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Preconception Health Promotion



I Introduction



Most Canadians view pregnancy as a nine-month event ending in the birth of a healthy infant. Yet, it is known that a healthy birth is also dependant on the health of the couple prior to pregnancy. Preconception health promotion efforts need to be sensitive to the diversity of families that may be considering a pregnancy. Families can mean heterosexual couples, homosexual couples or single parents.



Canadian families are changing, with many parents choosing to delay parenting and to have smaller families. In 1996 almost two thirds of all babies were born to mothers between the ages of 25 and 34 compared to only 39% in 1971. The average number of children in a Canadian family decreased steadily from 1.8 children per family in 1971 to 1.2 children per family in 1996 (Health Canada, 1999c; Canadian Institute of Child Health, 2000). Birth control has become more reliable, available and acceptable, helping couples choose to delay childbearing and/or have smaller families.



With couples planning smaller families, later on in life, there is increasing pressure to have a "premium baby" (Bushy, 1992).



Many factors influence pregnancy even before a woman knows she is pregnant. These factors include nutrition, physical activity, tobacco, alcohol and drugs, infections, special situations such as chronic illness, the environment, social support, domestic violence and abuse, as well as men's health.



Another challenge that preconception health promotion faces is that about half of Canadian pregnancies are unplanned. When pregnancies are unplanned, for whatever reason, the couple does not have the opportunity to assess and improve their health prior to conception. While preconception health promotion fails to serve couples with unplanned pregnancies, it can have substantial health benefits to couples that do plan their pregnancies

II Research and Strategies



Best Start's "Preconception and Health: Research and Strategies" approaches preconception health from many angles. This new resource can help program planners by making current research and practical approaches available. It includes a summary of current research on many aspects of preconception including infection, nutrition, exercise, alcohol, smoking, drugs, special situations, the environment, social support and violence. In addition, each chapter incorporates a synthesis of current approaches related to each topic, providing the reader with insights on program planning for preconception health.



For further information visit http://www.beststart.org to view "Preconception and Health: Research and Strategies" online in an 80 page PDF file [directly accessible at http://www.beststart.org/Preconpdf/Preconception.pdf].



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III Health of the Father



Preconception health looks at the health of a woman prior to pregnancy but also includes the health of the man. Although research in the area of male health and reproduction is limited, there is increasing evidence to suggest that paternal factors play a role in perinatal outcomes. The genetic contribution of the father has been well documented. However, a father's behaviour and general health status before and during conception are now considered important elements of preconception health (Yamey, 1999). A wide range of factors, including tobacco smoke, alcohol, workplace chemicals and heat, can adversely influence the health of men prior to conception. The most common reproductive consequence is infertility or reduced fertility. Men thinking about fatherhood are wise to adopt healthy lifestyle habits and to protect themselves from environmental and workplace toxins.



Although there are biological limits to a male's influence on reproductive outcomes, there are no limits to the ways in which he can support his partner. According to Cefalo and Moos (1995), a man can control his own alcohol, tobacco and drug exposures and change his nutritional habits as a means of aiding his partner in doing the same. Fathers can also make a difference by learning about pregnancy, cleaning the cat litter box, and being patient and supportive.



The impact of biology and lifestyle are not the only areas that affect men's health. Society's expectations of men have created an environment in which men are less able than women to recognize physical and emotional distress and to seek help (MacIntyre et al., 1996). Men are also relatively unaware of the length of time it takes for sperm to develop and of possible reproductive hazards. They may be less willing to request a protective reassignment or leave due to reproductive hazards at work. Consequently, program planning needs to be sensitive to these issues and other societal factors that affect men and their health.



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IV General Approaches



Preconception health promotion can include a combination of community supports, risk assessment, education, management or referral. The approaches can be individual or community wide.



a High Risk

Much of the current literature on preconception focuses on counseling for women with pre-existing conditions such as diabetes or epilepsy. Individuals at higher risk need to know how important it is to seek advice before getting pregnant (Health Canada, 1999). By supporting women and their partners before and early in pregnancy, parents are empowered to examine their own health and its influence on the health of their baby (Cefalo & Moos, 1995). While information for individuals with pre-existing medical concerns is important, it is not the only valid approach to preconception.



b Population Based

By directing preconception health promotion only at those women identified with a known health risk, a large proportion of the female population of reproductive age is missed. Consequently, the goal of preconception health promotion is to reach all women and their partners, enabling them to be in an optimal state of physical and emotional health at the onset of pregnancy (Wallace & Hurwitz, 1998).



c Broader Determinants of Health

Although there are many factors regarding pregnancy planning that individuals and families can have an impact on, there are also broader issues that influence pregnancy outcomes such as social assistance, workplace policies and organization and delivery of health services. Preconception health promotion informs the general population about the factors that contribute to a healthy pregnancy and a positive birth outcome, encouraging communities to share responsibility for maternal newborn health. Community resources and support systems can be identified, helping men and women to access these resources prior to pregnancy (Health Canada 2000b). Gaps in services can also be addressed, in order to meet the health needs of a community.



V Key Principles



Preconception health promotion includes many components that are based on the principles of family-centered maternity and newborn care. Individuals and groups promoting preconception health should strive to

* adopt practices that value pregnant women, children and families;

* encourage men and women to prepare actively for pregnancy;

* identify individuals with increased risks and provide information needed to make decisions and to reduce the risks;

* be aware of the many environmental factors influencing the family, including social, psychological, spiritual and physical ones;

* respect the diversity of people's lives and experiences; and

* help women and their partners understand health issues as they relate to pregnancy and conception, so that they may make informed choices about pregnancy.



VI Strategies



Effective preconception health promotion involves an array of affordable and accessible programs. Preconception programs are most effective when they are offered through a variety of methods, in a variety of community locations and as creatively as possible. It is important to keep in mind when developing preconception strategies the difficulty identifying those who could benefit from preconception health promotion.



Preconception awareness occurs in preconception classes but can also be raised during routine health care visits and patient education materials. Opportunistic approaches, such as talking about preconception when birth control is being re-assessed, can reach women who may not have considered improving their health prior to pregnancy. Other examples of opportunistic approaches for preconception promotion would be at bridal fairs, marriage preparation classes and school sexual health education.



Preconception strategies consist of risk assessment, health promotion and intervention (Schrander-Stumpel, 1999). Psychological readiness for parenting, physical readiness for conception and pregnancy, and necessary referrals are all-important components of preconception services. Approaches to preconception should include individuals with known risks, as well as the general population.



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VII Some Examples of Opportunistic Preconception Promotional Activities



a School Environment

Example: Your Fertile Future

The Waterloo Health Unit developed a tool for promoting preconception health in the school environment. The board game "Your Fertile Future" focuses on lifestyle choices, environmental factors, relationships and readiness for parenting. It is a fun way to promote thought and discussion about reproductive health.



b Work Environment

Example: New Beginnings

New Beginnings is a program binder developed by the University of North Carolina (Bendict, 1994) for the promotion of workplace reproductive health. A section of the binder covers promotion of preconception health in a workplace environment. Ideas include the use of classes, videos, games, literature and displays.



c For Physicians

Physicians are seen as credible sources of information by the general public and are the front line workers in the provision of preconception care.

Example: Preconception Training Event

Algoma Best Start and Algoma Health Unit planned a central training event for health professionals and community partners in 1996. Merry K. Moos, an expert on preconception from the University of North Carolina, was bought in for a full day workshop on the process of improving preconception health. This session provided the information, ideas and motivation necessary for the formation of working groups in several communities on preconception and health. For further ideas on how to work with physicians in your communities contact Best Start: Ontario's Maternal, Newborn and Early Child Development Resource Centre.



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VIII Research and Evaluation



Finally, successful preconception health promotion depends on health care providers having accurate and current research. Evaluation should be incorporated into all program plans. According to Jack and Culpepper (1990), the value of these basic services should not be discounted since they not only empower women and their partners to make informed decisions about themselves and the children they may have, but these services may ultimately reduce infant morbidity and mortality.



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IX Summary



Ultimately it is hoped that an increased number of effective approaches to preconception will

* decrease the number of unplanned pregnancies,

* increase the number of couples assessing their health and making appropriate changes prior to pregnancy,

* decrease the complications during pregnancy, and

* improve maternal and neonatal outcomes.