A Call for Investment in the Preconception Period to Improve Outcomes and Center Equity in Maternal, Infant, and Child Health

By Kathryn Mishkin, DrPH, MPH, MA and Anne O. Odusanya, DrPH, MPH



Mishkin K. and Odusanya A. A call for investment in the preconception period to improve outcomes and center equity in maternal, infant, and child health. HPHR. 2021;35.  


A Call for Investment in the Preconception Period to Improve Outcomes and Center Equity in Maternal, Infant, and Child Health​

Public Health Practice Implications

This paper offers recommendations for policy and programs that will have community impact through the reduction of preventable poor maternal, infant, and child health outcomes. It advocates for the development of an environment that promotes health equity through the advancement of preconception health.


There is a maternal, infant, and child health crisis occurring in the United States. Data from the Centers for Disease Control and Prevention (CDC) show that roughly 700 women die every year, and that maternal mortality rates among Black women are nearly three times that of White women (CDC, 2019b). The infant mortality rate remains high at 558 per 100,000 live births (CDC, 2021c). One in 33 babies (nearly 120,000 total) each year are impacted by birth defects (CDC, 2020c). Further, a closer look at health disparities finds that Black and Hispanic women and children are dying at higher rates compared to their White counterparts (CDC, 2019b). Birth defects such as congenital malformations, deformations and chromosomal abnormalities are among the leading causes of death for children (CDC, 2021a). Babies with birth defects require special care and interventions, especially early intervention to survive and thrive developmentally (CDC, 2020c). These health disparities have only become clearer with the COVID-19 pandemic. Maternal mortality disparities are expected to worsen (Volkin et al., 2020). Infants and children with genetic, neurological or metabolic conditions have an increased risk of having severe illness from COVID-19 compared to their counterparts without underlying medical conditions (CDC, 2021b). Additionally, a high fever (a symptom of COVID-19) in the first trimester can increase the likelihood of some birth defects (MotherToBaby, 2021).


Many of the causes of these tragic statistics are preventable and associated with underlying health conditions prior to pregnancy. For example, one-third of maternal mortality cases are linked to heart disease and stroke (CDC, 2019b) and although not all birth defects are preventable, practicing healthy behaviors and managing health conditions prior to becoming pregnant can increase the chances of having a healthy baby (CDC, 2020a). In this way, we can consider that these statistics offer us a glimpse into the state of health for women of reproductive age overall, and they do not solely relate to pregnant and postpartum health.


Historically, there has been great focus on engaging women and investing in systems to increase access and use of prenatal care and support to improve pregnancy and postpartum outcomes. Women are automatically eligible for Medicaid once pregnant–42% of all births are covered by Medicaid– and it has become the norm for health care providers to offer prenatal health care programs for a healthy pregnancy, safe childbirth, and preparation for the postpartum period (Centers for Medicare and Medicaid Services., 2021). Furthermore, most recently, there has been a call for more attention to enhancing the quality of care and support during the postpartum period. A 2016 Opinion Article authored by the American College of Obstetricians and Gynecologists calls for policy changes to facilitate postpartum care as an ongoing process that is tailored to the unique needs of individuals (American College of Obstetricians and Gynecologists, 2018).


While care and support in the prenatal and postpartum periods are critical, there is an opportunity to prevent some maternal, infant, and child health complications and issues through addressing preventable chronic health conditions and providing more support prior to pregnancy. We strongly advocate for the development of policy and programs to better the health and social conditions of women and their partners prior to pregnancy in the preconception period, as a means to improve these maternal, infant, and child health outcomes and reduce health disparities.


An innovative model to advance preconception health is needed to serve a variety of needs. First, the preconception model should ensure that all people of reproductive age have access to health insurance regardless of income level. This will reduce the health insurance barrier that can result in delayed care-seeking behaviors during the prenatal period. It will also help foster the planning of pregnancies. Considering that the Guttmacher Institute reports that nearly half of pregnancies in the United States are unplanned (Guttmacher Institute, 2021) millions of women enter pregnancy without preparation. Access to reproductive health providers, particularly for women in maternity care deserts, and a variety of birth control options through insurance coverage may reduce unplanned pregnancies.


Second, we have the opportunity to build and strengthen systems of support for people of reproductive age to enter pregnancy healthier. We advocate for policies to support the incorporation of reproductive and sexual health equity practices in all health and social service delivery to better meet the holistic needs of communities to plan for a healthy pregnancy (Dehlendorf et al., 2021). Creating and fortifying support systems is critically important considering the history and current practice of unequal and unjust treatment of some people, particularly those from marginalized and oppressed communities, by some medical practitioners (Alhusen et al., 2016; Prograis Jr & Pellegrino, 2007). To disrupt root causes of inequities that impact maternal, infant, and child outcomes, we must create systems and strategies to positively influence social and economic conditions for people planning for pregnancy. Simultaneously, we must address bias in the delivery of medical care in the preconception period to facilitate caring and empowering patient-provider interactions. This system would support culturally responsive education for people preparing for the maternal period. It would also establish supportive communities that are engaged to help people plan for and navigate pregnancy, labor and delivery, and the postpartum period.


These efforts will result in both better health equity and a healthier population, which would benefit all public health and social programs. The benefits of investing in the preconception period are great. As mentioned earlier, the CDC suggests that as many as 60% of maternal deaths are preventable (CDC, 2019b), and improving preconception health will better ensure that women enter pregnancy in better health, with fewer chronic conditions associated with maternal death. Good health in the preconception period is also linked to fewer incidences of conditions that are associated with infant mortality including low birth weight, Sudden Infant Death Syndrome, and birth defects or disabling conditions (CDC, 2020b; National Institutes of Health, 2016)


Improving preconception health will also support a reduction in health costs connected to poor outcomes. The lifetime costs of extreme preterm births have been estimated as high as $450,000 (Cheah, 2019) and cost of delivery with severe maternal morbidity (SMM) costing twice that of deliveries without SMM (Howland et al., 2018). Annual hospital expenses for children and adults with birth defects exceed $2.6 billion. This does not account for additional costs including provider charges and outpatient care (CDC, 2019a). By preventing these poor maternal, infant, and child health outcomes, we can reduce costs to the healthcare system overall.


How DrPH Training Informed This Work

This commentary is related to the DrPH because it is multidisciplinary in scope and synthesizes information from multiple sources and sectors. It uses data to tell the story to describe the problem and to inform the development of policy and program recommendations, which is a critical component of the DrPH training. The collaborative author team represents two disciplines within the field of maternal and child health including maternal and infant health and children with special health care needs.


  1. Alhusen, J. L., Bower, K. M., Epstein, E., & Sharps, P. (2016). Racial Discrimination and Adverse Birth Outcomes: An Integrative Review. Journal of Midwifery & Women’s Health, 61(6), 707–720. https://doi.org/10.1111/jmwh.12490
  2. American College of Obstetricians and Gynecologists. (2018). Optimizing Postpartum Care. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
  3. CDC. (2019a). Birth Defects are Common, Costly, and Critical. https://www.cdc.gov/ncbddd/birthdefects/infographic.html#:~:text=Birth defects are costly,care or many provider charges.
  4. CDC. (2019b). Pregnancy-related deaths. https://www.cdc.gov/vitalsigns/maternal-deaths/index.html#:~:text=Every pregnancy-related death is,a year afterward (postpartum).
  5. CDC. (2020a). Commit to Healthy Choices to Help Prevent Birth Defects. https://www.cdc.gov/ncbddd/birthdefects/prevention.html
  6. CDC. (2020b). Preconception Health. https://www.cdc.gov/preconception/overview.html
  7. CDC. (2020c). What are birth defects. Birth Defects. https://www.cdc.gov/ncbddd/birthdefects/facts.html#ref
  8. CDC. (2021a). Child Health. National Center for Health Statistics. https://www.cdc.gov/nchs/fastats/child-health.htm
  9. CDC. (2021b). COVID-19 in Children and Teens. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/symptoms.html
  10. CDC. (2021c). Infant health. National Center for Health Statistics. https://www.cdc.gov/nchs/fastats/infant-health.htm
  11. Centers for Medicare and Medicaid Services. (2021). Maternal & Infant Health Care Quality. https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/maternal-infant-health-care-quality/index.html
  12. Cheah, I. G. S. (2019). Economic assessment of neonatal intensive care. Translational Pediatrics, 8(3), 246–256. https://doi.org/10.21037/tp.2019.07.03
  13. Dehlendorf, C., Akers, A. Y., Borrero, S., Callegari, L. S., Cadena, D., Gomez, A. M., Hart, J., Jimenez, L., Kuppermann, M., Levy, B., Lu, M. C., Malin, K., Simpson, M., Verbiest, S., Yeung, M., & Crear-Perry, J. (2021). Evolving the Preconception Health Framework: A Call for Reproductive and Sexual Health Equity. Obstetrics and Gynecology, 137(2), 234–239. https://doi.org/10.1097/AOG.0000000000004255
  14. Guttmacher Institute. (2021). Unintended Pregnancy in the United States. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states
  15. Howland, R. E., Angley, M., Won, S. H., Wilcox, W., Searing, H., & Tsao, T.-Y. (2018). Estimating the Hospital Delivery Costs Associated With Severe Maternal Morbidity in  New York City, 2008-2012. Obstetrics and Gynecology, 131(2), 242–252. https://doi.org/10.1097/AOG.0000000000002432
  16. MotherToBaby. (2021). COVID-19. https://mothertobaby.org/fact-sheets/covid-19/
  17. National Institutes of Health. (2016). Are there ways to reduce the risk of infant mortality? https://www.nichd.nih.gov/health/topics/infant-mortality/topicinfo/reduce-risk
  18. Prograis Jr, L. J., & Pellegrino, E. D. (2007). African American bioethics: culture, race, and identity. Georgetown University Press.
  19. Volkin, S., Mayer, R. E., & Dingwall, A. (2020). Let COVID-19 Serve as a Catalyst to Fix National Crisis of Poor Maternal Mortality Data. Journal of Public Health Management and Practice, 26(6). https://journals.lww.com/jphmp/Fulltext/2020/11000/Let_COVID_19_Serve_as_a_Catalyst_to_Fix_National.4.aspx

About the Authors

Kathryn Mishkin

Dr. Kathryn Mishkin is a seasoned professional with over a decade of public health and international development policy, project management, and evaluation work in 14 countries. She currently serves as the Associate Director of Evaluation at March of Dimes where she leads local, state, and national project and program and quality improvement evaluation efforts. She holds leadership positions within the American Public Health Association and is on the Boards of Women of Peace Corps Legacy and the Washington, D.C. chapter of the National Organization of Women (NOW.) She has authored peer-reviewed manuscripts, APHA policy statements, and national and state-level public health reports. Dr. Mishkin holds a Doctorate in Health Policy, Management, and Behavior from the University at Albany, a Masters in Public Health from Emory University, and a Masters in Sustainable International Development at Brandeis University. She completed her undergraduate degree at Smith College.

Anne Odusanya

Dr. Anne Odusanya is the Children and Youth with Special Health Care Needs Director/Unit Supervisor at Wisconsin Department of Health Services in Madison, WI. Anne holds a DrPH in Community Health Behavior and Education from Georgia Southern University. Additionally, she received an MPH in Maternal and Child Health (MCH) from the University of South Florida and a BS in Biology from the University of San Francisco. She is experienced in MCH research, training, and education including children and youth with special health care needs.