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• W2074448198 abstract "Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of “W”omen will improve the health of mothers and children, we must focus on improving the health of “W”omen before pregnancy and put the “W” in Maternal and Child Health. Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of “W”omen will improve the health of mothers and children, we must focus on improving the health of “W”omen before pregnancy and put the “W” in Maternal and Child Health. Leaders in the United States were alarmed in the early 1980s when it was revealed that the country's ranking in infant death among developed countries had slipped from 10th in 1960 to 19th in 1980.1Institute of Medicine, Committee to Study the Prevention of Low Birth WeightPreventing low birth weight. National Academy Press, Washington, DC1985Google Scholar, 2National Center for Health StatisticsHealth, United States, 2007, with chartbook on trends in the health of Americans. National Center for Health Statistics, Hyattsville (MD)2007Google Scholar Health and public policy leaders took action and initiated many national programs to help improve pregnancy outcomes (much of the efforts at the time had been towards the care of women during pregnancy and helping women enter prenatal care early). In 1981, 6 lead organizations (the American College of Obstetricians and Gynecologists [ACOG], the March of Dimes, the American Academy of Pediatrics [AAP], the American Nurses Association, the National Congress of Parents and Teachers, and the US Public Health Service [US PHS]) established an informal coalition called “Healthy Mothers Healthy Babies” to improve the quality and to reach public and professional education related to prenatal and infant care.3National Healthy Mothers Healthy Babies Coalitionhttp://www.hmhb.org/Google Scholar In 1987, the US PHS convened a panel of experts that produced the landmark report titled Caring for Our Future: The Content of Prenatal Care.4Public Health ServiceCaring for our future: the content of prenatal care: a report of the Public Health Service Expert Panel on the Content of Prenatal Care. US Department of Health and Human Services, Washington, DC1989Google Scholar In 1985, concerned about the lack of progress in the reduction of maternal mortality rates worldwide and the limited attention being given to mothers in Maternal and Child Health (MCH), Rosenfield famously asked “Where is the M in MCH”?5Rosenfield A. Maine D. Maternal Mortality: a neglected tragedy: where is the M in MCH?.Lancet. 1985; 2: 83-85Abstract PubMed Scopus (326) Google Scholar From 1984-1989, the US Congress passed a series of incremental expansions of Medicaid that provided prenatal coverage for more than one million low-income women that Presidents Ronald Reagan and George H.W. Bush signed into law and state governments implemented. In 1991, the Healthy Start Initiative was launched in urban and rural communities where infant mortality rates were 1.5-2.5 times the national average to identify and develop community-based systems approaches to reducing infant deaths by 50% over the next 5 years and to improve the health and well-being of women, infants, children, and their families.6Community Involvement in the Federal Healthy Start ProgramA report from PolicyLink, June 2000.http://www.policylink.org/pdfs/HealthyStart.pdfGoogle ScholarDuring the last 30 years, the United States has succeeded in providing more focus on the “M”other; the percentage of women who had access to early prenatal care and those who received adequate prenatal care increased from 76.3% in 1980 to 83.9% in 2004.2National Center for Health StatisticsHealth, United States, 2007, with chartbook on trends in the health of Americans. National Center for Health Statistics, Hyattsville (MD)2007Google Scholar The United States has succeeded in reducing infant mortality rates from 12.6 deaths per 1000 live births in 1980 to 6.8 in 2004.2National Center for Health StatisticsHealth, United States, 2007, with chartbook on trends in the health of Americans. National Center for Health Statistics, Hyattsville (MD)2007Google Scholar However, other developed countries made more progress during the same period, which resulted in further deterioration of the United States ranking in infant deaths, mostly as a result of the increasing proportion of babies who are born preterm (from 9.4% in 1981 to 12.3% in 2003) or with low birthweight (from 6.8% in 1981 to 7.9% in 2003); in 2004, the United States ranked 29th among developed countries in infant death.7Martin J.A. Hamilton B.E. Sutton P.D. Ventura S.A. Menacker F. Kirmeyer S. Births: final data for 2004: national vital statistics reports. National Center for Health Statistics, Hyattsville, MD2006Google Scholar Efforts to reduce infant mortality rates and to improve pregnancy outcomes have focused primarily on prenatal care and the care of infants after birth. This approach reflects an emphasis on observing and monitoring a woman's health during pregnancy and intervening when and if needed (anticipation and management). However, improving the coverage, content, and use of prenatal care was a necessary, but not sufficient, step in the improvement of pregnancy outcomes in the United States.Current scientific evidence indicates that, in many cases, the improvement of a woman's health before pregnancy (preconception health and healthcare) will improve pregnancy outcomes for both mother and infant. Many women continue to enter pregnancy in poor health and at risk for poor pregnancy outcomes because of preexisting medical conditions or exposures to teratogenic factors or because proper, scientifically based preventive action (such as folic acid supplementation) has not been taken to prevent adverse pregnancy outcomes.8Anderson J. Ebrahim S. Floyd L. Atrash H. Prevalence of risk factors for adverse pregnancy outcomes during pregnancy and the preconception period: United States, 2002-2004.Matern Child Health J. 2006; 10: S101-S106Crossref PubMed Scopus (66) Google Scholar, 9Petrini J. Hamner H.C. Flores A.L. Mulinare J. Prue C. Use of supplements containing folic acid among women of childbearing age: United States, 2007.MMWR Morb Mortal Weekly Rep. 2008; 57: 5-8PubMed Google Scholar Moreover, millions of women remain at risk for unintended pregnancy. They might lack the knowledge or motivation necessary to carry out their personal plans for childbearing. Today, if we want to achieve further improvements in maternal and infant outcomes, we must act before pregnancy; we must shift the focus from “anticipation and management” in prenatal care into a paradigm of “prevention and health promotion” before pregnancy and throughout a woman's lifespan. Today, it is time to expand the “Healthy Mothers Healthy Babies” model into a “Healthy Women–Healthy Mothers–Healthy Babies” model. It is time to ask the question: where is the “W”oman in MCH?”Preconception Care is Not a New ConceptReference to the importance of preconception health and healthcare in the improvement of pregnancy outcomes are found in documents that are hundreds of years old. For example, in 1825, Dewees10Dewees W.P. A treatise on the physical and medical treatment of children 11th ed. Philadelphia: Blanchard and Lea; 1858 (preface page ix).http://books.google.com/books?id=vjQSqOtKeM0C&printsecGoogle Scholar stated that “The physical treatment of children should begin as far as may be practicable, with the earliest formation of the embryo; it will, therefore, necessarily involve the conduct of the mother, even before her marriage, as well as during her pregnancy.” In recent years, preconception care was first described by Chamberlain11Chamberlain G. The prepregnancy clinic.BMJ. 1980; 28: 29-30Crossref Scopus (41) Google Scholar, 12Chamberlain G. Lumley J. Prepregnancy care: a manual for practice. Wiley, Chichester (UK)1986Google Scholar as a specialty service for women who had had a previous poor reproductive outcome. It was then described in the United States by the US PHS in the landmark publication Preventing Low Birth Weight1Institute of Medicine, Committee to Study the Prevention of Low Birth WeightPreventing low birth weight. National Academy Press, Washington, DC1985Google Scholar and later by Moos and Cefalo13Moos M.K. Cefalo R.C. Preconceptional health promotion: a focus for obstetric care.Am J Perinatol. 1987; 47: 63-67Crossref Scopus (43) Google Scholar at the University of North Carolina. The concept was adopted by the US PHS Expert Panel on the Content of Prenatal Care,3National Healthy Mothers Healthy Babies Coalitionhttp://www.hmhb.org/Google Scholar, 14Jack B. Culpepper L. Preconception care.in: Merkatz I.R. Thompson J.E. Mullen P.D. Goldenberg R.L. New perspectives on prenatal care. Elsevier, New York1990: 69-88Crossref Scopus (69) Google Scholar which defined its components and emphasized that it is delivered most effectively as part of primary care services.,Development of the concept was identified as a priority in the 1990s by the US PHS, whose report included, among the health promotion and disease prevention objectives for the year 2000, a recommendation to increase the proportion of primary care providers who offer age-appropriate preconception care and counseling to at least 60%.15US Public Health ServiceHealthy People 2000: national health promotion and disease prevention objectives (DHHS publication No. 91-502212). US Department of Health and Human Services, Washington, DC1991Google Scholar, 16US Public Health ServiceHealthy People 2000: midcourse review and 1995 revisions. US Department of Health and Human Services, Washington, DC2000Google ScholarHealthy People 2010 includes many objectives that address preconception health. The National Committee on Perinatal Health, which was led by ACOG, AAP, and the March of Dimes, made recommendations for action and offered a prototype preconception screening tool. They encouraged all primary care providers to play an active role in promoting prevention before pregnancy.17Committee on Perinatal HealthToward improving the outcome of pregnancy (TIOP II): the 90s and beyond. March of Dimes, National Foundation, White Plains, NY1993Google Scholar The “Guidelines for Perinatal Care,” which was jointly issued by AAP and ACOG, recommended that “all health encounters during a woman's reproductive years, particularly those that are a part of preconception care, should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes.”18Gilstrap L.C. Oh W. American Academy of Pediatrics, American College of Obstetricians and Gynecologists Guidelines for perinatal care. 5th ed. American Academy of Pediatrics, Elk Grove Village, IL2002Google Scholar Other ACOG publications further emphasized the importance of preconception care in the continuum of women's healthcare.19American College of Obstetricians and GynecologistsGuidelines for women's health care.2nd ed. The College, Washington, DC2002Google Scholar, 20American College of Obstetricians and Gynecologists Preconception Work GroupThe importance of preconception care in the continuum of women's health care.Obstet Gynecol. 2005; 106: 665-666Crossref PubMed Scopus (160) Google Scholar, 21American College of Obstetricians and GynecologistsPreconceptional care: ACOG technical bulletin No.: 205, May 1995.Int J Gynaecol Obstet. 1995; 50: 201-207Abstract Full Text PDF PubMed Scopus (24) Google Scholar In 2002, the March of Dimes suggested that “as the key physician/primary care providers, the obstetrician/gynecologists must take advantage of every health encounter to provide preconception care and risk reduction before and between conceptions—the time when care really can make a difference.”22March of Dimes Birth Defects FoundationMarch of Dimes updates: is early prenatal care too late?.Contemp Obstet Gynecol. 2002; 12: 54-72Google Scholar The importance of preconception care as a concept was further articulated in family medicine,17Committee on Perinatal HealthToward improving the outcome of pregnancy (TIOP II): the 90s and beyond. March of Dimes, National Foundation, White Plains, NY1993Google Scholar, 23Gjerdingen D.K. Fontaine P. Preconception health care: a critical task for family physicians.J Am Board Fam Pract. 1991; 4: 237-250PubMed Google Scholar, 24Frey K.A. Preconception care by the non-obstetrical provider.Mayo Clin Proc. 2002; 77: 469-473PubMed Google Scholar, 25Jack B. Preconception care (or how all family physicians “do” OB).Am Fam Physician. 1995; 51: 1807-1808PubMed Google Scholar obstetrics and gynecology,20American College of Obstetricians and Gynecologists Preconception Work GroupThe importance of preconception care in the continuum of women's health care.Obstet Gynecol. 2005; 106: 665-666Crossref PubMed Scopus (160) Google Scholar, 21American College of Obstetricians and GynecologistsPreconceptional care: ACOG technical bulletin No.: 205, May 1995.Int J Gynaecol Obstet. 1995; 50: 201-207Abstract Full Text PDF PubMed Scopus (24) Google Scholar, 26Hobbins D. Prepping for healthy moms & babies: making the case for preconception care & counseling.AWHONN Lifelines. 2001; 5: 49-54Crossref PubMed Scopus (4) Google Scholar, 27American College of Obstetricians and GynecologistsAccess to women's health care: ACOG statement of policy. The College, Washington (DC)2003Google Scholar nurse midwifery,28Reynolds H.D. Preconception care: an integral part of primary care for women.J Nurse Midwifery. 1998; 43: 445-458Crossref PubMed Scopus (9) Google Scholar nursing,29Moos M.K. Preconceptional health promotion: opportunities abound.Matern Child Health J. 2002; 6: 71-73Crossref PubMed Scopus (19) Google Scholar, 30Moos M.K. Preconceptional wellness as a routine objective for women's health care: an integrative strategy.J Obstet Gynecol Neonatal Nurs. 2003; 32: 550-556Crossref PubMed Scopus (36) Google Scholar, 31Moos M.K. Preconceptional health promotion: progress in changing a prevention paradigm.J Perinat Neonatal Nurs. 2004; 18: 2-13Crossref PubMed Scopus (57) Google Scholar and public health.32Misra D.P. Guyer B. Allston A. Integrated perinatal health framework: a multiple determinants model with a life span approach.Am J Prev Med. 2003; 25: 65-75Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar Canada's National Guidelines on Family-Centered Maternity and Newborn Care devotes an entire chapter to preconception care and describes the multitude of intrinsic and extrinsic factors that influence preconception health. Various settings that are appropriate for the administration of preconception care interventions are discussed as well as a range of social and medical issues that included stress, social support, abuse and violence, healthy lifestyle practices, and nutrition.33Agrey N. Crowe K.M. Levitt C. MacDonald J. Mac Lean D. Polomeno V. Preconception care.in: Hanvey L. Family-centered maternity and newborn care: national guidelines. Health Canada, Minister of Public Works and Government Services, Ottawa2005: 5-30Google Scholar The American Diabetes Association,34American Diabetes AssociationPreconceptional care of women with diabetes.Diabetes Care. 2004; 27: S76-S78Crossref PubMed Google Scholar the American Academy of Neurology,35Practice parameter: management issues for women with epilepsy (summary statement) Report of the Quality Standards Subcommittee of the American Academy of Neurology.Neurology. 1998; 51: 944-948Crossref PubMed Scopus (187) Google Scholar and the American Heart Association/American College of Cardiologists36Hirsh J. Fuster V. Ansell J. Halperin J.L. American Heart Association; American College of Cardiology FoundationAmerican Heart Association/American College of Cardiology Foundation guide to warfarin therapy.Circulation. 2003; 107 (1): 1692-1711Crossref PubMed Scopus (470) Google Scholar promulgated recommendations on preconception care in their specialties.Despite this broad interest in preconception care, there has been only modest progress in the implementation of these concepts into clinical practice and the development of research studies to advance practice. Existing research indicates that most women realize the importance of optimizing their health before pregnancy, whether or not the pregnancy is planned,37Frey K. Files J. Preconception health care: what women know and believe.Matern Child Health J. 2006; 10: S73-S77Crossref PubMed Scopus (105) Google Scholar and that most physicians think preconception care is important.38Morgan M. Hawks D. Zinberg S. Schulkin J. What obstetrician-gynecologists think of preconception care.Matern Child Health J. 2006; 10: S59-S65Crossref PubMed Scopus (46) Google Scholar However, most providers do not recommend routinely or provide preconception care to their patients.39Williams J. Abelman S. Fassett E. et al.Health care provider knowledge and practices regarding folic acid, United States, 2002-2003.Matern Child Health J. 2006; 10: S67-S72Crossref PubMed Scopus (37) Google Scholar One randomized clinical trial found that, even when given specific training, physicians did not take action to follow up risks that were identified at the time of a negative pregnancy test.40Jack B.W. Culpepper L. Babcock J. Kogan M. Wesimiller D. How effectively are interventions initiated after preconception risk assessment at the time of a negative pregnancy test? A randomized controlled trial.J Fam Pract. 1998; 47: 33-38PubMed Google ScholarThe Centers For Disease Control and Prevention (CDC) Preconception Health and Health Care InitiativeIn November 2004, the CDC Workgroup on Preconception Health and Health Care, working with national experts and representatives of over 35 national, state, and local organizations, launched the Preconception Health and Health Care Initiative. The CDC workgroup includes representatives of 22 CDC programs that are concerned with the health of women and infants in areas such as infectious diseases, HIV/AIDS, injury prevention, reproductive health, nutrition, smoking, alcohol, birth defects, and genetics. The workgroup has recognized the importance of women's health in improving maternal and infant pregnancy outcomes, the immediate need to facilitate collaboration and coordinate efforts among various organizations across the country, and the need to develop consensus recommendations and to identify and address obstacles and opportunities for the promotion of preconception health and healthcare in all aspects of healthcare (clinical, public health, consumer, policy and finance, and research/surveillance/monitoring).In June 2005, the CDC convened a group of national experts (the Select Panel on Preconception Care) to develop “Recommendations on Preconception Health and Health Care.” The guiding principles, visions, and objectives of the aforementioned initiative and the recommendations for preconception health and healthcare were published in April 2006.41Centers for Disease Control and PreventionRecommendations for improving preconception health and health care: United States: a report of the CC/ATSDR Preconception Care Workgroup and the Select Panel on Preconception Care.MMWR, Morb Mortal Weekly Rep. 2006; 55: 1-23PubMed Google Scholar The panel's vision is that all women of childbearing age and all men have high reproductive awareness, that all pregnancies are intended and planned, and that all women of childbearing age have health coverage and are screened before pregnancy for risks that are related to adverse pregnancy outcomes. The panel's guiding principle called for improving women's health throughout the lifespan by emphasizing individual behavior and responsibility, with changes in clinical care and public policy to support such women and couples in carrying out their childbearing plans. The panel made a series of recommendations that are aimed at achieving 4 goals: (1) to improve the knowledge, attitudes, and behaviors of men and women related to preconception health; (2) to assure that all women of childbearing age in the United States receive preconception care services that will enable them to enter pregnancy in optimal health; (3) to reduce risks that are indicated by a previous adverse pregnancy outcome through interventions during the interconception period; and (4) to reduce disparities in adverse pregnancy outcomes.41Centers for Disease Control and PreventionRecommendations for improving preconception health and health care: United States: a report of the CC/ATSDR Preconception Care Workgroup and the Select Panel on Preconception Care.MMWR, Morb Mortal Weekly Rep. 2006; 55: 1-23PubMed Google Scholar The CDC panel further defined preconception care as “interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management by emphasizing those factors that must be acted on before conception or early in pregnancy to have maximal impact. Thus, it is more than a single visit and less than well-woman care. It includes care before a first pregnancy or between pregnancies (commonly known as “interconception care”).The Select Panel recognized that, to promote preconception health and healthcare, there was a need to go beyond developing and publishing recommendations. In June 2006, the CDC established 5 implementation workgroups (clinical, public health, consumer, policy and finance, and research and surveillance) to develop strategies for implementing the recommendations. These groups were to focus on core constituencies in which changes in knowledge, attitudes, and practices could lead to improvements in preconception health and healthcare. The workgroups were charged with fine-tuning and augmenting the proposed action steps, establishing priorities for follow-up action, and agreeing to take leadership for implementation of ≥ 1 action steps.The clinical workgroup, comprising > 20 physicians and nurses of various specialties, identified the definition of the content of preconception care and provider education as top priorities for the immediate future. The accompanying articles in this supplement are the result of efforts by 36 clinical care providers who worked together for > 2 years to define the clinical content of preconception care.Rationale for Preconception CareClinicians have counseled women regarding risk reduction in preparation for pregnancy for many years as part of routine preventive health care (eg, advising on avoiding teratogens and seeking family planning and genetic counseling), managing preexisting medical conditions (such as diabetes mellitus, hypertension, and sexually transmitted infections), and delivering preventive interventions (eg, HIV screening and vaccinations). During the past 20 years, there has been a growing realization that the development of a comprehensive program to assess and modify medical, psychosocial, and behavioral risks before pregnancy could prevent poor pregnancy outcomes for women and infants. This kind of care can help women and couples make decisions regarding the timing of conception and can improve their health in readiness for pregnancy.1Institute of Medicine, Committee to Study the Prevention of Low Birth WeightPreventing low birth weight. National Academy Press, Washington, DC1985Google Scholar, 13Moos M.K. Cefalo R.C. Preconceptional health promotion: a focus for obstetric care.Am J Perinatol. 1987; 47: 63-67Crossref Scopus (43) Google Scholar, 18Gilstrap L.C. Oh W. American Academy of Pediatrics, American College of Obstetricians and Gynecologists Guidelines for perinatal care. 5th ed. American Academy of Pediatrics, Elk Grove Village, IL2002Google Scholar, 27American College of Obstetricians and GynecologistsAccess to women's health care: ACOG statement of policy. The College, Washington (DC)2003Google Scholar, 28Reynolds H.D. Preconception care: an integral part of primary care for women.J Nurse Midwifery. 1998; 43: 445-458Crossref PubMed Scopus (9) Google Scholar, 31Moos M.K. Preconceptional health promotion: progress in changing a prevention paradigm.J Perinat Neonatal Nurs. 2004; 18: 2-13Crossref PubMed Scopus (57) Google Scholar, 32Misra D.P. Guyer B. Allston A. Integrated perinatal health framework: a multiple determinants model with a life span approach.Am J Prev Med. 2003; 25: 65-75Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 42Jack B.W. Culpepper L. Preconception care: risk reduction and health promotion in preparation for pregnancy.JAMA. 1990; 264: 1147-1149Crossref PubMed Scopus (73) Google Scholar, 43Cefalo R.C. Moos M.K. Preconceptional health promotion: a practical guide.2nd ed. Mosby, St. Louis1995Google Scholar, 44Bernstein P.S. Sanghvi T. Merkatz I.R. Improving preconception care.J Reprod Med. 2000; 45: 546-552PubMed Google Scholar, 45Allaire A.D. Cefalo R.C. Preconceptional health care model.Eur J Obstet Gynecol Reprod Biol. 1998; 78: 163-168Abstract Full Text PDF PubMed Scopus (24) Google ScholarThe goal of preconception care is to ensure that a woman and her partner are healthy and that they avoid hazardous exposures and practice healthy lifestyles before pregnancy. Many of the medical conditions, environmental exposures, personal behaviors, and psychosocial risks that are associated with negative pregnancy outcomes can be identified and modified or eliminated before conception. A comprehensive preconception care program has the potential to benefit women who desire pregnancy by reducing risks, promoting healthy lifestyles, and increasing readiness for pregnancy. For women who do not desire pregnancy, a preconception care program can reduce personal health risks and the risk of an unwanted pregnancy.First and foremost, preconception care is important because it provides an opportunity to optimize the health of the woman independently of whether she becomes pregnant. Moreover, intervention before pregnancy is essential for the optimization of outcomes for the pregnant woman (maternal outcomes), her child, or both. In a committee opinion that was published in 2005, ACOG's Committee on Gynecologic Practice recognized the Importance of Preconception Care in the Continuum of Women's Health Care.46American College of Obstetricians and GynecologistsThe importance of preconception care in the continuum of women's health care: ACOG committee opinion No.: 313. The College, Washington, DC2005Google Scholar The CDC's Recommendations for Preconception Health and Health Care call for the improvement of a woman's health by managing preexisting medical conditions (such as diabetes mellitus, obesity, epilepsy, and hypothyroidism), providing vaccines (such as rubella, hepatitis B), screening and treatment for other conditions (such as HIV/AIDS, sexually transmitted infections), and counseling for some behavioral risks (alcohol use and smoking).41Centers for Disease Control and PreventionRecommendations for improving preconception health and health care: United States: a report of the CC/ATSDR Preconception Care Workgroup and the Select Panel on Preconception Care.MMWR, Morb Mortal Weekly Rep. 2006; 55: 1-23PubMed Google Scholar Preconception care also provides a window of opportunity to reduce the risk of pregnancy complications that may threaten maternal health. For example, properly managing hypothyroidism before pregnancy reduces the risk of maternal hypertension, preeclampsia, placental abruption, anemia in pregnancy and postpartum hemorrhage; properly managing hypertension before pregnancy reduces the risk of preeclampsia47Dunlop A.L. Jack B.W. Bottalico J.N. et al.The clinical content of preconception care: women with chronic medical conditions.Am J Obstet Gynecol. 2008; 199: S310-S327Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar; properly managing overweight and underweight conditions reduces the risk of nutritional deficiencies, postpartum anemia, and cesarean delivery48Moos M.K. Dunlop A.L. Jack B.W. et al.Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age.Am J Obstet Gynecol. 2008; 199: S280-S289Abstract Full Text Full Text PDF PubMed Scopus (146) Go" @default.
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