Regional Overview on Maternal and Child Nutrition and Examples of Nutrition Governance and Policy Responses: Europe, Central Asia and Eastern Mediterranean Regions.

The Eastern Mediterranean Regions and Europe and Central Asia Regions are facing an epidemiological and nutrition transition, especially among vulnerable groups including mothers, children and adolescents. This has led to a double burden of malnutrition (DBM). Poor infant and young child feeding (IYCF), poor dietary diversity, excessive consumption of energy dense unhealthy foods, a growing obesogenic environment for children, including aggressive marketing of unhealthy foods for children, and reduced physical activity are among the main causes. In addition, several countries in the region lack the nutrition governance capacity to respond effectively to the DBM. This article reviews the context and provides a set of conclusions in which countries are called to reduce the marketing of unhealthy foods for children, enforce the fortification of staple foods with micronutrients to reduce micronutrient deficiencies and improve IYCF, including breastfeeding in the region. Also, the call is strong for cross-border multi-sectoral efforts to address the DBM in these regions.

Regional Overview on Maternal Nutrition and Examples of Health System Programme and Policy Responses: Asia and the Pacific.

BACKGROUND: The double burden of malnutrition in Asia and the Pacific is driving a renewed focus on maternal malnutrition. SUMMARY: Though adverse consequences of maternal malnutrition have been long recognized, there is slow progress in addressing nutritional problems of women/adolescent girls. Coverage and quality of current maternal nutrition interventions, mostly delivered through antenatal care programmes vary across countries, and are often sub-optimum. Further, despite a marked increase in overweight and obesity in women of reproductive age, at present, most programmes are focused on under-nutrition and micronutrient deficiencies. Key Messages: The recent antenatal care recommendations released by World Health Organization provide a benchmark for countries to evaluate their programmes and identify gaps and challenges to improving maternal nutrition. Asian and Pacific countries need to address all forms of maternal malnutrition. For countries that historically focused on maternal under-nutrition, expanding their programmes to incorporate interventions to address overweight and obesity will be challenging. Innovative methods for nutrition counselling, both in terms of content and using novel channels of communication, are needed. Protocols and guidance on managing excessive weight gain as well as determining appropriate pregnancy weight gains are needed, while managing micronutrient deficiencies, particularly in settings where inherited disorders of red blood cells exist.

Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: Latin America and the Caribbean.

BACKGROUND: Hunger, food insecurity, stunting, anemia, overweight, and noncommunicable diseases (NCDs) may coexist in the same person, household, and community in Latin America and the Caribbean (LAC). The double burden of malnutrition (DBM) is an important cause of disability and premature death, which could be addressed with comprehensive policies such as the Plan of Action for the Prevention of Obesity in Children and Adolescents. This paper summarizes the main policies and actions aimed to prevent undernutrition and obesity. SUMMARY: Several countries are implementing the Plan of Action, Caribbean Public Health Agency is actively supporting Ministries of Health, Education, and Sport to develop school nutrition policies and strategies to create health-promoting environments at school and in their surrounding communities. Chile is implementing the comprehensive child protection system "Chile Crece Contigo" that integrates health, social development, and educational activities to optimize growth and childhood cognitive-motor development. Brazil is implementing policies and plans to commit to international targets regarding food and nutrition security, NCDs and their risk factors. Key Messages: The DBM exists in the Americas and contributes to disability and premature death. The Region is making progress implementing policies and actions addressing the DBM. However, stronger political will and leadership are needed to enact legislation and policies that create and support enabling -environments.

Availability of Services Related to Achieving Pregnancy in U.S. Publicly Funded Family Planning Clinics.

BACKGROUND: Recognizing that quality family planning services should include services to help clients who want to become pregnant, the objective of our analysis was to examine the distribution of services related to achieving pregnancy at publicly funded family planning clinics in the United States. METHODS: A nationally representative sample of publicly funded clinics was surveyed in 2013-2014 (n = 1615). Clinic administrators were asked about several clinical services and screenings related to achieving pregnancy: basic infertility services, reproductive life plan assessment, screening for body mass index, screening for sexually transmitted diseases, provision of natural family planning services, infertility treatment, and primary care services. The percentage of clinics offering each of these services was compared by Title X funding status; prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated after adjusting for clinic characteristics. RESULTS: Compared to non-Title X clinics, Title X clinics were more likely to offer reproductive life plan assessment (adjusted PR [aPR], 1.62; 95% CI, 1.42-1.84), body mass index screening for men (aPR, 1.10; 95% CI, 1.01-1.21), screening for sexually transmitted diseases (aPRs ranged from 1.21 to 1.37), and preconception health care for men (aPR, 1.10; 95% CI, 1.01-1.20). Title X clinics were less likely to offer infertility treatment (aPR, 0.55; 95% CI, 0.40-0.74) and primary care services (aPR, 0.74; 95% CI, 0.68-0.80) and were just as likely to offer basic infertility services, preconception health care services for women, natural family planning, and body mass index screening in women. CONCLUSIONS: The availability of selected services related to achieving pregnancy differed by Title X status. A follow-up assessment after publication of national family planning recommendations is underway.

Preconception health in England: a proposal for annual reporting with core metrics.

There is growing interest in preconception health as a crucial period for influencing not only pregnancy outcomes, but also future maternal and child health, and prevention of long-term medical conditions. Successive national and international policy documents emphasise the need to improve preconception health, but resources and action have not followed through with these goals. We argue for a dual intervention strategy at both the public health level (eg, by improving the food environment) and at the individual level (eg, by better identification of those planning a pregnancy who would benefit from support to optimise health before conception) in order to raise awareness of preconception health and to normalise the notion of planning and preparing for pregnancy. Existing strategies that target common risks factors, such as obesity and smoking, should recognise the preconception period as one that offers special opportunity for intervention, based on evidence from life-course epidemiology, developmental (embryo) programming around the time of conception, and maternal motivation. To describe and monitor preconception health in England, we propose an annual report card using metrics from multiple routine data sources. Such a report card should serve to hold governments and other relevant agencies to account for delivering interventions to improve preconception health.

The Use of a Community-Based Preconception Peer Health Educator Training Intervention to Improve Preconception Health Knowledge.

This paper highlights the use of an adapted Office of Minority Health (OMH) Preconception Health Peer Educator program to address persistent infant mortality health disparities. The community-based Attack Infant Mortality (AIM Escambia) initiative was established to increase preconception health knowledge among African American women at risk for adverse birth outcomes. Participants (N = 122) attended a 6-h AIM peer educator training, completed pretest and posttest questionnaires about their health knowledge, health attitudes, and planned engagement in health behaviors. Study results support the use of preconception health education training to inform health knowledge, health attitudes, and planned health sharing behaviors. Multidisciplinary collaborations and targeted interventions should be considered when seeking to improve community health conditions and increase health knowledge and health literacy for minority populations.

Conditions and Dynamics That Impact Maternal Health Literacy among High Risk Prenatal-Interconceptional Women.

The purpose of the study was to describe conditions and dynamics in the lives of high-risk, low-income, Southern United States prenatal-interconceptional women (n = 37) in a home visiting program that promoted maternal health literacy progression. In the Life Course Health Development (LCHD) Model, conditions were risk and protective factors that impacted health. Dynamics drove the complex, epigenetic relationships between risk and protective factors. Maternal health literacy promotion helped participants address conditions and dynamics to create positive life changes. This research was a retrospective, mixed methods study of women's service records documenting care from prenatal admission to 24 months post-delivery. The Life Skills Progression Instrument (LSP) was scored to measure maternal health literacy progression. Ethnographic content analysis of visit notes triangulated with quantitative data enabled specificity of critical data elements. Subsequently, a complementary focus group was conducted with the Registered Nurse Case Managers (RNCM). Severe social conditions included devastating poverty, low educational achievement, transient housing, unstable relationships, incarceration, lack of continuous health insurance, and shortage of health care providers. Dynamics included severe psycho-social stressors, domestic violence, lack of employment, low income, low self-esteem and self-expectations, and social/family restraints upon women's intended positive changes. An important protective factor was the consistent, stable, evidence-informed relationship with the RNCM. Findings from the focus group discussion supported content analysis results.

The Link Between Reproductive Life Plan Assessment And Provision of Preconception Care At Publicly Funded Health Centers.

CONTEXT: Federal and clinical guidelines recommend integrating reproductive life plan assessments into routine family planning encounters to increase provision of preconception care. Yet, the prevalence of clinical protocols and of relevant practices at publicly funded health centers is unknown. METHODS: Administrators and providers at a nationally representative sample of publicly funded health centers that provide family planning services were surveyed in 2013-2014; data from 1,039 linked pairs were used to explore the reported prevalence of reproductive life plan protocols, frequent assessment of patients' reproductive life plan and frequent provision of preconception care. Chi-square tests and multivariable general linear models were used to examine differences in reports of protocols and related practices. RESULTS: Overall, 58% of centers reported having reproductive life plan assessment protocols, 87% reported frequently assessing reproductive life plans and 55% reported frequently providing preconception care. The proportions reporting protocols were lower in community health centers than in other center types (32% vs. 52-91%), in primary care centers than in those with another focus (33% vs. 77-80%) and in centers not receiving Title X funding than in those with such support (36% vs. 77%). Reported existence of a written protocol was positively associated with reported frequent assessment (prevalence ratio, 1.1), and the latter was positively associated with reported frequent preconception care (1.4). CONCLUSION: Further research is needed on associations between written protocols and clinical practice, and to elucidate the preconception care services that may be associated with reproductive life plan assessment.

Preconception care among low-risk mothers in a French perinatal network: Frequency of utilization and factors associated.

OBJECTIVE: Determine the frequency of preconception care use in France and factors impacting preconception visit. MATERIALS AND METHODS: An epidemiological study was conducted from September 2015 to October 2015 in 5 maternity hospitals within the "Alpes-Isère" perinatal network, comprising of French-speaking women, with uncomplicated pregnancies, who delivered a healthy term baby (≥37 weeks of gestational age). Two groups were compared: patients with and without preconception care. Descriptive, univariate and multivariate analyses were performed for the sociodemographic, the environmental characteristics and the gynecologic obstetric history. RESULTS: Among the 392 patients included in this study, only 62 (15.8% [12.0-20.0]) had used preconception care before their pregnancy. Multivariate analysis showed that the primiparous women (adjusted OR 2.47 [1.37-4.46]) and the women with a high socio-professional category (adjusted OR 2.32 [1.13-4.77]) were more likely to used preconception care. CONCLUSION: Despite the positive effects on mother and baby's health, preconception care is insufficiently used in France. Every effort must be made to improve awareness of preconception care among health workers and patients.

Developing social marketed individual preconception care consultations: Which consumer preferences should it meet?

AIMS: Preconception care (PCC) is care that aims to improve the health of offspring by addressing risk factors in the pre-pregnancy period. Consultations are recognized as a method to promote perinatal health. However, prospective parents underutilize PCC services. Uptake can improve if delivery approaches satisfy consumer preferences. Aim of this study was to identify preferences of women (consumers) as a first step to social marketed individual PCC consultations. METHODS: In depth, semi-structured interviews were performed to identify women's views regarding the four components of the social marketing model: product (individual PCC consultation), place (setting), promotion (how women are made aware of the product) and price (costs). Participants were recruited from general practices and a midwife's practice. Content analysis was performed by systematic coding with NVIVO software. RESULTS: The 39 participants reflected a multiethnic intermediately educated population. Product: Many participants had little knowledge of the need and the benefits of the product. Regarding the content of PCC, they wish to address fertility concerns and social aspects of parenthood. PCC was seen as an informing and coaching service with a predominant role for health-care professionals. PLACE: the general practitioner and midwife setting was the most mentioned setting. Promotion: A professional led promotion approach was preferred. Price: Introduction of a fee for PCC consultations will make people reconsider their need for a consultation and could exclude vulnerable patients from utilization. CONCLUSION: This study provides consumer orientated data to design a social marketed delivery approach for individual PCC consultations.

Patient Experiences with Pregnancy Planning and Perspectives on Reproductive Care in Community Health Centers: A Qualitative Study of African American Women in Chicago.

INTRODUCTION: Given the potential benefits of preventive reproductive health care for both women and children, it is important that clinicians routinely offer preconception and contraceptive counseling in ways that are responsive to patients' wishes. The goal of this study is to gain knowledge about the components of preventive reproductive health care that patients at Federally Qualified Health Centers value, and to elicit patient perspectives on how best to deliver this care. METHODS: We conducted three focus groups with African American women (n = 21) at two Federally Qualified Health Centers in Chicago. The groups were facilitated using an open-ended, semistructured interview guide. We asked women to reflect on past experiences, advice they would give their teenage daughters, and how to design an ideal clinic. All groups were recorded and transcribed verbatim. Transcripts were coded and analyzed using an inductive approach with ATLAS.ti software. RESULTS: Although participants wanted comprehensive information about sex and pregnancy, they reported receiving no information at all, or many negative messages. The idea of timing and spacing pregnancies was generally embraced by participants. They described an ideal clinic as having a patient population diverse in income, trusting relationships with providers, comprehensive services, and educational opportunities. CONCLUSIONS: The women in our study expressed a desire for more information and comprehensive care in the setting of an equitable clinic where they feel respected as individuals. Our findings support the idea behind the patient-centered medical home and challenge prior literature, which suggests the concept of pregnancy planning does not resonate with low-income African American women.

Delayed parenthood on the rise: A call for upstream preconception health promotion in Canada.

The trend toward delayed parenthood is on the rise across Canada. Societal emphasis on attaining higher education, career advancement and financial security may be some reasons why individuals delay becoming a parent; whatever the reason, this trend is linked to significant health and economic impacts. Many Canadians are unaware of the impact this may have on their fertility and potential birth outcomes. It is important that health care professionals apprise individuals in their reproductive years about these issues and the steps they can take to mitigate these risks. Implementing a health equity and broader determinants of health approach through social policy development may also prove beneficial. Such upstream approaches could enhance maternal and child health outcomes, and also help ensure that people of reproductive age are making an informed decision about delaying parenthood. This article calls for developing a comprehensive preconception health promotion and care strategy encompassing individual, community and population level approaches.

A new perspective on universal preconception care in China.

Many risk factors associated with adverse pregnancy outcomes can be identified and modified preconceptionally. Despite a broad consensus that preconception care should be provided to all couples of reproductive age, it has not been integrated in routine healthcare. There are several barriers to its implementation, and even in the most resourceful countries, it is only provided to some select high-risk groups, rather than being an organized healthcare service provision to all. Recently, China seems to be leading the way by implementing preconception care nationwide in all rural areas. Its National Free Preconception Health Examination Project is a unique model of comprehensive preconception care. Advantages of this ambitious project are now becoming evident and benefiting the most vulnerable sections of Chinese society. This commentary provides an overview of National Free Preconception Health Examination Project and highlights the concepts that could be further developed and adapted into a model of preconception care.

Interpregnancy care.

The aim of interconception care is to provide women who have had a prior adverse pregnancy outcome with optimal care in order to reduce risks that may affect the woman׳s health and any future birth she may choose to have. National recommendations call for action, and evidence supports specific clinical interventions. The need for interconception care is documented in national and state survey and surveillance data. Chronic diseases and behavioral risks affect the health of millions of U.S. women of childbearing age. Interconception care demonstration projects have used a "disease management" approach that includes medical care and case management. The increasing use of postpartum visits, as a gateway to interconception interventions, is essential. The Affordable Care Act emphasis on preventive services and expanded health coverage for women offers new opportunities to finance interconception care. Improved and enhanced clinical practices, along with the engagement of women, in interconception care have the potential to improve birth outcomes and reduce disparities.

Racial Disparities in Seeking Care for Help Getting Pregnant.

BACKGROUND: Fertility counselling and treatment can help women achieve their desired family size; however, disparities exist in the utilisation of this care. METHODS: This study examines the persistence of a racial disparity in visiting a doctor for help getting pregnant by estimating the direct effect of this association using data from the Furthering Understanding of Cancer Health and Survivorship in Adult Women's Study, a population-based cohort study. This cohort included 1073 reproductive age women (22-45 years) with 28% reporting infertility. We fit log binomial models to quantify the magnitude of the racial difference in reported care seeking after adjustment for hypothesised mediators using inverse probability weighting. RESULTS: Compared with white women, black women were less likely to visit a doctor in the total population [adjusted risk ratio (RR) 0.57, 95% confidence interval (CI) 0.41, 0.80] and in the subgroup of women with infertility [RR 0.75, 95% CI 0.56, 0.99]. In addition, black women waited twice as long, on average, before seeking help compared with white women. CONCLUSIONS: There were notable racial differences in visiting a doctor for help getting pregnant in this study although reports of infertility were similar by race. These differences may be mitigated through improved communication about the range of counselling and treatment options available.

Improving Medicaid: three decades of change to better serve women of childbearing age.

Over the past 3 decades, major changes enhanced Medicaid's role in improving the health of women and perinatal outcomes. Reforms in the 1980s and 1990s had impact not only on coverage but also on current policy debates. Whether or not states expand eligibility under the Affordable Care Act, Medicaid is important. Increased coverage for well-woman visits, preconception care, and contraceptive methods are opportunities in gynecology. As a critical source of maternity coverage, Medicaid can improve prenatal care, reduce preterm births, limit early elective deliveries, and increase postpartum visits. Obstetrician-gynecologists play a role in translating coverage into access to quality services.

Changes in Obstetrics and Gynecologic Care Healthcare Triple Aims: Moving Women's Healthcare From Volume to Value.

Healthcare costs in the United States are over 17% of GDP and climbing. Yet compared with other countries in the developed world, the US healthcare system has the worst record for quality of care in relation to cost. This poor performance and lack of improvement in cost versus quality has led to the development of the Triple Aim framework spearheaded by the Institute for Healthcare Improvement. The focus of the Triple Aim is to improve value of care by improving access to care, systems of care delivery, and quality of care while reducing the overall expenditure.

Premarital screening for hemoglobinopathies: experience of a single center in Kurdistan, Iraq.

BACKGROUND: A program for the prevention of major hemoglobinopathies was initiated in 2008 in the Kurdistan region of Iraq. This study reports on the achievements and challenges of the program. METHODS: A total of 102,554 individuals (51,277 couples) visiting a premarital center between 2008 and 2012 were screened for carrier status of hemoglobinopathies, and at-risk couples were counseled. RESULTS: A total of 223 (4.3/1,000) couples were identified and counseled as high-risk couples. Available data on 198 high-risk couples indicated that 90.4% proceeded with their marriage plans, and 15% of these married couples decided to have prenatal diagnosis (PND) in subsequent pregnancies with the identification of 8 affected fetuses; all were terminated as chosen by the parents. Thirty affected births were recorded among the high-risk couples. The premarital program managed to reduce the affected birth rate of major hemoglobinopathies by 21.1%. Of the 136 affected babies born during the study period, 77.9% were born to couples married prior to the start of the program, while 22.1% were born to couples identified as having a high risk. The main reason for not taking the option of PND was unaffordable costs. CONCLUSIONS: Financial support would have increased opting for PND by high-risk couples. Further reduction in affected birth rates could be achieved by including parallel antenatal screening programs to cover those married before the initiation of the premarital program and improving the public health education and counseling programs.

Preconception care policy, guidelines, recommendations and services across six European countries: Belgium (Flanders), Denmark, Italy, the Netherlands, Sweden and the United Kingdom.

OBJECTIVES: Preconception care is important for the screening, prevention and management of risk factors that affect pregnancy outcomes. We aimed to investigate pre-pregnancy care policies, guidelines, recommendations and services in six European countries. METHODS: In 2013, an electronic search and investigation was undertaken of preconception policy, guidelines, recommendations and services available to healthcare professionals and the general public in six European countries: Belgium (Flanders), Denmark, Italy, the Netherlands, Sweden and the United Kingdom. Findings were compared within five categories: Governmental policy and legislation; Professional bodies and organisations; Healthcare providers; Charitable organisations; Web-based public information and internet sites. RESULTS: All countries had preconception recommendations for women with chronic diseases, such as diabetes and epilepsy. Recommendations for healthy women and men were fragmented and inconsistent. Preconception guidance was often included in antenatal and pregnancy guidelines. Differences between countries were seen with regard to nutritional and lifestyle advice particularly in relation to fish, caffeine and alcohol consumption, and vitamin supplementation. CONCLUSIONS: Current guidelines are heterogeneous. Collaborative research across Europe is required in order to develop evidence-based guidelines for preconception health and care. There is a need to establish a clear strategy for promoting advice and guidance within the European childbearing population.