Guidelines for preventive activities in general practice

Reproductive and women’s health

Preconception

Guidelines for preventive activities in general practice
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Reproductive and women's health | Preconception

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Approximately 10% of reproductive-age (15–44 years) women get pregnant each year in Australia.1 Estimates are that 40% of these pregnancies are unintended (a pregnancy that occurs when no children or no more children are desired, which is defined as unwanted, or a pregnancy that occurs earlier than desired, which is defined as mistimed).2 The current birth rate is 56 pre 1000 women of reproductive age. Some 20% of births are from the lowest socioeconomic areas and 4.9% are Aboriginal and/or Torres Strait Islander people.3 In 2020, the average age of all women who gave birth was 30.9 years, with 26% of women giving birth aged over 35 years and 12% being aged under 25 years.3 Although almost 1 in 10 (9.2%) mothers who gave birth in 2020 smoked at some time during their pregnancy, 22% of pregnant women who smoke quit smoking during the pregnancy.3 In addition, 27% of mothers were overweight and 22% were obese.3 It is estimated that one in two (49%) women drank alcohol before they knew they were pregnant, with one in four (25%) drinking after they knew they were pregnant.4

Carriers of cystic fibrosis (CF), spinal muscular atrophy (SMA) and fragile X syndrome (FXS) are common in the Australian population.5 Approximately 1 in 20 people are carriers of one or more of these conditions. Most carriers do not have a family history of relatives affected by the disorder and are unaware that they are carriers.

Screening

Recommended as of: 28/06/2024
Recommendation Grade How often References

Reproductive carrier screening

Reproductive carrier screening (including screening for CF, SMA and FXS*) is recommended to anyone planning pregnancy. Refer to the Genetics chapter for further information.

* MBS items are available for carrier screening for cystic fibrosis, SMA and fragile X syndrome.		 Practice point Before pregnancy 6

Case finding

Recommended as of: 28/06/2024
Recommendation Grade How often References

Prepregnancy genetic counselling

Prepregnancy genetic counselling is recommended for couples at increased risk of a heritable disorder (see Preconception Box 1) based on the family history or ethnic background.

Prepregnancy genetic counselling helps determine a couple’s risk of an affected child and provides information about options for carrier screening, preimplantation genetic diagnosis, prenatal diagnosis and postnatal management.

Refer to the Genetics chapter for further information.		 Practice point Before pregnancy 6

Preventive activities and advice

Recommended as of: 28/06/2024
Recommendation Grade References

Assessment and stabilisation of pre-existing medical and mental health conditions

Assess and stabilise pre-existing medical and mental health conditions prior to pregnancy to optimise pregnancy outcomes. Discuss how these pre-existing conditions may affect, or be affected by, a pregnancy.		 Practice point 6

Review current medication for potential for teratogenicity in women and their partners  

This should include prescribed and over-the-counter medication, vitamins and other supplements. Switch to and stabilise on safe pregnancy alternatives where required.

Any cessation should balance the benefits and risks and may require referral to a specialist for further consideration.		 Practice point 7

Vaccination

Check vaccination history and update vaccinations for severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), measles, mumps, rubella, varicella zoster, diphtheria, tetanus and pertussis, as per recommendations published in the Australian immunisation handbook.

Consider hepatitis B, rubella and varicella immunisation for women with incomplete immunity.		 Practice point 6

Optimising weight and nutrition

All women, especially those who have become pregnant in adolescence or have closely spaced pregnancies (ie interpregnancy interval less than six months) require nutritional assessment and appropriate intervention (dietary modification, exercise and other therapies) in the preconception period with an emphasis on optimising maternal body mass index (BMI) and micronutrient reserves.		 Practice point 6

Folic acid and iodine supplementation

Folic acid supplementation, at least 0.4 mg daily, should be taken, for a minimum of one (1) month before conception and for the first three (3) months of pregnancy. Where there is an increased risk of neural tube defect (anticonvulsant medication, prepregnancy diabetes, previous child with or family history of neural tube defect, BMI >30 kg/m2), a 5-mg daily dose of folic acid should be used.

Dietary supplementation of 150 mcg iodine should be started prior to a planned pregnancy, or as soon as possible after a woman finds out she is pregnant.		 Practice point 6

 Alcohol consumption and substance use

Provide advice that to prevent harm from alcohol to their unborn child, women who are pregnant or planning a pregnancy should not drink alcohol. Counselling and pharmacotherapy for alcohol and/or substance use should be considered for either or both parents.		 Practice point 6

Effects of age on fertility and risk of chromosomal abnormality

Educate women and their partners that despite advances in assisted reproductive technology, the chance of conception decreases and the risks of chromosomal abnormalities and miscarriage increase with maternal age.		 Practice point 8

Fertility awareness and optimising conception

Offer women and their partners advice regarding fertility awareness and how to optimise the chance of conception.		 Practice point 9

Interpregnancy intervals

Women should be advised to avoid interpregnancy intervals shorter than six months and counselled about the risks of repeat pregnancy sooner than 18 months, especially after a caesarean section. Refer to the Interconception chapter for further information.		 Conditionally recommended 10

First antenatal visit

Encourage an early (ideally before 10 weeks) first antenatal appointment, if and when pregnancy occurs.		 Practice point 7

Smoking cessation

Identifying women and their partners who smoke, or have recently stopped smoking, at their first contact with a healthcare service, ideally in the preconception setting, is strongly recommended. Enquire about smoking history and current smoking patterns, including exposure to second-hand smoke. This information should be recorded so that it is available for the remainder of the pregnancy.		 Recommended (strong) 7,11

Due to high rates of unplanned pregnancy, every woman of reproductive age should be considered for preconception care (interventions that aim to identify and modify biomedical, behavioural and social risks to a woman's health or pregnancy outcome through prevention and management).

Due to high rates of unplanned pregnancy, every woman of reproductive age should be considered for preconception care (interventions that aim to identify and modify biomedical, behavioural and social risks to a woman’s health or pregnancy outcome through prevention and management).

A strategy worth considering is the ‘One Key Question’ (OKQ) approach,12 where practitioners routinely ask women of reproductive age, ‘Would you like to become pregnant in the next year?’ The clinician documents one of four patient responses: ‘Yes’; ‘I’m OK either way’; ‘I’m not sure’; or ‘No’. Depending on the answer, the clinician can then follow up with preconception care or an offer to discuss contraceptive methods and reproductive life planning. The latter involves discussion as to whether the woman wants to have children and, if so, the number, spacing and timing of them. The provision of effective contraception to enable the implementation of this plan and reduce the risk of an unplanned pregnancy can then occur. The use of this kind of questioning in general practice is acceptable to people of reproductive age.8,13
 

Preconception Box 1. Common heritable and chromosomal disorders in Australia5,14
  • Cystic fibrosis (CF)
  • Down syndrome
  • Fragile X syndrome
  • Haemoglobinopathies and thalassaemias
  • Breast and ovarian cancer
  • Colon cancer
  • Familial hypercholesterolaemia (FH)
  • Hereditary haemochromatosis (HHC)
  • Spinal muscular atrophy (SMA)

Consideration may need to be given to environmental risks and risks associated with travel.

The new topic of Preconception care will be included in the new edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, released mid-2024.

Antenatal care | National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people
Fetal alcohol spectrum disorder  | National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

GPs should be aware of the disparities in risk and outcomes in the populations they care for, but there is no current evidence to suggest that variation in care by race or ethnicity can improve outcomes.10 Younger women, women of colour, women of culturally and linguistically diverse and migrant backgrounds and those of low socioeconomic status are at risk of adverse pregnancy and overall poor health outcomes.15 These women may be least likely to receive prepregnancy care despite their disproportionate need.16

Further information on carrier screening and when to refer:
Reproductive carrier screening, Genomics in general practice | RACGP
 
Information on fetal alcohol spectrum disorder (FASD), including considerations for women planning pregnancy:
FASD Hub Australia

Fetal alcohol spectrum disorder | National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people
 
Advice and support for GPs helping patients to quit smoking:
Supporting smoking cessation: A guide for health professionals | RACGP
 
National public education program with patient information on understanding fertility:
Fertility Coalition
 
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) best practice position statement with advice on the counselling of women prior to pregnancy:
Pre-pregnancy counselling | RANZCOG

  1. Australian Institute of Health and Welfare (AIHW). Australia's mothers and babies. AIHW, 2023 [Accessed 20 April 2023].
  2. Organon. Impact of unintended pregnancy. Organon, 2022 [Accessed 20 April 2023].
  3. Australian Institute of Health and Welfare (AIHW). Health of mothers and babies. AIHW, 2023 [Accessed 20 April 2023].
  4. Australian Institute of Health and Welfare (AIHW). Australia's children. AIHW, 2022 [Accessed 2 June 2023].
  5. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Prenatal screening and diagnostic testing for fetal chromosomal and genetic conditions. RANZCOG, 2018 [Accessed 2 June 2023].
  6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Pre-pregnancy counselling. RANZCOG, 2021 [Accessed 20 April 2023].
  7. Department of Health. Clinical practice guidelines: pregnancy care. Australian Government, 2020 [Accessed 2 February 2024].
  8. Hammarberg K, Hassard J, de Silva R, Johnson L. Acceptability of screening for pregnancy intention in general practice: A population survey of people of reproductive age. BMC Fam Pract. 2020;21(1):40. doi: 10.1186/s12875-020-01110-3.
  9. Hampton K, Mazza D. Fertility – awareness, knowledge, attitudes and practices of women attending general practice. Aust Nurs Midwifery J 2016;24(1):42.
  10. American College of Obstetrics and Gynecologists (ACOG). Interpregnancy care. Obstetric care consensus number 8. ACOG, 2019 [Accessed 20 April 2023].
  11. The Royal Australian College of General Practitioners (RACGP). Supporting smoking cessation: A guide for health professionals. 2nd edn. RACGP, 2019 [Accessed 2 February 2024].
  12. Bellanca HK, Hunter MS. ONE KEY QUESTION®: Preventive reproductive health is part of high quality primary care. Contraception 2013;88(1):3–6. doi: 10.1016/j.contraception.2013.05.003.
  13. Fitch J, Dorney E, Tracy M, Black KI. Acceptability and usability of 'One Key Question'® in Australian primary health care. Aust J Prim Health 2023;29(3):268–75. doi: 10.1071/py22112.
  14. The Royal Australian College of General Practitioners (RACGP). Genomics in general practice. RACGP, 2022 Resources/Guidelines/Genomics-in-general-practice.pdf [Accessed 2 February 2024].
  15. American College of Obstetrics and Gynecologists (ACOG). ACOG committee opinion no. 649: Racial and ethnic disparities in obstetrics and gynecology. Obstet Gynecol 2015;126(6):e130–34. doi: 10.1097/AOG.0000000000001213.
  16. D'Angelo D, Williams L, Morrow B, et al. Preconception and interconception health status of women who recently gave birth to a live-born infant – Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR Surveill Summ 2007;56(10):1–35.
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