Strengths and limitations
The strength of this study relates to the qualitative approach, adding insight into the limited knowledge about ICC and showing GPs’ understanding, knowledge, and practices of ICC. The study aimed to recruit GPs who were in regular contact with women of childbearing age and, in doing so, the knowledge and perspectives of ICC may not be generalisable to all GPs. Similarly, the study attracted predominantly female and metropolitan GPs; however, this may be reflective of the GP workforce profile36,37 and patient preference for ICC services. Further research should obtain the views of male and rural GPs as well as other stakeholders in ICC.
Comparison with existing literature
ICC was largely opportunistic in nature as part of postpartum care or infant immunisations. Where ICC was targeted, the types of patient visits were ‘problem focused’, such as menstrual issues and oral contraceptive prescriptions. However, this approach does not address all aspects of ICC. Lessons from ICC literature identify that tailoring interventions to the health and social needs of women is needed, and support for embedding this into routine care is required.15 The ability of services to meet the needs of women requiring ICC can be problematic where women juggle caring and work demands,38 where existing models of care are fragmented between services,39 or where a subsequent appointment is required. For example, the delivery of efficacious forms of contraception care, such as long-acting reversible contraception, often require a return appointment.40 The integration of ICC into other appointments, such as for the child, is one solution proposed by international ICC experts,16,17,19,20,41 provided that mechanisms supporting this care include adequate provider remuneration and guidelines.16
Health optimisation through the prevention and management of lifestyle risk, biomedical risk factors, and adverse pregnancy outcomes were not discussed by participants, unless there was concern about a recurrence of poor pregnancy outcome. While also applicable to ICC more broadly, the integration of lifestyle risk reduction in consultations occurs where it is perceived as relevant and integrated into routine care.42 Similar to other literature about GP-led lifestyle interventions, the importance of addressing lifestyle behaviours was acknowledged; despite this, these discussions were described as being undertaken in an ad-hoc way.43 The potential impact of lifestyle and biomedical risks increase with maternal age and parity.44 Obesity, for example, can increase the risk of comorbidities during pregnancy, as well as offspring epigenetic and the mother’s ongoing chronic disease risk.45 Preconception and antenatal preparation for lifestyle risk reduction can be too late to see the outcomes needed for a subsequent pregnancy.46 To support the woman’s health and allow adequate time in the reduction of lifestyle risks, including dietary intake and inadequate physical activity, months or years prior to conception may need to be allocated1 and therefore discussed as part of routine ICC.
Participants perceived issues engaging women in ICC. This is consistent with other literature indicating that, while 74% plan their pregnancies, less than half seek out health professional advice.47,48 The disconnect between women planning a pregnancy and getting advice could be because of cost, patient time, accessibility of care, or the number of GPs providing this service. In addition, women’s engagement in primary care services postpartum is high but inconsistent.49 This may be due to the issues being faced by women at that time such as recovery, poor sleep patterns, adjustment, and mental health issues. Subsequent visits to the GP also focus on the baby rather than the mother, further impacting this engagement.
Participating GPs perceived that women do not prioritise their own health for a subsequent pregnancy unless there had been a complication. While participants also recognised that there are many competing priorities during the interconception period, there is evidence to suggest that multiparous women are more knowledgeable or relaxed about subsequent pregnancies.47 Engagement in care is also impacted by receptiveness to information about preconception health,50 costs, and having an ongoing relationship with a practice, GP, or nurse.14 To address increased risks from modifiable risk factors, age, and parity, health optimisation should be discussed across the lifespan, not just before pregnancy. Approaches that target those who may benefit from ICC could involve the colocation of publicly funded and family-friendly multidisciplinary services that could include nurses, midwives, diabetes educators, dietitians, and women’s health physiotherapists. In addition, the allocation of funded time for ICC in combination with well-child visits, such as coinciding with immunisation schedule presentations, is another possible solution.
Implications for research and practice
Most GPs do not currently view interconception as a distinct stage in a woman’s reproductive lifespan to promote health optimisation for a subsequent planned pregnancy. Funded opportunities and guidelines for care could facilitate routine incorporation of ICC into clinical practice. This includes outlining clinical content areas that fall under the banner of ICC, as well as the need for this care to occur months and years prior to conception. Research needs to elicit the views of both female and male, urban and rural GPs, and other key stakeholders, such as nurses and specialists, involved in ICC. In addition, the testing of new approaches that overcome barriers to delivering ICC is required. Publicly funded and family-friendly multidisciplinary care that considers when women are likely to present to general practice during interconception, such as well-child visits, are key opportunities for service provision.