Preconception Counseling: An Opportunity Not to Be Missed
William H. Herman, MD, MPH, and Denise Charron-Prochownik, RN, PhD
The American Diabetes Association position statement "Preconception Care of Women With Diabetes," reprinted on the following pages, outlines the elements of a preconception care program. The goals of preconception care are to educate and counsel about diabetes and pregnancy; to achieve and maintain excellent glucose control; to identify, evaluate, and treat complications of diabetes and risk factors for adverse maternal and fetal outcomes before pregnancy; and to postpone pregnancy until it is safe and wanted.
During the past decade, clinical trials of preconception care have shown that such care can reduce the incidence of malformations in infants of diabetic mothers from ~9 to 2%, a rate similar to that observed in infants of mothers without diabetes.1 Community trials of preconception care have shown that such care is associated with rates of malformations similar to those observed in clinical trials. Yet it is clear that in community practice in the United States, preconception care is the exception rather than the rule. In California between 1986 and 1988, only 7% of women identified by the California Diabetes and Pregnancy Program sought preconception care.2 In Maine between 1987 and 1990, 34% of eligible women sought preconception care through the Maine Diabetes in Pregnancy Program.3
Three studies have revealed some of the reasons why women with established diabetes may fail to seek preconception care. The first, a recently completed multisite study of teenage women with type 1 diabetes, demonstrated that the majority were unfamiliar with the term preconception counseling and were unaware of their and their infants' risks of perinatal morbidity and mortality. Moreover, the women participated in early and unsafe sexual practices with a high risk for unplanned pregnancies and pregnancy complications.4
The second study assessed psychosocial factors related to family planning behavior in 66 women with type 1 diabetes.5 Twenty-three women became pregnant, but only six of the pregnancies (26%) were planned. Consistent use of birth control was associated with positive attitudes toward birth control, defined as belief in the benefits and advisability of birth control and comfort with the procurement and use of birth control. In addition, social support for birth control, internal locus of control, and greater knowledge of diabetes were all associated with consistent use of birth control. Other important findings of this study were that women with diabetes often mistakenly believed that they would have difficulty conceiving and questioned the advisability of using oral contraceptives and thus were more likely than women without diabetes to choose less effective methods of birth control.
The third study compared women with established diabetes who were making their first preconception visit and those who were making their first prenatal visit without having received preconception care to identify characteristics that distinguish the groups.6 Women who sought preconception care were more likely to perceive benefits to themselves and their baby. Women who sought preconception care were also more likely to report greater instrumental social support, that is, practical, tangible aid with activities such as diabetes management and getting to medical appointments. Women who sought preconception care and those who did not were equally likely to report having providers for diabetes care and for gynecological care and to report prior pregnancies (and hence, opportunities for counseling regarding the importance of preconception care). Women who sought preconception care were more likely to report that their providers had discussed preconception care with them and had encouraged them to receive it. Women who did not seek preconception care were less confident of becoming pregnant and less likely to report that their pregnancies were planned. In fact, only one in four pregnancies were planned by women who failed to seek preconception care.
The strong association between unplanned pregnancies and the failure to seek preconception care suggests that the failure of women with established diabetes to seek preconception care may be related to a more general problemthat of unintended pregnancy. Data from the 1988 National Survey of Family Growth, a survey of a representative sample of women of childbearing age in the United States, revealed that at the time of conception, 39% of pregnancies resulting in live births were unintended.6 When unintended pregnancies ending in abortion are added to the total of live births, 56% of all pregnancies in the United States may be classified as unintended.7 Such pregnancies are more likely to occur in younger and older women, in those with lower education and income levels, and in those with limited access to health care. Unintended pregnancies are associated with unnecessary morbidity and mortality in the mother and her child and with delayed prenatal care.
Women will not seek preconception counseling if they do not know that it exists. Preconception care cannot occur if pregnancies are unplanned. Preconception "awareness counseling" should be provided by all primary health care providers to young women with diabetes starting at puberty. This counseling should focus on the risks of diabetes and pregnancy and the benefits of preconception counseling. Providers should ask all women with diabetes who are of childbearing age about sexual activity, deliver a strong positive message focusing on the benefits of preconception care to mothers and infants, and enlist the support of partners and families in encouraging preconception care. During routine medical visits, contraception and family planning should be explicitly discussed. It is imperative that patients' beliefs about fertility and contraception be explored and that providers encourage the use of acceptable, safe, and effective birth control.
1Kitzmiller JL, Buchanan TA, Kjos S, Combs CA, Ratner R: Preconception care of diabetes, congenital malformations, and spontaneous abortions (Technical Review). Diabetes Care 19:514-41, 1996.
2Cousins L: The California Diabetes and Pregnancy Program: a statewide collaborative program for the preconception and prenatal care of diabetic women. Clin Obstet Gynecol 5:443-60, 1991.
3Willhoite MB, Bennert HW, Palomaki GE, Zaremba MM, Herman WH, Williams JR, Spear NH: The impact of preconception counseling on pregnancy outcomes: the experience of the Maine Diabetes in Pregnancy Program. Diabetes Care 16:450-55, 1993.
4Charron-Prochownik D, Sereika S, Jacober C, Mansfield J, White N, Trial L, Giles L, Sorkin K: Reproductive health beliefs and behaviors in teens with diabetes: from theory to practice. Diabetes 48 (Suppl. 1):A8-9, 1999.
5St. James PJ, Younger MD, Hamilton BD, Waisbren SE: Unplanned pregnancies in young women with diabetes. Diabetes Care 16:1572-78, 1993.
6Janz NK, Herman WH, Becker MP, Charron-Prochownik D, Shayna VL, Lesnick TG, Jacober SJ, Fachnie JD, Kruger DF, Sanfield JA, Rosenblatt SI, Lorenz RP: Diabetes and pregnancy: factors associated with seeking preconception care. Diabetes Care 18:157-65, 1995.
7Piccinino LJ: Unintended pregnancy and childbearing. In From Data to Action: CDC's Public Health Surveillance for Women, Infants, and Children. Wilcox LS, Marks JS, Eds. Atlanta, Ga., U.S. Department of Health and Human Services, Public Health Service. Centers for Disease Control and Prevention, 1994, p. 73-82.
William H. Herman, MD, MPH, is an associate professor of internal medicine and epidemiology at the University of Michigan Medical Center, Department of Internal Medicine, in Ann Arbor. Denise Charron-Prochownik, RN, PhD, is an assistant professor at the University of Pittsburgh School of Nursing and School of Public Health, in Pittsburgh, Pa.
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