Family Practice Vol. 20, No. 2, 142-146
© Oxford University Press 2003
Clinical Research |
Women’s interest in GP-initiated pre-conception counselling in The Netherlands
Department of General Practice and Nursing Home Medicine,
a Department of Medical Decision Making, Leiden University Medical Center, PO Box 2088, 2301 CB Leiden and
b TNO Prevention and Health, Leiden, The Netherlands.
Correspondence to LC de Jong-Potjer; E-mail: L.C.de_Jong-Potjer{at}LUMC.nl
de Jong-Potjer LC, de Bock GH, Zaadstra BM, de Jong ORW, Verloove-Vanhorick SP and Springer MP. Women’s interest in GP-initiated pre-conception counselling in The Netherlands. Family Practice 2003; 20: 142–146.
Received 13 March 2002; Revised 5 September 2002; Accepted 4 November 2002.
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Abstract |
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Background. Pre-conception counselling has the potential to reduce pregnancy complications and congenital disorders. The timing of counselling, before conception, is crucial to maximize the benefit. As many couples are unaware of their risk status and the fact that the first period of pregnancy is crucial, they do not seek information before pregnancy occurs. To reach couples with timely information, it seems that a health care worker needs to take the initiative. In The Netherlands, the GP is in an ideal position to offer pre-conception counselling.
Objective. The aim of this study was to determine the interest of women aged 18–40 in pre-conception counselling if this is offered to them by their own GP.
Method. A cohort of women (n = 1206) received a personal letter from their own GP with an offer of pre-conception counselling. The women were requested to fill in a reply form, indicating if they were interested, might be interested (if they decided to become pregnant) or were not interested in an invitation for pre-conception counselling. When interested, they were asked to give an indication as to when they were planning a pregnancy. Women who were not interested were requested to give a reason.
Results. Almost 70% of the women returned the reply form. Up to the age of 29 years, at least 80% of the respondents were interested or might be interested should they decide to have children. Most women, especially the younger women, do not know exactly when they wish to become pregnant. Regardless of age, >70% of the respondents were interested. Only 11% of the respondents indicated specifically that they were not interested in advice.
Conclusion. Women are interested in GP-initiated pre-conception counselling. Further research is needed to assess the effect of programmed and systematic pre-conception counselling, offered by GPs, on pregnancy outcome and the health of the children. A randomized controlled trial to assess these effects currently is being conducted at the Department of General Practice in Leiden.
Keywords. General practice, pre-conception care, pregnancy.
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Introduction |
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GPs are confronted with a growing number of questions regarding pregnancy, but usually not until women are pregnant. The need for information on congenital disorders among fertile women has been assessed by the Dutch alliance of parent/patient organizations concerned with genetic and non-genetic congenital disorders (VSOP). They found that >80% of these women wished to receive more information, preferably from their own GP.1 Another Dutch study found that women who had given birth to their first child 3–9 months prior to the inquiry had inadequate knowledge of (the chances of) congenital disorders. Most women had not asked for this information, nor had had the intention of doing so.2 A group of women in the UK (16–48 years) were asked if they would consider consulting a health care professional when planning a pregnancy. Forty per cent believed this was essential before pregnancy.3
The foetus is especially vulnerable during organogenesis (day 17–56 post-conception), when many women are still unaware that they are pregnant. By addressing risk factors before conception, couples have the maximum opportunity to optimize their chances of an uncomplicated pregnancy and a healthy child. Risk factors that need additional testing (e.g. infectious diseases) or adjustments (e.g. medication, alcohol consumption, smoking and nutritional habits) may also be dealt with, without the pressure of time. Genetic research is particularly time consuming and may present couples with difficult decisions, which are even more complicated when one is already pregnant.
Over the past decades, a growing number of risk factors for pregnancies and the health of the (unborn) child have been identified in medical research. The effects of many pre-existing medical conditions, external exposures and medication on pregnancy have become clearer. The possibilities for preventive measures have increased. By giving information to couples about preventive measures and supporting them in making (lifestyle) changes, the number of adverse pregnancy outcomes may be diminished. Strict blood glucose levels for diabetics,4 for example, or medication adjustments for women with epilepsy reduce the number of congenital disorders.56 The use of folic acid periconceptionally may prevent neural tube defects.7 The options are numerous and differ for each couple. The potential benefit from preventive measures is apparent, but it is often unknown how crucial the timing is.
It may well be that women do not actively seek information in time because they are unaware of their risk status or do not know that the first period of pregnancy is crucial. In order to reach all couples in time, it appears necessary for a health care worker to take the initiative to offer pre-conception counselling and advice (PCA). The Dutch study ‘Parents to be’ was set up to enable GPs to offer PCA systematically to their patients. This paper reports on the first stage of this study in which the interest of women in PCA, when actively offered by their own GP, was measured.
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Methods |
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Setting
A university-linked primary health care centre in a coastal village was willing to participate. Six GPs are employed at this health care centre, where a total of 11 300 people are registered. Demographic figures for comparison were obtained through Statistics Netherlands.8
Eligibility
Pre-conception counselling is intended for couples planning pregnancy. As a population-based intervention, PCA was offered to women aged 18 (age of consent in The Netherlands) to 40 (age at which the pregnancy rate drops greatly).8 Each GP was asked to check his own patient records for exclusion criteria. The exclusion criteria were: already pregnant at the time of inclusion; surgery that resulted in infertility (woman or her partner); infertility treatment; an explicitly completed family; mental incompetence; and insufficient understanding of the Dutch language. Furthermore, GPs could exclude women if social circumstances made the offer of PCA inappropriate (e.g. divorce).
Selection of the study population
The selected women received a letter from their own GP offering pre-conception counselling. In this letter, the procedure was explained. A pre-paid reply envelop and reply form were enclosed in the mailing. The women were requested to fill in the form, indicating if they were interested in pre-conception counselling. If women were interested, they were asked to give an indication of when they were planning pregnancy (within 3 months, between 3 months and 1 year, >1 year, as yet unknown). Women could also indicate that they might be interested, but at the given moment did not know if they wished to become pregnant (again). If women were not interested, they were asked to give a reason (no wish for pregnancy, no need for advice and an open answer option). One reminder was sent to the non-respondents.
The PCA procedure
Before the interested women and their partners were invited to the health care centre, they were sent a questionnaire to assess their individual risk factors. After returning the questionnaire, a PCA consultation was scheduled. The GP discussed the individual risk factors of both partners, on the basis of the risk assessment, as well as general risk factors. Issues that were discussed were genetic counselling, obstetric risk factors, infection prevention, medication use, the use of foliates, intoxication (e.g. alcohol, smoking), nutrition and occupational hazards. In collaboration with the Clinical Genetics Centre, conditions that needed further genetic research were marked for referral. The couples also received brochures (VSOP) to go over the general information again at home. Evaluation of PCA took place during pregnancy.
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Results |
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Age and sex distribution in the GP practice is similar to that in the Dutch population. Other comparisons can only be made for the whole village, which gives a fair impression since nearly half of the village is registered at the participating practice. The percentage of villagers with an intermediate education level exceeds the national distribution (basic, intermediate and higher: 33, 50 and 17% versus 39, 40 and 21%). Local annual net family income is 10% higher (local 18 800 Euro versus national 17 100). The percentage of immigrants living in this coastal village is lower than nationally (12% versus 17%).8
In the health centre, the total number of women in the age group 18–40 years was 1773. The mean age was 28.6 years [95% confidence interval (CI) 28.3–28.9]. Data on this specific age group of women are not available, making comparison difficult. The percentage of women aged 15–44 years is comparable with the Dutch population (21.4% versus 22.1%). In Table 1
, the number and reasons for exclusion as assessed by the GP are listed.
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Over 50% of the 567 women were excluded because of a completed family. The mean age in this group was 36.0 years (95% CI 35.6–36.4) compared with 29.9 years (95% CI 29.2–30.6) in the rest of the excluded group. The main reasons for exclusion due to social circumstances were psychiatric problems, relationship problems and family circumstances. A total of 1206 women (65%) were included and they received a personal letter from their own GP. The mean age of the women included was 26.4 years (95% CI 26.1–26.7). Almost 70% of the women returned the reply form. The percentage of respondents increased slightly with age (Table 2
): respondents 26.7 (95% CI 26.3–27.1) and non-respondents 25.8 (95% CI 25.3–26.3).
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Up to the age of 29, at least 80% of the women were interested in or would definitely consider counselling should they decide to have children. The percentage of women who indicated that they were not interested increased with age. Of the total of 230 women who were not interested, 125 (54%) answered that they had no wish for (another) pregnancy. Nineteen (8%) women replied that they had no partner. The other 86 (38%) women indicated specifically that they had no need for advice, which corresponds to 11% of the total number of respondents (not shown in table).
Table 3 shows when the interested women were planning a pregnancy. Most women, especially the younger women, did not know exactly when they wished to become pregnant. The women who were planning pregnancy within the year were mostly between 26 and 33 years of age, whereas the women planning a pregnancy after more than a year were more equally divided between the age groups. In the 34–37 year age group, almost half the women who were still planning a pregnancy did not yet know when.
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Discussion |
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This study shows that women are certainly interested in pre-conception counselling when it is actively offered by their own GPs. Over two-thirds of the women in this study were either interested in or would definitely consider counselling should they decide to have children. The interest in counselling slowly diminishes with age, but with increasing age women more often know when they wish to become pregnant. Most women who indicated that they were not interested did so because they had no wish to become pregnant again. Only 11% of the respondents specifically answered that they had no need for advice. During the year that PCA was offered, 85 women actually received counselling. A few women were already pregnant at the time of counselling.
The results may have been influenced by the options on the reply form. The interest in PCA was not distinctly separated from the women’s plans for pregnancy. Furthermore, when asked to fill in when a pregnancy was planned in the long term, the options were limited to longer than 1 year or as yet unknown. It is possible that women had a more specific time plan but could not specify this on the reply form. Unfortunately, apart from their ages, no other data are known about the non-respondents. The fact that the group of younger women who showed the most interest also had the highest percentage of non-respondents cannot be explained. The influence of previous pregnancies, if any, on the interest in PCA would have been worth researching.
The fact that the village population has a higher income and educational level than the nation as a whole may influence the interest in PCA. People with a higher level of education tend to seek information more readily; the interest could therefore be higher in this population. On the other hand, the more highly educated may feel they have sufficient possibilities to find information themselves, as some actually replied. The influence of the lower number of immigrants is more difficult to assess. A lower percentage is to be expected in a village, but this might not be a correct representation of the women offered PCA. The offer was aimed at women with sufficient knowledge of Dutch, because the instruments developed to offer PCA systematically are in Dutch. It is therefor not exactly clear which immigrants were reached and if this is a specific group of immigrants. Reaching immigrants with information on preventive measures has proved to be difficult in the past, not only due to language problems. This is unfortunate because this is the very group who could benefit from preventive measures. Specific methods to reach immigrants will be developed in the future after the beneficial effect of PCA has been proved.
Compared with a study in the UK, the interest in GP-initiated PCA appears high. Wallace found that only 40% of a group of women 16–48 years of age were interested.3 These data are not completely comparable, as Wallace addressed an unselected group of women with a wider age range. Furthermore, these women were only asked by means of a questionnaire if they considered consulting a health care professional when planning a pregnancy. The women in our study were actively offered counselling. Actually being offered counselling and advice on risk factors from a familiar health care worker probably influences the interest. Cultural differences may also account for the different results.
Our study confirms the need for information as established by the VSOP. They found that 80% of fertile women wished to receive more information, preferably from their own GP.1 When actually offered PCA by their own GP, 80% of the younger women and >70% of the total group wished to be invited for pre-conception counselling.
Currently, Dutch women do receive information on risk factors and preventive measures, but not until the first prenatal visit, i.e. after the early critical period. A few other initiatives have been developed to offer counselling before conception. Two Dutch university medical centres have opened a pre-conception out-patient clinic. In the four and a half years that the pre-conception clinic in Nijmegen has existed, almost 500 women have visited the clinic; 65% of these women were referred by a gynaecologist, mostly after an adverse pregnancy outcome.9 These women are already aware of their risk status due to their prior experience. As many (nulliparous) women are not aware of their risk status and because the first period of pregnancy is crucial, they usually consult their GP too late. In order to reach all couples in time, it appears necessary for a health care worker to take the initiative to offer PCA. As everyone in The Netherlands is registered with a GP, they have the opportunity to offer PCA to couples planning pregnancy. An additional advantage is that the GP usually knows the couple and their medical history, and is often a confidant for patients. Furthermore, the Dutch situation is ideal to reach couples planning pregnancy in time, as 
90% of the pregnancies are planned.10 Even so, women often do not know years ahead when a pregnancy is desirable and, moreover, this wish may change over time and according to personal circumstances. By setting up a programme for GP-initiated PCA, it is brought to the attention of women and their partners when and where they can get information. As this study shows that women are indeed interested in GP-initiated pre-conception counselling, it is important to conduct further research to assess the effect of programmed and systematic pre-conception advice offered by GPs on pregnancy outcomes and the health of the children. The next stage of the Dutch study ‘Parents-to-be’ is now underway and will report on this effect.
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Acknowledgments |
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We would like to thank the GPs and assistants from the health care centre ‘Wantveld’ in Noordwijk for their time and effort. The study was funded by a grant from the Prevention Fund (ZON).
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References |
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1 de Weerdt I, Jonkers R, Spapen S. Verwachtingen. Haarlem: Rescon, 1994.
2 de Smit DJ. Information about Congenital Disorders. Amsterdam: Thesis Publishers, 1997.
3 Wallace M, Hurwitz B. Preconception care: who needs it, who wants it, and how should it be provided? Br J Gen Pract 1998; 48: 963–966.[Medline]
4 Kitzmiller JL, Gavin LA, Gin GD, Jovanovic-Peterson L, Main EK, Zigrang WD. Preconception care of diabetes. Glycemic control prevents congenital anomalies. J Am Med Assoc 1991; 265: 731–736.
5 Holmes LB, Harvey EA, Coull BA et al. The teratogenicity of anticonvulsant drugs. N Engl J Med 2001; 344: 1132–1138.
6 Fairgrieve SD, Jackson M, Jonas P et al. Population based, prospective study of the care of women with epilepsy in pregnancy. Br Med J 2000; 321: 674–675.
7 Czeizel AE. Prevention of congenital abnormalities by periconceptional multivitamin supplementation. Br Med J 1993; 306: 1645–1648.
8 Statistics Netherlands, http://www.cbs.nl
9 de Weerd S, Wouters MG, Mom-Boertjens J, Bos KL, Steegers EA. [Preconception counseling: evaluation of an outpatient clinic at a university hospital]. Ned Tijdschr Geneeskd 2001; 145: 2125–2130.[Medline]
10 Vennix P. [Oral Contraceptives and the Alternatives]. Nederlands Instituut voor Sociaal Sexuologisch Onderzoek. Delft: Eburon, 1990.
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