Health before Pregnancy

Key Messages

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These are the main health messages that should be conveyed to all potential, future, and new parents. These messages are aimed to help protect a person’s fertility and to provide guidance for individuals planning a pregnancy in the upcoming year. Although these key messages would be appropriate for all people of reproductive age, it may be difficult to reach those who do not want to have children, those who want children later on in life, and those who are not sure they want to have children. The messages have been written in second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic.


These key messages apply to all women, men, and those who consider themselves as lesbian, gay, bisexual, transgender, two-spirit, or queer (LGBTQ) of reproductive age. In these key messages, medications include prescription, over-the-counter, and herbal products. Drug use includes recreational or street drugs such as marijuana, cocaine, and others.

key message

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 family’ 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.

key message

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 Canada’s 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 children’s 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.
  • Canada’s 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.
  • For more information, contact the Motherisk Helpline 1-877-439-2744.
  • 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.
  • 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.

key message

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.

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:

key message

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 woman’s 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.
    • Abuse.
    • Smoking, alcohol, marijuana, or other recreational/street drug use.
    • Caesarean birth.
    • Preterm birth (birth before 37 weeks’ 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?

key message

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
    • Alcohol
    • Smoking
    • Medications and Drugs
    • Safety during Pregnancy
    • Abuse
    • Mental Health
  • Your health care provider
  • Your local public health unit 1-866-532-3161
  • Best Start Resource Centre
  • Dietitians of Canada
  • OMama
  • Public Health Agency of Canada

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Supporting Evidence

The information in this document is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with clients planning a pregnancy or who may become pregnant; it is meant to provide the background information and evidence for the key messages. It is not expected that prenatal education providers will provide the care recommended in this document; the intent is to provide the background information so that prenatal education providers will be able to explain to their clients what they can expect as part of their preconception health care. Preconception health is pertinent for all individuals in their reproductive years. However, the focus of this section is on individuals planning a pregnancy in the next year.

Defining preconception health

According to the 2014 Ontario Public Health Association’s SHIFT document “Preconception 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.”1

Preconception health is influenced by:

  • Knowledge about personal risk factors.
  • Skills to carry out health practices.
  • Motivation.
  • 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.

National and provincial statistics

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

Benefits of preconception health promotion and care

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

Who can provide preconception health promotion?

Many people can provide preconception health promotion and care. Ideally, preconception health promotion would begin early in a person’s 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.

Special populations

The goal of providing preconception health promotion and care is to:

  • Minimize a woman’s (and her child’s) 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 adolescent’s ability to consent within their relationship.11 Canadian law states that the age of consent for sexual activity is 16. A “close in age” 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 woman’s 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 individual’s 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  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

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 person’s 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 individual’s 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 individual’s home country. As a result, preconception care for newcomers must be delivered with cultural sensitivity and in an individual’s 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 “be respectful of nationality, culture, age, sex, political and religious beliefs, and sexual orientation.”38 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.

Planning

Reproductive life plans

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

Healthy lifestyles

Nutrition

All individuals should eat a healthy, balanced diet and follow an eating pattern based on by Canada’s 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.
  • 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).32
  • 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
Iron

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 woman’s 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

Calcium

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 Canada’s Food Guide) of low-mercury fish. For more information on choosing low-mercury fish, see the Healthy Eating and Weight Gain file.

Caffeine

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

Body mass index (BMI)

Being overweight, obese, or underweight can affect an individual’s 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 woman’s 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.
  • Diabetes.
  • 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:

  • Infertility.
  • 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 Canada’s Food Guide.52 For more information, see the Healthy Eating and Weight Gain file.

Physical activity

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 body’s 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.

Smoking

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.

Alcohol and Fetal Alcohol Spectrum Disorder

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 “there 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.”56 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.

Substance abuse

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.

Medications

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., Accutane®).
  • Anticoagulants (e.g., warfarin).
  • Anti-epileptic drugs (e.g., valproic acid).
  • Chemotherapeutics.
  • ACE inhibitors.
  • Methotrexate.58

For more information, see the Medications and Drugs file.

Preparation for parenting

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.

Mental health

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 woman’s 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.

Immunization

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 woman’s 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.

Table 1: Preconception immunization recommendations65

Immunization Preconception recommendations
Hepatitis B (HB)
  • All women who are at high risk and who have not been vaccinated previously should receive the hepatitis B vaccine before pregnancy.
Human papillomavirus (HPV)
  • Ideally, a woman would be vaccinated for HPV prior to conception. However, it is important to note that this vaccine is only publicly funded for females in grades 9 to 12.101
  • HPV4(Gardasil®) is recommended for males between 9 and 26 years, but is not publicly funded.101
Influenza
  • Recommended annually for all women.
  • Can be given before and/or during pregnancy, unless live attenuated vaccine is used.
Measles, mumps, and rubella (MMR)
  • Screen for immunity to rubella to be confirmed preconception.· If no immunity, vaccinate with MMR and wait at least one month before conception.
Varicella
  • Women with an unknown history of varicella should be screened for varicella immunity in the preconception period.· If no immunity, vaccinate with varicella (two doses) and then wait at least one month before conception.
Tetanus, diphtheria, and pertussis (Tdap)
  • Obtain history and if the last booster vaccine was greater than 10 years, vaccinate with Tdap.· Tdap is preferred to tetanus/diphtheria booster (Td) alone as pertussis poses a great risk for newborns.· Women of reproductive age should be up to date for tetanus toxoid because, in pregnancy, passive immunity for the fetus is likely protective against neonatal tetanus.


Sexually-transmitted infections

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 individual’s 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

Table 2: Sexually-transmitted infections and their effect on fertility, pregnancy, and birth outcomes67

Sexually-transmitted infections Potential effects Recommendations
Chlamydia
  • If left untreated, Chlamydia can lead to pelvic inflammatory disease, infertility, and an increased risk of HIV infection.34
  • Of women with Chlamydia, 10 to 15 percent will develop pelvic inflammatory disease, which is linked to infertility.
  • Untreated chlamydial infection has been linked to problems during pregnancy, including preterm labor, premature rupture of the membranes surrounding the baby in the uterus, and low birth weight.
  • Regular screening and treating individuals of reproductive age for Chlamydia is key.
  • Individuals of reproductive age should also be counselled about the risks associated with Chlamydia, such as infertility, to ensure appropriate prevention.
Gonorrhea
  • Although gonorrhea is often asymptomatic, in women, it can cause cervicitis and pelvic inflammatory disease, which can damage the fallopian tubes and cause infertility.34
  • Untreated gonorrhea in pregnancy has been linked to miscarriages, premature birth, low birth weight, and premature rupture of the membranes.
  • Perinatal transmission of gonorrhea in pregnancy can lead to blindness if left untreated.34
  • Testing and treating for gonorrhea during the preconception period with men and women of reproductive age is important.
Herpes simplex virus (HSV)
  • Since most cases of HSV are asymptomatic, sexually active men and women of reproductive age should be counselled about signs and symptoms of the disease and how to prevent infection with consistent condom use.34
  • Women with recurring genital HSV infection are recommended to be treated with acyclovir or valacyclovir suppression at 36 weeks’ gestation. This will help decrease the risk of viral shedding at time of birth and the risk of clinical lesions.91
  • Women with a history of HSV should be counselled about potential vertical transmission to the baby.
  • If HSV is active at the time of birth, caesarean birth is recommended.
  • In addition to antibiotic therapy, couples with an infected male partner should also be advised to consistently use condoms and avoid sexual intercourse when symptoms reoccur.34
Human immuno-deficiency virus (HIV)
  • HIV vertical transmission from mother to child may occur during pregnancy, labour and birth, or through breastfeeding.
  • Testing for HIV during the preconception period is critical. Knowing HIV status can allow for treatment and reduction of viral load before conception to reduce the risk of vertical transmission during pregnancy.
  • HIV-positive individuals can receive important health education on strategies to reduce risk of maternal-infant transmission in pregnancy and the postpartum period.34
  • All HIV-positive individuals who require combination antiretroviral therapy for their health during the preconception period should be advised to continue their current regimens, even when trying to get pregnant. Use of antiretroviral therapy during pregnancy has reduced the rate of transmission to baby to less than two percent.67
  • Breastfeeding with HIV is contraindicated.
  • Caesarean birth is recommended.
Syphilis
  • Syphilis has serious neonatal implications such as stillbirth and death shortly after birth.34· Syphilis has been linked to premature birth.
  • Screening and treatment in the preconception period are important for all individuals of reproductive age.
  • Treatment of mother before/during pregnancy can stop transmission to the baby.
  • Repeat testing is recommended for unplanned pregnancies among high-risk individuals (e.g., commercial sex workers, and those having sex with individuals engaged in high-risk behaviours).34


Other infectious diseases

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.

Table 3: Infections and preconception considerations

Infection Preconception health educational messages and interventions
Cytomegalovirus (CMV)
  • CMV is the most common viral infection in pregnancy.34
  • There is no vaccine for CMV and preconception testing for CMV is not recommended because there is no evidence that it reduces perinatal transmission.34
  • Universal precautions (e.g., using gloves when changing diapers) are recommended for those working in child care centres/schools or who have young children.68
  • Education should be provided on good hand washing.
Hepatitis C
  • If a hepatitis RNA qualitative test is negative, the vertical transmission rate would decrease almost to zero.71
  • Discuss the natural history of the disease, implications for pregnancy, consequences for the fetus, the risk of transmission, therapies, and risk reduction behaviours.69 Consider discussing appropriate breastfeeding support and possible changes to the treatment plan.
  • It is recommended that individuals with hepatitis C should be screened for immunity to hepatitis A and B; immunizations should be offered if needed.71
  • Combined therapy must have been completed for at least six months before embarking on a pregnancy.70
Parvovirus B19Fifth disease
  • Parvovirus is a common childhood illness. Infection before 20 weeks’ gestation can have implications on fetal health.
  • Currently, there is no evidence that screening for parvovirus in the preconception period or counselling on ways to prevent infection in pregnancy will improve pregnancy outcomes.34
  • Health education on good hand washing and universal precautions for those working in child care centres/schools is recommended.
  • Blood work to determine immunity can be completed as necessary.34
Listeriosis
  • During the preconception period and throughout pregnancy, women should be counselled about eating foods more likely to contain Listeria, including:
    • Soft, semi-soft, and mould-ripened cheeses such as brie, camembert, and blue-veined cheese if made from unpasteurized milk.
    • Hot dogs, especially the fluid in the packages.
    • Pate.
  • Make sure all meat is cooked thoroughly especially chicken.71
Toxoplasmosis
  • Toxoplasmosis is a disease caused by a parasite commonly found in raw meat or cat faeces.
  • Women should be counselled to avoid contact with cat faeces in litter boxes, wear gloves while gardening, and not to eat raw or undercooked meat during pregnancy to reduce the risk of infection with toxoplasmosis.72
  • For women who become infected during pregnancy, early treatment is recommended.
Tuberculosis (TB)
  • Screen individuals during the preconception period to allow for treatment and avoid conversion to active tuberculosis. This can also help to reduce the risk of poor pregnancy outcomes.
  • Individuals with a positive screening test result and who do not have evidence of active disease are usually treated with a nine-month regimen of isoniazid.34


Environmental exposures

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

Existing medical conditions

Better Outcomes Registry & Network (BORN) is Ontario’s 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.

Table 4: Preconception considerations for chronic medical conditions24

Chronic medical condition Considerations
Asthma
  • Since asthma symptoms may worsen during pregnancy, it is recommended that women delay conception until asthma is under good control.58
  • Women of reproductive age with asthma should be counselled about disease progression during pregnancy and the importance of good disease control before pregnancy to support informed reproductive life planning.
  • Medications should be reviewed.
Diabetes
  • Preconception care for women pre-gestational diabetes has shown to significantly improve birth outcomes such as stillbirth.77
  • Uncontrolled or poorly-controlled diabetes can lead to birth defects such as cleft palate.
  • The number of congenital anomalies attributable to poorly-controlled diabetes has increased over the last decade in Canada.23
  • There is a reduced risk of birth defects with optimal glycemic control.
  • Review medications, diet, and physical activity.
  • Increase the amount of folic acid to 5 mg at least 3 months before becoming pregnant and for 12 weeks after conception
  • If diabetes is not under control, encourage a reliable form of contraception.
  • Contraception that contains estrogen for women who have had diabetes for over 20 years is contraindicated.
Epilepsy
  • Review potential pregnancy outcomes related to seizure medications.
  • Increase the amount of folic acid to 4 mg – 5 mg before becoming pregnant and for 12 weeks after conception
  • Some anti-seizure medications may interfere with hormonal contraceptive methods.
Hypertension
  • Avoid estrogen-containing contraceptives.
  • Discuss preferred medications and avoid ACE inhibitors.
  • Assess for target organ damage.
Inflammatory bowel disease (IBD)
  • Counsel women to delay conception until the disease is in remission.
Phenylketonuria (PKU)
  • Encourage maintenance of low phenylalanine level during reproductive years.· Avoid products that contain aspartame.· Counsel women to delay conception until safe levels of phenylalanine are achieved.
Renal disease
  • Counsel women to delay conception until under control, including normal blood pressure.
  • Discuss preferred medications and avoid ACE inhibitors.
  • Consult with specialists.
Systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other autoimmune diseases
  • Counsel women to delay conception until good control is achieved.
  • Discuss natural history of disease during and after pregnancy.
  • Review preferred medications.
  • Avoid estrogen-containing contraceptives for women with SLE.
Thromboembolic disease
  • Discuss with women the increased risk of thrombosis with pregnancy.
  • Avoid estrogen-containing contraceptive options
  • Avoid warfarin for women planning a pregnancy.
Thyroid
  • Achieve euthyroid state prior to conception.
  • Assess complete blood count (CBC) and thyroid stimulating hormone (TSH) levels prior to conception. An increase in the dose of thyroid medication may be needed during pregnancy. Individuals are urged to contact their physician for specific dosing.


Oral health

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

Family/genetic history

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.

Table 5: Ethnic background and screening recommendations83,84,85,86

Ethnic background Carrier screening recommended
Eastern European Jewish descent (Ashkenazi Jews)
  • Ashkenazi Jewish screening panel for Bloom syndrome, familial dysautonomia (FD), Canavan disease, Fanconi anemia, Niemann-Pick disease, mucolipidosis IV (ML4), and Tay-Sachs disease.
AfricanMediterraneanSouth East Asian
  • Thalassemias.
  • Sickle cell disease.
French Canadians from Eastern Quebec
  • Tay-Sachs.


Relationships and abuse

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.

Contraceptive considerations and unplanned pregnancy

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 – 39 years old.28 Causes of unplanned pregnancies are highly variable,  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 individual’s 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 B® is available in Ontario over-the-counter (i.e., without a prescription). Plan B® 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 B® is effective, however, women who use plan B® 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

Conceiving

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 – 24 hours, and sperm can live up to five days in a woman’s reproductive tract.

Infertility

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 men’s 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 treatment

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 woman’s 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 woman’s 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

Interconception

Pregnancy spacing

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

When to refer

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.
  • Smoke.
  • 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).

Where to refer

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.

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Resources & Links

Please note this is not an exhaustive list of available resources, nor should any of these resources be used in place of seeking professional advice. The resources cited throughout this resource are not necessarily endorsed by the Best Start Resource Centre or the Government of Ontario. When in doubt, professionals should contact the organization responsible for issuing a specific recommendation/practice guideline.

Professional Guidelines

Professional Associations

Reports/Publications

Websites

Helplines

  • Assaulted Women’s Helpline 1-866-863-0511
  • Motherisk
    • Motherisk Helpline 416-813-6780
    • Exercise in Pregnancy Helpline 1-866-937-7678
    • Alcohol and Substance Use Helpline 1-877-327-4636
  • EatRight Ontario 1-877-510-5102
  • Drug and Alcohol Helpline 1-800-565-8603
  • Smokers Helpline 1-877-513-5333

Prenatal Education Provider Tools

Client Resources and Handouts

Apps

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References

  1. Ontario Public Health Association. (2014). SHIFT – Enhancing the Health of Ontarians: A call to Action for Preconception Health Promotion and Care. Toronto, Ontario.
  2. Alberta Perinatal Health Program (2007). Preconception Health Framework Retrieved from: http://www.aphp.ca/pdf/Preconception%20Report%20proof%2004.26.07.pdf
  3. Best Start Resource Centre. (2009). Preconception Health: Physician Practices in Ontario. Toronto, Ontario Canada: Author.
  4. 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
  5. 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.
  6. 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
  7. Best Start Resource Centre. (2009). Preconception Health: Awareness and Behaviours in Ontario. Toronto, Ontario, Canada: Author.
  8. 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.
  9. 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.
  10. 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
  11. 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.
  12. 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.
  13. 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.
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  75. Best Start and Canadian partnership of Children’s 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
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Health Before Pregnancy

Health Before Pregnancy

Routine Prenatal Care

Routine Prenatal Care

Physical Changes

Physical Changes

Healthy Eating & Weight Gain

Healthy Eating & Weight Gain

Active Living

Active Living

Alcohol

Alcohol

Smoking

Smoking

Medications & Drugs

Medications & Drugs

Safety During Pregnancy

Safety During Pregnancy

Abuse

Abuse

Mental Health

Mental Health

Pregnancy & Infant Loss

Pregnancy & Infant Loss

Preterm Labour

Preterm Labour

Labour Progress

Labour Progress

Labour Support

Labour Support

Interventions in Labour

Interventions in Labour

Pain Medications in Labour

Pain Medications in Labour

Caesarean Birth

Caesarean Birth

Vaginal Birth After Caesarean

Vaginal Birth After Caesarean

Breech Birth

Breech Birth

Newborn Care

Newborn Care

Newborn Safety

Newborn Safety

Breastfeeding

Breastfeeding

Recovery After Birth

Recovery After Birth

Transition to Parenthood

Transition to Parenthood