International Journal of Gynecology and Obstetrics 125 (2014) 144–145
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Preconception care in France Dominique Luton a, Anne Forestier b, Stéphanie Courau b, Pierre-François Ceccaldi a,⁎ a b
Department of Obstetrics and Gynecology, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, Université Paris VII, Paris, France Merck Médication Familiale, Dijon, France
a r t i c l e
i n f o
Article history: Received 24 June 2013 Received in revised form 2 October 2013 Accepted 17 January 2014 Keywords: Care Folate Preconception
a b s t r a c t Objective: Preconception care is advocated throughout the world as a tool for improving perinatal outcomes. However, the proportion of women in France who attend a dedicated medical preconception visit is unknown. Methods: We undertook a retrospective study among 401 women who delivered at a maternity clinic or hospital in France to determine how many of them had attended a preconception visit. We also collected information on various preconception care behaviors such as folate supplementation and alcohol or tobacco cessation. Results: In total, 21.6% of the women took a folate prescription, and 91.3% and 68.6% of women stopped alcohol and tobacco consumption, respectively. Of the 80.2% of women who visited a doctor within the 6 months before conception, only 13.8% discussed their planned pregnancy at this visit. Conclusion: Although the rate of vitamin supplementation remains low, there has been an increase in adequate preconception care behavior. This indicates that improvement is possible and should be implemented. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
2. Materials and methods
Pregnancy is a natural event with a normal outcome for most pregnant women and their neonates. Medical and/or psychosocial follow-up aims at maximizing the chances of an uncomplicated outcome, including avoidance of pre-eclampsia and preterm labor, and detection of conditions that can jeopardize fetal outcome, such as malformations, particularly neural tube defects [1–3]. Preconception care clearly improves overall pregnancy outcomes by educating women or couples about environmental hazards such as alcohol, tobacco, and various toxic substances [4,5]. The topics of balanced nutrition and supplementation with essential vitamins such as folic acid must also be discussed during the preconception visit. Moreover, given that increasing numbers of women give birth at advanced maternal age, it is important to screen for silent diseases such as hypertension, diabetes mellitus, and subclinical or overt hypothyroidism [6–14]. Knowing the infectious or genetic background of a woman can also be beneficial for the outcome of a future pregnancy [15,16]. Therefore, preconception care is recommended whenever possible [17,18]. Before 2008 in France, where state funding for prenuptial visits was removed for economic reasons in 2007, almost 65% of women did not consult a doctor before becoming pregnant, with a very low uptake (2%–15%) of folic acid supplementation [1,2,19]. The present retrospective study aimed to evaluate the occurrence and content of preconception visits at maternity units in France.
The study was conducted at 23 public or private maternity units throughout France between March 1 and June 1, 2008. The participating units offered varying levels of prenatal care. The midwives in charge of the postpartum units approached women during the week after their delivery and applied a questionnaire that had been approved by the Ethics Committee of the French College of Gynecologists and Obstetricians (CNGOF). Overall, 401 women answered the questionnaire, and data from 392 women were included in the final analysis. All participants provided oral informed consent. The questionnaire mainly contained questions about whether the pregnancy had been planned, the method of conception, the context of conception (e.g. after a previous pregnancy, after interruption of contraception), smoking or alcohol cessation, and receipt of behavioral advice before the pregnancy, including recommendations on vitamin supplementation. The data were analyzed with SPSS version 16.0 (IBM, Armonk, NY, USA) using descriptive statistics.
⁎ Corresponding author at: Hôpital Beaujon, Département de Gynécologie-Obstétrique, 100 Boulevard du Général Leclerc, 92110 Clichy, France. Tel.: +33 1 40 87 52 00; fax: +33 1 47 31 35 27. E-mail addresses: [email protected], [email protected] (P.-F. Ceccaldi).
3. Results The questionnaire was answered by 256 (65.3%) women using public maternity services and 136 (34.7%) women using private services. During the preconception period, 85 (21.6%) of the 392 women had taken nutritional supplements in preparation for their future pregnancy; 53 (62.4%) had taken supplements for more than 2 months and 72 (84.7%) reported that the supplement contained folic acid (vitamin B9). The pregnancy was planned by 346 (88.3%) women, and of these 199 (50.8%) considered that they had taken adequate preparations.
0020-7292/$ – see front matter © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.10.019
D. Luton et al. / International Journal of Gynecology and Obstetrics 125 (2014) 144–145
However, only 57 (28.6%) of the women with a planned pregnancy had been taking a supplement. The pregnancy resulted in behavioral modifications, with 127/185 (68.6%) of smokers and 231/253 (91.3%) of women with regular alcohol consumption stopping as soon as they knew they were pregnant. Although 312/389 (80.2%) women visited a doctor within 6 months before conception, only 43 (13.8%) of these women discussed their planned pregnancy at this visit. Of the 86 women who took a prenatal supplement, 62 (72.1%) had been advised by their doctor to do so, and 79 (92.0%) had seen a doctor during the 6 months before conception. For 4 (4.7%) of the women who took a prenatal supplement, the supplementation had been recommended by a pharmacist. Of the 207 women who discussed the interruption of contraception with their doctors, 43 (20.8%) received general advice about nutrition and vitamin supplementation, 78 (37.7%) received specific advice about how to prepare for a pregnancy, and 70 (33.8%) were given a prescription for vitamin supplements. Of the 166 women who specifically discussed their pregnancy plans during this visit, 87 (52.4%) received specific advice and 96 (57.8%) received a supplement prescription. 4. Discussion The present study found a considerable improvement in the uptake of preconception vitamin supplementation compared with previous data from France (21% versus 2%–15% [1,2]). The same trend was observed for preconception medical visits. However, the true rate of preconception visits in the present study can be considered to be 14%, which is lower than the 30% rate reported by the Centers for Disease Control and Prevention in 2007 [20]. Although the present results are promising, preconception care falls short of the official recommendations in France. Folic acid was a component of most supplements (84%). The majority of the women (88%) had planned their pregnancy, but only half of them had taken effective measures to prepare for it. This proportion is relatively low in comparison with official recommendations. Although 80% of the women of childbearing age had visited a general practitioner or a specialist during the 6 months before conception, only 14% of these women had discussed their planned pregnancy with their doctor. Of importance is the finding that planning to become, or being, pregnant induced behavior modifications such as stopping smoking or alcohol drinking in more than half of the women. This gives great hope for the prevention of other risks that pregnant women can address, such as neural tube defects resulting from folic acid deprivation. Even though most women in the present study had visited a doctor before conception, the rate of vitamin supplementation remains disappointing, highlighting that either the subject of preconception care is not discussed, or knowledge among doctors and/or women, or communication between them, is poor. Of the women who specifically discussed their pregnancy plans during the preconception visit, only half received a vitamin prescription and specific advice on how to prepare for their pregnancy. This means that there is a great need to improve knowledge among, and communication between, women and doctors. In summary, the rate of vitamin supplementation in France has risen since the early 2000s and doctors and women of childbearing age are becoming more aware of the concept of preconception care. Nevertheless, the rates of vitamin supplementation and preconception care visits remain considerably lower than what they should be (ideally 100%) if one agrees with the major impact of these measures on public health. As a next step, we will reinvestigate—within a short time interval—the same items among the same population in order to assess whether preconception behavior has improved as a result of information campaigns. Decision makers should also be aware that supplementation with folic acid is clearly more cost-effective than caring for future patients or terminating a pregnancy [21]. Efforts must be made by academic
145
and public health authorities, and also by patient lobby groups, to improve this situation [22,23]. Acknowledgments The study was funded by Merck Médication Familiale, Dijon, France. Conflict of interest S.C. and A.F. are employed by Merck Médication Familiale, Dijon, France. D.L. has received fees for consultancy from Merck Médication Familiale during 2007 and 2008. P-F.C. has no conflicts of interest. References [1] HAS. Improving information provision for pregnant women. http://www.has-sante. fr/portail/upload/docs/application/pdf/infos_femmes_enceintes_rap.pdf. Accessed September 23, 2013. [2] Dreux C, Crépin G, French Academy of Medicine. Report and recommendation by the French Academy of Medicine concerning the prevention risks for the child to come and the necessity for early information before pregnancy. Gynecol Obstet Fertil 2006;34(7–8):665–9. [3] Roland JM, Murphy HR, Ball V, Northcote-Wright J, Temple RC. The pregnancies of women with Type 2 diabetes: poor outcomes but opportunities for improvement. Diabet Med 2005;22(12):1774–7. [4] Atrash H, Jack BW, Johnson K. Preconception care: a 2008 update. Curr Opin Obstet Gynecol 2008;20(6):581–9. [5] Mitchell EW, Levis DM, Prue CE. Preconception health: awareness, planning, and communication among a sample of US men and women. Matern Child Health J 2012;16(1):31–9. [6] Ray JG, O'Brien TE, Chan WS. Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis. QJM 2001;94(8):435–44. [7] Herman WH, Janz NK, Becker MP, Charron-Prochownik D. Diabetes and pregnancy. Preconception care, pregnancy outcomes, resource utilization and costs. J Reprod Med 1999;44(1):33–8. [8] Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: the cost-effectiveness of the California Diabetes and Pregnancy Program. Am J Public Health 1992;82(2):168–75. [9] Atrash HK, Johnson K, Adams M, Cordero JF, Howse J. Preconception care for improving perinatal outcomes: the time to act. Matern Child Health J 2006;10(5 Suppl.): S3–S11. [10] Clark KA, Dawson S, Martin SL. The effect of implementing a more comprehensive screening for substance use among pregnant women in North Carolina. Matern Child Health J 1999;3(3):161–6. [11] Weber MK, Floyd RL, Riley EP, Snider Jr DE, National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect. National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect: defining the national agenda for fetal alcohol syndrome and other prenatal alcohol-related effects. MMWR Recomm Rep 2002;51(RR– 14):9–12. [12] Perlman SE, Rudy SJ, Pinto C, Townsend-Akpan C. Caring for women with childbearing potential taking teratogenic dermatologic drugs. Guidelines for practice. J Reprod Med 2001;46(2 Suppl.):153–61. [13] Barrett C, Richens A. Epilepsy and pregnancy: Report of an Epilepsy Research Foundation Workshop. Epilepsy Res 2003;52(3):147–87. [14] Raynal P. Preconception care. Gynecol Obstet Fertil 2010;38(7–8):481–5. [15] Mast EE, Weinbaum CM, Fiore AE, Alter MJ, Bell BP, Finelli L, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006;55(RR– 16):1–33. [16] Langfelder-Schwind E, Kloza E, Sugarman E, Pettersen B, Brown T, Jensen K, et al. Cystic fibrosis prenatal screening in genetic counseling practice: recommendations of the National Society of Genetic Counselors. J Genet Couns 2005;14(1):1–15. [17] Adams MM, Bruce FC, Shulman HB, Kendrick JS, Brogan DJ. Pregnancy planning and pre-conception counseling. The PRAMS Working Group. Obstet Gynecol 1993;82(6):955–9. [18] Centers for Disease Control and Prevention. Revised recommendations for HIV screening of pregnant women. MMWR Recomm Rep 2001;50(RR–19):63–85. [19] Tort J, Lelong N, Prunet C, Khoshnood B, Blondel B. Maternal and health care determinants of preconceptional use of folic acid supplementation in France: results from the 2010 National Perinatal Survey. BJOG 2014 (in press). [20] D'Angelo D, Williams L, Morrow B, Cox S, Harris N, Harrison L, et al. Preconception and interconception health status of women who recently gave birth to a liveborn infant–Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR Surveill Summ 2007;56(10):1–35. [21] Yi Y, Lindemann M, Colligs A, Snowball C. Economic burden of neural tube defects and impact of prevention with folic acid: a literature review. Eur J Pediatr 2011;170(11):1391–400. [22] Harelick L, Viola D, Tahara D. Preconception health of low socioeconomic status women: assessing knowledge and behaviors. Womens Health Issues 2011;21(4):272–6. [23] Delissaint D, McKyer EL. A systematic review of factors utilized in preconception health behavior research. Health Educ Behav 2011;38(6):603–16.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Preconception care in France Dominique Luton a, Anne Forestier b, Stéphanie Courau b, Pierre-François Ceccaldi a,⁎ a b
Department of Obstetrics and Gynecology, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, Université Paris VII, Paris, France Merck Médication Familiale, Dijon, France
a r t i c l e
i n f o
Article history: Received 24 June 2013 Received in revised form 2 October 2013 Accepted 17 January 2014 Keywords: Care Folate Preconception
a b s t r a c t Objective: Preconception care is advocated throughout the world as a tool for improving perinatal outcomes. However, the proportion of women in France who attend a dedicated medical preconception visit is unknown. Methods: We undertook a retrospective study among 401 women who delivered at a maternity clinic or hospital in France to determine how many of them had attended a preconception visit. We also collected information on various preconception care behaviors such as folate supplementation and alcohol or tobacco cessation. Results: In total, 21.6% of the women took a folate prescription, and 91.3% and 68.6% of women stopped alcohol and tobacco consumption, respectively. Of the 80.2% of women who visited a doctor within the 6 months before conception, only 13.8% discussed their planned pregnancy at this visit. Conclusion: Although the rate of vitamin supplementation remains low, there has been an increase in adequate preconception care behavior. This indicates that improvement is possible and should be implemented. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
2. Materials and methods
Pregnancy is a natural event with a normal outcome for most pregnant women and their neonates. Medical and/or psychosocial follow-up aims at maximizing the chances of an uncomplicated outcome, including avoidance of pre-eclampsia and preterm labor, and detection of conditions that can jeopardize fetal outcome, such as malformations, particularly neural tube defects [1–3]. Preconception care clearly improves overall pregnancy outcomes by educating women or couples about environmental hazards such as alcohol, tobacco, and various toxic substances [4,5]. The topics of balanced nutrition and supplementation with essential vitamins such as folic acid must also be discussed during the preconception visit. Moreover, given that increasing numbers of women give birth at advanced maternal age, it is important to screen for silent diseases such as hypertension, diabetes mellitus, and subclinical or overt hypothyroidism [6–14]. Knowing the infectious or genetic background of a woman can also be beneficial for the outcome of a future pregnancy [15,16]. Therefore, preconception care is recommended whenever possible [17,18]. Before 2008 in France, where state funding for prenuptial visits was removed for economic reasons in 2007, almost 65% of women did not consult a doctor before becoming pregnant, with a very low uptake (2%–15%) of folic acid supplementation [1,2,19]. The present retrospective study aimed to evaluate the occurrence and content of preconception visits at maternity units in France.
The study was conducted at 23 public or private maternity units throughout France between March 1 and June 1, 2008. The participating units offered varying levels of prenatal care. The midwives in charge of the postpartum units approached women during the week after their delivery and applied a questionnaire that had been approved by the Ethics Committee of the French College of Gynecologists and Obstetricians (CNGOF). Overall, 401 women answered the questionnaire, and data from 392 women were included in the final analysis. All participants provided oral informed consent. The questionnaire mainly contained questions about whether the pregnancy had been planned, the method of conception, the context of conception (e.g. after a previous pregnancy, after interruption of contraception), smoking or alcohol cessation, and receipt of behavioral advice before the pregnancy, including recommendations on vitamin supplementation. The data were analyzed with SPSS version 16.0 (IBM, Armonk, NY, USA) using descriptive statistics.
⁎ Corresponding author at: Hôpital Beaujon, Département de Gynécologie-Obstétrique, 100 Boulevard du Général Leclerc, 92110 Clichy, France. Tel.: +33 1 40 87 52 00; fax: +33 1 47 31 35 27. E-mail addresses: [email protected], [email protected] (P.-F. Ceccaldi).
3. Results The questionnaire was answered by 256 (65.3%) women using public maternity services and 136 (34.7%) women using private services. During the preconception period, 85 (21.6%) of the 392 women had taken nutritional supplements in preparation for their future pregnancy; 53 (62.4%) had taken supplements for more than 2 months and 72 (84.7%) reported that the supplement contained folic acid (vitamin B9). The pregnancy was planned by 346 (88.3%) women, and of these 199 (50.8%) considered that they had taken adequate preparations.
0020-7292/$ – see front matter © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.10.019
D. Luton et al. / International Journal of Gynecology and Obstetrics 125 (2014) 144–145
However, only 57 (28.6%) of the women with a planned pregnancy had been taking a supplement. The pregnancy resulted in behavioral modifications, with 127/185 (68.6%) of smokers and 231/253 (91.3%) of women with regular alcohol consumption stopping as soon as they knew they were pregnant. Although 312/389 (80.2%) women visited a doctor within 6 months before conception, only 43 (13.8%) of these women discussed their planned pregnancy at this visit. Of the 86 women who took a prenatal supplement, 62 (72.1%) had been advised by their doctor to do so, and 79 (92.0%) had seen a doctor during the 6 months before conception. For 4 (4.7%) of the women who took a prenatal supplement, the supplementation had been recommended by a pharmacist. Of the 207 women who discussed the interruption of contraception with their doctors, 43 (20.8%) received general advice about nutrition and vitamin supplementation, 78 (37.7%) received specific advice about how to prepare for a pregnancy, and 70 (33.8%) were given a prescription for vitamin supplements. Of the 166 women who specifically discussed their pregnancy plans during this visit, 87 (52.4%) received specific advice and 96 (57.8%) received a supplement prescription. 4. Discussion The present study found a considerable improvement in the uptake of preconception vitamin supplementation compared with previous data from France (21% versus 2%–15% [1,2]). The same trend was observed for preconception medical visits. However, the true rate of preconception visits in the present study can be considered to be 14%, which is lower than the 30% rate reported by the Centers for Disease Control and Prevention in 2007 [20]. Although the present results are promising, preconception care falls short of the official recommendations in France. Folic acid was a component of most supplements (84%). The majority of the women (88%) had planned their pregnancy, but only half of them had taken effective measures to prepare for it. This proportion is relatively low in comparison with official recommendations. Although 80% of the women of childbearing age had visited a general practitioner or a specialist during the 6 months before conception, only 14% of these women had discussed their planned pregnancy with their doctor. Of importance is the finding that planning to become, or being, pregnant induced behavior modifications such as stopping smoking or alcohol drinking in more than half of the women. This gives great hope for the prevention of other risks that pregnant women can address, such as neural tube defects resulting from folic acid deprivation. Even though most women in the present study had visited a doctor before conception, the rate of vitamin supplementation remains disappointing, highlighting that either the subject of preconception care is not discussed, or knowledge among doctors and/or women, or communication between them, is poor. Of the women who specifically discussed their pregnancy plans during the preconception visit, only half received a vitamin prescription and specific advice on how to prepare for their pregnancy. This means that there is a great need to improve knowledge among, and communication between, women and doctors. In summary, the rate of vitamin supplementation in France has risen since the early 2000s and doctors and women of childbearing age are becoming more aware of the concept of preconception care. Nevertheless, the rates of vitamin supplementation and preconception care visits remain considerably lower than what they should be (ideally 100%) if one agrees with the major impact of these measures on public health. As a next step, we will reinvestigate—within a short time interval—the same items among the same population in order to assess whether preconception behavior has improved as a result of information campaigns. Decision makers should also be aware that supplementation with folic acid is clearly more cost-effective than caring for future patients or terminating a pregnancy [21]. Efforts must be made by academic
145
and public health authorities, and also by patient lobby groups, to improve this situation [22,23]. Acknowledgments The study was funded by Merck Médication Familiale, Dijon, France. Conflict of interest S.C. and A.F. are employed by Merck Médication Familiale, Dijon, France. D.L. has received fees for consultancy from Merck Médication Familiale during 2007 and 2008. P-F.C. has no conflicts of interest. References [1] HAS. Improving information provision for pregnant women. http://www.has-sante. fr/portail/upload/docs/application/pdf/infos_femmes_enceintes_rap.pdf. Accessed September 23, 2013. [2] Dreux C, Crépin G, French Academy of Medicine. Report and recommendation by the French Academy of Medicine concerning the prevention risks for the child to come and the necessity for early information before pregnancy. Gynecol Obstet Fertil 2006;34(7–8):665–9. [3] Roland JM, Murphy HR, Ball V, Northcote-Wright J, Temple RC. The pregnancies of women with Type 2 diabetes: poor outcomes but opportunities for improvement. Diabet Med 2005;22(12):1774–7. [4] Atrash H, Jack BW, Johnson K. Preconception care: a 2008 update. Curr Opin Obstet Gynecol 2008;20(6):581–9. [5] Mitchell EW, Levis DM, Prue CE. Preconception health: awareness, planning, and communication among a sample of US men and women. Matern Child Health J 2012;16(1):31–9. [6] Ray JG, O'Brien TE, Chan WS. Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis. QJM 2001;94(8):435–44. [7] Herman WH, Janz NK, Becker MP, Charron-Prochownik D. Diabetes and pregnancy. Preconception care, pregnancy outcomes, resource utilization and costs. J Reprod Med 1999;44(1):33–8. [8] Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: the cost-effectiveness of the California Diabetes and Pregnancy Program. Am J Public Health 1992;82(2):168–75. [9] Atrash HK, Johnson K, Adams M, Cordero JF, Howse J. Preconception care for improving perinatal outcomes: the time to act. Matern Child Health J 2006;10(5 Suppl.): S3–S11. [10] Clark KA, Dawson S, Martin SL. The effect of implementing a more comprehensive screening for substance use among pregnant women in North Carolina. Matern Child Health J 1999;3(3):161–6. [11] Weber MK, Floyd RL, Riley EP, Snider Jr DE, National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect. National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect: defining the national agenda for fetal alcohol syndrome and other prenatal alcohol-related effects. MMWR Recomm Rep 2002;51(RR– 14):9–12. [12] Perlman SE, Rudy SJ, Pinto C, Townsend-Akpan C. Caring for women with childbearing potential taking teratogenic dermatologic drugs. Guidelines for practice. J Reprod Med 2001;46(2 Suppl.):153–61. [13] Barrett C, Richens A. Epilepsy and pregnancy: Report of an Epilepsy Research Foundation Workshop. Epilepsy Res 2003;52(3):147–87. [14] Raynal P. Preconception care. Gynecol Obstet Fertil 2010;38(7–8):481–5. [15] Mast EE, Weinbaum CM, Fiore AE, Alter MJ, Bell BP, Finelli L, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006;55(RR– 16):1–33. [16] Langfelder-Schwind E, Kloza E, Sugarman E, Pettersen B, Brown T, Jensen K, et al. Cystic fibrosis prenatal screening in genetic counseling practice: recommendations of the National Society of Genetic Counselors. J Genet Couns 2005;14(1):1–15. [17] Adams MM, Bruce FC, Shulman HB, Kendrick JS, Brogan DJ. Pregnancy planning and pre-conception counseling. The PRAMS Working Group. Obstet Gynecol 1993;82(6):955–9. [18] Centers for Disease Control and Prevention. Revised recommendations for HIV screening of pregnant women. MMWR Recomm Rep 2001;50(RR–19):63–85. [19] Tort J, Lelong N, Prunet C, Khoshnood B, Blondel B. Maternal and health care determinants of preconceptional use of folic acid supplementation in France: results from the 2010 National Perinatal Survey. BJOG 2014 (in press). [20] D'Angelo D, Williams L, Morrow B, Cox S, Harris N, Harrison L, et al. Preconception and interconception health status of women who recently gave birth to a liveborn infant–Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR Surveill Summ 2007;56(10):1–35. [21] Yi Y, Lindemann M, Colligs A, Snowball C. Economic burden of neural tube defects and impact of prevention with folic acid: a literature review. Eur J Pediatr 2011;170(11):1391–400. [22] Harelick L, Viola D, Tahara D. Preconception health of low socioeconomic status women: assessing knowledge and behaviors. Womens Health Issues 2011;21(4):272–6. [23] Delissaint D, McKyer EL. A systematic review of factors utilized in preconception health behavior research. Health Educ Behav 2011;38(6):603–16.
