Prepregnancy Care & Counseling

📚 Publications Used in This Tool

Prepregnancy Care and Counseling: A Review

Cooper KM, Szymanski LM, David PS, Allen SV, Breitkopf DM. JAMA. 2026. doi:10.1001/jama.2026.2888

Systematic Review

Primary source. 118 articles (2 RCTs, 15 systematic reviews/meta-analyses, 42 practice guidelines). Covers all major prepregnancy counseling domains. Basis for all recommendations and data in this tool.

Associations of Unintended Pregnancy with Maternal and Infant Health Outcomes

Nelson HD, Darney BG, Ahrens K, et al. JAMA. 2022;328(17):1714–1729.

Meta-Analysis

36 studies (524,522 participants). Unintended pregnancy: PPD aOR 1.51, preterm birth aOR 1.21, low birth weight aOR 1.09.

Preconception Care and Severe Maternal Morbidity in the United States

Dude AM, Schueler K, Schumm LP, et al. Am J Obstet Gynecol MFM. 2022;4(2):100549.

Cohort Study

1,514,759 Medicaid births. Contraceptive services year before conception: 8% reduced odds severe maternal morbidity (aOR 0.92). Routine exam with chronic disease: aOR 0.79.

Multivitamin Use and Adverse Birth Outcomes in High-Income Countries

Wolf HT, Hegaard HK, Huusom LD, Pinborg AB. Am J Obstet Gynecol. 2017;217(4):404.e1–404.e30.

Meta-Analysis

6 observational studies (12,524 patients). Folic acid/multivitamin: RR 0.67 (95% CI 0.52–0.87) for neural tube defects.

Influence of Maternal Body Mass Index on Pregnancy Complications

Zhang Y, Lu M, Yi Y, et al. Front Endocrinol (Lausanne). 2024;15:1280692.

Meta-Analysis

83 studies (1,966,026 patients). Overweight/obesity: GDM OR 2.92, hypertension OR 2.08, cesarean OR 1.44.

Systematic Review and Meta-Analyses of Perinatal Death and Maternal Tobacco Exposure

Pineles BL, Hsu S, Park E, Samet JM. Am J Epidemiol. 2016;184(2):87–97.

Meta-Analysis

142 studies. Smoking: stillbirth sRR 1.46, neonatal death sRR 1.22, perinatal death sRR 1.33. Cessation restores perinatal death risk to nonsmoker levels (sRR 1.02).

Association of Improved Periconception HbA1c with Pregnancy Outcomes in Women with Diabetes

Davidson AJF, Park AL, Berger H, et al. JAMA Netw Open. 2020;3(12):e2030207.

Cohort Study

3,459 births. Each 0.5% lower periconception HbA1c: −0.99% ARD for congenital anomalies; −3.20% ARD for preterm birth <37 wks.

Substance Use and Use Disorders During Pregnancy and the Postpartum Period

Habersham LL, Townsel C, Terplan M, Hurd YL. Am J Obstet Gynecol. 2025;232(4):337–353.

Meta-Analysis

51 studies (21,146,938 patients). Cannabis: low birth weight OR 1.75, preterm birth OR 1.52, SGA OR 1.57, perinatal mortality OR 1.29.

ACOG Committee Opinion No. 762: Prepregnancy Counseling

Obstet Gynecol. 2019;133(1):e78–e89.

Guideline

ACOG recommendations: folic acid, carrier screening, medication review, immunizations, glycemic targets (HbA1c <6.5%), weight management, STI screening.

Risk of Adverse Pregnancy Outcomes by Prepregnancy Body Mass Index

Schummers L, Hutcheon JA, Bodnar LM, et al. Obstet Gynecol. 2015;125(1):133–143.

Cohort Study

227,000 Canadian pregnancies. BMI dose-response for preeclampsia, GDM, macrosomia, stillbirth, cesarean. BMI reduction 40→28 associated with significant improvement across outcomes.

Risk of Major Congenital Malformations Following Prenatal Exposure to Smoking Cessation Medicines

Tran DT, Cohen JM, Donald S, et al. JAMA Intern Med. 2025;185(6):656–667.

Cohort Study

5.2 million births, 4 countries (2001–2020). No increased congenital anomaly risk with NRT, varenicline, or bupropion vs non-use.

Prepregnancy Care & Counseling

Evidence-based clinical decision support for optimizing maternal health before conception. Built from Cooper et al., JAMA 2026 — a systematic review of 118 publications.

66.4%

of US reproductive-aged women have ≥1 modifiable risk factor

17%

lower neonatal mortality with prepregnancy education

reduced severe maternal morbidity with preconception contraceptive care

🗂️ What this tool covers

Three-step assessment covering reproductive life planning, universal prepregnancy interventions (folic acid, immunizations, medication review, STI screening, substance use, BMI, IPV), and condition-specific counseling for obesity, pregestational diabetes, cardiovascular disease, hypertension, tobacco, opioids, cannabis, alcohol, and VTE. Every risk estimate is linked to its source publication.

Designed for primary care clinicians and OB/GYN providers. Does not replace individualized clinical judgment.

Reproductive Life Planning

Assess pregnancy intent and counsel accordingly. Unintended pregnancies carry measurable, quantified risks.

Pregnancy Intent

🤰 Planning pregnancy

Patient desires pregnancy within next year

🚫 Not planning pregnancy

Patient is not currently seeking pregnancy

❓ Unsure / Undecided

Patient undecided about future pregnancy

🔄 Interpregnancy interval

Prior delivery, considering next pregnancy

Risks of Unintended Pregnancy — Key Data

📊 vs Planned Pregnancies (meta-analysis, 36 studies, N=524,522)

aOR 1.51

(95% CI 1.40–1.70)

Postpartum depression: 15.7% vs 9.6%

Nelson HD et al. JAMA. 2022 [Ref 2]

aOR 1.21

(95% CI 1.12–1.31)

Preterm birth: 9.4% vs 7.7%

Nelson HD et al. JAMA. 2022 [Ref 2]

aOR 1.09

(95% CI 1.02–1.21)

Low birth weight: 7.3% vs 5.2%

Nelson HD et al. JAMA. 2022 [Ref 2]

Infertility Evaluation Thresholds (ACOG)

Age	ACOG Recommendation
<35 years	Evaluate after 12 months of attempted conception
35–39 years	Evaluate after 6 months
≥40 years	Immediate evaluation
Any age with risk factors*	Evaluate sooner than standard threshold

*Risk factors: painful/irregular periods (possible endometriosis/adenomyosis), prior endometriosis, PID, partner with low sperm count. [Ref 9]

Universal Prepregnancy Interventions

Recommended for all individuals desiring conception, regardless of medical history. Use as a counseling checklist.

Counseling Checklist

💊 Folic Acid Supplementation

400 μg/d for average risk. 4 mg/d if seizure disorder on anticonvulsants or prior NTD pregnancy. Begin ≥1 month before conception.

💉 Immunization Review

Assess: Tdap, MMR, hepatitis B, varicella, influenza, COVID-19, HPV (pre-conception). Avoid pregnancy for 1 month after live attenuated vaccines (MMR, varicella).

💊 Medication Review

Discontinue teratogenic medications; continue low-risk indicated medications. Known teratogens: TMP-SMX, topiramate, lisinopril, warfarin. Potential: gabapentin, methimazole, lithium, meloxicam.

🧬 Genetic Counseling / Carrier Screening

ACOG recommends universal carrier screening offer. Autosomal recessive: CF, SMA, hemoglobinopathies. X-linked: fragile X, Duchenne. Refer couples with autosomal dominant conditions.

🔬 STI Screening

Screen for HIV and syphilis before and during pregnancy. Age- and risk factor–based STI screening. Offer PrEP to high-risk individuals.

🩺 Substance Use Screening

Screen for tobacco, alcohol, cannabis, opioids with validated tools (e.g., TAPS). Brief intervention + referral to treatment (SBIRT) for identified use.

⚖️ BMI / Weight Assessment

Weight loss recommended for BMI ≥25. First-line: 500–1000 kcal/d deficit + 150–300 min/wk moderate-intensity exercise. Consider GLP-1 agonists (discontinue before conception); phentermine/topiramate: discontinue ≥2 months prior.

🩻 Intimate Partner Violence Screen

USPSTF: universal screening in all reproductive-aged women. Refer and support if positive screen. IPV is a leading cause of maternal death.

Condition-Specific Counseling

Select any applicable conditions for individualized evidence-based guidance. Multiple selections allowed.

Select all that apply

⚖️

Obesity / Overweight

Prevalence: overweight 49.8%, obese 24.3% of US reproductive-aged women

🩸

Pregestational Diabetes

Prevalence: 4.7% of US women of reproductive age; uncontrolled DM 51.5%

❤️

Cardiovascular Disease

Prevalence: 4% of women of reproductive age; CVD in 15% of US pregnancies

🩺

Chronic Hypertension

Prevalence: 14.5% of US women of reproductive age

🚬

Tobacco Use

Prevalence: 20.1% of US women of reproductive age

💊

Opioid Use Disorder

Opioid-related diagnoses: 3.5 → 8.2 per 1,000 delivery hospitalizations (2010–2017)

🌿

Cannabis Use

Prevalence: 11.8% of US women of reproductive age; 6.8% during pregnancy

🍷

Alcohol Use

Alcohol use disorder: 12.3% of US reproductive-aged women

🩸

VTE / Thrombophilia

Thromboembolic events: 0.5–2 per 1,000 pregnancies; PE: 9.3% of US maternal deaths

⚖️ Obesity — Prepregnancy Counseling

Risk Data (meta-analysis, 83 studies, N=1,966,026)

Complication	OR (95% CI)	Source
Gestational diabetes	2.92 (2.18–2.40)	Zhang Y et al. 2024 [Ref 5]
Gestational hypertension	2.08 (1.72–2.53)	Zhang Y et al. 2024 [Ref 5]
Cesarean delivery	1.44 (1.41–1.47)	Zhang Y et al. 2024 [Ref 5]

BMI 40 vs BMI 36 (Canadian cohort, N=227,000)

Outcome	BMI 40	BMI 36
Preeclampsia	21.4%	18%
Gestational diabetes	16.9%	14.5%
Macrosomia	4.3%	3.6%
Stillbirth	0.5%	0.4%

Management

🩸 Pregestational Diabetes — Counseling

HbA1c Target: <6.5% before conception

HbA1c Target Comparison

Population	HbA1c Target
Non-pregnant adults (general)	<7.0%
Planning conception (DM type 1 or 2)	<6.5%

❤️ Cardiovascular Disease — Counseling

Registry of Pregnancy and Cardiac Disease (2007–2018, N=5,739)

0.6%

Maternal mortality (death during pregnancy or within 7 days postpartum)

Roos-Hesselink J et al. Eur Heart J. 2019

11%

Heart failure requiring hospital admission, new treatment, or treatment changes — highest in: pulmonary arterial hypertension, cardiomyopathy, valvular disease

Roos-Hesselink J et al. Eur Heart J. 2019

WHO Modified Classification (risk stratification)

Class	Risk	Examples
I	Very low	Small PDA, mitral valve prolapse
II	Low	Repaired simple lesions, unrepaired ASD/VSD
III	High	Mechanical valves, systemic RV, Marfan (no aortic dilation)
IV	Extremely high — advise against pregnancy	PAH, severe systemic ventricular dysfunction, severe aortic dilation

🩺 Chronic Hypertension — Counseling

Setting	Target BP	Guideline
Non-pregnant (ACC/AHA)	<130/80 mmHg	ACC/AHA 2017
During pregnancy (ACOG)	<140/90 mmHg	ACOG PB 2019

🚬 Tobacco Use — Counseling

Perinatal Risks (meta-analysis, 142 studies)

sRR 1.46

(95% CI 1.38–1.54)

Stillbirth (57 studies)

Pinoles BL et al. Am J Epidemiol. 2016 [Ref 6]

sRR 1.22

(95% CI 1.14–1.30)

Neonatal death (28 studies)

Pinoles BL et al. Am J Epidemiol. 2016 [Ref 6]

sRR 1.33

(95% CI 1.25–1.41)

Perinatal death (46 studies)

Pinoles BL et al. Am J Epidemiol. 2016 [Ref 6]

OR 1.89

(95% CI 1.80–1.98)

Low birth weight (55 cohort studies, 21 million women)

Di HK et al. World J Pediatr. 2022

💊 Opioid Use Disorder — Counseling

🌿 Cannabis Use — Counseling

Perinatal Risks (meta-analysis, 51 studies, N=21,146,938)

OR 1.75

(1.41–2.18)

Low birth weight (20 studies)

[Ref 8]

OR 1.52

(1.26–1.83)

Preterm birth (20 studies)

[Ref 8]

OR 1.57

(1.36–1.81)

Small for gestational age (12 studies)

[Ref 8]

OR 1.29

(1.07–1.55)

Perinatal mortality (6 studies)

[Ref 8]

🍷 Alcohol Use — Counseling

🩸 VTE / Thrombophilia — Counseling

Counseling Summary

Evidence-based prepregnancy action items based on this assessment.

Universal Recommendations (All Patients)

Folic acid 400 μg/d (standard risk) or 4 mg/d (high risk). Start ≥1 month before conception. RR 0.67 for NTDs (Wolf HT et al. AJOG 2017).

Review and update immunizations: Tdap, MMR, hepatitis B, varicella, COVID-19, influenza, HPV.

Medication review: discontinue known/potential teratogens; continue indicated medications at lowest effective dose.

Offer universal carrier screening (ACOG): CF, SMA, hemoglobinopathies, fragile X, Duchenne.

Screen for HIV and syphilis; offer PrEP if high risk. STI behavioral counseling reduces new infections (OR 0.65, 95% CI 0.53–0.80; 3 RCTs).

Screen for tobacco, alcohol, cannabis, opioids (TAPS or SBIRT); brief intervention + referral for identified use.

Weight assessment: BMI ≥25 → counsel on weight loss. Recommend lifestyle modification first-line.

Universal IPV screening (USPSTF); IPV is a leading cause of maternal death.

Condition-Specific Referrals & Targets

No conditions selected — return to Step 3 to select applicable conditions.

Key Referral Thresholds

Infertility evaluation: <35 yrs → after 12 months; 35–39 yrs → after 6 months; ≥40 yrs → immediate. Sooner if endometriosis, PID, irregular periods, or partner factor.

Refer to MFM: lupus, congenital cardiac disease, prior preterm birth, stillbirth, or preeclampsia.

Avoid interpregnancy interval <6 months: preterm birth OR 1.55, fetal death OR 1.52 vs 18–23 month interval.

📖 Primary Citation

1. Cooper KM, Szymanski LM, David PS, Allen SV, Breitkopf DM. Prepregnancy Care and Counseling: A Review. JAMA. 2026. doi:10.1001/jama.2026.2888