The magnitude of preconception care utilization and associated factors among women in Ethiopia: Systematic review and Meta- analysis, 2024

doi:10.21203/rs.3.rs-4347404/v1

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The magnitude of preconception care utilization and associated factors among women in Ethiopia: Systematic review and Meta- analysis, 2024

https://doi.org/10.21203/rs.3.rs-4347404/v1

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Background

Nowadays globally a woman dies in every two minutes, and a neonate dies even in every 12 seconds, and more than two-thirds of these maternal deaths are preventable. Preconception care is a continuum of maternity care which is one of the proven strategies to reduce not only maternal mortality and morbidity but also neonatal mortality and morbidity by improving women’s health. Therefore, this study aimed to assess the pooled magnitude of preconception care utilization and its associated factors among women in Ethiopia.

Methods

Searching of studies done through PubMed, Medline, Embase, Cochrane Library, List of References, and Google Scholar. This systematic review and meta-analysis follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) godliness. The quality of studies was assessed by using a Newcastle- Ottawa Scale (NOS) assessment tool adapted for cross-sectional studies. Analysis was performed using a random effect model by using STATA 17 version software. Egger’s weighted regression and I² test were used to evaluate publication bias and heterogeneity respectively.

Results

In this systematic review and meta-analysis, a total of 6,808 women from 14 primary studies were included. The overall pooled magnitude of preconception care utilization in Ethiopia was 26% (95% CI: 18, 34). Educational status (OR = 2.18, 95%CI 1.54, 2.82), adequate knowledge of women regarding preconception care (OR = 2.69, 95%CI 1.90, 3.48), pre-existing medical illness (OR = 4.79, 95%CI 2.61, 6.06), history of adverse pregnancy outcome (OR = 3.18, 95%CI 2.74, 3.62), and husband /partner support (OR = 3.26, 95%CI 1.55, 4.97) were the identified predictors of utilization of preconception care.

Conclusion

The overall magnitude of preconception care utilization among Ethiopian women was significantly low. Educational status of women, knowledge of women regarding Preconception care, history of adverse birth outcome, pre-existing chronic medical illness, and either psychological or financial husband support were the identified predictors of preconception care utilization. Thus, healthcare organizations should work on strategies to improve the utilization of preconception care. In addition to this, advocating for better women's education, awareness creation, and encouraging male involvement is very essential to optimize service utilization.

PROSPERO registration: CRD42023492995 registered on 23/12/2023.

Preconception care

utilization

magnitude

women

systematic review

meta-analysis

Ethiopia

Preconception care is defined as a comprehensive set of interventions that aim to identify, and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management(1). The goal of preconception care is to provide the couple with all the information required to make informed decisions regarding their future reproductive planning(2). Reduction of maternal and childhood mortality and morbidity requires the provision of a continuum of maternity care that spans pregnancy, childbirth, infancy, childhood, and adolescence. This provision of comprehensive interventions before pregnancy occurs can increase the health and well-being of adolescents, adult women and men, and improve subsequent pregnancy and childbirth outcomes(3, 4).

Preconception care (PCC) comprises a wide range of interventions including reproductive planning, screening for modifiable risk factors, management of existing medical conditions, treatment of infectious disease, immunization, and supplementations like iron and folic acid: aimed at identifying and modifying medical, behavioral, and social risks during the reproductive years(5, 6)

Nowadays globally, an estimated 287,000 women die annually from pregnancy and childbirth related complications; this is equivalent to 800 maternal deaths every day and approximately one in every two minutes(7), with Sub-Saharan Africa (SSA) and South East Asia accounting for approximately 86% of all maternal deaths, and SSA alone contributed more than half of all maternal deaths (8). Most of these deaths occur during and immediately after childbirth due to hemorrhage which accounts for 25% of all maternal deaths, others may be due to medical conditions that develop during pregnancy or exist before pregnancy but worsen because of physiological changes in pregnancy. In addition to this, infectious diseases are considered to be serious when occurred during pregnancy(9, 10). The above problems are prevented or reduced through the evidence-based provision of a quality continuum of maternity care by skilled professionals before pregnancy as part of PCC, during pregnancy, during and after childbirth as postpartum care(11). Worldwide, an estimated 227 million pregnancies happen each year, of which 99 million (44%) are unintended and more than half (56%) of these unintended pregnancy ends with induced abortion(12). This unintended pregnancy and its complications can be avoided by the provision of quality family planning, and safe abortion care practice. These services are the crucial components of PCC(13, 14).

The sustainable development goal (SDG) under goal number 3 set a global target of, reducing the global maternal mortality ratio to less than 70 per 100,000 live births, reducing neonatal mortality to at least as low as 12 per 1,000 live births, and reducing under-five mortality to at least as low as 25 per 1,000 live births in all WHO region countries by 2030(15). In contrast to the above targets, the estimated global maternal mortality ratio in 2020 was 223 per 100,000 live births and high in the Sub- Saharan Africa including Ethiopia which is 547 per 100,000 live births(7, 16).

Despite substantial progress, 2.5 million neonates died in 2017 alone globally and countries with the highest neonatal mortality rates were concentrated in developing regions including Ethiopia. These neonatal deaths are mainly associated with conditions that arise before and during pregnancy, and complications related to the birth process (17, 18). Even though, the governments of Ethiopia give priority to maternal and child health services, mortality and morbidity among women and children are still high. According to the mini demographic health survey (mini EDHS) 2019 report, there were an estimated 401 maternal deaths per 100,000 live births. In addition to this, the under-five children's, infants, and neonatal mortality rates were 59, 47, and 33 per 1000 live births respectively(19). These are far from reaching the global targets and providing evidence-based preconception care is one of the proven strategies to reduce maternal and neonatal mortality and morbidity.

Evidence shows that preconception care may have an important role in preventing short and long-term adverse health outcomes for women and their offspring. A woman who is healthy before and at the time of conception is more likely to have a successful pregnancy and healthy child(20, 21). On the other hand, low utilization of preconception care increases the risk of low birth weight, preterm births, intrauterine growth restriction, intrauterine fetal death, perinatal death and birth defects(22, 23).

Under or overnutrition, and micronutrient deficiencies of women during the preconception period affect the health of the women, future life of the fetus, and adverse birth outcomes during childbirth. The imbalance of micronutrients before and during pregnancy affects the health of the mother and pregnancy outcome(24, 25). Deficiency of iron, and iron deficiency anemia before and during pregnancy contribute to 20% of mortality in the mother and increase the risk of spontaneous abortion, low birth weight, preterm birth, intrauterine fetal death, and neonatal death in the child. Folic acid deficiency before and during pregnancy increases the risk of neural tube defects (NTD) like spinal Bifida, anencephaly, and hydrocephalus in the unborn child, which in turn increases the likelihood of adverse birth outcomes including neonatal death(24, 26). Maternal overweight and obesity also increase the risk of obstetric complications such as pre-eclampsia/eclampsia, gestational diabetes, obstructed labor, and cesarean delivery on the mother, and fetal macrosomia, hypoglycemia, hypothermia, and other adverse pregnancy outcomes on the fetus (27, 28).

World Health Organization developed a package of preconception care interventions; areas addressed by this WHO package include nutritional supplementation (iron and folic acid), vaccine-preventable disease, infertility /subfertility, too early pregnancy, unintended, and rapid successive pregnancy, female genital mutilation, sexually transmitted infections including human immune deficiency virus (HIV), interpersonal violence /violence against women, psychoactive substance use, tobacco and genetic conditions(3).

Studies conducted around the world show that there are so many multiple and interlaced factors identified like women's poor knowledge of preconception care, women’s negative attitude towards preconception care, unintended pregnancy, lack access of to quality health facilities, and lack of support from husband related to maternal and child health services especially in developing countries were attributed to low utilization of preconception care(29, 30). Moreover, factors like age, residence, marital status(31), family monthly income, educational status, history of adverse birth outcome, presence of chronic diseases, postpartum care utilization in the previous pregnancy, and women's use of modern family planning before the recent pregnancy were factors associated with utilization of PCC(32–34). For instance, in one study of systematic review and meta-analysis to determine the association between knowledge of women and utilization of preconception care in SSA; having good knowledge among women regarding PCC increases their utilization of PCC by twofold(35). Similarly, another study shows women who had previous adverse birth outcomes increase the utilization of PCC by fivefold(33).

In Ethiopia, different studies were conducted across the country to determine the magnitude and associated factors of preconception care utilization among women. However, the magnitude of these separate studies ranges from as low as 6.3% in the study done at Mana district(36) to as high as 58.3% in the study done at Sendafa(37). This shows a wide and considerable variation related to the magnitude and the determinant factors. Therefore, our study aimed to determine the estimated pooled magnitude, and the associated factors of preconception care utilization among women in Ethiopia to provide evidence-based information to policymakers and healthcare providers to provide quality preconception care as part of a continuum of maternity care which in turn improves maternal, and child health.

Objectives of the review

In this systematic review and meta-analysis, there were two objectives to be addressed by the study. The first objective was to determine the estimated pooled magnitude of preconception care utilization among women in Ethiopia. The second objective was to determine the estimated pooled effect size of factors associated with preconception care utilization among women in Ethiopia.

Study design: Systematic review and meta-analysis

Study selection and eligibility criteria

In this systematic review and meta-analysis, studies were included if they were cross-sectional studies, done in the English language, both published and unpublished, in both study settings (facility, and community-based), done in Ethiopia from 2010 to 2024. Other eligibility criteria were studies that measure the magnitude of preconception care utilization, and the associated factors. However, conference abstracts, editorials, qualitative studies, and review articles were not eligible and excluded from this systematic review and meta-analysis. The last search was done on January 25, 2024. Screenings were done by three authors (the corresponding author Aysheshim Asnake, Sintayehu Shiferaw and Tadele Derbew) independently and cross-checked for consistency. When any disparities occurred, differences were resolved by further discussion, and consensus based on the above pre-determined inclusion and exclusion criteria.

Study participants

In this systematic review and meta-analysis, the study participants were women (reproductive age group or pregnant women) who received preconception care.

Types of studies

Types of studies to be included in this systematic review and meta-analysis, were all observational studies such as cross-sectional, case control, and cohort.

Measurements of the outcome

This systematic review and meta-analysis had two main outcomes. The first outcome had to estimate the pooled magnitude of preconception care utilization among women in Ethiopia. The second outcome was the association factors. For the first outcome, the magnitude was measured by women who received at least one service among the WHO-recommended packages of preconception care before pregnancy. The magnitude was calculated by the number of women who received at least one PCC service divided by the total number of women who participated in the study, and then multiplied by 100. For the second outcome, the pooled odds ratio with 95%CI was used to measure the levels of association between preconception care utilization and the factors.

Searching strategies

Searching of all published studies was done by using the following major databases: PubMed, MEDLINE, Embase, Cochrane Library, and as well as search for unpublished studies was done by using Google scholar. In addition to this List of Reference Index was also used to retrieve both the published and unpublished (Gray literature). Endnote X7 software was utilized to retrieve and organize the studies identified through the search strategy, as well as to eliminate any duplicate records. In order to locate relevant studies within the search databases, the following search terms were employed: (magnitude) OR (prevalence) OR (incidence) OR (proportion) AND (preconception care) OR (pre-pregnancy care) AND (utilization) OR (practice) AND (associated factors) OR (risk factors) OR (predictors) OR (determinants) AND (women) OR (reproductive age women) OR (pregnant women) AND (Ethiopia). Theses search terms were used individually as well as in combination, utilizing Boolean operators like “OR” and “AND”. When conducting this review, the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline was also strictly followed.

Data extraction process

Data were extracted from the included studies by the three authors (Aysheshim Asnake, Sintayehu Shiferaw and Tadele Derbew) independently by using a predetermined data extraction format. The data extracted format was prepared using the Microsoft Excel 16 version agreed by the five authors. The prepared data extraction format had the following structure: 1) author detail which name and year of publication, 2) year of study, 3) study design, 4) study setting (institutional versus community-based), 5) sample size, 6) sampling technique, 7) sampling procedure, 8) response rate, and 9) the region where the study was done. In addition to these, the number of women who received PCC, along with 95%CI was included in the data extraction format for the first outcome (magnitude of preconception care utilization). For the second outcome (factors associated with PCC utilization), data were collected in the form of two-by-two table, and the log odds ratio for each factor was calculated based on the primary study findings. Disagreements between the data extractors were resolved through discussion and Consensus.

Data quality assessment

The quality of each primary study was assessed by the Newcastle Ottawa Assessment (NOS) scale specifically adapted for cross-sectional studies. The quality assessment of the included studies was conducted independently by Aysheshim Asnake, Tadele Derbew and Sintayehu Shiferaw. Any subjectivity and disagreements between them were resolved through consensus, and further discussion. The assessment of quality, and eligibility of the screened articles was based on ten scores distributed in to the three major categories. Category I (selection): included scores for representativeness of the sample, sample size justification, response rate, and ascertainment of the exposure, category II (comparability) involved a score for controlling a confounding variable by adjusting data or results for relevant predictors, risk factors or confounders. Category III (outcome): comprised scores for the assessment of the outcome, and the use of appropriate statistical tests. Based on this, the NOS assessment tool classifies the quality of each study: a score of 0 to 4 points as unsatisfactory, 5 to 6 points as satisfactory, 7 to 8 points as good, and 9 to 10 points as very good study(38, 39). Accordingly, a score of 7 and above out of 10 were considered as having high quality (eligible for the study), and enrolled in to the meta-analysis (Table 1).

Table 1

Quality assessment of the included studies of the magnitude of preconception care utilization and associated factors among women in Ethiopia, by using NOS adapted for cross-sectional studies.
First author & publication year					Comparability	Outcome		Total
First author & publication year	Representativeness of sample size	Sample size justified	Non- Response rate	Ascertainment of the exposure (max **)	Cofounding controlled max (**)	Outcome assessment (max **)	Statistics	Total Score (max 10*)	Overall quality
Negash et al (2023)	*	*	*	*	*	**	*	8*	Good
Tsrity et al (2019	*	*	*	**	*	**	*	9*	Very Good
Yitayal et al (2018)	-	-	*	*	**	**	*	7*	Good
Addisu et al (2023)	*	*	*	*	*	**	*	8*	Good
Ketema et al (2021)	*	*	*	*	**	**	*	9*	Very Good
Elias et al (2022)	*	*	*	**	*	**	*	9*	Very Good
Daniel et al (2020)	*	*	*	*	**	**	*	9*	Very Good
Meron et al (2022)	*	*	*	*	*	**	*	8*	Good
Tesfanesh et al (2019)	*	*	*	*	**	**	*	9*	Very Good
Melsew et al (2022)	*	*	*	*	*	*	*	7*	Good
Tura (2021)	*	*	*	**	*	**	*	9*	Very Good
Alemu et al (2022)	*	*	*	*	**	**	*	9*	Very Good
Frianbon et al (2021)	*	*	*	*	**	**	*	9*	Very Good
Eriste et al (2022)	*	-	*	**	*	**	*	8*	Good
Note: * refers to get one point, and ** refers to get two points.

Dada analysis and synthesis

The data extracted in Microsoft Excel were exported to STATA version 17 software for analysis. A random effect meta-analysis model with a restricted maximum likelihood method was used to compute the estimated pooled magnitude of preconception care utilization since we consider heterogeneity among the included studies. Statistical heterogeneity of the study was assessed by using I- squired (I²) value. This statistic quantifies the proportion of total variation between studies that can be attributed to heterogeneity rather than chance. Accordingly, the result of I² value was interpreted as follows: <25 as low, 25–50 as moderate, 50–75 as high, and above 75 as very high heterogeneity(40). For high and very high values, subgroup analysis was done to identify the possible source of variation. Graphical, Funnel plot was used to assess the possible publication bias. Egger's weighted regression test also was done to estimate the publication bias. A forest plot was used to show the estimated pooled magnitude of preconception care utilization. In relation to the second outcome, OR with 95 percent confidence intervals (CI) were calculated to assess the relationship between preconception care utilization, and its associated factors. Finally, p-values less than or equal to 0.05 were considered statistically significant for the above analysis.

Search results:

In this review, a total of 5,425 study records were identified through database searching of PubMed, MIDLINE, Embase, Cochrane Library, Google Scholar, and from List of References. Of which, 525 records were duplicated, and removed. The remaining 4,900 records were screened by their title and abstracts. After assessing the title and their abstracts we also excluded 4,816 study records due to these articles were not related to our review. Then after assessing 84 full text articles, 70 were further excluded due to the specific outcome variable (the magnitude of preconception care utilization) were not reported. Even though unpublished studies (Gray literature) were searched through Google Scholar, no study was found. Finally, fourteen (14) primary studies were fulfilled the eligibility criteria, and included in this systematic review and meta-analysis (Fig. 1).

Characteristics of included studies

This systematic review and meta-analysis were carried out from 14 primary studies with a total of 6,808 study participants. From the total of 14 studies, 6 were done in the Oromia region, 3 were done in the Amhara region, 2 were done in South Nation Nationality People of Ethiopia region (SNNP), 2 were done in Addis Ababa city administration, and the remaining 1 was done in Tigray region. Of the total of 14 studies, nearly two-thirds (nine) studies were conducted at the community based while near to one-third or (fife) studies were done at the health facility. The sample size ranges from as low as 229 in the study done at Adet town in the Amhara region to as high as 669 in the study done at the West Shewa zone in the Oromia region. The lowest magnitude of preconception care utilization among women in Ethiopia was 6.3% reported in the study done at Mana district in the Oromia region, and the highest was 58.3% reported in the study conducted at Sendafa which was also in the Oromia region. Regarding study design, all studies were cross-sectional. No eligible study was found conducted through case control, and cohort study design. The lowest response rate was 95.8% reported in a study done at Sendafa town, and the highest was 100% reported in 5 studies. From the total, half (seven) studies were done by using simple random sampling (SRS) technique, six were done by using systematic random sampling technique, and the rest one was done by using consecutive sampling technique (Table 2).

Table 2

Summary of studies included in the systematic review and meta-analysis of the preconception care utilization among women in Ethiopia, 2024
Authors name	Year of publication	Study setting	Region	Sample size	Response rate (%)	Magnitude % with 95%CI	Sampling technique
Negash et al(41)	2023	Community	Oromia	388	98.7	21.6(17.7, 25.6)	Simple random
Tsrity et al (29)	2019	Community	Tigray	561	100	18.2(15, 21.4)	SRS
Yitayal et al(42)	2018	Community	Amhara	229	100	9.6 (5.8, 13.4	SRS
Addisu et al(43)	2023	Institutional	Addis Ababa	385	100	40 (35.1, 44.9)	Consecutive
Ketema et al(37)	2021	Institutional	Oromia	592	95.8	58.3(54.3, 62.3)	Systematic random
Elias et al(30)	2022	Community	Oromia	660	97.5	22.3 (18.9, 25.6)	Systematic random
Daniel et al(44)	2020	Community	Oromia	669	98.3	14.5 (11.8, 17.2)	SRS
Meron et al(45)	2022	Institutional	SNNP	400	100	19 (15.2, 22.8)
Tesfanesh et al(46)	2019	Community	Amhara	410	96.3	13.4 (10.1, 16.7)	Systematic random
Melsew et al(47)	2022	Community	SNNP	605	96.9	28.6 (24.9, 32.2)	Systematic random
Tura et al (48)	2021	Institutional	Oromia	455	100	49.9(47.6, 52.3)	Systematic random
Alemu et al(30)	2022	Community	Amhara	500	99.2	22.4(18.7, 26)	SRS
Frianbon et al(36)	2021	Community	Oromia	623	98	6.3 (4.4, 8.2)	SRS
Eriste et al (49)	2022	Facility	Addis Ababa	331	98.2	40.5% (35.3, 45.6)	SRS
Note: SNNP refers to South Nation Nationality People of Ethiopia, SRS refers to simple random Sampling.

Quality of the included studies

During our quality assessment, we found that all of the included studies exhibited reliable methodological quality. The Newcastle-Ottawa Scale 9NOS) scores ranged between 7 and 9 out of a total score of 10. This indicated that each primary study had high quality (Table 1).

The magnitude of preconception care utilization among Ethiopian women

To compute a meta-analysis, 14 primary studies with a total of 6,808 women were participated. A random effect model with a restricted maximum likelihood method was used to determine the estimated pooled magnitude, and a Forest plot was used to show graphically. Accordingly, the overall estimated pooled magnitude of preconception care utilization among women in Ethiopia was 26% (95% CI: 18, 34) with a heterogeneity index (I²) of 95.6% (p = 0.000) (Fig. 2).

Subgroup analysis

In the current meta-analysis, the I-squired test result (I² = 95.6%, P < 0.001) shows a significant heterogeneity among studies. Due to this reason subgroup analyses were done by using regions where the study was done, and study settings (institutional versus community-based) to identify the possible source of variation (heterogeneity) among studies. Accordingly, the lowest pooled magnitude of preconception care utilization was observed in Amhara region (15% (95% CI: 8.00, 22.00), I² = 69.13%), and the highest was in Addis Ababa city administration with 40% (95% CI: 33, 47) with I² 0.01%, followed by Oromia region (29.00% (95% CI: 12.00, 45.00), I² = 98.14%) (Fig. 3). Variation was also observed between institutional and community-based studies. Accordingly, the estimated pooled magnitude of preconception care utilization was low in the community-based studies 17% (95% CI: 1², 22), I² = 81.31%, and higher among institutional-based studies 42.0% (95% CI: 29, 55) with I² = 93.37%) (Fig. 4).

Publication bias

The publication bias of this study was assessed by using Funnel pot and Egger’s regression test. The graphical Funnel plot showed the asymmetry of the studies (Fig. 5). However, the Egger’s regression test result revealed that there was no significant publication bias.

Factors associated with preconception care utilization

Different determinant factors significantly affected the utilization of preconception care were identified by this systematic review and meta-analysis. Variables reported as significant factor in at least two primary studies were incorporated in the current meta-analysis. Hence, the educational status of women, knowledge of women regarding preconception care, history of previous adverse birth outcomes, presence or absence of chronic medical illness, and husband/partner support were significantly associated with preconception care utilization (Table 3).

Educational status of women was one of the determinant factors affecting the utilization of preconception care. To compute this specific meta-analysis, more than 2,117 women from four primary studies were incorporated. Accordingly, the odds of preconception care utilization were three times higher among women who attended college and above as compared to their counterparts OR = 2.94 (95%ci: 2.20, 3.68) (Fig. 6).

Other associated factor in this study was knowledge of women regarding preconception care. To compute this specific meta-analysis, more than 3,268 women from 7 primary studies were participated. Hence, the odds of preconception care utilization were higher among women who had good knowledge as compared to women who had poor knowledge [OR = 2.52(95% CI: 1.77, 3.26) I² = 36.46%, P < 0.001] (Fig. 7).

Previous adverse birth outcome was another associated factor positively affected the utilization of preconception care. To compute this specific meta-analysis, more than 1,890 women from 4 primary studies were participated. Accordingly, the odds of preconception care utilization were higher among women who had history of previous adverse birth outcome as compared to their counterparts OR = 3.18 (95% CI: 2.75, 3.62) with I² = 78%] (Fig. 8). Similarly, either financial or psychological support from husband /partner was also the associated factors affecting women’s utilization of preconception care. Hence, the odd of preconception care utilization was three and half times higher among women who got either financial or psychological support from their husband /partner as compared to their counterparts OR = 3.41 (95% CI: 2.45, 4.37) (Fig. 9). Finaly, among five primary studies, women who had chronic medical follow up were almost four times more likely to utilize preconception care as compared to women who didn’t have any chronic medical illness OR = 4.09, 95% CI: 2.89, 5.30) (Fig. 9) (Fig. 10).

Table 3

Summary of the associated factors of preconception care utilization among women in Ethiopia, 2024
Variables	Number of studies	Studies included	Pooled Odds ratio with 95% CI
educational status of women	4	Yitayal et al /2018	2.94 (2.20, 3.68 )
		Elias et al /2022
		Melsew et al /2022
		Frianbon et al /2021
Knowledge (good vs poor)	7	Negash et al /2023	2.52 (1.77, 3.26)
		Tsrity et al 2019
		Addisu et al /2023
		Elias et al /2022
		Daniel et al /2020
		Melsew et al /2022
		Meron et al /2022
Previous adverse pregnancy outcome	4	Alemu et al /2022	3.18 (2.75, 3.62)
		Meron et al /2022
		Melsew et al /2021
		Adieu et al /2023
Husband /partner support (yes, no)	4	Negash et al /2023	3.41 (2.45, 4.37)
		Tsrity et al 2019
		Ketema et al /2021
		Tura et al/2021
Presence of chronic medical illness	5	Negash et al /2023	4.09 (2.89, 5.30)
		Adieu et al /2023
		Tsrity et al /2019
		Alemu et al /2022
		Frianbon et al /2022

Centers for Disease Prevention and Control (CDC) and WHO recommend each woman, man, and couple should be encouraged to have a reproductive life span; all women of childbearing age should screened before pregnancy for risks related to the outcomes of pregnancy(50, 51). Moreover, it is also recommended that all health care providers screen all women for their intention to become pregnant to provide them with appropriate services(52). This systematic review and meta-analysis were carried out to estimate the pooled magnitude and associated factors of preconception care utilization in Ethiopia. The finding of this study will have an implication on policy makers, program planners, and specifically for health care providers since it gives the overall image of preconception care utilization. Hence, the estimated pooled magnitude of preconception care utilization in Ethiopia was 26% (955 CI: 18, 34). This finding was in line with different studies such as a systematic review and meta-analysis study conducted in Africa 18.6%(53), a study of Kenya 21.7% (54), a study conducted South East Nigeria (23.4%)(55), a study conducted in the Southern Sri-Lanka (27%)(56), study conducted in Southern part of Nigeria 34%(57), and a study conducted in Al Ahsa, Saudi Arabia(58). However, this finding was much lower than studies conducted in the Surveillance summary review of the CDC (79%)(59), a survey on the implementation of preconception care in Shanghai, China 40%(60), a study done in Iran 77%(61), and a study conducted in Malaysia 44%(62). This variation might be due to the differences in the socio-demographic status of study participants, study population (pregnant women verses reproductive age women), study settings (community-based verses health facility based), and variations in the access to healthcare facilities and healthcare systems within countries. Moreover, it could be explained by differences in policies and implementation strategies of maternal and child health services among countries. Variations might also be due to the difference between meta-analysis and the primary studies

On the other hand, the finding of the current study was higher than studies conducted in Sudan at 9%(63), and a study conducted in Brazil (15%)(64). Differences might be due to variations in sample size, study setting, and socio-demographic status of each country's study participants. The above variation could be also due to the nature of the studies between the meta-analysis and the primary studies.

According to subgroup meta-analysis results, the highest utilization of preconception care (40%; 95% CI: 33, 47) was seen in the Addis Ababa city administration, and the lowest (15% (95% CI: 8, 22) in Amhara region. Variations were also observed based on study settings; hence, the highest result 42% (95% CI: 29, 55) was seen among institutional-based studies, and the lowest (17%; 95% CI: 12, 22) was seen in community-based studies. The reason for the above-observed difference is obvious. Urban Ethiopian women tend to benefit from increased knowledge and access to maternal health services compared to their rural counterparts. Also, various health promotion programs, which use urban-focused mass media, advantage more urban residences. Moreover, rural women are highly influenced by traditional practices other than modern health care practices(65, 66).

The educational status of women is one of the identified determinant factors for the utilization of PCC. Women who had a diploma and above were two times more likely to utilize preconception care compared to those who didn't attend formal education. This finding is consistent with the study finding of systematic review and meta-analysis in SSA(67), and the study finding of qualitative research in Kenya (68). This might be due to educated women can read and accesses a wide range of information related to continuum of maternity care; this in turn increases maternal awareness, and have a better understanding of maternal health services. In addition to this, empowering women has a positive driving impact on the utilization of maternal and child health services. Education is one of the proven strategies for empowering women, especially in low and middle-income countries including Ethiopia.

Having a good knowledge regarding PCC increases service utilization by two and a half folds. This study is supported by a study of systematic review and meta-analysis to determine the correlation between women’s knowledge level and preconception care utilization in SSA(35), and a study conducted in South Africa(69). Knowing is the first entry point for either accepted or decline of the utilization of health care services. This could be explained by having good knowledge increases awareness and a positive attitude toward health-seeking behavior; this in turn increases the utilization of maternal health services(70)

History of previous adverse birth outcomes had a positive association with PCC utilization. Women who had at least one adverse birth outcome in the previous pregnancy were three times more likely to utilize PCC compared with those who had no history of adverse birth outcomes. This finding is supported by the study of previous adverse infant outcomes as a predictor of PCC use in Los Angeles(71), and a study of factors associated with folic acid intake in Sudan(72). This might be due to women experiencing adverse birth outcomes having a high alert for the future subsequent pregnancy; this leads to a need for health care before pregnancy. In addition to this, women who experience adverse infant outcomes get advice and counseling from their healthcare provider for the next pregnancy; for instance, folic acid supplementations before pregnancy to prevent neural tube defects on women who gave child with neural tube defects in the previous childbirth. Neural tube defects such as spinal bifuda, anencephaly, hydrocephalus, and meningocele are prevented by provision of folic acid at least two months prior to pregnancy and continued at least up to one after conception. Folic acid supplementation is one of the WHO components of preconception care.

Similarly, women with previous chronic medical health problems were almost four times more likely to utilize PCC as compared to their counterparts. This finding is supported by studies done in Malaysia(62), and a study done in Georgia(73). The reason for this might be due to women on follow-up of their medical illness had a greater chance of getting preconception care from their doctor or health care provider due to repeated contacts. In addition, it might also be due to the Doctor or health care provider giving more attention to screening diseases and counseling for women who had chronic medical illnesses compared to their counterparts. It is believed that proper preconception care utilization in women of chronic medical cases significantly reduces the risk of congenital malformation. One study of systematic review and meta-analysis on preconception care and risk of congenital malformation among diabetic women shows that utilization of PCC specifically folic acid supplementation significantly reduces congenital malformations in their offspring’s(74).

Lastly, the financial and psychological support of the husband had a strong positive association with PCC utilization. Accordingly, women obtaining either financial or psychological support from their husbands/partners were three times more likely to utilize PCC compared with their counterparts. This finding is supported by the study conducted in Shanghai, Chain(75). It is obvious male involvement improves maternal health service utilization. However, Iin many low and middle-income countries including Ethiopia, men are the key decision-makers and chief providers, often determining women's access to economic resources. Such practices have implications for maternal health as it determines mainly women's access to maternal health services. Moreover, the active participation of men in maternal health services encourages and supports their wives; these in turn improve the utilization of maternal health services by women(76, 77).

Limitation of the study

This systematic review and meta-analysis has its own limitations. The first one is all primary studies included in this study were cross-sectional study design, and the outcome variable may be affected by other confounding variables. Secondly, studies included in this systematic review and meta-analysis was from only five regions of the country. Nowadays, the country Ethiopia has eleven regions and it may not be fair to generalize the results.

The overall magnitude of preconception care utilization among Ethiopian women was significantly low as compared to the WHO, and CDC recommendations. Educational status of women, knowledge of women regarding PCC, previous history of adverse birth outcome, pre-existing chronic medical illness, and either psychological or financial husband support were the identified predictors of preconception care utilization. The government of Ethiopia gives priorities for maternal health services such as family planning, antenatal care, and skilled delivery care which avert the majority of causes of maternal mortality and morbidity. Even though Preconception care is one of the essential components of the continuum of maternity care which is given one step back to pregnancy, it gives less emphasis by the government of Ethiopia; this leads to less practice throughout the country. Based on this finding, we recommend that program planners and strategists need to formulate clear implementation strategies to implement the whole components of the continuum of maternity care. Doctors and health care workers shall provide all components of preconception care before pregnancy, and give information and deep understanding regarding the importance of preconception care to women, these may lead to better utilization.

CDC: Center for Disease Prevention and Control,

CI: Confidence Interval,

EDHS: Ethiopian Demographic Health Survey

NOS: Newcastle- Ottawa Scale

AOR: Adjusted Odds Ratio

PCC: Preconception Care

PRISMA: Proffered Reporting Items for Systematic Review and Meta-Analysis

SDG: Sustainable Development Goal

SNNP: South Nation Nationality and People

SSA: Sub-Saharan Africa

WHO: World Health Organization

Acknowledgment

We would like to acknowledge all authors of primary studies incorporated in this systematic review and meta-analysis.

Authors’ contribution

AA conceived the research idea. AA, SS and TD were participated in the search of studies, data extraction, data analysis and synthesis, and draft writing. On the other hand, WT and GA were participated in the data analysis, preparation of manuscript, and revision. All authors read, and approved the final manuscript.

Funding statement

This research work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Availability of data and materials

The data included in this systematic review and meta-analysis are available in the manuscript, as additional supporting information, and from the corresponding author with a reasonable request.

Author’s declarations

Ethical approval and consent for participants:

Not applicable

PROSPERO registration:

This study was registered on PROSPERO on the date of 23/12/2023 with registration number CRD42023492995.

Competing interests:

All authors declare that they have no competing interests.

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The magnitude of preconception care utilization and associated factors among women in Ethiopia: Systematic review and Meta- analysis, 2024

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