Health promotion

Family planning and reproduction life plan ¹⁶

Routine health promotion activities for all women of reproductive age should begin with screening women for their intentions to become or not become pregnant in the shortand long-term and their risk of conceiving (whether intended or not). Providers should encourage patients (women, men, and couples) to consider a reproductive life plan and educate patients about how their reproductive life plan impacts contraceptive and medical decision-making. Every woman of reproductive age should receive information and counseling about all forms of contraception and the use of emergency contraception that is consistent with their reproductive life plan and risk of pregnancy.

Physical aktivity

All women should be assessed regarding weightbearing and cardiovascular exercise and be offered recommendations appropriate to their physical abilities.

Weight status

All women should have their body mass index (BMI) calculated at least annually. All women with BMIs ≥ 26 kg/m² should be counseled about the risks to their own health, the risks for exceeding the overweight category, and the risks to future pregnancies, including infertility. These women should be offered specific behavioral strategies to decrease caloric intake and increase physical activity and be encouraged to consider enrolling in structured weight loss programs. All women with a BMI ≤ 19.8 kg/m² should be counseled about the short- and long-term risks to the own health and the risks to future pregnancies, including infertility. All women with a low BMI should be assessed for eating disorders and distortions of body image. Women unwilling to consider and achieve weight gain may require referral for further evaluation of eating disorders.

Nutrient intake

All women of reproductive age should be assessed for nutritional adequacy and receive a recommendation to take a multivitamin supplement if any question of ability to meet the recommended daily allowance through food sources is uncovered. Care must be taken to counsel against ingesting supplements in excess of the recommended daily allowance.

Folate

All women of reproductive age should be advised to ingest 0.4 mg (400 µg) of synthetic
folic acid daily from fortified foods and/or supplements and to consume a balanced, healthy diet of folate-rich food.

Substance use

All women should be assessed for use of tobacco at each encounter with the healthcare system; women who smoke should be counseled to limit exposure. All women should be assessed at least annually for alcohol use patterns and risky drinking behaviors and be provided with appropriate counseling; all women should be advised of the risks to the embryo/fetus of alcohol exposure in pregnancy and that no safe level of consumption has been established.

Medication

Prescription

As part of preconception care, all women should be screened for the use of teratogenic medications and should receive counseling about the potential impact of chronic health conditions and medications on pregnancy outcomes for mother and child. Whenever possible, potentially teratogenic medications should be switched to safer medications before conception. For women with chronic conditions with serious morbidity (to mother and infant), the fewest number and lowest dosages of essential medications that control maternal disease should be used. For women who do not desire pregnancy, a plan for contraception should be addressed and initiated.

Over-the-counter medication

Health care providers should educate women of reproductive age about the need to discuss the use of over-the-counter medications with their provider when planning a pregnancy. Women should be advised specifically not to use aspirin if they are planning a pregnancy or become pregnant.

Dietary supplements

Health care providers should educate women of reproductive age about the need to discuss the use of dietary supplements before pregnancy (which include herbs, weight loss products, and sport supplements) and should caution women about the unknown safety profile of many supplements. High-quality and prescription-quality dietary supplements should be encouraged.

Reproductive history

Prior preterm birth infant

Pregnancy history should be obtained from all women of reproductive age. Women with a history of preterm or low-birthweight infant should be evaluated for remediable causes to be addressed before the next pregnancy and should be informed of the potential benefit of treatment with progesterone in subsequent pregnancy.

Prior cesarean delivery

Preconception counseling of women with previous cesarean delivery should include counseling about waiting at least 18 months before the next pregnancy and about possible modes of delivery so the patient enters the next pregnancy informed of the risks and options. Ideally, the counseling should begin immediately after the cesarean delivery and continue at postpartum visits.

Prior miscarriage

Women with sporadic spontaneous abortion should be reassured of a low likelihood of recurrence and offered routine preconception care. Women with ≥ 3 early losses should be offered a work-up to identify a cause. Therapy that is based on the identified cause may be undertaken. For women with no identified cause, the prognosis is favorable with supportive care.

Prior stillbirth

At the time of the stillbirth, a thorough investigation to determine the cause should be performed and communicated to the patient. At the preconception visit, women with a previous stillbirth should receive counseling about the increased risk of adverse pregnancy outcomes and may require referral for support. Any appropriate work-up to define the cause of the previous stillbirth should be performed if it was not done as part of the initial workup. Risk factors that can be modified before the next pregnancy should be addressed (eg, smoking cessation).

Uterine anomalies

A uterine septum in a woman with poor previous reproductive performance should be corrected hysteroscopically before the next conception. All other anomalies call for specific delineation of the anomaly and any associated vaginal and renal malformations. Although surgical correction may be advised in some cases, heightened awareness and surveillance during a subsequent pregnancy and labor should help optimize outcomes.

Special populations

Women with disabilities

Women with disabilities should receive counseling about the risks of any medications that they use and about options to alter dosage or switch to safer medications before conception. The medical, social, and psychologic issues that are related to pregnancy and the disability should be assessed, and the woman and her family should be counseled about them. Healthcare providers should offer women with disabilities contraceptive choices that are practical and appropriate for the individual’s medical and personal needs. Issues that involve informed consent and guardianship must be addressed when caring for women with developmental disabilities in relation to contraception and pregnancy. Referral for genetic counseling, if appropriate, is indicated for all women before conception; however, it may raise difficult psychosocial issues for women with disabilities; therefore, counseling referrals should be handled sensitively.