Making a case for preconception care—the pregnancy experiences of women with pre-existing medical conditions in Ibadan, Nigeria

doi:10.21203/rs.3.rs-18571/v1

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Research article

Making a case for preconception care—the pregnancy experiences of women with pre-existing medical conditions in Ibadan, Nigeria

https://doi.org/10.21203/rs.3.rs-18571/v1

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posted 31 Mar, 2020

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Background

Factors that predispose to poor maternal and child health outcomes in most low and middle income countries include the presence of pre-existing medical conditions that are amenable to preconception care (PCC). Nigeria has an increasing pool of women of reproductive age with pre-existing medical conditions but PCC services are not provided routinely in the maternal and child health framework. This study explores the pregnancy experiences of women with pre-existing medical conditions to make a case for PCC as a routine service.

Methods

Nine women purposively selected because they has pre-existing medical conditions participated in in-depth interviews (IDIs) in this qualitative study. The IDIs were held in the obstetric outpatient clinics and lying-in wards of two referral hospitals for maternal and child health services in Ibadan North LGA of Oyo State, southwest Nigeria. The interviews lasted an average of 30 minutes, were digitally recorded and transcribed verbatim. Thematic analysis using a hybrid of inductive and deductive coding was done using MAXQDA 2018.

Results

Among the nine participants, seven were pregnant and two non-pregnant with pre-existing medical conditions including hypertension, diabetes mellitus, sickle cell disorder, chronic hepatitis, HIV, previous pregnancy loss of unknown cause and secondary infertility. None of the participants were aware of PCC and although they all desired their current pregnancy, there was no active preparation. None of the pregnant participants notified their health care providers about their desire for pregnancy and their medications were not adjusted or changed till after pregnancy. All except one of the participants believed they could have benefitted from PCC if they had been aware before pregnancy.

Conclusion

The regular contact with the health system afforded by their pre-existing medical conditions is an opportunity for them to have been adequately prepared for pregnancy through counselling and adjustment or change in treatment regimen to prevent complications. This opportunity was missed among the study participants. Health care providers need to be proactive and ask women of reproductive age about their pregnancy desires during routine clinic visits in order to make adequate preparation.

Preventive Medicine

Maternal & Fetal Medicine

Pregnancy desire

preparation for pregnancy

opinion about preconception care

benefit of preconception care

Preconception care (PCC) is defined as any intervention provided to women, men and couples of childbearing age, regardless of pregnancy status or desire, before pregnancy, to improve health outcomes for women, newborns and children [1, 2]. PCC services aim to detect, treat or counsel about pre-existing medical social and behavioural conditions that may impede positive reproductive outcomes [3]. Medical conditions that are amenable to PCC include non-communicable diseases like hypertension and diabetes, genetic disorders including sickle cell and thalassaemia, infectious disease including Hepatitis B and C, sexually transmitted infections including HIV [4, 5]. Also included within the coverage of PCC are lifestyle modifications such as reduction of alcohol intake, and cessation smoking and other substance use, encouraging a healthy diet and exercise [6, 7]. Addressing these conditions in the preconception period ensures optimal health before pregnancy occurs and improves the chances of a positive outcome for the mother and child [8, 9].

Low and middle income countries (LMIC) particularly in Asia and sub-Saharan Africa have the poorest maternal and child health indices globally [10]. Many of the predisposing factors to poor maternal and child health outcomes are due to diseases amenable to PCC. However, PCC services are either non-existent or weak in many LMICs. Studies from Jordan, Iran, Sudan, Ethiopia and Nigeria show low awareness and utilisation of PCC services [11–19]. In these studies, utilisation of PCC was influenced by health care providers’ provision of PCC information, presence of chronic medical conditions and sociodemographic factors including educational and wealth status .

In Nigeria, there is an increasing pool of women with pre-existing medical conditions that require PCC [3, 20, 21]. Hypertension, which had a prevalence of 25.2% among women is the most common non-communicable disease in Nigeria [22]. Diabetes mellitus has a prevalence ranging from 8 to 10% in the country [21] while the reported prevalence of gestational diabetes is 13.9% among urban women [23]. About a quarter of the Nigerian population have the sickle cell trait while the estimated prevalence of sickle cell disease is 2% [22]. The maternal mortality ratio in the 2018 demographic and health survey is 512/100,000; 67% of pregnant women received antenatal care and only 43% had skilled birth attendants at delivery [24]. The use of PCC has been shown to be significantly associated with timely antenatal care which is linked with improved birth preparedness and better maternal and child health outcomes [25]. PCC is identified as a primary prevention strategy for prevention of mother to child transmission of HIV in the Nigerian National Guidelines for the Prevention of Maternal to Child Transmission of HIV [26]. The guidelines however do not state any implementation strategy and the country has no specific PCC guidelines [26]. PCC services are therefore provided in an opportunistic manner when health care providers see the need for it [15, 27]. This explores the pregnancy experiences of women with pre-existing conditions to make a case for PCC services.

Study design and setting

This exploratory qualitative study used multiple case studies to make a case for PCC through the pregnancy experiences of women with pre-existing medical conditions. The study was conducted in the obstetric and gynaecological clinics and lying-in ward of two hospitals in Ibadan North LGA of Oyo State, southwest Nigeria. The first, Adeoyo Maternity Hospital is a secondary health facility while the second, University College Hospital (UCH), Ibadan is a tertiary health facility. Both facilities are referral centres for maternal and child health services in the state while the UCH also provides referral services in maternal and child health for most of the southwestern region of the country and beyond.

Participant characteristics and sampling

The study participants were women aged 18 to 49 years who were purposively selected from the obstetric or gynaecological clinic or the lying-in ward because they had pre-existing medical conditions that had affected their previous or current pregnancy. Pre-existing medical conditions commonly occurring among women of reproductive age in southwest Nigeria include hypertension, diabetes mellitus and sickle cell disorder [20–22]. These were represented among the study sample along with chronic hepatitis, HIV, previous pregnancy loss of unknown cause and secondary infertility.

Data collection

Data collection, held between June and December 2019 was through one on one in-depth interviews conducted by three research assistants supervised by the first author. The research assistants were female resident doctors in Community Medicine in the UCH who were familiar with qualitative data collection and were trained for the purpose of the study. Neither the first author nor the research assistants had any prior engagement with the participants before the interviews. The participants were identified with the assistance of chief nursing officers, also females, in the obstetrics and gynaecology department of the hospitals. They were then approached by the research assistants and invited to participate in the study. Everyone who was invited accepted to participate in the study. The plan was to conduct a minimum of five interviews and for the data collection to continue until saturation was reached. After nine interviews, responses to interview questions were similar in spite of the differences in pre-existing medical conditions among the participants and the interviews were discontinued. The interviews held in the obstetric or gynaecological clinic or the lying-in ward of the two hospitals.

Interview guides based on literature were used for the interviews. The interview guides were pretested and the questions that were unclear to the participants or generated ambiguous responses were rephrased. The main interview questions are shown in Table 1.

Table 1 Interview questions

S/N	Questions	Probes
1.	Please describe your experience during your most recent pregnancy	Did you want to be pregnant at the time or would you have wanted to delay it a little? Why? Did you receive any special care at the time? Why and for what? Were you healthy or ill? What medications were you using? Did they need to be changed or adjusted? Why?
2.	What is your understanding of preconception care?	What does the term mean to you? Who needs such care and for what?
3.	Then, a description of PCC was provided after which participants were asked: Can you describe your understanding of this concept before or around the time of your pregnancy?	In what way could an understanding of preconception care have helped you at the time, if at all? Would you say it could have helped your preparation for pregnancy in any way? Could your attitude to your treatment have been different in any way? Are there any consequences you have experienced that could have been avoided if you knew about and used preconception care? Please provide details.

All the interviews were digitally recorded and lasted an average of 30 minutes. The interviewers made field notes during the interviews.

Data management and analysis

The audio recordings were transcribed verbatim by the first author and integrated with the field notes to ensure all information was adequately captured. Thematic analysis was done by the first author using a hybrid of deductive and inductive coding [28, 29]. Analyst triangulation was done to improve credibility with an independent researcher who was not a part of the research team coding 20% of the transcripts (2 out of 9) [30, 31]. A total of 26 codes were derived from the data which were merged into six themes. Both coders met to review the codes, reached intercoder agreement and merged codes into themes. All the data analysis was done using MAXQDA 2018 qualitative data analysis software [32]. The study themes are shown in Table 2. The Consolidated criteria for reporting qualitative studies (COREQ) guided the development of this article [33].

Ethical consideration

The participants were provided with information sheets containing the details of the study and provided consent for the interview and audio recording before each interview. No identifying information was documented; audio recordings and transcripts were labelled with codes and saved in a password-enabled laptop accessible only to the authors. Ethical approval for the study was obtained from the ethics committee of the University College Hospital (UCH), Ibadan, Nigeria, Oyo State Ethics Committee and the Wits Human Research Ethics Committee.

Participants’ sociodemographic characteristics

Nine transcripts were analysed with the mean age of the participants being 36.2 ± 3.7 years. All the participants were married, completed secondary education and were employed. Seven of the women were pregnant at the time of the interview. The mean number of previous pregnancies was 2.4 ± 1.0 while the modal number of living children was one with three women having no living child at the time of the interview. Further details of the participants’ characteristics are shown in Table 2.

Table 2 Sociodemographic characteristics of the participants

Code*	Age	Number of		Medical problem	Pregnancy Status
		Previous pregnancies	Living children
PW1	37	3	1	HIV	Pregnant
PW2	38	1	2	Hypertension	Pregnant
PW3	30	1	1	Chronic Hepatitis	Pregnant
PW4	40	3	3	Diabetes Mellitus	Pregnant
PW5	38	3	0	Hypertension	Pregnant
PW6	41	4	3	Hypertension & Diabetes	Pregnant
PW7	33	3	0	Sickle cell disorder	Pregnant
NPW1	32	2	1	Previous pregnancy loss of unknown cause	Not pregnant
NPW2	37	2	0	Teenage pregnancy & Secondary infertility	Not pregnant
Mean	36.2 ±3.7	2.4 ± 1.0

*PW – Pregnant woman; NPW – Nonpregnant woman. Also used in the results.

Study themes

An initial set of 20 codes were identified from recurring patterns in the data which were merged into six themes through discussion to arrive at a consensus. The six themes identified in the study as shown in Table 3.

Table 3 Themes identified from the data

Theme	Description
Awareness about preconception care	Participant's awareness about preconception care. Includes responses stating knowledge of preconception care as a concept. Also includes description or opinion about awareness of preconception care in general
Desire for pregnancy	Participants state whether they desired their most recent pregnancy.
Preparation for pregnancy	Descriptions participants give about what they did either medically or in their homes as part of self-care in preparation for pregnancy. Includes description of visits to health facilities or discussion with medical personnel about what they need to do while preparing for pregnancy.
Use of medications before and during pregnancy	Includes participants description of the treatment they received for any pre-existing medical ailment, medications taken etc. before pregnancy. Also includes adjustments to treatment while planning for pregnancy and after they found out they were pregnant.
Opinion about preconception care	Participant's opinion about what preconception care is. Includes definitions, descriptions and perceptions. Also includes description of who requires preconception care, and conditions in which it is required.
Potential benefit of preconception care	Participant's description of how preconception care could have helped them in previous pregnancies if they had been aware of and/or used the service. Includes descriptions of experiences that could have been avoided or mitigated by preconception care. Also includes opinions on whether or not participants believe preconception care is necessary for them as individuals.

Awareness about preconception care

When asked to describe what they considered PCC to be, most of the participants stated that they were unaware of the concept.

I’m not aware of it. In fact, this is my first time of hearing anything about this. – PW1

When they were given the description of PCC, one of the participants said “but we don’t do that” while all the others declared “I’ve not heard of that before”. Only one participant remembered being told about something similar during a previous pregnancy.

I heard of something like this {preconception care} in the hospital during my last pregnancy about 6 years ago. – PW4

A participant said she realised her need for care before pregnancy when she had a spontaneous abortion. Before then she believed there was no need to seek medical attention before pregnancy. Her comment highlights the anecdotal report of beliefs within the community that pregnancy is expected after marriage and requires no intervention.

I didn’t know I was supposed receive any care before pregnancy. After marriage, the next thing is pregnancy. I believe that it’s those who are unable to conceive that should seek for care. Once a woman can conceive, she doesn’t need any care. But a woman who has delays needs to go for medical check-up. It was not until I had miscarriages that I realised I needed to come to the hospital to find out what I needed to do or to avoid. – NPW1

Desire for pregnancy

All the participants stated that they desired their current pregnancy while those who were not pregnant at the time of the study expressed their desire for pregnancy.

I wanted the pregnancy at the time it came, even before that time because I had lost two pregnancies earlier. – PW6

In support of their desire for pregnancy, two of the participants had discontinued the family planning method they had been using in anticipation.

I had been using family planning for seven years, but I stopped a year ago because we wanted another baby. – PW2

Although they desired and planned to have another pregnancy, two of the participants stated that timing was not in keeping with their desire. They had given up on their expectation for pregnancy when they finally became pregnant.

I wanted it, but I was not expecting it at this time. When I was pregnant in 2015, I expected and desired to get pregnant. But when the child became ill and died in 2016, I took my mind off having more children. I only prayed that God should keep the ones that are alive, but God knows the reason for this current pregnancy. I believe it is God’s will. – PW6

The pregnancy just came. I was planning and preparing for it, but it did not come on time as I expected. It just came suddenly. – PW4

Preparation for pregnancy

Preparations for pregnancy differed among the participants depending on their previous pregnancy experiences. Although all the participants stated that they had planned for their current pregnancies, special preparation for pregnancy were only described by those who had experienced complications in their previous pregnancies or had delay in achieving conception. For instance, one of the participants sought information on the internet because of her previous experience.

During my first pregnancy, my blood pressure became very high when I was around 7 months pregnant. I had eclampsia and became unconscious. I was referred to this hospital from the one I used close to my house. After the delivery, when I came out of coma the doctors told me I should have come earlier and they would have given me some drugs. So when we planned for this pregnancy, myself and my husband did a research on what happened then so that it will not happen again. We googled it at home and printed out the information so we were fully prepared. – PW2

Another participant who had lost a child after birth sought medical care because she thought the baby died due to complications of fibroids that were discovered while she was pregnant. In order to avoid a recurrence, she sought medical care only to be diagnosed with hypertension and diabetes for which she was receiving treatment when she became pregnant again.

The baby I had in 2015 died in 2016. During the pregnancy I found out I had fibroids. So after I had rested from all the stress of the baby’s death, I came to the hospital because I thought the fibroids affected the baby and caused the sickness and led to the death. I decided to come and take care of myself so that the same thing will not happen again. When I was examined, it was discovered that my blood pressure was high and I could not have the operation for the fibroids then. I was referred to the medical clinic for treatment. There, some other tests were done it was discovered that I have diabetes. I started treatment for both hypertension and diabetes. – PW6

One participant who had experienced delay in getting pregnant sought medical help to determine the cause of the delay.

I’ve had two pregnancies before now, the first one was a miscarriage at 3 months, then I had a delay of about 3 years before the second pregnancy. So, I went to the hospital to find out what was causing the delay then. That’s the same reason why I came to the hospital now because it’s now about 9 years since I had my second pregnancy. – NPW2

Use of medications before and during pregnancy

Those among the participants who had medical conditions that required treatment had been on medications. While some needed their medications to be changed or the dosage adjusted because of its potential impact in pregnancy, others did not. None of the participants informed their doctor of their desire for pregnancy however and change in medication was only effected during pregnancy for those who needed it.

I have been on mediations for HIV and the doctors have told me that it is safe for me to continue to use them even now that I am pregnant. – PW1

I did not tell my doctors that I desired to get pregnant. I was using medications for blood pressure and diabetes, but I was told to stop the blood pressure medications because it is now controlled. I am also using thyroid medications because it {the thyroid} was removed surgically. My diabetes medications was changed to insulin injection after I got pregnant because the doctor said those medications are not safe in pregnancy. – PW6

I have sickle cell disorder but I haven’t been on any medications apart from the routine paludrin {malaria prevention drugs} and folic acid because I haven’t had any crisis for the past 4 years. – PW7

Opinion about PCC

While some of the participants expressed the opinion that PCC is beneficial for everyone and awareness should be raised about it, others believed that the benefits are not for everyone. Those with latter view stated that PCC may be of greater benefit to those who are unable to achieve conception spontaneously.

The way I understand it, particularly for someone who has gone through the kind of health challenges I’ve had, if one wants to get pregnant it is better to let one’s doctor know about it. That way everything necessary would have been done to control all that the person is going through. They will be able to say what is the best time to get pregnant so that mother and the child will not be affected negatively. Awareness needs to be raised about this in our communities. – PW6

I understand that PCC is good especially for the baby, like now I was told that the folic acid is very important for the baby especially for their spinal cord and their brain. But to me not everybody needs PCC because our body system is not the same. Some people will have to see gynaecologists and maybe use fertility drugs. Other people won’t even look for the pregnancy before they have it. – PW7

Potential benefit of PCC

The participants varied in their views about the potential benefits of PCC to their health conditions. Most stated they would have benefitted either through having better information and treatment or delaying pregnancy to address potential complications. One of the participants however felt she had no need for PCC because in spite of her medical health status, she had experienced no complications that PCC could have prevented.

If I had known about PCC before now, I would have considered giving more gap before having this pregnancy. Then I could have been treated for the hepatitis before getting pregnant. I’ve just been told in the clinic that I can’t take the medications again until after delivery. Then they will have to treat the baby too. I would have avoided all that if I had known. – PW3

I think knowing about PCC would have helped me at the time I had my first pregnancy. I was a teenager then and my partner wanted a child. But I hadn’t even completed my National Diploma and I didn’t understand much. Maybe I would have delayed then and things would have been different now. – NPW2

I don’t think knowing about PCC could have helped me in any way because to me I have no issues. Yes, I have sickle cell but I don’t see it as a problem and my husband too doesn’t have any problem. The two pregnancies I lost, I think it was due to the carelessness of the people in the private hospital I used then because they couldn’t tell me what actually went wrong. That’s why I said I don’t think PCC would have helped me. – PW7

This study describes the need for preconception care services as part of maternal and child health care within the Nigerian health system using multiple case studies of women who had medical problems in pregnancy. The medical conditions experienced by the women in this study included hypertension, diabetes, HIV, chronic hepatitis, sickle cell disorder, teenage pregnancy and secondary infertility. These are all conditions that have been shown to be amenable to interventions available through PCC [5, 34, 35]. Most of the participants were unaware of PCC or its potential benefits to them at the time of their pregnancy. No participant informed their health provider about their intention to conceive and so did not have their medications adjusted where necessary until they were pregnant.

Only one of the nine participants in this study was aware of PCC and she had heard about the concept in the hospital during a previous pregnancy. Previous studies across Africa and Nigeria have shown that many women who are aware of PCC often receive their information from health facilities or health care providers [13–15, 19, 36, 37]. All the participants in this study had been diagnosed with different medical conditions before their pregnancy and had routine clinic visits for follow up. That they were unaware of the concept of PCC and its potential benefit for them implies a possible lack of awareness of the need among their health care providers. A study among health care workers in northern Nigeria showed that less than half of the participants had ever provided PCC [27]. PCC is recognised in the Nigerian National Guidelines for the Prevention of Maternal to Child Transmission of HIV as a primary prevention strategy [26]. However, the participant who was HIV positive was unaware of PCC, suggesting that the service had not been offered to her at any of her routine clinic visits before she became pregnant. By implication, there is a gap in the care of women of reproductive age who have chronic medical illnesses that should be filled by PCC services. There is a need for increased awareness among health care providers as an important source of information to this group of women. The health care providers’ role includes informing women about the risks associated with pre-existing conditions, screening for those who are unaware of their health risks and treatment modification for those who are receiving medications [38, 39]. Thus all health workers need to encourage their clients to discuss their pregnancy plans in order to begin or adjust treatment plans where necessary.

Although all the participants in the study stated their desire for pregnancy, the specific efforts by two participants was discontinuing their contraceptive methods, which is intuitive for anyone who desires pregnancy. Research on pregnancy intentions have shown that women with intended pregnancies are more likely to engage in positive health behaviours like use of vitamin supplements, including folic acid and avoiding alcohol and tobacco use [40, 41]. They are also more likely to seek medical interventions and use PCC services in order to avoid potential complications [11, 13], a fact that was prominent among the participants in this study who had experienced complications in their previous pregnancies. However, none of the participants told their health providers about their desire for pregnancy, thus missing out on the opportunity to adjust their medications or receive necessary counsel on lifestyle modifications before pregnancy. By implication, health care providers who care for women of reproductive age with chronic medical conditions should ask them about their desire for pregnancy routinely in order to counsel and adjust medications in a timely manner. Beyond addressing known health problems, PCC also includes identification of pre-existing conditions [8, 42] and should therefore not be restricted to women who have known complications. The experiences of two of the study participants buttresses this point – one who had chronic hepatitis was only diagnosed in the current pregnancy while another was diagnosed with diabetes in her previous pregnancy. Optimising health in the preconception period through medical screening would have been beneficial in both instances.

The participants expressed different opinions about the possible benefits of PCC to the general population and to themselves with respect to their medical conditions. While most believed that PCC services as described in the interviews would benefit anyone who used it irrespective of pre-existing medical conditions, one of the participants who had sickle cell disorder dissented. She believed that only those who had difficulty with conceiving would need such care. She also stated that in spite of her pre-existing medical condition, PCC would not have helped her in any way. Such dissenting voices need to be identified and targeted information provided on the potential benefits. For instance, in the case of this participant, sickle cell disorder would benefit from premarital counselling and screening [43], as well as optimising the health of the mother in the preconception period because of the documented higher risk of maternal and foetal complications [44, 45]. In addition, having preconception care followed by effective antenatal care has been shown to be associated with a reduction in the occurrence of complications among women with sickle cell disorder [45].

This study showed a lack of awareness of PCC among a group of women with pre-existing medical conditions who would have benefited from the use of the service. While they all desired pregnancy, none of the participants’ preparations included seeking information from their health care providers on what adjustments they may have needed to make to their treatment regimen. This implies a need for health care providers to include specific preconception information in their packages of care for women of reproductive age. There is also a need to improve awareness of the need for PCC among health care providers as they are an important source of information for women in the reproductive age group who have pre-existing medical conditions that can affect pregnancy negatively.

COREQ – Consolidated Criteria for Reporting Qualitative Research

HIV – Human Immunodeficiency Virus

LGA – Local Government Authority

LMIC – Low and middle income countries

NPW – Non-pregnant woman

PW – Pregnant woman

PCC – Preconception care

UCH – University College Hospital

WHO – World Health Organisation

Ethics approval and consent to participate

Ethical clearance for the study was obtained the Oyo State Ministry of Health Ethics Committee in September 2017 (Approval number AD/13/479/565), and from the University of Ibadan/University College Hospital (UI/UCH) Institution Review Board on February 6, 2018 – Clearance number UI/EC/17/0390, as well as the Wits Human Research Ethics Committee (Medical) – Clearance number M171054 on March 3, 2018. All participants were informed that their participation was voluntarily and that they could withdraw from the study at any time. All participants provided written consent to participate in the study.

Consent for publication

Not applicable.

Availability of data and materials

Due to the qualitative nature of the study, the data generated are not publicly available. However, further information about the data is available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was self-funded.

Authors’ contributions

Study concept and design: All authors. Acquisition of data: OOO. Analysis and interpretation of data: Both authors. Drafting of the manuscript: OOO. Critical revision of the manuscript for important intellectual content: Both authors. Final approval of the manuscript: Both authors.

Acknowledgements

We acknowledge the assistance of the resident doctors who conducted the interviews and the chief nursing officers who helped with recruitment of participants.

Authors’ information

OOO, a Community Health Physician with a Fellowship of the West African College of Physicians (Community Health) and a Master’s in Public Health is currently a PhD candidate at University of the Witwatersrand (Wits) School of Public Health, Johannesburg, South Africa. She has had experience in family and reproductive health services and research using qualitative and quantitative methods. This paper is part of her PhD research.

LI holds a PhD in Demography and Population Studies and has several years’ experience in the population and health fields. She has supervised a number of Masters and PhD students and conducted qualitative and quantitative studies. She is an Associate Professor at the University of the Witwatersrand (Wits) School of Public Health and an Adjunct Research Fellow of the Nigerian Institute of Medical Research (NIMR).

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Making a case for preconception care—the pregnancy experiences of women with pre-existing medical conditions in Ibadan, Nigeria

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Abstract

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Conclusion

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