Dumitru Siscanu, Ph.D.a, Sarah Verbiest, Dr.P.H.b, Anait Yu.Marianian, M.D., Ph.D.c, Corina Iliadi-Tulbure, Ph.D.d, Iurii Ariand , Viorica Chihaid
a Gheorghe Paladi Public Medical Institution Municipal Clinical Hospital, Chisinau, Republic of Moldova
b University of North Carolina at Chapel Hill, School of Medicine, Center for Maternal and Infant Health, Chapel Hill, NC, U.S.A.
c Federal State Public Scientific Institution Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation
d Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
A life course approach to improving maternal and child health by improving parental health prior to conception is gaining international interest. A major impediment to progress is the lack of resources required for the implementation of preconception health and care programs. Health care providers and researchers are seeking effective ways to increase women’s and men’s access to pre-pregnancy preparation, especially through primary care. At the same time, the preconception healthcare includes conversations about pregnancy planning which is a part of family planning services. Unfortunately, “family planning” has the same meaning as “contraception” for many people and health care providers, which is too simplistic in consideration of the multiple aspects of preconception health and well-being.
In the conditions of limited resources, the integration of preconception care services within the national family planning programs may be the best way to strengthen preconception health and pre-pregnancy preparation. Contraception and preconception care are two components of family planning that interact with each other. Before making the decision to discontinue a contraception, the woman / couple should evaluate their preconception risks and have support to reduce them. Access to all contraceptive methods is equally important for couples who do not wish to conceive and those who need to wait until they have been able to address risk factors / built protective factors.
Expanding the understanding of preconception health as inclusive of family planning and primary care has the potential to increase access to this important care while respecting people/couples sexual and reproductive rights, according to their reproductive plans.
Improving the health of the mother and child through programs focused on reducing risks prior to pregnancy in the context of a life-course approach is gaining international interest. Such an evolution in maternal and child health is logical and important. As such, the recommendation that couples planning a pregnancy should receive care may seem obvious to many medical workers and a considerable part of the population. Thus, discussions about the role of preconception health and care may seem unnecessary in the face of other more important and complicated issues.
The preparation for a future pregnancy is not a new topic, but it remains relevant for both the population and health professionals because globally, only about half of pregnancies are planned, and the number of couples who have received a preconception consultation is much smaller.
A major impediment to progress is the lack of resources required for the implementation of preconception health and care programs. At the European Congress on Preconception Health (Copenhagen, 2019), the participants, including those from economically developed countries, appreciated this issue as a very current one. In this context, one strategy recommended by many researchers is the integration of preconception care (PC) services into primary health care. It seems, however, that this process also faces some obstacles: frequently, the motivation of the family doctors / general practitioners (GPs) is not enough to achieve the integration in daily practice.
Some experts have suggested that interventions to improve reproductive and preconception health could be more relevant and efficient by integrating preconception care (PC) services into family planning (FP) programs, embedded into primary health care. The biggest challenge is that the concept of FP, with some exceptions, is considered to be synonymous with contraception, i.e., “family planning = contraception”. We propose a different approach hypothesis that “family planning = contraception + preconception care” (1,2). There was a surprising amount of resistance by some well-known people in the field of medicine, as well as among researchers and some international organizations, who promote the first approach. It is difficult to explain why preconception health care services have been ignored by the same international organizations responsible for developing global strategies and policies to advance family health, which determine health programs at regional and national level.
Preconception care is defined by the World Health Organization (WHO) as providing biomedical, behavioral, and social health interventions before pregnancy to improve health and modify behaviors and environmental influences. PC can contribute to reducing maternal and childhood mortality and morbidity, and to improving maternal and child health in both high- and low-income countries (3).
Even where strong public health programs are in place across the life-course, they do not guarantee that women enter pregnancy in good health (4). The concept of preconception healthcare was described almost two centuries ago when it was suggested that the medical treatment of children should begin with the earliest formation of the embryo and should include the mother before marriage as well as during pregnancy (5). Many years later, PC has not become part of the routine care of most reproductive-aged women.
Providing quality PC is the responsibility of all primary care providers, not just those who provide maternity care or handle a high volume of women’s preventive health visits. Innovative strategies that incorporate PC into routine primary care visits are needed (6). At the same time, doctors across specialties should also consider the possibility of pregnancy development in reproductive age women and they should inform them about possible risks for their health, for fetal and newborn risks, generated by disease evolution and treatment.
Integrating preconception planning services into primary health care is important to ensure that services reach larger numbers of people of reproductive age population and that people receive quality counseling and services from providers who know them (7). However, there continue to be barriers to preconception counseling into routine primary care.
A review by Shannon et al. (8) identified primary care as the most common setting for preconception health service. However, the authors also concluded that there is no agreed consensus on the best method to deliver care within primary care. It is possible that many strategies acting synergistically are needed to improve service delivery. Integration into routine care could be one strategy, but this would not be sufficient to reach the target population system for routine preventive care as seen in some other countries. In another aspect, Ukoha and Dube (9) reported that although PC is recognized as an important factor in improving pregnancy outcome; most primary health care nurses lack the necessary resources to provide PC.
Pre-pregnancy preparation as a component of family planning services
The shift to integrate preconception health promotion into the continuum of women’s healthcare requires a diverse multi-level and multi-strategic approach involving a range of sectors and health professionals to improve access to care and address the determinants of health. Considering multiple problems in preconceptional or interconceptional health services provision, especially the lack of resources for providers, on the one hand, and the modest motivation of the population to benefit from these services, on the other hand, managers in the field tried to integrate PC into family planning programs. There are not many published data on this subject.
Hussein (10) mentioned that FP clinic could be used as a potential starting point to introduce and implement PC. The FP clinic setting is potentially capable to capture women of reproductive age group. Although women come to FP clinics for contraceptive services, this could be an opportunity to inform and educate them about preconception care.
Preconception health messages, recommendations and guidelines originated in the USA and the preconception movement has gained momentum internationally with a variety of strategies developed and tested for improving preconception health and related outcomes (7, 11). The report titled “Providing Quality Family Planning Services: Recommendations of CDC and the US Office of Population Affairs” (2014) provides strategies developed collaboratively by the Centers for Disease Control and Prevention (CDC) and the Office of Population Affairs of the US Department of Health and Human Services. They advance recommendations for the provision of quality family planning services, which include contraceptive services, pregnancy testing and counseling, helping clients achieve pregnancy, basic infertility services, preconception health services, and sexually transmitted disease services. In this paper, Gavin et al. (12) conclude that providers of family planning services should offer preconception health services to female and male clients in accordance with CDC recommendations to improve preconception health and health care. Including PC in family planning services could ensure a higher quality of couple preparation for pregnancy occurrence, including more active involvement of men.
An important condition for improving PC services is to identify the financial resources needed for this activity. In another context, following the Population and Development Conference in Cairo in 1994, in many countries national programs were implemented for the development of FP services with the opening of specialized clinics, providing equipment and training for service providers. FP services were included in the basic packages of primary health services, and the state programs in the field of FP encouraged cross-sectoral collaboration across the public systems of health, education, social assistance, etc. National health systems have also ensured the interdisciplinary cooperation of the medical providers of different specialties in promoting and providing FP services. Thus, in the absence of sufficient financial resources, the inclusion of PC services in national FP programs could be the optimal short-term solution for many countries in increasing the access of the reproductive age population to services that prepare for pregnancy.
However, there are some controversies for this approach. In 2018, The World Health Organization (WHO) published “Family Planning. A Global Handbook for Providers (3rd edition)”, which is considered to be a key document that contributes to ensuring the quality and safety of FP services, encouraging all national health systems and other interested organizations to engage in this important topic (13). This document includes a very modest compartment regarding PC, the other part of the document being devoted to contraception. There are some very general recommendations for women only, including supplementation with folic acid and iron. This manual, along with other sources, confirms that in principle, FP is meant only to prevent pregnancy. The term “family planning” is often considered by the general population and health care providers as synonymous to contraception. In other words, “family planning = contraception”. This controversy is probably the main barrier to integrating PC into FP services. Another potential obstacle may be the insufficient level of competence in preparation for pregnancy of some health providers who offer FP counseling. In this context, it is necessary to develop protocols for providing preconception care during family planning visits. Important support for the development of such protocols can serve the WHO (2013) and CDC (2006, 2010) recommendations, as well as a significant number of PCHC clinical guidelines published in different countries.
The perception of the “family planning” concept among physicians, whose activity is related to reproductive health were the subject of research in the study “PerConcept” (2019) - a survey based on a unified questionnaire conducted in three cities in different countries: Chisinau (Republic of Moldova), Irkutsk (the Russian Federation) and Ciudad de Mexico (Mexico) (14). The survey involved 1.012 family physicians, obstetricians-gynecologists, urologists, andrologists, but also doctors of other specialties. From a professional perspective, 94.5% physicians consider that the concept of FP should also really include a component of PC, simultaneous with contraception. The majority of participants – 91.1%, had the opinion that strategies and programs in the field of FP should be revised, in order to integrate preconception health services. Although the “PerConcept” study had some limitations, the authors consider that the results are interesting because doctors from 3 regions of the world: Europe, Asia, and North America had a similar opinion about the need to expand the “family planning” concept, which should really include the PC, with an equal approach as another component – contraception. In practical aspect, the interviewees mentioned the importance of ensuring the access of the population to information and services in reproductive health, including PC, as “an effective tool to prevent some risks in maternal and infant wellbeing”.
The interaction between two components of family planning: contraception and preconception care
There is an important connection between pregnancy prevention and pregnancy preparation. In some cases, PC requires the use of a safe contraception method until the couple is able to address health and behavioral problems to minimizing the risks for a healthy pregnancy. At the same time, a couple’s decision to stop using contraception to become pregnant offers a “teachable moment” in providing preconception preparation information. Boukje van der Zee et al. (15) consider that an important requirement for preconception consultation is pregnancy planning, which is possible through the provision of contraceptives. Incorporating pregnancy intention screening into primary care to address unmet preconception and contraception needs may improve delivery of FP services and improve reproductive health and wellness overall (10,16). There is opportunity that working PC into the existing FP services would create a platform for improved reproductive health care.
In the Position Paper on Preconception Care of American Academy of Family Physicians one of the General Recommendations for Preconception Interventions for Women and Men is contraception (7). This position paper emphasizes the importance of incorporating routine identification of pregnancy intention for men and women of reproductive age to inform shared decision making around reproductive planning and risk reduction. Because reproductive choices and risks can change over time, preconception health risks and pregnancy desires should be routinely assessed during chronic disease management visits.
Primary care for women of childbearing age should include routine assessment of a woman’s reproductive goals and pregnancy intentions (“reproductive planning”) (17, 18). Women who could potentially become pregnant should be assessed for preconception risks and educated about the importance of maternal health in ensuring healthy pregnancies. For women not intending to obtain pregnancy in short term, PC should include counseling on effective contraception. Women with chronic medical conditions should be counseled about effective reversible methods such as intrauterine devices and contraceptive implants, which have few medical contraindications.
The strategies and resources used to facilitate the clinical and public health integration and dissemination of PC, including the role of group care, the medical home, workplace and school-based health promotion programs, and home visitation, will also impact future progress (19). Therefore, it is important that providers and clinics partner with public health professionals, community leaders, and policy makers to create healthy conditions where all people can survive and thrive.
In the conditions of limited resources, the integration of PC services within the national FP programs may be the best way to strengthen preconception health and pre-pregnancy preparation. This might be easier to implement with the technical support of interested international organizations. The development of the PC component within the concept of "family planning" by these organizations can be essential and would offer perspectives in improving the healthcare of mother and child. Modifying FP strategies and programs with the inclusion of the PC component, will contribute to:
- opening up the optimistic prospects for the integration of PC services into primary care, as FP programs have been implemented in many countries, involving financing operations and the infrastructure services system, in particular with the involvement of family doctors / GPs;
- respect for the sexual and reproductive rights of all persons / couples, regardless of their reproductive plans;
- continuity of reproductive health care;
- last but not least, increase the value of FP services for the population, as they will increase their impact on maternal and child health indicators.
Shishcanu D, Marianian AY, Iliadi-Tulbure C. Preconceptional care: opportunities and challenges. Acta biomedica scientifica. 3 (3), 69-74.
https://www.actabiomedica.ru/jour/article/view/586/587/ (accessed May 6th 2021)
- Siscanu D, Iliadi-Tulbure C, Bolun A, Chihai V, Gurau V. Suggestions about population perception on preconceptional care in Republic of Moldova. Buletin de Perinatologie. 2018, 3(79), 91-94.
Meeting to Develop a Global Consensus on Preconception Care to Reduce Maternal and Childhood Mortality and Morbidity. World Health Organization Headquarters, Geneva 6–7 February 2012, Meeting report.
https://apps.who.int/iris/handle/10665/78067 (accessed May 6th 2021).
Preconception care: maximizing the gains for maternal and child health. Policy brief. World Health Organization. Geneva. 2013.
http://www.who.int/maternal_child_adolescent/documents/preconception_care_policy_brief.pdf (accessed May 6th 2021).
- Lammers Cr. A New Focus on Preconception Healthcare and the Life Course Theory of Health. J Comm Pub Health Nursing. 2018. 4:216.
- Van Voorst S, Plasschaert S, de Jong-Potjer L, Eric SteegersEP, Denktaş S. Current practice of preconception care by primary caregivers in the Netherlands. Eur J Contracept Reprod Health Care. 21(3):251-8.
- American Academy of Family Physicians. Preconception care (position paper). 2016. https://www.aafp.org/about/policies/all/preconception-care.html (accessed May 6th 2021).
- Shannon GD, Alberg C, Nacul L, Pashayan N. Preconception healthcare delivery at a population level: construction of public health models of preconception care. Matern Child Health. 2014. 18(6):1512-31.
- Ukoha WC, Dube M. Primary health care nursing students’ knowledge of and attitude towards the provision of preconception care in KwaZulu-Natal. 2019. Afr J Prim Health Care Fam Med.11(1):e1-e8.
- Hussein N. (2016). Preconception assessment of reproductive genetic risk in primary care. Presented for the Ph.D. thesis, University of Nottingham. 2016.
http://eprints.nottingham.ac.uk/37967/2/Phd%20thesis.pdf (accessed May 6th 2021).
- Floyd RL, Johnson KA, Owens JR, Verbiest S, Moore CA, Boyle CA. A National Action Plan for Promoting Preconception Health and Health Care in the United States (2012-2014). J Womens Health (Larchmt). 22(10):797-802.
Gavin L., Moskosky S, Carter M, Curtis K, Glass E, Godfrey E. et al. Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs. Recommendations and Reports. 63(RR04);1-29.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm (accessed May 6th 2021).
- Family Planning. A GLOBAL HANDBOOK FOR PROVIDERS. Evidence-based guidance developed through worldwide collaboration, 3rd edition, 2018. https://apps.who.int/iris/bitstream/handle/10665/260156/9780999203705-eng.pdf;jsessionid=027939A21D681CBFFC67C66E0DBB28FD?sequence=1 (accessed May 6th 2021).
- Siscanu D, Iliadi-Tulbure C, Marianian AY, Aldama PC, Verbiest S, Dumbraveanu I et al. “PerConcept” Study: Provider Opinions about Integrating Preconception Care into Family Planning Services. Public Health, Economy and Management in Medicine. 2021. 91(4); 28-33.
- Van der Zee B, Inez de Beaufort ID, Steegers E A P. Perceptions of preconception counselling among women planning a pregnancy: a qualitative study. Family Practice. 2013. 30:341–346.
- Srinivasulu S, Falletta KA, Bermudez D, Almonte Y, Baum R, Coriano M. et al. Primary care providers’ responses to pregnancy intention screening challenges: community-based participatory research at an urban community health centre. Fam Pract. Nov 18;36(6):797-803.
- Callegari LS, Ma EW, Schwarz Preconception Care and Reproductive Planning in Primary Care. Med Clin North Am. 2015. 99(3):663-82.
- Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception care: promoting reproductive planning. Reprod Health. 2014. 11 Suppl 3(Suppl 3):S2.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196558/ (accessed May 6th 2021).
- Fleur MS, Damus K, Jack B. The future of preconception care in the United States: multigenerational impact on reproductive outcomes, Upsala Journal of Medical Sciences. 2016. 121:4, 211-215.