The National Preconception Care
Clinical Toolkit
(“PCC Toolkit”)
An Orientation: What It Offers and
How to Use It
What Is the Purpose of this Toolkit?
• This toolkit is designed to assist primary care
clinicians incorporate efficient, evidence-based
preconception messages and services into their
routine preventive care. This will help women
achieve:
– Better health, irrespective of pregnancy desires;
– Increased likelihood that any future pregnancies are desired
and planned;
– The lowest likelihood of pregnancy problems should
pregnancy occur.
Why Create a Toolkit?
• As the preconception health initiative has gained
momentum, primary care providers have repeatedly
said they wanted to help make a difference but are
unsure of what to do. . .
• This toolkit was created to help clinicians realize that
it won’t take many changes to their current care to
meet the preconception needs of the women in their
practices who are of childbearing age and might
become pregnant at some point in their futures.
Who is This Toolkit For?
Anyone involved in providing primary health care such as:
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Family practice clinicians
Gynecologists
Internists
Nurse practitioners
CNMs
Physician assistants
Registered nurses
Office and clinical support staff
The toolkit is not designed to meet the needs of specialists
dealing with complex preconception care needs.
Who Created This Toolkit?
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The National Preconception Health and Health Care (“PCHHC”)
initiative is a public-private partnership to advance preconception health
through consumer, clinical, public policy and other avenues.
The PCHHC initiative includes a Clinical Work Group of experts in
preconception care; they compiled “The Clinical Content of
Preconception Care”, the foundation for much of the toolkit (Jack, B &
Atrash HK (ed). AJOG, 2008; 199(6B): S3A-S395).
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In response to many requests, the Clinical Work Group, comprised of
Ob/GYN and FM physicians, nurse practitioners, nurse midwives and
representatives of major professional organizations engaged in the
clinical care of women of childbearing age, undertook creation of this
toolkit.
While much of the effort to create this tool was voluntary, the PCHHC
and the Clinical Work Group are grateful to the W.K. Kellogg
Foundation for its support of this work.
Why Has Preconception Health Become a
Prevention Focus for Primary Care?
• Prenatal care starts too late to prevent many poor
outcomes including:
• Birth defects;
• Some causes of miscarriage, low birth weight,
prematurity, stillbirths and infant death;
• Some serious, even life-threatening, maternal
complications.
• By “tweaking” routine primary care services slightly,
more women will receive the information they need to
make informed decisions about their own health and
the health of any future pregnancies.
Why Don’t Women Just Go See Their Chosen
Obstetrical Provider before They Get Pregnant?
• At least 50% of the pregnancies in this country occur by chance
rather than plan.
• In addition, the majority of women are unaware of the benefits to
themselves and their future children of addressing specific risks
before becoming pregnant.
• Most women who become pregnant already see a primary care
provider for routine care—those visits offer the opportunity to
provide important prevention messages for the woman’s own
health and the health of any children in her future.
I Want to Learn More About the Link Between
Primary Care and Reproductive Outcomes
• To learn more about the rationale and opportunities of
preconception care, take the free CME course on this site,
“Preconception Care: What It Is and What It Isn’t”
(www.beforeandbeyond.org  CE Modules).
• To learn more about how the prevention emphases within
primary care naturally intersect with preconception health
promotion, take the free CME course on this site,
“Every Woman, Every Time: Integrating Preconception
Health Promotion into Primary Care”
(www.beforeandbeyond.org CE Modules)
How Is this Toolkit Going to
Help Me?
• The toolkit is designed to help the busy clinician and practice
personnel:
– Focus on the general preventive care needs of every woman
who presents for routine care.
– Save time by tailoring preventive care based on a woman’s
(couple’s) specific desires regarding pregnancy in the next
year.
– Provide “at-your-fingertip” guidance with the option of
exploring more in-depth information and references.
– Connect quickly with relevant clinical tools and patient
education resources.
The PCC Toolkit Provides Guidance and
Resources to Enrich these Components of
Routine Care
• Family Planning and
Contraception
• Nutrition
• Infectious Disease and
Immunizations
• Chronic Diseases
• Medication Use
• Substance Use
• Previous Pregnancy
Outcomes
• Genetic History
• Mental Health History
• Interpersonal Violence
The topics in the PCC Toolkit are
already covered in my routine well
woman care—what’s the difference?
Comprehensive well woman care is preconception
care for women who may become pregnant. . .
with a few extra emphases.
PCC Toolkit Unique Features
• Designed to complement (not replace) the content of routine
primary care preventive services.
• Provides guidance based on a woman’s reproductive life plan
and desires for conception in the next year.
• Includes “At-Your-Fingertips” summaries to help the provider
incorporate important emphases based on a woman’s plans and
desires.
• For each of the 10 clinical topics the clinician can explore:
– Background information (overview of the topic)
– Clinical guidance (specific guidance—in many instances such as
infectious disease and chronic diseases the guidance is provided by specific
condition)
– Clinical tools ( a sampling of tools to help provide recommendations)
– Patient resources (a sampling of web resources to direct patients to)
– References (bibliography)
The Key to These Efforts :
Encourage everyone of
childbearing
potential to develop a
Reproductive Life Plan
What Is a Reproductive Life Plan?
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The Reproductive Life Plan (RLP) asks women and their partners to
consider if they want to have any (more) children and how many they
hope to have.
These decisions evolve over time and are best considered outside the
examining room but they can be reported via questionnaires (pre-visit
or in the waiting room) or during a face-to-face interaction.
A woman’s (couple’s) RLP should be assessed at least annually.
The RLP plan for the coming year is an efficient way to determine
what preconception recommendations and education should be
integrated into the visit. This can be assessed by asking EVERY
woman capable of becoming pregnant, “Do you hope to become
pregnant in the next year?”
Is There Guidance Available on Developing
and Assessing RLPs?
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A set of questions to help the provider individualize care for women
who do not want to become pregnant in the next year or who are
ambivalent or at risk for an unintended pregnancies is available at
http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf.
A handout to help women consider their reproductive plans in the
context of their life goals is provided at
http://www.cdc.gov/preconception/documents/reproductivelifeplanworksheet.pdf.
The tab titled “Reproductive Life Planning Assessment” on the left hand
menu bar provides additional information.
What Are the Possible Responses to
Assessing a Woman’s RLP
• Woman (couple) desires pregnancy within the next year.
• Woman (couple) ambivalent about pregnancy in next year or
engaging in contraceptive practices that place them at risk for
an unintended pregnancy
• Woman (couple) do not want pregnancy in the next year.
The Toolkit is Organized to
Help the Provider Offer Care
Specific To Pregnancy Desires
and Needs
Woman/Couple Desires Pregnancy
If a woman (couple) desires pregnancy in the next
year, she is likely to need
• Extra emphasis on preconception content in her routine
preventive visit.
The green (radio) button on the left side of the page
takes the clinician and support staff to information
especially appropriate to the preventive care of this
woman.
Woman/Couple At Risk For Unintended Pregnancy
If a woman (couple) is at risk for an unintended or
unplanned pregnancy in the next year, she is likely to
need:
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Some preconception content (she is at high risk for an unintended
pregnancy).
Extra emphasis on family planning and encouragement to deliberately
consider her short and long term pregnancy desires.
The yellow (radio) button on the left side of the page
takes the clinician and support staff to information
especially appropriate to the preventive care of this
woman.
Woman/Couple Do NOT Desire Pregnancy
If a woman (couple) does not desire pregnancy in the
next year, she is likely to need
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Routine preventive care and encouragement to seek additional care if
her plans about becoming pregnant change.
The red (radio) button on the left side of the page takes
the clinician and support staff to information appropriate
to the care of this woman.
How Will the Green, Yellow and Red Buttons
Help Me Individualize Care to the Woman’s
Preconception Needs?
Under each button you can choose to…
1)
Review all of the content available to guide the clinician, the practice
and the patient in achieving their goals:
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3)
background information, clinical guidance, clinical tools, patient resources and
references for all 10 clinical components of the toolkit.
Read only the Clinical Guidance section for one or more specific
components of care (e.g. nutrition, chronic diseases, family planning)
to get detailed guidance for addressing a woman’s specific needs and
risks.
Utilize the “At-Your-Fingertips” document which provides a summary
of all the general guidance recommended for a woman based on her
desires and risks for pregnancy in the next year. This document can
be downloaded as a pdf and printed.
Clicking on the Radio Button that Corresponds with
the Woman’s Desires and Likelihood of Pregnancy
Provides Access to Relevant Patient Care Guidance
Each of the 10 clinical topics is organized so
you can dig as deep as you want—simply by
choosing the desired tab(s) and clicking on
the radio buttons.
When Specific Diseases Are of Interest
the Clinical Guidance Buttons Organize Content
Alphabetically
(e.g. chronic and infectious diseases)
The Toolkit is Designed So You Can Easily
Determine Where You Are:
In this example, you are exploring the preconception significance of
nutrition for a woman at risk of an unintended pregnancy
A Summary Document that Covers All the General
Recommendations for a Woman Based on Her
Pregnancy Desires and Risks is Available Under
“At-Your-Fingertips”– a printable document
How to Maximize Benefit of the
Toolkit to Your Practice
• To appreciate all the toolkit has to offer explore the
various buttons and links—there is much to discover
BUT YOU ARE BUSY so. . .
• Don’t think you need to search the site every time
you see a patient—once you are familiar with the
general recommendations you will only need to come
back when you desire additional information or
resources.
The PCC Toolkit Is Dynamic and
Will Change as New
Evidence/Approaches Become
Available. . .
. . .Be sure to bookmark this site
and refer to it often. Encourage
colleagues and staff to become
familiar with the resource, too.
There are many ways to advance prevention in your
practice that are not clinician-dependent For instance,
nurses and other support staff might be empowered to do
much of the screening and education recommended in this
toolkit.
Let us know of innovations in your practice aimed at
achieving higher levels of women’s health, healthier
intended pregnancies for those desiring childbearing in their
futures and healthier maternal and infant outcomes.
mkmoos@med.unc.edu