B.P.

KOIRALA INSTITUTE OF HEALTH SCIENCES

COLLEGE OF NURSING
DHARAN, NEPAL

Seminar on Preconceptional Counseling and Care

SUPERVISED BY: SUBMITTED BY:

Ms. Kriti Chaudhary Roji Thakur
Assistant Professor M.Sc. Nursing, 1st Year
CON, BPKIHS CON, BPKIHS
 MASTER PLAN
Topic: Preconceptional Counseling and Care
Date:
Time:
Venue:

CONTENTS:
 Introduction of Preconceptional Counseling and Care
 Definition
 Facts/Epidemiology
 Goals/Objectives
 Purposes
 Areas
 Package

 Preconceptional Visit, Risk Assessment and Education

 Limitations
 Research Study
 Summary
 References
 Preconceptional Counseling and Care

Introduction
Organogenesis is completed by the 1st trimester. By the time the woman is seen first in the antenatal
clinic, it is often too late to advice. Because all the adverse factors have already begun to exert their
effects.
Preconceptual phase is the time to identify any risk factor that could potentially affect the perinatal
outcome adversely. The woman is informed about the risk factor and at the same time care is
provided to reduce or to eliminate the risk factor in an attempt to improve the pregnancy outcome.
Virtually preconceptional counseling is a part of preventive medicine.
There is growing experience in implementing preconception care initiatives both in high-income
countries, such as Italy, the Netherlands and the United States, and in low- and middle-income
countries, such as Bangladesh, the Philippines and Srilanka.

Definition
Preconception care is the provision of biomedical, behavioural and social health interventions to
women and couples before conception occurs. It aims at improving their health status, and reducing
behaviours and individual and environmental factors that contribute to poor maternal and child health
outcomes. Its ultimate aim is to improve maternal and child health, in both the short and long term.
Even if preconception care aims primarily at improving maternal and child health, it brings health
benefits to the adolescents, women and men, irrespective of their plans to become parents. (According
to WHO)
When a couple is seen and counseled about pregnancy, its course and outcome well before the time of
actual conception is called preconceptional counseling.

Facts/Epidemiology
 4 out of 10 women report that their pregnancies are unplanned. As a result, essential health
interventions provided once a woman and her partner decide to have a child will be too late in
40% of pregnancies.
 Maternal undernutrition and iron-deficiency anaemia increase the risk of maternal death,
accounting for at least 20% of maternal mortality worldwide.
 In 2010, 58 000 newborn babies died from neonatal tetanus.
 Female genital mutilation increases the risk of neonatal death (including stillbirths) by 15% to
55% .
 Perinatal deaths are 50% higher among children born to mothers under 20 years of age
compared to mothers aged 20–29 years.
 Up to 35% of pregnancies among women with untreated gonococcal infections result in low
 birth weight infants and premature deliveries, and up to 10% result in perinatal death.
 In the absence of interventions, rates of HIV transmission from mother to child are between
15 and 45%.
 Violence against girls and women results in adverse physical, psychological and reproductive
consequences, as well as increased risk for premature delivery and low-birth-weight infants.
 Women with epilepsy are at increased risk of having babies with congenital anomalies (both
epilepsy and the medications given for its control may have adverse effects on the baby).
 Estimates indicate that eliminating smoking before or during pregnancy could avoid 5–7% of
preterm related deaths and 23–24% of cases of sudden infant death syndrome.

Goals/Objectives
It’s objective is to:
 ensure that a woman enters pregnancy with an optimal state of health which would be safe
both to herself and the fetus.
 improve the knowledge, attitudes, and behaviors of men and women related to preconception care.
 assure that all women of childbearing age receive preconception care services.
 reduce disparities in adverse pregnancy outcomes.

Purposes of Preconception care

Preconception care has a positive effect on a range of health outcomes. Among others, preconception
care can:
 reduce maternal and child mortality
 prevent unintended pregnancies
 prevent complications during pregnancy and delivery
 prevent stillbirths, preterm birth and low birth weight
 prevent birth defects
 prevent neonatal infections
 prevent underweight and stunting
 prevent vertical transmission of HIV/STIs
 lower the risk of some forms of childhood cancers
 lower the risk of type 2 diabetes and cardiovascular diseases later in life

Areas addressed by the preconception care package (According to WHO)

 Nutritional conditions
 Vaccine-preventable diseases
 Genetic conditions
 Environmental health
  Infertility/ subfertility
 Female genital mutilation
 Too early, unwanted and rapid successive pregnancies
 Sexually transmitted infections
 Human immunodeficiency virus (HIV)
 Interpersonal violence
 Mental health
 Psychoactive substance use
 Tobacco use

Package of preconception care interventions (According to WHO)

Areas addressed by the Examples of evidence-based interventions

preconception care
package
Nutritional conditions  Screening for anaemia and diabetes
 Supplementing iron and folic acid
 Information, education and counselling
 Monitoring nutritional status
 Supplementing energy- and nutrient-dense food
 Management of diabetes, including counselling
people with diabetes mellitus
 Promoting exercise
 Iodization of salt
Tobacco use  Screening of women and girls for tobacco use
(smoking and smokeless tobacco) at all clinical visits
using “5 As” (ask, advise, assess, assist, arrange)
 Providing brief tobacco cessation advice,
pharmacotherapy (including nicotine replacement
therapy, if available) and intensive behavioural
counselling services
 Screening of all non-smokers (men and women) and
advising about harm of second-hand smoke and
harmful effects on pregnant women and unborn
children
Genetic conditions  Taking a thorough family history to identify risk
factors for genetic conditions
 Family planning
 Genetic counselling
  Carrier screening and testing
 Appropriate treatment of genetic conditions
 Community-wide or national screening among
populations at high risk
Environmental health  Providing guidance and information on environmental
hazards and prevention
 Protecting from unnecessary radiation exposure in
occupational, environmental and medical settings
 Avoiding unnecessary pesticide use/providing
alternatives to pesticides
 Protecting from lead exposure
 Informing women of childbearing age about levels of
methyl mercury in fish
 Promoting use of improved stoves and cleaner
liquid/gaseous fuels
Infertility/sub-fertility  Creating awareness and understanding of fertility and
infertility and their preventable and unpreventable
causes
 Defusing stigmatization of infertility and assumption
of fate
 Screening and diagnosis of couples following 6–12
months of attempting pregnancy, and management of
underlying causes of infertility/sub-fertility, including
past STIs
 Counselling for individuals/couples diagnosed with
unpreventable causes of infertility/sub-fertility
Interpersonal violence  Health promotion to prevent dating violence
 Providing age-appropriate comprehensive sexuality
education that addresses gender equality, human
rights, and sexual relations
 Combining and linking economic empowerment,
gender equality and community mobilization activities
 Recognizing signs of violence against women
 Providing health care services (including post-rape
care), referral and psychosocial support to victims of
violence
 Changing individual and social norms regarding
drinking, screening and counselling of people who are
problem drinkers, and treating people who have
 alcohol use disorders
Too-early, unwanted and  Keeping girls in school
rapid successive  Influencing cultural norms that support early marriage
pregnancies and coerced sex
 Providing age-appropriate comprehensive sexuality
education
 Providing contraceptives and building community
support for preventing early pregnancy and
contraceptive provision to adolescents
 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
Sexually transmitted  Providing age-appropriate comprehensive sexuality
infections (STIs) education and services
 Promoting safe sex practices through individual,
group and community-level behavioural interventions
 Promoting condom use for dual protection against
STIs and unwanted pregnancies
 Ensuring increased access to condoms
 Screening for STIs
 Increasing access to treatment and other relevant
health services
HIV  Family planning
 Promoting safe sex practices and dual method for birth
control (with condoms) and STI control
 Provider-initiated HIV counselling and testing,
including male partner testing
 Providing antiretroviral therapy for prevention and
pre-exposure prophylaxis
 Providing male circumcision
 Providing antiretroviral prophylaxis for women not
eligible for, or not on, antiretroviral therapy to prevent
mother-to-child transmission
 Determining eligibility for lifelong antiretroviral
therapy
 Mental health  Assessing psychosocial problems
 Providing educational and psychosocial counselling
before and during pregnancy
 Counselling, treating and managing depression in
women planning pregnancy and other women of
childbearing age
 Strengthening community networks and promoting
women’s empowerment
 Improving access to education for women of
childbearing age
 Reducing economic insecurity of women of
childbearing age
Psychoactive substance  Screening for substance use
use  Providing brief interventions and treatment when
needed
 Treating substance use disorders, including
pharmacological and psychological interventions
 Providing family planning assistance for families with
substance use disorders (including postpartum and
between pregnancies)
 Establishing prevention programmes to reduce
substance use in adolescents
Vaccine-preventable  Vaccination against rubella
diseases  Vaccination against tetanus and diphtheria
 Vaccination against Hepatitis B
Female genital mutilation  Discussing and discouraging the practice with the girl
(FGM) and her parents and/ or partner
 Screening women and girls for FGM to detect
complications
 Informing women and couples about complications of
FGM and about access to treatment
 Carrying out defibulation of infibulated or sealed girls
and women before or early in pregnancy
 Removing cysts and treating other complications

Preconceptional Visit, Risk Assessment and Education:

 Identification of high risk factors by detailed evaluation of obstetric, medical, family and
 personal history. Risk factors are assessed by laboratory tests, if required.
 Base level health status including blood pressure is recorded.
 Rubella and hepatitis immunization in a nonimmune woman is offered.
Active immunity can be conferred in non-immune subjects by giving live attenuated rubella
virus vaccine preferably during 11–13 years. It is not recommended in pregnant women.
When given during the child-bearing period, pregnancy should be prevented within
three months by contraceptive measure. However, if pregnancy occurs during the period,
termination of pregnancy is not recommended.
Pregnant woman exposed to HAV infection should receive immunoglobulin 0.02 mL/kg
within 2 weeks of exposure. She should also have hepatitis A vaccine single dose 0.06 mL. IM. It is
safe in pregnancy.
 Folic acid supplementation (4 mg a day) starting 4 weeks prior to conception up to 12
weeks of pregnancy is advised. This can reduce the incidence of neural tube defects.
 Maternal health is optimized preconceptionally. Problems of overweight, underweight,
anemia, abnormal papanicolaou smears are evaluated and treated appropriately.
 Fear of the incoming pregnancy is removed by preconceptional education.
 Patient with medical complications should be educated about the effects of the disease on
pregnancy and also the effects of pregnancy on the disease. In extreme situation, the
pregnancy is discouraged. Pre-existing chronic diseases (hypertension, diabetes, epilepsy)
are stabilized in an optimal state by intervention.
 Drugs used before pregnancy are verified and changed if required so as to avoid any
adverse effect on the fetus during the period of organogenesis. For example, anticonvulsant
drugs are checked, warfarin is replaced with heparin, oral antidiabetic drugs are replaced
with insulin.
 Woman should be urged to stop smoking, taking alcohol and abusing drugs. Addicted
woman is given specialized care.
 Inheritable genetic diseases (sickle cell disease, cystic fibrosis) are screened before
conception and risk of passing on the condition to the offspring is discussed.
 Importance of prenatal diagnosis for chromosomal or genetic diseases are discussed.
 Inheritable genetic diseases could be managed either by primary prevention (eliminating
the causal factor) or by secondary prevention (terminating the affected fetus).
 Couples with history of recurrent fetal loss or with family history of congenital
abnormalities (genetic, chromosomal or structural) are investigated and counseled
appropriately.

The counseling should be done by primary health care providers. The help of an
obstetrician, physician and geneticist may be required and should be extended.

Limitations: Unfortunately, only a small percentage of women take the advantage of preconceptual
care.
The important reasons are: (i) Lack of public awareness (ii) Many pregnancies are unplanned.

Research Study:
 In January 2017, a study was conducted on Knowledge and practice regarding preconception care among
antenatal mothers in Bharatpur hospital, Chitwan, Nepal by Gayatri Nepali and Shubha Devi Sapkota
and it was found that the knowledge and practice of the antenatal mothers regarding preconception care
 is relatively poor so awareness programs related to preconception care should be conducted to enhance
the knowledge of mother which consequently helps in increasing their standard practice as well.

 A study was conducted from April 2014 to February 2016 on Incidence of Congenital Fetal
Malformation Abnormalities in Tribhuwan University, Teaching Hospital, Kathmandu, Nepal: a
Hospital Based Study by Sunita Bajracharya, Deepak Rajbhandari, Binaya Gurung and Asma Rana and
it concluded that all the mothers who have, had previous malformed babies must undergo
preconceptional counseling, before planning next pregnancy in order to avoid recurrent mishap.

 A study was conducted from September 2009 to June 2010 on Educational Intervention about Awareness
of Preconceptional care: on Impact Among Bachelor Students in Kathmandu, Nepal by Dhakal, K. and it
concluded that educational intervention on preconceptional care can bring significant increase in
awareness of bachelor level students. Further, it is recommended that similar type of educational package
should be incorporated in college level to increase the awareness on preconceptional care among
reproductive age population.

Summary:
Preconception care is the provision of biomedical, behavioural and social health interventions to
women and couples before conception occurs.
Its objective is to ensure that a woman enters pregnancy with an optimal state of health which would
be safe both to herself and the fetus.

It mainly focuses on nutritional conditions, vaccine-preventable diseases, genetic conditions, environmental

health, infertility/ subfertility, female genital mutilation, too early, unwanted and rapid successive pregnancies,
sexually transmitted infections, Human immunodeficiency virus (HIV), interpersonal violence, mental health,
psychoactive substance use, tobacco use.

References
 Dutta D C. Tetbook of Obstetrics. Kolkata India. New Central Book Agency (P) Ltd. 2011. P 160-163.
 Retrieved from https://www.researchgate.net/profile/Shubha-
Sapkota/publication/319490058_Knowledge_and_practice_regarding_preconception_care_among_anten
atal_mothers/links/59aea959a6fdcce55a4794d0/Knowledge-and-practice-regarding-preconception-care-
among-antenatal-mothers.pdf
  Retrieved from https://www.europasianjournals.org/ejms/index.php/ejms/article/view/285
 Retrieved from https://web.a.ebscohost.com/abstract?
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 Retrieved from
https://www.who.int/maternal_child_adolescent/documents/preconception_care_policy_brief.pdf