The preconception care paradigm in US public health: An Interview Between Christine Morton and Miranda Waggoner

[Editor’s note:  in this post, Dr. Christine Morton interviews public health researcher Miranda Waggoner, PhD, on her work with Princeton University’s Office of Population Research.  Dr. Waggoner’s particular research interests lie in maternal, women’s and infant’s health.]

CM:  Please briefly describe your research on preconception/interconception for the Science & Sensibility readership

MW:  My current research focuses on the emergence of the preconception care paradigm in the U.S. and what it means for contemporary public health and clinical strategies that aim to improve maternal and child health. Advocacy for prenatal care began in the early part of the 20th century, and prenatal care utilization increased throughout the century. The problem, though, was that adverse birth outcomes, such as low birthweight and infant mortality, persisted despite increasing numbers of women getting early prenatal care. So, experts started to look for other approaches to tackle these problems, and a preconception care (PCC) framework emerged as a potential solution. In 2004, The Centers for Disease Control and Prevention (CDC) launched its Preconception Health and Health Care Initiative. The basic idea was that a new focus on clinical care prior to pregnancy would improve birth outcomes. This new focus on the preconception period was seen by many in the maternal and child health field as a paradigm shift. I study the evidence base for PCC and how the United States moved from focusing on the expansion of prenatal care services to what is now essentially a prenatal care model that includes the period prior to pregnancy. I am also interested in what this new paradigm means for how we think about women’s bodies, reproduction, and population health in our society.

CM:  What do you think is important for childbirth educators to consider when they provide information to expectant women (and their partners) about preconception/interconception issues?

MW:  As any childbirth educator will know from experience working with women and couples, many conceptions are unplanned or unintended. So, a good number of women will enter pregnancy without active knowledge about, or preparation for, “preconception health.” Discussing preconception health during pregnancy is too late and potentially induces undue stress on the pregnant woman.

A motto of the preconception care paradigm is “every woman, every time.” This is the idea that clinicians should address women’s preconception health at every clinical encounter. I have learned in my research that clinicians do not always find this to be a successful strategy. Clinicians reported that often when a patient is not planning to get pregnant, she usually does not want to be asked about how her behaviors will influence a pregnancy. The preconception care framework sees women’s bodies as inherently risky to future fetuses if women are not preparing for pregnancy and changing their health behaviors to prepare for a pregnancy. We have to worry about this kind of rhetoric if it makes women feel uncomfortable or guilty about their reproductive behaviors or lives. The New York Times and Washington Post both published pieces about PCC after the CDC launched its initiative, and they suggested that women now will be treated as forever “pre-pregnant.” I think we do have to worry about viewing women as pregnancy vessels, but the CDC’s initiative was more complex than what was captured in these news outlets. The PCC initiative outlines improvements to a woman’s health irrespective of whether or not she plans to have a baby. I’m writing right now about how this public health strategy impacts the way we think about women’s health and women as potential mothers.

If you are talking to a woman who is already pregnant about preconception care, you are really addressing her health for a future pregnancy. This is known as interconception care (ICC). However, not every woman wants a subsequent pregnancy. If a woman does not want another pregnancy, part of this care would include information on how to avoid future pregnancies. CBEs should include ICC in their curriculum to the extent that the patient wants to discuss, plan, or prevent a subsequent pregnancy.

CM:  What does a sociological perspective add to the public health vision of Preconception/Interconception health?  For example, in an earlier S&S post, Dr. Michael Lu of UCLA outlines a vision of “Prenatal Care 3.0” which puts the “Medical Home” in the center (not the OB, as in Prenatal Care 2.0).  Although he doesn’t include midwifery in his vision of the Medical Home, are there other components you think are important to consider?

For additional reading on this topic:

Atrash, H., et al. 2008. Where is the "W"oman in MCH? American Journal of Obstetrics and Gynecology 199 (6B): S259-S265.

Johnson, K., et al. 2006. "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 55(RR06):1-23. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.html

Finer, L.B. and Henshaw, S.K., 20016, "Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001." Perspectives on Sexual and Reproductive Health 38 (2): 90-96.).

The National Campaign to Prevent Teen and Unplanned Pregnancy: http://www.thenationalcampaign.org

MW:  It is important to distinguish between preconception health and preconception care. Preconception health refers to a woman’s health status, whereas preconception care focuses on the clinical context. The public health vision of preconception care and prenatal care currently highlights individual health behaviors of women, and prenatal care 3.0 is still very much focused on clinical interventions toward individual women. Not everything related to health is best addressed by individual behavior change or clinical interventions. That is, we need to attend to population health at the social level too, making sure that underlying factors related to health are addressed. The National Children’s Study, which Dr. Lu is involved in, hopes to shed light on some of these factors, such as environmental influences on child development. I hope that we turn attention to the social determinants of health and not simply focus on clinical interventions and telling women to change their behavior.  Health status is influenced by so much more than what an individual woman does or does not do. If we want to improve population health, we have to focus on the social factors related to health for all people, not just women.

Additionally, I think some of these frameworks could better consider women’s health for women’s health sake and not just focus on women’s health behaviors in terms of how they will impact a future pregnancy. What people are really talking about in the preconception care paradigm is improving women’s health overall and improving birth outcomes in particular.  Most of a contemporary woman’s life, though, is spent not pregnant. I think the term “preconception care” is sometimes misleading as people are increasingly adopting a life course perspective, as Dr. Lu and others have. The basic idea of “Prenatal Care 3.0” is expanding care to the entire reproductive life course, not just focusing on pregnancy. If we highlight a woman’s general well-being over her life course, and not just focus on her as a future mother, we would see the inclusion of midwives, doulas, and other women’s health support mechanisms in a broader vision of health care.

Miranda R. WaggonerMiranda R. Waggoner is a postdoctoral research fellow at the Office of Population Research at Princeton University. She received her PH.D. in sociology and social policy from Brandeis University. Dr. Waggoner's research focuses on the intersections of maternal health, infant health, and women's health. Her work has been funded by the National Institutes of Health, The National Science Foundation, and the Andrew W. Mellon Foundation.

1 Comment

The preconception care paradigm in US public health: An Interview Between Christine Morton and Miranda Waggoner

November 13, 2011 07:00 AM by Kathy Morelli
Hi Ms Waggoner - just wanted to jump into the conversation here. I'm struggling with the pre-pregnancy and childbirth education discourse that is out there at the moment. I was once a childbirth educator, a body worker, a doula, and now I am a licensed special counselor. there are so many needs out there, and the pot is shrinking so much, and it is so difficult to be a healthcare provider nowadays.... I love my work, and I feel such sadness at all there needs to be done, yet our healthcare system in our social support system is so broken.

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