Assessing preconception health in Australia to support better outcomes in the first 2000 days - A critical need for building a core indicator framework.

In 2021, the Preconception Health Network Australia co-developed preconception health core indicators identified as critical to ensuring optimal maternal and child outcomes following conception. We conducted an audit of perinatal databases across each state and territory to identify whether preconception core indicator data were available. Seven health domains co-developed by the Preconception Health Network were mapped against the data collected in the perinatal databases. Indicator data were lacking across all seven health domains, with data missing for social determinants of health indicators. Better data linkage and developing a national evidence-based framework would allow ongoing monitoring of women's preconception health nationally.

Using a validated instrument to assess pregnancy planning and preconception care at antenatal booking visits: a retrospective cohort study.

OBJECTIVE: To determine the completion rate for the London Measure of Unplanned Pregnancy (LMUP), a psychometrically validated measure of a woman's intention with regard to a current or recent pregnancy, during booking visits at two metropolitan antenatal care clinics; to identify socio-demographic characteristics associated with unplanned pregnancy. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study; analysis of LMUP data for women attending antenatal care booking consultations as public patients in the Sydney Local Health District, 31 December 2019 - 30 November 2020. MAIN OUTCOME MEASURES: Proportions of women with LMUP scores indicating unplanned (0-9) or planned pregnancies (10-12); associations between planned pregnancy and socio-demographic characteristics, crude and adjusted for age, parity, and socio-economic status (Index of Relative Socioeconomic Disadvantage). RESULTS: Of 4993 women with antenatal care bookings, the LMUP was completed by 2385 (47.8%; 1142 of 3564 women at the tertiary referral hospital [32.0%], 1118 of 1160 at the secondary hospital [96.3%]). Planned pregnancies were indicated by the total LMUP scores of 1684 women (70.6%); 1290 women (59.1%) reported no health actions in preparation for pregnancy. In multivariable analyses, planned pregnancies were more likely in all age groups than for women aged 24 years or younger (30-34 years: adjusted odds ratio [aOR], 2.54; 95% confidence interval [CI], 1.76-3.66; 35-39 years: aOR, 2.91; 95% CI, 1.95-4.33). The likelihood of planned pregnancy declined with increasing parity (v no previous births: three previous births: aOR, 0.25; 95% CI, 0.16-0.40; four or more previous births: aOR, 0.10; 95% CI, 0.05-0.19). CONCLUSION: Seven in ten women who completed the LMUP had planned their pregnancies, but fewer than half had undertaken health-related actions prior to conceiving. Higher parity was associated with unplanned pregnancy, indicating the importance of postpartum contraception advice. Overcoming barriers to implementing the LMUP more widely would enhance preconception health monitoring.

Addressing Preconception Behavior Change Through Mobile Phone Apps: Systematic Review and Meta-analysis.

BACKGROUND: Positive health behavior changes before pregnancy can optimize perinatal outcomes for mothers, babies, and future generations. Women are often motivated to positively change their behavior in preparation for pregnancy to enhance their health and well-being. Mobile phone apps may provide an opportunity to deliver public health interventions during the preconception period. OBJECTIVE: This review aimed to synthesize the evidence of the effectiveness of mobile phone apps in promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods), which may improve future outcomes for mothers and babies. METHODS: Five databases were searched in February 2022 for studies exploring mobile phone apps as a prepregnancy intervention to promote positive behavior change. The identified studies were retrieved and exported to EndNote (Thomson Reuters). Using Covidence (Veritas Health Innovation), a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) study flow diagram was generated to map the number of records identified, included, and excluded. Three independent reviewers assessed the risk of bias and conducted data extraction using the Review Manager software (version 5.4, The Cochrane Collaboration), and the data were then pooled using a random-effects model. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess the certainty of the evidence. RESULTS: Of the 2973 publications identified, 7 (0.24%) were included. The total number of participants across the 7 trials was 3161. Of the 7 studies, 4 (57%) included participants in the interconception period, and 3 (43%) included women in the preconception period. Of the 7 studies, 5 (71%) studies focused on weight reduction, assessing the outcomes of reductions in adiposity and weight. Of the 7 studies, nutrition and dietary outcomes were evaluated in 2 (29%) studies, blood pressure outcomes were compared in 4 (57%) studies, and biochemical and marker outcomes associated with managing disease symptoms were included in 4 (57%) studies. Analysis showed that there were no statistically significant differences in energy intake; weight loss; body fat; and biomarkers such as glycated hemoglobin, total cholesterol, fasting lipid profiles, or blood pressure when compared with standard care. CONCLUSIONS: Owing to the limited number of studies and low certainty of the evidence, no firm conclusions can be drawn on the effects of mobile phone app interventions on promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods). TRIAL REGISTRATION: PROSPERO CRD42017065903; https://tinyurl.com/2p9dwk4a. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13643-019-0996-6.

To what extent do postpartum contraception policies or guidelines exist in Australia and New Zealand: A document analysis study.

Women are susceptible to unintended, rapid repeat pregnancies in the first 12 months postpartum. Access to postpartum contraception, specifically long-acting reversible contraception, enables better planning of pregnancy timing and spacing and allows optimisation of health before the next conception. Clinical Practice Guidelines (CPG), and implementation policies, supported by consumer input, can improve such access. We searched publicly available Australian and New Zealand guidelines and policy documents addressing postpartum contraception. One CPG detailed specific information about postpartum contraception and, although of high quality, requires modification to local contexts to support implementation and policy development.

The preferences of people in Australia to respond and engage with advertisements to promote reproductive health: Results of a discrete choice experiment.

Objectives: The health of people prior to pregnancy impacts pregnancy outcomes and childhood health, making the preconception period an important time to optimise health behaviours. Low awareness of the importance of this issue is a recognised barrier to achieving good preconception health. Public health messaging can help to address this barrier. Methods: A discrete choice experiment to assess the preferences of people of reproductive age for a health promotion advertisement for preconception health was conducted. Attributes of the advertisement image, title, additional text content and positioning, and the location of advertisement were assessed by fitting a mixed logit model to the choices made. Results: Three hundred and thirty-four responses were obtained, from people of reproductive age, both planning and not planning a pregnancy, in Australia. Participants placed most importance on the image, and the location in which they saw the advertisement. An image of adult and baby hands was preferred to adult hands only, and healthcare settings were preferred to more general media locations such as advertising online or on public transport. Preference was also given to the advertisement title of "Healthy you, Healthy baby", closely followed by "Are you ready for pregnancy?". The location and content of additional text did not significantly impact engagement with the advertisement. Conclusion: The image and title on the advertisement, and the locations in which they are placed were the most significant features to impact engagement with a health promotion advertisement for preconception health. This can inform health promotion efforts for preconception health.

A cross-sectional study of factors associated with immediate postpartum uptake of contraceptive implants in Papua New Guinea.

OBJECTIVES: In 2016 the Port Moresby General Hospital in Papua New Guinea introduced a midwife led postpartum contraception service to educate patients and provide contraceptive implants. This study examines the factors that were associated with immediate postpartum uptake of the implants. STUDY DESIGN: We conducted a cross-sectional study of patients on the hospital postnatal ward who gave birth between March 2017 and January 2018. Patients aged 16-45 who had a vaginal birth with a singleton, live baby not requiring admission to the special care nursery were eligible for inclusion and invited to complete a survey prior to discharge. RESULTS: Of 2082 patients approached, all consented to participate in the survey. Of those completing the survey, 531 (25.5%) chose to have the contraceptive implant provided immediately postpartum. Excluding patients who chose tubal ligation (n = 330), in multivariable analysis, higher odds of implant uptake was associated with no prior contraception use compared to prior use (aOR 1.38; 95% CI 1.07 -1.77), unplanned pregnancy compared to planned (aOR 1.37, 95% CI 1.07-1.79), and having received antenatal education about the implant compared to no information (AOR 1.65, 95% CI 1.23-2.10). CONCLUSIONS: Antenatal education about the contraceptive implant impacted on likelihood of immediate postpartum method uptake. Patients who had no prior use of contraception and those with unplanned pregnancies were also more likely to request the implants, suggesting that the midwife-led postpartum service is successfully reaching patients with a previous unmet need for contraception. IMPLICATIONS: This study demonstrates successful delivery of a postpartum implant program in a setting where community access to contraception is limited. Antenatal information and education can support implant uptake and that the program provides the opportunity for birth spacing and limiting in patients with a previous unmet need.

Introduction of the London Measure of Unplanned Pregnancy at the booking visit and the midwives' perspective.

BACKGROUND: Pregnancy planning and preconception care benefit women, their children, and future generations. The London Measure of Unplanned Pregnancy (LMUP) is a tool that can be used in antenatal care to identify women with unintended pregnancies who require improved access to such services. This tool was recently implemented into routine antenatal care in two maternity centres in New South Wales, Australia. This study explores midwives' attitudes to the LMUP 12 months after it was introduced into the booking visit and their understanding of its application to their scope of practice. METHODS: This is a qualitative study using in-depth semi-structured interviews with midwives from two maternity care centres in Australia. All midwives performing antenatal booking visits were eligible to take part. Interviews were transcribed, analysed, and coded to define key themes. Recruitment ceased when thematic saturation was reached. RESULTS: Ten midwives from two maternity centres were interviewed. Midwives support the inclusion of the LMUP into the booking visit and felt it was in their scope of practice to be using the tool. Time constraints, the impact of COVID-19 and the lack of structured referral pathways were identified as barriers to the implementation of the LMUP in routine care. CONCLUSIONS: Midwives support the inclusion of the LMUP into the antenatal booking visit and see that it falls within their scope of practice. Service barriers were identified at the individual, organisational and external context levels. These need to be addressed to enhance the potential of this tool.

Acceptability and usability of 'One Key Question'® in Australian primary health care.

BACKGROUND: Around one-third of pregnancies in women attending antenatal care are unintended. This means a substantial number of women enter pregnancy without optimising their health prior to conception. Primary care practitioners are uniquely placed to counsel women about how to plan for pregnancy and about how to avoid unintended conception. The One Key Question® (OKQ®) tool facilitates a discussion of pregnancy intention and opens up subsequent discussions regarding preconception or contraception care. This study aimed to assess the acceptability and usability of the OKQ® tool in the Australian primary care setting. METHODS: We undertook a pilot study consisting of quantitative and qualitative componentsacross two general practice settings in Sydney, New South Wales, Australia. We documented women's responses to being asked the OKQ® as part of their consultation. We collected data on the characteristics of the participating GPs and their experience of using the OKQ® tool and conducted semi-structured interviews with all participating GPs. RESULTS: Fifty-six patients were asked the OKQ®, with the majority stating they were happy to be asked about their reproductive choices and felt it was relevant to their general health. The 10 participating GPs felt the OKQ® was easy to use and although 62.5% reported it extended the consultation time, the medium time taken was 2min. GPs felt framing the OKQ® helped introduce pregnancy intention discussions into a consultation. CONCLUSIONS: The OKQ® is acceptable to patients and easy for GPs to use. This tool facilitates a proactive and routine discussion to enhance the delivery of preconception care and contraceptive counselling.

Protecting mental health in quarantine: Exploring lived experiences of healthcare in mandatory COVID-19 quarantine, New South Wales, Australia.

Objectives: In response to the COVID-19 pandemic, Australia implemented mandatory hotel quarantine for returned international travellers from March 2020-November 2021. Healthcare was rapidly transformed and scaled up to facilitate delivery of face-to-face and virtual healthcare within quarantine facilities. We sought to understand, from the patient perspective, what a virtual model of healthcare may need to be aware of to respond to, protect, and mitigate people's mental health within a 'public health protection' context of quarantine. Design: Qualitative study design using in-depth semi-structured interviews exploring experiences of the virtual model of healthcare in quarantine. Setting: Special Health Accommodation (SHA) quarantine facilities following Australian Federal and New South Wales (NSW) State quarantine policy, NSW, Australia. Participants: 25 returned international travellers aged 18 years or older of any COVID-19 status who quarantined within SHA between October 2020-March 2021. Results: Participants identified three broad areas of concern. Firstly, their potential to transmit COVID-19, that created anxiety for all participants. Secondly, the effects of losing personal freedoms in quarantine to protect the wider Australian community. Thirdly, many participants entered quarantine during intense biographical moments in their lives, compounding the stress of their experience. Participants felt lost within the 'faceless' quarantine administrative system they navigated prior to their actual arrival in Australia and during their mandated quarantine period. This cumulative experience compromised their expectations and experiences of person-centred care once in quarantine. Conclusions: Quarantine has been a critical public health measure for managing COVID-19 in Australia. The pandemic provides opportunities to learn from quarantine implementation. Participants struggled to separate healthcare provision from the broader quarantine systems and processes. Due to this confusion, blame was directed at healthcare providers for many, and in some cases all difficulties, including those encountered getting into and once within quarantine. Valuable lessons can be learnt from engaging with patients' perspectives to adapt and strengthen future quarantine to deliver responsive, person-centred healthcare.

Impact Evaluation of the Get Healthy in Pregnancy Program: Evidence of Effectiveness.

The efficacy of lifestyle interventions for reduced gestational weight gain (GWG) is established, but evidence of their effectiveness is limited. The Get Healthy in Pregnancy (GHiP) program is a telephone health coaching program supporting healthy GWG delivered state-wide in New South Wales, Australia. This evaluation explores the impact of GHiP on behavioural outcomes and GWG, analysing GHiP participant data (n = 3702 for 2018-2019). We conducted McNamar's tests to explore within-individual change for behavioural outcomes and logistic regression to assess associations between demographic characteristics, participant engagement and behavioural and weight outcomes for women who completed the program. Participants who completed ten coaching calls made significant improvements (all p < 0.001) in more health-related behaviours (walking, vigorous physical activity, vegetable consumption, takeaway meals and sweetened drink consumption) than those who completed fewer calls. Among women with valid weight change data (n = 245), 31% gained weight below, 33% gained weight within, and 36% gained weight above GWG guidelines. Pre-pregnancy BMI was the only factor significantly associated with meeting GWG guidelines. Women with pre-pregnancy overweight and obesity had lower odds than those with a healthy weight of having GWG within the guidelines. The majority of these women did not gain weight above the guidelines. A higher proportion of women with pre-pregnancy obesity gained weight below the guidelines (33.8%) than above the guidelines (28.5%). GHiP has the potential to support all pregnant women, including those with pre-pregnancy obesity, to achieve a healthier pregnancy.

Measures of Pregnancy Intention: Why Use Them and What Do They Tell Us?

Understanding pregnancy intention is an important public health measure that captures the ability of individuals to access information, resources, and services needed to plan the timing and spacing of pregnancies. Pregnancy intention is a complex construct impacted by social, emotional, financial, cultural, and contextual factors. In this review, we will examine the range of available tools for individuals and populations to evaluate pregnancy intention, the timing of the tools in relation to pregnancy, their interpretation, and use for policy and practice. Traditionally, pregnancy intention was only assessed in population health surveys; however, more sophisticated tools and measures have been developed. These tools can be used at several time points: before pregnancy, during pregnancy, or after the pregnancy has ended. It is important to appreciate the varied contexts globally for women and their partners when assessing pregnancy intention, and the ability of a given tool to capture this when used retrospectively or prospectively. These tools can inform targeted delivery of services for a person or couple before, during, and after pregnancy. This knowledge can inform strategies at an individual, community, and population level as an indicator of access to sexual and reproductive health information and knowledge and uptake of preconception health.

A Systematic Review of Clinical Guidelines for Preconception Care.

Preconception care (PCC) involves a wide-ranging set of interventions to optimize health prior to pregnancy. These interventions seek to enhance conception rates, pregnancy outcomes, childhood health, and the health of future generations. To assist health care providers to exercise high-quality clinical care in this domain, clinical practice guidelines from a range of settings have been published. This systematic review sought to identify existing freely accessible international guidelines, assess these in terms of their quality using the AGREE II tool, and assess the summary recommendations and the evidence level on which they are based. We identified 11 guidelines that focused on PCC. Ten of these were classified as moderate quality (scores ranging from 3.5 to 4.5 out of 7) and only one was classified as very high quality, scoring 6.5. The levels of evidence for recommendations ranged from the lowest possible level of evidence (III) to the highest (I-a): the highest quality evidence available is for folic acid supplementation to reduce risk of neural tube defects and the role of antiviral medication to prevent HIV transmission. This systematic review identified that high-quality guidelines on PCC are lacking and that few domains of PCC recommendations are supported by high-quality evidence.

Setting Preconception Care Priorities in Australia Using a Delphi Technique.

Preconception health affects fertility, pregnancy, and future health outcomes but public awareness of this is low. Our aims were to rank priorities for preconception care (PCC), develop strategies to address these priorities, and establish values to guide future work in preconception healthcare in Australia. A Delphi technique involved two rounds of online voting and mid-round workshops. Inputs were a scoping review of PCC guidelines, a priority setting framework and existing networks that focus on health. During July and August, 2021, 23 multidisciplinary experts in PCC or social care, including a consumer advocate, completed the Delphi technique. Ten priority areas were identified, with health behaviors, medical history, weight, and reproductive health ranked most highly. Six strategies were identified. Underpinning values encompassed engagement with stakeholders, a life course view of preconception health, an integrated multi-sectorial approach and a need for large scale collaboration to implement interventions that deliver impact across health care, social care, policy and population health. Priority populations were considered within the social determinants of health. Health behaviors, medical history, weight, and reproductive health were ranked highly as PCC priorities. Key strategies to address priorities should be implemented with consideration of values that improve the preconception health of all Australians.

Interconception care.

BACKGROUND: The importance of interconception care - defined as care given to women, and their partners, between one pregnancy and the next to optimise their health - is increasingly important, with rising rates of overweight, obesity, diabetes and hypertension among people of reproductive age. Women frequently visit their general practitioner (GP) in the first six months postpartum. This is an opportune time to discuss ideal interpregnancy intervals (IPIs) and advise women about contraception and healthy behaviours. OBJECTIVE: The aim of this article is to review available research and guidelines on interconception care and IPIs, and propose best-practice care for the general practice setting. DISCUSSION: GPs are uniquely placed to deliver the different aspects of interconception care including reviewing the outcomes of the previous pregnancy, advising women on optimal IPIs and providing contraception and lifestyle guidance. Studies have found that GPs may feel they lack the time and resources to provide interconception care, but support is available through online tools and easy-to-access checklists. As the prevalence of obesity and chronic diseases increases, interconception care has the potential to reduce future adverse perinatal outcomes.

Preconception care.

BACKGROUND: Preconception care (PCC) comprises counselling and the provision of biomedical, behavioural and social health interventions to optimise the health of women and their partners prior to pregnancy and improve health related outcomes for themselves and their children. OBJECTIVE: With a focus on women, the aim of this paper is to discuss the evidence for PCC, available guidelines and strategies to increase primary care access. DISCUSSION: Each year an estimated 10% of women in Australia become pregnant. There is increasing evidence that optimising health in the preconception period is crucial to improving short-term and long-term outcomes for mothers and babies. General practitioners can have a key role in assisting women to identify modifiable and non­modifiable preconception risks and to make informed decisions about planning or avoiding pregnancy. The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice includes a chapter on preventive activities prior to pregnancy, which is a useful resource. The critical first step is screening women for their pregnancy intentions by asking a simple question that can help facilitate the start of the PCC conversation.

Accuracy of inflationary versus deflationary oscillometry in pregnancy and preeclampsia: OMRON-MIT versus OMRON-M7.

OBJECTIVE: To assess the accuracy of the OMRON-MIT (inflationary) and OMRON-M7 (deflationary) devices for measuring blood pressure in a pregnant population, including women with preeclampsia, according to the British Hypertension Society protocol. METHODS: Forty-five pregnant women, including 15 with preeclampsia, were recruited at a large teaching hospital. Nine sequential same arm measurements were taken from each patient alternating between the test device and mercury sphygmomanometry. Both devices were assessed in the same women. Data were analysed according to the British Hypertension Society protocol. RESULTS: The OMRON-MIT achieved an A/A grade in both pregnancy and preeclampsia with an overall mean difference (SD) of -1.3 (5.6) mmHg and 0.4 (5.6) mmHg for systolic and diastolic pressures, respectively. The OMRON-M7 achieved an A/A grade in pregnancy and a B/B grade in preeclampsia with an overall mean difference (SD) of -5.3 (6.6) mmHg and -3.5 (6.9) mmHg. CONCLUSION: Both the OMRON-MIT and the OMRON-M7 can be recommended for use in pregnancy and preeclampsia. Inflationary oscillometry (OMRON-MIT) was more accurate in preeclampsia.