General
The study showed that overall knowledge about PCC is low among women in reproductive age group, who are desiring to become pregnant within one year from four blocks of Nashik district, Maharashtra, India; very few of them practiced behaviour related to optimizing the body mass index and improvement in haemoglobin levels and very few accessed services related to PCC. Preconception is a sort of health promotion and for health promotion self-care is indispensable [7]. Many studies on PCC are interviews of women coming to hospitals, which also reported similar low levels of knowledge [8-14]. Sporadic efforts are made to provide information about preconception care. A systematic review revealed the tools used impart knowledge usually focus on fertility, folic acid supplementation, alcohol consumption, mental health and some questions about men’s health [15]. In a study in the US, lack of knowledge was identified as the biggest barrier to the practice of pre-conception behaviour, the second most important barrier being the cost [16]. China is a world leader in implementation of PCC covering its entire rural population. National Preconception Health Care Project was scaled up to all the rural areas of the country since 2013 and all couples planning pregnancy within six months were assessed for risk factors using an ABCDX category of pre-conception risk factors. It was found that 68.29% of couples had one or more pre-conception risk factors of avoidable risks like smoking and alcohol consumption or benefiting from targeted medical interventions like anaemia, reproductive tract infections in women and abnormal liver or renal functions in men or controllable risk factors including diseases and conditions that cannot be cured but risk factors can be modified [17]. In India, PCC is largely restricted to use of contraceptives for family planning purposes, rather than for promoting woman’s and new-born’s health and use of peri-conceptual folic acid for preventing neural tube defects.
Planning of pregnancy
In the study area, the decision for planning first pregnancy is influenced by the mother-in-law. However, the couple have greater decision making power for planning the subsequent pregnancies. In India, it is estimated that in 2015 out of a total of 48.1 million pregnancies, only 52% were intended and rest 48% is unintended; of which 33% were aborted, 5% were miscarriages from unintended pregnancies and 11% were unintended births. [18]. Unintended pregnancies every year result in 25 million unsafe abortions and 47,000 maternal deaths globally as per estimates of world health organization [19]. Implementation of comprehensive PCC will go a long way for preventing unintended pregnancies, thereby reducing the burden on women for abortion and thus prevent maternal ill-health and deaths due to unsafe abortion.
Nutrition and body weight
Women were knowledgeable about intake of various types of food groups, however they did not know about the ideal weight, when they should conceive. In the study area women were not aware about use of multiple micronutrients for preventing adverse pregnancy outcomes. In USA women had better knowledge about folic acid supplementation before pregnancy [13].
Medical advice prior to pregnancy
It is acknowledged that women had limited knowledge about risk of chronic medical condition particularly diabetes and hypertension affect planning of pregnancy [16]. Contrarily in another study many women opined that anaemia, obesity and diabetes must be treated before pregnancy; hypertension before or during pregnancy causes miscarriage [8].
Tobacco and alcohol consumption
In Kenya majority of the women stated that alcohol should be avoided both before pregnancy and during pregnancy [8]. In USA women knew effects of alcohol and drug use during the preconception period [13]. It emerged from discussions that the habit of tobacco consumption is decreasing certainly among young generations and is corroborated by national level surveys [18].
Preconception services: Knowledge and utilization
Knowledge or awareness about PCC differs widely in different countries. A systematic review of 34 studies from 14 countries with data collected in 2000 to 2017 revealed the preconception health knowledge tools usually focus on fertility, folic acid supplementation, alcohol consumption, mental health and some issues about men’s health [11,15,20,21]. Another systematic review of studies done during 1998 and 2008 focusing on factors related to preconception health behaviors among childbearing age women in the United States, developed countries, and developing countries identified six major thematic areas: frequency of alcohol intake prior and during pregnancy, glycemic control/diabetes management, physical activity before and during pregnancy, pregnancy planning behavior, cystic fibrosis carrier screening, and other risk factors [22]. In UK, women from different geographical regions have only modest knowledge [23]. Overall, participants in USA demonstrated low to moderate knowledge of issues related to preconception health [24]. The proportion of women having knowledge about PCC varied from 7% to 85% in different countries like Nepal, Zambia, Nigeria, United States, Ethiopia and Nepal [9,10,12,13,25,26]. Usually most of the women have positive attitude towards seeking PCC as demonstrated in studies conducted in countries like Malaysia, Iraq [12,14,21,27]. About one third men and 60% women strongly agreed that parental health may have serious effects on health of expectant baby in Jordan [28]. In a study in South Ethiopia, about 20% of the women who just delivered were found to have good knowledge about PCC. In a study in Colorado, United States it was observed that young women demonstrated greater motivation for pregnancy prevention and contraception rather than promoting preconception health. In another study among predominantly low-income Mexican American population in the United States, participants agreed about improving preconception health and most of them desired to get information from obstetricians [13]. There was not only lack of knowledge about PCC among women with diabetes mellitus, hypertension and obesity but there was also lack on intent for pre-conception health promotion and pregnancy planning among women in Hershey, United States [16]. About 15% women were aware about preconception folic acid supplementation in North-western Ethiopia [29]. Highest knowledge was in the area of RCH risk factors had and lowest about health promotion [26]. Most women had average knowledge of PCC including effects of verbal, physical and sexual abuse [13].
Irrespective of knowledge and attitudes, only about 32% to 50% women sought PCC in countries like Nepal, Nigeria, Malaysia and Iraq [9,11,12,26].
Barriers include lack of social support, lack of awareness, objectives may be promoting healthy baby rather than preventing unhealthy baby [30].
Knowledge on PCC is usually found to be associated with education, age of the woman, number of children, family planning measures, receipt of information, chronic health problems and monthly income in Zambia, Northwest Ethiopia and Nepal [10,25,29,31].
Comprehensive PCC is comparatively new area in India. Women consulting obstetricians may receive some information and services. Federation of Obstetrics and Gynaecological Societies of India has come out with document giving recommending actions for their members indicating strength of recommendation and extent of evidence in 2016, however few private practitioners provide PCC in a comprehensive manner [32].
The study has a few limitations. Even though mother in law and husbands influence the decision on first pregnancy in newly married women, they were not included in the study. Further, preconception health in man is not included in the intervention as well as impact assessment study as it was felt that men’s involvement in PCC, though very critical, will be challenging. Further, as the study was implemented in rural and tribal settings, the findings may not be representative to the urban areas or for the state of Maharashtra. In a few FGDs, all members did not participate, which may result in bias.