Preconception education interventions

Evidence Rating  
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Disparity Rating  
Disparity rating: Inconclusive impact on disparities

Strategies with this rating do not have enough evidence to assess potential impact on disparities.

Health Factors  
Date last updated

Preconception education interventions provide information about the risks and benefits of behaviors that affect a birthing person’s overall health before, during, and after pregnancy; improving certain health behaviors prior to pregnancy reduces risks to birthing parents’ and infants’ health. Preconception health promotion and education interventions cover a variety of topics, such as nutrition, exercise and weight management, birth control methods, STI prevention, controlling chronic disease, reducing alcohol consumption, quitting smoking and other tobacco use, or improving mental health1, 2. Interventions can be delivered by medical providers, public health professionals1, or others with relevant education and training, such as clinical pharmacists3.

Preconception health describes the health of all people of reproductive age, regardless of their gender, sexual orientation, or intention to become pregnant or have children. Ongoing wellness visits with providers, sometimes called well-woman care, and education for partners, are a standard part of preconception care1. Wellness visits are covered as preventive care visits under the Affordable Care Act (ACA).

We at times use “women” or “maternal” when referring to people who may become pregnant or who may give birth. We acknowledge that not all people who can become pregnant or give birth identify as women, however current research on preconception health has primarily focused on those who identify as women.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased healthy behaviors

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Increased preconception planning

  • Improved health-related knowledge

  • Improved birth outcomes

What does the research say about effectiveness?

There is some evidence that preconception education interventions increase healthy behaviors among participating cis women1, 4, 5, 6, 7. Additional evidence is needed to confirm interventions’ effects on behaviors and birth outcomes, for what health conditions, and impacts on all individuals of reproductive age1, particularly among understudied groups, such as men and LGBTQ+ populations8.

Preconception interventions that address multiple risk factors appear to alter targeted behaviors6. For example, participants in the Central Pennsylvania Women’s Health Study’s Strong Women program reported increases in their intent to eat healthier and be physically active, as well as increased physical activity, consumption of folic acid, and self-efficacy following the program’s six bi-weekly education sessions9. An intensive intervention covering both alcohol consumption and contraception appeared to reduce binge drinking among risky drinkers7. Studies of a web-based conversational agent suggests it can change preconception health-related behaviors among women who are Black4, 5, and web-based education 7-10 days before a well woman visit may increase reproductive health discussions with providers10. Interventions targeting smoking may also reduce smoking pre-pregnancy6.

Preconception nutrition interventions appear to increase consumption of folic acid. A study of nutrition lessons for women of reproductive age with lower incomes, for example, appeared to increase their intake of dietary folate6. Various other individual programs, usually involving both education and supplement provision6, and collective interventions (e.g., public education campaigns and fortification of food products) have been shown to increase consumption of folic acid and reduce the risk of birth defects6, 11.

Risk assessment followed by individualized counseling appears to increase participants’ knowledge of healthy behaviors. In five urban primary care clinics, for example, risk assessment and brief counseling for women who have low incomes and are Black or Hispanic appeared to increase knowledge of the importance of folic acid, the need to treat and control chronic health conditions, and the importance of preconception medication review with a provider12. In a greater Atlanta area-based study, women who are Black and attended WIC clinic nutrition classes received brief counseling based on their risk assessment results and reported that counseling was both acceptable and important13.

Integrating preconception and interconception care into the ongoing care that women with diabetes receive may reduce congenital malformation, preterm delivery, and perinatal infant mortality14, however, additional evidence is needed to confirm effects15, 16.

How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.

It is unclear what impact preconception education interventions may have on disparities in pregnancy and birth outcomes. Available evidence suggests that programming specific to at risk groups can have a positive impact on health knowledge or behaviors among women with lower incomes6, 12, or who are Black4, 5, 12 or Hispanic12.

Preconception health is impacted by many things, including age, race and ethnicity, location, rurality, and insurance status28. A study looking at 37 states suggests that the average person had three or more preconception health risk factors or behaviors28. Populations who have been racially or ethnically minoritized or are disabled29, who have lower incomes28, who are sexually minoritized30, and those who live in rural areas28, 31 are more likely to have higher risks than their white, able-bodied, cis-gender, heterosexual, or urban counterparts. Preconception health is worse in the South and the Midwest, particularly in states that did not expand Medicaid28. LGBTQ+ birthing people face additional barriers and discrimination interfering with adequate care, including provider bias and physicians misunderstanding transgender and queer reproductive health care needs32. Efforts should be customized by region, particularly for areas with health disparities33, and preconception education intervention should be culturally tailored for LGBTQ+ populations30.

The maternal mortality rate in the U.S. is higher than in any other high-income country34, and there are stark disparities in maternal outcomes and maternal mortality between women who are Black, American Indian or Alaska Native, and women who are white34, 35, 36, as well as between those living in rural areas, compared to their urban counterparts35. Studies establish that women who are Black experience racial bias and discrimination in maternity care34; this may be true for other groups as well. Women in rural areas often live in counties without obstetricians or maternity care centers, reducing their access to care37.

What is the relevant historical background?

The Federal Housing Administration’s redlining practices concentrated poverty38 and entrenched racial residential segregation in the U.S., resulting in fewer health care facilities, resources, and funding in urban areas with largely Black populations39, 40. Past residential redlining and present-day disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods with residents that are primarily Black and low income39. Living in redlined areas exposes pregnant women to a variety of factors that can contribute to preterm birth, including poor quality housing, reduced neighborhood resources, and urban heat islands40. Segregation continues to be associated with increased risk of preterm birth and low birthweight for patients who are Black, with risks increasing as segregation in neighborhoods increases41.

Efforts to improve maternal and child health outcomes and disparities began in the 1960s with a focus on hospital care, switching to a prenatal care focus in the 1980s, and then preconception care in the 1990s42. However, there has been little evidence that any of these can impact disparities in birth outcomes, and experts suggest that all these services are necessary but cannot improve disparities in birth outcomes on their own42. More recent research has been exploring potential factors, such as toxic stress, that may have long lasting impacts which lead to perinatal disparities in future generations42.

Addressing preconception health is important for all people, as many pregnancies are unintended. Prior to Dobbs v. Jackson Women’s Health Organization overturning Roe v. Wade in 2022, making abortion illegal in almost half of U.S. states, many unwanted pregnancies were terminated28. This, and other increased barriers to abortion may increase existing disparities in maternal and infant health43 as more unwanted pregnancies are carried to term28.

Equity Considerations
  • What disparities in birth and maternal outcomes exist in your community?
  • What resources are available for preconception care in your community? Are certain groups less able to access the care and services available?
  • What are the barriers to high quality, linguistically and culturally appropriate preconception care?
Implementation Examples

The U.S. Department of Health and Human Services’ “Healthy Women, Healthy Pregnancies, Healthy Futures: Action Plan to Improve Maternal Health in America” includes improving preconception education17 through efforts such as the Collaborative Improvement and Innovation Network (CoIIN) on Infant Mortality’s preconception CoIIN work18.

Several states have developed preconception health campaigns that incorporate education as one component, including Every Woman California, Delaware Thrives, Every Woman North Carolina, Arizona’s Power Me A2Z, and Utah’s Power Your Life, Power Your Health19, 20, 21, 22, 23. Ever Thrive Illinois’s Healthy Choices Health Futures Toolkit is designed for use by families and social service providers24.

Many non-profit and university organizations also provide preconception education interventions. PASOs, a program serving the Latino community in South Carolina, includes a culturally appropriate preconception health education workshop as part of its wider preconception health efforts25, 26.

The Show Your Love national campaign encourages healthy behaviors for all women27.

Implementation Resources

Resources with a focus on equity.

AMCHP-Innovation hub - Association of Maternal & Child Health Programs (AMCHP). Innovation hub: Innovations database.

Before and Beyond - Before, Between & Beyond Pregnancy. Preconception Health and Healthcare Initiative. Chapel Hill: The University of North Carolina at Chapel Hill.

CDC-Humphrey 2012 - Humphrey JR, Floyd RL. Preconception health and health care environmental scan. Atlanta: Centers for Disease Control and Prevention (CDC); 2012.

EverThrive Illinois - EverThrive Illinois. (2020). Healthy Choices, Healthy Futures.

Every Woman California - Every Woman California. Preconception Health Council of California.

Show Your Love - Show Your Love. Preconception Health and Health Care Initiative.

NBDPN-Awareness - National Birth Defects Prevention Network (NBDPN). National Birth Defects Awareness Month.

Footnotes

* Journal subscription may be required for access.

1 Brown 2017 - Brown M, Vaclavik D, Dennis WP, Wilka E. Predictors of homeless services re-entry within a sample of adults receiving homelessness prevention and rapid re-housing program (HPRP) assistance. Psychological Services. 2017;14(2):129-140.

2 Khekade 2023 - Khekade, H., Potdukhe, A., Taksande, A. B., Wanjari, M. B., & Yelne, S. (2023). Preconception care: A strategic intervention for the prevention of neonatal and birth disorders. Cureus.

3 DiPietro Mager 2016 - DiPietro Mager, N. A. (2016). Fulfilling an unmet need: Roles for clinical pharmacists in preconception care. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 36(2), 141–151.

4 Bickmore 2020 - Bickmore, T., Zhang, Z., Reichert, M., Julce, C., & Jack, B. (2020). Promotion of preconception care among adolescents and young adults by conversational agent. Journal of Adolescent Health, 67(2), S45–S51.

5 Jack 2015 - Jack, B., Bickmore, T., Hempstead, M., Yinusa-Nyahkoon, L., Sadikova, E., Mitchell, S., Gardiner, P., Adigun, F., Penti, B., Schulman, D., & Damus, K. (2015). Reducing preconception risks among African American women with conversational agent technology. The Journal of the American Board of Family Medicine, 28(4), 441–451.

6 Temel 2014 - Temel S, van Voorst SF, Jack BW, Denkta S, Steegers EAP. Evidence-based preconceptional lifestyle interventions. Epidemiologic Reviews. 2014;36(1):19-30.

7 Cochrane-Whitworth 2009 - Whitworth M, Dowswell T. Routine pre-pregnancy health promotion for improving pregnancy outcomes. Cochrane Database of Systematic Reviews. 2009;(4):CD007536.

8 Brown 2020 - Brown SS. What will it take to further reduce teen pregnancy in the U.S.? Journal of Adolescent Health. 2020;66(5):522-523.

9 Hillemeier 2008 - Hillemeier MM, Symons Downs D, Feinberg ME, et al. Improving women's preconceptional health: Findings from a randomized trial of the strong healthy women intervention in the central Pennsylvania women's health study. Women's Health Issues. 2008;18(6 Suppl 1):87-96.

10 Batra 2018 - Batra, P., Mangione, C. M., Cheng, E., Steers, W. N., Nguyen, T. A., Bell, D., Kuo, A. A., & Gregory, K. D. (2018). A cluster randomized controlled trial of the MyFamilyPlan online preconception health education tool. American Journal of Health Promotion, 32(4), 897–905.

11 CG-Folic acid campaigns - The Guide to Community Preventive Services (The Community Guide). Pregnancy health: Community-wide campaigns to promote the use of folic acid supplements

12 Dunlop 2013b - Dunlop AL, Logue KM, Thorne C, Badal HJ. Change in women's knowledge of general and personal preconception health risks following targeted brief counseling in publicly funded primary care settings. American Journal of Health Promotion. 2013;27(3 Suppl 1):50-57.

13 Dunlop 2013a - Dunlop AL, Dretler AW, Badal HJ, Logue KM. Acceptability and potential impact of brief preconception health risk assessment and counseling in the WIC setting. American Journal of Health Promotion. 2013;27(3 Suppl 1):58-65.

14 Wahabi 2010 - Wahabi HA, Alzeidan RA, Bawazeer GA, Alansari LA, Esmaeil SA. Preconception care for diabetic women for improving maternal and fetal outcomes: A systematic review and meta-analysis. BMC Pregnancy and Childbirth. 2010;10:63.

15 Cochrane-Tieu 2017 - Tieu, J., Shepherd, E., Middleton, P., & Crowther, C. A. (2017). Interconception care for women with a history of gestational diabetes for improving maternal and infant outcomes. Cochrane Database of Systematic Reviews, (8), CD010211.

16 Cochrane-Tieu 2017a - Tieu, J., Middleton, P., Crowther, C. A., & Shepherd, E. (2017). Preconception care for diabetic women for improving maternal and infant health. Cochrane Database of Systematic Reviews, (8), CD007776.

17 US DHHS-HWHPHF 2020 - U.S. Department of Health and Human Services. (2020). Healthy women, healthy pregnancies, healthy futures: Action plan to improve maternal health in America.

18 Before and Beyond-CoIIN - Before, Between & Beyond Pregnancy. Preconception : Collaborating to improve well woman care. Chapel Hill: The University of North Carolina at Chapel Hill.

19 Every Woman California - Every Woman California. Preconception Health Council of California.

20 Delaware Thrives - Delaware Thrives: Women's health. Delaware Health and Social Services Division of Public Health and Delaware Healthy Mother & Infant Consortium.

21 Every Woman North Carolina - Every Woman North Carolina. March of Dimes North Carolina Preconception Health Campaign.

22 Power Me A2Z - Power Me A2Z. Arizona Department of Health Services.

23 UDOH-Power Your Life - Utah Department of Health (UDOH). Power Your Life, Power Your Health.

24 EverThrive Illinois - EverThrive Illinois. (2020). Healthy Choices, Healthy Futures.

25 PASOs - Perinatal Awareness for Successful Outcomes (PASOs). Healthy Latino communities contributing to a stronger South Carolina.

26 Torres 2013a - Torres ME, Smithwick-Leone J, Willms L, et al. Developing a culturally appropriate preconception health promotion strategy for newly immigrated Latinos through a community-based program in South Carolina. American Journal of Health Promotion. 2013;27(3):S7-S9.

27 Show Your Love - Show Your Love. Preconception Health and Health Care Initiative.

28 Haiman 2023 - Haiman, M. D., & Cubbin, C. (2023). Impact of geography and rurality on preconception health status in the United States. Preventing Chronic Disease, 20(E101), 230104.

29 Horner-Johnson 2021 - Horner-Johnson, W., Akobirshoev, I., Amutah-Onukagha, N. N., Slaughter-Acey, J. C., & Mitra, M. (2021). Preconception health risks among U.S. women: Disparities at the intersection of disability and race or ethnicity. Women’s Health Issues, 31(1), 65–74.

30 Limburg 2020 - Limburg, A., Everett, B. G., Mollborn, S., & Kominiarek, M. A. (2020). Sexual orientation disparities in preconception health. Journal of Women’s Health, 29(6), 755–762.

31 DiPietro Mager 2023 - DiPietro Mager, N. A., Zollinger, T. W., Turman, J. E., Zhang, J., & Dixon, B. E. (2023). Preconception health status and associated disparities among rural, midwestern women in the United States. Birth, 50(1), 127–137.

32 Wingo 2018 - Wingo, E., Ingraham, N., & Roberts, S. C. M. (2018). Reproductive health care priorities and barriers to effective care for LGBTQ people assigned female at birth: A qualitative study. Women’s Health Issues, 28(4), 350–357.

33 DiPietro Mager 2024 - DiPietro Mager, N., Menegay, M., Bish, C., & Oza-Frank, R. (2024). Geographic differences in preconception health indicators among Ohio women who delivered live births, 2019–2021. Preventing Chronic Disease, 21(E08), 230244.

34 Tucker 2021 - Tucker CM, Felder TM, Dail RB, Lyndon A, Allen K-C. Group prenatal care and maternal outcomes: A scoping review. MCN: The American Journal of Maternal/Child Nursing. 2021;46(6):314-322.

35 ASPE-Knocke 2022 - Knocke K, Chappel A, Sugar S, De Lew N, Sommers BD. Doula care and maternal health: An evidence review. Issue Brief no. HP-2022-24. Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services; 2022.

36 CWF-Hostetter 2019 - Hostetter M, Klein S. Improving health for women by better supporting them through pregnancy and beyond. New York: The Commonwealth Fund (CWF); 2019.

37 March of Dimes-Brigance 2022 - Brigance C, Lucas R, Jones E, et al. Nowhere to go: Maternity care deserts across the U.S. (Report No. 3). March of Dimes; 2022.

38 Kaplan 2007 - Kaplan J, Valls A. Housing discrimination as a basis for Black reparations. Public Affairs Quarterly. 2007;21(3):255-273.

39 Lee 2023 - Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Social Science and Medicine. 2023;328:116009.

40 Lee 2022c - Lee EK, Donley G, Ciesielski TH, et al. Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis. Social Science and Medicine. 2022;294:114696.

41 Mehra 2017 - Mehra R, Boyd LM, Ickovics JR. Racial segregation and adverse birth outcomes: A systematic review and meta-analysis. Social Science & Medicine. 2017;191:237-250.

42 St Fleur 2016 - St. Fleur, M., Damus, K., & Jack, B. (2016). The future of preconception care in the United States: Multigenerational impact on reproductive outcomes. Upsala Journal of Medical Sciences, 121(4), 211–215.

43 KFF-Hill 2022 - Hill L, Artiga S, Ranji U. Racial disparities in maternal and infant health: Current status and efforts to address them. KFF. 2022.