are preconception visits covered by insurance

An official website of the United States government

Here's how you know

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• U.S. Department of Health & Human Services

Call the OWH HELPLINE: 1-800-994-9662 9 a.m. — 6 p.m. ET, Monday — Friday OWH and the OWH helpline do not see patients and are unable to: diagnose your medical condition; provide treatment; prescribe medication; or refer you to specialists. The OWH helpline is a resource line. The OWH helpline does not provide medical advice.

Please call 911 or go to the nearest emergency room if you are experiencing a medical emergency.

Preconception health

Preconception health is a woman's health before she becomes pregnant. It means knowing how health conditions and risk factors could affect a woman or her unborn baby if she becomes pregnant. For example, some foods, habits, and medicines can harm your baby — even before he or she is conceived. Some health problems, such as diabetes, also can affect pregnancy.

Why preconception health matters

Every woman should be thinking about her health whether or not she is planning pregnancy. One reason is that about half of all pregnancies are not planned. Unplanned pregnancies are at greater risk of preterm birth and low birth weight babies. Another reason is that, despite important advances in medicine and prenatal care, about 1 in 8 babies is born too early. Researchers are trying to find out why and how to prevent preterm birth. But experts agree that women need to be healthier before becoming pregnant. By taking action on health issues and risks before pregnancy, you can prevent problems that might affect you or your baby later.

Five most important things to boost your preconception health

Women and men should prepare for pregnancy before becoming sexually active — or at least three months before getting pregnant. Some actions, such as quitting smoking, reaching a healthy weight, or adjusting medicines you are using, should start even earlier. The five most important things you can do for preconception health are:

• Take 400 to 800 micrograms (400 to 800 mcg or 0.4 to 0.8 mg) of folic acid every day if you are planning or capable of pregnancy to lower your risk of some birth defects of the brain and spine, including spina bifida . All women need folic acid every day. Talk to your doctor about your folic acid needs. Some doctors prescribe prenatal vitamins that contain higher amounts of folic acid.
• Stop smoking and drinking alcohol.
• If you have a medical condition, be sure it is under control. Some conditions that can affect pregnancy or be affected by it include asthma , diabetes , oral health, obesity , or epilepsy .
• Talk to your doctor about any over-the-counter and prescription medicines you are using. These include dietary or herbal supplements. Be sure your vaccinations are up to date.
• Avoid contact with toxic substances or materials that could cause infection at work and at home. Stay away from chemicals and cat or rodent feces.

Talk to your doctor before you become pregnant

Preconception care can improve your chances of getting pregnant, having a healthy pregnancy, and having a healthy baby. If you are sexually active, talk to your doctor about your preconception health now. Preconception care should begin at least three months before you get pregnant. But some women need more time to get their bodies ready for pregnancy. Be sure to discuss your partner's health too. Ask your doctor about:

• Family planning and birth control.
• Taking folic acid.
• Vaccines and screenings you may need, such as a Pap test and screenings for sexually transmitted infections (STIs), including HIV.
• Managing health problems, such as diabetes, high blood pressure, thyroid disease, obesity, depression, eating disorders, and asthma. Find out how pregnancy may affect, or be affected by, health problems you have.
• Medicines you use, including over-the-counter, herbal, and prescription drugs and supplements.
• Ways to improve your overall health, such as reaching a healthy weight, making healthy food choices, being physically active, caring for your teeth and gums, reducing stress, quitting smoking, and avoiding alcohol.
• How to avoid illness.
• Hazards in your workplace or home that could harm you or your baby.
• Health problems that run in your or your partner's family.
• Problems you have had with prior pregnancies, including preterm birth.
• Family concerns that could affect your health, such as domestic violence or lack of support.

Bring a list of talking points (PDF, 182 KB) to be sure you don't forget anything. If you run out of time at your visit, schedule a follow-up visit to make sure everything is covered.

Your partner's role in preparing for pregnancy

Your partner can do a lot to support and encourage you in every aspect of preparing for pregnancy. Here are some ways:

• Make the decision about pregnancy together. When both partners intend for pregnancy, a woman is more likely to get early prenatal care and avoid risky behaviors such as smoking and drinking alcohol.
• Screening for and treating sexually transmitted infections (STIs) can help make sure infections are not passed to female partners.
• Male partners can improve their own reproductive health and overall health by limiting alcohol, quitting smoking or illegal drug use, making healthy food choices, and reducing stress. Studies show that men who drink a lot, smoke, or use drugs can have problems with their sperm. These might cause you to have problems getting pregnant. If your partner won't quit smoking, ask that he not smoke around you, to avoid harmful effects of secondhand smoke.
• Your partner should also talk to his doctor about his own health, his family health history, and any medicines he uses.
• People who work with chemicals or other toxins can be careful not to expose women to them. For example, people who work with fertilizers or pesticides should change out of dirty clothes before coming near women. They should handle and wash soiled clothes separately.

Genetic counseling

The genes your baby is born with can affect your baby's health in these ways:

• Single gene disorders are caused by a problem in a single gene. Genes contain the information your body's cells need to function. Single gene disorders run in families. Examples of single gene disorders are cystic fibrosis and sickle cell anemia .
• Chromosome disorders occur when all or part of a chromosome is missing or extra, or if the structure of one or more chromosomes is not normal. Chromosomes are structures where genes are located. Most chromosome disorders that involve whole chromosomes do not run in families.

Talk to your doctor about your and your partner's family health histories before becoming pregnant. This information can help your doctor find out any genetic risks you might have.

Depending on your genetic risk factors, your doctor might suggest you meet with a genetic professional. Some reasons a person or couple might seek genetic counseling are:

• A family history of a genetic condition, birth defect, chromosomal disorder, or cancer
• Two or more pregnancy losses, a stillbirth , or a baby who died
• A child with a known inherited disorder, birth defect, or intellectual disability
• A woman who is pregnant or plans to become pregnant at 35 years or older
• Test results that suggest a genetic condition is present
• Increased risk of getting or passing on a genetic disorder because of one's ethnic background
• People related by blood who want to have children together

During a consultation, the genetics professional meets with a person or couple to discuss genetic risks or to diagnose, confirm, or rule out a genetic condition. Sometimes, a couple chooses to have genetic testing. Some tests can help couples to know the chances that a person will get or pass on a genetic disorder. The genetics professional can help couples decide if genetic testing is the right choice for them.

Related information

• Folic acid fact sheet
• Preconception visit – print-and-go guide (PDF, 182 KB)
• Quitting smoking
• HHS Non-Discrimination Notice
• Language Assistance Available
• Accessibility
• Privacy Policy
• Disclaimers
• Freedom of Information Act (FOIA)
• Use Our Content
• Vulnerability Disclosure Policy
• Kreyòl Ayisyen

A federal government website managed by the Office on Women's Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services.

1101 Wootton Pkwy, Rockville, MD 20852 1-800-994-9662 • Monday through Friday, 9 a.m. to 6 p.m. ET (closed on federal holidays).

Your Preconception Checkup

Medical review policy, latest update:.

Medically reviewed to ensure accuracy.

How should I prepare for my preconception checkup?

What tests and screenings will i get at my preconception appointment, read this next, what fertility tests might my doctor do, what vaccines do i need to get before i get pregnant, other appointments to make before getting pregnant.

Remember, even if you've never had a sick day, seeing your doctor(s) and dentist for thorough preconception checkups before you start trying to get pregnant will help ensure that all baby-making systems are go and that you're setting yourself up for a healthy pregnancy and a healthy baby.

Updates history

What our community is talking about, trending on what to expect, early signs of pregnancy, pregnancy calculator, ⚠️ you can't see this cool content because you have ad block enabled., the signs of ovulation to know, prepregnancy diet: best foods to eat when you're trying to get pregnant.

Learn how UpToDate can help you.

Select the option that best describes you

• Medical Professional
• Resident, Fellow, or Student
• Hospital or Institution
• Group Practice
• Patient or Caregiver
• Find in topic

RELATED TOPICS

INTRODUCTION

Barriers to providing preconception care at the office level include time constraints due to competing priorities within the practice setting, lack of resources to assist with conveying information, and lack of adequate reimbursement for screening tests and counseling [ 2 ]. Preconception care screening tools and online informational resources can help with some of these logistics.

At the patient level, it is important to recognize that most females do not schedule a preconception care visit. Factors that facilitate uptake of preconception care include adequate health insurance coverage, the availability of patient informational resources such as brochures and handouts, and waiting room posters outlining the benefits and availability of preconception care consultations. Preconception care may not be an option for patients in some resource-limited areas. In Malawi, for example, it is not a key component of maternal and child health policy. In a study of over 4000 pregnant individuals, nearly two-thirds took no actions to prepare for their pregnancies and among the one-third who did, eating more healthily (72 percent) and saving money (43 percent) were the most common forms of preparation [ 3 ].

This topic will discuss preconception care in cisgender women. Prenatal care is reviewed separately (see "Prenatal care: Initial assessment" and "Prenatal care: Second and third trimesters" ). Reproductive planning in sexual minority women (eg, lesbian, gay, bisexual, transgender, queer, and other women, or LGBTQ+) is also reviewed separately. (See "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care", section on 'Reproductive health and parenting issues' and "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care", section on 'Prevention of unintended pregnancy' .)

TARGET POPULATION

Preconception Health and Health Care

Preconception health focuses on taking steps now to protect the health of a baby in the future. The tips outlined here are beneficial for all people, whether or not they plan to have a baby one day.

What is preconception health and health care?

Tips for women who are planning a pregnancy.

Women and their partners who are thinking about pregnancy should talk with their doctor or healthcare provider about how to prevent Zika.

Treating for Two is an initiative that aims to improve the health of people and their babies by identifying the safest treatment options for common conditions before, during, and after pregnancy.

Fetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person who was exposed to alcohol before birth.

Exit Notification / Disclaimer Policy

• The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
• Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
• You will be subject to the destination website's privacy policy when you follow the link.
• CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

• Getting Pregnant
• Fertility & Family Planning

What Happens at a Preconception Appointment?

If you’re hoping to get pregnant in the near future, it’s a good idea to prepare your body for the journey ahead . One of the first steps? Book yourself a preconception appointment—it’s a great way to start your pregnancy off on a healthy foot. Ahead, read about what to expect from your preconception checkup, how to prepare and what questions to ask your doctor.

What Is a Preconception Checkup?

A preconception checkup is an opportunity to get a holistic view of your own health if you’d like to start trying for a baby. At this appointment, you can “discuss your health history, lifestyle, medications, family history and any other factors that may influence your pregnancy,” explains Nisarg Patel , MBBS, MS, an ob-gyn in Ahmedabad, India. Your doctor will also perform some tests and screenings to assess your overall and reproductive health, giving you the chance to learn about any chronic conditions or medical problems that need to be treated before pregnancy, says Patel.

Abby Eblen , MD, a fertility and in vitro fertilization (IVF) specialist with the Nashville Fertility Center, says your doctor might also check whether your vaccinations are current, and might encourage you to start taking prenatal vitamins , including folic acid . They might also recommend lifestyle changes such as “[stopping smoking], achieving optimal weight, moderate daily exercise and eating a nutrient-rich diet,” she says.

You might choose to see an obstetrician, family physician, maternal-fetal medicine specialist, family nurse practitioner, women’s health nurse practitioner or midwife for your preconception checkup, notes March of Dimes .

How to Prepare for Your Preconception Appointment

In general, this appointment is similar to a regular annual checkup. If you have a medical condition like diabetes, high blood pressure, a heart condition or an autoimmune disorder, Eblen recommends seeing your primary-care physician to make sure you’re ready to become pregnant. “If your medical condition isn’t well controlled, it should be stabilized before conception,” she adds.

Here are some ways you can prepare for your preconception checkup:

• Make a list of medications you’re currently taking. Your provider will review your medications to make sure they’re safe to use during pregnancy, as well as let you know which ones you’ll need to stop taking well before you conceive, says Eblen.
• Know your medical history. Your doctor (especially if you’re meeting with a new one) will want to know about previous illnesses, surgeries and hospitalizations, as well as any allergies, says Patel. Be prepared to talk about your family history as well.
• Know your gynecological history. When was your last period and how regular are your cycles? Have you ever been pregnant before? Have you had an abortion or a miscarriage? Do you take birth control, and if so, what type? These are just some of the preconception checkup questions your provider might ask, notes Patel.
• Gather a list of questions for the doctor. We’ll dive deeper into this one later.

What Tests Happen at a Preconception Appointment?

At your preconception visit, some physicians will perform a basic exam that mirrors an annual physical or well-check, while others might take a more detailed approach. “If you’re not up to date for your yearly checkup, then a breast and pelvic exam will be done,” says Eblen. She notes that your doctor might also perform a pap smear, which can be used as a screening test for cervical cancer. “If you’re 40 or older, it’s important to have a mammogram,” she adds.

Your physician might also order blood tests, which could include the following:

• Antibody titers. These tests check whether you’re immune to certain infections that could be harmful in pregnancy, such as rubella and chickenpox, says Ashley Wiltshire , MD, a reproductive endocrinology and infertility specialist and ob-gyn with the Columbia University Fertility Center. “If you’re non-immune, then the preconception visit would be the perfect time to get vaccinated, as some vaccines are contraindicated in pregnancy,” she says.
• Complete blood count to check blood type. Patel says your doctor could check your blood type and Rh factor —which is important to know before you’re pregnant, since a condition called Rh incompatibility can cause an immune reaction in some pregnant women.
• Genetic carrier screening. This screening is commonly offered to check future parents’ carrier status for a panel of genetic conditions to find out whether baby has a higher likelihood of inheriting a particular condition, says Wiltshire.

Does Fertility Testing Happen at the Preconception Appointment?

If you’ve struggled with your fertility , your provider might choose to do some fertility testing at your preconception appointment.

According to Patel, here are some of the fertility tests you might undergo as a part of your preconception counseling:

• Ovulation test. This test checks when and whether you ovulate by measuring the levels of hormones in your urine or blood.
• Basal body temperature. Your doctor might ask you to take your temperature each morning and chart the results to get a sense of your monthly cycle and when your fertile days are.
• Ovarian reserve. This test checks the quantity and quality of your eggs by measuring the levels of hormones such as follicle-stimulating hormone (FSH), anti-Mullerian hormone (AMH), estradiol and others.
• Tubal patency test. This test checks to see if your fallopian tubes are open and functional by injecting a dye or air into them and taking an X-ray or ultrasound.
• Uterine cavity test. During this test, a provider inserts a thin tube with a camera into your uterus to check for problems such as fibroids, polyps or adhesions.

Does Genetic Testing Happen at the Preconception Appointment?

During a routine preconception checkup, providers typically don’t perform genetic testing unless you have a family history of genetic or chromosomal disorders or birth defects, or you’re part of an ethnic group that is at a higher risk for certain genetic conditions, says Patel.

Patel shares a few of the more common genetic tests your doctor might order if you have a family history of genetic disorders.

• Carrier screening. This genetic test checks whether you or your partner carry any genes that could cause an autosomal recessive disorder, such as cystic fibrosis, sickle cell disease or Tay-Sachs disease.
• Chromosomal analysis. This common genetic test checks if you or your partner have any extra or missing chromosomes that could cause a chromosomal disorder in baby, such as Down syndrome, Turner syndrome or Klinefelter syndrome, among others.
• Preimplantation genetic diagnosis (PGD). If you’re doing IVF, this panel checks to see if your embryos have any genetic or chromosomal abnormalities before transferring them to your uterus.

Preconception Appointment Questions to Ask

Your preconception appointment is a chance to ask your doctor any questions you might have about embarking on your pregnancy journey. Whether you’d like to bring up concerns or fears, discuss your chances of getting pregnant or have any other health questions, now’s the time to ask away—and don’t worry, no question is off the table.

Here are some questions you might want to ask during your preconception counseling appointment, according to Patel.

• How long should I wait after stopping birth control before trying to conceive?
• How can I track my ovulation and find out my fertile window ?
• How often and when should I have sex to increase my chances of getting pregnant?
• What are the symptoms of early pregnancy ?
• What are the recommended vaccinations and supplements before and during pregnancy?
• How often and where will I have my prenatal checkups and tests?
• What are the signs and symptoms of labor ?

Other Appointments to Make Before Pregnancy

Aside from your preconception visit, you might want to make appointments for specific health conditions and concerns if you need them—as well for routine checkups like a dental cleaning that you might not get to during pregnancy. (After all, dental issues are common in pregnant people, and the American College of Obstetricians and Gynecologists (ACOG) says dentist appointments are critical during pregnancy.)

Your preconception checkup is a great opportunity to make sure your health is in order and that you can create the best environment possible for a growing baby. So if you’re thinking of trying to conceive, give your doctor a call.

Please note: The Bump and the materials and information it contains are not intended to, and do not constitute, medical or other health advice or diagnosis and should not be used as such. You should always consult with a qualified physician or health professional about your specific circumstances.

Plus, more from The Bump:

Preconception 101: How to Prepare for Pregnancy

How to Get Pregnant Fast: Tips for Trying to Conceive

10 Things to Avoid When Trying to Conceive

Abby Eblen , MD, is a fertility and IVF specialist with the Nashville Fertility Center in Nashville, Tennessee. She is board-certified in obstetrics and gynecology and subspeciality-certified in reproductive endocrinology and infertility. She earned her medical degree from the University of Tennessee Health Science Center.

Nisarg Patel , MBBS, MS, is an ob-gyn and laparoscopic surgeon in Ahmedabad, India. He practices at the Nisha IVF Centre. He earned his MS in obstetrics and gynecology from the Pravara Institute of Medical Sciences in India.

Ashley Wiltshire , MD, is a reproductive endocrinology and infertility specialist and ob-gyn with the Columbia University Fertility Center. She earned her medical degree from the University of Connecticut School of Medicine.

March of Dimes, Your Checkup Before Pregnancy , September 2020

The American College of Obstetricians and Gynecologists, The Rh Factor: How It Can Affect Your Pregnancy , June 2022

The American College of Obstetricians and Gynecologists, Oral Health Care During Pregnancy and Through the Life Span , August 2013

Learn how we ensure the accuracy of our content through our editorial and medical review process .

Navigate forward to interact with the calendar and select a date. Press the question mark key to get the keyboard shortcuts for changing dates.

Next on Your Reading List

ELIZABETH D. CLOSE, MD, APRIL O. GUNN, DO, AND ALEXANDRIA COOKE, MD

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2023;108(6):605-613

Author disclosure: No relevant financial relationships.

Primary care for women and other patients with similar reproductive potential can include a discussion about pregnancy and, depending on the patient’s intent, contraceptive care or preconception care. Folic acid supplementation of at least 400 mcg per day is recommended to reduce the risk of neural tube defects, because many pregnancies are unplanned. Having a body mass index of 18.5 to 24.9 kg per m 2 before pregnancy also reduces complications. Patients with a history of bariatric surgery should delay pregnancy for at least 12 months post-procedure and ensure that their nutritional status is adequate before conception. It is essential to review the patient’s medications and chronic medical conditions to avoid teratogens and optimize treatment before conception to reduce maternal and fetal morbidity and mortality. Having a prepregnancy A1C level of less than 6.5% is strongly recommended for patients with diabetes mellitus to minimize congenital anomalies and complications. Vaccinations should be updated to prevent adverse outcomes related to infections. Infectious disease screenings should be updated before conception to allow for treatment, prophylaxis, or timing of pregnancy to avoid complications. Screening and counseling should be provided for substance use and potential environmental exposures to identify and mitigate detrimental exposures before pregnancy.

The World Health Organization recognizes preconception care as a way to improve the health of women before pregnancy and to improve pregnancy-related maternal and fetal outcomes. 1 Individuals with reproductive potential should be encouraged during routine visits to develop a reproductive plan, regardless of their intent to become pregnant, because about 45% of pregnancies in the United States are unintended. 2

Preconception counseling can be initiated during any clinical encounter by inquiring whether the patient would like to be pregnant within the next year. 3 For those planning to become pregnant, this can be followed by a discussion about optimizing their health before conception. For those not planning to become pregnant, contraceptive options can be discussed.

Preconception visits for individuals planning a pregnancy should address preventive measures and optimize care of existing conditions. Chronic conditions such as diabetes mellitus, hypertension, thyroid disease, and psychiatric illness typically require medication and treatment evaluation before and during pregnancy. However, women who may become pregnant have often been prescribed high-risk, potentially teratogenic medications without receiving contraception 4 ( Table 1 5 – 16 ) . [corrected] Such medications should be avoided or reduced to the lowest dosage possible if they are essential to control conditions. 2 – 4 Referrals to specialists should be considered before conception to further evaluate patients’ medication regimens if they cannot be discontinued.

Physicians should also screen for sexually transmitted infections and other communicable diseases ( Table 2 17 – 23 ) and update immunizations ( Table 3 24 – 30 ) for patients who desire pregnancy. Other issues that should be addressed during preconception visits include reproductive history, substance use ( Table 4 31 , 32 ) , exposure to environmental hazards ( Table 5 31 , 33 – 35 ) , the need for psychosocial care, and risk of genetic conditions, with appropriate counseling if indicated. 3 , 36 If a patient has potential exposure to environmental hazards, physicians can recommend mitigation and avoidance strategies.

The following is a more detailed discussion of issues commonly encountered in medical visits that should be discussed, when appropriate, during preconception visits. The recommendations are pertinent only to preconception counseling in higher-income countries; the World Health Organization has separate recommendations for lower-income countries. 37 As most of the cited studies and guidelines use the term “women,” this article uses the same term to include cisgender women and other patients with similar reproductive potential. Preconception counseling recommendations for patients with advanced maternal age or those experiencing infertility or recurrent pregnancy loss are not included in this review.

Folic Acid Supplementation

The U.S. Preventive Services Task Force and other groups recommend that all women and others who could become pregnant take supplements containing 400 to 800 mcg of folic acid per day (grade A recommendation) beginning at least one month before conception and continuing through the first two to three months of pregnancy. 36 , 38 , 39 According to the American College of Medical Genetics and Genomics, pregnant individuals at high risk of neural tube defects (due to factors such as obesity, diabetes, or a family history of neural tube defects) should be counseled to take 4,000 mcg of folic acid per day, beginning three months before conception and continuing through the first trimester. 39

Body Mass Index

Prepregnancy body mass index (BMI) affects pregnancy outcomes and infant health outcomes. 40 For example, obesity during pregnancy increases the risk of preeclampsia, large-for-gestational-age infants, shoulder dystocia, cesarean delivery, stillbirth, and neonatal death. Congenital malformations such as neural tube defects, cleft lip and palate, limb reduction, and hydrocephalus are also more commonly reported in pregnancies of patients who are obese. 41

When counseling women who are overweight or obese on weight loss before pregnancy, physicians should explain the benefits of having a BMI of 18.5 to 24.9 kg per m 2 . In these patients, weight loss of 10% can reduce complications of preeclampsia, gestational diabetes, indicated preterm delivery, macrosomia, and stillbirth. 40 , 41 Further reductions of BMI by 20% to 30% reduce the risk of cesarean delivery, shoulder dystocia, neonatal intensive care unit admission, and in-hospital newborn mortality. 40

Preconception counseling for patients who are overweight or obese should include discussion of attainable weight-loss targets before pregnancy and health optimization. Intensive individual counseling, effective dietary support, and behavioral and exercise modification are some of the most effective elements of this planning. 42

Patients should be encouraged to engage in 75 minutes of vigorous activity, or 150 minutes of moderate activity, each week in addition to muscle strengthening sessions at least twice per week. 43 Setting exercise goals in the preconception time frame can help establish expectations for physical activity during pregnancy. Pharmacotherapy or bariatric surgery can also help patients reach a healthy weight before conception.

Preconception use of weight-loss medications should include discussion about the waiting time between medication stoppage and pregnancy. General recommendations based on the pharmacodynamics of glucagon-like peptides in animal studies are to stop use two months before pregnancy. 44 Phentermine hydrochloride/topiramate (Qsymia) should be stopped when a pregnancy is planned or identified, based on topiramate’s known risk for neural tube defects and cleft palate. 45

Bariatric Surgery

Bariatric weight loss procedures, including sleeve gastrectomy, Roux-en-Y gastric bypass, and adjustable gastric band insertion, may be reasonable options for patients with class II obesity with comorbidities (BMI of 35 to 39 kg per m 2 ) or class III obesity (BMI greater than 40 kg per m 2 ). 46 These procedures can lower prepregnancy weight and reduce obesity-related complications. More than 250,000 bariatric surgery procedures are completed annually, and about one-half are in individuals with reproductive potential. 47 , 48

The American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinology, and the American College of Obstetricians and Gynecologists recommend patients avoid pregnancy until 12 to 24 months after bariatric surgery; this is the period of most rapid weight loss and potential nutritional deficiencies. 49 – 52 Small-for-gestational-age infants and preterm births are more common in patients who have had bariatric surgery, whereas rates of preeclampsia and gestational diabetes are lower. 53 , 54 Long-acting reversible contraceptives are likely the most effective contraceptives before and after bariatric surgery; oral contraceptives can have decreased effectiveness due to gastrointestinal malabsorption. 55

Current guidelines for preconception testing in patients who have had bariatric surgery recommend assessment of folate, ferritin, vitamin D, vitamin B 12 , zinc, and calcium levels. 48 , 52 Supplementation should include at least 10 mg of zinc, 1 mg of copper, and a maximum of 5,000 IU of vitamin A as beta carotene per day. Dosages of other supplements should be adjusted to correct any deficiencies based on preconception laboratory testing results. 56

Diabetes Mellitus

Diabetes is an increasingly prevalent condition in individuals of reproductive age, with about 1% of pregnancies in the United States affected by preexisting diabetes. 57 The American Diabetes Association recommends that all women of reproductive age who have diabetes be counseled about the risks of the condition in pregnancy and offered contraception if pregnancy is not desired. However, when pregnancy is desired, physicians should offer contraception until the patient’s A1C level is controlled. An A1C of less than 6.5% is recommended to reduce the risks of macrosomia, preterm birth, perinatal death, and preeclampsia associated with diabetes. 57 , 58 There is also an increased risk of congenital anomalies with prepregnancy diabetes and gestational diabetes, with relative risks of 2.44 and 1.28, respectively. 58 , 59

Preconception screening for diabetic retinopathy is necessary because pregnancy can adversely affect the development and progression of this condition. 58 Many medications used to treat diabetes and its comorbid conditions are not recommended in pregnancy and should be discontinued as part of preconception planning.

Hypertension

In the CHAP (Chronic Hypertension and Pregnancy) trial, patients with blood pressure less than 140/90 mm Hg had fewer adverse outcomes in pregnancy, including preeclampsia with severe features, preterm birth, placental abruption, and fetal death. 60 Therefore, women should be counseled on the risks of uncontrolled hypertension before and during pregnancy, with a goal of obtaining blood pressure control before conception. 60 Women with a diagnosis of hypertension who are also considering pregnancy should begin taking antihypertensives that are safe for use in pregnancy. 61

Thyroid Disease

Uncontrolled thyroid disease has been shown to affect early fetal development and increases the risk of fetal loss. Individuals with thyroid disease who are considering pregnancy should be counseled to delay pregnancy until euthymia is achieved to minimize risk to the fetus. A patient on thyroid replacement therapy with stable hypothyroidism should increase their medication by two additional doses per week if pregnancy is identified and contact their physician. 62 , 63

For hyperthyroidism, management focuses on achieving euthymia and minimizing exposure to antithyroid medications. 62 If definitive therapy with radioactive iodine ablation is performed, patients should be counseled to avoid pregnancy for six months after. If medical treatment is preferred, methimazole may be continued until conception and then patients would be transitioned to propylthiouracil for the duration of the first trimester. 63 Methimazole is contraindicated during the first trimester due to teratogenic risk, but it can be safely used during the second and third trimesters. 63

Intimate Partner Violence

The U.S. Preventive Services Task Force issued a grade B recommendation to screen all women of reproductive age for intimate partner violence and offer referral or provide ongoing support services to patients who screen positive. 64 Several screening tools are available for intimate partner violence including HITS (hurt, insult, threaten, scream); WAST (woman abuse screening tool); and STaT (slap, threaten, and throw). 64 A previous American Family Physician article ( https://www.aafp.org/pubs/afp/issues/2016/1015/p646.html ) provides examples of these screening instruments.

For cisgender women and transgender men of childbearing potential with HIV infection, primary care physicians should discuss the desire for pregnancy regularly and provide treatment with effective antiretroviral therapy (ART). 65 Effective treatment significantly minimizes the risk of vertical transmission to the infant.

HIV treatment should be individualized and focus on maintaining an undetectable viral load before and during pregnancy with continued use of ART; preexposure prophylaxis should be offered to partners before conception. 65 Alternatively, reliable contraception should be offered when pregnancy is not desired. Patients with HIV infection should be counseled on the decreased effectiveness of combined oral contraception and ART. 65

It should be noted that the ART agent dolutegravir has been associated with neural tube defects. An alternative ART agent may be appropriate in those planning to conceive and should be discussed with the patient and an HIV specialist.

This article updates previous articles on this topic by Farahi and Zolotor , 66 Lu , 67 and Brundage . 68

Data Sources: We searched databases of the American Academy of Family Physicians, PubMed, Cochrane Library, American College of Obstetricians and Gynecologists, Centers for Disease Control and Prevention, Women’s Preventive Services Initiative, Essential Evidence Plus (provided by editorial staff), American Diabetes Association Standards of Care, and U.S. Preventive Services Task Force on the following terms: preconception counseling, preconception care, prepregnancy counseling, prepregnancy care, reproductive health, immunizations, screening guidelines alone and in conjunction with chronic diseases including diabetes, hepatitis, HIV, obesity, bariatric surgery, thyroid disease, and infectious disease. Search dates: November 2022; January 19, 2023; February 9 and 22, 2023; and October 27, 2023.

World Health Organization. Preconception care: maximizing the gains for maternal and child health. Policy brief. Geneva 2013. Accessed October 27, 2023. https://www.who.int/publications/i/item/WHO-FWC-MCA-13.02

Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843-852.

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 762: prepregnancy counseling. Obstet Gynecol. 2019;133(1):e78-e89.

Panchal BD, Cash R, Moreno C, et al. High-risk medication prescriptions in primary care for women without documented contraception. J Am Board Fam Med. 2019;32(4):474-480.

Cragan JD, Friedman JM, Holmes LB, et al. Ensuring the safe and effective use of medications during pregnancy: planning and prevention through preconception care. Matern Child Health J. 2006;10(5 suppl):S129-S135.

Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114(3):703-713.

Gluck JC, Gluck PA. Asthma controller therapy during pregnancy. Am J Obstet Gynecol. 2005;192(2):369-380.

Anderson KN, Dutton AC, Broussard CS, et al. ADHD medication use during pregnancy and risk for selected birth defects: National Birth Defects Prevention Study, 1998–2011. J Atten Disord. 2020;24(3):479-489.

Huybrechts KF, Hernández-Díaz S, Patorno E, et al. Antipsychotic use in pregnancy and the risk for congenital malformations. JAMA Psychiatry. 2016;73(9):938-946.

ElSayed NA, Aleppo G, Aroda VR, et al.; on behalf of the American Diabetes Association. 15. Management of diabetes in pregnancy: standards of care in diabetes-2023. Diabetes Care. 2023;46(suppl 1):S254-S266.

ElSayed NA, Aleppo G, Aroda VR, et al.; on behalf of the American Diabetes Association. 10. Cardiovascular disease and risk management: standards of care in diabetes-2023 [published correction appears in Diabetes Care . 2023; 46(4): 898]. Diabetes Care. 2023;46(suppl 1):S158-S190.

Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum [published correction appears in Thyroid . 2017; 27(9): 1212]. Thyroid. 2017;27(3):315-389.

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017;130(2):e81-e94.

Harden CL, Hopp J, Ting TY, et al.; American Academy of Neurology; American Epilepsy Society. Practice parameter update: management issues for women with epilepsy—focus on pregnancy (an evidence-based review): obstetrical complications and change in seizure frequency: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009;73(2):126-132.

Beyer-Westendorf J, Tittl L, Bistervels I, et al. Safety of direct oral anticoagulant exposure during pregnancy: a retrospective cohort study. Lancet Haematol. 2020;7(12):e884-e891.

Silver RM, Warren JE. Preconception counseling for women with thrombophilia. Clin Obstet Gynecol. 2006;49(4):906-919.

U.S. Preventive Services Task Force. Chlamydia and gonorrhea: screening. September 14, 2021. Accessed January 19, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening

U.S. Preventive Services Task Force. Genital herpes infection: serologic screening. February 14, 2023. Accessed October 27, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/genital-herpes-serologic-screening

U.S. Preventive Services Task Force. Hepatitis B virus infection in adolescents and adults: screening. December 15, 2020. Accessed January 19, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-screening

U.S. Preventive Services Task Force. Hepatitis C virus infection in adolescents and adults: screening. March 2, 2020. Accessed January 19, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening

U.S. Preventive Services Task Force. Human immunodeficiency virus (HIV) infection: screening. June 11, 2019. Accessed January 19, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/human-immunodeficiency-virus-hiv-infection-screening

U.S. Preventive Services Task Force. Syphilis infection in nonpregnant adolescents and adults: screening. September 27, 2022. Accessed January 19, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/syphilis-infection-nonpregnant-adults-adolescents-screening

U.S. Preventive Services Task Force. Latent tuberculosis infection in adults: screening. May 2, 2023. Accessed October 27, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening

Weng MK, Doshani M, Khan MA, et al. Universal hepatitis B vaccination in adults aged 19–59 years: updated recommendations of the Advisory Committee on Immunization Practices - United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(13):477-483.

Grohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices - United States, 2022–23 influenza season. MMWR Recomm Rep. 2022;71(1):1-28.

McLean HQ, Fiebelkorn AP, Temte JL, et al.; Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP) [published correction appears in MMWR Recomm Rep . 2015; 64(9): 259]. MMWR Recomm Rep. 2013;62(RR-04):1-34.

Marin M, Güris D, Chaves SS, et al.; Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention (CDC). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):1-40.

Centers for Disease Control and Prevention. Adult immunization schedule by age. Accessed January 19, 2023. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

Meites E, Szilagyi PG, Chesson HW, et al. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68(32):698-702.

Centers for Disease Control and Prevention. COVID-19 vaccines for people who would like to have a baby. Updated September 22, 2023. Accessed October 27, 2023. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/planning-for-pregnancy.html

Lassi ZS, Imam AM, Dean SV, et al. Preconception care: caffeine, smoking, alcohol, drugs and other environmental chemical/radiation exposure. Reprod Health. 2014;11(suppl 3):S6.

Lo JO, Hedges JC, Girardi G. Impact of cannabinoids on pregnancy, reproductive health, and offspring outcomes. Am J Obstet Gynecol. 2022;227(4):571-581.

Sathyanarayana S, Focareta J, Dailey T, et al. Environmental exposures: how to counsel preconception and prenatal patients in the clinical setting. Am J Obstet Gynecol. 2012;207(6):463-470.

American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Reducing prenatal exposure to toxic environmental agents: ACOG committee opinion, number 832. Obstet Gynecol. 2021;138(1):e40-e54.

Segal TR, Giudice LC. Before the beginning: environmental exposures and reproductive and obstetrical outcomes. Fertil Steril. 2019;112(4):613-621.

Raghuraman N, Tuuli MG. Preconception care as an opportunity to optimize pregnancy outcomes. JAMA. 2021;326(1):79-80.

World Health Organization. Preconception care to reduce maternal and childhood mortality and morbidity: policy brief. 2013. Accessed October 27, 2023. https://iris.who.int/handle/10665/340533

U.S. Preventive Services Task Force. Folic acid supplementation to prevent neural tube defects: preventive medication. August 1, 2023. Accessed October 27, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication

Prasad P, Mori M, Toriello HV; ACMG Professional Practice and Guidelines Committee. Focused Revision: policy statement on folic acid and neural tube defects [published correction appears in Genet Med . 2021; 23(12): 2469]. Genet Med. 2021;23(12):2464-2466.

Schummers L, Hutcheon JA, Bodnar LM, et al. Risk of adverse pregnancy outcomes by prepregnancy body mass index: a population-based study to inform prepregnancy weight loss counseling. Obstet Gynecol. 2015;125(1):133-143.

Delcore L, Lacoursiere DY. Preconception care of the obese woman. Clin Obstet Gynecol. 2016;59(1):129-139.

Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-2171.

Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for Americans. JAMA. 2018;320(19):2020-2028.

Ozempic highlights of prescribing information. Accessed February 22, 2023. https://www.ozempic.com/prescribing-information.html

Bjørk MH, Zoega H, Leinonen MK, et al. Association of prenatal exposure to antiseizure medication with risk of autism and intellectual disability [published correction appears in JAMA Neurol . 2022; 79(7): 727]. JAMA Neurol. 2022;79(7):672-681.

Banerjee ES, Schroeder R, Harrison TD. Metabolic surgery for adult obesity: common questions and answers. Am Fam Physician. 2022;105(6):593-601.

American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011–2021. June 2022.Accessed February 23, 2023. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers

Ciangura C, Coupaye M, Deruelle P, et al.; BARIA-MAT Group. Clinical practice guidelines for childbearing female candidates for bariatric surgery, pregnancy, and post-partum management after bariatric surgery [published correction appears in Obes Surg . 2020; 30(9): 3650–3651]. Obes Surg. 2019;29(11):3722-3734.

Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741.

Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Endocr Pract. 2013;19(2):337-372.

American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol. 2009;113(6):1405-1413.

Chapmon K, Stoklossa CJ, Benson-Davies S; Integrated Health Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. Nutrition for pregnancy after metabolic and bariatric surgery: literature review and practical guide. Surg Obes Relat Dis. 2022;18(6):820-830.

Galazis N, Docheva N, Simillis C, et al. Maternal and neonatal outcomes in women undergoing bariatric surgery: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2014;181:45-53.

Alamri SH, Abdeen GN. Maternal nutritional status and pregnancy outcomes post-bariatric surgery. Obes Surg. 2022;32(4):1325-1340.

Shawe J, Ceulemans D, Akhter Z, et al. Pregnancy after bariatric surgery: consensus recommendations for periconception, antenatal and postnatal care. Obes Rev. 2019;20(11):1507-1522.

Snoek K, van de Woestijne N, Willemsen S, et al. The impact of preconception gastric bypass surgery on maternal micronutrient status before and during pregnancy: a retrospective cohort study in the Netherlands between 2009 and 2019. Nutrients. 2022;14(4):736.

Alexopoulos AS, Blair R, Peters AL. Management of preexisting diabetes in pregnancy: a review. JAMA. 2019;321(18):1811-1819.

American Diabetes Association. Standards of care in diabetes-2023 abridged for primary care providers [published correction appears in Clin Diabetes . 2023; 41(2): 328]. Clin Diabetes. 2022;41(1):4-31.

Wu Y, Liu B, Sun Y, et al. Association of maternal prepregnancy diabetes and gestational diabetes mellitus with congenital anomalies of the newborn. Diabetes Care. 2020;43(12):2983-2990.

Tita AT, Szychowski JM, Boggess K, et al.; Chronic Hypertension and Pregnancy (CHAP) Trial Consortium. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386(19):1781-1792.

Ogunwole SM, Chen X, Mitta S, et al. Interconception care for primary care providers: consensus recommendations on preconception and postpartum management of reproductive-age patients with medical comorbidities. Mayo Clin Proc Innov Qual Outcomes. 2021;5(5):872-890.

Wilson SA, Stem LA, Bruehlman RD. Hypothyroidism: diagnosis and treatment. Am Fam Physician. 2021;103(10):605-613.

Okosieme OE, Khan I, Taylor PN. Preconception management of thyroid dysfunction. Clin Endocrinol (Oxf). 2018;89(3):269-279.

U.S. Preventive Services Task Force. Intimate partner violence, elder abuse, and abuse of vulnerable adults: screening. October 23, 2018. Accessed May 5, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening

Thompson MA, Horberg MA, Agwu AL, et al. Primary care guidance for persons with human immunodeficiency virus: 2020 update by the HIV Medicine Association of the Infectious Diseases Society of America [published corrections appear in Clin Infect Dis . 2022; 74(10): 1893–1898, and Clin Infect Dis . 2022; 75(11): 2052]. Clin Infect Dis. 2021;73(11):e3572-e3605.

Farahi N, Zolotor A. Recommendations for preconception counseling and care. Am Fam Physician. 2013;88(8):499-506.

Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76(3):397-400.

Brundage SC. Preconception health care. Am Fam Physician. 2002;65(12):2507-2515.

Continue Reading

More in AFP

More in pubmed.

Copyright © 2023 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Preconception Care: In the Continuum of Women’s Healthcare

• Reference work entry
• First Online: 02 December 2023
• Cite this reference work entry

• Megan Bernstein 2 ,
• Yalda Afshar 2 &
• Christina S. Han 2  

344 Accesses

The goals of preconception care are (1) to identify potential risks to the mother, fetus, and pregnancy, (2) to educate the individual about these risks and provide options for intervention and management, and (3) to initiate interventions to provide optimal maternal, fetal, and pregnancy outcomes. Preconception counseling involves interventions that include health education and counseling related to reproductive risks and optimizing the control of medical disorders. If pregnancy is not desired, then contraceptive options should be discussed as preconception care begins with family planning to optimize the timing and intention of pregnancy. As such, all people with the potential to become pregnant should develop a reproductive health plan in the context of their personal reproductive and sexual health needs. Evidence supports an association between preconception counseling and positive changes in maternal behavior before and during pregnancy.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Durable hardcover edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

ACOG Committee Opinion. Exercise during pregnancy and the postpartum period. Number 267, January 2002. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2002;77(1):79–81.

Article   Google Scholar  

ACOG Committee Opinion No. 691. Carrier screening for genetic conditions. 2017. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/03/carrier-screening-for-genetic-conditions

ACOG Committee opinion no. 549: obesity in pregnancy. Obstet Gynecol. 2013;121(1):213–7.

ACOG Committee Opinion No. 762. Prepregnancy counseling. Obstet Gynecol. 2019;133(10):e78–89.

Google Scholar  

ACOG Practice Advisory. Novel coronavirus 2019 (COVID-19). 2020. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019

ACOG Practice Advisory. COVID-19 vaccination considerations for obstetric–gynecologic care. 2021. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/covid-19-vaccination-considerations-for-obstetric-gynecologic-care

ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstet Gynecol. 2005;105(3):675–85.

Baishya J, Jose M, Reshma AS, Sarma PS, Thomas SV. Do women with epilepsy benefit from epilepsy specific pre-conception care? Epilepsy Res. 2020;160:106260. https://doi.org/10.1016/j.eplepsyres.2019.106260 . Epub 2019 Dec 23.

Article   CAS   PubMed   Google Scholar  

Bateman BT, Bansil P, Hernandez-Diaz S, Mhyre JM, Callaghan WM, Kuklina EV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol. 2012;206(134):e1–8.

Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet. 2009;373(9677):1773–9.

Camprubi C, Iglesias-Platas I, Martin-Trujillo A, Salvador-Alarcon C, Rodriguez MA, Barredo DR, Court F, Monk D. Stability of genomic imprinting and gestational-age dynamic methylation in complicated pregnancies conceived following assisted reproductive technologies. Biol Reprod. 2013;89(3):50.

Article   PubMed   Google Scholar  

Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, Mital S, Rose C, Silversides C, Stout K, American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; Council on Functional Genomics and Translational Biology; and Council on Quality of Care and Outcomes Research. Management of pregnancy in patients with complex congenital heart disease: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2017;135(8):e50–87. https://doi.org/10.1161/CIR.0000000000000458 . Epub 2017 Jan 12.

Carlotti K, Hines K, Weida J, Lah M, Schwantes-An TH. Perceived barriers to paternal expanded carrier screening following a positive maternal result: to screen or not to screen. J Genet Couns. 2021;30(2):470–7. https://doi.org/10.1002/jgc4.1333 . Epub 2020 Oct 3.

Committee opinion No. 478: Family history as a risk assessment tool. Obstet Gynecol. 2011;117(3):747–50.

Cornish J, Tan E, Teare J, Teoh TG, Rai R, Clark SK, Tekkis PP. A meta-analysis on the influence of inflammatory bowel disease on pregnancy. Gut. 2007;56(6):830–7.

Cunningham FG, Leveno KJ. Childbearing among older women – the message is cautiously optimistic. N Engl J Med. 1995;333(15):1002–4.

Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J Med. 1992;327(26):1832–5.

Dolan SM, Moore C. Linking family history in obstetric and pediatric care: assessing risk for genetic disease and birth defects. Pediatrics. 2007;120(Suppl 2):S66–70.

Dombrowski MP, Schatz M. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy. Obstet Gynecol. 2008;111(2 Pt 1):457–64.

PubMed   Google Scholar  

Elsinga J, de Jong-Potjer LC, van der Pal-de Bruin KM, le Cessie S, Assendelft WJ, Buitendijk SE. The effect of preconception counselling on lifestyle and other behaviour before and during pregnancy. Womens Health Issues. 2008;18(6 Suppl):S117–25.

Finer LJ, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. NEJM. 2016;374(9):843–52.

Fitzpatrick DL, Russell MA. Diagnosis and management of thyroid disease in pregnancy. Obstet Gynecol Clin N Am. 2010;37(2):173–93.

Frost JJ, Darroch JE, Remez L. Improving contraceptive use in the United States. Issues Brief (Alan Guttmacher Inst). 2008;1:1–8.

Getahun D, Fassett MJ, Longstreth GF, Koebnick C, Langer-Gould AM, Strickland D, Jacobsen SJ. Association between maternal inflammatory bowel disease and adverse perinatal outcomes. J Perinatol. 2014;34(6):435–40.

Grainger DA, Frazier LM, Rowland CA. Preconception care and treatment with assisted reproductive technologies. Matern Child Health J. 2006;10(5 Suppl):S161–4.

Gray KJ, Bordt EA, Atyeo C, Deriso E, Akinwunmi B, Young N, Baez AM, Shook LL, Cvrk D, James K, De Guzman R, Brigida S, Diouf K, Goldfarb I, Bebell LM, Yonker LM, Fasano A, Rabi SA, Elovitz MA, Alter G, Edlow AG. Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol. 2021; https://doi.org/10.1016/j.ajog.2021.03.023 . S0002-9378(21)00187-3. Epub ahead of print. PMID: 33775692; PMCID: PMC7997025.

Green DM, Whitton JA, Stovall M, Mertens AC, Donaldson SS, Ruymann FB, Pendergrass TW, Robison LL. Pregnancy outcome of female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Am J Obstet Gynecol. 2002;187(4):1070–80.

Hadar E, Ashwal E, Hod M. The preconceptional period as an opportunity for prediction and prevention of noncommunicable disease. Best Pract Res Clin Obstet Gynaecol. 2015;29(1):54–62.

Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief. 2020;360:1–8.

JGDC. Jewish Genetic Disease Consortium. 2015. Retrieved November 2015, from http://www.jewishgeneticdiseases.org/genetics-and-carrier-screening/ .

Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG, C. A. P. C. W. Group and C. Select Panel on Preconception. Recommendations to improve preconception health and health care – United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006;55(RR-6):1–23.

Kwon HL, Belanger K, Bracken MB. Asthma prevalence among pregnant and childbearing-aged women in the United States: estimates from national health surveys. Ann Epidemiol. 2003;13(5):317–24.

Lockwood CJ. Heritable coagulopathies in pregnancy. Obstet Gynecol Surv. 1999;54(12):754–65.

Mahadevan U, Robinson C, Bernasko N, Boland B, Chambers C, Dubinsky M, Jain R. Inflammatory bowel disease in pregnancy clinical care pathway: a report from the American Gastroenterological Association IBD Parenthood Project Working Group. Inflamm Bowel Dis. 2019;25(4):627–41.

McDiarmid MA, Gardiner PM, Jack BW. The clinical content of preconception care: environmental exposures. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S357–61.

Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, Coustan DR, Hadden DR, McCance DR, Hod M, McIntyre HD, Oats JJ, Persson B, Rogers MS, Sacks DA. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002.

Moos MK, Bangdiwala SI, Meibohm AR, Cefalo RC. The impact of a preconceptional health promotion program on intendedness of pregnancy. Am J Perinatol. 1996;13(2):103–8.

NCHPEG. National coalition for health professional education in genetics. Genetic red flags: quick tips for risk assessment; 2015.

Owe KM, Nystad W, Bø K. Correlates of regular exercise during pregnancy: the Norwegian Mother and Child Cohort Study. Scand J Med Sci Sports. 2009;19(5):637–45.

Rollins LG, Sokol NA, McCallum M, England L, Matteson K, Werner E, Stroud LR. Electronic cigarette use during preconception and/or pregnancy: prevalence, characteristics, and concurrent mental health conditions. J Womens Health (Larchmt). 2020;29(6):780–8. https://doi.org/10.1089/jwh.2019.8089 . Epub 2020 Feb 28. PMID: 32109175; PMCID: PMC7307667.

Sathyanarayana S, Focareta J, Dailey T, Buchanan S. Environmental exposures: how to counsel preconception and prenatal patients in the clinical setting. Am J Obstet Gynecol. 2012;207(6):463–70.

Short VL, Hand DJ, Gannon M, Abatemarco DJ. Maternal characteristics associated with preconception Marijuana use. Am J Prev Med. 2020;59(4):555–61. https://doi.org/10.1016/j.amepre.2020.04.010 . Epub 2020 Aug 12

Sibai BM, Anderson GD. Pregnancy outcome of intensive therapy in severe hypertension in first trimester. Obstet Gynecol. 1986;67(4):517–22.

CAS   PubMed   Google Scholar  

Signorello LB, Mulvihill JJ, Green DM, Munro HM, Stovall M, Weathers RE, Mertens AC, Whitton JA, Robison LL, Boice JD Jr. Stillbirth and neonatal death in relation to radiation exposure before conception: a retrospective cohort study. Lancet. 2010;376(9741):624–30.

Article   PubMed   PubMed Central   Google Scholar  

Simeone RM, Shapiro-Mendoza CK, Meaney-Delman D, Petersen EE, Galang RR, Oduyebo T, Rivera-Garcia B, Valencia-Prado M, Newsome KB, Perez-Padilla J, Williams TR, Biggerstaff M, Jamieson DJ, Honein MA, Zika GP, Working F, Ahmed S, Anesi KE, Arnold D, Barradas D, Barter J, Bertolli AM, Bingham J, Bollock T, Bosse KK, Bradley D, Brady CM, Brown K, Bryan V, Buchanan PD, Bullard A, Carrigan M, Clouse S, Cook M, Cooper S, Davidson A, DeBarr T, Dobbs T, Dunams J, Eason A, Eckert P, Eggers SR, Ellington A, Feldpausch CR, Fredette J, Gabel M, Glover M, Gosciminski M, Gay R, Haddock S, Hand J, Hardy ME, Hartel AK, Hennenfent SL, Hills J, House I, Igbinosa L, Im H, Jeff S, Khan L, Kightlinger JY, Ko S, Koirala L, Korhonen V, Krishnasamy K, Kurkjian M, Lampe S, Larson EH, Lee L, Lind S, Lindquist J, Long J, Macdonald J, MacFarquhar DP, Mackie M, Mark-Carew B, Martin A, Martinez-Quinones J, Matthews-Greer SA, McGee J, McLaughlin V, Mock E, Muna H, Oltean J, O’Mallan HP, Pagano SY, Park D, Peterson KN, Polen CC, Porse CY, Rao A, Ropri J, Rinsky S, Robinson AY, Rosinger I, Ruberto E, Schiffman C, Scott-Waldron S, Semple T, Sharp K, Short K, Signs SA, Slavinski T, Stevens J, Sweatlock EA, Talbot J, Tonzel R, Traxler S, Van Tubach C, Houten E, VinHatton M, Viray D, Virginie MD, Warren C, Waters P, White T, Williams AI, Winters, Wood S, Zaganjor I. Possible Zika virus infection among pregnant women – United States and Territories, May 2016. MMWR Morb Mortal Wkly Rep. 2016;65(20):514–9.

Sistersong. What is reproductive justice? October 31, 2020. https://www.sistersong.net/reproductive-justice .

Stagnaro-Green A, Pearce E. Thyroid disorders in pregnancy. Nat Rev Endocrinol. 2012;8(11):650–8.

Williams JF, Smith VC. Fetal alcohol spectrum disorders. Pediatrics. 2015;136(5):e1395–406.

Wilson RD, Davies G, Desilets V, Reid GJ, Summers A, Wyatt P, Young D. The use of folic acid for the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can. 2003;25(11):959–73.

Xanthakos SA, Inge TH. Nutritional consequences of bariatric surgery. Curr Opin Clin Nutr Metab Care. 2006;9(4):489–96.

Yoon PW. The family history public health initiative. Atlanta: CDC; 2004.

Download references

Author information

Authors and affiliations.

Division of Maternal Fetal Medicine; Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA

Megan Bernstein, Yalda Afshar & Christina S. Han

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Yalda Afshar .

Editor information

Editors and affiliations.

Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Donna Shoupe

Rights and permissions

Reprints and permissions

Copyright information

© 2023 Springer Nature Switzerland AG

About this entry

Cite this entry.

Bernstein, M., Afshar, Y., Han, C.S. (2023). Preconception Care: In the Continuum of Women’s Healthcare. In: Shoupe, D. (eds) Handbook of Gynecology. Springer, Cham. https://doi.org/10.1007/978-3-031-14881-1_18

Download citation

DOI : https://doi.org/10.1007/978-3-031-14881-1_18

Published : 02 December 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-031-14880-4

Online ISBN : 978-3-031-14881-1

eBook Packages : Medicine Reference Module Medicine

Share this entry

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• J Womens Health (Larchmt)

Insurance Differences in Preventive Care Use and Adverse Birth Outcomes Among Pregnant Women in a Medicaid Nonexpansion State: A Retrospective Cohort Study

Yhenneko j. taylor.

1 Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina.

Tsai-Ling Liu

Elizabeth a. howell.

2 Department of Population Health Science and Policy, Department of Obstetrics, Gynecology, and Reproductive Science, and the Blavatnik Family Women's Health Research Institute at the Icahn School of Medicine at Mount Sinai, New York, New York.

Background: Lack of quality preventive care has been associated with poorer outcomes for pregnant women with low incomes. Health policy changes implemented with the Affordable Care Act (ACA) were designed to improve access to care. However, insurance coverage remains lower among women in Medicaid nonexpansion states. We compared health care use and adverse birth outcomes by insurance status among women giving birth in a large health system in a Medicaid nonexpansion state.

Materials and Methods: We conducted a population-based retrospective cohort study using data for 9,613 women with deliveries during 2014–2015 at six hospitals associated with a large vertically integrated health care system in North Carolina. Adjusted logistic regression and zero-inflated negative binomial models examined associations between insurance status at delivery (commercial, Medicaid, or uninsured) and health care utilization (well-woman visits, late prenatal care, adequacy of prenatal care, postpartum follow-up, and emergency department [ED] visits) and outcomes (preterm birth, low birth weight, preeclampsia, and gestational diabetes).

Results: Having Medicaid at delivery was associated with lower rates of well-woman visits (rate ratio [RR] 0.25, 95% CI 0.23–0.28), higher rates of ED visits (RR 2.93, 95% CI 2.64–3.25), and higher odds of late prenatal care (odds ratio [OR] 1.18, 95% CI 1.03–1.34) compared to having commercial insurance, with similar results for uninsured women. Differences in adverse pregnancy outcomes were not statistically significant after adjusting for patient characteristics.

Conclusions: Findings suggest that large gaps exist in use of preventive care between Medicaid/uninsured and commercially insured women. Policymakers should consider ways to improve potential and realized access to care.

Introduction

The United States has the highest maternal mortality rate in the developed world with an estimated 26.4 deaths per 100,000 live births in 2015 and is one of the few countries where maternal mortality is increasing. 1 Similarly, rates of severe maternal morbidity, life threatening complications associated with delivery, are increasing. 2 These increases and stark disparities in maternal morbidity and mortality have heightened focus on understanding and addressing the causes of poor pregnancy outcomes among women, especially those from marginalized groups. 3 , 4 Current evidence suggests that variations in obstetric care, high rates of chronic disease before pregnancy, and limitations in data sources for measuring maternal mortality are major contributing factors to this upward trend. 5 Improving the quality of care received before, during, and after pregnancy is an important modifiable target for intervention. 3 , 6 Among low-income women, availability and access to care are additional concerns.

Low-income women have lower rates of preventive care. Barriers include lack of insurance, inability to afford care, no usual source of care, problems obtaining transportation, and poor experiences with the health care system. 7 When low-income women do seek care, it may occur only after they realize that they are pregnant, 8 , 9 and care may be of low quality. With limited access to prenatal and primary care, maternal complications amenable to prevention can result in hospitalizations and higher costs. 10 Prior research also suggests that women with lower incomes may experience insurance-based discrimination during prenatal care, labor, and delivery. 11 , 12

The 2010 Affordable Care Act (ACA) sought to address gaps in access to care by expanding insurance coverage for individuals with low incomes. The ACA also mandated coverage for preventive care, including prenatal care. Among states that expanded Medicaid, some researchers have found higher use of preventive care 13 , 14 and increases in timely prenatal care 15 among insured women, while others found no early impact. 16 Evidence exists that women who have insurance in the preconception period are more likely to initiate prenatal care in the first trimester and have lower risk of adverse birth outcomes such as preterm births. 9 , 17 However, few studies have examined the role of insurance in pregnancy-related health care use and outcomes in a Medicaid nonexpansion state.

The goal of this study was to compare health care use and adverse pregnancy outcomes by insurance status among women giving birth following the implementation of the ACA in 2014. We hypothesized that use of prenatal and postpartum care would be lower, while use of emergency care would be higher for women with Medicaid or no insurance compared to women with commercial insurance. We also hypothesized that adverse pregnancy outcomes would be higher for uninsured and Medicaid-insured women in comparison to commercially insured women. While prior research has examined variations in prenatal care use by income and insurance, the current study provides new evidence regarding differences in health care use between women with commercial insurance and those with Medicaid or no insurance during the prenatal and postpartum periods for pregnant women in a Medicaid nonexpansion state.

Materials and Methods

Setting and data sources.

This study was conducted in North Carolina, one of 26 U.S. states that opted out of an expansion of Medicaid when the ACA was first approved and one of 14 states that still have not adopted the Medicaid expansion. 18 In North Carolina, pregnant women are eligible for Medicaid coverage if their monthly family income is less than 196% of the federal poverty level ($3,961 a month for a family of four in 2015), and coverage is limited to conditions that affect the pregnancy. 19 Nondisabled adults are eligible for coverage outside of pregnancy if they are parents or a caretaker of a dependent child and have a family income of less than $744 a month for a family of four. While only 11.4% of North Carolina's population was uninsured in 2014–2015, 18.5% of women aged 18–44 were uninsured and 18.2% of those with coverage had Medicaid (authors' analysis of data from the U.S. Census Bureau Current Population Survey's 2014–2015 Annual Social and Economic Supplement, available at www.census.gov/cps/data/cpstablecreator.html ).

We conducted a population-based retrospective cohort study using data from the Atrium Health electronic data warehouse, a centralized data repository that includes clinical and billing data from all hospitals and physician offices affiliated with the large vertically integrated health care system based in North Carolina. The electronic data warehouse contains a wide range of data on: (i) patient demographics such as age, race/ethnicity, gender, and health insurance status; (ii) health care encounters, including admission and discharge dates and diagnosis and procedure codes; and (iii) laboratory results. Data for this study came from six Atrium Health hospitals serving Mecklenburg County, a large metropolitan county with a population of over one million. These facilities include a Level I trauma center, which also serves as an academic medical center, a Level III trauma center, two community hospitals, and two specialty care hospitals with a combined total of 2,067 beds. Patient addresses were geocoded and linked by census tract to neighborhood poverty rates and high school graduation rates from the 2011 to 2015 American Community Survey ( www.census.gov/programs-surveys/acs ). The Atrium Health Institutional Review Board approved this study and granted a waiver of informed consent.

Study sample

The study cohort consisted of 14,130 women aged 18 and older, who had a live birth during 2014–2015 and resided in Mecklenburg County. Women were excluded from the analysis for the following reasons: (i) gestational age at delivery missing or >42 weeks ( n  = 2,056); (ii) invalid address ( n  = 987); (iii) no documented prenatal care visits ( n  = 1,403 women who may have received care in other settings that our data did not capture); (iv) insurance status not classified as commercial, Medicaid, or uninsured ( n  = 55); (v) missing neighborhood-level data ( n  = 7); or (vi) missing body mass index ( n  = 9). The final analytic sample included 9,613 women. For women with more than one delivery during the study period, we included only the first delivery in our analysis.

We examined five measures of health care use: number of well-woman visits (in the two-year period before pregnancy), timing of prenatal care (care initiated in first, second, or third trimester), adequacy of prenatal care, six-week postpartum follow-up visit, and number of emergency department (ED) visits during pregnancy. International Classification of Disease (ICD) ninth and tenth revision codes were used to identify well-woman (V70.0, V72.31, V72.32, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42), prenatal care (V22.1, V22.0, V23.9, Z34.xx), and postpartum (V24.2, Z39.2) visits. Adequacy of prenatal care was defined using the Adequacy of Prenatal Care Utilization (APNCU) index, which determines adequacy of prenatal care based on timely initiation of care and percentage of expected visits completed. 20 The four categories of care range from inadequate to adequate plus. We counted all ED visits (for any reason) that occurred between the time of conception and delivery as determined by gestational age at delivery. We examined the following adverse pregnancy outcomes that are potential targets for prevention and quality improvement 21–26 : low birth weight (based on birth weight <2,500 g), preterm birth (based on gestational age <37 weeks), preeclampsia (ICD-9: 642.4x, 642.5x, 642.6x, 642.7x; ICD-10: O14.xx), and gestational diabetes (ICD-9: 648.8; ICD-10: O24.xx).

The primary independent variable was insurance status, which we classified as Medicaid, uninsured, or commercial, based on the primary payor source at delivery.

Statistical analysis

Differences in health care use and adverse outcomes by insurance status were initially assessed using chi-square statistics. We then used multivariate regression models to estimate the adjusted odds or adjusted rate of each outcome by insurance status. Logistic regression models were used for binary outcomes, while zero-inflated negative binomial models were used for count outcomes. These models were adjusted for the following covariates previously shown to be associated with health care use and adverse pregnancy outcomes: age at delivery, race/ethnicity, location of residence, preexisting hypertension, preexisting diabetes, overweight or obesity prepregnancy, neighborhood poverty rate, and neighborhood high school education rate. Timeliness of prenatal care was included in initial models for adverse birth outcomes and later excluded because of collinearity with insurance status. Analyses were conducted using SAS version 6.4 (SAS Institute, Cary, NC). All tests were two sided, and p -value <0.05 indicated statistical significance.

Table 1 presents overall demographics of the sample and bivariate associations with insurance status at delivery. Of the 9,613 women, 4,441 (46.2%) had commercial insurance, 4,990 (51.9%) had Medicaid, and 182 (1.9%) were uninsured. There were more uninsured women among those with births in 2014 than among those with births in 2015. Most women were aged 25–34 and lived within the Charlotte city limits. Compared to commercially insured women, women with Medicaid or no insurance were younger, less likely to be non-Hispanic White, more likely to have comorbid diabetes, and lived in neighborhoods with higher average rates of poverty and less than high school education.

Distribution of Characteristics of Women Living in Mecklenburg County Who Gave Birth Within Atrium Health, by Insurance Status (2014–2015)

SD, standard deviation.

Health care use outcomes are presented in Table 2 . Compared to women with commercial insurance, women classified as Medicaid-insured or uninsured at delivery had a lower mean number of well-woman visits in the two years before giving birth and a higher mean number of ED visits during pregnancy. Compared to women with Medicaid or no insurance, women with commercial insurance were more likely to initiate prenatal care in the first trimester (commercial: 57.9%; Medicaid: 28.6%; uninsured: 20.9%, p  < 0.01), to have prenatal care that was classified as adequate plus (commercial: 38.7%; Medicaid: 23.5%; uninsured: 12.1%, p  < 0.01), and to have a postpartum checkup within six weeks of delivery (commercial: 90.0%; Medicaid: 49.2%; uninsured: 41.2%, p  < 0.01).

Distribution of Health Care Use by Insurance Status, Women Living in Mecklenburg County Who Gave Birth Within Atrium Health (2014–2015)

ED, emergency department.

As shown in Figure 1 , the prevalence of adverse birth outcomes also varied significantly by insurance status. Women with Medicaid or no insurance had higher unadjusted rates of preterm birth, preeclampsia, and low birth weight compared to women with commercial insurance.

Adverse pregnancy outcomes by insurance status, women living in Mecklenburg County who gave birth within Atrium Health (2014–2015). Unadjusted p -value <0.05 for all outcomes from chi-square tests.

After adjustment for patient characteristics, many of the relationships between health care use and insurance status remained ( Table 3 ). Medicaid-insured women had a rate of well-woman visits that was one-fourth that of women classified as commercially insured (rate ratio [RR] 0.25, 95% CI 0.23–0.28) and a nearly three times greater rate of ED visits during pregnancy (RR 2.93, 95% CI 2.64–3.25). Results for uninsured women were similar. Women with Medicaid insurance at delivery also had 18% greater odds of not receiving prenatal care in the first trimester, while uninsured women had 84% greater odds compared to women with commercial insurance (Medicaid odds ratio [OR] 1.18, 95% CI 1.03–1.34; uninsured OR 1.84, 95% CI 1.45–2.35). Uninsured women also had 52% lower odds of adequate prenatal care (OR = 0.48, 95% CI 0.39–0.60). Among the adverse pregnancy outcomes examined, no differences by insurance status remained statistically significant after adjustment for patient characteristics ( Table 4 ). Factors associated with higher odds of adverse pregnancy outcomes included older maternal age (age 35+), preexisting hypertension, preexisting diabetes, and race/ethnicity.

Association Between Insurance Status and Health Care Use, Women Living in Mecklenburg County Who Gave Birth Within Atrium Health (2014–2015) *

CI, confidence interval; RR, rate ratio; OR, odds ratio.

Association Between Insurance Status and Birth Outcomes, Women Living in Mecklenburg County Who Gave Birth Within Atrium Health (2014–2015) *

BMI, body mass index.

We found that women with Medicaid or no insurance at delivery were less likely to use preventive care and more likely to use emergency care than women with commercial insurance. While we also found that preterm birth, low birth weight, preeclampsia, and gestational diabetes were higher among Medicaid-insured and uninsured women compared to women with commercial insurance, these differences did not remain statistically significant after adjusting for demographic, clinical, and neighborhood factors. Our results add to limited research regarding insurance status and health care utilization before and during and immediately after pregnancy in nonexpansion states. 27 Our findings of low rates of preventive care and high rates of ED use among pregnant women highlight important opportunities for improving care for women with low incomes.

Our finding that women with Medicaid at delivery were more likely to enter prenatal care late is consistent with prior research. 9 , 28 We also found that these women were less likely to have well-woman visits before pregnancy and postpartum visits following delivery. Preconception care and postpartum care are thought to be important time points to optimize women's health and have been suggested as important foci for reducing the rising rates of maternal morbidity and mortality in the United States. 29 , 30 Mothers insured by Medicaid in our study had 1.5 times higher odds of nonattendance at the six-week postpartum visit than women who were commercially insured, which is consistent with findings from New York 31 and California. 32 Women insured by Medicaid in our study were largely Hispanic (49.4%) or non-Hispanic Black (32.0%).

Previous reports suggest that women of color are at higher risk of postpartum care nonattendance than White women although reasons why are not entirely clear. 31 , 33 , 34 While insurance provides potential access to care, low-income women have shared that they desire flexible timing and convenient location options for postpartum care, which are not always available. 35

Our results regarding higher use of ED visits among women who did not have commercial insurance confirm those of a smaller study in a sample of 233 postpartum women in 2012. 36 Kilfoyle et al. 36 found that women with public insurance were five times more likely to use the ED for nonurgent reasons than women with private insurance. Pregnant women may visit the ED for nonurgent reasons because of uncertainty regarding symptoms, a lack of consistent medical care, or psychosocial issues such as substance abuse. 36 , 37 The nearly threefold higher rate of ED visits during pregnancy among the low income women in our study highlights a need for innovative strategies to promote access to lower care cost options, provide education on symptom management, and address psychosocial issues that may contribute to greater ED use. Centering Pregnancy and Nurse Family Partnerships are two promising approaches for improving health care use and perinatal outcomes among low-income and minority women, which involve peer support and home visitation. 38

None of the four adverse pregnancy outcomes that we examined remained significantly associated with insurance status in adjusted analyses. However, previous research has found an association between Medicaid coverage and adverse birth outcomes. A prior study of women with pregnancy-related hypertension found that those with Medicaid at delivery were more likely to experience preterm birth and eclampsia than those with private insurance. 39 Another study using a large sample of women from 32 states found that women who were uninsured before conception had 20% higher risk of preterm birth than women who were insured. 17 Differences between these findings and those in our study may reflect differences in the populations studied, differences in how insurance status was determined, or the size of our sample. Our finding that older maternal age (age 35+) and preexisting hypertension were associated with higher odds of all outcomes examined (preterm birth, gestational diabetes, preeclampsia, and low birth weight) aligns with prior research 40 , 41 and suggests these subgroups as potential targets for interventions.

Our findings provide support for increasing insurance coverage as one strategy for improving access to preventive care for low-income women. In the absence of universal health care or an expansion of Medicaid, some states have used Medicaid Family Planning Waivers, which provide coverage for contraception and education and testing for sexually transmitted diseases, to increase access to care for reproductive-aged women. 42 While useful for preventing pregnancy, these programs are limited in that they do not provide coverage for the treatment or management of chronic diseases or related risk factors. Texas has used a combination of waivers and state funds for their Healthy Texas Women program, which provides comprehensive health care, including pregnancy tests, contraception, and screening and treatment for cholesterol, diabetes, and hypertension for women aged 15–44. 43 However, the program is not well known, and attempts to exclude providers like Planned Parenthood have yielded adverse results. 43 Opportunity exists to build on these approaches by leveraging existing provider networks to offer more comprehensive care for women.

In addition to expanding coverage, women need education and outreach regarding the services available to them. A 2016 survey of U.S. women aged 18–44 found that women were more likely to use preventive care when they had greater knowledge of covered services. 14 Addressing potential language and cultural barriers is important for engaging Hispanic/Latina women and other groups. 31 , 44 While examining the interplay between race/ethnicity and health care use was not the focus of the current study, we found that Hispanic ethnicity was associated with lower rates of well-woman visits before pregnancy, lower odds of adequate prenatal care, and lower odds of six-week postpartum follow-up compared to Whites ( Table 3 ). We also found that Black race was associated with higher rates of ED visits during pregnancy. Policies designed to improve access to care should consider the needs of women of color and address institutional and community-level factors ( e.g ., discrimination and biases) that may impede care.

Limitations

Data used in this study were from a single public not-for-profit health care system. As such, we were unable to capture care received from unaffiliated providers. Because delivery privileges are limited to affiliated providers, we expect that deliveries to patients who received prenatal care from unaffiliated providers would be limited to emergencies. Future studies using claims data and studies that capture care received from free clinics, community health centers, and nontraditional sources of care may provide a more comprehensive look at health care use. Our analysis of ED visits did not distinguish between urgent and nonurgent visits. Additional research that examines ED visit urgency would be helpful for tailoring interventions. To account for changes in medical coding in 2015, we used both ICD-9 and ICD-10 codes to identify preeclampsia and gestational diabetes. Potential coding errors in the electronic medical record should be nondifferential between the groups of patients studied. We used insurance status at delivery to classify patients and did not account for changes in coverage before or after delivery. Approximately 65% of women using Medicaid for delivery are uninsured at some point during the nine months before delivery and 55% are uninsured at some point during the six months postdelivery. 45 We were unable to determine the parity of patients in our sample. Therefore, our models did not adjust for parity. Finally, results are based on data from a single metropolitan region in a Medicaid nonexpansion state in the southeastern United States and may not be generalizable to other geographic regions.

Implications for policy and/or practice

Low rates of preventive care and high rates of ED use among pregnant women with Medicaid and those with no insurance highlight important opportunities for improving care for low-income women. Health care providers can address gaps in the use of preventive care among low income women by providing education about the need for preventive care, including postpartum care, and using home-based or virtual care delivery models that overcome structural barriers to access. There is an urgent need to improve potential and realized access to care.

Conclusions

Compared to privately insured women, women who have Medicaid or no insurance at delivery experience barriers to preventive care before, during, and after pregnancy. Policymakers in states that did not expand Medicaid should consider ways to expand insurance coverage for women in addition to other methods to improve access to care.

Acknowledgments

This study was funded by a grant from AcademyHealth and the March of Dimes. Y.J.T. was funded, in part, by the National Institute of Minority Health and Health Disparities (Contract No. L60 MD009805). The funders did not participate in study design, collection, analysis, and interpretation of data, writing of the article, or the decision to submit this article for publication.

Author Disclosure Statement

No competing financial interests exist.

Consumer prices moved higher in March. Auto insurance costs were a major reason.

Wednesday's inflation report showed consumer price growth continues to drift higher.

The Bureau of Labor Statistics reported price growth accelerated to 3.5% in March , from 3.2% in February.

Few categories had as big a jump year on year than auto insurance, which soared 22% from March 2023, the most significant year-on-year jump in that category since 1976.

And over the last few years, average auto insurance rates have surged 43%.

As of April, the national  average cost of car insurance  is $2,314 per year for full coverage and $644 per year for the bare minimum, according to Bankrate.

That works out to about $193 a month for full coverage and $54 for minimum coverage.

A host of factors determine how much insurance companies charge drivers, but the cost of nearly all of them seem to be increasing.

One major factor is simply the rising cost of modern vehicles themselves. Today, a new vehicle costs about $10,000 more than it did before the pandemic. Blame supply-chain issues that drove up the cost of vehicle parts, increased labor costs and customer demand, which has naturally pushed prices upward.

The increasing sophistication of the technology in today’s vehicles also contributes to rising costs, said Robert Passmore, department vice president of personal lines at American Property Casualty Insurance Association. Cameras and sensors, which are used for various driver-assistance technologies, like emergency braking, automated parking and blind-spot monitoring, require parts that are more expensive to replace. They're also subject to higher labor costs, Passmore said.

More complex and expensive repairs are also taking longer, and that shows up as higher vehicle costs, Passmore said. And worker shortages have resulted in higher pay for technicians.

Meanwhile, the higher cost of buying a vehicle has prompted some drivers to hold on to their existing cars for longer. As a vehicle ages, the likelihood of breakdowns rises, increasing the demand for repair services, said Sarah House, managing director and senior economist at Wells Fargo.

“Insurers are trying to recoup very costly claims,” House said.

Other factors are at work, too. According to the Insurance Information Institute, which represents insurance companies and the insurance industry, the severity of claims, including the medical and litigation costs that arise in claim disputes, are also on the rise. In the years immediately after the outset of the Covid-19 pandemic, insurance companies took large losses — due in part to an increase in bad driver behaviors . As a result, they have pushed state regulators, who determine how high rates can go, to allow them to charge higher premiums while, in some cases, threatening to leave states entirely if they don't. According to S&P Global Market Intelligence, those companies have been able to win huge rate increases as a result.

The bad news is there is no end in sight to the cost pressures.

Insurance companies filed for rate increases throughout the end of 2023 and at the start of this year, Bankrate analyst Shannon Martin said in an email. Because such rate changes hit auto policies only upon renewal, U.S. drivers are just starting to feel the impact, Martin said. 

“Car insurance inflation is sticky, and while inflation has slowed down and supply chain issues are improving, the premium increases we are seeing and will continue to see in 2024 are based on losses carriers experienced over the last few years," Martin said.

"The ultimate goal is for rates in the insurance industry to stabilize, but that might not happen until sometime next year.”

Rob Wile is a breaking business news reporter for NBC News Digital.