Parental perspectives on the awareness and delivery of preconception care

The focus group sessions were audiotaped and transcribed verbatim. NVivo 10 software was used to extract and analyze the data. Thematic analysis was employed to identify key issues and themes [24]. One author (MP) developed an initial coding frame by reading and rereading the extracted findings. Additional topics that emerged from reviewing the transcripts were used to refine the initial coding frame. Extraction and coding was verified by a second author (HvS). Discrepancies were discussed until consensus was attained and both authors agreed on final analyses.

Six focus group sessions were held between June and September 2014 with 29 women and 5 men (Fig. 1). Non-responders were either not available at the given date and time to participate in a focus group or did not respond to the invitation. The characteristics of the participants are presented in Table 1. All participants were residents of the municipality of Zeist. Thirty-one participants were Dutch and three female participants originated from non-Western countries, i.e. China, Turkey and Afghanistan respectively. Ten women had a higher risk for pregnancy complications preceding their latest pregnancy, which concerned either a lifestyle risk (smoking, using alcohol or having a BMI >30), a medical risk (prior pregnancy complications, chronic/hereditary illness or medication use), or both. One man had a hereditary chronic disease.

In all focus group sessions, both women and men were generally unfamiliar with PCC. The common notion was that couples have to try to conceive for over 1 year before they are allowed to consult a healthcare provider. Many participants had no clear idea of the concept of PCC and experienced difficulties understanding the phrase “Preconception Care”. Almost all participants considered PCC suitable in the presence of certain risk factors (fertility problems, previous pregnancy complications, higher age, chronic illness, hereditary diseases and lifestyle issues, such as being overweight, smoking, alcohol or drug use), as these factors may require professional advice. Envisaging the relevance of PCC for all couples contemplating pregnancy was not as straightforward. Being young, healthy and already having children diminished the perceived need for PCC. In four focus group sessions, it was proposed to raise awareness by promoting PCC as a common type of care for every couple with a (future) child wish, stipulating that it is not necessary to wait until fertility issues arise (Quotes in Table 2).

Most women mentioned the Internet as their primary source of information regarding preconception health and were able to retrieve reliable preconception health information online. Especially higher educated women found themselves capable of segregating objective from subjective information online. Some lower to middle educated women acknowledged the presence of many social platforms and unreliable websites that have the potential to induce anxiety. Yet, in the majority of the focus group sessions both men and women expressed that a preconception consult with a healthcare provider could be valuable, as professional information was considered reliable and up-to-date. Moreover, personal contact was appreciated as it allows for dialogue, asking questions and suited applicable information. Some participants even believed that the prospect of PCC could relieve stress. Men especially valued the possibility of support and guidance and the opportunity to discuss any concerns or doubts. They felt to be branched at the sideline as women are considered the center of attention during pregnancy. Both men and women felt that men should be more involved in the pregnancy process, including the preconception period (Quotes in Table 2).

Women expressed that their intrinsic motivators to use PCC are pregnancy preparation, having a healthy pregnancy, becoming a healthy mother and having a healthy baby. Optimizing the chances of one’s future child was the major reason to attend a preconception care consult, as it was mentioned in four focus group sessions. Moreover, women stipulated that they felt responsible for their pregnancy and their choices on lifestyle matters, to resist temptations such as smoking and alcohol use and to change their eating habits during pregnancy. A few women believed that health professionals have a responsibility as well to inform their patients regarding their future pregnancy, especially when this professional is aware of the presence of (lifestyle) risks (Quotes in Table 2).

During focus group sessions, it was expressed that pregnancies are not always deliberately planned. Conceiving sooner than expected hindered some women to seek out PCC. Both men and women expressed having a planning attitude of “let things happen” and “we will see”. Men acknowledged that it is in their nature to react rather than to prepare. Apart from this, in one focus group session it was suggested that PCC could induce stress, make pregnancy plans too real and thereby interfere with the natural process of becoming pregnant. By contrast, one woman valued PCC as it could actually prevent her from going into the medical realm. In four focus group sessions, women emphasized that their pregnancy wish was an intimate decision between them and their partners. They were reluctant to share their plans with other people, including health professionals. This wish for secrecy was reflected in three focus group session in which women’s fear and shame was discussed to be spotted by relatives or acquaintances in the waiting room of a midwifery practice or gynecologist office. Yet, the waiting room of a GP was considered less intimidating, as one could visit the GP for a variety of other reasons than pregnancy plans. Still, women admitted to prefer the privacy of their own home to search for information. Therefore, it was suggested to offer PCC in alternative forms through the use of e-health. To guarantee anonymity, one woman suggested PCC to be offered in another municipality (Quotes in Table 3).

Participants felt that PCC should become just as self-evident as prenatal care. In four focus group sessions, it was urged for PCC to become a more common, usual, and standard type of care for every couple with a (future) child wish. Preferably, attending PCC becomes an obvious step, like midwifery visits once pregnancy occurs. To accomplish this, raising the social dialogue for PCC was considered useful. In two focus group sessions, participants expressed that word-of-mouth marketing would be a good way to enlarge awareness. Although privacy was identified as an interfering factor to openly discuss current pregnancy attempts, women explained that it is common to discuss issues regarding pregnancy and childbirth with relatives, female friends and wider social circles. In one focus group session it was suggested that, when women start to point out the relevance and need for PCC to each other, the responsibility for PCC could be shared socially. In all focus group sessions, it was proposed to send promotional messages through formal and informal channels and to use existing social networks and community settings. In addition to formal and healthcare related settings, suggestions were made to display marketing materials in schools, community centers, day care facilities, city hall, public places, mosques, churches, grocery stores, the library, the cinema, gyms, the swimming pool, etc. (Quotes in Table 3).

There were contrasting views among both men and women regarding the acceptability of health professionals opportunistically offering PCC. Approximately half of the participants felt the inquiry about pregnancy plans to be meddlesome, confronting or even painful. The other half of the participants had the opinion that more information would not be harmful and that it is up to a couple to decide to act upon this information. However, it was acknowledged that it may be hard for professionals to estimate whether future pregnancy plans are in order. Commonly, opportunistically offering PCC by healthcare providers was considered more acceptable when the subject was deliberately raised, for example while discussing contraceptives, pap smears, chronic illness, lifestyle risks or drug prescriptions. Men clearly expressed not to appreciate an “out of the blue” question regarding their child wish (Quotes in Table 3).

In all focus group sessions, it was recommended to make PCC more accessible by offering multiple forms: group sessions, individual consultations, walk-in-hours and online sessions. Participants advised to make PCC available for everyone, addressing a wider public, while offering customized care. During one focus group session, it came across that PCC was expected to be time-consuming, making it difficult to attend in women’s already busy lives. Additionally, some participants felt reluctant to bother health professionals with a high workload with questions regarding PCC. Walk-in-hours, telephone consultation, e-mail and Skype were proposed as less time-consuming alternatives for PCC (Quotes in Table 4).

The majority of participants regarded GP’s or midwives the most suitable PCC providers, while gynecologists, dieticians, physiotherapists, social workers and pharmacists were less frequently mentioned. The GP was denoted as the first health professional by whom PCC could be discussed confidently, as GP’s were considered most familiar, knowing about the family situation and the presence of risks factors, diseases or medication. By contrast, some participants felt more at ease discussing their pregnancy plans with an outsider, a professional who is unaware of their personal situation. Above all, individual provider characteristics such as experience, empathy and communication skills were regarded most important. In one focus group session, participants stressed that messages will not come across by information alone, but that cogency is needed to accomplish lifestyle changes (Quotes in Table 4).

The highly educated subgroup was most explicit in the opinion that PCC is suited for other people with risks. Moreover, participants from this subgroup experienced a lesser need for PCC as they found themselves very capable of retrieving the right preconception health information. From all subgroups, the non-western ethnicity subgroup valued the involvement of the social network the most, as they elaborated on social dialogue, word-of-mouth marketing and social responsibility. The male subgroup discussion did not yield any new themes other than topics men would like to discuss during a preconception care consult, such as how to support their female partner during pregnancy.

Corresponding with the findings of other studies on women’s views, our results showed that PCC is a rather unfamiliar concept [21, 25‐29]. Once aware of PCC, PCC was regarded more appropriate for couples with risk factors or fertility issues. Other studies confirm that women tend not to consider themselves as a target group for PCC [8, 16, 20, 21, 25, 28, 29]. We found that parents especially appraised the potential benefit of PCC to their future child’s health, which was the most important intrinsic motivator to use PCC. A previous study on couples’ notions for preconception health found similar motivating factors for planners and interconceptional couples [22]. One of our particular findings was the perception that couples have to try to conceive for over 1 year before they are allowed to consult a healthcare provider. In accordance with the findings of a previous qualitative study by van der Zee et al., our study demonstrates that subjective norms, such as planning, privacy and medicalization may interfere with the intention to attend PCC [20]. In a study by Hosli et al. one of three most important motives for women not to respond to an invitation for PCC was perceived sufficient knowledge [8]. Although our subjects were all experienced parents, this theme did not emerge in our focus group sessions. The Internet was frequently consulted, yet having a PCC consult with a healthcare provider was still considered of added value as it allows for dialogue and suited, reliable information.

Our study reveals that, according to parents, investing in the accessibility of PCC could positively affect uptake rates. Corresponding to our findings, PCC was expected to be time-consuming in three other studies on PCC attendance [25, 27, 30]. Therefore, it was encouraged to expand on ways in which PCC is currently offered, by introducing walk-in-hours and online sessions. Previous studies have also suggested to expand access to PCC by enhancing services at community health centers and publicly-funded family planning providers [15, 31, 32]. Besides improving the accessibility, our results indicate that parents expect PCC to become more self-evident when awareness increases. Parents proposed the use of several informal channels and local settings to send promotional messages. Interestingly, raising the social dialogue and stimulating word-of-mouth marketing were regarded most efficient to make PCC a more “common” type of care, as women turn to other women for support. Evidence indeed suggests that the use of (health) services is strongly influenced by word-of-mouth and women actively seek the advice of family and friends [33]. Yet, raising the social dialogue is very difficult to attain, since it requires effort to find a way into social networks, as each community has its own specific features and needs [34].

Although the literature often recommends to engage men in PCC, our study is one of the few to consider both women’s and men’s views on PCC. A previous study by Frey et al. on the perspective of men found that although men understand the importance of optimizing their health prior to conception, this topic is hardly ever addressed by a primary care physician [23]. In our study, participating men expressed the feeling of having a neglected role when it comes to pregnancy, which was confirmed by female participants. These findings point out the need to involve men more during PCC.

Although ethnic minorities were not well represented among the study’s participants, our results indicate that social networks are more important among these groups. Therefore, we encourage the implementation of PCC prevention activities within community settings. For example, “Uma Tori”, a gender specific and culturally appropriate STI/HIV-prevention intervention, which uses interactive, multi-faceted, small-group sessions, showed a promising effect to increase awareness and improve sexual decision-making skills among women [35].

Strengths of this study were the amount of participants and the use of a diverse population and purposefully stratified focus groups. Although the number of participating male partners was limited, we are one of the few to have conducted a focus group session with men [22, 23]. Moreover, we used a broad approach and assessed both experiences and needs from the study population. A limitation of this study was the selection strategy, as we included participants who were already parents during the focus group sessions. This selection strategy allowed to easily identify possible participants, since they were registered at the community midwifery practice. Moreover, the experience of being a parent contributed to detailed reflections which were based on real experiences. However, due to this selection participants could have had a more positive attitude towards healthcare providers based on their experiences. Although it would have been of added value to include nulliparous couples, they are more difficult to reach, since healthcare providers are generally not aware of childbearing plans until women present after pregnancy recognition [9, 36, 37]. Therefore almost all studies concerning preconception health obtain information retrospectively, while it is surely possible with increased effort to conduct a prospective study [38]. A limitation of this research was the use of a local setting, which could potentially limit the generalizability of the results. While the population of Zeist is mostly representative for the Netherlands, educational and income levels are relatively high. Therefore, we put an effort to include participants in stratified focus groups with varying ethnic backgrounds and educational level. However, due to cancellation and no-show the study population was less diverse than was aimed at. Nevertheless, our results correspond with the findings in similar studies from other Western countries on women’s perceptions regarding PCC.