Practice recommendations
- Offer smoking cessation interventions to all women of childbearing age who smoke. (A)
- Offer folic acid supplementation to all pregnant women as well as women of childbearing age. (A)
- Offer women with diabetes intensive glycemic control before pregnancy. (B)
- Offer women who take antiepileptic medications folic acid supplementation and a transition to monotherapy, while avoiding phenytoin and valproic acid if possible. (B)
- Screen pregnant women and women of childbearing age to further reduce the incidence of congenital rubella syndrome. (C)
- Alcohol cessation advice has not consistently been shown to decrease alcohol intake or morbidity in women. Written information on the fetal effects of alcohol should be provided to women who use alcohol during pregnancy. (B)
This article reviews 6 important, evidence-based recommendations for periconception care: smoking cessation, folic acid supplementation and multivitamin use, diabetes care, epilepsy drug use, rubella immunization, and alcohol abuse. With time so limited during primary care visits, physicians often miss opportunities to provide periconception health care. However, some of the recommendations do not take long to convey. And though others may require significant effort on the part of the physician and patient, the benefits can be substantial.
In 2000, women aged 18 to 44 years made 4.1 million outpatient visits to family physicians.1 Each of these visits was an opportunity to educate a patient about periconception health. Opportune encounters include well-woman exams, discussions about a negative pregnancy test, and follow-up visits for spontaneous or therapeutic abortions. Sexually active women using less-than-effective birth control (or none at all) would also benefit from preconception counseling. For women of childbearing age who have diabetes or epilepsy, make preconception interventions part of their routine medical care.
Smoking cessation
Twenty-five percent of women of reproductive age in the US are cigarette smokers—higher than the percentage of smokers among all women.2 Up to 90% continue to smoke during pregnancy.3 The 2001 Surgeon General’s Report on Women and Smoking reports that cigarette smoking causes the highest proportion of preventable problems related to pregnancy and the neonatal period. The report estimates that smoking cessation would reduce all infant deaths by 10%.
How smoking adversely affects pregnancy
One meta-analysis found that women who smoke during pregnancy have significantly increased risks of placenta previa, placental abruption, ectopic pregnancy, and preterm premature rupture of membranes (level of evidence [LOE]: 2a).4 Maternal cigarette smoking also increases the risk of stillbirth, intrauterine growth retardation, and sudden infant death syndrome (SIDS). Smoking cessation during pregnancy, especially early on, reduced the risk of most of these conditions.5
Interventions that work
The best evidence for the effectiveness of smoking cessation interventions is found in studies of nonpregnant patients. Such evidence would likely be applicable to women seeking preconception care.
Multiple Cochrane Database reviews have addressed smoking cessation in nonpregnant patients. The reviews are meta-analyses of randomized, controlled trials (LOE: 1a) and provide strong evidence for the value of smoking cessation interventions in the general population. Interventions that increase quit rates include the following: brief physician advice,6 telephone counseling,7 nicotine replacement therapy (primarily gum and patches were studied),8 group therapy,9 and bupropion or nortriptyline10 (Table).
A Cochrane Database review of smoking cessation in pregnancy found that 6.4% fewer women smoked during the third trimester of pregnancy after intervention (LOE: 1a).11 Studies that looked at neonatal outcomes showed a reduction in low birth weight and preterm birth (number needed to treat [NNT]=75 for low birthweight; NNT=90 for preterm birth). There were no differences in other outcomes; however, the trials were not powered to detect such differences. Interventions found to be effective included informing women about the effects of smoking on a fetus and the benefits of quitting, recommending to smokers that they quit, and teaching cognitive-behavioral strategies for smoking cessation.
Data sources
Our data were found through a search of the following databases: Medline, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and the American College of Physicians Journal Club. We selected the areas with the strongest evidence available for reduction of congenital anomalies available for review. We also focused on subjects whose interventions proved to be effective in improving neonatal outcomes.
TABLE
Effective smoking cessation interventions
| Intervention | Number of studies | Number of participants | OR* (95% CI) | NNT |
|---|---|---|---|---|
| Brief physician advice | 16 | 13,575 | 1.69 (1.45–1.98) | 58 |
| Telephone counseling | 13 | 16,462 | 1.56 (1.38–1.77) | 40 |
| Nicotine replacement therapy | 97 | 37,760 | 1.74 (1.64–1.86) | 16 |
| Group therapy vs self-help | 16 | 4395 | 1.97 (1.57–2.48) | 22 |
| Group therapy vs no treatment | 6 | 775 | 2.19 (1.42–3.37) | 10 |
| Bupropion | 16 | 5374 | 1.97 (1.67–2.34) | 11 |
| Nortriptyline | 5 | 861 | 2.80 (1.81–4.32) | 9 |
| Smoking cessation interventions in pregnancy | 34 | 9945 | 1.89 (1.67–2.13) | 16 |
| *Odds ratio for successful smoking cessation. For an explanation of odds ratios, see the Language of Evidence, page 108. | ||||
| OR, odds ratio; CI, confidence interval; NNT, number needed to treat | ||||