For Doctors in a Hurry
- Clinicians need evidence-based strategies to address the 66.4% of reproductive-aged women who possess at least one modifiable risk factor for adverse pregnancy outcomes.
- The researchers reviewed clinical data regarding prepregnancy interventions, including substance cessation, immunizations, and chronic disease management, to optimize maternal and neonatal health.
- Folic acid supplementation reduces fetal neural tube defects by a relative risk of 0.67, while unintended pregnancies increase postpartum depression risk by 51%.
- The authors conclude that prepregnancy counseling and targeted interventions significantly reduce maternal morbidity and neonatal mortality rates for individuals contemplating pregnancy.
- Physicians should prioritize reproductive goal discussions, infection screening, and substance use counseling during routine primary care visits to improve long-term pregnancy outcomes.
Prepregnancy Care: A Foundation for Healthier Pregnancies
Prepregnancy care optimizes maternal health before conception to improve outcomes for both mother and infant [1]. In the United States, 66.4% of reproductive-aged women possess at least one modifiable risk factor for adverse pregnancy outcomes, ranging from chronic disease to lifestyle behaviors [2, 3]. Addressing these factors through evidence-based interventions is essential for reducing maternal morbidity and neonatal mortality [4, 5]. While the efficacy of specific interventions is well-documented, this review offers a consolidated perspective on key clinical measures to enhance pregnancy preparedness.
Core Interventions: Supplementation, Immunizations, and Screening
Universal recommendations for individuals desiring pregnancy begin with folic acid supplementation, which significantly mitigates the risk of fetal neural tube defects. The study found that prepregnancy folic acid use reduced the relative risk (RR) of these defects to 0.67 (95% CI, 0.52-0.87). Beyond nutritional support, clinicians should prioritize immunizations against hepatitis B virus, varicella, and rubella to prevent neonatal infection and mortality. Furthermore, screening for syphilis and HIV prior to and during pregnancy is a standard of care that directly decreases rates of fetal and neonatal infection. These foundational steps allow physicians to address preventable infectious and developmental risks before they compromise a pregnancy. The clinical impact of these measures is substantial, as prepregnancy immunizations and infection screenings are among the most effective strategies for decreasing neonatal mortality and long-term morbidity.
Addressing Substance Use Before Conception
Substance use cessation is a primary pillar of preconception counseling, as tobacco, alcohol, cannabis, and opioids pose significant risks to the developing fetus. Maternal tobacco smoking is particularly hazardous, associated with a summary relative risk (sRR) of 1.46 (95% CI, 1.38-1.54) for stillbirth and an sRR of 1.22 (95% CI, 1.14-1.30) for neonatal death, which is defined as the death of a live-born infant within the first 28 days of life. The risk of perinatal death (a composite measure of stillbirths and early neonatal deaths) also increases, with an sRR of 1.33 (95% CI, 1.25-1.41). For patients with opioid use disorder, the researchers emphasize the use of buprenorphine or methadone (long-acting opioid agonists used to stabilize patients and prevent withdrawal) to improve outcomes. Early intervention allows for the transition to safer pharmacological management before conception occurs, reducing the likelihood of neonatal abstinence syndrome and other complications.
Optimizing Health for Chronic Conditions and Weight Management
For patients with chronic conditions, routine health examinations and contraceptive care in the year before conception are associated with a decreased risk of severe maternal morbidity, a clinical category encompassing life-threatening complications such as organ failure or the need for blood transfusions. Weight management is equally critical, as the study recommends weight loss for individuals with a body mass index (BMI) of 25 or greater to reduce the risk of gestational diabetes, gestational hypertension, and cesarean delivery. In patients with pregestational type 1 or type 2 diabetes, achieving a hemoglobin A1c of less than 6.5% before pregnancy is associated with a decreased risk of fetal anomaly compared to higher glycemic levels. Furthermore, because cardiovascular complications occur in 15% of pregnancies, patients with preexisting heart disease require multidisciplinary management involving cardiology and maternal-fetal medicine to oversee medication adjustments and hemodynamic monitoring. This collaborative approach ensures that medications are adjusted for pregnancy safety and that the physiological demands of gestation do not exceed the patient's cardiovascular reserve.
The Impact of Pregnancy Planning
Pregnancy intention serves as a powerful predictor of both maternal mental health and neonatal outcomes. The study found that unintended pregnancies are associated with a 15.7% incidence of postpartum depression, compared to 9.6% in planned pregnancies, representing an adjusted odds ratio (aOR) of 1.51 (95% CI, 1.40-1.70). Neonatal risks are similarly elevated in unintended pregnancies, with the risk of preterm birth (delivery before 37 weeks) rising to 9.4% from 7.7% (aOR, 1.21; 95% CI, 1.12-1.31). Additionally, the risk of low infant birth weight (less than 2,500 grams) was 7.3% in unintended pregnancies versus 5.2% in planned ones (aOR, 1.09; 95% CI, 1.02-1.21). These statistics highlight the clinical necessity of reproductive life planning to ensure patients enter pregnancy in an optimized state, with adequate psychological and social resources to manage the transition to parenthood.
Primary Care's Role in Optimizing Outcomes
The researchers concluded that integrated prepregnancy care is a highly effective strategy for reducing maternal and neonatal morbidity and mortality. Primary care clinicians are uniquely positioned to lead these efforts through discussions of reproductive goals, which is the clinical process of identifying a patient's desires regarding the timing and number of future children. This proactive approach facilitates the delivery of folate supplementation, which reduces the relative risk of neural tube defects to 0.67 (95% CI, 0.52-0.87), and ensures that immunizations and screenings for syphilis and HIV are completed. By identifying and managing modifiable risks such as substance use and chronic disease before conception, clinicians can significantly improve the safety and health trajectory of both the patient and the future infant. Ultimately, the integration of these interventions into routine primary care visits represents a vital opportunity to prevent adverse perinatal outcomes across the population.
References
1. Dorney E, Boyle JA, Walker R, et al. A Systematic Review of Clinical Guidelines for Preconception Care.. Seminars in reproductive medicine. 2022. doi:10.1055/s-0042-1748190
2. Caut C, Leach M, Steel A. Dietary guideline adherence during preconception and pregnancy: A systematic review. Maternal and Child Nutrition. 2019. doi:10.1111/mcn.12916
3. Giouleka S, Tsakiridis I, Koutsouki G, et al. Obesity in Pregnancy: A Comprehensive Review of Influential Guidelines. Obstetrical and Gynecological Survey. 2023. doi:10.1097/OGX.0000000000001091
4. Graafland N, Rousian M, Zwart MDD, Steegers-Theunissen R, Steegers E, Posthumus A. Parental conditions, modifiable lifestyle factors, and first trimester growth and development: a systematic review. Human Reproduction Update. 2025. doi:10.1093/humupd/dmaf001
5. Albairmani RA, Basheer BMA, Macky MM, et al. Management of Diabetes in Pregnancy: A Review of Clinical Guidelines and Practices. Cureus. 2025. doi:10.7759/cureus.79334
