Preconception health policy, health promotion, and health services to achieve health in current and future generations: a narrative review

Non-communicable diseases (NCDs) represent the leading cause of death and disability worldwide, and those NCDs contributing most burden - cardiometabolic illness, diabetes, cancer, chronic respiratory disease - can be largely prevented through improvements in health behaviours such as tobacco use, harmful use of alcohol, exposure to environmental hazards, unhealthy dietary habits, and physical inactivity. Despite concerted efforts at all levels of health care provision and policy, population-level health behaviour change still presents an ongoing challenge to primary care clinicians, public health practitioners, health promotion specialists and government agencies around the world. An individual's age can influence their health behaviour decision-making as younger people often perceive the potential implications of their current poor health behaviours as remote in time and possibility, which may significantly limit their motivation to make a positive health behaviour change in the present. Yet public health researchers and practitioners recognise that a lifecourse approach to public health policies and interventions has the potential to reduce the risk of NCDs developing before conception and throughout life, as well as impacting the transmission of the benefits of health improvement from one generation to the next. Given the growing awareness of the benefits of a lifecourse approach to public health, a focus on improving preconception health at a population-level provides a unique opportunity for behaviour change motivation, NCD prevention and reducing inequalities across generations. Through this narrative review, we describe how three main public health strategies - health policy, health promotion and health services - may address the challenge of improving preconception health. We also explore the potential value of leveraging parental motivation in the preconception period to achieve positive health behaviour change and, in doing so, meet broader public health goals. We set out a framework for drawing on established public health methods and priorities to address structural inequalities and harness parental motivation and concern for their offspring to build and enable new and positive health behaviours that benefit current and future generations.

Prevention of alcohol related harm though preconception care: A scoping review of barriers and enablers

Objective

To understand the perspectives of healthcare practitioners and women of reproductive age regarding addressing prevention of an alcohol exposed pregnancy before conception.

Methods

A scoping review of mixed methods, qualitative and quantitative research was conducted. Medline, CINAHL, EMBASE and PsychInfo databases were searched for literature published by March 2022. Data were extracted and synthesized.

Results

Twenty-three studies were included. Views varied between healthcare practitioners and women about addressing alcohol with women before pregnancy. Healthcare practitioners agreed prevention was important but believed they were ill-prepared to provide support, and that it might be intrusive if women were not contemplating pregnancy. Whereas women would welcome advice from healthcare practitioners, particularly if offered during appointments or visits for services related to reproductive health. A knowledge deficit about pregnancy and fetal harms from alcohol was expressed by both healthcare practitioners and women.

Conclusions

Investment in alcohol education and skills training for healthcare professionals is required to ensure a coherent message is communicated across services, and that shared decision making about healthcare between service users and health professionals is facilitated. Future research should explore implementation of interventions to prevent alcohol exposed pregnancy in settings where women are seeking reproductive health support.

Pregnancy planning health information and service needs of women with chronic non-communicable conditions: a systematic review and narrative synthesis

Background

Preparing for pregnancy and being in the best possible health before conception improves reproductive outcomes. For women living with a chronic non-communicable disease (NCD), pregnancy planning is essential to allow optimal disease control in preparation for pregnancy.

Aim

The aim was to review the literature relating to the pregnancy planning health information and service needs of women with NCDs.

Method

The MEDLINE (Ovid), Embase (Ovid), Emcare (Ovid), PsycINFO (Ovid), CINAHL and Scopus databases were searched. Studies were included if they were published in peer-reviewed English language journals between January 2010 and June 2020 and reported on the pregnancy planning health information and service needs of women with rheumatic diseases, asthma, cystic fibrosis, depression and/or anxiety, type 1 diabetes mellitus, epilepsy, or multiple sclerosis. Risk of bias was assessed using QualSyst. The characteristics of the studies were tabulated and summarised. Key findings of the included studies were analysed thematically using an inductive approach, where the study findings determined the themes. Findings are reported in a narrative synthesis.

Results

The database searches yielded 8291 results, of which 4304 remained after duplicates were removed. After abstract screening 104 full-text papers were reviewed. Of these 15 met inclusion criteria and were included in analysis. The narrative synthesis of the included studies revealed six themes: ‘Women with chronic conditions have unmet preconception health information needs’, ‘Women with chronic conditions want personalised preconception health information’, ‘Preferred sources of preconception health information’, ‘Learning from the experiences of other women’, ‘Improving preconception health discussions with health care professionals’, and ‘Women want holistic care’. These themes were consistent across all studies, highlighting the similarity of experiences and needs of women with different chronic conditions.

Conclusion

To improve pregnancy outcomes for women living with NCDs, health care providers need to ask women of reproductive age proactively and routinely about their pregnancy intentions and provide them with personalised advice on how to avoid unplanned pregnancy and be in optimal health when they wish to conceive.

PROSPERO registration number CRD42020176308.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04498-1.

Australian primary health care nurses

Preconception care (PCC) entails counselling and interventions to optimise health before pregnancy. Barriers to this service delivery include access and time. Primary healthcare nurses (PHCNs) are uniquely placed to deliver PCC. The aim of this study was to understand PHCNs' knowledge, practice and attitudes to PCC. A cross-sectional study was performed of a convenience sample of PHCNs in Australia who were seeing people of reproductive age. Recruitment was via the Australian Primary Health Care Nurses Association (APNA) electronic communication platforms. The 18-item, online, anonymous survey captured demographics, as well as PCC knowledge, practices and attitudes. Descriptive statistics were used to describe our findings. In all, 152 completed surveys were received. Of all respondents, 74% stated they discuss PCC in their practice, although only 13% do so routinely. Of these, more preconception discussions are held with women than with men. In total, 95% of respondents identified at least one barrier to delivery of PCC, with lack of time and knowledge being the most common. The findings of this study can inform targeted strategies, including education programs and resources, and consideration of incentives to support PHCNs deliver PCC. This study identifies areas for improvement at the individual, organisational and health system levels to enhance the role of PHCNs in PCC.

Evaluation of an online learning module to improve nurses' and midwives' capacity to promote preconception health in primary healthcare settings

Optimal parental preconception health improves the likelihood of a successful pregnancy and a healthy child. Although primary healthcare professionals believe that it is within their role to promote preconception health to people of reproductive age, few do this routinely, in part because they lack knowledge on the topic and confidence to discuss it with their patients. The aim of this study was to evaluate the efficacy and acceptability of a free online learning module to assist nurses and midwives in primary health care to promote preconception health in their practice. A repeat online survey was administered before and after completion of the online learning module. The survey included questions gauging knowledge about and attitudes towards promoting preconception health. In all, 121 nurses/midwives completed the two surveys and the learning module. There were statistically significant improvements in the knowledge scores (from 6.42 to 8.31; P < 0.001) and in the proportion of participants who reported feeling confident in their knowledge about preconception health (from 15% to 53%). Almost all (95%) were satisfied with the duration and content of the learning module. The findings of this study suggest that the learning module is acceptable and improves nurses' and midwives' capacity to promote preconception health in their practice.

Men's preconception health care in Australian general practice: GPs' knowledge, attitudes and behaviours

Potentially modifiable factors can affect male fertility and reproductive outcomes, including smoking, obesity, and older paternal age. This study surveyed GPs' knowledge about, attitudes towards, and needs for promoting fertility and preconception health to male patients. The survey, conducted February to June 2018 and completed by 304 GPs, included questions relating to men's preconception health, the potential barriers and enablers to discussing preconception health with male patients, and the types of resources that would enable GPs to discuss parenthood intentions with men of reproductive age. Most GPs (90%) did not feel confident in their knowledge about modifiable factors that affect male fertility. Two-thirds agreed that it was their role to discuss these factors with male patients, but nearly 80% practised this only occasionally. Lack of knowledge, the sensitivity of the subject and fertility being perceived as a female issue, were identified as barriers to discussing fertility and preconception health with male patients. To facilitate discussions, GPs wanted trustworthy websites and factsheets to refer patients to. Men do not typically receive fertility or preconception health advice in general practice. A national framework for preconception health care that includes men, GP education and training, and reproductive health resources for men is needed.

Opportunities for enhancing pregnancy planning and preconception health behaviours of Australian women

PROBLEM AND BACKGROUND

The preconception period provides a significant opportunity to engage women in healthy behaviour change for improved maternal and child health outcomes. However, there is limited research exploring women's pregnancy planning in Australia.

AIM

This study investigated associations between pregnancy planning, socio-demographics and preconception health behaviours in Australian women.

METHODS

A retrospective cross-sectional survey of pregnant women ≥18-years-of-age recruited through a Victorian public maternity service and a national private health insurer.

RESULTS

Overall 317 women (30±4.7 years) participated (public: n=225, private: n=92). Planned pregnancies were reported by 74% of women and were independently associated with marital status (AOR=5.71 95% CI 1.92-17.00, p=0.002); having ≤2 children (AOR=3.75 95% CI 1.28-11.05, p=0.016); and having private health insurance (AOR=2.51 95% CI 1.08-5.81, p=0.03). Overall, women reported preconception: any folic-acid supplementation (59%), up-to-date cervical screening (68%), weight management attempts (75%), accessing information from health professionals (57%) and immunisation reviews (47%). Pregnancy planners were more likely to use folic-acid (AOR=17.13 95% CI 7.67-38.26, p<0.001), review immunisations (AOR=2.09 95% CI 1.07-4.10, p=0.03) and access information (AOR=3.24 95% CI 1.75-6.00, p<0.001) compared to non-planners. Women <25-years-of-age were less likely to access information (AOR=0.38 95% CI 0.16-0.89, p=0.03) and take folic-acid (AOR=0.23 95% CI 0.09-0.59, p=0.002) and were more likely to smoke 3-months preconception (AOR=6.68 95% CI 1.24-36.12, p=0.03).

CONCLUSIONS

Women with planned and unplanned pregnancies reported variable preconception health behaviour uptake and limited healthcare engagement. Opportunities exist to improve awareness and healthcare engagement for optimising preconception health and pregnancy planning benefits including collaborative health promotion. Population-based and targeted approaches reaching pregnancy planners and non-planners are required.

Acceptability of screening for pregnancy intention in general practice: a population survey of people of reproductive age

Background

Optimal parental preconception health benefits reproductive outcomes. However, preconception health promotion is not routinely offered in primary health care settings to people of reproductive age. The aim was to gauge the planned preconception health behaviours and attitudes towards being asked about pregnancy intention by a general practitioner (GP) among people of reproductive age in Australia.

Method

The research was conducted on a single wave of Australia’s first and only probability-based online panel, Life in Australia™. Members of the Life in Australia™ panel are Australian residents aged 18 years or over. All active members between the ages of 18 and 45 years were eligible to participate. Eligible panel members were invited to complete a survey about fertility and childbearing. Data were collected from 18 February to 4 March 2019.

Results

In all 965 female and male members of Life in Australia™ aged between 18 and 45 years were invited to complete the survey. Of these, 716 (74.2%) agreed. Most respondents indicated that if they were planning to have a child they would try to optimise their preconception health by adopting a healthier diet (80%), seeing a GP for a health check-up (78%), reducing alcohol consumption (78% of those consuming alcohol), getting fitter (73%), and stopping smoking (70% of smokers). Three in four (74%) stated that they would not mind if their GP asked them about their pregnancy intentions.

Conclusion

Findings suggests that routinely asking people of reproductive age about their pregnancy intentions and advising those who are planning pregnancy about what they can do to ensure optimal preconception health would be acceptable to most people and may improve reproductive outcomes.

Perspectives on preconception health among migrant women in Australia: A qualitative study

BACKGROUND

Cultural beliefs, practices and experiences significantly influence pregnancy preparation. Limited in-depth information exists regarding how women from migrant and refugee backgrounds (migrant women) prepare for pregnancy. This study explored pregnancy planning, preconception lifestyles, awareness, experiences and healthcare needs of migrant women in Australia.

METHODS

Semi-structured interviews and focus groups were conducted with 25 women recruited through a diverse community in Melbourne, Australia (November 2017-February 2018). Discussions explored pregnancy planning, preconception health awareness, experiences and information needs. Qualitative data was analysed iteratively, through content and thematic analysis.

FINDINGS

Four themes were identified: pregnancy planning experiences and perspectives, preconception health awareness and behaviours, social and cultural influences on pregnancy planning, and health information needs. Women had limited understanding of the concept or importance of preconception health, limited access to preconception health information and most women with children had experienced at least one unplanned pregnancy. Cultural mores constrained community discussion of preconception health in the context of sexual and reproductive health. Social factors emerged as predominant preconception concerns. Women reported wanting more information on preconception health through multiple, broad-reaching avenues, paired with timely, sensitive healthcare engagement.

CONCLUSION

Information for women addressing preconception health and pregnancy planning is limited. Our study demonstrates additional cultural and social nuances that need to be understood when working with migrant women. Discomfort raising reproductive and preconception health discussions with healthcare providers was a reported concern. Integration of culturally-sensitive preconception care within routine client assessments warrants exploration. Emphasis of the importance of preconception care for all women is needed.