Preconception care: delivery strategies and packages for care

To prevent teenage pregnancy and improve preconception care this package proposes comprehensive counselling, education and life skills development. Published papers highlighted the evidence regarding the adverse effects of teenage pregnancy on maternal and neonatal outcomes [12‐15]. School-based prevention programs underscored the importance of the intervention by reducing psychological, physical and sexual dating violence [16‐19], this was further confirmed in reviews which reported multi component programs reduce the assaults and incidence of domestic violence [7, 20, 21]. Considering these evidence, preconception counseling should be made available especially in schools, community centers, and adolescent health centers. These facilities can provide a space where sexually active young men and women know the risks of teen pregnancy, understand the use of condoms as well as long-acting methods of contraception. Sexual education appears to be more effective if it is integrated with broader life skills and education programs, including vocational abilities, effective communication, responsible decision making, proactive approach to personal health care and an increased awareness of health related issues. Since academic failure and teenage pregnancies are seen to be so closely interlinked, a special emphasis should be made to ensure that teenage girls complete a basic secondary education which will include educating young minds on preventing teenage pregnancies. The purpose of education is to develop the knowledge to observe, understand, reason and make rational judgment about the known realities of the world for optimum survival. Teens that have dropped out of high school are more likely to become pregnant, and their children are more likely to be deficient in terms of child development milestones such as language, communication, and cognition [22]. This has long-term implications for them as individuals, their families and communities [23]. Analysing the key issues in a community may help to identify what or who are the major contributors; for example service and health care providers may not be offering adequate counselling, sexual health information or contraceptive methods, or school systems may be deficient in providing a comprehensive sexual health class or may have failed to provide a safe environment where teens may discuss their problems. In short, adolescent sexual and reproductive health programs should include counselling, reproductive planning and contraception, and screening and management of sexually transmitted infections (STIs). On the other hand, girls in marginalized areas can be provided with preconception counseling in community settings by community health workers and outreach workers [7].

A teenager's biggest asset is knowledge. Education is the gradient process of acquiring knowledge. Knowledge gives a teenager the tools for rational reasoning and judgment. Knowledge helps a teen make better choices. Knowledge gives you options. The more knowledge a teen has, the more opportunities a teenager will have for making money. It is, therefore, important to underscore the benefits of completing secondary education among adolescents.

Nutrition plays a paramount role in supporting the future pregnancy. Nutritional counselling of women prior to conception receives less importance compared to nutritional counselling of pregnant women; however if family planning and reproductive health services took a more integrated approach and included nutritional counselling – this could improve coverage. Preconception counselling will allow women at higher risks of malnutrition, such as older women (older than 35), teenage girls with restricted diets, or malnourished women with vitamin deficiencies, to be highlighted before conception so that appropriate action may be taken. Adolescents typically consume a diet that does not satisfy the required intake of iron, folate, or vitamin B6 and have high chances of being anaemic. Thus an integrated approach should be applied wherein couples who come in for family planning services may be targeted for nutrition counselling since they are at a preconception stage where they are looking to plan a future family and thus would want to adopt the best practices and habits to do so. In low and middle income countries (LMICs) and in marginalized parts of high income countries (HICs) where food insecurity is an issue, community programs to grow food or buy it collectively should be incorporated into nutritional programs.

Evidence has showed that pre-pregnancy underweight and overweight are risk factors for an array of composite adverse pregnancy and neonatal outcomes [63, 124‐155]. It is suggested that pre-pregnancy body mass index (BMI) should be maintained within the normal range of 18.5–24.9 kg/m² and controlled via diet and exercise modifications (Refer to Paper 3[8]). The interventions for healthy diet and exercise should be encouraged from late childhood and early adolescent years to be effective [156‐166]. Routine preconception care with regards to weight should include calculating BMI for women of reproductive age, increasing awareness regarding the risks associated with being overweight or underweight, and helping women develop individualized dietary plans including consumption of a variety of healthy foods in appropriate amounts, and dietary supplements (especially a multivitamin containing 400 μg of folic acid, calcium and vitamin D, and iron). Balanced protein energy supplementation and appropriate micronutrient supplementation can reduce the risk of outcomes related with pre-pregnancy underweight, especially in LMICs. All women should be encouraged to get their risks assessed for cardiovascular health with regards to weight bearing and offered appropriate lifestyle modifications. Women with high BMI’s should be counselled to understand the risks of infertility that are a part of increased weight gain. A focus on screening, treating and preventing sexually transmitted infections (STIs) in the preconception period is vital, as well as educating parents about the risk of vertical transmission of such infections to the child.

Multicomponent youth development programs which encompass social, family, peer, community, educational and health disciplines are deigned to meet youth developmental needs and help them become healthy, happy and productive adults. Youth and particularly older children should be encouraged to take part in these programs. A proper and effective program will also help reduce problems such as substance abuse and teenage pregnancies [167‐169]. Mentoring will be an essential component of these programs where developing youth are supported and encouraged to develop competencies, to take on leadership responsibilities, and to integrate into positive peer groups. By focusing on health and self-confidence issues, guidelines on how to eat healthy and reach desired BMI, as well as sexual health issues such as practicing safe sex and when and how to deal with STIs may be included. Programs that deal with alcohol or substance abuse as well as smoking cessation programs [29] can also be packaged into these multicomponent youth development programs to be highly effective [11].

The evidence highlights the importance of women’s health status including the presence of chronic diseases, current infections or syndromes, and promotes general screening and management for other chronic health related matters [229‐264]. Another major component of health, which is mental health, is also highlighted as a package to reduce depression or anxiety disorders which may have adverse effects on the child’s health [265, 266]. On par with that, domestic violence will also have a negative impact on emotional health and mental wellbeing such as posttraumatic stress disorder or psychiatric issues with abuse or rape [267‐315]. This package serves to highlight the importance of empowering women to take control of their own health issues, to report physical or sexual harassment and abuse, and to be proactive in matters concerning their own health by screening and testing for chronic infections before planning a pregnancy [10, 316‐328].

All women who are chronic carriers of a disease such as hepatitis B should be counselled to receive vaccination if not done previously and instructed on how to prevent vertical transmission to future child or horizontal transmission to close contacts. Women with chronic health problems such as hypertension or hyper/hypothyroidism should be counselled about the risks associated with their disease during pregnancy, and the necessity to change medication regimens while pregnant or conceiving to optimize hormonal levels and to prevent any harm to the foetus. Management and counselling of diabetic women during the preconception period is more beneficial than during pregnancy [329, 330]. Preconception care for women with pre-gestational diabetes should include education about the importance of strict glycaemic controls (with an HbA1C level of less than 6-7%) to prevent congenital anomalies; teaching self-management skills with pre-set monitoring targets; counselling on the effect of poor glycaemic control on maternal complications and fetal complications; counselling about diet (as per protocol for diabetes); and healthy physical activity for weight management [10]. Testing to detect pre-diabetes or type-2 diabetes should be a priority for high-risk women who are obese or overweight or those who have a strong family history of diabetes.

Information and services must be made available to adolescents to educate them on their sexuality and protect themselves from unwanted pregnancies, STIs, or risks of infertility. School-wide accepted sexed programs have shown to delay the onset of sexual activity and increase safer sexual practices by those that are already sexually active. All females should be counselled through regular school health programs about eating disorders, such as anorexia or bulimia and the risks to fertility and future pregnancies it might have. The reproductive and sexual health program should be integrated as a vital component of the school curricula and must be tested upon to emphasize its importance. Adolescents should be guided as to how to make responsible decisions concerning their sexual lives, as well as how to practice safe sex, and how to prevent unwanted pregnancies.

The primary level health workers are the backbone to the whole establishment of primary health care. By delivering health services to the doorsteps of the community as in the case of community health workers (CHWs), concepts such as family planning, vaccinations or immunizations, proper growth monitoring, nutrition for neonates and control of common diseases can be implemented. CHWs can be trained to offer guidance and increase awareness regarding STIs, to assess maternal health and nutrition status in order to improve postpartum outcomes. They can also provide information about all forms of contraceptives, their benefits and efficacy and also provide information on emergency contraception to the female population of child bearing age in a community. Folic acid, iron and micronutrient supplementations may also be distributed in this way along with a basic orientation of the importance of such supplements to improve maternal and child health. Health education that is a vital part of preconception care and health promotion, but which may be impractical to distribute effectively in most clinical settings, especially in busy health clinics with large patient to doctor ratios can utilize CHWs to increase awareness levels.

Pre-marital counselling and screening allows couples to test for the presence of infectious diseases such as HIV/AIDS, Hepatitis B and C, syphilis or for genetic diseases such as beta-thalassemia or sickle cell haemoglobinopathies in both male and female to ensure proper care is taken before a pregnancy is planned. Such services should be available at all clinics/outreach clinics and doctors should make patients aware that this is a necessary and important step to take before starting a family. Regular screening should be conducted in high risk families by testing them and having them sit down with a geneticist and receive counselling on the best course of action. This would greatly reduce the occurrence of hereditary disorders.

During the first days to weeks after birth, the postnatal period is the ideal time to deliver interventions to improve the health and survival of both the newborn and the mother, a facility that a majority of mothers currently avail. However, an efficient strategy would be to expand post-natal care to include preconception care as well to optimize chances of a healthy conception, pregnancy and delivery. Programs should also aim to provide earlier and more integrated care as a majority of pregnancy complications may be avoided with proper screening, personal history, nutritional counseling, and genetic counseling so parents can be better equipped to handle a pregnancy and subsequent birth.

For most patients coming in for regular check-ups to a general physician in walk-in clinics, emergency department and sports medicine clinics must take an accurate and detailed history complete with relevant tests and refer to a specialist when needed. The doctor can also offer basic care and guidance regarding reproductive health to patients to improve maternal, neonatal and child health.

Integrate essential components of nutrition such as folic acid, iron, zinc, and micronutrient supplementation alongside programs that have a high coverage such as vaccination or immunization programs which could target both pregnant women as well as neonates.

Community-based programs that provide pre-conception services will cater directly to the specific needs of the particular community. Instead of a larger scale system of preconception care, support groups will be able to distribute care into smaller communities, villages, and rural areas. Members of support groups are usually facing similar issues and can benefit greatly from the shared experiences, advice and health support of the other participants. Key issues of the community such as a high rate of teenage pregnancies or poor family planning services can also be targeted and interventions can then be tailored and implemented accordingly. For example, through support group sessions, teenage girls can be taught confidence and empowerment skills to contest early or forceful marriages; they can also be taught some sort of self defence mechanism if rape and unwanted sexual advances are an issue.

Modern marketing techniques and social communications have been successfully used in many regions to promote the importance of reproductive health. Many of the interventions can be delivered through health facilities but to reach a larger audience mass mobile text messages or radio announcements may also be used where applicable. Mass campaigns regarding immunization programs in a locality or on the importance of family planning and availability of family planning clinics in different areas may be advertised on TV channels, radio programs or through text messages. Mass media campaigns for TV, radio and print media may be utilized to promote safer sexual practices, especially using condoms to prevent STIs. Local celebrities or personas may be used to promote a healthy image of utilizing pre-conception care at local health facilities. A challenge faced by many at-risk young adults in developing countries is the fact that most of them are illiterate, or have poor exposure to educational programs – mass media may be a very useful tool for effectively transmitting basic health messages to such a population. It can also be an instrument for changing behavioural stereotypes, pre-formed attitudes, myths and misconceptions regarding reproductive health.

Educational workshops may be conducted that are mandatory in workplace venues where men and women both need to attend sessions on sexual health/STI’s, smoking cessation, and other health-related topics. By providing access to sexual rehabilitation programs for employees and their spouses, which would include coping mechanisms for infertility, menopause, late pregnancies, miscarriages, or pregnancy complications, a significant reduction in risky sexual behaviors and practices as well as distress resulting from infertility or other issues may be achieved. A high prevalence of sexual problems with age may be secondary to other medical conditions which must be investigated; when left untreated, these problems will lead to a decreased quality of life, depression, peer and spouse conflicts.

Food fortification is the practice of adding micronutrients to processed foods for an increase in the micronutrient status of a population and a decrease in deficiencies and related programs. A very cost-effective program, the addition of folic acid to enrich flour, rice and pasta takes advantage of existing technologies and local distribution networks.

Support groups for high-risk couples and women, including those who have experienced a previous poor outcome. Such programs provide outreach, case management, risk reduction, support, prenatal/preconception care, health education and community development to high-risk women and couples. Such women and couples who have had a previous miscarriage, delivery of a low birth weight (LBW) infant, lack of family planning, repeated STI’s, early pregnancies, substance abuse, and lack of access to reproductive health care would be the target group for maximum benefit. The individual’s case would be assessed and a goal plan drawn out involving the patient at every step; from here on, the support group staff ensures compliance with services and keeps updated with the achievement of personal goals.