What preconception health services would the public find when searching the internet in Australia?: results from a simulated internet-search study

BACKGROUND

Australian preventive health strategy outlines the importance of preconception health in improving health in the community, across multiple generations and places primary and community healthcare services as a central pillar to effective preconception care. However, there is no national implementation plan to see preconception care proactively offered in healthcare settings in Australia. Instead, there is evidence that most women search the internet for information about pregnancy planning and preparation. In response, this study explores the availability and characteristics of health services found by searching for preconception care online in Australia.

METHOD

Simulated Google searches were conducted using search terms 'preconception' and the name of a city/town with a population > 50,000. Related terms, 'fertility' and 'pregnancy' were also searched. Characteristics of the health services and the information available on relevant websites were extracted and reported descriptively.

RESULTS

The searches identified 831 website links, including 430 websites for health services. The health services were most often located in cities/towns with populations equal to or less than 200 000 (54.2%), and housing multiple health professionals (69.8%) including a specialist doctor (66.5%), nurse (20.9%), psychologist/counsellor (2.0%) and/or naturopath (13.0%). All the health services identified online explicitly mentioned women among their target populations, while 69.1% (n = 297) also referred to providing services for men or partners. More than one third of websites included blogs (36.9%) while external links were included in 10.8% of the online sites.

CONCLUSIONS

This study provides a preliminary examination of health services that may be found through internet-based searching by Australian consumers seeking health advice or support prior to becoming pregnant. Our descriptive results suggest couples may find a variety of health professionals when seeking health services for preconception care. Future research involving co-design of search terms with consumers, ongoing monitoring of health services and ensuring access to meaningful, and accurate information found through internet-searching are all necessary to ensure people of reproductive age are able to access the preconception health information and care they need.

Paternal preconception modifiable risk factors for adverse pregnancy and offspring outcomes: a review of contemporary evidence from observational studies

BACKGROUND

The preconception period represents transgenerational opportunities to optimize modifiable risk factors associated with both short and long-term adverse health outcomes for women, men, and children. As such, preconception care is recommended to couples during this time to enable them to optimise their health in preparation for pregnancy. Historically, preconception research predominately focuses on maternal modifiable risks and health behaviours associated with pregnancy and offspring outcomes; limited attention has been given to inform paternal preconception health risks and outcomes. This systematic review aims to advance paternal preconception research by synthesising the current evidence on modifiable paternal preconception health behaviours and risk factors to identify associations with pregnancy and/or offspring outcomes.

METHODS

Medline, Embase, Maternity and Infant care, CINAHL, PsycINFO, Scopus, and ISI Proceedings were searched on the 5^th of January 2023, a date limit was set [2012-2023] in each database. A Google Scholar search was also conducted identifying all other relevant papers. Studies were included if they were observational, reporting associations of modifiable risk factors in the preconception period among males (e.g., identified as reproductive partners of pregnant women and/or fathers of offspring for which outcomes were reported) with adverse pregnancy and offspring outcomes. Study quality was assessed using the Newcastle-Ottawa Scale. Exposure and outcome heterogeneity precluded meta-analysis, and results were summarised in tables.

RESULTS

This review identified 56 cohort and nine case control studies. Studies reported on a range of risk factors and/or health behaviours including paternal body composition (n = 25), alcohol intake (n = 6), cannabis use (n = 5), physical activity (n = 2), smoking (n = 20), stress (n = 3) and nutrition (n = 13). Outcomes included fecundability, IVF/ISCI live birth, offspring weight, body composition/BMI, asthma, lung function, leukemia, preterm birth, and behavioural issues. Despite the limited number of studies and substantial heterogeneity in reporting, results of studies assessed as good quality showed that paternal smoking may increase the risk of birth defects and higher paternal BMI was associated with higher offspring birthweight.

CONCLUSION

The current evidence demonstrates a role of paternal preconception health in influencing outcomes related to pregnancy success and offspring health. The evidence is however limited and heterogenous, and further high-quality research is needed to inform clinical preconception care guidelines to support men and couples to prepare for a health pregnancy and child.

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

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

Preconception health and care policies and guidelines in the UK and Ireland: a scoping review

BACKGROUND

Preconception health and care strategies can substantially improve maternal and infant outcomes, and thus optimise intergenerational health. Given the burden of high-risk preconception health and social risk factors, as well as the absence of a review of preconception health and care policies and recommendations in the UK and Ireland since 2013, an update is now warranted. We undertook a scoping review to assess the nature of and summarise preconception health and care strategies, policies, guidelines, frameworks, and recommendations available in the UK and Ireland.

METHODS

Searches were conducted on May 4-May 18, 2022, on Google Advanced, OpenAire, NICE, ProQuest, and relevant public health websites. The methodological process was informed by Arksey and O'Malley's work (2005) and the updated guidance for conducting Joanna Briggs Institute scoping reviews (2021). This review included grey literature resources focusing on preconception health and care in adults of reproductive age (18-44 years) as addressed in strategies, policies, guidelines, frameworks, and recommendations across the UK and Ireland. Searches on services provided in Northern Ireland, as a case study, were done and supplemented by audits with key stakeholders. Resources were included only if published, reviewed, or updated during or after 2011. Data were extracted using Microsoft Excel (MSO 365, version 2209) and NVivo (version 2020), with 10% or more of the data being double-coded, and presented using a narrative approach with thematic analysis.

FINDINGS

Relevant strategies, policies, guidelines, frameworks, and recommendations addressing preconception health and care were found (n=277). Themes included behavioural (eg, folic acid intake and smoking) and biomedical health (eg, mental and physical health conditions) and wider determinants of health (eg, ethnicity and deprivation). These themes were usually embedded within documents on other topics, rather than being the stand-alone focus. Resources also highlighted the importance of preconceptual counselling and the need for improved access to care and multidisciplinary collaborations.

INTERPRETATION

Focused efforts are needed to implement identified strategies, policies, guidelines, frameworks, and recommendations. Online platforms, schools, general practitioner consultation rooms, pharmacies, and community centres are some of the avenues suitable to promote awareness of preconception health, facilitating informed decision-making about parenthood for all individuals and encouraging risk reduction.

FUNDING

Department for the Economy Northern Ireland, and National Institute for Health and Social Care Research Southampton Biomedical Research Centre (IS-BRC-1215-20004).

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

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

A Systematic Review of Clinical Guidelines for Preconception Care

Preconception care (PCC) involves a wide-ranging set of interventions to optimize health prior to pregnancy. These interventions seek to enhance conception rates, pregnancy outcomes, childhood health, and the health of future generations. To assist health care providers to exercise high-quality clinical care in this domain, clinical practice guidelines from a range of settings have been published. This systematic review sought to identify existing freely accessible international guidelines, assess these in terms of their quality using the AGREE II tool, and assess the summary recommendations and the evidence level on which they are based. We identified 11 guidelines that focused on PCC. Ten of these were classified as moderate quality (scores ranging from 3.5 to 4.5 out of 7) and only one was classified as very high quality, scoring 6.5. The levels of evidence for recommendations ranged from the lowest possible level of evidence (III) to the highest (I-a): the highest quality evidence available is for folic acid supplementation to reduce risk of neural tube defects and the role of antiviral medication to prevent HIV transmission. This systematic review identified that high-quality guidelines on PCC are lacking and that few domains of PCC recommendations are supported by high-quality evidence.

Are anti-smoking social norms associated with tobacco control mass media campaigns, tax and policy changes? Findings from an Australian serial cross-sectional population study of smokers

BACKGROUND

Anti-smoking social norms are associated with subsequent quitting behaviours. We examined if exposure to tobacco control advertisements and policy changes predict subjective (perceived disapproval of smoking among close family and friends) and internalised injunctive norms (embarrassed about telling others you are a smoker).

METHODS

A serial cross-sectional population survey of Australian adult smokers (n=6649; 2012 to 2015). Logistic regression analyses examined associations of social norms with exposure to different types of tobacco control advertisements, tax increases and other tobacco control policies, adjusting for key demographic, smoking and media exposure covariates. Interaction analyses examined differences by age and socioeconomic status (SES).

RESULTS

Greater past month exposure to predominantly fear-evoking advertisements was associated with increased odds of perceiving disapproval (per 1000 gross rating points: adjusted OR (AOR) 2.69, 95% CI: 1.34 to 5.39), while exposure to advertisements evoking multiple negative emotions (fear, guilt, sadness) reduced perceived disapproval (AOR 0.61, 95% CI: 0.42 to 0.87). Increased perceived disapproval was also associated with anticipation (AOR 1.38, 95% CI: 1.02 to 1.88), and implementation of a series of annual 12.5% tobacco tax rises (AOR 1.41, 95% CI: 1.03 to 1.94). Associations were consistent across age and SES. There were no associations nor subgroup interactions between advertisement exposure or policy changes and feeling embarrassed about telling others you are a smoker.

CONCLUSION

Smokers' perceptions of family and friends' disapproval of their smoking was more common after exposure to fear-evoking tobacco control campaigns and after large tobacco tax increases were announced and implemented.

Dietary and lifestyle behaviours in the preconception period

Observational studies have shown strong associations of preconception nutrition and lifestyle behaviours with maternal and child health outcomes; however, awareness of these links among lay people, policy makers and health professionals is very limited. Poor nutrition and obesity are common among women of reproductive age, and the preconception period therefore has underutilised potential as a point of intervention. Intervention studies to improve dietary intake and physical activity during pregnancy have not been successful in reducing adverse maternal and newborn health outcomes, but relatively few interventions have examined effects of modifying diet and lifestyle prior to pregnancy. Despite limited evidence from human clinical trials, increasing evidence from observational studies and from animal trials for the benefits of optimal preconception health suggests public health efforts to increase awareness and improve preconception health behaviours are needed as strategies for disease prevention across generations. This presentation will provide an overview of the evidence for the impact of nutrition and lifestyle behaviours on short and long-term maternal and child health outcomes. This will provide workshop participants with an understanding of health behaviours across the life course that should be considered when building preconception care into existing health services.

Antismoking Social Norms Increase Cessation Behaviours Among Lower and Higher SES Smokers: An Australian Population-Based Study

Background: Disapproval of smoking from close others, observation of others' quitting activity and denormalisation of smoking in the broader community can provide an environment that helps smokers to quit. However, it remains unclear which social norms have the greatest influence, and if there is a similar impact on quitting-related cognitions and behaviors among lower and higher socioeconomic status (SES) smokers. Aim: This study sought to examine the influence on quitting-related cognitions and behaviors of a variety of social norms: subjective (perceived disapproval of smoking among close family and friends); internalized injunctive (feeling embarrassed about being a smoker); and close descriptive norms (living in a household with someone who, successfully or unsuccessfully, tried to quit in the past 12 months). Methods: A telephone survey was conducted among 1454 Australian adult smokers between 2012 and 2014 who were followed-up ∼1 week after the baseline interview. Logistic regression analyses examined prospective associations of baseline social norms with quitting-related cognitions and behaviors at follow-up. Analyses were adjusted for baseline demographic characteristics, addiction level, tobacco control policies (cost increases, plain packaging implementation and mass media campaign exposure) and quitting-related outcomes measured at baseline. Differences in associations between lower and higher SES smokers (based on educational attainment and area-based disadvantage) were examined through interaction terms and stratified analyses. Results: Sixty-three percent of participants perceived disapproval from family and friends, 30% felt embarrassed to be a smoker, and 12% lived with a recent quitter. Baseline disapproval, embarrassment and household quitting activity were each associated with having quitting as a high priority and with setting a firm date to quit in the next month. Both disapproval and embarrassment also predicted engaging in behaviors to limit smoking, and only embarrassment was associated with increased likelihood to talk about quitting with family or friends and to make a quit attempt. No associations were found between social norms and being highly confident to quit and seeking help to quit. Associations were mostly comparable for lower and higher SES smokers, with no significant negative effects of social norms on quitting thoughts and behaviors overall or among subgroups. Conclusion: Within the strong tobacco control environment in Australia, smokers from lower and higher SES groups who perceive that their family and friends disapprove of their smoking, feel embarrassed to be a smoker and/or who live in a household with a recent quitter are more likely to prioritize quitting and intend to quit soon. These findings also indicate that the internalized injunctive social norm (i.e., feeling embarrassed) was the strongest predictor of smokers' quitting related behaviors, including making a quit attempt.