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Abstract: Preconception healthcare is a way to enhance positive pregnancy outcomes by encouraging women to engage in healthy lifestyles before they become pregnant. Because approximately 50% of pregnancies are unplanned, fetal development may be affected before a woman receives prenatal care. Young women are especially vulnerable to poor outcomes due to risky behaviors. Education about preconception health is not common practice. This article describes a peer education preconception health program for college women that provided a basis for an expanded program with larger, more diverse populations. Nursing students as peer educators presented the program to over 100 young women using the mnemonic REFRAMED PLUS to address eight preconception risk areas and reproductive life planning. Materials to augment the program, developed by peer educators, included a brochure on preconception health, a risk assessment tool, a DVD with stories of young women who experienced unplanned pregnancies, and a Reproductive Life Plan book. Peer educators administered a pretest, showed the DVD, guided discussions, assessed each woman's health risks and administered a posttest. The risk assessment revealed that young women have several preconception health risks. Following the preconception program, posttest scores indicated increased knowledge of preconception health. For preconception healthcare to be successful, preconception risk assessments, education and counseling must be addressed by nurses every time a young woman receives care. When possible, peer educators should be used to disseminate the message to all women of childbearing age.
Unintended pregnancies account for approximately 50% of all pregnancies in the United States with higher numbers projected for teens (Finer & Henshaw, 2006). Unintended pregnancy is associated with increased maternal morbidity and poor pregnancy outcomes. Even when pregnancies are planned, most women do not have their first prenatal visit until after the critical period of fetal development. A news release from the Institute of Medicine indicated the need to change the women's health focus from prenatal care to preconception care, a continuum of care starting before conception (The National Academies, 2006).
Preconception care, defined by the Select Panel on Preconception Care (SPPC), is "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" (Center for Disease Control and Prevention [CDC], 2006a p. 4). This focus takes a life course perspective in which birth outcomes are the end product of the women's entire life leading up to pregnancy and not just the 40 weeks of pregnancy (Misra & Grason, 2006). Evidence suggests this approach may improve women's health throughout the life span and contribute to positive reproductive outcomes, which in turn may enhance outcomes for their offspring at birth and beyond (Atrash, Jack, & Johnson, 2008; Misra & Grason, 2006). To address preconception care, experts from CDC and Agency for Toxic Substances and Disease Registry (ATSDR) formed the Preconception Care Work Group and Select Panel on Preconception Health and Health Care (CDC, 2006a). The Work Group and Select Panel developed recommendations for preconception health and care (Box 1). The recommendations were aimed at achieving the following goals:
Goal 1: Improve the knowledge and attitudes and behaviors of men and women related to preconception health.
Goal 2: Assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health.
Goal 3: Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children.
Goal 4: Reduce the disparities in adverse pregnancy outcomes (CDC, 2006a, p. 12).
Despite the evidence, preconception healthcare is not common practice. The purpose of this article is to describe a preconception care program for college-aged women at a university in the Eastern United States. The university has a population of about 20,000 graduate and undergraduate students. The majority of the students are female and White with about one-third described as being non-White. College students are particularly vulnerable to poor birth outcomes as most of the pregnancies are unintended, and many young women have not established healthy lifestyles to prepare their bodies for conception.
The preconception care program focused on the first three recommendations in Box 1. The first recommendation addresses the life course perspective by suggesting the need for men and women to have a reproductive life plan. Consumer awareness, recommendation two, emphasizes the importance of using information and tools to increase the public's awareness of the importance of preconception health behaviors and preconception care services. The third recommendation focuses on risk assessment and educational and health promotion counseling of all women of childbearing age. Using peer educators, the program followed a curriculum framework to address these recommendations and begin outreach to primary care providers.
Based on a review of research evidence, the CDC/ATSDR Preconception Care Work Group and the SPPC identified preconception risks associated with adverse pregnancy outcomes (CDC, 2006a). These risks included various chronic and genetic conditions, certain medications, substance abuse including tobacco and alcohol, folic acid deficiency, obesity, sexually transmitted diseases, vaccine preventable diseases, and social determinants of health including domestic violence. Freda, Chazotte, Bernstein, and Harrison (2002) used the mnemonic REFRAMED to design a preconception health curriculum for four medical specialties. The curriculum is supported by the March of Dimes and provides a framework for nurses as well as primary care providers with an easy way for recalling the essential elements of preconception healthcare (Gottesman, 2004). We adapted this framework to our peer educator program and added PLUS. The PLUS addresses information that women need to make informed decisions about their pregnancy, labor, and delivery. The inclusion of the PLUS component was to emphasize that knowledge about pregnancy and labor leads to understanding for self-empowerment. Box 2 identifies each element of REFRAMED PLUS. The curriculum framework was incorporated into every aspect of the program.
This preconception program used peer-led interventions by recruiting and training college-aged nursing students to serve as mentors and role models for other college students. Peer educators provided information and support for college-aged women about preconception health. Interventions that include college students, specifically nursing students who are of the same age, have been found to be effective in portraying positive health messages (Becket-Milburn & Wilson, 2000). Kim and Free (2008) cited that peer-led approaches were effective in improving knowledge, attitudes, and intentions related to positive healthy sexual behavior in peers. In addition, peer-led interventions provide peer leaders valuable opportunities to develop interpersonal skills, gain self-knowledge, and grow emotionally (Becket-Milburn & Wilson, 2000). Peer-led interventions were found to be effective in influencing health behaviors wherein relationships, respect, sensitivity, and positive role modeling are integral in the support of positive behavior change (Kim & Free, 2008).
As part of high-risk maternity and adolescent health elective nursing courses students were asked to develop preconception health materials and prepare a program to counsel and educate peers on preconception health. These elective courses included 38 junior and senior nursing students. With faculty guidance, students used the REFRAMED PLUS mnemonic to develop a risk assessment tool, a brochure about preconception health, a reproductive life plan booklet, and the script for a DVD to supplement educational sessions.
Before implementing the program, the project was reviewed and approved for use with human subjects by the Institutional Review Board of the associated university. Students in the high-risk maternity and adolescent health elective nursing courses planned the program and recruited other college students to pilot the materials. An assignment was built into the nursing electives whereby individual students as peer educators presented the program to other student groups on campus. The peer educators conducted health fairs at the University's Student Center and recruited students who visited their booths. Peer educators informed students that the program would take about 2 hours of their time and ensured them that their participation was completely voluntary. Consent was assumed by students showing up for the program at the scheduled meeting time. Through their recruitment efforts, peer educators presented the program to sororities, during residence hall meetings, and other student groups. Most participants were freshman and sophomore women. At the completion of the 2-hour program, participants received a gift pack with items representing each aspect of REFRAMED PLUS. Specifics about each component of the program follow.
Risk assessment tools are needed to determine young women's vulnerability to poor birth outcomes. Despite a call from the consumer Work Group of the Preconception Care Implementation Committee in June 2006 for preconception and screening tools, responses were limited. Most tools identified did not address all preconception risk areas (Verbiest & McCullough, 2007).
The REFRAMED PLUS risk assessment tool addresses all risk areas identified in the curriculum. The tool can be self-administered and is easily answered with a Yes, No, or NA. The NA indicates that the individual believes the issue is not applicable to one's life or that the individual does not know the answer. Based on the responses, there is a place for peer educators to check if a referral is needed. A sample of the questions for each letter in the mnemonic is included in Table 1.
As part of the Preconception Peer Education Program, the risk assessment was given to a total of 115 young women. These participants represented a convenience sample of college-aged women from the target population. Table 2 lists some of the results. Of those participants who claimed they were sexually active, a large percentage did not use birth control or condoms. Only a third of respondents took a multivitamin while even fewer admitted to taking folic acid. From the responses, it appeared that several women bear a significant genetic history while more than half admitted to regularly taking medications. A small number of respondents admitted to treatment for a sexually transmitted infection. Even though the numbers for domestic violence and psychosocial issues were small, these responses warrant the need for additional follow-up. Responses to the PLUS assessment indicate that most are interested in becoming parents but were unaware of or uninterested in developing a reproductive life plan.
The peer educators developed a brochure entitled "Ladies Are You Ready." The tri-fold brochure included information about each REFRAMED PLUS element and available resources. The purpose of the brochure was to provide brief information about preconception care that would entice readers to seek more information. Resources and contact information also were included. The intent was to display these materials in primary care providers' offices or during appropriate health fairs.
With the assistance of a faculty advisor, peer educators developed a script for a DVD to supplement their teaching. In addition to information related to REFRAMED PLUS, the DVD contained video clips of three young women who had experienced an unintended pregnancy. The final section of the DVD included a simulated birth using a high-fidelity female birthing simulator. To better relate to the intended population, the DVD was narrated by a young woman. The DVD was 20 minutes in length and followed by a discussion with the peer educators. The DVD has been displayed at various events as an introduction to preconception health. Young women from high school through college have commented positively about the presentation and the information provided.
The CDC recommends that everyone should have a reproductive life plan. A reproductive life plan is a set of personal goals about the individual's plan to have or not have children (CDC, 2006b). The plan encourages young women to address their personal goals.
Peer educators developed the Reproductive Life Plan booklet with sections for each element of REFRAMED PLUS. At the end of each section, there is a page where women can ask questions, keep notes, and identify areas of need or risk. For example, under R for reproductive awareness, there is information on forms of birth control and sexually transmitted infections. At the end there are questions to help them focus on birth control that would work best for them, their options, and questions for a primary care provider. Questions also were developed in the PLUS section to allow women to think ahead about the type of healthcare provider, hospital setting, and type of birth plan they would choose. The booklet also provides pages for journaling and self-reflection.
The 18-item pre-/posttest was piloted with 53 students in a sophomore health promotion nursing course. This group was selected because they had not had any maternal child nursing courses and represented the target population of college women. The test addressed each REFRAMED PLUS component with a four choice response set. Internal consistency was moderate (Kuder Richardson = .54) and mean item difficulty was .849. The pre- and posttest were designed to measure baseline knowledge of preconception health and determine if the preconception education program improved baseline knowledge.
Following the pilot, the pretest was administered to all participants in the Preconception Education program. After viewing the DVD, completing the assessment and discussing preconception health, participants were given the posttest. There was a statistically significant (p = .01) increase between pretest (mean = 72.4, SD = 12.6) and posttest (mean = 89.3, SD = 9.1) mean scores with decreased variability, indicating that participants had an increased awareness of preconception health immediately following participation in the program.
One of the recommendations for preconception care is to include risk assessment, education, and health counseling to all women of childbearing age with each primary care visit (CDC, 2006a). Others suggest that preconception services also should be provided with visits to specialists and that "Ask every woman" should be the mantra of preconception care (Bernstein, 2005). Despite the recognized importance, most physicians do not routinely provide preconception care (Atrash et al., 2008; Frey & Files, 2006). Most obstetricians and gynecologists agree that preconception care is important but often delay any counseling until women are planning a pregnancy (Morgan, Hawks, Zinberg, & Schulking, 2006).
Much of the care provided to women in their reproductive years is preconception care (Bernstein, 2005). Healthcare providers need to reframe some of their thinking to realize the patient with high blood glucose may be pregnant the next time she presents for care. A study conducted in the United Kingdom revealed that many physicians provide preconception care on an opportunistic basis (Hayes, Long, & Mathers, 2004). Most of the care focused on chronic disease and medical treatment instead of issues such as nutritional status. Policies about preconception care were not part of their practice. Furthermore, physicians had not received any education related to preconception care.
Little is known about whether preconception counseling and interventions are offered by primary care providers during routine primary care visits. To determine whether preconception care was practiced by primary care providers, a letter with a copy of the brochure was sent to 877 physicians and nurse practitioners throughout the state. A return post card with questions about inclusion of preconception care in their practice was enclosed. Providers were also queried about whether they would like copies of the brochure. Only six responses were received with requests for additional brochures for their offices or waiting rooms. Based on this low response rate and the limited support in the literature, preconception care may not be part of the routine practice of primary care providers in this state.
Since the inception of the Preconception Peer Education program, preconception education has been integrated into the undergraduate nursing curriculum. Sophomore students receive a class on preconception health as part of a Health Promotion course. When available, peer educators contribute to the class. By including this content in a nursing course, aspiring nurses are introduced to the importance of preconception health and reproductive life planning for self and their future practice. The Preconception Peer Education program continues to be a part of the High-Risk Maternity elective. Students enjoy presenting the program and spreading the word about preconception health to their peers.
Last year, four students from our college participated in the Office of Minority Health (OMH) Peer Educator Program for college students and became preconception peer educators. This year, the peer educators presented the OMH program to other students within our college and at a historically black university (HBU) in the state. Currently there are over 25 preconception peer educators in the state. The materials, developed by the original peer educators, will be further tested with other populations as the OMH program is implemented throughout the HBU and other community sites.
In addition to addressing campus and community outreach, the peer educators have partnered with the Delaware Healthy Mothers and Infant Consortium (DHMIC). The DHMIC was established to decrease infant mortality in the state. A major focus of the DHMIC is on preconception health. Some of the materials developed by the original peer educators were used to develop a Life Plan Booklet for teens and young women. Social marketing campaigns are being developed to disseminate the message of preconception health to both men and women. Through the partnership with DHMIC, peer educators actively participate in statewide initiatives and are an integral part of community outreach.
Nurses may be the best providers to ensure that preconception education and care is addressed at every health and illness visit. Although there is no evidence in the literature, most likely nurses do perform aspects of preconception care in their practice. After all, preconception care is about healthy living. Nurses can address the components of preconception care by using the mnemonic REFRAMED PLUS. For preconception healthcare to be successful, the message must be delivered by nurses every time a young woman receives care. Box 3 highlights some suggested clinical implications for ensuring that preconception health is addressed with all women of childbearing age.
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Perinatal Orientation and Education Program-Module I Preconception and Interconception Health
Before, Between & Beyond Pregnancy.
CDC Preconception Care.
Life Course Tool Box.
March of Dimes: Working together for stronger, healthier babies.
North Carolina Preconception Programs.
Atrash, H., Jack, B. W., & Johnson, K. (2008). Preconception care: A 2008 update. Current Opinion in Obstetrics and Gynecology, 20, 581-589. doi: 10.1097/GCO.Ob013e328317a27c [Context Link]
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Hayes, T., Long, S., & Mathers, N. (2004). Preconception care: Practice and beliefs of primary care workers. Family Practice, 21(1), 22-27. doi: 10.1093/fampra/cmh106 [Context Link]
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The National Academies. (July 13, 2006). Preterm births cost U.S. $26 billion a year: Multidisciplinary research effort needed to prevent early births. News from the National Academies. Retrieved from http://www8.nationalacademies.org/opinews/newsitem.aspx?RecordID=11622[Context Link]
Verbiest, S., & McCullough, A. (April, 2007). Preconception Screening and Assessment Tools. Report for the Consumer Work Group of the Preconception Care Implementation Committee. Retrieved from http://www.mombaby.org/PDF/Summary%20of%20Preconception%20Tools.pdf[Context Link]
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