PRE-CONCEPTION CARE

Sussy* is a 37 year old lady who has just found out that she is pregnant. She is a single mother of a fourteen-year old boy who was born with spina bifida occulta, a congenital disorder that affects the spinal cord that left him with weakness of the legs. Persistent physiotherapy and follow-up care has enabled him to live a fairly full life but it may or may not have cost Sussy her marriage.

After fourteen years of focusing on raising her son and climbing the career ladder, she has finally settled down with a new partner and they already expecting a new baby. For Sussy, the pregnancy evokes several emotions. She is excited and happy to be experiencing parenting again but at the same time, she is scared. She is fearful that her baby may be born with an abnormality, considering her previous history, and may not know how to communicate this to her new partner. She isn’t even sure she would know how to handle it herself.

Congenital disorders essentially are abnormal conditions existing in a fetus before they are born. They may be obvious physical anomalies that may or may not be compatible with life, or may be less subtle genetic abnormalities that interfere with normal function of the baby at metabolic level, resulting in physical symptoms.

These are just but part of the complications that may arise in pregnancy. Mitigation of these complications is the premise on which pre-conception care exists. Unfortunately, over 95% of women in Kenya will go on to get pregnant without the benefit of the service, the main reason being ignorance. It is common-place to have people go for an annual medical check-up for employment purposes, get vaccinated for travel purposes, get malaria prophylaxis for their children prior to travel to the village but never a visit to the doctor when contemplating conception.

With over 40% of pregnancies in Kenya being unintended, the absence of pre-conception care is compounded even further. Some of the unintended pregnancies will occur in young girls and women, who will take time to acknowledge their pregnancy state and delay even further in initiating pre-natal care.

What is pre-conception care? According to the World Health Organization Policy Brief, Preconception care is the provision of biomedical, behavioural and social health interventions to women and couples before conception occurs. It aims at improving their health status, and reducing behaviours and individual and environmental factors that contribute to poor maternal and child health outcomes. Its ultimate aim is to improve maternal and child health, in both the short and long term.

This care provides for an opportunity to fully optimize a woman’s state of health before conception. It also allows for reduction of risks that result in poor outcomes for both the mother and the newborn. It involves a full evaluation of a woman’s health, any medical conditions present that require correcting in advance, such as diabetes, high blood pressure, thyroid dysfunction, obesity, cardiac disease and fibroids. It is also important to review any long-term medicines the woman may be taking and their impact on the fetus in the womb, such as anti-convulsants (medication for seizures), anti-coagulants (blood thinners), anti-microbials and many others. Infections such as syphilis, that have been shown to have direct impact on the fetus, are treated and eradicated before conception. This vigilance is heightened during times of epidemics that come with devastating effects such as the Zika virus.

There is room for reviewing pre-existing risks such as a history of deep vein thrombosis in a previous pregnancy which will require prophylaxis during a new pregnancy to prevent recurrence, or supporting HIV-positive or HIV-discordant couples to conceive safely without increasing risk to themselves. There is time to advice on weight loss for the woman with hormonal imbalance, and to plan on when to insert a stitch in the cervix to prevent a miscarriage in a woman with an incompetent cervix.

The doctor has time to advocate to the soon to be mom on eradication of harmful habits such as smoking, heavy drinking and recreational drug use; habits that can negatively impact on the baby. Preventive treatments such as high dose folic acid supplementation is initiated even before conception in patients like Sussy, to minimize recurrence of congenital brain and spinal cord defects. Where necessary, mineral and vitamin supplements are initiated for high risk moms such as iron for mothers prone to anemia or vitamin B12 for strict vegans.

Discussions around familial inherited disorders such as sickle cell disease are initiated via genetic counselling for affected couples in this period. The couples may require to be tested for carrier states, and the information used to advise appropriately on expected outcomes and risks. For example, a woman who knows she is a sickle cell trait carrier has a 50% chance of giving birth to a baby who carries the same. But this will change dramatically if her partner is found to be a carrier too. The risk of having a carrier baby may remain at 50% but now there is a 25% chance of the baby suffering sickle cell disease and only a 25% chance of a normal baby. These statistics may not change the couple’s desire to have a baby but at least they are better prepared for any eventualities that may arise.

The importance of pre-conception care cannot possibly be over-emphasized. Massive efforts have gone into ensuring that every woman is able to access pre-natal care and now we can proudly boast that 96% of women who have delivered a baby in the past five years in Kenya had at least one pre-natal care clinic visit (Kenya Demographic Health Survey 2014). We must strive to match these figures at pre-conception care level. It is a powerful tool in improving maternal and neonatal health outcomes as major contributor to meeting the third Sustainable Development Goal.

*Names have been changed for confidentiality