Preconception Health - A Survey among Health Care

Practitioners

Presented at CityMatCH annual conference

September 12, 2005

Steve Abelman, MBA

Acknowledgements

Jennifer Williams, Eliazbeth Fasset - CDC

Joann Petrini - March of Dimes

Cheryl Stone - Cheryl Stone Marketing

Margaret Watkins, Kathryn Lyon Daniel, Christine Pure, Joe Mullinare - CDC

Karla Damus - March of Dimes

Objectives

• Knowledge of unintended pregnancies

• Practice regarding recommendations for healthy behavior prior to pregnancy

• Knowledge of aspects of folic acid - benefits, dosage, timing of consumption

Objectives

• WHO

• WHY

• WHEN

• HOW

Methodology

• Random Sample Telephone Surveys

• 2002 - 611 OB/GYNs and 250 FPs

• 2003

– 200 CNMs

– 101 NPs

– 55 PAs

– 144 RNs

Perceived Percentage of Unintended Pregnancies

4%

36%

52%

9%

5%

30%

48%

16%

0% 10% 20% 30% 40% 50% 60%

"DK/Not sure"

"About 25%"

"About 50%"

"About 75%"Providers-2003MDs-2002

% Eligible Patients Seen for Preconception Care

6%

1%

11%

4%5%

27% 27%

22%22%

26%25%

1%

6%4%4%

8%

0%

10%

20%

30%

None 1-5% 6-9% 10-19% 20-39% 40-59% 60-79% 80%+

Providers-2003 MDs-2002

Mean % Seen for Preconceptional VisitProviders-2003: 22%MDs-2002: 20%

Association: Perceived % of Unintended Pregnancies and % of

Patients Seen for Preconception Care

18% 17%16%

13%14%

30%

25% 25%

22% 23%

18%

22%

8%

26%

18% 18%

0%

5%

10%

15%

20%

25%

30%

DK/Not Sure About 25% About 50% About 75%

CNMOther Non-MDOBGFP

The chart shows the mean % of patients seen for preconceptional care by segments of providers estimating the % of unintended pregnancies at about 25%, 50%, 75%, or “don’t know/not sure” – by type of provider.

% prenatal patients seenfor preconceptional care

-------------------- % Unintended Pregnancies in US --------------------

Optimal Time for Starting Folic Acid

1%

2%

3%

5%

89%

2%

1%

4%

3%

90%

0% 20% 40% 60% 80% 100%

DK/Not sure

Other: post-conception

Other: pre-conception

By 8th week of pregnancy

At least a month before conception

Providers-2003MDs-2002

Issues Addressed at Annual Well-Woman Exam

2002 2003 2002 2003 2002 2003 2002 2003MDs NonMD MDs NonMD MDs NonMD MDs NonMD

Annual Pap tests 91% 89% 7% 9% 2% 2% 0% 1%Breast self-exam 81% 84% 16% 14% 3% 2% 0% 1%Birth control 58% * 67% 28% 24% 13% 8% 1% 2%Smoking 71% 67% 21% 23% 8% 10% 1% 1%STD prevention 44% * 56% 30% 28% 24% 15% 1% 1%Mammograms 69% * 63% 20% 19% 11% 17% 1% 1%Alcohol use 37% * 45% 26% 22% 34% 31% 3% 2%Multivitamins 21% * 35% 32% 34% 42% 31% 5% 1%Calcium supplements 36% 39% 35% 36% 27% 23% 3% 2%Folic acid supplements 23% 27% 30% 31% 44% 40% 3% 3%Weight control (diet/exercise) 42% * 36% 36% 39% 22% 24% 0% 1%Iron supplements 11% * 15% 23% 28% 62% 53% 4% 4%

Always Usually Occasionally Never

Issues “Always” or “Usually” Addressed at Annual Well-Woman

Exam

34%

53%

63%

53%

71%

78%

89%

75%

92%

86%

98%

97%

42%

57%

67%

68%

75%

75%

82%

84%

90%

90%

97%

97%

0% 25% 50% 75% 100%

Iron supplements

Folic acid supplements

Alcohol use

Multivitamins

Calcium supplements

Weight control

Mammograms

STD prevention

Smoking

Birth control

Annual Pap tests

Breast self-exam

Providers-2003

MDs-2002

Association:Frequency of Addressing Multivitamins in Well-Woman Visit

and % Seen for Preconceptional Care

18%16% 16% 16%

32%

22%

30%

26%

14%

18%20%

22%

13%

17%

22%

33%

0%

5%

10%

15%

20%

25%

30%

35%

Never Occasionally Usually Always

CNMOther Non-MDOBGFP

% prenatal patients seenfor preconceptional care

---------- How Often Recommend Multivitamins in Well-Woman Visit ----------

When (How) Do Providers Recommend Multivitamins or

Folic Acid?MD NonMD MD NonMD MD NonMD MD NonMD

Among patients who express interest in becoming pregnant

84% 88% 12% 7% 3% 4% 1% 1%

At annual GYN exams with non-pregnant women

24% 25% 34% 25% 35% 46% 6% 5%

At other types of visits by non-pregnant women, regardless of reason for visit

12% 16% 25% 22% 54% 49% 9% 14%

Always Usually Occasionally Never

Perceived Benefits of Folic Acid

MD NonMD MD NonMD MD NonMD

Prevent some birth defects 97% 97% 0% 1% 3% 2%

Prevent some cardiovascular events 61% 58% 10% 10% 29% 31%

Prevent osteoarthritis 7% 16% 41% * 34% 52% 50%

Decrease risk of Alzheimer's 25% * 31% 28% 19% 48% 50%

Lower risk of colorectal cancer 36% * 44% 22% 15% 42% 41%

Decreases homocysteine levels 59% * 37% 7% 12% 34% 52%

Most grain products in US are fortified with folic acid

57% * 66% 19% 17% 24% 17%

Because grain supply is fortified with folic acid, women of childbearing age do not need folic acid supplements

7% 2% 82% 93% 12% 5%

True False Not Sure

Perceived Nutrient Requirements for Non-Pregnant Women of

Childbearing AgeFolic acid 500+ mcg* 400 mcg 200-300 mcg* <=140 mcg* DK/R-MD 31% 47% 5% 8% 9%-NonMD 13% 52% 6% 13% 15%

Calcium 1200+ mg* 1200 mg 1000 mg <=800 mg* DK/R-MD 10% 44% 33% 11% 3%-NonMD 6% 48% 33% 8% 5%

Iron 18+ mg* 15 mg 10 mg <=8 mg* DK/R-MD 35% 16% 18% 9% 21%-NonMD 33% 16% 16% 5% 31%

Reasons Providers Don’t Always Recommend Folic Acid or

MultivitaminsCNM Other Total

41% 36% 38%

Too busy/not enough time 35% 27% 30%

Don't always remember to mention it 11% 10% 10%

Not relevant for patient[Not planning to get pregnant; not necessary for all patients; not reason for visit]

No need/there's enough in food supply 3% 4% 3%

Not a high priority 3% 4% 4%

Lack of patient compliance 2% 1% 1%

All others[Cost, questionable efficacy, not covered by insurance, not a priority for provider, etc.]

No reason 7% 4% 5%

Don't know why 7% 12% 10%

No answer 7% 4% 5%

Lack of knowledge about: folic acid, nutrition, unintended pregnancy

12% 13%

5% 7%

2003 Survey 2002

12%

8%

40%

30%

14%

8%

5%

4%

13%

OBG/FP

4%

3%

0.2%

5%

Summary of Findings

• Good knowledge on timing and benefits of folic acid

• Incomplete knowledge on rate of unintended pregnancies and appropriate dosage of folic acid

• Low rate of prenatal patients seen preconceptionally

• Inconsistency in addressing preconception issues during a well-woman exam

• Lack of knowledge and lack of time in addressing preconception issues

Summary of Findings

• WHO - all women of childbearing age

• WHY - prevention of birth defects among other issues

• WHEN - all patient encounters

• HOW - Verbal and written communication

Lessons Learned• Lack of knowledge and practice regarding

some preconception issues on a timely basis

• Providers of health care to women of childbearing age need to be educated about the rate of unintended pregnancies

• Providers need to be encouraged to address preconception and prenatal planning issues during every patient encounter

Next StepsFocus groups among leadership and practitioners

of selected professional organizations to identify reasons for the gap between knowledge and practice; identify how providers who do incorporate practice guidelines regarding folic acid and preconceptional care are able to do so; assess barriers to change; and brainstorm strategies or interventions that would lead to significant improvement in implementation of these guidelines within health care practices.