The effects of preconception interventions on improving reproductive health and pregnancy outcomes in primary care: A systematic review

Figures & data

Figure 1. Study flow of papers for inclusion in review.

Table 1(a). Characteristics of included studies involving multifactorial reproductive health risks interventions.

Study ref.	Country	Design	Setting	Participants	Number of women recruited	Duration of intervention and follow-up	Intervention	Comparator	Outcome measures
(21)	Netherlands	Cluster RCT at general practice level	General practices	Women aged 18–40 years old planning a pregnancy	Intervention: 30 GPs Control: 37 GPs 14915 women eligible. 6782 (45%) responded. Of these, 1820 intended to get pregnant within one to five years. Only 348 (2.3%) attended PCC within the study period.	Single GP consultation; follow-up immediately after consultation and two months after subsequent delivery	PCC by trained GPs on general and specific risks based on risk assessment questionnaire: e.g. genetics, infection, medication use, folate, alcohol, smoking. Brochures on preconception health were given.	Usual clinic consultation	Knowledge: Knowledge of pregnancy-related risks and its prevention (20 items on hazardous substances, prevention of infection, folate and timing of conception) Maternal risk behavioural change: folate intake, alcohol, smoking Adverse pregnancy: low birth weight, preterm delivery  <37 weeks, congenital abnormalities, perinatal death
(22)	Netherlands	Cluster RCT at general practice level	General practices	Women aged 18–40 years old planning a pregnancy	Intervention: 30 GPs Control: 37 GPs 14 915 women eligible. 6782 (45%) responded. Of these, 1820 intended to get pregnant within one to five years. Only 348 (2.3%) attended PCC within the study period.	Single GP consultation; follow-up immediately after consultation and two months after subsequent delivery	PCC by trained GPs on general and specific risks based on risk assessment questionnaire; e.g. genetics, infection, medication use, folate, alcohol, smoking. Brochures on preconception health were given.	Usual clinic consultation	Psychological stress due to receiving information: Spielberger State-Trait Anxiety Inventory (STAI) score
(23)	Iran	RCT	Premarital counseling clinics	Women aged 18–35 years old planning to conceive in the first year of marriage	Intervention: 120 Control: 120	One day; follow-up two weeks	Preconception health education by facilitators qualified in health education and women’s health programme; individual session followed by group session of 8–12 women covering healthy lifestyle and physical activity. Includes routine premarital clinic sessions.	Routine premarital clinic sessions which also covered screening of genetic conditions, drug abuse, sexually transmitted infections and family planning	Multidimensional Health Locus of Control (HLOC) score: Internal HLOC and external HLOC. Physical exercise self-efficacy score
(24)	USA	RCT	Community based centres (Women-infant clinics and family planning clinics)	Women aged 18–35 years old capable of becoming pregnant (no history of tubal ligation, hysterectomy or other known cause of infertility)	Intervention: 473 Control: 219	Twelve weeks; follow-up 14 weeks	Six group sessions (2-h each) by trained facilitators on preconception health, stress, physical activity, smoking, nutrition, gynaecological infection, healthy eating demonstration. Participants who were unable to attend certain sessions were provided with session materials.	Usual clinic consultation	Self-efficacy: To eat healthier food and physically active, preconceptional control of birth outcomes. Maternal risk behavioural change: Folate intake
(25)	Australia	RCT	Home visits	Women after delivery of first pregnancy	Intervention: 777 Control: 802	One day home visit; follow-up at delivery of subsequent pregnancy	Home visit by pre-pregnancy midwives; discussion on pre-pregnancy health and preparation for next pregnancy; advice on smoking, alcohol, drugs; offer referral for problems such as genetic conditions; arrange for rubella vaccination.	Discussion on experience of labour, birth and postpartum	Adverse pregnancy outcomes: low birth weight (<2,500 g, preterm birth, congenital abnormalities, perinatal death

Table 1(b). Characteristics of included studies involving single reproductive health risk interventions.

Study ref.	Country	Design	Setting	Participants	Number of women recruited	Duration of intervention and follow-up	Intervention	Comparator	Outcome measures
(26)	USA	RCT	Urgent care clinic	Women aged 18–45 years old planning a pregnancy within a year	Intervention: 227 Control: 219	15 min; follow-up six months	A short computerized counselling consists of video segments of a doctor addressing preconception folate intake. A free bottle of 200 folate tablets was given.	Computerized counselling on emergency contraception	Knowledge: On folate can prevent birth defect Maternal risk behavioural change: Folate intake
(27)	USA	Cluster RCT	Women-infant clinics and Food Stamp Program offices	Any women aged 18–45 years old	Intervention: 77 Control: 78	One day; follow-up four weeks	Group education on folate-focused nutrition by trained facilitators from the Food Stamp Nutrition Education program offices.	Group education on resource management	Maternal risk behavioural change: Folate and folate-related food intake.
(28)	USA	RCT	Primary care practices	Women aged 18–44 years old planning to become pregnant within the next nine months	Intervention: 416 Control: 414	Fourteen weeks; follow-up at three, six and nine months	Intensive counselling sessions by trained counsellors on alcohol and one contraception counselling by physician or family planning nurse. Sessions over 14 weeks, two to three weeks between sessions and each session was 45–60 min.	Brochures on alcohol use and women’s health in general were given.	Maternal risk behavioural change: Reduced on risky drinking—binge drinking (consume five or more standard drink/day; frequent drinking (eight or more drinks/week; practice on contraception (assessed using timeline follow back (TLFB) method (shown to be reliable and valid)
(29)	USA	RCT	Gynaecology outpatient clinics	Any women aged 18–45 years old	Intervention: 160 Control: 162	30–60 s of counselling and booster call at one to two weeks; follow-up two months	Brief counselling by a gynaecologist evidenced- based benefits of folate following a prepared script. A free bottle of 30 folate tablets and pamphlet on folate was given.	Brief counselling on one of the following preventive healthcare; breast self-exam; seat belt use; and sunscreen use. A pamphlet on folate and a coupon for free folate tablets was also given.	Maternal risk behavioural change: Self-reported frequency of folate intake

Table 2(a). Summary of results of included studies involving multifactorial reproductive health risks interventions on maternal knowledge; self-efficacy and health locus of control; risk behaviour change; adverse pregnancy outcomes and psychological stress.

Study ref.	Country	Outcome measures	Results
(21)	Netherlands	Knowledge	Improvement in knowledge:
			Difference in knowledge score in women who has never been pregnant: 11.3(95% CI: 4.6–18.0)
			Difference in knowledge score in women who has been pregnant: 3.0 (95% CI:1.2–4.84)
			Maternal risk behavioural change:
		Maternal risk behavioural change	Folate intake: OR: 5.40 (95%CI: 3.15–9.28)
			No binge drinking on alcohol on ≥1 occasion before or during pregnancy: OR: 1.52 (95% CI: 0.64–3.60).
			No alcohol use during first 3 months of pregnancy: OR: 1.68 (95% CI: 1.03–2.75).
			Quit smoking before pregnancy: OR: 3.04 (95% CI: 0.95–9.69).
			Adverse pregnancy outcomes:
		Adverse pregnancy outcomes	Total number of adverse pregnancy outcomes in the intervention group is 23/145
			(N); 16.2% as compared to control group 343/1740 (N); 20.2%. OR: 0.77 (95% CI:0.48–1.22).
			Congenital abnormalities 5/145 (N) (3.9%) in the intervention group as compared
			in the control group 68/1740 (N) (4.5%). OR: 0.88 (95% CI: 0.35–2.21).
			Low birth weight OR 0.58 (95% CI: 0.21–1.61)
			Preterm delivery <37 weeks OR: 0.76 (95% CI: 0.36–1.59).
			Perinatal death OR: 0.86 (95% CI: 0.11–6.55).
(22)	Netherlands	Psychological stress due to receiving information	Psychological stress due to receiving information:
			Change in mean score between STAI-1 and STAI-2: 3.6 (95% CI: 2.4–4.8) in
			intervention group
			Mean scores of the STAI-3 were 38.7 (95% CI: 37.9–39.5) in intervention group
			versus 38.5 (95% CI: 37.7–39.3) in control group
(23)	Iran	Multidimensional Health Locus of Control (HLOC)	Difference in mean score:
			Internal HLOC score 6.4 (95% CI: 5.41–7.39), P < 0.001
			External HLOC score -0.3 (95% CI: -1.49-0.89) P = 0.62
		Self-efficacy	Physical exercise self-efficacy score 15.4 (95% CI: 13.74–17.06), P < 0.001
(24)	USA	Self-efficacy	Improvement in self-efficacy:
			To eat healthier food OR: 1.757, P = 0.008
			Physically active OR: 2.185, P <0.0001
			Preconceptional control OR: 1.916, P = 0.031
		Maternal risk behavioural change	Maternal risk behavioural change:
			Daily multivitamin with folate intake OR: 6.595, P = 0.0001
(25)	Australia	Adverse pregnancy outcomes	Adverse pregnancy outcomes:
			Low birth weight <2500 g OR:1.85 (95% CI: 0.91–3.91)
			Preterm birth <37 weeks OR: 1.44 (95% CI: 0.73–2.91)

Table 2(b). Summary of results of included studies involving single reproductive health risk interventions on maternal knowledge; self-efficacy and health locus of control; risk behaviour change; adverse pregnancy outcomes and psychological stress.

Study ref.	Country	Outcome measures	Results
(26)	USA	Knowledge	Improvement in knowledge:
			Knowledge on folate can prevent birth defect OR: 4.19 (95% CI: 1.98–8.85)
			Knowledge on folate is important in the first few weeks of pregnancy OR 2.7 (95% CI: 1.75–4.26)
		Maternal risk behavioural change	Maternal risk behavioural change:
			Folate intake increased in the last few months OR: 1.55 (95% CI: 0.88–2.72)
(27)	USA	Maternal risk behavioural change	Maternal risk behavioural change:
			Mean folate intake from all sources (naturally occurring and synthetic) (μg DFE/d)
			increased in the 197.9 ± 58.2 in the intervention group versus 46.8 ± 85.4 in the
			control group. P = 0.035
(28)	USA	Maternal risk behavioural change	Maternal risk behavioural change:
			Reduced risky drinking on alcohol at three months follow-up OR: 1.79 (95% CI:1.28–2.51)
			Reduced risky drinking on alcohol at six month follow-up OR: 1.64 (95% CI: 1.15–2.33)
			Reduced risky drinking on alcohol at nine month follow-up OR: 1.54 (95% CI: 1.09–2.18)
(29)	USA	Maternal risk behavioural change	Maternal risk behavioural change:
			Daily folate intake increased 67% in the intervention group relative to baseline as
			compared to 54% in the control group P = 0.549.
			Weekly folate intake increased 68% in the intervention group relative to baseline
			as compared to 20% in the control group. P = 0.008

Study references (21) and (22) are from one large study.

HLOC: Health Locus of Control; OR: odds ratio; PCC: preconception care counselling; RCT: randomized controlled trial; STAI: Spielberger State-Trait Anxiety Inventory.

Table 3. Assessment of risk of bias: Review authors’ judgements about each methodological quality item for each included studies of multifactorial and single reproductive health risk interventions.

	Multifactorial reproductive health risks interventions				Single reproductive health risk interventions
Study reference	(21,22)	(23)	(24)	(25)	(26)	(27)	(28)	(29)
Sequence generation	Unclear	Low risk	Unclear	Low risk	Low risk	Unclear	Low risk	Unclear
Allocation concealment	Unclear	Unclear	Unclear	Unclear	Low risk	Unclear	Low risk	Unclear
Blinding	High risk	High risk	High risk	High risk	Low risk	High	High risk	High risk
Incomplete outcome data	High risk	Unclear	High risk	High risk	Low risk	Unclear	Unclear	Unclear
Selective outcome reporting	Unclear	Low risk	Unclear	Unclear	Low risk	Low risk	Low risk	Low risk

Study references (21) and (22) are from one large study.

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