Family Practice Vol. 21, No. 1, 22-27
© Oxford University Press 2004, all rights reserved.
Article |
Preconception care
Practice and beliefs of primary care workers
Institute of General Practice and Primary Care, University of Sheffield, Sheffield, UK
Correspondence to Tom Heyes, Darton Health Centre, Barnsley S75 5HQ, UK; E-mail: tom.heyes{at}blueyonder.co.uk
Received 17 December 2002; Revised 28 May 2003; Accepted 8 September 2003.
Heyes T, Long S and Mathers N. Preconception care. Practice and beliefs of primary care workers. Family Practice 2004; 21: 22–27.
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Abstract |
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Background. A number of lifestyle modifications and medical interventions can be of benefit to maternal and neonatal health, when applied prior to conception. These include smoking cessation, supplementation with folic acid, cessation or moderation of alcohol intake and improvement of diabetic control. However, preconception care (PCC) is not widely practised in the UK, despite being apparently acceptable to health professionals and to women of childbearing age.
Objectives. The aims of the study were to describe the current practice of PCC in Barnsley and to assess the beliefs and attitudes of primary health care practitioners. This information would help direct appropriate educational and clinical governance intervention to this service in the locality in the light of other evidence about the effectiveness of PCC.
Methods. A questionnaire was devised to explore the beliefs about, and practice in providing, PCC in primary care in the Barnsley Health Authority area and sent to all known GPs, practice nurses (PNs), health visitors (HVs) and midwives (MWs) in practices in the area in July 2000. A total of 163 completed questionnaires were received (one reminder, response rate 60.1%).
Results. Few practices had a written policy on PCC. Most respondents were providing it mainly on an opportunistic basis and had done so less than five times in the previous 3 months; GPs and PNs were most commonly involved. They agreed that advice about smoking, drug use, folic acid, genetic counselling, chronic disease, alcohol, and maternity care and screening for rubella, genital infections, hepatitis, human immunodeficiency virus and cervical cytology were important. They felt that advice about diet, exercise, supplements, food safety, occupational hazards and State benefits, and screening for nutritional status were less important. Although respondents felt that PCC was effective, and important to women of childbearing age, it was not a high priority in their workload. They indicated that this care was best provided in general practice and that they had the appropriate skills. Barriers to providing PCC included lack of resources and lack of contact with women planning to conceive. Few had received any training on PCC since qualifying in their discipline.
Conclusions. The practitioners who responded to this survey agreed to a large extent about the importance of the subject, and about the content and effectiveness of PCC. Factors hindering the delivery of this service include resource constraints, lack of training and practice policies and procedures, and difficulty in targeting couples planning conception. Further research is needed into ways to increase the provision and uptake of PCC.
Keywords. Preconception care, pregnancy, preventive care, primary care.
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Introduction |
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The researchers wished to disseminate information about effective interventions in preconception care (PCC) in the Barnsley district. No data were available about current practice or the knowledge or beliefs of health professionals, and the survey was devised to determine these so that appropriate educational interventions could be designed.
Barnsley is a deprived area, with 14 out of its 15 wards in the lowest 50% of the former Department for Environment, Transport and the Regions index of multiple deprivation ranking; nine are in the lowest 20% and three in the lowest 10%. In 1994–1996, the incidence of low birth weight was 7.30%, and perinatal mortality was 0.891%; despite the worse deprivation statistics, these are both similar to the incidences for the UK as a whole.
In a recent population survey, reported levels of physical activity were lower than for Trent as a whole; only two-thirds of the population reported eating fruit or vegetables every day or most days. In women in the 16–34 age group, body mass index (BMI) distribution is as follows: <20, 18.8%; 20–24, 45.6%; 25–29, 20.3%; and 
30, 15.3%. The survey also showed that 23.6% are daily smokers and 33.9% consume alcohol once a week or more.
There is evidence that smoking cessation and reduction or cessation of excessive alcohol consumption1 during pregnancy and supplementation with folic acid before conception2 can contribute significantly to maternal and child health. Other preconception interventions are worthy of research, including vitamin D, zinc and magnesium supplementation, smoking cessation strategies and antibiotic treatment for bacterial vaginosis and other urinary and genital tract infections.3,4 Despite this, comparatively little research attention appears to have been given to PCC, and we have found no published experimental work from British primary care on interventions before conception. PCC is not widely practised in the UK, despite being apparently acceptable to health professionals and to women of childbearing age.5 Theoretically, many of the interventions may be more effective delivered before conception than they are during pregnancy.6
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Methods |
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The questionnaire was devised and refined in discussion with GPs and primary care researchers at the Institute of General Practice in Sheffield University, and can be viewed on the journal's web site at http://fampra.oupjournals.org/content/vol21/issue1/index.shtml. It was concerned with five topics: the structure and content of PCC in the respondent's practice; the important elements of PCC; attitudes to PCC covering four themes (personal qualification, priority, pattern of provision, belief in efficacy); training received; and the perceived obstacles to providing PCC.
It was piloted with a sample of five GPs, seven practice nurses (PNs), four health visitors (HVs) and six midwives (MWs) in Sheffield, and modifications were made.
The local research ethical committee was notified of the proposed study and the chairman confirmed that there was no objection.
The questionnaire was sent to all GPs (117), PNs (68), MWs (28) and HVs (58) known to be working in the Barnsley Health Authority area. One postal reminder was sent.
Quantitative results were entered and analysed using SPSS. Qualitative data were analysed using narrative analysis, a recognized qualitative methodology7 that demonstrates rigour and reflects the depth of data.
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Results |
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A total of 163 completed questionnaires were received, an overall response rate of 60.1%, after one postal reminder.
The response rate was highest from MWs and lowest from GPs (GPs, 53.0%; PNs, 54.4%; MWs, 92.9%; HVs, 65.5%).
Pattern of provision
Of those who responded, 4.3% reported that their practice had a written policy on PCC.
To the question about who in the practice provides PCC, 17.8% of the total responded ‘don't know’. Of the remainder, 91 (69.5%) reported that at least one professional in the practice provided PCC and 40 (30.5%) that it was not provided. Respondents could indicate more than one person, and in most practices GPs and PNs were the providers. Seventy-nine (79.8% of valid responses) replied that it was provided by a GP, 58 (58.6%) by a PN, 39 (39.4%) by an MW, and 36 (37.1%) by an HV.
Of the respondents, 55.8% provided PCC opportunistically, though care was also delivered in well woman clinics (20.2%), new patient medicals (12.9%), family planning (10.4%), child health (9.2%) and dedicated preconception clinics (4.9%). Most (60.4%) had provided PCC 1–4 times during the previous 3 months (46/61 GPs, 22/36 PNs, 17/35 HVs, and 11/27 MWs). A minority (30.2%) had not provided any in the last 3 months.
Beliefs and attitudes
Respondents rated the different aspects of PCC in terms of importance (see Table 1). They gave the highest rating to advice about smoking cessation and about drug use. A majority rated as very important the following topics: checking rubella immunity, advising about folic acid supplementation, advice about genetic and chronic health problems where these existed, advice about alcohol consumption and maternity care, screening for genital infections and screening for hepatitis and human immunodeficiency virus (HIV), recently introduced as part of routine antenatal care in all parts of the UK.
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The subjects were asked to indicate their agreement or disagreement with a series of statements (see Table 2). A majority felt that PCC would have an effect on pregnancy outcome, and that there was evidence to demonstrate its effectiveness. They believed that general practices, not hospitals, were the most suitable locations for providing PCC, and that they as primary care workers were the appropriate people and had the skills needed to do it. Although they agreed that PCC was important, it was not a high priority for them and they did not have time to provide a dedicated clinic, which they felt was a ‘luxury’ service. They also believed that women in their client population often did not plan their pregnancies.
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The responses of the four different professions to each of the statements in Table 2 were compared. The significance of any difference was evaluated using a Kruskal–Wallis test. A P-value of <0.02 was taken as significant in view of the number of tests performed. There were significant differences in the responses to five of the statements. This showed that GPs and PNs were more likely than HVs or MWs to feel that a dedicated clinic for PCC was a luxury service (P < 0.001). They were also more likely to feel that there was not enough time to provide a PCC clinic (P = 0.002), and that general practice was the best place to provide PCC (P < 0.001). GPs and MWs were more likely to disagree with the statement that they did not have the appropriate skills to offer PCC (P < 0.001), and GPs were more likely than the others to agree that there is little evidence base for PCC (P = 0.014).
Analysis of free text responses
Barriers to providing PCC.
All professional groups cited lack of resources such as money, space, manpower and, crucially, time as the main obstacles to providing PCC. There were some responses that question the priority given to PCC by different professions.
"This is a depressed area. People and professionals do not have the time to organize preconception clinics. We struggle to get people to other clinics." HV"I believe we as midwives are often ‘closing the door after the horse has bolted’. It is not given a high enough priority within the trust, practice or as health professionals but there is enough evidence to prove it is not the luxury it is perceived as and should be where education begins." MW
"This reveals to me what a rotten service we give our patients and I would love to do something about it, but time is a very precious resource for all of us and I'm not sure what the answer is. Help!" GP
Another barrier mentioned by respondents concerned patients' perception of the importance of PCC and the accessibility of the service provided in that the initial contact with the primary care teams was often after conception.
"I feel that it would be difficult to target the people who would need to have preconceptual care." MW"Most pregnancies are unplanned, or if planned this is not known to us. Perhaps we should advertise preconceptual care in the waiting room." GP
"Getting the patients most at risk to come is an obstacle. Preconception clinics are full of well-motivated, well-articulated non-smoking women with a reasonably high IQ." GP
The comments offered at the end of the questionnaire suggest that the obstacles might come from the professionals themselves. There was some confusion over who should deliver PCC.
"Primarily preconception care is an issue for midwives." HV"I feel this topic is a political/public health one and relevant to midwives NOT GPs." GP
And from a midwife;
"Who is responsible for preconceptual advice? Should it be one person or all health professionals who are approached?" MW
There was some resistance to adding to workload, and evidence to suggest that it was a low priority.
"Why should I offer yet another service when I struggle to provide existing services?" GP"I think at present there are more important issues to deal with." GP
"I have approached management but have been told there is no money/time and my priorities should lie elsewhere." MW
However, there were some positive comments regarding PCC.
"Although I strongly believe in the importance of preconceptual care, I do not think as much attention is paid to it as it deserves." HV"We have a 3-page leaflet written by us for people planning pregnancy and give it out opportunistically, and on request." GP
"I feel preconceptual counselling is an essential component of parenthood preparation and think it should be more high profile." MW
Training. Of the respondents who completed this question, members of all professions had gained knowledge about PCC through their initial training. Some had gathered additional knowledge through further courses, study days or self-directed study. However, HVs and PNs cited lack of training as an obstacle to providing PCC.
The most commonly perceived current need was an up-date, or refresher day where new evidence was brought to them and team members could share this learning together.
"I feel that this issue is not fully addressed and would appreciate training. It would be useful, if training was organized, that it included GPs, PNs and MWs together, which would encourage a multi-disciplinary approach to this topic." PN
Others requested the production of evidence-based guidelines and patient information.
GPs were more precise in stating their learning needs and cited specific clinical topics as the basis for further training; toxoplasmosis and other infections; genetics and conditions affecting ethnic minorities; advice on hepatitis and HIV screening.
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Discussion |
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Strengths and limitations of the study
All the relevant primary care workers in Barnsley were addressed by the survey. The questionnaire was carefully developed and piloted. The response rate (60.1%) was good for a postal questionnaire, more so among the non-medical staff, and can be expected to be representative, even though no demographic information about the practitioners was collected to enable a comparison of responders and non-responders. The qualitative data presented highlight some strongly held views, both positive and negative. Primary care workers in other areas in Britain and Europe may hold similar views, depending on the degree of development of local PCC services.8 The study does not provide evidence about the effectiveness of PCC or about the proportion of potential recipients who are reached by current services.
Main findings
Most practices give PCC opportunistically during routine consultations as well as in clinics and during health promotion checks. The reported numbers suggest they are only reaching a minority of the potential recipients. Very few have a written policy on what it should comprise or how it should be delivered, suggesting that the care provided may be of variable quality and not evidence based. The professional most often reported to be involved is the GP, although PNs, MWs and HVs all contribute. Conflicting views are expressed as to who is the most appropriate professional to deliver PCC.
The results suggest that there is a dilemma for primary care workers in that there is agreement about much of the content of PCC and that it is an important health issue for women of childbearing age, and can have an effect on pregnancy outcome. PCC is thought to be most appropriately delivered in general practice and, despite a paucity of good training, practitioners feel they have the appropriate skills and are suitable people to offer this care. Conversely, however, it is not a high priority for them, and they do not feel they have enough resources to offer this service. Most also believe that their clients do not often plan their pregnancies, reducing the opportunity for PCC to be given. It appears that service access problems and resource constraints may be preventing the delivery of an important and useful service, which could benefit the health of the population. Perhaps the clinical and logistical complexity of PCC has led to a defeatist attitude. Health needs assessment should take into account the serious effects of poor pregnancy outcomes and the missed opportunities this survey demonstrates.
It could be argued that advice about benefits and a healthy diet including supplements may be more important than suggested by the subjects, as many families in this district are subsisting on a poor diet and low income, and improved nutrition may lead to better pregnancy outcomes for mothers and babies.9
Implications for policy and planning, practice organization and training
This survey suggests that with better resources, organization and training, practices could provide a valued service to women planning pregnancy. Local primary care organizations such as the Primary Care Trust (PCT) should investigate the feasibility and cost-effectiveness of providing PCC to the population, directing appropriate resources to primary care practices and resolving the conflicts over how PCC should be delivered. Practices should consider their role in providing PCC and make arrangements within their multi-disciplinary teams to improve their contact with women who may be planning pregnancy. This could be done by publicity campaigns and by opportunistic contacts. Reminders in computer or manual templates used for well woman clinics and for epilepsy and diabetes checks could trigger discussion with a GP or PN about PCC in appropriate cases. Couples at risk of pregnancy problems, such as those with diabetes,10 epilepsy, smoking, alcohol or drug use, or a previous low birth weight pregnancy could be particularly targeted to be given advice opportunistically during routine contacts, in the postnatal period, or by the practices actively making contact. Services such as family planning, sexual health and smoking cessation support would need to be involved, whether delivered in the practice or by referral. The provision of sexual health services to known drug users should be improved.
Training would need to be provided to all primary care workers to enable them to deliver this care more confidently and to raise their awareness and skills.
Barnsley MWs showed a great interest in this topic, evidenced by their exceptionally high response rate in the survey (92.9%). Their attitudes were strongly positive and they may represent a significant resource that could be used to provide PCC in local practices. Other professionals supported this idea, and the MWs are more likely than the other professionals to feel that they have the skills and the time to give to this work. To achieve this, new systems would have to be devised to give couples preparing for pregnancy access to MWs. The MW would become a more integral part of the primary care team and would need to share the medical records and appointment system for the practice, rather than the separate arrangements that now prevail locally.
Further research
More work is needed to devise and test interventions that could increase the uptake of measures known to reduce adverse pregnancy outcomes. These include smoking cessation and folic acid supplementation. Topics for more qualitative research include understanding the decisions people make about planning and preparing for pregnancy, and discovering more details about professionals' attitudes. Other topics would include identifying and contacting the target population, who can most effectively deliver PCC and how to encourage appropriate lifestyle changes in pre-pregnant women and to promote PCC delivery by practices.
There is also a need for more clinical effectiveness work to evaluate the various elements of PCC and their contribution to better birth outcomes for parents and infants as well as to the future health of both parties.
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Acknowledgments |
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We thank all the members of the Barnsley Health Community who have helped with this project, and Gillian Armstrong who advised on the statistical analysis. The Trent NHSE R&D Development Fund supported this work by funding granted to Dr Heyes.
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