Improving Preconception Health &Healthcare in Tulsa

Michael C. Lu, MD, MPHAssociate Professor

Department of Obstetrics & GynecologyDavid Geffen School of Medicine at UCLA

Department of Community Health SciencesUCLA School of Public Health

Tulsa, OklahomaOctober 11, 2011

Why Preconception Care?

Why Preconception Care?

Early prenatal care is too late.

When Does the FetalHeart Begin to Beat?

Early Prenatal Care Is Too LateTo 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

Early Prenatal Care Is Too LateTo Prevent Implantation Errors

Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400-8.

The Role of the Placenta in Fetal Programming

Godfrey KM. The role of the placenta in fetal programming-a review. Placenta. 2002;23 Suppl A:S20-7.

Early Prenatal Care Is Too Late from A Life-Course Perspective

Early prenatal care is too late to restore allostasis and optimize women’s health before pregnancy

What Is Preconception Care?

What is Preconception Care?

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.

Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1-23.

Summary of the CDC/ATSDR Select Panel’s Recommendations to Improve Preconception Health and Health Care in the United States

Recommendation 1. Individual responsibility across the life span. Each woman, man and couple should be encouraged to have a reproductive life plan.

Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts.

Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.

Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions (i.e. those with evidence of effectiveness and greatest potential impact).

Recommendation 5. Interconception care. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birthweight, or preterm birth).

Recommendation 6. Prepregnancy checkup. Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy.

Recommendation 7. Health insurance coverage for women with low incomes. Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care.

Recommendation 8. Public health programs and strategies. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.

Recommendation 9. Research. Increase the evidence base and promote the use of the evidence to improve preconception health.

Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health.

Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1-23.

Components of Preconception Care

Risk Assessment Health Promotion Medical & Psychosocial Interventions

Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.

Preconception Health Promotion

1. Ask about reproductive life plan2. Start prenatal care before you get pregnant3. Start eating for two4. Eat more brain foods5. Avoid toxic foods6. Take a multivitamin everyday7. Achieve a healthy weight8. Learn how not to get stressed out9. Give your immune system a tune-up10.Detoxify your environment

Get ready to get pregnant

Tip #1 Ask About

Reproductive Life Plan

Reproductive Life Plan

A set of personal goals about having (or not having) children based on personal values and resources

A plan to achieve those goals

http://www.cdc.gov/ncbddd/preconception/QandA.htm#5

Examples of a Reproductive Life Plan

1. Do you hope to have any (more) children?2. How many children do you hope to have?3. How long do you plan to wait until you (next)

become pregnant?4. How much space do you plan to have between

your pregnancies?5. What do you plan to do until you are ready to

become pregnant?6. What can I do today to help you achieve your

plan?

Tip #2 Start prenatal care

before you get pregnant

Components of Preconception Care

Risk Assessment Reproductive life plan Past pregnancy history Past medical & surgical history Medications & allergies Family & genetic history Social history Behavioral & nutritional assessment Mental health Laboratory testing

Health Promotion

Medical & Psychosocial Interventions Preventive services and primary care Individualized for identified risks

Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.

Examples of Drugs to Avoid

Agent Comments

ACE inhibitors, ARBs Kidney abnl if exposed in 2nd or 3rd tri

Statins Abnormalities if exposure 4–9th week

Testosterone Masculinization of female fetus

Carbamazapine Fetal death, mental retardation, malformations of heart, genitals;cleft palate and arteries

Coumadin derivatives(warfarin)

Risk of bone+ cartilage deformities, mental retardation, vision problems

Lithium Increased risk of CV anomalies

Phenytoin Risk of fetal hydantoin syndrome

Valproic acid Use in 3-4 divided doses; not with carbamazapine + phenobarbitol

Isotretinoin Elevated risk of SAB and anomalies

Questions about Drug Use in Pregnancy

OTIS (Organization of Teratogen Information Specialists) http://www.otispregnancy.org Toll-free (866) 626-OTIS

Tip #3 Start “eating for two”(in quality, not in quantity)

Make Healthy Food Choices

Whole grain foods: 5-7 servings Plant oils: 6 teaspoons Vegetable and fruits: 5 servings Nuts, beans and lentils: ½ to 1 cup Fish, poultry or egg: 1 serving a day Dairy: 3 servings Multivitamin: 1 a day

http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid

Make Healthy Food Choices

Eat more whole foods and less processed foods

Use a menu planner www.MyPyramid.gov

Tip #4Eat more brain foods

Top 10 Brain Foods Beans Eggs Nuts & seeds Olive oil Alaskan wild salmon Yogurt & kefir Whole grains Spinach, collards, kale & broccoli Prunes, raisin, blueberries Oranges, red bell pepper, tomato

Tip #5Eat less toxic foods

Top 10 Toxic Foods Swordfish, shark, king mackerel and tile fish Soft cheese and unpasteurized milk Hot dogs, luncheon meats, deli meats, raw or smoked

seafood Raw or undercooked meat Unwashed vegetables, raw vegetable sprouts, and

unpasteurized juices Liver Saturated fats, trans fats, and partially hydrogenated

oils Added sugars Refined flour Herbal preparations

Fish:Brain Food or Toxic Food?

What You Need to Know about Mercuryin Fish & Shellfish

2004 EPA/FDA Joint Advisory for Women who might become pregnant Women who are pregnant Nursing mothers Young children

Do not eat Shark, Swordfish, King Mackerel, or Tilefish Eat up to 12 ounces (2 average meals) a week

Shrimp, canned light tuna, salmon, pollock, catfish are low in mercury

Albacore (“white”) tuna has more mercury than canned light tuna

Check local advisories about locally caught fish www.epa.gov/ost/fish

www.epa.gov/mercury

Tip #6Take a multivitamin

everyday

Micronutrients:Choosing Your Multivitamin

Folic acid 400 mcg a day 4000 mcg a day with prior NTD

Avoid excess (more isn’t always better) A>10,000 IU D>4,000 IU

Nutrition first!

Tip #7Achieve a healthy weight

Achieve A Healthy Pre-Pregnancy Weight

Underweight: BMI<18.5 Normal: BMI = 18.5-24.9 Overweight: BMI = 25-29.9 Obese BMI>30

National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov

Achieve A Healthy Pre-Pregnancy Weight

For weight loss, Decrease calories in Increase calories out (exercise) Keep track of weight & nutrition

Maintain a healthy weight for 3-6 months before pregnancy

National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov

Tip #8Learn How Not to Get

Stressed Out

Stress & Preterm Birth

And his daughter in law, Phinehas' wife, was with child, near to be delivered; and when she heard the tidings that the ark of God was taken, and that her father in law and her husband were dead, she bowed herself and travailed; for her pains came upon her.

Samuel 4:19

Fetal HPA Maturation

Hypothalamus

Pituitary

Adrenal

+ CRH

+ ACTH

CRH

Placenta

(+) Cortisol DHEA-S

(+)

(+)

Maternal HPA Activation

Hypothalamus

Pituitary

Adrenal

+ CRH

+ ACTH

CRH

Placenta

(+) Cortisol DHEA-S

(+)

(+)Hypothalamus

Pituitary

Adrenal

(+)

CRH

ACTH

Cortisol Norepinephrine

Exercise Eat right Get a good night’s sleep

Learn how not to get stressed out

Relaxation techniques Breathing exercises Progressive relaxation Meditation Mindfulness

Learn how not to get stressed out

Positive Mental Health A sense of meaning Self-acceptance Autonomy Positive relations with others Satisfaction with life Optimism

Learn how not to get stressed out

Develop Positive Mental Health Find your purpose (“follow your bliss”) Use your strengths Count your blessings Live in gratitude Learn to forgive Savor life’s joy Spend time with friends and families Practice daily acts of kindness Learn to be optimistic

Learn how not to get stressed out

Relationality is primary,All else is derivative.

- Ronald David

Learn how not to get stressed out

Tip #9Tune-up your

immune system

How to Give Your Immune System A Tune-Up?

Get rid of ongoing infections & inflammation Make lifestyle changes to improve immune fitness

Immune Tune-Up

Brush Floss Go see your dentist

How to Avoid Toxoplasmosis

Wear gloves when you garden Cook all meat thoroughly Wash raw vegetables thoroughly Exercise precautions around cats

Have someone else change the litter box Wear gloves when you change the litter box Change the litter box daily Cover outdoor sandboxes Never feed your cat raw meat Keep indoor cats indoors

www.cdc.gov/ /toxoplasmosis

How to Avoid Cytomegalovirus

Wash hands with soap and water after contact with diapers or saliva

Do not share food, drinks, or utensils (spoons or forks) with young children

Check your CMV titer if you work in day care

www.cdc.gov/cmv

Immune Tune-Up

Update your immunizations Tdap Hepatitis B Influenza MMR Chickenpox HPV

Tip #10Detoxify Your Environment

Detoxify Your Home

Bathroom Get rid of antibacterial soap

triclocarban and triclosan

Get rid of air fresheners phthalates, formaldehyde, glycol ethers, and petroleum

Get rid of personal care products containing Phthalates, formaldehyde, glycol ethers, petroleum

Get rid of bathroom cleaners containing ammonia, alkylphenol ethoxylate, chlorine bleach, glycol ether,

sodium hydroxide, sodium lauryl sulfate

Get rid of molds & mildew

Detoxify Your Home

Kitchen & dining room Get rid of non-stick pans

perfluorinated chemicals

Don’t microwave plastic Unless it says “microwave safe”

Get rid of glass & window cleaners containing Glycol ethers or ammonia

Get rid of stovetop, countertop & oven cleaners Lye, sodium hydroxide, chlorine bleach, silica

Get rid of drain cleaners containing Sodium hydroxide, sodium hypochlorite

Avoid using pesticides

Detoxify Your Home

Living Room and Bedrooms Get rid of vinyl wallpapers & blinds

Phthalates

Replace furniture containing urea-formaldehyde (ask for “exterior grade” products)

Replace mattress & sofas containing polybrominated diphenyl ethers (PBDEs)

Replace old carpets Volatile organic compounds, dusts & dustmites

Which # Plastic Bottles Should Be Avoided?

Tap vs. Bottled Water

Tap water Test your tap water for lead Use a water filter

www.nsf.org

Bottled water Check the recycle number on bottle

Plastics to Avoid#3 (polyvinyl chloride, which may contain phthalates) #6 (polystyrene) #7 (polycarbonate, which may contain BPA)

Keep bottled water away from heat Don’t reuse water bottles

Avoid Occupational Exposures

OSHA (Occupation Safety and Health Act) MSDS (Material Safety Data Sheet) OTIS (Organization Teratogen Information Specialists

http://www.otispregnancy.org Toll-free (866) 626-OTIS

Preconception Care for Men

Preconception Care for Men Protect Your Sperm DNA

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

How Many SpermDoes a Man Make

in a Lifetime?

Preconception Care for Men? Reproductive life plan Past reproductive history Current medical conditions Medications Family history & genetic risks Work & hobbies Risk behaviors Mental health Weight Blood pressure Physical examinations Laboratory testing Immunizations Go see your dentist

Where is the FIn MCH?

Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Maidenberg M, Jones D, Garfield C, Rowley DL. Where is the F in MCH? Father involvement in African American Families. Ethn Dis. 2010;20:S2-49-61.

Father InvolvementBarriers

Individual Knowledge, attitude, behaviors Human capital

Interpersonal Gender relations (mother, grandmother, new partner)

Institutional & community Unemployment Incarceration Sterotypes Racism

Society & policy Temporary Assistance for Needy Families Earned Income Tax Credit Child Support

Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Jones D. et al. Where is the F in MCH? Father involvement in African American families. Ethnicity and Disease. 2010

Improving Father InvolvementAn Ecological Approach

Individual Educational programs Employment related services Legal & social services

Interpersonal Marriage counseling, family therapy Communication skills, conflict resolution skills, emotional intelligence

Institutional & community Full employment economy Criminal justice system Change norms, expectations, values, stereotypes Undo racism

Policy reforms Temporary Assistance for Needy Families Earned Income Tax Credit Child Support

Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Jones D. et al. Where is the F in MCH? Father involvement in African American families. Ethnicity and Disease. 2010

Father InvolvementA Life-Course Perspective

How do boys become men, and how do men become fathers?

The primary task of every civilization is to teach young men how to be fathers.

Margaret Mead

Interconception

Care

The definition of insanity is doing the same thing over and over and expecting different results

Benjamin Franklin

"We must become the change we want to see.”

- MOHANDAS GANDHI