DOI: https://doi.org/10.21203/rs.2.13877/v1
Background Preconception care (PCC) is a recognised strategy for optimising maternal health and improving maternal and neonatal outcomes. Research has however shown that preconception care services are not routinely provided as part of maternal health services in Nigeria. This study explored the perceptions about preconception care services among health care workers in Ibadan, Nigeria.
Methods This was a qualitative descriptive study involving 25 in-depth interviews among 16 specialist physicians and nine nurses covering 10 specialties: Obstetrics/Gynaecology, Cardiology, Endocrinology among others at the primary, secondary and tertiary health care levels. Interviews were digitally recorded, transcribed verbatim and analysed on MAXQDA using thematic analysis.
Results Six main themes were identified from the data – what PCC is, people who require PCC, where PCC services can be provided, acceptability of PCC services, the relevance of PCC to different specialties including gynaecologists, cardiologists, nephrologists, psychiatrists and the possible benefits of PCC. PCC was viewed as care for women, men and couples before pregnancy to optimise health status and ensure positive pregnancy outcomes. Almost all the participants stated that PCC services should be offered at all three levels of health care with referral when needed from the lower to higher levels. The prevailing opinion on the circumstances when PCC is required was that although all people of reproductive age would benefit, those who had medical problems such as hypertension, sickle cell disease, diabetes and infertility would benefit more. Acceptance and use of PCC services could however be hindered by the attitude of potential clients especially for those without any known pre-existing condition who may not use the service even if they were aware of its existence. All specialist physicians identified the relevance of PCC to their practice and identified potential benefits of PCC. The potential benefits outlined included opportunity to plan and prepare for pregnancy to ensure positive pregnancy outcomes.
Conclusion Preconception care is important for positive pregnancy outcomes in people with known medical problems and is relevant to different specialities of medical practice. Its uptake will however depend on its acceptability to the people who will benefit from the service.
Preconception care (PCC) has been recommended by the World Health Organisation (WHO), the US Centres for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynaecologists (ACOG) for both women and men in the childbearing ages as a strategy for optimising parental health and improving maternal and neonatal outcomes [1]. PCC is defined as "the provision of biomedical, behavioural and social health interventions to women and couples before conception occurs. It aims at improving their health status and reducing behavioural, individual and environmental factors that contribute to poor maternal and child health outcomes” [2]. PCC includes preventive (e.g. vaccinations and genetic screening), therapeutic (treatment for chronic medical conditions) and behavioural (e.g. alcohol reduction and smoking cessation) interventions [3,4]. For PCC to be effective, the services must cover the entire reproductive period which spans about four decades of a woman’s lifetime. This implies a need for counselling on appropriate medical care and healthy behaviour at every encounter a woman has with the health system [4]. Health care workers, irrespective of their specialty and level of healthcare, need to be aware of PCC and its components. They also need to have some understanding of the need among their clientele in order to be able to provide counselling and referral if necessary. Previous studies among health workers in the Netherlands and United Kingdom showed that their ability to provide PCC services was influenced by their attitudes and perception of the service [1,5]. Systematic reviews of research among health workers showed that provision of PCC was hindered by lack of familiarity with the concept and its potential benefits. Negative attitudes towards PCC and poor conviction of its importance were also noted [1,5]. Other studies have also shown that confusion about who should provide PCC [3,6,7], perception of lack of opportunity to provide PCC [8] and lack of motivation to provide PCC are barriers to provision by health care workers [9]. On the other hand, good knowledge and having a positive attitude towards PCC have been identified as facilitators of provision of PCC services by health care workers [1,6,7,10].
In Nigeria, the few studies that have assessed PCC have been on the awareness and utilisation among women within health facilities [11–14]. In one of the studies, participants attributed their lack of awareness to the fact that health care workers do not talk about PCC during routine health visits [14]. On the other hand, participants who had some knowledge about PCC had obtained information from antenatal clinics during their previous pregnancies [11,14,15]. Given that the likelihood of using PCC services is dependent on health care workers’ knowledge, attitudes and providing information on PCC to their patients [1], this study explored the perceptions about PCC services among health care workers, as well as their opinions about acceptability of PCC services in the Nigerian health system.
This study used a descriptive qualitative approach to explore the perceptions of health care workers about PCC. In this study, face to face in-depth interviews were conducted among 26 health care workers at the different levels of health care in Nigeria. The Nigerian health care system runs at three levels—tertiary, secondary and primary—managed in a concurrent manner by the three tiers of government (federal, state and local government) as follows: The federal government provides strategic oversight and manages tertiary health care which is provided by the teaching hospitals; the states have a technical function and provide secondary health care in the state specialist hospitals while the local government level is operational and includes primary health care services provided at the grassroot level [16]. A two-way referral method operates within the health system with patients referred to higher levels for more specialised services and stepped down to lower levels when the specialised services are no longer needed [16].
The study was conducted in Ibadan North Local Government Area (LGA), one of the five urban LGAs in Ibadan metropolis, Oyo State, southwest Nigeria. The site was purposively selected because of its peculiarity in housing health facilities at the three levels of health care in Nigeria. These include: the University College Hospital (UCH), which provides tertiary services for the state and most of the south-western region of the country. All medical and surgical specialties are available in the hospital. The Adeoyo Maternity Hospital and some private health facilities provide secondary maternal health services. Primary health care services are provided by the Primary Health Centres (PHCs) of which there are 10, one located in each of the 10 political wards in the LGA. The Medical Officer of Health (MOH), which is a Public Health physician is the only medical doctor in the LGA and is supported by other cadres of health workers including nurses, midwives and community health officers.
The health workers selected for this study were specialist physicians and nurses/midwives whose specialty includes care for women and men within the childbearing years. Paediatricians were also included because the health of newborn babies is a function of the health of their parents. At the tertiary health facility, specialist physicians in Cardiology, Endocrinology, Family Medicine, Haematology, Nephrology, Neurology, Obstetrics/Gynaecology, Paediatrics, Psychiatry and Public Health were interviewed. Public health nurses and clinical nurses also participated in the study. At the secondary level of care, two Obstetrician/Gynaecologists were selected, one from the Adeoyo Maternity Hospital, a government-owned hospital and the other from a private hospital where assisted reproductive services are provided. One Paediatrician and one clinical nurse were also selected form the Adeoyo Maternity Hospital. The Medical Officer of Health, the Director of Maternal Health Services in the LGA and one clinical nurse were interviewed at the LGA level. All the participants were purposively selected because of the relevance of their specialties to the care of women and men in the childbearing ages.
Data collection was supervised by the first author, conducted by four Masters students from the Faculty of Public Health, University of Ibadan, Nigeria who were experienced in qualitative data collection and had been trained for the purpose of the study. The research assistants worked in pairs with one facilitating and the other taking field notes. Debriefing sessions were held with the first author to discuss the interviews, highlighting any issues raised with the questions and making decisions on subsequent interviews. Each interview, lasting an average of 30 minutes, was digitally recorded in English language, and conducted in the offices of the participants. In-depth interview guides containing open-ended questions with probes were used for data collection. The questions were developed for this study using information from existing literature. The main interview questions were: What form of care should be provided for women of childbearing age that differs from other patients seen in your practice? Would you say men require similar care? What do you understand by the term preconception care? A definition of preconception care was provided to the participants here following which they were asked: Would you say there is a role for preconception care services in your practice? For which category of people?
The interviews were transcribed verbatim. The transcripts were read, integrated with the field notes and compared with the audio recordings individually to ensure there was no missing information. A hybrid of inductive and deductive coding were used in the development of the codebook for thematic data analysis [17,18]. To enhance trustworthiness and avoid introduction of the researchers’ biases into the analysis, a sample of the transcripts was given to two independent coders along with the study objectives. The coders identified recurring patterns in the data and developed a set of codes. A consensus on the themes and subthemes of codes was reached through discussion between the independent coders and the study team. The initial set of twenty-seven codes generated were merged into six themes to form the codebook. A third, more experienced qualitative researcher independently reviewed the codebook with the transcripts to achieve inter-coder agreement. The codebook was applied to the transcripts and suitable quotes were selected for the research report. All data analysis was done on MAXQDA 2018. The themes generated from the data are shown in Table 2. The Standards for Reporting Qualitative Research (SRQR) checklist was used in developing this article [19].
Information sheets containing the details of the study were provided to all participants and consent obtained 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 research team. Ethical approval for the study was obtained from the ethics committee of the University College Hospital (UCH), Ibadan, Nigeria and the Wits Human Research Ethics Committee.
Twenty-five in-depth interview transcripts were analysed. There were nine nurses and sixteen specialist physicians who had worked for between one and 32 years (median 13.5years) in the health system. Three interviews were held at the primary level, five at the secondary level and 18 at the tertiary level. Participants’ details are shown in Table 1.
The main themes generated from the data are shown in Table 2 and described thereafter.
The health workers provided definitions of what they understood PCC to be. They also described PCC in terms of its components and who should be involved in its provision.
While some of the participants referred to PCC as care specifically for women, others described it as care for both women and men or couples who are preparing for childbearing.
"Preconception care is care that is given to women of child bearing age before they get pregnant”—Tertiary care level, Public Health Nurse (Ob/Gyn)
"Preconception care is a form of care given to people, men and women prior to the time that they plan to get pregnant as a form of preparation”—Primary care level, Public Health Physician
Some of the participants described PCC in relation to the timing of conception as care provided at least three months before a woman gets pregnant.
"In my own opinion, preconception care is any care that is given to women of reproductive age at least three months before they get pregnant”—Secondary care level, Ob/Gyn
Mention was also made of PCC as care provided for couples who have peculiar health problems that may affect pregnancy. In such instances, PCC was described as care to address health problems before pregnancy occurs.
"Pre-conception care refers to the services you offer a couple prior to pregnancy especially because there are health issues that may influence the anticipated pregnancy. Services such as medical, counselling services, indicated by peculiar health issues that could potentially affect the pregnancy.””—Tertiary care level, Neurologist
Other respondents gave their description in terms of the timing of PCC, think that such care should start as early as possible in a girl’s life. In this instance, the description of PCC was provided in terms of service content with emphasis on the need to provide preventive measures like vaccinations and HIV prevention in adolescence.
"Preconception care is the care that women receive prior to conception and should be given right from school. If we take the Nigerian setting, right from the secondary school, a woman should have tetanus toxoid vaccination, her nutrition, sexual and reproductive care generally and how she would not contract HIV are part of preconception care. So, preconception care starts as early as possible and includes every care given to a girl child before pregnancy.””—Tertiary care level, Cardiologist
The components of PCC identified include health education and counselling on adoption of a healthy lifestyle through improved nutrition, use of folic acid and immunisation against diseases like tetanus. Also mentioned were the need to determine haemoglobin genotype and rhesus compatibility, identify and treat diseases including sexually transmitted infections and HIV, as well as planning towards a desired number and spacing of children.
"The elements of preconception care may be primordial, primary or secondary. For primordial you tell a woman to take folic acid before conception to prevent neural tube defect in the baby. For primary, you tell the woman to take tetanus toxoid, have hepatitis screening and immunisation before she gets pregnant. If the woman is rhesus negative, we tell her to use certain medications to prevent complications. For secondary care, women who have delay in getting pregnant can be offered curative treatment after identifying the cause.””—Primary care level, Public Health Physician
"Preconception care … starts with a girl or a boy determining his or her genotype. Those who have been diagnosed with noncommunicable diseases at a very young age (less than 40) either hypertension or sickle cell disease need to take good care of themselves using their medications appropriately. We take history of congenital abnormalities in the family; ensuring they don’t have any sexually transmitted disease prior to conception, take folic acid, eat balanced diet and see a health personnel for preconception counselling. It also includes family planning”—Tertiary care level, Public Health Physician
"It is composed of health education, immunisations, supplementations for example, of folic acid which we normally give when they come to ANC but it is late then, folic acid should be preconception. Screening for HIV, diabetes, hypertension, syphilis and hepatitis, genotype and blood group; these are the prongs that constitute preconception care.””—Tertiary care level, Paediatric Cardiologist
Opinions varied regarding who should provide PCC services in the health care setting. The need for a multidisciplinary approach was described as participants identified areas that ought to be covered by different specialties. In terms of primary responsibility for PCC though, some participants felt family physicians should be in charge since they are usually the first contact people have with the health system. Others stated that PCC is specialised and should be provided by obstetricians and gynaecologists who are primarily responsible for women’s reproductive health.
"As a paediatrician, I would say the paediatrician is the best to provide the service but, not to be biased, Family Physicians are in the best position. They are the ones people go to when they want to do all the entry things {i.e. First point of contact in hospital settings}. The Paediatricians should be involved too, Obstetricians come later then everybody involved in Health Education. It is multidisciplinary. We need politicians as well because they formulate policies.””—Tertiary care level, Paediatrician
"Doctors usually gynaecologists, nurses, the whole team that provides antenatal care can also provide preconception care.””—Secondary care level, Ob/Gyn
"Actually, preconception care should be run by the obstetrics and gynaecological practitioners—the doctors, the nurses—because that is their area not just the general practitioner”—Tertiary care level, Clinical Nurse
On the other hand, some participants believe that any doctor or health care provider who comes in contact with women should be able to offer PCC.
"To the best of my knowledge, it is the healthcare provider or doctor who is the first person you see in the clinic. I am not aware of any particular specialist for preconception care. I think every healthcare provider should be able to do provide preconception care.””—Tertiary care level, Nephrologist
With regards to providing preconception counselling particularly to adolescents and youth, the public health specialists in particular were of the opinion that teachers should be involved in PCC.
"If it is for education or counselling, I believe the teachers in secondary schools should be involved. Then when it comes to rendering particular care, health workers should be involved too. As long as you come in contact with any youth, health workers or teachers should be able to provide this type of care either in the form of counselling or actual care”—Tertiary care level, Public Health Nurse
Generally, most of the health workers interviewed were of the opinion that all women and men in their childbearing years should have preconception care. This includes those who are preparing for their first pregnancy and those who have had children before but will like to have more. Such people also need PCC to prepare for subsequent pregnancies.
“Women of reproductive age group will benefit more from preconception care, from adolescents to young adults, single or married because it is not everybody who gets married that easily gets pregnant immediately. Then it is also meant for people who after conception and birth need to know what to do to prepare themselves for subsequent pregnancies”..—Tertiary care level, Public Health Physician
Some of the participants felt that every girl child should be included in the provision of PCC since they all have the potential for childbearing and it is impossible to say who may or may not want to have children when they grow older.
"It is required for every girl child. How many people know whether they are going to get married or get pregnant? So, everybody should have it.”—Tertiary care level, Paediatric Cardiologist
Further, they provided descriptions of circumstances when PCC may be very crucial because of the possibility of negative pregnancy outcomes. These include instances when couples have health challenges that may affect their ability to conceive or impact negatively on pregnancy outcomes. The health challenges mentioned include genetic conditions, hypertension, diabetes and epilepsy for which women require medications that may need to be modified before pregnancy to prevent abnormalities in the baby.
"I think preconception care is required by women and their partners who may have a peculiar health challenge, for instance, a genetic condition that is potentially transmissible to their children. Women of reproductive age group who have epilepsy also need preconception care along with their partners because there are anti-epileptic drugs that are potentially teratogenic {can cause abnormalities in the baby}.”—Tertiary care level, Neurologist
"It’s for women who have risk factors for having a child with congenital problems or pregnancy with adverse outcomes. Patients with high blood pressure need to have their blood pressure stabilised. Patients who are on drugs may need to change their drugs prior to conception because many of the drugs predispose those patients to congenital abnormalities. Those who are diabetic and are on oral hypoglycaemic agents you want to switch to insulin. At the end of the day you want to have a healthy child and a healthy mother during pregnancy.””—Tertiary care level, Ob/Gyn
Participants also described the need for determining haemoglobin genotype compatibility in the preconception period in order to avoid having children with the sickle cell disorder (Sickler).
"In cases of genotype incompatibility (the AS, SS) you want to provide preconception care to tell them the kind of person that will suit them. Somebody that is SS should not marry somebody that is AS otherwise they have at least 50% chance of having a Sickler and you know the burden of taking care of a Sickler. Same applies to those who are AS, they should at least marry AA so they don’t have children who are Sicklers.””—Tertiary care level, Clinical Nurse
In discussing the most appropriate location for PCC, participants mentioned facilities that already provide maternal health services. This includes any facility that provides family planning services, antenatal and delivery care where potential clients for PCC already receive care.
"Preconception care should be provided in any centre where care is offered to women of reproductive age since they are the ones who need to access preconception care. Any centre where they offer antenatal services, obstetrician and gynaecological services, family planning, mother and child care, are potential places where clients that will benefit can be found.””—Secondary care level, Ob/Gyn
A few of the participants advocated for a specialised clinic where people of reproductive age can be referred for preconception counselling. The proponents of this idea believe that PCC is a specialised care and since it is for people who are otherwise healthy, the potential clients may not want to use the regular health facilities catering to those who are ill.
"I think the best way to do it is to have a standardized clinic for this age group. So, any physician that comes across people of this age group will refer them to that clinic for a briefing, not because they are ill but for them to be given some information on preconception care.””—Tertiary care level, Family Physician
The general reluctance to engage with health facilities in the community made some of the participants suggest the provision of PCC—particularly health education and information services—through community outreaches, social media outlets and youth friendly health centres.
"Well, it would have been a good idea for preconception care to be rendered in a place like the obstetrics and gynaecology clinic but it seems our culture here has not imbibed that. So, we may have to go out to the schools or community since people most likely will not come until they have problem trying to get pregnant. There can be community outreaches to discuss a number of things like blood group, blood level, genetic counselling which many of them need”—Tertiary care level, Public Health Nurse
"Preconception care can also be provided in youth friendly centres I mean clinics where youth, teenagers and adolescents can walk in. It is a very good avenue where we can counsel, screen and provide the necessary information. On the social media, awareness can be created on reasons why women need to check themselves before pregnancy.””—Tertiary care level, Clinical Nurse
The place of PCC within the three levels of health care in the Nigerian health system was highlighted. Some participants stated that PCC services should be provided at all three levels of health care with emphasis on the primary health care level since it is a health promoting/primary prevention service. Moreover, the laboratory facilities and equipment needed for medical screenings are either already present or can be provided at the primary health level. In this instance, referral to higher levels of care can be provided as needed. This opinion was proffered more by the health workers at the primary and secondary levels of care and the public health specialists.
"Preconception care should be at the 3 levels—the primary, secondary and tertiary. The primary, is the grass root level, where we meet many clients between 15–49 years. But people in that age group are also at the secondary and tertiary levels so it {preconception care} should be available at the three levels.””—Primary care level, Public Health Nurse
"Preconception care should ideally be provided in primary health care just like antenatal care service is primary health care because it is closer to the public. But the primary health care providers should be able to tell if someone needs to be referred to secondary health care like they do for antenatal.””—Secondary care level, Ob/Gyn and Tertiary care level, Public Health Nurse
Some respondents believed that because of the level of expertise needed for some aspects of PCC like genetic counselling, the minimum should be at secondary care level.
"Preconception care can’t be approached in primary health centres, I think it is best handled in tertiary health centres”—Tertiary care level, Haematologist
"Preconception care should be provided in hospital facilities like in secondary health centres or in tertiary health centres, basically, because we need to have the manpower for it. We need nurses, genetic counsellors, social workers–an outreach team (because sometimes you need to know where the patients live), lab facilities to do some medical screening, and doctors, obstetricians who will take most of the decisions. So, it should be in a facility like a secondary health centre where you can always take decisions prior to the woman getting pregnant and of course in tertiary health centres but not in primary health centres.””—Tertiary care level, Ob/Gyn
The participants were of the opinion that PCC may not be accepted generally by the people who should use the service. They believe the concept of PCC is new to the prevailing culture therefore the likelihood of using the service may be low. The general attitude towards health issues is that many people tend to avoid going to health facilities unless there is a problem. Even those who have known illnesses such as hypertension that requires regular follow up often miss their clinic appointments when they feel well. As such the chances of going to a preconception clinic to determine if they are healthy is slim when they feel no physical evidence or symptom of ill-health. In addition, acceptance of PCC may be affected by the fact that the services are not free. Health services generally require out of pocket payment in the country except for a few people who have some form of health insurance. Even then, the health insurance schemes often exclude preventive services, catering more for curative ones.
"Preconception care on its own is not something that is popular. Generally, our people don’t believe that there is something wrong with them until they have some pain or discomfort. When women are not pregnant and you ask them to come for investigation, they will look at you wondering what you are talking about. … Even hypertensives will not go to the clinic unless they have a problem; they will say my clinic is tomorrow, but I’m ok. So, women will usually not come for preconception care for you to be able to detect anything till the point of booking for the pregnancy.””—Tertiary care level, Public Health Nurse
"Acceptance may be an issue; patients accepting that they do need it {PCC} especially when they need to pay for the services. The services are not covered by health insurance, patients have to pay from their pockets. NHIS {National Health Insurance Scheme} covers antenatal but it does not cover preconception care. Many people are not well informed, they don’t have adequate formal education and they see hospital as a place they only go when complication has arisen. But preconception care is a preventive measure before they even show any sign of disease. Even when they are sick people are reluctant to come to the hospital, how much more when they don’t have symptoms.””—Tertiary care level, Ob/Gyn
The different specialists described the importance of PCC to their clients. For the paediatricians, PCC would improve the health of the newborn since many potential problems would have been addressed before pregnancy and detailed attention paid during pregnancy to whatever issues were detected in the preconception period. Other specialties like the cardiologist, endocrinologist, neurologist and nephrologist would have addressed chronic illnesses, controlled the condition or modified the medications used in the preconception period to prevent development of congenital abnormalities in the baby. For the family physician, PCC is seen as part of routine daily duties for every woman of reproductive age seen in clinic.
"Some of our patients have hypertension, migraine and other chronic illnesses that require medications. Some of these anti-hypertensives and other drugs could affect pregnancy, some of them are teratogenic {can cause abnormality in the child} and are contraindicated in the pregnancy. So, we give them information about the drug and tell them ‘if you get married and want to get pregnant, let us know so that we can change this medication to the one that will be suitable’.”—Tertiary care level, Neurologist
"Having preconception care will reduce the rate of disease we see in neonates (babies in the first 28 days). Many neonates develop complications that are due to certain experiences while they were in the womb. Having preconception care will improve the quality of health of the babies that women bear.””—Tertiary care level, Paediatrician
"As Family Physicians, preconception care is part of our job. We provide counselling, health promotion and health education to our patients. Most of our patients don’t know about their health especially about preconception care and in this area where emphasis is laid on childbearing, if the patient has a fertility problem, it is a big issue socially, within the family and in the whole community. We educate women of reproductive age to take folic acid before pregnancy to prevent congenital abnormalities especially spina bifida.””—Tertiary care level, Family Physician
Participants identified possible benefits of PCC services to potential users. These include the opportunity to make plans for childbearing in terms of number and spacing of children as well as to prepare financially for the baby.
"Well, I think preconception care enables couples to have a reproductive life plan and helps them to achieve their childbearing goals—when they want to get pregnant and how many times. People will draft a plan like I want to go to school now, I don’t want to get pregnant while I’m in school, after school I want to get married. If I’m sexually active now and I don’t want to get pregnant yet because I’m in school I know I have to get contraceptives.”—Tertiary care level, Public Health Physician
"There are a lot of benefits from it. It improves the health outcome for the baby and the mother. It also helps to prepare them financially for pregnancy and the baby that is coming.”—Secondary care level, Ob/Gyn
In addition, the fact that PCC leads to improved health status of parents and increases the likelihood of positive pregnancy outcomes was mentioned. The promotion of the use of folic acid for prevention of neural tube defects in the child was also highlighted.
"Women receive treatment for their health conditions giving them a better chance of getting pregnant at the time they want. Preconception care will help them to eliminate pre-existing conditions paving a way for them to easily get pregnant and sustain that pregnancy.””—Tertiary care level, Public Health Nurse
"Preconception care will help women to be in the best state of health to carry their pregnancy to full term. They will avoid foetal malformations, unnecessary pregnancy losses, increase the chances that the pregnancy gets to full term and reduce problems with delivery.””—Tertiary care level, Endocrinologist
"If a woman starts using folic acid up to 13 weeks before getting pregnant as encouraged during preconception care, she will avert some congenital anomalies like neural tube defect or spinal bifida.”—Tertiary care level, Paediatrician
Reduction in the chances of transmitting genetic diseases from parents to children was also mentioned as a possible benefit. The example of diseases which do not manifest in the parents but can be carried over to the children was given. Such diseases may be identified through genetic screening in the preconception period.
"It is all about dodging a bullet really, anticipating what can potentially happen and taking proactive steps to avoid or mitigate whatever issues the condition may be associated with. For instance, muscular dystrophies manifest in childhood usually before the age of 20 and often lead to death. Women who are carriers of the defective genes are not affected but they can potentially have sons who develop the disease. With adequate preconception care, testing and counselling it’s possible to avoid having a child with these conditions.””—Tertiary care level, Neurologist
In addition, the possibility of a couple planning for marriage checking their HIV status and deciding if they want to continue their relationship and plan for childbearing was mentioned.
"Preconception care is also important for intending couples, a preconception clinic visit can change the dynamic of a {planned} marriage. Some people are not aware of their HIV status for instance, and only get to know that one of them is HIV positive when they are ready to marry. Breaking up at this time is more painful. But if during the courtship people come to the preconception clinic, they can have the information and decide if they want to continue or not. It is important to face reality and know what you are going into, who you are going to marry. That’s one area where preconception care can help.”Tertiary care level, Ob/Gyn
…
This study explored the perceptions about PCC among health workers at the three levels of health service provision in Ibadan, Nigeria. This is the first study to explore the perceptions about PCC among health care providers in Nigeria with the previous studies examining the awareness, knowledge and utilisation of PCC among women of reproductive age. One other study among health workers in Africa was a cross-sectional study in Ethiopia [20]. This limits the extent to which the findings from this study can be compared with previous literature. The provision of PCC in Nigeria can be described as haphazard as there are no guidelines for PCC or recognised PCC clinics in the country. Women who are aware of PCC are often in the higher socioeconomic and educational groups and seek care from health care providers when they desire pregnancy [11,14,15].
The descriptions of PCC and its components given by the participants was similar to the definition and components described by the WHO and CDC [2–4]. Although varied, the descriptions included salient points such as providing care to optimise the health of women and men before conception. The components identified by the participants included mainly preventive and therapeutic services. Participants described the importance of vaccinations as well as screening for and managing health conditions like infections and chronic non-communicable diseases. The need for genetic counselling and treatment modification was also emphasised as part of PCC. In addition, reproductive health planning and its benefits including financial readiness of the couple was mentioned. In comparison, studies among health workers in other places such as Australia [21], New Zealand [8], Iran [22] and Ethiopia [20] reported low knowledge and awareness of PCC, although these studies were quantitative in nature. On the other hand, a qualitative study among physicians in rural Pennsylvania, US showed awareness of the need for pregnancy planning and the importance of optimal maternal health prior to pregnancy and described its necessity for women with high risk conditions like hypertension, seizure disorder, depression and diabetes [6].
The areas highlighted by the study participants speak to the prevailing issues in maternal and child health services both within the country and the African continent. Key populations identified as requiring PCC by the African subgroup in the WHO meeting to develop a global consensus for PCC include people with diabetes, sickle cell disease, epilepsy and adolescents [2]. Furthermore, in Nigeria, maternal anaemia [23,24], hypertension [25,26], sickle cell disease [27,28], diabetes and unplanned pregnancies [24,29] are major maternal and child health issues. The WHO preconception guidelines gives room for countries to identify specific areas to be targeted depending on their identified needs [2,30]. Health care providers in Nigeria can therefore develop guidelines based on the prevalent health problems that can be mitigated by PCC.
The participants in this study had different opinions on who should be in charge of provision of PCC. While some believed that every health care provider should be able to provide PCC at every contact with people in the reproductive age bracket, others felt family physicians or obstetricians/gynaecologists should be responsible. Studies in Australia [21], London [31] and Netherlands [7] have also shown that family physicians and general practitioners believe they should provide PCC. Another study among a different group of general practitioners in London found that the respondents believed that public health specialists should be the primary providers of PCC [9]. This opinion is consistent with that of some of our study participants who believed that PCC should be offered at the primary health care level with referrals to the higher levels of care when needed. The suggestion by some of the study participants that PCC should be provided at every contact with the health care system is also documented in literature. Providing PCC at every contact with the health system is referred to as opportunistic PCC and ensures that women’s awareness about their health is raised. It also serves to improve their health status irrespective of pregnancy intention [32,33]. Thus, every health care provider has the obligation to ask their patients about reproductive health plans at every contact in order to provide necessary information and counselling. This may also improve the chances of modification of management plans for people who have chronic diseases and reduce the chances of congenital abnormality in their babies. As things stand presently, many of such cases are only detected after pregnancy has occurred as stated by the study participants.
The culture of avoiding the health care system until when it is absolutely necessary was highlighted in this study as a possible barrier to the acceptance and utilization of PCC. Similar to this finding, a study among physicians in Ontario, Canada reported clients not visiting health facilities till they are pregnant as a barrier to the use of PCC services [34]. To combat this, our study participants mentioned use of community outreaches, social media, secondary schools and youth friendly health centres as avenues for provision of PCC. The WHO African subgroup at the meeting to develop a global consensus on PCC also identified community- and faith-based organisations, the educational system and existing Ministries of Health programs as avenues for provision of PCC services [2]. In addition, the need to pay out of pocket for health services was another potential problem that may hinder acceptance and use of PCC.
That PCC is beneficial to the individual and couple was well noted by the study participants. Benefits highlighted include prevention of transmission of genetic diseases, opportunity to plan ahead financially and improvement in the health status of the individual. The potential to improve individual health status is one of the justifications providing for opportunistic PCC. This implies the use of every clinic encounter to discuss weight management, dietary requirements, exercise, reduction/cessation of alcohol and tobacco use and making deliberate decisions concerning family planning and contraceptives among others [33].
This study highlights the perceptions about preconception care among health care workers at the three levels of the health care system in Nigeria. The respondents were generally positive about PCC. This suggests a potential for including preconception care services in the maternal, new born and child health services in the country as it is seen as an important service for improving maternal and child health outcomes. For preconception care services to be provided however, there is a need to reorient the people for whom the services are to be provided as attitudes towards the use of preventive services need to be improved.
ACOG—American College of Obstetricians and Gynaecologists
CDC—Centre for Disease Control
COREQ—Consolidated Criteria for Reporting Qualitative Research
HIV—Human Immunodeficiency Virus
LGA—Local Government Authority
MOH—Medical Officer of Health
Ob/Gyn—Obstetrician/Gynaecologist
PCC—Preconception care
PHC—Primary Health Centre
UCH—University College Hospital
UI/UCH—University of Ibadan/University College Hospital
WHO—World Health Organisation
Ethical approval for the study was obtained on February 6, 2018 from the University of Ibadan/University College Hospital (UI/UCH) Institution Review Board– Clearance number UI/EC/17/0390 and on March 3, 2018 from the Wits Human Research Ethics Committee (Medical)– Clearance number M171054. 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.
Not applicable.
For confidentiality purposes, the data generated in this study are not publicly available due to the qualitative nature of the study. Further information about the data is available from the corresponding author upon reasonable request.
The authors declare that they have no competing interests.
This study was self-funded.
Study concept and design: OOO and LI. Acquisition of data: OOO. Analysis and interpretation of data: OOO and LI. Drafting of the manuscript: OOO. Critical revision of the manuscript for important intellectual content: OOO and LI. Final approval of the manuscript: OOO and LI.
We are grateful to the Masters students from the University of Ibadan, Nigeria who assisted with the interviews.
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. 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).
Table 1 Sociodemographic characteristics of the study participants
|
Sociodemographic characteristics |
Doctors |
Nurses |
Total |
||||
|
Sex |
Male |
13 |
0 |
13 |
|||
|
|
Female |
4 |
9 |
13 |
|||
|
Age |
26-35 |
1 |
2 |
3 |
|||
|
|
36-45 |
9 |
4 |
13 |
|||
|
|
≥46 |
7 |
3 |
10 |
|||
|
Specialty |
Cardiology |
1 |
– |
1 |
|||
|
|
Clinical nursing |
– |
4 |
4 |
|||
|
|
Endocrinology |
1 |
– |
1 |
|||
|
|
Family Medicine |
1 |
– |
1 |
|||
|
|
Haematology |
1 |
– |
1 |
|||
|
|
Nephrology |
1 |
– |
1 |
|||
|
|
Neurology |
1 |
– |
1 |
|||
|
|
Obstetrics/Gynaecology |
5 |
– |
5 |
|||
|
|
Paediatrics |
2 |
– |
2 |
|||
|
|
Psychiatry |
1 |
– |
1 |
|||
|
|
Public Health |
3 |
– |
3 |
|||
|
|
Public Health Nursing |
– |
5 |
5 |
|||
|
Level of Healthcare |
Primary |
1 |
2 |
3 |
|||
|
|
Secondary |
3 |
2 |
5 |
|||
|
|
Tertiary |
13 |
5 |
18 |
|||
Table 2 Themes generated from the data
|
Themes |
Description/Subthemes |
|
What preconception care is |
· Description of PCC |
|
|
· Components of PCC |
|
|
· Who should be involved in the provision of PCC |
|
People who require PCC |
· Participant’s description of people who have health conditions that require PCC |
|
Where PCC services can be provided |
· Type of facility for provision of PCC services |
|
|
· Level of health care for PCC services |
|
Acceptability of preconception care |
· Participant’s perceptions of the acceptability of PCC to community members |
|
Relevance of PCC to specialties |
· Opinions about the importance of PCC to clients seen in each participant’s specialty |
|
Possible benefits of PCC |
· Descriptions of the potential benefits of PCC |