Preconception Report 04.17.07.indd - Alberta Perinatal Health ...

Preconception Health
Framework
April, 2007

Expert Consulting Group
• Dr. Nestor Demianczuk, Division of Maternal Fetal Medicine, Royal Alexandra
Hospital, Capital Health
• Margaret Wanke, Evaluation, Charis Management Consultants
• Ms. Penny Lightfoot, Director, Population Health and Research, Capital Health
• Dr. Martin Lavoie, Medical Officer of Health, David Thompson Health Region
• Dr. Suzanne Tough, Associate Professor, Department of Community Health
Sciences & Pediatrics, University of Calgary
• Dr. Jeanne Besner, Director, Health Systems & Workforce Research Unit,
Calgary Health Region
• Dr. Beverley O’Brien, Professor, Faculty of Nursing, University of Alberta
Submitted by Karen McGeary, RN, MN
on behalf of the Alberta Perinatal Health Program

Executive Summary
Despite advances in medical science, universal access to health services and high
quality prenatal care, rates of adverse perinatal outcomes persist and some problems are
increasing. Alberta’s Low Birth Weight rate among all births remains higher (6.4% in
2006) than the national average (5.9% in 2004) and has been increasing slightly since
2001, when the rate was reported as 6.1%. Although not statistically significant, the
increasing rate is of concern (Reproductive Health Report Working Group, 2006).
Atrash, Johnson, Adams, Codero and House (2006) argue that one of the reasons that
progress in improving pregnancy outcomes has reached a plateau is that we have failed to
intervene before pregnancy to inform, screen, manage and modify preconception health
conditions and risk factors that contribute to adverse maternal and infant outcomes.
In 2004, the Alberta Perinatal Health Program (APHP) identified the need to expand
their scope to include preconception health promotion and prevention as a means of
improving maternal and child health. From April 2006 to March 2007 a preconception
action plan evolved through a process of expert consultations. The action plan was
intended to focus on upstream strategies to support individuals to be in optimal health as
they approach each pregnancy and also to focus more broadly on changing structure with
a view to positively impact reproductive health outcomes.
In addition to reviewing the literature and consulting provincially, four focus groups were
conducted with healthcare providers and consumers to contribute to the development
of the action plan. Through this process an action framework was developed and three
key strategies were identified to improve preconception health both at the individual and
environmental levels.
In the first key strategy, Promote Public Awareness and Knowledge, four activities are
suggested to increase the target populations’ awareness and understanding about health
promoting practices and preconception risk factors:
• Develop a provincial preconception health communication campaign using a
multilevel approach;
• Align public awareness efforts;
• Target education to youth in school and women and men in workplaces; and
• Enable self-help.
i

In the second key strategy, Build Capacity to Provide Preconception Health Services,
six activities are suggested to develop appropriate screening, education, management and
support for those planning a family, those likely to have a family later on in life, as well as
for those who could get pregnant:
• Develop resources for health professionals/paraprofessionals;
• Develop continuing education and post secondary modules and curriculum to increase
knowledge, skills and practices in preconception primary prevention;
• Expand the use of alternate care providers for preconception risk screening and
counselling thereby increasing access to preconception health services;
• Integrate preconception into existing programs and services;
• Identify the need to develop/consolidate practice guidelines for preconception care as
they relate to secondary prevention; and
• Re-examine the structure and content of prenatal care for those women with
preconception/interconception risk factors.
In the third strategy, Champion Preconception Health Supporting Environments,
four activities are suggested to help future families raise healthy children:
• Develop a preconception health position statement;
• Collaborate across sectors to increase understanding of the issues and to lever action
to address policies that make the decision to have a family an easier one, i.e. postsecondary
student finance, work-life balance, maternity and parental leave and
benefits, and child care benefits;
• Work with other provincial initiatives that can have an impact on preconception
health; and
• Foster learning and innovation to advance knowledge of effective strategies and
methods to improve preconception health and the delivery of preconception care.
Recommended next steps for the APHP include efforts to increase awareness among
the public; building resources that can be integrated into current health programs
and services; developing and measuring preconception indicators; working with other
provincial initiatives that will impact preconception health; and supporting research to
advance knowledge of effective preconception health and healthcare strategies.
ii

Contents
Executive Summary ......................................................................................i
Setting the Context ..................................................................................... 1
The Background ........................................................................................... 3
Responding to the Background:
A Preconception Framework for Action ..................................................... 9
Possible Levels of Action ...........................................................................11
Individual Factors Influencing Preconception Health ............................12
Environmental Factors Influencing Preconception Health ....................18
Principles ....................................................................................................22
Key Settings ...............................................................................................23
Key Strategies ............................................................................................24
1. Promote Public Awareness and Knowledge ................................. 24
2. Build Capacity to Provide Preconception Health Services ........... 28
3. Champion Preconception Health Supporting Environments ...... 33
Summary and Recommendations ............................................................36
Appendix A
Alberta Perinatal Health Advisory Committee Membership List ...... 38
Appendix B
Focus Group Methodology ............................................................... 40
Appendix C
Focus Group Question Guides .......................................................... 43
Appendix D
Partnership Accord Membership List ............................................... 46
Appendix E
Preconception Risk Factors: Evidence Based Interventions .............. 48
Appendix F
A Framework for Action ................................................................... 50
Appendix G
Examples of Initiatives ...................................................................... 51
References ..................................................................................................55
iii

Preconception Health Framework
Setting the Context
Methodology
The Alberta Perinatal Health Program (APHP) was established to promote maternal
health, positive birth outcomes and healthy infancy by providing leadership and
support to health regions, health professionals, Alberta Health and Wellness, and other
stakeholders in Alberta. As the provincial rates of low birth weight and preterm birth are
higher than national rates, the need for a coordinated perinatal program to address health
status indicators was identified as a priority. In 2004, the APHP also identified the need
to expand beyond the current scope to include the realm of preconception inclusive of a
population health approach (McDermot Consulting). This approach would recognize the
multiple health and social factors that have a significant influence on women’s and men’s
reproductive health prior to pregnancy.
In 2005, the APHP submitted a funding proposal to develop a preconception action plan
which would include strategies focused on individuals and those focused more broadly on
changing structure with a view to positively impact reproductive health outcomes.
The development of the preconception action plan evolved from a process of expert
consultations. The expert consultants, represented perspectives from midwifery and
post secondary education, public health, population health, research and evaluation,
epidemology and perinatology. In the initial phase in April 2006, advice was provided
on the critical components of a preconception health framework, resulting in a draft
discussion paper in May 2006.
In the second phase of planning during the months of May and June 2006, the
framework was refined and validated. This phase resulted in a draft action plan in August
2006, which was then circulated to several of the expert consultants. The feedback
provided was then incorporated into a revised draft action plan (September 2006). The
September action plan was presented for input to the Alberta Perinatal Health Advisory
Committee on September 12, 2006. Members of the Advisory Committee are listed in
Appendix A.
In phase three (October 2006), under the direction of the APHP Coordinating
Committee; Quality Safety and Health Imformation of Calgary Health Region were
contracted to plan and conduct focus groups with healthcare providers and consumers
to provide thematic results which would contribute to the development of the
action plan. Specifically, the purpose of the qualitative inquiry with the healthcare
providers was designed to:
1. Gain an understanding of the knowledge and resources needed by professionals to
enhance their capacity to provide preconception care;
1

2. Determine ways in which providers would like to obtain information about
preconception care;
3. Document current preconception care services/strategies;
4. Discuss the applicability of the Centers for Disease Control and Prevention
Recommendations to Improve Preconception Health and Health Care in the
United States (2006);
5. Explore suggested strategies for providing preconception information to varying
target audiences;
6. Explore strategies for incorporating preconception health information into
existing services;
7. Identify gaps in current services and resources; and
8. Identify supports and enablers for an integrated provincial preconception action plan.
Consumer-based focus groups were designed to:
1. Gain an understanding of current knowledge about preconception health behaviours;
2. Determine barriers for women and men to participate in preconception health
practices/behaviours;
3. Identify how women and men would like to receive preconception health
information and from whom;
4. Explore where preconception information should be made available; and
5. Explore how preconception healthcare can be incorporated into existing services.
Four focus groups were conducted in November 2006; two groups of Primary Care
providers and two consumer groups. Refer to Appendix B for a discussion of the focus
group methodology and Appendix C for the question guides used in the focus groups.
Following the focus group findings in January 2007, the recommended activities in the
action plan were expanded resulting in a revised draft of the preconception action plan.
The draft plan was then circulated in February 2007, to the expert consultant group,
Alberta Health and Wellness, the Coordinating Committee, Program Leads, APHP and
the Partnership Accord committee to provide input into the action plan. The Partnership
Accord provides the structure for all health regions in Alberta to provide input into
decisions, business planning and implementation of strategies for the APHP. Members
of the Partnership Accord are listed in Appendix D.
2

The Background
In the final phase (March 2007), feedback received from the reviewers was incorporated
into the final draft of the action plan and presented to the Alberta Perinatal Health
Advisory Committee for approval on March 13, 2007, prior to submission of the final
document to Alberta Health and Wellness on March 30, 2007.
Adverse birth outcomes are a concern in Alberta. Maternal and child health outcomes,
such as neonatal mortality, low birth weight, and preterm births are often used as
indicators of the overall health status in a population. In Alberta, the incidence of low
birth weight (LBW) (

Low birth weight that results from suboptimal intrauterine growth (SGA) is associated
with four major categories of risk factors: cigarette smoking during pregnancy which
accounts for 30% to 40% of growth restriction; genetically related factors for about
20% to 30%; nutritional factors for about 10% to 15%; and parity and general maternal
mortality for 5% to 10% (Wu Wen, cited in Canadian Perinatal Health Report, 2003).
The small for gestational age (SGA) singleton birth rate declined between 1996 and
2002, and has since levelled off. In 2005, the SGA rate was 7.9%. Age is a variable in
the SGA rates, with a U-shaped curve revealing the lowest rates between 30 and 34 (7%
from 2003 to 2005), and highest for women over 39 (9.7% from 2003 to 2005), and
slightly increased for younger mothers (8.6% from 2003 to 2005) (Reproductive Health
Report Working Group, 2006).
Three out of every four low birth weight births in Alberta (2005), were preterm births
(Reproductive Health Report Working Group, 2006). The preterm birth rate (PTB) has
been climbing steadily in Alberta, more rapidly than the Canadian rate (since 1999),
with the majority of births occurring at 35 or 36 weeks gestation. In 1996, the PTB
rate was 7.4% and 9.1% in 2005, a rate increase of 23% over 10 years (Reproductive
Health Report Working Group, 2006). A worrisome trend given the significant lifetime
consequences of prematurity. In 2004, Alberta at 9.1% exceeded the national rate of
8.0% (Statistics Canada, 2006 cited in Reproductive Health Report Working Group,
2006). The majority (75%) of all PTB are LBW and over 50% of all PTB are multiple
births. Contributing factors to the increasing rates in the moderately preterm births
(32-36 weeks gestation) is the increasing frequency of births to women older than 35
years, and the associated use of fertility treatments with their significant enhancement
of multiple birth rates (Green, Damus, Simpson, Iams, Reece, Hobel, Merkatz, Greene,
Schwarz & the March of Dimes Scientific Advisory Committee on Prematurity, 2005).
In fact, Tough, Newburn-Cook, Johnston, Svenson, Rose & Belik identified that delayed
childbearing accounted for 78% of the increase in low birth weight rate and 36% of the
change in preterm birth rates (2002).
Total low birth weight rates (PTB and SGA) vary with maternal age. The low birth
weight rate (2000 to 2004) among all births is high in the youngest (less than 20 years)
(7.0%); and especially high in the oldest maternal age groups (greater than 35 years)
(7.8%); reflecting a U shaped curve; with the lowest risk evident among women ages
25 to 34 (5.5%) (APHP, 2006).
In Alberta, the highest birth rate still remains in the age cohort of best pregnancy
outcomes, i.e. ages 25 to 34. Teen births (under the age of 20) have been decreasing over
time to a rate of 5% in 2004 (APHP, 2006), in fact there was been a 28% decline in teen
pregnancy rates between 1996 and 2005 (Reproductive Health Report Working Group,
2006). On the other hand, there has been an upward trend in delaying childbearing
(past the age of 35). Currently, in Alberta (2005) 15.1% of women over 35 years are
4

giving birth, an increase of 19% in the last decade (Reproductive Health Report Working
Group, 2006). It should be noted that risk factors for delivering preterm infants are
multiple and complex and it has been suggested that known risk factors may explain only
a small fraction of these outcomes (p.33 APHP, 2006).
Data on the use of fertility treatments are difficult to find, and can be hard to interpret
related to data collection processes; Tough, Tofflemire & Jack (2006) reported that 10%
of urban Alberta women over the age of 35 had some type of fertility assistance, either
fertility drugs and/or a medical procedure such as invitro fertilization (IVF) as compared
to 0.6% of women under 30 years of age using fertility assistance.
Multiple birth rates in Alberta may be stabilizing after years of steady increase. In 2005,
the rate was 3.2% in Alberta and 3.0% in Canada, Statistics Canada, 2005 cited in
(Reproductive Health Report Working Group, 2006).
In summary, despite prenatal care, low birth weight rates have not decreased. In fact,
rates have slightly increased in the last few years and the preterm birth rate for moderately
preterm infants (32 to 36 weeks gestation) is increasing, associated with the trend to delay
childbearing and the subsequent rise in reproductive assistance and multiple births. This
cohort of preterm infants experience a great risk for health and developmental problems
compared with the risks for infants born at term. At school age, children who were born
with moderate low birth rate (1500 to 2499 grams) are more likely than children of
normal birth weight to have mild learning disabilities, attention disorders, developmental
impairments, and breathing problems such as asthma (Shiono & Behrman, 1995). These
trends are of concern, given the significant health consequences to the infant and the
emotional and economic costs for the families and communities.
In Canada, in 1999, preterm birth was the leading cause of neonatal mortality (

the hospital care of this cohort of LWB infants based on having minor health problems
in 2004, was six million dollars.
Cigarette smoking is the single largest modifiable risk factor for low birth weight (Shiono
& Behrman, 1995). Smoking in pregnancy is associated with younger maternal age
(less than 25 years of age). In Alberta (2000 to 2004), 33% of all LBW births occurred
among smokers (Siever & Tough, 2006). The rate of Alberta women reporting smoking
during pregnancy in 2004 was 18.5% (Reproductive Health Report Working Group,
2006). Miller and Hill (2004), identified that from 2000 to 2001 more than one third of
pregnant women in Alberta regularly inhaled cigarette smoke, either directly or indirectly
through exposure to second hand smoke (cited in Reproductive Health Report Working
Group, 2006). While this rate has decreased over time, similar to the trend across
Canada, Alberta’s rate is higher than the national average of 14% in 2003 and remains
a public health concern. Despite clear and convincing evidence that smoking cessation
during pregnancy can prevent growth restriction and low birth weight, intensive smoking
cessation interventions are not a routine part of most prenatal care programs (Shiono &
Behrman, 1995).
Medical care and technology have gone a long way toward the survival of low birth
weight infants. Much less progress has been made in finding solutions to prevent preterm
labour or low birth weight, suggesting the need for an expanded approach to enhancing
healthy births using the preconception period to inform, screen, educate and modify risk
factors that can contribute to adverse maternal and infant outcomes.
Congenital Anomalies:
In Canada (1999), congenital anomalies were the second leading cause of neonatal
mortality (Health Canada, 2003). In Alberta, from 2000 to 2004 combined, 22.5% of
neonatal deaths were due to chromosomal anomalies.
Prenatal care begins with the first prenatal visit, usually at 12 to 13 weeks of pregnancy.
However, many obstetrical outcomes have already been determined before the prenatal
provider ever meets the woman; as the greatest period of environmental sensitivity for
the developing fetus is between days 17 and 56 days after conception or 4 to 10 weeks
from the last menstrual period (LMP) (Moore & Persaud, 1998). Neural tube defects
occur at approximately 25 to 27 days following conception, a time when most women
are not even aware that they are pregnant. During the first weeks of pregnancy, exposure
to alcohol, tobacco and other drugs and workplace hazards can adversely affect fetal
development at critical periods identified by the graph below.
6

Critical Periods of Development
Weeks gestation
from LMP
Most susceptible
time for major
malformation
4 5 6 7 8 9 10 11 12
Central Nervous System
Heart
Arms
Eyes
Legs
Teeth
Palate
External genitalia
Ear
Missed Period
Mean Entry into Prenatal Care
Reprinted with permission, March of Dimes, 1991
Evidence demonstrates that issues concerning teratogenesis need to be addressed prior
to the first prenatal visit. Fetal Alcohol Spectrum Disorder (FASD) has been recognized
in Canada as the leading cause of preventable birth defects resulting in developmental
and cognitive disabilities in children which last a life time (Health Canada, 2002). The
self reported incidence of alcohol consumption during pregnancy in Alberta was 4.0%
(Reproductive Health Report Working Group, 2006). As these data are self reported,
rates are probably higher as alcohol in pregnancy is considered socially undesirable. In
fact, in a recent Alberta survey, 80% of urban Alberta primiparous women reported
preconception alcohol consumption, with behaviour that did not change, (even though
80% were planning for pregnancy), until they recognized that they were pregnant (5
weeks post conception) (Tough, Tofflemire, Clarke, and Newburn-Cook, 2006). Of
women who could get pregnant, 67% are not taking a folic acid supplement (Public
Health Agency of Canada, 2003) despite the clear evidence that periconceptual use of
supplements containing folic acid substantially reduces the risk of occurrence of neural
tube defects (NTD) (Health Canada, 2002).
Obesity is on the rise with 21.5% of females between 25 to 34 years of age overweight
and a further 15.6 % obese (Source: Statistic Canada, Canadian Community Health
Survey 2005, CANSIM table 105-0407). In Alberta (2004), 8.8% of women giving birth
weighed more than 91kg prior to pregnancy. This rate increased between 2000 and 2004
7

(Reproductive Health Report Working Group, 2006). Accumulated evidence suggests
that obese women have approximately a two-fold increase in the risk of having a NTD
affected pregnancy, and some evidence suggests that folic acid may not have the same
protective effect in obese women (Health Canada, 2002).
In addition, about 11% of women giving birth in Alberta (2000-2004 combined)
have pre-existing medical conditions such as diabetes, heart disease, hypertension and
renal disease that can negatively affect pregnancy if unmanaged (Reproductive Health
Report Working Group, 2006). Diabetes and epilepsy are two maternal medical
conditions that contribute to increased risks for congenital anomalies. While the rates for
preconception diabetes have remained stable since 2000, at 0.6 % (Reproductive Health
Report Working Group, 2006); preconception care offers an opportunity for effective
management of conditions prior to pregnancy.
These factors pose risks to pregnancy that could be better addressed preconceptually,
thereby enabling women and their partners, where appropriate, to maximize their
chances of having a healthier pregnancy and infant.
In summary, Alberta’s low birth weight rate and preterm birth rate are higher than the
national average and are increasing over time (Reproductive Health Report Working
Group, 2006). Waiting until a positive pregnancy test or until the first prenatal visit
before making behaviour changes (i.e. stopping alcohol use, protecting oneself against
environmental hazards, changing medications, taking a folic acid supplement, and having
a healthy weight) is often too late to have a positive effect on fertility and puts the fetus
at risk during a highly sensitive period of embryonic development. For health promotion
and disease prevention to exercise influence on reproductive outcomes, action is needed
sooner than the first prenatal visit with a clinician. The window of opportunity needs
to be purposefully widened to include preconception health promotion and primary
prevention as the starting point.
In a comprehensive review of the literature a long list of risk factors suggested to be
included in comprehensive preconception care were identified (Korenbrot, Steinberg,
Bender, & Newberry, 2002). The strength of evidence supporting the efficacy of the
various components of preconception care varies greatly. Clinical practice guidelines
(CPGs) have been developed for reducing the risk related to some of these factors. The
Select Panel on Preconception Care (Centers for Disease Control and Prevention, 2006)
identified 14 conditions for which CPGs exist and for which there is scientific evidence
demonstrating effectiveness in improving pregnancy outcomes. Refer to Appendix E
for a description of the risk factors. In addition, health conditions that are amenable to
preconception care include hypertension, thromboembolic disease, repetitive pregnancy
loss, dental carries or oral disease, eating disorders, substance abuse, domestic violence,
and poor nutrition. Addressing these problems before pregnancy can not only yield
8

enefits to women’s health but also positively impact later pregnancy outcomes. What is
not known at this time is; what are the effective methods for delivering preconception care
and improving preconception health (Centers for Disease Control & Prevention, 2006).
Responding to the Background: A Preconception Framework for Action
This section describes an approach to respond to factors influencing perinatal
outcomes using a preconception framework for action to guide discussion and further
development. The framework includes a vision, goal, possible levels of action, principles,
and suggested key strategies and outcomes. Each element is defined and described.
Appendix F provides a visual depiction of the framework for action.
What is Preconception Health
Consistent with the World Health Organization’s definition of health (Ottawa Charter
for Health Promotion, 1986), preconception health refers to a state of complete physical,
mental and social well-being rather than the mere absence of disease. This definition is a
positive concept emphasizing social and personal resources as well as physical capabilities
which permits people to lead a productive life.
In practical terms, preconception health refers to the positive health practices that youth/
adults of reproductive age can make to improve their health before pregnancy. Health
practices include:
• Safeguarding fertility;
• Preparing for pregnancy;
• Modifying risk factors; and
• Optimizing the early fetal environment (17-56 days after conception) during the most
critical period of organogenesis.
These personal health practices are influenced by many factors:
• Knowledge: need to know which health practices will improve preconception health;
• Skills: must have the skills to carry out the health practices;
• Motivation: need to feel good about engaging in personal health practices;
• Opportunity and access: opportunities to carry out the health practices given one’s
life experiences; and
• Supportive environments: that makes it easier to engage in healthy behaviours.
Preconception health is not a neatly defined period of time; rather it is the health
practices of women and men throughout their reproductive lifespan. Preconception is
an essential period as it lays the foundation for children’s health, learning and behavior.
9

The health of the parents, their lifestyle choices, and the environment in which they live
before and during pregnancy have potentially significant and lifelong implications for
their infants. The evidence is extensive, describing the critical importance of supporting
optimal early childhood (p.11, Healthy Kids Alberta, 2006). The challenge lies in
developing strategies for those who could get pregnant, those planning a family, and
those who may have a family later on in life.
What is Preconception Care
Preconception care refers to the interventions that identify and modify risks to women
and men’s reproductive health and future pregnancies. In the CDC Report (2006),
fourteen selected preconception risk factors for adverse pregnancy outcome and their
evidence for effective preconception care were identified as follows:
Giving Protection
1. Folic acid supplements
2. Rubella immunization
3. HIV/AIDS testing
4. Hepatitis B immunization
Avoiding Teratogens
5. Alcohol
6. Tobacco
7. Anti-epileptic drugs
8. Oral anticoagulants
9. Accutane®
Managing Conditions
10. Diabetes
11. Maternal PKU
12. Obesity
13. STIs
14. Hypothyroidism
Refer to Appendix E for detail.
10

The Goal
Centers for Disease Control and Prevention (2006) recommend Primary Care visits
including preconception risk screening to improve preconception care for all women
and men of reproductive age. The following 10 specific areas are identified for
preconception screening:
1. Reproductive history;
2. Environmental hazards and toxins;
3. Medications that are known teratogens;
4. Nutrition, folic acid intake, and weight management;
5. Genetic conditions and family history;
6. Substance use, including tobacco and alcohol;
7. Chronic diseases (e.g. diabetes, hypertension, and oral health);
8. Infectious diseases and vaccinations;
9. Family planning; and
10. Social support, domestic violence, and housing.
The preconception goal that “women and men are in optimal health as they approach
each pregnancy”, recognizes that optimal health for expectant mothers and the infants
that are born each year (APHP, Vision) is influenced by many factors that impact on
women’s and men’s health prior to conception. Optimal health is defined as a balance of
physical, emotional, social, spiritual and intellectual health (Ontario Health Promotion
Resource System).
Possible Levels of Action
Including a population health approach to promoting health in the preconception
period means taking action at both the individual and environmental levels focussing not
only on modifiable risk factors but also on the environmental determinants influencing
preconception health.
11

Individual Factors:
At the individual level, actions are
directed at strengthening the knowledge,
skills and capabilities of women and men
of reproductive age to improve health as
they approach each pregnancy.
Environmental Factors:
At the environmental level, actions
are directed towards influencing
social, environmental and economic
factors to improve conditions for
preconception health.
Individual Factors Influencing Preconception Health
Folic Acid:
• Randomized controlled studies have demonstrated that periconceptual daily use
of supplements containing 0.4mg of folic acid reduces the incidence of neural tube
defects (NTDs) by 60-70% (Van Allen, McCourt & Lee, 2002).
• Preconception maternal risk factors for NTDs. i.e. diabetes, obesity, and epilepsy,
warrant increased dosage of folic acid under the care of a healthcare provider (Van
Allen et al, 2002).
• There is also evidence for the potential of folic acid multivitamins to decrease the risk
of other congenital anomalies. Using the Alberta Congenital Anomalies Surveillance
System; Godwin, Sibbald, Bedard, Lowry, Kuzeljevic & Arbour (2006) reported
a decrease in the prevalence of atrial septal defects with increases in the prevalence
of obstructive urinary tract defects when comparing pre-fortification and postfortification
time periods.
• Food fortification with folic acid was implemented as a public health strategy in
November 1998 (Appendix G). The current level of fortification increases the level
of folic acid in women by 25% (0.1mg), which does not meet the recommended
daily requirements of 0.4 mg to prevent NTDs. While rates of NTDs have decreased,
fortification levels are not currently high enough to prevent NTDs. Nationally and
provincially, the birth prevalence of both anencephaly and spinal bifida have decreased
from 1989 to 1999. Increased use of vitamin supplements, prenatal diagnosis and
termination of affected pregnancies may have contributed to the reduction of NTD
birth prevalence. The full impact of folic acid fortification (November 1998) is not
likely apparent in the 1999 figures (Congenital Anomalies, 2002).
• Despite national and local educational initiatives, including SOGC Clinical Practice
Guidelines (Wilson, 2003); Health Canada Resource Document (Van Allen and
McCourt, 2002); Calgary Health Region Position Paper (Ramaliu, 2003); the message
to take folic acid is not getting through to enough women of childbearing age. Surveys
of periconceptual folic acid knowledge and use in various groups of Canadian women
in Alberta, Ontario, and Newfoundland, report that while 50% of women were aware
12

of the importance of folic acid, only 28-32% were taking supplements containing
folic acid (Tough, Benzies, Fraser-Lee, Newburn-Cook, 2007; Tam, McDonald, Wen,
Smith, Windrim & Walker, 2005; and the Public Health Agency of Canada, 2003).
• Less than 60% of family physicians and obstetricians in Canada are discussing taking a
folic acid supplement prior to conception (Tough, Clarke, Hicks, and Cook, 2006).
• Health Living, Healthy Babies, Calgary Health Region in their review of the school
curriculum for folic acid education (2006) identified that the only folic acid education
currently delivered in the schools occurs in Biology 30, which is an optional course
delivered in Grade 12. Hence folic acid information is not accessible to all students,
nor is the folic acid information available to teachers on their provincial website
www.teachingsexualhealth.ca which supports teachers in delivering sexual health
information (House, 2006).
• Despite fortification of cereal based products in the Unites States since 1998, CDC
in 2007 reported a 16% decrease in serum folate among nonpregnant women of
childbearing age from 1999-2004, which they suggest may be related to 1) a lower
fruit and vegetable intake associated with lower income and obesity, and 2) lowcarbohydrate
diets linked with decreasing consumption of fortified grains.
• These findings emphasize the need for initiatives that address both barriers and
motivations for folic acid supplementation. As well, providing information on folic
acid early in the reproductive life course would be important as youth are often
amenable to behavior change.
Alcohol and Tobacco use:
• Eighty percent of urban Alberta primiparous women reported preconception alcohol
consumption, with behaviour that didn’t change (even though 80% were planning for
pregnancy) until they recognized that they were pregnant (5 weeks post conception)
(Tough, Tofflemire, Clarke, and Newburn-Cook, 2006).
• Although the effects of in utero alcohol exposure have been clearly documented the
dose of alcohol required to cause such effects has still not been established (Caprara,
Soldin & Koren, 2004).
• The cost burden of FASD in Canada is profound, with annual costs for children
(1 to 21 years) born with FASD of just over three million dollars (Stade, Unger,
Stevens, Beyene & Koren, 2006).
• Smoking rates in Alberta are highest among individuals aged 20-24, with males more
likely to report smoking than females. Overall, 23% of Albertans report being smokers
(Alberta Health and Wellness, 2006) Smoking has grave effects on both male and
female reproductive health. It is associated with infertility, spontaneous abortion and
ectopic pregnancy (The Practice Committee of the American Society for Reproductive
Medicine, 2004).
13

Obesity:
• An American study showed that infants born to mothers who smoke have an increased
neonatal cost of $724. (Adams, Miller, Ernst, Nishimura, Melvin & Merritt, 2002
cited in Hutson, 2006).
• Alberta Alcohol and Drug Abuse Commission’s business plan (2005-08) identifies a
reduction in the prevalence of smoking among Alberta youth as a target performance
measure of 13% (Alberta Health & Wellness, 2005).
• For men specifically, there is evidence to suggest that smoking can result in alterations
of the male sex hormones and is a key cause and contributor to erectile dysfunction
(Peate, 2005), conception delay, and primary as well as secondary infertility
(Rosenthal, Melvin, & Barker, 2006).
• Less than 50% of healthcare providers in Canada discussed smoking, alcohol use or
addiction history with women of childbearing age (Tough, Clarke, Hicks et al, 2006).
• A Midwest USA survey of family physicians, reported that although family physicians
had a general knowledge base about alcohol use in pregnancy, FASD knowledge
deficits were identified and barriers affecting their practice were the lack of clinical
training in medical school, residency, and continuing education (Mengel, Ulione,
Cook, Wedding, Rudeen, Braddock & Ohlemiller, 2006).
• The Alberta Medical Association recommendations for the prevention of Fetal
Alcohol Syndrome, 1999 do not currently provide preconception guidelines to
identify at risk women.
• The majority (60%) of Canadians are either overweight (BMI 25-29.9) or
obese (BMI>30) with the associated health risks of hypertension, diabetes and
cardiovascular disease (cited in Tjepkema, 2005).
• A striking increase has been in the age cohort of 25-34, who currently have the highest
number of pregnancies. For this age group, obesity rates have more than doubled in
2004 to 20.5% (cited in Tjepkema, 2005).
• Obesity rates for people of Aboriginal origin (off reserve) are 1.6 times the
national average (cited in Tjepkema, 2005).
• Maternal obesity is associated with infertility, neural tube defects, preterm birth,
diabetes, caesarean section, and hypertensive and thromboembolic disease (cited in
Tjepkema, 2005).
• The likelihood of being obese is related to an inadequate diet (less than 3 fruits/
vegetables daily) and physical inactivity (cited in Tjepkema, 2005).
• In 2003, about half of all Albertan’s reported being physically active and less than half
met the recommended daily consumption of fruits and vegetables (Alberta Health and
Wellness, 2006).
14

Maternal Age:
• In just over a decade the number of births to women over 35 years has increased
by 38%. In Alberta in 2005, 15.1% of all live births were to women over 35 years
(Reproductive Health Working Group, 2006).
• The mean maternal age at first birth has also increased linearly to 27.4 years in 2005
(Reproductive Health Working Group, 2006).
• In a recent survey (Tough, Benzies, Fraser-Lee & Newburn-Cook, 2007) reported that
although 76% of women planned to have children at some point, with approximately
45% recognizing that the ideal time to have a child was between 25-29 years; some
women are delaying their decision to have a child, related to relationship and financial
security; and partner’s suitability to parent.
• Advanced maternal age was a factor in the number of women (ages 30-39) who
continued to drink small amounts of alcohol after pregnancy recognition (Tough,
Tofflemire, Clarke et al, 2006).
• Advanced maternal age (>35 years) is a well established risk factor for Down Syndrome
(DS) (Health Canada, 2002). Rates for DS show significant increasing linear
trends over time (1996-2005); given the increasing average maternal age in Alberta
(Reproductive Health Report Working Group, 2006) these data are of concern.
• Research suggests that women and men are postponing childbearing without having
sufficient information on the consequences, i.e. declining fertility resulting in the need
for assisted reproductive technologies, preterm delivery and the associated risks for the
child (Lampic, Svanberg, Karlstrom & Tyden 2006 and Benzies, Tough, Tofflemire,
Frick, Faber & Newburn-Cook, 2006).
• There are career benefits to delaying childbearing related to wage growth and
promotions both of which tend to occur earlier in one’s career and may be associated
with the flexibility in making decisions about promotions when women are childless.
Drolet in a Canadian study, reported that when the timing of children is taken into
account, women that postpone having children earn at least 6% more than women
who have children early (2002).
Paternal Age:
• Maternal age of 35 years or over is a well known risk factor for human reproduction
that has been extensively investigated. Whereas the state of knowledge about
reproductive changes in aging men, as well as possible age-related paternal genetic
risk factors, lags far behind.
• In general, the genetic quality of sperm produced by older men may be reduced for
several reasons; age-related increases in germ cell mutations, impairment of DNA
repair mechanisms and decreases in apoptotic processes are the most likely (Kuhnert &
15

Nieschlag, 2004; Rolf & Nieschlag, 2001; Yhu, Madsen, Vestergaard, Olesen, Basso
& Olsen, 2005; Wheeler & Bianchi, 2000).
• The risk of having an infant with an autosomal dominant condition, such as
achondroplasia, Marfan syndrome, and Apert syndrome increases above the baseline
population risk with advanced paternal age (approximately 40 years) (Wheeler &
Bianchi, 2000) (Shapiro & Dolan, 2006). Currently, there is no clear evidence
for a paternal effect on structural or numeric chromosome anomalies (Rolf &
Nieschlag, 2001).
• Whether paternal age also affects fertility remains unclear. Auger and Jouannet (2005)
in a review of the data, state that while advanced paternal age (40 years or over) has
been associated with increased time to pregnancy and subfecundity, there remain wide
individual variations in these changes (De La Rochebrochard & Thonneau, 2005).
Changes which may also be explained by a reduced libido and sexual activity both of
which may be associated with a decrease in serum testosterone associated with aging
(Auger & Jouannet, 2005).
• Further studies are warranted given that more couples are delaying childbearing,
and the interaction of the ages of the two partners maybe increasing the risks of
infecundity, congenital anomalies and adverse perinatal outcomes.
Planned Pregnancies:
Gender:
• An Ontario survey (Einerson & Koren, 2006) reported that 70% of women were
planning pregnancies, contrary to data published in the USA which reports 50% of
all pregnancies are not planned (Henshaw, 1998). Planned pregnancies are associated
with healthier behaviours (Perinatal Partnership Program of Eastern and Southern
Ontario, 2001).
• In a 1995 Statistics Canada survey, 96% of women and 94% of men (ages 20-29)
say they want at least one child (Johnson, Lero & Rooney, 2001).
• Gender is an important component of preconception health. It includes the impact of
men’s health behaviors and their role in influencing their partner’s health promoting
behaviours. Also, it is important to consider both women and men as it is essentially
their combined contributions which when adversely affected by their environment can
lead to adverse outcomes (Younglai, Holloway and Foster, 2005). We also know that
active father involvement is a supportive and protective condition for healthy child
development and resiliency (Public Health Agency of Canada, 2002).
16

Culture:
• Aboriginal Canadians face higher risks of adverse pregnancy and infant health
outcomes independent of socio-economic status and neighbourhood (Public Health
Agency of Canada, 2005). In Alberta, mothers of Aboriginal treaty status have less
prenatal care, are more likely to delivery a large for gestational age infant (LGA)
(>4000 grams), and maternal diabetes is more prevalent (Yan Jin, Truman &
Johnson, 2000).
• Ethnicity plays a role in risks for genetic conditions. Certain ethnic groups are at
increased risk for specific genetic conditions, i.e. Ashkenazi Jewish descent, French-
Canadian, Mediterranean ancestry, and Southeast Asian descent. Five genetic
conditions as they relate to ethnicity can affect pregnancy outcomes and are therefore
important to include in preconception genetic counselling. These genetic conditions
include; Tay-Sachs, and Canavan’s disease, sickle cell anemia, thalassemia, and cystic
fibrosis (Edwards, Seibert, Macri, Covington, and Tilghman, 2004). Preconception
genetic screening is an important component of preconception screening to identify
couples at increased risk (over the background population risk) for specific genetic
conditions based on their ethnicity, thereby assisting and supporting these couples
in decision making about their reproductive choices prior to conception (Health
Canada, 2002).
Health Services:
• In Alberta, 88% of adult Albertans had contact with the healthcare system in 2006;
the highest interaction was with family doctors (72%), pharmacists (71%), and
lab testing services (68%); while contact with community walk-in clinics (39%),
diagnostic testing (39%), and specialists (36%) fall into a second level (Health Quality
Council of Alberta, 2006).
• In 2006, 26% of adult Albertans used the Alberta Health Link and the vast majority
(87%) did exactly as recommended by the nurse (Health Quality Council of
Alberta, 2006).
• Access to healthcare services was reported as easy by 26% of Albertans surveyed
in 2006 (Health Quality Council of Alberta, 2006). Several regions report lower
scores in overall access than the provincial response, specifically regions 3, 7, 8 and 9.
The most important factor in overall accessibility is coordination of efforts of
healthcare professionals.
• Women identify health professionals as the primary source of preconception
information (Einerson & Koren, 2006).
• Sixty percent of Canadian healthcare providers (who recommend alcohol abstinence
during pregnancy) asked women about personal use of alcohol; depression (

and fewer still inquired about family (25%); and partner use of alcohol (11%); all
factors correlated with women’s risk for alcohol consumption (Tough, Clarke, Hicks,
and Clarren, 2004).
These factors are compelling. Without the correct preconception information and access
to healthcare providers, women and men of reproductive age may not have sufficient
information to make informed decisions or obtain the necessary care to enhance
pregnancy and birth outcomes before they conceive.
Environmental Factors Influencing Preconception Health
Education:
• Most Canadians become sexually active in their adolescent years, with teens having
the highest rates of STIs among young people (McCall & McKay, 2004).
• The school health curriculum is a major source of sexual health information
among adolescents.
• Canadian studies, reviews, and other data indicate that the quality of sexual health
education and sexual health services being provided to our youth are inadequate
(McCall & McKay, 2004).
• Albertan’s have the highest level of educational attainment in Canada (Anielski, 2001).
An important factor given that among individual measures of socioeconomic status,
education is considered an important determinant of health.
• The largest shift in educational attainment has been with women. In 2001, in Canada,
15% of women had a university degree compared to 16% of Canadian men. The gap
is closing as women currently (2001) constitute the majority of all students enrolled in
a Canadian university (Statistics Canada, 2006).
• The cost of pursuing post secondary education in Canada is expensive. University
undergraduate tuition fees have nearly tripled since 1990 and college fees have more
than doubled (Canadian Council on Learning, 2005). Alberta’s undergraduate
university and college fees for 2005 to 2006 were the second highest in Canada.
Tuition fees in Alberta increased 212% from 1989 to 2003, compared with the
Canadian increases of 164% (Alberta GPI: Educational Attainment). Despite Alberta’s
attempts to respond to rising fees by continuing to raise student loan limits and by
creating a student loan relief program (which automatically repays Alberta student
loan debt accumulated beyond $2500 per semester or $5000 per year) (Alberta
Learning, October, 2004) undergraduate debt continues to rise.
• Students are taking on more debt to finance their studies. Statistics Canada’s National
Graduates Survey (released Spring, 2004) found that 45% of undergraduates left
school with an average of $20,000 dollars owing to government student loan
18

Workplace:
programs. University students who completed their programs in 2000 owed 68%
(college students owed 63%) more than did their counterparts in 1990 (Canadian
Council on Learning, 2005).
• While student loans are covering some portion of the rising costs, employment income
is the principle source of income.
As student debt rises, students are taking longer to complete their studies, living at
home longer and starting their careers later; in addition women’s increasing educational
attainment, are all factors contributing to a delay in childbearing.
• More women than ever before are gainfully employed. In 2004, 64% of women in
Alberta had jobs, the highest employment level across Canada, just 12 percentage
points lower than men whose employment level is 76% (Statistics Canada, 2006).
• With their partners in the workforce, men’s responsibilities for home and child rearing
have expanded. A number of studies have shown that although work is unquestionably
a powerful source of male identity and satisfaction, family is equally as strong (cited in
McNaughton, 2001).
• There is a decline in women working in female dominated occupations (from 72% in
1987 to 67% in 1996) with a resultant increase in employment in several professional
fields, i.e. medicine, dentistry and social science.
• Changes in employment and resultant dual earner families are causing work life
conflict as both women and men try to balance life and well being with work
demands. In their studies, Canadian researchers Duxbury and Higgins (1996) found
that while women still experience more role overload and stress than men, the extent
to which the work demands interfere with family is approximately equal for mothers
and fathers (cited in McNaughton, 2001).
• A recent study released by the Institute for Research on Public Policy, reported that
35% of Canadians are very time-stressed related to three interrelated factors; growing
work responsibilities for highly educated workers, an expectation of increasing leisure
time, and the value placed on spending time with children in a society dominated by
two-earner families (Pronovost, 2007).
• More Albertans are working longer hours, with overtime rates more than twice the
national average (Mackay, 2007).
• According to Statistics Canada’s labour force survey, worker absenteeism rates are on
the rise. In 2001, on average each full time employee lost 8.5 days, with 7.0 of those
days due to illness or disability, and 1.5 days due to personal and family responsibilities
(Canadian Council on Learning, 2006).
19

• As the baby boom generation reaches retirement age, the pool of workers is ever
smaller, resulting in a great deal more competition to attract employees. The new
generation “X and Y” workers are insisting on more time outside of work to live their
lives, hence the challenge for employers to respond to the social priority of work and
well-being (The Vanier Institute of the Family, 2004).
Further research is needed to explore how and what healthy workplace strategies will
be supportive of the new generation of employees to encourage parenting without the
subsequent negative impacts on salary increases, job security, promotional opportunities,
and work-life balance.
Income:
• In 2003, 19.8% of all Albertans lived below the Low Income Cut Off (LICO),
a Statistics Canada measure to denote poverty level incomes. According to the Alberta
Genuine Progress Indicator (GPI), the level of poverty has increased by an estimated
17% between 1961 and 2003 (Alberta GPI: Poverty). Low income rates are highest
among recent immigrants, Aboriginal people living off reserves, lone parent families,
and persons with a work-limiting disability (Policy Research Initiative, 2004).
• Despite Alberta’s booming economy, evidence shows that the poor are getting poorer,
personal savings are declining, and personal and household debt continues to increase.
Albertans are reporting being financially stressed, with 23% not having enough savings
to last beyond one month of expenditures (Alberta Sustainability Trends, 2000).
• Women living on a low income are at higher risk for poor pregnancy outcomes,
including preterm birth and especially intrauterine growth restriction. They are also
less likely to initiate prenatal care (Public Health Agency of Canada, 2005). Research
has demonstrated that women living in poorer neighbourhoods coupled with lower
education levels (individual SES measure) are more vulnerable to adverse birth
outcomes and may benefit from targeted public health programs (Luo, Wilkins, &
Kramer, 2006).
• Income is a significant predictor of folate intake. Women of childbearing age in
households with an income below the LICO had lower folate intake. The difference
in consumption for those below the LICO was due solely to lower consumption of
naturally occurring folate and not due to less consumption of fortified flour and pasta
(Public Health Agency of Canada, 2003).
Income inequality exists in Alberta, and can adversely influence pregnancy and
birth outcomes.
20

Physical Environment:
• The physical environment where women and men of reproductive age live and
work is an important determinant of reproductive health. Occupational hazards are
of particular concern since 77% of women (aged 25-44) and 85% of men of the
same age grouping were part of the paid work force in Canada in 2004 (Statistics
Canada, 2006).
• Most chemicals in the workplace have not been evaluated for reproductive toxicity,
and where exposure limits do exist, they are generally not designed to mitigate
reproductive risk, but rather other toxic effects (McDiarmid & Gehle, 2006). This gap
in the regulatory safety net allows reproductive toxicants to be encountered in work
settings by both female and male workers (Grajewski, Coble, Frazier & McDiarmid,
2005). Female workers predominate in some of the employment sectors with known
reproductive toxicants, i.e. healthcare, printing, dry cleaning and cosmetology. For
men, chronic occupational exposure to heat is a risk factor for male infertility, and has
been described in the following occupations; welding, professional driving and the
ceramics industry (Sheiner, Sheiner, Hammel, Potashnik & Carel, 2003).
• As well as work exposures, there are dietary cautions which women contemplating
pregnancy should be made aware of, i.e. exposure to food born listeria infections
and methylmercury in fish.
• Household exposures are numerous, and may involve women and men deciding to
avoid activities that pose reproductive risks when actively trying to conceive. For
example, cleaning cat litter; home renovations; second hand smoke; and bringing
home work contaminants on shoes or dirty work clothes.
• Risk estimates in the physical environment are challenging at best given the
limitations of available knowledge and the qualitative nature of the exposure estimates
as well as what is know about other non-occupational risk factors contributing to
birth outcomes.
The issue of the physical environment as a reproductive risk factor is relatively new; there
are no best practices or widely accepted approaches to address possible environmental
risks prior to conception. Ontario Best Start Resource Center, in their Playing IT Safe
manual (2006) recommended a precautionary approach, stating the science is incomplete
and the risks are not fully measured or measurable, we just are not sure, and thus
recommend messaging focusing on lower risk alternatives.
21

Principles
Four guiding principles direct the actions of the key preconception strategies; Social
Justice and Equity, Multiple Strategies, Intersectoral Collaboration, and Evidence
Informed Decision Making.
Social Justice and Equity:
All activities proposed for preconception health must reflect the principles of social
justice and equity, which means that everyone has an equal opportunity to develop and
maintain their reproductive health through fair and just access to resources for health.
Equity means fairness. Equity in health means that people’s needs guide the distribution
of opportunities for well being. For example, increased provision of post secondary
scholarships and bursaries for Aboriginal students to reduce financial barriers.
Multiple Strategies:
A population approach calls for innovative and interconnected action strategies that
consider the range of health determinants applied within multiple settings. The
Hamilton & Bhatti Population Health and Promotion Model, 1996 demonstrates the
interconnection by asking questions related to; “On what determinants should we take
action”, “Who is the target population” and “How should we take action”.
Intersectoral Collaboration:
Intersectoral collaboration is the joint action between health and other government
sectors, as well as representatives from private, voluntary and non-profit groups.
Intersectoral action takes different forms such as cooperative initiatives, alliances,
coalitions or partnerships. The Population Health Template, (Health Canada, 2001)
refers to two different roles the health sector assumes i.e. leader or facilitator based on
whether the initiative falls within its mandate. Regardless of the role, inherent in the
collaboration is that the different sectors and levels are working together to meet goals
and objectives upon which they have mutually agreed.
Evidence Informed Decision Making:
Evidence informed decisions occur at all stages of development of the preconception
action plan from analysis of the health issue to priority setting and taking action.
Evidence informed information means taking the summary of relevant research as the
starting point and incorporating other kinds of information such as; values, interests and
experience as necessary supplements to the research base (retrieved from http://chsrf.
ca/other_documents/evidence_e.php on February 21, 2007).
22

Key Settings
Home/Family:
Schools:
Workplaces:
Community:
Health Services:
Preconception health is rooted in key settings that provide the greatest potential for
reaching youth and adults of reproductive age. In addition, the settings provide a focus
for coordinated integrated action. Key settings are as follows:
Friends, peers and parents serve as important role models for positive health behaviors.
Adolescents and young adults spend a large percent of their time in schools. Schools can
provide opportunities to learn about preconception health either through curriculum or
activities that demonstrate the positive benefits of healthy choices.
Most adults spend eight hours or more each day at work. Business, industry and
government have responsibilities to address work-life balance and reproductive
hazards, factors that can influence preconception healthy choices. Workplaces can
provide opportunities to engage in health enhancing pregnancy planning by providing
possibilities for a flexible work schedule, job changes to minimize hazards, extended
maternity and paternity leaves, daycare support and on the job workshops and
educational opportunities.
Women’s groups and shelters, churches, pharmacies, licensing bureaus, mortgage centers
and recreation centers are all key places for offering informational support and resources
to encourage preconception healthy practices.
The majority of Canadians interact with the health system several times a year.
Outpatient settings, community health centers, Primary Care Networks (PCNs), and
doctor’s offices are settings that can re-enforce the adoption and maintenance of positive
preconception health behaviors.
23

Target Population
Key Strategies
The target population for preconception health promotion is all women and men of
reproductive age even if they are not planning to conceive. A life course perspective draws
attention to variations in childbearing age and the possibilities of differing interventions
based on these variations.
The following three key strategies are proposed to make preconception health easier for
all Albertans where they live, work, play and learn:
1. Promote Public Awareness and Knowledge.
2. Build Capacity to Provide Preconception Health Services.
3. Champion Preconception Health Supporting Environments.
In addition, there are fourteen initiatives proposed that identify collective action to
address the challenges identified in the individual and environmental factors which are
currently facing Albertans of reproductive age. Examples of completed initiatives are
described in Appendix G.
1. Promote Public Awareness and Knowledge
Considerations for Action
Public awareness and educational strategies are essential health promotion activities
aimed at increasing awareness and knowledge of the optimal health factors for
conception and early pregnancy. Healthcare providers in the Primary Care Network focus
groups stressed the need to first increase general public awareness to create a “patientdriven”
request for service (Silzer, 2007). Currently, the general public and those in highrisk
groups are not accessing healthcare providers until they are pregnant, which is often
too late to have a positive impact on birth outcomes.
Research demonstrates that women of reproductive age are aware of the importance of
optimizing their health prior to a pregnancy, but deficiencies exist in their knowledge
of modifiable risk factors that can impact maternal and fetal health (Frey & Files, 2006;
Einarson & Koren, 2006; March of Dimes, 2002; Public Health Agency of Canada,
2004; Tough, Benzies, et al, 2007). The women and men consumer focus groups findings
validated this lack of knowledge about preconception risk factors and positive health
practices (Silzer, 2007). In both groups there was a lack of knowledge about the role
men’s physical health plays in producing a child. The men’s focus group reported “their
own health to be worth 5% of the equation while a woman’s physical health impacted
24

95% of the equation” (p.39). The women’s focus group responses focused on a man’s
obligation/requirement to provide emotional support to their female partner rather than
specific health issues for the male (Silzer, 2007). “My partner needs to act as if he is…
pregnant…it means he shouldn’t smoke or drink to support me… (p.28)”.
Four activities in key settings identified in the Framework for Action (Appendix F)
are proposed to deliver compelling and consistent messages and information about the
connection between establishing health practices before conception and those that
are expected during pregnancy, with an emphasis on the male’s role in producing a
healthy child.
Objective:
Increase awareness and understanding about health promoting practices and
preconception risk factors.
Suggested Activities:
1. Health Communication. To promote awareness across the reproductive lifespan,
a suggested activity is to develop a provincial preconception health communication
campaign using a multilevel approach, i.e. simultaneous launch of activities within
each health region in different settings. Research shows that theory-driven mediated
health promotion programming can reinforce health messages, stimulate people
to seek further information, and in some instances bring about sustained healthy
lifestyles (Ontario Health Promotion Resource System). The focus groups (Silzer,
2007) were very emphatic that all women and men of reproductive age were the
target, i.e. those planning and not planning a family. The following vehicles were
suggested by the focus groups (Silzer, 2007) as a means of getting the message out:
• “Use the television, everyone has a TV it doesn’t matter how broke you are;
television commercials, “Ask your doctor”…, specialty talk shows, these will all
work…” (p.20).
• Use the internet; put a banner on the web (YouTube) http://www.youtube.
com/. Men identified the internet as the most frequent source of accessing health
information.
• Create pamphlets, posters with website information to be made available at
healthcare visits such as; doctor, dentist, pharmacist, and lab testing; and at
community contacts such as; churches, marriage preparation courses, bridal fairs,
and daycare centers. Using the social context of where health information is
exchanged is an important consideration in planning a campaign.
25

• The media, transit ads, public service announcements, information on
contraceptive packages and feminine hygiene products were all identified as
suitable channels for sending the message.
• The male focus group felt that the message needs to be specifically targeted to
them. “Getting it on the radar” was considered an important component of any
campaign, because pregnancy is considered women’s work, somehow you need to
get our [men’s] attention. Put the information where you [men] sit (or stand) and
do nothing such as in the washrooms, urinals at the Saddledome, at the dentist or
doctor’s office, on a television advertisement when you are at the bar or watching
a game with a link to a men’s website to learn more. Ideas which were all cited
as possible ways of sending the message. Catching men’s attention with tag lines;
“you’re more than just a donor…” or subliminal messages through internet popups
were also suggested, specifically for those who don’t plan a pregnancy and are
therefore not actively seeking this information. According to Best Start (2006),
men prefer the internet as a source of information because it is a place where they
can be anonymous, private and in control of the information.
A comprehensive approach to an awareness campaign for preconception health will need
to include both mainstream approaches and strategies for sub-population groups. For
example, women living on a low income may need different types of information or more
comprehensive assistance, i.e. free multivitamin supplements containing folic acid in
order to be able to make positive health choices. Men want information that is designed
specifically for them. Also, low birth weight rates are most common in the youngest
(under 20 years) and the oldest maternal age group (over 35 years) (Reproductive Health
Report Working Group, 2006). It will be very important to develop messages and present
them in a format that allows them to be adapted to differing social and cultural groups,
including both rural and urban populations.
2. Align Public Awareness Efforts. Working with other initiatives, programs and
organizations to integrate reproductive messages into other health promotion
messages will enhance consistent messaging and ultimately have a greater impact. For
example, campaigns to reduce obesity, tobacco and alcohol use among youth could
include parallel messages regarding the potential impact on reproductive health.
3. Health Education. Unlike health communication campaigns which are usually
directed at larger audiences, health education initiatives refer to opportunities for
learning to improve health literacy (knowledge, personal skills and confidence to take
action). Based on a life course perspective, two key settings are proposed to provide
preconception health education:
• Schools. Liaise with School Health and Wellness, Alberta Education (K to 12)
to identify opportunities to integrate preconception lesson plans and resources
26

into existing curriculum for Health and Life Skills, Career and Life Management
(CALM) and sexual health. The focus groups (PCNs and consumers) were very
clear in their recommendation to direct efforts of health and education to target
children and youth in schools in an “upstream” manner to provide reproductive
health and preconception information (Silzer, 2007). It was the consensus of the
focus groups that current sexual and reproductive health education programs do
not meet the needs of our youth and that advocacy for the inclusion of appropriate
and mandatory sexual health information in the school curriculum was essential
(Silzer, 2007). The PCN focus groups also recommended increasing access to
Public Health Nurses within the educational system to provide the necessary
educational support for sexual health education.
In addition to curriculum changes, building partnerships with youth is a critical
component to encourage youth to initiate health practices early in order to raise
healthy children later on. Conducting a survey or youth led focus group is a way to
involve teens in identifying preconception learning needs. Working cooperatively
with teens and school personnel to develop and implement educational activities
that will have an impact on youth is essential, as peers are a substantial and credible
source of information and often act as change agents (Best Start, 2000).
• Workplaces. Build partnerships with workplaces and with representatives from
Workplace Health and Safety, to build on existing wellness/safety initiatives by
providing resources, displays or preconception information sessions for employees;
activities which makes good use of limited opportunities, time and resources.
Connect with occupational health specialists in settings where women and/or men
may be at greater reproductive risk, i.e. contractors to find out what information
they might need about take home exposures and risks associated with home
renovations. Women in the consumer focus group referred to the business of
family life, lack of support, absence of knowledge, and work place stress causing
mental health issues, as barriers to preconception health practices (Silzer, 2007).
4. Self-help. “Individuals play the greatest role in supporting health and wellness for
themselves, their families and their communities” (p.8 Alberta Government, Health
Policy Framework, 2006). A suggested activity to enable self-help is to use existing
health technology networks to enhance health literacy by making preconception
health information available on existing health web sites, i.e. Healthy U Alberta,
Alberta Healthy Living Network, Alberta Health Link. Participants in the women’s
consumer focus group and the Primary Care Network participants suggested
including preconception health information in the book “From Here through
Maternity” (Silzer, 2007). The women’s consumer focus group also suggested that a
similar book be developed which targets men with practical information related to
preconception and “post birth” (p.32). Development of consumer-friendly tools can
help women and men self-access risks, make plans and take action to improve their
27

health, such tools could be made available at touch-screen kiosks where women and
men live, learn, work and play.
Key Outcomes:
Short-term
• Increased level of public awareness of reproductive factors contributing to a healthy
pregnancy and healthy infant by population groups of interest.
• Increased availability of public information about risk factors and health promoting
practices across the life course.
• Better collaboration and integration of consistent preconception health messaging into
other health promotion initiatives.
Medium-term
• Increased number of women, men and youth who engage in healthy behaviors.
Long-term
• Improved perinatal outcomes.
2. Build Capacity to Provide Preconception Health Services
Considerations for Action
Working within health and community based settings to strengthen access to primary
prevention and health promotion will require building partnerships with service
providers, finding out what information and resources they might need to be able to
provide quality preconception health/information services. There was a general consensus
amongst both Primary Care Network focus groups (urban and rural) that there is a lack
of health service activity with respect to preconception care (Silzer, 2007).
Primary Care Network providers in the focus groups indicated that while the majority of
healthcare providers have a general sense of all the risk factors and information related to
preconception care, they are not aware of the details. Participants identified specific areas
where professional knowledge is often lacking (specific drugs; thyroid, PKU, and rubella
testing; folic acid supplementation) (p.9).
Although women report healthcare providers as their primary source of information,
evidence exists that preconception risk factors are not routinely discussed with women
of childbearing age (Tough, Benzies, et al, 2007; Tough, Toffelmire, Clark & Newburn-
Cook, 2006; Tough, Clarke, Hicks & Clarren, 2004). In a survey of healthcare providers
in the United States in 2002-2003, it was reported that all providers knew that folic
acid prevents birth defects, but only 58% knew the correct folic acid dosage (Williams,
Abelman, Fassett, Stone, Petrini, Damus, Mulinare, 2006).
28

The following six activities are proposed to build capacity to provide preconception
health services.
Objective:
Develop appropriate screening, education, management and support for those planning
a family and for those not planning a family.
Suggested Activities:
Primary Prevention
1. Resource Development:
• Participants in the PCN focus groups suggested multiple channels are needed “to
trigger” healthcare providers to include preconception content where warranted
(Silzer, 2007). Channels suggested were; written information, website, and e-mail
attachments. All PCN focus group participants stressed that the resource material
should be clear, “evidence-informed”, simply presented and easy to access in order
to be utilized by busy practitioners. “We need a quick summary of information,
just the latest information... a one pager…” (p.11).
• The CDC, 2006 recommends evidence based risk screening for all women
of childbearing age in the United States with emphasis on the 10 areas
for preconception risk assessment (e.g. reproductive history, genetic, and
environmental risk factors). In Alberta, the Primary Care providers in the focus
groups did not believe that a specific counselling tool would be beneficial in their
practice, primarily because they did not see the area of preconception as “their
responsibility”, other than as a means of supporting a larger initiative (Silzer,
2007). “Our offices are inundated with tools, I don’t know if tools are the right
thing…” (p.24). It would be prudent to consult with physicians and other Primary
Care providers in private practice who may have differing professional needs and
engage in counselling activities that differ from those of Primary Care Network
Providers. As well, to work with the Quality Improvement functional area, APHP
to use existing mechanisms to identify needs for resource tools and information.
• Currently two health regions in Alberta are offering preconception educational
sessions which have been individually developed (Appendix G). Harnessing the
power of a collective group would enable an evidence-informed educational
tool available to all the health regions. Resources would need to be adapted and
translated and be appropriate to Alberta’s diverse communities.
29

2. Education:
• Continuing Education. The healthcare providers in the PCN focus groups
identified one educational strategy, i.e. to link with the Managing Obstetrical
Risk Efficiently (MORE OB) program of the Society of Obstetricians and
Gynaecologists of Canada (SOGC) to include a chapter with updated information
on preconception (although it was recognized that the MORE OB program
only targeted healthcare providers in acute care, participants felt the structure
was effective) (Silzer, 2007). Providers in the PCN focus group recognized the
challenges of keeping current. “Doctors are terrible, absolutely abysmal at keeping
up. How do you bring healthcare providers to the point of evidence – based
medicine without recertification It’s a nightmare!” (Silzer, 2007, p.11). Further
work in this area would be warranted to be able to design continuing education
opportunities that meet the needs of a broad range of practicing healthcare
providers. In the APHP, Rural Strategies Focus group report, it was recommended
to consider using electronic means of providing distance education to nurses
(Wanke, Gardner, Deuchar-Fitzgerald, 2007).
• Post Secondary Education. Collaborate with Professional Associations and Post
Secondary Educational Institutions, i.e. medicine, dentistry, pharmacy, nursing,
physical education and recreation to develop and implement preconception
curriculum for healthcare professionals. The need to strengthen basic nursing
education to include experience in normal obstetrics was identified in the APHP
Rural Strategies Baseline Evaluation report (Wanke, Gardner and Deuchar-
Fitzgerald, 2007).
3. Workforce Capacity. Expand the use of alternate care providers for preconception
risk screening and counselling thereby increasing access to preconception health
services. The Primary Care providers in the focus groups indicated that time and
resources do not allow for the foray into what they considered wellness activities,
especially when you are trying to effectively deal with “the illness side of things”
(Silzer, 2007). “We [Primary Care providers] can’t target everyone. We don’t have
time” (p.15). There was recognition of a Primary Care role when patients have risk
factors, regardless of whether the individuals were planning a pregnancy. Within
the PCN focus group, “alternate care providers” (nurses, nurse-midwives and nurse
practitioners) were identified as an alternative provider of preconception information
and screening during birth control visits or contacts with young clients or during well
women care (Silzer, 2007). Revisiting the expanded use of alternate service providers
was also identified as a regional health action in the Rural Strategies Evaluation report
(Wanke, Gardner & Deuchar-Fitzgerald, 2007). The Alberta Government’s Health
Policy Framework, 2006 recognizes that by using the skills and training of health
professionals to their fullest in a team based approach to care will enable people
30

to get the help they need quickly from the most appropriate provider. The SOGC
(2003) stated that the “integration of midwifery into the obstetrical healthcare team
is fostering excellence in maternity care for Canadian women and their families”;
currently Alberta Health and Wellness does not fund midwifery services (Canadian
Health Services Research Foundation, June 2006). A challenge is to change the
“fee for service” to compensation for a “collection of services” that might include
preconception care as part of maternity care or part of well women care.
Use alternate service providers to meet the needs of higher risk sub-populations
who are currently not seeking help from healthcare providers for preconception risk
factors. Developing preconception skills and knowledge of paraprofessionals working
with higher risk populations such as family support workers, peer counsellors, and
outreach workers may provide a complementary source of informational support.
A dialogue with government, populations at higher risk, and community agencies
whose target populations are low-income families, Immigrant and Aboriginal families
would assist in developing services to meet the needs of marginalized population
groups. Both provider focus groups focused on income disparities throughout
the discussions, primarily in terms of defining those “planning” versus those “not
planning” a pregnancy, the latter not seeking resources and information when they
are in fact the target group most at risk (Silzer, 2007). An underlying theme relating
to the provision of culturally appropriate information and care was “the right
provider at the right time and the right place”. Emphasis was on going to where the
people are and tailoring the activity to meet the needs of the specific community,
cultural group or age range targeted (Silzer, 2007). The PCN group stated “One size
does not fit everybody. You need different strategies for different groups” (p.16).
4. Integration into existing programs and services. Everyone is busy and there are
many conflicting demands on our time and attention. Using the existing range of
services will help to ensure consistent and coordinated information and messages.
Working with community agencies that provide services to the target population,
explore ways to integrate preconception health information and messages into already
existing community health programs and community based services, i.e. public
health programs, school programs, home visitation programs, parenting programs,
Community Action Program for Children (CAPC) and Canada Prenatal Nutrition
Programs (CPNP), Aboriginal health projects, etc. Focus group participants in
the PCNs identified opportunities for interconception care at regional Well Baby
Clinics and at the federal CPNPs located throughout the province (Silzer, 2007).
®
Women in the consumer focus groups identified access to timely information and
connecting with a network or support system to assist and encourage healthy choices
as paramount to achieving success (Silzer, 2007).
31

Secondary Prevention
5. Provide clinical services to those families/individuals with preconception risk
factors that put them at higher risk for having an adverse perinatal outcome.
In partnership with the medical professional associations, identify the need to
develop/consolidate practice guidelines for preconception care, as they relate to
secondary prevention, i.e. management of prepregnancy medical conditions, assisted
reproductive technologies to reduce multiple gestations; in particular, attention
should be paid to the transfer of single embryo, use of ovulation drugs and other
nonassisted reproductive technologies (Behrman & Butler, 2006).
6. Change the structure of prenatal care. A second suggested activity related to
secondary prevention, is to re-examine the structure and content of prenatal care
(i.e. physician visits) based on risk status. Explore the feasibility of funding a
preconception visit for those women with preconception and/or interconception
risk factors, and whether changing the timing of visits based on needs could improve
birth outcomes for high risk women.
Key Outcomes:
Short-term
• Increased access for health professionals/paraprofessionals to resources for providing
preconception risk screening, health counselling and education.
• Increased knowledge, skills and practices in preconception primary prevention.
• Better collaboration and integration of preconception health information and
education into existing programs and services targeting women, men and youth
of reproductive age.
Medium-term
• Increased proportion of women, men and youth who engage in healthy behaviors.
• Increased access to preconception health services.
• Increased proportion of women, men and youth who seek assistance for preconception
risk factors.
Long-term
• Improved perinatal outcomes.
32

3. Champion Preconception Health Supporting Environments
Considerations for Action
Albertans of reproductive age live, learn, work and play in environments that can make
it difficult to make preconception healthy choices. Championing health supporting
environments is all about enhancing youth and adults ability to make positive health
choices during their reproductive years and to address barriers in communities that are
most in need. Four activities are delineated to help champion preconception health
supporting environments.
Objective:
Help future families raise healthy children. Preconception health promotion and disease
prevention extends beyond the scope of the health sector alone. The reproductive health
of Albertans’ is affected by the physical environment, education, workplace, income
and other determinants. Bringing these different areas together will be critical to the
success of “healthy mothers and infants that are born each year in Alberta”. A recently
released study by the Canadian Center for Policy Alternatives, demonstrates a growing
income inequality in Canadian families raising children, beginning in the late 1990’s and
continuing today despite strong economic growth (Yalnizyan, 2007). In fact, only the
richest 10% of Canadian families are experiencing gains from Canada’s economic growth,
reporting a 30% increase in earnings this last decade; making more money than 95%
of families raising children. The fact that Canadian families are getting better educated,
delaying family formation and working harder is not paying off in terms of increased
(inflation-adjusted) earnings. These data underscore the importance of strong federal
and provincial programs that support families raising children throughout the income
spectrum (Yalnizyan, 2007).
Suggested Activities:
1. Develop a position statement. A position statement on preconception health
is a way of building support for policies supportive of promoting and protecting
reproductive health. The statement can then be endorsed by key decision making
bodies. Using a credible spokesperson with lived experience, is another suggested way
of building support for policies.
2. Collaborate across sectors to build policies that support future families raising
healthy children. Intersectoral collaboration makes possible the knowledge and
means of understanding the issues whose solutions lie outside the reach of a single
sector. Through working with partners across sectors (i.e. health, government; such
as education, finance, environment as well as non-government representatives from
voluntary, non-profit, and private sectors) courses of political action to support
33

future families can be identified based on available evidence, community preferences,
political realities and resource availability. The following family focused policy areas
are proposed for collaboration to further understand and explore actions that would
help future families raise healthy children:
• Promote policies related to reducing student debt for post secondary education
for Alberta youth, as financial debt associated with undergraduate education is a
factor in delayed childbearing. Certain subpopulations do not have equitable access
to post secondary education and policies supportive of access to youth living on
low-incomes and Aboriginal youth is needed. Education is a determinant of health
and while we have high enrolment rates, the demographics are not representative
of equitable opportunities.
• Advocate for policies that make the decision to have a family an easier one for
low to middle income families. Battle (2006) recommends changes to the new
Federal Universal Child Care Benefit (UCCB) to make it more equitable for lower
income families. He argues for delivery of the UCCB through the Canada Child
Tax Benefit program (non-taxed income tested program), which would result in a
regulated child care allowance, and while not available for high-income families,
would significantly benefit low to middle income families. The UCCB has also
been critiqued because it only covers a fraction of the cost of child care, and does
not address the most pressing need for affordable quality child care (Battle, 2006).
• Related to the recent trends in increasing work hours and decreasing leisure time;
policies that support creative work-life balance are needed to enable parents to
adjust their work schedules to accommodate family responsibilities. Pronovost’s
study indicated that it was not so much the number of hours worked but in fact
the inability to adapt one’s work schedule that was contributing to the stress. He
goes on to say that the challenge is to change the current traditional notion of
work as a fixed activity independent of family life (2007). Common flexible work
arrangements include: flexible start and finish times, compressed work week,
reduced hours, job sharing, and telecommuting (working at home for all or some
of their scheduled work hours (McNaughton, 2001).
• Maternal benefits and job security are based on prior earnings and on the woman’s
employment record before conception, thus providing strong incentives for
women to work full time prior to giving birth or even to postpone childbirth
until their earnings are sufficiently high. The higher the woman’s education, the
higher her wages and thus her time opportunity costs (loss of working hours,
and experience, and human capital depreciation). There is no compelling reason
why the replacement rate for parental leave should be the same as unemployment
(55% of average insured earnings). Lefebvre & Merrigan (2003) make the case for
policies that increase maternity and parental leave benefits to a rate of 70 to 85%
34

of gross insured earnings (similar to provincial programs that cover temporary
loss of income from a work or car accident) which would be more consistent with
the objectives of parental leave. In addition, increased benefits might provide
incentives for men to use parental leave. The current paid leave of 50 weeks in
Alberta (2004) recognizes the value of breastfeeding and parental attachment. Less
educated women are more likely to leave the labour market prior to giving birth
and never return. One of the obstacles may be child care costs which make it more
profitable for women to care for their own child. Lefebvre & Merrigan (2003)
argue that for women with no access to Employment Insurance, no entitlements
or insured earnings, flat monthly benefits paid for approximately 6 months would
seem to be a fair treatment.
• Advocate for workplace policies that would protect fertility and the critical period
of organogenesis for both female and male workers who are intending to have a
family and wish to be removed from working conditions that may be hazardous.
There is no legislation in place that grants any worker the right to be reassigned
during the period prior to conception to avoid reproductive hazards (Sarra, 1996
cited in Best Start, 2001). Quebec, France, Finland, Italy and Denmark have
progressive workplace policies that provide protective reassignment and paid
leave for women and in the case of Finland, men too; from jobs that could harm
the unborn child (Best Start, 2001). Expanding the definition of reproduction
to include preconception, would permit an exploration of workplace policies
supportive of pregnancy planning.
• Support policies that control alcohol and smoking consumption, i.e. beverage
warning labels, responsible service, and increased taxation.
3. Work with other Provincial initiatives whose mandate is to make healthy choices
the easiest choice, specifically initiatives that will impact preconception health,
i.e. AADAC, Healthy Kids Alberta, Alberta Healthy Living Network and
Healthy Schools, etc.
4. Foster Learning and Innovation:
• Support research to inform policy development by advancing knowledge of
the impact on reproductive health of occupational and environmental hazards,
including the following; chemical substances, biological agents, ergonomic
considerations, physical factors, and work schedules. Encourage innovation and
dissemination of less toxic production alternatives (Best Start, 2001).
• Prepare an evidenced based/informed review of policies that would be supportive
of helping future families raise healthy children.
35

• Utilize the Alberta Quality Matrix, 2005 http://www.hqca.ca/index.phpid=87 as
a framework to develop and measure preconception indicators.
• Encourage and support evaluation of preconception model programs and projects,
including integrated service delivery and community health promotion projects.
• Support research to advance knowledge of effective strategies to improve
preconception health and effective methods for delivering preconception care.
Outcomes:
• Increased collaboration and planning across health and “non-health” sectors of
approaches that address social and living conditions that will promote and protect
preconception health.
• Development of a research agenda that will foster learning and innovation in the area
of preconception health promotion.
• Commitment to fund strategies to address issues related to improving reproductive
health so that future families can raise healthy children.
Summary and Recommendations
Preconception health promotion and prevention are essential components to improving
perinatal outcomes. Despite advances in prenatal care, low birth weight and preterm
birth weight rates continue to be of concern. A good proportion of women are
approaching pregnancy with risk factors for adverse perinatal outcomes. There is evidence
that intervening before conception using a life course perspective to improve reproductive
health will be beneficial for both women and men, irrespective of their desire to have
a family.
Three strategies are proposed to increase public awareness and knowledge of the
optimal health factors for conception and early pregnancy; to build capacity to provide
preconception health services and lastly to champion for supportive environments that will
help future families raise healthy children.
The Alberta Perinatal Health Program in collaboration with its stakeholders has completed
the first step in preconception health promotion and disease prevention by developing a
plan for action to address the issues of public awareness, health services, and environmental
conditions. These three issues were delineated in the preconception focus group report and
are well supported by the literature.
The next steps to move the agenda of preconception heath forward are for the APHP to
decide on the suitability of the action plan given the other priorities of the Consensus
Development Conference - Healthy Mothers Healthy Babies: How to prevent low birth
weight in May, 2007 and the developing Provincial Perinatal Health Strategy. Also for the
36

APHP to dialogue with the Regional Health Authorities through the Partnership Accord
to decide how the preconception action plan might complement other activities at the
regional level.
Lastly, further qualitative data gathering and analysis are recommended to increase the
generalizability of the focus group results to the larger population of females and males
of reproductive age. As well, to consult with physicians and other Primary Care providers
in private practice who may have differing professional needs and engage in counselling
activities that differ from those of Primary Care Networks. Community providers should
also be included in qualitative data gathering and analysis to collect information on other
programs/services offered in the community and to solicit suggestions for appropriate
services to target at risk groups.
37

Appendix A
Alberta Perinatal Health Advisory Committee Membership List – Dec. 2006
Sauve, Dr. Reg
Professor
Department of Community Health Sciences
University of Calgary
Benzies, Dr. Karen
Associate Professor
Institute of Maternal & Child Health
University of Calgary
Cross, Dr. James (Jay)
Director, Institute of Maternal and Child Health
Faculty of Medicine
University of Calgary
Clark, Dr. Virginia
Professional Corporation
Calgary
Lee, Dr. Shoo
Integrated Centre for Care Advancement
Through Research (iCARE)
Capital Health Authority
Lightfoot, Ms. Penny
Director, Population Health and Research
Capital Health Authority
Muir, Dr. Brian
Obstetrician
Grande Prairie, Alberta
Rowntree, Dr. Carol
Family Practice Physician
Greenwood Family Physicians
Sundre, Alberta
Co-Chairs
Committee Membership
MacDonald, Mr. Neil
Executive Director
Population Health Strategies Branch
Alberta Health and Wellness
De Villiers, Dr. Albert
Medical Officer of Health
Peace Country Health
Foulston, Dr. Charlotte
Pediatrician
Medicine Hat, Alberta
Lange, Dr. Ian
Department Head, Obstetrics and Gynecology
Calgary Health Region
Foothills Hospital
Sadoway, Ms. Delmarie
Senior Operating Officer
Capital Health Authority
Tough, Dr. Suzanne
Associate Professor
Department of Community Health Sciences
& Pediatrics
Alberta Children’s Hospital
Van Aerde, Dr. John
Regional Director for Newborn Services
Northern Alberta Neonatal Intensive Care Program
Clinical Professor, University of Alberta
Young, Ms. Heather
Director of Nursing Services
Health Canada, Alberta Region
First Nations and Inuit Health Branch
Edmonton, Alberta
38

Appendix A
Berezanski, Ms. Joan
Director, Office of Medical Care Consultant
Alberta Health and Wellness
Blahitka, Ms. Laurie
Director, Women’s Health
Calgary Health Region
Frick, Ms. Corine
Director, Alberta Perinatal Health Program
Calgary Health Region
Hnydyk, Dr. William
Assistant Executive Director
Professional Affairs Alberta Medication Association
Edmonton, Alberta
Ex Officio Members
Janes-Kelley, Ms. Selikke
Patient Care Director, Women’s Health Program
Royal Alexandra Hospital
Keays, Dr. Gloria
Provincial Health Officer
Alberta Health and Wellness
Mazurenko, Ms. Irene
Project Manager
Population Health Strategies Branch
Alberta Health and Wellness
Robb, Mr. Jonathan
Acting Manager, Sub-Population
Surveillance Unit
Alberta Health & Wellness, Public Health
Surveillance & Environmental Health
39

Appendix B
Focus Group Methodology
Primary Care Network Provider Groups:
The first two focus groups were comprised of members of two distinct Primary Care
Networks in Alberta which were identified for potential recruitment by the Coordinating
Committee of the APHP. One urban and one rural collaborative were identified for
participation. Recruitment through the Primary Care Network project managers was
conducted by the Preconception Coordinator, APHP following consultation with the
provincial program director for the Primary Care Initiative. A cover letter was sent to
each of the networks to invite them to participate in a two-hour focus group that would
contribute to the development of an action plan for preconception health. Proposed
dates and times during November 2006 were provided, enabling each team to choose a
two-hour time that would be more convenient to individual schedules. Participants were
offered a light meal and an honorarium for independent (fee-for-service) practitioners
was available.
At the request of one of the Primary Care Networks, pre-reading materials were forwarded
to group members. Both groups received the same background materials, which included
“Recommendations to Improve Preconception Health and Health Care” (CDC, 2006)
and “Preconception Risk Factors: Evidence-Based Interventions” (APHP, 2006 based
on the CDC, 2006 Report). General discussion questions and a reminder notice were
e-mailed to the respective key contact for each group prior to the focus group date.
The groups were moderated by a staff member from Survey and Evaluation, Calgary
Health Region, who traveled with the Preconception Coordinator, APHP to the
individual communities to conduct the focus groups in November 2006. An identical
question guide, developed in conjunction with the Preconception Coordinator, APHP
and based on predetermined focus group objectives was used for both Primary Care
Network groups. Focus group questions were reviewed by Ontario Best Start and the Peel
Health Region based on their expertise in preconception health program planning and
implementation and subsequently approved by the Director, APHP. The question guide
used for the Primary Care Network focus groups is listed in Appendix C.
Participants were provided with background and contact information for the APHP
should there be any queries for which the moderator was unable to provide an adequate
response at the time of the focus group discussion. The discussion was audio taped
and field notes were taken. The moderator had no previous contact with focus group
participants. Tape-based analysis of the audiotapes was conducted and themes were
identified based on the question guide. The information that emerged from the analysis
was aggregated and themed and provided the basis for the provider perspective of
preconception health service needs and opportunities.
40

Appendix B
Consumer Groups (Women and Men):
The Calgary Health Region Population Survey (CHRPS) was used to recruit women and
men ages 18-44 years for the third and fourth focus groups. This telephone survey, which
assesses a number of population health indicators among the general healthy population,
provides an on-going random sample of the adult population in the region. Survey
respondents are asked if they are interested in participating in focus groups in the future,
and from this list, trained telephone interviewers are assigned to contact respondents for
participation in targeted focus groups. Women and men within the specified age range
were recruited into separate groups in order to identify preliminary themes relating
to preconception knowledge and behaviors of each of these groups. Although not
generalized to the larger population, thematic results provide the groundwork to begin
health promotion program planning.
Due to a relatively low response among the male target population two weeks prior to
the focus group date, advertising for this group was also conducted by the Preconception
Coordinator at the local university and community college in an attempt to increase
participation rate, particularly among young adult males. Permission was obtained from
the respective educational institution sites to post focus group advertisements in accepted
student areas. All potential focus group participants were given a general description
of the focus group topic, and assured that it was not necessary to be a parent or to be
planning to have children in the future in order to participate. A light meal and $50
honorarium was offered. Attendance was confirmed via telephone with all focus group
participants one working day prior to each session by the same individual who had
recruited for the focus groups. The two hour focus groups were held at the new Alberta
Children’s Hospital in Calgary, Alberta during the last week of November, 2006.
The same moderator, in conjunction with an assistant moderator from the Survey and
Evaluation Unit, Calgary Health Region conducted the groups. A question guide was
developed with the assistance of the Preconception Coordinator of the APHP following
the delineation of specific focus group objectives. Focus group questions were reviewed
by Ontario Best Start and Peel Health Region with their suggestions incorporated into
the final question guide, which was then approved by the Director, APHP (Appendix C -
Focus Group Question Guide for Consumer Groups). Individuals from each focus group
were asked to complete one page of demographic information, including data pertaining
to age, education, marital status, number and ages of children, and current/future
intentions to become pregnant/have children. As an icebreaker, participants were asked
to introduce themselves and to relate their worst health-related habit to the group. This
concept was introduced in a non-judgmental style, and prepared group members to think
about their own health in a non-threatening and introspective manner.
41

Appendix B
To conclude the discussions, general preconception awareness information was provided
while “filling in the gaps” in areas where participants appeared to lack preconception
health knowledge. This allowed participants to gain a general awareness of preconception
information so that they could suggest potential methods of sharing this information to
the general public and to specific target audiences based on perceived importance. Both
groups were asked about how this type of information should be shared effectively and
specifics about the target population for which the information should be made available.
The discussions were audiotaped and field notes were taken. Neither the moderator nor
the assistant moderator had any previous clinical contact with focus group participants.
Following the group session, participants were provided with the option of receiving
contact information for Health Link Alberta, in addition to copies of resources from the
Ontario Best Start Program. These resources included “My 9 Months, Are you Ready
for a Baby” and “Men’s Information, How to Build a Healthy Baby”. Once again,
tape-based analysis of the audiotapes was conducted and themes were identified based
on the question guide. The information that emerged from each analysis was aggregated
(but presented separately for each group to highlight differences between women and
men) and formed the basis for the consumer perspective on awareness and knowledge of
preconception health.
42

Appendix C
Focus Group Question Guide for Primary Care Network Providers
Questions
Given the preconception risk factors for adverse pregnancy outcomes identified by the CDC (2006):
1. What additional information do you and your colleagues need about preconception
healthcare
2. How would you prefer to receive this information
3. What current activities for providing preconception healthcare are you using in your practice
4. Given the Action Plan from the CDC, 2006 outlining recommendations for building
Preconception Health and Health Care services for the United States:
Does this plan “fit” or apply to your Primary Care Network Why or why not
5. Think about your current practice, are there gaps in preconception services that exist
If yes, what are these gaps
Do gaps in preconception resources exist If yes, what are these gaps
6. What other activities or strategies would you suggest using How would you see these
carried out
Who should be the target population All women All men All women and men or those
currently planning a pregnancy Why do you say this
7. What supports would be needed to carry this out
8. What ways are you currently addressing or could you address cultural, language and income
disparities when implementing these strategies
9. Following summary of discussion:
How well does this describe what was discussed tonight Have we missed anything
43

Appendix C
Focus Group Question Guide for Consumer Groups (women and men,
separate groups)
Questions
1. What kinds of things are you doing to be healthy
2. Is it important to you to be healthy What are the benefits of being healthy
3. Where do you normally get information about health
4. In terms of health, what are the first things people should do when they find out
they’re pregnant
5. Are these habits important for anyone to do regardless of gender
6. Taking a look at the list of things that you have identified here, are these things important
for someone to do even if they are not pregnant or not planning a pregnancy
Why or why not
Where did you hear about these factors
7. What are the barriers to (participating in) these health habits before pregnancy
(Women’s Group - Go to Q 8, 9 / Men’s Group - Go to Q 10, 11)
8. What role do you think a woman’s health plays in producing a healthy child
Is it different for men Why and in what way
9. What can a woman do to maintain her health and prepare for a pregnancy, planned
or unplanned
What can a man do
(Now go to Q 12)
44

Appendix C
10. What role do you think a man’s health plays in producing a healthy child
Is this role different for a woman Why and in what way
11. What can a man do to maintain his health and prepare for a pregnancy, planned or unplanned
What can a woman do
12. Where should the information that we talked about tonight be available
How should the information be shared
Where would you like to receive the information
Who should be the target of this information
13. Synopsis - How well does this describe what was discussed tonight Have we missed anything
45

Appendix D
Partnership Accord Membership List - April 2007
Chair phone fax
Ms. Selikke Janes-Kelley (Chairperson)
Director, Patient Care Director,
Women’s Health Program
4773 Women’s Centre
Royal Alexandra Hospital
10240 Kingsway Avenue
Edmonton, AB T5H 3V9
E-mail: sjaneske@capitalhealth.ca
(780) 735-4802 (780) 735-5051
Admin. Assistant: Shannon Fitzgerald
E-mail: sfitzger@capitalhealth.ca
Chinook Regional Health – Region 1
Ms. Linda Lacny
Director, Women’s Health
Chinook Health Region
(780) 735-4804 (780) 735-5051
(403) 388-6281 (403) 388-6613
960 – 19th Street South
Lethbridge, AB T1J 1W5
E-mail: llacny@chr.ab.ca
Palliser Health Region – Region 2
Ms. Linda Iwasiw
Senior Vice President
Health Services
666 – 5th Street SW
Medicine Hat, AB T1A 4H6
E-mail: liwasiw@palliserhealth.ca
Admin. Assistant: Laura Schattle-Weiss
E-mail: lschattleweiss@palliserhealth.ca
Ms. Susan Schank
Regional Program Manager
Pediatrics & Perinatal
(403) 528-5622 (403) 529-8998
(403) 529-8052 (403) 529-8998
(403) 502-8260 (403) 529-8976
666 – 5th Street SW
Medicine Hat, AB T1A 4H6
E-mail: sschank@palliserhealth.ca
46

Calgary Health – Region 3 (Calgary)
Ms. Laurie Blahitka
Director, Child and Women’s Health
Foothills Medical Centre
Room 132, North Tower
1403 – 29th Street NW
Calgary, AB T2N 2T9
E-mail: laurie.blahitka@calgaryhealthregion.ca
Admin. Assistant: Yasmin Lalji
E-mail: yasmin.lalji@calgaryhealthregion.ca
Dr. Brent Friesen
Medical Officer of Health
Southeast Community Portfolio
10101 Southport Road SW
Calgary, AB T2W 3N2
E-mail: brent.friesen@calgaryhealthregion.ca
Admin. Assistant: France Millette
E-mail: france.millette@calgaryhealthregion.ca
(403) 944-2189 (403) 944-2184
(403) 944-1879 (403) 944-2184
(403) 943-1280/79 (403) 943-1294
(403) 943-1280 (403) 943-1294
David Thompson Regional Health – Region 4 (Red Deer)
Ms. Debbie Leitch
(403) 343-4541 (403) 343-4866
Professional Practice Leader
Patient Care, Red Deer Regional
Hospital Centre
Nursing Administration
P.O. Bag 5030
3942 – 50A Avenue
Red Deer, AB T4N 6R2
E-mail: dleitch@dthr.ab.ca
Ms. Jennifer Currie
Public Health Nursing Leader
Red Deer Bremner Community
Health Centre
2845 Bremner Avenue
Red Deer, AB T4R 1S2
E-mail: jcurrie@dthr.ab.ca
(403) 309-8175 (403) 341-2167
47

East Central Regional Health – Region 5 (East Central)
Ms. Elizabeth Francis
(780) 336-4786
Program Leader Obstetrics
Cell:
Viking Health Centre
(780) 385-0250
Box 60, 5110 – 57th Avenue
Viking, AB T0B 4N0
E-mail: elizabeth.francis@ech.ab.ca
(780) 336-4983
Lois Sonnega
Acting Director of Acute Services
Lloydminster Hospital
(306) 820-6183 (306) 825-9880
3820 – 43rd Avenue
Lloydminster, SK S9V 1Y5
E-mail: lois.S@pnrha.ca
Cindy Wilford, RN
Acting Manager, Obstetrics/Surgery
Lloydminster Hospital
(306) 820-6105 (306) 825-9880
3820 – 43rd Avenue
Lloydminster, SK S9V 1Y5
E-mail: cindy.W@pnrha.ca
Capital Health – Region 6 (Edmonton)
Ms. Selikke Janes-Kelley
Patient Care Director, Women’s Health Program
(780) 735-4802 (780) 735-5051
4773 Women’s Centre
Royal Alexandra Hospital
10240 Kingsway Avenue
Edmonton, AB T5H 3V9
E-mail: sjaneske@capitalhealth.ca
Admin. Assistant: Shannon Fitzgerald
E-mail: sfitzger@capitalhealth.ca
(780) 735-4804 (780) 735-5051
48

Aspen Regional Health Authority – Region 7
Mr. Tony Brannen
Director of Health Services (Acute Care)
10220 – 93rd Street – 2nd Floor
Westlock AB T7P 2G4
E-mail: abrannen@aspenrha.ab.ca
Admin. Assistant: Judy Hardement
E-mail: judy.hardement@aspenrha.ab.ca
Ms. Fiona Murray-Galbraith
Community Health Services Manager
Hinton Community Health Services
1280A Switzer Drive
Hinton, AB T7V 1T5
E-mail:fiona.murray-galbraith
@aspenrha.ab.ca
Admin. Assistant: Lynne Loranger
E-mail: Lynne.loranger@aspenrha.ab.ca
Ms. Lisa McConnell
Facility Supervisor
Hinton Healthcare Centre
1280 Switzer Drive
Hinton, AB T7V 1V2
E-mail: lisamcconnell@aspenrha.ab.ca
(780) 349-6913
x 224
(780) 350-3006
Cell:
(780) 349-0995
(780) 349-6913
x 221
(780) 349-5723
(780) 817-4116 (780) 865-3727
(780) 817-4122
(780) 817-5001
(Direct)
(780) 865-3333
x 1101
(780) 865-1099
Peace Country – Region 8 (Grande Prairie)
Ms. Deborah Jesso, MSW
Director, Acute Care Services
Women and Children’s Health
Queen Elizabeth II Hospital
(780) 538-7542
10409 – 98 Street
Grande Prairie, AB T8V 2E8
E-mail: deborah.jesso@pchr.ca
Admin. Assistant: Sherrill Blackman
E-mail: sherill.blackman@pchr.ca
49

Ms. Donna Koch
Director, Regional Community
Health Services
Peace County Health
Queen Elizabeth II Hospital
Regional Directors Office
(780) 538-7544 (780) 538-7126
10409 – 98 Street
Grande Prairie, AB T8V 2E8
E-mail: donna.koch@pchr.ca
Admin. Assistant: Nellie Klassen
(780) 538-7151 (780) 538-7126
E-mail: Nellie.klassen@pchr.ca
Ms. Tracey Parsons
(780) 538-7273 (780) 538-7621
Queen Elizabeth II Hospital
10409 – 98 Street
Grand Prairie, AB T8V 2E8
E-mail: tracey.parsons@pchr.ca
Northern Lights Regional Health Services Region 9 (Fort McMurray)
Sandra Janzen
(780) 791-6163 (780) 791-6042
Director, Acute Care Services
Northern Lights Regional Health Centre
7 Hospital Street
Fort McMurray, AB T9H 1P2
E-mail: sjanzen@nlhr.ca
Admin. Assistant: Anne Marie Butt
(780) 791-6222
E-mail: abut@nlhr.ca
Vicki Greening
(780) 791-6163 (780) 791-6029
Manager, Obstetrics
Northern Lights Regional Health Services
7 Hospital Street
Fort McMurray, AB T9H 1P2
E-mail: vgreening@nlhr.ca
50

APHP Coordinating Committee Members phone fax
Dr. William Hnydyk
(780) 482-2626 (780) 482-5445
Assistant Executive Director
Professional Affairs
Alberta Medical Association
12230 – 106 Avenue, NW
Edmonton, AB T5N 3Z1
E-mail: william.hnydyk@albertadoctors.org
Admin. Assistant: Myrna Patterson
E-mail: myrna.patterson@albertadoctors.org
(780) 482-2626 (780) 482-5445
Ms. Selikke Janes-Kelley
Director, Patient Care Director,
Women’s Health Program
4773 Women’s Centre
Royal Alexandra Hospital
10240 Kingsway Avenue
Edmonton, AB T5H 3V9
E-mail: sjaneske@capitalhealth.ca
Admin. Assistant: Shannon Fitzgerald
E-mail: sfitzger@capitalhealth.ca
Ms. Laurie Blahitka
Director, Child and Women’s Health
Foothills Medical Centre
Room 132, North Tower
1403 – 29th Street NW
Calgary, AB T2N 2T9
E-mail:laurie.blahitka@calgaryhealthregion.ca
Admin. Assistant: Yasmin Lalji
E-mail: yasmin.lalji@calgaryhealthregion.ca
Ms. Corine Frick
Foothills Medical Centre
1403 – 29th Street NW
Suite 310, South Tower
Calgary, AB T2N 2T9
E-mail: corine.frick@calgaryhealthregion.ca
Admin. Assistant: Lorraine Pearson
E-mail: lorraine.pearson@calgaryhealthregion.ca
(780) 735-4802 (780) 735-5051
(780) 735-4804 (780) 735-5051
(403) 944-2189 (403) 944-2184
(403) 944-1879 (403) 944-2184
(403) 944-3034 (403) 944-1243
(403) 944-3034 (403) 944-1243
51

APHP Advisory Committee
Ms. Irene Mazurenko
Population Health Strategies, Alberta Health
and Wellness
23rd Floor, 10025 – Jasper Avenue NW
Box 1360 Stn. Main
Edmonton, Alberta T5J 2N3
E-mail: irene.Mazurenko@gov.ab.ca
Admin. Assistant: Shirani Samaratunga
E-mail: shirani.samaratunga@gov.ab.ca
APHP Staff (North Office)
Ms. Nancy Bott
Coordinator, Information Management
Alberta Perinatal Health Program
Kingsway Professional Centre
Suite 300, 10611 Kingsway Avenue
Edmonton, AB T5G 3C8
E-mail: nbott@capitalhealth.ca
Ms. Lesly Deuchar-Fitzgerald
Coordinator, Education
Alberta Perinatal Health Program
Kingsway Professional Centre
Suite 300, 10611 Kingsway Avenue
Edmonton, AB T5G 3C8
E-mail: ldeuchar@capitalhealth.ca
Ms. Grace Guyon
Coordinator, QI/QA
Alberta Perinatal Health Program
Kingsway Professional Centre
Suite 300, 10611 Kingsway Avenue
Edmonton, AB T5G 3C8
E-mail: graceguyon@capitalhealth.ca
(780) 427-3488 (780) 422-5474
(780) 415-0616 (780) 422-5474
(780) 735-1002 (780) 735-1024
(780) 735-1012 (780) 735-1024
(780) 735-1006 (780) 735-1024
52

Ms. Ann Hense
Coordinator, MORE OB Program
Alberta Perinatal Health Program
Kingsway Professional Centre
Suite 300, 10611 Kingsway Avenue
Edmonton, AB T5G 3C8
E-mail: ahense@capitalhealth.ca
Ms. Betty Jennissen
Coordinator, QI/QA
Alberta Perinatal Health Program
Kingsway Professional Centre
Suite 300, 10611 Kingsway Avenue
Edmonton, AB T5G 3C8
E-mail: bjennissen@capitalhealth.ca
Ms. Laureen McPeak
Coordinator, Education
Alberta Perinatal Health Program
Kingsway Professional Centre
Suite 300, 10611 Kingsway Avenue
Edmonton, AB T5G 3C8
E-mail: laureenmcpeak@capitalhealth.ca
APHP Staff (South Office)
Ms. Tammie Bunnah
Analyst, Information Management
Foothills Medical Centre
1403 – 29th Street NW
Suite 310, South Tower
Calgary, AB T2N 2T9
E-mail: tammie.bunnah@calgaryhealthregion.ca
Ms. Jeannie Yee
Coordinator, Education
Foothills Medical Centre
1403 – 29th Street NW
Suite 310, South Tower
Calgary, AB T2N 2T9
E-mail: jeannie.yee@calgaryhealthregion.ca
(780) 735-1003 (780) 735-1024
(780) 735-1007 (780) 735-1024
(780) 735-1009 (780) 735-1024
(403) 944-1423 (403) 944-1243
(403) 944-4697 (403) 944-1243
53

Appendix E
Preconception Risk Factors: Evidence Based Interventions that included
Clinical Practice Guidelines
Risk Factor Intervention Proven Health Effect
Alcohol use Eliminating
alcohol use
No time during pregnancy is safe to drink alcohol, and
harm can occur early, before a woman has realized that
she is or might be pregnant. Fetal alcohol syndrome and
other alcohol-related birth defects can be prevented if
women cease intake of alcohol before conception.
Anti-epileptic
drugs
Diabetes
(preconception)
Folic acid
deficiency
Hepatitis B
HIV/AIDS
Anti-epileptic
drug (AED) use
management
Diabetes
management
Folic acid
supplementation
Hepatitis B
vaccination
for women of
reproductive age
HIV/AIDS
screening and
treatment
Hypothyroidism Hypothyroidism
management
Certain anti-epileptic drugs are known teratogens (e.g.,
valproic acid). Recommendations suggest that before
conception, women who are on a regimen of these
drugs and who are contemplating pregnancy should be
prescribed a lower dosage of these drugs.
The three-fold increase in the prevalence of birth defects
among infants of women with type 1 and type 2 diabetes
is substantially reduced through proper management
of diabetes.
Daily use of vitamin supplements containing folic acid
has been demonstrated to reduce the occurrence of
neural tube defects by two thirds.
Vaccination is recommended for men and women
who are at risk for acquiring hepatitis B virus (HBV)
infection. Preventing HBV infection in women of
childbearing age prevents transmission of infection
to infants and eliminates risk to the woman of HBV
infection and sequelae, including hepatic failure, liver
carcinoma, cirrhosis, and death.
If HIV infection is identified before conception, timely
antiretroviral treatment can be administered, and women
(or couples) can be given additional information that can
help prevent mother-to-child transmission.
The dosages of Levothyroxine® required for treatment
of hypothyroidism increase during early pregnancy.
Levothyroixine® dosage needs to be adjusted for proper
neurologic development of the fetus.
54

Appendix E
Risk Factor Intervention Proven Health Effect
Isotretinoins
Maternal
phenylketonurea
(PKU)
Obesity
Oral
anticoagulant
Rubella
seronegativity
Smoking
STIs
Accutane® use
management
Maternal PKU
management
Obesity
management
Oral anticoagulant
use management
Rubella vaccination
Smoking cessation
counselling
STIs screening and
treatment
Use of isotretinoins (e.g., Accutane®) in pregnancy to
treat acne can result in miscarriage and birth defects.
Effective pregnancy prevention should be implemented
to avoid unintended pregnancies among women with
childbearing potential who use this medication.
Women diagnosed with PKU as infants have an
increased risk for delivering neonates/infants with
mental retardation. However, this adverse outcome
can be prevented when mothers adhere to a low
phenylalanine diet before conception and continue it
throughout their pregnancy.
Adverse perinatal outcomes associated with maternal
obesity include neural tube defects, preterm delivery,
diabetes, caesarean section, and hypertensive and
thromboembolic disease. Appropriate weight loss and
nutritional intake before pregnancy reduces these risks.
Warfarin, which is used for the control of blood clotting,
has been demonstrated to be a teratogen. To avoid
exposure to warfarin during early pregnancy, medications
can be changed to a nonteratogenic anticoagulant before
the onset of pregnancy.
Rubella vaccination provides protective seropositivity and
prevents congenital rubella syndrome.
Preterm birth, low birth weight and other adverse
perinatal outcomes associated with maternal smoking
in pregnancy can be prevented if women stop smoking
before or during early pregnancy. Because only 20%
of women successfully control tobacco dependence
during pregnancy, cessation of smoking is recommended
before pregnancy.
Chlamydia trachomatis and Neisseria gonorrhoea
have been strongly associated with ectopic pregnancy,
infertility, and chronic pelvis pain. STIs during
pregnancy might result in fetal death or substantial
physical and developmental disabilities, including mental
retardation and blindness. Early screening and treatment
prevents these adverse outcomes.
Source: Centers for Disease Control and Prevention (MMWR) (2006:55 No. RR-6)
55

Appendix F
A Framework for Action
Vision
Optimal health for expectant mothers & the infants that are born each year in Alberta (APHP)
Goal
Women and men are in optimal health as they approach each pregnancy
Possible
Levels of
Action
Individual Factors:
Target for action are
the health behaviours
of men and women of
reproductive age.
Environmental
Factors:
Target for action are
the environmental
factors that can support
preconception health.
Key
Settings:
• Homes
• Schools
• Workplaces
• Community
• Health
Services
Target
Population:
• Youth &
adults of
reproductive
age
Principles
Social Justice
& Equity
Multiple
Strategies
Intersectoral
Collaboration
Evidence
Informed
Key
Strategies
Promote Public
Awareness &
Knowledge:
• Health communication
• Health education
(school & workplace)
• Self-help
Build Capacity to
Provide Preconception
Health Services:
• Resource development
• Education
• Workforce capacity
• Integration
Champion Preconception
Health Supporting
Environments:
• Develop position statement
• Collaborate across sectors
• Work with other provincial
initiatives
• Foster learning & innovation
Outcomes
Short-Term
• Increased knowledge by
population groups of interest
• Increased access to health
information/resources
• Better collaboration &
integration of efforts
Medium-Term (Changes in
Health Determinants)
• Increases in the proportion
of individuals who engage in
healthy behaviors
• Increased capacity to
create health promoting
environments
• Increased access to
preconception health services
Long-Term (Changes in
Health Status)
• Reduction in health disparities
• Improved perinatal outcomes
56

Appendix G
Examples of Initiatives
1. Initiatives to Promote Public Awareness and Education:
• In March 2005, Ontario Best Start (http://www.beststart.org) launched a Provincial
Preconception Campaign with the theme “Your Health Before Pregnancy Makes a
Difference…Think About It!” Their target audience was men and women between
the ages of 20-35 living in Ontario who were planning a pregnancy (http://www.
healthbeforepregnancy.ca). The key messages were:
- Reproductive health begins long before a baby is conceived, and
- A healthy baby is dependent upon the health of the mother and father prior
to pregnancy.
The community wide social marketing campaign components entailed:
- Using provincial mass media strategies including transit and movie theatre ads.
Camera-ready articles and TV and radio news clips were also developed.
- Supporting local activities by providing local groups with resources and information
for local interviews.
Evaluation results indicated an increase in awareness that women should make sure
they are healthy/visit their doctor before pregnancy from the pre (23%) to the postcampaign
survey (30%). In addition, there was a change in understanding men’s
responsibilities from “do nothing before pregnancy” (10% in the pre-campaign survey)
which decreased to 5% in the post-campaign survey.
• The Region of Peel (2006) implemented a strategy to encourage sexually active
young adults (22-34), who were not planning a pregnancy, to modify their attitudes
and behaviors (i.e. drugs, smoking, diet, folic acid, alcohol and exercise) that can
impact on the health of an unborn baby. Their key message was “What are the Odds”
with specific information directed at young men, with the question “What are your
boys swimming in” with the accompanying visual image of testicles at the bottom
of a martini glass and for young women “Quick, what have you had to drink in the
last 30 days” with the accompanying visual image of a positive pregnancy test. The
marketing campaign entailed poster distribution, condom packages with information
inserts, print ads, bookmarks, media coverage, and an interactive website (http://
www.peelregion.ca/health/preconception/index.htm#start). Evaluation results were
not available.
• In follow up to the mandatory fortification of folic acid (November, 1998) in white
flour, enriched pasta and cornmeal, Health Canada launched a national educational
folic acid campaign (2002) (http://www./healthcanada.ca/folicacid).
57

Appendix G
• In January 2006, the National Council on Folic Acid sponsored a national folic acid
awareness week entitled “FOLIC ACID: You Don’t Know What You’re Missing”
(http://www.folicacidinfo.org/campaign). The campaign awareness materials and a
national educational teleconference reached 2,300 healthcare providers in 43 States.
Results from March of Dimes telephone surveys conducted by Gallup (2002),
indicate that awareness of folic acid had increased from 52% in 1995 to 80% in 2002.
However, despite the increase in awareness reported in 2002, folic acid intake still
remains low with only 1 out of 3 women reporting taking a vitamin containing folic
acid daily.
• On March 1, 2007, the Minister of Health invested 3 million dollars to launch a five
week “Healthy Pregnancy” national public health campaign, to raise awareness of the
health considerations for a healthy pregnancy for both before conception and after.
Strategies include ads in buses, subways, doctor’s waiting rooms, restaurants and on
the internet (www.healthypregnancy.gc.ca). The campaign will also display materials
designed for First Nations and Inuit, including radio advertisements, posters and a
direct mail brochure. A new resource was also developed entitled “The Sensible Guide
to a HEALTHY Pregnancy”, which is available free of charge by visiting the web site
www.healthycanadians.ca.
2. Initiatives to Build Capacity to Provide Preconception Health Services:
• As a preterm birth prevention strategy, Capital Health Region through its Primary
Care Division, Community Health Services has been offering a free monthly
preconception education class since February 2006. The preconception curriculum
was developed by a working group and approved by the Women’s Health Council.
A focus group of parents attending childbirth education classes provided input into
the format and content. Specific topics requested were fertility awareness and genetic
screening. The location for the Saturday class changes monthly to increase accessibly,
and is offered at the various Community Health Centers. The class consists of 6
to 12 couples, including on occasion extended family participants, the majority of
participants are over 30 years of age, planning a family, middle class with one known
medical risk factor. Participants are recruited from advertisements on the Capital
Health web page and through the Capital Health Link. Evaluation data was not
available (C. Kimik, personal communication, October 6, 2006).
• Calgary Health Region, Women’s Health Resources offers a preconception workshop
for women entitled “Are you ready to start a family” Since 2002, registrations have
been low resulting in workshop cancellations. In January 2007, the workshop will be
revised and renamed “Before you become pregnant…” and will be available to male
registrants as well (I. Jackson, personal communication, September 27, 2006).
58

Appendix G
• March of Dimes has an on-line continuing education program for physicians on
preconception. In addition, March of Dimes has available a continuing education
module for Registered Nurses and Certified Nurse-Midwives entitled “Preconception
Health Promotion: A Focus for Women’s Health, 2003” (http://www.marchofdimes.
com/professionals/professionals.asp).
• Centers for Disease Control and Prevention (www.cdc.gov) has just recently developed
two new preconception e-mail based health education programs, entitled “Pregnancy
Planning: What to Know About your Health Before You Get Pregnant” and “Healthy
Living: How Women of Childbearing Age Can Get and Stay Healthy”. Both programs
are free and are offered through the Interactive Health Record (i Health Record)
located on-line at http:\\www.ihealthrecord.org.
• Pregnancy Foresight Project (http://www.swedishmedical.org/PregnancyForesight/
Home.html) provides a free on-line project targeting provider education. Funded by
March of Dimes, this website is designed as a resource tool for healthcare providers.
In addition, the project provides a preconception care program designed for doctors
to implement.
• Screening tools are available from March of Dimes (http://www.marchofdimes.
com/) – free on-line and the Wisconsin Association for Prenatal Care (http://www.
perinatalweb.org/association/) - for purchase.
• Patient education materials are available from March of Dimes for purchase as well
as the Wisconsin Association for Prenatal Care. The Ontario Best Start program
provides free on-line public educational materials (http://www.beststart.org/resources/
index.html).
• Alberta Medical Association, Toward Optimized Practice has received a grant
(2007) from Alberta Health and Wellness to implement a strategy to enhance
physicians’ contribution to the prevention of FASD, looking in particular at the
preconception phase.
3. Initiatives to Champion Preconception Health Supporting Environments:
• In November, 1998, Health Canada instituted a public health policy to increase
dietary consumption of folic acid by fortification of white flour, enriched pasta and
cornmeal with the expectation that the prevalence of Neural Tube Defects (NTDs)
might be reduced. While the birth prevalence of NTDs has declined over the past
decade in Canada, the full impact of this population based strategy is yet to be
determined (Health Canada, 2002) since the minimum effective dose of folic acid is
not known at this time. Food fortification coupled with eating according to Canada’s
Food Guide meets 50% of the recommended daily folate intake, hence Health
Canada’s recommendation for a folic acid supplement of .4mg per day in addition to
healthy eating (Van Allen, McCourt & Lee, 2002).
59

Appendix G
• In 2005, the Alberta Heritage Foundation for Medical Research announced a
new policy, one of the first of its kind in Canada, which extends female medical
research awards an additional year to 6 years, to allow for maternity leave, a means
of protecting women’s careers while they take time out to be a mother (http://www.
ahfmr.ab.ca).
• On May 3, 2006, MP Paul Szabo reintroduced his private member’s bill. Bill C-251
would have amended the Food and Drugs Act to require labels on alcoholic beverages,
warning that alcohol causes birth defects if consumed during pregnancy. This warning
is used in the United States, Australia, the Yukon and the NWT. The pros and cons of
labelling are explored in an article by Caprara et al (2004) and they argue that factual
proof that ensures no adverse consequences associated with labelling is warranted to
justify the possible benefits, on the other hand maybe warning labels will change the
culture of drinking even if not effective in changing the pattern of problem drinkers.
• In 2006, the Ad Hoc Prioritization Committee, APHP submitted a proposal to the
Alberta Advisory Committee on Health Technology Assessment to fund single embryo
transfers as a means of reducing the number of multiple gestations (C. Frick personal
communication, February 14, 2007).
• In September 2005, Alberta Education implemented 30 minutes of Daily Physical
Activity for all students in grades 1-9, to help students develop positive daily
physical activity habits. To accompany this health initiative, a resource handbook
was developed for teachers, as well as workshops and in-service opportunities to help
teachers implement the initiative.
60

References
Alberta Genuine Progress Indicators (GPI). (2003). Educational Attainment. The
Pembina Institute for Appropriate Development, Drayton Valley.
Alberta Genuine Progress Indicators (GPI). (2003). Poverty. The Pembina Institute for
Appropriate Development, Drayton Valley.
Alberta Health and Wellness, Ed. (2005). Business Plan 2005-2008. Edmonton.
Alberta Health and Wellness. (2006). Report on the Health of Albertans. Edmonton.
Alberta Government. (August 2006). Getting on with Better Health Care. Health Policy
Framework. Retrieved February 7, 2007 from http://www.health.gov.ab.ca.
Alberta Learning. (October 2004). Facts on Post-Secondary Education in Alberta. Retrieved
November 4, 2006, from http://www.learning.gov.ab.ca.
Alberta Medical Association. (June 1999). Recommendations for the Prevention of Fetal
Alcohol Syndrome (FAS).
Alberta Perinatal Health Program. (March 2006). Provincial Perinatal Health Report.
Alberta Sustainability Trends 2000. The Genuine Progress Indicators Report 1961 to
1999. The Pembina Institute for Appropriate Development. Drayton Valley.
Anielski, M. (2001). The Alberta Genuine Progress Indicator Accounts: Human Health and
Wellness. Report #9. Pembina Institute for Appropriate Development. Drayton Valley.
Atrash, Hani K., Johnson, Kay, Adams, Myron, Cordero, José F., & Howse, Jennifer.
(2006). Preconception Care for Improving Perinatal Outcomes: The Time to Act.
Maternal Child Health Journal, 10: S3-11.
Auger, J. & Jouannet, P. (2005). Age and Male Fertility: Biological Factors. Revue d
Epidemiologie et de Sante Publique, 2: 2S25-35.
61

Battle, Ken. (April 2006). The Incredible Shrinking $1,200 Child Care Allowance: How to
Fix It. Caledon Institute of Social Policy, Retrieved February 14, 2007 from http://
www.caledoninst.org.
Behrman, Richard E., & Butler, Adrienne, Stith. (2006) (Eds.). Preterm Birth:
Causes, Consequences, and Prevention (Free Executive Summary). Committee on
Understanding Premature Birth and Assuring Healthy Outcomes, Retrieved May 4,
2006 from http://www.nap.edu/catalog/11622.html.
Benzies, K., Tough, C.S., Tofflemire, K., Frick, C., Faber, A., & Newburn-Cook, C.
(2006). Factors Influencing Women’s Decisions about Timing of Motherhood.
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35(5): 625-633.
Best Start: Ontario’s Maternal, Newborn and Early Child Development Resource
Center. (2000). How to Build Partnerships with Youth. Ontario Prevention
Clearinghouse, Toronto.
Best Start: Ontario’s Maternal, Newborn and Early Child Development Resource
Center. (2001). Workplace Reproductive Health: Research & Strategies. Ontario
Prevention Clearinghouse, Toronto.
Best Start: Ontario’s Maternal, Newborn and Early Child Development Resource
Center. (2006). Playing IT Safe: Service Provider Strategies to Reduce Environmental
Risks to Preconception, Prenatal and Child Health. Ontario Prevention
Clearinghouse, Toronto.
Canadian Council on Learning. (2005). Working To Learn: Meeting University and College
Costs. Retrieved June 28, 2006 from http://www.ccl-cca/CCL/Reports/Lesson.
Canadian Council on Learning. (2006). Can Workplace Learning Create Healthier
Employees Retrieved June 28, 2006, from http://www.ccl-cca/ccl/reports/lesson.
62

Canadian Health Services Research Foundation. (June 2006). Allow Midwives to
Participate as Full Members of the Healthcare Team. Evidence Boost, Retrieved
February 27, 2007, from http://www.chsrf.ca.
Canadian Institute for Health Information. (2004). Providers of Maternity and Infant
Care. Giving Birth in Canada. Ottawa.
Canadian Institute for Health Information. (2006). The Costs. Giving Birth in
Canada. Ottawa.
Caprara, D., Soldin, Offie, & Koren, G., (2004). To Label or Not to Label: The Pros and
Cons of Alcohol Warning Labels in Pregnancy. JFAS International, 2: 1-3.
Centers for Disease Control and Prevention. (2006). Recommendations to Improve
Preconception Health and Health Care -United States: A Report of the CDC/
ATSDR Preconception Care Work Group and the Select Panel on Preconception
Care. Morbidity and Mortality Weekly Report, 55(6): 1-23.
Centers for Disease Control and Prevention. (2007). Folate Status in Women of
Childbearing Age, by Race/Ethnicity---United States, 1999-2000, 2001-2002, and
2003-2004. Morbidity and Mortality Weekly Report, 55(51): 1377-1380.
De La Rochebrochard, E., & Thonneau, P. (2005). Paternal Age: Are the Risks of
Infecundity and Miscarriage Higher When the Man is Aged 40 Years or Over Revue
d Epidemiologie et de Sante Publique, 2: 2S47-55.
Drolet, Marie. (2002). Wives, Mothers and Wages: Does Timing Matter (No.186).
Statistics Canada, Ottawa.
Edwards, Quannetta, T., Seibert, D., Macri, C., Covington, C., & Tilghman, J., (2004).
Assessing Ethnicity in Preconception Counselling: Genetics-What Nurse Practitioners
Need to Know. Journal of the American Academy of Nurse Practitioners, 16(11): 472-480.
63

Einerson, A. & Koren, G. (2006). A Survey of Women’s Attitudes Concerning Healthy
Lifestyle Changes Prior to Pregnancy. JFAS International, 4(2): 1-6.
Godwin, K., Sibbald, B., Bedard, T., Lowry, B., Kuzeljevic, B., & Arbour, L. (2006).
The Impact of Folic Acid Fortification on the Prevalence of Congenital Anomalies
other than Neural Tube Defects. Abstract from the Canadian Congenital Anomalies
Surveillance Network 5 th Scientific Meeting, Ottawa, Ontario.
Grajewski, Barbara, Coble, Joseph, B., Frazier, Linda, M. & McDiarmid, Melissa, A.
(2005). Occupational Exposures and Reproductive Health: 2003 Teratology Society
Meeting Symposium Summary. Birth Defects Research (Part B). 74: 157-163.
Green, N.S., Damus, K., Simpson, J.L., Iams, J., Reece, A., Hobel, C.J., Merkatz, I.R.,
Greene, M.F., Schwartz, R.H., & the March of Dimes Scientific Advisory Committee
on Prematurity. (2005). Research Agenda for Preterm Birth: Recommendations from
the March of Dimes. American Journal of Obstetrics & Gynaecology, 193: 626-35.
Hamilton, N. & Bhatti, T. (February 1996). Population Health Promotion: An
Integrated Model of Population Health and Health Promotion. Health Promotion
Development Division.
Health Canada. (July 2001). The Population Health Template: Key Elements and Actions
That Define a Population Health Approach. Strategic Policy Directorate, Population
and Public Health Branch.
Health Canada. (2002). Congenital Anomalies in Canada-A Perinatal Health Report, 2002.
Ottawa, Minister of Public Works and Government Services Canada.
Health Canada. (2003). Canadian Perinatal Health Report. Ottawa, Minister of Public
Works and Government Canada.
64

Health Quality Council of Alberta. (2006). Satisfaction with Health Care Services: A
Survey of Albertans 2006. Executive Summary, Edmonton.
Health Surveillance. (2003). Low Birth Weight in Alberta: A Synthesis Report on Impact
and Risk Factors. Edmonton, Alberta Health and Wellness.
Health Surveillance. (2005). Child Health Surveillance Report 2005. Edmonton, Alberta
Health and Wellness.
Healthy Kids Alberta! Achieving Wellness for Children and Youth. (January, 2006). Draft
Discussion Paper.
Henshaw, S.K. (1998). Unintended pregnancy in the United States. Family Planning
Perspectives, 30(1): 1-16.
House, J. (Ed.). (2006). Folic Acid Project. Unpublished document. Healthy
Babies Coordinator, Healthy Living, Southeast Community Portfolio, Calgary
Health Region.
Hutson, Janine. (2006). A Prenatal Perspective on the Cost of Substance Abuse in
Canada. JFAS International, 4: 1-4.
Johnson, K., I., Lero, D.S., & Rooney, J.A. (2001). Work-Life Compendium: 150
Canadian Statistics on Work, Family and Well-Being. Center for Families, Work and
Well-Being, University of Guelph.
Korenbrot, Carol, C., Steinberg, Alycia, Bender, Catherine & Newberry, Sydne.
(2002). Preconception Care: A Systematic Review. Maternal and Child Health
Journal: 6(2): 75-88.
Kuhnert, B., & Nieschlag, E. (2004). Reproductive Functions of the Ageing Male. Human
Reproduction Update, 10(4): 327-39.
65

Lampic, C., Svanberg, S., Karlstrom, P., & Tyden, T. (2006). Fertility Awareness,
Intentions Concerning Childbearing, and Attitudes Towards Parenthood Among
Female and Male Academics. Human Reproduction, 21(2): 558-564.
Lefebvre, Pierre & Merrigan, Philip. (June 2003). Assessing Family Policy in Canada: A
New Deal for Families and Children. Choices, Institute for Research on Public Policy,
Retrieved February 26, 2007 from http://www.irpp.org.
Luo, Cheng-Zhong, Wilkins, Russell, & Kramer, Michael, S., (2006). Effect of
Neighbourhood Income and Maternal Education on Birth Outcomes: A Population-
Based Study. CMAJ, 174(10): 1415-1421.
MacKay, Diana. (February 8-9, 2007). Roundtable on Socio-Economic Determinants of
Health. Meeting Notes, Conference Board of Canada.
McCall, D. & McKay, A. (June 2004). School-Based and School-Linked Sexual Health
Education and Promotion in Canada. Journal of Obstetrics and Gynaecologists of
Canada, 26(6): 596-600.
McDermot, Consulting. (2004). Alberta Perinatal Health Program: Background
Information Report for Business Planning Process. Edmonton.
McNaughton, A. Marie. (2001). Family-Friendly Workplaces: The Case for Supporting
Work-Life Balance. The Calgary Children’s Initiative, September 2001.
March of Dimes. (May 2002). Folic Acid and the Prevention of Birth Defects: A National
Survey of Pre-Pregnancy Awareness and Behaviour Among Women of Childbearing Age,
1995-2002: 65.
66

Mengel, Mark, B., Ulione, Margaret, Cook, Keely, Wedding, Danny, Rudeen, Kevin,
Braddock, Stephen, & Ohlemiller, Melinda. (2006). Midwest Family Physicians’
Knowledge and Attitudes about FAS, FASD, and Alcohol Use During Pregnancy.
JFAS International, 4(7): 1-10.
Moore, Keith L., & Persaud, T.V.N. (1998). The Developing Human: Clinical Oriented
Embryology (6 th ed.). Toronto: W. B. Saunders.
Ontario Health Promotion Resource System. Health Promotion On-line Course. Retrieved
January 24, 2006, from http://www.ohprs.ca/hp101/main.htm.
Ottawa Charter for Health Promotion. (1986). An International Conference on Health
Promotion. Ottawa.
Peate, Ian. (2005). The Effects of Smoking on the Reproductive Health of Men. British
Journal of Nursing, 14(7): 362-366.
Perinatal Partnership Program of Eastern and Southeastern Ontario. (2001).
Preconception and Health: Research & Strategies. Toronto, Best Start: Ontario’s
Maternal, Newborn and Early Child Development Resource Center: 80.
Policy Research Initiative. (December, 2004). Horizons. 7(2). Retrieved March 1, 2007,
from http://www.policyresearch.gc.ca.
Pronovost, Gilles. (February, 2007). The Time in all of These Situations: The Time for Work,
the Time for Leisure and the Time for the Family in the 21 st Century. Policy
Brief. Institute for Research on Public Policy. Retrieved March 1, 2007, from http://
www.irpp.org.
Public Health Agency of Canada. (2002). Father Toolkit. My Daddy Matters Because…
CAPC/CPNP National Projects Fund.
67

Public Health Agency of Canada. (2003). Evaluation of Food Fortification with Folic Acid
for the Primary Prevention of Neural Tube Defects. Executive Summary, 1997-2003.
Public Health Agency of Canada. (2005). Make Every Mother and Child Count: A Report
on Maternal and Child Health in Canada.
Ramaliu, Anila. (2003). Folic Acid and Neural Tube Defects: A Position Paper. Healthy
Communities, Calgary Health Region.
Reproductive Health Report Working Group. (2006). Alberta Reproductive Health:
Pregnancies and Births Report 2006. Edmonton, AB: Alberta Health and Wellness.
Rolf, C. & Nieschlag, E. (2001). Reproductive Functions, Fertility and Genetic Risks of
Ageing Men. Experimental & Clinical Endocrinology & Diabetes, 109(2): 68-74.
Sheiner, Einat, K., Sheiner, E., Hammel, Rachel, D., Potashnik, Gad, Carel, Refael.
(2003). Effect of Occupational Exposures on Male Fertility: Literature Review.
Industrial Health, 41: 55-62.
Shiono, P., H. & Behrman, R. E. (1995). Low Birth Weight: Analysis and
Recommendations. Vol. 5. No. 1 Spring. Retrieved January 20, 2006, from http://
www.futureofchildren.org/information2826/information_show.
Siever, J. & Tough, S. (February 15, 2006). Alberta Perinatal Health Data: 2000-2004.
Silzer, J. (2007). Focus Group Final Report. Consumer and Provider Perspectives:
Informing Preconception Strategy Development. Calgary, Quality Safety and Health
Information, Survey and Evaluation, Calgary Health Region.
Stade, Brenda, Unger, Wendy J., Stevens, Bonnie, Beyene, Joseph, & Koren, Gideon.
(2006). The Burden of Prenatal Exposure to Alcohol: Measurement of Cost. JFAS
International, 4: 1-14.
68

Statistics Canada. (2006). Women in Canada: A Gender-Based Statistical Report. Fifth
Edition. Ottawa: 309.
Tam, Larissa, E., McDonald, Sarah, D., Wen, Shi Wu., Smith, Graeme N., Windrim,
Rory, C., Walker, Mark, C. (March 2005). A Survey of Preconceptional Folic Acid
Use in a Group of Canadian Women, Journal of Obstetrics and Gynaecologists of
Canada, 232.
The Practice Committee of the American Society for Reproductive Medicine. (2004).
Smoking and Infertility. Fertility and Sterility, 81(4): 1181-1186.
The Vanier Institute of the Family. Ed. (2004). Profiling Canada’s Families 111. Ottawa,
Library and Archives Canada Cataloguing in Publication.
Tjepkema, M. (2005). Adult obesity in Canada: Measured height and weight. Retrieved
August 16, 2006 from http://www.statcan.ca/english/research/82-620-MIE
2005001/articles/adults/obesity.htm.
Tough, S.C., Benzies, K., Fraser-Lee, N., & Newburn-Cook, C. (2007). Factors
Influencing Childbearing Decisions and Knowledge of Perinatal Risks among Canadian
Men and Women. Maternal Child Health Journal.
Tough, C.S., Clarke, M., Hicks, M. & Clarren, S. (2004). Clinical Practice
Characteristics and Preconception Counseling Strategies of Health Care Providers
Who Recommend Alcohol Abstinence During Pregnancy. Alcoholism: Clinical and
Experimental Research, 28(1): 1724-1731.
Tough, C.S., Clarke, M., Hicks, M. & Cook, J. (2006). Pre-Conception Practices
Among Family Physicians and Obstetricians-Gynaecologists: Results from a National
Survey. Journal of Obstetrics and Gynaecology of Canada, 28(9): 780-788.
69

Tough, S. C., Newburn-Cook, C., Johnston, D., W., Svenson, L., W., Rose S., & Belik, J.
(2002). Delayed Childbearing and its Impact on Population Rate Changes in Lower
Birth Weight, Multiple Birth, and Preterm Delivery. Pediatrics, 109(3): 399-403.
Tough, C.S., Tofflemire, K., Clarke, M., & Newburn-Cooke, C. (2006). Do Women
Change Their Drinking Behaviors While Trying to Conceive An Opportunity for
Preconception Counseling. Clinical Medicine & Research, 4(2): 97-105.
Tough, S., Tofflemire, K., & Jack, Monica. (2006). Reproduction in Alberta: A Look at
the Preconception, Prenatal and Postnatal Periods. Prepared for the Alberta Centre for
Child, Family and Community Research.
Van Allen, M.I., McCourt, C. & Lee, N.S. Preconception Health: Folic Acid for the
Primary Prevention of Neural Tube Defects. A Resource Document for Health
Professionals, 2002. Ottawa, Ontario. Minister of Public Works and Government
Services Canada.
Wanke, M., Gardner, L., & Deuchar -Fitzgerald, L. (January, 2007). Alberta Perinatal
Health Program: Rural Strategies Evaluation Baseline Results, Charis Management
Consulting, Inc.
Wheeler, Patricia, G., Bianchi, Diana, W. (2000). Genetic Screening in Patients of
Reproductive Age: How Do You Advise Prospective Parents Who Want to Know
Specific Risks Postgraduate Medicine/Genetic Screening, 107(6): 121-135.
Wilson, D. R. (November 2003). The Use of Folic Acid for the Prevention of Neural
Tube Defects and Other Congenital Anomalies. Journal of Obstetrics and Gynecologists
of Canada, 138: 1-7.
70

Yalnizyan, Armine. (March 2007). The Rich and the Rest of Us: The Changing Face of
Canada’s Growing Gap. Canadian Center for Policy Alternatives, Retrieved March 5,
2007 from http://www.GrowingGap.ca.
Yan Jin, M.A., Truman, C. & Johnson, D. (2000). Technical Report: Influence of
Aboriginal and Socioeconomic Status on Maternal Deliveries and Birth Outcomes.
Edmonton, Alberta Center for Health Services Utilization Research and Information
Analysis, Alberta Health & Wellness.
Younglai, E.V., Holloway, A.C., & Foster, W.G. (2004). Environmental and
Occupational Factors Affecting Fertility and IVF Successes. Human Reproduction
Update, 11(1): 43-57.
Yhu, Jin, l., Madsen, Kreesten, M., Vestergaard, Mogens, Olesen, Anne, V., Basso,
Olga & Olsen, Jorn. (2005). Paternal Age and Congenital Malformations. Human
Reproduction, 20(11): 3173-7.
71