the importance of reproductive life planning ......jul 31, 2013 · widespread adoption of...
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The Importance of Reproductive Life Planning & Preconception Care
Michael C Lu, MD, MPH Associate Administrator
Maternal and Child Health Bureau Health Resources and Services Administration
Department of Health and Human Services
Title X National Grantee Meeting
Seattle, WA
July 31, 2013
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Maternal & Child Health Bureau
HHS
HRSA
MCHB
NIH AHRQ CDC FDA
CMS ACF ATSDR IHS SAMHSA ACL
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Mission
• Improve the health of all women, children, and families in our nation
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MCHB
• Annual budget of $1.2 billion • Title V MCH Services Block Grant
• Maternal, Infant, and Early Childhood Home Visiting Program
• Other Categorical Programs • Autism and other developmental disabilities
• Traumatic brain injury
• Sickle cell service demonstration
• Universal newborn hearing screening
• Heritable disorders
• Emergency medical services for children
• Family-to-Family information centers
• Healthy Start
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MCHB
• Title V MCH Services Block Grant • State Block Grant
• Special Projects of Regional & National Significance (SPRANS)
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MCHB
• Maternal, Infant, and Early Childhood Home Visiting Program
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MCHB
• Other Categorical Programs • Autism and other developmental disabilities
• Traumatic brain injury
• Sickle cell service demonstration
• Universal newborn hearing screening
• Heritable disorders
• Emergency medical services for children
• Family-to-Family information centers
• Healthy Start
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Preconception • any time that a woman of reproductive
potential is not pregnant but at risk for becoming pregnant, or when a man is at risk for getting someone pregnant.
CDC. Recommendations to improve preconception health and health care – United States. In:
Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.
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Preconception Care • A set of interventions that aim to identify
and modify biomedical, behavioral and social risks to the woman's health or pregnancy outcome through prevention and management
CDC. Recommendations to improve preconception health and health care – United States. In:
Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.
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Preconception Care • Reproductive life plan
• Medical history
• Sexual health assessment
• Intimate partner and sexual violence
• Alcohol and other drug use
• Tobacco use
• Immunizations
• Depression
• Height, weight and BMI
• Blood pressure
• Chlamydia, gonorrhea, syphilis and HIV/AIDS
• Diabetes.
CDC. Recommendations to improve preconception health and health care – United States. In:
Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.
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Preconception Care & Family Planning
Family planning services are necessary for the widespread adoption of preconception care for two reasons. First, preconception care is more likely if pregnancies are planned, and family planning services encourage pregnancy planning. Second, family planning services usually include counseling, and counseling provides an opportunity to discuss the advantages of preconception care.
Klerman LV. Family Planning Services: An Essential Component of Preconception Care. Matern Child Health J. 2006
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Reproductive Life Plan • A set of personal goals about having (or not
having) children based on personal values and resources, and a plan to achieve those goals.
CDC. Recommendations to improve preconception health and health care – United States. In:
Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.
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Reproductive Life Plan • Do you have any children now?
• Do you want to have (more) children?
• How many (more) children would you like to have and when?
CDC. Recommendations to improve preconception health and health care – United States. In:
Recommendations and Reports, April 21, 2006. MMWR. 2006;55 (No. RR-06):1-23.
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Importance of Preconception Care • Prenatal care may be too late
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Importance of Preconception Care • Prenatal care may be too late
• To prevent some birth defects
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Early Prenatal Care Is Too Late to prevent some birth defects
• The heart begins to beat at 22 days after conception
• The neural tube closes by 28 days after conception
• The palate fuses at 56 days after conception
• Critical period of teratogenesis – Day 17 to Day 56
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Importance of Preconception Care • Even early prenatal care may be too late
• To prevent some birth defects
• To prevent implantation errors
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Early Prenatal Care Is Too Late to prevent some birth defects
Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400-8.
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Importance of Preconception Care • Even early prenatal care may be too late
• To prevent some birth defects
• To prevent implantation errors
• To restore allostasis
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Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/
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Allostasis: Maintain Stability through Change
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
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Allostastic Load: Wear & Tear from Chronic Stress
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
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Stressed vs. Stressed Out • Stressed
• Increased cardiac output • Increased available glucose
• Enhanced immune functions • Growth of neurons in
hippocampus & prefrontal cortex
• Stressed Out
• Hypertension & cardiovascular diseases
• Glucose intolerance & insulin
resistance • Infection & inflammation • Atrophy & death of neurons in
hippocampus & prefrontal cortex
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Allostasis & Allostatic Load
McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002
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Rethinking Preterm Birth
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Racial & Ethnic Disparities Preterm Births < 37 Weeks
17.9
11.5
0
2
4
6
8
10
12
14
16
18
African American White
Percent of Live Births
NCHS 2006
Year 2010 Goal
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Preterm Birth & Infant Mortality, US, 2007
Source: NCHS, linked birth/infant death data set
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Racial & Ethnic Disparities Preterm Births < 37 weeks
Percent of Live Births
Year 2010 Goal
NCHS 2010
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Racial & Ethnic Disparities Very Preterm Births < 32 Weeks
Percent of Live Singleton Births
Year 2010 Goal
NHS 2010
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Racial & Ethnic Disparities Infant Mortality
Deaths Per 1,000 Live Births
NCHS 2010
Year 2010 Goal
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Rethinking Preterm Birth
Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course (early programming & cumulative allostatic load)
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Preterm Birth & Maternal Ischemic Heart Disease
Kaplan-Meier plots of cumulative probability of survival without admission or death from ischemic heart disease after first pregnancy in relation to preterm birth
Smith et al Lancet 2001;357:2002-06
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Take Home Message #1 • Even early prenatal care may be too late
• To prevent some birth defects
• To prevent implantation errors
• To restore allostasis
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Take Home Message #2 • An important objective of preconception care
is to restore allostasis and optimize women’s health
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Take Home Message #3 • If we want to improve maternal and child
health, we start by improving women’s health
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Preconception Care for Men • Xenobiotics
• Pesticides, insecticides, fumigants
• Nonylphenol (super detergents)
• Polycyclic aromatic hydrocarbons (PAHs) (smoking)
• Polychlorinated biphenyls (fishing, old appliances)
• Dioxins (animal fat)
• Phthlates (plastics)
• Acrylamide (overcooking)
• Heavy metals (lead, cadmium, etc)
• Infection/inflammation
• Hyperthermia
• Radiation
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Preconception Care for Men • Reproductive life plan
• Medical history
• Sexual health assessment
• Screening for alcohol and other drug use
• Tobacco use
• Depression screening
• height, weight and BMI
• STDs (chlamydia, gonorrhea, syphilis and HIV/AIDS)
• Diabetes
Frey KA NS, Kotelchuck M, Lu M The clinical content of preconception care: preconception care for men. . AJOG. 2008;December:S389-95.
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Interconception Care
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The definition of insanity is doing the same thing over and over and expecting different results.
Benjamin Franklin
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We must become the change we want to see.
Mohandas Gandhi
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Contact Information
Michael C. Lu, MD, MPH
Associate Administrator
Maternal and Child Health Bureau
Health Resources & Services Administration