What Does 'Preconception Health' Mean to People? A Public Consultation on Awareness and Use of Language.

INTRODUCTION: There is growing scientific and policy recognition that optimising health before a potential pregnancy (preconception health) improves reproductive outcomes and the lifelong health of future children. However, public awareness on this topic is low. We conducted a public consultation to develop language recommendations and identify and prioritise approaches to inform research and improve public awareness of preconception health. METHODS: A public consultation was undertaken with people of any gender aged 18-50 years living in the United Kingdom who were not currently expecting a child. Public contributors were recruited through patient and public involvement, community and support groups, an existing cohort study, and an LGBTQ+ charity. An initial round of online group discussions (February/March 2021) explored public contributors' knowledge of preconception health, their recommendations for appropriate language, and ideas about public health approaches. In a subsequent discussion round (May 2021), language recommendations were refined and suggested approaches prioritised. Discussions were summarised based on notes taken by two researchers. RESULTS: Fifty-four people joined the initial discussion round (66% women, 21% men, 13% nonbinary or transgender; 55% aged 18-30 years, 30% 31-40 years, 15% 41-50 years). Of these, 36 people (67%) participated in the subsequent round. Very few had heard the term 'preconception health', understood what it means, or why and for whom it is important. They recommended avoiding unfamiliar terms without further explanation (e.g., preconception health, medical terms), using language that is positive, encouraging and gender-sensitive where possible, and using messages that are specific, nonjudgmental and realistic. The phrases 'health and well-being during the childbearing years', 'health and well-being before pregnancy and parenthood' and 'planning for parenthood' resonated with most public contributors. School-based education, social media campaigns and the National Health Service emerged as priority approaches/settings for raising awareness. CONCLUSION: This public consultation produced recommendations from a diverse group of people of reproductive age in the United Kingdom to improve language and prioritise approaches that increase public understanding of preconception health in ways that are relevant and appropriate to them. This should begin in schools and will require adaptation of curricula, alongside co-development of public awareness campaigns and guidance for healthcare professionals. PATIENT OR PUBLIC CONTRIBUTION: This public consultation included a diverse group of members of the public. They were not involved in the original design of the project, but following the initial round of online group discussions, they contributed to the interpretation and refinement of the emerging concepts in a subsequent round of group meetings. After the consultation activity, public contributors formed a Public Advisory Group and have subsequently been involved in other studies on the same topic. Two public contributors (E.R. and F.F.) provided critical input in the preparation and revision of this manuscript and are co-authors of the paper.

Preconception indicators and associations with health outcomes reported in UK routine primary care data: a systematic review.

BACKGROUND: Routine primary care data may be a valuable resource for preconception health research and informing provision of preconception care. AIM: To review how primary care data could provide information on the prevalence of preconception indicators and examine associations with maternal and offspring health outcomes. DESIGN AND SETTING: Systematic review of observational studies using UK routine primary care data. METHOD: Literature searches were conducted in five databases (March 2023) to identify observational studies that used national primary care data from individuals aged 15-49 years. Preconception indicators were defined as medical, behavioural and social factors that may impact future pregnancies. Health outcomes included those that may occur during and after pregnancy. Screening, data extraction and quality assessment were conducted by two reviewers. RESULTS: From 5,259 records screened, 42 articles were included. The prevalence of 30 preconception indicators was described for female patients, ranging from 0.01% for sickle cell disease to >20% for each of advanced maternal age, previous caesarean section (among those with a recorded pregnancy), overweight, obesity, smoking, depression and anxiety (irrespective of pregnancy). Few studies reported indicators for male patients (n=3) or associations with outcomes (n=5). Most studies had low risk of bias, but missing data may limit generalisability. CONCLUSION: Findings demonstrate that routinely collected UK primary care data can be used to identify patients preconception care needs. Linking primary care data with health outcomes collected in other datasets is underutilised but could help quantify how optimising preconception health and care can reduce adverse outcomes for mothers and children.

Implementation of the London Measure of Unplanned Pregnancy in routine antenatal care: A mixed-methods evaluation in three London NHS Trusts.

INTRODUCTION: Unplanned pregnancies are associated with increased risks. Despite this, they are currently not routinely detected during antenatal care. This study evaluates the implementation of the London Measure of Unplanned Pregnancy (LMUP) - a validated measure of pregnancy planning - into antenatal care at University College London Hospital, Homerton Hospital, and St Thomas' Hospital, England, 2019-2023. METHODS: We conducted a mixed methods evaluation of the pilot. Uptake and acceptability were measured using anonymized data with non-completion of the LMUP as a proxy measure of acceptability overall. We conducted focus groups with midwives, and one-to-one interviews with women, to explore their thoughts of asking, or being asked the LMUP, which we analyzed with a Framework Analysis. RESULTS: Asking the LMUP at antenatal appointments is feasible and acceptable to women and midwives, and the LMUP performed as expected. Advantages of asking the LMUP, highlighted by participants, include providing additional support and personalizing care. Midwives' concerns about judgment were unsubstantiated; women with unplanned pregnancies valued such discussions. CONCLUSIONS: These findings support the implementation of the LMUP in routine antenatal care and show how it can provide valuable insights into the circumstances of women's pregnancies. This can be used to help midwives personalize care, and potentially reduce adverse outcomes and subsequent unplanned pregnancy. Integration of the LMUP into the Maternity Services Data Set will establish national data collection of a validated measure of unplanned pregnancy and enable analysis of the prevalence, factors, and implications of unplanned pregnancies across subpopulations and over time to inform implementation.

The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study.

STUDY OBJECTIVES: Although treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy is effective, adherence is often poor. Understanding the patient perspective is needed to inform adherence-promoting interventions. This qualitative study assessed the experiences, preferences, facilitators, and barriers surrounding PAP therapy for the management of OSA in patients from adolescence to older adulthood. METHODS: Eligible participants ages 19 and older were identified from administrative health care claims; adolescent participants ages 12-18 and their parents/caregivers were identified via electronic health records of a tertiary sleep specialty clinic at a large children's hospital. Forty English-speaking patients and 10 parents of adolescents diagnosed with OSA and prescribed PAP therapy completed semistructured 60-minute telephone interviews conducted by a trained facilitator. Common themes and illustrative quotes were identified. RESULTS: Themes around OSA diagnosis, initiating OSA treatment, learning about OSA/PAP, decision to start PAP, PAP benefits and challenges, and reasons for nonadherence were identified. Participants suggested design and delivery changes to improve PAP devices. Issues unique to adolescents and their parents were discussed. CONCLUSIONS: The unique perspectives of patients regarding PAP therapy should be taken into consideration when developing interventions to increase PAP adherence and improve clinical care. Based on identified themes, opportunities for intervention may exist at all stages of care, from diagnosis to treatment initiation. Involving partners, parents, and other caregivers in PAP therapy may be beneficial for optimizing adherence. CITATION: Simon SL, Stephenson JJ, Haynes K, et al. The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study. J Clin Sleep Med. 2024;20(3):407-416.

Health related social needs and whole person health: Relationship between unmet social needs, health outcomes, and healthcare spending among commercially insured adults.

Commercially-insured adults comprise a majority of health plan members but are least likely to be surveyed about their social needs. Little is known, consequently, about health-related social needs (HRSNs) in this population. The primary aim of this study was to assess the prevalence of HRSNs and health among commercially-insured adults and estimate their relationship with health outcomes and spending. This cross-sectional study used survey data from a representative sample of Elevance Health commercially insured members residing in Georgia and Indiana (U.S.) Adult members reported on HSRNs across nine different domains. Survey data were linked to medical claims data, and regression models were used to estimate the relationship between HRSNs and self-reported health, emergency department visits, three major health outcomes, and healthcare spending (medical and pharmaceutical). Of 1,160 commercially insured adults, 76 % indicated ≥ 1 HRSN, and 29 % reported > 3 HRSNs, (i.e., "high" HRSN). Each HRSN was associated with 2.2 (95 % CI, 1.84-2.55) additional unhealthy days per month, 3.0 percent (95 % CI 1.36 - 4.57) higher prevalence of anxiety/depression, 2.2 percent (95 % CI 0.88 - 3.50) higher prevalence of hypertension, 3.9 more ED visits per 1,000 member-months (95 % CI, 0.29-7.42), and $1,418 higher total healthcare spending (95 % CI, $614.67-$2,220.39) over a 12-month period. The widespread prevalence of HRSNs among commercially insured adults demonstrates the importance of screening all health plan members for HRSNs-not just Medicare and Medicaid members. Commercially insured members who experience high HRSN are at significantly higher risk for worse health, even after controlling for income and demographic characteristics.

Predictive ability of the Desire to Avoid Pregnancy scale.

BACKGROUND: A longstanding gap in the reproductive health field has been the availability of a screening instrument that can reliably predict a person's likelihood of becoming pregnant. The Desire to Avoid Pregnancy Scale is a new measure; understanding its sensitivity and specificity as a screening tool for pregnancy as well as its predictive ability and how this varies by socio-demographic factors is important to inform its implementation. METHODS: This analysis was conducted on a cohort of 994 non-pregnant participants recruited in October 2018 and followed up for one year. The cohort was recruited using social media as well as advertisements in a university, school, abortion clinic and outreach sexual health service. Almost 90% of eligible participants completed follow-up at 12 months; those lost to follow-up were not significantly different on key socio-demographic factors. We used baseline DAP score and a binary variable of whether participants experienced pregnancy during the study to assess the sensitivity, specificity, area under the ROC curve (AUROC) and positive and negative predictive values (PPV and NPV) of the DAP at a range of cut-points. We also examined how the predictive ability of the DAP varied according to socio-demographic factors and by the time frame considered (e.g., pregnancy within 3, 6, 9 and 12 months). RESULTS: At a cut-point of 2 on the 0-4 range of the DAP scale, the DAP had a sensitivity of 0.78, a specificity of 0.81 and an excellent AUROC of 0.87. In this sample the cumulative incidence of pregnancy was 16% (95%CI 13%, 18%) making the PPV 43% and the NPV 95% at this cut-point. The DAP score was the factor most strongly associated with pregnancy, even after age and number of children were taken into account. The association between baseline DAP score and pregnancy did not differ across time frames. CONCLUSIONS: This is the first study to assess the DAP scale as a screening tool and shows that its predictive ability is superior to the limited pre-existing pregnancy prediction tools. Based on our findings, the DAP could be used with a cut-point selected according to the purpose.

Handling Missing Data in Health Economics and Outcomes Research (HEOR): A Systematic Review and Practical Recommendations.

BACKGROUND: Missing data in costs and/or health outcomes and in confounding variables can create bias in the inference of health economics and outcomes research studies, which in turn can lead to inappropriate policies. Most of the literature focuses on handling missing data in randomized controlled trials, which are not necessarily always the data used in health economics and outcomes research. OBJECTIVES: We aimed to provide an overview on missing data issues and how to address incomplete data and report the findings of a systematic literature review of methods used to deal with missing data in health economics and outcomes research studies that focused on cost, utility, and patient-reported outcomes. METHODS: A systematic search of papers published in English language until the end of the year 2020 was carried out in PubMed. Studies using statistical methods to handle missing data for analyses of cost, utility, or patient-reported outcome data were included, as were reviews and guidance papers on handling missing data for those outcomes. The data extraction was conducted with a focus on the context of the study, the type of missing data, and the methods used to tackle missing data. RESULTS: From 1433 identified records, 40 papers were included. Thirteen studies were economic evaluations. Thirty studies used multiple imputation with 17 studies using multiple imputation by chained equation, while 15 studies used a complete-case analysis. Seventeen studies addressed missing cost data and 23 studies dealt with missing outcome data. Eleven studies reported a single method while 20 studies used multiple methods to address missing data. CONCLUSIONS: Several health economics and outcomes research studies did not offer a justification of their approach of handling missing data and some used only a single method without a sensitivity analysis. This systematic literature review highlights the importance of considering the missingness mechanism and including sensitivity analyses when planning, analyzing, and reporting health economics and outcomes research studies.

How common is natural conception in women who have had a livebirth via assisted reproductive technology? Systematic review and meta-analysis.

STUDY QUESTION: What is the proportion of women who experience natural conception after a livebirth via assisted reproductive technology (ART)? SUMMARY ANSWER: Current evidence suggests that natural conception pregnancy may occur in at least one in five women after having a baby via IVF or ICSI. WHAT IS KNOWN ALREADY: It is widely known that some women having babies via ART go on to conceive naturally. This reproductive history is of media interest and often described as 'miracle' pregnancies. STUDY DESIGN, SIZE, DURATION: A systematic review with meta-analysis was carried out. Ovid Medline, Embase, and PsycINFO were searched until 24 September 2021 for English language, human studies from 1980. Search terms were used for the concepts of natural conception pregnancy, assisted reproduction, and livebirth. PARTICIPANTS/MATERIALS, SETTING, METHODS: The inclusion criterion was studies with an outcome measure of the proportion of women experiencing natural conception pregnancy after an ART livebirth. Quality of studies was assessed using the Critical Appraisal Skills Programme cohort study checklist or AXIS Appraisal tool for cross-sectional studies, and a risk of bias assessment was carried out. No studies were excluded based on quality. Random-effects meta-analyses were adopted to produce a pooled effect estimate of the proportion of natural conception pregnancy after ART livebirth. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 1108 distinct studies were identified, resulting in 54 studies after screening by title and abstract. Eleven studies including 5180 women were selected for this review. The included studies were mostly of moderate quality with a maximum follow-up period ranging from 2 to 15 years. Four studies reported natural conception livebirths which were used as known underestimates of natural conception pregnancies. The pooled estimate for the proportion of women having natural conception pregnancies after ART livebirth was 0.20 (95% CI, 0.17-0.22). LIMITATIONS, REASONS FOR CAUTION: The studies varied widely according to methodology, population, cause of subfertility, type and outcome of fertility treatment, and length of follow-up, leading to potential bias relating to confounding, selection bias, and missing data. WIDER IMPLICATIONS OF THE FINDINGS: Current evidence suggests that contrary to widely held views, natural conception pregnancy after ART livebirth is far from rare. National, data-linked studies are needed to provide more accurate estimates of this incidence and analysis of associated factors and trends over time to facilitate tailored counselling of couples considering further ART. STUDY FUNDING/COMPETING INTEREST(S): This work was conducted as part of an academic clinical fellowship awarded to AT by the National Institute for Health Research (NIHR). NIHR has had no input into the study design, data collection, and analysis, nor the writing of this study. No authors have any conflicts of interest. REGISTRATION NUMBER: PROSPERO (CRD42022322627).

Patient Perspectives on the Burden of Heart Failure with Preserved Ejection Fraction in a US Commercially Insured and Medicare Advantage Population: A Survey Study.

Background: Patient-reported health related quality of life (HRQOL) is not routinely assessed in clinical practice. Little is known about health status outcomes reported by patients with heart failure with preserved ejection fraction (HFpEF) in non-clinical trial settings. Purpose: To better understand patient burden of HFpEF in terms of HF-specific functional and symptom status, HRQOL, healthcare resource utilization (HCRU) and costs in a US-based commercial and Medicare Advantage insured population. Patients and methods: We conducted a cross-sectional survey of patients with HFpEF and linked their survey and administrative claims data. Consenting, eligible patients completed a survey that included the 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ-23) and the PROMIS Global Health-10 (GH-10) questionnaire, as well as clinical and demographic questions. HF medication use, HCRU and costs during the 12-month baseline period before the survey were determined from claims data. Generalized linear regression was used to assess the associations between baseline characteristics and the KCCQ-23 overall summary score. Results: Of 598 survey respondents with survey and claims data, 54.7% were female with mean age 74.0 years. The KCCQ-23 overall summary and clinical summary scores were 64.8 and 63.0, respectively, and the GH-10 physical and mental health summary scores were 39.9 and 45.5. Factors related to lower KCCQ-23 overall summary scores were HF treatment and symptom changes during the past 4-weeks before the survey, hospital admission during the past year, low household income, high comorbidity index, and morbid obesity (BMI>40). Total all-cause healthcare costs were $38,243 during the year prior to the survey, of which 42% were HF-related. Conclusion: Patient-reported outcome measure scores indicated impairment due to HF symptoms and physical limitations in this real-world sample of patients with HFpEF, highlighting a need to assess patient-reported outcomes as well as the clinical and economic outcomes traditionally assessed by clinicians, health systems and payers.

The physical-mental health interface in the preconception period: analysis of 131 182 women planning pregnancy in the UK.

OBJECTIVE: The physical and mental health of women prior to conception can have a significant impact on pregnancy and child outcomes. Given the rising burden of non-communicable diseases, the aim was to explore the relation between mental health, physical health and health behaviour in women planning a pregnancy. METHODS: Cross-sectional analysis of responses from 131 182 women to a preconception health digital education tool, providing data on physical and mental health and health behaviour. Logistic regression was used to explore associations between mental health and physical health variables. RESULTS: Physical health conditions were reported by 13.1% and mental health conditions by 17.8%. There was evidence for an association between self-reported physical and mental health conditions (odds ratio [OR] 2.22, 95% CI 2.14-2.3). Those with a mental health condition were less likely to engage with healthy behaviour at preconception such as folate supplementation (OR 0.89, 95% CI 0.86-0.92) and consumption of the recommended amount of fruit and vegetables (OR 0.77, 95% CI 0.74-0.79). They were more likely to be physically inactive (OR 1.14, 95% CI 1.11-1.18), smoke tobacco (OR 1.72, 95% CI 1.66-1.78) and use illicit substances (OR 2.4, 95% CI 2.25-2.55). CONCLUSIONS: Greater recognition of mental and physical comorbidities is needed and closer integration of physical and mental healthcare in the preconception period, which could support people to optimise their health during this time and improve long-term outcomes.

Women's preconception health in England: a report card based on cross-sectional analysis of national maternity services data from 2018/2019.

OBJECTIVE: To present the first national-level report card on the state of women's preconception health in England. DESIGN: Cross-sectional population-based study. SETTING: Maternity services, England. POPULATION: All pregnant women in England with a first antenatal (booking) appointment recorded in the national Maternity Services Dataset (MSDS) from April 2018 to March 2019 (n = 652 880). METHODS: We analysed the prevalence of 32 preconception indicator measures in the overall population and across socio-demographic subgroups. Ten of these indicators were prioritised for ongoing surveillance based on modifiability, prevalence, data quality and ranking by multidisciplinary UK experts. RESULTS: The three most prevalent indicators were the proportion of the 22.9% of women who smoked 1 year before pregnancy who did not quit smoking before pregnancy (85.0%), those who had not taken folic acid supplementation before pregnancy (72.7%) and previous pregnancy loss (38.9%). Inequalities were observed by age, ethnicity and area-based deprivation level. The ten indicators prioritised were not taking folic acid supplementation before pregnancy, obesity, complex social factors, living in the most deprived areas, smoking around the time of conception, overweight, pre-existing mental health condition, pre-existing physical health condition, previous pregnancy loss and previous obstetric complication. CONCLUSIONS: Our findings suggest important opportunities to improve the state of preconception health and reduce socio-demographic inequalities for women in England. In addition to MSDS data, other national data sources that record further and possibly better quality indicators could be explored and linked to build a comprehensive surveillance infrastructure.

Interventions to support contraceptive choice and use: a global systematic map of systematic reviews.

BACKGROUND: To review the highest level of available evidence, a systematic map identified systematic reviews that evaluated the effectiveness of interventions to improve contraception choice and increase contraception use. METHODS: Systematic reviews published since 2000 were identified from searches of nine databases. Data were extracted using a coding tool developed for this systematic map. Methodological quality of included reviews was assessed using AMSTAR 2 criteria. FINDINGS AND CONCLUSION: Fifty systematic reviews reported evaluations of interventions for contraception choice and use addressing three domains (individual, couples, community); Meta-analyses in 11 of the reviews mostly addressed interventions for individuals. We identified 26 reviews covering High Income Countries, 12 reviews covering Low Middle-Income Countries and the rest a mix of both. Most reviews (15) focussed on psychosocial interventions, followed by incentives (6) and m-health interventions (6). The strongest evidence from meta-analyses is for the effectiveness of motivational interviewing, contraceptive counselling, psychosocial interventions, school-based education, and interventions promoting contraceptive access, demand-generation interventions (community and facility based, financial mechanisms and mass media), and mobile phone message interventions. Even in resource constrained settings, community-based interventions can increase contraceptive use. There are gaps in the evidence on interventions for contraception choice and use, and limitations in study designs and lack of representativeness. Most approaches focus on individual women rather than couples or wider socio-cultural influences on contraception and fertility. This review identifies interventions which work to increase contraception choice and use, and these could be implemented in school, healthcare or community settings.

Desire to Avoid Pregnancy scale: clinical considerations and comparison with other questions about pregnancy preferences.

BACKGROUND: Clinicians and women of reproductive age would benefit from a reliable way to identify who is likely to become pregnant in the next year, in order to direct health advice. The 14-item Desire to Avoid Pregnancy (DAP) scale is predictive of pregnancy; this paper compares it with other ways of assessing pregnancy preferences to shortlist options for clinical implementation. METHODS: A cohort of 994 UK women of reproductive age completed the DAP and other questions about pregnancy preferences, including the Attitude towards Potential Pregnancy Scale (APPS), at baseline and reported on pregnancies quarterly for a year. For each question, DAP item and combinations of DAP items, we examined the predictive ability, sensitivity, specificity, area under the receiver operating curve (AUROC), and positive and negative predictive values. RESULTS: The AUROCs and predictive ability of the APPS and DAP single items were weaker than the full DAP, though all except one had acceptable AUROCs (>0.7). The most predictive individual DAP item was 'It would be a good thing for me if I became pregnant in the next 3 months', where women who strongly agreed had a 66.7% chance of pregnancy within 12 months and the AUROC was acceptable (0.77). CONCLUSION: We recommend exploring the acceptability to women and healthcare professionals of asking a single DAP item ('It would be a good thing for me if I became pregnant in the next 3 months'), possibly in combination with additional DAP items. This will help to guide service provision to support reproductive preferences.

Exploring fertility knowledge amongst healthcare professional and lay population groups in the UK: a mixed methods study.

As the average age of first-time parents continues to rise, there has been a concerted effort by educators, policy makers and several reproductive health groups to improve fertility awareness. This study explored fertility knowledge of lay men and women and healthcare professionals (HCPs) using the same test instrument, providing a new and unique perspective compared with previous studies. Results were obtained from 1082 survey respondents: 347 HCPs, 319 men and 413 women, 105 of whom were trying to conceive (TTC). A total of 35 interviewees were purposively sampled to include 9 HCPs, 13 men and 13 women from the reproductive age range and of varying ethnic and educational backgrounds. Interview data were transcribed and analysed using the framework method. The proportion of HCPs correctly answering the survey knowledge questions was 47.1 (95% CI = 41.7%, 52.5%) compared to 44.4% for women (95% CI = 38.9%, 50.1%); 49.9% (95% CI = 39.0, 59.9%) for women TTC; and 32.5% (95% CI = 27.1%, 37.9%) for men. HCPs were ranked as the most trusted source for seeking fertility information. Overall HCPs did not demonstrate better fertility knowledge than lay participants, with inconsistencies regarding where responsibility lies for providing the right information to patients. HCPs need to improve their knowledge about fertility to help improve patient's fertility awareness.

Addressing reproductive health needs across the life course: an integrated, community-based model combining contraception and preconception care.

Prevention of pregnancy (contraception) and preparation for pregnancy (preconception care) are services that most people need during their reproductive life course. Despite increased attention, and growing recognition that health before pregnancy is crucial to addressing disparities in maternity outcomes, service provision is far from routine. We bring together evidence from the literature, new quantitative and qualitative data on women's preferences, and case studies of existing practice, to develop an integrated, community-based model that synthesises reproductive life planning, contraception, and preconception care. Our model provides a holistic, life course approach, encompassing school-based education, social media, and national campaigns, and highlights the need for training and system-level support for the range of health-care professionals who can deliver it. This high-level model can be adapted across settings, leading to a step change in the provision of preconception care in the community with consequent improvements in health and wellbeing, and reductions in inequalities at population level.

Pre-pregnancy health of women with pre-existing diabetes or previous gestational diabetes: Analysis of pregnancy risk factors and behavioural data from a digital tool.

AIMS: To examine health behaviours and risk factors in women with pre-existing diabetes or previous gestational diabetes mellitus who are planning pregnancy. METHODS: Health behaviour, risk factor and demographic data obtained from a digital pregnancy planning advisory tool (Tommy's charity UK) were analysed. Descriptive statistical analysis was performed, stratified by diabetes type. RESULTS: Data from 84,359 women, including 668 with type 1 diabetes, 707 with type 2 diabetes and 1785 with previous gestational diabetes obtained over a 12-month period (September 2019-September 2020) were analysed. 65%, 95%CI (61,68%) of women with type 2 diabetes and 46%, 95%CI (43,48%) with previous gestational diabetes were obese (BMI ≥30 kg/m2 ), compared with 26%, 95%CI (26,26%) without diabetes. Use of folic acid supplements was low; 41%, 95%CI (40,41%) of women without diabetes and 42%, 95%CI (40,45%) with previous gestational diabetes reported taking folic acid (any dose) while 47%, 95%CI (43.50%) women with type 1 diabetes and 44%, 95%CI (40,47%) women with type 2 diabetes respectively reported taking the recommended dose (5 mg). More women with type 1 diabetes and type 2 diabetes reported smoking (20%, 95%CI [17,23%] and 23%, 95%CI [20,26%] respectively) and taking illicit/recreational drugs (7%, 95%CI [6,10%] and 9%, 95% CI [7,11%]) compared to women without diabetes (smoking 17%, 95% CI [16,17%], drug use 5%, 95%CI [5,5%]). Alcohol consumption, low levels of physical activity and of fruit and vegetable intake were also evident. CONCLUSIONS: This study highlights the potential of online pregnancy planning advisory tools to reach high-risk women and emphasises the need to improve pre-pregnancy care for women with pre-existing diabetes and previous gestational diabetes, many of whom are actively seeking advice. It is also the first to describe pre-pregnancy health behaviours in women with previous gestational diabetes.

What does family building mean? A qualitative exploration and a new definition: a UK-based study.

BACKGROUND: The importance of improving men's and women's knowledge of sexual and reproductive health has been emphasised in numerous global health policies. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, recent concerted effort to improve fertility-awareness warrants a closer investigation of basic reproductive health terminologies. The objective of this study is to explore participants' views of "family building" and provide a definition. METHODS: We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. We asked participants about terms such as 'family planning' and 'family building' to elicit views and explored the appropriateness of the term "family building." Data were transcribed and analysed via Framework analysis. RESULTS: When asked what 'family planning' meant to them, study participants stated that the term meant the avoidance of pregnancy. They viewed it as an "umbrella term for the use of contraception methods," that "paradoxically, the term family planning almost has a negative connotation regarding having a family," but could not state similar terminology for planning a family. Reasons cited for this perspective include the focus of school education and usage in clinical settings. CONCLUSIONS: In the absence of an explicit definition in literature, we generated a new definition for family building as follows: "Family building refers to the construction or formation of a family, which can include steps or actions taken by an individual towards having children. In contrast to family planning, the intent focuses on pregnancy planning and childbearing rather than pregnancy prevention. However, it can also include actions taken to space the number of children one has." Some balance in the global public health messages, including bridging the gap in reproductive health literature, policies, processes and practices may contribute to the effort to improve fertility knowledge. Use of appropriate terminologies help optimise reproductive health services in order to enable men and women achieve their desired fertility intentions, whatever they may be. Trial registration Not applicable.

Global health policies have emphasised the importance of improving individual's knowledge of sexual and reproductive health. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, the recent concerted effort to improve fertility awareness warrants a closer investigation of basic terminologies in the field. For example, although the term family planning encompasses attaining the desired number of children and spacing pregnancies, it is almost synonymous with not having children, while there is currently no widely accepted equivalent terminology for planning to have children, either in general usage or clinical settings. We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. When asked what 'family planning' meant to them, study participants stated avoidance of pregnancy. They viewed it as an "umbrella term for the use of contraception methods", that "paradoxically, the term family planning almost has a negative connotation regarding having a family," but could not state similar terminology for planning a family. We introduced family building and provided a new definition. We believe that some balance in the global public health messages, including revisiting widely used terminologies can help bridge the gap in reproductive health literature, and contribute to the effort to improve fertility knowledge. Additionally, this has implications for promotion of preconception and optimising reproductive health in relevant policies, processes and practices, in order to help people achieve their desired fertility intentions, whatever they may be.

Factors influencing contraception choice and use globally: a synthesis of systematic reviews.

BACKGROUND: Unintended pregnancy has a huge adverse impact on maternal, child and family health and wealth. There is an unmet need for contraception globally, with an estimated 40% of pregnancies unintended worldwide. METHODS: We systematically searched PubMed and specialist databases for systematic reviews addressing contraceptive choice, uptake or use, published in English between 2000 and 2019. Two reviewers independently selected and appraised reports and synthesised quantitative and qualitative review findings. We mapped emergent themes to a social determinants of health framework to develop our understanding of the complexities of contraceptive choice and use. FINDINGS: We found 24 systematic reviews of mostly moderate or high quality. Factors affecting contraception use are remarkably similar among women in very different cultures and settings globally. Use of contraception is influenced by the perceived likelihood and appeal of pregnancy, and relationship status. It is influenced by women's knowledge, beliefs, and perceptions of side effects and health risks. Male partners have a strong influence, as do peers' views and experiences, and families' expectations. Lack of education and poverty is linked with low contraception use, and social and cultural norms influence contraception and expectations of family size and timing. Contraception use also depends upon their availability, the accessibility, confidentiality and costs of health services, and attitudes, behaviour and skills of health practitioners. INTERPRETATION: Contraception has remarkably far-reaching benefits and is highly cost-effective. However, women worldwide lack sufficient knowledge, capability and opportunity to make reproductive choices, and health care systems often fail to provide access and informed choice.