Preconception Health: Has the 2006 Call to Action Been Acted Upon?

Pamela K. Xaverius, PhD

& Joanne Salas, M.P.H

CDC Fact Sheet: Preventing and Managing Chronic Disease to Improve the Health of Women and Infants

Any Al-cohol

Binge Drink

Heavy Drink

Smoke Leisure Activity

Folic Acid0

2

4

6

8

10

12

14

10.9

7.1 6.9

2.9

1.4

0.8

8.4

6.25.7

2.7

1.2

0.1

11.9

7.2 7.5

2.41.6

0.2

12.0

7.2

5.9

2.1 1.7

0.3

Adjusted Odds: Referent Group of Pregnant Women

Intending Pregnancy High Risk (HR) Moderate Risk (MR) Low Risk (LR)

2006 Renewed Called to Action

• Recommends a reproductive health plan

• Ongoing clinical assessment of pregnancy intention

• Risk factor modification for all women of reproductive age.

RESEARCH QUESTION

The question addressed in this study is whether there have been any significant changes in health behaviors or clinical assessments before and after this 2006 call to action.

Methods

What are the changes in the prevalence of preconception behaviors between two time periods, before 2006 (time 1) and after 2006 (time 2)?

• Secondary analysis of cross-sectional data from the BRFSS (2004-2009).

• Subjects were a sample of non-institutionalized, 18-44 year old, non-pregnant, fertile women (n = 384,687) grouped into two categories: 2004-2006 (n = 118,771) and 2007-2009 (n = 202,916).

• Overall crude prevalence odds ratios (cPOR) and adjusted prevalence odds ratios (aPOR) were calculated regarding lifestyle behaviors.

Measures

Behaviors• Any alcohol use• Binge alcohol use• Heavy Alcohol Use• Smoking• Leisure Activity• Chronic Condition (i.e., obesity, hypertension,

diabetes)

Screening• Pap testing• HIV testing• Dental Visits

Demographic Changes

36.6%

58.8%63.0%

57.9%

20.5%

40.6%

61.7%64.9%

62.4%

19.7%

0%

10%

20%

30%

40%

50%

60%

70%

Advanced Age(35-44)

Married More than HighSchool

At least $35k No HealthInsurance

2004-2006 (n=181,771) 2007-2009 (n=202,916)

Table 1. Demographic characteristics by time period, non-pregnant women, 18-44 years old, BRFSS 2004-2009 (N = 384,687)  2004-2006 (n=181,771) 2007-2009 (n=202,916)    Prevalence % (95% CI) Prevalence % (95% CI) p-value Race /Ethnicity     .30

White, non-Hispanic 62.4 (61.9, 62.9) 62.0 (61.6, 62.5)  Non-White 37.6 (37.1, 38.1) 38.0 (37.5, 38.4)  

Age     <.00118-20 10.6 (10.3, 11.0) 9.8 (9.5, 10.1)  21-34 52.8 (52.3, 53.3) 49.6 (49.2, 50.0)  35-44 36.6 (362, 37.1) 40.6 (40.3, 41.0)  

Marital status     <.001Not married 41.2 (40.7, 41.6) 38.3 (37.9, 38.7)  

Married 58.8 (58.4, 59.3) 61.7 (61.3, 62.1)  Education     <.001

Less than HS grad 10.7 (10.3. 11.0) 10.3 (9.9, 10.6)  HS grad 26.3 (25.9, 26.7) 24.8 (24.4, 25.2)  

More than HS 63.0 (62.6, 63.5) 64.9 (64.5, 65.4)  Income     <.001

Less than $35k 42.1 (41.6, 42.6) 37.7 (37.2, 38.1)  At least $35k 57.9 (57.4, 58.4) 62.4 (61.9, 62.8)  

Employment     <.001Employed 63.2 (62.7, 63.7) 61.6 (61.2, 62.0)  

Other 36.8 (36.3, 37.3) 38.4 (38.0, 38.8)  Health Insurance     .004

No 20.5 (20.1, 20.9) 19.7 (19.4, 20.1)  Yes 79.5 (79.1, 79.9) 80.3 (79.9, 80.7)  

2004-2006 (n=181,771) 2007-2009 (n=202,916)Prevalence % (95% CI) Prevalence % (95% CI) OR (95% CI)

Lifestyle / BehavioralAny alcohol use 53.1 (52.7, 53.6) 51.1 (50.7, 51.5) 0.92 (0.90, 0.95)Binge drink 13.4 (13.1, 13.7) 15.0 (14.7, 15.3) 1.14 (1.10, 1.18)Heavy drink 5.1 (4.9, 5.3) 4.9 (4.7, 5.1) 0.95 (0.89, 1.01)Smoke 20.7 (20.4, 21.1) 19.1 (18.8, 19.4) 0.90 (0.88, 0.93)Leisure Activity 77.3 (76.9, 77.7) 76.8 (76.5, 77.2) 0.97 (0.94, 1.01)Any medical condition 25.1 (24.7, 25.5) 30.2 (29.9, 30.6) 1.30 (1.26, 1.33)Screening/TestsPap Test 90.3 (89.9, 90.8) 90.2 (89.7, 90.7) 0.99 (0.91, 1.07)HIV Test 51.8 (51.3, 52.3) 54.9 (54.5, 55.3) 1.13 (1.10, 1.16)Dental Visit in Last Year 70.6 (70.1, 71.1) 70.2 (69.5, 70.9) 0.98 (0.94, 1.02)

Table 2. Weighted prevalence estimates and crude odds ratios of selected risk factors, by time period comparing 2007-2009 to 2004-2006, non-pregnant women, 18-44 Years, BRFSS, 2004-2009(N = 384,687)Behaviors

Any Alcohol Use: 8% reduction Binge Alcohol Use: 14% increaseHeavy Alcohol Use: 5% reduction Any Medical Condition: 30% increaseSmoking: 10% reductionLeisure Activity: 3% reduction

Screening

No significant changes in pap testing; HIV testing, and Dental VisitsChange from 04-06 to 07-09

Adjusted Odds Ratios

Table 3. Adjusted odds ratios (95% CI) for selected behavioral conditions comparing 2007-2009 to 2004-2006, non-pregnant women, 18-44 years, BRFSS, 2004-2009(N = 384,687)a

  aOR (95% CI)Lifestyle / BehavioralAny alcohol use 0.91 (0.88, 0.93)Binge drink 1.20 (1.16, 1.25)Heavy drink 0.97 (0.91, 1.03)Smoke 0.95 (0.92, 0.98)Leisure Activity 0.94 (0.91, 0.98)Any medical condition 1.31 (1.27, 1.34)Screening/TestsPap Test 0.90 (0.82, 0.99)HIV Test 1.13 (1.10, 1.16)Dental Visit in Last Year 0.94 (0.89, 0.98)a Adjusted for race, age, marital status, education, income, employment, health insurance

Behaviors

Any Alcohol Use: 9% reduction Binge Alcohol Use: 20% increaseHeavy Alcohol Use: No change Any Medical Condition: 31% increaseSmoking: 5% reductionLeisure Activity: 6% reduction

Screening

Pap testing: 10% reductionHIV testing: 13% increase Dental visits: 6% reduction

Key Findings

Overall, the prevalence of health behaviors remained at unacceptable levels during the 2007-2009 time period• Any alcohol use at 51.1%• Binge drinking at 15.0%• Heavy drinking at 4.9%• Smoking at 19.1%• Leisure activity at 76.8% • Having a medical condition at 30.2%

When odds ratios were adjusted for race, age, marital status, education, income, employment, and health insurance, significant increases remained among • binge drinking (20% increase) • having any medical condition (30% increase).

Limitations

• BRFSS is a cross-sectional survey, therefore the cohort surveyed in time 1 may be different than the cohort surveyed in time 2.

• BRFSS relies on self-reported information from survey data, and as such, this may be subject to errors such as recall bias. 

• Pregnancy intention is not considered in this analysis.

• Proxies to preconception clinical care, such as pap smear, HIV, or detail visits, are insufficient.

Public Health Implications

More work is needed in educating women and providers regarding the importance of improved health before pregnancy.

Women with chronic conditions represent a high-risk group that may be growing and draining more resources if this trend is not reversed.

Misra, Guyer, & Allston (2003)

Has the 2006 Call to Action Been Acted Upon?

Outcomes?* Improved the knowledge and attitudes and behaviors * Assured that all women of childbearing age in the United States receive preconception care services

Action?In Missouri, we have multiple local, county, and state level initiatives addressing preconception

…. So yes, I think it is being acted upon… the outcomes just don’t show it yet!