Born Too Soon: Care before and between pregnancy to prevent preterm births: from evidence to action

Preconception care has, until recently, been a weak link in the continuum of care. Providing care to women and couples before and between pregnancies (interconception care) improves the chances of mothers and babies being healthy, and awareness is growing. Preconception care may be defined as "any intervention provided to women and couples of childbearing age, regardless of pregnancy status or desire, before pregnancy, to improve health outcomes for women, newborns and children"[1], or "a set of interventions that aim to identify and modify biomedical, behavioral and social risks to a woman's health or pregnancy outcome through prevention and management" [2]. An expanded scope and definitions for preconception care are provided in Figure 1.

Preconception care emphasizes outcomes for maternal and child health; however, it is vital to recognize that all girls and boys have the right to grow and develop in good health, just as all women and men have the right to be healthy -- physically, psychologically and socially. Extending the RMNCH continuum to the preconception period improves the health and wellbeing of mothers, newborns and children as well as the health and wellbeing of girls and women, and boys and men, in their own right.

As shown in Figure 2, the conceptual framework for preconception care encompasses broader initiatives such as women's education and empowerment, and more targeted health interventions such as vaccination and micronutrient supplementation. Preconception care allows the time necessary for behavioral interventions to take effect. In various countries, it has been provided in schools, primary health care facilities or community centers, and has involved husbands, health care providers, youth leaders and community volunteers in achieving healthier outcomes for mothers and babies.

Many women, however, are unaware of how their health before conception may influence their risk of having an adverse outcome of pregnancy. As shown by the RMNCH continuum of care [3], health education and other programs delivered to all women during adolescence, before conception and between pregnancies can improve women's own health during pregnancy as well as that of their babies [4–6]. The imperative for preconception health is even greater given that 41% of all women report that their pregnancies were unplanned [7]. Thus, waiting to provide needed health interventions until a woman and her partner decide to have a child will be too late in 4 out of 10 pregnancies.

Preconception care simultaneously promotes reproductive planning and interventions to reduce risk, allowing women to enter pregnancy in the best possible health and to have the best possible chance of giving birth to a healthy newborn. Outreach and awareness must begin in adolescence if it is to truly improve the health of women and newborns and reduce the rates of prematurity and low birthweight (Figure 3). The contextual and individual risks that increase the likelihood of preterm births and other adverse pregnancy outcomes are present from the time a girl reaches adolescence, and they continue during and between pregnancies.

The objectives of this paper are to review the evidence based interventions and services for preventing preterm births; report the findings from research priority exercise to list and rank important research options in preconception care; and prescribe actions for taking this agenda further.

Factors that have been shown to be strongly predictive of preterm risk, but cannot be modified, include history of previous spontaneous preterm birth, cervical procedures, including biopsies, primiparity, grand multiparity, and multiple gestations. Factors associated with socioeconomic and racial disadvantage will, hopefully, be amenable to positive transformation over the longer term, but this will require fundamental structural changes to society and a deep-seated shift in social values and norms.

The growing interest in preconception care is fairly recent; thus, there are limited data specific to the period prior to and between pregnancies, particularly relating to preterm birth risks and outcomes. Risk factors and interventions that have been studied only in adolescents or only during pregnancy also may be relevant in the preconception period. For instance, exposure to indoor air pollution during pregnancy leads to 20% more stillbirths and low birth weight babies [103]. Yet many women are exposed to biomass smoke and second-hand tobacco smoke long before pregnancy is established. Similarly, interventions such as smokeless stoves or smoking cessation programs that reduce overall levels of exposure also would benefit women who later become pregnant. For many women, a positive pregnancy test is a stimulus to cease smoking, yet most women require multiple attempts to quit. Smoking cessation programs for adult men and women have been evaluated and demonstrate higher rates of women who quit before or during the first trimester [104]. Given the strong evidence of risk for preterm birth and low birth weight with tobacco use in pregnancy, it may be inferred that fewer women smoking translates to lower rates of preterm birth.

Many interventional studies in the preconception period report different health outcomes, which is also the case for studies on pregnancy and childbirth [105]. This precludes a complete assessment of the impact that an intervention could have on multiple pregnancy outcomes. For instance, research to reduce the prevalence of STIs among women may assess safe sexual behaviors or rates of transmission as outcomes; however, many studies do not indicate how many women later became pregnant or change in rates of preterm birth.

Until now, preconception care has been provided through three avenues: pre-pregnancy health visits for couples contemplating pregnancy; programs to increase awareness, screening and management for a particular risk; or participatory women's groups in the community. The diversity of contexts and risks among adolescent girls and women will require that preconception care be tailored to different settings and groups. The approaches used are a step in the right direction; but could be broadened to include earlier health care and health promotion for women and couples and address risks more holistically.

There is widespread agreement that in order to reduce maternal and childhood mortality, a continuum of care needs to be provided and that actions are needed at the community, primary care and referral care levels to deliver this continuum [4]. Packages of interventions to improve maternal and newborn health have been developed; yet, these focus largely on care during pregnancy and after birth [106]. However, it is important to realize that most of the health risk behaviors that are emphasized during pregnancy are generally the ones that are advised before pregnancy. Steering the action from preconception period will improve gearing the risk factors soonest and can lead to profound benefits for health and well-being of women and couples and improve subsequent pregnancy and child health outcomes. Tracking progress and scaling up delivery of preconception interventions has been a challenge, with preconception initiatives in individual countries delivering different services to different segments of the population (women, couples or adolescents).

In some high-income countries, such as the United States, Hungary, Australia and the Netherlands, an attempt has been made to provide preconception care to couples of reproductive age through family physicians or a special preconception clinic [98, 107–111]. Evidence-based recommendations for the content of preconception care also have been published [2, 112–114], and components have been incorporated into major national and international health guidelines [11, 115]. In the United States, a website has been developed to support clinical education and practice in this area http://www.beforeandbeyond.org.

In some countries (India, Pakistan, Bangladesh and Nepal), women's support groups have been teaching birth preparedness to women and their partners [101, 116–119]. Many large-scale trials for individual preconception interventions also have been carried out in low- and middle-income countries. While individual settings will require context-specific approaches to providing preconception care, a number of effective and culturally-acceptable interventions already exist. An example of an opportunity to build on existing programs is the integration of interconception health into home visits during the postnatal period.

The evidence base for risks and interventions before conception is still being strengthened because preconception care, as noted, is a relatively new concept. Therefore, an agreed-upon package of evidence-based interventions and opportunities for scale up in the preconception period has yet to be decided.

For some important risk factors that have been identified, epidemiologic data are lacking. National, regional and global databases are needed that track adolescent girls and women exposed to a particular risk (for example pre-pregnancy underweight, anemia or infection) and rates of preterm birth in high-risk versus healthy mothers. Additionally, monitoring systems must be in place to evaluate the effect of introducing or scaling up interventions on the incidence of preterm birth and other pregnancy outcomes. Epidemiologic measurement is critical to establish goals, track progress and compare intervention strategies. Replicating these interventions in larger studies of adolescent girls and women before first pregnancy, or between pregnancies, is needed to assess the relative benefit that may be obtained through preconception care across different populations.

There is a need for discovery research to further elucidate the etiology of preterm birth and identify ways to screen women. There is also a great need for innovative interventions and new ways to implement existing interventions, especially ways to assess and reduce exposure to risk factors that are not directly amenable to medical intervention, such as environmental pollution.

The development of national and international guidelines specific to preconception care would increase the visibility of the issue for health care providers and the population in general. While there is need for a defined and tested preconception care package, that can be adapted to various settings and models of service delivery at scale, much is still undiscovered, both in terms of what interventions work to reduce risks such as pre-pregnancy underweight and obesity or mental health problems and how to integrate effective preconception interventions into broader programs and initiatives across the continuum of RMNCH.

The interventions with proven benefit and national data, such as family planning, require further operational research including how to maximize provision of preconception care in the healthcare setting and community, and how to promote uptake by adolescents and women particularly those who are at high-risk for a preterm birth. The feasibility of scaling up preconception interventions will need to be assessed, including improvements to infrastructure, supply chain and health management systems also may increase coverage of preconception services.

Piloted interventions to improve the health of adolescent girls and women, which can lead to prevention of preterm birth, are often not categorized as preconception care; thus, they present a missed opportunity for linking to preterm birth research. Continued research will be necessary to identify tailored interventions for women from different strata and with different risk profiles within the same communities. There also is need to develop simple, accessible and user-friendly ways to provide individualized preconception care to women in contexts where resources are lacking or where health systems are weaker.

Addressing contextually-relevant ways to increase demand for and access to preconception care services is especially necessary in developing countries. While many countries have implemented behavior change strategies to increase awareness on birth preparedness and women's empowerment, more strategies for assessing benefit particularly for preterm birth are needed, especially culturally appropriate ways to involve adolescent boys, men and communities.

Even with current tools used to diagnose disease such as hypertension, the development of simpler, cost-effective diagnostic tests will enable efficient point-of-care testing with timely results and minimize the need for multiple visits. Likewise, affordable, easy-to-administer preventive and treatment options that are woman-friendly are in demand, such as oral insulin or better female-controlled contraceptive methods. With the knowledge gaps for preconception care, there is room for testing innovative technology and for implementation research.

Although preconception care is now recognized as a way to better the health of women and couples and improve pregnancy and newborn outcomes, a package of essential preconception interventions has not yet been agreed upon, nor is there global consensus on how to incorporate preconception care into the overall maternal, newborn and child health strategy. A meeting was organized by the World Health Organization in early 2012 to meet these objectives, and develop an action plan for moving the agenda for preconception care forward [121]. The meeting brought together leading researchers in the field, individuals with programmatic implementation experience of preconception care, and a number of organizations working to improve maternal and child health worldwide who were interested in developing an action plan for preconception care. There was a strong sense of the importance of preconception care, and a common understanding of preconception care as part of a continuum of care to improve the health of adolescents, women, couples of reproductive age, mothers, newborns and children. It was agreed that there is a need to distinguish between proximal preconception care that would occur one to two years before conception and distal preconception care that would extend even earlier, since the target populations and interventions for each may differ. Target population groups should include all women and men of reproductive age who may or may not be currently contemplating pregnancy with special efforts to reach vulnerable groups such as adolescent girls, those who are socioeconomically marginalized, and couples with previous adverse reproductive and pregnancy outcomes. It is important to specifically target adolescent and young women because health habits initiated during that period of age have profound impact on future health and their future pregnancy outcomes. Risky behaviors such as use of alcohol, tobacco and illicit drugs are significant challenges to their health, while, risky sexual behavior put them at high risk for unintended pregnancy and HIV/STIs. It was emphasized that preconception care is needed in low- and middle-income countries which have the highest burden of maternal and child mortality and morbidity, but it also relevant and important for women in high-income countries who are socioeconomically deprived. Further, all participants wanted to agree on an essential package of preconception interventions, with the possibility for regions and countries to select additional preconception care services and delivery strategies based on contextual factors. It would therefore be important that preconception care programs are documented, evaluated and disseminated so that others can learn from such experiences in adapting preconception care services to their setting.

Effective preconception interventions that decrease maternal and child mortality and morbidity should be delivered using appropriate methods that include health education, vaccination, nutritional supplementation and food fortification, contraceptive information and services, screening and management of medical and social risk factors. There are certain risk factors which lead to some behavioral effects and complex outcomes. To illustrate, risky sexual behavior and cases of intimate partner violence are higher among those who consume alcohol and are also involved in substance abuse. Disentangling these factors and effects may be difficult. Hence ameliorating these linked risk factors and behaviors can prevent a host of factors for poor pregnancy outcomes. In the health care setting, an essential package of interventions and a checklist of risk factors to be screened for might be a feasible starting point. In some countries, mandatory screening for hereditary diseases before marriage drastically reduced rates of thalassemia, and whether preconception care could be delivered through a similar means has not been explored [122]. Packaging these interventions further ensures translation of knowledge into action. The packages feature opportunities for delivery and highlight the implementation of intervention packages via existing health care and public health programs. A package of existing antenatal program, for example, if includes preconception care can be an effective strategy in low-income countries and would capture a wide audience. School health and reproductive health programs, on the other hand, can guide adolescent as to how to make responsible decisions concerning their sexual lives, as well as how to practice safe sex, and how to prevent unwanted pregnancies.

Provision of preconception care must also be extended beyond those who are traditionally involved in women's health, by incorporating the concept into training for current and future health care providers. For some risks, such as chronic diseases, until diagnosis and treatment can become more affordable, policymakers and donor organizations must work in conjunction to make screening and care widely available. Increasing coverage of postpartum care would also help to improve women's health in future pregnancies, for example, through the integration of preconception care in postnatal home visits. Men are critical and equal partners in family planning and reproductive health practices and their involvement in preconception care can bring positive outcomes. They play a major role in supporting women with which they can not only foster healthy practices but can also discourage risky behaviors such as smoking and intake of alcohol in their partners. Furthermore involving males can exert positive impact on their own behaviors and practices and hence influence the family at large.

Also of importance will be the encouragement of dialogue and collaboration with other sectors -- for example, education food and agriculture and telecommunications and media -- which are already engaged with young people of preconception age to promote greater demand for preconception care, and to reach girls, women and couples beyond the health care system. In some cases, integrated programs have already been shown to be feasible and effective, such as youth development programs, contraceptive provision in school for adolescents and incorporating maternal health into child vaccination days. It is also essential to develop a way to involve men, community leaders, volunteers and families in support for and provision of preconception care.

Until recently, the provision of care to women and couples before and between pregnancies to improve maternal and newborn health has not had sufficient priority on the RMNCH continuum of care. As with research, care must focus increasingly "upstream" from birth if the true potential for prevention of preterm birth is to be realized. Effective preconception care involves a broad variety of partners, including men, health care providers, youth leaders and community volunteers; and delivery sites such as schools, primary health care facilities and community centers. Outreach and awareness must begin in adolescence if it is to truly improve the health of women and newborns and reduce the rates of prematurity. If tackled, however, with vigorous and evidence-based interventions, preconception care offers the earliest opportunity to reduce risk, allowing women to enter pregnancy in the best possible health and to have the greatest chance of giving birth to a healthy baby.