Graduation Year


Document Type




Degree Granting Department

Public Health

Major Professor

Robert McDermott, Ph.D.

Committee Member

Ellen Daley, Ph.D.

Committee Member

John Ferron, Ph.D.

Committee Member

Karen Perrin, Ph.D.

Committee Member

Hamisu Salihu, Ph.D.


preconception framework, PRAMS, preventive health behaviors, prenatal factors, environmental factors, personal factors


Statement of Purpose

The purpose of this study is to examine the impact of preconception health on adverse pregnancy outcomes through the theoretical lens of reciprocal determinism. Thus, this study aims to develop a preconception health conceptual framework that accounts for the interactive relationships among behavior, the environment, and the person.

Rationale for the Study

Women may not recognize a pregnancy until the first or second missed menstrual cycle, a full four to eight weeks or more after conception. Once a woman realizes the possibility of a pregnancy, it takes further time to confirm the pregnancy with a home pregnancy kit or a visit to the health care provider. In that time period, the woman may have unknowingly exposed her embryo to nutritional deficiencies, over-the-counter drugs, tobacco, alcohol, or other toxins. Because nearly half of all pregnancies are unintended, yielding about three million unintended pregnancies in the U.S. annually, there is a need to shift care to an earlier period in a woman's life cycle with greater potential to prevent birth defects and other adverse pregnancy outcomes, also known as preconception care.

The preconception health movement began with the rationale that many adverse pregnancy outcomes are determined prior to prenatal care initiation. Thus, in addition to prenatal care, the need for preconception health arose. The empirical literature makes a strong case for the benefit of individual preconception health components and their effects on adverse pregnancy outcomes. However, the actual effectiveness of collective preconception health in reducing adverse pregnancy outcomes has not yet been demonstrated. In an effort to evaluate the impact of preconception health on maternal morbidity, infant morbidity, and infant mortality, this study examined the reciprocal relationships between environmental, personal, and preconception behavioral factors and their associations with adverse pregnancy outcomes.


A secondary data analysis was conducted using the Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2005-2008 to test a preconception framework. Project 1 examined all variables in the preconception framework among the following states: Maine, New Jersey, Ohio, and Utah. Project 2 examined all variables except of two among all PRAMS-participating states. All of the variables in the proposed framework were derived from questions in the PRAMS survey or from PRAMS-linked birth certificate data. The research questions posed in this study were resolved through the path analyses of reduced and full iterations of the preconception framework in Projects 1 and 2.


In Project 1, list-wise deletion of missing data resulted in a decrease from the original 27,933 participants to 12,239 participants. In Project 2, this action resulted in a decrease from the original 200,008 participants to 128,551 participants. The analysis of the reduced frameworks for both projects revealed extremely low R-squared values (1.1% or less). Subsequent analyses examining the full framework in Projects 1 and 2, as well as an additional post hoc analysis with supplementary PRAMS variables, resulted in R-squared values of 13.1%, 11.4%, and 30.5%, respectively.


This study examined the impact of preconception health behaviors on adverse pregnancy outcomes through the theoretical lens of reciprocal determinism. Preconception health behaviors alone accounted for a negligible portion of the variance associated with adverse pregnancy outcomes. As hypothesized, preconception health behaviors work in concert with environmental factors, personal influences, prenatal and natal factors. Significant predictors supported in the literature included lower socioeconomic status, pregnancy intention, pregnancy history, older maternal age, black maternal race, Hispanic ethnicity, overweight maternal BMI, tobacco use prior to pregnancy, maternal complications, hospitalization during pregnancy, later prenatal care initiation, fewer prenatal care visits, plurality, and cesarean section. Even so, there is a large portion of the variance in adverse pregnancy outcomes that is not accounted for, and further examination is required.