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Multigenerational Impact on Reproductive Outcomes Upsala Journal of Medical Sciences ISSN: 0300-9734 (Print) 2000-1967 (Online) Journal homepage: http://www.tandfonline.com/loi/iups20 The future of preconception care in the United States: multigenerational impact on reproductive outcomes Michelle St. Fleur, Karla Damus & Brian Jack To cite this article: Michelle St. Fleur, Karla Damus & Brian Jack (2016): The future of preconception care in the United States: multigenerational impact on reproductive outcomes, Upsala Journal of Medical Sciences, DOI: 10.1080/03009734.2016.1206152 To link to this article: http://dx.doi.org/10.1080/03009734.2016.1206152 © 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Published online: 19 Jul 2016. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iups20 Download by: [64.223.195.157] Date: 20 July 2016, At: 07:59 UPSALA JOURNAL OF MEDICAL SCIENCES, 2016 http://dx.doi.org/10.1080/03009734.2016.1206152 REVIEW ARTICLE The future of preconception care in the United States: multigenerational impact on reproductive outcomes Michelle St. Fleur, Karla Damus and Brian Jack Department of Family Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA ABSTRACT ARTICLE HISTORY The future of preconception care will require an innovative multigenerational approach to health pro- Received 25 March 2016 motion for women and men to achieve optimal reproductive health outcomes. In this paper we provide Revised 20 June 2016 a summary of historical trends in perinatal interventions in the United States that have effectively Accepted 22 June 2016 reduced adverse perinatal outcomes but have not improved disparities among ethnic/racial groups. We KEY WORDS describe evidence pointing to an enhanced preconception care paradigm that spans the time periods Epigenetics; health before, during, and between pregnancies and across generations for all women and men. We describe disparities; perinatal how the weathering, Barker, and life course theories point to stress and non-chromosomal inheritance outcomes; preconception as key mediators in racial disparities. Finally, we provide evidence that indicates that humans exposed care; preconception health to toxic stress can be impacted in future generations and that these phenomena are potentially related to epigenetic inheritance, resulting in perinatal disparities. We believe that this expanded view will define preconception care as a critical area for research in the years ahead. Introduction predictions about the future of preconception care must inte- grate all of these issues into a cohesive context, reflecting Given the myriad of factors that influence preconception how each of the factors might influence the future of PCC. health (1), the future of preconception care will depend on In this paper, after a brief summary of historical trends in how well the progress made so far can be leveraged and seminal perinatal outcomes in the United States (USA), we expanded. It will also rely on how new scientific evidence can will present an overview of some of these factors that under- be integrated into the content, risk assessment, and mitiga- score the need for PCC from the lens of the persistent ethnic/ tion of preconception risks. The strategies and resources used racial disparities and describe how an innovative epigenetic to facilitate the clinical and public health integration and dis- transgenerational approach can portend the future of precon- semination of preconception care, including the role of group ception care. care, the medical home, workplace and school-based health promotion programs, and home visitation, will also impact future progress. Although in the past decade preconception Downloaded by [64.223.195.157] at 07:59 20 July 2016 Historical trends and ethnic/racial disparities in health (PCH) and preconception care (PCC) have gained perinatal outcomes in the USA momentum, the number and types of effective evidence- based interventions are limited and have remained relatively From 1940 to 2005 the overall infant, neonatal, and post-neo- stable, and, as for all maternal child health (MCH) interven- natal annual mortality rates in the USA declined substantially tions, there is wide global variability, reflecting regional and (2). The infant (age less than one year) mortality rate (IMR) national specific challenges and resources. Some of these key decreased by 85%, from 47 per 1,000 live births in 1940 to influencing factors include: the priorities placed on women’s, 6.9 in 2005; the neonatal (age less than 28 days) rate men’s, and families’ health, women’s reproductive rights, pol- decreased by 84%, from 28.8 to 4.54; and the post-neonatal itical will, access to and support for preventive health serv- (age greater than 28 days but less than one year) rate ices, raising public health awareness and education, health decreased by 87%, from 18.3 to 2.34 (3). After a plateauing of care provider training, reimbursement of services, developing, IMRs in the USA from 2005 to 2010, rates began to fall again, implementing, and disseminating evidence-based interven- reaching a historical low of 6.0 in 2013 (4). But despite this tions, baseline perinatal outcomes, and population health sta- progress, the USA continues to have the highest IMR of all tus. There is also strong support of other key variables that Organization for Economic Co-operation and Development impact PCH/PCC with equal if not greater international vari- (OECD) countries (5). Furthermore, ethnic/racial disparities in ability, such as the importance and influence of the social perinatal outcomes continue to persist in the USA. For determinants of health, the role of childhood adverse events, example, in 2013 the majority (76.1%) of the nearly 4 million toxic stress, and epigenetics. Therefore, discussions and births in the USA were white and 16.1% were black (6), and CONTACT Michelle St. Fleur [email protected] Boston Medical Center, Department of Family Medicine, Dowling 5, 1 BMC Place, Boston, MA, USA ß 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 M. ST. FLEUR ET AL. the 2013 IMR for black infants was 11.1 per 1,000 births com- phenylketonuria, and many others (23). However, to date pared to 5.1 for white infants. Therefore, black babies were there is no study showing that the ‘package’ of PCC services still twice as likely to die in their first year of life compared to improves MCH outcomes. Data exist that we can identify PCC white babies. In addition, black women were also almost risks, but there are no data that this impacts MCH outcomes twice as likely to deliver a low-birth-weight (LBW) baby or disparities (2). It is possible that intrapartum, antepartum, (2,500 g) and three times as likely to deliver a very-low- and preconception services are necessary but not sufficient to birth-weight baby (<1,500 grams) than white women (7). improve perinatal outcomes among black women in the USA. Socioeconomic factors (8), genetics, health behaviors, experi- More recent and emerging data show that factors impact- ence of stressful life events (9), and toxic stress (10) have all ing prior generations can possibly explain perinatal outcome been studied, but despite decades of programs and research, disparities. Since 2005, there has been a focus on better the factors that contribute to this disparity and effective inter- understanding risk factors that impacted previous generations ventions to promote equity remain poorly understood (11). and potential transgenerational effects. Explanatory mecha- With LBW and short-term gestation being the leading cause nisms have included the life course perspective (9), Barker of mortality for black infants (3,12), we will not optimize hypothesis (24), adverse childhood events (25), toxic stress maternal child health (MCH) outcomes until we reduce these (10), healthy immigrant effect (26), impact of stress and soci- disparities (13,14). etal racism (27,28), weathering hypothesis (29), and epigenet- ics (30) as possible mechanisms. Strategies used to improve maternal child health outcomes Life course theory and the Barker hypothesis Maternal child health (MCH) research over the past 40 years The life course perspective by Lu et al. (31) posits that dispar- has focused on improving hospital care, prenatal care, and, ities in birth outcomes are the consequences of differential more recently, preconception care. In an effort to improve developmental trajectories that are set by early life experien- MCH outcomes, research has continued to go back in time to ces and cumulative allostatic load over the life course (31). It address the root causes. Intrapartum, antenatal, and precon- is especially important in MCH, where one developmental ception care have contributed to improved outcomes, but stage often gets disconnected from another. In perinatal they have been shown only minimally to impact disparities in health, the focus is so much on events occurring in the IMR and LBW. Between the 1960s and 1990s, the focus was 40 weeks of pregnancy that it is forgotten that there are a on improving labor and delivery. This included hospital deliv- great deal of life course influences on perinatal outcomes eries, medicalization of birth, electronic fetal monitoring, and which impact health and illness potential throughout life (31). ultrasound. Some outcomes improved, some worsened, but For example, in explaining the black–white gap in infant mor- the disparities remained (15). tality, for decades there was a search for maternal risk factors From the 1980s to 1990s the focus then shifted to ante- during pregnancy rather than looking at the mothers’ cumula- natal care.
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