The present community-based study is larger than several studies. It was observed that most of the variables were statistically significant between intervention and control group as well as between tribal and non-tribal groups (Tables 1 and 2) (p<0.01). This statistical significance was observed sheer due to the large sample size. However, the chi-square values for difference between tribal and non-tribal groups were many-fold of the value between intervention and control groups. Women residing in tribal and nontribal areas differ substantively.
In India, due to cultural norms most of the married women, especially in the rural areas are expected to remain pregnant soon after marriage. The period after the marriage and before the pregnancy although, critical to her health is usually ignored. Most of the women become pregnant within one year of the marriage. Often women who get married below eighteen years of age and tend to have an unplanned pregnancy and are most likely to be anemic and malnourished at the time of conception and likely to have a miscarriage or stillbirths . The concept of “continuum of care” for improving pregnancy outcomes, and reduction of maternal and neonatal mortality implies the need for preconception care . A wide gap, however, exists in the continuum of care because of focus only on pregnancy care and almost indifference towards preconception care. The pre-conception period is the most critical, and to acknowledge its importance, we need to include preconception in the continuum of care and rename the program as Reproductive, Preconception, Maternal Neonatal Child Health and Adolescents (RPMNCHA).
In the USA, the Behavioral Risk Factor Surveillance System (BRFSS) and Pregnancy Risk Assessment Monitoring System (PRAMS) include preconception risk factors and publish the reports regularly. The known risk factors as well included in these reports can be grouped into socio-demographic, diseases based on examinations/investigations and service components. The number of risk factors considered in various studies ranged from 5 to 14 [10,11,18–22]. All studies have considered smoking as a risk factor. Almost all considered alcohol consumption, BMI outside normal weight range, unintended pregnancy, presence of non-communicable diseases and absence of preconception care component. A study in Italy identified 11 risk factors including social and did not use any laboratory investigations for assessment like the present study; but risk factors like citizenship, married status were different which were not considered in the present study . A large study analyzing selected five risk factors, observed that 52% women had some risk factor (18.7% of the women had multiple risk factors, 33.3% had only one risk factor) and 48.0% had none . The present study observed about two third women have some risk factor. Whereas a study in a district adjacent considered 22 risk factors and revealed that all women had at least one risk factor .
Teenage pregnancy: The problem is typical of India and other Low and Middle-Income Countries (LMICs). As per national-level surveys for the state of Maharashtra 33.7% of women begun childbearing at the age of 18 or 19 years . Despite being pregnant, around 34.5% of women do not undergo any checkup in the first three months of the pregnancy . It means, by the time women visit the health care system for pregnancy care most of the fetal organs have been formed. This highlights the fact that for improvement of the quality outcome of current and subsequent pregnancy, women who plan to conceive should seek preconception care .
The current study reported that 15.9% of married women below the age of 19 years were desirous of becoming pregnant within the next one year; and the proportion was higher among women from the tribal area (p<0.001). Another study conducted in a Municipal Corporation area in an adjacent district identified that teenage pregnancy was 18% . This age distribution is similar to population-based studies conducted in other parts of India [17, 23–25]. Marriage at a younger age leading to early conception is a health risk that is significantly associated with postnatal complications and other adverse pregnancy outcomes and high chances of unplanned pregnancies [26,27]. Social pressure to marry early, and pressure for early childbearing soon after marriage, often prevents these married women and young girls from accessing contraception . The educational opportunities and better socioeconomic status in non-tribal areas might be the reasons for lower proportion of teenage pregnancies in non-tribal parts. Illiteracy can be seen as a social health risk for the women, it was reported more in tribal than non-tribal women (p<0.001). The other two studies also considered lower education as a risk factor [10,11].
Multiparity: This study reports that about 5% of women despite giving birth to three or more children desire pregnancy in the next one year. The difference was statistically significant between tribal and non-tribal (p<0.001). A multi-centric study also reports that 6% of women with parity of 3 or above desire pregnancy in the next one year. This highlights the scope for extension of family planning services and the importance of interventions that may also reduce unintentional births [28–29].
Tobacco consumption: Smoking in the preconception period is linked to delayed time to conceive and infertility . Convincing studies about the effect of smoking during the preconception period are lacking, excepting one showing a higher risk of gastroschisis and omphalocele . However, indirect evidence of impact at the population level is evident from the introduction of smoke-free legislation in different countries which has been associated with significant reductions in preterm births . Among non-pregnant and not undergone hysterectomy, 18.5 % of women smoke in the USA . The results of a meta-analysis reported that maternal active and passive smoking is associated with a higher risk of congenital heart disease among the offspring [28,30]. In the current study, however, the prevalence of smoking was low i.e., 1.3% of the women in tribal blocks were smokers. But the prevalence of consumption of tobacco in any form was 3.8%. Tobacco use was significantly more in tribal women than nontribal (p<0.001). Mishri use is very common in the tribal area. One study among women in the reproductive age group reports slightly higher tobacco use rates of 11% .
Alcohol consumption: Maternal alcohol consumption leads to a variety of fetal alcohol spectrum disorders and also a 30% increase in spontaneous abortion . Since many pregnancies are unplanned the scope for action at the individual level is limited. This highlights the importance of cost-effective public health actions to reduce risk behaviors in the whole population and the safest approach is to abstain from alcohol when planning a pregnancy as well as during pregnancy [2,4]. In the current study, the reported alcohol consumption was very low among the women i.e., 0.7% compared to other studies [9,20] and particularly from the USA (16%) . In some areas, the proportion may be as high as 70% . Smoking, alcohol consumption, and refusal to HIV testing are considered important risk factors and the overall proportion of any of the three risk factors has been reported as more than 50% .
BMI: In western countries, obesity is the commonest preconception risk factor . In the current study, almost one-third of women were undernourished (BMI<18.5) similar to other studies [24,32,33]. In the tribal block, the proportion was more than 40%. This is commensurate to their calorie and protein intake noticed in the national survey . Overall undernutrition was more and overweight was less in the present study compared to observations in the NFHS 5 report. There could be three reasons; our data is about three years later, secondly, the population is exclusively women desiring pregnancy in immediate future and the population consisted of a substantial number of women from tribal areas. The reasons for the high prevalence of underweight among pre-pregnant women may not be attributed to discrimination against young women since in the current study majority of women consumed food along with other family members or husband. Undernutrition can be attributed to other factors like exposure to infectious disease, poor sanitation, and poor diets all contributing to low body mass among women. Interestingly, irrespective of other factors the women in this study are satisfied with their food consumption practices. Surprisingly although the majority of women perceived that they consumed adequately to abundant food still many were undernourished. The undernutrition needs to be addressed before they become pregnant to improve their pregnancy outcome.
All studies reported an association between pre-pregnancy BMI and the risk of adverse perinatal outcomes i.e. infants whose mothers were underweight had a significantly higher risk of being small for gestational age, low birth weight, or the possibility of preterm birth as reported by studies [33–39]. All women, especially in the adolescent age group or women who delivered require appropriate pre-pregnancy advice as well as interventions on optimizing the BMI [36,38].
A study in Asia did not find a significant association between low pre-pregnancy BMI and preterm birth the reason may be the paucity of well-conducted cohort studies .
Authors used 24-hour dietary recall method for the assessment of dietary intake for two reasons; its feasibility and there is almost no loss to recall memory. This method is most commonly used for nutritional surveys .
One study reported the proportion of women consuming less than 50% of the RDA was 15.8% for energy, 39.6% for protein . This is in contrast to the current study where only 1.4% of the women were consuming less than 50% of their daily energy and protein requirements. While almost half of the women were consuming 70% or more of their recommended energy intake per day.
Consanguinity: Only two studies considered consanguineous marriage as a risk factor and prevalence was 2.9 and 20% [11,18]. In a study in North Karnataka, India 26.9% of women had a history of consanguineous marriage, while the current study reported it to be 19%. Consanguinity is associated with adverse perinatal outcomes, pregnancy loss, stillbirths and low birth weight babies .
Limitations: The 24-hour dietary recall method doesn’t capture weekly variations (usually substantial) and also had difficulty in precisely estimating the quantity of intake. The missing data was high. The assessment of risk factors was not supported by laboratory investigations.