Preconception Women’s Health and Pediatrics: An Opportunity to Address Infant Mortality and Family Health

Abstract

The U.S. infant mortality rate remains unacceptably high, with large disparities found by race.1Kochanek K.D. Kirmeyer S.E. Martin J.A. et al.Annual summary of vital statistics: 2009.Pediatrics. 2012; : 338-348Crossref PubMed Scopus (153) Google Scholar, 2MacDorman MF, Mathews TJ. Recent trends in infant mortality in the United States. National Center for Health Statistics Data Brief 2008;9. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/data/databriefs/db09.pdf. Accessed April 1, 2011.Google Scholar Increasingly, research has demonstrated that interventions must go beyond ensuring access to care and prenatal focus to address the preconception health of women.3Centers for Disease Control and PreventionRecommendations 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. 2006; 55: 1-23PubMed Google Scholar, 4Markus AR, Atrash H, Johnson K, eds. Women’s health issues: policy and financing issues for preconception and interconception health. Women’s Health Issues. 2008;18: S1−S125.Google Scholar Critical fetal development occurs in the earliest weeks after conception, often before a woman is aware of her pregnancy. The Maternal Child Health Bureau’s life course initiatives5Fine A, Kotelchuck M. Rethinking MCH: The MCH Life Course Model as an Organizing Framework. U.S. DHHS, HRSA, Maternal and Child Health Bureau. 2010. Available at: http://mchb.hrsa.gov/lifecourse/rethinkingmchlifecourse.pdf. Accessed July 29, 2011.Google Scholar and the Centers for Disease Control’s preconception health initiatives5Fine A, Kotelchuck M. Rethinking MCH: The MCH Life Course Model as an Organizing Framework. U.S. DHHS, HRSA, Maternal and Child Health Bureau. 2010. Available at: http://mchb.hrsa.gov/lifecourse/rethinkingmchlifecourse.pdf. Accessed July 29, 2011.Google Scholar are placing infant mortality and child health in a life course context, that is, uniting the reproductive health and pediatric longitudinal perspectives. In the recent report “Clinical Preventive Services for Women”, the Institute of Medicine recommended annual well-women visits incorporating preconception care,6Board on Population Health and Public Health Practice, Institute of MedicineClinical Preventive Services for Women: Closing the Gaps. The National Academies Press, Washington, DC2011Google Scholar and Healthy People 2020 includes a section of objectives on preconception health and behaviors.7U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC: Maternal, Infant, and Child Health Objectives. Available at: http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26. Accessed March 10, 2012.Google Scholar With growing scientific recognition that early antecedents of child and adult health start prenatally and even preconceptionally, women’s health is key.Pediatric clinicians have been leaders in the efforts to reduce infant mortality and in family-centered care, but how can pediatrics further contribute? A golden opportunity exists to serve as preconception care (PCC) clinicians for preconceptional adolescents and interconceptional mothers seen in practice.Why Be Involved in Women’s Health?First, healthy women make healthy mothers. Maternal depression, substance use, and physical health—topics routinely addressed in pediatrics—have a major impact on a child’s health.8England M.J. Sim L.J. Committee on Depression, Parenting Practices, and the Healthy Development of Children; National Research Council; Institute of Medicine. Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention. The National Academies Press, Washington, DCJune 9, 2009Google ScholarSecond, preconceptional maternal health directly influences infant, child, and adult health. Considerable evidence demonstrates the impact of baseline maternal health (eg, diabetes, cardiovascular diseases, depression) and behaviors (eg, smoking, drug use, nutrition) on child and adult outcomes.9Weincrot A. Nannini A. Manning S.E. et al.Neonatal outcomes and mental illness, substance abuse, and intentional injury during pregnancy.Maternal Child Health J. 2011 Jun 2; (Epub ahead of print. Available at:) (Accessed May 18, 2012)http://www.springerlink.com/content/xr61u46514784426/fulltext.pdfGoogle Scholar, 10Orr S.T. Miller C.A. Maternal depressive symptoms and the risk of poor pregnancy outcome.Epidemiol Rev. 1995; 17: 165-171Crossref PubMed Scopus (250) Google Scholar, 11Castro L.C. Avina R. Maternal obesity and pregnancy outcome.Curr Opin Obstet Gynecol. 2002; 14: 601-606Crossref PubMed Scopus (188) Google Scholar, 12Xiong X. Buekens P. Fraser W.D. et al.Periodontal disease and adverse pregnancy outcome; a systematic review.BJOG. 2006; 113: 135-143Crossref PubMed Scopus (356) Google Scholar, 13Kleinman J.C. Pierre M.B. Madans J.H. et al.The effects of maternal smoking on fetal and infant mortality.Am J Epidemiol. 1988; 127: 274-282Crossref PubMed Scopus (251) Google Scholar, 14Zuckerman B. Frank D.A. Hingson R. et al.Effects of maternal marijuana and cocaine use on fetal growth.N Engl J Med. 1989; 320: 762-768Crossref PubMed Scopus (713) Google Scholar The story of folic acid supplementation is a powerful example of how a preconception intervention influences child health. The educational campaign and fortification of grains led to a 26% decrease in the rate of neural tube defects.15Howse J.L. Marching forward: action steps to optimize the health of women and babies.Women’s Health Issues. 2008; 18S: S10-S12Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 16De-Regil L.M. Fernández-Gaxiola A.C. Dowswell T. et al.Effects and safety of periconceptional folate supplementation for preventing birth defects.Cochrane Database Syst Rev. 2010; 10: CD007950PubMed Google ScholarThird, preventing unwanted pregnancies improves child and family well-being. A principal risk factor for late prenatal care is the “wantedness” of the pregnancy,17Pagnini D.L. Reichman N.E. Psychosocial factors and the timing of prenatal care among women in New Jersey’s HealthStart Program.Family Planning Perspect. 2000; 32: 56-64Crossref PubMed Scopus (73) Google Scholar which is associated with subsequent child well-being.18Hummer R.A. Hack K.A. Raley R.K. Retrospective reports of pregnancy wantedness and child well-being in the United States.J Family Issues. 2004; 25: 404-428Crossref Scopus (28) Google Scholar, 19Gipson J.D. Koenig M.A. Hindin M.J. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature.Studies in Family Planning. 2008; 39: 18-38Crossref PubMed Scopus (581) Google Scholar Research demonstrates that rapid repeat pregnancy and short interpregnancy intervals entail risks to the mother and her family.20Conde-Agudelo A. Rosas-Bermudez A. Kafury-Goeta A.C. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.JAMA. 2006; 295: 1809-1823Crossref PubMed Scopus (742) Google Scholar With 50% of U.S. pregnancies unwanted or mistimed,21Finer L.B. Zoina M.R. Unintended pregnancy in the United States; incidence and disparities, 2006.Contraception. 2011; 84: 478-485Abstract Full Text Full Text PDF PubMed Scopus (972) Google Scholar the discussion of desired family size and reproductive awareness can impact family health.Finally, pediatric clinicians have access to women of child-bearing age, possibly more contact than other clinicians.22Jack B.W. Atrash H. Bickmore T. et al.The future of preconception care: a clinical perspective.Women’s Health Issues. 2008; 18S: S19-S25Abstract Full Text Full Text PDF Scopus (25) Google Scholar, 23Wise P.H. Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health.Women’s Health Issues. 2008; 18S: S13-S18Abstract Full Text Full Text PDF Scopus (55) Google Scholar A survey of women ages 18 to 44 years found that only 55% had seen an obstetrician−gynecologist in the previous year; low-income women and women in poor health were less likely to have had a visit.24Salganicoff A. Ranji U. Wyn R. Women and health care: a national profile: key findings from the Kaiser Women’s Health Survey. Kaiser Family Foundation, Menlo Park, CA2005http://www.kff.org/womenshealth/upload/Women-and-Health-Care-A-National-Profile-Key-Findings-from-the-Kaiser-Women-s-Health-Survey.pdfGoogle Scholar By contrast, virtually all young children have had a well visit in the past year (96.8% of children 0−4 years),25Bloom B. Cohen R.A. Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2009. National Center for Health Statistics.Vital Health Stat. 2010; 10Google Scholar often accompanied by their mother, and large percentages of teens have had an annual check-up. Recommendations include 10 primary care well visits in the first 2 years of life and annual adolescent visits,26American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Bright Futures Steering CommitteeRecommendations for Preventive Pediatric Health Care.Pediatrics. 2007; (120:1376. Accessed at:) (Accessed July 27, 2011)http://pediatrics.aappublications.org/content/suppl/2007/12/03/120.6.1376.DC1/Preventive_Health_Care_Chart.pdfGoogle Scholar making pediatrics a logical contact point for PCC.How Could Pediatrics Impact Women’s Health?The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have outlined the areas of history-taking and risk assessment for PCC (Table 1).27Jack B.W. Atrash H. Coonrod D.V. et al.The clinical content of preconception care: An overview and preparation of this supplement.Am J Obstet Gynecol. 2008; : S266-S279Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Figure 1 outlines pediatric clinician contributions:•Reproductive awareness: Clinicians should discuss desired family size and reproductive planning with all adolescents and with parents that come with their children. If childbearing is not desired, discussion of family planning methods and/or referral makes sense.•Risk screening and counseling: Clinicians should screen mothers for PCC issues, many already recommended by the American Academy of Pediatrics for child health. For instance, assessing maternal smoking and smoke exposure, drug and alcohol use, depression, intimate partner violence, and family psychosocial needs are currently recommended for child health.28Thackeray J.D. Hibbard R. Dowd M.D. and the Committee on Child Abuse and Neglect, and the Committee on Injury, Violence, and Poison PreventionAmerican Academy of Pediatrics Clinical Report: Intimate Partner Violence: the role of the pediatrician.Pediatrics. 2010; 125: 1094-1100Crossref PubMed Scopus (109) Google Scholar, 29Hagan J.F. Shaw J.S. Duncan P.M. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. American Academy of Pediatrics, Elk Grove Village, IL2008Google Scholar, 30Earls M.F. and the Committee on Psychosocial Aspects of Child and Family HealthAmerican Academy of Pediatrics Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice.Pediatrics. 2010; 126: 1032-1039Crossref PubMed Scopus (327) Google Scholar Screening for these and other PCC issues listed in Table 1 could be implemented in pediatric practice with checklists or other modalities. Referral and/or brief counseling regarding these issues could be provided. Discussions should be in the context of the health of the mother, child and future children.•Health care for families: Clinicians should inquire about family health, access to, and use of care and chronic health concerns and provide PCC or refer if necessary.31Lu M.C. Kotelchuck M. Culhane J.F. et al.Preconception care between pregnancies: the content of internatal care.Matern Child Health. J. 2006; 10: S107-S122Crossref PubMed Scopus (101) Google ScholarTable 1Components of Preconception Care∗Adapted from the American Academy of Pediatrics, American College of Obstetricians and Gynecologists Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Washington, DC: American College of Obstetricians and Gynecologists; 2007.•Reproductive awareness and pregnancy spacing•History and risk screening○Family history, genetic history○Obstetric and gynecologic history○Medical conditions and medications○Substance use, including alcohol, tobacco and illicit drugs○Domestic abuse and violence○Nutrition and folic acid○Environmental toxins and teratogens○Immunity and immunization status○Risk factors for sexually transmitted infections○Psychosocial concerns, including depression, anxiety, and stress○Assessment of socioeconomic, educational, and cultural context•Physical assessment•Vaccinations•Counseling∗ Adapted from the American Academy of Pediatrics, American College of Obstetricians and Gynecologists Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Washington, DC: American College of Obstetricians and Gynecologists; 2007. Open table in a new tab How Can Women’s Health Be Integrated?Expansion to include greater emphasis on women’s health is not a departure for pediatrics, but an evolution from what is already occurring. It brings pediatrics more in line with evolving life course initiatives,32Kotelchuck M. Rethinking MCH: The MCH Life Course Model as an Organizing Framework. MCH Bureau 75th Anniversary Conference. Washington DC, October 2010. Available at: http://webcast.hrsa.gov/conferences/mchb/TitleV75/Theory_to_Practice.htm. Accessed July 27, 2011.Google Scholar addressing continuities of services across professions, breaking down narrowly defined professional silos, and focusing holistically on factors influencing health. Pediatrics has implemented this model, albeit for specialized populations. Teen-tot programs have a long history, and investigators in studies document reductions in rapid repeat pregnancy and improved parenting.33Akinbami L. Cheng T.L. Kornfeld D. Review of the effectiveness of teen-tot programs: comprehensive care for young parents and their children.Adolescence. 2001; 36: 381-393PubMed Google Scholar, 34Beers L.S. Hollo R.E. Approaching the Adolescent-Headed Family: A Review of Teen Parenting.Curr Prob Pediatr Adolesc Health Care. 2009; 39: 216-233Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar Practices are experimenting with combined maternal and child health care in Centering Parenting programs35Centering Parenting: A Group Model of Dyad Care. Available at: http://centeringhealthcare.org/pages/centering-model/parenting-overview.php. Accessed July 27, 2011.Google Scholar or co-located services.PCC is a paradigm shift for pediatrics, and there are barriers, including insurance coverage for women and available referral services. Change will only come when there is reimbursement and training for PCC. As the concept of the family-centered medical home is evolving, inclusion of family health in the pediatric home is needed and must be part of the financing and payment model.ConclusionWomen’s health is key to infant mortality and subsequent child health. Pediatric professionals have ready access to preconceptional women and a golden opportunity to implement PCC. It is time for the pediatric medical home to open its doors to women’s health. The U.S. infant mortality rate remains unacceptably high, with large disparities found by race.1Kochanek K.D. Kirmeyer S.E. Martin J.A. et al.Annual summary of vital statistics: 2009.Pediatrics. 2012; : 338-348Crossref PubMed Scopus (153) Google Scholar, 2MacDorman MF, Mathews TJ. Recent trends in infant mortality in the United States. National Center for Health Statistics Data Brief 2008;9. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/data/databriefs/db09.pdf. Accessed April 1, 2011.Google Scholar Increasingly, research has demonstrated that interventions must go beyond ensuring access to care and prenatal focus to address the preconception health of women.3Centers for Disease Control and PreventionRecommendations 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. 2006; 55: 1-23PubMed Google Scholar, 4Markus AR, Atrash H, Johnson K, eds. Women’s health issues: policy and financing issues for preconception and interconception health. Women’s Health Issues. 2008;18: S1−S125.Google Scholar Critical fetal development occurs in the earliest weeks after conception, often before a woman is aware of her pregnancy. The Maternal Child Health Bureau’s life course initiatives5Fine A, Kotelchuck M. Rethinking MCH: The MCH Life Course Model as an Organizing Framework. U.S. DHHS, HRSA, Maternal and Child Health Bureau. 2010. Available at: http://mchb.hrsa.gov/lifecourse/rethinkingmchlifecourse.pdf. Accessed July 29, 2011.Google Scholar and the Centers for Disease Control’s preconception health initiatives5Fine A, Kotelchuck M. Rethinking MCH: The MCH Life Course Model as an Organizing Framework. U.S. DHHS, HRSA, Maternal and Child Health Bureau. 2010. Available at: http://mchb.hrsa.gov/lifecourse/rethinkingmchlifecourse.pdf. Accessed July 29, 2011.Google Scholar are placing infant mortality and child health in a life course context, that is, uniting the reproductive health and pediatric longitudinal perspectives. In the recent report “Clinical Preventive Services for Women”, the Institute of Medicine recommended annual well-women visits incorporating preconception care,6Board on Population Health and Public Health Practice, Institute of MedicineClinical Preventive Services for Women: Closing the Gaps. The National Academies Press, Washington, DC2011Google Scholar and Healthy People 2020 includes a section of objectives on preconception health and behaviors.7U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC: Maternal, Infant, and Child Health Objectives. Available at: http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26. Accessed March 10, 2012.Google Scholar With growing scientific recognition that early antecedents of child and adult health start prenatally and even preconceptionally, women’s health is key. Pediatric clinicians have been leaders in the efforts to reduce infant mortality and in family-centered care, but how can pediatrics further contribute? A golden opportunity exists to serve as preconception care (PCC) clinicians for preconceptional adolescents and interconceptional mothers seen in practice. Why Be Involved in Women’s Health?First, healthy women make healthy mothers. Maternal depression, substance use, and physical health—topics routinely addressed in pediatrics—have a major impact on a child’s health.8England M.J. Sim L.J. Committee on Depression, Parenting Practices, and the Healthy Development of Children; National Research Council; Institute of Medicine. Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention. The National Academies Press, Washington, DCJune 9, 2009Google ScholarSecond, preconceptional maternal health directly influences infant, child, and adult health. Considerable evidence demonstrates the impact of baseline maternal health (eg, diabetes, cardiovascular diseases, depression) and behaviors (eg, smoking, drug use, nutrition) on child and adult outcomes.9Weincrot A. Nannini A. Manning S.E. et al.Neonatal outcomes and mental illness, substance abuse, and intentional injury during pregnancy.Maternal Child Health J. 2011 Jun 2; (Epub ahead of print. Available at:) (Accessed May 18, 2012)http://www.springerlink.com/content/xr61u46514784426/fulltext.pdfGoogle Scholar, 10Orr S.T. Miller C.A. Maternal depressive symptoms and the risk of poor pregnancy outcome.Epidemiol Rev. 1995; 17: 165-171Crossref PubMed Scopus (250) Google Scholar, 11Castro L.C. Avina R. Maternal obesity and pregnancy outcome.Curr Opin Obstet Gynecol. 2002; 14: 601-606Crossref PubMed Scopus (188) Google Scholar, 12Xiong X. Buekens P. Fraser W.D. et al.Periodontal disease and adverse pregnancy outcome; a systematic review.BJOG. 2006; 113: 135-143Crossref PubMed Scopus (356) Google Scholar, 13Kleinman J.C. Pierre M.B. Madans J.H. et al.The effects of maternal smoking on fetal and infant mortality.Am J Epidemiol. 1988; 127: 274-282Crossref PubMed Scopus (251) Google Scholar, 14Zuckerman B. Frank D.A. Hingson R. et al.Effects of maternal marijuana and cocaine use on fetal growth.N Engl J Med. 1989; 320: 762-768Crossref PubMed Scopus (713) Google Scholar The story of folic acid supplementation is a powerful example of how a preconception intervention influences child health. The educational campaign and fortification of grains led to a 26% decrease in the rate of neural tube defects.15Howse J.L. Marching forward: action steps to optimize the health of women and babies.Women’s Health Issues. 2008; 18S: S10-S12Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 16De-Regil L.M. Fernández-Gaxiola A.C. Dowswell T. et al.Effects and safety of periconceptional folate supplementation for preventing birth defects.Cochrane Database Syst Rev. 2010; 10: CD007950PubMed Google ScholarThird, preventing unwanted pregnancies improves child and family well-being. A principal risk factor for late prenatal care is the “wantedness” of the pregnancy,17Pagnini D.L. Reichman N.E. Psychosocial factors and the timing of prenatal care among women in New Jersey’s HealthStart Program.Family Planning Perspect. 2000; 32: 56-64Crossref PubMed Scopus (73) Google Scholar which is associated with subsequent child well-being.18Hummer R.A. Hack K.A. Raley R.K. Retrospective reports of pregnancy wantedness and child well-being in the United States.J Family Issues. 2004; 25: 404-428Crossref Scopus (28) Google Scholar, 19Gipson J.D. Koenig M.A. Hindin M.J. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature.Studies in Family Planning. 2008; 39: 18-38Crossref PubMed Scopus (581) Google Scholar Research demonstrates that rapid repeat pregnancy and short interpregnancy intervals entail risks to the mother and her family.20Conde-Agudelo A. Rosas-Bermudez A. Kafury-Goeta A.C. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.JAMA. 2006; 295: 1809-1823Crossref PubMed Scopus (742) Google Scholar With 50% of U.S. pregnancies unwanted or mistimed,21Finer L.B. Zoina M.R. Unintended pregnancy in the United States; incidence and disparities, 2006.Contraception. 2011; 84: 478-485Abstract Full Text Full Text PDF PubMed Scopus (972) Google Scholar the discussion of desired family size and reproductive awareness can impact family health.Finally, pediatric clinicians have access to women of child-bearing age, possibly more contact than other clinicians.22Jack B.W. Atrash H. Bickmore T. et al.The future of preconception care: a clinical perspective.Women’s Health Issues. 2008; 18S: S19-S25Abstract Full Text Full Text PDF Scopus (25) Google Scholar, 23Wise P.H. Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health.Women’s Health Issues. 2008; 18S: S13-S18Abstract Full Text Full Text PDF Scopus (55) Google Scholar A survey of women ages 18 to 44 years found that only 55% had seen an obstetrician−gynecologist in the previous year; low-income women and women in poor health were less likely to have had a visit.24Salganicoff A. Ranji U. Wyn R. Women and health care: a national profile: key findings from the Kaiser Women’s Health Survey. Kaiser Family Foundation, Menlo Park, CA2005http://www.kff.org/womenshealth/upload/Women-and-Health-Care-A-National-Profile-Key-Findings-from-the-Kaiser-Women-s-Health-Survey.pdfGoogle Scholar By contrast, virtually all young children have had a well visit in the past year (96.8% of children 0−4 years),25Bloom B. Cohen R.A. Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2009. National Center for Health Statistics.Vital Health Stat. 2010; 10Google Scholar often accompanied by their mother, and large percentages of teens have had an annual check-up. Recommendations include 10 primary care well visits in the first 2 years of life and annual adolescent visits,26American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Bright Futures Steering CommitteeRecommendations for Preventive Pediatric Health Care.Pediatrics. 2007; (120:1376. Accessed at:) (Accessed July 27, 2011)http://pediatrics.aappublications.org/content/suppl/2007/12/03/120.6.1376.DC1/Preventive_Health_Care_Chart.pdfGoogle Scholar making pediatrics a logical contact point for PCC. First, healthy women make healthy mothers. Maternal depression, substance use, and physical health—topics routinely addressed in pediatrics—have a major impact on a child’s health.8England M.J. Sim L.J. Committee on Depression, Parenting Practices, and the Healthy Development of Children; National Research Council; Institute of Medicine. Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention. The National Academies Press, Washington, DCJune 9, 2009Google Scholar Second, preconceptional maternal health directly influences infant, child, and adult health. Considerable evidence demonstrates the impact of baseline maternal health (eg, diabetes, cardiovascular diseases, depression) and behaviors (eg, smoking, drug use, nutrition) on child and adult outcomes.9Weincrot A. Nannini A. Manning S.E. et al.Neonatal outcomes and mental illness, substance abuse, and intentional injury during pregnancy.Maternal Child Health J. 2011 Jun 2; (Epub ahead of print. Available at:) (Accessed May 18, 2012)http://www.springerlink.com/content/xr61u46514784426/fulltext.pdfGoogle Scholar, 10Orr S.T. Miller C.A. Maternal depressive symptoms and the risk of poor pregnancy outcome.Epidemiol Rev. 1995; 17: 165-171Crossref PubMed Scopus (250) Google Scholar, 11Castro L.C. Avina R. Maternal obesity and pregnancy outcome.Curr Opin Obstet Gynecol. 2002; 14: 601-606Crossref PubMed Scopus (188) Google Scholar, 12Xiong X. Buekens P. Fraser W.D. et al.Periodontal disease and adverse pregnancy outcome; a systematic review.BJOG. 2006; 113: 135-143Crossref PubMed Scopus (356) Google Scholar, 13Kleinman J.C. Pierre M.B. Madans J.H. et al.The effects of maternal smoking on fetal and infant mortality.Am J Epidemiol. 1988; 127: 274-282Crossref PubMed Scopus (251) Google Scholar, 14Zuckerman B. Frank D.A. Hingson R. et al.Effects of maternal marijuana and cocaine use on fetal growth.N Engl J Med. 1989; 320: 762-768Crossref PubMed Scopus (713) Google Scholar The story of folic acid supplementation is a powerful example of how a preconception intervention influences child health. The educational campaign and fortification of grains led to a 26% decrease in the rate of neural tube defects.15Howse J.L. Marching forward: action steps to optimize the health of women and babies.Women’s Health Issues. 2008; 18S: S10-S12Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 16De-Regil L.M. Fernández-Gaxiola A.C. Dowswell T. et al.Effects and safety of periconceptional folate supplementation for preventing birth defects.Cochrane Database Syst Rev. 2010; 10: CD007950PubMed Google Scholar Third, preventing unwanted pregnancies improves child and family well-being. A principal risk factor for late prenatal care is the “wantedness” of the pregnancy,17Pagnini D.L. Reichman N.E. Psychosocial factors and the timing of prenatal care among women in New Jersey’s HealthStart Program.Family Planning Perspect. 2000; 32: 56-64Crossref PubMed Scopus (73) Google Scholar which is associated with subsequent child well-being.18Hummer R.A. Hack K.A. Raley R.K. Retrospective reports of pregnancy wantedness and child well-being in the United States.J Family Issues. 2004; 25: 404-428Crossref Scopus (28) Google Scholar, 19Gipson J.D. Koenig M.A. Hindin M.J. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature.Studies in Family Planning. 2008; 39: 18-38Crossref PubMed Scopus (581) Google Scholar Research demonstrates that rapid repeat pregnancy and short interpregnancy intervals entail risks to the mother and her family.20Conde-Agudelo A. Rosas-Bermudez A. Kafury-Goeta A.C. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.JAMA. 2006; 295: 1809-1823Crossref PubMed Scopus (742) Google Scholar With 50% of U.S. pregnancies unwanted or mistimed,21Finer L.B. Zoina M.R. Unintended pregnancy in the United States; incidence and disparities, 2006.Contraception. 2011; 84: 478-485Abstract Full Text Full Text PDF PubMed Scopus (972) Google Scholar the discussion of desired family size and reproductive awareness can impact family health. Finally, pediatric clinicians have access to women of child-bearing age, possibly more contact than other clinicians.22Jack B.W. Atrash H. Bickmore T. et al.The future of preconception care: a clinical perspective.Women’s Health Issues. 2008; 18S: S19-S25Abstract Full Text Full Text PDF Scopus (25) Google Scholar, 23Wise P.H. Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health.Women’s Health Issues. 2008; 18S: S13-S18Abstract Full Text Full Text PDF Scopus (55) Google Scholar A survey of women ages 18 to 44 years found that only 55% had seen an obstetrician−gynecologist in the previous year; low-income women and women in poor health were less likely to have had a visit.24Salganicoff A. Ranji U. Wyn R. Women and health care: a national profile: key findings from the Kaiser Women’s Health Survey. Kaiser Family Foundation, Menlo Park, CA2005http://www.kff.org/womenshealth/upload/Women-and-Health-Care-A-National-Profile-Key-Findings-from-the-Kaiser-Women-s-Health-Survey.pdfGoogle Scholar By contrast, virtually all young children have had a well visit in the past year (96.8% of children 0−4 years),25Bloom B. Cohen R.A. Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2009. National Center for Health Statistics.Vital Health Stat. 2010; 10Google Scholar often accompanied by their mother, and large percentages of teens have had an annual check-up. Recommendations include 10 primary care well visits in the first 2 years of life and annual adolescent visits,26American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Bright Futures Steering CommitteeRecommendations for Preventive Pediatric Health Care.Pediatrics. 2007; (120:1376. Accessed at:) (Accessed July 27, 2011)http://pediatrics.aappublications.org/content/suppl/2007/12/03/120.6.1376.DC1/Preventive_Health_Care_Chart.pdfGoogle Scholar making pediatrics a logical contact point for PCC. How Could Pediatrics Impact Women’s Health?The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have outlined the areas of history-taking and risk assessment for PCC (Table 1).27Jack B.W. Atrash H. Coonrod D.V. et al.The clinical content of preconception care: An overview and preparation of this supplement.Am J Obstet Gynecol. 2008; : S266-S279Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Figure 1 outlines pediatric clinician contributions:•Reproductive awareness: Clinicians should discuss desired family size and reproductive planning with all adolescents and with parents that come with their children. If childbearing is not desired, discussion of family planning methods and/or referral makes sense.•Risk screening and counseling: Clinicians should screen mothers for PCC issues, many already recommended by the American Academy of Pediatrics for child health. For instance, assessing maternal smoking and smoke exposure, drug and alcohol use, depression, intimate partner violence, and family psychosocial needs are currently recommended for child health.28Thackeray J.D. Hibbard R. Dowd M.D. and the Committee on Child Abuse and Neglect, and the Committee on Injury, Violence, and Poison PreventionAmerican Academy of Pediatrics Clinical Report: Intimate Partner Violence: the role of the pediatrician.Pediatrics. 2010; 125: 1094-1100Crossref PubMed Scopus (109) Google Scholar, 29Hagan J.F. Shaw J.S. Duncan P.M. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. American Academy of Pediatrics, Elk Grove Village, IL2008Google Scholar, 30Earls M.F. and the Committee on Psychosocial Aspects of Child and Family HealthAmerican Academy of Pediatrics Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice.Pediatrics. 2010; 126: 1032-1039Crossref PubMed Scopus (327) Google Scholar Screening for these and other PCC issues listed in Table 1 could be implemented in pediatric practice with checklists or other modalities. Referral and/or brief counseling regarding these issues could be provided. Discussions should be in the context of the health of the mother, child and future children.•Health care for families: Clinicians should inquire about family health, access to, and use of care and chronic health concerns and provide PCC or refer if necessary.31Lu M.C. Kotelchuck M. Culhane J.F. et al.Preconception care between pregnancies: the content of internatal care.Matern Child Health. J. 2006; 10: S107-S122Crossref PubMed Scopus (101) Google ScholarTable 1Components of Preconception Care∗Adapted from the American Academy of Pediatrics, American College of Obstetricians and Gynecologists Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Washington, DC: American College of Obstetricians and Gynecologists; 2007.•Reproductive awareness and pregnancy spacing•History and risk screening○Family history, genetic history○Obstetric and gynecologic history○Medical conditions and medications○Substance use, including alcohol, tobacco and illicit drugs○Domestic abuse and violence○Nutrition and folic acid○Environmental toxins and teratogens○Immunity and immunization status○Risk factors for sexually transmitted infections○Psychosocial concerns, including depression, anxiety, and stress○Assessment of socioeconomic, educational, and cultural context•Physical assessment•Vaccinations•Counseling∗ Adapted from the American Academy of Pediatrics, American College of Obstetricians and Gynecologists Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Washington, DC: American College of Obstetricians and Gynecologists; 2007. Open table in a new tab The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have outlined the areas of history-taking and risk assessment for PCC (Table 1).27Jack B.W. Atrash H. Coonrod D.V. et al.The clinical content of preconception care: An overview and preparation of this supplement.Am J Obstet Gynecol. 2008; : S266-S279Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Figure 1 outlines pediatric clinician contributions:•Reproductive awareness: Clinicians should discuss desired family size and reproductive planning with all adolescents and with parents that come with their children. If childbearing is not desired, discussion of family planning methods and/or referral makes sense.•Risk screening and counseling: Clinicians should screen mothers for PCC issues, many already recommended by the American Academy of Pediatrics for child health. For instance, assessing maternal smoking and smoke exposure, drug and alcohol use, depression, intimate partner violence, and family psychosocial needs are currently recommended for child health.28Thackeray J.D. Hibbard R. Dowd M.D. and the Committee on Child Abuse and Neglect, and the Committee on Injury, Violence, and Poison PreventionAmerican Academy of Pediatrics Clinical Report: Intimate Partner Violence: the role of the pediatrician.Pediatrics. 2010; 125: 1094-1100Crossref PubMed Scopus (109) Google Scholar, 29Hagan J.F. Shaw J.S. Duncan P.M. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. American Academy of Pediatrics, Elk Grove Village, IL2008Google Scholar, 30Earls M.F. and the Committee on Psychosocial Aspects of Child and Family HealthAmerican Academy of Pediatrics Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice.Pediatrics. 2010; 126: 1032-1039Crossref PubMed Scopus (327) Google Scholar Screening for these and other PCC issues listed in Table 1 could be implemented in pediatric practice with checklists or other modalities. Referral and/or brief counseling regarding these issues could be provided. Discussions should be in the context of the health of the mother, child and future children.•Health care for families: Clinicians should inquire about family health, access to, and use of care and chronic health concerns and provide PCC or refer if necessary.31Lu M.C. Kotelchuck M. Culhane J.F. et al.Preconception care between pregnancies: the content of internatal care.Matern Child Health. J. 2006; 10: S107-S122Crossref PubMed Scopus (101) Google Scholar How Can Women’s Health Be Integrated?Expansion to include greater emphasis on women’s health is not a departure for pediatrics, but an evolution from what is already occurring. It brings pediatrics more in line with evolving life course initiatives,32Kotelchuck M. Rethinking MCH: The MCH Life Course Model as an Organizing Framework. MCH Bureau 75th Anniversary Conference. Washington DC, October 2010. Available at: http://webcast.hrsa.gov/conferences/mchb/TitleV75/Theory_to_Practice.htm. Accessed July 27, 2011.Google Scholar addressing continuities of services across professions, breaking down narrowly defined professional silos, and focusing holistically on factors influencing health. Pediatrics has implemented this model, albeit for specialized populations. Teen-tot programs have a long history, and investigators in studies document reductions in rapid repeat pregnancy and improved parenting.33Akinbami L. Cheng T.L. Kornfeld D. Review of the effectiveness of teen-tot programs: comprehensive care for young parents and their children.Adolescence. 2001; 36: 381-393PubMed Google Scholar, 34Beers L.S. Hollo R.E. Approaching the Adolescent-Headed Family: A Review of Teen Parenting.Curr Prob Pediatr Adolesc Health Care. 2009; 39: 216-233Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar Practices are experimenting with combined maternal and child health care in Centering Parenting programs35Centering Parenting: A Group Model of Dyad Care. Available at: http://centeringhealthcare.org/pages/centering-model/parenting-overview.php. Accessed July 27, 2011.Google Scholar or co-located services.PCC is a paradigm shift for pediatrics, and there are barriers, including insurance coverage for women and available referral services. Change will only come when there is reimbursement and training for PCC. As the concept of the family-centered medical home is evolving, inclusion of family health in the pediatric home is needed and must be part of the financing and payment model. Expansion to include greater emphasis on women’s health is not a departure for pediatrics, but an evolution from what is already occurring. It brings pediatrics more in line with evolving life course initiatives,32Kotelchuck M. Rethinking MCH: The MCH Life Course Model as an Organizing Framework. MCH Bureau 75th Anniversary Conference. Washington DC, October 2010. Available at: http://webcast.hrsa.gov/conferences/mchb/TitleV75/Theory_to_Practice.htm. Accessed July 27, 2011.Google Scholar addressing continuities of services across professions, breaking down narrowly defined professional silos, and focusing holistically on factors influencing health. Pediatrics has implemented this model, albeit for specialized populations. Teen-tot programs have a long history, and investigators in studies document reductions in rapid repeat pregnancy and improved parenting.33Akinbami L. Cheng T.L. Kornfeld D. Review of the effectiveness of teen-tot programs: comprehensive care for young parents and their children.Adolescence. 2001; 36: 381-393PubMed Google Scholar, 34Beers L.S. Hollo R.E. Approaching the Adolescent-Headed Family: A Review of Teen Parenting.Curr Prob Pediatr Adolesc Health Care. 2009; 39: 216-233Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar Practices are experimenting with combined maternal and child health care in Centering Parenting programs35Centering Parenting: A Group Model of Dyad Care. Available at: http://centeringhealthcare.org/pages/centering-model/parenting-overview.php. Accessed July 27, 2011.Google Scholar or co-located services. PCC is a paradigm shift for pediatrics, and there are barriers, including insurance coverage for women and available referral services. Change will only come when there is reimbursement and training for PCC. As the concept of the family-centered medical home is evolving, inclusion of family health in the pediatric home is needed and must be part of the financing and payment model. ConclusionWomen’s health is key to infant mortality and subsequent child health. Pediatric professionals have ready access to preconceptional women and a golden opportunity to implement PCC. It is time for the pediatric medical home to open its doors to women’s health. Women’s health is key to infant mortality and subsequent child health. Pediatric professionals have ready access to preconceptional women and a golden opportunity to implement PCC. It is time for the pediatric medical home to open its doors to women’s health.