Twenty-six in-depth interview transcripts were analysed. There were nine nurses and seventeen specialist physicians who had worked for between one and 32 years (median 13.5years) in the health system. Three interviews were held at the primary level, five at the secondary level and 18 at the tertiary level. Participants’ details are shown in Table 1.
Table 1 Sociodemographic characteristics of the study participants
Sociodemographic characteristics
|
Doctors
|
Nurses
|
Total
|
|
Sex
|
Male
|
12
|
0
|
12
|
|
Female
|
5
|
9
|
14
|
Age
|
26-35
|
1
|
2
|
3
|
|
36-45
|
9
|
4
|
13
|
|
≥46
|
7
|
3
|
10
|
Specialty
|
Cardiology
|
1
|
–
|
1
|
|
Clinical nursing
|
–
|
4
|
4
|
|
Endocrinology
|
1
|
–
|
1
|
|
Family Medicine
|
1
|
–
|
1
|
|
Haematology
|
1
|
–
|
1
|
|
Nephrology
|
1
|
–
|
1
|
|
Neurology
|
1
|
–
|
1
|
|
Obstetrics/Gynaecology
|
5
|
–
|
5
|
|
Paediatrics
|
2
|
–
|
2
|
|
Psychiatry
|
1
|
–
|
1
|
|
Public Health
|
3
|
–
|
3
|
|
Public Health Nursing
|
–
|
5
|
5
|
Cadre
|
Fellow
|
14
|
–
|
14
|
|
Senior Registrar
|
3
|
–
|
3
|
|
Senior Nursing Officer
|
–
|
5
|
5
|
|
Chief Nursing Officer
|
–
|
2
|
2
|
|
Deputy Director of Nursing
|
–
|
2
|
2
|
Level of Healthcare
|
Primary
|
1
|
2
|
3
|
|
Secondary
|
3
|
2
|
5
|
|
Tertiary
|
13
|
5
|
18
|
The main themes generated from the data are shown in Table 2 and described thereafter.
Table 2 Themes generated from the data
Themes
|
Description/Subthemes
|
Scope of preconception care
|
· Description of PCC
|
|
· Components of PCC
|
|
· Personnel who should be involved in provision of PCC
|
People who require PCC
|
· Participant’s description of people who require PCC
|
Where PCC services can be provided
|
· Type of facility for provision of PCC services
|
|
· Level of health care for PCC services
|
Acceptability of preconception care
|
· Participant’s perceptions of the acceptability of PCC to community members
|
Relevance of PCC to specialties
|
· Opinions about the importance of PCC to clients seen in each participant’s specialty
|
Possible benefits of PCC
|
· Descriptions of the potential benefits of PCC
|
SCOPE OF PRECONCEPTION CARE
The health workers provided definitions of the scope of services that they understood PCC to cover. They described PCC in terms of its components and who should be involved in its provision.
Description of PCC
While some of the participants referred to PCC as care specifically for women, others described it as care for both women and men or couples who are preparing for childbearing.
“Preconception care is care that is given to women of child bearing age before they get pregnant” – Tertiary care level, Public Health Nurse (Ob/Gyn)
“Preconception care is a form of care given to people, men and women prior to the time that they plan to get pregnant as a form of preparation” – Primary care level, Public Health Physician
From the perspectives of some of the participants PCC can be described in relation to the timing of conception as care provided at least three months before a woman gets pregnant.
“In my own opinion, preconception care is any care that is given to women of reproductive age at least three months before they get pregnant” – Secondary care level, Ob/Gyn
Other opinions about PCC described it as care provided for couples who have peculiar health problems that may affect pregnancy. In such instances, participants described PCC as care to address health problems before pregnancy occurs.
“Pre-conception care refers to the services you offer a couple prior to pregnancy especially because there are health issues that may influence the anticipated pregnancy. Services such as medical, counselling services, indicated by peculiar health issues that could potentially affect the pregnancy.” – Tertiary care level, Neurologist
Other participants who gave their description in terms of the timing of PCC, stated that such care should start as early as possible in a girl’s life. In this instance, the description of PCC was provided in terms of service content with emphasis on the need to provide preventive measures like vaccinations and HIV prevention in adolescence.
“Preconception care is the care that women receive prior to conception and should be given right from school. If we take the Nigerian setting, right from the secondary school, a woman should have tetanus toxoid vaccination, her nutrition, sexual and reproductive care generally and how she would not contract HIV are part of preconception care. So, preconception care starts as early as possible and includes every care given to a girl child before pregnancy.” – Tertiary care level, Cardiologist
Components of PCC
The participants gave their opinions on what the components of PCC should be, identifying health education and counselling on adoption of a healthy lifestyle through improved nutrition, use of folic acid and immunisation against diseases like tetanus. They further mentioned the need to determine haemoglobin genotype and rhesus compatibility, identify and treat diseases including sexually transmitted infections and HIV, as well as planning towards a desired number and spacing of children.
“The elements of preconception care may be primordial, primary or secondary. For primordial you tell a woman to take folic acid before conception to prevent neural tube defect in the baby. For primary, you tell the woman to take tetanus toxoid, have hepatitis screening and immunisation before she gets pregnant. If the woman is rhesus negative, you give her certain medications to prevent complications. For secondary care, women who have delay in getting pregnant can be offered curative treatment after identifying the cause.” – Primary care level, Public Health Physician
“Preconception care … starts with a girl or a boy determining his or her genotype. Those who have been diagnosed with noncommunicable diseases at a very young age (less than 40) either hypertension or sickle cell disease need to take good care of themselves, using their medications appropriately. We take history of congenital abnormalities in the family; ensuring they don’t have any sexually transmitted disease prior to conception, take folic acid, eat balanced diet and see health personnel for preconception counselling. It also includes family planning” – Tertiary care level, Public Health Physician
“It is composed of health education, immunisations, supplementations for example, of folic acid which we normally give when they come to ANC but it is late then, folic acid should be given preconception. Screening for HIV, diabetes, hypertension, syphilis and hepatitis, genotype and blood group; these are the prongs that constitute preconception care.” – Tertiary care level, Paediatric Cardiologist
Personnel who should be involved in provision of PCC
The participants’ views varied regarding who should provide PCC services in the health care setting. The need for a multidisciplinary approach was brought forward as participants described services they believed should be provided by different specialties. Regarding primary responsibility for PCC however, some participants stated that family physicians should oversee provision of PCC services since they are usually the first contact most people have with the health system. Others believed PCC as a specialised service and should be provided by obstetricians and gynaecologists who are primarily responsible for women’s reproductive health.
“As a paediatrician, I would say the paediatrician is the best to provide the service but, not to be biased, Family Physicians are in the best position. They are the ones people go to when they want to do all the entry things {i.e. First point of contact in hospital settings}. The Paediatricians should be involved too, Obstetricians come later then everybody involved in Health Education. It is multidisciplinary. We need politicians as well because they formulate policies.” – Tertiary care level, Paediatrician
“Doctors usually gynaecologists, nurses, the whole team that provides antenatal care can also provide preconception care.” – Secondary care level, Ob/Gyn
“Actually, preconception care should be run by the obstetrics and gynaecological practitioners – the doctors, the nurses – because that is their area not just the general practitioner” – Tertiary care level, Clinical Nurse
On the other hand, some participants expressed the opinion that any doctor or health care provider who provides care for women should be able to offer PCC.
“To the best of my knowledge, it is the healthcare provider or doctor who is the first person you see in the clinic. I am not aware of any particular specialist for preconception care. I think every healthcare provider should be able to do provide preconception care.” – Tertiary care level, Nephrologist
With regards to providing preconception counselling particularly to adolescents and youth, some of the public health specialists expressed the opinion that teachers should be involved in PCC, particularly with counselling and health education.
“If it is for education or counselling, I believe the teachers in secondary schools should be involved. Then when it comes to rendering particular care, health workers should be involved too. If you come in contact with any youth, {either as} health workers or teachers should be able to provide this type of care either in the form of counselling {as teachers and health workers} or actual care {as health workers}” – Tertiary care level, Public Health Nurse
PEOPLE WHO REQUIRE PCC
Generally, most of the health workers interviewed indicated that all women and men in their childbearing years should have preconception care. In their opinion, this includes those who are preparing for their first pregnancy and those who have had children before but will like to have more. They believed that such people also need PCC to prepare for subsequent pregnancies.
“Women of reproductive age group will benefit more from preconception care, from adolescents to young adults, single or married because it is not everybody who gets married that easily gets pregnant immediately. Then it is also meant for people who after conception and birth need to know what to do to prepare themselves for subsequent pregnancies”. – Tertiary care level, Public Health Physician
Some of the participants stated that every girl child should be included in the provision of PCC since they all have the potential for childbearing, and it is impossible to say who may or may not want to have children when they grow older.
“It is required for every girl child. How many people know whether they are going to get married or get pregnant? So, everybody should have it.” – Tertiary care level, Paediatric Cardiologist
Further, they provided descriptions of circumstances where they believed PCC may be very crucial because of the possibility of negative pregnancy outcomes. Their descriptions included instances when couples have health challenges that may affect their ability to conceive or impact negatively on pregnancy outcomes. The health challenges mentioned include genetic conditions, hypertension, diabetes and epilepsy for which women require medications that may need to be modified before pregnancy to prevent abnormalities in the baby.
“I think preconception care is required by women and their partners who may have a peculiar health challenge, for instance, a genetic condition that is potentially transmissible to their children. Women of reproductive age group who have epilepsy also need preconception care along with their partners because there are anti-epileptic drugs that are potentially teratogenic {can cause abnormalities in the baby}.” – Tertiary care level, Neurologist
“It’s for women who have risk factors for having a child with congenital problems or pregnancy with adverse outcomes. Patients with high blood pressure need to have their blood pressure stabilised. Patients who are on drugs may need to change their drugs prior to conception because many of the drugs predispose those patients to congenital abnormalities. Those who are diabetic and are on oral hypoglycaemic agents you want to switch to insulin. At the end of the day you want to have a healthy child and a healthy mother during pregnancy.” – Tertiary care level, Ob/Gyn
Participants also stated their opinions on the need for determining haemoglobin genotype compatibility in the preconception period to avoid having children with the sickle cell disorder (Sickler).
“In cases of genotype incompatibility (the AS, SS) you want to provide preconception care to tell them the kind of person that will suit them. Somebody that is SS should not marry somebody that is AS otherwise they have at least 50% chance of having a Sickler and you know the burden of taking care of a Sickler. Same applies to those who are AS, they should at least marry AA so they don’t have children who are Sicklers.” – Tertiary care level, Clinical Nurse
WHERE PCC SERVICES CAN BE PROVIDED
Type of health facility for provision of PCC services
In expressing their views about the most appropriate location for provision of PCC services, participants mentioned facilities that already provide maternal health services. They indicated that any facility that provides family planning services, antenatal and delivery care are centres where potential clients for PCC already receive care. This opinion was more common among the secondary level service providers and the public health specialists.
“Preconception care should be provided in any centre where care is offered to women of reproductive age since they are the ones who need to access preconception care. Any centre where they offer antenatal services, obstetrician and gynaecological services, family planning, mother and child care, are potential places where clients that will benefit can be found.” – Secondary care level, Ob/Gyn
A few of the participants, particularly the tertiary level specialists, advocated for a specialised clinic where people of reproductive age can be referred for preconception counselling. The proponents of this idea believe that PCC is a specialised care and since it is for people who are otherwise healthy, the potential clients may not want to use the regular health facilities catering to those who are ill.
“I think the best way to do it is to have a standardized clinic for this age group. So, any physician that comes across people of this age group will refer them to that clinic for a briefing, not because they are ill but for them to be given some information on preconception care.” – Tertiary care level, Family Physician
Some of the participants highlighted a general reluctance to engage with health facilities in the community. In their opinion, many people at the community level are hesitant about the use of health facilities unless it is necessary. These participants suggested the provision of PCC – particularly health education and information services – through community outreaches, social media outlets and youth friendly health centres.
“Well, it would have been a good idea for preconception care to be rendered in a place like the obstetrics and gynaecology clinic, but it seems our culture here has not imbibed that. So, we may have to go out to the schools or community since people most likely will not come until they have problem trying to get pregnant. There can be community outreaches to discuss a number of things like blood group, blood level, genetic counselling which many of them need” – Tertiary care level, Public Health Nurse
“Preconception care can also be provided in youth friendly centres I mean clinics where youth, teenagers and adolescents can walk in. It is a very good avenue where we can counsel, screen and provide the necessary information. On the social media, awareness can be created on reasons why women need to check themselves before pregnancy.” – Tertiary care level, Clinical Nurse
Level of health care for PCC services
The participants discussed their views about the place of PCC within the three levels of health care in the Nigerian health system. Some participants stated that PCC services should be provided at all three levels of health care with emphasis on the primary health care level since it is a health promoting/primary prevention service. In their opinion, the laboratory facilities and equipment needed for medical screenings are either already present or can be provided at the primary health level. They believed that referral to higher levels of care can be provided as needed. This opinion was proffered more by the health workers at the primary and secondary levels of care and the public health specialists.
“Preconception care should be at the 3 levels – the primary, secondary and tertiary. The primary, is the grass root level, where we meet many clients between 15-49 years. But people in that age group are also at the secondary and tertiary levels so it {preconception care} should be available at the three levels.” – Primary care level, Public Health Nurse
“Preconception care should ideally be provided in primary health care just like antenatal care service is primary health care because it is closer to the public. But the primary health care providers should be able to tell if someone needs to be referred to secondary health care like they do for antenatal.” – Secondary care level, Ob/Gyn and Tertiary care level, Public Health Nurse
Some participants, mainly at the tertiary level stated that because of the level of expertise needed for some aspects of PCC like genetic counselling, the minimum should be provision at secondary care level.
“Preconception care can’t be approached in primary health centres, I think it is best handled in tertiary health centres” – Tertiary care level, Haematologist
“Preconception care should be provided in hospital facilities like in secondary health centres or in tertiary health centres, basically, because we need to have the manpower for it. We need nurses, genetic counsellors, social workers–an outreach team (because sometimes you need to know where the patients live), lab facilities to do some medical screening, and doctors, obstetricians who will take most of the decisions. So, it should be in a facility like a secondary health centre where you can always take decisions prior to the woman getting pregnant and of course in tertiary health centres but not in primary health centres.” – Tertiary care level, Ob/Gyn
ACCEPTABILITY OF PCC
The participants expressed the opinion that PCC may not be accepted generally by the people who should use the service. They believed the concept of PCC is new to the prevailing culture, therefore the likelihood of using the service may be low. They further indicated that the general attitude towards health issues is that many people tend to avoid going to health facilities unless there is a problem. They stated that even those who have known illnesses such as hypertension which require regular follow up clinic visits, often miss their appointments when they feel well. Thus, they felt that the chances of such people going to a preconception clinic to determine if they are healthy is slim when they have no physical evidence or symptom of ill-health. In addition, they suggested that the acceptance of PCC may be affected by the fact that the services are not free. Health services generally require out of pocket payment in the country except for a few people who have some form of health insurance. Even then, the health insurance schemes often exclude preventive services, catering more for curative ones.
“Preconception care on its own is not something that is popular. Generally, our people don’t believe that there is something wrong with them until they have some pain or discomfort. When women are not pregnant and you ask them to come for investigation, they will look at you, wondering what you are talking about. ... Even hypertensives will not go to the clinic unless they have a problem; they will say my clinic is tomorrow, but I’m ok. So, women will usually not come for preconception care for you to be able to detect anything till the point of booking for the pregnancy.” – Tertiary care level, Public Health Nurse
“Acceptance may be an issue; patients accepting that they do need it {PCC} especially when they need to pay for the services. The services are not covered by health insurance, patients have to pay from their pockets. NHIS {National Health Insurance Scheme} covers antenatal but it does not cover preconception care. Many people are not well informed, they don’t have adequate formal education and they see hospital as a place they only go when complication has arisen. But preconception care is a preventive measure before they even show any sign of disease. Even when they are sick people are reluctant to come to the hospital, how much more when they don’t have symptoms.” – Tertiary care level, Ob/Gyn
RELEVANCE OF PCC TO SPECIALTIES
The different specialists gave their views on the importance of PCC to their clients. The paediatricians believed PCC would improve the health of the newborn since many potential problems would have been addressed before pregnancy and detailed attention paid during pregnancy to whatever issues were detected in the preconception period. Other specialties like the cardiologist, endocrinologist, neurologist and nephrologist stated that they would have addressed chronic illnesses, controlled the condition or modified the medications used in the preconception period to prevent development of congenital abnormalities in the baby. The family physician viewed PCC as part of routine daily duties for every woman of reproductive age seen in clinic.
“Some of our patients have hypertension, migraine and other chronic illnesses that require medications. Some of these anti-hypertensives and other drugs could affect pregnancy, some of them are teratogenic {can cause abnormality in the child} and are contraindicated in the pregnancy. So, we give them information about the drug and tell them ‘if you get married and want to get pregnant, let us know so that we can change this medication to the one that will be suitable’.” – Tertiary care level, Neurologist
“Having preconception care will reduce the rate of disease we see in neonates (babies in the first 28 days). Many neonates develop complications that are due to certain experiences while they were in the womb. Having preconception care will improve the quality of health of the babies that women bear.” – Tertiary care level, Paediatrician
“As Family Physicians, preconception care is part of our job. We provide counselling, health promotion and health education to our patients. Most of our patients don’t know about their health especially about preconception care and in this area where emphasis is laid on childbearing, if the patient has a fertility problem, it is a big issue socially, within the family and in the whole community. We educate women of reproductive age to take folic acid before pregnancy to prevent congenital abnormalities especially spina bifida.” – Tertiary care level, Family Physician
POSSIBLE BENEFITS OF PCC
Participants described possible benefits of PCC services to potential users. They perceived that PCC provides an opportunity to make plans for childbearing in terms of number and spacing of children as well as to prepare financially for the baby.
“Well, I think preconception care enables couples to have a reproductive life plan and helps them to achieve their childbearing goals – when they want to get pregnant and how many times. People will draft a plan like I want to go to school now, I don’t want to get pregnant while I'm in school, after school I want to get married. If I'm sexually active now and I don’t want to get pregnant yet because I'm in school I know I have to get contraceptives.” – Tertiary care level, Public Health Physician
“There are a lot of benefits from it. It improves the health outcome for the baby and the mother. It also helps to prepare them financially for pregnancy and the baby that is coming.” – Secondary care level, Ob/Gyn
In addition, they stated that PCC leads to improved health status of parents and increases the likelihood of positive pregnancy outcomes was mentioned. They also highlighted promotion of the use of folic acid for prevention of neural tube defects in the newborn.
“Women receive treatment for their health conditions giving them a better chance of getting pregnant at the time they want. Preconception care will help them to eliminate pre-existing conditions paving a way for them to easily get pregnant and sustain that pregnancy.” – Tertiary care level, Public Health Nurse
“Preconception care will help women to be in the best state of health to carry their pregnancy to full term. They will avoid foetal malformations, unnecessary pregnancy losses, increase the chances that the pregnancy gets to full term and reduce problems with delivery.” – Tertiary care level, Endocrinologist
“If a woman starts using folic acid up to 13 weeks before getting pregnant as encouraged during preconception care, she will avert some congenital anomalies like neural tube defect or spinal bifida.” – Tertiary care level, Paediatrician
Reduction in the chances of transmitting genetic diseases from parents to children was also mentioned as a possible benefit. The example of diseases which do not manifest in the parents but can be carried over to the children was given. Such diseases may be identified through genetic screening in the preconception period.
“It is all about dodging a bullet really, anticipating what can potentially happen and taking proactive steps to avoid or mitigate whatever issues the condition may be associated with. For instance, muscular dystrophies manifest in childhood usually before the age of 20 and often lead to death. Women who are carriers of the defective genes are not affected but they can potentially have sons who develop the disease. With adequate preconception care, testing and counselling it's possible to avoid having a child with these conditions.” – Tertiary care level, Neurologist
In addition, the possibility of a couple planning for marriage checking their HIV status and deciding if they want to continue their relationship and plan for childbearing was mentioned.
“Preconception care is also important for intending couples, a preconception clinic visit can change the dynamic of a {planned} marriage. Some people are not aware of their HIV status for instance, and only get to know that one of them is HIV positive when they are ready to marry. Breaking up at this time is more painful. But if during the courtship people come to the preconception clinic, they can have the information and decide if they want to continue or not. It is important to face reality and know what you are going into, who you are going to marry. That’s one area where preconception care can help.” – Tertiary care level, Ob/Gyn