Planning is not equivalent to preparing, how Dutch women perceive their pregnancy planning in relation to preconceptional lifestyle behaviour change - a cross-sectional study.

BACKGROUND: Unhealthy prenatal lifestyle behaviours are associated with adverse pregnancy outcomes, but little is known about what motivates women to comply with preconceptional lifestyle recommendations or consciously plan their pregnancy. Therefore, the objective of this study is to explore the associations between preconceptional lifestyle behaviours, health beliefs and pregnancy planning among Dutch pregnant women. METHODS: In this cross-sectional study based on the data of the APROPOS-II study, 1,077 low-risk pregnant women were eligible for inclusion. Preconception lifestyle behaviours and actively preparing for pregnancy were assessed in relation to planned pregnancies (based on the London Measure of Unplanned Pregnancies) and health beliefs (14 statements). The following preconceptional lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester of pregnancy: fruit intake, vegetable intake, caffeine intake, (second-hand)smoking, alcohol intake, folic acid supplement use and exercise. Data were analysed using multivariate logistic regression analyses. RESULTS: A total of 921 (85.5%) women in our cohort had a planned pregnancy. However, of these women, 640 (69.5%) adequately used folic acid supplements and 465 (50.5%) women consumed alcohol at any point during pregnancy. Of the women considering themselves 'healthy enough and not needing preconception care', 48 (9.1%) women had an adequate vegetable intake, 294 (55.6%) women consumed alcohol at any point during pregnancy and 161 (30.4%) women were either over-or underweight. CONCLUSION: Despite consciously planning their pregnancy, most women did not adhere to preconceptional lifestyle behaviour recommendations. Women's health beliefs and overestimation of their health status seem to interfere with actively planning and preparing for pregnancy. Findings from our study may encourage the development of prospective health-promoting interventions that focus on health beliefs and actively preparing for pregnancy, to improve preconceptional lifestyle behaviours, thereby optimizing the health of future generations.

Exploring male perceptions regarding the need to engage in preconception care - a mixed-method study amongst Dutch (prospective) fathers.

PURPOSE: While most preconception care (PCC) interventions are aimed at women, men are also in need of PCC to reduce risk factors affecting the spermatozoa quality. The objective of this study is to explore male perceptions regarding the need to engage in PCC. MATERIALS AND METHODS: In a mixed-method cross-sectional study, 229 men participated with a questionnaire and 14 individual semi-structured interviews were conducted. Questionnaires data were analysed using multiple regression analyses. The interviews were analysed using thematic analyses. RESULTS: Most men did not retrieve preconceptional information (n = 135; 59.0%) nor visited a preconceptional consult (n = 182; 79.5%). Men who categorised their preconceptional lifestyle as unhealthy (score ≤6 out of 10) less often retrieved information (adjusted OR 0.36 [95% CI 0.14-0.93]) than men with a healthy preconceptional lifestyle. While several men expressed their fear for infertility, this did not lead to an increased uptake of PCC as men felt they were healthy enough already. CONCLUSION: Despite high awareness of the positive influence of a healthy lifestyle, the perceived need for preparing for pregnancy among men remains low. Tailoring preconceptional information towards male needs provides a window of opportunity to improve men's reproductive health and possibly the health of future generations.

How to improve preconception care in a local setting? Views from Dutch multidisciplinary healthcare providers.

OBJECTIVE: To explore healthcare providers' views on improving preconception care in their region. DESIGN: Mixed-methods study. SETTING: Working conferences aimed to educate healthcare providers on preconceptional risk factors and conduct a region-specific analysis of barriers and facilitators for implementing preconception care, were organised in ten municipalities in the Netherlands. PARTICIPANTS: 250 healthcare providers of various disciplines attended a working conference and participated in the study. MEASUREMENTS AND FINDINGS: Participants were asked to both fill out a questionnaire concerning statements and experiences with preconception care and to participate in a workshop, to identify barriers and facilitators for the implementation of a local preconception care program. Almost all healthcare providers suggested that the responsibility for providing preconception care consultations lies within primary care (general practitioners (n = 239; 95.6%) and midwives (n = 236; 94.4%)). Professionals other than midwives found it significantly more difficult to start a conversation about a wish to conceive compared to midwives (26.8% versus 20.2%, p-value = 0.006) and felt less competent to provide preconceptional information (32.3% versus 15.1%, p-value = <0.001). Innovative facilitators were mentioned to improve reaching the target population with preconceptional information, i.e. the use of social media and local ambassadors. KEY CONCLUSION: While the responsibility for providing preconception care consultations is best suited with primary care, many other healthcare providers involved may act as referrers towards preconception care. Still, approximately 1 in 7 midwives (strongly) disagree with the statement that it is part of their job to provide preconceptional information to couples with a wish to conceive. IMPLICATIONS FOR PRACTICE: There is a need for integrating preconception care in many curricula and postgraduate courses, especially for non-midwives, to improve the delivery of preconception care. Insights in the suggested barriers and facilitators can improve the implementation of (local) preconception care programs.

Associations between periconceptional lifestyle behaviours and adverse pregnancy outcomes.

BACKGROUND: While the potential adverse outcomes of prenatal exposure to unhealthy lifestyle are widely evidenced, little is known about these exposures in the periconception period. We investigated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle behaviours. METHODS: A secondary analysis took place within a prospective multicentre cohort study in the Netherlands, including 3,684 pregnant women. Baseline characteristics and preconceptional and first trimester lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester. Adverse pregnancy outcomes (hypertensive disorders in pregnancy (HDP), small for gestational age (SGA), gestational diabetes (GDM) and spontaneous preterm birth (sPTB)) were reported by healthcare professionals. Data were collected between 2012 and 2014 and analysed using multivariate logistic regression. RESULTS: Women who are overweight, and especially obese, have the highest odds of developing any adverse pregnancy outcome (adjusted odds ratio (aOR) 1.61 (95 % Confidence Interval (CI) 1.31-1.99) and aOR 2.85 (95 %CI 2.20-3.68), respectively), particularly HDP and GDM. Women who prenatally continued smoking attained higher odds for SGA (aOR 1.91 (95 %CI 1.05-1.15)) compared to the reference group, but these odds decreased when women prenatally quit smoking (aOR 1.14 (95 %CI 0.59-2.21)). Women who did not use folic acid supplements tended to have a higher odds of developing adverse pregnancy outcomes (aOR 1.28 (95 %CI 0.97-1.69)), while women who prenatally started folic acid supplements did not (aOR 1.01 (95 %CI 0.82-1.25)). CONCLUSIONS: Our results indicate that smoking cessation, having a normal body mass index (BMI) and initiating folic acid supplements preconceptionally may decrease the risk of adverse pregnancy outcomes. Therefore, intervening as early as the preconception period could benefit the health of future generations.

Feasibility of the PalliSupport care pathway: results from a mixed-method study in acutely hospitalized older patients at the end of life.

BACKGROUND: A transitional care pathway (TCP) could improve care for older patients in the last months of life. However, barriers exist such as unidentified palliative care needs and suboptimal collaboration between care settings. The aim of this study was to determine the feasibility of a TCP, named PalliSupport, for older patients at the end of life, prior to a stepped-wedge randomized controlled trial. METHODS: A mixed-method feasibility study was conducted at one hospital with affiliated primary care. Patients were ≥ 60 years and acutely hospitalized. The intervention consisted of (1) training on early identification of the palliative phase and end of life conversations, (2) involvement of a transitional palliative care team during admission and post-discharge and (3) intensified collaboration between care settings. Outcomes were feasibility of recruitment, data collection, patient burden and protocol adherence. Experiences of 14 professionals were assessed through qualitative interviews. RESULTS: Only 16% of anticipated participants were included which resulted in difficulty assessing other feasibility criteria. The qualitative analysis identified misunderstandings about palliative care, uncertainty about professionals' roles and difficulties in initiating end of life conversations as barriers. The training program was well received and professionals found the intensified collaboration beneficial for patient care. The patients that participated experienced low burden and data collection on primary outcomes and protocol adherence seems feasible. DISCUSSION: This study highlights the importance of performing a feasibility study prior to embarking on effectiveness studies. Moving forward, the PalliSupport care pathway will be adjusted to incorporate a more active recruitment approach, additional training on identification and palliative care, and further improvement on data collection.

A feasibility study of implementing a patient-centered outcome set for pregnancy and childbirth.

BACKGROUND AND AIMS: Patient-reported outcome and experience measures (PROM and PREM) can facilitate shared decision making and hold potential to improve healthcare quality. However, their adoption in perinatal care is still limited. The International Consortium for Health Outcomes Measurement (ICHOM) developed a Pregnancy and Childbirth (PCB) outcome set, including PROM and PREM questionnaires. We studied the feasibility to use these PROMs/PREMs in Dutch perinatal care, addressing both women's and professionals' perspective. METHODS: Patients and professionals in primary and hospital care participated. Women under care at one of five timepoints for PROM/PREM collection of the PCB set (2 during pregnancy, 3 postpartum) were e-mailed a questionnaire and discussed their answers with their obstetric professional the next regular visit. Compliance was recorded. After discussing the PROMs/PREMs, usability and experience were assessed with separate surveys amongst women and professionals. RESULTS: Of 26 women approached, 21 completed and discussed their PROM/PREM questionnaire. Mean questionnaire completion rate was 97%. Average reported time completing the questionnaires was 10 minutes; most women (90%) stated this was acceptable. Women preferred completing questionnaires digitally and discuss their answers with an obstetric professional rather than other care professionals, also 6 months postpartum. Over half of women agreed PROMs/PREMs supported shared decision making (58%), ability to raise issues (60%), and patient-clinician relationship (52%). Six professionals participated: two obstetricians, two clinical midwives, and two community midwives. Most professionals experienced sufficient time to discuss the responses, except at 6 months postpartum. They knew what items to discuss but did not always feel responsible to act upon them. Professionals agreed PROMs/PREMs supported symptom detection and personalized care. CONCLUSIONS: Patients and obstetric professionals consider the PCB set a feasible instrument for PROM/PREM assessment, with good compliance, acceptability and usability. Important determinants of successful implementation are a well-equipped ICT-tool, agreements regarding professionals' responsibilities and how outcomes are discussed or acted upon.

Health Care Providers' Views on the Transition Between Hospital and Primary Care in Patients in the Palliative Phase: A Qualitative Description Study.

CONTEXT: Inadequate handovers between hospital and home can lead to adverse health outcomes. A group particularly at risk is patients at the end of life because of complex health problems, frequent care transitions, and involvement of many professionals. OBJECTIVES: To investigate health care providers' views and experiences with regard to the transition from hospital to primary care in palliative care. METHODS: This was a descriptive qualitative study. Three focus group discussions were held with 28 nurses and two focus groups with nine physicians. Participants were recruited from primary and hospital care. The focus groups were audiorecorded, transcribed verbatim, and analyzed thematically. RESULTS: The following themes emerged from the data: lack of identification of and communication about the last phase of life; incomplete and insufficient handover; and uncertainty about responsibilities. Professionals emphasize the importance of proper handovers and transitional processes in these vulnerable patients. The transition between hospital to primary care is hindered by a lack of identification of the palliative phase and uncertainties about patient awareness. Direct communication between professionals is needed but lacking. The handover itself is currently primarily focused on physical aspects where psychosocial aspects were also found necessary. Furthermore, uncertainties with regard to physicians' responsibility for the patient seem to further hinder professionals in the transitional process. CONCLUSION: Efforts should be made to enhance knowledge and skills around identification of palliative needs and communication with patients about the end of life, especially in the hospital setting.

Study design of a stepped wedge cluster randomized controlled trial to evaluate the effect of a locally tailored approach for preconception care - the APROPOS-II study.

BACKGROUND: In a previous feasibility study (APROPOS) in a single municipality of the Netherlands, we showed that a locally tailored preconception care (PCC) approach has the potential to positively affect preconceptional lifestyle behaviours. Therefore, we designed a second study (APROPOS-II) to obtain a more robust body of evidence: a larger group of respondents, more municipalities, randomization, and a more comprehensive set of (clinical) outcomes. The aim of this study is to assess the effectiveness and the implementation process of a local PCC-approach on preconceptional lifestyle behaviours, health outcomes and the reach of PCC among prospective parents and healthcare providers. METHODS: This study is an effectiveness-implementation hybrid type 2 trial. This involves a stepped-wedge cluster randomized controlled trial design aiming to include over 2000 future parents from six municipalities in the Netherlands. The intervention has a dual-track approach, focusing on both the uptake of PCC among future parents and the provision of PCC by healthcare providers. The PCC-approach consists of 1) a social marketing strategy directed towards prospective parent(s) and 2) a local care pathway to improve interdisciplinary collaboration. Data will be collected before and after the introduction of the intervention through questionnaires and medical records in each of the participating municipalities. The primary outcome of this study is change in lifestyle behaviours (e.g. folic acid use, smoking and alcohol use). Secondary outcomes are pregnancy outcomes (e.g. miscarriage, preterm birth, gestational diabetes) and the uptake of PCC. Moreover, a process evaluation will be performed, providing information on the efficacy, feasibility, barriers and facilitators regarding the implementation of the intervention. DISCUSSION: The APROPOS-II study introduces a locally tailored PCC-approach in six municipalities in the Netherlands that will contribute to the body of evidence regarding the effectiveness of PCC and its implementation. If this intervention has a positive effect on lifestyle behaviour changes, leading to improved pregnancy outcomes and the future health of prospective parents and their offspring, it could subsequently be upscaled to (inter)national implementation. TRIAL REGISTRATION: Dutch Trial register: NL7784 (Registered June 6th, 2019).

The effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care.

PURPOSE: The objective of this study was to investigate the effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care (PCC). MATERIAL AND METHODS: This quasi-comparative study was carried out between February 2015 and February 2016 at a community midwifery practice in the Netherlands. The intervention consisted of a dual track approach (i) a promotional campaign for couples who wish to conceive and (ii) a PCC pathway for health care providers. Questionnaires were collected from a sample of women who received antenatal care during the pre-intervention (n = 283) and post-intervention (n = 257) period. Main outcome measures were preconceptional lifestyle changes and PCC use (defined as searching for information and/or consulting a health care provider). RESULTS: Women who were exposed to the intervention were significantly more likely to make at least one lifestyle change during the preconception period [adjusted OR 1.56 (95% CI 1.02-2.39)]. Women were especially more likely to preconceptionally reduce or quit [adjusted OR 1.72 (95% CI 1.05-2.83)] their alcohol consumption after exposure to the intervention. Although non-significant, it appeared that women who were exposed to the intervention more often prepared themselves for pregnancy by means of independently searching for preconception health information [adjusted OR 1.13 (95% CI 0.77-1.65)] or consulting a health care provider regarding their wish to conceive [adjusted OR 1.24 (95% CI 0.81-1.92)]. CONCLUSIONS: Exposure to a local promotional campaign targeted at preconceptional health was associated with improved preconceptional lifestyle behaviours, especially with regard to alcohol consumption, and has the potential to improve the use of PCC.

Actively preparing for pregnancy is associated with healthier lifestyle of women during the preconception period.

OBJECTIVE: To assess whether actively preparing for pregnancy by women is associated with lifestyle changes during the preconception period. DESIGN: retrospective cross-sectional study. SETTING: primary care community midwifery practice in the Netherlands. PARTICIPANTS: convenience sample of 283 women who received antenatal care. MEASUREMENTS AND FINDINGS: the association between pregnancy preparation (defined as searching for information and/or consulting a healthcare provider) and preconception lifestyle changes (healthier diet, folic acid, alcohol and tobacco cessation) was measured and adjusted for age, body mass index and educational level. Almost 60% (n=160) of women acquired preconception information themselves and 25% (n=68) consulted a healthcare provider regarding their pregnancy wish. The former group was significantly more likely to quit drinking (adjusted OR 5.46 (95% CI 1.76-16.96)), improve their diet (adjusted OR 7.84 (95% CI 3.03-20.30)) and use folic acid (adjusted OR 3.90 (95% CI 2.00-7.62)) compared with women who did not prepare for pregnancy. Effect sizes were even larger for women who (also) consulted a healthcare provider with regard to folic acid use, healthier diet and smoking cessation. KEY CONCLUSIONS: gathering preconception information, either by women themselves or by means of a PCC consult, is associated with women positively changing lifestyles during the preconception period. IMPLICATIONS FOR PRACTICE: we recommend to not solely focus interventions on increasing the uptake of PCC consults, yet providing a suitable offer of preconception health information, which enables women to properly inform themselves.

Why Do Women Not Use Preconception Care? A Systematic Review On Barriers And Facilitators.

IMPORTANCE: Preconception care (PCC) has the potential to optimize pregnancy outcomes. However, awareness of PCC among the target population is generally limited, and the use of PCC remains low. IMPORTANCE: The objective of this study was to review the literature on women's perceptions regarding barriers and facilitators for the use of PCC. EVIDENCE ACQUISITION: A systematic search was conducted in MEDLINE, Embase, CINAHL, and PsycINFO for published studies until February 2015. Original qualitative and quantitative peer-reviewed studies from Western countries in English, holding women's perceptions regarding barriers and facilitators for the use of PCC. Data extraction and analysis were performed using NVivo version 10 software. A coding frame was derived from the findings and applied by 2 authors. Thematic analysis was used to identify key topics and themes. RESULTS: Twenty-one good-quality articles were included, of which 10 qualitative and 11 quantitative studies. Seven main themes were identified: preconditions, emotions and beliefs, perceived need, knowledge and experience, social structure, accessibility, and provider characteristics. "Not (fully) planning pregnancy", "perceived absence of risks", "lack of awareness", and "pregnancy experiences" were the most frequently identified barriers and "believing in the benefits" and "availability of PCC" the most frequently identified facilitators for PCC use. CONCLUSIONS AND RELEVANCE: Women perceive more barriers than facilitators related to PCC uptake, which explains why the use of PCC remains low. Our results provide a starting point to refocus interventions and strategies, aiming on enlarging the awareness, perceived importance, and accessibility of PCC to improve its uptake.