preconception care in italy: the “pensiamoci prima project” · – renata bortolus, verona...
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Preconception Care in Italy: the “Pensiamoci Prima Project”
Pierpaolo MastroiacovoProfessor of PaediatricsDirector of ICBD - Alessandra Lisi International Centre on Birth Defects and Prematurity, WHO Collaborating CentreDirector of the Headquarter of the International Clearinghouse for Birth Defects Surveillance and Research
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The Italian situation before 2008
• September 10, 1998• Ministry of Health Decree No. 245• No added cost (ticket) for:
– Brief preconception risk assessment – The standard lab examinations:
• Rubella and Toxo antibodies, full blood counts, AB0-Rh, Pap test, HIV, VDRL/TPHA
• If needed: Hb anomalies, Coombs, post miscarriages exam
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The Italian situation before 2008
• No data to evaluate the frequency of preconception care (PC)• Anecdotal: PC very rarely performed, < 1%; mainly “genetic
counseling”• Use of folic acid supplements during the peri-conception
period– around 5%, – Although …
• the 0.4 mg of folic acid supplement free of charge since 2004 • National Network to Promote Folic Acid operating since 2003
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The Italian situation in 2008
• Total births: 576.659– Italians: 505.000, Foreigners: 71.000 (12%)– 1° born: 50%; 2° or more born: 50%
• Planned pregnancy: 50-70%• Periconception use of FA: 20%• Induced abortions (IVG): 121.406
– Italians: 80.000; Foreigners: 41.000 (34%) – ETOPFA: 5,0 per 1,000 = <> 3.000
• Total prevalence of:– Premature births 6,7% – Congenital malformations: 3%
• Neural tube defects: 1.0 per 1,000• Mortality
– Infant (0-1 y): 3.7 per 1,000
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The “Pensiamoci Prima” project
• Started on October 1°, 2007• Three working units
– ICBD (coordination)– OPBG – Pediatric Hospital (Alberto Tozzi) – INRAN – Nutrition Institute (Stefania Ruggeri)
• To be concluded on September 31, 2011• Aims:
– Promote reproductive health and preconception health and care• major promotion activity periconception FA supplements
– Evaluate in Italy the need of food fortification with FA
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Working methodology
• Working group: GLISP
• Collaboration with 21 scientific societies
• Consultation meeting with general practitioners
• Consultation meeting with expert group for communication
• Contract with communication agency30 Novembre 2010
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Main achievements
• Concepts
• Systematic reviews
• Website
• Educational material
• Tools
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Concepts
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Preconception care is the recognized new paradigm of the maternal and child health
Healthy Sexual Life Education
PrenatalCare
ChildCare
Perinatal& Neonatal
Care Preconception
Care
All women in childbearing age30 Novembre 2010
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Main concepts
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• Preconception care is based on:– Full understanding of the the critical relevance of the
periconception period:• Embryos’ development steps• Epigenetic influence
– Evidence based recommendations (see guidelines)
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The critical relevance of the periconception period
16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 462 4 6 8 10 12 14 48
Gestational age, weeks
Days
3° 4° 5° 6° 7°
16 18 20 22 24 26 28 30 32 342 4 6 8 10 12 14
First heart beatFour-chamber
heart
Embryonal age Days
Neura tubecloses
1° day ofLMP
Conception(mean)
Pregnancy may besuspected
(mean)
Periconception period Starts when a fertility control method is stoppedEnds at the end of the first trimester
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1° early prenatal, visit
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Main concepts
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• The aims of preconception care are : – To promote the women’s health, in general
– To reduce the frequency of preventable risk factors of adverse reproductive outcomes
• Health promotion• Risk assessment• Empowerment and counseling• Intervention
– To reduce the prevalence of the many adverse reproductive outcomes
– To empower the parents to identify and understand genetic risk
– To provide anticipatory guidance for in-pregnancy decisions
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Promote women’s health
Healthy embryo
Healthy pregnancy
Healthy women
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Preventable risk factors
• Unplanned pregnancy • Lifestyle behaviors
– Non mediterranean nutrition– Low folate status– Overweight and obesity– Smoking– Alcoholic beverages– Illicit drugs
• Pregestational diseases– E.g.: diabetes, thyroid
diseases
• Infections– Rubella, chickenpox, influenza– Toxoplasmosis, CMV– Sexually transmitted diseases
• Psyco-social stressors• Working place hazards• Harmful medications• High fever• (Environmental hazard)
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Adverse reproductive outcomes
• Malformations• Premature births• IUGR• Congenital disabilities
• Genetic diseases
• Cerebral palsy • Congenital tumors• Sudden infant deaths
• Gestational diabetes• (Pre-)Eclampsia • Abruptio placentae• PROM• Infections
• Spontaneous abortions• Elective terminations • Subfertility and infertility
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Main concepts
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• Preconception care practice: – Preconception care is a continuum– Counseling methodology is the most important tool:
• Use the wording “risk reduction” instead of “prevention”• Protect women that in spite of a full compliance to recommendations will
have an adverse outcome• Make clear the meaning of primary prevention and the difference
between prevention and renounce– Disadvantaged groups (immigrants, low SES) should have priority
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Promotion of preconception health (or better reproductive health) is a continuum
The health care provider (s) has (have) many opportunities to give, endorse or reinforce one or more recommendations
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Counseling methodology
Health CareProvider
Women(couple)
Counseling ability
Prescription
LabExams
Info
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In conclusion…
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The 5 W and How
• Who – Any health care provider (including midwifes)
• Where– Any setting (e.g.: local services, hospital, maternity hospital)
• To whom– Any women in childbearing age (reproductive health promotion) and
any women not using fertility control methods (preconception health promotion and care)
– Special efforts to reach disadvantaged women • What
– Evidence based information and intervention
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The five W and how• When
– Every time, integrated in the daily practice, and more deeply when the women does not use fertility control methods
• How– Using:
• scientific knowledge• communication skills (counseling)
– Taking in consideration: • previous clinical, familiar and reproductive history• values, needs, barriers
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… and so what ?Pr
eval
ence
of A
ROs
by t
ype
Today Tomorrow After tomorrow T i m e
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Pensiamoci Prima
What has been realized ?
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Main products: CME• Direct courses• By cascade courses• Workshops and presentations at National
Obstetric & Gynecology Meetings • Free available set of slides on website• Pubblications
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Main products: guideline• 28 recommendations
– Synthetic statements– Wider explanation on 179 slides, FAQ, literature updating
• Based on: – “Preconception care: a good beginning”. Health Council of the
Netherlands, 2007– Recommendations prepared by a US expert panel Am J Obst &
Gynecol December 2008 Supplement– Updated literature
• Endorsed by 21 scientific societies• Published on June 23, 2009; next review June 2011
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Main products: tools• Tools for clinicians
– How to do… 5 steps for a good preconception counseling– How to do… 5 steps to promote preconception health in my office– Screening questionnaire– Desk top summary memo – Fact sheets to interact with women (couples)
• Tools for public health professionals– Plan to implement preconception care– Questionnaire to evalute knowledge and attitude on CM primary prevention
• Tools for women (couples)– Leaflets – Fact sheets to interact with HCP
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A desk top memo
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• Folic acid• Obesity and overweight• Alcoholic drinks• Medications• Epilepsy• Diabetes
• Immunization– Rubella– Chickenpox
• Toxoplasmosis• CMV
• Previous pregnancies
• Down syndrome
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The leaflet
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The leaflet with sponsor’s space
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The “folic acid” leaflet
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Plans for the future• Direct any effort to reach the disadvantaged groups
• Revision and updating of recommendations
• Translate the recommendations in “simple” messages
• Assist local implementation of preconception care projects and their evaluation
• Continue and improve courses and meetings
• Complete fact sheets series, including anticipatory guidance for pregnancy and delivery
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Credits
FNCO
SIN
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Credits• GLISP – Gruppo di Lavoro Italiano Salute Preconcezionale
– G.Battista Ascone, Roma Dante Baronciani, Modena– Renata Bortolus, Verona Wilma Buffolano, Napoli– Elena Cesari, Gallarate Marco De Santis, Campobasso– Faustina Lalatta, Milano Pierpaolo Mastroiacovo, Roma– Silvana Quadrino, Torino Gioacchino Scarano, Benevento– Alberto Tozzi, Roma
– Simonetta Zezza, Roma
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Thank you
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