A new study that provides the "first national picture of the current state of preconception health among women in England", found that 9 in 10 women in enter pregnancy with at least one indicator that might increase health risks to them and their baby. The results have prompted a call from experts for a national policy to improve health before and during pregnancy, or 'preconception health'.
The health, behaviours, and wider circumstances of women and men of reproductive age "influence their own future health", are "key determinants of a healthy pregnancy", and can have "far-reaching consequences" for the health and development of the next generation, emphasised the authors of the new study, published in the BJOG.
"Women who are healthy and well when they enter pregnancy are less likely to develop complications, and their children tend to have better long-term developmental and health outcomes," highlighted the authors.
"This national picture of preconception health improves our understanding of the population's preconception needs and identifies a need to improve and reduce inequalities for better population health outcomes," said the authors. "It forms the foundation for future report cards and ongoing national surveillance.
Many Women Continue Smoking and Don't Take Folic Acid
The cross-sectional population-based study, researchers from the National Institute for Health and Care Research (NIHR) Southampton Biomedical Research Centre set out to present the first national-level report card on the state of women's preconception health in England.
They analysed routine maternity services data routinely collected by midwives from 652,880 pregnant women in England with a first antenatal appointment recorded in the national Maternity Services Dataset from April 2018 to March 2019, and investigated the prevalence of 32 preconception indicator measures in the overall population and across socio-demographic subgroups.
The 10 indicators prioritised were: not taking folic acid supplementation before pregnancy, obesity, complex social factors, living in the most deprived areas, smoking around the time of conception, overweight, pre-existing mental health condition, pre-existing physical health condition, previous pregnancy loss, and previous obstetric complication. Inequalities were observed by age, ethnicity, and area-based deprivation level.
Women had a mean age of 30 years at their booking appointment, with a median gestational age of 9 weeks and 5 days, and 37.9% of women were pregnant for the first time.
The three most prevalent indicators were the proportion of the 22.9% of women who smoked 1 year before pregnancy but who did not quit smoking before pregnancy (85.0%), those who had not taken folic acid supplementation before pregnancy (72.7%) and previous pregnancy loss (38.9%).
Common indicators varied widely based on women's age, ethnicity, and the level of deprivation in the area where they lived, the authors pointed out. These included women from a Black ethnic background being more likely to be living with obesity, and not to have taken folic acid supplementation before pregnancy, but less likely to smoke around the time of getting pregnant, compared with White women. Younger women were less likely to have had a previous obstetric complication and to have a pre-existing physical health condition, less likely to take folic acid supplementation before pregnancy, more likely to smoke around the time of conception, and more likely to have a pre-existing mental health condition.
'Health Inequalities Before Pregnancy Must be Narrowed'
Professor Nisreen Alwan, professor of public health, University of Southampton, and co-author, said that: "Health inequalities before pregnancy must be narrowed, with population-level policies across multiple sectors to address the wider determinants of health. This is to benefit all parents-to-be in society and allow them to prioritise their health and wellbeing, particularly those affected by social and economic hardship."
The number of initiatives and calls for action to improve preconception health is "growing" in the UK, and consequently awareness of the importance of preconception health among policy makers, health professionals and the community is "likely to increase", explained the authors, with further interventions that promote pregnancy planning and preparation likely to be developed.
To inform and evaluate existing and new initiatives, and to track progress towards optimising and reducing inequalities in preconception health, there is a need for "regular monitoring" of the state of preconception health in England, they advised.
Dr Danielle Schoenaker, lead author and research fellow at University of Southampton, said: "Our analysis shows that there is an urgent need for the Government, NHS and public health agencies to develop and put in place population-level policies and programmes that support all women to be as healthy as possible before and between pregnancies."
Bare Necessities Identified
The authors put forward a number of suggested actions to achieve comprehensive ongoing national surveillance in England, which included annual reporting of priority indicators, exploring the use of additional and potentially better-quality preconception indicators, and ongoing review of priority indicators based on changes in routine data collection, available data sources, and national priorities.
"Population-level policies and programmes are needed to optimise the health behaviours and their wider social, economic, and environmental determinants among all women of reproductive age," they explained. "Various socio-demographic subgroups may require targeted interventions," they indicated.
Dr Schoenaker postulated that future policies may start from "educating children" about the importance of being healthy before starting a family, to "improving" the food environment and affordability, and implementing effective "mandatory" flour fortification with folic acid.
"Routine conversations and support for pregnancy preparation could also be offered by primary healthcare services," she suggested.
The study was funded by the British Heart Foundation, the European Union, the National Institute for Health Research, and the UK Medical Research Council. KMG has received reimbursement for speaking at conferences sponsored by companies selling nutritional products, and is part of an academic consortium that has received research funding from Abbott Nutrition, Nestec, BenevolentAI Bio Ltd, and Danone. The other authors declare no conflicts of interest.