Primary care teams have an important role to play in supporting their patients to have healthy pregnancies and babies if and when they choose to. Improvements in the care for pregnant women in the last decades have successfully reduced maternal and infant morbidity and mortality rates. However, the frequency of adverse pregnancy outcomes and the potentially life-long and intergenerational consequences for mothers and children remains unacceptably high. It is important to recognise that the main drivers of adverse pregnancy outcomes have their origins before pregnancy. For example, in the UK, 1 in 2 pregnancies are unintended, almost 3 in 4 maternal deaths are in women with pre-existing medical conditions,1 and 1 in 5 preterm births are attributable to socioeconomic deprivation.2 Nonetheless, there are important opportunities during routine interactions and appointments for primary care teams to address risks in women of reproductive age (and their partners), particularly the risk of unintended pregnancy and those relating to an intended pregnancy.
‘MAKING EVERY CONTACT COUNT’
In line with National Institute for Health and Care Excellence guidance on preconception care, primary care teams are encouraged to initiate discussions about preconception health when appropriate, and to assess, manage, and potentially optimise a range of physical and mental health conditions, health behaviours, and social needs prior to pregnancy.3 Discussing pregnancy intentions is acceptable to most patients, particularly during visits for contraception, cervical screening, postnatal appointments, and long-term condition and medication reviews.
Our analysis of common preconception care needs of women of reproductive age in general practice in England showed nine in ten women have at least one risk factor4 that, if minimised or well-controlled before conception, may reduce risks in a future pregnancy.5 While the needs of individual patients will vary widely, the generally poor preconception health and wellbeing of women of reproductive age highlights the need to make every contact count.
CHALLENGES
Most women in the UK who become pregnant are not currently identified nor supported to prepare for pregnancy. Known challenges to delivering preconception care in primary care include lack of time, knowledge, resources, pay-for-performance indicators, and patient awareness.
Conversations and advice about pregnancy preparation may also unintentionally increase guilt, and burden women with the responsibility of having a healthy pregnancy and baby. While appropriate conversations with patients about their risks, and their social circumstances that support or hinder them to reduce risks, may help empower them to be as healthy as possible, this is not enough. System-wide approaches that address the wider determinants of health, health literacy, and reproductive rights and justice are critical.
To further develop practical guidance for primary care teams, research is underway to identify the most effective question(s) to ask patients to identify those intending to become pregnant. Moreover, preconception programmes are being co-developed and tested with and for local patient communities and health systems to address the complex interactions of poor preconception health and socioeconomic inequalities.
WHAT CAN WE DO?
Since 2011, a series of initiatives have been introduced in England to avoid valproate prescriptions for women of reproductive age, unless a pregnancy prevention programme is in place, to reduce serious pregnancy-associated risks. Although valproate prescription rates in primary care have fallen as a result, contraception prescriptions have not increased.6 Moreover, of all women prescribed valproate who had a pregnancy, 1 in 5 had a prescription for valproate during pregnancy.6 This suggests more can and should be done to ensure women receive the best possible care before pregnancy.
Other opportunities for preconception care include conversations about pregnancy intentions at relevant contacts, in particular for contraception and long-term condition and medication reviews. Building on this, a gradual change in mindset towards a ‘Making Every Contact Count’ approach to preconception care will help create awareness and normalise pregnancy preparation, and support patients to have healthier pregnancies to benefit their own health and wellbeing, and that of the next generation.
Notes
Funding
Danielle Schoenaker is funded by
the NIHR Southampton Biomedical Research Centre (reference: IS-BRC-1215-20004). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2022
