Association Between Recommended Preconception Health Behaviors and Screenings and Improvements in Cardiometabolic Outcomes of Pregnancy

Kaitlyn K. Stanhope, PhD, MPH; Michael R. Kramer, PhD, MMSc


Prev Chronic Dis. 2021;18(1):e06 

In This Article

Abstract and Introduction


Introduction: Gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are associated with increased risk of maternal and infant illness and long-term elevated cardiometabolic risk. Little information exists on the prevention of either disorder before pregnancy. Our goal was to describe the association between preconception indicators and risk of gestational diabetes and hypertensive disorders of pregnancy.

Methods: We used logistic regression to analyze cross-sectional data from the 2016–2017 Pregnancy Risk Assessment Monitoring System (N = 68,493) to quantify the association between 14 preconception health indicators (across domains of health care, nutrition and physical activity, tobacco and alcohol, chronic conditions, mental health, and emotional and social support) and, separately, GDM and HDP. We accounted for sampling weights and controlled for maternal age, race/ethnicity, prepregnancy insurance, prepregnancy body mass index, and report of a check-up in the year before pregnancy.

Results: Prepregnancy obesity was the strongest predictor of both HDP (adjusted odds ratio [aOR], 3.1; 95% CI, 2.8–3.5) and GDM (aOR, 3.1; 95% CI, 2.7–3.5). Individual behaviors (eg, exercise, attending a check-up) were not associated with either HDP or GDM. A diagnosis of diabetes before pregnancy predicted HDP (aOR, 2.3; 95% CI, 1.7–3.0).

Conclusion: Prepregnancy chronic disease and obesity predicted pregnancy complications (ie, GDM and HDP). Given the challenges in reversing these conditions in the year before pregnancy, efforts to improve preconception health may be best directed broadly to expand access to primary care for all women.


Since the early 1990s, pediatricians, obstetricians, and public health practitioners have focused on promoting preconception health to improve pregnancy outcomes.[1,2] Preconception health encompasses physical, mental, and social health indicators and allows for assessing population-level well-being among individuals of reproductive age.[3] For individuals, preconception health is often operationalized as recommended behavior changes in the year before pregnancy.[4] For example, the Centers for Disease Control and Prevention (CDC) recommends that women attend preventive health visits, achieve a healthy weight, maintain control of chronic diseases, meet recommended levels of exercise, and avoid drinking or smoking.[2] Evidence about how women's individual behaviors in the year before pregnancy contribute to maternal outcomes is limited.[5]

Rates of hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM) have increased over the past 2 decades, particularly among women of racial and ethnic minorities. In this population, rates of HDP increased from 3.8% in 2001 to 8.0% in 2019, and rates of GDM increased from 3.7% in 2000 to 6.9% in 2019.[6–8] GDM and HDP are associated with increased risk of maternal illness and death[9,10] and increased risk of cardiovascular disease.[11–13] Evidence for the effectiveness of preconception behavior changes for preventing GDM or HDP is sparse.[14,15] The only behavior with strong evidence of effectiveness is control of preexisting diabetes to reduce risk of HDP, which applies only to the small number of women with chronic diabetes.[16,17] Although preconception obesity is associated with increased risk of both GDM and HDP,[18,19] no evidence indicates that weight loss interventions in the year before pregnancy (eg, diet, exercise) reduce risk of either HDP or GDM.[14,15,20]

Identifying risk factors for GDM and HDP modifiable in the year before pregnancy would provide individuals planning their pregnancies with a way to prevent adverse maternal and cardiovascular outcomes. The goal of this article is to describe the association between preconception health indicators and risk of GDM and HDP.