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INTRODUCTION

In 2017, the number of births in the United States was 3,853,472, 2% less than in 2016 and the lowest in 30 years. Although most infants are born healthy, it is of critical importance that the infant mortality rate in the United States ranks 26th among developed nations and is the only developed country where maternal morbidity and mortality are rising, despite advances in perinatal care.

Many factors contribute to the current maternal and infant morbidity and mortality rate in the United States. Birth rates are declining for women under 40, but rising for women over 40. Older age at conception brings with it a higher likelihood of other concomitant chronic medical conditions, pregnancy-related conditions like preeclampsia, increased risk for genetic disorders, and increased risk of preterm birth. Racial and socioeconomic disparities in access to care, rising rates of substance abuse and obesity, and increasing rates of mental health conditions have also been implicated.

In 2016, the Clinical Workgroup of the National Preconception Health and Health Care Initiative proposed nine core measures to be assessed at initiation of prenatal care that would serve as a measure of a woman’s preconception wellness: (1) pregnancy intention, (2) access to care, (3) multivitamin with folic acid use, (4) tobacco avoidance, (5) absence of uncontrolled depression, (6) healthy weight, (7) absence of sexually transmitted infections, (8) optimal glycemic control, and (9) teratogen avoidance in chronic conditions. These recommendations are based on the idea that healthier women have healthier pregnancy outcomes.

Given that over 50% of pregnancies in the United States are unintended, to improve outcomes for women and infants, we must transform the way we provide preconception care. Instead of separating preconception care into its own silo and only addressing these issues at a preconception or first prenatal visit, we must challenge ourselves to provide preconception care at every visit for women of childbearing age. We must integrate assessment of folic acid intake, social risk factors and mental health, review of medication lists, management of chronic medical conditions, and counseling on family planning routinely into ongoing primary care. This could be during a visit for routine health maintenance, an examination for school or work, at premarital or family planning visits, after a negative pregnancy test, or during well-child care for another family member. Maternal chronic health conditions and social behaviors ideally need to be addressed prior to pregnancy. Medications need to be prescribed thoughtfully to all women of childbearing age, and provision of comprehensive prenatal care and interconception care and access to reliable family planning methods are essential for all women throughout their reproductive lives.

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Frayne  D, Verbiest  S, Chelmow  D,  et al. Health care system measures to advance preconception wellness: consensus recommendations of the clinical workgroup of the national preconception health and health care initiative. Obstet Gynecol. 2016;127(5):863–872.
[PubMed: 27054935]  
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Hamilton  BE, Martin  JA, Osterman  MJK, ...

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