Preconception health care interventions: A scoping review

Digital preconception interventions targeting weight, diet and physical activity: A systematic review

AIM

Optimising preconception health increases the likelihood of conception, positively influences short- and long-term pregnancy outcomes and reduces intergenerational chronic disease risk. Our aim was to synthesise study characteristics and maternal outcomes of digital or blended (combining face to face and digital modalities) interventions in the preconception period.

METHODS

We searched six databases (PubMed, Cochrane, Embase, Web of Science, CINHAL and PsycINFO) from 1990 to November 2022 according to the PRISMA guidelines for randomised control trials, quasi-experimental trials, observation studies with historical control group. Studies were included if they targeted women of childbearing age, older than 18 years, who were not currently pregnant and were between pregnancies or/and actively trying to conceive. Interventions had to be delivered digitally or via digital health in combination with face-to-face delivery and aimed to improve modifiable behaviours, including dietary intake, physical activity, weight and supplementation. Studies that included women diagnosed with type 1 or 2 diabetes were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality criteria checklist. Study characteristics, intervention characteristics and outcome data were extracted.

RESULTS

Ten studies (total participants n=4,461) were included, consisting of nine randomised control trials and one pre-post cohort study. Seven studies received a low risk of bias and two received a neutral risk of bias. Four were digitally delivered and six were delivered using blended modalities. A wide range of digital delivery modalities were employed, with the most common being email and text messaging. Other digital delivery methods included web-based educational materials, social media, phone applications, online forums and online conversational agents. Studies with longer engagement that utilised blended delivery showed greater weight loss.

CONCLUSION

More effective interventions appear to combine both traditional and digital delivery methods. More research is needed to adequately test effective delivery modalities across a diverse range of digital delivery methods, as high heterogeneity was observed across the small number of included studies.

Building Healthy Babies: A Mixed-Methods Needs Assessment for a Pre-Conception Program in Ontario

OBJECTIVES

The objective of this study was to gather Ontario clinicians' and public members' views on the design of a pre-conception patient education program.

METHODS

In this mixed-methods study, online surveys comprised of rank order, multiple choice, and short answer questions were completed by clinicians and public members. Semi-structured focus groups consisting of 2-6 participants each were then held via videoconference. Demographic variables and survey responses were analyzed quantitatively using descriptive and summary statistics. Descriptive thematic qualitative analysis using the constant comparative method of grounded theory was completed on each transcript to generate themes.

RESULTS

A total of 168 public members and 43 clinicians in Ontario completed surveys, while 11 clinicians and 11 public members participated in the focus groups. A pre-conception program in Ontario was felt to be important. An individual appointment with a primary care provider was the favoured program format per survey responses, whereas a virtual format with an interactive component was preferred among focus group participants. Important topics to include were pre-conception health (infertility, genetic screening, folic acid), prenatal and postpartum counselling (diet, activity, substance use, prenatal care, postpartum course), and medical optimization in pregnancy (high-risk medical conditions, medications, mental health). Both groups emphasized the need to consider accommodations for marginalized populations and various cultures and languages.

CONCLUSION

A standardized pre-conception patient education program is felt to be of high value by Ontario clinicians and public members. A pre-conception program may help improve obstetrical outcomes and decrease rates of major congenital anomalies in Ontario.

Real-world insights on nutritional awareness and behaviors among preconception and pregnant women in three Asia Pacific countries

Introduction

In many parts of Asia Pacific (APAC), insufficient intake of micronutrients that are important for conception and pregnancy remains a prevalent issue among women of reproductive age. It is crucial to gain insights into women's nutritional awareness and nutrition-related behaviors, as well as how these relate to their health literacy (HL). This understanding can help identify gaps and guide the development of appropriate intervention strategies. However, there appears to be limited relevant data available for the APAC region. We therefore examined nutritional awareness and behaviors among preconception and pregnant women in three APAC countries, and explored how these were related to women's HL.

Methods

Cross-sectional online surveys were conducted among preconception (i.e., planning to conceive within the next 12 months or currently trying to conceive) and pregnant women in Australia (N = 624), China (N = 600), and Vietnam (N = 300). The survey questionnaire included a validated tool for HL (Newest Vital Sign) and questions to examine awareness and behaviors relating to healthy eating and prenatal supplementation during preconception and pregnancy.

Results

Despite recommendations for a quality diet complemented by appropriate supplementation during preconception and pregnancy, many respondents in each country were not aware of the specific impact of adequate nutrition during these stages. While many respondents reported changes in their diet to eat more healthily during preconception and pregnancy, a substantial proportion were not taking prenatal supplements. Higher HL was related to greater nutritional awareness and higher use of prenatal supplements.

Discussion

Our findings suggest that there are gaps in nutritional awareness and practices of many preconception or pregnant women in the three countries. Interventions to improve HL would be valuable to complement conventional knowledge-centric nutrition education, and enhance understanding and empower women to adopt appropriate nutritional practices throughout their preconception/pregnancy journey.

A Scoping Review of Barriers and Facilitators for Preconception Care: Lessons for Global Health Policies and Programs

Preconception care (PCC) encompasses a set of actions taken before pregnancy to support the health and well-being of women before conception to improve maternal and child health (MCH) outcomes. The utilization of PCC services is influenced by multifaceted factors that can either enable or impede women's capacity to access and utilize them effectively. This scoping review examines the barriers and facilitators influencing the utilization of PCC services among women of reproductive age (15-49 years) at both individual and community levels. Through an extensive review of published articles from 2004 to 2021, including peer-reviewed sources, barriers and facilitators were identified. At the individual level, barriers included limited knowledge about PCC, neglect of self-health, and financial constraints. Community-level barriers encompassed insufficient supply of supplements, restricted access to health care, high health care costs, and setbacks due to delayed delivery of MCH services. Conversely, individuals reported that credible sources of information, such as friends, family, and community health volunteers, facilitated their engagement with PCC services. At the community level, facilitators included government-regulated supply chains for supplements and the involvement of community workers in health monitoring. Understanding and addressing these factors can help improve the utilization of PCC services among women of reproductive age (WRA) and improve MCH outcomes.

Holistic preconception care: Providing real-time guidance via a mobile app to optimise maternal and child health

Introduction

Preconception is a critical period to optimise gamete function and early placental development, essential for successful conception and long-term maternal-child health. However, there is a lack of preconception services and consequently, global fertility rates continue to fall and mothers embark on their pregnancy journey in poor health. There is an urgent need to implement a holistic community-level preconception care programme to optimise risk factors for poor fecundability and improve long-term maternal-child health.

Method

We reviewed current evidence on fecundability lifestyle risk factors, the efficacy of existing preconception interventions and the use of digital platforms for health optimisation, to create a new digital-based preconception intervention model that will be implemented via an app. We present the theory, content and mode of delivery of this holistic model targeting couples planning for pregnancy.

Results

We propose a new model featuring a user-friendly mobile app, which enables couples to self-assess fecundability risks through a personalised risk score that drives a tailored management plan. This tiered management provides anticipatory guidance supported by evidence-based recommen-dations, and promotes ongoing engagement for behavioural optimisation and specialist referrals as required. Based on the health belief model, this new model delivered with a mobile app seeks to shift couples' perceptions about their susceptibility and severity of subfertility, benefits of making a change and barriers to change.

Conclusion

Our proposed digital-based intervention model via a mobile app stands to enhance preconcep-tion care by providing personalised risk assessments, real-time feedback and tiered management to optimise preconception reproductive health of couples. This model forms a reference content framework for future preconception care intervention delivery.

Exploring preconception health in adolescents and young adults: Identifying risk factors and interventions to prevent adverse maternal, perinatal, and child health outcomes-A scoping review

BACKGROUND

Preconception health provides an opportunity to examine a woman's health status and address modifiable risk factors that can impact both a woman's and her child's health once pregnant. In this review, we aimed to investigate the preconception risk factors and interventions of early pregnancy and its impact on adverse maternal, perinatal and child health outcomes.

METHODS

We conducted a scoping review following the PRISMA-ScR guidelines to include relevant literature identified from electronic databases. We included reviews that studied preconception risk factors and interventions among adolescents and young adults, and their impact on maternal, perinatal, and child health outcomes. All identified studies were screened for eligibility, followed by data extraction, and descriptive and thematic analysis.

FINDINGS

We identified a total of 10 reviews. The findings suggest an increase in odds of maternal anaemia and maternal deaths among young mothers (up to 17 years) and low birth weight (LBW), preterm birth, stillbirths, and neonatal and perinatal mortality among babies born to mothers up to 17 years compared to those aged 19-25 years in high-income countries. It also suggested an increase in the odds of congenital anomalies among children born to mothers aged 20-24 years. Furthermore, cancer treatment during childhood or young adulthood was associated with an increased risk of preterm birth, LBW, and stillbirths. Interventions such as youth-friendly family planning services showed a significant decrease in abortion rates. Micronutrient supplementation contributed to reducing anaemia among adolescent mothers; however, human papillomavirus (HPV) and herpes simplex virus (HSV) vaccination had little to no impact on stillbirths, ectopic pregnancies, and congenital anomalies. However, one review reported an increased risk of miscarriages among young adults associated with these vaccinations.

CONCLUSION

The scoping review identified a scarcity of evidence on preconception risk factors and interventions among adolescents and young adults. This underscores the crucial need for additional research on the subject.

The cost of inaction on preconception health in Nigeria: An economic impact analysis

A growing body of evidence has shown the effects of poor preconception health on adverse pregnancy outcomes and, subsequently, maternal and child morbidity and mortality. However, the cost of poor preconception health remains relatively unexplored. Using the case of Nigeria, this study provides the first estimate of the disease and economic burden of poor preconception health at a country level. Using data from international databases and the scientific literature, the study used a cost-of-illness approach to quantify the foregone productivity and direct healthcare costs resulting from six preconception risk factors (adolescent pregnancy, short birth interval, overweight and obesity, intimate partner violence, female genital mutilation, folate deficiency). The results indicate that 6.7% of maternal deaths, 10.9% of perinatal deaths, and 10.5% of late neonatal deaths were attributable to the selected preconception risk factors in 2020. The economic burden of poor preconception health in Nigeria was estimated at US$ 3.3 billion in 2020, of which over 90% was generated by premature mortality. If prevalence rates remain constant, total economic losses could amount to US$ 46.2 billion by 2035. This analysis paves the way for further studies investigating the economic costs and benefits of preconception interventions and policies in low and middle-income countries.

Pre-Conceptional and Antenatal Care for Improved Newborn and Child Survival in India: A Review

There is sufficient scientific evidence that quality pre-conceptional care and antenatal care can improve newborn survival. This review was conducted to understand the concept of pre-conceptional care and its implementation status in India. The review documents the specific interventions that have been proven to effectively improve pregnancy outcome when provided as pre-conception care. Healthcare providers, particularly obstetricians/gynecologists and general physicians, should prioritize pre-conception care as an essential component of healthcare for women. However, the lack of continuum of care and program linkages are some of the key barriers in ensuring pre-conceptional and ante-natal care in India. Culturally and linguistically appropriate care should be provided to ensure that all women can access and understand the information and services needed to optimize their reproductive health and improve pregnancy outcomes. Prioritizing pre-conception and prenatal care, healthcare providers can improve maternal and fetal outcomes, reduce healthcare costs, and promote lifelong health for women and their families. The primary healthcare reforms being done in India can be and should be used to strengthen pre-conceptional and ante-natal care services and quality.

Factors Related to the Implementation of Preconception Care Recommendations in Selected Districts of Limpopo Province: A Qualitative Study

Preconception care (PCC) is the provision of biomedical, behavioural, and social health interventions to women and couples before they fall pregnant. The World Health Organization (WHO) developed PCC recommendations in 2013, which were included in the South African maternity care guidelines in 2016. The purpose of PCC is to lessen behaviours and environmental factors leading to maternal ill-health, thus reducing maternal and perinatal mortality rates.

OBJECTIVE

To determine the implementation of PCC recommendations at health facilities in the selected districts of Limpopo Province and the associated factors.

METHODS

A qualitative exploratory design was used. Nonprobability, purposive sampling was used to sample 29 professional nurses (PNs), and 51 women of childbearing age (WCBA) (19-35 years) from clinics and community health centres (CHCs). Data were collected through in-depth interviews with the professional nurses and focus group discussions with the WCBA. Data analysis was performed through open coding. Measures of trustworthiness were adhered to. Permission to conduct the study was obtained from relevant stakeholders, participation was voluntary and participants signed a consent form prior to data collection.

RESULTS

The findings of the study revealed that there was partial implementation of the PCC recommendations in the selected districts of Limpopo Province, PCC provision was dependent on clients' initiation, a knowledge gap regarding PCC recommendations was identified from the professional nurses, and a lack of awareness regarding PCC from the WCBA.

CONCLUSION

The preconception period is an important determinant of the pregnancy outcome; therefore, focus should be redirected to the pre-pregnancy period and not only to when the woman is already pregnant. However, to achieve this, professional nurses and WCBA should be empowered regarding PCC and its benefits.

Investigating the pathways from preconception care to preventing maternal, perinatal and child mortality: A scoping review and causal loop diagram

In recent years, there has been a growing recognition that developing preconception care provides an opportunity to significantly reduce maternal and child mortality and morbidity. This involves targeting multiple risk factors through a large array of medical, behavioural and social interventions. In this study, we created a Causal Loop Diagram (CLD) to describe several pathways by which a set of preconception interventions may lead to women's improved health and better pregnancy outcomes. The CLD was informed by a scoping review of meta-analyses. It summarises evidence on the outcomes and interventions related to eight preconception risk factors. The authors reviewed literature from two databases (PubMed and Embase) and used the framework developed by Arksey and O'Malley. The CLD includes 29 constructs categorised into five different levels (mortality, causes of death, preconception risk factors, intermediate factors, interventions or policies). The model indicates interconnections between five sub-systems and highlights the role of preventing early and rapidly repeated pregnancies, as well as optimising women's nutritional status in the preconception period. It also shows the prevention of preterm birth as a privileged route for lowering child mortality and morbidity. The CLD demonstrates the potential benefits of strategies that address multiple preconception risk factors simultaneously and can be used as a tool to promote the integration of preconception care into efforts to prevent maternal and child mortality. With further improvements, this model could serve as a basis for future research on the costs and benefits of preconception care.

Socioeconomic Characteristics, Lifestyle Behaviors, and Health Conditions Among Males of Reproductive Age With and Without Disabilities, NHANES 2013-2018

Health status during the reproductive years influences fecundity, fertility, and the future health of males and their offspring. There remains a dearth of literature examining men's preconception health, especially among high-risk populations, such as those with disabilities. The objective of this study was to examine indicators of preconception health, including chronic medical conditions, lifestyle behaviors, and health care utilization, among males of reproductive age with and without disabilities in the United States. Data were from 3,702 males of reproductive age (18-44 years) who participated in the National Health and Nutrition Examination Surveys, 2013-2018. Approximately 14% of males reported having at least one disability related to vision, hearing, cognition, mobility, self-care, or independent living. Among all men, suboptimal preconception health indicators were prevalent including poor or fair self-rated health; low education and household income status; lack of health insurance and no recent utilization of health care and dental care; cigarette smoking; frequent alcohol consumption and binge drinking; marijuana and illegal drug use; obesity; low fruit and vegetable intake and no multi-vitamin use; low physical activity; short sleep durations; depressive symptoms; and hypertension and asthma. Compared to males with no disabilities, males with any disabilities were more likely to have suboptimal preconception health indicators. Strategies to promote and improve sexual health, preconception care, and family planning services among all men are needed. For males with disabilities, specifically, further investigation of their specific health needs related to sex, reproduction, family planning, and fatherhood, as well as interactions with health care providers, is required.

Perceptions and Beliefs About Preconceptional Care Among Primary Healthcare Workers in Jeddah City, Saudi Arabia: An Analytical Cross-Sectional Study

Introduction Preconception care (PCC) is one of the important aspects of reproductive health and family planning, from the preventive aspect as primordial prevention for future offspring and primary prevention for females before pregnancy. However, there is no written protocol about PCC and it is not routinely practiced in Saudi Arabia. This study aimed to assess the perceptions and beliefs among care workers regarding PCC. Methods A cross-sectional study was conducted on general practitioners (GP), family physicians (FP), practitioner nurses (PN), and midwives (MW) in primary healthcare centers (PHC) in Jeddah City using a validated questionnaire that assesses their preconception practices, perceptions, and beliefs. Results This study included 201 participants, of whom 98.5% were Saudi nationals and 80.1% were female. Most (64.7%) were 30-39 years old, followed by 40-49 years old (21.9%). The majority (67.7%) were married and had one or two children (37.3%). Most (36%) were practitioner nurses, followed by family physicians (31%), and had 11-15 years of experience (32%), followed by six to 10 years of experience. The majority (44%) reported providing PCC one to five times last month. Of all participants, 72.63% agreed that PCC affected pregnancy outcomes, and 83% agreed that PCC is important. However, 51.7% agreed there is not enough time to provide PCC services. The service rated as the highest priority was providing advice regarding smoking cessation (82.1%), alcohol cessation (84.6%), control of chronic diseases (85.1%), and information about drug use (86.6%). Most participants rated rubella screening as highly important (89.9%), followed by hepatitis screening (88.6%). Family physicians and practitioner nurses perceived PCC as more important than general practitioners and midwives (p=0.026) and were more likely to perceive hospitals as the optimal setting for PCC (p=0.015). General practitioners were more likely to believe in the insufficient evidence base for PCC (p < 0.001). Conclusion The study found that healthcare workers had good perceptions, knowledge, and attitudes toward the PCC, but their practice was poor. Most lacked formal training and had differing perspectives on PCC, depending on their professions. The findings could inform strategies and measures to improve PCC practice among healthcare workers and raise awareness as well as capacity building by enhancing the training of healthcare workers.

The impact of paid sick leave mandates on Women's health

The United States does not have a national program to provide job-protected paid leave to workers when they or a family member are ill or need to seek medical care. Many workers receive paid sick leave through their employers, but women, particularly parents, those without a college degree, and Latinas, are less likely than their counterparts to receive employer-provided paid sick leave (PSL). To address the shortfall in PSL coverage, several states and localities have passed laws mandating employers to provide PSL. I examine the impacts of three recent state-level paid sick leave policies on women's self-reported health using data from the Behavior Risk Factor Surveillance System. Using static and event-study difference-in-differences models, I find that PSL mandates decreased the proportion of women reporting fair or poor health by an average of 2.4 percentage points and reduced the number of days women reported their physical and mental health was not good by 0.68 days and 0.43 days in the past 30 days respectively. Effects were concentrated among parents, women without college degrees, and women of color. This study demonstrates that despite being a low-intensity policy, PSL improves women's health and well-being and that mandating workplace benefits may play a role in achieving health equity.

Development and Validation of Conversational Agent to Pregnancy Safe-education

Pregnant women constantly need some information to support nutritional decisions during pregnancy, and many do not receive such assistance at all. This study aims to present a conversational agent to provide reliable information to pregnant women, focusing on nutritional education and evaluating the perception of pregnant women and health professionals about the agent. As a scientific contribution, this article developed and implemented a conversational agent in a real environment capable of generating reliable responses on the basis of a set of health documents. We proposed an intervention study with 25 women and 10 healthcare providers through a survey to measure the perceptions of these groups towards conversational agents. The results show that the intended design could ensure positive support for pregnant women, clarify certain issues for the public, and remove some knowledge barriers. The results showed no significant difference between the groups (p-value = 0.713). Depending on the perception of the pregnant group, the conversational agent model can teach new knowledge during the prenatal period (Mean = 4.56). The model presented for health professionals could already be indicated as a support tool for pregnant women (Mean = 4.7).

Knowledge, attitudes and behaviours surrounding preconception and pregnancy health: an Australian cross-sectional survey

OBJECTIVE

To understand Australian women's knowledge, attitudes and behaviours surrounding preconception and pregnancy health and their preferences for information about these periods.

DESIGN

Cross-sectional survey.

SETTING

Making healthy changes can optimise preconception and pregnancy outcomes. Clinical practice guidelines inform preconception and pregnancy care in Australia. Women often have access to multiple sources of information on reproductive and pregnancy health.

PARTICIPANTS

Women of reproductive age were asked to complete a web-based survey. The survey development was informed by preconception guidelines, consensus statements and the national pregnancy care guidelines. The survey was distributed through social media, local and national networks from 2017 to 2018.

RESULTS

Completed surveys were received from 553 women.The majority (80.4%) had high educational attainment. Checking immunisation status and ensuring good mental health were rated as equally important actions both preconception (65%) and during pregnancy (78%). Limiting sedentary activities was not rated as an important action to take either preconception (36%), or during pregnancy (38%). Although women have good knowledge about the impact of weight on their own health outcomes (eg, gestational diabetes), there was less knowledge about adverse outcomes for babies like stillbirth and preterm birth. Women access many sources for reproductive health information, however, the most trusted source was from healthcare professionals.

CONCLUSION

Most women of reproductive age in Australia have knowledge of the key health recommendations for preconception and pregnancy. However, there are gaps related to lifestyle behaviours particularly connected to weight gain and outcomes for babies. There is a strong preference to receive trusted information from healthcare providers through multiple resources.

Acceptability and feasibility of a planned preconception weight loss intervention in women with long-acting reversible contraception: the Plan-it mixed-methods study

BACKGROUND

Women with overweight (a body mass index of ≥ 25 kg/m²) or obesity (a body mass index of ≥ 30 kg/m²) are at greater risk of experiencing complications during pregnancy and labour than women with a healthy weight. Women who remove their long-acting reversible contraception (i.e. coils or implants) are one of the few groups of people who contact services as part of their preparation for conception, creating an opportunity to offer a weight loss intervention.

OBJECTIVES

The objectives were to understand if routine NHS data captured the pathway from long-acting reversible contraception removal to pregnancy and included body mass index; to identify the suitable components of a preconception weight loss intervention; and to engage with key stakeholders to determine the acceptability and feasibility of asking women with overweight/obesity to delay the removal of their long-acting reversible contraception in order to take part in a preconception weight loss intervention.

DESIGN

This was a preparatory mixed-methods study, assessing the acceptability and feasibility of a potential intervention, using routine NHS data and purposefully collected qualitative data.

PARTICIPANTS

The NHS routine data included all women with a long-acting reversible contraception code. There were three groups of participants in the surveys and interviews: health-care practitioners who remove long-acting reversible contraception; weight management consultants; and women of reproductive age with experience of overweight/obesity and of using long-acting reversible contraception.

SETTING

UK-based health-care practitioners recruited at professional meetings; and weight management consultants and contraceptive users recruited via social media.

DATA SOURCES

Anonymised routine data from UK sexual health clinics and the Clinical Practice Research Datalink, including the Pregnancy Register; and online surveys and qualitative interviews with stakeholders.

RESULTS

The records of 2,632,871 women aged 16-48 years showed that 318,040 had at least one long-acting reversible contraception event, with 62% of records including a body mass index. Given the identified limitations of the routine NHS data sets, it would not be feasible to reliably identify women with overweight/obesity who request a long-acting reversible contraception removal with an intention to become pregnant. Online surveys were completed by 100 health-care practitioners, four weight management consultants and 243 contraceptive users. Ten health-care practitioners and 20 long-acting reversible contraception users completed qualitative interviews. A realist-informed approach generated a hypothesised programme theory. The combination of weight discussions and the delay of long-acting reversible contraception removal was unacceptable as an intervention to contraceptive users for ethical and practical reasons. However, a preconception health intervention incorporating weight loss could be acceptable, and one potential programme is outlined.

LIMITATIONS

There was very limited engagement with weight management consultants, and the sample of participating stakeholders may not be representative.

CONCLUSIONS

An intervention that asks women to delay long-acting reversible contraception removal to participate in a preconception weight loss intervention would be neither feasible nor acceptable. A preconception health programme, including weight management, would be welcomed but requires risk communication training of health-care practitioners.

FUTURE WORK

Work to improve routine data sets, increase awareness of the importance of preconception health and overcome health-care practitioner barriers to discussing weight as part of preconception care is a priority.

TRIAL REGISTRATION

This trial is registered as ISRCTN14733020.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 1.

Survival patterns of neonates born to adolescent mothers and the effect of pregnancy intentions and marital status on newborn survival in Kenya, Uganda, and Tanzania, 2014-2016

Background

Adolescent pregnancy and associated neonatal mortality are major global health challenges. In low-income settings where 90% of the 21 million global adolescent pregnancies occur, half are unintended and a fifth experience unsafe abortion. In Kenya, Uganda, and Tanzania, the survival patterns of neonates born to adolescents are unclear.

Objectives

To assess survival patterns among neonates born to adolescents and the effect of pregnancy intentions and marital status on survival in Kenya, Uganda, and Tanzania.

Methods

Cross-sectional data from demographic and health surveys in Kenya, Uganda, and Tanzania 2014–2016 were used. Kaplan-Meier estimates investigated patterns of neonatal survival among adolescent mothers, aged 15–19 years, compared to mothers aged 20–29 years. Cox proportional hazards regression determined the hazard ratios (HR) for the predictors of neonatal survival.

Results

About 50% of adolescent pregnancies were unintended and neonatal death rate was twice as high than older mothers (26.6 versus 12.0 deaths/1000 live births). The median survival time was two days for adolescent-born babies and four days among older mothers. The hazard of death for all adolescent-born neonates was about twofold that of 20–29 years-old-mothers, HR 1.80 (95% CI 1.22–2.63). Among married adolescents with unintended newborn pregnancies, the HR was 4-folds higher than corresponding older mothers, HR 4.08 (95% CI 1.62–10.31). Among married, primiparous adolescents with unintended pregnancies, the HR was six times higher than corresponding older mothers.

Conclusion

Our findings reveal how unintended pregnancies and deaths of neonates born to adolescents contribute substantially to preventable neonatal deaths in East Africa. Full implementation of existing adolescent health policies and utilization of contraceptives should be ensured. Partnership with youths and novel efforts that address sociocultural norms to reduce adolescent pregnancies or marriage should be supported. Regulations requiring adolescents’ obstetric care conducted by only skilled personnel should be introduced and implemented.

Couples-based behaviour change interventions to reduce metabolic syndrome risk. A systematic review

BACKGROUND AND AIMS

Metabolic Syndrome (MetS), is a major risk factor for non-communicable diseases including type 2 diabetes mellitus, cardiovascular disease, and cancer. Although MetS risk is transferred via the epigenome from both biological parents, periconceptional lifestyle interventions are generally directed towards mothers. There is a need for interventions to reflect the shared nature of epigenetic MetS risk between both biological parents. Couples-based lifestyle interventions have previously been used to improve adherence to behaviour change in conditions with shared risk responsibility such as sexually transmitted diseases. This systematic literature review sought to answer the research question: Are couples-based interventions more effective than individual interventions to address overweight and obesity as the primary modifiable risk for MetS in addition to other associated factors.

METHODS

Couples-based studies involving randomised controlled trials, published between 01/01/1990-31/12/2021, were identified in Medline, CINAHL, PsycINFO, Psychology and Behavioural Sciences Collection, Cochrane, and Scopus.

RESULTS

After screening 4742 articles, only five eligible trials remained. Statistically significant post-intervention maintenance of low glycaemic levels was observed in one study. Otherwise, no statistically significant group differences between couples' groups and control groups were observed in any of the five included studies.

CONCLUSIONS

The included studies concluded that couple-based interventions can lead to weight reduction, maintenance, and adherence to modified health behaviours similar to interventions that target individuals. Overall, the findings indicate that, notwithstanding the paucity of authentic couples-based interventions, there is potential for such approaches to moderate MetS risk factors likely to flow onto epigenetic transmission of risk.

The effect of a locally tailored intervention on the uptake of preconception care in the Netherlands: a stepped-wedge cluster randomized trial (APROPOS-II study)

BACKGROUND

The preconception period provides a window of opportunity for interventions aiming to reduce unhealthy lifestyle behaviours and their negative effect on pregnancy outcomes. This study aimed to assess the effectiveness of a locally tailored preconception care (PCC) intervention in a hybrid-II effectiveness implementation design.

METHODS

A stepped-wedge cluster randomized controlled trial was performed in four Dutch municipalities. The intervention contained a social marketing strategy aiming to improve the uptake (prospective parents) and the provision (healthcare providers) of PCC. Prospective parents participated by administering a questionnaire in early pregnancy recalling their preconceptional behaviours. Experiences of healthcare providers were also evaluated through questionnaires. The composite primary outcome was adherence to at least three out of four preconceptional lifestyle recommendations (early initiation of folic acid supplements, healthy nutrition, no smoking or alcohol use). Secondary outcomes were preconceptional lifestyle behaviour change, (online) reach of the intervention and improved knowledge among healthcare providers.

RESULTS

A total of 850 women and 154 men participated in the control phase and 213 women and 39 men in the intervention phase. The composite primary outcome significantly improved among women participating in the municipality where the reach of the intervention was highest (Relative Risk (RR) 1.57 (95% Confidence Interval (CI) 1.11-2.22). Among women, vegetable intake had significantly improved in the intervention phase (RR 1.82 (95%CI 1.14-2.91)). The aimed online reach- and engagement rate of the intervention was achieved most of the time. Also, after the intervention, more healthcare providers were aware of PCC-risk factors (54.5% vs. 47.7%; p = 0.040) and more healthcare providers considered it easier to start a conversation about PCC (75.0% vs. 47.9%; p = 0.030).

CONCLUSION

The intervention showed some tentative positive effects on lifestyle behaviours among prospective parents. Primarily on vegetable intake and the knowledge and competence of healthcare providers. The results of this study contribute to the evidence regarding successfully implementing PCC-interventions to optimize the health of prospective parents and future generations.

TRIAL REGISTRATION

Dutch Trial Register: NL7784 (Registered 06/06/2019).

Effectiveness of a complex, pre-conception intervention to reduce the risk of diabetes by reducing adiposity in young adults in Malaysia: The Jom Mama project - A randomised controlled trial

Background

Pre-conception interventions have the potential to lower non-communicable disease risk in prospective parents and reduce transmission of risk factors such as obesity to the next generation. The Jom Mama project in Malaysia investigated the effectiveness of a combined behaviour change communication and e-health intervention in young married couples prior to first pregnancy. This paper reports the evaluation of the effectiveness of this trial.

Methods

Jom Mama was a non-blinded, randomised controlled trial (RCT) conducted in Seremban, Malaysia, over a period of 33 weeks, covering six contact points between trained community health workers and newly married couples before the conception of a first child. Out of 2075 eligible nulliparous women, 549 participated and 305 completed the intervention, with 145 women in the intervention and 160 in the control group. The intervention group received a complex behavioural change intervention, combining behaviour change communication provided by community health promoters and access to a habit formation mobile application, while the control group received the standard care provided by public health clinics in Malaysia. The primary outcome was a change in the woman’s waist circumference. Secondary outcomes were anthropometric and metabolic measures, dietary intake (Food Frequency Questionnaire, FFQ), physical activity (International Physical Activity Questionnaire, IPAQ) and mental health (Depression Anxiety Stress Scale, DASS 21). An extensive process evaluation was conducted alongside the trial in order to aid the interpretation of the main findings.

Results

There were no significant differences of change in the woman’s waist circumference between intervention and control groups at the start and end of the intervention. While the weight, waist circumference and Body Mass Index (BMI) of women in both groups increased, there was a significantly lower increase in the intervention vs the control group over the period of the trial among women who are obese (0.1 kg vs 1.7 kg; P = 0.023, in the intervention and control group respectively). In terms of BMI, the obese intervention subgroup showed a slight reduction (0.01) compared to the obese control subgroup whose BMI increased by 0.7 (P = 0.015). There were no changes in the other secondary outcomes.

Conclusions

The Jom Mama pre-conception intervention did not lead to a reduction in waist circumference or significant changes in other secondary outcomes over the eight months prior to conception. However, there was a significantly smaller weight gain in the intervention vs the control group, predominantly in women with pre-existing obesity.

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.

Validating PreCHAT: A Digital Preconception Health Risk Assessment Tool to Improve Reproductive, Maternal and Child Health

Study background

Despite the growing understanding of preconception care, numerous barriers to its delivery still exist, including a lack of evidence-based, accessible screening tools.

Purpose

To validate a new digital Preconception Health Assessment Tool (PreCHAT) against the current best practice, physician-delivered tool in Ontario, Canada, and explore how PreCHAT’s design impacts its risk identification abilities relative to the comparison tool.

Methods

A criterion validation study was conducted with 53 female participants aged 18–44 years. Participants completed both tools in a controlled setting. PreCHAT was completed on a tablet individually by participants, while the comparison tool was administered by a physician. Three physicians administered the comparison tool. Measures of strength of agreement between PreCHAT and the comparison tool were calculated using percent agreement, Cohen's Kappa, and prevalence-adjusted and biased-adjusted kappa (PABAK).

Results

PreCHAT identified 135 individual risk factors, while the comparison tool identified 102. Both tools shared the same 14 domains of preconception care and 88 risk factors; of the 88 risk factors, PreCHAT identified an average of 3.42 (p < 0.0001) more risks per participant than the comparison tool. PABAK scores indicated almost perfect agreement between PreCHAT and the comparison tool.

Conclusions

This study suggests that PreCHAT is valid against the current best practice tool and is broader in its risk identification among individuals of reproductive age. PreCHAT's patient-facing, digital, EMR-integrated design may offer unique benefits to providers and patients. PreCHAT offers providers an innovative approach to deliver preconception care and may positively impact reproductive, maternal, and child health.

Sex, Gender, and Alcohol Use: Implications for Women and Low-Risk Drinking Guidelines

Alcohol use is coming under increasing scrutiny with respect to its health impacts on the body. In this vein, several high-income countries have issued low-risk drinking guidelines in the past decade, aiming to educate the public on safer levels of alcohol use. Research on the sex-specific health effects of alcohol has indicated higher damage with lower amounts of alcohol for females as well as overall sex differences in the pharmacokinetics of alcohol in male and female bodies. Research on gender-related factors, while culturally dependent, indicates increased susceptibility to sexual assault and intimate partner violence as well as more negative gender norms and stereotypes about alcohol use for women. Sex- and gender-specific guidelines have been issued in some countries, suggesting lower amounts of alcohol consumption for women than men; however, in other countries, sex- and gender-blind advice has been issued. This article reports on a synthesis of the evidence on both sex- and gender-related factors affecting safer levels of drinking alcohol with an emphasis on women’s use. We conclude that supporting and expanding the development of sex- and gender-specific low-risk drinking guidelines offers more nuanced and educative information to clinicians and consumers and will particularly benefit women and girls.

How do women prepare for pregnancy in a low-income setting? Prevalence and associated factors

Background

Despite growing evidence of pregnancy preparation benefits, there is little knowledge on how women in developing countries prepare for pregnancy and factors influencing their preparedness for pregnancy. Here, we determine how women in Malawi prepare for pregnancy and factors associated with pregnancy preparation.

Methods

We used data from a previous cohort study comprising 4,244 pregnant mothers, recruited between March and December 2013 in Mchinji district, Malawi. Associations of pregnancy preparation with socio-demographic and obstetric factors were tested for using mixed effects ordinal regression, with the likelihood ratio and Wald’s tests used for variable selection and independently testing the associations.

Results

Most mothers (63.9%) did not take any action to prepare for their pregnancies. For those who did (36.1%), eating more healthily (71.9%) and saving money (42.8%) were the most common forms of preparation. Mothers who were married (adjusted odds-ratio (AOR 7.77 (95% CI [5.31, 11.25]) or with no or fewer living children were more likely to prepare for pregnancy (AOR 4.71, 95% CI [2.89,7.61]. Mothers with a period of two to three years (AOR 2.51, 95% CI [1.47, 4.22]) or at least three years (AOR 3.67, 95%CI [2.18, 6.23]) between pregnancies were more likely to prepare for pregnancy than women with first pregnancy or shorter intervals. On the other hand, teenage and older (≥ 35 years old) mothers were less likely to prepare for pregnancy (AOR 0.61, 95%CI [0.47, 0.80]) and AOR 0.49 95%CI [0.33, 0.73], respectively).

Conclusion

While preconception care may not be formally available in Malawi, our study has revealed that over a third of mothers took some action to prepare for pregnancy before conception. Although this leaves around two thirds of women who did not make any form of pregnancy preparation, our findings form a basis for future research and development of a preconception care package that suits the Malawian context.

Raising awareness of pre-conception care in community pharmacies: a feasibility study

Background

There is growing evidence to support the introduction of pre-conception interventions to optimise the health of mothers and their future children. At present, there is poor awareness regarding the importance of pre-conception care (PCC) amongst healthcare professionals and couples planning a pregnancy. Community pharmacies are ideally placed to reach a range of prospective couples planning a pregnancy and could effectively provide information about PCC.

Methods

This study assessed feasibility of an intervention to raise awareness of PCC in community pharmacies in Northern Ireland over 3 months. Inclusion criteria: women of childbearing age (16–45 years) engaging with services at participating pharmacies. Study resources: campaign posters, information cards, crib sheets for pharmacy staff. A mixed methods approach was employed, including, brief information provision for women, record of staff interactions with customers, customer feedback cards and qualitative interviews with pharmacy staff. Descriptive statistics assessed distribution of study resources and staff interviews were analysed using a thematic analysis framework.

Results

There were eight participating pharmacies, three of which consented to post-study interviews. Three pharmacies chose not to deliver the planned intervention. Distribution of campaign cards (n = 456) varied (0–86%). Analysis of customer feedback cards (n = 9) demonstrated that the majority of respondents were happy to receive information on pre-conception health. Of the women who responded to this question (n = 8), all were ‘extremely likely’ or ‘likely’ to act on the information provided. Four main themes emerged from analysis of staff interviews: (1) training and experience in providing health advice, (2) intervention resources, (3) understanding the aims of the intervention, (4) perceived value of the intervention. Barriers to intervention delivery included non-engagement from pharmacies and need for additional training of staff.

Conclusions

An intervention to raise awareness of PCC within a community pharmacy setting was feasible and acceptable to both women and staff in participating pharmacies. This study indicates that a number of factors must be considered to enhance implementation and effectiveness of PCC interventions in this setting. In particular, better understanding of non-engagement, provision of adequate training and support for staff, and exploring incentives for pharmacies to prioritise PCC.

Empowering Village Health Workers to Influence Preconception Behavior and Increase Utilization of Preconception Health Services in the Deli Serdang Regency

BACKGROUND: Preconception health care are critical in addressing modifiable risk factors to prevent maternal death, neonatal death, unplanned pregnancies, birth defects, premature birth and retardation of fetal growth in the womb. AIM: The aim of this study was to determine the impact of preconception health cadres empowerment on changed in preconception health behaviors of brides and grooms-to-be, as well as improved utilization of preconception health services at eight community health centers in the Deli Serdang district. METHODS: This research is part of a dissertation study entitled Preconception Period Service Strategy on Brides and Grooms-to-Be through Empowerment of Preconception Health Cadres in Deli Serdang Regency. The effect of the empowerment of preconception health cadres in preconception health behaviors performed by Wilcoxon Signed Rank Test with the statistical significance test with CI 95% and significant difference value p<0,05. The Normalized Gain (N-gain score) test is used to assess the effectiveness of the intervention. RESULTS. There is a significant influence of preconception health cadres empowerment interventions on the knowledge, attitudes, and actions of brides and grooms-to-be in preconception health with the same probability value of p=0.001. Most brides and grooms-to-be (80%) take advantage of preconception health services at health centers after following the intervention of empowerment of preconception health cadres. CONCLUSIONS. Interventions empowering preconception health cadres significantly affect the behavior of the brides and grooms-to-be and quite effective in increasing knowledge and actions of brides and grooms-to-be in preconception health.

Preconception Counseling: Identifying Ways to Improve Services

Objective  The aim of this retrospective study was to evaluate the maternal conditions for which preconception services are provided and the routine services and recommendations offered through the Maternal Fetal Medicine group at the University of Colorado (CU). The study sought to determine how services and recommendations differ by maternal condition, demographics, and reproductive health history. Materials and Methods  Charts of patients who received preconception counseling through the CU MFM department during 2018 were reviewed to evaluate maternal conditions and the type of counseling patients received. Patients were grouped by their referral reason and subsequently by counseling recommendations to either proceed with immediate conception, defer immediate conception pending completion of further recommendations or to not conceive. Results  Of the fifty-nine patients referred to preconception counseling, 52% ( n = 31) of the women were referred for maternal disease, 40% ( n = 24) for infertility, 32% ( n = 19) for previous poor obstetric outcomes, 30% ( n = 18) for advanced maternal age and finally, 15% ( n = 9) for gynecologic anatomic abnormalities. Conclusion  During the initial evaluation, 58% ( n = 34) of patients were determined to have no concern for immediate conception while 7% ( n = 4) were ultimately advised to not conceive. Using this data, we identified areas of preconception counseling that standardization will improve by ensuring patients receive comparable services and advice.

Trends in maternal body mass index in Northern Ireland: a cross-sectional and longitudinal study

Objectives

Explore (1) associations between maternal body mass index (BMI), demographic and clinical characteristics, (2) longitudinal trends in BMI, (3) geographical distributions in prevalence of maternal overweight and obesity.

Design

Retrospective population-based study.

Setting

Linked, anonymised, routinely collected healthcare data and official statistics from Northern Ireland.

Participants

All pregnancies in Northern Ireland (2011–2017) with BMI measured at ≤16 weeks gestation.

Methods

Analysis of variance and χ² tests were used to explore associations. Multiple linear regression was used to explore longitudinal trends and spatial visualisation illustrated geographical distribution. Main outcomes are prevalence of overweight (BMI ≥25 kg/m²) and obesity (BMI ≥30 kg/m²).

Results

152 961 singleton and 2362 multiple pregnancies were included. A high prevalence of maternal overweight and obesity in Northern Ireland is apparent (singleton: 52.4%; multiple: 48.3%) and is increasing. Obesity was positively associated with older age, larger numbers of previous pregnancies and unplanned pregnancy (p<0.001). BMI category was also positively associated with unemployment (35% in obese class III vs 22% in normal BMI category) (p<0.001). Higher BMI categories were associated with increased rate of comorbidities, including hypertension (normal BMI: 1.8% vs obese III: 12.4%), diabetes mellitus (normal BMI: 0.04% vs obese III: 1.29%) and mental ill-health (normal BMI: 5.0% vs obese III: 11.8%) (p<0.001). Prevalence of maternal obesity varied with deprivation (most deprived: 22.8% vs least deprived: 15.7%) (p<0.001). Low BMI was associated with age <20 years, nulliparity, unemployment and mental ill-health (p<0.001).

Conclusions

The prevalence of maternal BMI >25 kg/m² is increasing over time in Northern Ireland. Women are entering pregnancy with additional comorbidities likely to impact their life course beyond pregnancy. This highlights the need for prioritisation of preconception and inter-pregnancy support for management of weight and chronic conditions.

Preconception interventions to reduce the risk of alcohol-exposed pregnancies: A systematic review

BACKGROUND

The preconception period provides a unique opportunity to optimize the health of women and children. High rates of alcohol use and unintended pregnancies are common across many Western societies, and alcohol-exposed pregnancies (AEPs) are a possible unintended outcome. The aim of the current study was to evaluate preconception interventions for the prevention of AEPs.

METHODS

A systematic search of four electronic databases (PubMed, Embase, CINAHL, and PsycINFO) was undertaken for relevant peer-reviewed articles published from 1970 onward. Studies were included if they enrolled women and/or their support networks during the preconception period.

RESULTS

Nineteen studies met the inclusion criteria. The majority of studies (n = 14) evaluated CHOICES-based interventions, which incorporate motivational interviewing approaches to change alcohol and/or contraceptive behavior. The other five interventions included a range of different approaches and modes of delivery. The majority of interventions were successful in reducing AEP risk. Changes in AEP risk were more often driven by changes in contraceptive behavior, although some approaches led to changes in both alcohol and contraceptive behavior.

CONCLUSIONS

The review indicated that many interventions were efficacious at reducing AEP risk during the preconception period through preventing unplanned pregnancy. The effectiveness estimated from these clinical trials may be greater than that seen in interventions when implemented in practice where there is a lack of blinding and greater attrition of participants during follow-up. Further research investigating the real-world effectiveness of these intervention approaches implemented across a wide range of clinical settings would be beneficial.

Implementing Interconception Care in a Dyadic Adolescent Mother-Child Clinic

INTRODUCTION

The birth of a second child to an adolescent woman worsens the adverse medical, socioeconomic, educational, and parenting outcomes for the woman and her children. Despite the known high efficacy of long-acting reversible contraception (LARC), many postpartum adolescents use less effective or no contraception. Interconception care (ICC) focuses on modifying maternal risks between pregnancies and promoting healthy birth spacing to improve outcomes for women and children. Research shows that women regularly attend their child's health care visits even if they do not seek care for themselves between pregnancies. These visits present a potential opportunity for providers to educate women on available LARC options.

METHODS

In an adolescent mother-child clinic, demographic and ICC screening data were collected on women presenting for well child visits of children age 0-24 months. These data were analyzed using logistic regression models to identify independent predictors of LARC initiation and repeat pregnancy.

RESULTS

Mother-child dyads were screened an average of two times in the study period. Participants with only one visit were less likely to initiate LARC. Of the participants, 5.5% became pregnant again, with patients having only one ICC visit being slightly, but not significantly more likely. Hispanic ethnicity and having ≥ 2 visits were significant independent predictors of LARC initiation. The only independent predictor of repeat pregnancy was not initiating LARC.

CONCLUSIONS

This study suggests that optimal ICC may rely on consistent and frequent touch points with providers and not solely on the medical management during the interconception period, making it adaptable to a traditional pediatric medical home. Tying the worlds of pediatric and maternal healthcare is pivotal for successful ICC.

Health behaviours in 131,182 UK women planning pregnancy

BACKGROUND

A woman's health at the time of conception lays the foundation for a healthy pregnancy and the lifelong health of her child. We investigated the health behaviours of UK women planning pregnancy.

METHODS

We analysed survey data from the 'Planning for Pregnancy' online tool (Tommy's, UK). We described all women planning pregnancy and compared the frequency of non-adherence to preconception recommendations in women who had already stopped contraception (active planners) and those who had not (non-active planners).

RESULTS

One hundred thirty-one thousand one hundred eighty-two women from across the UK were included, of whom 64.8% were actively planning pregnancy. Of the whole cohort, twenty percent were smokers and less than one third took folic acid supplements (31.5%). Forty two percent engaged in less than the recommended 150 min of weekly physical activity and only 53.3% consumed five portions of fruit or vegetables 4 days a week. Smokers were 1.87 times more likely to be active planners than non-smokers (95% CI 1.79-1.94), and women who took folic acid were 7 times more likely to be active planners (95% CI 6.97-7.59) compared to women who did not. Smoking, drug use and lack of folic acid supplementation were common in younger women and those who were underweight.

CONCLUSIONS

This unique survey of UK women has identified poor adherence to preconception recommendations in those planning pregnancies and supports the need for a greater public health focus on preconception health. This study provides a contemporary basis from which to inform preconception health advice and a benchmark to measure changes over time.

Utilization and associated factors of reproductive health services among 20-39-year-old women in rural China: a cross-sectional study

Background

The use of reproductive health (RH) services is important to promote RH. However, little is known about RH services in rural areas, especially in low- and middle-income countries. China is the most populous country in the world, and 40.4% of its population is rural. Our study determined the utilization of and factors associated with RH services in rural China.

Methods

A cross-sectional study of 978 20- to 39-year-old women was performed in four villages of four cities in Hunan Province. A researcher-created structured questionnaire was used to collect the data. The data were entered into EpiData v3.0 and analysed using SPSS v18.0. Statistical significance was defined as a two-sided P-value of less than 0.05. Descriptive statistics were used to examine the socio-demographic factors and the use of RH services by the sample population. Chi-square tests were used to assess associations between categorical variables. Logistic regression analyses were performed to examine factors that correlated with the use of RH services.

Results

The top three services used were antenatal examinations (90.2%), postpartum visits (73.0%) and free folic acid supplements (71.6%). Age, monthly household income, employment, spousal education level, and artificial abortion history were associated with RH service utilization (P < 0.05). The most desired RH service was cervical/breast cancer prevention services (58.9%). The most preferred method participants used to obtain information on RH services was the internet.

Conclusions

The utilization rate for RH services in rural China needs improvement. Future efforts should target high-risk populations of women by providing them with RH-related information and cultivating positive attitudes towards RH services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01182-z.

Reproductive health (RH) services are recognized worldwide as a cost-effective strategy to promote RH. However, little is known about RH services in rural areas, especially in low- and middle-income countries. China is the most populous country in the world, and 40.4% of its population is rural. Due to the implementation of China’s universal two-child policy, women between 20 and 39 years old are likely to experience more RH problems related to childbirth. Our study investigated the utilization of and factors associated with RH services in rural China. The top three services used among the 978 participants were antenatal examinations (90.2%), postpartum visits (73.0%) and free folic acid supplements (71.6%). Age, monthly household income, employment, spousal education level, and artificial abortion history were associated with RH service utilization. The participants most desired services pertained to the prevention of cervical/breast cancer, and the most preferred methods used to obtain information related to RH services was the internet.

In conclusion, the utilization of RH services requires improvement, and future efforts should target high-risk populations of women by providing them with RH-related information and cultivating positive attitudes towards RH services.

Fecundability in reproductive aged women at risk of sexual dysfunction and associated risk factors: a prospective preconception cohort study

BACKGROUND

Female sexual dysfunction (FSD) is a prevalent problem, affecting up to 41% of reproductive aged women worldwide. However, the association between female sexual function (FSF) and fecundability in women attempting to conceive remains unclear. We aimed 1) to examine the association between FSF in reproductive-aged preconception Asian women and fecundability, as measured by time-to-pregnancy in menstrual cycles, and 2) to examine lifestyle and behavioral factors associated with FSF.

METHODS

From the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO) prospective cohort, we evaluated FSF using the 6-item Female Sexual Function Index (FSFI-6) and ascertained time-to-pregnancy within a year of baseline assessment. We estimated fecundability ratio (FR) and 95% confidence interval (CI) using the discrete-time proportional hazards model, accounting for left-truncation and right censoring. We used multivariable logistic and linear regression models to identify potential factors related to FSF.

RESULTS

Among 513 participants, 58.9% had low FSF as defined by a total FSFI-6 score at or below the median value of 22. Compared to women with high FSF, those with low FSF had a 27% reduction in fecundability (FR 0.73; 95% CI 0.54, 0.99), with adjustment for age, ethnicity, education, parity and body mass index. Overall, the FRs generally reduced with decreasing FSFI-6 scores. Physical activity, obesity, absence of probable depression and anxiety were independently associated with reduced odds of low FSF and increased FSFI-6 scores, after adjusting for sociodemographic characteristics.

CONCLUSIONS

Low FSF is associated with a longer time-to-pregnancy. Early evaluation and optimization of FSF through increased physical activity and optimal mental health may help to improve female fecundity. The finding of obese women having improved FSF remains uncertain which warrants further investigations on plausibly mechanisms. In general, the current finding highlights the importance of addressing FSF in preconception care service for general women, which is currently lacking as part of the fertility promotion effort in the country.

Early marriage and spousal age difference: predictors of preconception health of young married women in Delhi, India

Purpose

This study aims to assess the associations of early marriage and spousal age difference (independent of early marriage) with reproductive and sexual health and autonomy in decision-making among married women before conception.

Design/methodology/approach

The present study was a part of a three-year community intervention to improve the preconception health of young married women (20–35 years) in the West Delhi district of India. The six key outcomes assessed were: knowledge of reproductive health, discussions related to sexual health, history of anemia, use of contraceptives by women, frequency of consumption of meals per day and the autonomy in decision-making for household expenditures. Unadjusted and adjusted logistic regression models were used to explore the associations between the two key predictors (early marriage or spousal age difference), sociodemographic variables and six outcomes. The results were expressed as odds ratio (OR) and 95% confidence interval (CI). A total of 2,324 women, enrolled from four wards in the district using cluster-based sampling, were interviewed.

Findings

Around 17% of women were married by the exact age of 18, and 20% were elder or just one year younger than their husbands. Women who were married early had low reproductive health knowledge (OR (95% CI): 0.48 (0.38–0.60)) and a lower probability of expressing autonomy (OR (95% CI): 0.78 (0.62–0.97)). However, women older than men or younger by just one year in the married relationship had higher reproductive health knowledge (OR (95% CI): 1.25 (1.01–1.54)) than women younger than men more than two years.

Originality/value

Under the umbrella of the preconception care domain, frontline workers should emphasize counseling girls and young women to marry late and delay the first pregnancy.

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.

Optimizing mother-baby wellness during the 2019 coronavirus disease pandemic: A case for telemedicine

Background:

The 2019 coronavirus disease pandemic poses unique challenges to healthcare delivery. To limit the exposure of providers and patients to severe acute respiratory syndrome coronavirus 2, the Centers for Disease Control and Prevention encourages providers to use telehealth platforms whenever possible. Given the maternal mortality crisis in the United States and the compounding 2019 coronavirus disease public health emergency, continued access to quality preconception, prenatal, intrapartum, and postpartum care are essential to the health and well-being of mother and baby.

Objective:

This commentary explores unique opportunities to optimize virtual obstetric care for low-risk and high-risk mothers at each stage of pregnancy.

Methods:

In this review paper, we present evidence-based literature and tools from first-hand experience implementing telemedicine in obstetric care clinics during the pandemic.

Results:

Using the best evidence-based practices with telemedicine, health care providers can deliver care in the safest, most respectful, and appropriate way possible while providing the critical support necessary in pregnancy. In reviewing the literature, several studies endorse the implementation of specific tools outlined in this article, to facilitate the implementation of telemedicine. From a quality improvement standpoint, evidence-based telemedicine provides a solution for overburdened healthcare systems, greater confidentiality for obstetric services, and a personalized avenue for health care providers to meet maternal health needs in the pandemic.

Conclusion:

During the COVID-19 pandemic, continued access to quality prenatal, intrapartum, and postpartum care are essential to the health and well-being of mother and baby.

Preconceptional Lipid-Based Nutrient Supplementation in 2 Low-Resource Countries Results in Distinctly Different IGF-1/mTOR Placental Responses

BACKGROUND

Preconceptional maternal small-quantity lipid-based nutrient supplementation (SQLNS) improved intrauterine linear growth in low-resource countries as demonstrated by the Women First Preconception Maternal Nutrition Trial (WF). Fetal growth is dependent on nutrient availability and regulated by insulin-like growth factor 1 (IGF-1) through changes in placental transfer capacity, mediated by the mechanistic target of rapamycin (mTOR) pathway.

OBJECTIVES

Our objective was to evaluate the role of placental mTOR and IGF-1 signaling on fetal growth in women from 2 low-resource countries with high rates of stunting after they received preconceptional SQLNS.

METHODS

We studied 48 women from preconception through delivery who were from Guatemala and Pakistan and received SQLNS or not, as part of the WF study. Placental samples were obtained at delivery (control, n = 24; SQLNS, n = 24). Placental protein or mRNA expression of eukaryotic translation initiation factor binding protein-1 (4E-BP1), ribosomal protein S6 (rpS6), AMP-activated protein kinase α (AMPKA), IGF-1, insulin-like growth factor receptor (IGF-1R), and pregnancy associated plasma protein (PAPP)-A, and DNA methylation of the IGF1 promoter were determined. Maternal serum IGF-1, insulin-like growth factor binding protein (IGFBP)-3, IGFBP-4, IGFBP-5, PAPP-A, PAPP-A2, and zinc were measured.

RESULTS

Mean ± SEM maternal prepregnancy BMI differed between participants in Guatemala (26.5 ± 1.3) and Pakistan (19.8 ± 0.7) (P < 0.001). In Pakistani participants, SQLNS increased the placental rpS6(T37/46):rpS6 ratio (1.5-fold) and decreased the AMPKA(T172):AMPKA ratio. Placental IGF1 mRNA expression was positively correlated with birth length and birth weight z-scores. Placental PAPP-A (30-fold) and maternal serum zinc (1.2-fold) increased with SQLNS. In Guatemalan participants SQLNS did not influence placental mTOR signaling. Placental IGF-1R protein expression was positively associated with birth length and birth weight z-scores. SQLNS increased placental PAPP-A (40-fold) and maternal serum IGFBP-4 (1.6-fold).

CONCLUSIONS

In Pakistani pregnant women with poor nutritional status, preconceptional SQLNS activated placental mTOR and IGF-1 signaling and was associated with improved fetal growth. In contrast, in Guatemalan women SQLNS did not activate placental nutrient-sensing pathways. In populations experiencing childhood stunting, preconceptional SQLNS improves placental function and fetal growth only in the context of poor maternal nutrition. This trial was registered at clinicaltrials.gov as NCT01883193.

Prevention of Gestational Diabetes: The Role of Dietary Intake, Physical Activity, and Weight before, during, and between Pregnancies

Gestational diabetes mellitus (GDM) is the most common complication of pregnancy and a significant clinical and public health problem with lifelong and intergenerational adverse health consequences for mothers and their offspring. The preconception, early pregnancy, and interconception periods represent opportune windows to engage women in preventive and health promotion interventions. This review provides an overview of findings from observational and intervention studies on the role of diet, physical activity, and weight (change) during these periods in the primary prevention of GDM. Current evidence suggests that supporting women to increase physical activity and achieve appropriate weight gain during early pregnancy and enabling women to optimize their weight and health behaviors prior to and between pregnancies have the potential to reduce rates of GDM. Translation of current evidence into practice requires further development and evaluation of co-designed interventions across community, health service, and policy levels to determine how women can be reached and supported to optimize their health behaviors before, during, and between pregnancies to reduce GDM risk.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Nurse-Led Initiative to Improve Implementation of HIV Preconception Care Services

ABSTRACT

United States guidelines recommend preconception care (PCC) as an integral part of primary care to improve maternal and fetal/newborn outcomes and promote planned pregnancies. Persons living with HIV have additional, specialized needs for PCC. However, PCC is not reliably integrated in HIV care, and few studies have examined strategies to improve the provision of PCC services. We describe a successful, nurse-led initiative that incorporated collaborative strategic planning in conjunction with staff education and continuous quality improvement to strengthen implementation of PCC in a small urban HIV care clinic. Key features of this project included consensus building, training, and action planning with clinic staff; addressing clinic-specific barriers; and providing ongoing support/technical assistance. Continuous quality improvement reviews at 12, 18, and 36 months demonstrated improved and sustained implementation of PCC services for women and men. Our experiences serve as a model for HIV primary care clinics working to advance implementation of PCC services.

Reproductive Health Knowledge About Miscarriage: A Cross-Sectional Study of University Students

OBJECTIVE

To assess university students' knowledge of reproductive health information about miscarriage.

METHODS

A single-centre, cross-sectional study was carried out using an online survey at a higher education institution in the Republic of Ireland between April and May of 2016. A total of 746 university students' responses were analysed.

RESULTS

Approximately 60% and 70% of college students correctly identified features of first and second trimester miscarriage. After adjusting for confounders, male students were two times more likely to have a poor knowledge of features of miscarriage compared to females (aOR 2.0, 95% CI 1.3-3.0 and aOR 1.7, 95% CI 1.1-2.6 for first and second trimester respectively). Poor knowledge of features of first trimester miscarriage was less common among older students and students who were married, cohabiting or in a relationship (aOR 0.4, 95% CI 0.2-0.6 and aOR 0.4, 95% CI 0.3-0.8 respectively). Students who studied Medicine and Health were more likely to identify any type of treatment for miscarriage compared to students who studied other disciplines. Students who studied Arts and Social Science were more likely to overestimate the percentage of miscarriages with an identified cause compared to students who studied Medicine and Health.

CONCLUSION

Our results provide additional information about the gap of knowledge in regards to reproductive health information about miscarriage, specifically among university students.

Preconception Health Characteristics of Women with Disabilities in Ontario: A Population-Based, Cross-Sectional Study

Background: There is growing recognition that preconception health, defined as the health of all reproductive-age individuals, impacts reproductive and perinatal outcomes. Although women with disabilities are becoming pregnant at increasing rates, little is known about their preconception health. Our objective was to describe the preconception health characteristics of women with physical, sensory, and intellectual/developmental disabilities and compare these characteristics with women without disabilities. Materials and Methods: We conducted a population-based cross-sectional study of 15- to 44-year-old women with physical (n = 253,184), sensory (n = 93,170), intellectual/developmental (n = 8,986), and multiple disabilities (n = 29,868), and women without these disabilities (n = 2,307,822) using Ontario health administrative data (2017-2018). We described preconception health variables related to social determinants of health, physical health status, psychosocial well-being, history of assault, medication use, and continuity of primary care and compared women with and without disabilities in crude and age-standardized analyses, with standardized differences >0.10 indicating clinically meaningful results. Results: Women with physical, sensory, intellectual/developmental, and multiple disabilities had poorer preconception health than women without disabilities. Disparities were pronounced for physical health status, psychosocial well-being, use of potentially teratogenic medications, and history of assault. Of all groups, women with intellectual/developmental disabilities had the greatest disparities. Conclusion: Further research is needed to identify contributors to poor preconception health among women with disabilities and to develop tailored preconception health interventions to meet their unique needs and experiences.

Defining preconception: exploring the concept of a preconception population

Background

Health prior to conception can significantly impact offspring health, however, a clear definition of the attributes of the preconception population is currently lacking. We aimed to use existing literature to explore the concept and attributes of a preconception population by: [1] identifying characteristics and research recruitment methods; and [2] generating an attribute-based working definition of a preconception population.

Methods

A rapid review of current literature using CINAHL and the subject heading ‘pre-pregnancy care’ was conducted (Stage 1). Data extracted included definitions of preconception, participant inclusion/exclusion criteria, participant characteristics, and recruitment methods. Stage 2 involved a wider search of relevant publications beyond peer-reviewed literature followed by a concept analysis of the phrase “preconception population” applying Walker and Avant’s framework (Stage 2).

Results

Twenty-three papers (19 studies) were included in Stage 1. “Preconception” was explicitly defined in one study. Twelve studies specified participants must be planning a pregnancy. Stage 2 included 33 publications. Four key perspectives for the concept of the preconception population were derived: [1] intentional; [2] potential; [3] public health; and [4] life course.

Conclusions

Adopting these perspectives may allow researchers to accurately define, identify and recruit preconception populations and to develop interventions that are appropriately broad or tailored depending on population needs. We hope the definitions will facilitate research with this population and will subsequently improve the wellbeing of preconception men and women, which is essential to ensuring the health of future generations.

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.

Beyond Birth Control: Noncontraceptive Benefits of Hormonal Methods and Their Key Role in the General Medical Care of Women

Contraceptives that contain estrogen and/or progestins are used by millions of women around the world to prevent pregnancy. Owing to their unique physiological mechanism of action, many of these medications can also be used to prevent cancer and treat multiple general medical conditions that are common in women. We performed a comprehensive literature search. This article will describe the specific mechanisms of action and summarize the available data documenting how hormonal contraceptives can prevent ovarian and uterine cancer and be used to treat women with a variety of gynecological and nongynecological conditions such as endometriosis, uterine fibroids, heavy menstrual bleeding, polycystic ovary syndrome, acne, and migraines. Contraceptive methods containing estrogen and progestin can be used for a wide variety of medical issues in women.

Study design of a stepped wedge cluster randomized controlled trial to evaluate the effect of a locally tailored approach for preconception care - the APROPOS-II study

Background

In a previous feasibility study (APROPOS) in a single municipality of the Netherlands, we showed that a locally tailored preconception care (PCC) approach has the potential to positively affect preconceptional lifestyle behaviours. Therefore, we designed a second study (APROPOS-II) to obtain a more robust body of evidence: a larger group of respondents, more municipalities, randomization, and a more comprehensive set of (clinical) outcomes. The aim of this study is to assess the effectiveness and the implementation process of a local PCC-approach on preconceptional lifestyle behaviours, health outcomes and the reach of PCC among prospective parents and healthcare providers.

Methods

This study is an effectiveness-implementation hybrid type 2 trial. This involves a stepped-wedge cluster randomized controlled trial design aiming to include over 2000 future parents from six municipalities in the Netherlands. The intervention has a dual-track approach, focusing on both the uptake of PCC among future parents and the provision of PCC by healthcare providers. The PCC-approach consists of 1) a social marketing strategy directed towards prospective parent(s) and 2) a local care pathway to improve interdisciplinary collaboration. Data will be collected before and after the introduction of the intervention through questionnaires and medical records in each of the participating municipalities. The primary outcome of this study is change in lifestyle behaviours (e.g. folic acid use, smoking and alcohol use). Secondary outcomes are pregnancy outcomes (e.g. miscarriage, preterm birth, gestational diabetes) and the uptake of PCC. Moreover, a process evaluation will be performed, providing information on the efficacy, feasibility, barriers and facilitators regarding the implementation of the intervention.

Discussion

The APROPOS-II study introduces a locally tailored PCC-approach in six municipalities in the Netherlands that will contribute to the body of evidence regarding the effectiveness of PCC and its implementation. If this intervention has a positive effect on lifestyle behaviour changes, leading to improved pregnancy outcomes and the future health of prospective parents and their offspring, it could subsequently be upscaled to (inter)national implementation.

Trial registration

Dutch Trial register: NL7784 (Registered June 6th, 2019).