B5124

SEA-CAH-16
Preconception care
Report of a regional expert group consultation
6–8 August 2013, New Delhi, India
© World Health Organization 2014
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Printed in India
Contents
Acronyms v
1. Introduction 1
2. Meeting objectives and participants 4
3. Proceedings 6
4. Conclusions and recommendations 52
References 55
Annexes
1. Health problems, risky behaviours and risk factors

that can be addressed through preconception
and related interventions 56
2. Summary of Group work 2: Defining packages

of pre-conception care in SEAR 68
3. Summary of Group work-3: Defining delivery

channels for the identified packages of
pre-conception care in SEAR 73
4. Programme 78
5. List of participants – international and regional experts 80
iii Regional Expert Group Consultation on Preconception Care

Acronyms
ANM Auxilliary Nurse Midwife
AIIMS All India Institute of Medical Sciences, New Delhi, India
AWW Anganwadi Worker
CDC Centers for Disease Control and Prevention, Atlanta, USA
CSR Corporate Social Responsibility
HPV human papilloma virus
IPPF International Planned Parenthood Federation
IVF In vitro fertilization
MDG Millennium Development Goals
mHealth mobile technology for health
MNCH maternal, newborn and child health
MMR maternal mortality ratio
MoD March of Dimes Foundation
NGO Nongovernmental organization
NTD neural tube defect
PCHHC National Initiative on Pre-conception Health and Health Care
PHFI Public Health Foundation of India
PHM public health mid-wife
PMNCH Partnership for Maternal, Newborn and Child Health
PMTCT prevention of mother-to-child transmission (of HIV)
RMNCAH reproductive, maternal, newborn, child and adolescent health
RMNCH reproductive, maternal, neonatal and child health
STI sexually-transmitted infection
TB tuberculosis
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USA United States of America
USAID United States Agency for International Development
WHO World Health Organization
v Regional Expert Group Consultation on Preconception Care

© WHO/C. Tephaval
1
Introduction
Sexual and reproductive health is fundamental for individuals, couples and
families, as well as for the social and economic development of communities
and nations. Everyone has the right to enjoy reproductive health, which is the
basis for having healthy children, a healthy reproductive life and happy families.
Women living in low- and middle-income countries suffer excessively from
unintended pregnancies; maternal death and disability; sexually transmitted
infections (STIs), including HIV; gender-based violence; and other problems
related to their reproductive system and their partners’ sexual behaviour.
Young people often face barriers in trying to get the information and care
they need, which places adolescent reproductive health as another issue
that needs attention. According to the World Health Organization (WHO)
publication, “A framework for implementing the reproductive health strategy
in the South-East Asia Region” (1), the critical importance of reproductive
health to development has been acknowledged at the highest level, with the
commitment to achieve universal access to reproductive health by 2015. This
is the culmination of more than a decade of advocacy since the consensus
and Programme of Action of the International Conference on Population and
Development held in Cairo in 1994 (2).
There is widespread agreement that, to reduce maternal and childhood

mortality, a continuum of care needs to be provided through pregnancy, childbirth,
the postnatal period, infancy and childhood, adolescence and adulthood. An
effective continuum of care must address the health needs of the adolescent
or woman before, during and after her pregnancy, as well as the care of the
newborn and child throughout the life-cycle, wherever care is provided. Based
on these agreements, a package of health interventions for family planning, safe
abortion care, and maternal, newborn and child health (MNCH) was developed
by WHO, with inputs from the United Nations Children’s Fund (UNICEF), the
United Nations Population Fund (UNFPA), the World Bank and the Partnership
for Maternal, Newborn and Child Health (PMNCH) (3).
However, there has been increasing recognition that a gap exists in this
continuum of care. A growing body of evidence is showing that preconception
care could reduce this gap in the continnum of care, by increasing the
health and well-being of women and couples, and improving the subsequent
pregnancy and child-health outcomes. However, until now, preconception
care and counselling have largely been provided through two avenues. In
high-income countries, couples planning a pregnancy meet with a health-care
professional to identify biomedical risks, whereas in low- and middle-income
countries, community groups educate women about pregnancy and birth
preparedness. Importantly, interventions in both settings have the potential
1 Regional Expert Group Consultation on Preconception Care

to improve maternal behaviours, such as by increasing the use of folic acid
and safe delivery kits; and to reduce rates of adverse pregnancy outcomes,
for example, neonatal mortality.
After the global consensus meeting on preconception care in Geneva

in 2012 (4), a regional meeting for the WHO South-East Asia Region was
organized in August 2013; this was a logical step in the direction of percolating
the global concept of preconception care to the regional level and developing
a consensus on positioning preconception care as part of an overall strategy
for reproductive, maternal, neonatal, child and adolescent health (RMNCAH).
However, the approach in each country of the South-East Asia Region will
depend on its sociodemographic and epidemiological situation.
Effective preconception care programmes can only be accomplished by

developing a strategy that reflects global, regional, national and local dimensions,
including ethical, legal and social issues. Such programmes must be evidence-
based, to advocate for resources and assure sustainability, and flexible enough
to be adaptable to accommodate local priorities in the countries.
Regional Expert Group Consultation on Preconception Care 2

© WHO
2 Meeting objectives and

participants

Objectives
The main objectives of the regional expert group meeting were to:
ρρ review the evolving global and regional thinking on preconception care;
ρρ present available evidence for interventions in preconception care;
ρρ develop consensus on the need and content of services for preconception
care, through “healthy transitions for adolescents” and “pre-pregnancy
care”
ρρ identify modalities for delivering the interventions within the existing
reproductive, maternal, newborn, child and adolescent health (RMNCAH)
and related programmes; and
ρρ outline research priorities in “healthy transitions for adolescents” and
“pre-pregnancy care” for the Region.
Meeting participants
The meeting brought together numerous stakeholders: experts from the groups
who have led reviews and research on preconception care – The Centers for
Disease Control and Prevention (CDC), United States of America (USA), the
March of Dimes Foundation (MoD), United Nations agencies (UNICEF and UNFPA,
and WHO); programme managers from ministries of health of selected Member
States; partners such as the Bill and Melinda Gates Foundation, FHI 360, the
International Association of Adolescent Health, the International Paediatric
Association, the International Planned Parenthood Federation (IPPF), JHPIEGO,
PATH, NGOs, and the United States Agency for International Development
(USAID); experts from institutions of excellence, WHO collaborating centres
and academic institutes in the Region.

© WHO
3 Proceedings

Inaugural session
Dr Vinod K Paul, Head of the Department of Paediatrics, All India Institute
of Medical Sciences (AIIMS), New Delhi, India, welcomed the participants on
behalf of the organizers. He emphasized the importance of preconception care,
especially in countries of the WHO South-East Asia Region, where maternal
and child death due to preventable causes still remains high. He also stated
that RMNCAH programmes being well-established in the Member States of the
Region, this is the best time to initiate preconception care and look beyond
the achievement of Millennium Development Goals (MDG). He emphasized
that pre-conception care must not be limited to a vertical programme targeted
only to those who are planning a pregnancy.
Dr Neena Raina, Regional Adviser, Child and Adolescent Health, WHO Regional
Office for South-East Asia, New Delhi, India, welcomed the experts attending
the meeting and expressed confidence that the deliberations would achieve
the objective of developing a consensus and way forward for preconception
care. The aim should be for all women in their reproductive years, and their
partners, to receive preconception care at any contact with a health-care
provider, regardless of pregnancy status or desire, and to involve communities
and policy-makers so that demand for and provision of preconception care is
universal. She thanked the Department of Paediatrics, AIIMS for organizing
the meeting.
Dr Venkatraman Chandra-Mouli, Scientist, Reproductive Health and

Research, WHO headquarters, Geneva, Switzerland, stated that all mothers and
children deserve to grow to their full potential, which can be assisted by good
programmes. Though pregnancy is a natural process, it is not always risk-free.
Even high-income countries like Canada and Denmark realize that there are
risk factors to address, for which they have designed specific programmes. He
stressed that a strong programme is the key and it should include different
country-specific initiatives. He informed participants that the discourse on
preconception has expanded since the global consensus meeting in Geneva
(4), and is expected to progress further as a result of region-specific meetings
like the present one in the South-East Asia Region.
Dr Debashish Dutta, UNICEF East Asia and Pacific Region, Bangkok,

Thailand, indicated that preconception care is rather a new concept to deal
with well-known problems. Over the the past few years, there has been an
increasing recognition that pregnancies are happening during adolescence.
Some adolescents have greater access to education and information and a
growing ability to make well-informed choices about their lives. On the other

hand, social and economic deprivation for many other adolescents means
malnourishment, lack of education, unemployment and inability to develop
and live to their full potential. He emphasized the necessity to clearly define
preconception care. He further stated that the range of issues covered under
preconception care would require strong convergence with other sectors.
Dr Andres de Francisco, Deputy Executive Director, PMNCH, Geneva,

Switzerland, welcomed the particpants and stated that the global meeting has
set a platform to develop consensus on a package of promotive, preventive and
curative health interventions to be delivered in the context of pre-conception
care. As a next step, a common understanding has to evolve on mechanisms
of delivering the package through existing public health programmes in low-
and middle-income countries, to prevent maternal and childhood mortality and
morbidity. He further stated that it is important to work further on advocacy
at policy level and also to work at regional and country levels.
Dr Coleen A Boyle, Director, National Center on Birth Defects and

Developmental Disabilities at Centers for Disease Control and Prevention, Atlanta,
USA, stated that the World Health Assembly has identified birth defects as a
global problem and that their prevention and control is critical to achievement
of MDG 4. She said that CDC shares this priority. The meeting presents an
important landmark to prevent and control birth defects and overall positive
reproductive health and wellbeing and through the initiative of preconception
care in the Member States of the WHO South-East Asia Region. She further
stated that most women do not realize that they are pregnant until some
weeks have passed, and by the time they do, the fetus has already started
developing. She detailed several prevention and control efforts for birth defects,
including the necessity for surveillance. She emphasized that surveillance and
research have shown the role of folic acid fortification and supplementation
in preventing folic acid-preventable neural tube defects (NTDs), and that well-
implemented preconception care could be the desired initiative to prevent folic
acid-preventable NTDs and other birth defects.
Dr Christopher Howson, Vice President for Global Programmes, March of

Dimes Foundation, New York, USA, stated that pre-conception care is the weak
link in the continnum of care. Every pregnant women and child who does not
survive represents a failure of the health and social system. The goal-based
perspective of the MDGs has helped, by placing all countries on one platform
with sets of goals and targets. He further stated that it is now required to build
further on the existing system and experience to reach out to broader goals.

Dr Arvind Mathur, Medical Officer, Making Pregnancy Safer, WHO Regional
Office for South-East Asia, New Delhi, India, introduced participants and reviewed
the objectives of the meeting. He stated that the purpose of the meeting was
to develop shared understanding of the place of preconception care as part of
an overall strategy to prevent maternal and childhood mortality and morbidity,
and to develop different approaches to implementation of preconception care
in Member States of the South-East Asia Region.
Dr Rajesh Mehta, Medical Officer, Child and Adolescent Health, WHO

Regional Office for South-East Asia, New Delhi, India, briefed the particpants
about the agenda and process to be followed during the expert group meeting.
He welcomed active deliberations by the experts from various constituencies,
to evolve the packages for “healthy transitions for adolescents” and “pre-
pregnancy care” for improving the health and well being of adolescent boys
and girls, women, adults and children.
Preconception care: Global perspective

Chairs: Dr K Srinath Reddy and Dr Andres de Francisco
Preconception care: rationale and definition

Dr Valentina Baltag, WHO Headquarters, Geneva, Switzerland
There is a growing recognition that adolescent pregnancies and poorly spaced

pregnancies contribute to maternal, perinatal and infant mortality, and the vicious
cycle of ill-health and poverty. The “Global Strategy for Women’s and Children’s
Health,” launched by the United Nations Secretary-General in September 2010
(5), stresses the importance of addressing the health and welfare of adolescent
girls, especially towards achieving MDG 5 – reduction in maternal mortality.
The WHO Department of Maternal, Child and Adolescent Health (MCA)

with its 4S Framework (6), has used two programmatic “entry points” to
strengthen the health sector response to adolescent health and development:
HIV prevention, care and support; and preventing early pregnancy and related
morbidity and mortality.
Despite the interventions in place, progress in maternal and child health

outcomes over the last 20 years has been slow.
ρρ Globally four out of 10 women report that their pregnancies are
unplanned.
ρρ Perinatal deaths are 50% higher among babies born to adolescent mothers.

ρρ Up to 10% of pregnancies among women with untreated gonococcal
infections result in perinatal death.
ρρ Women with epilepsy are at increased risk of having babies with congenital
anomalies.
ρρ Maternal undernutrition and iron-deficiency anemia account for at least
20% of maternal mortality. In India, about half of girls aged 15–19 years
are underweight and anaemic.
It was mentioned that most of the risk factors like tobacco use and substance
misuse are initiated in the age group of 11–15 years. The median age for the
onset of mental disorders like anxiety and impulse control disorders is also in
this age range, and 75% of mental disorders are already present before 24
years of age. The ongoing interventions in most countries of the South-East
Asia Region are made available during pregnancy, childbirth, postnatal period
(for newborns and mother) and during infancy and child health across the
life-course continuum as shown in Figure 1.
Figure 1: Life-course continuum: Priority interventions for mothers,

newborns and children
Postpartum Maternal health

Pregnancy Birth
Newborn Infancy Childhood
The adverse effects of childbearing in adolescents (especially with risk factors)

also extend to the health of their infants. Perinatal deaths are found to be
50% higher among babies born to mothers under 20 years of age than among
those born to mothers aged 20–29 years. Babies of adolescent mothers are
also more likely to be of low birth weight, with the risk of associated long-term
effects. The current scenario of adolescent health and current interventions for
this group provides a growing body of evidence recommending preconception
care to maximize the gains in maternal and child health in these settings.
Preconception care was defined as the provision of biomedical, behavioural

and social health interventions to women and couples before conception
occurs. Preconception care provides a full range of effective interventions,
focused primarily on the health of women of reproductive age, and their
partners, prior to or between pregnancies, that promote the opportunity

for safe motherhood and the birth of a healthy infant with the expectation
of healthy longevity.
Preconception care brings attention to the missing component in the existing

health system for addressing the needs of adolescents, young women and
their partners before pregnancy is planned or occurs (see Figure 2). Thus, it
offers a process of delivering direct or indirect health-care interventions with
the potential to identify and modify the biomedical, behavioural and social risk
factors that determine reproductive health outcomes. It aims at improving the
overall health status of adolescents, women and children, as well as ensuring
healthy adulthood by targeting risk behaviours for noncommunicable diseases.
Figure 2. Pre-conception care completes the coverage across the life course
During adolescence Postpartum Maternal health

and/or before Pregnancy Birth
pregnancy Newborn Infancy Childhood
Overall, preconception care has a positive impact on a range of outcomes,

including:
ρρ reduction in mortality and improvement in health outcomes for the
mother, offering long-term benefits for the woman;
ρρ improved health outcome for the neonate/child, which will lead to health
benefits in later life as an adolescent and adult;
ρρ reduction in the incidence of too-early and too-frequent pregnancies
and abortions; and
ρρ improvement in the nutritional status of mothers and women.
Additional benefits
In addition, the following benefits are also expected:
ρρ social and economic benefits for families and communities;
ρρ participation by men in women’s health and improvement in their own
health, irrespective of immediate plans to become parent(s); and
ρρ controlling exposure to environmental risk factors in early life and their
long-term effect (for example, eliminating smoking before or during
pregnancy could avoid 5–7% of preterm-related deaths and 23–24% of
cases of sudden infant death syndrome).

Participants were informed that WHO headquarters would support regions
and countries in implementing step-by-step processes to improve the availability
of and access to preconception care, in order to:
ρρ create regional/national platforms and partnerships to advance
preconception care;
ρρ expose professionals in individual countries to international experience,
research, evidence and good practices;
ρρ provide a methodology to analyse and understand the strengths and
weaknesses of the preconception care system and opportunities for
improvement;
ρρ explore various delivery strategies for preconception care and their
comparative advantages in terms of coverage, feasibility, acceptability
and cost;
ρρ adapt the package of preconception care interventions to regional and
country priorities and health-systems contexts;
ρρ explore and document innovative ways to deliver preconception care
outside the traditional maternal and child health programmes, while
recognizing the importance of integrated delivery mechanisms;
ρρ develop a roadmap to make changes over time; and
ρρ monitor, evaluate and document progress.
It was also mentioned that the WHO Regional Office for South-East Asia
is the first region to conduct a consultative meeting on preconception care as
per the plan made at the global meeting in Geneva in 2012 (4).
Evidence for preconception care

Dr Venkatraman Chandra-Mouli and Dr Charlotte Christiansen, WHO
Headquarters, Geneva, Switzerland
Participants were informed that exhaustive reviews of the evidence of

preconception care interventions in contributing to a range of health and
development outcomes have been carried out by CDC, USA; Erasmus University,
the Netherlands; Aga Khan University, Pakistan; and the Health Council of the
Netherlands.

Information drawn from these reviews has been supplemented with up-to-date
WHO technical guidelines and discussion with relevant WHO departments. In
the global meeting held in WHO in 2012 (4), there were extensive deliberations
on an array of issues that directly or indirectly affect maternal and child health.
Figure 3: Major risk factors affecting maternal and child health outcomes
Mental
health
Human
Nutritional Infertility/ immuno-
conditions subfertility deficiency
Too early,
unwanted and virus (HIV)
Genetic Psychoactive
rapid
conditions substance
successive
Vaccine Female pregnancies use
preventable genital Interpersonal
diseases mutilation violence
Sexually
Environmental transmitted Tobacco use
Health infections
The WHO global meeting also provided perspectives on alternative definitions

of pre-conception care and discussed sensitive issues, possible target groups,
delivery mechanisms and any region-specific considerations. The deliberations
covered the rationale and evidence for the selected health issues, the possible
interventions, and their delivery mechanisms at the global level.
The process followed in the global meeting was explained by citing the
example of the nutrition issues that focus on the three areas described in Table 1.
There is a growing experience in implementing preconception care initiatives

in both middle- and high-income countries. Countries with particular experience
are Italy, the Netherlands, the Philippines, Sri Lanka and USA. However, the
evidence on how to deliver preconception care has been weak.

Table 1: Nutrition issues for preconception care
Health problems/problem
behaviours/risk factors
Evidence-based preven- Existing delivery mecha-
that could be addressed
tive and curative health nisms that could be used
through promotional,
interventions that could to deliver interventions at
preventive and curative
be delivered in pre-preg- scale in low- and middle-
health interventions in
nancy/inter-pregnancy income countries
pre-pregnancy/inter-
pregnancy
Consequences of folic acid Iron and folic acid supple- Food fortification (e.g. pro-
deficiency mentation motion of national policies,
use of in-home micronutri-
ent powders containing
folic acid); folic acid supple-
mentation (higher dose for
women with previously af-
fected pregnancies); public-
awareness campaigns (with
physicians recommending
use); primary care
Consequences of anaemia Iron and folic acid supple- Food fortification (e.g. pro-
and iron deficiency mentations; screening for motion of national policies,
anaemia use of in-home micronutri-
ent powders containing
iron); primary care
Underweight Micronutrient education Community-based educa-
(counselling about risks tion; primary care; com-
to own health and future munity-based food supple-
pregnancies); nutritional mentation; dietary diversity
monitoring; provision of programmes
energy- and nutrient-dense
supplementary foods; inter-
ventions to improve food
security
Preconception care: experience from developed countries

Dr Coleen A. Boyle, Centers for Disaease Control and Prevention, Atlanta, USA
The importance of pre-conception care; evidence-based interventions; the

National Initiative on Preconception Health and Health Care (PCHHC) in the
USA; CDC’s role in advancing and supporting the PCHHC programme and
activities in the USA; partnerships/collaborations; and monitoring and evaluation
were highlighted.

For many women, “early prenatal care is too late”. By the time a pregnant
woman makes it to her first early prenatal visit, most fetal organs have already
been formed, and many interventions to prevent birth defects and other adverse
maternal and infant outcomes may be too late to have any desired effect (see
Figure 4).
Figure 4. Critical periods of development
Weeks of gestation from last menstrual period
4 5 6 7 8 9 10 11 12
Central Nervous System
Early prenatal
care is not Heart
enough, and in Arms
many cases it is
Eyes
too late!
Legs
Teeth
Palate
External Genitalia
Ears
Missed menstruation Mean entry into

prenatal care in the
USA
An issue of CDC’s “Morbidity and Mortality Weekly Report” in 2006 (7)

presents 10 recommendations for implementation of preconception care;
these cover: individual responsibility across the lifespan; consumer awareness;
preventive visits; interventions for identified risks; interconception care; pre-
pregnancy check-ups; health coverage for low-income women; public health
programmes and strategies; research; and monitoring.
The presenter further shared evidence, reviews and 14 recommendations

for preconception care in clinical settings, published in the “American Journal
of Obstretrics and Gynecology 2008” (8). The systematic review of the evidence
to support the implementation of preconception care in clinical settings was
conducted by more than 60 experts in maternal and child health. She also
briefed the participants on PCHHC, which was first established as a public–private
partnership to promote the goals and recommendations of the “Mortality and
Morbidity Weekly Report” published in 2006. CDC developed five workgroups,

namely consumer, clinical, public health, policy and finance, surveillance, and
research, with ongoing activities including development of:
ρρ an evidence-based clinical toolkit for preconception care;
ρρ a national social marketing campaign;
ρρ a resource centre for preconception information;
ρρ materials to describe coverage available to women under health reform; and
ρρ metrics/benchmarks for use in monitoring and tracking the initiative’s
activities.
In 2013, CDC released an action plan after this initiative, to describe a

two-year plan of activities to promote PCHHC in the USA. The evaluation of
the plan is under way and will use specific measures developed by CDC and
each workgroup. CDC’s current programmes and activities that support and
advance preconception care are aimed at:
ρρ increasing awareness of preconception care: CDC launched a
campaign on 14 February 2013 “Show Your Love”, to improve the health
of women and babies by promoting preconception health and health
care. This campaign was developed by the PCHHC Consumer Workgroup
and CDC, to increase the number of women who plan their pregnancies
and engage in healthy behaviours before becoming pregnant, and to
encourage the choice of healthy behaviours for those women who do
not want to start a family in the near future or at all;
ρρ identifying and reducing risks for adverse pregnancy outcomes:
CDC has initiated research to learn the causes of and risk factors for
birth defects and developmental disabilities, using large epidemiological
studies and modelling the potential public health impact of maternal
conditions and exposures, with the help of the Center for Birth Defect
Research and Prevention. CDC’s efforts to prioritize known risk factors
by reviewing the evidence and conditions that are modifiable during the
preconception period, in order to avoid adverse pregnancy outcomes
were also mentioned. The priorities are based on:
-- the severity of outcome and health-care burden to the individual,
the family, and society;
-- the attributable risk;
-- the prevalence of individual risk factors;
-- the preventable fraction of outcome, based on intervention to
change the risk factor;

-- the amount of time it takes to change risk by changing the risk
factor; and
-- the availability of interventions to address the risk factor;
ρρ improving the quality of preconception care and reducing disparities
in access: as medication use during pregnancy is fairly common, CDC
has developed an initiative “Treating for Two”, with its partners, which
is a kit for safer medication use during pregnancy to improve the quality
of data on medication use, translate this information into safe and
effective health care for pregnant women, and make it easily accessible
to health-care providers.
The priority risk factors/maternal conditions are recommended for screening

in the USA based on the strongest supporting evidence were highlighted. These
include: weight status, tobacco use, alcohol use, diabetes mellitus, folic acid
supplementation, and use of prescription medications. It was emphasized that
the priorities may vary in different countries, depending on local epidemiology.
Regarding the challenges of preconception care in the USA, approximately

50% of pregnancies are unplanned and education on preconception care among
providers and consumers is inadequate. There is a misperception that healthy
behaviour is relevant only after conception, and preconception care is still not
considered as a part of overall health promotion or an integral part of any
health encounter. Furthermore, discussion on male inclusion in preconception
care still needs to take place. There are very few proven delivery models/
programmes for preconception care and the US health system still lacks clinical
tools on preconception care.
To address these issues, CDC has partnered with the US Office of the
Assistant Secretary of Health, to further reduce teenage pregnancy and address
social disparities in teenage pregnancy and birth rates. CDC works with state
and local public health agencies, to monitor preconception health and health
care in the USA.
The programme goals in targeted communities are to:

ρρ reduce the rates of pregnancies and births among youth;
ρρ increase youth access to evidence-based prevention programmes;
ρρ increase linkages between teenage pregnancy-prevention programmes
and community-based clinical services; and
ρρ educate stakeholders about relevant evidence-based strategies to reduce
teenage pregnancy, and provide data on needs and resources.

Finally, a few programmes and their components were listed:
ρρ Healthy Start Interconception Care Learning Community: the components
include family planning, healthy weight, interconception screening,
maternal depression, primary care linkages;
ρρ Collaborative Improvement and Innovation Network (COIN): this network
considers public-private partnership to reduce infant mortality and improve
birth outcomes;
ρρ Secretary’s Advisory Committee on Infant Mortality (SACIM): this
committee considers public-private partnership to advise the Secretary
on the Department of Health and Human Services’ programmes that are
directed at reducing infant mortality and improving the health status of
pregnant women and infants.
She informed participants that states in the USA have identified 45 specific
indicators in 11 domains as core state indicators and CDC supports data systems
that can be used for monitoring, such as the Pregnancy Risk Assessment
Monitoring System (PRAMS).
Preconception care: experience from developing countries

Dr Christopher Howson, March of Dimes Foundation, New York, USA
Though there has been growing global interest in preconception care in the
past three years, the interventions are being conducted only in middle- and
high-income countries with preconception care components. However, most
of the interventions are not methodologically robust and lack quality or
convincing outcome data, with the notable exception of folic acid fortification/
supplementation. In low-income countries, there is no preconception care
component in existing programmes. Preconception care has not been widely
implemented because its aims and objectives are not widely understood and
accepted. The potential benefit of preconception care thus remains largely
unrealized. It needs collaborative, multi-country studies, systematic reviews,
and economic data on benefits and the impact of preconception care.
The lack of interest among policy-makers may partly be due to:

ρρ too much focus on MDGs and saving lives; there is no mention of
preconception care as a component to adress maternal and child health;
ρρ the time lag between the delivery of preconception care interventions
and the visible positive outcome is quite long, and there is difficulty in
assessing the success of interventions; and
ρρ the paucity of data on the effectiveness and economic value of
preconception care interventions.

It was informed that the situation is now changing, owing to the availability
of systematic reviews, and the global consensus on preconception care in the
report from the WHO meeting (4). The global action report “Born too soon” (9)
(see Box 1) emphasizes priority interventions and packages before pregnancy
to reduce rates of preterm birth. The report identifies the following activities
for implementation of preconception care.
ρρ Professional education/capacity-building of health functionaries should
be undertaken.
ρρ Consumer education and public awareness, must begin during
adolescence to truly improve the health of women and neonates in
schools, workplaces and health clinics.
ρρ Other innovative, culturally relevant approaches like media campaigns,
social media and mobile technology for health (mHealth) could also be
utilized to increase the outreach.
ρρ Health systems must be strengthened to make high-quality preconception
health-care services accessible and affordable for all;
ρρ A broad variety of partners, including men, health-care providers, youth
leaders and community volunteers, and delivery sites such as schools,
primary health-care facilities and community centres should be involved.
Box 1. “Born too soon”: priority interventions and packages

before pregnancy to reduce rates of preterm birth
Preconception care services for the prevention of preterm birth for all women
ρρ preventing pregnancy in adolescence;
ρρ preventing unintended pregnancies and promote birth spacing and
planned pregnancies;
ρρ optimizing pre-pregnancy weight;
ρρ promoting healthy nutrition, including supplementation/fortification of
essential foods with micronutrients; and
ρρ promoting vaccination of children and adolescents (e.g. rubella, human
papilloma virus [HPV]).
Preconception care services for women with special risk factors that increase the
risk for preterm birth:
ρρ screening for, diagnosing and managing mental health disorders and
preventing intimate partner violence;
ρρ preventing and treating STIs, including HIV/AIDS; and
ρρ screening for, diagnosing and managing chronic diseases, including diabe-
tes and hypertension.

Regional networks (like the Regional Network on Newborn Health supported
by the WHO Regional Office for South-East Asia) could help create, implement
and evaluate healthy transitions for adolescents, pre-pregnancy care, and health
education programmes for girls, and young women, boys and young men, in
ways that are collaborative, complementary, methodologically rigorous and
accountable.
A school-based model and mHealth were highlighted as two approaches

to deliver healthy transitions for adolescents/preconception care for education
of girls and young women. The school-based intervention has a limitation
that it cannot reach out to the girls who are not enrolled in schools, which is
common in several low-income countries. Other limitations include a lack of
human resources, a relatively high cost for travel and training, and interruptions
in class schedules. In addition, it is noted that contact with students is limited
(1–2 sessions a year) and there is also limited opportunity for continuous
longer-term engagement. The question and answer sessions with students in
schools are usually brief and dominated by the most vocal participants.
mHealth interventions can overcome some of the above-mentioned limitations.

It is estimated that globally there are 6 billion cell phone subscribers – which
means about 86% of the world’s population has direct access to mobile phones,
and mobile technology for health (mHealth) can reach millions of people at
low cost, using basic phones; it can also break down the vertical nature of
health programmes, by covering clients of all age groups (e.g. adolescents,
preconception, maternal health service clients) and several interventions
concurrently (e.g. smoking, HIV, contraception).
Some other benefits of mHealth, include the following.

ρρ It is able to reach boys and young men as easily as girls and young women.
ρρ It encourages and enables the growth of peer networks.
ρρ It encourages involvement of local health professionals, nongovernmental
organizations (NGOs) and universities, to promote local ownership of
the programme.
ρρ It reassures ministries of health to support scale-up.
ρρ It makes the programme content and design available for download,
adaptation and application in other countries.
The mHealth programme in Lebanon for the age group of 18–25 years,
aims to evaluate the impact of a mobile-technology-based preconception health
education programme to improve the health knowledge and behaviour of

young women. The study is partnered with the American University of Beirut,
Lebanese ministries of education and health, and Text to Change (Uganda). The
intervention will use text messages containing evidence-based preconception
education, using a two-way web-based platform. Phase 1 will compare the
effectiveness of an mHealth preconception education programme with a
classroom-based approach and will be evaluated by pre–post knowledge,
behaviour surveys and focus group discussions.
Phase 2 will then offer mHealth preconception education to all students on

the two campuses included in phase 1. The content and methods developed
will serve as a model for replication in other countries of the Region.
It was also suggested that March of Dimes Foundation, the WHO Regional
Office for South-East Asia and other partners can take the following steps
together in a preconception care initiative:
ρρ agree to provide health education to girls and young women (and boys
and young men) in targeted measurable ways;
ρρ partner in refining a needs assessment tool;
ρρ incorporate novel methods for reaching and engaging target populations;
ρρ incorporate economic analyses;
ρρ partner with civil society, academic institutions, media and government
in supporting this effort;
ρρ publish findings on an ongoing basis in peer-reviewed literature.
Preconception care: Regional perspective

Chairs: Dr Vinod Paul and Dr Coleen Boyle
“Healthy transitions for adolescents” package: rationale and

objectives for preconception care for young people aged 10–19 years
Dr Neena Raina, WHO Regional Office for South-East Asia, New Delhi, India
A situation analysis of adolescents in the WHO South-East Asia Region was

presented. The presenter stated that adolescence is the period of transition
from childhood to adulthood, during which young people go through many
physical, intellectual and social changes. It is a period of capacity development
and one of increased vulnerability and risk, especially for girls. Many of the
problems adolescents experience are related to their relative lack of power.

The main health issues affecting adolescents include sexual and reproductive
health; nutritional problems; substance use, including tobacco and alcohol;
injuries; accidents and violence; mental health problems; and acute and
chronic diseases (e.g. asthma, diabetes, tuberculosis). Adolescent pregnancy
is likely to have higher chances of complications, high maternal mortality and
morbidity, and high neonatal and infant mortality as compared to pregnancy
in older women. Contraceptive use among married adolescent women (15–19
years) ranges from 5.8% to 75%, being high in Sri Lanka and Thailand and
low in India, Nepal and Timor-Leste for both 15–19-year-old and 20–24-year-
old women. Unmet needs for family planning, especially for spacing, are high
among adolescents. Selected studies from India, Nepal and Thailand reveal
that a large percentage of young women go in for abortion, which is often
carried out in unsafe conditions. More than 1.6 million young people in the
Region are living with HIV/AIDS, and there is an increasing prevalence of HIV
among injecting drug users and sex workers in countries like India, Indonesia,
Myanmar, Nepal and Thailand. STIs are also increasing among young people.
Health, education, media and other sectors were identified as the major
stakeholders to contribute to adolescent health and development. The health
sector is mainly responsible for the provision of health and counselling services.
In contrast, the education sector should be responsible for building life skills,
and the media should contribute to acquisition of appropriate knowledge.
The responsibility of providing a safe and supportive environment is shared by
families, schools and society at large.
The WHO 4S Framework for adolescent health (6), comprises:

ρρ strategic information, which requires improvement of the collection,
analysis, interpretation and dissemination of the data required for
advocacy, policies and programmes;
ρρ supportive evidence-informed policies, which requires synthesis,
dissemination and contribution to the evidence base for policies (and
programmes) that have an impact the health and development of
adolescents;
ρρ services for adolescents, which comprises increasing young people’s
access to, and use of, appropriate health services and commodities that
respond to a number of priority health conditions; and
ρρ strengthening collaboration with other sectors, i.e. mobilizing and
supporting other sectors to maximize their contributions to adolescent
health delivery – both what they can do to strengthen the health sector
response and what the health sector can do to support their actions.

It was highlighted that WHO provides assistance to countries to make
progress in all four of these strategic areas and there are still several challenges.
Inadequate information on adolescents prevents their identification as a priority
group within public health programmes. There is a lack of convergence within
the ministries of health, low resource allocation, limited capacities at country
level, hindrances in scaling up, and lack of mechanisms for collaboration with
other sectors. However, there are numerous opportunities as well. Specific
interventions that are effective and can be delivered to adolescents are already
recognized, and will require a multisectoral approach (see Box 2).
Box 2. Adolescent health interventions and

delivery mechanisms
Evidence-based preventive and curative health interventions for adolescents:
ρρ provision of age-appropriate sexual health education
ρρ promotion of safer sex
ρρ provision of HIV counselling and testing
ρρ provision of treatment for HIV, if needed
ρρ enrolment of adolescents and women for antenatal care and prevention
of mother-to-child transmission (PMTCT) of HIV
ρρ provision of contraceptive services, including condoms
ρρ provision of iron and folic acid
ρρ immunization
ρρ prevention of substance use
Existing delivery mechanisms that could be used to deliver interventions at scale:
ρρ school health programmes
ρρ nutrition programmes
ρρ youth programmes
ρρ adolescent-friendly health service
ρρ HIV testing and counselling
ρρ HIV clinics
ρρ PMTCT programmes
ρρ noncommunicable disease service
ρρ mental health service

Concern was expressed that when health information and services of
good quality are not made available and accessible to adolescents, it results in
countless missed opportunities for the prevention of health problems and the
early detection and effective treatment of health problems. It was emphasized
that adolescent girls should be the focus for prevention of birth defects. Some
modifiable risk factors like nutrition pattern, insufficient folic acid/vitamins,
smoking, alcohol use/abuse, use of illicit drugs, obesity, diabetes, infectious
diseases, selected medications, working activity, psychosocial stressors and
environment can increase the risk of several congenital conditions, which requires
linking of neonatal health to prevention of birth defects. The first step in this
direction will be screening the mother for risk factors and addressing these by
giving protection (folic acid, vitamin B12, rubella seronegativity), early detection
and appropriate management of chronic conditions (diabetes, hypothyroidism,
obesity etc.), and avoiding teratogens (alcohol use, medication use, smoking).
Participants were also briefed on progress made by the Regional Office for
South-East Asia in the area of prevention of birth defects. The initiative began
with an expert group meeting on prevention of birth defects in November
2011, followed by a regional programme managers’ meeting on birth defects
March 2012, followed by a series of dissemination meetings, namely a birth
defects surveillance meeting in April 2012, a regional situation analysis on
birth defects, a regional strategy for prevention of birth defects, a regional
network meeting on strengthening neonatal health and birth defects in April
2013, and the most recent regional workshop on birth defect surveillance,
15–18 July 2013.
Strengthening of preconception care in the RMNCAH continuum (see

Figure 5), would lead to better maternal and child health outcomes. A good
preconception care programme can detect pregnancy-related risk factors (birth
defects) at an early stage, which can be treated with effective medications or
behaviour change. There are currently crucial gaps in the continnum of care in
health programmes where the critical age group (5–14 years) does not come
under child health, maternal health or adolescent health programmes. Also,
women before and between pregnancies do not benefit from the ongoing
maternal and child health programme.
In the health and development continnum, addition of pre-conception care

and healthy transtions would ensure health throughout the life-course from
adolescence to adulthood (prevention of noncommunicable disease; reduction

in problems related to tobacco use and harmful use of alcohol, and their cost;
STI/HIV prevention), in addition to overall positive reproductive health outcomes
(reduction in the prevalence of prematurity, low birth weight, birth defects
and reduction in maternal, fetal, neonatal and child mortality).
Figure 5.: Continuum of care – life-course
Pre-pregnancy Pregnancy Neonatal Infancy U5 6-9 10-14 (VYA) Ado 15-19

Birth period
Antenatal care – Skilled
Preconception care
Adolescent-friendly
Adolescent-friendly
health services
health services
Education and
Newborn care
Immunization
development
development
Child health,
care at birth
Early child
Preconception care
Preconception care in the WHO South-East Asia Region: pre- and inter-
pregnancy care
Dr Arvind Mathur, WHO Regional Office for South-East Asia, New Delhi, India
Worldwide, the maternal mortality ratio (MMR) declined from 400 per 100 000
births in 1990 to 260 per 100 000 births in 2008, a 34% decline over this
period, with an annual change of 2–3%. This decline reflects a decrease in
maternal deaths from 546 000 in 1990 to 348 000 in 2008. Across all WHO
regions, MMR has declined since 1990, but by less than the 75% reduction
called for by MDG 5. The greatest decline in MMR of 59% occurred in the WHO
South-East Asia and African regions. In the WHO African Region, it declined
from 850 per 100 000 births in 1990 to 620 per 100 000 births in 2008, a
27% decline in MMR with an annual change of 1.7%.
See Figure 6 for the country-wise maternal mortality rates in countries of

the South-East Asia Region.

Figure 6: Maternal mortality in countries of the WHO South-East Asia Region (10)
(Annual number of maternal deaths and proportion of the deaths
in the Region-2010)
IND
56 000 (73%)
DPRK, 280 (0%) BAN

7200 (9%) INO
BHU, 27 (0%) 9600 (13%)
TLS, 130 (0%)
THA, 400 (1%)
SRL, 130 (0%)
MAV, 3 (0%)
NEP, 1200 (2%)
MMR, 1600 (2%)
BAN: Bangladesh; BHU: Bhutan; DPRK: Democratic People’s Republic of Korea; IND: India; INO: Indonesia;
MAV: Maldives; MMR: Myanmar; NEP: Nepal; SRL: Sri Lanka; TLS: Timor-Leste; THA: Thailand.
It was further stated that reducing unwanted pregnancies leads to reduction

in overall births, including those among adolescent women, and therefore, this
reduces maternal deaths and unsafe abortions. The impact of birth spacing on
maternal health is also important. Women with short inter-pregnancy intervals
have a significantly higher risk of pre-eclampsia, high blood pressure and
premature rupture of membranes; also, a preceding inter-pregnancy interval
of less than six months’ duration is associated with a somewhat elevated risk
of maternal mortality compared to intervals of 27–50 months; this can be
seen in Figure 7, which shows that the mortality rate for children aged under
five years is higher for birth intervals of less than two years.
In relation to recommendations for birth spacing, it was stated that after a

live birth, the recommended interval before attempting the next pregnancy is
at least 24 months, in order to reduce the risk of adverse maternal, perinatal
and infant outcomes, whereas for spacing after a miscarriage or induced
abortion, the recommended minimum interval to the next pregnancy is at
least six months, in order to reduce the risks of adverse maternal and perinatal
outcomes. It is also recommended that adolescents use an effective family
planning method of their choice continuously until they are 18 years old, before
trying to become pregnant.

Figure 7: Mortality rates for children aged under five years, for different birth
intervals
Mali Rwanda Cambodia Timor-Leste

322
245
219
189 170
141 143138 132 143
101 97
84 73
65
46
< 2 years 2 years 3 years 4 years +
It was mentioned that the effect of longer birth intervals is to reduce the
risk of child death, fetal death, fetuses that are small for gestational age, low
birth weight and preterm birth and subsequent stunting and underweight in
childhood. Not only does appropriate birth spacing affect the child’s health
positively, but it also affects the mother’s health by lowering the risks of
maternal death, puerperal endometritis, premature rupture of membranes,
third-trimester bleeding and anaemia (which is prevalent in almost 48% of
pregnant women and 36% of non-pregnant women in countries of the WHO
South-East Asia Region). He further stated that it is very important to train
both health providers and the community regarding preconception care, as
in most countries the first antenatal check-up happens in the third month of
pregnancy, by which time the neural tube has already closed (by day 28 of
gestation) – before many women realize they are pregnant.
Preconception counselling for all women of reproductive age can improve

the chances of a successful pregnancy, especially counselling on how:
ρρ folate intake and folic acid supplementation reduce NTDs (neural tube
defects)
ρρ alcohol ingestion during pregnancy can cause fetal alcohol syndrome;
ρρ exposure to environmental contaminants affects reproductive health.
The term “preconception” suggests that it mainly concerns women. Its

benefits and target groups need to be clearly defined, as it is very important
that policy-makers understand the term in the right context. Although different
periodic surveys have been undertaken for planning and monitoring of the

national reproductive, maternal, neonatal and child health (RMNCH) programmes
in different countries of the South-East Asia Region, the information gaps
continue within these surveys. These include lack of age- and sex-disaggregated
data; non-inclusion of unmarried men and women in samples at national, state
and district levels; lack of data on 10–14 year olds and on special groups of
adolescents and youth; and no information on miscarriages or still births. In
India, there is a very high burden of low-birth-weight babies, owing to maternal
undernutrition, early marriage and lack of child spacing. He also emphasized
the importance of partnerships with the community to ensure good utilization
of services.
Preconception care interventions: existing situations in countries of

the WHO South-East Asia Region
Dr Sanjay Chauhan, National Institute of Research in Reproductive Health,
Indian Council of Medical Research, Mumbai, India
It was stated that many of the pre-conception care interventions are currently
available to adolescents and women, as well as to couples. However, they are
not systematically delivered as a defined service package for preconception care
in the WHO South-East Asia Region. The highlights of the existing interventions
were described as below.
Family planning programmes

All the countries of the South-East Asia Region are implementing family planning
programmes. However, each country shows variation in the methods that are
available and accepted in its programmes. In most countries of the Region,
family planning programmes cover both married couples and adolescents, except
in Bangladesh and Maldives, where access to reproductive health services,
including contraceptives for unmarried adolescent youth, is not promoted.
The participants were informed that abortion is legal in all countries of the
Region, though each of these countries allows abortion on different grounds.
Some countries allow abortion in cases of rape, incest or fetal impairment
or on other grounds. Some restrict abortion by requiring parental or spousal
authorization. Countries that allow abortion on socioeconomic grounds, or
without restriction as to reason, have gestational age limits (generally the first
trimester); abortions may be permissible after the specified gestational age,
but only on prescribed grounds.

Infertility/subfertility
It was stated that there is a significant burden of infertility in the South-East
Asia Region, although the data on primary and secondary infertility are not
available for all countries of the Region. Currently, no country has a programme/
interventions for the management and prevention of infertility. Almost all
components of prevention treatment come under the private sector. Major
emphasis is given to assisted reproduction methods such as in vitro fertilization
(IVF) and the prevention of infertility is next to non-existent in all the health
programmes of countries of the Region.
Work in the area of infertility has been initiated by the WHO Regional
Office for South-East Asia, with four WHO collaborating centres in India, where
research has been conducted to assess the capacity of the public health system.
Following this, guidelines have been developed on prevention and management
of infertility, focusing on the level of primary health care.
Immunization
As per the WHO Regional Office for South-East Asia initiative to intensify
immunization efforts (11), pentavalent vaccine (DTP [diphtheria, tetanus,
pertussis] + hepatitis +Hib [Haemophilus influenzae type B]) has been introduced
in Bangladesh, Bhutan, Nepal, Sri Lanka and in eight states in India in the last
two years. The vaccines relevant for pre-conception programmes include the
following.
ρρ Rubella vaccination has been introduced in Bangladesh, Bhutan, India
(some states), Maldives, Nepal, Sri Lanka and Thailand in their national
Expanded Programme on Immunization (EPI).
ρρ HPV vaccination is included in two countries, namely Bhutan and Nepal. In
Bhutan, it is included in the national immunization programme. In Nepal,
an HPV vaccination programme is implemented by the Australian Cervical
Cancer Foundation with support from government and nongovernment
organizations, though at present it is not part of the national immunization
programme. Other countries of the Region have not included HPV as
part of their immunization programme, owing to the high cost of the
vaccination. However, pilot studies to include HPV vaccine are ongoing
in these countries.
Nutrition
Most countries of the South-East Asia Region have functional large-scale nutrition
programmes that focus on maternal and child undernutrition.

ρρ Iron and folic acid supplementation is available in all countries except
the Democratic People’s Republic of Korea. A weekly iron/folic acid
supplementation with deworming has been initiated for adolescents
aged 10–19 years in India.
ρρ Nutrition education and counselling for under- and overnutrition is part
of programmes in all countries.
Maternal health
Almost all the countries of the Region are implementing the standard
components in their maternal and child health programme: antenatal care that
includes screening for anaemia and STI/HIV; PMTCT; skilled care at birth; and
postpartum care. The scale of implementation of these interventions varies
among and within countries.
Genetic services
Genetic services and counselling are available in many institutions in major
cities in most countries of the Region. Screening for genetic conditions is
available in selected institutions in some cities of the countries. Pre-marital and
pre-conception counselling is offered in a limited manner.
HIV/reproductive tract infection/sexually transmitted infection

All countries except Timor-Leste have a programme on HIV/reproductive tract
infection (RTI)/STI, where the initiative is limited to awareness generation
because of the low prevalence. Screening and management could be offered
in the pre-pregnancy period.
Noncommunicable disease
All countries except the Democratic People’s Republic of Korea and Timor-
Leste have initiated national programmes for prevention and management of
noncommunicable diseases. Prevention programmes could be effectively offered
during adolescence, by promoting health behaviours and lifestyles through a
preconception care package.
Mental health
India, Maldives and Nepal have national mental health programmes. Bhutan,
Indonesia and Thailand have community-based mental health programmes.
Bangladesh, Sri Lanka and Timor-Leste each have a mental health policy
and strategy. Mental health promotion could be an essential element in

preconception care packages that could be delivered in an age-appropriate
manner to adolescents and women.
Tobacco control
The tobacco burden in the South-East Asia Region is one of the highest among
WHO regions. The widespread use of many forms of tobacco, including smokeless
tobacco, complicates efforts to implement effective tobacco-control initiatives.
Nevertheless each country in the Region has taken important steps to combat
the tobacco epidemic. Ten out of 11 countries of the Region have ratified
the WHO Framework Convention on Tobacco Control. Although Indonesia is
not yet a party to the Convention, it has recently undertaken initiatives at the
subnational level. Services for prevention of tobacco use should be offered
to adolescents before they initiate tobacco use. Cessation programmes are
essential for the periconceptional period and pregnancy.
Alcohol and drug abuse

Many countries in the Region have legislation against the use of alcohol among
young people and against illegal drugs. Prevention and management programmes
for alcohol and substance use could be started during adolescence before
their initiation, and screening and management is essential before conception.
Although RMNCAH programmes in countries of the Region are addressing

several components of preconception care, it is observed that ongoing programmes
are vertical in nature, with focus on antenatal care, safe delivery and postnatal
care. Nevertheless, the existing public health programmes do offer opportunities
to build / strengthen delivery of interventions as pre-conception care package,
several of which could be made available right from adolescent age.
Adolescent health programmes in the WHO South-East Asia Region:

broadening the service package towards “healthy transitions for
adolescents”
Dr Rajesh Mehta, WHO Regional Office for South-East Asia, New Delhi, India
The regional situation of adolescent health and progress of adolescent health

programmes in countries of the Region was discussed. The regional strategy
for adolescent health was released in 2011. Member countries have designated
national programme managers and allocated budgets, and developed national
strategies for adoelscent health. The WHO training package has been adapted
by countries for training health-care providers for delivery of adolescent-friendly
health services.

The scale of implementation of adolescent-friendly health services is variable
in the Region (see Table 3), as reported by Member States.
Table 3: The scale of implementation of adolescent-friendly health services
Number of
Geographic
public health Outreach
coverage of Other sites for
services services
implementation adolescent-
Country implementing through
of adolescent- friendly health
adolescent- public health
friendly health services
friendly health system
services
services
Bangladesh 40/60 districts 100% No NGO
NGO and
India All 35 states No data Yes
private clinics
Indonesia 196/477 districts 25% No NGO
Youth health
Maldives 2/20 atolls 2 hospitals No
café NGO
National
Myanmar 18/75 townships 100% No
organization
National
Nepal 10/75 districts 20% No
organization
Sri Lanka 2008 No data Yes NGO
Marie Stopes
Timor-Leste 2010 Data not available No
Clinic (Dili)
NGO: nongovernmental organization.
The current service package in most Member States comprises antenatal care,
childbirth care, abortion services, HIV counselling and testing, STI treatment,
PMTCT, contraceptive services (where legal), emergency contraception, control
of anaemia, and counselling for psychosocial issues. There have been increasing
examples of collaboration between health and other sectors.
It was stated that adolescent programmes in countries of the Region focus

on sexual and reproductive health, including prevention of too early pregnancy
and contraception. They offer an opportunity to add other components of
preconception care under the “healthy transitions for adolescents” package
(see Figure 8), to address nutrition, substance use, tobacco and alcohol use,
injury and violence, vaccine-preventable diseases, genetic conditions, mental
health, physical activities, and noncommunicable diseases, to promote overall
health among adolescents.

Figure 8: “Healthy transitions for adolescents”
“Healthy transitions for adolescents”

Ensuring health across life-course
ρρ Healthy adolescence
ρρ Healthy adulthood
-- Noncommunicable diseases prevention
-- Reduction in problems related to tobacco use and harmful use
of alcohol
-- STIs and HIV prevention
ρρ Healthy reproductive health outcomes
-- Reduction in prevalence of prematurity, low birth weight, birth
defects
-- Reduction in maternal, fetal, neonatal and child mortality
Integrated approaches and interlinkage between programmes will play a

very significant part in the implementation of pre-conception care programmes.
There will be also a need to generate a demand for these services. It is important
to strengthen research to understand the determinants (risk and protective
factors) of health-related behaviours of adolescents, gatekeepers and service
providers, and determine appropriate delivery mechanisms for the identified
services. Sound adolescent programmes would foster global commitments and
partnerships for MDG 4 and 5 beyond 2015 and this would also enhance the
commitment of national governments to adolescent health programmes and
earmarking of domestic resources.
Preconception care case-studies from the WHO South-East Asia Region

Chairs: Dr Christopher Howson and Dr Quamrun Nahar
Sri Lanka
Dr Nethanjalie Mapitigama, Family Health Bureau, Ministry of Health,
Colombo, Sri Lanka
With a well-established and well-staffed health system, Sri Lanka has been ahead
of many countries in the South-East Asia Region with respect to maternal and
child health indicators. However, it was observed that the rate of progress for
these indicators remained stagnant in the last few decades, where 72–75%
of maternal deaths were still preventable. In November 2011, the Ministry of
Health launched a new package focusing on newly married couples. The main
objectives of this initiative were:

ρρ to improve reproductive health outcomes by improving the health of
newly-married couples;
ρρ to extend the maternal health continuum further before pregnancy occurs,
as some curable and correctable medical conditions were not detected
until the woman became pregnant;
ρρ to scale up evidence-based interventions and strategies to further reduce
maternal and neonatal mortality and morbidity and ensure quality survival
for mothers and their babies; and
ρρ to fine tune the existing programme.
Delivery channel
This package would be delivered by the medical officer of the health team.The
services provided under the package are risk screening, physical assessment,
vaccinations, raising awareness, counselling and provision of other services.
The tools used in the package are:
ρρ invitation card: congratulating the couple, to wish them a happy married
life and fixing an appointment with a trained health worker to discuss
reproductive health;
ρρ screening tool: to screen both partners for risk factors, including selected
past and present medical conditions and use of medications, family
history, sexual and reproductive health, family nutrition and lifestyle,
environmental conditions, psychosocial concerns (depression/violence)
and rubella vaccination and folic acid supplementation (see Figure 9);
ρρ guide book for health workers: includes guidelines to screen for risk
factors by using the screening tool and clinical examination by trained
health workers (PHM – public health midwife), basic investigations,
measurement of body mass index, and referral for further diagnosis/
treatment/for specialized care and follow up.
ρρ book for the new couples: during the home visit, the PHM hands over
a book to raise awareness among couples on topics including sexuality
and sexual relationship, sexually transmitted diseases and responsible
sexual behaviour, a planned family, good nutrition, good health habits/
healthy behaviour/healthy lifestyle, good marital relationship and well-
being of the family, benefits of nonviolence, health before conception,
male participation and parenthood, and tobacco and alcohol.

Figure 9: The screening tool
Screening tool
Screen both husband and wife for risk factors:
ρρ Selected past and present medical conditions,
medications and family history
ρρ Sexual and reproductive health
ρρ Family nutrition, lifestyle
ρρ Environmental conditions
ρρ Psychosocial concerns (depression/violence)
ρρ Rubella vaccine/folic acid
ρρ Physical assessment, height, weight
ρρ Clinical examination
ρρ Basic investigations
ρρ Referral for further diagnosis/treatment/for specialized care
The programme is to be implemented initially in 14 districts out of 25

districts in Sri Lanka and will be expanded to all districts by end of next year.
The expected outcomes of the package are:
ρρ increased reproductive health awareness of the couple and thereby
increased knowledge, changed attitudes, and reduction of unhealthy
behaviour, in order to improve the health and well-being of the family;
ρρ improved health status of women/men before the woman becomes
pregnant;
ρρ addressing risk conditions/issues of women/men before they attain
parenthood; and
ρρ reduction in the probable adverse pregnancy-related outcomes and
thereby a reduction in maternal and childhood mortality and morbidity.
Area of improvement
Though this package provides a broad range of preventive services (covering
preconception care components), it is restricted to married couples and does
not include adolescents. Sri Lanka has a high prevalence of thalassaemia and
yet the screening tool in this package does not include thalassaemia screening.

India
Two studies related to preconception care were presented: one in a school
setting and one for prevention of birth defects in a community setting.
School-based preconception care interventions: Public Health

Foundation of India
Dr Monika Arora, Public Health Foundation of India, New Delhi, India
Project MYTRI (2004–2006) was a multi-component intervention to prevent

tobacco use among 14 000 students in 32 schools, both government and
private, in Chennai and Delhi. This project was a joint collaboration between
HRIDAY, an NGO working in tobacco control in India, and the University of
Texas, USA.
The project covered adolescents in grades 6 and 8, aged 10–16 years; with
a two-year intervention. The programme components consisted of:
ρρ classroom curriculum: to increase knowledge about the health and
social consequences of tobacco use and increase skill to identify and
resist influences to use tobacco;
ρρ school posters and parents’ post card: to provide opportunities to
learn about school and community policies on tobacco; and
ρρ peer-led health activism: to create tobacco-free norms in school, the
home and surrounding neighbourhoods, and to increase exposure to
non-tobacco-using role models.
At the end of the two-year programme: (Figure 10)

ρρ overall, current tobacco use increased by 68% in the control group and
decreased by 17% in the intervention group over the study duration;
ρρ intention to smoke increased by 5% in the control group, whereas
intention to smoke decreased in intervention schools by 11%;
ρρ intention to chew tobacco decreased by 12% in the control group; there
was a 28% decrease in the intervention group.

Figure 10: Survey outcomes: Tobacco use (Unpublished data)
Trend in current tobacco use among girls Trend in Intention to smoke among 10-14
year old youth
2.5 9
2.38 8.41
8
2 7
1.76 6.24
6
Prevalence
Prevalence
1.5
5
1.14 4 4.07
1
3
0.76 0.83
0.5 0.69 2 2.14
1 1.69
1.24
0 0
Baseline Intermediate Endline Baseline Intermediate Endline
Study condition: Intervention Control
Cost effectiveness of project MYTRI

ρρ Programmes such as MYTRI are less expensive to implement in India
compared with similar programmes in high-income countries.
ρρ The cost per quality-adjusted life-year added, due to averted smoking,
was US$ 2057.
ρρ Project MYTRI was estimated to be over 24 times more cost-effective
than dialysis in the USA, which costs USD 50 000 for a life-year.
Knowledge to policy
ρρ Evaluation of project MYTRI showed an increased sensitization and
acceptance by schools of the need for lifestyle-related health intervention
for adolescents, and inculcating healthy lifestyle practices among Indian
youth.
ρρ The project provided robust research evidence and has been used
effectively by HRIDAY, to advocate with policy-makers for scaling up the
Government of India’s tobacco-control efforts. As a result, school health
programmes form a key component of the National Tobacco Control
Programme.

Using key informants to identify birth defects and childhood disability
Dr GVS Murthy, Indian Institute of Public Health, Hyderabad, India
The main objective of the project are:

ρρ to summarize existing research evidence on the public health impact of
folic acid deficiency;
ρρ to assess the use of 500 key informants for identification of visible NTDs
and oro-facial clefts;
ρρ to conduct epidemiological characterization and identify risk factors for
NTDs and oro-facial clefts in India;
ρρ assess the benefit of pre- and early pregnancy folate supplementation
among mothers with prior adverse pregnancy outcomes.
The components of the programme will include systematic review, key

informant interviews, case-control study and folic acid supplementation in the
pre-pregnancy period.
The project area is a rural settlement (Mehboob Nagar) in Andhra Pradesh

and urban slum and resettlement colonies in New Delhi, consisting of 50 000
population in each location.
Figure 11. The programme to use key informants to identify birth defects and
childhood disability
ρρ Identify KI from each village (AWW; Others)

ρρ Train (disability sensitization; awareness; visible defects and
KI history of adverse pregnancy outcomes)
ρρ 4-6 week period for listing

ρρ SMS used for information sharing
List
ρρ GPS coordinates mapped
ρρ Lists validated with ANMs

ρρ Cases examined by medical officer
Confirm
ρρ Descriptive data collected
ρρ Identified mothers offered supplement

ρρ KI follow up for monitoring
Supplement
ρρ Trial
ANM: Auxilliary nurse midwife ; AWW: Anganwadi workers; KI: key informant;

The programme will use the following strategies for implementation (see
Figure 11):
ρρ the key informants will be identified from each village (anganwadi
workers; others) and will be trained (for disability sensitization; awareness;
visible defects and history of adverse pregnancy outcomes);
ρρ there will be a 4–6-week period for listing and SMS will be used for
information sharing; GPS coordinates will be mapped;
ρρ the lists will be validated with ANMs (auxilliary nurse midwives), after
which the cases will be examined by the medical officer and descriptive
data will be collected;
ρρ after the data collection, the mothers identified will be offered supplements
and key informants will conduct the timely follow-ups.
Discussions
The session ended with a strong sense that preconception care would be a
useful adjunct to providing the continuum of care across the RMNCAH life
course and it would be important to include adolescents and young adults.
There was an agreement that this is just as relevant for low- and middle-
income countries as it is for high-income countries. The participants largely
agreed to the range of issues that it could address to ensure overall health of
men and women through their life. However, it was strongly felt that it was
important to use an appropriate term for programmes to ensure acceptability
at community level and policy- and decision-making levels. It was clear from the
presentations that the programme must include both adolescents and young
adults. The service package and delivery channels of such a programme must
be designed to suit the needs of the target groups.
Delivery of preconception care interventions in the WHO South-East

Asia Region: opportunities and challenges
Chairs: Dr Christopher Howson and Dr Quamrun Nahar
Interventions in the various programmes of WHO Regional Office for

South-East Asia that could contribute to preconception care:
Panel discussion moderated by Dr Rajesh Mehta
Dr Rajesh Mehta moderated discussions with the panel of regional advisers

from various technical units of the WHO Regional Office for South-East Asia
regarding their existing work that may be relevant for and contribute to
preconception care packages. The technical units for nutrition, immunization,

noncommunicable diseases, gender and women’s health, and injuries prevention
shared their areas of work and how collaboration could help achieve the
gains from preconception care packages in the short term (health during
adolescence and pregnancy outcomes) and long term (healthy adulthood).
The panel discussion highlighted that several key behaviours that predispose to
health risks in the immediate future as well as later in life are initiated during
adolescence. Health promotion and anticipatory guidance to adopt healthy
behaviours should be made available to all adolescent girls and boys as well
as young women and their partners.
Benefits and risks of preconception care

The benefits and risks of preconception care were listed after considering both
short- and long-term risks and benefits. In addition, “the terms to be used to
describe preconception care and reasons thereof were also discussed”.
Alternate term to be used for preconception care (Summary of Group work)

It was agreed that the definition needs to be consistent, simple, clear and
understandable for the public, policy-makers and other stakeholders. The
proposed package has the potential to address several issues. Participants
suggested that preconception care programme should cover a wide age group,
from 10 to 35 years with different packages of services depending upon the
age, level of health-care delivery. Preconception care should not be limited to
reproductive health and women and should ensure male involvement as well
as involvement of the families.
There was intensive debate on the nomenclature. It was also suggested

that there may be a need to field-test the term to see how the community
perceives it, and to make it very catchy so that it resonates with lay people
and donor organizations/policy-makers. This may require further discussions
to identify the diversities of the potential beneficiaries.
Participants felt that “preconception care” should be seen to address

both unmarried and married individuals, and should begin early to target
adolescent boys and girls. It was felt that although the term “preconception
care” is meaningfully used by the scientific community, it may be more difficult
for lay people to understand. They may understand the term “pre-pregnancy
care” more easily, and it would be easier to translate in local languages in
the Region in comparison to preconception care. However, it was recognized
that the term “pre-pregnancy care” places the entire onus on women, which
is quite misleading and actually not intended.

The participants felt that a term is needed that covers not only healthy
motherhood and childhood but also preparing for a healthy life and in doing
so must accommodate adolescent boys and girls. However, both terms
“preconception care” and “pre-pregnancy care” point to a period just before
pregnancy. Another term that was considered was “pre-parenting care”, which
includes both men and women. However, it was argued that the term assumes
all couples/women wants to become parents, which is not always the case
and even “pre-parenting care” does not focus on the lifespan as a whole. In
addition, all these terms exclude the inter-pregnancy period.
The participants felt that “healthy transitions” is dynamic term that

implies movement forward, with a life-cycle approach embedded in the name
(e.g. transitioning from adolescence to adulthood and beyond). It also links
to addressing risk behaviours responsible for chronic disease and impairment.
Therefore, participants were in favour of using “healthy transitions” as an
appropriate term for the package of services to be delivered to adolescents,
young people and couples, with a short-term aim to improve pregnancy outcomes
and a long-term aim of improving health during adulthood.
After discussions, the participants agreed to consider the concept of

preconception care in two parts. One would be “healthy transitions for
adolescents” to ensure healthy adolescence (immediate) and healthy adulthood
(long term) and the second would be “pre-pregnancy care”, which would
cover young adults and include the inter-pregnancy period to largely address
reproductive health outcomes. The interventions for the two tracks would
be packaged and delivered differently for appropriate targeting of intended
beneficiaries. At the same time the content and mechanisms of delivery of
preconception care will need to be tailored to the realities of different countries
of the WHO South-East Asia Region. It was also agreed that there is a need
for a conceptual framework in which to embed such packages.
Effective approaches must be based on detailed research, thorough analysis

and good-quality data. There is a need to evaluate existing programmes and
policies in order to learn from experience and to identify the strengths and
weaknesses of existing approaches. This will be a good foundation for designing
suitable preconception care programmes in each Member State.
Benefits of pre-conception care (Summary of Group work)

From the perspective of health outcomes, pre-conception care would have
both short-term and long-term benefits. Short-term benefits would be reducing

pregnancies that are too early, or that are too close together, and unplanned
pregnancies, thereby improving maternal and child health outcomes and reducing
mortality. It could also contribute to improving the health and well-being of
women including appropriate nutrition, addressing infertility and subfertility,
prevention and management of intimate partner violence.
Preconception care, when combined with lifestyle interventions would

ensure better acceptability of sexual and reproductive health issues within
an expanded package. Preconception care intervention would also reach out
to men, by creating awareness of the importance of men’s health and their
behaviours for maternal and child health outcomes.
Preconception care beginning with adolescent boys and girls could

contribute to long-term benefits by promoting healthy behaviours and life styles,
mental health, prevention of substance use, screening for genetic disorders
and environmental exposure etc., thereby laying a foundation for healthier
adulthood. A broad approach could thus contribute to social and economic
development of families and communities.
In this way, preconception care could make useful contributions to MDGs

1, 3, 4, 5 and 6.
From the community perspective, preconception care will lead to greater

participation of families, contributing to increase in demand for services, and
facilitate families and individuals to take charge of their health and their life. It
will also bring benefits to providers and to families, building greater confidence
in the health system. Preconception care increases the scope of intersectoral
linkages of programmes, building a stronger force to deal with health and
social issues affecting men’s and women’s health.
From the programme prespective, preconception care provides a window to

include interventions that were traditionally not a part of MNCH programmes,
such as for the age groups of 5–9 years and 10–14 years, that is, children
and adolescents, who get very low or no focus. It increases the potential for
exploring counselling on unmet issues such as contraception and STIs among
unmarried boys and girls.
All participants agreed on the benefits mentioned in the global consensus

on preconception care (4), and recommended that the benefits could be
identified in context of several entities including:

ρρ individual girls, boys, women and men;
ρρ couples;
ρρ families;
ρρ communities;
ρρ country/region;
ρρ health-care providers;
ρρ policy-makers and politicians;
A broad approach envisaged for preconception care would need multisectoral

convergence.
The participants emphasized that arguments of financial–economic benefits

of preconception care must be developed for effective advocacy at policy level.
Many times an argument on the cost of doing nothing is found effective to
convince decision-makers.
Risks of implementing preconception care programmes

(Summary of Group work)
The major challenge of preconception care could be that the interventions are
not confined only to the health sector and would require intensive coordination
with several stakeholders in different sectors and a high commitment to deliver
the package. Preconception care may also suffer from administrative challenges
in having the health sector accountable for determinants that operate beyond
their domain. Engagement of the private sector may result in conflict of
interest, particularly with industries like tobacco and alcohol. Corporate social
responsibility (CSR) initiatives from such industrial houses would require strict
regulation.
A strong focus on preconception care could run the risk of defining girls
as being in perpetual preconception state, even before their menarche, and
viewing a woman as somebody who delivers and raises children for the
entire duration of her fertile period. This could lead to women being barred
from participating in some situations or taking up work in some areas, on the
grounds that it would increase the risk of adverse maternal and child health
outcomes. Further, in relation to predisposing factors such as tobacco and
alcohol, it could lead to moral policing, particularly for girls, stigmatizing them
for their conduct, such as for smoking or drinking alcohol.
Further, an emphasis on preconception care could reinforce the notion that

the focus of all efforts to improve the health of girls and women should be at

improving maternal and child health outcomes, rather than at improving the
health of girls and women as individuals in their own right. In addition, blanket
approaches to preconception care could be seen to imply that all girls and
women will inevitably become mothers. There is also a risk that women and
couples will be stigmatized and blamed, or will blame themselves, for adverse
reproductive outcomes (e.g. those who have genetic conditions, those who
are overweight, those who smoke). To minimize these risks, preconception
programmes should be implemented cautiously, and supported by well-researched
communication activities and campaigns.
Packages of preconception care

It was unanimously agreed to divide preconception care into two packages,
namely “healthy transitions for adolescents” targeting older children and
adolescents and “pre-pregnancy programme” consisting mainly of maternal
and reproductive health package for partners/couples.
The proposed “healthy transitions for adolescents” package would cover:

ρρ personal hygiene;
ρρ mental health including screening for depression;
ρρ vaccine-preventable diseases;
ρρ prevention of noncommunicable diseases;
ρρ tobacco, drugs and alcohol exposure (effect on fertility, the fetus and
the neonate);
ρρ substance and medication abuse;
ρρ healthy diet and physical activity;
ρρ screening for eye problems and other diseases, diabetes, body mass index;
ρρ nutritional conditions (deworming, emerging deficiencies, e.g. vitamin
D deficiency);
ρρ iron and folic acid supplementation;
ρρ too-early, unwanted and repeated adolescent pregnancies;
ρρ contraception information services (including emergency contraception);
ρρ genetic conditions (sickle cell anaemia and thalassaemia);
ρρ information on infertility;
ρρ STI/HIV;
ρρ reproductive knowledge and managing menstruation and masturbation;

ρρ sex/gender and violence;
ρρ interpersonal violence (both sexes, bullying, teasing, domestic violence);
ρρ injury prevention;
ρρ sexual abuse and harassment, violence;
ρρ environmental health (e.g. indoor pollution – cooking practices, evidence
base at country level, lead/arsenic/endocrine disruption)
The “pre-pregnancy programme package for partners/couples”, will be same

as the basic and expanded packages, as mentioned in the global consensus
report (4) covering the maternal and reproductive health issues through a
variety of delivery channels that will be specific to each Member State.
Basic package
ρρ Family planning (more than just contraception)
ρρ Vaccine-preventable diseases
ρρ Nutrition and micronutrients (including food and micronutrient supplementation,
food fortification, nutrition education)
ρρ Tobacco cessation (including exposure to second-hand smoke)
ρρ Reducing harmful environmental exposures (e.g. indoor air pollution)
ρρ Improving sexual health and behaviour (screening, counselling, treatment)
Expanded package (basic package plus the following issues)

ρρ Mental health problems
ρρ Intimate partner and sexual violence
ρρ Genetic conditions
ρρ Prevention of noncommunicable disease
ρρ Environmental health
ρρ Substance and drug use
ρρ Injury prevention
ρρ Non-population-specific genetic diseases (e.g. Down syndrome)
The country-specific package should include region/country-specific genetic

diseases. It was suggested that it may be useful to propose a basic or minimum
package for all countries to use, along with an extended package for countries
that have the means to implement it.

These interventions would need to be delivered using a mix of methods:
ρρ health education and promotion;
ρρ vaccination;
ρρ nutritional supplementation and food fortification;
ρρ provision of contraceptive information and services;
ρρ screening, counselling and management (medical and social).
The preconception interventions delivered in a particular setting will depend

on the local epidemiology, the interventions already being delivered, and the
mechanisms and resources in place to deliver additional interventions. As a
way forward, it was agreed that the countries of the Region should design
a holistic package of preconception care interventions that will meet the
following criteria:
ρρ interventions will be age-specific and appropriate for developmental
stage of individuals;
ρρ appropriate interventions would be delivered as a package, not as single
interventions;
ρρ interventions would be delivered through appropriate channels e.g.
facility (health, school), outreach, community-oriented or family-oriented
channels;
ρρ the interventions that can be delivered in countries with constraints of
human and financial resources;
ρρ the interventions are expanded incrementally so as not to suddenly
overwhelm the existing capacity.
Delivery mechanisms for preconception care

Chairs: Dr Nethanjalie Mapitigama and Dr Swati Bhave
The health problems/health risk behaviours/risk factors (see Annex 1) contribute

to maternal or childhood morbidity or mortality and are of promotive, preventive
and curative character. The interventions can be delivered through:
ρρ health facilities at various levels;
ρρ community-based and family-based outreach;
ρρ multisectoral approaches – school/college, social media, peers, etc.;
ρρ school-based services; and
ρρ electronic and mobile technology (mHealth).

Participants observed that in most countries of the Region, ongoing
programmes are vertical in nature and address limited components; for example,
the maternal and child health programmes focus on antenatal care, safe delivery
and postnatal care. With increasing prevalence of HIV and substance use and
other lifestyle diseases (diabetes, hypertension, obesity, cardiovascular disease,
etc.), preconception care programmes could be a crucial step for integration.
Efforts must also be made to work with other sectors such as schools and
workplaces, and with civil society groups such as faith-based organizations.
Participants discussed possible delivery mechanisms to address different risk

factors in addition to the delivery mechanisms presented in the global report
(4). The delivery mechanisms presented in the tables in Annex 3 include specific
ones proposed by the participants in the context of the South-East Asia Region.
Conclusion
The health, economic and social benefits of preconception care need to be
communicated effectively to decision-makers at the international level, whose
support is crucial for global and regional action and research, as well as to
decision-makers at the country level, whose support is critical to incorporating
preconception care into existing programmes. Beyond that, the community
must be educated about preconception care, and informed about ways to
avail these services.
Participants suggested that, for advocacy, an appealing document that clearly

defines and explains preconception care, and its crucial role, should be developed.
Concurrently, key stakeholders must be reached for support. Preconception care
must be promoted actively among the stakeholders including communities using
a variety of methods, including the mass media and social media. Countries
of the Region must also come forward and initiate cost-effective pilot projects
according to country needs to build local evidence that would collectively build
a case for implementing preconception care programme in the Region.
Actions are needed on at least three fronts. First, policy-makers and funding
agencies must be convinced that there is a need to include preconception
care – “healthy transitions for adolescents” and “pre-pregnancy” packages in
the existing national effort to prevent maternal and childhood mortality and
morbidity; that such packages can be delivered successfully; that its delivery
will lead to improved functioning of related social sector programmes; and
that, as a whole, it will bring tangible health outcomes and other benefits.

Second, decisions will need to be made with programme managers on
which preconception interventions need to be delivered, the population groups
to be targeted, and the mechanisms through which the interventions can be
delivered given the available human and financial resources.
Third, the social and cultural sensitivities need to be considered carefully,

in deciding how best to communicate about delivering preconception care
in a way that empowers women and couples and adolescents, rather than
subjecting them to blame (including self-blame) and stigma.
It was concluded that, in delivering preconception care, efforts must be

made to ensure that:
ρρ both existing and innovative mechanisms are used;
ρρ preconception care is integrated into ongoing programmes;
ρρ preconception care is presented as part of the care across life-course
continuum rather than on its own;
ρρ preconception activities that are under way in several countries within
existing RMNCAH programmes are identified and strengthened to evolve
a consistent package;
ρρ information and activities related to preconception care are included in
community-level activities in order to reach out, build positive attitudes
and made into personal responsibility of each individual;
ρρ every opportunity of a woman contacting a health facility is used to
provide preconception messages and interventions;
ρρ work is carried out both within and outside the health sector, using a
variety of settings, including the mass media and popular technologies
such as electronic and mobile phone technology.

© WHO
4 Conclusions and
recommendations

Setting a regional agenda for preconception care
Chairs: Dr Bunyarit Sukrat and Dr Debasish Dutta
Identified research areas

One of the major objectives of the consultation was to identify research
priorities on preconception care for “healthy transition for adolescents” and
“pre-pregnancy care”.
Desk review of the available documents has raised a number of themes

and approaches for identifying needs and/or evaluating interventions intended
to create – among other benefits – conditions that support later, safer, more
informed, voluntary and protected sexual initiation among young adolescents,
and the reduction of STIs, including HIV, and unsafe pregnancy.
Research area: Target population

1. Collecting primary data at ground and province/state levels from health
facilities, through routine management information systems, as well as
from research and academic institutions in the public and private sectors.
The data that are periodically collected through national surveys should be
analysed on the basis of age, sex and location/demographic disaggregation.
Additionally, the age group of 10–14 years should be considered for inclusion
for data collection in the national surveys from the next rounds. Such strategic
information would be extremely useful to not only understand the current
status of adolescents but also to guide strategic planning for adolescents/
young people to address their needs more effectively.
2. Engaging in research that will pay special attention to marginalized or
disadvantaged populations of young adolescents, such as the collection of basic
data on the needs and concerns of isolated young married girls in rural areas,
where high proportions of female adolescents are not currently attending or
have never attended school; boys and girls living on the city streets; female
domestic workers; young adolescents living in AIDS-affected families or in
slum areas; disabled young people; refugees; and other vulnerable groups
Research area: Community (stakeholders/gatekeepers)

1. Undertaking community-based knowledge, attitude and practice studies to
understand the target population.

2. Engaging in research to identify the social determinants of young adolescents’
sexual and reproductive health. This research approach would consider
questions such as the following:
ρρ What characteristics of the institutional and social environment predispose
10–14 year-old girls and boys to health-compromising behaviour in
different settings?
ρρ Why, in the face of group vulnerability, do some young people make
good choices and others poor ones?
ρρ What protective factors are most effective in buffering young adolescents’
vulnerabilities, and how can these be strengthened? Analysis by single
years, sex, and socioeconomic and cultural characteristics is an essential
part of this approach.
3. Examining cost effectiveness/affordability in access to preconception care.
Research area: Policy

1. Engaging in research on the effectiveness of existing health, education and
social-sector policies and programmes at the national or subnational or local
levels in countries of the South-East Asia Region, and identifying those that
are successful in reaching young adolescents with the information, services
and social and legal supports that they need.
2. Identifying gaps at policy and implementation levels.
Research area: Health-system

1. Developing an understanding of the capacity of the health facility at primary,
secondary and tertiary levels, with respect to delivering preconception care;
2. Setting standards for preconception care and develop guidelines for each
level of health care;
3. Conducting human-resource analysis and develop cadre-wise clear job
descriptions to avoid overlapping of responsibilities;
4. Examining the cost effectiveness of adding recommended mechanisms
of preconception care, which include risk assessment (screening), health
promotion (education and counselling), and intervention or referral in existing
programmes;

5. Assessing the benefits of delivering comprehensive preconception care and the
effectiveness or added value of “packaging” or “bundling” these interventions;
6. Examining current health-care coverage and financing for women of
childbearing age;
7. Conducting capacity-building at different levels;
8. Examining the health-seeking behaviour of target groups;
9. Conducting impact assessment of communication activities;
10. Analysising current management information systems, and issues covered; and
11. Developing clinically relevant decision tools, using quality-improvement
techniques, and monitoring performance.
Research area: Education-sector and social-sector

1. Reviewing current capacity to reach out to adolescents.
2. Reviewing other initiatives – as points of intervention for research on the
most effective way to reach different subgroups of young male and female
adolescents.
3. Reviewing available resources to implement preconception care in school
health.
4. Carrying out capacity-building.
5. Identifying the link for converging programmes and initiatives under
preconception care.
6. Reviewing available resources in other related programmes (national tobacco
control programme, noncommunicable diseases, national diabetes control
programme, HIV/AIDS, TB control programme, etc.).
These studies may require desk review, pilot studies and exploratory studies.
The process needs to be carried forward to suit individual countries according to
their context. The situation and the environment in Member States is different,
and it also differs in different population groups within countries The profile of
intervention packages chosen would depend on the epidemiological situation/
disease burden and disease profile, as well as the national policy.

Conclusions
1. The expert group identified some limitations of the term “preconception care”
for the South-East Asia Region and discussed the use of an alternative term.
“Healthy transitions for healthier families” was considered, since it addresses
the needs of a broader group of people, is less politically charged, is not limited
to improvement of reproductive health only, and enlists the participation of
males. It promises to help in attaining a healthy adult life and beyond.
2. The preconception care programme would aim to address maternal mortality,
neonatal mortality, pregnancy wastage, birth defects, preterm births and
intrauterine growth retardation, as well as to keep adolescent boys and girls
healthy, and ensure that they grow into healthy adults.
3. Accordingly, two packages “healthy transitions for adolescents” and “pre-
pregnancy care” have been agreed upon under preconception care.
4. The situation and the environment in Member States is different. The profile
of intervention packages chosen would depend on the epidemiological
situation/disease burden and disease profile, as well as the national policy.
For the baseline, there is a need to more accurately document pregnancy
wastage, birth defects, preterm births and intrauterine growth retardation
in the Region.
5. Countries need to prioritize the evidence-based interventions identified
globally, based on local needs and feasibility. Such intervention packages
need to be implemented through integration within the health system and
convergence beyond.
6. In some countries, several interventions with potential to contribute to
preconception care may be in place. These need to be rigorously documented
and published taking into account the cost-effectiveness including the
implications of not doing anything specific. Work already done or in progress
should be documented as country case studies to know where interventions
are working and to identify the gaps.
7. Well-designed demonstration/pilot projects should be implemented to make
a strong case for healthy transitions and healthier families. These pilots can
answer key questions related to policy, strategy, intervention packages,
delivery channels and evaluation.
8. The delivery channels for implementation of the intervention packages within
the health system and in other sectors and specific roles of stakeholders were
identified. This process needs to be carried forward to suit the countries

according to their context. The target population in the Member countries
is enormous. Innovative ways are needed to reach the largest proportion
through m-health and similar delivery mechanisms.
9. The inputs from adolescents, young people, families and programme
managers from the Member countries were considered crucial for designing
the preconception care programmes.
10. Influencing the national policy is critical as also the deployment of essential
resources. A strong case has to be made based on the documentation of
success and gaps.
Recommendations
ρρ consolidate the experience in the Member States and undertake a situation
analysis, elaborate on successes and lessons learnt, and publish and
disseminate the experiences to expand the efforts;
ρρ document pregnancy wastage, birth defects, preterm births and intrauterine
growth retardation and maternal risk factors;
ρρ expand and elaborate the intervention packages, delivery channels,
stakeholders, and implementation mechanisms in preconception care in the
country situation;
ρρ optimize established programmes, such as maternal, reproductive, child health
and adolescent health programmes, and existing “entry points”, such as birth
defects surveillance, prevention of adolescent pregnancy, and prevention of
noncommunicable diseases.
ρρ develop and sustain partnerships within the health sector and other key
stakeholders (multisectoral), including adolescents and young people to
provide support to preconception care programmes.
ρρ support demonstration/pilots that are rigorously implemented with cost-
effectiveness built into them, in order to make a stronger case for healthy
transitions for healthier families.
ρρ organize meetings of health programme managers, officials from health
and non-health sectors, including partners to advocate and promote
national policies, plans, and strategies for implementing preconception care
programmes.

References
1. A framework for implementing the Reproductive Health Strategy in the South-East
Asia Region. New Delhi: World Health Organization Regional Office for South-East
Asia; 2008 (http://apps.searo.who.int/PDS_DOCS/B3170.pdf, accessed 12 May 2014).
2. United Nations Population Fund. Master plans for development. ICPD – International
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Health. Geneva: The Partnership for Maternal, Newborn and Child Health; 2010
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adolescent/documents/cah_adh_flyer_2010_12_en.pdf?ua=1,
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the Children, World Health Organization. Born too soon. The global action report
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pr1540/en/, accessed 16 May 2014).

Annex 1
Health problems, risky behaviours and
risk factors that can be addressed through
preconception and related interventions
The analytical framework for the matrices was developed during the Global
Consensus Meeting on Preconception Care in Geneva, by a working group
consisting of Zulfikar Bhutto (Aga Khan University), F Donnay and K Teela (Bill
and Melinda Gates Foundation), Christopher Howson and M-E Reeve (March of
Dimes Foundation), Y Poortman and A Christianson (Preparing for Life Initiative)
and E Mason, Charlotte Christiansen and Venkatraman Chandra-Mouli (WHO
Department of Maternal, Newborn, Child and Adolescent Health).
These matrices were used as reference in the regional expert group

concultation, as the problems, risk behaviours and issues that affect adolescent,
maternal and child health are same around the world, but the magnitudes
of morbidity and mortality due to these risk factors are different in different
regions.
However, the delivery mechanisms have been developed in the context of

the WHO South East Asia Region (presented in Annex 2)
Table 1: Health problems, problem behaviours and risk factors related to tobacco
use that contribute to maternal and childhood mortality and morbidity
Health problems/risky Contribution to Contribution to childhood

behaviours/risk factors maternal mortality mortality and morbidity
and morbidity
Smoking in the Infertility, conception
preconception period delay
Smoking in the Spontaneous Preterm birth, low birth weight,
preconception period and in abortion, ectopic birth defects (including oral cleft,
pregnancy pregnancy, placenta limb-reduction defects, clubfoot,
praevia, placental defects of eyes and gastrointestinal
abruption, premature system, especially gastroschisis and
rupture of membranes abdominal hernias), sudden infant
death syndrome
Use of smokeless tobacco Stillbirth, preterm birth, low birth
in the preconception period weight
and in pregnancy
Exposure to second- Lower birth weight, birth defects
hand smoke during the
preconception period and
pregnancy

Table 2: Health problems, problem behaviours and risk factors related to
psychoactive substance use that contribute to maternal and
childhood mortality and morbidity
Health problems/risky Contribution to maternal Contribution to childhood

behaviours/risk factors mortality and morbidity mortality and morbidity
Alcohol use before Unwanted pregnancy; risk Fetal alcohol spectrum
conception of sexually transmitted disorders, ranging from
infections (STIs)/ severe neurodevelopmental
HIV; alcohol-related disorder to behavioural
health conditions (e.g. problems and mild
liver disease, injuries, intellectual disability;
depression); increased risk miscarriage; prematurity
of interpersonal, social, legal
and financial problems (e.g.
violence, domestic abuse)
Drug use before conception Unwanted pregnancy; HIV transmission from
increased risk of STIs/ mother to child; impaired
HIV; drug-related health preparedness in mother
conditions (e.g. hepatitis C, for pregnancy, delivery and
depression); increased risk childcare; child neglect
of interpersonal, social, legal
and financial problems (e.g.
violence, domestic abuse)

Table 3: Health problems, problem behaviours and risk factors related to a genetic
condition that contribute to maternal and childhood mortality and morbidity

Single-gene disorders, Depending on the disorder, Depending on the
e.g. sickle-cell disease, these may contribute to disorder, these may
thalassaemia, glucose-6- some of the following: contribute to some of the
phosphate dehydrogenase recurrent miscarriage, following: intrauterine
deficiency, bleeding pregnancy complications death, hydrops fetalis (in
disorders (particularly (e.g. pre-eclampsia, maternal alpha- thalassaemia and
haemophilia), cystic fibrosis, death), intellectual or other red-cell disorders),
Tay–Sachs disease, inborn physical disability fetal growth retardation,
errors of metabolism, preterm birth, complications
X-linked mental retardation, of delivery (e.g. early
genetic blindness or death, respiratory distress,
deafness haemorrhage, anoxia),
neonatal complications/
manifestations (e.g.
anaemia, haemolysis,
convulsions, respiratory
distress, cardiac failure)
Chromosome disorders, e.g. Recurrent miscarriage, Intrauterine death, fetal
Down syndrome, disorders preterm labour, premature growth retardation,
due to translocations rupture of membranes preterm birth,
complications of delivery,
neonatal complications/
manifestations

Table 4: Health problems, problem behaviours and risk factors related to mental
health that contribute to maternal and childhood mortality and morbidity

Perinatal depression, Complications during Preterm birth; underweight
including antenatal and pregnancy and stunting; reduced
postpartum depression breastfeeding; increased
episodes of diarrhoea;
lower compliance with
immunization schedules;
delayed psychosocial
development
Bipolar disorder Complications during
pregnancy; postpartum
bipolar event; high risk of
alcohol or substance use
during pregnancy and
postpartum period
Psychosis Postpartum psychosis
Epilepsy Perinatal complications Neurodevelopmental
impairments
Use of psychotropic drugs Birth defects
(e.g. for epilepsy or mood
disorders)

Table 5: Health problems, problem behaviours and risk factors realted to nutrition
that contribute to maternal and childhood mortality and morbidity

Folic acid and multivitamin Neural tube defects, other
insufficiency birth defects, multiple
congenital anomalies
Iron-deficiency anaemia Maternal morbidities and Child mortality, low birth
mortality weight, preterm birth, low
child cognition (intelligence
quotient)
Maternal underweight, Complications during Preterm birth, low birth
often combined with low pregnancy and delivery, weight, stillbirth, type 2
stature nutrient deficiencies diabetes and cardiovascular
(potentially resulting in disease in later life
obstetric complications)
Maternal overweight and Pre-existing type 2 diabetes, Birth defects, neural tube
obesity hypertensive disease of defects, preterm delivery,
pregnancy, gestational stillbirth, macrosomia
diabetes, hypertensive and
thromboembolic disorders,
postpartum haemorrhage
and anaemia, caesarean
delivery, induction of labour,
instrumental delivery,
shoulder dystocia
Untreated diabetes mellitus Type 2 diabetes, Birth defects, stillbirth,
(type 2 and gestational) spontaneous abortion, macrosomia with shoulder
worsening of existing dystocia/nerve palsy
microvascular complications, if delivered vaginally,
urinary tract and other hypoglycaemia after birth,
infections, preterm labour, type 2 diabetes in later life
obstetric trauma, caesarean
section, hypertension,
pre-eclampsia, gestational
diabetes mellitus, obstetric
trauma, caesarean section
Iodine Abortion, stillbirth, mental
retardation, cretinism,
increased neonatal/
infant mortality, goitre,
hypothyroidism
Calcium Maternal eclampsia, pre-
eclampsia

Table 6: Evidence-based interventions to address infertility/subfertility-related health
problems, problem behaviours and risk factors, and mechanisms of delivering them
Health problems/risky Evidence-based Existing delivery

behaviours/risk factors preventive and curative mechanisms that could
in pre-pregnancy inter- health interventions that be used to deliver
pregnancy could be delivered in interventions at scale in
pre-pregnancy/ inter- countries of the WHO
pregnancy South-East Asia Region
Consequences of Anticipatory guidance All levels of health facility
misunderstanding of from health-care providers (general or specific clinics,
contraceptives by the to create awareness e.g. family planning clinics);
woman, her family and the and understanding of community settings,
community (thus resulting fertility and infertility women’s forum, self-help
in decreased uptake of (e.g. temporary state of groups, social workers, mass
contraceptive use) subfertility/infertility during media
contraceptive use and
following discontinuation of
long-acting contraceptives)
Consequences of Anticipatory guidance from All levels of health facility
misunderstanding biological health-care providers to (general or specific clinics,
causes of infertility/ improve understanding e.g. family planning clinics);
subfertility (e.g. mental of preventable and community settings,
health disorders, depression, unpreventable causes women’s forum, self-help
broader chronic diseases) of infertility/subfertility; groups, social workers,
guidance on actions that mass media, counselling
individuals and couples on menstrual cycle and
could take to check fertility cycle, counselling to
for additional causes reduce stress and anxiety,
of infertility/subfertility suggestion for adoption,
(improving nutrition, information, education and
improving mental health, communication about risk
immunization, avoiding factors (both female and
alcohol abuse); expanding male) and referral services
beyond misunderstanding Strengthening of
that prevention will solve programmes on
most underlying diseases/ reproductive tract infection
disabilities and infertility; (RTI), sexually transmitted
counselling for individuals/ infection (STI), tuberculosis,
couples diagnosed with tobacco control and
unpreventable causes of maternal health; duration of
infertility/subfertility investigations increased to
two years
Evidence shows that there
is a 15–20% chance of
conception in the second
year; this increases to 85%
at the end of two years
(Social factors – early
marriage and societal
pressure. This is for the
younger age group, below
35 years)

Health problems/risky Evidence-based Existing delivery
behaviours/risk factors preventive and curative mechanisms that could
in pre-pregnancy inter- health interventions that be used to deliver
pregnancy could be delivered in interventions at scale in
pre-pregnancy/ inter- countries of the WHO
pregnancy South-East Asia Region
Consequences of Screening and diagnosis All levels of health facility
unprotected sexual of couples following 6–12 (general or specific clinics,
intercourse to achieve months and following 12 e.g. family planning clinics);
pregnancy, especially in months of attempting community settings,
populations at high risk of pregnancy, using an including target group and
HIV/sexually transmitted algorithm involving minimal gatekeepers, women’s
infection (STI) intervention at the primary forum, self-help groups,
level; screening, diagnosis social workers, mass
and management at the media, CSR public–private
tertiary level; diagnosis and partnership, professional
management of underlying associations and bodies
causes of infertility/
subfertility, including past
reproductive tract infection/
STI; need for specific
guidance directed towards
populations at high risk
Consequences of Defusing stigmatization of Community settings,
misunderstanding social infertility and assumption including target group and
causes of infertility/ of fate by introducing gatekeepers; mass media,
subfertility evidence- based educational women’s forum, self-help
tools to understand the groups, social workers, mass
causes of and care solutions media
for infertility; expanding
beyond misunderstanding
that prevention will solve
most underlying diseases/
disabilities and infertility;
introducing tools for
national-level discussions
to address ethics and
legal/social implications
of introducing infertility
diagnosis/care; advocacy
targeting communities,
civil society, governments,
policy-makers and funding
agencies

Table 7: Health problems, problem behaviours and risk factors related to too-early,
unintended and rapidly successive pregnancy that contribute to maternal and

Too-early pregnancy Complications in pregnancy, Perinatal death, low birth
death weight, preterm birth
Unintended pregnancy Morbidity related to Less attention to care of
complications of unsafe self and unborn child during
abortion (may lead to pregnancy, with adverse
death), psychosocial effects on infant and child
consequences health
Short birth intervals (<24 Complications during Prematurity, fetal death, low
months) pregnancy (e.g. preterm birth weight, small size for
labour), increased likelihood gestational age (associated
of depression with birth intervals of <6–18
months), increased risk of
neonatal and postneonatal
(one month to one year)
death
Table 8: Health problems, problem behaviours and risk factors related

to vaccine-preventable disease that contribute to maternal and

Rubella Spontaneous or therapeutic Stillbirth, congenital rubella
abortion syndrome
Tetanus Maternal infection, death Neonatal infection, death
Hepatitis B Chronic liver disease, Neonatal hepatitis B
premature death infection

Table 9: Health problems, problem behaviours and risk factors related to HIV that
contribute to maternal and childhood mortality and morbidity
Health problems/risky Contribution to Contribution to childhood

behaviours/risk factors maternal mortality mortality and morbidity
and morbidity
HIV infection in Untreated HIV Untreated HIV infection progresses
adolescents, women and infection can to HIV-related illnesses and death
their sexual partners/ contribute to in the mother, which leads to
spouses increased maternal orphanhood (major risk factor
mortality and for poor child health and social
morbidity (related outcome); untreated HIV infection
to childbirth) and in the mother leads to a high risk
progresses to HIV- (up to 35%) of transmission of HIV
related premature from the mother to the neonate,
illnesses and death resulting in chronic and fatal illness
in the child

to sexually transmitted infection that contribute to maternal and

Gonorrhoea Preterm delivery, chronic Preterm delivery, neonatal
pelvic pain, pelvic conjunctivitis, low birth
inflammatory disease (not weight
specific to pregnancy and
childbearing), infertility,
ectopic pregnancy,
spontaneous abortion,
postpartum endometritis,
prelabour rupture of
membranes (specific to
pregnancy and childbearing)
Chlamydia Pelvic inflammatory disease, Preterm delivery, low
chronic pelvic pain (not birth weight, neonatal
specific to pregnancy and conjunctivitis, pneumonia,
childbearing), infertility, otitis
ectopic pregnancy
Syphilis Neurological, cardiovascular Preterm delivery, congenital
and other systemic infection abnormalities,
complications resulting stillbirth, low birth weight,
from tertiary syphilis (not enhanced mother-to-child
specific to pregnancy and transmission of HIV in
childbearing), spontaneous mothers living with both HIV
abortion, fetal loss, and syphilis
postpartum endometritis,
prelabour rupture of
membranes (specific to
Genital herpes Aseptic meningitis, Preterm delivery, neonatal
transverse myelitis (not herpes, encephalitis,
specific to pregnancy and dissemination of infection,
childbearing), dissemination skin/eye/mouth infection,
of infection (especially third enhanced mother-to-child
trimester), spontaneous transmission of HIV
abortion (specific to
Hepatitis B Chronic hepatitis, cirrhosis, Perinatal hepatitis B
liver cancer (not specific to
Trichomonas Chronic inflammation Preterm delivery, low birth
of mucosa, leading to weight
enhanced risk of HIV
transmission to women

to interpersonal violence that contribute to maternal and

Consequences of intimate Unintended pregnancy, Increased childhood mortality;
partner violence and sexual gynaecological problems, behavioural and emotional
violence abortion, sexually disturbances (may be
transmitted infections/HIV, associated with perpetration
depression, post-traumatic or experience of violence
stress disorder, emotional later in life); morbidity
distress, suicide attempts, (e.g. diarrhoeal disease,
sleep difficulties, eating malnutrition)
disorders
Consequences of intimate Miscarriage Low birth weight, stillbirth,
partner violence and sexual preterm delivery
violence during pregnancy
to environmental factors that contribute to maternal and

Ionizing radiation First-trimester miscarriage Fetal growth restriction,
impaired brain function,
microcephaly, childhood
cancers
Pesticides Early spontaneous abortion Childhood cancers
Lead or mercury pollution Miscarriage, early Central nervous system
spontaneous abortion, damage, fetal growth
stillbirth, anaemia restriction, preterm births
Indoor air pollution Stillbirth, chronic Pneumonia, fetal growth
obstructive pulmonary restriction
disease, lung cancer (from
coal use)

Annex 2
Defining packages of pre-conception care
Table 1: Tobacco use: prevention and control
Intervention area Target group Health-sector Hospitals and Outreach Community and Other sectors
policy health facilities families as partners
Preventing initia- Children, adoles- Ban on advertising, Health-education Community-based Media, schools,
tion of tobacco use cents and young high taxation, age messages during organizations workplace and
Regional Expert Group Consultation on Preconception Care

(including passive people below which it is outreach law enforce-
smoking) through not allowed ment
68
communication
Screening for to- Yes Yes Schools and
bacco use workplace
Cessation interven- Addicts Yes (de-addiction

tion centres)
Table 2: Alcohol use: prevention and control
Preventing initia- Children, adoles- Ban on advertising, Health-education Community-based Media, schools,
tion of alcohol use cents and young high taxation, age messages during organizations workplace and
through communi- people below which it is outreach law enforce-
cation not allowed, statu- ment
tory warning
Screening for alco- Yes Yes Schools and
hol use workplace
Cessation interven- Yes (de-addiction Community-

tion centres) based organi-
69
zations, e.g.
Alcoholics
Anonymous

Table 3: Drug use: prevention and control
Intervention area Target group Health-sector Hospitals and Outreach Community and Other sectors as
policy health facilities families partners
Preventing initiation Children, adoles- Over-the-counter Health-educa- Media, schools,

of drug use (includ- cents and young sale of some drugs tion mes- workplace, law
ing injecting drug people that are abused; sages during enforcement
use, and abuse of link to HIV pro- outreach (narcotic bureau)
drugs like sleeping grammes (espe-
pills etc.) through cially for injecting
communication drug users)

Screening for drug Integrated counsel- Yes Yes Schools and
use ling and testing workplace
70
centres, reproduc-
tive tract infection/
sexually trans-
mitted infection
centres
Cessation interven- Yes (de-addiction Community-

tion centres for based organiza-
rehabilitation tions, e.g. Narcot-
and counselling, ics Anonymous
including occupa-
tional rehabilita-
tion)
Table 4: Genetic disorders: prevention and control
Promotion – con- Community and Laws for pre- Awareness Raise awareness Media, schools,
sanguinity, age at family venting consan- raising on consanguinity workplace, law
pregnancy guinity and promote timely enforcement
childbearing
Prevention – folic acid Adolescents, Policy guideline Yes, especially Distribution Schools and
newly-wed for folic acid adolescent clin- workplace
couples, and distribution ics, family plan-
inter-pregnancy ning clinics
Screening – for high Adolescents, Mandatory History-taking Identificatibased Raise aware-

risk and presence of newly-wed screening (family history, on history of ness by media
71
genetic disorders couples, and past history), high risk and and through
inter-pregnancy laboratory tests referral education
for prevalent sector and
disorders, e.g. workplace
thalassaemia
and prenatal
testing for spe-
cific disorders
Management Those diagnosed Management Specific man- Care and sup- Care and support
with genetic guidelines agement and port, community
disorders counselling rehabilitation

Table 5: Mental health promotion and management of illnesses
Intervention area Target group Policy and law Hospitals and Outreach Community and Other sectors
health facilities families as partners
Promotion of men- Adolescents, young Promotion of Promotional efforts Counselling in

tal health people and families mental health a on locally prevalent schools, work-
a right; reduce practices, such as places, promo-
pressures relating yoga meditation tion by media to
to education and advocate
work

Screening for Same as above Policy guidelines Use screen- Application of Promote self-as- Media, schools
diagnosis of mental on mental health ing tools for simple screening sessment by use of and workplaces,
health problems and early diagnosis tools simple criteria to enhance
72
referral of depression, awareness of
stress and anger, common symp-
suicidal ten- toms
dency, psychiatric
disorders
Prevention Target group af- Standard guide- Psychiatric Community- Family-based sup- Prevent stigmati-
fected by mental lines, service-de- treatment and based rehabilita- port and care zation of those
health problems livery system to counselling tion and support affected
support mental
health
Management High-risk individu- Management Provision of ser- Community- Community-based
als or those who guidelines vices in tertiary based care and care and support
are diagnosed care hospitals support
with mental health
disorder
Annex 3
Defining delivery channels for the identified
packages of pre-conception care
Table 1: Nutrition
Preventive and curative interventions Delivery channel

Information; education on health and nutrition (counselling School health/community,
about risks to own health and future pregnancies); nutrition peer groups, youth and
counselling (lower/higher caloric intake, increase physical women’s forum, self-help
activity); iron and folic acid supplementation (e.g. food for- groups, social workers,
tification, administration of tablets, use of micronutrient pow- mass media, all levels of
ders containing folic acid); information; education continued health facility
breastfeeding); community-based prevention programmes
(e.g. increasing opportunities for physical exercise and eating
healthy foods
Salt iodization; nutritional monitoring; provision of energy-

and nutrient-dense supplementary foods; continued breast-
feeding; community-based prevention
National-level screening among populations at high risk;

blood glucose monitoring (screening for pre-existing type 2
diabetes and every 1–3 years after gestational diabetes)
Treatment of anaemia; management of diabetes (glycaemic Primary, secondary and
control before, during and after pregnancy) tertiary health facilities
It is important to use extensive information, education and communication

interventions to create awareness on junk food, balanced diet using naturally
sources of food, the importance of calcium and and vitamin B12, and promoting
kitchen gardens. There was a special mention of serving palatable supplementary
food, preferably as per local taste, to ensure sustainability of supplementation
programmes. A ban on junk food in school canteens was also suggested.

Table 2: Infertility

Anticipatory guidance from health-care providers to create Community, peer groups,
awareness and understanding of fertility and infertility (e.g. women’s forum, self-help
temporary state of subfertility/infertility during contraceptive groups, social workers,
use and following discontinuation of long-acting contracep- mass media, all levels of
tives) and preventable and unpreventable causes of infertili- health facility
ty/subfertility
Counselling on menstrual cycle and fertility cycle; informa-

tion, education and counselling on risk factors (both female
and male) and referral services
Advocacy targeting communities, civil society, governments,

policy-makers and funding agencies
Guidance on actions that individuals and couples could Community-level workers
take to address preventable causes of infertility/subfertility and volunteers, school-
(improving nutrition, improving mental health, immunization, based counselling, mass
avoiding alcohol abuse); expand beyond misunderstanding media, primary and sec-
that prevention will solve most underlying diseases/disabil- ondary health facilities
ities and infertility; counselling for individuals/couples diag-
nosed with unpreventable causes of infertility/subfertility
Screening and diagnosis of couples following 6–12 months

and following 12 months of attempting pregnancy, using an
algorithm involving minimal intervention at the primary level;
and screening diagnosis and management at the tertiary
level; diagnosis and management of underlying causes of
infertility/subfertility, including past reproductive tract infec-
tion/sexually transmitted infection; need for specific guidance
directed towards populations at high risk
Management of infertility/subfertility Primary, secondary and ter-
tiary level of health facility
It was suggested to initiate investigations only after two years, as evidence

shows that 15–20% of couples have a chance of conception in the second
year and 85% at the end of two years, for the younger age group below
35 years. Counselling must be part of the health facility visit, to reduce stress
and anxiety of the couple/partners.

Table 3: Unwanted/too-early/too-frequent pregnancy

Keeping girls in school; influencing cultural norms that sup- School health/community,
port early marriage, through community mobilization, visible, peer groups, youth and
high-level support for pregnancy-prevention programmes; women’s forum, self-help
educating girls and boys about sexuality; building community groups, social workers,
support for preventing early pregnancy mass media, all levels of
health facility
Educating adolescents about sexuality, sexual and repro-
ductive health and contraceptive use; building community
support for contraceptive provision to adolescents; enabling
adolescents to obtain contraceptive services
Empowering girls to resist coerced sexual intercourse; chang-

ing social norms that condone coerced sexual intercourse;
engaging men and boys to critically assess norms and prac-
tices regarding gender-based violence and coerced sexual
intercourse; educating women and couples about dangers
to the baby and mother of short birth intervals; provision of
contraception
Safe abortion services All levels of health facility
Intensive information, education and communication campaigns on the

use of contraceptives and emergency contraceptives, particularly in the case
of coerced sexual intercourse and sexual assault, and about the dangers of
unsafe abortion were suggested. The importance of raising awareness and
counselling on the benefits of health timing and spacing of pregnancy for
the mother, neonate, child and the family as a whole was also emphasized.

Table 4: Immunization

Rubella-containing vaccine (monovalent rubella [R] or mea- National immunization
sles–rubella [MR] or measles–mumps–rubella [MMR]) for programme
women who have not been vaccinated previously
Tetanus- and diphtheria-containing (Td) vaccine for women National immunization
who were not fully immunized in childhood or previous programme
pregnancies
Hepatitis B vaccination National immunization
programme
Table 5: HIV/AIDS

Access to condoms (emphasis on dual protection) Facility setting, social mar-
keting, demand creation
Information and education (age-specific services) School setting, social me-
dia, health facility
Voluntary counselling and testing centres Health facility
Screening and treatment for sexually transmitted infection Links with other health-
and any other risks care services in public and
private settings
Emergency contraception (post-exposure prophylaxis) Social marketing, health
facility
Injecting drug users, men who have sex with men, sex work- Strengthening targeted
ers, unmarried adolescents intervention
Preventing unwanted pregnancy in HIV-positive women Strengthening programmes
for the prevention of
parent-to-child transmission
of HIV

Table 6: Reproductive tract infection/sexually transmitted infection

Education for promotion of safer sex School programme, youth
Increase awareness – multiple opportunities club, health facility, social
campaign
Education materials for
literate people, street plays
Infection-prevention measures Health facility
Education and testing during antenatal care, obstetrics and Health facility
gynaecology services, family planning services, management
Screening and management Health facility
Sex workers, men who have sex with men Targeted programmes
Table 7: Prevention of violence

Awareness and education School programme (includ-
ing in the curriculum),
Empowerment (life-skills education) youth club in community,
social media, public cam-
Peer group support paign, health facility
Provision of health care Multiple sectors like educa-
tion, legal, health, police;
Reframe sex-selective abortion as gender-based violence
requires policy, guidelines
Making post-exposure prophylaxis (emergency contraception) and interlinkages
available to victims of sexual violence
One-stop crisis centre
Table 8: Environmental health

Awareness Multisectoral approach like
agriculture, legal, trade,
Public education health, corporate social
responsibility
Policy and guidelines
Community outreach
Collecting evidence
School curriculum
Micro-financing and subsidy

Annex 4
Agenda
Preconception care: global perspective

ρρ Preconception care: rationale and definition
ρρ Evidence for preconception care
ρρ Preconception care: experience from developed countries
Preconception care: regional perspective

ρρ “Healthy transitions for adolescents” package: rationale and objectives
for preconception care for young people aged 10–19 years
ρρ Preconception care in the WHO South-East Asia Region: pre- and inter-
pregnancy care
ρρ Preconception care interventions: existing situations in countries of the
WHO South-East Asia Region
ρρ Adolescent health programme in the WHO South-East Asia Region:
broadening the service package towards “healthy transitions for
adolescents”
ρρ Preconception care case-studies from the WHO South-East Asia Region
Delivery of preconception care interventions in the WHO South-East Asia

Region: opportunities and challenges
ρρ Interventions for primary care in the WHO South-East Asia Region
ρρ Benefits and risks of preconception care
ρρ Defining packages of preconception care in the WHO South-East Asia
Region
Delivery of preconception care interventions in the WHO South-East Asia

Region: opportunities and challenges
ρρ Identifying delivery mechanisms for preconception care in the WHO
South-East Asia Region
Setting a regional agenda for preconception care

ρρ Regional agenda for action
ρρ Regional agenda for research
ρρ Consensus statement

Annex 5
List of participants
International and regional experts 7. Dr G V S Murthy
Director
1. Dr Coleen A. Boyle Indian Institute of Public Health
Director Hyderabad, India
National Center on Birth Defects and
Developmental Disabilities 8. Dr K Srinath Reddy
Centers for Disease Control and President
Prevention Public Health Foundation of India
Atlanta, USA New Delhi
2. Dr Christopher P. Howson 9. Dr Monika Arora

Vice President for Global Programme Adjunct Professor
The March of Dimes Foundation Public Health Foundation of India
New York, USA New Delhi
3. Dr. Quamrun Nahar 10. Dr Vinod K Paul

Project Coordinator Head, Department of Pediatrics
Centre for Population, Urbanization and WHO Collaborating Centre for Training
Climate Change and Research in Newborn Health
International Centre for Diarrhoeal All India Institute of Medical Sciences
Disease Research New Delhi
Dhaka , Bangladesh
11. Dr Madhulika Kabra
4. Dr Sanjay Chauhan Professor, Division of Genetics
Scientist WHO Collaborating Centre for Training
Department of Operational Research in Clinical & Laboratory Genetics in
National Institute for Research in Developing Countries, Department of
Reproductive Health Paediatrics
Mumbai, India All India Institute of Medical Sciences
New Delhi
5. Dr Beena Joshi
Assistant Director (Scientist D) 12. Dr Neerja Gupta
Department of Operational Research Scientist, Division of Genetics
National Institute for Research in Department of Paediatrics
Reproductive Health All India Institute of Medical Sciences
Mumbai, India New Delhi
6. Mrs Aruna Vijay 13. Dr Dipika Deka

Consultant Professor
Department of Operational Research Dept. of Obstetrics & Gynaecology
National Institute for Research in All India Institute of Medical Sciences
Reproductive Health New Delhi
Mumbai, India

14. Prof Nutan Agarwal 21. Dr Lakhbir Dhaliwal
Dept of Obstetrics & Gynaecology Prof & Head, Dept. of Obst. &
All India Institute of Medical Sciences Gynaecology
New Delhi WHO Collaborating Centre for Human
Reproduction at the Department of
15. Dr Anu Thukral Obstetrics and Gynaecology Partners
Senior Research Associate Post Graduate Institute of Medical
Department of Paediatrics Education and Research (PGIMER)
All India Institute of Medical Sciences Chandigarh
New Delhi
22. Dr Sunil Mehra
16. Dr Pratima Mittal Executive Director
Senior Consultant MAMTA Institute of Mother and Child
Dept. of Obstetrics & Gynaecology Health
Safdarjung Hospital New Delhi
New Delhi
Partners
17. Dr Vijay Kumar
Executive Director (Hony) 1. Prof. Ashma Rana
SWACH Foundation President Elect
Panchkula, Haryana South Asian Federation of Obstetrics
and Gynaecology (SAFOG)
18. Dr Nethanjalie Mapitigama Kathmandu, Nepal
Consultant Community Physician
(CCP) on Gender and WH 2. Dr Swati Bhave
Family Health Bureau Representative
Ministry of Health International Paediatrics Association and
Colombo, Sri Lanka International Association of Adolescent
Health
19. Dr Bunyarit Sukrat New Delhi
Deputy Director
Bureau of Reproductive Health 3. Dr Debasish Dutta
Department of Health ??????????
Ministry of Public Health c/o UNICEF EAPRO
Thailand Bangkok, Thailand
20. Assistant Prof. Kanokwan Tharawan 4. Ms Sita Shankar Wunnava

WHO Collaborating Centre for Research Director
in Human Reproduction Maternal and Child Health/Nutrition
Institute for Population and Social PATH India Office
Research (IPSR) New Delhi
Mahidol University
Thailand 5. Dr Bitra George
Country Director
FHI 360
New Delhi

6. Dr Andres de Francisco WHO/HQ
Deputy Executive Director
Partnership for Maternal Newborn and 15. Dr Venkatraman CHANDRA-MOULI
Child Health (PMNCH) Scientist
The Secretariat hosted by WHO Office Department of Reproductive Health and
Geneva , Switzerland Research
WHO/HQ, Geneva
7. Dr Jameel Zamir
Programme Officer - Access 16. Dr Valentina Baltag
IPPF House Technical Officer
New Delhi Department of Maternal, Newborn,
Child and Adolescent Health
8. Mr Manish Mitra WHO/HQ
Programme Officer Geneva
Young People and Adolescents
IPPF House, New Delhi 17. Dr Charlotte Sigurdson Christiansen
Department of Maternal, Newborn,
9. Dr Sanjay Sinho Child and Adolescent Health
Deputy Director WHO/HQ
Global Policy and Advocacy and Geneva
Government Liaison
Bill & Melinda Gates Foundation (BMGF) WHO/SEARO
New Delhi
1. Dr Sangay Thinley
10. Dr Bulbul Sood Director
Country Director Department of Family Health and
JHPIEGO—an affiliate of Johns Hopkins Research
University
2. Dr Pem Nangyal
11. Dr Rashmi Asif Vaccines Preventable Diseases
Clinical Services and Training JHPIEGO— Department of Family Health and
an affiliate of Johns Hopkins University Research
New Delhi
3. Dr Neena Raina
12. Dr Saswati Das Regional Adviser
Senior Advisor: Clinical Services and Child and Adolescent Health
Training JHPIEGO—an affiliate of Johns Department of Family Health and
Hopkins University Research
New Delhi
4. Dr Rajesh Mehta
13. Dr S. Vijay Paulraj Medical Officer
Project Management Specialist Child and Adolescent Health
USAID Office of Health American Department of Family Health and
Embassy Research
New Delhi
5. Dr Arvind Mathur
14. Dr Anchita Patil Medical Officer
NPO-RCH & HIV/AIDS Making Pregnancy Safer
UNFPA, INDIA Department of Family Health and
Research

6. Dr Martin Weber 11. Dr Chamaiparn Santikarn
Regional Adviser Regional Adviser
Maternal and Reproductive Health Disability, Injury Prevention and
Department of Family Health and Rehabilitation
Research Department of Sustainable Development
and Healthy Environments
7. Dr Patanjali Dev Nayar
Programme Management Officer 12. Dr Alfrida Silitonga
Programme, Planning & Coordination Junior Public Health Professional
and Governing bodies Child and Adolescent Health
Department of Family Health and
8. Dr Kunal Bagchi Research
Regional Adviser
Nutrition and Food Safety WHO Country Offices
Department of Family Health and
Research 1. Dr Tini Setiawan
National Professional Officer-
9. Dr Prakin Suchaxaya Adolescent Health
Coordinator – Gender, Equity and WHO Representative’s Office in
Human Rights Indonesia
Department of Health Systems and Jakarta, Indonesia
Development
2. Dr Kiran Sharma
10. Dr Renu Garg National Professional Officer-
Regional Adviser Adolescent Health
Noncommunicable Diseases WHO Representative’s Office in India
Department of Sustainable Development New Delhi
and Healthy Environments

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2. Meeting objectives and participants 4

4. Conclusions and recommendations 52

1. Health problems, risky behaviours and risk factors

2. Summary of Group work 2: Defining packages

3. Summary of Group work-3: Defining delivery

5. List of participants – international and regional experts 80

iii Regional Expert Group Consultation on Preconception Care

v Regional Expert Group Consultation on Preconception Care

There is widespread agreement that, to reduce maternal and childhood

1 Regional Expert Group Consultation on Preconception Care

After the global consensus meeting on preconception care in Geneva

Effective preconception care programmes can only be accomplished by

Regional Expert Group Consultation on Preconception Care 2

2 Meeting objectives and

Regional Expert Group Consultation on Preconception Care 4

5 Regional Expert Group Consultation on Preconception Care

Regional Expert Group Consultation on Preconception Care 6

Dr Venkatraman Chandra-Mouli, Scientist, Reproductive Health and

Dr Debashish Dutta, UNICEF East Asia and Pacific Region, Bangkok,

7 Regional Expert Group Consultation on Preconception Care

Dr Andres de Francisco, Deputy Executive Director, PMNCH, Geneva,

Dr Coleen A Boyle, Director, National Center on Birth Defects and

Dr Christopher Howson, Vice President for Global Programmes, March of

Regional Expert Group Consultation on Preconception Care 8

Dr Rajesh Mehta, Medical Officer, Child and Adolescent Health, WHO

Preconception care: Global perspective

Preconception care: rationale and definition

There is a growing recognition that adolescent pregnancies and poorly spaced

The WHO Department of Maternal, Child and Adolescent Health (MCA)

Despite the interventions in place, progress in maternal and child health

9 Regional Expert Group Consultation on Preconception Care

Figure 1: Life-course continuum: Priority interventions for mothers,

Postpartum Maternal health

The adverse effects of childbearing in adolescents (especially with risk factors)

Preconception care was defined as the provision of biomedical, behavioural

Regional Expert Group Consultation on Preconception Care 10

Preconception care brings attention to the missing component in the existing

During adolescence Postpartum Maternal health

Overall, preconception care has a positive impact on a range of outcomes,

11 Regional Expert Group Consultation on Preconception Care

Evidence for preconception care

Participants were informed that exhaustive reviews of the evidence of

Regional Expert Group Consultation on Preconception Care 12

The WHO global meeting also provided perspectives on alternative definitions

There is a growing experience in implementing preconception care initiatives

13 Regional Expert Group Consultation on Preconception Care

Preconception care: experience from developed countries

The importance of pre-conception care; evidence-based interventions; the

Regional Expert Group Consultation on Preconception Care 14

Figure 4. Critical periods of development

Weeks of gestation from last menstrual period

Missed menstruation Mean entry into

An issue of CDC’s “Morbidity and Mortality Weekly Report” in 2006 (7)

The presenter further shared evidence, reviews and 14 recommendations

15 Regional Expert Group Consultation on Preconception Care

In 2013, CDC released an action plan after this initiative, to describe a

Regional Expert Group Consultation on Preconception Care 16

The priority risk factors/maternal conditions are recommended for screening

Regarding the challenges of preconception care in the USA, approximately

The programme goals in targeted communities are to:

17 Regional Expert Group Consultation on Preconception Care

Preconception care: experience from developing countries