Preconception Health and Care: A Life Course Approach Jill Shawe Eric A. P. Steegers Sarah Verbiest Editors 123 Preconception Health and Care: A Life Course Approach Jill Shawe • Eric A. P. Steegers Sarah Verbiest Editors Preconception Health and Care: A Life Course Approach Editors Jill Shawe Eric A. P. Steegers Faculty of Health Department of Obstetrics and Gynaecology University of Plymouth Erasmus University Medical Center, Plymouth Erasmus MC Devon Rotterdam UK The Netherlands Sarah Verbiest Center for Maternal and Infant Health Jordan Institute for Families, University of North Carolina at Chapel Hill Chapel Hill NC USA ISBN 978-3-030-31752-2 ISBN 978-3-030-31753-9 (eBook) https://doi.org/10.1007/978-3-030-31753-9 © Springer Nature Switzerland AG 2020 This work is subject to copyright. 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Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword How do paradigms shift? Not easily, not smoothly, not without refinement, expan- sions, and retrenchment, and not without pushback and champions. At least 40 years ago, a movement began to rethink traditional efforts for addressing the major causes of infant mortality and morbidity in industrialized nations: congenital anomalies and low birth weight. Review of observational studies in Europe and basic embryol- ogy caused the venerable adage, “prevention in order to be truly preventive must be antenatal” (Ballantyne 1902) to be questioned. The need for a new approach to impact healthy pregnancy outcomes came with recognition that women enter into prenatal care too late to prevent congenital anom- alies and the impact of numerous antecedents to low birth weight including intend- edness of the conception, interpregnancy intervals, maternal age, maternal pregravid weight status, prepregnancy chronic disease control, exposures to medications and other drugs, and timing of entry into prenatal care. With recognition of these limita- tions, a new approach to benefit pregnancy outcomes emerged which was designed to reach women with prevention opportunities before conception. In doing so, women and couples would be able to enter into pregnancy informed about risks to their own health and to the health of their pregnancies and offspring and to have taken any preventive steps that made sense to them and their circumstances. The potential significance of this shift can be appreciated by comparing the tradition of prescribing folic acid through multivitamins for its preventive benefits at the first prenatal visit (by which time the window for preventing neural tube defects has closed) versus educating women about the benefits of adequate folic acid exposure prior to entry into prenatal care and providing them with strategies for achieving the recommendation. Original efforts to include a preconception emphasis in reproductive health care were vested with obstetricians as they represent the usual gateway to pregnancy- related care at least in the USA and have the most power in defining its parameters. Their acceptance of a paradigm shift was judged essential to successfully prevent common threats to healthy pregnancy outcomes. The earliest known prepregnancy clinic was established in London in 1978 as a hospital-based service. The clinic largely served an interconceptional population of women who were referred because of previous poor pregnancy outcomes including maternal, fetal, and neonatal complications; occasionally a woman referred herself. The founder of the clinic noted that rarely was a physical exam performed; rather, v vi Foreword “opinion” was usually based on a combination of the woman’s own history, her past medical records (if available), and a careful assessment of the woman’s current fears and future worries (Chamberlain 1980). Engagement of obstetrical providers in the paradigm change was echoed in the USA with the 1987 article, Preconception Health Promotion: A Focus for Obstetric Care (Moos and Cefalo 1987). This article introduced the benefits of systematic assessment in exploring preconceptional issues for women contemplating pregnancy and reaching women not considering pregnancy in the immediate future in nontraditional settings such as family planning clinics. Shortly thereafter, the first known call to reach all women of childbearing poten- tial with preconception information was put forth (Moos 1989). “Until the health care community incorporates prepregnancy counseling into the routine services available to all women of childbearing age … the rights of women to exercise personal choices about their reproductive futures will not be realized and opportunities for primary prevention will be lost” (p. 67). The article posited that the primary purpose of preconception care is education: providing women with the information they need to make informed decisions about their reproductive futures and risks they may want to address prior to conception: in other words, the agenda is about empowerment. Engaging women directly without the initial information gateway being man- aged through a clinical encounter is one way to shift power. To introduce and rein- force the idea that the weeks around conception are at least as important as the later weeks of pregnancy in impacting some pregnancy outcome requires repeated expo- sure to this information. With the goal of introducing the importance of the earliest weeks of pregnancy to as many people as possible, numerous programs were cre- ated including school curriculum, health fair exhibits, brochures written at low read- ing levels, work place strategies, innovative and interactive health appraisals, and eventually internet-based health education strategies. Initially, these approaches resulted in many women arriving at their annual gyne- cologic exam or a specifically scheduled obstetrical visit with prepregnancy ques- tions only to be confronted with provider confusions or a perceived patronizing response that the woman should not worry—the questions would be addressed fully at their first prenatal visit. The dissonance in messages created frustration for patients and providers, alike—perhaps an unavoidable conflict when venerable tra- ditions are disrupted. Hoping to create a bridge between women’s expectations and providers’ preparation, the first comprehensive book for health-care providers (not just physicians or obstetricians) to understand the hows and whys of preconception health care, including literature-based recommendations for specific prepregnancy conditions, was published (Cefalo and Moos 1988, 1995). All of these initiatives stimulated increasing enthusiasm about the promise of preconception health promotion among governmental agencies, professional and advocacy groups, scientific advisory bodies and regulatory agencies in both the USA and the European Union and the World Health Organization, and thus the way clinical care frames the prevention window around pregnancy began to change. Foreword vii The unintended consequences of well-intentioned actions must be considered with any paradigm shift: Who might be hurt? Who could be left out? How might the new emphasis be misunderstood? Is it feasible, fundable, effective? Recognizing that preconception interactions around pregnancy risks could easily veer toward paternalism, disempowerment, or biases about who should or should not become pregnant, the intent of preconception counseling was deliberately promoted by pio- neers in the field as egalitarian and woman-centered (Cefalo and Moos 1988). The intent of preconception programs should not be to make reproductive decisions for women; it should not be to encourage reproduction in one group and discourage it in another. The intent … should be to provide enough information so that all women can make informed decisions about conception, life style and choices in medical care. Care-givers have a legal obligation to provide patients with accurate information on which to base deci- sions; they do not have the right to make those decisions for them. (p. 7) The preconception initiative was the first to identify that the traditional silos of reproductive care make little sense and provide less than the maximal benefit to outcomes: the prepregnancy, prenatal, postpartum and interconceptional periods should and can be approached as an integrated pathway of understanding and care for each woman. It is a small leap from the concept of integration to appreciating that healthy women have healthier pregnancy outcomes and that, for the most part, there is little that can be recommended in preconception care that would not benefit women of similar age who are not considering pregnancy. Examples include recom- mendations about healthy weight, tobacco cessation, no more than moderate alco- hol exposure, depression identification and treatment, screening for and addressing intimate partner violence, and many more. Thus, the preconception care paradigm shift is, in reality, a call for better prevention efforts throughout the life span. From this appreciation, the life course concept takes shape. Should primary prevention influences and efforts start with one’s own conception, childhood exposures, adoles- cent health choices, and adult health status or with prenatal and intrapartum experi- ences? Ultimately, the goal for preventive services should be that all people achieve the highest level of wellness possible, whatever stage of life they are in—calling for a true life course approach. As should occur with all new paradigms that impact multiple interest groups, the work should be constantly interrogated and be able to shift and evolve. The first wave of the preconception agenda has been fairly critiqued noting important con- cerns around pronatalism, a focus on the individual instead of the social determi- nants of health and health equity, implicit biases toward the LGBTQ population, paternalism, accessibility of related vocabulary, lack of engagement of men, women of color, people with low incomes, and others. Reproductive justice leaders and women of color have called for expanded conversations around historic trauma, bodily autonomy, and centering communities in creating their own solutions. As the new decade begins, collaborative steps and plans on how to move forward are a necessity. With this new volume, Shawe, Steegers, and Verbiest take an important and needed step to move the preconception initiative forward using a collaborative, viii Foreword international perspective; they look to the “what next” and address the evolving frame of preconception care, always mindful that this work should fully engage women, couples, men, and communities, and respect people’s values, interests, and needs. Importantly, they provide the current scientific underpinnings for specific recommendations that might be directed to people seeking preconception informa- tion. Shawe, Steegers, and Verbiest give us reason to believe that Ballantyne’s adage of nearly 120 years ago is being rewritten: “Prevention, in order to be preventive, must start before pregnancy.” The results will be healthier women throughout their lifetimes, healthier pregnancies should a woman become pregnant and healthier fetuses and neonates—all of this centered with a life course perspective that recog- nizes the necessity of grounding the work in a healthy community. Could there be a more far-reaching impact? Center for Maternal and Infant Health Women’s Health Care Merry-K. Moos University of North Carolina at Chapel Hill, Chapel Hill, NC, USA References 1. Chamberlain G. The prepregnancy clinic. Br Med J. 1980;281:29. https://doi.org/10.1136/ bmj.281.6232.29. 2. Moos MK, Cefalo RC. Preconception health promotion: a focus for obstetric care: Am J Perinatol. 1987;49(1):63–7. 3. Moos MK. Preconceptional health Promotion: a health education opportunity for all women. Women Health. 1989;15(3):55–68. 4. Cefalo RC, Moos MK. Preconceptional health promotion: a practical guide. Rockville: Aspen Publication; 1988. 5. Cefalo RC, Moos MK. Preconception health care: a practical guide (2nd ed). St Louis: Mosby—Year Book, Inc.; 1995. Contents 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Jill Shawe, Eric A. P. Steegers, and Sarah Verbiest Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2 Preconception Health: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Sarah Verbiest 2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.2 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.3 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.4 Key Components of Preconception Care . . . . . . . . . . . . . . . . . . . . . . 12 2.5 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.6 Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3 The Science of Preconception. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Jeffrey Hoek, Régine Steegers-Theunissen, Kevin Sinclair, and Sam Schoenmakers 3.1 General Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.3 Development of the Gametes (Eggs and Sperm), Embryo, Placenta, and Fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.4 Mechanisms Underlying Conception, Embryogenesis, and Placentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3.5 Preconception Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 3.6 General Recommendations for Practice . . . . . . . . . . . . . . . . . . . . . . . 32 3.7 Concluding Remark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 4 Genetic Health Care Before Conception . . . . . . . . . . . . . . . . . . . . . . . . . 35 Martina C. Cornel, Selina Goodman, and Lidewij Henneman 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 4.2 Genetic Health Care in Relation to Preconception Care . . . . . . . . . . 37 4.3 Counselling Couples about Genetic Risk . . . . . . . . . . . . . . . . . . . . . 37 ix x Contents 4.4 The Importance of Communication in Families Affected by Genetic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 4.5 Family History and Patterns of Inheritance . . . . . . . . . . . . . . . . . . . . 39 4.6 Patterns of Inheritance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 4.7 Consanguinity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.8 Carrier Status in Relation to Ancestry . . . . . . . . . . . . . . . . . . . . . . . . 43 4.9 From Ancestry-Based Carrier Testing to Universal Screening . . . . . 45 4.10 Genetic Issues in the Fertility Clinic . . . . . . . . . . . . . . . . . . . . . . . . . 47 4.11 Techniques Available for Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.12 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 5 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Ilse Delbaere and Jenny Stern 5.1 Family Planning and Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 5.2 Unintended Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.3 Age as a Predictive Factor for Fertility: Women and Men . . . . . . . . . 56 5.4 Methods to Monitor the Window of Fertility . . . . . . . . . . . . . . . . . . . 58 5.5 Subfertility and Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 5.6 Fertility Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 5.7 Interventions for Increasing Fertility Awareness . . . . . . . . . . . . . . . . 70 5.8 Conclusion and Recommendations for Practice . . . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Zainab Akhter, Melissa van der Windt, Rianne van der Kleij, Nicola Heslehurst, and Régine Steegers-Theunissen 6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 6.2 Micronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 6.3 Recommendations for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 7 Lifestyle: Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Annick Bogaerts, Amanda Bye, Margriet Bijlholt, Kate Maslin, and Roland Devlieger 7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 7.2 Measuring Weight Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 7.3 Prevalence of Underweight, Overweight, and Obesity . . . . . . . . . . . 106 7.4 Weight Monitoring Before Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 108 7.5 Weight Monitoring During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 108 7.6 Associations Between Maternal Weight and Reproductive Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 7.7 Impact on Women and Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 7.8 Postpartum Weight Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 7.9 Impact on the Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 7.10 Maternal Weight and Mental Well-Being . . . . . . . . . . . . . . . . . . . . . 114 7.11 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115