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  1. Disparities in Preconception Health Care: An Overview Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D. Senior Advisor on Women’s Health CDC National Summit on Preconception Care Atlanta, June 21-22, 2005

  2. Prenatal Care in the United States • 2000 • 7.6% of babies were born at ≤ 2,500 grams – LBW • 1.4% of babies were born at ≤ 1,500 grams – VLBW • 7.2 infant deaths per 1,000 live births (vs. 6.9 in 1998) • About 83% of women had prenatal care 1st trimester 2003 NHQR/NHDR; Vital Statistics 2000

  3. Prenatal Care Mothers with prenatal care in the first trimester by race, ethnicity, and education, 2000-2001 National Vital Statistics System -- Natality, 2000-2001; 2004 National Healthcare Disparities Report

  4. Preconception & Prenatal Care Risk reduction obstetric complications Improved pregnancy outcomes

  5. Percent of Births By Age Groups

  6. Racial/ethnic minority women of child-bearing age have particularly poor access to care MEPS 2001

  7. Poorer communication with health care providers MEPS 2001

  8. Women’s Perception of Cultural Competency % 2003 NHQR/NHDR

  9. Essential Components of Preconception Care in the Primary Care Setting • Risk assessment • Health promotion • Intervention

  10. Preconception Health Care Checklist • Genetic • Folic acid supplement • Carrier screening-ethnic background: sickle cell anemia, Thalassemia, Tay-Sachs disease • Carrier screening –family history: cystic fibrosis, nonsyndromic hearing loss (connexin-26)

  11. Preconception Health Care Checklist • Screening for infectious diseases, treatment, immunization, counseling: • HIV/AIDS • Hepatitis B • Rubella • Varicella • Toxoplasmosis • Cytomegalovirus • Parvovirus-19

  12. Preconception Health Care Checklist • Environmental toxins: • Occupational exposures • Household chemicals • Smoking cessation • Alcohol screening • Illegal drug use screening

  13. Preconception Health Care Checklist • Medical assessment: • Diabetes • Hypertension • Epilepsy • DVT • Depression/anxiety

  14. Preconception Health Care Checklist • Lifestyle: • Screen for domestic violence • Exercise • Avoidance of hyperthermia • Obesity & underweight • Nutritional deficiencies • Avoidance of overuse of vitamins A and D, caffeine

  15. Race/Ethnicity & Genetic Risks (Cowchick et al, 1994)

  16. Genetic Risks – Family History and Age • Cystic fibrosis • Congenital hearing loss • Child-bearing after age 35 Brundage, 2002; Grody et al, 2001

  17. Folic Acid • Supplementation reduces incidence of neural tube defects (spina bifida, anencephaly) • Average woman: 100mcg/day • Pregnancy: 400mcg/day, starting at least one month before pregnancy through first three months • Special risk groups: • Diabetes 1mg/day • Epilepsy 1mg/day • Prior birth with neural tube defect 4mg/day Brundage, 2002; Grody et al, 2001

  18. Disparities in Preconception CareFolic Acid • Hispanic women are less likely to be aware of the benefits from folic acid • About 1/3 of Hispanic women report taking folic acid compared to 50% of nonHispanic women between 1999-2002 • Physicians have been increasingly reported as an important source of information about folic acid CWHS (1997-2002)

  19. Disparities in Preconception CareFolic Acid • Women with lower levels of education – less than high school – and lower socioeconomic power or with no health insurance are less likely to be aware of or to take folic acid Brundage, 2002; Grody et al, 2001

  20. Disparities - New HIV/AIDS Cases in Women(number of cases per 100,000 population) HIV/AIDS Surveillance System, 2000

  21. Women Aged 18 and Older with Diabetes,* by Race/Ethnicity,** 2002 *Reported a health professional has ever told them they have diabetes; **rates reported are not age-adjusted; ***non-Hispanic; includes Asian/Pacific Islander, American Indian/Alaska Native, and persons of more than one race. † Rate per 1,000 Women † National Health Interview Survey, CDCP, NCHS

  22. Effects of Diabetes on Conception & Pregnancy • Birth defects • Ventricular septal defects • Neural tube defects • Caudal regression syndrome • Other fetal effects • Macrosomia • Obstetric complications • Preeclampsia • Urinary tract infection • Premature labor

  23. Adults With Diabetes Who Had All Five Recommended Services • HBA1c • Lipid profile • Retinal eye exam • Foot exam • Influenza vaccination Hispanics 33% less likely 2004 NHQR/NHDR, 2000/2001MEPS Data

  24. WomenDiabetes Women with diabetes who had a retinal eye exam in the past year by race, ethnicity, and income, 2000-2001 Medical Expenditure Panel Survey, 2000-2001; 2004 National Healthcare Disparities Report

  25. Overweight and Obesity* in Women Aged 18 and Older, by Age, 2002 *In the National Health Interview Survey, obesity was defined as a body mass index of 30.0 or higher. Overweight was defined as a body mass index of 25.0 or higher, including all those defined as obese. Percent of Women Years National Health and Nutrition Examination Survey, CDCP, NCHS

  26. Women Aged 18 and Older with Hypertension,* by Race/Ethnicity,*** 2002 *Respondents who reported a health professional has ever told them that they have hypertension; **rates reported are not age-adjusted; ***non-Hispanic; includes Asian/Pacific Islander, American Indian/Alaska Native, & persons of more than one race. † Rate per 1,000 Women National Health Interview Survey, CDCP, NCHS

  27. Disparities in Hypertension Care • Rates for blood pressure screening are 90% (blacks with higher rates), but only 25% of those with high blood pressure have it under control. Current Best Practices • Blood pressure measurement • Follow-up treatment plan NHQR/NHDR 2003; AMA 2003

  28. Females Age 15-44 Reporting Past Month Use of Cigarettes, by Race/Ethnicity and Pregnancy, 2002 36 31.1 % of Women 24.1 25.3 17.3 18.8 NP 7.3 P 6 Source: Substance Abuse & Mental health Administration, National on Drug Use & Health

  29. Final Remarks • Primary care clinicians should discuss with women of child-bearing age of all races and ethnicities ways to improve pregnancy outcomes • The effort at risk reduction involves coordinated collaboration among health care professionals • This collaboration should be a continuous process at each routine visit before and during pregnancy

  30. Final Remarks • Disparities in preconception care exist and may lead to poor outcomes. Hispanic women are significantly affected • Identification of reasons behind disparities and development of effective interventions to reduce or eliminate them are priorities. • Patient/provider communication may require further attention to enhance women’s awareness and provider’s cultural competence.

  31. Thank You! rcorrea@ahrq.gov