Public Health Researcher & PhD Candidate, Monash University
Optimising women's health before pregnancy - shifting the prevention paradigm
The United Nations Population Fund emphasise how unmet needs for sexual and reproductive health deprive women’s rights to make "crucial choices about their own bodies and futures". This affects women’s future health, life opportunities, the health and welfare of their pregnancies, children and families. Primary prevention, preconception care and contraception are vital components for optimising women’s health and well-being throughout the life-course. However, women’s health education and care remain siloed, their reproductive needs and rights commonly overlooked until pregnancy and engagement in prenatal care.
Globally, close to half of all pregnancies remain unplanned and awareness of the impact of preconception health factors and access to services is often limited. Therefore, significant opportunities are missed to influence reproductive health, preparation for pregnancy, and critical fetal developmental stages which have already occurred before healthcare initiation. It has become increasingly clear that this impacts health across generations due to genetic and other responses to developmental exposures before and during pregnancy.
Preconception, health factors to assess include: diet, physical activity, weight, smoking, recreational drug and alcohol use, mental health and chronic medical conditions. However, large gaps remain in the evidence-base for many of these preconception messages, interventions, clinical-practice, and understandings of how best to engage and motivate women.
The preconception health movement has grown over the last three decades. It is imperative that researchers, policy-makers and the healthcare system continue to rethink the primary prevention paradigm, shifting focus to integrate preconception within the continuum of healthcare enabling the best start in life.
The challenge therefore is to increase awareness of the importance of the preconception life-stage for women, communities and health providers, and to implement changes that facilitate improved health. This research program explores the experiences and needs of diverse women in this life-stage in Australia in order to inform appropriate health services, resources, programs and policy to improve women’s health.
Abstract: By addressing the reproductive intentions and contraceptive practices and needs of every patient, providers may be able to decrease women's chances of experiencing unintended pregnancies and support women in achieving planned and well-timed pregnancies. By addressing the health promotion needs of every patient and examining and addressing her health profile for reproductive risks, irrespective of her desires for pregnancy, it is likely that more women will enter pregnancy with high levels of preconception wellness and that healthier women and healthier pregnancies and infants will result. The importance of the integration of reproductive planning and health promotion into women's routine healthcare is further emphasized when the potentially far-reaching effects of reproductive outcomes (such as unintended pregnancies, adverse pregnancy outcomes, pregnancy complications, and sexually transmitted infections) on women's health, well-being, and life circumstances are considered.
Pub.: 17 Dec '08, Pinned: 31 Aug '17
Abstract: Despite strong evidence of the benefits of preconception interventions for improving pregnancy outcomes, the delivery and uptake of preconception care and periconceptional folate supplementation remain low. General practitioners play a central role in the delivery of preconception care. Understanding general practitioners' perceptions of the barriers and enablers to implementing preconception care allows for more appropriate targeting of quality improvement interventions. Consequently, the aim of this study was to examine the barriers and enablers to the delivery and uptake of preconception care guidelines from general practitioners' perspective using theoretical domains related to behaviour change.We conducted a qualitative study using focus groups consisting of 22 general practitioners who were recruited from three regional general practice support organisations. Questions were based on the theoretical domain framework, which describes 12 domains related to behaviour change. General practitioners' responses were classified into predefined themes using a deductive process of thematic analysis.Beliefs about capabilities, motivations and goals, environmental context and resources, and memory, attention and decision making were the key domains identified in the barrier analysis. Some of the perceived barriers identified by general practitioners were time constraints, the lack of women presenting at the preconception stage, the numerous competing preventive priorities within the general practice setting, issues relating to the cost of and access to preconception care, and the lack of resources for assisting in the delivery of preconception care guidelines. Perceived enablers identified by general practitioners included the availability of preconception care checklists and patient brochures, handouts, and waiting room posters outlining the benefits and availability of preconception care consultations.Our study has identified some of the barriers and enablers to the delivery and uptake of preconception care guidelines, as perceived by general practitioners. Relating these barriers to a theoretical domain framework provides a clearer understanding of some of the psychological aspects that are involved in the behaviour of general practitioners towards the delivery and uptake of preconception care. Further research prioritising these barriers and the theoretical domains to which they relate to is necessary before a methodologically rigorous intervention can be designed, implemented, and evaluated.
Pub.: 02 Feb '13, Pinned: 31 Aug '17
Abstract: Preconception care may decrease adverse pregnancy outcomes associated with pre-existing diabetes mellitus. Aboriginal Australians are at high risk of type 2 diabetes mellitus (T2DM), with earlier onset. We explored practitioner views on preconception care delivery for women with T2DM in the Northern Territory, where 31% of births are to Aboriginal women.Mixed-methods study including cross-sectional survey of 156 health practitioners and 11 semi-structured interviews.Practitioners reported low attendance for preconception care however, 51% provided counselling on an opportunistic basis. Rural/remote practitioners were most likely to find counselling feasible. The majority (69%) utilised appropriate guidelines and addressed lifestyle modifications including smoking (81%), weight management (79%), and change medications appropriately such as ceasing ACE inhibitors (69%). Fewer (40%) prescribed the recommended dose of folate (5mg) or felt comfortable recommending delaying pregnancy to achieve optimal preconception glucose control (42%). Themes identified as barriers to care included the complexity of care setting and infrequent preconception consultations. There was a focus on motivation of women to make informed choices about conception, including birth spacing, timing and contraception. Preconception care enablers included cross-cultural communication, a multi-disciplinary care team and strong client-based relationships.Health practitioners are keen to provide preconception counselling and reported knowledge of evidence-based guidelines. Improvements are needed in recommending high dose folate and optimising glucose control. Cross-cultural communication and team-based care were reported as fundamental to successful preconception care in women with T2DM. Continued education and policy changes are required to support practitioners in opportunities to enhance pregnancy planning.
Pub.: 19 May '17, Pinned: 31 Aug '17
Abstract: Preconception wellness reflects a woman's overall health before conception as a strategy to affect health outcomes for the woman, the fetus, and the infant. Preconception wellness is challenging to measure because it attempts to capture health status before a pregnancy, which may be affected by many different service points within a health care system. The Clinical Workgroup of the National Preconception Health and Health Care Initiative proposes nine core measures that can be assessed at initiation of prenatal care to index a woman's preconception wellness. A two-stage web-based modified Delphi survey and a face-to-face meeting of key opinion leaders in women's reproductive health resulted in identifying seven criteria used to determine the core measures. The Workgroup reached unanimous agreement on an aggregate of nine preconception wellness measures to serve as a surrogate but feasible assessment of quality preconception care within the larger health community. These include indicators for: 1) pregnancy intention, 2) access to care, 3) preconception multivitamin with folic acid use, 4) tobacco avoidance, 5) absence of uncontrolled depression, 6) healthy weight, 7) absence of sexually transmitted infections, 8) optimal glycemic control in women with pregestational diabetes, and 9) teratogenic medication avoidance. The focus of the proposed measures is to quantify the effect of health care systems on advancing preconception wellness. The Workgroup recommends that health care systems adopt these nine preconception wellness measures as a metric to monitor performance of preconception care practice. Over time, monitoring these baseline measures will establish benchmarks and allow for comparison within and among regions, health care systems, and communities to drive improvements.
Pub.: 08 Apr '16, Pinned: 31 Aug '17
Abstract: To determine the extent to which women plan and prepare for pregnancy.Cross-sectional questionnaire survey of pregnant women attending three maternity services in London about knowledge and uptake of preconception care; including a robust measure of pregnancy planning, and phone interviews with a range of health care professionals.We recruited 1173/1288 (90%) women, median age of 32 years. 73% had clearly planned their pregnancy, 24% were ambivalent and only 3% of pregnancies were unplanned. 51% of all women and 63% of those with a planned pregnancy took folic acid before pregnancy. 21% of all women reported smoking and 61% reported drinking alcohol in the 3 months before pregnancy; 48% of smokers and 41% of drinkers reduced or stopped before pregnancy. The 51% of all women who reported advice from a health professional before becoming pregnant were more likely to adopt healthier behaviours before pregnancy [adjusted odds ratios for greatest health professional input compared with none were 2.34 (95% confidence interval 1.54-3.54) for taking folic acid and 2.18 (95% CI 1.42-3.36) for adopting a healthier diet before pregnancy]. Interviews with 20 health professionals indicated low awareness of preconception health issues, missed opportunities and confusion about responsibility for delivery of preconception care.Despite a high level of pregnancy planning, awareness of preconception health among women and health professionals is low, and responsibility for providing preconception care is unclear. However, many women are motivated to adopt healthier behaviours in the preconception period, as indicated by halving of reported smoking rates in this study. The link between health professional input and healthy behaviour change before pregnancy is a new finding that should invigorate strategies to improve awareness and uptake of pre-pregnancy health care, and bring wider benefits for public health.
Pub.: 25 Jul '14, Pinned: 31 Aug '17
Abstract: Despite the importance attributed to good pre-pregnancy care and its potential to improve pregnancy and child health outcomes, relatively little is known about why women invest in pre-pregnancy health and care. We sought to gain insight into why women invested in pre-pregnancy health and care.We carried out 20 qualitative in-depth interviews with pregnant or recently pregnant women who were drawn from a survey of antenatal clinic attendees in London, UK. Interviewees were purposively sampled to include high and low investors in pre-pregnancy health and care, with variation in age, partnership status, ethnicity and pre-existing medical conditions. Data analysis was conducted using the Framework method.We identified three groups in relation to pre-pregnancy health and care: 1) The "prepared" group, who had high levels of pregnancy planning and mostly positive attitudes to micronutrient supplementation outside of pregnancy, carried out pre-pregnancy activities such as taking folic acid and making changes to diet and lifestyle. 2) The "poor knowledge" group, who also had high levels of pregnancy planning, did not carry out pre-pregnancy activities and described themselves as having poor knowledge. Elsewhere in their interviews they expressed a strong dislike of micronutrient supplementation. 3) The "absent pre-pregnancy period" group, had the lowest levels of pregnancy planning and also expressed anti-supplement views. Even discussing the pre-pregnancy period with this group was difficult as responses to questions quickly shifted to focus on pregnancy itself. Knowledge of folic acid was poor in all groups.Different pre-pregnancy care approaches are likely to be needed for each of the groups. Among the "prepared" group, who were proactive and receptive to health messages, greater availability of information and better response from health professionals could improve the range of pre-pregnancy activities carried out. Among the "poor knowledge" group, better response from health professionals might yield greater uptake of pre-pregnancy information. A different, general health strategy might be more appropriate for the "absent pre-pregnancy period" group. The fact that general attitudes to micronutrient supplementation were closely related to whether or not women invested in pre-pregnancy health and care was an unanticipated finding and warrants further investigation.
Pub.: 04 Oct '15, Pinned: 31 Aug '17
Abstract: Despite strong evidence of the benefits of preconception interventions to improve pregnancy outcomes, the delivery and uptake of preconception care in general and periconceptional folate supplementation in particular remains low. The aim of this study was to determine women's views of the barriers and enablers to the uptake of preconception care and periconceptional folate supplementation.Focus groups were undertaken in 2007 with 17 women of reproductive age (18-45 years). To identify key issues and themes within the data, focus groups were analysed using an inductive process of thematic analysis.Most women were unaware of the need to attend for preconception care and were surprised at the breadth of issues involved. Women also felt general practitioners (GPs) should be more proactive in promoting preconception care availability but acknowledged that they themselves had to be thinking about pregnancy or becoming pregnant to be receptive to it. Barriers to periconceptional folate supplementation included confusion about reasons for use, dose, duration, timing and efficacy of folate use. Enablers included the desire to do anything they could to ensure optimum pregnancy outcomes, and promotional material and letters of invitation from their GP to advise them of the availability and the need for preconception care.A number of important barriers and enablers exist for women regarding the delivery and uptake of preconception care and periconceptional folate supplementation. It is essential that these patient perspectives are addressed in both the implementation of evidence based clinical practice guidelines and in the systematic design of an intervention to improve preconception care delivery.
Pub.: 25 Dec '10, Pinned: 31 Aug '17
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