PROTOCOL: Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low‐ and middle‐income countries: A systematic review

The compliance of free folic acid supplements among pregnant women in rural areas of Northwestern China: The role of related knowledge

Background

High prevalence of neural tube defects remains one of the major threats to newborns in rural China. Folic acid supplementation before and during early pregnancy can effectively reduce the risk of neural tube defects. Despite the efforts of the free folic acid mass distribution, the actual usage of folic acid supplements was still suboptimal among rural pregnant women in China. The objective of this study is to investigate if and how knowledge can influence the picking up and intake of the free folic acid supplements distributed by the government.

Methods

We collected survey data from 821 pregnant women in rural areas of Shaanxi, China, in March and December of 2021. Face-to-face interviews and questionnaire surveys were conducted with every participant. Univariate and multivariate logistic regression analyses were performed to test the relationship between knowledge and dependent variables.

Results

Our study found that there were 76.4% of pregnant women would pick up folic acid supplements distributed by the government and only 44.5% of women would use folic acid before current pregnancy. Awareness of folic acid policy both affects the picking up (OR: 6.708, 95% CI: 4.672-9.632) and periconceptional intake (OR: 1.912, 95% CI:1.326-2.758) of folic acid supplements. Knowledge of health and nutrition in pregnancy showed no significant relationship with the picking up and periconceptional intake of folic acid supplements but was positively associated with the intake duration (Coefficient: 9.278, 95% CI: 2.966-15.591).

Conclusion

Despite the relatively high level of picking up, the actual folic acid usage was not ideal among pregnant women in rural areas of China. Folic acid policy awareness was positively associated with the picking up and intake of folic acid before and during conception. Knowledge of health and nutrition about pregnancy was related to a longer duration of folic acid intake but had no impact on the picking up rate and periconceptional intake of folic acid supplements.

Perceptions of and challenges faced by primary healthcare workers about preconception services in rural India: A qualitative study using focus group discussion

Background

Providing preconception care through healthcare workers at the primary health care level is a crucial intervention to reduce adverse pregnancy outcomes, consequently reducing neonatal mortality. Despite the availability of evidence, this window of opportunity remains unaddressed in many countries, including India. The public health care system is primarily accessed by rural and tribal Indian population. It is essential to know the frontline healthcare workers perception about preconception care. The study aimed to identify barriers and suggestions for framing appropriate strategies for implementing preconception care through primary health centers.

Methods

The authors conducted a qualitative study using focus group discussions (FGDs) with 45 healthcare workers in four FGDs (8-14 participants in each), in four blocks of Nashik district. The transcribed discussions were analyzed in MAXQDA software using the Socio-Ecological Model as an initial coding guide, including four levels of factors (individual, interpersonal, community, and institutional) that influenced an individual's behavior to use preconception care services.

Results

Healthcare workers had some knowledge about preconception care, limited to adolescent health and family planning services. The interpersonal factors included heavy workload, stress, lack of support and co-operation, and paucity of appreciation, and motivation. The perceived community factors included poverty, migration, poor knowledge of preconception care, lack of felt need for preconception services, the influence of older women in the household decision, low male involvement, myths and misconceptions regarding preconception services. The identified institutional factors were lack of human resources, specialized services, logistics, and challenges in delivering adolescent health and family planning programs. Healthcare workers suggested the need for program-specific guidelines, training and capacity building of human resources, an un-interrupted supply of logistics, and a unique community awareness drive supporting preconception care services.

Conclusion

Multi-level factors of the Socio-Ecological Model influencing the preconception care services should be considered for framing strategies in the implementation of comprehensive preconception care as a part of a continuum of care for life cycle phases of women.

Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: A systematic review

Background

The preconception period is an ideal time to introduce interventions relating to nutrition and other lifestyle factors to ensure good pregnancy preparedness, and to promote health of mothers and babies. In adolescents, malnutrition and early pregnancy are the common challenges, particularly among those who live in low- and middle-income countries (LMIC) where 99% of all maternal and newborn deaths occur. These girls receive little or no attention until their first pregnancy and often the interventions after pregnancy are too late to revert any detrimental health risks that may have occurred due to malnutrition and early pregnancy.

Objectives

To synthesise the evidence of the effectiveness of preconception care interventions relating to delayed age at first pregnancy, optimising inter-pregnancy intervals, periconception folic acid, and periconception iron-folic acid supplementation on maternal, pregnancy, birth and child outcomes.

Search Methods

Numerous electronic databases (e.g., CINAHL, ERIC) and databases of selected development agencies or research firms were systematically searched for all available years up to July 2019. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished studies.

Selection Criteria

Primary studies, including large-scale programme evaluations that assessed the effectiveness of interventions using randomised controlled trials (RCTs) or quasi-experimental designs (natural experiments, controlled before-after studies, regression discontinuity designs, interrupted time series [ITS]), that targeted women of reproductive age (i.e., 10-49 years) during the pre- and periconceptional period in LMICs were included. Interventions were compared against no intervention, standard of care or placebo.

Data Collection and Analysis

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data and assessed risk of bias. We used random-effects model to conduct meta-analyses, given the diverse contexts, participants, and interventions, and separate meta-analyses for the same outcome was performed with different study designs (ITS, RCTs and controlled before after studies). For each comparison, the findings were descriptively summarised in text which included detailing the contextual factors (e.g., setting) to assess their impact on the implementation and effectiveness of each intervention.

Main Results

We included a total of 43 studies; two of these were included in both delaying pregnancy and optimising interpregnancy intervals resulting in 26 studies for delaying the age at first pregnancy (14 RCTs, 12 quasi-experimental), four for optimising interpregnancy intervals (one RCT, three quasi-experimental), five on periconceptional folic acid supplementation (two RCTs, three quasi-experimental), and 10 on periconceptional iron-folic acid supplementation (nine RCTs, one quasi-experimental). Geographically, studies were predominantly conducted across Africa and Asia, with few studies from North and Central America and took place in a combination of settings including community, schools and clinical. The education on sexual health and contraception interventions to delay the age at first pregnancy may make little or no difference on risk of unintended pregnancy (risk ratio [RR], 0.42; 95% confidence internal [CI], 0.07-3.26; two studies, =490; random-effect; χ ² p .009; I ² = 85%; low certainty of evidence using GRADE assessment), however, it significantly improved the use of condom (ever) (RR, 1.54; 95% CI, 1.08-2.20; six studies, n = 1604; random-effect, heterogeneity: χ ² p .004; I ² = 71%). Education on sexual health and and provision of contraceptive along with involvement of male partneron optimising interpregnancy intervals probably makes little or no difference on the risk of unintended pregnancies when compared to education on sexual health only (RR, 0.32; 95% CI, 0.01-7.45; one study, n = 45; moderate certainty of evidence using GRADE assessments). However, education on sexual health and contraception intervention alone or with provision of contraceptive showed a significant improvement in the uptake of contraceptive method. We are uncertain whether periconceptional folic acid supplementation reduces the incidence of neural tube defects (NTDs) (RR, 0.53; 95% CI, 0.41-0.77; two studies, n = 248,056; random-effect; heterogeneity: χ ² p .36; I ² = 0%; very low certainty of evidence using GRADE assessment). We are uncertain whether preconception iron-folic acid supplementation reduces anaemia (RR, 0.66; 95% CI, 0.53-0.81; six studies; n = 3430, random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessment) even when supplemented weekly (RR, 0.70; 95% CI, 0.55-0.88; six studies; n = 2661; random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessments),and in school set-ups (RR, 0.66; 95% CI, 0.51-0.86; four studies; n = 3005; random-effect; heterogeneity: χ ² p < .0001; I ² = 87%; very low certainty of evidence using GRADE assessment). Data on adverse effects were reported on in five studies for iron-folic acid, with the main complaint relating to gastrointestinal side effects. The quality of evidence across the interventions of interest was variable (ranging from very low to moderate) which may be attributed to the different study designs included in this review. Concerning risk of bias, the most common concerns were related to blinding of participants and personnel (performance bias) and whether there were similar baseline characteristic across intervention and comparison groups.

Authors' Conclusions

There is evidence that education on sexual health and contraception interventions can improve contraceptive use and knowledge related to sexual health, this review also provides further support for the use of folic acid in pregnancy to reduce NTDs, and notes that weekly regimes of IFA are most effective in reducing anaemia. However the certainty of the evidence was very low and therefore more robust trials and research is required, including ensuring consistency for reporting unplanned pregnancies, and further studies to determine which intervention settings (school, community, clinic) are most effective. Although this review demonstrates promising findings, more robust evidence from RCTs are required from LMICs to further support the evidence.

Effects of Preconception Care and Periconception Interventions on Maternal Nutritional Status and Birth Outcomes in Low- and Middle-Income Countries: A Systematic Review

Pregnancy in adolescence and malnutrition are common challenges in low- and middle-income countries (LMICs), and are associated with many complications and comorbidities. The preconception period is an ideal period for intervention as a preventative tactic for teenage pregnancy, and to increase micronutrient supplementation prior to conception. Over twenty databases and websites were searched and 45 randomized controlled trials (RCTs) or quasi-experimental interventions with intent to delay the age at first pregnancy (n = 26), to optimize inter-pregnancy intervals (n = 4), and supplementation of folic acid (n = 5) or a combination of iron and folic acid (n = 10) during the periconception period were included. The review found that educational interventions to delay the age at first pregnancy and optimizing inter-pregnancy intervals significantly improved the uptake of contraception use (RR = 1.71, 95% CI = 1.42-2.05; two studies, n = 911; I2 = 0%) and (RR = 2.25, 95% CI = 1.29-3.93; one study, n = 338), respectively. For periconceptional folic acid supplementation, the incidence of neural tube defects were reduced (RR = 0.53; 95% CI = 0.41-0.77; two studies, n = 248,056; I2 = 0%), and iron-folic acid supplementation improved the rates of anemia (RR = 0.66, 95% CI = 0.53-0.81; six studies; n = 3430, I2 = 88%), particularly when supplemented weekly and in a school setting. Notwithstanding the findings, more robust RCTs are required from LMICs to further support the evidence.