Preconception education interventions
Preconception education interventions provide information about the risks and benefits of behaviors that affect a birthing person’s overall health before, during, and after pregnancy; improving certain health behaviors prior to pregnancy reduces risks to birthing parents’ and infants’ health. Preconception health promotion and education interventions cover a variety of topics, such as nutrition, exercise and weight management, birth control methods, STI prevention, controlling chronic disease, reducing alcohol consumption, quitting smoking and other tobacco use, or improving mental health (Brown 2017, Khekade 2023). Interventions can be delivered by medical providers, public health professionals (Brown 2017), or others with relevant education and training, such as clinical pharmacists (DiPietro Mager 2016).
Preconception health describes the health of all people of reproductive age, regardless of their gender, sexual orientation, or intention to become pregnant or have children. Ongoing wellness visits with providers, sometimes called well-woman care, and education for partners, are a standard part of preconception care (Brown 2017). Wellness visits are covered as preventive care visits under the Affordable Care Act (ACA).
We at times use “women” or “maternal” when referring to people who may become pregnant or who may give birth. We acknowledge that not all people who can become pregnant or give birth identify as women, however current research on preconception health has primarily focused on those who identify as women.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
- Increased healthy behaviors
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
- Increased preconception planning
- Improved health-related knowledge
- Improved birth outcomes
What does the research say about effectiveness? -+
There is some evidence that preconception education interventions increase healthy behaviors among participating cis women (Brown 2017, Bickmore 2020, Jack 2015, Temel 2014, Cochrane-Whitworth 2009). Additional evidence is needed to confirm interventions’ effects on behaviors and birth outcomes, for what health conditions, and impacts on all individuals of reproductive age (Brown 2017), particularly among understudied groups, such as men and LGBTQ+ populations (Brown 2020).
Preconception interventions that address multiple risk factors appear to alter targeted behaviors (Temel 2014). For example, participants in the Central Pennsylvania Women’s Health Study’s Strong Women program reported increases in their intent to eat healthier and be physically active, as well as increased physical activity, consumption of folic acid, and self-efficacy following the program’s six bi-weekly education sessions (Hillemeier 2008). An intensive intervention covering both alcohol consumption and contraception appeared to reduce binge drinking among risky drinkers (Cochrane-Whitworth 2009). Studies of a web-based conversational agent suggests it can change preconception health-related behaviors among women who are Black (Bickmore 2020, Jack 2015), and web-based education 7-10 days before a well woman visit may increase reproductive health discussions with providers (Batra 2018). Interventions targeting smoking may also reduce smoking pre-pregnancy (Temel 2014).
Preconception nutrition interventions appear to increase consumption of folic acid. A study of nutrition lessons for women of reproductive age with lower incomes, for example, appeared to increase their intake of dietary folate (Temel 2014). Various other individual programs, usually involving both education and supplement provision (Temel 2014), and collective interventions (e.g., public education campaigns and fortification of food products) have been shown to increase consumption of folic acid and reduce the risk of birth defects (Temel 2014, CG-Folic acid campaigns).
Risk assessment followed by individualized counseling appears to increase participants’ knowledge of healthy behaviors. In five urban primary care clinics, for example, risk assessment and brief counseling for women who have low incomes and are Black or Hispanic appeared to increase knowledge of the importance of folic acid, the need to treat and control chronic health conditions, and the importance of preconception medication review with a provider (Dunlop 2013b). In a greater Atlanta area-based study, women who are Black and attended WIC clinic nutrition classes received brief counseling based on their risk assessment results and reported that counseling was both acceptable and important (Dunlop 2013a).
Integrating preconception and interconception care into the ongoing care that women with diabetes receive may reduce congenital malformation, preterm delivery, and perinatal infant mortality (Wahabi 2010), however, additional evidence is needed to confirm effects (Cochrane-Tieu 2017, Cochrane-Tieu 2017a).
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities. -+
It is unclear what impact preconception education interventions may have on disparities in pregnancy and birth outcomes. Available evidence suggests that programming specific to at risk groups can have a positive impact on health knowledge or behaviors among women with lower incomes (Temel 2014, Dunlop 2013b), or who are Black (Bickmore 2020, Jack 2015, Dunlop 2013b) or Hispanic (Dunlop 2013b).
Preconception health is impacted by many things, including age, race and ethnicity, location, rurality, and insurance status (Haiman 2023). A study looking at 37 states suggests that the average person had three or more preconception health risk factors or behaviors (Haiman 2023). Populations who have been racially or ethnically minoritized or are disabled (Horner-Johnson 2021), who have lower incomes (Haiman 2023), who are sexually minoritized (Limburg 2020), and those who live in rural areas (DiPietro Mager 2023, Haiman 2023) are more likely to have higher risks than their white, able-bodied, cis-gender, heterosexual, or urban counterparts. Preconception health is worse in the South and the Midwest, particularly in states that did not expand Medicaid (Haiman 2023). LGBTQ+ birthing people face additional barriers and discrimination interfering with adequate care, including provider bias and physicians misunderstanding transgender and queer reproductive health care needs (Wingo 2018). Efforts should be customized by region, particularly for areas with health disparities (DiPietro Mager 2024), and preconception education intervention should be culturally tailored for LGBTQ+ populations (Limburg 2020).
The maternal mortality rate in the U.S. is higher than in any other high-income country (Tucker 2021), and there are stark disparities in maternal outcomes and maternal mortality between women who are Black, American Indian or Alaska Native, and women who are white (ASPE-Knocke 2022, Tucker 2021, CWF-Hostetter 2019), as well as between those living in rural areas, compared to their urban counterparts (ASPE-Knocke 2022). Studies establish that women who are Black experience racial bias and discrimination in maternity care (Tucker 2021); this may be true for other groups as well. Women in rural areas often live in counties without obstetricians or maternity care centers, reducing their access to care (March of Dimes-Brigance 2022).
What is the relevant historical background? -+
The Federal Housing Administration’s redlining practices concentrated poverty (Kaplan 2007) and entrenched racial residential segregation in the U.S., resulting in fewer health care facilities, resources, and funding in urban areas with largely Black populations (Lee 2023, Lee 2022c). Past residential redlining and present-day disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods with residents that are primarily Black and low income (Lee 2023). Living in redlined areas exposes pregnant women to a variety of factors that can contribute to preterm birth, including poor quality housing, reduced neighborhood resources, and urban heat islands (Lee 2022c). Segregation continues to be associated with increased risk of preterm birth and low birthweight for patients who are Black, with risks increasing as segregation in neighborhoods increases (Mehra 2017).
Efforts to improve maternal and child health outcomes and disparities began in the 1960s with a focus on hospital care, switching to a prenatal care focus in the 1980s, and then preconception care in the 1990s (St Fleur 2016). However, there has been little evidence that any of these can impact disparities in birth outcomes, and experts suggest that all these services are necessary but cannot improve disparities in birth outcomes on their own (St Fleur 2016). More recent research has been exploring potential factors, such as toxic stress, that may have long lasting impacts which lead to perinatal disparities in future generations (St Fleur 2016).
Addressing preconception health is important for all people, as many pregnancies are unintended. Unwanted pregnancies could be terminated in all 50 states prior to the 2022 Dobbs v. Jackson Women’s Health Organization Supreme Court decision which made abortion illegal in almost half of U.S. states (Haiman 2023). This change in law, and other increased barriers to abortion, may increase existing disparities in maternal and infant health (KFF-Hill 2022) as more unwanted pregnancies are carried to term (Haiman 2023).
Equity Considerations -+
- What disparities in birth and maternal outcomes exist in your community?
- What resources are available for preconception care in your community? Are certain groups less able to access the care and services available?
- What are the barriers to high quality, linguistically and culturally appropriate preconception care?
Implementation Examples -+
The U.S. Department of Health and Human Services' “Healthy Women, Healthy Pregnancies, Healthy Futures: Action Plan to Improve Maternal Health in America” includes improving preconception education (US DHHS-HWHPHF 2020) through efforts such as the Collaborative Improvement and Innovation Network (CoIIN) on Infant Mortality’s preconception CoIIN work (Before and Beyond-CoIIN).
Several states have developed preconception health campaigns that incorporate education as one component, including Every Woman California, Delaware Thrives, Every Woman North Carolina, Arizona's Power Me A2Z, and Utah's Power Your Life, Power Your Health (Every Woman California, Delaware Thrives, Every Woman North Carolina, Power Me A2Z, UDOH-Power Your Life). Ever Thrive Illinois’s Healthy Choices Health Futures Toolkit is designed for use by families and social service providers (EverThrive Illinois).
Many non-profit and university organizations also provide preconception education interventions. PASOs, a program serving the Latino community in South Carolina, includes a culturally appropriate preconception health education workshop as part of its wider preconception health efforts (PASOs, Torres 2013a).
The Show Your Love national campaign encourages healthy behaviors for all women (Show Your Love).
Implementation Resources -+
‡ Resources with a focus on equity.
AMCHP-Innovation hub - Association of Maternal & Child Health Programs (AMCHP). Innovation hub: Innovations database.
Before and Beyond - Before, Between & Beyond Pregnancy. Preconception Health and Healthcare Initiative. Chapel Hill: The University of North Carolina at Chapel Hill.
CDC-Humphrey 2012 - Humphrey JR, Floyd RL. Preconception health and health care environmental scan. Atlanta: Centers for Disease Control and Prevention (CDC); 2012.
EverThrive Illinois‡ - EverThrive Illinois. (2020). Healthy Choices, Healthy Futures.
Every Woman California - Every Woman California. Preconception Health Council of California.
NBDPN-Awareness - National Birth Defects Prevention Network (NBDPN). National Birth Defects Awareness Month.
Show Your Love - Show Your Love. Preconception Health and Health Care Initiative.
Citations -+
* Journal subscription may be required for access.
ASPE-Knocke 2022 - Knocke K, Chappel A, Sugar S, De Lew N, Sommers BD. Doula care and maternal health: An evidence review. Issue Brief no. HP-2022-24. Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services; 2022.
Batra 2018* - Batra, P., Mangione, C. M., Cheng, E., Steers, W. N., Nguyen, T. A., Bell, D., Kuo, A. A., & Gregory, K. D. (2018). A cluster randomized controlled trial of the MyFamilyPlan online preconception health education tool. American Journal of Health Promotion, 32(4), 897–905.
Before and Beyond-CoIIN - Before, Between & Beyond Pregnancy. Preconception : Collaborating to improve well woman care. Chapel Hill: The University of North Carolina at Chapel Hill.
Bickmore 2020* - Bickmore, T., Zhang, Z., Reichert, M., Julce, C., & Jack, B. (2020). Promotion of preconception care among adolescents and young adults by conversational agent. Journal of Adolescent Health, 67(2), S45–S51.
Brown 2017* - Brown M, Vaclavik D, Dennis WP, Wilka E. Predictors of homeless services re-entry within a sample of adults receiving homelessness prevention and rapid re-housing program (HPRP) assistance. Psychological Services. 2017;14(2):129-140.
Brown 2020 - Brown SS. What will it take to further reduce teen pregnancy in the U.S.? Journal of Adolescent Health. 2020;66(5):522-523.
CG-Folic acid campaigns - The Guide to Community Preventive Services (The Community Guide). Pregnancy health: Community-wide campaigns to promote the use of folic acid supplements
Cochrane-Tieu 2017* - Tieu, J., Shepherd, E., Middleton, P., & Crowther, C. A. (2017). Interconception care for women with a history of gestational diabetes for improving maternal and infant outcomes. Cochrane Database of Systematic Reviews, (8), CD010211.
Cochrane-Tieu 2017a* - Tieu, J., Middleton, P., Crowther, C. A., & Shepherd, E. (2017). Preconception care for diabetic women for improving maternal and infant health. Cochrane Database of Systematic Reviews, (8), CD007776.
Cochrane-Whitworth 2009* - Whitworth M, Dowswell T. Routine pre-pregnancy health promotion for improving pregnancy outcomes. Cochrane Database of Systematic Reviews. 2009;(4):CD007536.
CWF-Hostetter 2019 - Hostetter M, Klein S. Improving health for women by better supporting them through pregnancy and beyond. New York: The Commonwealth Fund (CWF); 2019.
Delaware Thrives - Delaware Thrives: Women's health. Delaware Health and Social Services Division of Public Health and Delaware Healthy Mother & Infant Consortium.
DiPietro Mager 2016* - DiPietro Mager, N. A. (2016). Fulfilling an unmet need: Roles for clinical pharmacists in preconception care. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 36(2), 141–151.
DiPietro Mager 2023* - DiPietro Mager, N. A., Zollinger, T. W., Turman, J. E., Zhang, J., & Dixon, B. E. (2023). Preconception health status and associated disparities among rural, midwestern women in the United States. Birth, 50(1), 127–137.
DiPietro Mager 2024 - DiPietro Mager, N., Menegay, M., Bish, C., & Oza-Frank, R. (2024). Geographic differences in preconception health indicators among Ohio women who delivered live births, 2019–2021. Preventing Chronic Disease, 21(E08), 230244.
Dunlop 2013a* - Dunlop AL, Dretler AW, Badal HJ, Logue KM. Acceptability and potential impact of brief preconception health risk assessment and counseling in the WIC setting. American Journal of Health Promotion. 2013;27(3 Suppl 1):58-65.
Dunlop 2013b* - Dunlop AL, Logue KM, Thorne C, Badal HJ. Change in women's knowledge of general and personal preconception health risks following targeted brief counseling in publicly funded primary care settings. American Journal of Health Promotion. 2013;27(3 Suppl 1):50-57.
EverThrive Illinois - EverThrive Illinois. (2020). Healthy Choices, Healthy Futures.
Every Woman California - Every Woman California. Preconception Health Council of California.
Every Woman North Carolina - Every Woman North Carolina. March of Dimes North Carolina Preconception Health Campaign.
Haiman 2023 - Haiman, M. D., & Cubbin, C. (2023). Impact of geography and rurality on preconception health status in the United States. Preventing Chronic Disease, 20(E101), 230104.
Hillemeier 2008 - Hillemeier MM, Symons Downs D, Feinberg ME, et al. Improving women's preconceptional health: Findings from a randomized trial of the strong healthy women intervention in the central Pennsylvania women's health study. Women's Health Issues. 2008;18(6 Suppl 1):87-96.
Horner-Johnson 2021* - Horner-Johnson, W., Akobirshoev, I., Amutah-Onukagha, N. N., Slaughter-Acey, J. C., & Mitra, M. (2021). Preconception health risks among U.S. women: Disparities at the intersection of disability and race or ethnicity. Women’s Health Issues, 31(1), 65–74.
Jack 2015* - Jack, B., Bickmore, T., Hempstead, M., Yinusa-Nyahkoon, L., Sadikova, E., Mitchell, S., Gardiner, P., Adigun, F., Penti, B., Schulman, D., & Damus, K. (2015). Reducing preconception risks among African American women with conversational agent technology. The Journal of the American Board of Family Medicine, 28(4), 441–451.
Kaplan 2007* - Kaplan J, Valls A. Housing discrimination as a basis for Black reparations. Public Affairs Quarterly. 2007;21(3):255-273.
KFF-Hill 2022 - Hill L, Artiga S, Ranji U. Racial disparities in maternal and infant health: Current status and efforts to address them. KFF. 2022.
Khekade 2023* - Khekade, H., Potdukhe, A., Taksande, A. B., Wanjari, M. B., & Yelne, S. (2023). Preconception care: A strategic intervention for the prevention of neonatal and birth disorders. Cureus.
Lee 2022c* - Lee EK, Donley G, Ciesielski TH, et al. Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis. Social Science and Medicine. 2022;294:114696.
Lee 2023* - Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Social Science and Medicine. 2023;328:116009.
Limburg 2020* - Limburg, A., Everett, B. G., Mollborn, S., & Kominiarek, M. A. (2020). Sexual orientation disparities in preconception health. Journal of Women’s Health, 29(6), 755–762.
March of Dimes-Brigance 2022 - Brigance C, Lucas R, Jones E, et al. Nowhere to go: Maternity care deserts across the U.S. (Report No. 3). March of Dimes; 2022.
Mehra 2017* - Mehra R, Boyd LM, Ickovics JR. Racial segregation and adverse birth outcomes: A systematic review and meta-analysis. Social Science & Medicine. 2017;191:237-250.
PASOs - Perinatal Awareness for Successful Outcomes (PASOs). Healthy Latino communities contributing to a stronger South Carolina.
Power Me A2Z - Power Me A2Z. Arizona Department of Health Services.
Show Your Love - Show Your Love. Preconception Health and Health Care Initiative.
St Fleur 2016* - St. Fleur, M., Damus, K., & Jack, B. (2016). The future of preconception care in the United States: Multigenerational impact on reproductive outcomes. Upsala Journal of Medical Sciences, 121(4), 211–215.
Temel 2014 - Temel S, van Voorst SF, Jack BW, Denkta S, Steegers EAP. Evidence-based preconceptional lifestyle interventions. Epidemiologic Reviews. 2014;36(1):19-30.
Torres 2013a* - Torres ME, Smithwick-Leone J, Willms L, et al. Developing a culturally appropriate preconception health promotion strategy for newly immigrated Latinos through a community-based program in South Carolina. American Journal of Health Promotion. 2013;27(3):S7-S9.
Tucker 2021* - Tucker CM, Felder TM, Dail RB, Lyndon A, Allen K-C. Group prenatal care and maternal outcomes: A scoping review. MCN: The American Journal of Maternal/Child Nursing. 2021;46(6):314-322.
UDOH-Power Your Life - Utah Department of Health (UDOH). Power Your Life, Power Your Health.
US DHHS-HWHPHF 2020 - U.S. Department of Health and Human Services. (2020). Healthy women, healthy pregnancies, healthy futures: Action plan to improve maternal health in America.
Wahabi 2010* - Wahabi HA, Alzeidan RA, Bawazeer GA, Alansari LA, Esmaeil SA. Preconception care for diabetic women for improving maternal and fetal outcomes: A systematic review and meta-analysis. BMC Pregnancy and Childbirth. 2010;10:63.
Wingo 2018 - Wingo, E., Ingraham, N., & Roberts, S. C. M. (2018). Reproductive health care priorities and barriers to effective care for LGBTQ people assigned female at birth: A qualitative study. Women’s Health Issues, 28(4), 350–357.