Preconception Counseling Educational Format Faculty Expertise Required Expertise in the Field of Study

2019 AAFP FMX Needs Assessment

Body System: Women’s Health Session Topic: Preconception Counseling Educational Format Faculty Expertise Required Expertise in the field of study. Experience teaching in the field of study is desired. Preferred experience with audience Interactive REQUIRED response systems (ARS). Utilizing polling questions and Lecture engaging the learners in Q&A during the final 15 minutes of the session are required. Expertise teaching highly interactive, small group learning environments. Case-based, with experience developing and Problem- teaching case scenarios for simulation labs preferred. Other Based workshop-oriented designs may be accommodated. A typical OPTIONAL Learning PBL room is set for 50-100 participants, with 7-8 each per (PBL) round table. Please describe your interest and plan for teaching a PBL on your proposal form.

Learning Objective(s) that will close Outcome Being Professional Practice Gap the gap and meet the need Measured  Physicians frequently do 1. As a part of primary care visits, Learners will not offer preconception provide pregnancy intendedness submit written counseling. screening for all women of commitment to  Women with chronic reproductive age and then education change statements health conditions are at and health promotion counseling to on the session risk for developing those sexually active and not using evaluation, maternal and neonatal contraception to reduce reproductive indicating how complications. risk and improve pregnancy they plan to  Physicians have medical outcomes. implement knowledge gaps with 2. Counsel pregnant and postpartum presented practice regard to counseling patients on interconception health recommendations. patients about the safety care needs including needed and efficacy of immunizations, new and ongoing risk prescription medications factors for future pregnancies, and during preconception. contraception options to prevent  The US department of unintended pregnancy and to space HHS require new health pregnancies for optimum health. plans to include these 3. Use pregnancy visits and postpartum services as part of visits as an opportunity to review and insurance policies. encourage good health habits such as  Adherence to medical exercise, smoking cessation, and recommendation by healthy diet. women with high risk 4. Preconception visits should include pregnancies is dependent advice about foods to avoid during upon the patient’s pregnancy, folic acid, smoking perception of their cessation, BMI measurement with medical risk; therefore, discussion of health weights and these patients require depression screening.

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counseling to encourage early initiation of prenatal care and careful attention to their health  Despite considerable proof of efficacy, there is still a large number of cases of Rh D alloimmunization because of failure to follow established protocols in the prevention of Rh disease.

Faculty Instructional Goals Faculty play a vital role in assisting the AAFP to achieve its mission by providing high- quality, innovative education for physicians, residents and medical students that will encompass the art, science, evidence and socio-economics of family medicine and to support the pursuit of lifelong learning. By achieving the instructional goals provided, faculty will facilitate the application of new knowledge and skills gained by learners to practice, so that they may optimize care provided to their patients.  Provide up to 3 evidence-based recommended practice changes that can be immediately implemented, at the conclusion of the session; including SORT taxonomy & reference citations  Facilitate learner engagement during the session  Address related practice barriers to foster optimal patient management  Provide recommended journal resources and tools, during the session, from the American Family Physician (AFP), Family Practice Management (FPM), and Familydoctor.org patient resources; those listed in the References section below are a good place to start o Visit http://www.aafp.org/journals for additional resources o Visit http://familydoctor.org for patient education and resources  Provide updates on new treatment therapies, changes to therapies, or warnings associated with existing therapies. Provide recommendations regarding new FDA approved medications; including safety, efficacy, tolerance, and cost considerations relative to currently available options. Include relevant FDA REMS education for any applicable medications.  Provide recommendations such that 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 risk and improve pregnancy outcomes.  Provide strategies to integrate components of preconception health into existing well- woman care plans, including emphasis on inter-conception interventions for women with previous adverse outcomes.  Provide strategies and resources to counsel women with diabetes mellitus about the importance of glycemic control before conception, with emphasis on achieving an A1C level as close to normal as possible to reduce the risk of congenital anomalies.

 Provide recommendations to assess the patient's risk of chromosomal or genetic disorders based on family history, ethnic background, and age; offer cystic fibrosis and other carrier screening as indicated.

Needs Assessment: Nearly half (49%) of all pregnancies are unintended, and increasing to 4 out of 5 for women 19 years and younger.1,2 The CDC has stated that every woman of reproductive age who is capable of becoming pregnant is a candidate for preconception care, even if she is not planning to conceive.3 They consider this a significant public health concern because despite major advances in medical care, about half of all pregnancies are classified as “unintended,” and improper planning combined with poor health before conception and during pregnancy have contributed to poor birth outcomes.2 As evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes; physicians must be prepared to promote preconception health can potentially improve women's health and pregnancy outcomes.4 Up to two-thirds of women with diabetes have unplanned pregnancies, and teens in particular are at risk for maternal and neonatal complications; however, targeted preconception counseling programs aimed at teenage girls with diabetes appears to have a positive impact on reproductive health over time. US maternal mortality statistics are the worst in the developed world and it continues to rise, with black women dying at a rate 4 to 12 times higher than white women, depending upon where they live. Better baseline health prior to pregnancy may be one modifiable risk factor.

Data from a recent American Academy of Family Physicians (AAFP) CME Needs Assessment survey indicate that family physicians have knowledge gaps with regard to preconception-related care an management topics, including sexual counseling, well-woman care generally, and sexuality/teen pregnancy prevention.5 More specifically CME outcomes data from 2011-2015 AAFP FMX (formerly Assembly): Preconception Counseling sessions suggest that physicians have knowledge and practice gaps with regard to identifying patients who would benefit the most from preconception counseling; becoming aware of the need to offer preconception counseling; counseling patients about the safety and efficacy of prescription medications during the preconception period; taking a more thorough history during the preconception period; screening and risk assessments; and immunizations.6-9

A review of the literature suggests that many primary care physicians have inaccurate perceptions of rates of unintended pregnancy, contributing to the fact that many physicians rarely provide preconception and contraceptive counseling.10 In fact, some studies indicate that as few as 1 in 6 primary care physicians provide preconception counseling to the women for whom they provided prenatal care.11

The following exerpt from the AAFP position paper on preconception care outlines barriers to the delivery of care:12

Traditionally, preconception care has focused on those patients planning a pregnancy and has primarily been delivered at the well-woman/preventive care visit. However, since 50% of U.S. pregnancies are currently reported as unintended at the time of conception,

the timing of addressing preconception risks poses a challenge.2Additionally, until they are pregnant, many women of child bearing age do not seek care for themselves or may not have access to care.18 There are also barriers to achieving goals of interconception care; these goals include educating women about avoiding unintended rapid repeat pregnancy, following up on health risks identified during pregnancy, and transitioning into appropriate primary care. The postpartum visit provides one opportunity for interconception care; however, patient attendance is not guaranteed. Some women may lose insurance coverage in the early postpartum period, which makes it difficult for them to get access to appropriate follow up care.

In 1990, Jack and Culpepper identified seven barriers to preconception care:

1. Women most in need of preconception care are the least likely to receive counseling 2. Fragmented health care service delivery system 3. Lack of treatment services for high-risk behaviors 4. Inadequate physician reimbursement providing counseling services 5. Lack of efficacy of counseling provided to unmotivated patients and their partner 6. Limited number of conditions with evidence-based preconception interventions 7. Lack of emphasis on risk assessment/health promotion in training programs.

Unfortunately, most of these barriers still exist. In a 2006 study, more than 95% of women surveyed recognized both the need to achieve optimal health prior to conception and the benefit of receiving information prior to conception. However, a majority of women did not recall receiving any preconception counseling. In addition, while the majority of preconception counseling is important, most neither provide nor recommend counseling for their patients of childbearing age. Another study showed that in 2015, the number of women receiving preconception care services during ambulatory care visits (OB-GYN or FP) is only 14%.

Changes in the current healthcare landscape are removing some of these barriers through expanded health insurance coverage, improved reimbursement for preventive services, and public health initiatives. In addition, clinical practice guidelines based on good- quality evidence have been developed for preconception interventions that improve maternal and fetal outcomes. Family physicians have a unique opportunity to make an impact by improving maternal and fetal outcomes in the United States.

Physicians may improve their care of patients who are planning to become pregnant, and those who have become pregnant unintentionally, by engaging in continuing medical education that provides practical integration of current evidence-based guidelines and recommendations into their standards of care, including, but not limited to the following:3,12-17  Ask women of reproductive age about intention to become pregnant. Provide contraceptive counseling tailored to patients' intentions.  Discuss smoking cessation and provide resources for all women of reproductive age  Screen for periodontal, urogenital, and sexually transmitted infections as indicated.

 Assess the patient's risk of chromosomal or genetic disorders based on family history, ethnic background, and age; offer cystic fibrosis and other carrier screening as indicated.  Assess the patient's anthropometric (i.e., body mass index), biochemical (e.g., anemia), clinical, and dietary risks.  Counsel the patient about possible toxins and exposure to teratogenic agents (e.g., heavy metals, solvents, pesticides, endocrine disruptors, allergens) at home, in the neighborhood, and at work; review Material Safety Data Sheets and consult a local teratology information specialist as needed.  Screen for depression, anxiety, domestic violence, and major psychosocial stressors.  Advise folic acid supplementation (400-800 mcg daily) to reduce the risk of neural tube defects.  Assess body mass index, and counsel women who are overweight, obese, or underweight about achieving a healthy body weight before becoming pregnant.  Counsel women with diabetes mellitus about the importance of glycemic control before conception. Assist patients in achieving an A1C level as close to normal as possible to reduce the risk of congenital anomalies.  Check for use of teratogenic medications as part of preconception care, and change to safer medications if possible. Use the fewest medications at the lowest dosages needed to control disease.  Update hepatitis B; influenza; measles, mumps, rubella; Tdap; and varicella immunizations as needed in patients who wish to become pregnant.  Each woman, man, and couple should be encouraged to have a reproductive life plan.  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.  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 risk and improve pregnancy outcomes.  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).  Use the inter-conception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (e.g., infant death, fetal loss, birth defects, low birthweight or preterm birth).  Offer, as a component of maternity care, one pre-pregnancy visit for couples and persons planning pregnancy, and more as needed if modifiable risk factors are identified.  Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and inter-conception care.  Integrate components of preconception health into existing local public health and related programs, including emphasis on inter-conception interventions for women with previous adverse outcomes.  Increase the evidence base and promote the use of evidence to improve preconception health.

 Maximize public health surveillance and related research mechanisms to monitor preconception health.  A woman's reproductive plan should be discussed at each visit because her plans may change depending on life circumstances.  Health concerns in men such as diabetes mellitus, erectile dysfunction, and testicular conditions may affect fertility.  A man's lifestyle factors, including tobacco smoking and sexually transmitted infections, can directly impact his partner's pregnancy.

These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of America. To be effective, the recommendations must be implemented. As such, physicians require continuing medical education to assist them with making decisions about specific clinical considerations.

Resources: Evidence-Based Practice Recommendations/Guidelines/Performance Measures  Recommendations for Preconception Care3  Recommendations for preconception counseling and care13  AAFP Immunization Schedules18  AAFP Preconception Care (Position Paper)12  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 11  Engaging Patients in Collaborative Care Plans19  Health Coaching: Teaching Patients to Fish20  Documenting and coding preventive visits: a physician’s perspective21  Encouraging patients to change unhealthy behaviors with motivational interviewing22  Vaccine administration: making the process more efficient in your practice23  FamilyDoctor.org: Take Care of Yourself Before Pregnancy (patient resource)24  FamilyDoctor.org: Preconception Carrier Screenings (patient resource)25  FamilyDoctor.org: Obesity and Pregnancy (patient resource)26

References

1. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478-485.

2. Centers for Disease Control and Prevention. Unintended Pregnancy Prevention. 2018; http://www.cdc.gov/reproductivehealth/unintendedpregnancy/. Accessed Apr, 2018. 3. Lu MC. Recommendations for preconception care. American family physician. 2007;76(3):397-400. 4. Robbins CL, Zapata LB, Farr SL, et al. Core state preconception health indicators - pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009. Morbidity and mortality weekly report Surveillance summaries (Washington, DC : 2002). 2014;63(3):1-62. 5. AAFP. 2012 CME Needs Assessment: Clinical Topics. In: American Academy of Family Physicians; 2012. 6. American Academy of Family Physicians (AAFP). AAFP FMX CME Outcomes Report. In. Leawood KS: AAFP; 2015. 7. American Academy of Family Physicians (AAFP). AAFP Assembly CME Outcomes Report. In. Leawood KS: AAFP; 2014. 8. American Academy of Family Physicians (AAFP). 2011 AAFP Scientific Assembly: CME Outcomes Report. In. Leawood KS: AAFP; 2011. 9. American Academy of Family Physicians (AAFP). 2013 AAFP Scientific Assembly: CME Outcomes Report. In. Leawood KS: AAFP; 2013. 10. Parisi SM, Zikovich S, Chuang CH, Sobota M, Nothnagle M, Schwarz EB. Primary care physicians' perceptions of rates of unintended pregnancy. Contraception. 2012;86(1):48- 54. 11. Johnson K, Posner SF, Biermann J, et al. 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 Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports / Centers for Disease Control. 2006;55(RR-6):1-23. 12. Wilkes J. AAFP Releases Position Paper on Preconception care. American family physician. 2016;94(6):508-510. 13. Farahi N, Zolotor A. Recommendations for preconception counseling and care. American family physician. 2013;88(8):499-506. 14. Centers for Disease Control and Prevention. Information for Health Professionals Recommendations. Preconception Health and Health Care 2012; http://www.cdc.gov/preconception/hcp/recommendations.html. Accessed August, 2014. 15. Dunlop AL, Jack B, Frey K. National recommendations for preconception care: the essential role of the family physician. Journal of the American Board of Family Medicine : JABFM. 2007;20(1):81-84. 16. Zolotor AJ, Carlough MC. Update on prenatal care. American family physician. 2014;89(3):199-208. 17. U. S. Preventive Services Task Force. Folic Acid Supplementation for the Prevention of Neural Tube Defects: Recommendation Statement. American family physician. 2017;95(10):Online. 18. American Academy of Family Physicians (AAFP). AAFP Immunization Schedules. 2018; https://www.aafp.org/patient-care/public-health/immunizations/schedules.html. Accessed Jul, 2018. 19. Mauksch L, Safford B. Engaging Patients in Collaborative Care Plans. Family practice management. 2013;20(3):35-39.

20. Ghorob A. Health Coaching: Teaching Patients to Fish. Family practice management. 2013;20(3):40-42. 21. Owolabi T, Simpson I. Documenting and coding preventive visits: a physicians's perspective. Family practice management. 2012;19(4):12-16. 22. Stewart EE, Fox CH. Encouraging patients to change unhealthy behaviors with motivational interviewing. Family practice management. 2011;18(3):21-25. 23. Hainer BL. Vaccine administration: making the process more efficient in your practice. Family practice management. 2007;14(3):48-53. 24. FamilyDoctor.org. Take Care of Yourself Before Pregnancy. 2018; https://familydoctor.org/take-care-pregnancy/. Accessed Apr, 2018. 25. FamilyDoctor.org. Preconception Carrier Screenings. 2018; https://familydoctor.org/preconception-carrier-screenings/. Accessed Apr, 2018. 26. FamilyDoctor.org. Obesity and Pregnancy. 2018; https://familydoctor.org/obesity-and- pregnancy/. Accessed Apr, 2018.