Advancing preconception health in the United States: strategies for change

In January 2015, the US Preconception Health and Health Care Initiative (PCHHC) established a new national vision that all women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have. Achieving this vision presents both challenges and opportunities. This manuscript describes the reasons why the US needs to prioritize preconception health as well as its efforts historically to advance change. The authors share lessons from past work and current strategies in the US to reach this ambitious goal.


Introduction
In 2015, the United States' Preconception Health and Health Care Initiative established a new national vision that all women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have. Key components of the vision include the addition of men as a point of focus and intervention and the importance of improving the health and wellness of young adults of reproductive age, regardless of their immediate desire for children. The vision also elevates the life course concept, which invites discussion about the lifelong and intergenerational impact of preconception wellness.
Achieving this vision presents both challenges and opportunities. This manuscript describes the reasons why the US needs to prioritize preconception health as well as its efforts historically to advance change. The authors share lessons from past work and current strategies in the US to reach this ambitious goal.

Call for action
The United States has progressed in reducing infant and maternal mortality rates. Despite these improvements, infant and maternal deaths remain high and disparities persist, particularly among non-Hispanic black and American Indian/ Alaska native populations (1,2). The US infant mortality and maternal mortality rates are higher than most industrialized nations, despite significant health care system investments and health expenditures (1, 3,4). US women of reproductive age (18-44 years) report a host of challenges to achieving optimal preconception health. For example, only 29.7% of women consume daily folic acid supplementation, over 25% use tobacco, 24.9% are overweight immediately prior to pregnancy, and 22.1% are obese prior to pregnancy. Further, 3.8% of women report physical abuse, and 42.9% report that their most recent pregnancy was unintended (5).
The introduction of the Patient Protection and Affordable Care Act (ACA) has prompted a sharp decline in the number of US women who are uninsured, yet 12.8 million women remain without health insurance (6). Almost one-third (29%) of uninsured women are not eligible for assistance under the ACA because they fall into the coverage gap created by their state's decision not to expand Medicaid (13%) or they are undocumented immigrants (16%). Many of these 3.6 million women live in the US South-where the majority of the 19 states that opted not to expand Medicaid eligibility to people with incomes less than 138% of the Federal Poverty Level regardless of their family or disability status or age are located-meaning that their access to affordable insurance coverage is severely curtailed (6).
Defined as a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management (7), preconception care is a critical component of a comprehensive women's health package to improve maternal and infant health outcomes (8). Despite the clear benefits of receiving preconception care and managing preconception health, many women in the US are not as healthy as they could be, and the US has not yet achieved its Healthy People 2020 objectives for increasing the proportion of women who receive preconception care and practice positive preconception behaviors (9,10).

National initiative
Founded in 2004, the National Preconception Health and Health Care Initiative (PCHHC) is a public-private partnership that aims to foster connection and multiply local impact through national collaborative efforts. The Initiative comprises five implementation workgroups focused on consumers, clinicians, public health, policy and finance, and surveillance and data. These efforts are synchronized to address cross-cutting issues through the PCHHC leadership team. Representatives include federal agencies, as well as national maternal and child health organizations, professional organizations, statelevel maternal and child health leaders, researchers, policymakers, and private foundations. PCHHC has directly and indirectly influenced other national projects, strategies, and policies, including the US Department of Health and Human Services' National Prevention Strategy and the Office of Population Affairs' Quality Family Planning Guidelines (11).
In 2006 the Centers for Disease Control and Prevention (CDC) and the Select Panel on Preconception Health issued national recommendations to advance the field. The recommendations focused on 10 areas, including: individual responsibility across the lifespan, consumer awareness, preventive visits, interventions for identified risks, interconception care, pre-pregnancy checkup, health coverage for women with low incomes, public health programs and strategies, and research and monitoring improvements (7). PCHHC has focused on responding to these recommendations for 10 years.
To this end, the Initiative has convened three national summit meetings, two Preconception Health Select Panels, and supported the five workgroups. The Initiative has published reports and articles, including four journal supplements (Maternal and Child Health Journal in 2006, Women's Health Issues in 2008, American Journal of Obstetrics and Gynecology in 2008, and the American Journal of Health Promotion in 2013-available at www.beforeandbeyond.org). The Initiative has carried out a series of strategic action plans, including the Action Plan for the National Initiative on Preconception Health and Health Care: A Report of the PCHHC Steering Committee (2012-2014) (12). In 2014, it launched a website for clinicians, including a comprehensive clinical resource guide on preconception health (www.beforeandbeyond.org).
In November 2014, the Preconception Select Panel was reconvened to review successes and challenges to the movement and make recommendations for future action. In order to accelerate the implementation of preconception health in the US, the Panel highlighted the importance of action in the following areas: (1) addressing the social determinants of health to create improved conditions for all women and men of reproductive age; (2) expanding social marketing and consumer engagement efforts; (3) focusing on the implementation of the ACA's coverage of well-woman visits and clinical preventive service benefits; (4) improving clinical care support, provider and health system changes; (5) increasing the use of health information technology; (6) expanding measurement to increase accountability; and (7) developing resources and partnerships (11). The full report is available online for review.

Current strategies
Based on lessons learned, PCHHC redoubled its efforts in 2015, with increased focus on measures and metrics, strategies for integrating preconception services into routine clinical care, consumer engagement, and expanded partnerships. This work is built on a platform that calls for a new social movement in the US to address reproductive and social justice issues. A multi-sector approach is essential for fully actualizing the potential of preconception health. Some current efforts are described below.

Measures
Two major efforts are underway to enhance metrics on preconception health at both the clinic and population health levels. First, the CDC Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health, has convened an internal surveillance and data workgroup to develop a set of state-based indicators to monitor improvements in preconception health, evaluate the effectiveness of preconception health programs, and assess the need for new programs. These indicators are the foundation for future national and state report cards, annual reporting, and media and policy-maker attention. The workgroup has reviewed an existing list of 45 indicators (13) as well as new potential indicators for inclusion. They agreed on evaluation criteria and, in partnership with state-level maternal and child health experts, are prioritizing indicators based on these criteria. A final list of indicators will be published at the end of 2016. Efforts then will turn to strengthening the capacity of states and territories to develop surveillance summaries with data-to-action efforts. Second, at the clinic level, the PCHHC Clinical Workgroup developed a set of preconception wellness metrics in February 2015. With the advent of health care finance reforms in the US, measures were needed to assess preconception health care delivery (14). Based on the premise that a woman's level of well-being at the time of conception reflects her preconception wellness, and grounded in prior research, the workgroup proposed a set of nine preconception wellness measures to be collected at a woman's first prenatal assessment. These measures include: (1) intended/planned to become pregnant; (2) entered prenatal care in the first trimester; (3) daily folic acid/multivitamin consumption; (4) tobaccofree; (5) not depressed (mentally well/under treatment); (6) healthy body mass index; (7) free of sexually transmitted infections; (8) optimal blood sugar control; and (9) medications (if any) are not teratogenic (14). A complete review of the indicators and methodology has been published (14).

Integrating preconception into clinical care
In tandem with developing clinical measures, the Clinical Workgroup is focused on identifying promising practices for integrating preconception health into clinic settings where women receive routine care. This is being accomplished by partnering with four clinics and 14 health care systems in collaborative learning networks. Through these networks process barriers and facilitators to implementation of preconception health will be identified, and new tools and resources will be developed to support clinicians and systems better. Preconception care is not likely to be fully adopted until health system leaders see such care as a driver for achieving the triple aim-improved patient experience, improved population health, and reduced health care costs.
Ongoing partnership with professional associations, such as the American Congress of Obstetricians and Gynecologists (ACOG), is essential, particularly in the development of protocols and expectations for quality well-woman care. Defined as an annual preventive health assessment, the well-woman visit includes screenings, evaluation, counseling, and immunizations and is now covered by health plans. The recently released American Academy of Family Physicians' position paper on preconception care (15) offers another example of critical partnerships to promote change so that health systems/clinicians routinely offer woman-centered preconception care services, including connecting women and men with information and resources necessary to act on provider recommendations.
Two major federal programs, the Maternal and Child Health Block Grant Program (Title V) and the Family Planning Program (Title X) of the US Public Health Service Act, have increased their focus on preventative health, including preconception and interconception care. Title V has made the percentage of adolescents and adult women who report an annual visit in the last 12 months key performance measures for states. The national Family Planning Program has expanded its focus beyond providing women with a contraceptive method to providing adolescent and adult women and men with comprehensive reproductive life planning services that include an increased focus on preventing and promoting early management of chronic conditions, such as hypertension, diabetes, and obesity.

Consumer education
Recognizing the necessity of pairing clinical care with excellent patient education and resources, the Consumer Workgroup conducted formative research to understand women's knowledge, attitudes, and behaviors as these relate to preconception health and reproductive life planning. In 2013, the Consumer Workgroup launched their flagship program, Show Your Love, a national campaign to improve the health of young adults through optimal preconception health and reproductive life planning. Show Your Love's target audience is women and men aged 18-44 who are currently planning to become pregnant, as well as those who do not wish to conceive.
In June 2016, the Consumer Workgroup launched a new Show Your Love consumer-facing campaign, beginning with www.showyourlovetoday.com, the first and only national consumer-focused preconception health educational and community-building platform in the US (Figure 1). Show Your Love's website objectives include: (1) enabling young adults to manage their personal and family well-being by making realistic health and lifestyle improvements daily; (2) educating young adults and their loved ones about tools and resources available to support healthy lifestyles; and (3) bridging the gap in access to and communication between young adults and their health care provider by helping them understand critical components about preconception health care, life planning, and health insurance (including pre-and post-doctor dialogues, information about access to care) and (4) empowering young adults to become health advocates in their communities by getting involved with Show Your Love.
To spur action among young adults in low-income, diverse, or higher-risk communities, efforts are underway to partner with organizations across the nation to diversify and expand preconception health messaging to resonate better with adults of various ethnicities, races, languages, cultures, identities, and communities across the US.
Show Your Love campaign materials that are relatable to these populations, including videos, public service announcements, posters, digital ads, doctor dialogue toolkits, and healthy habits checklists, will be rolled out by Show Your Love in the fall of 2016. Engaging consumers on national, regional, and local levels through a comprehensive public relations/marketing campaign that encompasses digital, social media, event-based, and media relations tactics is a cornerstone strategy. Tied to the launch of the Show Your Love website, the Consumer Workgroup launched their social media properties on Twitter (www.twitter.com/SYL_Today) and Facebook (www.Facebook.com/ShowYourLoveToday), coining the hashtag: #ShowYourLoveToday. For the first time, PCHHC is actively engaging with consumers and social media to share messages and interact on key pulse points and issues that are trending. In addition, PCHHC leaders are actively participating in national media interviews and platforms to share research, best practices, and expert insight on actions needed to move the needle on preconception health.

Health equity
It is critical that young women and men not only have knowledge about key preconception messages, but access to resources to act on the messages to take control of their health. There is significant momentum toward addressing health equity in the US-including new calls by the American Academy of Social Work and Social Welfare and the American Public Health Association, among others, to focus on the social determinants of health and promote increased integration across sectors to foster innovation and address the barriers that keep young people from actualizing protective preconception behaviors and wellness.
Leaders from the Public Health Workgroup have highlighted the importance of the following strategies to improve preconception health equity: (1) access to comprehensive, quality, culturally appropriate health care services for all; (2) facilitating change through crucial conversations and listening sessions; (3) developing collaborative, comprehensive programs within and beyond public health that support preconception health, reproductive equity, and life planning; and (4) educating and engaging the maternal and child health workforce and consumers on local and national issues that address the social determinants of health (16). Moving forward, resources will be developed to support meet-ups, town hall meetings, crucial conversation training, and tools and resources for engaging young adults. At the policy and finance level, PCHHC recently launched a Preconception Policy Action Network comprising advocacy organizations in women's and children's health and reproductive and social justice. This network will focus on increasing knowledge about preconception health and health care and building skills on appropriate and effective framing of preconception health and equity messages. Through this work connections will be fostered and new relationships will be built so as to have preconception health-primed colleagues at policy tables across the country.

Looking forward
After decades of steady progress in advancing preconception health, momentum has grown and is pushing toward a tipping point. Moving this work forward requires a thoughtful framing of preconception health messages. Activating young adults to attend to their health and plan their families is essential and challenging, particularly for those who live in resource-constrained environments. Paternalist frames that ignore the context of men's and women's lives will not resonate and may in fact cause harm. Elevating consumer-generated strategies and messages paired with available and accessible health-promoting resources can make a difference.
Building engagement and investment from federal, private foundation, and corporate sector funders is essential. Resources to expand traditional prenatal and infant mortality prevention strategies to preconception wellness for young adults who are not planning to become pregnant are rare. Leaning in to this new paradigm requires funders to consider their strategies and shift their work to support different points of the life course trajectory. Resources are necessary to advance research and build evidence-based practice for fully implementing preconception health as well as fully to expand social marketing and health system change strategies.
Given the complexity of preconception health promotion, partnership across fields and sectors is required. Connecting with scientists, clinicians, consumers, policy-makers, community leaders, and activists nationally and internationally will generate new ideas and the spread of knowledge and practice. In the US, there are opportunities to build on current points of focus and energy, including the annual well visit, expanded and improved postpartum care, screening for reproductive intention, the promotion of long-acting reversible contraception, quality measures, and health reform. Socially and politically, there are ripe opportunities for crucial conversations on equal rights, equal pay, racism, sexism, civic engagement, and reproductive justice. Ultimately, the health of all young adults is linked to their access to education, employment and career opportunities, quality physical and behavioral health services, and safe communities where they can thrive. Attention to the health and well-being of adolescents and young adults is critical for the health of our current society and generations to come.