Preconception healthcare delivery at a population level: construction of public health models of preconception care

Core recommendations of effective preconception counselling services in low-and-middle-income countries - A scoping review

BACKGROUND

Extensive guidelines and recommendations are available for preconception counselling service in high-income-countries. However limited comprehensive recommendations are available for preconception care and counselling in low-and-middle-income countries (LMICs), where most of maternal mortality occurs in the settings.

AIM/OBJECTIVES

This review aims to identify any design, model or set of recommendations for their potential adoption to develop preconception care and counselling service for LMICs context.

METHODS

A systematic literature search was conducted in five major databases to identify articles covering any designs, models or recommendations on preconception care, for or from LMICs settings published between 2013-2023. Articles on any single screening for preconception counselling, those evaluating the service without specific model or sets of recommendations were excluded. Articles satisfied the inclusion criteria were then appraised and were extracted and analysed using inductive approach of thematic analysis.

FINDINGS

A total of nine articles were eligible for complete review, mostly were review papers, editorials and commission articles with moderate manuscript quality. Three themes of recommendations emerged from the analysis: Platforms, Core Principles, and Women Empowerment. The Platform contains recommendations on the settings, while Core principles provide essential recommendation of screening and management, while the theme Women Empowerment highlights the importance of empowering women to prepare and decide on their pregnancy.

IMPLICATIONS

Actual model of preconception care in LMICs is deficient, results of this review will inform research on the development of appropriate preconception care in LMICs . We also propose for access equity and strategies to promote women empowerment as the key to succeed the preconception care in LMICs.

Homelessness in the Perinatal Period and Associations With Reproductive Interconception Care: 2016-2019 Pregnancy Risk Assessment Monitoring System

OBJECTIVES

Women experiencing homelessness have higher rates of unintended pregnancy than stably housed women and may benefit from reproductive interconception care. How reproductive interconception care differs between women who did and did not experience perinatal homelessness is not known. We estimated prevalence ratios of reproductive interconception behaviors among US women experiencing homelessness during the perinatal period.

METHODS

We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System to calculate the prevalence of 5 reproductive interconception care outcomes: attending a maternal postpartum checkup, participating in a conversation with a health care provider about birth intervals, receiving family planning counseling, obtaining a prescription for short-acting contraception, and having a long-acting reversible contraceptive inserted. We used complex survey weights, stratified by perinatal homelessness, and converted adjusted logistic regression odds ratios between housing status and outcome variables to adjusted prevalence ratios (aPRs) and 95% CIs.

RESULTS

Among participants, approximately 2.4% (weighted percentage; unweighted 2953 of 100 706) experienced homelessness sometime in the 12 months before their children were born; the majority were non-Hispanic (83.2%) and White (69.4%), were not married (82.2%), and had public health insurance (56.8%). Perinatal homelessness was significantly associated with a lower prevalence of attending a postpartum maternal visit (aPR = 0.90; 95% CI, 0.87-0.94) and a higher prevalence of having a conversation about birth intervals with their health care providers (aPR = 1.13; 95% CI, 1.03-1.21).

CONCLUSIONS

Findings suggest that improving attendance at postpartum visits and evaluating birth interval conversations may strengthen interconception care practices while contextualizing social determinants such as housing stability. Improving uptake of postpartum visits may reduce unintended pregnancy, short birth intervals, and adverse birth outcomes in future pregnancies among women experiencing homelessness.

Reproductive Interconception Care Among Women Recently Pregnant and Homeless: A Qualitative Analysis

Reproductive interconception care provided at maternal postpartum visits may help reduce unintended pregnancies and elongate birth intervals for women experiencing homelessness. To improve interconception care uptake, this qualitative study aimed to identify barriers and facilitators to reproductive interconception care from the perspectives of women who were recently pregnant and homeless. A semi-structured interview guide and demographic survey were developed based on epidemiological findings, Information-Motivation-Behavioral Skill framework components, and a review by community health workers for content validity. After conducting 12 interviews with women recently pregnant and homeless in a local continuum of care in 2022, audio-recorded interviews were transcribed, iteratively coded using a priori and emerging codes, and thematically analyzed. Key themes were identified to determine implications and next steps to improving reproductive interconception care uptake. Interrelated themes focused on information (e.g., knowledge and misconceptions about pregnancy, birth intervals, contraception), motivation (e.g., attitudes about interconception care experiences, perinatal social influences), behavioral skills (e.g., objective ability to obtain interconception care and perceived self-efficacy related to attending maternal postpartum visits and increasing birth intervals), and macro-level factors (e.g., obtaining housing, contextualizing socioeconomic factors, navigating COVID-19). The findings suggest the need for flexible, streamlined, and personalized interconception care delivery that acknowledges pressing housing and relationship considerations and supports women's autonomy. Improvements to reproductive interconception care may reduce future unintended pregnancies, increase birth intervals, and improve birth outcomes among women experiencing homelessness.

Descriptive Report of a Pharmacist-Directed Preconception Care Outreach Program in a Rural Maternity Care Desert

Preconception care is the prevention and management of biomedical, behavioral, and social risk factors to improve pregnancy outcomes and overall health for reproductive-age patients. A community-based pharmacist-directed preconception care outreach program was developed for women ages 18-45 years living in a rural maternity care desert to help them identify potential health risks and provide them with the needed education, counseling, or referrals to address these risks. Supervised student pharmacists, pharmacy practice residents, and pharmacy faculty from a local University collaborated to provide this program at four community events in conjunction with a mobile health clinic. A summative evaluation was performed after the events concluded, modeled after the RE-AIM framework. One hundred and forty-one women were served by the outreach program. Nearly 98% reported at least one preconception health risk, and 45% reported a barrier preventing them from being able to have an appointment with a physician in the last year. The outreach program was feasible to implement and can be adapted to different settings. Pharmacist-directed outreach programs in rural communities may benefit patients who are not receiving or do not have access to such care in traditional healthcare settings.

Utilization of preconception care and associated factors among pregnant mothers in Fiche Town, Central Ethiopia: a community-based cross-sectional study 2021

Introduction

Preconception care is an important preventive intervention for adverse pregnancy outcomes. It is recognized as a strategy to optimize women's health and pregnancy outcomes in Western countries. However, preconception care is underutilized in sub-Saharan Africa, like Ethiopia, where maternal mortality is high. Evidence is scarce in the study area about the prevalence and factors associated with preconception care utilization. Therefore this study aimed to assess the proportion of preconception care utilization and associated factors among pregnant mothers in Fiche town, central Ethiopia, 2021.

Method

A community-based cross-sectional study was done from May 10 to June 25, 2021. A systematic random sample technique was used to choose 393 pregnant women for the study. A structured, pre-tested, interviewer-administered questionnaire was used to collect data. The data were entered into Epi Data version 3.1 and then exported into SPSS version 25 for analysis. A Bivariable and multivariable logistic regression analysis was used to check for the association. Odds ratio along with 95% was used to describe the association. Finally, a significant association was declared at a p-value less than 0.05.

Results

388 respondents participated in this study, making the response rate 98.7%. Of total study participants only 84 (21.6%; 95% CI, 18, 25.8) utilized preconception care. The study found that diploma or higher level of education (AOR = 3.47, 95% CI: 1.27, 9.53), psychological and financial support from a partner (AOR = 3.86, 95% CI: 2.1, 7.10), joint discussion and plan with a partner (AOR = 3.32, 95% CI: 1.55, 7.13), history of chronic disease (AOR = 3.47, 95% CI: 1.67, 7.25), and good knowledge about preconception care (AOR = 2.42, 95% CI: 1.34, 4.38) were significantly associated with preconception care utilization.

Conclusions

Overall, less than a quarter of the pregnant mothers utilized preconception care, indicating that awareness is very low. Pregnant mothers who have a higher educational level, have good communication and support from their partners, have chronic health problems, and have good knowledge about preconception care were more likely to utilize the service. Preconception care is a better opportunity to intervene and maintain the mother in the continuum of care.

Preconception health status and associated disparities among rural, Midwestern women in the United States

BACKGROUND

Little is known about the preconception/interconception health and behaviors of reproductive-age women in the rural Midwest of the United States. The purpose of this study was to quantify preconception/interconception health status and to identify disparities compared with statewide estimates.

METHODS

In this cross-sectional study, we collected data on 12 health conditions and behaviors that are risk factors for adverse maternal and infant health outcomes from nonpregnant women ages 18-45 years in rural northwestern Ohio. Statistical tests were used to identify associations between selected demographic characteristics and a subset of eight high-priority health measures (smoking, diabetes, heavy alcohol use, folic acid intake, normal weight, sufficient physical activity, and effective contraception use); all but physical activity could be compared with Ohio estimates derived from the Behavioral Risk Factor Surveillance System and Ohio Pregnancy Assessment Survey.

RESULTS

Three hundred-fifteen women participated, with 98.4% reporting at least one high-priority risk factor. Statistically significant differences were identified among subpopulations related to smoking, folic acid, normal weight, sufficient physical activity, and effective contraception use. In addition, the proportion of participants reporting hypertension (P < 0.001), smoking (P < 0.001), abnormal weight (P = 0.002), and lack of daily folic acid intake (P = 0.006) were statistically significantly higher than expected based on statewide estimates.

CONCLUSIONS

Women in the rural Midwest of the United States are at risk for poor health and pregnancy outcomes. Statewide estimates tracking preconception/interconception health status may obscure variation for at-risk groups, particularly in rural or underserved areas. These findings illustrate the need for interventions to advance preconception/interconception health and improve methods to capture and analyze data for rural women.

Addressing reproductive health needs across the life course: an integrated, community-based model combining contraception and preconception care

Prevention of pregnancy (contraception) and preparation for pregnancy (preconception care) are services that most people need during their reproductive life course. Despite increased attention, and growing recognition that health before pregnancy is crucial to addressing disparities in maternity outcomes, service provision is far from routine. We bring together evidence from the literature, new quantitative and qualitative data on women's preferences, and case studies of existing practice, to develop an integrated, community-based model that synthesises reproductive life planning, contraception, and preconception care. Our model provides a holistic, life course approach, encompassing school-based education, social media, and national campaigns, and highlights the need for training and system-level support for the range of health-care professionals who can deliver it. This high-level model can be adapted across settings, leading to a step change in the provision of preconception care in the community with consequent improvements in health and wellbeing, and reductions in inequalities at population level.

Preconception care practices among primary health care nurses working in public health facilities in KwaZulu-Natal

BACKGROUND

Preconception care (PCC) is necessary to identify and deal with all the risk factors before conception. Some aspects of PCC, like folic acid supplementation, would be relevant to people desiring a pregnancy. Alternatively, PCC could provide contraceptive support to those with no pregnancy intention. In South Africa, primary healthcare nurses provide a comprehensive package of essential services in public health facilities to about 90% of the population at no cost. Therefore, they are the key providers of promotive, preventive, and curative services, including PCC.

OBJECTIVE

This study aimed to determine the level of PCC practice among primary healthcare nurses and identify determinants of effective practice.

METHODS

This cross-sectional descriptive survey was conducted among 196 nurses undertaking a specialisation Primary HealthCare program in a selected higher education institution. A pretested questionnaire was used to collect data that were analysed with SPSS version 27 software.

RESULTS

The overall practice of PCC was 87.8%. Older participants were significantly less likely to exhibit good PCC practice than their younger counterparts. Female participants were also less likely to have good PCC practices than their male counterparts. Married participants were significantly more likely to practice PCC than their unmarried counterparts. Participants practicing in rural areas were also less likely to have good PCC practices than their urban counterparts.

CONCLUSION

The PCC practice of most primary healthcare nurses in the study is relatively high. The study also identified the determinants of good PCC practice that can enhance its practice. There is a need to revisit the PCC training of healthcare workers, as most indicated the need for further training.

Studying the Opinions of Medical Workers about Preconception Care

Abstract. Objective: to study the opinion of medical personnel (doctors and nurses) on the methods of preconception care and measures to improve the provision of medical care before conception in Kazakhstan (Karaganda region). Design: The data obtained during the study were subjected to statistical processing by the method of variation statistics using the free version of the EPI InfoTM program. The arithmetic mean (M) and standard deviation (±SD) were calculated for quantitative indicators, the data were presented as M±SD. The Krusk-Wallis test (H test) was used to compare means. Absolute (n) and relative (%) values ​​describe qualitative variables. χ2 were used to compare frequencies and qualitative variables. The critical significance level (p) when testing statistical hypotheses was taken as 0.05. Conditions: In the Karaganda region, a survey was conducted among doctors of the specialty general practitioner, general practitioner/family doctor, obstetrician-gynecologist and nursing staff. The survey was aimed at identifying the knowledge of health professionals about preconception care and at identifying barriers and factors preventing preconception care. Participants: 365 doctors and 375 nurses/midwives took part in the survey. Results: medical staff were asked to fill out a questionnaire, which addressed issues related to the ways of providing PC, barriers to the implementation of PC. 40% (n=292) of respondents noted that preconception care should be carried out by specialists from the family planning office. 24.3% (n=180) do not conduct conversations on preconception care due to lack of time, knowledge, a clear algorithm for conducting PC, and because they do not consider it their functional duty. Measures were proposed to improve the level of provision of preconception training in the Republic of Kazakhstan.    

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.

Relationships between Women's and Men's Modifiable Preconception Risks and Health Behaviors and Maternal and Offspring Health Outcomes: An Umbrella Review

Parental health before conception effects maternal and offspring health outcomes. Preconception care provides healthcare to prospective parents addressing modifiable preconception risks and health behaviors. This umbrella review aimed to consolidate evidence on women's and men's modifiable preconception risks or health behaviors associated with maternal and offspring health outcomes. MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, and PsycINFO were searched from March 4, 2010, to March 4, 2020. Eligible studies were systematic reviews or meta-analyses of observational studies examining associations between modifiable preconception risks or health behaviors and maternal and offspring health outcomes. Screening, data extraction, and methodological quality assessment (AMSTAR 2) occurred independently by two reviewers. Degree of overlap was examined. Findings were summarized for evidence synthesis. Twenty-seven systematic reviews were included. Modifiable preconception risks and health behaviors were identified across categories: body composition (e.g., overweight, obesity), lifestyle behaviors (e.g., caffeine, smoking), nutrition (e.g., micronutrients), environmental exposures (e.g., radiation), and birth spacing (e.g., short interpregnancy intervals). Outcomes associated with exposures affected embryo (e.g., embryonic growth), maternal (e.g., gestational diabetes mellitus), fetal/neonate (e.g., preterm birth), and child (e.g., neurocognitive disorders) health. For real-world practice and policy relevance, evidence-based indicators for preconception care should include body composition, lifestyle, nutrition, environmental, and birth spacing.

Relationship between achieving Sustainable Development Goals and promoting optimal care and prevention of birth defects globally

Birth defects affect eight million newborns annually worldwide. About 8% of global under-5 mortality is attributable to birth defects. The United Nations (UN) Sustainable Development Goals (SDGs) have set 17 global goals for human growth and development to be achieved by 2030 using multi-sectorial approaches. The third goal (SDG-3) focuses on ensuring healthy lives and promoting well-being; achieving SDG-3 improves birth defects care and prevention. However, we aimed to show how achieving other SDGs also influence optimal care and prevention of birth defects. SDGs focused on poverty reduction, access to nutritious food, universal health coverage, equitable education, gender equality, environment, inclusivity through infrastructure innovation, and strengthening social justice is crucial to addressing social determinants of health for individuals and families affected by birth defects. Understanding birth defects in the context of several relevant SDGs will allow practitioners, researchers, and policymakers to leverage the momentum generated by SDGs and make a case for commitment and allocation of funding and resources for advancing birth defects surveillance, care, and prevention. SDGs are built on principles of equity and social justice and we urge policy-makers to approach birth defects using various SDGs as a catalyst. The synergy between several SDGs helps to optimize birth defect outcomes and prevention. Our effort to present a more comprehensive look at various SDGs and their relationship with birth defects is parallel to several other health advocacy groups conducting a similar mapping exercise, thus bringing to the forefront millions of lives that are impacted by birth defects worldwide.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions.  OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness.

SEARCH METHODS

We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews.  MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.

Perceptions and Practice of Preconception Care by Healthcare Workers and High-Risk Women in South Africa: A Qualitative Study

Preconception care is biomedical, behavioural, and social health interventions provided to women and couples before conception. This service is sometimes prioritised for women at high risk for adverse pregnancy outcomes. Evidence revealed that only very few women in Africa with severe chronic conditions receive or seek preconception care advice and assessment for future pregnancy. Thus, this study aimed to explore the perceptions and practice of preconception care by healthcare workers and high-risk women in Kwa-Zulu-Natal, South Africa. This exploratory, descriptive qualitative study utilised individual in-depth interviews to collect data from 24 women at high risk of adverse pregnancy outcomes and five healthcare workers. Thematic analysis was conducted using Nvivo version 12. Five main themes that emerged from the study include participants’ views, patients’ access to information, practices, and perceived benefits of preconception care. The healthcare workers were well acquainted with the preconception care concept, but the women had inconsistent acquaintance. Both groups acknowledge the role preconception care can play in the reduction of maternal and child mortality. A recommendation is made for the healthcare workers to use the ‘One key’ reproductive life plan question as an entry point for the provision of preconception care.

Development of a health literacy scale for preconception care: a study of the reproductive age population in Japan

BACKGROUND

Preconception care aims to improve both maternal and child health in the short as well as long term, along with providing health benefits to adolescents, women, and men, whether or not they plan to become parents. However, there is limited evidence regarding the effectiveness of interventions for improving preconception health in population-based settings. To accumulate evidence in this field, this study focused on the concept of health literacy, and aimed to develop a self-report health literacy scale in Japanese, focusing on preconception care.

METHODS

We conducted a cross-sectional online survey. Participants were recruited from December 2019 to February 2020 from the registered members of a web-based research company. Participants were Japanese men and women aged 16-49 (n = 2000). A factor analysis was conducted to select both factors and items for health-related behavior and skills (33 initial items were generated), along with an item response theory analysis to examine how the 16 items were related to people's knowledge of preconception care.

RESULTS

We developed a 6-factor (including "appropriate medical examinations," "appropriate diet," "stress coping," "healthy weight," "safe living environment," and "vaccinations"), 25-item behavior and skills scale, as well as a 13-item knowledge scale, to evaluate participants' health literacy around preconception care. A shortened version, consisting of 17 items, was also prepared from the 25 items. The reliability coefficients of total scores and each factor of the behavior and skills scale were comparatively high, with weak-to-moderate correlation between behavior and skills and knowledge.

CONCLUSIONS

The new scale will, ideally, provide information on the current state of preconception care health literacy of the general population. In addition, this scale, which consists of both behavioral/skills and knowledge dimensions, should help support the effective implementation of risk assessment programs and interventions aimed at promoting behavioral changes using a population-based approach. Future studies using different question/administration formats for diverse populations, and considering respondents' opinions on health literacy scales should be effective in improving this scale.

Veteran-Reported Receipt of Prepregnancy Care: Data from the Examining Contraceptive Use and Unmet Need (ECUUN) Study

OBJECTIVES

To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care.

METHODS

We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18-45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics.

RESULTS

Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively).

CONCLUSIONS FOR PRACTICE

Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.

Knowledge of preconception care and its association with family planning utilization among women in Ethiopia: meta-analysis

Preconception care (PCC) increases the chance of couple's being healthy and having a healthier baby. It is an important strategy to prevent maternal and perinatal complications. The level of knowledge on preconception care increases its uptake. It is also considered as an input for further intervention of reduction in maternal and neonatal mortality enabling progress towards sustainable development goals (SDGs). Therefore, this systematic review and meta-analysis aimed to estimate the pooled knowledge level of PCC and its association with family planning usage among women in Ethiopia. All observational studies regardless of publication status were retrieved. Important search terms were used to search articles in Google scholar, African Journals Online, CINHAL, HINARI, Science Direct, Cochrane Library, EMBASE, and PubMed/Medline. Independent critical appraisal of retrieved studies was done using the Newcastle-Ottawa assessment checklist. The meta-analysis was conducted using STATA version 14 software. The I² statistics were used to test heterogeneity, whereas publication bias was assessed by Begg's and Egger's tests. The results of the meta-analysis were explained in the Odds ratio (OR) with a 95% confidence interval (CI) and presented using forest plots. A total of seven articles were included in the current systematic review and meta-analysis. Based on the data retrieved from the articles, 35.7% of women in Ethiopia had good knowledge about preconception care. The subgroup analysis based on region revealed the lowest (22.34%) and highest (45.06%) percentage of good knowledge on preconception care among women who were living in Amhara and Oromia regions, respectively. Moreover, women who utilized family planning services were three and more times (OR 3.65 (95% CI 2.11, 6.31)) more likely to have a good level of knowledge about preconception care. One-third of Ethiopian women had good knowledge about preconception care. Family planning utilization had a positive impact on women's knowledge of preconception care.

Interventions to Increase Multivitamin Use Among Women in the Interconception Period: An IMPLICIT Network Study

INTRODUCTION

Each year, 3% of infants in the Unites States (US) are born with congenital anomalies, including 3000 with neural tube defects. Multivitamins (MVIs) including folic acid reduce the incidence of these birth defects. Most women do not take recommended levels of folic acid prior to conception or during the interconception period.

METHODS

The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) ICC model was implemented to screen mothers who attend well child visits (WCVs) for their children aged 0-24 months. Mothers were queried for maternal behavioral risks known to affect pregnancy including multivitamin use and use of family planning methods to enhance birth spacing. When appropriate, interventions targeted at those at risk behaviors are offered. A mixed effects logistic regression model was used to calculate the odds ratio (OR) of behavior change in MVI use among mothers who reported not using MVIs.

RESULTS

37.7% of mothers reported not using MVIs at WCVs. 64.0% of mothers received an intervention to improve MVI use in this model. Mothers who received an intervention were more likely to report taking an MVI at the subsequent WCV if they received advice to take MVIs (OR 1.64) or directly received MVI samples (OR 3.09).

CONCLUSIONS

Dedicated maternal counseling during pediatric WCVs is an opportunity to influence behavioral change in women at risk of becoming pregnant. Direct provision of MVIs increases the odds that women will report taking them at a higher rate than provider advice or no counseling at all.

Prevention of noncommunicable diseases by interventions in the preconception period: A FIGO position paper for action by healthcare practitioners

With the increase in obesity prevalence among women of reproductive age globally, the risks of type 2 diabetes, gestational diabetes, pre-eclampsia, and other conditions are rising, with detrimental effects on maternal and newborn health. The period before pregnancy is increasingly recognized as crucial for addressing weight management and reducing malnutrition (both under- and overnutrition) in both parents to reduce the risk of noncommunicable diseases (NCDs) in the mother as well as the passage of risk to her offspring. Healthcare practitioners, including obstetricians, gynecologists, midwives, and general practitioners, have an important role to play in supporting women in planning a pregnancy and achieving healthy nutrition and weight before pregnancy. In this position paper, the FIGO Pregnancy Obesity and Nutrition Initiative provides an overview of the evidence for preconception clinical guidelines to reduce the risk of NCDs in mothers and their offspring. It encourages healthcare practitioners to initiate a dialogue on women's health, nutrition, and weight management before conception. While acknowledging the fundamental importance of the wider social and environmental determinants of health, this paper focuses on a simple set of recommendations for clinical practice that can be used even in short consultations. The recommendations can be contextualized based on local cultural and dietary practices as part of a system-wide public health approach to influence the wider determinants as well as individual factors influencing preconception health.

Cluster Randomized Trial of a Pre/Interconception Health Intervention for Mothers in Pediatric Visits

OBJECTIVE

Recognizing that pediatric primary care focuses on family health and is an important location of contact for women of childbearing age, this project assessed the effectiveness of a pre/interconception women's health intervention delivered during pediatric primary care using a cluster randomized trial.

METHODS

Pediatric clinicians were randomized to a screening and brief educational intervention group or usual care comparison group. Intervention group clinicians received training on pre/interconception care, including recommended counseling and referral resources for needs identified. Women presenting to primary care with their child ≤12 months were enrolled and assigned to the group corresponding to the assignment of their child's clinician. Mothers seen by clinicians in the intervention group completed a pre/interconception health screening tool and discussed results with their child's clinician during the visit. These mothers were compared to mothers seen by comparison group clinicians who did not receive the screening tool or clinician discussion. All enrolled mothers (Intervention and Comparison) received written preconception health information and a 90-day supply of multivitamins. Primary outcomes at 6 and 12 months post enrollment included contraception use, pregnancy, and access to and use of preventive health care. Secondary outcomes included daily folic acid supplementation, smoking, and substance use.

RESULTS

A total of 415 women were enrolled and those who had at least 1 follow-up assessment were included in the analysis (n = 383). There was no significant effect of the intervention on contraceptive use, pregnancy incidence, or use of preventive care. Assignment to the intervention increased the odds of daily folic acid use (odds ratio 1.82, 95% confidence interval 1.25, 2.63) during follow-up. Intervention mothers were less likely to smoke at 6, but not 12 months.

CONCLUSIONS

Pediatric visits are an opportune location for addressing maternal health and this intervention demonstrated feasibility and improved outcomes for some but not all outcomes. Attention to maternal health needs in pediatric visits during infancy may be important for maintaining positive pre/interconception health behaviors.

"It's Never Too Early": Preconception Care and Postgenomic Models of Life

In this article, we are concerned with the expanded public health interest in the "preconception period" as a window of opportunity for intervention to improve long-term population health outcomes. While definitions of the "preconception period" remain vague, new classifications and categories of life are becoming formalized as biomedicine begins to conduct research on, and suggest intervention in, this undefined and potentially unlimited time before conception. In particular, we focus on the burgeoning epidemiological interest in epigenetics and Developmental Origins of Health and Disease (DOHaD) research as simultaneously a theoretical spyglass into postgenomic biology and a catalyst toward a public health focus on preconception care. We historicize the notion that there are long-term implications of parental behaviors before conception, illustrating how, as Han and Das have noted, "newness comes to be embedded in older forms even as it transforms them" (Han and Das, 2015, p. 2). We then consider how DOHaD frameworks justify a number of fragmented claims about preconception by making novel evidentiary assertions. Engaging with the philosophy of Georges Canguilhem, we examine the relationship between reproductive risk and revised understandings of biological permeability, and discuss some of the epistemic and political implications of emerging claims in postgenomics.

Adult Perceptions of Healthy Pregnancy: A Focus-Group Study

The fastest aging society with the lowest fertility rate can be buffered by support for healthy pregnancies using sociocultural approaches. We aimed to address adult perceptions of a healthy pregnancy and explored their needs and concerns about childbirth across the lifespan. We conducted a qualitative study using content analysis to investigate general perceptions of a healthy pregnancy after focus-group interviews with adult men and women. We interviewed 60 participants in nine group sessions of 5 to 8 people per group. Three major themes emerged that affect healthy pregnancies: Taking responsibility for a prepared pregnancy, factors that interfere with a healthy pregnancy, and improving strategies for a healthy pregnancy. For the first theme, the two main concerns were financial and parenthood preparation. Factors interfering with a healthy pregnancy had direct and indirect causes, considering personal, social, and cultural changes. Strategies for a healthy pregnancy included family and workplace support, systematic education, and governmental support for financial preparation and health screening. Participants averred that various kinds of support (financial, healthcare, and career) are needed for a healthy pregnancy and childbirth. This public awareness could promote better decisions toward healthy pregnancy with more sociocultural approaches in the various settings of home, school, and the workplace.

Husband Support Rises Women’s Awareness of Preconception Care in Northern Ethiopia

Background. Preconception care (PCC) aims to improve pregnancy and health outcomes of mothers and their offspring. However, there is no adequate evidence of awareness on preconception care in Ethiopia. Therefore, the present study was performed to assess the level of awareness and associated factors of preconception care among currently delivered mothers. Method. A community-based cross-sectional study was conducted among 561 mothers in Northern Ethiopia. Data were collected using a pretested, structured questionnaire. Odds ratio presented with 95% confidence interval, and a p value <0.25 at bivariable and p value <0.01 at multivariable logistic regression were used to declare statistical significance. Results. 39.0% of mothers were aware of preconception care. Awareness of preconception care was lower among mothers who did not have joint plan discussion with their partner (AOR = 0.15; 95% CI (0.08, 0.28)); did not have a history of adverse pregnancy outcome (AOR = 0.45; 95% CI (0.25, 0.83)), and did not receive husband support (AOR = 0.10; 95% CI (0.05, 0.19)). Conclusion. Women’s awareness of preconception care remains low. Joint plan discussion with the partner, previous history of adverse pregnancy outcome, and husband support were statistically significant predictors of awareness of preconception care. Thus, informing and sensitizing women and advocating husband support on preconception care are needed.

Primary health care nursing students' knowledge of and attitude towards the provision of preconception care in KwaZulu-Natal

BACKGROUND

Sub-Saharan African countries have been the worst affected by the high incidence of maternal and child mortality rates and HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) pandemic. Preventive care is the area that requires serious attention as a lot of maternal and child morbidity and mortality can be averted through rendering comprehensive care to women of child-bearing age. Preconception care (PCC) is recognised as an important factor in improving pregnancy outcome; yet, most primary health care (PHC) nurses lack the necessary resources to render PCC.

AIM

To describe the PHC nursing student's knowledge of and attitude towards the provision of PCC.

SETTING

Higher Education Institution that offers PHC programme at six different sites to nurses working in the PHC clinics in the province.

METHODS

A quantitative, non-experimental, descriptive study design was used. The total population from three sites selected, based on their geographical location were all invited to participate in the study. Questionnaire was used to collect data which was subsequently analysed using the Statistical Package for Social Sciences (SPSS) version 24.

RESULTS

The response rate was approximately 85% (n = 138). The respondents have practised in the PHC clinic for more than 1 year. Study centre, age and area of employment were found to be predictors of knowledge, but no direct association was found between the demographic factor and attitude. Furthermore, a significant difference was found between knowledge and age, and between the area of employment and attitude.

CONCLUSION

PHC nursing students were knowledgeable and had a favourable attitude towards PCC, but the absence of PCC resources in many practices has hindered them to a greater extent. It is recommended that for proper implementation of PCC to occur, health care workers should be provided with the necessary resources.

Medical and Psychosocial Risk Profiles for Low Birthweight and Preterm Birth

OBJECTIVES

Low birthweight and preterm birth are risk factors for infant mortality and persistent problems. This study uses representative data to assess whether distinct latent profiles of co-occurring medical and psychosocial factors have implications for preterm birth and low birthweight.

METHODS

Data are from the Pregnancy Risk Assessment Monitoring System, a cross-sectional survey constituting representative data on pregnancies from 2012 to 2013. Latent class analysis derived classes of pregnant women potentially at risk for low birthweight and/or preterm birth.

RESULTS

Latent class analysis identified five homogenous profiles of interrelated psychosocial and medical factors. Risk was greatest for the profile marked by high rates of medical factors, followed by a high risk for a profile marked by a combination of very low income and psychosocial factors. Two profiles involving low income and very low income also indicated greater risk for adverse birth outcomes related to socioeconomic status.

CONCLUSIONS

More attention should be paid to screening for and addressing psychosocial risk in concert with prenatal care. Women who show high-risk profiles can be monitored and supported by an interdisciplinary care team, when warranted.

Understanding and provision of preconception care by general practitioners

BACKGROUND

Preconception care (PCC) defines health interventions prior to conception aimed at improving pregnancy and infant outcomes.

AIM

To explore the understanding and provision of PCC by general practitioners (GPs) within the Sydney Local Health District.

MATERIALS AND METHODS

A questionnaire developed with GPs assessed structure and content of PCC provided, attitudes toward PCC and perceived barriers and facilitators.

RESULTS

One hundred and ten GPs completed the survey: 84% reported that GPs should be the main providers of PCC; however, only 53% were aware of PCC guidelines. Seventy-five percent of responders initiated PCC discussion with women of reproductive age, 56% provided PCC to women at higher risk of adverse outcomes and 16% waited for the discussion to be initiated by the patient. Smoking, vaccination, alcohol and supplements/medication use were the most discussed PCC components, while serology, full blood count and blood pressure were the most performed assessments. Most respondents stated that PCC is essential for women with pre-existing diabetes, previous pregnancy complications or chronic illness. However, only 45% stated PCC was essential for women >35 years and 39% for women who were overweight. Importantly, weight and mental health were among the least discussed PCC components.

CONCLUSION

General practitioners are key providers of PCC; however, only half are aware of PCC guidelines and most do not recognise overweight to be a significant preconception issue. The most common barriers to PCC delivery were time constraints, lack of knowledge and lack of resources for patients. Improved resources and education are required to support adequate PCC provision.

The effect of a preconception care outreach strategy: the Healthy Pregnancy 4 All study

Background

Preconception care has been acknowledged as an intervention to reduce perinatal mortality and morbidity. However, utilization of preconception care is low because of low awareness of availability and benefits of the service. An outreach strategy was employed to promote uptake of preconception care consultations. Its effect on the uptake of preconception care consultations was evaluated within the Healthy Pregnancy 4 All study.

Methods

We conducted a community-based intervention study. The outreach strategy for preconception care consultations included four approaches: (1) letters from municipal health services; (2) letters from general practitioners; (3) information leaflets by preventive child healthcare services and (4) encouragement by peer health educators. The target population was set as women aged 18 to 41 years in 14 Dutch municipalities with relatively high perinatal morbidity and mortality rates. We evaluated the effect of the outreach strategy by analyzing uptake of preconception care consultations between February 2013 and December 2014. Registration data of applications for preconception care as well as participant questionnaires were obtained for analysis.

Results

The outreach strategy led to 587 applications for preconception care consultations. The majority of applications (n = 424; 72%) were prompted by the invitation letters (132,129) from the municipalities and general practitioners. The effect of the municipal letter seemed to fade out after 3 months.

Conclusions

Outreach strategies amongst the general population promote uptake of preconception care consultations, although on a small scale and with a temporary effect.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3882-y) contains supplementary material, which is available to authorized users.

Results of a Dutch national and subsequent international expert meeting on interconception care

Introduction: The potential value of preconception care and interconception care is increasingly acknowledged, but delivery is generally uncommon. Reaching women for interconception care is potentially easier than for preconception care, however the concept is still unfamiliar. Expert consensus could facilitate guidelines, policies and subsequent implementation. A national and subsequent international expert meeting were organized to discuss the term, definition, content, relevant target groups, and ways to reach target groups for interconception care.Methods: We performed a literature study to develop propositions for discussion in a national expert meeting in the Netherlands in October 2015. The outcomes of this meeting were discussed during an international congress on preconception care in Sweden in February 2016. Both meetings were recorded, transcribed and subsequently reviewed by participants.Results: The experts argued that the term, definition, and content for interconception care should be in line with preconception care. They discussed that the target group for interconception care should be "all women who have been pregnant and could be pregnant in the future and their (possible) partners". In addition, they opted that any healthcare provider having contact with the target group should reach out and make every encounter a potential opportunity to promote interconception care.Discussion: Expert discussions led to a description of the term, definition, content, and relevant target groups for interconception care. Opportunities to reach the target group were identified, but should be further developed and evaluated in policies and guidelines to determine the optimal way to deliver interconception care.

The evolving landscape of expanded carrier screening: challenges and opportunities

Carrier screening allows individuals to learn their chance of passing on an autosomal or X-linked condition to their offspring. Initially introduced as single-disease, ancestry-based screening, technological advances now allow for the possibility of multi-disease, pan-ethnic carrier screening, which we refer to as “expanded carrier screening.” There are numerous potential benefits to expanded carrier screening, including maximizing the opportunity for couples to make autonomous reproductive decisions, and efficiency and marginal additional costs of including more conditions if the test is already being offered. While numerous laboratories currently offer expanded carrier screening services, it is not yet commonly used in clinical practice, and there is a lack of consensus among experts about the service, including whether this should be offered to individuals and couples, whether this should be offered preconception or prenatally, and what conditions to include in screening programs. Challenges for expanded carrier screening programs include a lack of demand from the public, low prioritization by health systems, the potential for pressure to undergo screening, the possibility of disability-based discrimination, needed adaptations to pre- and post-test counseling, technical limitations, and the evolving technological and socio-political landscape.

Adolescence and the next generation

Adolescent growth and social development shape the early development of offspring from preconception through to the post-partum period through distinct processes in males and females. At a time of great change in the forces shaping adolescence, including the timing of parenthood, investments in today's adolescents, the largest cohort in human history, will yield great dividends for future generations.

Barriers in the Uptake and Delivery of Preconception Care: Exploring the Views of Care Providers

Objectives To examine health care professionals’ views of their role and responsibilities in providing preconception care and identify barriers that affect the delivery and uptake of preconception care. Methods Twenty health care professionals who provide preconception care on a regular basis were interviewed using semi-structured interviews. Results We interviewed twelve community midwives, three General Practitioners, three obstetricians, one cardiologist specialized in congenital heart diseases and one gastroenterologist.We identified four barriers affecting the uptake and delivery of preconception care (PCC): (1) lack of a comprehensive preconception care program; (2) limited awareness of most future parents about the benefits of preconception care, hesitance of GP’s about the necessity and effectiveness of PCC; (3) poor coordination and organization of preconception care; (4) conflicting views of health care professionals on pregnancy, reproductive autonomy of patients and professional responsibility. Conclusion We have identified four barriers in the uptake and delivery of preconception care. Our findings support the timely implementation of a comprehensive program of PCC (already advocated by the Health Council of the Netherlands) and increasing awareness and knowledge of PCC from care providers and future parents. We emphasize the need for further research on how organizational barriers lead to suboptimal PCC and how interdisciplinary collaboration and referral can lead to optimally tailored intervention approaches.

The effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care

PURPOSE

The objective of this study was to investigate the effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care (PCC).

MATERIAL AND METHODS

This quasi-comparative study was carried out between February 2015 and February 2016 at a community midwifery practice in the Netherlands. The intervention consisted of a dual track approach (i) a promotional campaign for couples who wish to conceive and (ii) a PCC pathway for health care providers. Questionnaires were collected from a sample of women who received antenatal care during the pre-intervention (n = 283) and post-intervention (n = 257) period. Main outcome measures were preconceptional lifestyle changes and PCC use (defined as searching for information and/or consulting a health care provider).

RESULTS

Women who were exposed to the intervention were significantly more likely to make at least one lifestyle change during the preconception period [adjusted OR 1.56 (95% CI 1.02-2.39)]. Women were especially more likely to preconceptionally reduce or quit [adjusted OR 1.72 (95% CI 1.05-2.83)] their alcohol consumption after exposure to the intervention. Although non-significant, it appeared that women who were exposed to the intervention more often prepared themselves for pregnancy by means of independently searching for preconception health information [adjusted OR 1.13 (95% CI 0.77-1.65)] or consulting a health care provider regarding their wish to conceive [adjusted OR 1.24 (95% CI 0.81-1.92)].

CONCLUSIONS

Exposure to a local promotional campaign targeted at preconceptional health was associated with improved preconceptional lifestyle behaviours, especially with regard to alcohol consumption, and has the potential to improve the use of PCC.

Parental perspectives on the awareness and delivery of preconception care

BACKGROUND

The attention for Preconception Care (PCC) has grown substantially in recent years, yet the implementation of PCC appears challenging as uptake rates remain low. The objective of this study was to assess parental perspectives on how PCC should be provided.

METHODS

Recruitment of participants took place among couples who received antenatal care at a Dutch community midwifery practice. Between June and September 2014, five focus group sessions were held with 29 women and one focus group session with 5 men. Thematic analysis was conducted using NVivo 10 software.

RESULTS

Participants were generally unfamiliar with the concept of PCC. It was proposed to raise awareness by means of a promotional campaign, stipulating that PCC is suited for every couple with a (future) child wish. Suggestions were made to display marketing materials in both formal and informal (local community) settings. Addressing existing social networks and raising social dialogue was expected to be most efficient. It was recommended to make PCC more accessible by offering multiple forms and to involve male partners. Opportunistic offering PCC by healthcare providers was considered more acceptable when the subject was deliberately raised, for example while discussing contraceptives, lifestyle risks or drug prescriptions. GP's or midwifes were regarded the most suitable PCC providers, however provider characteristics such as experience, empathy and communication skills were considered more important.

CONCLUSIONS

This study showed that from the parental perspective it is recommended to address every couple with a (future) child wish by means of enlarging the awareness and accessibility of PCC. In order to enlarge the awareness, it is recommended to address social networks, to raise the social dialogue and to conduct promotional campaigns regarding PCC. In order to improve the accessibility of PCC, it was suggested to simultaneously offer multiple forms: group sessions, individual consultations, walk-in-hours and online sessions, and to involve male partners.

Healthcare providers' views on the delivery of preconception care in a local community setting in the Netherlands

BACKGROUND

The attention for preconception care (PCC) has grown substantially in recent years, yet PCC is far from routine in daily practice. One of the major challenges for the implementation of PCC is to identify how it can best be organized and provided within the primary care setting. The aim of this study was to identify bottlenecks and solutions for the delivery of PCC from a healthcare providers' perspective in a local community setting in the Netherlands.

METHODS

Health professionals within the region of Zeist, the Netherlands, were invited for a meeting on the local implementation of PCC. Five parallel group sessions were held with 30 participants from different disciplines. The sessions were moderated based on the Nominal Group Technique, in which bottlenecks (step 1) and solutions (step 2) for the delivery of PCC were gathered, categorized and prioritized by the participants.

RESULTS

Participants expressed that the provision of PCC is challenging due to lack of awareness, the absence of a costing structure and unclear allocation of responsibilities. The most pragmatic approach considered was to make interdisciplinary arrangements within the local primary care setting. Participants recommended to 1) settle a costing structure by means of third party reimbursement, 2) improve collaboration by means of a local cooperation network and an adequate referral system, 3) invest in education, tools and logistics and 4) increase uptake rates by the routine opportunistic offer of PCC and promotional campaigns.

CONCLUSIONS

From a provider's perspective a tailored approach is advocated in which interdisciplinary arrangements for collaboration and referral are set up within the local primary care setting.

Interventions to prevent maternal obesity before conception, during pregnancy, and post partum

Prevention of obesity in women of reproductive age is widely recognised to be important both for their health and for that of their offspring. Weight-control interventions, including drug treatment, in pregnant women who are obese or overweight have not had sufficient impact on pregnancy and birth outcomes, which suggests that the focus for intervention should include preconception or post-partum periods. Further research is needed into the long-term effects of nutritional and lifestyle interventions before conception. To improve preconception health, an integrated approach, including pregnancy prevention, planning, and preparation is needed, involving more than the primary health-care sector and adopting an ecological approach to risk reduction that addresses personal, societal, and cultural influences. Raising awareness of the importance of good health in the period before pregnancy will require a new social movement: combining bottom-up mobilisation of individuals and communities with a top-down approach from policy initiatives. Interventions to reduce or prevent obesity before conception and during pregnancy could contribute substantially to achievement of the global Sustainable Development Goals, in terms of health, wellbeing, productivity, and equity in current and future generations.

General practitioners' knowledge, attitudes and views of providing preconception care: a qualitative investigation

BACKGROUND

Preconception health and care aims to reduce parental risk factors before pregnancy through health promotion and intervention. Little is known about the preconception interventions that general practitioners (GPs) provide. The aim of this study was to examine GPs' knowledge, attitudes, and views towards preconception health and care in the general practice setting.

METHODS

As part of a large mixed-methods study to explore preconception care in England, we surveyed 1,173 women attending maternity units and GP services in London and interviewed women and health professionals. Seven GPs were interviewed, and the framework analysis method was used to analyse the data.

FINDINGS

Seven themes emerged from the data: Knowledge of preconception guidelines; Content of preconception advice; Who should deliver preconception care?; Targeting provision of preconception care; Preconception health for men; Barriers to providing preconception care; and Ways of improving preconception care. A lack of knowledge and demand for preconception care was found, and although reaching women before they are pregnant was seen as important it was not a responsibility that could be adequately met by GPs. Specialist preconception services were not provided within GP surgeries, and care was mainly targeted at women with medical conditions. GPs described diverse patient groups with very different health needs.

CONCLUSION

Implementation of preconception policy and guidelines is required to engage women and men and to develop proactive delivery of care with the potential to improve pregnancy and neonatal outcomes. The role of education and of nurses in improving preconception health was acknowledged but remains under-developed.

Facilitators and Barriers for Successful Implementation of Interconception Care in Preventive Child Health Care Services in the Netherlands

Objectives Successful implementation of preconception and interconception care contributes to optimizing pregnancy outcomes. While interconception care to new mothers could potentially be provided by Preventive Child Health Care services, this care is currently not routinely available in the Netherlands. The purpose of this study was to identify facilitators and barriers for implementation of interconception care in Preventive Child Health Care services. Methods We organized four focus groups in which Preventive Child Health Care physicians and nurses, related health care professionals and policymakers participated. A semi-structured interview approach was used to guide the discussion. The transcribed discussions were analyzed. Results All four groups agreed that several facilitators are present, such as the unique position to reach women and the expertise in preventive health care. Identified barriers include unfamiliarity with interconception care among patients and health care providers, as well as lack of consensus about the concept of interconception care and how it should be organized. A broad educational campaign, local adaptation, and general agreement or a guideline for standard procedures were recognized as important for future implementation. Conclusions for practice This study identifies potentially important facilitators and barriers for the implementation of interconception care in Preventive Child Health Care services or comparable pediatric settings. These factors should be considered and strategies developed to achieve successful implementation of interconception care.

Effectiveness of general preconception care accompanied by a recruitment approach: protocol of a community-based cohort study (the Healthy Pregnancy 4 All study)

INTRODUCTION

Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relative unfavourable perinatal outcomes. In response, a nationwide study Healthy Pregnancy 4 All (HP4ALL) has been initiated. One of the substudies within HP4ALL focuses on preconception care (PCC). PCC is an opportunity to detect and eliminate risk factors before conception to optimise health before organogenesis and placentation. The main objectives of the PCC substudy are (1) to assess the effectiveness of a recruitment strategy for the PCC health services and (2) to assess the effectiveness of individual PCC consultations.

METHODS/ANALYSIS

Prospective cohort study in neighbourhoods of 14 municipalities with perinatal mortality and morbidity rates exceeding the nation's average. The theoretical framework of the PCC substudy is based on Andersen's model of healthcare utilisation (a model that evaluates the utilisation of healthcare services from a sociological perspective). Women aged 18 up to and including 41 years are targeted for utilisation of the PCC health service by a four armed recruitment strategy. The PCC health service consists of an individual PCC consultation consisting of (1) initial risk assessment and risk management and (2) a follow-up consultation to assess adherence to the management plan. The primary outcomes regarding the effectiveness of consultations is behavioural change regarding folic acid supplementation, smoking cessation, cessation of alcohol consumption and illicit substance use. The primary outcome regarding the effectiveness of the recruitment strategy is the number of women successfully recruited and the outreach in terms of which population is reached in comparison to the approached population. Data collection consists of registration in the database of women that enrol for a visit to the individual PCC consultations (women successfully recruited), and preconsultation and postconsultation measurements among the included study population (by questionnaires, anthropometric measurements and biomarkers). Sample size calculation resulted in a sample size of n=839 women.

ETHICS AND DISSEMINATION

Approval for this study has been obtained from the Medical Ethical Committee of the Erasmus Medical Center of Rotterdam (MEC 2012-425). Results will be published and presented at international conferences.

Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States

OBJECTIVE

Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC)-preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States.

STUDY DESIGN

Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.

RESULTS

We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.

CONCLUSION

Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.