Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

Preconceptional micronutrient adequacy among women in Greece: a prospective epidemiological study

INTRODUCTION

The importance of micronutrient intake during the preconceptional and early pregnancy period for both maternal and fetal outcomes is well-known, however, relevant data are not available for Greek pregnant women. The aim of the present study is to delineate the nutritional status preceding conception among a representative cohort of Greek pregnant women.

METHODS

This was a prospective study of pregnant women from routine care, recruited at 11+0-13+6 gestational weeks, between December 2020 and October 2022, at the 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece. Eligible participants for the study included healthy pregnant women aged 20 years or older, possessing a proficient understanding of the Greek language, and not engaged in specific nutritional programs. A validated Food Frequency Questionnaire was applied to gather information regarding nutritional habits in the last 6 months prior to conception. The consumption of nutrients was compared to the reference intake levels suggested by the European Food Safety Authority. Further analyses between different participants' subgroups were performed.

RESULTS

Overall, 1100 pregnant women (mean age: 32.4 ± 4.9 years) were enrolled. Almost all examined micronutrients' intake was significantly different from dietary reference values. Furthermore, nutrient adequacy ratio was below 60% in 6 out of 22 micronutrients examined, and Mean Adequacy Ratio was 93%. However, Mean Adequacy Ratio is characterized by extreme variance between the examined values. Iodine, folic acid, potassium, and vitamin D intake levels were significantly lower than the recommended intake levels (p < .001 for all), while vitamin K and niacin (p < .001 for both) were consumed in great extent. Sodium median intake, without calculating extra salt addition also exceeded the reference value levels (p = .03). Notably, magnesium intake exceeded the upper safety limits in 12.4% of the sample.

CONCLUSION

Potential inadequacies in important micronutrients for uneventful pregnancy outcomes have been revealed.. Special attention is needed for magnesium to balance possible toxicity with evident benefits.

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

BACKGROUND

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

AIM/OBJECTIVES

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

METHODS

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

FINDINGS

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

IMPLICATIONS

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

The Association Between ACE Score and Having Pre-Pregnancy Health Conversations with a Healthcare Provider (2016-2020)

OBJECTIVES

Adverse Childhood Experiences (ACEs) increase health risks leading to negative pregnancy outcomes, thus prompting the need for preconception care to address these risks. The aim of this study is to assess the association between ACEs score and self-report of having pre-pregnancy health conversations with a healthcare provider.

METHODS

Secondary analysis of PRAMS data from 2016 to 2020 was performed from 3 states and Washington, DC. ACEs score was categorized as 0 (low risk), 1-3 (intermediate risk), and ≥ 4 (high risk). Pre-pregnancy health conversations were measured using reports of being asked about the desire to have children, use birth control to prevent pregnancy, and/or improve health during any visit in the 12 months prior to pregnancy. Multivariate Poisson Regression was performed to adjust for potential confounders: age, race/ethnicity, income, education, insurance type, marital status, pregnancy intention, and parity.

RESULTS

A total of 10,448 PRAMS survey responses from 2016 to 2020 were included in the analysis. More than half of women reported having at least 1 ACE (51%). Those with an ACE score of ≥ 4 had 1.19 (95% CI: 1.01-1.41) times higher adjusted Prevalence Ratio (aPR) and those with an ACE score of 1-3 had about the same aPR 1.00 (95% CI: 0.93-1.09) of reporting pre-pregnancy health conversations with a healthcare provider compared to those with no ACEs. CONCLUSIONS FOR PRACTICE: The overall low percentage of respondents reporting receipt of pre-pregnancy health conversations with a health care provider indicates the need for these conversations to be had on a more routine basis.

Racial and Socioeconomic Disparities in Preconception Health Risk Factors and Access to Care

Background: Black birthing people have significantly higher risks of maternal mortality and morbidity compared with White people. Preconception chronic conditions increase the risk of adverse pregnancy outcomes, yet little is known about disparities in preconception health. This study applies an intersectional framework to examine the simultaneous contributions of racial marginalization and economic deprivation in determining disparities in preconception risk factors and access to care. Methods: Using data from the Pregnancy Risk Assessment Monitoring System, 2016-2020 (N = 123,697), we evaluated disparities by race and income in self-reported preconception hypertension, diabetes, obesity, depression, and smoking, as well as preconception insurance coverage and utilization of health care. We estimated linear regression models and calculated predicted probabilities. Results: Black respondents experienced higher probabilities of preconception obesity and high blood pressure at every income level compared with White respondents. Higher income did not attenuate the probability of obesity for Black respondents (linear trend p = 0.21), as it did for White respondents (p < 0.001). Conversely, while White respondents with low income were at higher risk of preconception depression and smoking than their Black counterparts, higher income was strongly associated with reduced risk, with significantly steeper reductions for White compared with Black respondents (difference in trends p < 0.001 for both risk factors). White respondents had higher probabilities of utilizing preconception care across all income levels, despite similar probabilities of insurance coverage. Conclusions: Higher income does not protect against the risk of preconception obesity and other preconception risk factors for Black birthing people as it does for White birthing people. Results point to the need to consider multiple forms of intersecting structural factors in policy and intervention research to improve preconception and maternal health.

Implementation of preconception care for preventing adverse pregnancy outcomes in rural and tribal areas of Nashik District, India

Introduction

The World Health Organization has suggested preconception care to improve pregnancy outcomes. Hence, the study aimed to compare the effect of preconception care on pregnancy outcomes, particularly prematurity and low birth weight.

Methods

We carried out interventions in one tribal and one non-tribal block. For comparison, one adjacent tribal block and one non-tribal block were included in Nashik district, India. The total study period was from April 2018 to July 2021. All reproductive age group women desiring pregnancy within one year in selected four blocks participated in the study. The services included clinical examination, laboratory investigations, treatment, six-monthly deworming, anemia management, folic acid supplementation, family planning services, and behavioral change communication using different media. The existing healthcare workers provided services to the women until they became pregnant or until the end of the follow-up period (27 months). We monitored pregnancy outcomes, including abortion, stillbirth, and live birth; among live births, low birth weight, preterm birth, congenital physical anomaly, and neonatal death.

Results

The study enrolled 7,875 women, and 3,601 had outcomes. The proportion of preterm births in the intervention and comparison block was 11.18 % and 14.99 %, respectively (p = 0.001), and the proportion of low-birth-weight babies was 9.23 % and 11.25 %, respectively (p = 0.01). The adjusted prevalence ratio showed that the risk of preterm births in the absence of intervention was 1.3 (CI: 1.1-1.6). Preterm birth was a mediator between preconception care and low birth weight.

Conclusion

Reduction in proportion of low birth weight and preterm babies can be achieved through preconception care using minimal additional resources.

Preconception Care Interventions for Adolescents and Young Adults to Prevent Adverse Maternal and Child Health Outcomes: Protocol for an Evidence Gap Map

BACKGROUND

Preconception is the period before a young woman or woman conceives, which draws attention to understanding how her health condition and certain risk factors affect her and her baby's health once she becomes pregnant. Adolescence and youth represent a life-course continuum between childhood and adulthood, in which the prepregnancy phase lacks sufficient research.

OBJECTIVE

The aim of the study is to identify, map, and describe existing empirical evidence on preconception interventions that enhance health outcomes for adolescents, young adults, and their offspring.

METHODS

We will conduct an evidence gap map (EGM) activity following the Campbell guidelines by populating searches identified from electronic databases such as MEDLINE, Embase, CINAHL, and Cochrane Library. We will include interventional studies and reviews of interventional studies that report the impact of preconception interventions for adolescents and young adults (aged 10 to 25 years) on adverse maternal, perinatal, and child health outcomes. All studies will undergo title or abstract and full-text screening on Covidence software (Veritas Health Innovation). All included studies will be coded using the Evidence for Policy and Practice Information (EPPI) Reviewer software (EPPI Centre, UCL Social Research Institute, University College London). Cochrane Risk of Bias tool 2.0 and Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2) tool will be used to assess the quality of the included trials and reviews. A 2D graphical EGM will be developed using the EPPI Mapper software (version 2.2.4; EPPI Centre, UCL Social Research Institute, University College London).

RESULTS

This EGM exercise began in July 2023. Through electronic search, 131,031 publications were identified after deduplication, and after the full-text screening, 18 studies (124 papers) were included in the review. We plan to submit the paper to a peer-reviewed journal once it is finalized, with an expected completion date in May 2024.

CONCLUSIONS

This study will facilitate the prioritization of future research and allocation of funding while also suggesting interventions that may improve maternal, perinatal, and child health outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56052.

Cost-effectiveness of a complex continuum of care intervention targeting women and children: protocol for an economic evaluation of the Bukhali trial in South Africa

INTRODUCTION

As nearly two-thirds of women presenting at their first antenatal visit are either overweight or obese in urban South Africa, the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and non-communicable diseases. This protocol describes the planned economic evaluation of an individually randomised controlled trial of a complex continuum of care intervention targeting women and children in Soweto, South Africa (Bukhali trial).

METHODS AND ANALYSIS

The economic evaluation of the Bukhali trial will be conducted as a within-trial analysis from both provider and societal perspectives. Incremental costs and health outcomes of the continuum of care intervention will be compared with standard care. The economic impact on implementing agencies (programme costs), healthcare providers, participants and their households will be estimated. Incremental cost-effectiveness ratios (ICERs) will be calculated in terms of cost per case of child adiposity at age years averted. Additionally, ICERs will also be reported in terms of cost per quality-adjusted life year gained. If Bukhali demonstrates effectiveness, we will employ a decision analytical model to examine the cost-effectiveness of the intervention over a child's lifetime. A Markov model will be used to estimate long-term health benefits, healthcare costs and cost-effectiveness. Probabilistic sensitivity analyses will be conducted to explore uncertainty and ensure robust results. An analysis will be conducted to assess the equity impact of the intervention, by comparing intervention impact within quintiles of socioeconomic status.

ETHICS AND DISSEMINATION

The Bukhali trial economic evaluation has ethical approval from the Human Ethics Research Committee of the University of the Witwatersrand, Johannesburg, South Africa (M240162). The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trials Registry (PACTR201903750173871; https://pactr.samrc.ac.za).

Association between preconception care and family planning and previous adverse birth outcomes in Ethiopia: systematic review and meta-analysis

OBJECTIVES

Inconsistent findings on the associations of preconception care with the utilisation of family planning and previous adverse birth outcomes have not been systematically reviewed in Ethiopia. Thus, this review aims to estimate the pooled association of preconception care with the utilisation of family planning and previous adverse birth outcomes in Ethiopia.

DESIGN

Systematic review and meta-analysis of observational studies.

DATA SOURCES

MEDLINE Complete, CINAHL Complete, Scopus and Global Health were searched from inception to 28 July 2023.

ELIGIBILITY CRITERIA

Observational studies that reported preconception care as an outcome variable and the use of family planning before pregnancy or previous adverse birth outcomes as exposure variables were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently conducted study screening, data extraction and quality assessment. A fixed-effects model was used to determine the pooled association of preconception care with the utilisation of family planning and previous adverse birth outcomes.

RESULTS

Eight studies involving a total of 3829 participants were included in the review. The pooled meta-analysis found that women with a history of family planning use had a higher likelihood of using preconception care (OR 2.09, 95% CI 1.74 to 2.52) than those women who did not use family planning before their current pregnancy. Likewise, the pooled meta-analysis found that women with prior adverse birth outcomes had a higher chance of using preconception care (OR 3.38, 95% CI 1.06 to 10.74) than women with no history of prior adverse birth outcomes.

CONCLUSION

This review indicated that utilisation of preconception care had a positive association with previous use of family planning and prior adverse birth outcomes. Thus, policymakers and other relevant stakeholders should strengthen the integration of preconception care with family planning and other maternal healthcare services.

PROSPERO REGISTRATION NUMBER

CRD42023443855.

Development of the Ready to Care Survey for VA Women's Health Primary Care Provider

INTRODUCTION

Women Veterans are at increased risk for poor pregnancy outcomes and are increasingly using Veteran Affairs (VA) for maternity benefits. VA Women's Health Primary Care Providers (WH-PCPs) are well positioned to improve maternal outcomes for women Veterans, yet little is understood about their experience and comfort with perinatal care. The objective of this study was to develop and validate a survey that could be utilized to assess WH-PCPs' experience, comfort, and attitudes towards perinatal care.

METHODS

After a review of the literature, we adapted a previously published survey to address four content areas including clinical experience, comfort level, and attitudes towards perinatal care and knowledge of VA specific maternity services. This survey was piloted with five WH-PCPs before undergoing two rounds of content validation with content experts. Content validity indexes (CVI) were calculated based on the content experts' ratings. Qualitative feedback from the content experts were summarized and reviewed by the research team. The CVI and qualitative responses were utilized to guide the decision to revise, refine, or delete survey questions.

RESULTS

After the first round of content validation, we deleted three questions, revised three questions, and add three questions to the content areas of clinical experience and comfort. In the domain of attitudes towards perinatal care, we deleted one question and revised two questions and three questions were added to the knowledge of VA specific maternity services domain. After the second round of content validation, only one question was deleted from the attitudes domain.

DISCUSSION

We developed and validated the Ready to Care Survey for VA WH-PCP using two rounds of content validation. The final survey had face and content validity. This survey tool can be used to assess VA WH-PCP's knowledge and readiness in caring for Veterans of child-bearing age for operational and research needs.

Continuum of care in maternal and child health in Indonesia

AIM

This paper aims to empirically analyze the socioeconomic and demographic correlates of maternal and child health (MCH) care utilization in Indonesia using the continuum of care (CoC) concept.

BACKGROUND

The concept of CoC has emerged as an important guiding principle in reproductive, maternal, newborn, and child health. Indonesia's maternal mortality rate, neonatal mortality, and under-five mortality rates are among the highest in the Southeast Asian region.

METHODS

Using pooled data from four successive waves of the nationally representative Indonesian Demographic and Health Survey (IDHS) conducted in the years 2002, 2007, 2012, and 2017, we use multivariate regression models to analyze care across four components of the continuum: antenatal care (ANC), institutional delivery, postnatal care for children, and full immunization (IM).

FINDINGS

CoC at each stage of MCH care has improved continuously over the period 2002-2017 in Indonesia. Despite this, just less than one out of two children receive all four components of the CoC. The overall coverage of CoC from its second stage (four or more ANC visits) to the final stage (full child IM) is driven by the dropouts at the ANC visit stage, followed by the loss of postnatal checkups and child IM. We find that the probability of a child receiving CoC at each of the four stages is significantly associated with maternal age and education, the household's socioeconomic and demographic characteristics, and economic status.

CONCLUSION

Complete CoC with improved, affordable, and accessible MCH care services has the potential to accelerate the progress of Sustainable Development Goal 3 by reducing maternal and childhood mortality risks. Our findings show that in Indonesia, the CoC continuously declines as women proceed from ANC to other MCH services, with a sharp decline observed after four ANC visits. Our study has identified key socioeconomic characteristics of women and children that increase their probability of failing to access care.

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.

FIGO Preconception Checklist: Preconception care for mother and baby

The preconception period is a unique and opportunistic time in a woman's life when she is motivated to adopt healthy behaviors that will benefit her and her child, making this time period a critical "window of opportunity" to improve short- and long-term health. Improving preconception health can ultimately improve both fetal and maternal outcomes. Promoting health before conception has several beneficial effects, including an increase in seeking antenatal care and a reduction in neonatal mortality. Preconception health is a broad concept that encompasses the management of chronic diseases, including optimal nutrition, adequate consumption of folic acid, control of body weight, adoption of healthy lifestyles, and receipt of appropriate vaccinations. Use of the FIGO Preconception Checklist, which includes the key elements of optimal preconception care, will empower women and their healthcare providers to better prepare women and their families for pregnancy.

A meta-analysis into the mediatory effects of family planning utilization on complications of pregnancy in women of reproductive age

BACKGROUND

Despite conflicting findings in the current literature regarding the correlation between contraceptives and maternal health consequences, statistical analyses indicate that family planning may decrease the occurrence of such outcomes. Consequently, it is crucial to assess the capability of family planning to mitigate adverse maternal health outcomes.

OBJECTIVES

This review investigates the effects of modern contraceptive use on maternal health.

SEARCH METHODS

This systematic review is registered on Prospero (CRD42022332783). We searched numerous databases with an upper date limit of February 2022 and no geographical boundaries.

SELECTION CRITERIA

We included observational studies, including cross-sectional, cohort, case-control studies, and non-RCT with a comparison group. We excluded systematic reviews, scoping reviews, narrative reviews, and meta-analyses from the body of this review.

MAIN RESULTS

The review included nineteen studies, with five studies reporting a reduction in maternal mortality linked to increased access to family planning resources and contraceptive use. Another three studies examined the impact of contraception on the risk of preeclampsia and our analysis found that preeclampsia risk was lower by approximately 6% among contraceptive users (95% CI 0.82-1.13) compared to non-users. Two studies assessed the effect of hormonal contraceptives on postpartum glucose tolerance and found that low-androgen contraception was associated with a reduced risk of gestational diabetes (OR 0.84, 95% CI 0.58-1.22), while DMPA injection was possibly linked to a higher risk of falling glucose status postpartum (OR 1.42, 95% CI 0.85-2.36). Two studies evaluated high-risk pregnancies and births in contraceptive users versus non-users, with the risk ratio being 30% lower among contraceptive users of any form (95% CI 0.61, 0.80). None of these results were statistically significant except the latter. In terms of adverse maternal health outcomes, certain contraceptives were found to be associated with ectopic pregnancy and pregnancy-related venous thromboembolism through additional analysis.

A qualitative analysis of community health worker perspectives on the implementation of the preconception and pregnancy phases of the Bukhali randomised controlled trial

Community health workers (CHWs) play an important role in health systems in low- and middle-income countries, including South Africa. Bukhali is a CHW-delivered intervention as part of a randomised controlled trial, to improve the health trajectories of young women in Soweto, South Africa. This study aimed to qualitatively explore factors influencing implementation of the preconception and pregnancy phases of Bukhali, from the perspective of the CHWs (Health Helpers, HHs) delivering the intervention. As part of the Bukhali trial process evaluation, three focus group discussions were conducted with the 13 HHs employed by the trial. A thematic approach was used to analyse the data, drawing on elements of a reflexive thematic and codebook approach. The following six themes were developed, representing factors impacting implementation of the HH roles: interaction with the existing public healthcare sector; participant perceptions of health; health literacy and language barriers; participants' socioeconomic constraints; family, partner, and community views of trial components; and the HH-participant relationship. HHs reported uses of several trial-based tools to overcome implementation challenges, increasing their ability to implement their roles as planned. The relationship of trust between the HH and participants seemed to function as one important mechanism for impact. The findings supported a number of adaptations to the implementation of Bukhali, such as intensified trial-based follow-up of referrals that do not receive management at clinics, continued HH training and community engagement parallel to trial implementation, with an increased emphasis on health-related stigma and education. HH perspectives on intervention implementation highlighted adaptations across three broad strategic areas: navigating and bridging healthcare systems, adaptability to individual participant needs, and navigating stigma around disease. These findings provide recommendations for the next phases of Bukhali, for other CHW-delivered preconception and pregnancy trials, and for the strengthening of CHW roles in clinical settings with similar implementation challenges. Trial registration: Pan African Clinical Trials Registry; PACTR201903750173871, Registered March 27, 2019.

Women's views on content and delivery methods for interventions to improve preconception health: a qualitative exploration

Background

Systematic review evidence suggests preconception health interventions may be effective in improving a range of outcomes. However, few studies have explored women's views on potential content and delivery methods for these interventions.

Methods

Participants were purposively sampled from respondents (n = 313) of a survey. Semi-structured, in-depth interviews were conducted to explore their views on seven candidate delivery methods for preconception health interventions: general practitioners (GPs), nurse practitioners, pharmacists, social media, personal texts and emails, pregnancy tests, and health education in schools. Data were analyzed using a data-driven framework analysis.

Results

Twenty women were interviewed. Women wanted interventions to be easily accessible but allow them to conceal their pregnancy plans. They preferred to choose to receive preconception interventions but were receptive to health professionals raising preconception health during 'relevant' appointments such as contraceptive counseling and cervical smear tests. They wanted intervention content to provide trustworthy and positively framed information that highlights the benefits of good preconception health and avoids stigmatizing women for their weight and preconception actions. The inclusion of support for preconception mental health and the use of visual media, personalization, simple information, and interesting and unfamiliar facts were viewed favorably.

Conclusion

Interventions to improve preconception health should reflect the sensitivities of pregnancy intentions, be easy to access in a way that enables discretion, and be designed to seek consent to receive the intervention. These interventions should ideally be tailored to their target populations and provide trustworthy information from reputable sources. The potential for unintended harmful effects should be explored.

The MidPIC study: Midwives' knowledge, perspectives and learning needs regarding preconception and interconception care

Preconception and interconception care improves health outcomes of women and communities. Little is known about how prepared and willing Australian midwives are to provide preconception and interconception care. The aim of this study was to explore midwives' knowledge, perspectives and learning needs, and barriers and enablers to delivering preconception and interconception care. We conducted a cross-sectional exploratory study of midwives working in any Australian maternity setting. An online survey measured midwives' self-rated knowledge; education needs and preferences; attitudes towards pre and interconception care; and views on barriers, enablers; and, future service and workforce planning. Quantitative data were analysed descriptively and demographic characteristics (e.g., years of experience, model of care) associated with knowledge and attitudes regarding pre- and interconception care were examined using univariate logistic regression analysis. Qualitative data were captured through open-ended questions and analysed using inductive content analysis. We collected responses from (n = 338) midwives working across all models of care (full survey completion rate 96%). Most participants (n = 290; 85%) rated their overall knowledge about pre and interconception health as excellent, above average or average. Participants with over 11 years of experience were more likely to report above average to excellent knowledge (OR 3.11; 95% CI 1.09, 8.85). Online e-learning was the most preferred format for education on this topic (n = 244; 72%). Most (n = 257; 76%) reported interest in providing pre and interconception care more regularly and that this is within the midwifery scope of practice (n = 292; 87%). Low prioritisation in service planning was the most frequently selected barrier to providing preconception and interconception care, whereas continuity models and hybrid child health settings were reported as enablers of pre and interconception care provision. Findings revealed that midwives are prepared and willing to provide preconception and interconception care. Pre and post registration professional development; service and funding reform; and policy development are critical to enable Australian midwives' provision of pre and interconception care.

Intensified Nutrition Interventions in Antenatal Care Services Increased Consumption of Iron and Folic Acid Supplements and Early Breastfeeding Practices in Burkina Faso: Results of a Cluster-Randomized Program Evaluation

BACKGROUND

Alive & Thrive supported the Government of Burkina Faso to strengthen the provision of iron and folic acid (IFA) supplementation and interpersonal counseling on maternal nutrition and breastfeeding through antenatal care (ANC) services and community-based contacts in 2 regions.

OBJECTIVES

We assessed the impacts of intensified nutrition interventions during ANC compared with standard ANC services on intervention coverage and maternal nutrition practices.

METHODS

A cluster-randomized evaluation compared 40 health center catchment areas in intervention areas with 40 in control areas. Repeated cross-sectional surveys in 2019 and 2021 (960 pregnant women and 1920 women with children 0-5 mo of age per survey round) provided data on impact indicators, intervention exposure, and other factors. We derived difference-in-difference (DID) effect estimates, adjusted for geographic clustering, for maternal dietary diversity, IFA consumption, and early breastfeeding practices.

RESULTS

More women in intervention areas had 4+ ANC visits (DID: 8.3 percentage points [pps]) and started ANC during the first trimester (DID: 10.5 pp), compared with control areas. Improvements were achieved in exposure to nutrition counseling on dietary diversity (DID: 44.4 pp), food quantity (DID: 42.9 pp), adequate weight gain (DID: 35.1 pp), and breastfeeding (DID: 25.9 pp). Women in intervention areas consumed more IFA supplements during pregnancy (DID: 21 tablets). Early initiation of and exclusive breastfeeding also improved (DID: 17.0 and 8.3 pp, respectively). However, dietary diversity (4 out of 10 food groups) and mean probability of adequacy of micronutrient intake (14%) among pregnant women remained low in both areas.

CONCLUSIONS

Strengthening maternal nutrition interventions delivered through government ANC services was feasible and effective in improving maternal nutrition practices. Continued efforts to strengthen the delivery and use of maternal nutrition services may be required for greater behavior changes, and to address family support, social norms, and other factors to improve women's diets during pregnancy.

Complete continuum of maternity care and associated factors among mothers who gave birth in the last twelve months in Mekane Selam town North-East Ethiopia: A community-based cross-sectional study,2021

BACKGROUND

Complete continuum of maternity care has significant value in improving the health and wellbeing of mothers and newborns. Assessing the complete continuum of maternity care is a global priority, particularly in developing countries. Despite the fact that the complete continuum of maternity care prevents more than half of all maternal and neonatal deaths, Ethiopia remains one of the largest contributors to the global burden of maternal and neonatal deaths due to the low implementation of the complete continuum of maternity care. Thus, this study aimed to assess the coverage of the complete continuum of maternity care and associated factors among mothers who gave birth in the last 12 months in the study area.

METHODS

A community-based cross-sectional study with a multistage sampling technique was conducted among 479 mothers who gave birth in the last 12 months in Mekane Selam town. Data were collected from September 1 to November 30/2021 using an interviewer-administered questionnaire. Binary logistic regression analysis was computed. In multivariable logistic regression analysis, an adjusted odds ratio (AOR) with a 95% confidence interval (CI) and a P- value< 0.05 were used to identify significantly associated factors.

RESULTS

The coverage of a complete continuum of maternity care was 42.4% (95% CI: 37.9%, 47%). Respondents with higher educational status (AOR = 4.17, 95% CI: 1.52, 11.44), pre-pregnancy contraception utilization (AOR = 3.53, 95% CI: 1.80, 6.92), planned pregnancy (AOR = 2.97, 95% CI: 1.27, 6.97) and early initiation of antenatal care (AOR = 4.57, 95% CI: 2.86, 7.31) were significantly associated with complete continuum of maternity care.

CONCLUSION

The coverage of complete continuum of maternal care was low in the study area. The coverage could be expanded by making the necessary interventions on the associated factors. It is essential for women to acquire education, utilize contraception, plan their pregnancies, and begin antenatal care at an early age in order to enhance the coverage of complete continuum of maternity care.

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

Introduction

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

Method

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

Results

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

Conclusions

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

Addressing inequalities and improving maternal and infant outcomes: the potential power of nutritional interventions across the reproductive cycle

Maternal nutrition is essential for optimal health and well-being of women and their infants. This review aims to provide a critical overview of the evidence-base relating to maternal weight, obesity-related health inequalities and dietary interventions encompassing the reproductive cycle: preconception, pregnancy, postnatal and interpregnancy. We provide an overview of UK data showing that overweight and obesity affects half of UK pregnancies, with increased prevalence among more deprived and minoritised ethnic populations, and with significant health and cost implications. The existing intervention evidence-base primarily focuses on the pregnancy period, where extensive evidence demonstrates the power of interventions to improve maternal diet behaviours, and minimise gestational weight gain and postnatal weight retention. There is a lack of consistency in the intervention evidence-base relating to interventions improving pregnancy health outcomes, although there is evidence of the potential power of the Mediterranean and low glycaemic index diets in improving short- and long-term health of women and their infants. Postnatal interventions focus on weight loss, with some evidence of cost-effectiveness. There is an evidence gap for preconception and interpregnancy interventions. We conclude by identifying that interventions do not address cumulative maternal obesity inequalities and overly focus on individual behaviour change. There is a lack of a joined-up approach for interventions throughout the entire reproductive cycle, with a current focus on specific stages (i.e. pregnancy) in isolation. Moving forward, the potential power of nutritional interventions using a more holistic approach across the different reproductive stages is needed to maximise the benefits on health for women and children.

Preconception Care: A Strategic Intervention for the Prevention of Neonatal and Birth Disorders

Preconception care is a strategic intervention to improve neonatal and birth outcomes by addressing modifiable risk factors and optimizing maternal and fetal health before pregnancy. This review article examines the importance of preconception care and its impact on preventing neonatal and birth disorders. The methodology involved a comprehensive review of peer-reviewed articles, research studies, and authoritative reports. Key components of preconception care, evidence-based interventions, and their effectiveness in reducing specific neonatal and birth disorders are discussed. The review also highlights the challenges and barriers in implementing preconception care, such as lack of awareness, socioeconomic factors, health system limitations, and policy considerations. Strategies for promoting preconception care, including integration into healthcare systems, raising awareness, healthcare professional education, and collaborations are presented. The conclusion emphasizes the significance of preconception care as a strategic intervention and calls for action by healthcare providers, policymakers, and individuals to prioritize preconception care for better neonatal and birth outcomes.

Vitamins and minerals, education, and self-care need during preconception to 1000 days of life in Southeast Asia: An expert panel opinion

Addressing maternal malnutrition and its drivers is paramount in Southeast Asia. This article summarizes the key clinical learnings and evidence-based opinions from the experts to understand the need for vitamins and minerals supplementation, education, and self-care from preconception to the first 1000 days of life, which warranted further attention since COVID-19 pandemic. Evidence describing the importance of vitamins and minerals during preconception, pregnancy, and lactation stages was identified using literature databases. A pre-meeting survey was conducted to determine the current practices and challenges in Southeast Asia. Based on the literature review and clinical experience, experts defined the topics, and an online meeting was held on 13th July 2021. During the meeting, nine experts from Southeast Asia provided evidence-based opinion on the vitamins and minerals supplementation, education, and self-care need during preconception, pregnancy, and lactation stages. The expert opinions underpin maternal malnutrition as a prevalent issue and discuss appropriate interventions and prevention strategies for women in Southeast Asia. The recent pandemic further impacted nutrition status, pregnancy, and neonatal health outcomes. The expert panel emphasized a need to improve existing inadequacies in education, self-care, and social support, and discussed the role of policymakers in addressing the barriers to dietary changes. As inadequacies in regular vitamins and minerals supplementation, education, and self-care for women of reproductive age implicate maternal and child health outcomes, there is an urgent need for addressing malnutrition concerns in this population. Thus, a strong partnership between policymakers, healthcare professionals, and other relevant sectors is required.

Smoking Behaviors Among Indigenous Pregnant People Compared to a Matched Regional Cohort

INTRODUCTION

Smoking commercial tobacco products is highly prevalent in American Indian and Alaska Native (Indigenous) pregnancies. This disparity directly contributes to maternal and fetal mortality. Our objective was to describe cigarette smoking prevalence, cessation intervention uptake, and cessation behaviors of pregnant Indigenous people compared to sex and age-matched regional cohort.

AIMS AND METHODS

Pregnancies from an Indigenous cohort in Olmsted County, Minnesota, identified in the Rochester Epidemiology Project, were compared to pregnancies identified in a sex and age-matched non-Indigenous cohort from 2006 to 2019. Smoking status was defined as current, former, or never. All pregnancies were reviewed to identify cessation interventions and cessation events. The primary outcome was smoking prevalence during pregnancy, with secondary outcomes measuring uptake of smoking cessation interventions and cessation.

RESULTS

The Indigenous cohort included 57 people with 81 pregnancies, compared to 226 non-Indigenous people with 358 pregnancies. Smoking was identified during 45.7% of Indigenous pregnancies versus 11.2% of non-Indigenous pregnancies (RR: 3.25, 95% CI = 1.98-5.31, p ≤ .0001). Although there was no difference in uptake of cessation interventions between cohorts, smoking cessation was significantly less likely during Indigenous pregnancies compared to non-Indigenous pregnancies (OR: 0.23, 95% CI = 0.07-0.72, p = .012).

CONCLUSIONS

Indigenous pregnant people in Olmsted County, Minnesota were more than three times as likely to smoke cigarettes during pregnancy compared to the non-indigenous cohort. Despite equivalent uptake of cessation interventions, Indigenous people were less likely to quit than non-Indigenous people. Understanding why conventional smoking cessation interventions were ineffective at promoting cessation during pregnancy among Indigenous women warrants further study.

IMPLICATIONS

Indigenous pregnant people in Olmsted County, Minnesota, were greater than three times more likely to smoke during pregnancy compared to a regional age matched non-Indigenous cohort. Although Indigenous and non-Indigenous pregnant people had equivalent uptake of cessation interventions offered during pregnancy, Indigenous people were significantly less likely to quit smoking before fetal delivery. This disparity in the effectiveness of standard of care interventions highlights the need for further study to understand barriers to cessation in pregnant Indigenous people.

Preconception care knowledge and information delivery modes among adolescent girls and women: a scoping review

Purpose: The aim of this study was to conduct a scoping review of knowledge and information delivery modes related to preconception care (PCC) among adolescent girls and women Methods: A scoping review was performed on studies selected from five electronic databases (Cochrane Library, PubMed, Science Direct, CINAHL/EBSCO, and ProQuest), published between 2012 and 2022, with predetermined keywords and criteria. We included English-language research articles available in full text and excluded irrelevant articles.Results: This study included eight articles, comprising seven quantitative studies and one qualitative study conducted among adolescent girls and women. Five were from low- and middle-income countries and three were from high-income countries. The synthesized themes generated from the data were PCC knowledge and PCC information delivery modes and effectiveness. In general, adolescent girls and women were found to have basic PCC knowledge, including risk prevention and management and a healthy lifestyle, although more extensive knowledge was found in higher-income countries than in lower-income countries. The delivery modes of PCC information have grown from individual face-to-face conventional methods, which are used predominantly in lower-income countries, to more effective digital mass media.Conclusion: Globally, many women still have insufficient knowledge regarding PCC, as not all of them receive access to PCC information and support. PCC promotion efforts should be initiated earlier by involving a wider group of reproductive-age women and combining individual, in-group, face-to-face, and electronic delivery modes.

Preconception-Health-Related Attitudes of Bulgarian Women of Reproductive Age

Preconception care (PC) is relatively new area of practice. While the volume and quality of PC activities depend on local settings, the awareness of women is critical for the successful promotion of PC services. The aim of this study was to examine the preconception-health-related attitudes and experiences of Bulgarian women of reproductive age. A qualitative study conducted among 20 women aged 18 to 49 years was performed between May and July 2022. Two focus groups were used with mixed samples of nulligravida, pregnant, and postpartum women. The participants thought that the Internet and their obstetrician-gynecologist were the only places where they could learn about getting pregnant. Only two of them discussed their PC plans with their physicians. Women pointed out that general practitioners (GPs) need to be more proactive in promoting PC. All respondents outlined the need for a web-based educational platform that could serve as a primary source of health information for future families. The role and functions of GPs in the continuum of PC should be reconsidered. We recommend targeted educational measures for all stakeholders, including women and GPs. In this regard, an easily accessible, knowledge-based web platform could enhance Bulgarian women’s awareness and perceptions of PC.

Exploration of spatial clustering in maternal health continuum of care across districts of India: A geospatial analysis of demographic and health survey data

INTRODUCTION

The continuum of care (CoC) throughout pregnancy, delivery and post-delivery has recently been highlighted as an integrated intervention programme for maternal, new-born, and child health. Existing literature suggests the importance of continuum of care (CoC) for improved maternal and child health outcomes. However due to unavailability of data at the lowest administrative levels, literature on spatial pattern of uptake of full CoC is lacking. The present study attempts to focus on the spatial analysis of CoC in maternal health care in India.

DATA AND METHODS

The study is based on the fourth round of National Family Health Survey data conducted in 2015-16 in India. The outcome variable used is maternal health continuum of care which includes- at least 4 ANC visits, delivery through skilled birth attendant and postnatal check-up within 48 hours of delivery. Univariate and bivariate Local Indicator of Spatial Association (LISA) maps have been generated to show the spatial pattern of CoC across 640 districts in India. We also employed spatial regression techniques to explore the determinants of CoC.

FINDINGS

Percentage of women who followed full CoC was observed to be least for East Kameng (0.0%) district of Arunachal Pradesh and highest in North Goa district (90.4%). Majority of districts where uptake of full CoC was more than 80 percent were found concentrated in southern region on India. Equivalently, findings indicated a strong spatial clustering of full CoC with high-high clusters mostly concentrated in southern districts. Low-low district clusters are concentrated in the states of Uttar Pradesh, Bihar and Madhya Pradesh. For complete CoC the global Moran's I is 0.73 indicating the spatial dependence. The spatial regression analysis suggested that modern contraceptive use, meeting with health worker, urbanization and secondary or above education for women have positive impact on the utilisation of CoC.

CONCLUSION

The spatial pattern indicates district level clustering in uptake of CoC among women. The study suggests policymakers and stakeholders to implement comprehensive interventions at sub-regional levels for ensuring the completion of CoC for women which acts as a preventive measure for adverse outcomes such as-maternal and child mortality.

Nationwide-free preconception care strategy: Experience from China

Preconception care has emerged as a developing field in maternal and child healthcare worldwide. This care type provides couples of reproductive age with the opportunity for early detection and management of biomedical, behavioral, and social health problems. In 2010, the Chinese government launched a nationwide preconception care program as a welfare project. During the past decade, this project has received international attention, and experiences from the project have been published in the literature. In this review, we summarize the history, implementation, and evaluation of preconception care services in China, and its related maternal and children's health service initiatives, to thereby provide knowledge for policymakers and clinicians in other countries.

An Exploratory Analysis of Maternal Health Variables Increasing the Severity of Congenital Heart Disease in Infants

BACKGROUND

Congenital heart defects (CHD) are the most prevalent birth anomaly and leading cause of infant morbidity and mortality worldwide. Heart defects are often attributed to chromosomal abnormality or environmental factors, but most causes remain unknown. The purpose of this analysis was to explore maternal health variables and the relationships to birth outcomes in infants with CHD.

METHODS

Secondary analysis of data from the Wisconsin Pediatric Cardiac Registry.

RESULTS

Maternal history of CHDs (odds ratio [OR] = 2.38; 95% confidence interval [CI], 1.42-3.98) and serious health conditions (OR = 1.537; 95%: CI, 1.08-2.17) increase infant risk and CHD severity. Maternal history of hypertension, serious health conditions, CHD, obesity, and income were predictors of birth weight (R² = 0.049, P < .05). Maternal history of hypertension, influenza, serious health conditions, and housing were predictors of gestational age (R2 = 0.045, P < .05). Birth weight (BW) and gestational age (GA) did not correlate to the severity of CHD in this study (simple vs complex, BW = -0.014, GA = 0.011, r).

DISCUSSION

Maternal well-being influences the health of infants born with CHD. Positive maternal health contributes to near-normal birth weight and gestational age.

CONCLUSION

Nurses must discuss optimal reproductive life planning strategies for decreasing risk of CHD and other infant disorders.

Preconception care utilization and associated factors among reproductive age women in Mizan-Aman town, Bench Sheko zone, Southwest Ethiopia, 2020. A content analysis

Background

Preconception care is highly important in reducing a number of adverse pregnancy outcomes and helps to improve maternal health. Preconception care optimizes women’s health and improves pregnancy outcomes. It is a cost-effective first-line preventive strategy for birth defects. However, preconception care utilization in Ethiopia was very low. Studies on these issues are limited in Ethiopia in general and in Mizan-Aman town in particular.

Objective

To assess preconception care utilization and associated factors among reproductive age women in Mizan-Aman town, Bench-Sheko Zone, Southwest Ethiopia.

Methods

A community based cross-sectional study design was employed from April 16 to May 26, 2020 in Mizan-Aman town. The total study participants were 624 reproductive age women. Data were collected by using pre-tested interviewer administered questionnaires and entered into Epi-data version 3.1 then exported to STATA version 14 and analyzed accordingly. Univeriate and Bivariable analysis was done by analysis of variance (ANOVA) and independent t-test. Multivariable statistical analysis using generalized linear regression model (GLM) approach was used to classify factors of preconception care utilization. Since our response variable is measured in terms of count variable, we used a Poisson regression model with a log link function. Finally, Statistical significance between dependent and independent variables were assessed by odds ratios and 95% confidence intervals.

Results

Overall, 28.6% of the women receipt atleast one item of preconception care while only 1.5% were taken the whole recommended components of preconception care services. The most common item received in the study area was taking micronutrient supplementation (18.5%). Age of women, educational status, husbands educational status, husbands occupation, wealth status, distance from the health facility, waiting time to get services, planning to pregnancy, age at first pregnancy, previous ANC use, Previous PNC use, adverse pregnancy experience, women’s knowledge of preconception care, and attitude on preconception care were determinants of preconception service utilization.

Conclusions

Preconception care component utilization was lower as compare with recommended service with different disparities. Multipurpose tailored strategies which incorporate a woman with no formal education, poor knwledge on preconception care,never take maternal services previously and distant from health facility could improve preconception care service utilization. Advocative strategies on preconception care component and planning pregnancy may elicite more women to use the services of preconception care.

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

Background

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

Methods

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

Results

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

Conclusion

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

Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis

Background

Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB.

Methods

In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I²: 74.33%).

Conclusion

We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness.

Trial registration number

This review was prospectively registered with PROSPERO (CRD42020220915).

Factors Influencing Provider Behavior Around Delivery of Preconception Care

OBJECTIVE

Despite growing consensus about the clinical value of preconception care (PCC), gaps and disparities remain in its delivery. This study aimed to examine the factors influencing behavior of health care providers around PCC in outpatient clinical settings in the United States.

METHODS

Twenty health care providers who serve people of reproductive age were interviewed using semi-structured interviews. Data was coded based on a modified Theoretical Domains Framework and analyzed using deductive content analysis.

RESULTS

We interviewed eight family medicine physicians, four obstetricians/gynecologists, seven nurse practitioners, and one nurse midwife. Overall, we found a wide variety in practices and attitudes towards PCC. Barriers and challenges to delivering PCC were shared across sites. We identified six themes that influenced provider behavior around PCC: (1) lack of knowledge of PCC guidelines, (2) perception of lack of preconception patient contact, (3) pessimism around patient "compliance," (4) opinion about scope of practice, (5) clinical site structure, and (6) reliance on the patient/provider relationship.

CONCLUSIONS FOR PRACTICE

Overall, our findings call for improved provider understanding of PCC and creative incorporation into current health care culture and practice. Given that PCC-specific visits are perceived by some as outside the norm of clinical offerings, providers may need to incorporate PCC into other encounters, as many in this study reported doing. We amplify the call for providers to understand how structural inequities may influence patient behavior and the value of standardized screening, within and beyond PCC, as well as examination of implicit and explicit provider bias.

"Is the health system ready?" A qualitative exploration of stakeholders' opinions about the feasibility of preconception care services in the Nigerian health system

Background

Preconception care (PCC) services aim to improve reproductive health outcomes through the provision of biomedical, behavioural and social health interventions to women and couples before conception occurs. Countries that have deployed PCC services have policies that guide the services provided. In Nigeria, PCC is poorly developed and is often provided in an opportunistic manner with no guidelines in place to direct the provision. This study explored the opinions of policymakers and health workers about the feasibility of deploying PCC services in the country.

Methods

This study was a qualitative exploration of opinions about PCC service deployment within the Nigerian health system in which 39 in-depth interviews were conducted with policymakers at the federal and state tiers of government as well as health workers at the tertiary, secondary and primary levels of health care. The transcripts were analysed thematically using a hybrid of deductive and inductive coding on MAXQDA 2018 qualitative data analysis software.

Results

Four main themes emerged from the data—issues around policy for PCC, service integration and collaboration, health system readiness and challenges to PCC service deployment. While noting that the country has no PCC policy, participants identified existing policies into which PCC can be integrated. The participants also described the importance of policy to PCC provision and provided information on existing collaborations that can help the policy development and implementation process. Although many of the participants believed the health system is prepared for PCC deployment, they identified challenges related to policy formulation and implementation, including financial challenges that could hinder the process.

Conclusion

Deployment of PCC services in the Nigerian health system is achievable as there are existing health-related policies into which the guidelines can be integrated. However, there is a need to consider the possible implementation challenges and address them as part of the planning process.

Optimising the health of women and men in preparation for childbearing can influence pregnancy outcomes positively. This optimisation can be achieved through the provision of preconception care. In many low- and middle-income countries including Nigeria, preconception care is provided in a haphazard manner with no guidelines to structure the service. In this article, the findings from discussions with health care providers and policymakers in Nigeria are presented. These findings show that preconception care can be deployed in a structured manner through collaboration between health care providers and integration with the existing maternal and child health services. Guiding policies can be provided by inclusion of preconception care in the existing health-related policies in the country.

Current state of preconception care in sub-Saharan Africa: A systematic scoping review

Background

Preconception care (PCC) utilisation is essential to extend and complete the health continuum. However, these services are not yet incorporated into many low-income countries’ existing maternal health services.

Aim

This study aims to review the current literature on the knowledge, utilisation and provision of PCC.

Setting

This included women and healthcare workers (HCWs) in Sub-Saharan African (SSA) countries.

Methods

Arksey and O’Malley’s scoping review methodology framework is used in this study. The following databases, Google Scholar, Science Direct, PubMed, Scopus and Dissertation via ProQuest, were searched. Articles that met the eligibility criteria were included in this study.

Results

Out of the 451 retrieved articles, 39 were relevant. In most studies, women’s utilisation and HCW’s provision of PCC were considered limited. Their knowledge, however, varies between studies, and there were a few studies conducted among women with chronic conditions. Several factors influenced women and HCWs’ knowledge, utilisation and provision of PCC, including age, level of education, employment, practice area, resources and knowledge. Preconception care interventions most commonly identified, utilised and provided were HIV testing, counselling and family planning, while preconception folic acid supplementation was the least.

Conclusion

The estimates of knowledge and utilisation were suboptimal among women, while provision was the worst affected among HCWs. Gaps exist between the HCW knowledge and practice of PCC. There is a need to promote, prioritise, integrate and optimise the opportunistic provision of PCC in SSA. There is also a need for more studies on PCC provision and utilisation among women with chronic medical conditions.

Determinants of practice of birth preparedness and complication readiness among pregnant women in Sodo Zuria District, Southern Ethiopia: Content analysis using Poisson’s regression

Objectives:

Every pregnancy can face risk. One of the World Health Organization recommendations for health promotion interventions for maternal and newborn health was to increase birth preparedness and complication readiness. The main objective of this recommendation was to increase the use of skilled care at birth and to increase the timely use of facility care for obstetric and newborn complications. However, to the best of our knowledge, there is a dearth of documented evidence on the magnitude of birth preparedness and complication readiness and factors associated with it in our study area. Thus, the aim of this study was to identify factors affecting the practice of birth preparedness and complication readiness.

Methods:

A community-based cross-sectional study was carried out from 15 February to 15 March 2020. A total of 698 pregnant women were randomly selected and interviewed using a pretested semi-structured questionnaire. A multivariate generalized linear regression with Poisson link was carried out to see the effect of each independent variable on the dependent variable.

Result:

Of the sampled 710 participants, 698 participated, which made a response rate of 98.3%. The mean score of practice of birth preparedness and complication readiness was 3.3 (standard deviation = 1.8). Mothers who used pre-pregnancy contraception methods (adjusted odds ratio = 1.22 (95% confidence interval = 1.09, 1.37)), used bare feet as a mode of transportation (adjusted odds ratio = 1.11 (95% confidence interval = 1.01, 1.21)), used more antenatal care content (adjusted odds ratio = 1.09 (95% confidence interval = 1.06, 1.13)), and whose husbands were educated at the primary level of education (adjusted odds ratio = 1.19 (95% confidence interval = 1.03, 1.37)) were predictors in multivariable general.

Conclusion:

The mean score and overall practice of birth preparedness and complication readiness were low. This study revealed a low level of birth preparedness and complication readiness. In order to improve access to lifesaving care for women and neonates, there is a pressing need for implementation of existing strategies to increase practice of birth preparedness and complication readiness.

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.

Development and validation of preconception care improvement scale (PCIS) in a resource-limited setting

BACKGROUND

Preconception care helps to close the gaps in a continuum of care. It is of paramount importance to reduce maternal and child adverse pregnancy outcomes, increase the utilization of services such as antenatal care, skilled delivery care, and post-natal care, and improve the lives of future generations. Therefore, a validated instrument is required. The purpose of this study was to develop and validate the preconception care improvement scale (PCIS) in a resource-limited setting.

METHODS

A mixed-method study was carried out from 02, March to 10, April 2019 in Manna district, Oromia region, Ethiopia to test the reliability and validity of the scale. Items were generated from literatures review, in-depth interviews with different individuals, and focused group discussions with women of reproductive age groups. A pretested structured questionnaire was used and a survey was conducted among 623 pregnant women in the district. The collected data were entered into EPI-data version 3.1 software and exported to SPSS version 23 software and data were analyzed for internal consistency and validity using reliability analysis and factor analysis.

RESULTS

The PCIS has 17 items loaded into six factors: Substance-related behaviors, screening for common non-communicable and infectious diseases, micronutrient supplementation and vaccination, seeking advice, decision and readiness for conception, and screening for sexually transmitted diseases. Factor analysis accounted for 67.51% of the observed variance. The internal consistency (Cronbach's alpha) of the scale was 0.776. Diversified participants of the qualitative study and experts' discussions assured the face and content validity of the scale. Factor loading indicated the convergent validity of the scale. Three of the PCIS subscale scores had a positive and significant association with the practice of preconception care and antenatal care visits, which confirmed the predictive validity of the scale.

CONCLUSION

The PCIS exhibited good reliability, face validity, content validity, convergent validity, and predictive validity. Thus, the scale is valid and helps to improve preconception care, especially in resource-limited settings.

"Nobody talks about it": Preconception health and care among women in the rural, Midwestern United States

INTRODUCTION

Good preconception and interconception health are fundamental to optimizing women's health and reducing risk factors for adverse maternal-infant outcomes. Although rural women in the United States tend to experience health disparities, no published qualitative studies have focused on their preconception/interconception health. The purpose of this study was to determine what rural, Midwestern women perceive to be their most pressing health needs and effective ways to provide outreach and education regarding preconception/interconception health and care.

METHODS

Non-pregnant, reproductive-age women in Hardin County, Ohio, regardless of parity, were recruited through convenience sampling. Semi-structured interviews with four domains (beliefs and behaviors; perceived needs; knowledge and information sources; barriers to care) were conducted in May-June 2021 until saturation was reached. Qualitative methods were used to analyze data and determine themes. Binomial tests were used to compare selected demographic characteristics of participants to the county's reproductive-age residential female population.

RESULTS

Nineteen women aged 20-44 years were individually interviewed. Comparing race/ethnicity, education, and insurance status, participants appeared to be representative of the county population. Four themes were identified: (1) needs regarding healthcare and other resources; (2) lack of preconception/interconception care and perceived unimportance due to intergenerational knowledge transfer and paucity of healthcare providers; (3) difference in understanding of the term "women's health" and low health literacy; and (4) suggested interventions including education and outreach.

CONCLUSION

Interviews with rural Midwestern women revealed needs regarding preconception/interconception health and care and potential ways to raise awareness. These findings can inform strategies to improve rural women's health and birth outcomes.

Maternity continuum of care and its determinants among mothers who gave birth in Legambo district, South Wollo, northeast Ethiopia

BACKGROUND

Maternity continuum of care is the continuity of maternity health care services that a woman uses for antenatal care, skill birth attendant, and postnatal care. Maternal and child mortality is still big challenge in Ethiopia. Little is known about continuum of maternity care in Ethiopia and where the study area in the district revealed that there is a big discrepancy in the completion of maternity care.

OBJECTIVE

Assessment of maternity continuum of care and associated factors among mothers who gave birth in Legambo district, South, Wollo, and northeast Ethiopia.

METHOD

A community-based cross-sectional study design was conducted among 732 mothers from Feb-Mar 2020. Multistage sampling was used and data were collected through face-to-face interviewer-administered semi-structured questionnaire. Completed data were entered using Epi-Data version 3.1, cleaned, and analyzed using SPSS version 25 Statistical Software. Descriptive statistics using Frequency, proportion, summary measures were done. Binary logistic regressions were and model fitness was checked by Hosmer and Lemeshow test which was not significant. Multivariable logistic regression was conducted and P value less than .05 and adjusted odds ratio with 95% confidence interval was considered as statistically significant.

RESULT

The prevalence of maternity continuum of care among mother was found 11.2% (95%, CI: 9.0-13.8). Residence (AOR:1.837, CI:1.026-3.288), planned pregnancy (AOR: 2.448, CI:1.361-4.403), prepregnancy contraceptive utilization (AOR: 2.721, CI:1.469-5.042), follow mass media (AOR: 2.33, CI:1.146-4.736) and mother health care decision making autonomy (AOR: 3.712, CI:1.924-7.161) were determinant factors to continuum of maternity care.

CONCLUSION

The prevalence of maternity continuum of care in the district was low. Information education and counseling about continuum of care are still crucial. Awareness creation for both clients and care provider will improve the service. Efforts on improving and cultivating those significant factors should be done by stakeholders.

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

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

Exposure to conflicts and the continuum of maternal healthcare: Analyses of pooled cross-sectional data for 452,192 women across 49 countries and 82 surveys

BACKGROUND

Violent conflicts are observed in many parts of the world and have profound impacts on the lives of exposed individuals. The limited evidence available from specific country or region contexts suggest that conflict exposure may reduce health service utilization and have adverse affects on health. This study focused on identifying the association between conflict exposure and continuum of care (CoC) services that are crucial for achieving improvements in reproductive, maternal, newborn, and child health and nutrition (RMNCHN).

METHODS AND FINDINGS

We combined data from 2 sources, the Demographic Health Surveys (DHS) and the Uppsala Conflict Data Program's (UCDP) Georeferenced Event Dataset, for a sample of 452,192 women across 49 countries observed over the period 1997 to 2018. We utilized 2 consistent measures of conflict-incidence and intensity-and analyzed their association with maternal CoC in 4 key components: (i) at least 1 antenatal care (ANC) visit; (ii) 4 or more ANC visits; (iii) 4 or more ANC visits and institutional delivery; and (iv) 4 or more ANC visits, institutional delivery, and receipt of postnatal care (PNC) either for the mother or the child within 48 hours after birth. To identify the association between conflict exposure and components of CoC, we estimated binary logistic regressions, controlling for a large set of individual and household-level characteristics and year-of-survey and country/province fixed-effects. This empirical setup allows us to draw comparisons among observationally similar women residing in the same locality, thereby mitigating the concerns over unobserved heterogeneity. Around 39.6% (95% CI: 39.5% to 39.7%) of the sample was exposed to some form of violent conflict at the time of their pregnancy during the study period (2003 to 2018). Although access to services decreased for each additional component of CoC in maternal healthcare for all women, the dropout rate was significantly higher among women who have been exposed to conflict, relative to those who have not had such exposure. From logistic regression estimates, we observed that relative to those without exposure to conflict, the odds of utilization of each of the components of CoC was lower among those women who were exposed to at least 1 violent conflict. We estimated odds ratios of 0.86 (95% CI: 0.82 to 0.91, p < 0.001) for at least 1 ANC; 0.95 (95% CI: 0.91 to 0.98, p < 0.005) for 4 or more ANC; and 0.92 (95% CI: 0.89 to 0.96, p < 0.001) for 4 or more ANC and institutional delivery. We showed that both the incidence of exposure to conflict as well as its intensity have profound negative implications for CoC. Study limitations include the following: (1) We could not extend the CoC scale beyond PNC due to inconsistent definitions and the lack of availability of data for all 49 countries across time. (2) The measure of conflict intensity used in this study is based on the number of deaths due to the absence of information on other types of conflict-related harms.

CONCLUSIONS

This study showed that conflict exposure is statistically significantly and negatively associated with utilization of maternal CoC services, in each component of the CoC scale. These findings have highlighted the challenges in achieving the Sustainable Development Goal 3 in conflict settings, and the need for more concerted efforts in ensuring CoC, to mitigate its negative implications on maternal and child health.

A Strategic Program for Risk Assessment and Intervention to Mitigate Environmental Stressor-Related Adverse Pregnancy Outcomes in the Indian Population

The Problem: Global environmental stressors of human health include, but are not limited to, conflict, migration, war, natural disasters, climate change, pollution, trauma, and pandemics. In combination with other factors, these stressors influence physical and mental as well as reproductive health. Maternal stress is a known factor for adverse pregnancy outcomes such as preterm birth (PTB); however, environmental stressors are less well-understood in this context and the problem is relatively under-researched. According to the WHO, major Indian cities including New Delhi are among the world's 20 most polluted cities. It is known that maternal exposure to environmental pollution increases the risk of premature births and other adverse pregnancy outcomes which is evident in this population.

Response to the Problem: Considering the seriousness of this problem, an international and interdisciplinary group of researchers, physicians, and organizations dedicated to the welfare of women at risk of adverse pregnancy outcomes launched an international program named Optimal Pregnancy Environment Risk Assessment (OPERA). The program aims to discover and disseminate inexpensive, accessible tools to diagnose women at risk for PTB and other adverse pregnancy outcomes due to risky environmental factors as early as possible and to promote effective interventions to mitigate these risks. OPERA has been supported by the Worldwide Universities Network, World Health Organization (WHO) and March of Dimes USA.

Addressing the Problem: This review article addresses the influence of environmental stressors on maternal-fetal health focusing on India as a model population and describes the role of OPERA in helping local practitioners by sharing with them the latest risk prediction and mitigation tools. The consequences of these environmental stressors can be partially mitigated by experience-based interventions that build resilience and break the cycle of inter- and-transgenerational transmission. The shared knowledge and experience from this collaboration are intended to guide and facilitate efforts at the local level in India and other LMIC to develop strategies appropriate for the jurisdiction for improving pregnancy outcomes in vulnerable populations.