asuhan Pranikah

KONSEP KESEHATAN REPRODUKSI WANITA MASA PRA KONSEPSI

Baksono WinardiDept obstetric & Gynecology

Medical facultyFKUA

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Lingkup Bahasan

Definisi dan objektif Mengapa perlu asuhan kespro wanita

prakonsepsi ? Komponen Evidence base Rekomendasi Praktek terkini Tantangan yang harus dihadapi dalam

implementasinya. Perubahan yang perlu dilakukan

Improving Preconception Health

“Optimizing a woman’s health before and between pregnancies is an ongoing process that requires full participation of all segments of the health care system.”

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Askeb Prakonsepsi : sasaran Meminimalisir risiko pada ibu dan

janinnya serta memperbaiki hasil akhir kehamilan : AKPK terdiri atas intervensi perilaku dan biomedik yang dapat meningkatkan hasil akhir kehamilan.

Intervensi prakonsepsi harus dilakukan dengan baik sebelum dimulaina suatu kehamilan.

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Definisi AKPK

Sejumlah intervensi yang bertujuan untuk menemukan dan mengubah risiko biomedik, perilaku, dan sosial untuk mewujutkan kesehatan perempuan atau hasil kehamilan melalui pencegahan dan Pengelolaan yang menyangkut faktor-factor tersebut yang haurs dilaksanakan sebelum terjadinya konsepsi atau ada masa kehamilan dini untuk menndapatkan hasil yang maksimal.

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Mengapa perlu AKPK

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Healthy Baby, Healthy Adult

Fetal Origins of Adult Disease - term infants who are small for their gestational age are predisposed to obesity and have an increased susceptibility to cardiovascular disease and Type II diabetes (impaired glucose tolerance) in adulthood as a consequence of physiologic adaptations to under-nutrition during fetal life.

Robinson R. The fetal origins of adult disease. Brit Med J 2001;322:375-376.

The importance of nutrition in achieving a healthy pregnancy.The specific roles of key nutrients that are especially important during pregnancy.The various factors that influence a pregnant woman’s ability to obtain these key nutrients.The implications of both overeating and under-eating during pregnancy.The importance of nutrition pos-partum.

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Maternal Mortality Rates, United States 1960-2000

1

10

100

1000

1960 1970 1980 1990 2000

Year

Log-

Mat

erna

l Dea

ths

per 1

00,0

00 L

ive

Birt

hs WhiteOtherAA/B71% Decrease

13% Decrease

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Low Birthweight, United States 1980-2002

024

68

10121416

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Year

Per

cent

Low

Birt

hwei

ght

WhiteAA/BHispanic

14.7% Increase

Very low birthweigh births increased 25.9%

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Preterm Delivery, United States 1980-2002

02468

101214161820

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

Year

Per

cent

Pre

term

Birt

hs

WhiteAA/BHispanic

26% Increase

8.2% Increase in very preterm births

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Infant Mortality Rates, United States 1920-2000

1

10

100

1960 1970 1980 1990 2000Year

Log-

Infa

nt D

eath

s pe

r 1,0

00 L

ive

Birt

hs WhiteOtherAA/B

52% Decrease

45% Decrease

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Five Leading Causes of Infant Death, United States, 1960, 1980 and 2002

3,5

8

11

12,1

20,3

0 5 10 15 20 25

10,5

13,8

15,8

20

20,1

0 5 10 15 20 25

3,5

8

11

12,1

20,3

0 5 10 15 20 25

Congenital Anomalies

Asphyxia/AtelactasisImmaturity

LBW/PTDRDS

Congenital AnomaliesSIDS

SIDSComplications of Pregnancy

Congenital AnomaliesLBW/PTD

Complications of Pregnancy

Unintentional Injury

1980IMR = 12.645,526 Infant Deaths



Birth injuriesInfluenza and pneumonia

Congenital Anomalies

Asphyxia/AtelactasisImmaturity

LBW/PTD

Congenital AnomaliesSIDS

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Incidence of Adverse Pregnancy Outcomes

Major birth defects 3.3% of birthsFetal Alcohol Syndrome 0.2-1.5 /1,000 LBLow Birth Weight 7.9% of birthsPreterm Delivery 12.3%Complications of pregnancy 30.7%C-section 27.6%Unintended pregnancies 49%Unintended births 31%

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Prevalence of Risk Factors

Pregnant orgave birth

Smoked during pregnancy 11.0%Consumed alcohol in pregnancy 10.1%Had preexisting medical conditions 4.1%Rubella seronegative 7.1%HIV/AIDS 0.2%Received inadequate prenatal Care 15.9%

At risk of getting pregnant

Diabetic 3.8%On teratogenic drugs 2.6%Obese 30.8%Not taking Folic Acid 69.0%

Critical Periods of DevelopmentCritical Periods of Development

4 5 6 7 8 9 10 11 12Weeks gestation from LMP

Central Nervous SystemCentral Nervous System

HeartHeart

ArmsArms

EyesEyes

LegsLegs

TeethTeeth

PalatePalate

External genitaliaExternal genitalia

EarEar

Missed Period Mean Entry into Prenatal Care

Most susceptible time for major malformation

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Early prenatal careis not enough,

and in many casesit is too late!

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Komponen AKPK

1. Skrining Risiko2. Melakukan Health Education

3. Melaksanakan intervensi efektif.

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Components Of Preconception Care

Maternal Assessment

Vaccinations Screening Counseling

Components of Preconception CareMaternal assessment

Family planning and pregnancy spacing

Family history Genetic history (maternal

and paternal) Medical, surgical,

pulmonary and neurologic history

Current medications (prescription and OTC)

Substance use, including alcohol, tobacco and illicit drugs

Nutrition

Domestic abuse and violence

Environmental and occupational exposures

Immunity and immunization status

Risk factors for STDs Obstetric history Gynecologic history General physical exam Assessment of

Socioeconomic, educational, and cultural context

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Components of Preconception CareVaccinations Vaccinations should be offered to women found to be

at risk for or susceptible to:RubellaVaricellaHepatitis B

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Components of Preconception CareScreening Tests

Screening for HIV should be strongly recommended

A number of tests can be performed for specific indications:

Screening for STDs Testing to assess proven etiologies of

recurrent pregnancy loss Testing for specific diseases based on medical

or reproductive history Mantoux skin test with purified protein

derivative for Tuberculosis

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Components of Preconception CareScreening Tests Screening for other genetic disorders

based on family history: CF, Fragile X, mental retardation, Duchene muscular dystrophy.

Screening for genetic disorders based on racial/ethnic background:

Sickel hemoglobinopathies (African Americans) Β-Thalassemia (Mediterraneans, SE Asia, AA/B) α-Thalassemia (AA/B and Asians) Tay Sachs disease (Ashkhenazi Jews, French

Canadians, Cajuns) Gaucher’s, Canavan, and Nieman-Pick Disease

(Ashkenazi Jews) Cystic Fibrosis (Caucasians and Ashkenazi Jews)

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Components of Preconception CareCounseling Patients should be counseled regarding

the benefits of the following activities: Exercising Reducing weight before pregnancy, if overweight Increasing weight before pregnancy, if

underweight Avoiding food additives Preventing HIV infection Determining the time of conception by an

accurate menstrual history Abstaining from tobacco, alcohol, and illicit drug

use before and during pregnancy Consuming Folic Acid Maintaining good control of any pre-existing

medical conditions

Science, Guidelines, Recommendations, Practice

Adakah manfaat AKPK ?

Science: There is evidence that individual components of Preconception Care work:

Rubella vaccination HIV/AIDS screening Management and

control of: Diabetes Hypothyroidism PKU Obesity

Folic Acid supplements

Avoiding teratogens: Smoking Alcohol Oral anticoagulants Accutane

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Clinical Practice Guidelines Exist

Clinical practice guidelines for preconception care of specific maternal health conditions have been developed by professional organizations:

American Diabetes Association (Diabetes -2004) American Association of Clinical Endocrinologists

(Hypothyroidism – 1999) American Academy of Neurology (Anti-epileptic drugs) American Heart Association/American College of

Cardiologists (Anti-epileptic drugs - 2003)

Where do people stand?

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ACOG/AAP (2002) All health encounters during a woman’s reproductive years, particularly those that are a part of preconceptional care should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes.ACOG/AAP Guidelines for perinatal care, 5th edition, 2002

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US Public Health Service

HP 2000 Objectives 5.10 and 14.12 Increase to at least

60 percent the proportion of primary care providers who provide age-appropriate preconception care and counseling.

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USPHS “Every woman (and, when possible, her

partner) contemplating pregnancy within one year should consult a prenatal care provider. Because many pregnancies are not planned, providers should

include preconception counseling, when appropriate, in contacts with women and men of reproductive age….Such care should be integrated into primary care services.”

USPHS Expert Panel on the Content of Prenatal Care, 1989

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Sebagian besar rovider belum melakukan.

Sebagian besar HI belum memberikan kompenasasi.

Sebagian besar konsumen tidak menanyakannya.

AKPK saat ini belum dilaksanakan ( dengan baik )!

http://conception.parenthood.com/articles.html?article_id=1012&segment=conception

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Percent Eligible Patients Seen for Preconceptional Care by Type of Provider (2002-2003)

0

5

10

15

20

25

30Pe

rcen

t

CNM OB/GYN F/GP Other non-MD

CNM = Certified Nurse Midwives; OB/GYN = Obstetricians/ Gynecologists; F/GP = Family / General Practitioners;

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Tantangan untuk implemetasi Challenges to Implementation1. Tidak ada kebijakan nasional. 2. Minimnya peralatan klinik.3. Sedikit sekali adanya contoh

/ model pelaksanaan yang sahih.

4. Pendidikan provider / kustumer yang kurang.

ConveningStudyingReporting

The Preconception Care InitiativeA Collaborative Effort of over 35 National Organizations

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Purposes of CDC InitiativeDevelop national recommendations to

improve preconception health Improve provider knowledge, attitudes,

and behaviors Identify opportunities to integrate PCC

programs and policies into federal, state, local health programs

Develop tools and promote guidelines for practice

Evaluate existing programs for feasibility and demonstrated effectiveness

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apa yang sudah kita lakukan ?Pembelajaran di tingkat pendidikan

( saja ?) .- kurikulum untuk siapa ? Badan penasihat perkawinan ? ( apa

isinya ?)Pertemuan / lokakarya ? ( sebatas pada

organisasi profesi ? ) Rekomendasi ?Diskusi mahasiswa / himawari ? ...Why not. Journal ilmiah ( siapa yang membaca ? )Atau kita masih terlau sibuk bergelut

dengan PENAKIB ?

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Next Steps

Publish and disseminate the recommendations Increase awareness among public/private

providers Identify opportunities to integrate PCC

programs and policies into state, local, and community health programs

Develop tools and guidelines for practiceEvaluate existing programs for feasibility and

demonstrated effectiveness

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What results of this process? Through collaboration and consensus:

• Assessed current scientific knowledge• Identified best and promising practices• Identified issues needing further

attention • Refined definition• Developed vision and goals • Develop recommendations and action

steps• Produced documents to share across

professional fields.

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Preconception Care Framework

Action StepsResearch – Surveillance – Clinical

interventionsFinancing – Marketing – Education and training

RecommendationsIndividual Responsibility - Service Provision

Access – Quality – Information – Quality Assurance

GoalsCoverage – Risk Reduction

Empowerment – Disparity Reduction

Vision Improve health and pregnancy

outcomes

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Themes / Areas for Action

Social marketing and health promotion for consumers

Clinical practice Public health and community Public policy and finance Data and research

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A Vision for Improving Preconception Health and Pregnancy Outcomes

All women and men of childbearing age have high reproductive awareness (i.e., understand risk and protective factors related to childbearing).

All women have a reproductive life plan (e.g., whether or when they wish to have children, how they will maintain their reproductive health).

All pregnancies are intended and planned. All women of childbearing age have health

coverage. All women of childbearing age are screened prior

to pregnancy for risks related to outcomes. Women with a prior pregnancy loss (e.g., infant

death, VLBW or preterm birth) have access to intensive interconception care aimed at reducing their risks.

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Goals for Improving Preconception Health

Goal 1. To improve the knowledge, attitudes, and behaviors of men and women related to preconception health.

Goal 2. To assure that all U.S. women of childbearing age receive preconception care services – screening, health promotion, and interventions -- that will enable them to enter pregnancy in optimal health.

Goal 3. To reduce risks indicated by a prior adverse pregnancy outcome through interventions in the interconception (inter-pregnancy) period that can prevent or minimize health problems for a mother and her future children.

Goal 4. To reduce the disparities in adverse pregnancies outcomes.

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Recommendations for Improving Preconception Health (1-2)

Recommendation 1. Individual responsibility across the life span. Encourage each woman and every couple to have a reproductive life plan.

Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and increase individuals’ use of preconception care services using information and tools appropriate across varying age, literacy, health literacy, and cultural/linguistic contexts.

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Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and counseling to all women of childbearing age to reduce risks related to the outcomes of pregnancy.

Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow up to preconception risk screening, focusing on high priority interventions.

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Recommendation 5. Interconception care. Use the interconception period to provide intensive interventions to women who have had a prior pregnancy ending in adverse outcome (e.g., infant death, low birthweight or preterm birth).

Recommendation 6. Pre-pregnancy check ups. Offer, as a component of maternity care, one pre-pregnancy visit for couples planning pregnancy.

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Recommendation 7. Health coverage for low-income women. Increase Medicaid coverage among low-income women to improve access to preventive women’s health, preconception, and interconception care.

Recommendation 8. Public health programs and strategies. Infuse and integrate components of preconception health into existing local public health and related programs, including emphasis on those with prior adverse outcomes.

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Recommendation 9. Research. Augment research knowledge related to preconception health.

Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health.

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Diffusion of Innovation Theory

Evidence

Guidelines forbest practice

Early adopters

Opinionleaders

Innovators

Change in dominant practiceEarly and late majorityLater - laggards

Change Agents

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Opportunities for Action

Examples of “Low Hanging Fruit” Permit states to use family planning waivers

for more interconception care. Permit coverage of more uninsured women

using Medicaid and SCHIP. Direct public health agencies to use resources

to: Develop programs, test models, fill gaps Evaluate and monitor progress

Thank You

asuhan Pranikah

Documents

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