Knowledge and practices of preconception care among rural Japanese women: findings from a mixed methods investigation

Awareness about the essentiality of preconception care for improving the health of mothers and children is growing globally [1‐3]. Preconception care is defined as “the provision of biomedical, behavioral, and social health interventions to women and couples before they become pregnant [4]”. Currently, there are high maternal and perinatal mortality rates due to low nutrition, anemia, smoking, and other health complications among women giving birth, and around 40% of pregnancies are unintended [4]. Therefore, interventions to enhance the health management behavior of women and families must initialize before pregnancy [3]. Specific items suggested as “preconception care” include adequate folic acid intake, cessation of smoking and alcohol, maternal health management such as maintaining proper weight, eating a balanced diet, prevention of sexually transmitted diseases, early detection of human papillomavirus infection (HPV) and rubella infections, screening for cervical cancer, and family planning [4, 5]. Healthcare professionals, on the one hand, have mutual knowledge about the concept of preconception care, but regional variations exist in the aspect of penetration of practicing it. For example, official recommendations for preconception care started in the United States in 2006 [1] and in the UK in 2008 [6]. The promotion of preconception care in low-income countries has been lower, where the health care attention is much on saving lives [3].

Japan has one of the safest perinatal care systems in the world [7, 8]. However, there is a pressing need to promote preconception care. A Preconception Care Center to disseminate the concept in the country was not opened by the National Center for Child Health and Development [9] until 2014. Despite having safe perinatal care, problems exist. The occurrence of neural tube defects was 3.6 cases per 10,000 deliveries in 1990, and it increased to 5.2 in 2012 [10]. The increase may be due to insufficient folic acid intake as only 8% of women consume it before pregnancy [11]. The rate of low birth weight infants is rising, reaching 9.4% in 2018, higher than in any other advanced country [12, 13]. Further concern originates from approximately 13% to 21% of women in their 20s to 40s being underweight [14]. Furthermore, the rate of cervical cancer screening among women in their 20s to 40s remains around 45% [15] considerably lower than in advanced countries [16] even though screening once every two years is recommended and funded by the government [17]. The reported syphilis cases have constantly increased since 2010, particularly for women in their 20s [18]. The number of other sexually transmitted diseases has not been mitigated in the recent past [19]. Furthermore, the Japan Environment and Children’s Study, which is a nationwide cohort study with samples of approximately 100,000 unique mothers, indicated regional differences in the rate of obese and underweight pregnant women and smoking rates in the early stages of pregnancy [20, 21]. These trends require interventions for young women and families to boost their health management behavior for potential future pregnancy. Community-based techniques are needed to respond to the unique characteristics of each region.

Preconception care covers a wide range of items and often involve preventive medical practices and lifestyle modifications. Despite high expectations for primary care providers to implement preconception care, it has not yet become a part of daily primary care practice [22, 23]. According to the Health Belief Model [24], to promote preventive health behavior, people need to be enlightened about the risk of developing a condition or disease, and support in lowering their beliefs about the tangible and psychological costs of practicing them. To devise effective interventions for preconception care from the field of primary care, researchers, clinicians, and policymakers need to understand appropriately women's views toward preconception care. However, most studies have fixated on one item or category of a wide range of preconception care [25, 26]. Furthermore, prior studies have used questionnaires to seek women's knowledge or behavior for preconception care. These quantitative techniques lack information about women's nature, including their needs, expectations, and barriers to accessing services [26‐28]. To fix this gap, in this research, we sought to investigate women's views and experiences about preconception care by conducting interviews with women of the target age and then developing a questionnaire based on the interview outcomes. Our research questions were: 1) How much do women know about preconception care? 2) How much are they practicing preconception care and what are the information sources of their behavior? 3) Do the women's preconception care behavior associated with accurate knowledge? We sought to comprehend preconception care not only to expand the medical body of knowledge but also to understand the context of women’s reality and to employ the findings to develop efficient interventions for the community.

We interviewed 13 women aged 22–43 years. The mean age among them was 30.9 years, with seven parous women who were married (mean age of 35.4 years), and six nulliparous women who were unmarried (mean age of 25.6 years).

Among preconception care items, we classified those that indicated similar trends in participants’ knowledge and behavior and found five thematic areas: folic acid intake, cessation of smoking and alcohol, weight management and nutritionally balanced diet, rubella vaccine, and screening for cervical cancer and sexually transmitted infections.

In the current study, we fixated our analysis on participants’ knowledge and practices about preconception care and how it connects to their pregnancy experience. Figure 2 depicts a joint display of our qualitative findings and the survey items we created [42]. On the left side, our focused themes are listed with colors that are knowledge in yellow, behavior in red, and information sources in green. In the following two columns, major quotes from Phase I interviews by preconception care item were expressed. The columns were classified into parous women and nulliparous women. Since the elements of the three themes were merged in each quote, we categorized the words by theme colors. The middle of the table describes the hypothesis we derived from the qualitative data analysis. The right side of the table indicates the structure of the questionnaire. We developed knowledge tests of preconception care to check the knowledge of the target population, questions to ask about the experience of practicing preconception care for parous women and a question about information sources about preconception care with listed options based on the interview data.

The current study investigated preconception care knowledge and behavior among women of childbearing age in a rural area of Japan. We detected great knowledge gaps between nulliparous and parous women. Previous studies of women's knowledge and behavior regarding preconception care have investigated the specific items (e.g., folic acid, smoking, alcohol) using questionnaires [11, 26, 37‐39, 43, 44]. In Japan, most studies have focused on medical students [36, 37, 43] and pregnant women [43, 44]. In comparison, the current study used random sampling for women living in the study district and included comprehensive preconception care items. In addition, interviews were conducted in the first phase to understand how preconception care fits into in women's lives from their perspective [27]. These approaches revealed that there were differences in the accuracy of knowledge and level of practice for each of the preconception care items and whether they had experience of pregnancy or not. To encourage women to engage in preconception care behaviors, interventions should be delivered at an appropriate time in an individual's life stage [45, 46], considering the unique barriers for each recommended practice. Effective methods for communicating this knowledge to women and families are discussed below.

First, promoting information sharing among women can have a positive impact on knowledge acquisition and effective implementation [39, 43]. In this study, the knowledge of folic acid intake among nulliparous women was low, and the rate of taking folic acid supplements before pregnancy was only 3.5%. The result regarding the knowledge was comparable to that of Mikamo et al. (2012), where the participants included nulliparous nursing students and the rate of women who knew the need for folic acid intake before pregnancy was around 20% [37]. In terms of practice behavior, our outcome was much worse than that of overall Japan, where the rate was 8% [11]. However, our qualitative study revealed that advice from mothers and close female friends was beneficial when initiating folic acid supplementation. According to Nagusa & Sasaki (2020), women's behavior regarding folic acid intake improved after a three-month preconception care educational intervention that included a seminar, group discussion, and some follow-up interaction [47]. Such educational opportunities which include learning with peers in addition to advice from health professionals, may influence information sharing among women and lead to their behavior change.

Second, healthcare professionals may need to communicate with the community to share the idea of preconception care. This is especially important for younger generations, to reduce barriers to accessing clinical services. Our study observed two types of barriers for women in practicing cervical cancer and sexually transmitted infection screening. One is a lack of knowledge, as these behavior and knowledge were related, and the other is the hesitance of young women to undergo pelvic examinations. Kanamasa et al. (2018) described that even medical students in Japan tend to be hesitant to see a gynecologist due to embarrassment and anxiety [48]. There is a need to inform young people about the risks of infectious diseases, why they should be screened for preconception care, how gynecological examinations are conducted [49], and that there are public services to lower their financial burden. Primary care providers should be able to provide such interventions, but another concern in Japan is that more than 50% of the young generation aged 18–39 do not have a primary care physician [50]. Therefore, primary care providers need to extend opportunities to communicate this issue to broader targets outside the clinic. As an example in the research area, Ito et al. (2014) undertook an intervention study in which family physicians educated middle school students about HPV vaccination and cervical cancer screening, and improved the knowledge of both young girls and their mothers [51]. Partnering with school-based education or women’s community can be a technique to reach younger generations and spread knowledge about preconception care to their friends and family.

Third, we need to recognize the impact of mass media on women's perceptions of their health and lifestyle management. Intriguingly, the well-practiced behavior in the current study such as smoking cessation and alcohol cessation were not correlated with accurate knowledge, but women received messages from the media that such behavior were detrimental to pregnancy. When the media disseminate medically appropriate information, it can be highly effective. However, the opposite can also happen. For example, we were concerned about participants' preference for thinness in the interview, and the correct answer rate for the weight management questions in the survey knowledge test was low, approximately 50%. Prior studies have highlighted that Japanese female students are exposed to media pressure to lose weight from middle school to high school levels [52] and that the negative effects on pregnancy are not understood by them [37]. Thus, when media-reinforced values conflict with preferred interventions for women's health [52, 53], healthcare providers need to evaluate women's perceptions and update their knowledge about what is required for a healthy pregnancy.

Finally, to promote women's access to preconception care, we should focus more on the presence of the women's health industry. In this study, participants who practiced preconception care made the most use of the Internet as a source of information. In recent years, Female Technology, also known as the “femtech” industry, has been growing extensively around the world and comprises services, products, and software that support the health management and well-being of women at different stages of life [54]. A Japanese menstrual cycle management app called ”Lunaluna” has reached 17 million downloads since its inception in 2000 [55]. Barker (2018) highlights the need for social movements and political will to support interventions and engagement with market interests to improve preconception nutrition management in women [45]. The same can be said for preconception care in general. Emerging femtech platforms are a compatible tool for delivering preconception care information to women who frequently do not come to the clinic until they become pregnant. Healthcare providers may need to collaborate with these companies that are developing technologies to offer right knowledge about women’s health, family planning, and preconception care.

This study had some limitations. First, the response rate was low. This may be because of the sensitive nature of the subject matter, and participants may be biased toward those who are more inclined to the topic. Second, survey respondents may tend to over-report socially desirable behavior, and under-report undesirable behavior. However, the strength of this study is that the target participants were randomly chosen from the residents of the research area, which enabled us to survey a wide range of ages and women with and without pregnancy experience. Furthermore, we conducted a comprehensive study of preconception care and detected the areas in which the knowledge and practice behavior correlate. This study is highly original in its focus on Japan, and the rural setting. Critical suggestions were made concerning the current knowledge and behavior of preconception care among the target population and the techniques that can be taken to reach them.

In rural Japan, women of childbearing age lack knowledge about preconception care. The incentive to be exposed to preconception care recommendations is low, particularly among women before their first pregnancy. The behavior that should be reinforced for the target population are starting folic acid intake before the pregnancy, updating the idea of proper weight for a healthy pregnancy, and the importance of screening for cervical cancer and sexually transmitted diseases. Recommendations from close friends and family members could encourage women to engage in preconception care. Primary care providers should try outreach to schools and women’s groups in the community, and work with modern technology to enhance the knowledge and practice of preconception care.