Perceptions about preconception care among health care providers in Ibadan, southwest Nigeria - A qualitative study

Background: Preconception care (PCC) is a recognised strategy for optimising maternal health and improving maternal and neonatal outcomes. Research has shown that PCC services are minimally available and yet to be fully integrated into maternal health services in Nigeria. This study explored the perceptions about PCC services among health care providers in Ibadan, Nigeria. Methods: This was a case study research among 26 health care providers – 16 specialist physicians and nine nurses covering 10 specialties: Obstetrics/Gynaecology, Cardiology, Endocrinology among others at the primary, secondary and tertiary health care levels. In-depth interviews were digitally recorded, transcribed verbatim and analysed on MAXQDA using thematic analysis. Results: Six main themes were identified from the data – scope of PCC, people who require PCC, where PCC services can be provided, acceptability of PCC services, relevance of PCC to different specialties including gynaecologists, cardiologists, nephrologists, psychiatrists and 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 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. Participants opined that delayed health care seeking observed in the community may influence acceptability of PCC especially for people without known pre-existing conditions. 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 perceived as being more important for promoting positive pregnancy outcomes in people with known medical problems and is relevant to different specialities of medical practice. Provision of the service will however require establishment of guidelines and its uptake will depend on acceptability to people with known medical problems who will benefit from the service.

BACKGROUND 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].
Strategies for improving reproductive health outcomes have gone through several paradigm changes over the years. The most recent is the continuum of care approach recognised as an effective means of delivering reproductive, maternal, newborn and child health (RMNCH) [5,6]. An effective continuum of care caters to the health needs of women and adolescents in two dimensions -[a.] time (throughout the life cycle i.e. before, during and after pregnancy) and [b.] place (wherever care can be provided i.e. households, communities and health facilities) [5,6]. PCC is a risk reduction strategy that fills the gap in the continuum of care approach to RMNCH by catering to the health needs of the adolescent girl and woman before and between pregnancies. Although advocacy for PCC to improve reproductive health outcomes has been on for more than three decades, the attention of the research community, health providers and policy makers to the concept is more recent. The shift in focus followed the 2006 establishment of the Preconception Care Work Group and the Select Panel on Preconception Care by the United States Centres for Disease Control and Prevention (CDC) [7]. Subsequently, promotion of the PCC strategy has gained strength in the United States and globally. The WHO identified the place of PCC in the prevention of preterm births and subsequently convened a meeting of experts who developed a global consensus on PCC to reduce maternal and child morbidity and mortality [2,7,8].
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 [1,9]. 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 [1,9]. Other studies have also shown that confusion about who should provide PCC [3,10,11], perception of lack of opportunity to provide PCC [12] and lack of motivation to provide PCC are barriers to provision by health care workers [13]. 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 [1,10,11,14].
Globally, a large proportion of maternal deaths are attributable to indirect causes (i.e. pre-existing medical conditions) including cardiovascular diseases and hypertension, endocrine disorders like diabetes, chronic respiratory diseases and cancers [15]. In sub-Saharan Africa, this proportion is 28.6% while HIV attributable maternal deaths are 6.4% [15]. Nigeria, with a maternal mortality ratio of 576/100,000 live births, accounts for almost 20% of global maternal deaths [16,17].
Pre-existing medical conditions including hypertension and diabetes which are associated with the indirect causes of maternal deaths are prevalent and increasing in magnitude among women of reproductive age in Nigeria [18][19][20][21]. In addition, hypertensive disorders of pregnancy constitute a substantial proportion of maternal deaths and near-misses in the country [22]. PCC can provide an important link between services providing maternal care and those managing these pre-existing medical conditions. However, preconception care services are still evolving in Nigeria. There is evidence that health workers sometimes provide preconception care services although most studies that have assessed PCC in the country have been on the awareness and utilisation among women within health facilities [23][24][25][26]. In one of these studies, participants attributed their lack of awareness to the fact that health care workers do not talk about PCC during routine health visits [26]. On the other hand, participants who had some knowledge about PCC had obtained information from antenatal clinics during their previous pregnancies [23,26,27]. The only study found among health workers was a cross-sectional study among doctors and nurses in a teaching hospital in northern Nigeria which reported 83.3% awareness and 23% with knowledge of up to three-quarters (¾) of the components of PCC [28]. 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.

Study design and setting
We used a case study approach to explore the perceptions of health care workers at various levels of the Nigerian health system about PCC. Case study approach to qualitative studies is appropriate for illustrating specific issues in a real life contemporary setting [29,30]. We explore PCC within the Nigerian health system from the perspectives of health care providers at the three levels of the health system. 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 [35]. 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 [35].
These services are provided mainly at the primary health care level although they are also available at the secondary and tertiary levels. PCC also includes treatment of pre-existing medical conditions [2][3][4]which are provided mainly at the tertiary and secondary level although with the two-way referral system, such services can be provided at the primary care level. Ibadan North Local Government Area (LGA), one of the five urban LGAs in Ibadan metropolis, Oyo State, southwest Nigeria was thus purposively selected because it has health facilities at the three levels of health care. These include: the University College Hospital (UCH), which provides tertiary services for the state and most of the south-western region of the country.

Participant characteristics and sampling
The aim was to determine the perception about preconception care from the potential providers and specialists whose clients are more likely to require preconception care for management of pre-existing conditions. The health workers selected for this study were therefore 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. We set out to interview a minimum of 12 physicians, that is at least one physician from each specialty and one from the secondary and primary levels of care. The numbers selected were based on the services available at each of the health care available in the LGA as described above. In addition, we planned to interview at least two nurses at each level of the health system. At the tertiary health facility, specialist physicians who were fellows or trainees at the senior registrar level in Cardiology, Endocrinology, Family Medicine, Haematology, Nephrology, Neurology, Obstetrics/Gynaecology, Paediatrics, Psychiatry and Public Health were interviewed. These specialists were selected due to their relevance to the management of many of the pre-existing medical conditions that require PCC services. Public health nurses and clinical nurses who were at least senior nursing officers 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 who is the only physician at the LGA, the Director of Maternal Health Services in the LGA (who is also a public health nurse) and one clinical nurse who covers the PHC at the LGA headquarters 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 process
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. These research assistants were younger and less experienced in biomedical sciences than the participants. The researchers had no direct relationship with the participants prior to the study and contact was only made during the interviews. The first author set up the time for the face to face interviews with the study participants but was not directly involved in the data collection. All the health workers approached for the study agreed to participate and were interviewed at their convenience. 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?

Data management and analysis
The interviews were transcribed verbatim by the research assistants who conducted the interviews. The transcripts were read by the first author, 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 by the first author in the development of the codebook for thematic data analysis [36,37]. Deductive codes were derived from the objectives and study instruments while inductive codes were developed through reading the transcripts. To enhance trustworthiness and avoid introduction of the researchers' biases into the analysis, a sample of the transcripts and the study objectives were given to two independent coders who are not co-authors on this article but have some experience in qualitative research. The coders identified recurring patterns in the data and developed a set of codes. The initial set of twenty-seven codes generated were merged into six themes to form the codebook. A third researcher who had more experience in qualitative research than the first set of independent coders also reviewed the codebook with the transcripts to achieve inter-coder agreement. A consensus on the themes and subthemes of codes was reached through discussion between the independent coders and the authors. The first author applied the codebook to the transcripts and suitable quotes were selected for the paper. 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 [38].

Ethical considerations
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 authors. 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.

RESULTS
Twenty-six in-depth interview transcripts were analysed. There were nine nurses and seventeen 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.

SCOPE OF PRECONCEPTION CARE
The health workers provided definitions of the scope of services that they understood PCC to cover. They described PCC in terms of its components and who should be involved in its provision.

ACCEPTABILITY OF PCC
The participants expressed the opinion that PCC may not be accepted generally by the people who should use the service. They believed the concept of PCC is new to the prevailing culture, therefore the likelihood of using the service may be low.
They further indicated that the general attitude towards health issues is that many people tend to avoid going to health facilities unless there is a problem. They stated that even those who have known illnesses such as hypertension which require regular follow up clinic visits, often miss their appointments when they feel well.

RELEVANCE OF PCC TO SPECIALTIES
The different specialists gave their views on the importance of PCC to their clients.
The paediatricians believed 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 "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, they stated that PCC leads to improved health status of parents and increases the likelihood of positive pregnancy outcomes was mentioned. They also highlighted promotion of the use of folic acid for prevention of neural tube defects in the newborn.  [23][24][25][26]. In addition, a previous study among health workers in northern Nigeria used quantitative methods to assess the awareness and knowledge about PCC [28]. One other study among health workers in Africa was a cross-sectional study in Ethiopia [39]. This limits the extent to which the findings from this study can be compared with previous literature. The health workers in our study described their understanding of the scope of PCC, individuals who need PCC services as well as health facilities and the level within the health system where PCC services ought to be provided. They also provided their opinions about the acceptability of PCC services, its relevance to their practice and the possible benefits of PCC services. The provision of PCC in Nigeria is relatively new and gradually developing in different parts of the country [28].
Previous studies have shown there is some uptake of PCC services in the country, mainly among women in the higher socioeconomic and educational groups who request PCC from health care providers when they desire pregnancy [23,26,27].
Whereas previous studies show a low knowledge and awareness of PCC among health workers in other countries such as Australia [40], New Zealand [12], Iran [41], and Ethiopia [39], our study shows that knowledge and awareness of PCC and its primary components among health workers at all levels are high and in line with those described by the WHO and CDC [2][3][4]. This has major implications of facilitating access and acceptability of PCC at the population level and can improve reproductive health outcomes when integrated with routine maternal and child health services.
Although varied, the descriptions provided by our study participants included salient points such as providing care to optimise the health of women and men before conception. The components identified by the participants were preventive and therapeutic services and reproductive health planning to ensure readiness for childbearing. These highlighted areas speak to the prevailing issues affecting reproductive health outcomes both within the country and in the African continent.
For instance, 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 [42,43], hypertension [19,44], sickle cell disease [20,21], diabetes and unplanned pregnancies [43,45] are major maternal and child health issues. Considering that the WHO preconception guidelines gives room for countries to identify specific areas to be targeted depending on their identified needs [2,46]; guidelines for PCC in Nigeria can be developed to mitigate these prevalent reproductive health problems.
The participants in this study had different opinions on who should oversee 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 [40], London [47] and Netherlands [11] have also shown that family physicians and general practitioners believe they should oversee PCC services. Another study among a different group of general practitioners in London found that the participants believed that public health specialists should be the primary providers of PCC [13]. 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. By implication, PCC should be available at every level in the health care system as the services required may differ per person. Thus, while some level of screening such as for hypertension and diabetes may be provided at the primary level, other more specialised care like genetic screening will require secondary or tertiary level services.
The suggestion by some of our study participants that PCC should be provided at every contact with the health care system is also documented in literature [48,49].
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 at every opportunity [50][51][52]. It also serves to improve their health status irrespective of pregnancy intention [52,53]. Thus, every health care provider has the obligation to ask their patients about reproductive health plans at every contact 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. The variations in opinions about who should oversee and where to provide PCC services implies a flexibility within the health system in terms of integration of PCC services with existing services. When developed, PCC guidelines can make allowance for opportunistic education, information and counselling for all people of reproductive age at whatever level of the health care they are seen. The guidelines can also regulate the referral system for different areas of care needed by everyone.
The culture of delayed health care seeking was observed by our study participants 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 [54]. In addition, the fact that many pregnancies are unplanned means that many women are only seen in health facilities after pregnancy and men are hardly catered for [43,45,55]. 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]. Community outreaches, social and other media outlets have the advantage of being available to people in their comfort zones. Information, education and counselling regarding preconception health status can therefore be provided through these means. The importance of reproductive health planning and the need for PCC can potentially reach the community level without individuals having to visit the health facility.
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 [52].

CONCLUSION
This study highlights the perceptions about preconception care among health care workers at the three levels of the health care system in Nigeria. The participants had high level of knowledge of the components of PCC and were generally positive about the services. 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 develop guidelines for the services to be offered at each level of care. The guidelines must include algorithms for two-way referral for more specialised care and step down to lower levels when the need for specialised care has been met. There must also be provisions for PCC services in the available health insurance schemes to improve uptake. The services must be integrated within the existing maternal and child health services to improve delivery and encourage uptake within the community.

LIMITATIONS
There were some limitations in the course of the study. The first author who supervised the data collection opted not to conduct the interviews to avoid desirability bias affecting the responses being a Community Physician who had worked with some of the participants. hence, research assistants were trained to conduct the interviews. The younger age and lower qualification status of the interviewers with respect to the participants may have influenced their ability to probe further on some of the points raised by the participants. Also, the fact that member checking was not done due to some logistic constraints may have affected the trustworthiness of the data. 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.

Consent to publish
Not applicable.