Make a reproductive life plan.
You decide if and when you want to have children. About 50 percent of pregnancies are not planned. When pregnancies are planned, you have time to make sure you are healthy and prepared before you have a baby. Having a reproductive life plan can help. A reproductive life plan helps you to set goals and understand how children may fit into your goals. For example, what are your plans for school, work, and travel? How do children fit into these plans?
Reproductive life planning often includes thinking about:
- Your general medical health.
- Your mental health and support systems.
- Your familyâ health history.
- Your reproductive health.
Work with your health care provider to develop your reproductive life plan. There are also online tools available to help.
If you are sexually active and not planning a pregnancy, see your health care provider about the birth control method best for you.
Talk to your health care provider if you want to delay having children until later in your life. It becomes more difficult for many women and men 35 years and over to achieve a pregnancy. Women 35 years and over may have a more difficult pregnancy and birth. They may also have greater risks of medical problems during pregnancy. The baby may also be born with health problems. The quality of a man’s sperm also declines in his mid-thirties. His health problems may also increase. Even though there are fertility treatments available to assist with getting pregnant, such as in vitro fertilization, the success of treatment also declines with age.
Live a healthy lifestyle and protect your fertility.
Fertility means your ability to make a baby. The following tips can help you live a healthy lifestyle, which can also help to protect your fertility.
- Eat a well-balanced diet by following Canadaâs Food Guide.
- If you are a woman, take a daily multivitamin with 0.4 mg folic acid. Since so many pregnancies are unplanned, it is helpful if women take folic acid daily, just in case. Talk to your health care provider to find out if you need more than 0.4 mg folic acid daily.
- Maintain a healthy weight. Being underweight or overweight can affect:
- Your health.
- Your fertility.
- Having a healthy pregnancy.
- Your future childrenâs health.
- Speak to your health care provider to learn more about healthy weight.
- Exercise regularly and reduce the time you spend sitting down. Exercise can help you:
- Maintain a healthy weight.
- Reduce stress.
- Have a more comfortable pregnancy.
- Quit smoking and keep your home and car smoke-free. Smoking can affect your fertility and the health of your baby.
- Canadaâs Low-Risk Alcohol Drinking Guidelines recommend women drink no more than two alcoholic drinks a day, and men drink no more than three alcoholic drinks a day. However, there is no known safe level of alcohol use during pregnancy. Alcohol can affect the health of your growing baby. The safest choice for a woman who is pregnant or planning a pregnancy is not to drink alcohol at all.
- Avoid the use of recreational/street drugs. They can have serious effects on your fertility and the health of a growing baby during pregnancy.
- Talk to your health care provider if you smoke, drink alcohol, or use recreational/street drugs. Services are available to help you quit.
- If you are taking prescription medication, over-the-counter medication, or herbal products, speak to your health care provider to ensure they are safe to use if you become pregnant.
- Take care of your mental health. If you or your family have experienced or are experiencing mental health issues, talk to your health care provider about:
- Where to find support.
- Medications that are safe to use during pregnancy.
- Take time to relax. High levels of stress can affect your fertility. There are many ways to help you reduce stress in your life. For example, you can try the following options:
- Getting at least seven to eight hours of sleep every night.
- Connecting with family and friends for support.
- A healthy relationship is respectful, trusting, and supportive. This is important for your overall health. If you do not feel safe and secure in your relationship, you may be in an abusive relationship. See the Abuse file for more information and resources.
- If you have a medical condition, talk to your health care provider before you become pregnant. Make sure your condition is under good medical control before you become pregnant to improve birth outcomes.
- Know your family and genetic history. Some health conditions can be passed on to your baby.
- See your health care provider to make sure your immunizations are up to date. This can prevent diseases that can impact fertility or health of a growing baby during pregnancy. Some immunizations cannot be given while a woman is pregnant.
- You or your partner may have a sexually-transmitted infection (STI) and not even know it. STIs such as Chlamydia and gonorrhea may not have symptoms. STIs can cause permanent damage to your ability to have children by causing infection in the fallopian tubes, and health problems for you and your unborn baby. Get tested for STIs and seek treatment if needed.
- Keep your home safe from harmful chemicals and toxic substances and be aware of workplace exposures. There are substances at home and at work that can:
- Affect your health.
- Affect your fertility.
- Have long-term effects on the health of a baby.
- Take time to relax. High levels of stress can affect your fertility. There are many ways to help you reduce stress in your life. For example, you can try the following options:
- See the Safety during Pregnancy file for more information and resources.
- See your dentist regularly. Problems with your teeth and gums may affect your health and your pregnancy.
See your health care provider if you are planning to have a baby in the next few years.
A checkup before pregnancy can help make sure you are as healthy as possible before you become pregnant. Discuss upcoming travel plans, especially if they involve regions where the Zika virus is present.
People without partners and same-sex partners who want to start a family may wish to consult a fertility specialist regarding options for achieving a pregnancy. The following websites may be helpful:
Space your pregnancies and learn from your past pregnancies.
After the birth of your baby, it is best to wait at least 18 months before trying to get pregnant again. This gap gives a womanâs body time to recover and gives a better chance for the next baby to be healthy.
If possible, try not to wait more than five years to become pregnant again. If you have had miscarriage, speak to your health care provider for more information on when to plan your next pregnancy.
When preparing for a future pregnancy, consider your previous pregnancy and the health of your baby. Things to consider and discuss with your health care provider:
- Did you experience any of the following in a past pregnancy or birth?
- Gestational diabetes, hypertension, placental abnormalities, or other complication of pregnancy.
- High or low weight gain.
- Mental health concerns before, during, or after pregnancy.
- Smoking, alcohol, marijuana, or other recreational/street drug use.
- Caesarean birth.
- Preterm birth (birth before 37 weeksâ gestation).
- Multiple births.
- Low birth weight (less than 2500 grams or 5 pounds and 8 ounces).
- High birth weight (more than 4500 grams or 9 pounds and 15 ounces).
- Birth defect.
- Baby with medical issues.
- Infant/fetal loss.
- Have you started new medication since your last pregnancy?
- Are your immunizations up to date?
Learn more about health before pregnancy.
You can find out more about health before pregnancy from the following resources. More suggestions can be found in the Resources and Links section.
- Other Key Messages files:
- Routine Prenatal Care
- Healthy Eating and Weight Gain
- Active Living
- Medications and Drugs
- Safety during Pregnancy
- Mental Health
- Your health care provider
- Your local public health unit 1-866-532-3161
- Best Start Resource Centre
- Dietitians of Canada
- Public Health Agency of Canada
According to the 2014 Ontario Public Health Associationâs SHIFT document âPreconception health refers to the health of all individuals during their reproductive years, regardless of gender identity, gender expression or sexual orientation. It is an approach that promotes healthy fertility and focuses on actions that individuals can take to reduce risks, promote healthy lifestyles, and increase readiness for pregnancy, whether or not they plan to have children one day.â1
Preconception health is influenced by:
- Knowledge about personal risk factors.
- Skills to carry out health practices.
- Opportunity and access to carry out health practices.
- Supportive environments.2
Approaching fertility through a preconception lens encourages individuals to be involved in planning their reproduction and working towards achieving optimal health prior to conception occurring. Preconception health not only addresses health prior to a first pregnancy but also the time between pregnancies, which is called interconception. In this resource, preconception health will also include interconception health.
For the purpose of this resource, preconception health focuses on universal health information (not individual medical advice) for individuals wishing to plan a pregnancy in the following year. It is recommended that preconception health promotion and care be integrated into all wellness visits throughout the reproductive years whether or not an individual is planning to become a parent. It is also recommended for all individuals of reproductive age to access a health care provider prior to conception, and for health care providers to conduct a preconception health assessment and provide appropriate preconception health promotion and care.
In a survey conducted by the Best Start Resource Centre (BSRC) in 2009, the majority (58 percent) of respondents said that their health care provider had not discussed preconception health.3 Women were significantly more likely to say they received preconception information from their health care provider than were men (48 percent as compared to 20 percent).3 Only a small number of respondents mentioned receiving printed preconception information (two percent) and very few recalled being advised to see a health care provider before conception (0.4 percent).3 Health Canada emphasizes that parental health before pregnancy is vital to the health of the baby. Since approximately 50 percent of pregnancies in Canada are unplanned, every contact that a health care provider has with an individual in their reproductive years is an opportunity to speak about an individual’s reproductive life plan (RPL).1 Currently, fewer than 50 percent of health care providers in Canada discuss smoking, alcohol use, or addiction history with women and men of reproductive age.3 It is also estimated that between 44 percent and 52 percent of health care providers discuss nutrition and weight management with women of reproductive age.3
Individuals who plan their pregnancies are more likely to be aware of changes they can make to optimize their health. Such changes may help to increase the likelihood of getting pregnant, having a healthy pregnancy, and having a healthy birth outcome. The World Health Organization (WHO) reports that preconception health is vital in that it can prevent preterm births, improve birth weight, prevent neural tube defects and other congenital anomalies, and reduce infant and maternal mortality.4
When individuals receive adequate preconception health promotion and care, and take appropriate action, the prevention of poor health outcomes for mother and baby can be seen. This also reduces health care dollars spent on medical treatment for adverse maternal and birth health outcomes.1
Being healthy before pregnancy improves the chances of:
- Making healthy sperm and eggs.
- Getting pregnant.
- Having a healthy pregnancy.
- Giving a future baby a healthy start in life.5,6
Many people can provide preconception health promotion and care. Ideally, preconception health promotion would begin early in a personâs life, starting in primary school with messaging and health education from parents, teachers, media, and effective curriculum throughout the educational system.
Typically, clinical preconception health care is provided by health care providers, such as doctors, nurses, Nurse Practitioners, midwives, and Registered Dietitians. These providers are currently seen as the most effective source of preconception health promotion and care.7 However, preconception health promotion can also be provided by trained educators, pharmacists, and other health professionals. For example, pharmacists can optimize preconception health by screening for tobacco use; required immunizations; and prescription, over-the-counter, and herbal supplement use.8 Within their scope of practice, pharmacists can also provide counselling on folic acid supplementation and the safe and effective management of chronic health conditions.8
Workplaces can also play a large role in promoting preconception health messages and optimizing preconception health by supporting necessary accommodations and promoting healthy work environments. Prenatal education services can provide individuals with interconception health information through prenatal classes, printed resources, and online material.
The goal of providing preconception health promotion and care is to:
- Minimize a womanâs (and her childâs) risk of poor pregnancy and birth outcomes if she becomes pregnant.
- Optimize the health of all individuals.
- To help all individuals create their own reproductive life plan.9
To ensure that preconception health promotion and care is accessible to all individuals, it important to ensure a population-wide approach to providing universal preconception health key messages. However, some individuals may be at greater risk for not receiving adequate preconception health promotion and care.
With this in mind, the following groups of individuals should receive targeted preconception health promotion and care. Individuals belonging to these groups may require tailored messaging and care due to pre-existing health or social issues, which may put them at higher risk of difficulties conceiving, pregnancy complications, and poor birth outcomes. Reaching these individuals during the preconception period is critical to supporting healthy fertility and pregnancy if desired.
Adolescents under 19 years of age
Adolescents are more likely to engage in risky behaviours, such as using alcohol or substances and not consistently using a reliable contraceptive, which can result in an unplanned pregnancy. The highest rate of unplanned pregnancy occurs among adolescents age 15 to 19 years old. Preconception health care including effective birth control, lifestyle assessment, and personal health issues is important for all adolescents.10 Using teen-focused preconception health resources, such as the booklet My Life My Plan from Best Start Resource Centre, is recommended where possible.
Adolescent pregnancies have a higher risk of poor birth outcomes such as preterm birth, low birth weight, intrauterine growth restriction (IUGR), and stillbirth; anemia and congenital anomalies are common.11 A low socioeconomic status and violence are also often reported during pregnancy.11
When working with adolescents, it is important for health care providers to disclose that autonomy and confidentiality are values they will respect. However, it may be difficult to uphold depending on the care setting and circumstances.11 This may happen when individuals live in small communities where an individual may personally know the health care provider providing care; when individuals are being cared for in the same health care facility as other family members; and if child protective agencies become involved in their plan of care.11
It is recommended for health care providers to examine an adolescentâs ability to consent within their relationship.11 Canadian law states that the age of consent for sexual activity is 16. A âclose in ageâ exception exists for 14 or 15 year olds and for 12 and 13 year olds. If it is determined that no consent was given, it is necessary to report this relationship to child protective agencies as it violates Canadian law.11
Individuals 35 years and older
Given the growing number of individuals in Ontario who delay having children, the importance of preconception health promotion and care is even more emphasized.12
Semen quality, volume, and motility start to decline by age 35 in men.13 After age 40, sperm have significantly more damage to their DNA, and there is a decline in their viability.13
Women 35 years and older are more likely than younger women to seek out information prior to pregnancy and to talk with a health care provider and make changes to their health before getting pregnant.
Women in this group may have greater difficulties conceiving and have a greater risk of complications during pregnancy due to the following age-related factors:14
- Decreased fertility and need to use reproductive technology to conceive.15
- Increased rates of having pre-existing medical conditions that may complicate pregnancy.16
- Increased chance of being on medications that affect pregnancy.13
- Increased rates of pre-eclampsia and placenta previa.17
- Increased rates of preterm labour.14
- Increased rates of caesarean birth.14
- Increased risk of having a baby that has a congenital abnormality such as Down syndrome.12
Women with a previous poor birth outcome
Women who have experienced a poor birth outcome, such as a stillbirth, preterm birth, or an infant with a congenital abnormality, are at a greater risk of having a similar outcome with subsequent pregnancies.18 For this reason, it is important to provide interconception health promotion and care between pregnancies to help improve pregnancy and birth outcomes in the future if possible or desired.
Individuals who are overweight or underweight
A womanâs weight before pregnancy directly impacts her ability to conceive and her pregnancy experience. While often the focus of risk assessment is overweight and obese women, women with a very low body mass index (BMI) or who are underweight are also an important group for preconception health promotion and care. Women who are overweight/obese may have difficulty conceiving and are at an increased risk for many pregnancy complications including neural tube defects, preterm birth, diabetes, hypertension, pre-eclampsia, and cardiovascular disease.19 Men who are overweight or obese have a greater risk of infertility due to lower testosterone levels, and poor sperm quality and quantity.20 The risk of infertility for men increases by approximately 10 percent for every 20 pounds overweight.21 Since safe and healthy weight loss can take time, it is beneficial to address the topic in the preconception period.
Women who are underweight may also have a difficult time conceiving, and once pregnant, their developing baby may also be at risk for preterm birth, low birth weight, and reduced fetal growth.10,22 Men who are underweight are also at risk of infertility, as they tend to have lower sperm quantity than men with normal BMIs.13
Women with disabilities
Women with disabilities may experience physical, administrative, social, and attitudinal barriers in accessing preconception health care.9 Despite these barriers, the preconception period can be an important time to support and prepare women with physical or mental disabilities to plan for their desired reproductive futures, including healthy pregnancy. There are specific preconception health promotion and care practices that can support healthy conception, pregnancy, and birth outcomes. For example, genetic counselling, if appropriate, may be beneficial for some women with disabilities.9 Prior to conception, there should be discussion about the media, social, and psychological effects related to pregnancy and the disablity.9 Plans for additional parenting support, resources, or adaptive equipment should also be discussed.
Women with disabilities may experience more severe conditions during pregnancy such as fatigue, bladder dysfunction, and fluid retention.9 Those in a wheelchair or with limited mobility have an increased risk of deep vein thrombosis.9 Women with neurological conditions may be more prone to respiratory dysfunction, urinary incontinence, urinary tract infections, pressure ulcers, and constipation during pregnancy.9 Disabilities like rheumatoid arthritis (RA) and multiple sclerosis (MS) may exacerbate in the postpartum period.9 For this reason, a multidisciplinary team including medical specialists, nurses, social workers, as well as occupational and physiotherapists will optimize preconception care for women with disabilities.9
Individuals who have an existing medical condition
Many medical conditions, such as diabetes, hypertension, asthma, and epilepsy have implications on an individualâs fertility and risk for pregnancy complications. There is emerging evidence that congenital anomalies, such as congenital cardiovascular defects and gastrointestinal defects, due to maternal pre-pregnancy diabetes are increasing in Canada.23 Being aware of these issues and achieving stability in Â medical conditions either through lifestyle or medication prior to pregnancy may mitigate many of the risks.24 In addition, some medications used to manage medical conditions can be harmful to the developing baby. Regular evaluation of medications with a health care provider prior to pregnancy is recommended.
Cancer survivors, both women and men, may face challenges integrating their experience of cancer, and its resultant treatment, on their future reproductive life plans.9 There are potential negative physical and psychological impacts of cancer survival, such as the increased risk of permanent infertility or compromised fertility.9
For women who received pelvic or abdominal radiation or alkylating chemotherapeutic agents, there is a risk of premature ovarian failure and, if pregnancy is achieved, having a low-birth-weight baby.25 For men, cancer treatment can affect sperm morphology, motility, quantity, and DNA integrity.25,9
Assessing the type of cancer and treatment used during the preconception period can help to determine the risk of infertility as well as determine appropriate intervention for healthy conception and pregnancy. For this reason, preconception health counselling and the review of medication are recommended to reduce harmful maternal and child health effects.25
Fertility preservation is an important topic. Individuals who are newly diagnosed with cancer and plan to have children need to be educated about their options for fertility preservation and referred to a reproductive specialist for further care, if fertility preservation is desired and available as an option for them.25
In addition, genetic testing for genetic mutations may be considered in the preconception period as these tests were found to be highly sensitive.9
Individuals with mental health issues
Poor mental health in the preconception period may negatively impact the ability to conceive.21 It is also linked to poor pregnancy outcomes such as a low-birth-weight baby and a difficult transition to parenting.26 For this reason, it important to have mental health concerns addressed and cared for in the preconception period to optimize pregnancy and birth outcomes.
Individuals with addictions
Due to the prevalence of substance use among individuals of reproductive age and the impact on their own health as well as the health of their future children, it is important to address substance use during the preconception period.27 Alcohol, tobacco, marijuana, and other recreational and street drugs are known teratogens that can affect the fertility of men and women by damaging sperm and egg DNA.21
Ideally, an individual planning a pregnancy would cease the use of all substances; however, for individuals with addiction to substances such abstinence may take time. Alcohol, tobacco, marijuana, and other recreational and street drugs are linked to adverse birth outcomes, including Fetal Alcohol Spectrum Disorder (FASD), preterm labour, low birth weight, and neonatal abstinence syndrome.28 Alcohol use in early pregnancy, often before a woman knows she is pregnant, can affect the developing baby.29
A harm-reduction approach is recommended when working with individuals who use substances. It aims to reduce the harms associated with high-risk behaviours and to promote better health and social outcomes for clients. While abstinence from certain substances is desired before conception, for some individuals this may be a difficult goal. A harm-reduction approach involves establishing realistic and achievable goals to reduce their usage. Contraception counselling for women who require assistance in stopping their alcohol and drug use is recommended.30 For women with addictions, it is recommended that they consume 5 mg of folic acid before becoming pregnant.31 Partners can play a key role in supporting a woman’s choice not to drink or use substances by refraining from using themselves when planning to have a baby.21
Individuals living in poverty
Income is a determinant of health that can influence a personâs health and well-being. Poverty can cause chronic stress, which has been linked to poor pregnancy and birth outcomes such as preterm birth.32 The effect of poverty on preconception health is no exception. Poverty can make it more difficult to obtain adequate, safe, and culturally-appropriate food, shelter, and other basic necessities needed for a healthy pregnancy.32 These are all factors that may impact an individualâs preconception health.
Furthermore, individuals living in poverty may have poorer overall health; this may be due to limited accessibility of health care services due to their inability to afford out-of-pocket expenses related to medication and the shortages of health care providers in their communities.
For this reason, it is important for health care providers to provide supports and links to resources such as income assistance during the preconception period to help to mitigate the effects of poverty when pregnancy is achieved if desired.32
Individuals experiencing abuse
Individuals who experience preconception or prenatal violence are 30 percent less likely to have adequate prenatal care.32 In addition, abuse often escalates during pregnancy.32 Women experiencing abuse are at a greater risk of being isolated, using substances, having mood disorders, not accessing health care, and being in poorer health putting them at risk for poor pregnancy outcomes. For this reason, it is important to provide women with information on where to access preconception and prenatal care and the community supports that are available to them.
Individuals who are newcomers
Newcomers may face many physical, social, and emotional barriers that may affect their preconception health. Arrival in a new country can pose many stressors on an individual such as the lack of family support, language and cultural barriers, being unfamiliar with the medical system, or having limited access to health care.25 Newcomers who arrive as refugees may experience even more psychological and physical stress as a result of stressful conditions in refugee camps or their home country (e.g., war, persecution, etc.) which may have caused them to leave and move to Canada.25
The concept of seeking health promotion and prevention care, (i.e., care when no illness or health problem is present) may vary widely depending on cultural beliefs and medical practices in an individualâs home country. As a result, preconception care for newcomers must be delivered with cultural sensitivity and in an individualâs preferred language.25 This will enable health care providers to provide culturally-competent care and ensure the accurate interpretation and translation of health messages thus meeting the cultural, social, and language needs.33
It is recommended newcomers be screened for hepatitis B (HB) and tuberculosis (TB) as it may be endemic in their home countries or in countries where they spent time in prior to arrival in Canada. Treatment should be provided for those who require it and preferably this should be done before pregnancy.25 Birth control options may be explored until treatment is complete. Newcomers may be employed as seasonal workers in unregulated workplaces, which can increase their risk of exposure to environmental hazards and poor working conditions. This may affect fertility for men and women as well as impact fetal development.34 Lastly, another factor to consider when providing preconception health promotion and care is that women from certain countries may have experienced rituals that affect their reproductive systems, such as genital cutting/mutilation, which is practiced in sub-Saharan Africa, Egypt, and Sudan.35
Individuals from certain ethnic backgrounds
Ethnicity may increase the risk for certain genetic disorders, such as Tay-Sachs disease and sickle cell disease (SCD). Providing preconception counselling, including genetic screening, is recommended. Individuals of African, Southeast Asian, and Mediterranean descent are at increased risk of being carriers of genetic disorders of hemoglobin.36 See the section on family/genetic history for more information.
Individuals who are Aboriginal
Aboriginal Canadians face higher risks of adverse pregnancy and infant health outcomes independent of socioeconomic status and neighbourhood.37 Aboriginal individuals are at a greater risk for many preconception risk factors, including diabetes, tuberculosis, obesity, human immunodeficiency virus (HIV), sexual abuse, substance use, and mood disorders.37
When caring for Aboriginal Canadians it is important to acknowledge cultural safety, which refers to the impact of power imbalances, colonization, colonial relationships, and institutional discriminations related to health care.38 Cultural safety requires health care providers to âbe respectful of nationality, culture, age, sex, political and religious beliefs, and sexual orientation.â38 It encourages health care providers to become aware of their cultural beliefs, values, attitudes, and outlooks that shape their behaviours consciously or unconsciously.33 If successful, cultural safety will encourage individuals to speak openly about their needs and how they can be best met by their health care provider, making them active partners in the process of health care.33
Individuals who are lesbian, gay, bisexual, transgender, or queer (LGBTQ)
Individuals who are LGBTQ may face challenges conceiving and accessing support due to heterosexism within medical and social systems. These challenges also contribute to higher levels of perinatal mood disorders.1 For this reason, it is important to provide inclusive language that is respectful of diverse sexual orientation and individual identity. Helpful information may be found in the Best Start Resource Centre manual: Welcoming and Celebrating Sexual Orientation and Gender Diversity in Families From Preconception to Preschool.
Health care providers can encourage all clients of reproductive age to consider a reproductive life plan (RLP). An RLP is a tool that can help individuals explore their personal goals and aspirations.1 It can help individuals examine whether or not they want to have children in the future, or if and when children fit into their life plan.1 The use of an RLP is supported by the Ontario Public Health Association, Best Start Resource Centre, and Centers for Disease Control and Prevention.1 It can also be used to help facilitate communication between health care providers and their client regarding contraception use.1
An RLP can help individuals with:
- Deciding when, or if, they want to have children.
- Planning the timing and spacing of children.
- Identifying factors (medical, behavioural, financial, environmental, or social) that may impact pregnancy outcomes.
- Preventing unintended pregnancies.
- Choosing an appropriate contraceptive method.1
All individuals should eat a healthy, balanced diet and follow an eating pattern based on by Canadaâs Food Guide incorporating a variety of vegetables, fruit, and whole grains while limiting added sugars and processed foods. Following these guidelines will assist in ensuring adequate nutritional stores for pregnancy and may also lower the risk conditions linked to poor nutrition, including sub-optimal BMI (e.g., low or high), anemia, and diabetes. The likelihood of being overweight/obese is related to a diet of fewer than three fruits/vegetables a day.39 It is important to screen for access to food, nutrition, storage, cooking facilities, and supplements (folic acid) and to provide appropriate referrals as necessary.
While all nutrients are important for a healthy, balanced diet, there are several nutrients that are key to supporting a healthy pregnancy.
Folic acid (folate)
Folic acid is a critical vitamin during the early prenatal period for development. Most women have difficulty getting an adequate amount of folate from food sources alone. Taking a multivitamin that contains at least 0.4 mg of folic acid is recommended for all women of reproductive age. Consuming an adequate amount of folic acid can reduce the risk of having a baby with a neural tube defect, such as spina bifida, anencephaly, and encephalocele.40 Based on their risk factors and in consultation with their health care providers, some women may require a higher dose of folic acid (up to 5 mg).
The following women should consult their health care provider with regards to increasing their folic acid dose before pregnancy:41,42
- Women with a previous history of giving birth to an infant with a neural tube defect.
- Women with an immediate family member with a neural tube defect, including maternal or paternal history of a neural tube defect.
- Women with an ethnic background that is known to present a greater risk of having a child with a neural tube defect.
- Women with certain food selection and preparation requirements (e.g., use of non-fortified rice, use of maize flour, and prolonged stewing).42
- Women with epilepsy, liver disease, insulin-dependent diabetes, impaired glucose metabolism, hyperinsulinemia, or obesity (BMI > 35).42
- Women taking medications that interfere with folate metabolism.42
- Women who smoke or abuse alcohol.42
- Women with malabsorption and gastric bypass surgery.42
- Women on kidney dialysis.42
The preconception period is a good time to ensure individuals have adequate iron stores going into pregnancy.43 Research suggests that iron stores at the time of conception are a strong indicator of a womanâs risk for iron-deficiency anemia later in pregnancy when iron needs to be increased dramatically. Iron deficiency during pregnancy may raise the risk for preterm birth. Testing blood levels of ferritin, a reflection of stored iron in the body, is the best way to determine iron-deficiency anemia. Women who are trying to get pregnant should get 18 mg of iron daily (the recommended dietary allowance). To help increase absorption of iron, include sources of vitamin C with iron-rich foods.44
Women of reproductive age are recommended to take 1000 mg of calcium daily through food and or supplements. Calcium is responsible for hormonal secretion, blood coagulation, muscle function, and nerve transmission.45 Calcium is also a mineral involved in the formation and maintenance of bones and teeth.
Omega-3 fatty acids
Eating fish helps provide omega-3 fatty acids that help with brain development. It is recommended to eat 150 g or two servings each week (as outlined by Canadaâs Food Guide) of low-mercury fish. For more information on choosing low-mercury fish, see the Healthy Eating and Weight Gain file.
Health Canada recommends that women of reproductive age consume no more than 300 mg of caffeine per day. This is equal to about two or three cups of coffee per day, or four to six cups of tea each day.46,47 In the preconception period, caffeine consumption has been linked to delayed pregnancy of more than 9.5 months. During pregnancy, excessive caffeine consumption (more than four cups of coffee) can have negative effects such as miscarriage, spontaneous abortion, fetal death, and stillbirth.13
Being overweight, obese, or underweight can affect an individualâs fertility. While most research and health promotion messaging have focused on risks of overweight and obesity, there are also important concerns regarding being underweight. Being at the low- or high-end of the BMI scale can affect a womanâs menstrual cycle which can make it harder to get pregnant. Current evidence suggests that a woman with a pre-pregnancy BMI between 18.5 and 24.9 will have a better health outcome for her and her baby with a lower chance of disease.
Approximately one-third of Canadian women begin pregnancy with a BMI equal or greater than 25. Women who are overweight/obese with a BMI over 25 during their pregnancy are more at risk for:
- Neural tube defects.
- Preterm birth.
- Caesarean birth.
- Hypertensive disease.
- Thromboembolic disease.48,49
Interventions directed towards attaining a healthy weight ideally begin in the preconception period as weight reduction strategies are multipronged and gradual.50
Women who have a BMI under 18.5 are at greater risk of:
- Poor nutrition.
- Having a baby with gastroschisis.
- Preterm birth.
- Small for gestational age babies.48,49
In addition, men who are overweight or obese have a greater risk of having lower testosterone levels, poor sperm quality, and reduced fertility.51 The risk of infertility for men increases by approximately 10 percent for every 20 pounds overweight. There are impacts on fertility for men being underweight as well. For example, being underweight can impact sperm quantity.13
Steps to achieve a healthy BMI for men and women include engaging in 150 minutes of moderate-to-vigorous-intensity physical activity per week and following Canadaâs Food Guide.52 For more information, see the Healthy Eating and Weight Gain file.
Regular and moderate amounts of physical activity are recommended for everyone as part of a healthy and active lifestyle. Furthermore, by being active before becoming pregnant, you are preparing your body for pregnancy and birth. The Canadian Physical Activity Guidelines recommend adults to engage in 150 minutes of moderate-to-vigorous-intensity aerobic physical activity per week, and to engage in muscle and bone strengthening activities at least two days per week.52
Exercise can also help to improve fertility. Moderate physical activity in men has been linked to improved sperm morphology.13 Exercise might also improve mental health (reducing stress through an increase in endorphins and a decrease in cortisol) and assist with achieving and maintaining a healthy BMI.52 However, excessive physical activity in women may decrease fertility, by having negative impacts on the bodyâs energy balance and reproductive system (impacting gonadotropin releasing hormone and hypothalamic function) which can lead to menstrual abnormalities.13
For more information, see the Active Living file.
Tobacco use in women and men can reduce fertility. In women, tobacco use can reduce ovarian and tubal function and uterine receptiveness to implantation.53 For men, tobacco use is associated with lower sperm count, lower sperm motility, and altered sperm quality. Altered sperm quality may have implications on birth outcomes including low birth weight.54 Smoking may also cause gene damage to human gametes and embryos. Smoking during pregnancy is associated with miscarriage, preterm birth, low birth weight, and increased risk of an oral cleft palate. After birth, smoking is associated with a greater risk of Sudden Infant Death Syndrome (SIDS). The negative effect of tobacco is dose related so even decreasing the frequency or amount is beneficial and should be seen as an effective mechanism for harm reduction.21 For maximum benefits, it is recommended that smoking cessation occurs prior to pregnancy.
For more information, see the Smoking file.
Health care providers are encouraged to have an open discussion about the effects of alcohol on pregnancy with all women of reproductive age.55 Approximately 50 percent of pregnancies are unplanned and with 62.4 percent of women reporting drinking alcohol during the three months prior to pregnancy, alcohol is a definite risk with unplanned pregnancy.28 The Low-Risk Alcohol Drinking Guidelines (LRDGs) for Canadians state that âthere is no known safe level of alcohol use during pregnancy, so it is safest for a woman not to drink when pregnant or planning to become pregnant.â56 Alcohol consumption can harm a developing baby at any point in the pregnancy, particularly during the early stages of pregnancy, before a woman may realize that she is pregnant.29 Fetal Alcohol Spectrum Disorder (FASD) and other alcohol-related birth defects can be prevented if women stop drinking alcohol before a pregnancy.29 For more information about FASD, see the Alcohol file.
Several recreational and street drugs have been linked to male infertility, including marijuana, opiates, cocaine, tobacco, and anabolic steroids.22,57 For men, marijuana has been shown to reduce testosterone production, sperm count, and sperm quality. For women, marijuana use may decrease luteinizing hormone levels, which may increase her risk of infertility.13 Opiate use in men can decrease sperm motility.13 Heroin use in women with placental abruption can cause infertility.13 Cocaine has also been associated with decreased sperm count and abnormal sperm motility. The effects of cocaine on sperm quality and quantity can last up to two years. Anabolic steroids can also reduce testosterone level and sperm quality.22,57 For more information about drug use, see the Medications and Drugs file.
Individuals of reproductive age can experience acute and chronic health conditions. If unmanaged, these conditions can result in adverse health outcomes for the individual and future baby. As part of routine preconception health care, all individuals are encouraged to regularly speak with their health care providers to review their prescription medications, over-the-counter medication, and herbal supplements. Health care providers will help determine if benefits of taking medication before or during pregnancy outweigh the risks of not taking the medication.29
Some medications are known teratogens and should only be taken when effective contraceptives are being used, or dosages and/or alternatives have been discussed. These medications include:
- Isotretinoins (e.g., AccutaneÂź).
- Anticoagulants (e.g., warfarin).
- Anti-epileptic drugs (e.g., valproic acid).
- ACE inhibitors.
For more information, see the Medications and Drugs file.
Planning a pregnancy can place additional stress on relationships and the ability to cope with change. Emotional well-being and stress should be considered as important as physical well-being in the preconception period.59 In addition, women who experience high stress are also more likely to engage in high-risk behaviours and also have less access to prenatal care.1
Social determinants of health including employment, income, and housing should be addressed prior to having a baby. Individuals should be aware of the maternity benefits they are entitled to through their employer or government as well as other income supports available.60
The Federal Employment Insurance program provides maternal benefits for up to 15 weeks. Information about eligibility for employment insurance for maternal and parental benefits can be found on the Government of Canada website. Women who experience complications of pregnancy or other illness-related problems and who are deemed unable to continue working are eligible for sickness benefits rather than maternal benefits.61
The Employment Standards Act, 2000 (ESA) provides eligible employees who are pregnant or are new parents with the right to take unpaid time off work. In contrast, the federal Employment Insurance Act provides eligible employees with maternity and/or parental benefits that may be payable to the employee during the period he or she is off work.61 For more information, see the Transition to Parenthood file. To learn more about the benefits and requirements, visit the Government of Canada Employment Insurance Maternity and Parental Benefits website.
The significance of mental health before pregnancy is an area of emerging research and attention. Poor mental health prior to pregnancy is a significant risk factor for pregnancy complications, including stillbirth and low birth weight.26 The rates of substance use including alcohol and illicit drugs before and during pregnancy are much greater in women with poor mental health. Depression and other mental health disorders such as schizophrenia can also increase a womanâs risk of self-harm and other harmful behaviours that affect a pregnancy.1
Counselling, support, and positive lifestyle practices such as exercise, diet, and social connectedness are all avenues that can be explored as a means of achieving optimal mental health. If medications are part of the treatment plan, preconception counselling can provide an opportunity to review and change medications if needed. Any changes to medication are recommended prior to conception to decrease exposure of multiple medications to the fetus.61 Most antidepressants are not considered to be teratogens. Women need to be counselled that stopping medications for the purpose of pregnancy is usually not necessary and may actually pose more of a risk in terms of mental health complications.1
For more information, see the Mental Health file.
All individuals of reproductive age should have their vaccination history reviewed and updated annually. Some vaccinations act by preventing congenital infection; others act by preventing transmission. The preconception period can be an important period for updating vaccination as some cannot be given while a woman is pregnant and others have maternal benefits because they avoid treatment that might have adverse consequences for the pregnancy.62 Furthermore, attaining immunity before pregnancy can help to reduce the risk of complications from infection during pregnancy as well as offer potential passive immunity to the baby during pregnancy. Some infections can also impact fertility and ensuring vaccinations are updated offers primary prevention of such complications. For example, mumps acquired by men before conception can cause swelling in the testes and may compromise fertility.64 Some vaccines are recommended in the preconception period because there is a recommended wait time between dosing with a live vaccine (e.g., rubella) and conception due to a theoretical risk of exposure to the developing baby.64 For all of these reasons, the immunization status of individuals of reproductive age is an important component of comprehensive preconception health promotion and care.63
Although all vaccines should be reviewed and updated with individuals of reproductive age, vaccines of particular importance during the preconception period include diphtheria, pertussis, measles, mumps, rubella, and varicella.64 Depending on a womanâs lifestyle, exposure to work hazards, and her health, she may need to have additional vaccines.64 Women who plan to travel out of the country should also speak with a health care provider for information on any additional vaccines they may need. Lastly, individuals in regular contact with pregnant women should also be encouraged to have their vaccinations up to date, to reduce and prevent the transmission of infections. The immunizations listed in Table 1 are recommended for women and their partners to obtain in the preconception period.
Sexually-transmitted infections (STIs) can impact pregnancy outcomes as well as overall reproductive health of men and women including fertility.34 Some STIs are asymptomatic. For this reason, appropriate, routine screening for STIs in an individualâs reproductive years can prevent infertility and adverse pregnancy outcomes. Individuals should be screened for STIs, counselled about potential future pregnancy outcomes (if STI remains untreated), and given access to treatment during the preconception period. Counselling around safe sex practices is recommended for individuals with multiple sexual partners.65
Table 2 outlines STIs that may impact fertility, pregnancy, and birth outcomes.66
A number of other infectious diseases can impact a pregnancy. Screening for such infections during the preconception period can help to identify potential risks to reproductive health, future pregnancies, and allow these risks to be addressed before pregnancy.34 Table 3 outlines the primary topics for infectious diseases to be covered by preconception health promotion and care.
Many chemicals found in the home, workplace, and the outdoor environment can be harmful to fertility and pregnancy.73,74 For men, these substances can affect the quantity, morphology, motility, and DNA integrity of sperm.13,75 It can also influence male sexual performance, including the ability to achieve or maintain erections.13 For women, exposure to harmful environment substances can alter hormonal balances and regularity of menstruation and in some cases lead to infertility.13 Some environmental toxins can also have impacts on pregnancy outcomes.13 For example, organic solvents and pesticides may increase the risk of low birth weight, preterm birth, and birth defects.13
Unfortunately, there is no complete list of reproductive hazards in a workplace. However, substances such as lead and radiation have been identified to be harmful. In addition, more than 1000 workplace chemicals have been shown to have reproductive effects on animals; most have not been studied in humans. Harmful substances can enter the body by inhalation, contact with the skin, or ingestion (if workers do not properly wash their hands before eating, drinking, or smoking).13
Individuals in the workplace are encouraged to:
- Check with their workplace health and safety advisor, occupational health nurse, or doctor about any potential risks. Risks include the effect of heat on fertility and the effects of prolonged standing and strenuous activity during pregnancy. They should ask to look at the Material Safety Data Sheet (MSDS). This is a document that contains information on the potential hazards (health, fire, reactivity and environmental) and how to work safely with the chemical product.
- Ensure that workplace health and safety practices and procedures are followed.
- Wear appropriate protection (e.g., gloves, mask) when using any chemical products including household cleaners, pesticides, paints, and thinners.
- Wash hands thoroughly after using any chemical product and before eating or drinking.75
At home and in the environment the following precautions can help limit exposures to hazards:
- Avoid tobacco smoke.
- Use alternate, safer commercial products usually labelled eco, non-toxic, safe, or EcoLogo for cleaning.
- Use non-toxic personal care products (e.g., non-aerosol).
- Use safe food handling/preparation.
- Limit intake of fish with higher levels of mercury (e.g., barracuda, tilefish, marlin, tuna steak, and any raw fish or shellfish).
- Avoid plastic products that may contain bisphenol A (BPA), vinyl chloride, and phthalates.
- Ensure a safe water source.
- Avoid the use of chemical pesticides.
- Avoid exposure to renovation dust, especially in older homes.
- Use VOC-free and water-based materials (e.g., paint, glue, and flooring material) if renovating.
- Wear gloves when cleaning, gardening, and changing cat litter.
- Avoid radon exposure and radiation.
- Avoid hot tubs and saunas.24,74
Better Outcomes Registry & Network (BORN) is Ontarioâs pregnancy, birth, and childhood registry and network. A BORN report using 2011/2012 data indicated that 28 percent of Ontario women giving birth in Ontario had pre-existing medical conditions such as diabetes, heart disease, hypertension, and renal disease.77 These conditions can negatively affect fertility and the ability to conceive, as well as pregnancy and birth outcomes if untreated or poorly controlled.76
The preconception period is an important time for diagnosis, treatment, and care for women with chronic medical conditions to optimize fertility and pregnancy outcomes.58 To support an informed reproductive life planning, women with medical conditions need to be provided with information related to the risks associated with pregnancy, impact of the condition on fertility, medication use on fertility and pregnancy outcomes, and possibly overall timing of pregnancy if desired.58 Table 4 discusses considerations for chronic medical conditions in the preconception period.
Care for women with chronic diseases during the preconception period can include:
- Optimizing disease control.
- Reviewing all medications and modifying, as necessary, the type or dosage based on risk to fertility and pregnancy.
- Counselling to use a reliable method of birth control to delay or prevent pregnancy until the medical condition is controlled.
- Supporting reproductive life planning.
Maternal oral health may have implications for birth outcomes. Dental caries and oral diseases are quite common in women in the reproductive years.78
As part of oral health promotion during the preconception period, women in their reproductive years should be encouraged to:
- Practice good oral hygiene such as brushing and flossing daily.
- See a dentist to have their teeth examined prior to becoming pregnant. Women are encouraged to brush and floss every day.
An oral health assessment during the preconception period will allow for diagnosis and if needed treatment for oral health issues prior to pregnancy. This is important as many oral health screening and treatment options (e.g., x-rays and certain antibiotics) may be contraindicated once a woman is pregnant. In addition, many women experience bleeding gums due to hormonal changes during pregnancy, which makes them more vulnerable to plaque, making the preconception period an ideal time for dentists to provide oral health screening and treatment.79
A family medical history prior to pregnancy provides an opportunity to identify conditions and risk factors that might affect a future pregnancy. Ideally, this should include a comprehensive and complete three-generation family medical history of both sides of a family for all couples wishing to have children.80 This will identify known congenital malformations, genetic disorders, developmental delays, and ethnicity-based genetic-related risk factors.81
The preconception period is an ideal time to complete a family medical and genetic history as it allows individuals and couples to make an informed reproductive life plan. When risks are understood before pregnancy, referral to a counsellor or clinical geneticists can be made.81 Further tests may be done if there is a suspected genetic disorder.81 Screens can be conducted to determine if an individual is at risk for passing conditions to his or her future baby (e.g., cystic fibrosis (CF), Tay-Sachs disease, sickle cell disease, phenylketonuria, Down syndrome, and others.81
Individuals can also explore alternative reproductive options that may ensure a healthy pregnancy and birth outcome, such as the use of donor sperm or eggs, in vitro fertilization (IVF), pre-implantation genetic testing, and in some cases birth control options to time or avoid pregnancy.81 Adoption and the use of a surrogate are other options that can be explored for individuals planning a family.
As mentioned above, individuals from certain ethnic backgrounds have an increased risk of being a carrier for certain genetic-related risk factors, which can be passed onto their offspring.82 The carrier screens listed in Table 5 are recommended for the individuals in the identified ethnic groups.
Heath Canada reports that 21 percent of abused women surveyed reported physical, emotional, and sexual violence during pregnancy.88 Of these women, 40 percent reported that the violence began before pregnancy.87 Screening for current and past abuse should be incorporated into the primary care of all women. Women are more likely to disclose abuse if repeated screening is completed. Screening of women in the preconception period should occur during routine health care visits, family planning/contraception visits, and preconception visits. When the pregnancy is unplanned or undesired, women are more likely to suffer increased abuse than when the pregnancy is desired. Preconception health care is an opportunity to inform women that violence often worsens during pregnancy, make appropriate referrals, and discuss a safety plan88 For more information, see the Abuse file.
Family planning enables individuals to determine whether, when, and how often to have children. Pregnancy planning is vital for maternal and child health. Adverse maternal and child health outcomes can be reduced by pregnancy spacing.
Approximately 50 percent of pregnancies are unplanned and of these pregnancies almost one-half of the women were using some form of birth control.28 Rates of unplanned pregnancies are highest in adolescents and lowest in those 35 â 39 years old.28 Causes of unplanned pregnancies are highly variable,Â including perceived infertility, contraceptive failure, unplanned sex (which can occur more often when there is alcohol/substance use) and/or forced sexual encounters. Contraception is most effective when the method used is in line with an individualâs lifestyle, personal and cultural background, medical history, and developmental stage.28
With correct use, birth control methods are effective in preventing pregnancies. However, due to human error typical failure rates are in the range of three percent to nine percent.88 It is important to note that not all birth control methods will protect against STIs. For this reason, regular STI testing is recommended, and condom use may be the preferred method of birth control and STI protection. In Canada, 50 percent of sexually-active women use hormonal contraceptives primarily oral contraceptives (43.8 percent) followed by Depo-Provera (2.4 percent) contraceptive patch (1.2 percent), and contraceptive vaginal ring (0.6 percent).89
The intrauterine device (IUD) is another effective form of reversible birth control. IUD is currently recommended for adolescents, first-time contraception users, and contraception users who have not previously had a pregnancy or birth.90
Emergency contraception is a safe and effective way to prevent pregnancy after unprotected intercourse. Plan BÂź is available in Ontario over-the-counter (i.e., without a prescription). Plan BÂź is effective if used up to three days after unprotected sex for women who weigh less than 75 kg or 165 lbs.91 A copper IUD can also be used as an emergency contraceptive up to five days after unprotected sex. With correct use, plan BÂź is effective, however, women who use plan BÂź repetitively should be encouraged to find a preventive method of birth control to use regularly.
It is recommended that women who want to conceive after being on hormone birth control or having an IUD wait for at least one normal menstrual cycle before conceiving.92 Although there are no documented adverse effects, it is recommended that a woman who becomes pregnant while taking hormonal birth control stop using them right away.93
Pregnancy is more likely to happen when intercourse occurs during ovulation, which is approximately 14 days before her next expected menstrual period. A woman might notice a change in her vaginal discharge at this time; it will be clear, sticky, and abundant. When an egg is released, it lives for 12 â 24 hours, and sperm can live up to five days in a womanâs reproductive tract.
Approximately one in six couples in Canada experience infertility.93 The number has doubled since the 1980s.94 The definition of infertility is not conceiving after a period of having sexual intercourse without birth control. The time period is one year for women who are under 35 years and six months for women over 35 years.95 Population studies indicate that for women, fertility rates decline sharply by the age of 35.95 In addition, the quality of menâs sperm and semen also begin to decline by age 35, which may contribute to infertility.13
Women who are planning a pregnancy should speak with their primary health care provider if they have had:
- Painful periods and pain during sex, which could be indicative of endometriosis.
- No periods or irregular periods.
- Gynaecological surgery.
- One or more miscarriages.
- History of sexually-transmitted infections.
- Cancer treatment.96
Men who are planning a pregnancy should speak with their primary health care provider if they have had:
- Surgery or injury to the testicles.
- History of sexually-transmitted infections.
- Cancer treatment.
- Premature ejaculation.22
Fertility treatments include:
- Fertility drugs.
- Surgery of the reproductive organs.
- Assisted human reproduction (AHR) such as:
- Intrauterine insemination (IUI): A method that involves using a thin tube to place sperm directly into a womanâs uterus. The sperm used can be from a partner or a donor (if the male is infertile or for a woman without a partner or a same-sex partner).
- In vitro fertilization (IVF): A procedure in which eggs (ova) from a woman’s ovary are removed. The eggs are fertilized with sperm in a laboratory procedure; the fertilized egg(s) (embryo) is returned to the woman’s uterus.
- Embryo transfer: A procedure in which one or more embryos are inserted into the womanâs uterus after in vitro fertilization (IVF).96
For some individuals planning a pregnancy, the only possibility of getting pregnant may be using sperm, eggs, or embryos that are donated by someone else.
There are many reasons for using donated sperm, eggs, or embryos, including:
- Infertility issues.
- Being single or a same-sex couple.
- Having an inherited genetic condition that would be detrimental if passed on to a baby.
Adoption and the use of a surrogate are other options that can be explored for individuals planning a family.
In October 2015, the Ministry of Health and Long-Term Care announced that the province of Ontario would fund one IVF cycle per eligible individual per lifetime with all forms of infertility, regardless of family status, sexual orientation, gender, and sex.94 One cycle of IVF will include one egg retrieval, which may produce multiple eggs, resulting in multiple embryos.94 After speaking to their health care provider to determine if IVF is appropriate for them, women up to the age of 42 (i.e., 42 years of age plus 364 days), will be eligible to receive IVF funding.94 In addition, individuals must have a valid health card and be eligible for OHIP coverage.94
Optimal spacing of pregnancy is an important aspect of interconception care as it allows for the healthiest pregnancy and birth outcomes for women, newborns, and their families.96 It is recommended to wait at least 18 to 24 months but less than five years after a live birth before attempting a subsequent pregnancy.97
A report from the World Health Organization (WHO) found birth-to-pregnancy intervals of around 18 months or shorter are associated with:
- Neonatal and perinatal mortality.
- Low birth weight.
- Small size for gestational age.
- Preterm birth.98
It is important to note that the WHO report was published in 2006 and only examined pregnancy and birth outcomes in various developing countries.
A pregnancy five years or more after giving birth is associated with an increased risk of:
- High blood pressure and pre-eclampsia.
- Low birth weight.
- Small size for gestational age.
- Preterm birth.98,99
The Centre for Effective Practice (CEP) recommends women with previous caesarean birth wait 18 months before becoming pregnant again.24 Research also suggests there is an increased risk of uterine rupture in women who attempt vaginal birth after caesarean (VBAC) less than 18 months after a previous birth.100
The WHO (2006) also recommends a minimum interval between pregnancies of at least six months after a miscarriage or induced abortion to reduce risks of adverse maternal and perinatal outcomes.98
Health care providers should take the opportunity during the interconception period to provide additional health education to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defect(s), low birth weight, or preterm birth). Care, including education and intervention directed toward mitigating any risk factors that contributed to the previous poor outcome, is essential.
Research has also shown that a large percentage of women who had a BMI higher than 25 with their first baby will enter subsequent pregnancies with even a higher BMI.49 Interconception care around nutrition and physical activity to achieve a healthy BMI between pregnancies is important.
Interconception health assessments will also help identify any changes in chronic medical conditions, medications, psychosocial factors, and modifiable risk factors such as smoking and drug use prior to the next pregnancy.
Referrals to the appropriate community resources should be considered for women and men who:
- Experience abuse.
- Have disabilities.
- Are new to Canada.
- Use alcohol and/or recreational or street drugs.
- Have fertility concerns.
- Are marginalized.
- Require genetic testing and/or counselling.
- Have poor nutrition and/or are physically inactive and/or have an unhealthy BMI.
- Are lesbian, gay, bisexual, transgender, two-spirit, or queer (LGBTQ).
Professionals are encouraged to refer women to specialized services that will be able to offer them the assistance they may require. Some suggestions are listed below. More resources can be found in the Resources and Links section of this file, and in the Resources and Links section of other specific topics of this tool.
- Adoption Council of Canada (ACC)
- Canadian Fertility and Andrology Society (CFAS)
- Government of Canada
- LGBTQ Parenting Network
- Ontario Association of Foodbanks (OAFB) 1-866-220-4022
- Ontario Council of Agencies Serving Immigrants (OCASI)
- Ontario Immigration
- Ontario Ministry of Community and Social Services
- Ontario Ministry of Health and Long-Term Care
- Public Health Units
Resources & Links
- Public Health Agency of Canada
- National Alcohol Strategy
- Society of Obstetricians and Gynaecologists of Canada (SOG)
- Clinical Practice Guideline: Canadian HIV Pregnancy Planning Guidelines (2012)
- Clinical Practice Guideline: Carrier Screening for Thalassemia and Hemoglobinopathies (2008)
- Clinical Practice Guideline: Female Genital Cutting (2013)
- Clinical Practice Guideline: Obesity in Pregnancy (2010)
- Clinical Practice Guideline: Pregnancy Outcomes After Assisted Human Reproduction (2014)
- Clinical Practice Guideline: Rubella in Pregnancy (2008)
- Clinical Practice Guideline: Teratogenicity Associated With Pre-Existing and Gestational Diabetes (2007)
- Clinical Practice Guideline: Toxoplasmosis in Pregnancy: Prevention, Screening, and Treatment (2013)
- Committee Opinion: Genetic Considerations for a Womanâs Pre-conception Evaluation (2011)
- Consensus Clinical Guidelines: Alcohol Use and Pregnancy (2010)
- Consensus Guideline: Health Professionals Working With First Nations, Inuit, and MĂ©tis (2013)
- Executive Summary: Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy (2014)
- Association of Ontario Midwives (AOM)
- National Aboriginal Council of Midwives (NACM)
- Society of Obstetricians and Gynaecologists of Canada (SOGC)
- The College of Family Physicians of Canada (CFPC)
- Ministry of Children and Youth Services
- Ontario Public Health Association (OPHA)
- Aboriginal Sexual Health
- Canadian Centre for Occupational Health and Safety
- Canadian Lung Association
- Canadian Partnership for Childrenâs Health & Environment
- Dietitians of Canada
- Genetics Home Reference
- Health Before Pregnancy
- Health Canada
- LGBTQ Parenting Network
- Occupational Health Clinic for Ontario Workers (OHCOW)
- Public Health Agency of Canada – Family-Centred Maternity and Newborn Care: National Guidelines
- Prenatal Screening Ontario
- Rainbow Health Ontario (RHO)
- Assaulted Womenâs Helpline 1-866-863-0511
- Drug and Alcohol Helpline 1-800-565-8603
- Smokers Helpline 1-877-513-5333
- TeleHealth Ontario 1-866-797-0000; TTY 1-866-797-0007
Prenatal Education Provider Tools
- Before, Between & Beyond Pregnancy
- Best Start Resource Centre (BRSC)
- Centers for Disease Control and Prevention (CDC)
- Centre for Effective Practice (CEP) and Ontario College of Family Physicians (OCFP)
- College of Family Physicians of Canada/Canadian Centre on Substance Abuse
- PRIMA (Pregnancy-Related Issues in the Management of Addictions)
Client Resources and Handouts
- Best Start Resource Centre (BRSC)
- Dietitians of Canada
- Ontario Public Health Association. (2014). SHIFT â Enhancing the Health of Ontarians: A call to Action for Preconception Health Promotion and Care. Toronto, Ontario.
- Alberta Perinatal Health Program (2007). Preconception Health Framework Retrieved from: http://www.aphp.ca/pdf/Preconception%20Report%20proof%2004.26.07.pdf
- Best Start Resource Centre. (2009). Preconception Health: Physician Practices in Ontario. Toronto, Ontario Canada: Author.
- World Health Organization (2013). Preconception care; maximizing the gains for maternal and child health. Retrieved from: http://www.who.int/maternal_child_adolescent/documents/preconception_care_policy_brief.pdf
- Society of Obstetricians and Gynaecologists of Canada. (2009). Healthy beginnings giving your baby the best start from preconception to birth 4th edition. Mississauga, Ontario. John Wiley & Sons Canada Ltd.
- Best Start Resource Centre (2007) Reflecting on the Trend: Pregnancy After Age 35. Retrieved from: http://www.beststart.org/resources/rep_health/pdf/bs_pregnancy_age35.pdf
- Best Start Resource Centre. (2009). Preconception Health: Awareness and Behaviours in Ontario. Toronto, Ontario, Canada: Author.
- El-Ibiary, S. Y., Raney, E. C., & Moos, M. K. (2014). The pharmacist’s role in promoting preconception health. Journal of the American Pharmacists Association, 54(5), e288-e303.
- Ruhl, C. & Moran, B. (2008). The clinical content of preconception care: preconception care for special populations. American journal of obstetrics and gynecology,199(6), S384-S388.
- Public Health Agency of Canada (2013). Perinatal health indicators for Canada 2013: A report from the Canadian perinatal surveillance system. Retrieved from: http://sogc.org/wp-content/uploads/2014/05/REVISEDPerinatal_Health_Indicators_for_Canada_2013.pdf
- Fleming, N., O’Driscoll, T., Becker, G., Spitzer, R. F., Allen, L., Millar, D., . . . & Spitzer, R. (2015). Adolescent Pregnancy Guidelines. Journal of Obstetrics and Gynaecology Canada: JOGC, 37(8), 740-756.
- Lisonkova, S., Janssen, P.A., Sheps, S. B., Lee, S. K., Dahlgren, L. (2010). The effect of maternal age on adverse birth outcomes: does parity matter? Journal of Obstetrics and Gynaecology Canada. 32(6), 541-548.
- Sharma, R., Biedenharn, K. R., Fedor, J. M., & Agarwal, A. (2013). Lifestyle factors and reproductive health: taking control of your fertility. Reprod Biol Endocrinol, 11(66), 1-15.
- Best Start Resource Centre (2002). Preconception health in Ontario. Retrieved from http://www.beststart.org/events/detail/bsannualconf09/webcov/presentations/A3-Wendy%20Burgoyne.pdf
- Katwijk, V. C., Peeters, L. (1998). Clinical aspects of pregnancy after the age of 35 years: a review of the literature. Human reproduction update 4(2), 185-194.
- Usta, M., Nassar, A. H., (2008). Advanced maternal age. Part 1: Obstetric complications. American Journal of perinatology. 25(8), 521-534.
- Jacobsson, B., Ladfors L., Milson, (2004). Advanced maternal age and adverse perinatal outcome. Obstetrics and gynecology. 104(4), 727-733.
- World Health Organization (2005). Report of a WHO Technical Consultation on Birth Spacing. Retrieved from: http://www.who.int/maternal_child_adolescent/documents/birth_spacing.pdf
- Health Canada. (2010) Prenatal Nutrition Guidelines for Health Professionals: Gestational weight gain. Retrieved from http://www.hc-sc.gc.ca/fn-an/alt_formats/pdf/nutrition/prenatal/ewba-mbsa-eng.pdf
- Preconception health and health care. (2014). Centres for Disease Control and Prevention. Information for men. Retrieved from http://www.cdc.gov/preconception/men.html
- Frey, K.A., Navarro, S.M., Kotelchuck, M. (2008). The clinical content of preconception care: preconception care for men. American Journal of Obstetrics & Gynecology December 2008, S389-S394.
- Moos, M. K., Dunlop, A. L., Jack, B. W., Nelson, L., Coonrod, D. V., Long, R., . . . & Gardiner, P. M. (2008). Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age. American journal of obstetrics and gynecology, 199(6), S280-S289.
- Liu, S., Rouleau, J., LĂ©on, J. A., Sauve, R., Joseph, K. S., & Ray, J. G. (2015). Impact of pre-pregnancy diabetes mellitus on congenital anomalies, Canada, 2002-2012. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 34(5). Retrieved from http://www.phac-aspc.gc.ca/publicat/hpcdp-pspmc/35-5/ar-01-eng.php
- Centre for Effective Practice, Ontario College of family physicians (2015). Preconception Health Care Tool. Retrieved from: http://www.effectivepractice.org/index.cfm?id=67174
- Centers for Disease Control and Prevention (2014). Special populations. Retrieved from http://www.cdc.gov/preconception/careforwomen/populations.html
- Witt, W.P., Wisk, L.E., Cheng, E.R., Hampton, J. et al (2012) Preconception mental health predicts pregnancy complications and adverse birth outcomes: A national population based study. Maternal and child health Journal. 16(7), 1525-1541.
- Floyd, R. L., Jack, B. W., Cefalo, R., Atrash, H., Mahoney, J., Herron, A., . . . Sokol, R. J. (2008). The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures. American journal of obstetrics and gynecology,199(6), S333-S339.
- British Columbia Centre of Excellence for Womanâs health. (2012). Alcohol, Contraception and preconception: Information for service providers. Retrieved from: http://bccewh.bc.ca/wp-content/uploads/2014/08/FASD-Sheet-3_Alcohol-Preconception-Contraception-Dec-6.pdf
- Chandranipapongse, W., Koren, G. (2013).Preconception counseling for preventable risks. Retrieved from: http://www.motherisk.org/prof/updatesDetail.jsp?content_id=1059
- Tough, S., Clarke, M., Clarren, S., (2005). Preventing fetal alcohol spectrum disorders. Preconception counselling and diagnosis. Canadian Family Physician. 51(9): 1199-1201.
- Society of Obstetricians and Gynaecologists of Canada (2014).Folic Acid for Preconception and Pregnancy. Retrieved from: http://sogc.org/publications/folic-acid-for-preconception-and-pregnancy
- Klerman L, Jack B, Coonrod D, Lu M, Fry-Johnson Y, Johnson K. (2008). The clinical content of preconception care: care of psychosocial stressors. American Journal of Obstetrics and Gynecology. 199(6):S290-S295.
- National Collaborating Centre for Aboriginal Health (2013). Towards Cultural Safety for Metis: An Introduction for Health Care Providers. Retrieved from http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/76/CulturalSafety_Web_EN.pdf
- Coonrod, D., Jack, B., Stubblefield, P., et al (2008). The clinical content of preconception care: Infectious diseases in preconception care. American Journal of obstetrics and Gynecology. 296-309.
- Society of Obstetricians and Gynaecologists of Canada (2013) Female Genital Cutting. Retrieved from: http://sogc.org/wp-content/uploads/2013/10/gui299CPG1311E.pdf
- Society of Obstetricians and Gynaecologists of Canada (2011).Genetic Considerations for a womanâs pre-conception evaluation. Retrieved from: http://sogc.org/guidelines/genetic-considerations-for-a-womans-pre-conception-evaluation-committee-opinion/
- Society of Obstetricians and Gynaecologists of Canada (2013). Health Professionals working with first nations, Inuit, Metis Consensus Guideline. Retrieved from: http://sogc.org/wp-content/uploads/2013/06/June-JOGC-2013-CPG293_Supplement_Eng_Online-Final_NO-cropmarks_REV-F.pdf
- National Aboriginal Health Organization (2008). Cultural Competence and Safety: A Guide for Health Care Administrators, Providers and Educators. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/first_nations_framework_e.pdf
- Tjepkema, M. (2005). Adult obesity in Canada: Measured height and weight. Retrieved from: http://www.statcan.gc.ca/pub/82-620-m/2005001/article/adults-adultes/8060-eng.htm
- Society of Obstetricians and Gynaecologists of Canada (2014). Folic Acid: for preconception and pregnancy. Retrieved from: http://sogc.org/publications/folic-acid-for-preconception-and-pregnancy/
- Wilson, R. D., (2015). Pre-conception folic acid and multivitamin supplementation for the primary and secondary prevention of neural tube defects and other congenital anomalies. Journal of Obstetrics and Gynaecology Canada, 37(6), 534-549. https://doi.org/10.1016/S1701-2163(15)30230-9
- Government of Canada. Prenatal Nutrition Guidelines for Health Professionals – Folate Contributes to a Healthy Pregnancy. Retrieved from http://www.hc-sc.gc.ca/fn-an/nutrition/prenatal/fol-qa-qr-eng.php
- Centers for Disease Control and Prevention (2014) Preconception health and health care: Nutrition. Retrieved from: http://www.cdc.gov/preconception/careforwomen/nutrition.html
- Scholl T. (2005). Iron status during pregnancy: Setting the stage for mother and infant. American Journal of Clinical Nutrition. 81(5):1218S-1222S.
- Health Canada (2012). Food and nutrition Vitamin D and Calcium: Updated Dietary Reference Intakes. Retrieved from http://www.hc-sc.gc.ca/fn-an/nutrition/vitamin/vita-d-eng.php#a6
- Public Health Agencies of Canada. (2011). Caffeine and Pregnancy. Retrieved from: http://www.phac-aspc.gc.ca/hp-gs/know-savoir/caffeine-eng.php
- Ward E. M., Prime the Body for Pregnancy. (2008). Preconception Care and Nutrition for Moms-to-Be Todayâs Dietitian. Vol. 10 No. 12 P. 26.
- IOM (Institute of Medicine). (2009), Weight gain during pregnancy: re-examining the guidelines. Washington, C.: National Academies Press.
- Best Start Resource Centre. (2013) Obesity in preconception and pregnancy. Toronto, Ontario, Canada: Author.
- Davies GA, Maxwell C, McLeod L, Gagnon R. et al (2010).Obesity in Pregnancy. Journal of Obstetrics and Gynaecology Canada.32(2):165-73
- Preconception health and health care. (2014). Centres for Disease Control and Prevention. Information for men. Retrieved from http://www.cdc.gov/preconception/men.html
- Canadian Society for Exercise Physiology (CSEP). (2012) Canadian Physical activity guidelines. Ottawa, Ontario.
- Greaves, L., Poole, N., Okoli, C.T.C., et al (2011) Expecting to quit: a best practice review of smoking cessation interventions for pregnant and postpartum girls and women.
- Zenzes, M. T. (2000). Smoking and reproduction: Gene damage to human gametes and embryos. Human Reproduction Update. 6(2). 122-131.
- Carson, G., Vitale, L., Crane, J. Croteau, P., et al (2010). Alcohol use and pregnancy consensus clinical guidelines. Journal of Obstetrics and Gynecology Canada. 32(8). 51-531.
- Canadian Centre on Substance Abuse (2014). Women and alcohol. Retrieved from http://www.ccsa.ca/Resource%20Library/CCSA-Women-and-Alcohol-Summary-2014-en.pdf
- Finnegan, L. (2103). Substance abuse in Canada: Licit and illicit drug use during pregnancy: maternal, neonatal and early childhood consequences. Canadian Centre on substance abuse. Report No: ISBN 978-1-771-78-041-4.
- Dunlop, A. Jack, B. Bottalico, G., Lu, M., (2008). The clinical content of preconception care: Women with chronic medical conditions. American journal of obstetrics and gynecology. 199(6). S310-S327.
- Hobel, C. I., Goldstein, A., Barrett, E. S. (2008).Psychosocial stress and pregnancy outcome Clinical obstetrics and gynecology. 51(2). 333-348.
- Society of Obstetricians and Gynaecologists of Canada (2011).Maternity Leave in normal pregnancy. Retrieved from: http://sogc.org/wp-content/uploads/2013/01/gui263PS1108E.pdf
- Frieder, A., Dunlop, A. L., Culpepper, L., & Bernstein, P. S. (2008). The clinical content of preconception care: women with psychiatric conditions. American journal of obstetrics and gynecology, 199(6). S328-S332.
- Public Health Agency of Canada. (2014). Part 3 Vaccination of specific populations. Retrieved from: http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-04-eng.php
- Coonrod, D. V., Jack, B. W., Boggess, K. A., Long, R., Conry, J. A., Cox, S. N., . . . & Dunlop, A. L. (2008). The clinical content of preconception care: immunizations as part of preconception care. American Journal of Obstetrics and Gynecology, 199(6). S290-S295.
- Society of Obstetricians and Gynaecologists of Canada. (2009) Immunization in pregnancy. Journal of Obstetrics and Gynaecology. November 1085-1092.
- Society of Obstetricians and Gynaecologists of Canada. (2012) Sexuality and you. Retrieved from: http://www.sexualityandu.ca/stis-stds/types-of-stis-stds
- Public Health Agency of Canada. (2014). Canadian guidelines on sexually transmitted infections. Retrieved from: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php
- Society of Obstetricians and Gynaecologists of Canada. (2012). Canadian HIV Pregnancy planning Guidelines Retrieved from: http://sogc.org/guidelines/canadian-hiv-pregnancy-planning-guidelines-2/
- Centers for Disease Control and Prevention (2011).Cytomegalovirus and Congenital CMV Infection. Retrieved from: http://www.cdc.gov/cmv/risk/preg-women.html
- Society of Obstetricians and Gynaecologists of Canada. (2013). The Reproductive Care of Women Living With Hepatitis C Infection- Retrieved from: http://sogc.org/wp-content/uploads/2013/01/gui96ECPG0010wDisclaimer.pdf
- Boucher, M., & Gruslin, A. (2000). The reproductive care of women living with hepatitis C infection. J SOGC, 22, 820-44.
- Ministry of Health and Long term Care. (2012). Diseases and Conditions: Listeria. Retrieved from: http://www.health.gov.on.ca/en/public/publications/disease/listeria.aspx
- Kravetz, J. D., Federman, D.G. (2005) Prevention of Toxoplasmosis in Pregnancy: Knowledge of Risk Factors. Infectious Diseases in Obstetrics and Gynecology, 13(3) (pp 161-165).
- Wilson D. et al (2009) Principles of human teratology; drug, chemical and infectious exposure. Journal of Obstetrics and Gynaecology Canada. 199:911-917.
- Centers for Disease Control and Prevention. (1996). The effects of workplace hazards on male reproductive health Retrieved from http://www.cdc.gov/niosh/docs/96-132/
- Best Start and Canadian partnership of Childrenâs Health and the Environment (2006) Playing it safe: service provider strategies to reduce environmental risks to preconception, prenatal and child health. Retrieved from: http://s.cela.ca/files/uploads/enviro_strategies.pdf
- Better Outcomes Registry and Network Ontario (BORN). (2011). Perinatal Health Reports 2009â2010. Retrieved from: https://www.bornontario.ca/en/resources/reports/lhin-regional-reports/
- King, P., Westcott, C., Ruston, S., Gale, K., Ashton-Cleary, S., Tan, G. PROCEED (preconception care for diabetes in Derby/Derbyshire): A âteams without wallsâ approach. Diabetic Medicine, 29, 152.
- Public Health Agency of Canada. (2012). The Healthy Pregnancy Guide: Oral Health. Ottawa, Ontario. Report number ISBN 978-1-100-11672-3
- NHS (2014). Teeth and Gums in Pregnancy. Retrieved from http://www.nhs.uk/conditions/pregnancy-and-baby/pages/teeth-and-gums-pregnant.aspx#close
- Solomon, B. D., Jack, B. W., & Feero, W. G. (2008). The clinical content of preconception care: genetics and genomics. American journal of obstetrics and gynecology. 199(6), S340-S344.
- Genetic Considerations for a Womanâs Pre-conception Evaluation Wilson. D. (2011). JOGC January, (253): 57-64.
- Society of Obstetricians and Gynaecologists of Canada (2011).Genetic considerations for a womanâs pre-conception evaluation. Retrieved from:(http://sogc.org/guidelines/genetic-considerations-for-a-womans-pre-conception-evaluation-committee-opinion/
- Society of Obstetricians and Gynaecologists of Canada. (2006). Carrier screening for genetic disorders in individuals of Ashkenazi Jewish descent. Retrieved from: http://sogc.org/guidelines/carrier-screening-for-genetic-disorders-in-individuals-of-ashkenazi-jewish-descent/
- Society of Obstetricians and Gynaecologists of Canada. (2008). Carrier screening for Thalassemia and hemoglobinopathies in Canada. Retrieved from: http://sogc.org/guidelines/carrier-screening-for-thalassemia-and-hemoglobinopathies-in-canada/
- Park, N. J., Morgan, C., Sharma, R., Li, Y., Lobo, R. M., Redman, J. B., . . . & Strom, C. M. (2010). Improving accuracy of Tay Sachs carrier screening of the non-Jewish population: analysis of 34 carriers and six late-onset patients with HEXA enzyme and DNA sequence analysis. Pediatric research, 67(2), 217-220.
- The Hospital for Sick Children (2014). Ashkenazi Jewish Screening Panel. Retrieved from http://www.sickkids.ca/paediatriclabmedicinems/test-catalogue/Genome-Diagnostics/41664.html
- Society of Obstetricians and Gynaecologists of Canada. (2005). Intimate partner violence consensus statement. Journal of Obstetrics and Gynaecology (157). 365-388.
- Kost, K., Singh, S., Vaugha, B., Trussell J., Bankole, A. (2008) Estimates of contraceptive failure from the 2002 national survey of family growth. 77(1); 10-21.
- Society of Obstetricians and Gynaecologists of Canada (2008) Missed hormonal contraceptives: New recommendations. SOGC 219.
- American College of Obstetricians and Gynecologists (2012). Adolescence and long acting reversible contraception: Implants and intrauterine devices. Obstetrics and Gynecology. 120(4). : 983-988.
- Society of Obstetricians and Gynaecologists of Canada (2012) Sexuality and U Retrieved from: http://www.sexualityandu.ca/birth-control/emergency-contraception-morning-after-pill
- Best Start Resource Centre (2011). Health before pregnancy workbook: Is there a baby in your future? Plan for it. Retrieved from: http://www.beststart.org/resources/preconception/pdf/BSpre_bro_rev3.pdf
- Ministry of Health and Long-Term Care (2015). Improving access to fertility treatments for Ontario Families. Retrieved from http://news.ontario.ca/mohltc/en/2015/10/improving-access-to-fertility-treatments-for-ontario-families-1.html?utm_source=ondemand&utm_medium=email&utm_campaign=p
- Government of Canada (2013).Fertility Treatment Options. Retrieved from: http://healthycanadians.gc.ca/healthy-living-vie-saine/pregnancy-grossesse/fertility-fertilite/treatment-traitement-eng.php
- Society of Obstetricians and Gynaecologists of Canada (2013). Age and fertility. Retrieved from http://pregnancy.sogc.org/fertility-and-reprodction/age-and-fertility/
- United States Agency for International Development (USAID) (2014) Health timing and spacing of pregnancy: Everything you want to know about healthy timing and spacing of pregnancy. Retrieved from: http://www.who.int/pmnch/topics/maternal/htsp101.pdf
- Mayo Clinic (2013). Getting Pregnant. Retrieved from http://www.mayoclinic.org/healthy-lifestyle/getting-pregnant/in-depth/family-planning/art-20044072
- WHO, 2006. Report of a WHO Technical Consultation on Birth Spacing. Retrieved from: http://www.who.int/maternal_child_adolescent/documents/birth_spacing.pdf
- Mayo Clinic (2014). Family planning: Get the facts about pregnancy spacing. Retrieved from: http://www.mayoclinic.org/healthy-lifestyle/getting-pregnant/in-depth/family-planning/art-20044072
- Society of Obstetricians and Gynaecologists of Canada. (2005) Guidelines for vaginal birth after previous caesarean birth. Retrieved from: http://sogc.org/guidelines/guidelines-for-vaginal-birth-after-previous-caesarean-birth-replaces-147-july-2004/
- Public Health Agency of Canada (2012) Canada Communicable Disease Report â Update on Human Papillomavirus (HPV) Vaccines. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/12vol38/acs-dcc-1/index-eng.php#a3-2
- Government of Canada. Zika Virus Prevention and Treatment Recommendations. Retrieved from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/zika-virus-prevention-treatment-recommendations.html#tb1