Associations Between Modifiable Preconception Care Indicators and Pregnancy Outcomes

Ashwini Kamath Mulki; Melanie B. Johnson; Nicole M. Burgess; Kyle Shaak; Katie Nisbett; Katarzyna Jabbour; Roya Hamadani; Beth Careyva

doi:10.3122/jabfm.2024.240133R1

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Table 1.

Operationalization of Preconception Care Indicators for Data Collection

Preconception Care Indicators	Definition for Preconception Visits (Yes/No Response)	Definition for Prenatal Intake Visit (Yes/No Response)^12,28
Pregnancy intention	Contraception counseling	Planned pregnancy
Access to care	Any primary care visit w/in 2 years	Prenatal intake visit <12 weeks gestational age (first trimester)
Preconception multivitamin with folic acid use	Education on use before conception	Use of a daily multivitamin with folic acid for at least 3 months before conception
Tobacco avoidance	Counseling on avoidance	Tobacco avoidance
Absence of uncontrolled depression	Depression screening negative (Negative PHQ-2 or PHQ-9 <10)	Depression screening negative (Negative PHQ-2 or PHQ-9 <10)
Healthy weight	BMI >18 and <30	BMI >18 and <30
Absence of STIs^*	STI screening low risk^**	STI screening negative
Optimal glycemic (if have pre-existing diabetes diagnosis)	Counseling on goal A1c <6.5%	A1c <6.5%
Teratogenic medication avoidance	Counseling on pregnancy risk with teratogenic drugs in pregnancy (previously, category X with mention of teratogenicity as the reason for being pregnancy category X)	No use of teratogenic drugs in pregnancy
Controlled chronic HTN	BP value ≤120/80	BP value ≤120/80
Harmful substance use avoidance	Counseling on avoidance of harmful substances (eg, marijuana, alcohol)	Avoidance of harmful substances (eg, marijuana, alcohol)

↵* STI screening included testing for gonorrhea, chlamydia, HIV, hepatitis B and syphilis.
↵** STI low risk included a no response to all these patient-related questions: 1) Sexually active and >25 years old, 2) a new sex partner, 3) more than 1 sex partner, 4) a sex partner who has concurrent partners, 5) a sex partner who has an STI, 6) inconsistent condom use among persons who are not in mutually monogamous relationships, 7) personal history of STIs, 8) exchanging sex for money or drugs, 9) patient asks for STI screening, or simply agrees if offered by clinician.
Abbreviations: W/in, Within; PHQ-2, 2-item Patient Health Questionnaire; PHQ-9, 9-item Patient Health Questionnaire; BMI, body mass index; STI, sexually transmitted infection; HTN, hypertension; BP, blood pressure.

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Table 2.

Patient Demographics (N = 663) Stratified by Delivery Status

	Entire Sample (N = 663)	Term Delivery (n = 442)	Preterm Delivery (n = 221)	P value
Age mean ± standard deviation	29.22±5.6	29.14±5.4	29.36±5.8	0.64*
Race, n (%)				0.23^†
Amer Indian/Alaska Native	1 (0.2)	1 (0.2)	0 (0.0)
Asian	18 (2.7)	12 (2.7)	6 (2.7)
Black or African American	52 (7.8)	29 (6.6)	23 (10.4)
Multiracial	59 (8.9)	35 (7.9)	24 (10.9)
Native Hawaiian or Other Pacific Islander	1 (0.2)	0 (0.0)	1 (0.5)
White	445 (67.1)	304 (68.8)	141 (63.8)
Other	70 (10.6)	51 (11.5)	19 (8.6)
Refused/NA/Unknown	17 (2.6)	10 (2.3)	7 (3.2)
Ethnicity, n (%)				0.67^†
Hispanic or Latino	187 (28.2)	121 (27.4)	66 (29.9)
Not Hispanic or Latino	471 (71.0)	318 (71.9)	153 (69.2)
Declined/Unknown	5 (0.8)	3 (0.7)	2 (0.9)
Language n (%)				0.04^‡
English	609 (91.9)	404 (91.4)	205 (92.8)
Spanish	42 (6.3)	26 (5.9)	16 (7.2)
Other	12 (1.8)	12 (2.7)	0 (0.0)
Patient PCP Specialty				0.11^†
Critical care medicine	1 (0.2)	1 (0.2)	0 (0.0)
Diagnostic radiology	1 (0.2)	1 (0.2)	0 (0.0)
Family medicine	470 (70.9)	321 (72.6)	149 (67.4)
Geriatric medicine	1 (0.2)	0 (0.0)	1 (0.5)
Gerontology	2 (0.3)	2 (0.5)	0 (0.0)
Infectious disease	1 (0.2)	1 (0.2)	0 (0.0)
Internal medicine	174 (26.2)	105 (23.8)	69 (31.2)
Obstetrics and gynecology	7 (1.1)	7 (1.6)	0 (0.0)
Pediatrics	6 (0.9)	4 (0.9)	2 (0.9)
Pre-gravid BMI, median (IQR)^§	27.5 (23.4-32.6)	26.5 (23.1-31.4)	29.0 (24.5-33.9)	<0.001^‖

↵* Independent-samples t-test.
↵† Fisher’s Exact test.
‡ Chi-square test of independence.
§ 47 records (23 term, 24 preterm) missing pre-gravid BMI.
‖ Mann-Whitney U test. Highlighted bold values indicate statistical significance.
Abbreviations: Amer, American; BMI, Body mass index; NA, Not Available; PCP, primary care physician.

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Table 3.

Associations Between Preconception Care Indicators and Preterm Delivery

	Entire Sample	Term Delivery	Preterm Delivery	P value	Preterm OR	95% CI
Contraception counseling (n = 652)				0.16^*
Yes (REF)	233	164 (70.4)	69 (29.6)		---	---
No	419	272 (64.9)	147 (35.1)		1.29	0.91-1.82
Prim care encounter ≤2 Years (n = 663)				0.50^*
Yes (REF)	481	317 (65.9)	164 (34.1)		---	---
No	182	125 (68.7)	57 (31.3)		0.88	0.61-1.27
Multivitamin education (n = 620)				0.28^*
Yes (REF)	73	45 (61.6)	28 (38.4)		---	---
No	547	372 (68.0)	175 (32.0)		0.76	0.46-1.25
Tobacco avoidance counseling (n = 657)				0.40^*
Yes (REF)	75	47 (62.7)	28 (37.3)		---	---
No	582	393 (67.5)	189 (32.5)		0.81	0.49-1.33
Depression screening (n = 161)				0.30^*
Negative (REF)	140	96 (68.6)	44 (31.4)		---	---
Positive	21	12 (57.1)	9 (42.9)		1.64	0.64-4.17
BMI (n = 475)				0.07^*
BMI >18 and <30 (REF)	298	206 (69.1)	92 (30.9)		---	---
BMI ≤18 and ≥30	177	108 (61.0)	69 (39.0)		1.43	0.97-2.11
STI Risk (n = 663)				0.51^*
Low risk (REF)	518	342 (66.0)	176 (34.0)		---	---
High risk	145	100 (69.0)	45 (31.0)		0.87	0.59-1.30
A1c goal counseling (n = 27)				0.53^†
Yes (REF)	3	0 (0.0)	3 (100.0)		---	---
No	24	9 (37.5)	15 (62.5)		n/a	n/a
Teratogenic med counseling (n = 658)				0.72^*
Yes (REF)	16	10 (62.5)	6 (37.5)		---	---
No	642	429 (66.8)	213 (33.2)		0.83	0.30-2.31
Blood pressure (n = 488)				0.002^*
<120/80 (REF)	287	204 (71.1)	83 (28.9)		---	---
≥120/80	201	115 (57.2)	86 (42.8)		1.84	1.26-2.68
Substance use counseling (n = 659)				0.16^*
Yes (REF)	60	45 (75.0)	15 (25.0)		---	---
No	599	396 (66.1)	203 (33.9)		1.54	0.84-2.83

↵* Chi-square test-of-independence.
↵† Fisher’s Exact test. Highlighted values indicate statistical significance.
Abbreviations: OR, Odds ratio; REF, Reference; Prim, Primary; BMI, Body mass index; STI, Sexually transmitted infection; Med, Medication.

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Table 4.

Associations Between Preconception Care Indicators and Pregnancy Risk at Intake Visit

	Entire Sample	Low-Risk Preg	High-Risk Preg	P value	High-Risk Preg OR	95% CI
Contraception counseling (n = 630)				0.27^*
Yes (REF)	228	159 (69.7)	69 (30.3)		---	---
No	402	263 (65.4)	139 (34.6)		1.22	0.86-1.73
Prim care encounter ≤2 Years (n = 640)				0.48^*
Yes (REF)	470	318 (67.7)	152 (32.3)
No	170	110 (64.7)	60 (35.3)		1.14	0.79-1.65
Multivitamin education (n = 598)				0.75^*
Yes (REF)	72	49 (68.1)	23 (31.9)
No	526	348 (66.2)	178 (33.8)		1.09	0.64-1.85
Tobacco avoidance counseling (n = 635)				0.17^*
Yes (REF)	73	54 (74.0)	19 (26.0)
No	562	371 (66.0)	191 (34.0)		1.46	0.84-2.54
Depression screening (n = 157)				0.26^*
Negative (REF)	137	99 (73.2)	38 (27.7)
Positive	20	12 (60.0)	8 (40.0)		1.74	0.66-4.58
BMI (n = 462)				0.25^*
BMI >18 and <30 (REF)	287	200 (69.7)	87 (30.3)
BMI ≤18 and ≥30	175	113 (64.6)	62 (35.4)		1.26	0.85-1.88
STI Risk (n = 640)				0.02^*
Low risk (REF)	499	322 (64.5)	177 (35.5)
High risk	141	106 (75.2)	35 (24.8)		0.60	0.39-0.92
A1c goal couns (n = 24)				0.34^†
Yes (REF)	3	1 (33.3)	2 (66.7)
No	21	2 (9.5)	19 (90.5)		4.75	0.29-78.74
Teratogenic med counseling (n = 635)				0.71^*
Yes (REF)	16	10 (62.5)	6 (37.5)
No	619	414 (66.9)	205 (33.1)		0.83	0.30-2.30
Blood pressure (n = 474)				0.02^*
<120/80 (REF)	276	199 (72.1)	77 (27.9)
≥120/80	198	122 (61.6)	76 (38.4)		1.61	1.09-2.38
Substance use counseling (n = 636)				0.16^*
Yes (REF)	60	45 (75.0)	15 (25.0)
No	576	380 (66.0)	196 (34.0)		1.55	0.84-2.85

↵* Chi-square test-of-independence.
↵† Fisher’s Exact test. Highlighted values indicate statistical significance.
Abbreviations: Preg, Pregnancy; OR, Odds ratio; CI, Confidence interval; REF, Reference; Prim, Primary; STI, Sexually transmitted infection; Med, Medication; BMI, Body Mass Index.

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Table 5.

Associations Between Prenatal Care Indicators and Preterm Delivery

	Entire Sample	Term Delivery	Preterm Delivery	P value	Preterm OR	95% CI
Pregnancy intention (n = 549)				0.72^*
Intended (REF)	331	229 (69.2)	102 (30.8)		---	---
Unintended	218	154 (70.6)	64 (29.4)		0.93	0.64-1.36
Prenatal intake visit (n = 660)				0.61^*
Intake visit <12 wks gestation (REF)	567	381 (67.2)	186 (32.8)		---	---
No intake visit <12 wks gestation	93	60 (64.5)	33 (35.5)		1.13	0.71-1.78
Multivitamin use (n = 169)				0.17^*
≥3 Months of prenatal use (REF)	96	51 (53.1)	45 (46.9)		---	---
<3 Months of prenatal use	73	31 (42.5)	42 (57.5)		1.54	0.83-2.84
Tobacco avoidance (n = 653)				0.80^*
Yes (REF)	583	391 (67.1)	192 (32.9)		---	---
No	70	48 (68.6)	22 (31.4)		0.93	0.55-1.59
Depression screening (n = 542)				0.68^*
Negative (REF)	482	341 (70.7)	141 (29.3)		---	---
Positive	60	44 (73.3)	16 (26.7)		0.88	0.48-1.61
BMI (n = 647)				<0.001^*
BMI >18 and <30 (REF)	374	274 (73.3)	100 (26.7)		---	---
BMI ≤18 and ≥30	273	163 (59.7)	110 (40.3)		1.85	1.33-2.58
STI screening (n = 622)				0.07^*
Negative (REF)	604	422 (69.9)	182 (30.1)		---	---
Positive	18	9 (50.0)	9 (50.0)		2.32	0.91-5.94
A1c goal (n = 59)				0.07^*
<6.5 (REF)	43	22 (51.2)	21 (48.8)		---	---
≥6.5	16	4 (25.0)	12 (75.0)		3.14	0.87-11.30
Teratogenic medication use (n = 661)				0.33^†
No (REF)	660	440 (66.7)	220 (33.3)		---	---
Yes	1	0 (0.0)	1 (100.0)		n/a	n/a
Blood pressure (n = 634)				0.002^*
<120/80 (REF)	364	264 (72.5)	100 (27.5)		---	---
≥120/80	270	165 (61.1)	105 (38.9)		1.68	1.20-2.35
Harmful drug use (n = 653)				0.69^*
Avoided harmful substances (REF)	604	402 (66.6)	202 (33.4)		---	---
Use of harmful substances	49	34 (69.4)	15 (30.6)		0.88	0.47-1.65

↵* Chi-square test-of-independence.
↵† Fisher’s Exact test. Highlighted values indicate statistical significance.
Abbreviations: OR, Odds ratio; CI, Confidence interval; REF, Reference; Wks, Weeks; BMI, Body mass index; STI, Sexually transmitted infection.