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

Association of ideal cardiovascular health and history of gestational diabetes mellitus in NHANES 2007-2018

BACKGROUND

Population-based studies of ideal cardiovascular health (CVH) and gestational diabetes mellitus (GDM) are scarce.

METHODS

We conducted a cross-sectional analysis of 2007-2018 National Health Examination and Nutrition Survey women aged ≥ 20 years, who had data on Life's Simple 7 (LS7) metrics and self-reported GDM history. Each LS7 metric was assigned a score of 0 (non-ideal) and 1(ideal) and summed to obtain total ideal CVH scores (0-7). We used logistic regression models to assess associations between LS7 ideal CVH scores (0-7) and GDM history, accounting for socio-demographic factors.

RESULTS

Among 9199 women (mean age: 46 years, 8 % with a GDM history), there was a progressive decrease in the odds of past GDM history across increasing ideal CVH scores. Compared to females with 0-1 ideal CVH scores, females with ideal CVH scores of 3, 4 and 5-7 had an associated 39 % lower [odds ratio: 0.61 (95 % CI: 0.41-0.90)], 50 % lower [0.50 (0.33-0.76)] and 66 % lower [0.34 (0.20-0.56)] odds of past GDM history, respectively. There were notable racial/ethnic and citizenship/nativity differences in these associations.

CONCLUSIONS

Women with higher ideal CVH scores had lower odds of GDM history. Our findings underscore the importance of optimizing cardiometabolic health among women with GDM history.

What Does 'Preconception Health' Mean to People? A Public Consultation on Awareness and Use of Language

INTRODUCTION

There is growing scientific and policy recognition that optimising health before a potential pregnancy (preconception health) improves reproductive outcomes and the lifelong health of future children. However, public awareness on this topic is low. We conducted a public consultation to develop language recommendations and identify and prioritise approaches to inform research and improve public awareness of preconception health.

METHODS

A public consultation was undertaken with people of any gender aged 18-50 years living in the United Kingdom who were not currently expecting a child. Public contributors were recruited through patient and public involvement, community and support groups, an existing cohort study, and an LGBTQ+ charity. An initial round of online group discussions (February/March 2021) explored public contributors' knowledge of preconception health, their recommendations for appropriate language, and ideas about public health approaches. In a subsequent discussion round (May 2021), language recommendations were refined and suggested approaches prioritised. Discussions were summarised based on notes taken by two researchers.

RESULTS

Fifty-four people joined the initial discussion round (66% women, 21% men, 13% nonbinary or transgender; 55% aged 18-30 years, 30% 31-40 years, 15% 41-50 years). Of these, 36 people (67%) participated in the subsequent round. Very few had heard the term 'preconception health', understood what it means, or why and for whom it is important. They recommended avoiding unfamiliar terms without further explanation (e.g., preconception health, medical terms), using language that is positive, encouraging and gender-sensitive where possible, and using messages that are specific, nonjudgmental and realistic. The phrases 'health and well-being during the childbearing years', 'health and well-being before pregnancy and parenthood' and 'planning for parenthood' resonated with most public contributors. School-based education, social media campaigns and the National Health Service emerged as priority approaches/settings for raising awareness.

CONCLUSION

This public consultation produced recommendations from a diverse group of people of reproductive age in the United Kingdom to improve language and prioritise approaches that increase public understanding of preconception health in ways that are relevant and appropriate to them. This should begin in schools and will require adaptation of curricula, alongside co-development of public awareness campaigns and guidance for healthcare professionals.

PATIENT OR PUBLIC CONTRIBUTION

This public consultation included a diverse group of members of the public. They were not involved in the original design of the project, but following the initial round of online group discussions, they contributed to the interpretation and refinement of the emerging concepts in a subsequent round of group meetings. After the consultation activity, public contributors formed a Public Advisory Group and have subsequently been involved in other studies on the same topic. Two public contributors (E.R. and F.F.) provided critical input in the preparation and revision of this manuscript and are co-authors of the paper.

Exploring online reproductive health promotion in Canada: a focus on behavioral and environmental influences from a sex and gender perspective

BACKGROUND

Reproductive health promotion can enable early mitigation of behavioral and environmental risk factors associated with adverse pregnancy outcomes, while optimizing health of women + (all genders that can gestate a fetus) and babies. Although the biological and social influences of partners on pregnancy are well established, it is unknown whether online Canadian government reproductive health promotion also targets men and partners throughout the reproductive lifespan.

METHODS

Reproductive health promotion, designed for the general public, was assessed in a multi-jurisdictional sample of Canadian government (federal, provincial/territorial, and municipal) and select non-governmental organization (NGO) websites. For each website, information related to environmental and behavioral influences on reproductive health (preconception, pregnancy, postpartum) was evaluated based on comprehensiveness, audience-specificity, and scientific quality.

RESULTS

Government and NGO websites provided sparse reproductive health promotion for partners which was generally limited to preconception behavior topics with little coverage of environmental hazard topics. For women + , environmental and behavioral influences on reproductive health were well promoted for pregnancy, with content gaps for preconception and postpartum stages.

CONCLUSION

Although it is well established that partners influence pregnancy outcomes and fetal/infant health, Canadian government website promotion of partner-specific environmental and behavioral risks was limited. Most websites across jurisdictions promoted behavioral influences on pregnancy, however gaps were apparent in the provision of health information related to environmental hazards. As all reproductive stages, including preconception and postpartum, may be susceptible to environmental and behavioral influences, online health promotion should use a sex- and gender-lens to address biological contributions to embryo, fetal and infant development, as well as contributions of partners to the physical and social environments of the home.

An Evaluation of Food and Nutrient Intake among Pregnant Women in The Netherlands: A Systematic Review

Nutritional deficiencies during pregnancy can have serious consequences for the health of the (unborn) child. This systematic review provides an updated overview of the available food and nutrient intake data for pregnant women in The Netherlands and an evaluation based on the current recommendations. Embase, MEDLINE, and national institute databases were used. Articles were selected if they had been published since 2008 and contained data on food consumption, nutrient intake, or the status of healthy pregnant women. A qualitative comparison was made with the 2021 Dutch Health Council recommendations and reference values. A total of 218 reports were included, representing 54 individual studies. Dietary assessments were primarily performed via food frequency questionnaires. Protein, vitamin A, thiamin, riboflavin, vitamin B₆, folate, vitamin B₁₂, vitamin C, iron, calcium, and magnesium intakes seemed to be adequate. For folate and vitamin D, supplements were needed to reach the recommended intake. The reasons for concern are the low intakes of fruits, vegetables, and (fatty) fish, and the intakes of alcohol, sugary drinks, and salt. For several foods and nutrients, no or limited intake data were found. High-quality, representative, and recent data are needed to evaluate the nutrient intake of pregnant women in order to make accurate assessments and evaluations, supporting scientific-based advice and national nutritional policies.

Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association

This scientific statement summarizes the available preclinical, epidemiological, and clinical trial evidence that supports the contributions of prepregnancy (and interpregnancy) cardiovascular health to risk of adverse pregnancy outcomes and cardiovascular disease in birthing individuals and offspring. Unfavorable cardiovascular health, as originally defined by the American Heart Association in 2010 and revised in 2022, is prevalent in reproductive-aged individuals. Significant disparities exist in ideal cardiovascular health by race and ethnicity, socioeconomic status, and geography. Because the biological processes leading to adverse pregnancy outcomes begin before conception, interventions focused only during pregnancy may have limited impact on both the pregnant individual and offspring. Therefore, focused attention on the prepregnancy period as a critical life period for optimization of cardiovascular health is needed. This scientific statement applies a life course and intergenerational framework to measure, modify, and monitor prepregnancy cardiovascular health. All clinicians who interact with pregnancy-capable individuals can emphasize optimization of cardiovascular health beginning early in childhood. Clinical trials are needed to investigate prepregnancy interventions to comprehensively target cardiovascular health. Beyond individual-level interventions, community-level interventions must include and engage key stakeholders (eg, community leaders, birthing individuals, families) and target a broad range of antecedent psychosocial and social determinants. In addition, policy-level changes are needed to dismantle structural racism and to improve equitable and high-quality health care delivery because many reproductive-aged individuals have inadequate, fragmented health care before and after pregnancy and between pregnancies (interpregnancy). Leveraging these opportunities to target cardiovascular health has the potential to improve health across the life course and for subsequent generations.

Evaluation outcomes of an alcohol and pregnancy campaign targeting multiple audiences

INTRODUCTION

The aim of this study was to evaluate the effectiveness of a mass media campaign alerting the public to the potential harms of alcohol to unborn babies and to inform future intervention efforts.

METHOD

An online survey was administered to 889 adult Western Australians. The survey assessed demographic characteristics, typical alcohol use, recognition and perceptions of the campaign, and behavioural changes resulting from campaign exposure. A multiple regression analysis was conducted to identify factors associated with perceived campaign effectiveness.

RESULTS

Most respondents reported having seen/heard the campaign on at least one form of media (71%). Most considered the campaign to be believable (89%), clear (88%), trustworthy (87%), memorable (82%) and among the best they had seen (78%). As a result of campaign exposure, a large majority reported increased concern about drinking during pregnancy (85%) and most female respondents reported being much less likely to use alcohol during a pregnancy (83%). One-third of female respondents (33%) reported that as a result of being exposed to the campaign they had decided not to consume alcohol while pregnant. Confidence to abstain, awareness of strategies to abstain, lower socioeconomic position, residing in the metropolitan area and recognising the campaign were significantly associated with greater perceived campaign effectiveness.

DISCUSSION AND CONCLUSIONS

Results indicate the campaign was well received by respondents, increased concern about drinking alcohol during pregnancy and positively influenced women's intentions to refrain from drinking while pregnant. Well-designed campaigns on alcohol avoidance during pregnancy can be considered acceptable and effective by target audiences.

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

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

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).

Planning is not equivalent to preparing, how Dutch women perceive their pregnancy planning in relation to preconceptional lifestyle behaviour change - a cross-sectional study

BACKGROUND

Unhealthy prenatal lifestyle behaviours are associated with adverse pregnancy outcomes, but little is known about what motivates women to comply with preconceptional lifestyle recommendations or consciously plan their pregnancy. Therefore, the objective of this study is to explore the associations between preconceptional lifestyle behaviours, health beliefs and pregnancy planning among Dutch pregnant women.

METHODS

In this cross-sectional study based on the data of the APROPOS-II study, 1,077 low-risk pregnant women were eligible for inclusion. Preconception lifestyle behaviours and actively preparing for pregnancy were assessed in relation to planned pregnancies (based on the London Measure of Unplanned Pregnancies) and health beliefs (14 statements). The following preconceptional lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester of pregnancy: fruit intake, vegetable intake, caffeine intake, (second-hand)smoking, alcohol intake, folic acid supplement use and exercise. Data were analysed using multivariate logistic regression analyses.

RESULTS

A total of 921 (85.5%) women in our cohort had a planned pregnancy. However, of these women, 640 (69.5%) adequately used folic acid supplements and 465 (50.5%) women consumed alcohol at any point during pregnancy. Of the women considering themselves 'healthy enough and not needing preconception care', 48 (9.1%) women had an adequate vegetable intake, 294 (55.6%) women consumed alcohol at any point during pregnancy and 161 (30.4%) women were either over-or underweight.

CONCLUSION

Despite consciously planning their pregnancy, most women did not adhere to preconceptional lifestyle behaviour recommendations. Women's health beliefs and overestimation of their health status seem to interfere with actively planning and preparing for pregnancy. Findings from our study may encourage the development of prospective health-promoting interventions that focus on health beliefs and actively preparing for pregnancy, to improve preconceptional lifestyle behaviours, thereby optimizing the health of future generations.

Associations between periconceptional lifestyle behaviours and adverse pregnancy outcomes

Background

While the potential adverse outcomes of prenatal exposure to unhealthy lifestyle are widely evidenced, little is known about these exposures in the periconception period. We investigated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle behaviours.

Methods

A secondary analysis took place within a prospective multicentre cohort study in the Netherlands, including 3,684 pregnant women. Baseline characteristics and preconceptional and first trimester lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester. Adverse pregnancy outcomes (hypertensive disorders in pregnancy (HDP), small for gestational age (SGA), gestational diabetes (GDM) and spontaneous preterm birth (sPTB)) were reported by healthcare professionals. Data were collected between 2012 and 2014 and analysed using multivariate logistic regression.

Results

Women who are overweight, and especially obese, have the highest odds of developing any adverse pregnancy outcome (adjusted odds ratio (aOR) 1.61 (95 % Confidence Interval (CI) 1.31–1.99) and aOR 2.85 (95 %CI 2.20–3.68), respectively), particularly HDP and GDM. Women who prenatally continued smoking attained higher odds for SGA (aOR 1.91 (95 %CI 1.05–1.15)) compared to the reference group, but these odds decreased when women prenatally quit smoking (aOR 1.14 (95 %CI 0.59–2.21)). Women who did not use folic acid supplements tended to have a higher odds of developing adverse pregnancy outcomes (aOR 1.28 (95 %CI 0.97–1.69)), while women who prenatally started folic acid supplements did not (aOR 1.01 (95 %CI 0.82–1.25)).

Conclusions

Our results indicate that smoking cessation, having a normal body mass index (BMI) and initiating folic acid supplements preconceptionally may decrease the risk of adverse pregnancy outcomes. Therefore, intervening as early as the preconception period could benefit the health of future generations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03935-x.

Perinatal emotional states: a comparative study between two cohorts recruited in a Mediterranean environment

Experiencing negative emotional states during pregnancy has been linked to adverse outcomes for mother and offspring. Our study aims were to compare the perinatal emotional states and obstetrical variables between pregnant women recruited in Spain (n = 202) and Italy (n = 103), and to investigate prenatal anxiety related factors. The study had two phases. In the 1^st phase (3^rd trimester of pregnancy), prenatal anxiety was assessed using the State-Trait Anxiety Inventory (STAI); other prenatal and sociodemographic variables were also collected. In the 2^nd phase (40 days postpartum), the STAI and the Edinburgh Postnatal Depression Scale were administered. Compared to the Spanish sample, the Italian sample presented higher STAI state and STAI factor 1 mean scores (22.5 vs. 18.6 and 10.0 vs. 7.2), shorter gestations (mean gestation weeks: 39.1 vs. 39.8), more unplanned pregnancies (31.1% vs. 16.4%), and more cesareans deliveries (42.5% vs. 16.0%). Low socioeconomic levels, younger ages, previous miscarriages and unplanned pregnancies were related to prenatal anxiety. Postpartum depression rates was 31.3% and there were no differences between countries. Our results suggested that it may be interesting in both countries to create a prenatal monitoring protocol that attaches more importance to emotional wellbeing both during pregnancy and in the long term.

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).

Socio-ecological determinants of lifestyle behavior of women with overweight or obesity before, during and after pregnancy: qualitative interview analysis in the Netherlands

Background

Maternal overweight and obesity are related to several health risks in the periods before, during and after pregnancy including a higher risk of gestational diabetes mellitus, preeclampsia and preterm birth. At the same time, women’s daily life quickly changes in these periods. Therefore, we hypothesize that the value of determinants of lifestyle behavior within different levels of the socio-ecological model differ accordingly and influence lifestyle behavior. These dynamics of determinants of lifestyle behavior in the periods before, during and after pregnancy are unexplored and therefore evaluated in this study. These insights are needed to offer appropriate guidance to improve lifestyle in women of childbearing age.

Methods

Individual semi-structured interviews were conducted before, during or after pregnancy in 26 women with overweight or obesity living in the Netherlands. Questions covered all levels of the socio-ecological model, i.e. intrapersonal, interpersonal, institutional and environmental/societal. All interviews were transcribed and coded.

Results

Determinants at all levels of the socio-ecological model were perceived as relevant by women of childbearing age. Various determinants were mentioned including knowledge of a healthy lifestyle, social support, access to customized lifestyle guidance, and distance to healthy lifestyle supporting activities. The importance women attributed to determinants differed between the periods before, during and after pregnancy. Before pregnancy, child’s wellbeing as motivator for adopting a healthy lifestyle was mentioned less frequently than during and after pregnancy. Women described that the interplay and balance between determinants varied on a daily basis, and not merely per period. This was often expressed as fluctuation in energy level per day which influences their willingness to put effort in making healthy choices.

Conclusions

Findings of this study confirm the importance of determinants at multiple socio-ecological levels for shaping lifestyle behavior in women of childbearing age. The findings add to current insights that the perceived importance of determinants and their interplay differ before, during and after pregnancy. They influence lifestyle behavior decisions, not only per period but even on a daily basis, in particular in this phase of life. This perspective can be helpful in optimizing lifestyle guidance for women of childbearing age in order to prevent perinatal complications.

Food Consumption, Nutrient Intake and Status during the First 1000 days of Life in the Netherlands: a Systematic Review

Adequate nutrition is essential for growth and development in early life. Nutritional data serves as a basis for national nutritional guidelines and policies. Currently, there is no insight into the availability of such data during the first 1000 days of life. Therefore, a systematic review was performed, following the PRISMA reporting guideline, to identify studies on food consumption, nutrient intake or status in the Netherlands. Potential gaps were identified, and the quality of the studies is discussed. The databases Embase and Medline were used, as well as databases from national institutes. Articles published in 2008-2018 were screened by two independent reviewers. In total 601 articles were identified, of which 173 were included. For pregnant women, 32 studies were available with nutritional data, for young children 40 studies were identified. No studies were available for breastfeeding women. A large variety of foods and nutrients were assessed, however certain nutrients were lacking (e.g., vitamin K). Overall, the studies had methodological limitations, making the data unsuitable to assess nutrient inadequacies. There is a need for recent, high quality nutritional research to strengthen the understanding of the nutritional needs and deficiencies during early life, and is fundamental for national guidelines and policies.