdictions, there is no consistent set of national guidelines for this important component of well-woman care. We believe family physicians can make a crucial difference by incorporating preconception care into routine practice and urging a national discussion about approaches to prenatal health.

Why adopt preconception care?

There are several reasons why it is urgent that preconception care be adopted. From the standpoint of both women’s and children’s health, our current practices are failing. In the United States, for example, the proportion of preterm babies rose from 9.4% in 1981 to 12.3% in 2003, and the proportion of those with low birth weight rose from 6.8% in 1981 to 7.9% in 2003.⁴ In Canada, the rate of preterm birth rose gradually through the 1980s and 1990s, and has been stable at between 7% and 8% since 2000.⁵ There are various reasons for these trends, including infertility treatments; rising maternal age; tobacco, drug and alcohol use; obesity; and chronic disease.⁶ The primary strategy for combating these risks has been aggressive prenatal health promotion. Preconception care would provide a much-needed complement to prenatal care that could improve neonatal outcomes by taking a long-term approach to the health of women.

Most prenatal approaches focus primarily on the fetus, treating it as the patient, and regarding the woman as a vessel who needs to change problematic behaviour and choices.^7,8 These approaches have been criticized for their shaming effects (particularly in cases of health issues such as nicotine or alcohol dependence) and might deter some childbearing women, especially pregnant women, from disclosing their substance use and seeking treatment.^9,10 Even when interventions are accessible and successful, their focus on fetal health means that women’s health is often an afterthought. For example, tobacco and alcohol cessation efforts are often abandoned in the postpartum period, resulting in rates of relapse as high as 90% once the fetus is no longer a motivator or a reference point for medical treatment.^11,12

Conversely, preconception care provides an opportunity to improve routine care for women across the lifespan and integrate it with their reproductive plans, for instance by discussing contraception, fertility, and interactions between women’s overall health and their reproductive health. A woman-centred approach would address the health of any hypothetical future children via the health of the woman, not as a separate goal. As Moos argues, preconception care should benefit the woman’s health first and, should she become pregnant, “the benefits are expanded.”¹³ This would both strengthen baseline well-woman care and connect it meaningfully to prenatal and neonatal health.

There is a further key reason to think beyond traditional prenatal care paradigms: many women conceive unintentionally and might not even realize they are pregnant until the first trimester has passed. By this point damage might already have been done. Approximately 49% of American pregnancies are unintended,¹⁴ and while there are no national data on the prevalence of unintended pregnancy in Canada,¹⁵ the rate is presumed to be similar. Hence, prenatal care— when it exists or when it is accessed—might be too little or too late. In the 3 months before conception or realizing they were pregnant, 15.8% of women in Canada used tobacco and 62.4% drank alcohol.¹⁶ Preconception care would prompt treatment of women for the kinds of problems that affect birth outcomes and maternal health on an ongoing basis, rather than waiting until they set out to become pregnant. Incorporating preconception care into routine women’s health care might also reduce the incidence of unwanted pregnancy and help identify unwanted pregnancies sooner for those women who choose not to carry their pregnancies to term.

Despite these compelling reasons for adopting preconception care as part of overall women’s health care, there is little practical action in Canada that reflects a preconception approach to women’s health. For example, less than half of health care providers in Canada discuss substance use with women of childbearing age and fewer than 60% of family doctors and obstetricians discuss specific issues such as folic acid supplementation before conception.¹⁷ Preconception care is practised inconsistently and incompletely across jurisdictions and institutions, despite evidence of its effectiveness.¹⁸

Absence of national guidelines

This state of affairs is not surprising in light of the absence of Canadian national guidelines. Importantly, while the Society of Obstetricians and Gynaecologists of Canada has published Healthy Beginnings,¹⁹ a book that covers preconception to postpartum health, it does not have clinical practice guidelines for preconception care. The Public Health Agency of Canada published preconception guidelines in 2000, urging that “preconception care and education be incorporated into school curricula and the workplace, delivered through the media, and offered through community-based agencies.”²⁰ However, while these were promising steps, it is not evident that the Society of Obstetricians and Gynaecologists of Canada or the Public Health Agency of Canada recommendations have been taken up in any systematic way.

Nonetheless, several preconception initiatives have taken place at the provincial level in Alberta, British Columbia, and Ontario, testing and illustrating the promise of this approach. For example, the Best Start Resource Centre, the Ontario maternal, newborn, and early child development resource centre, released a series of brochures and resources provincewide between 2001 and 2006 addressing different components of preconception health. Best Start also issued a trio of reports in 2009 on preconception health in Ontario following surveys of physicians, public health units, and the public.^21–23 It found that most public health units (88%) had implemented at least 1 preconception initiative in the past 5 years.²³ The survey of family physicians found that 78.4% claimed to deliver preconception care at least weekly.²² Conversely, 58% of women and men surveyed in the same series claimed their health care providers had not brought up the topic of preconception health.²¹ While awareness campaigns might have had some effect, there still appears to be a lack of clarity and communication between family physicians and the public about what preconception care consists of and why it is necessary.

Such provincial efforts are interesting and encouraging, but would reach more Canadian women in a more equitable manner if national guidelines were articulated, complete with implementation plans, associated funding, and evaluation. National preconception guidelines exist in the United States, where the Centers for Disease Control and Prevention released a comprehensive report on preconception health and care in 2006 that detailed 10 recommendations.²⁴ Since the publication of the Centers for Disease Control and Prevention guidelines, a number of federally funded efforts have resulted in preconception programs in specific cities, targeting the populations that are most vulnerable to poor maternal and newborn outcomes and least likely to have access to prenatal care.²⁵

Like the most effective practices in other facets of women’s health, preconception care should respect and support women’s autonomy and take a social determinants approach.^26–28 As part of developing national guidelines, the experiences of the provinces that have tried this approach could be built upon and used as a basis for evidence-informed practice and programming, and a starting point for broader application. National leadership to foster collaborative development of authoritative guidelines and goals could reduce existing confusion and encourage more comprehensive and consistent application of preconception care, setting the stage for a more integrated approach. The development of national guidelines on preconception care would draw attention to the schisms in our health system—between women’s health care and neonatal care, and between routine care and acute care—and assist in creating more equitable approaches across Canada.