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03/08/2016

Zika: An opportunity to improve pre-conception care.

by Andrea L. Kalfoglou, Ph.D.

The Zika virus is spreading rapidly throughout parts of South and Central America. Public health officials are concerned because there is a correlation between the emergence of the Zika virus and a dramatic increase in number of babies born in Brazil with a severe birth defect called microcephaly.

The CDC has warned women from the U.S. who are pregnant or thinking about becoming pregnant not to travel to certain areas in Central and South America. Additionally, infectious disease specialists are concerned that Zika may adapt to transmission by a type of mosquito common in 32 states in the U.S.

There is no commercial test available to diagnose Zika; however, there are testing protocols available through the CDC and some state health departments.

According to Francis Collins, Director of the National Institutes of Health, researchers are working to develop a diagnostic test that could be widely available. If such a test becomes available, pregnant women may seek out this test to determine whether they have been infected. Additionally, because microcephaly is such a severe birth defect, women considering pregnancy may begin to request diagnostic testing for Zika. This consumer-driven demand for pre-conception testing could create a window of opportunity to improve delivery of pre-conception care should primary-care providers seize on this opportunity.

Pre-conception care is not routinely provided to women of reproductive age. Primary-care providers have said this is because women do not seek out this care and primary-care providers do not have time to provide this care given all of the competing health-prevention needs.

Why is pre-conception care important?

Comprehensive pre-conception care can improve birth outcomes and maternal health. The CDC has issued recommendations for pre-conception care that are designed to help the U.S. reach certain public health goals related to maternal and infant health.

What are the benefits of pre-conception care?

First, we know that healthier women tend to have healthier pregnancies and healthier babies. Prior to conception, primary-care providers could counsel women to quit smoking and reduce or eliminate their consumption of alcohol and recreational drugs. Certain pharmaceutical drugs like bupropion (Zyban) and nicotine replacement therapy can help people quit smoking, and these treatments could be initiated prior to pregnancy.

Second, primary-care providers could discuss the benefits of improved nutrition. They could encourage women to take prenatal vitamins, particularly folic acid. Folic acid supplementation reduces birth defects such as spina bifida, but increased intake should begin before a woman becomes pregnant.

Primary-care providers who treat women who lack access to nutritional food or an understanding about nutrition, may be able to provide referrals to social services, nutritional counseling, and other community-based programs.

Third, pregnant women are screened for multiple diseases that could harm the fetus and are advised to avoid certain vaccinations. If women received screening and treatment for sexually transmitted diseases, learned their HIV status, and were able to receive recommended vaccines before they became pregnant, women’s health, as well as birth outcomes, might improve.

Fourth, genetic screening for carrier status is becoming more common in the prenatal setting. The American College of Obstetricians and Gynecologists and the American College of Medical Genetics recommend that cystic fibrosis carrier screening be offered to all women who are pregnant or planning to become pregnant. Other genetic carrier tests may be recommended for women with specific racial and ethnic backgrounds (Ashkenazi Jews are frequently encouraged to be screened for a panel of diseases including Tay Sachs disease and women of African descent may be offered sickle cell carrier testing). Offering such screening increases a woman’s reproductive choices by informing her of her risk of having a child with a particular genetic disease. Giving a woman this information after she is already pregnant creates anxiety and necessitates additional testing of the fetus in order to accurately inform the woman about her baby’s health. If the fetus is affected by the genetic disease, the couple’s only option is abortion or preparing for the birth of a child with a severe illness. A woman who screens positive before becoming pregnant has time to test her partner and consult with a genetic counselor about her reproductive options.

Fifth, women could be screened for injury risk, domestic violence, and depression/anxiety. Injuries are the leading causes of death among women of reproductive age. Multiple public health/primary care screening tools that ask about seatbelt use, gun possession, and domestic violence could create opportunities for health-care providers to engage women in discussions about how to avoid injuries and stay safe. Depression and anxiety are also extremely common among women of reproductive age. Suicide is among the top five causes of death in this age range. Identifying women who are depressed or experiencing anxiety creates an opportunity for treatment.

Finally, many women of reproductive age are being treated for a chronic illness like depression, heart disease, or diabetes. Women with chronic conditions, particularly mental illness, frequently do not have access to accurate medical advice about how to manage these conditions while pregnant. Primary-care providers seeing women for pre-conception care have the opportunity to discuss the risks and benefits of different types of interventions with their patients, alleviate their patient’s fears about certain treatment options during pregnancy, and develop a treatment plan that is likely to lead to the best possible outcomes for moms and their babies.

The tragedy of Zika and microcephaly may have a silver lining: Concern about exposure to Zika among women of reproductive age may lead to increased consumer-driven demand for pre-conception care. Changing how we plan for pregnancy, and making pre-conception care the new normal, could lead to better health for women and their future children.

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