To be effective, counseling about potential pregnancy risks and strategies to prevent them must be provided before conception. By the time most women realize they are pregnant—1 to 2 weeks after the first missed period—the fetal spinal cord has already formed and the heart is beating (Moore, 1983). Many prevention strategies, for example, folic acid to prevent neural-tube defects, are ineffective if initiated at this time. The Centers for Disease Control and Prevention (1999) estimate that up to half of all pregnancies are unplanned, and there is evidence that these may be at greatest risk.
Adams and colleagues (1993) conducted a population-based survey of almost 12,500 women in four states and found that women with unintended pregnancies were more likely than those with planned pregnancies to have an indication for preconceptional counseling. Hellerstedt and co-workers (1998) surveyed nearly 7200 pregnant women and found that women with unintended pregnancies were more likely to have high-risk behaviors. Jack and associates (1995) administered a comprehensive risk survey to 136 women at the time of a negative pregnancy test. They found that (1) the majority did not want to be pregnant, (2) half reported a medical or reproductive risk that could adversely affect pregnancy, (3) half reported a genetic risk, and (4) one fourth reported risks for human immunodeficiency virus (HIV) and hepatitis B infection or alcohol or recreational drug use. Unwanted pregnancies are particularly common in the unmarriedurban poor (Besculides and Laraque, 2004).
An important measure of the effectiveness of preconceptional counseling is, therefore, its influence in reducing the number of unintended pregnancies. Moos and colleagues (1996) instituted a preconceptional care program for reproductive-aged women who visited a health department clinic and then also studied 1378 women who sought prenatal care. They reported that the 456 women who had preconceptional counseling had a 50-percent greater likelihood of describing their pregnancies as intended compared with that of 309 women with health care but no counseling, and a 65-percent greater likelihood compared with that ofwomen with no health care prior to pregnancy.