The Promise of Preconception Care in Prevention of Birth Defects and Preterm Births

1. The Promise of Preconception Care in Prevention of Birth Defects and Preterm Births Dr Neena Raina Regional Advisor Child and Adolescent Health WHO - SEARO WHO-SEARO

2. Structure of presentation • What is Pre-conception Care • Do we have evidence based interventions • Why is it important in SEAR • Opportunities for introducing it in SEAR • “Healthy Transitions” for Adolescents • Way forward WHO-SEARO

3. 1.What is Pre-conception Care WHO-SEARO

4. Pre-pregnancy health status and health behaviors have direct or indirect implications for maternal and neonatal outcomes Intervening during pregnancy is too late for many interventions Many health risk behaviours are initiated during adolescence • Intervening after a woman is pregnant has limited impact: • First few weeks after conception are critical for fetal development • Week 5: brain, spinal cord, heart begin to form • Week 6: Neural tube closes; the heart is pumping • Week 7: Brain and face are rapidly developing • Most women do not seek prenatal advice/care before 12 weeks when it is too late to modify many risks WHO-SEARO

5. Modifiable risk factors are common toseveral “congenital conditions” ICBDSR presentation in Regional Meeting 2012 WHO-SEARO

6. Modifiable risks for birth defects and prematurity that need to be addressed before conception Age at pregnancy Too close and too many pregnancies Infections: TORCH Use of medications during early pregnancy Exposure to toxins Exposure to tobacco • Undernutrition and anaemia • Folic Acid insufficiency • Obesity • Diabetes • Hypertension • Epilepsy • Alcohol use WHO-SEARO Many risk factors are initiated during adolescence

7. Pre-Conception Care • Preconception care is the provision of biomedical, behavioral and social health interventions to women and couples before conception occurs. Aims: • Improving health status and reducing behaviors and individual and environmental factors to improve maternal and child health outcomes. Boundary:the period before pregnancy may be divided into a proximal and a distal period: • Proximal period immediately preceding pregnancy • Distaladolescence (10-19 years) WHO-SEARO

8. Life course – when to intervene?

9. 2.Do we have evidence based interventions WHO-SEARO

10. Gathering evidence: Global consultation Global consultation in WHO Headquarters, Geneva - February 2012 Meeting to develop a global consensus on preconception care to reduce maternal and childhood mortality and morbidity

11. Three questions were answered: What are the health problems, risk behaviours and risk factors contributing to maternal and childhood mortality and morbidity? What are the effective interventions to address them? What are the effective means of delivering these interventions?

12. Gathering evidence: Existing reviews Using existing evidence and reviews from: The Centers for Disease Control and Prevention Erasmus University Aga Khan University Health Council of the Netherlands

13. Evidence for Pre-Conception Care Recommendations to Improve Preconception Health – United States by the Centers for Disease Control and Prevention (2006) Systematic Review of Preconception Evidence by the Aga Khan University in Karachi, Pakistan (2011) WHO-SEARO

14. Consultation with various relevant WHO departments: • Maternal, Newborn, Child and Adolescent Health • Reproductive Health and Research • Nutrition for Health and Development • HIV • Mental Health and Substance Abuse • Immunization, Vaccine and Biologicals • Public Health and Environment • Tobacco-Free Initiative • Violence and Injury Prevention • Partnership for Maternal, Newborn and Child Health Gathering evidence: WHO departments

15. Strength of evidence • There is growing experience in implementing preconception care initiatives: • In high-income countries, such as Italy, the Netherlands and the United States • In low- and middle-income countries, such as Bangladesh, the Philippines and Sri Lanka

16. Preconception care has a positive effect on a range of health outcomes child mortality maternal mortality birth defects Reduced too early pregnancy preterm birth Reduced abortion congenital and neonatal infections Improved mental health cretinism Improved mother nutritional status macrosomia childhood cancers Low birth weight vertical transmission of HIV/STIs Underweight and stunting hypothyroidism diarrhoea

17. Tobacco use and youth health: a potential for Healthy Transitions 90% of adult smokers are estimated to have started smoking before age 20 years

18. Exposure to environmental toxins in early life and its long term effect eliminating smoking before or during pregnancy could avoid 5–7% of preterm related deaths and 23–24% of cases of sudden infant death syndrome

19. Areas addressed by preconception care package WHO-SEARO

20. Area addressed by the preconception care package Evidence-based interventions Nutritional conditions • Screening for anemia • Supplementing iron and folic acid • Information, education and counselling • Monitoring nutritional status • Supplementing energy- and nutrient-dense food • Screening for diabetes mellitus • Management of diabetes mellitus • Counselling people with diabetes mellitus • Monitoring blood glucose (also in pregnancy) • Promoting exercise • Salt iodization Evidence-based interventions: Selected examples WHO-SEARO

21. Areas addressed by the preconception care package Evidence-based interventions Genetic conditions • Screening for anemia • Taking a thorough family history • Family planning • Genetic counselling • Carrier screening and testing • Appropriate treatment • Providing community-based education • Community-wide or national screening among populations at high risk • Population-wide screening Evidence-based interventions: Selected examples WHO-SEARO

22. Areas addressed by the preconception care package Evidence-based interventions • Keeping girls in school • Influencing cultural norms that support early marriage and coerced sex • Creating visible, high-level support for pregnancy prevention programmes • Educating girls and boys about sexuality, reproductive health and contraceptive use • Building community support for preventing early pregnancy and for contraceptive provision to adolescents • Enabling adolescents to obtain contraceptive services • Empowering girls to resist coerced sex • Engaging men and boys to critically assess norms and practices regarding gender-based violence and coerced sex • Educating women and couples about the dangers to the baby and mother of short birth intervals • Providing contraceptives Too-early, unwanted and rapid successive pregnancy Evidence-based interventions: Selected examples WHO-SEARO

23. 3.Why Preconception care is important in SEAR WHO-SEARO

24. Source: World Health Statistics 2013

25. The Region is not likely to reach MDG4 Decline in NMR has been slower WHO-SEARO

26. Newborn mortality remains high in SEAR • Responsible for 54% of under-five deaths • Three congenital conditions: Prematurity, Birth Asphyxia and Birth Defects account for 35-55% of under-5 mortality • These causes of mortality share many risk factors WHO-SEARO

27. Prematurity, Birth Asphyxia and Birth Defects account for 35% (Myanmar) to 55% (Thailand) of under-5 mortality Source: World Health Statistics 2011 http://www.who.int/whosis/whostat/2011/en/index.html WHO-SEARO

28. Estimates of Birth Defects in SEAR March of Dimes Global Report on Birth Defects (2006) 28 WHO-SEARO

29. Birth Defects Situation Analysis:WHO-SEARO and US-CDC WHO-SEARO

30. Estimates of Pre Term BirthsBorn Too Soon Report: 2012 WHO-SEARO

31. Eleven countries with PT birth >15% by RankBorn Too Soon Report: 2012 WHO-SEARO

32. 4.Preconception Care in SEAR Twin track: Pre- and Inter-pregnancy care: Maternal Health Healthy Transitions for adolescents: Adolescent Health WHO-SEARO

33. Is there a gap in Continuum of Care? • Healthcare provided across the lifecycle through strong public health programs can ensure that all women and babies are healthy • There is a gap in the continuum of care for adolescent girls (and boys) and women before pregnancy.

34. Strengthening pre-conception care in the RMNCAH Continuum CHILDBIRTH CARE • Emergency obstetric care • Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation • PMTCT EMERGENCY NEWBORN AND CHILD CARE • - Hospital care of newborn and childhood illness including HIV care • - Extra care of preterm babies including kangaroo mother care • - Emergency care of sick newborns • Post-abortion care • - STI case management Clinical Outreach/outpatient • Healthy home care including: • Newborn care (hygiene, warmth) • Nutrition including exclusive breastfeeding and appropriate complementary feeding • Seeking appropriate preventive care • - Danger sign recognition and careseeking for illness • - Oral rehydration salts for prevention of diarrhoea • - Where referral is not available, consider case management for pneumonia, malaria, neonatal sepsis • Optimising Adolescent and pre-pregnancy nutrition • Health education and counseling on risk factors prevention - Counselling and preparation for newborn care, breastfeeding, birth and emergency preparedness • - Where skilled care is not available, consider clean delivery and immediate newborn care including hygiene, warmth and early initiation of breastfeeding Family/community • Screening and management of chronic diseases especially diabetes • Genetic counselling ANTENATAL CARE - 4-visitfocused ANC package • - IPTp and bednets for malaria • - PMTCT • Multivitamin and folic acid supplementation • Family planning • Youth development programs • Prevention of obesity POSTNATAL CARE • - Promotion of healthy behaviors • - Early detection of and referral for illness • - Extra care of LBW babies • - PMTCT INTERSECTORAL Improved living and working conditions – Housing, water and sanitation, and nutrition education and female empowerment WHO-SEARO Pregnancy Pre-pregnancy Birth

35. Infancy U5 Neonatal period Pregnancy Birth Pre-pregnancy care for prevention birth defects Life course Continuum 10-19 Pre-Pregnancy CH Immunization Newborn Care Ado Health SBA PCC ANC Interventions to address MH risk factors for BD and PT births WHO-SEARO

36. Sri LankaPackage for newly married couplesGoal: To have improved reproductive health outcomes by improving the health of the newly married couples. WHO-SEARO

37. Package for newly married couples • RISK SCREENING • CLINICAL ASSESSMENT • IMMUNIZATION • AWARENESS AND COUNSELLING • PROVISION OF OTHER SERVICES WHO-SEARO

38. TOOLS IN THE PACKAGE • INVITATION CARD • SCREENING TOOL • GUIDE FOR HEALTH WORKERS • BOOK FOR THE NEW COUPLE • BMI CALCULATOR WHO-SEARO

39. Screen for risk factors by using the screening tool by PHM/MOH Basic investigations Physical assessment by PHM Height, weight and BMI Clinical examination by MOH Refer for further diagnosis /treatment/ for specialized care Follow up SCREENING TOOL WHO-SEARO

40. ♣ SEXUALITY AND SEXUAL RELATIONSHIP ♣ SEXUALLY TRANSMITTED DISEASES AND RESPONSIBLE SEXUAL BEHAVIOUR ♣ A PLANNED FAMILY ♣ GOOD NUTRITION ♣ GOOD HEALTH HABITS/ HEALTHY BEHAVIOUR/ HEALTHY LIFE STYLE ♣ GOOD MARITAL RELATIONSHIP AND WELL BEING OF THE FAMILY ♣ BENEFITS OF NON VIOLENCE ♣ BEFORE CONCEPTION ♣ MALE PARTICIPATION AND PARENTHOOD ♣ TOBACCO AND ALCOHOL Book for the New Couple WHO-SEARO

41. 5.Many health risk behaviours are initiated during adolescence: Need to catch them young“Healthy Transitions” WHO-SEARO

42. Large number of adolescents in SEAR with many health problems Adolescents in SEAR Proportion of adolescents (10-19) • Sexual and reproductive health problems • Nutritional problems • Substance use: Tobacco, alcohol • Injuries, accidents and violence • Mental health problems 1.2 billion adolescents (10-19) globally About 350 Millions in SEAR of which 230 million in India WHO-SEARO Source: World population prospects: The 2006 Revision Population Database.

43. Health problems start during Adolescent period • Heterogeneous groups and circumstances with variable needs: • Boys and girls • Urban and rural • In school and out of school • Unmarried and married: Pregnant and mothers • At home and homeless (on streets) • In employment (formal and informal • Age parameter: 10-19 years • Confounding factors: • Biological: Early or late onset of puberty • Social-cultural factors • Experiencing rapid growth and development: • Physical: Body image and form • Sexual: Reproductive capacity • Mental: Mind • Emotional-psychological • Social • Formative Phase: • Attitudes • Behaviours

44. Early Marriage and child- bearing Proportion of adolescents who have begun childbearing Per cent married by Age 18 among adolescents (15-19 yrs) Poor women aged 15-19 are more likely to begin child bearing early Source: Bangladesh DHS 2007; India NFHS-3 2005-06; Indonesia DHS 2007; Nepal DHS 2006; Sri Lanka DHS 2005-06; Timor-Leste DHS 2003 WHO-SEARO

47. Adolescent Pregnancy: Higher Child Mortality Source: Bangladesh DHS 2011; India NFHS3 2005-06; Indonesia DHS 2007; Maldives DHS 2009; Myanmar FRHS 2007; Nepal DHS 2011; Sri Lanka DHS 2006-07; Timor-Leste DHS 2009-10 WHO-SEARO

48. Large number are under-nourished and anaemic WHO-SEARO Source: Bangladesh DHS 2011; India NFHS3 2005-06; Nepal DHS 2011; Sri Lanka DHS 2006; Maldives DHS 2009; Timor-Leste DHS 2009-10

49. Dietary behaviors, Overweight & Obesity (13-15 years) Source: Latest Global school-based student health survey (GSHS) WHO-SEARO

50. Early Tobacco use among adolescents (13-15 years) Source: Latest Global Youth Tobacco Survey (GYTS) WHO-SEARO