Abstract

Background

Optimising women's pre-pregnancy health is a policy priority for benefits spanning pregnancy and throughout the mother and baby's life. In the UK pre-pregnancy care (PPC) tends to be delivered in primary care, with the onus on women to seek services. We aimed to describe women鈥檚 engagement with General Practice (GP) in the year preceding pregnancy, including specific PPC; to explore whether women with recognised risk factors for poor pregnancy outcomes receive targeted care.

Methods

Data for women aged 18-48yrs and registered for $\ge$ 12听months with a GP on 01/01/2017, were drawn from English Clinical Practice Research Datalink (CPRD) GOLD, a source of electronic health record data. Demographic characteristics, lifestyle factors and health conditions were described. CPRD Pregnancy Register and linked hospital data were used to identify pregnancies in 2017/18 and to describe PPC in the year preceding pregnancy.

Results

Of 193,578 women included, 14,326 had a confirmed pregnancy. 7.6% of the pregnant women had records indicating specific PPC in the preceding year, whilst 41.0% had records of health promotion (advice on nutrition, smoking, weight, alcohol and contraception). More women with pre-existing medical conditions received health promotion (46.0%-83.9% for various risk groups), although the levels of PPC remained low (4.7%-14.9%).

Conclusions

PPC was rarely recorded, likely reflecting low levels of consultation for, or discussion of, pregnancy planning. This represents a missed opportunity for maximising women鈥檚 health, particularly in those with recognised risk factors for poor pregnancy, perinatal and longer-term outcomes.

Background

Engaging women in improving their health prior to pregnancy has been identified as an important public health policy [1, 2]. Optimising a woman鈥檚 health before she conceives benefits her at the time, in her subsequent pregnancy and birth, and has positive effects for her longer-term health and that of her infant [3, 4]. However, interventions cannot solely target those planning to conceive; just 55% of UK births follow a 鈥減lanned 鈥樷�� pregnancy [1, 5]. Thus women of reproductive age are an important target population for public health interventions designed to have lasting impacts on health and, as a consequence, improve health outcomes, reduce health care costs and demands on services.

Women with pre-existing conditions are more likely to experience adverse pregnancy, maternal and perinatal health outcomes compared with those without [6,7,8,9,10,11]. For example, pre-existing hypertension, diabetes and obesity are all risk factors for pre-eclampsia [6, 7], and contribute to an elevated risk of preterm birth [8, 9]. Women with pre-existing health conditions account for a non-negligible proportion of women of reproductive age and proactive management of the conditions prior to pregnancy can improve their pregnancy wellbeing and outcomes [9, 12,13,14,15,16].

Current guidance in England and other European countries states that pre-pregnancy care (PPC) should encompass a wide range of checks and advice. This includes health improvements such as stopping smoking, eating a healthy diet, maintaining a healthy weight, and being physically active, as well as addressing mental health and psychosocial stress [17, 18]. Pregnancy-specific advice entails taking folic acid supplements, and discussing birth spacing with women who already have a child. Specific high-risk groups are also highlighted, for example where women have pre-existing health conditions that must be managed through pregnancy (e.g. diabetes or epilepsy) or take medications detrimental to the foetus (e.g. valproate).

In the Women鈥檚 Health Strategy for England, the Department of Health and Social Care has stated their 10-year ambition to 鈥渟upport women and their partners to optimise their health and wellbeing prior to conception鈥� [19]. Although guidance exists, a specific 鈥榩re-pregnancy鈥� General Practice (GP) appointment is not currently standard care in England and the National Health Service (NHS) recommends women seek advice only if they are in specific risk groups. It is therefore unclear how many women receive any pre-conception advice prior to becoming pregnant (or between pregnancies), or whether GPs discuss these issues unless the women themselves start the conversation.

The overall aim of this study is to gain a better understanding of women鈥檚 engagement with GP services in the year prior to pregnancy, and specifically PPC received in GP services. Specific objectives include:

• i) To establish whether it is feasible to identify PPC using routine health records;

• ii) To investigate whether women who have pre-existing risk factors are targeted for PPC;

• iii) To describe women鈥檚 overall engagement with GP services in the year prior to pregnancy to explore opportunities to optimise women鈥檚 health before pregnancy.

Methods

The data sources

This study was approved by the CPRD Independent Scientific Advisory Committee (ISAC, protocol number: 20_000220). Primary care data were drawn from the Clinical Practice Research Datalink (CPRD) GOLD dataset, which covers around 6.9% of the UK population, and is broadly representative in terms of age, sex and ethnicity [20]. Pregnancy data were available in the CPRD Pregnancy Register (PR) and CPRD Mother Baby Link (MBL), and in the maternity tables from linked Hospital Episode Statistics (HES) Admitted Patient Care records [21]. CPRD PR uses an algorithmic approach to identify pregnancies in the coded primary care records [20, 22]. CPRD MBL identifies births in women鈥檚 records and links mothers with babies in the same family within the appropriate time-period. HES maternity data contains details of hospital and out of hospital births where care is provided by NHS staff, including some details about the baby [21, 23]. Linkage to HES records allows pregnancies to be included that may have been missed in the primary care records.

Study population and setting

All women with research-quality data, registered at an English GP participating in CPRD were included if they were aged 18-48yrs on 01/01/2017, had a year of prior registration and were eligible for hospital data linkage. The required registration period ensured that they would be eligible for inclusion in the Pregnancy Register and that there would be sufficient time for their records to reflect pre-conception care, health and demographic characteristics.

Identification of pregnancies

We used the PR, augmented by the MBL and HES maternity data, to identify those women who were not pregnant on 31st December 2016 but subsequently became pregnant by 31st December 2018. An algorithm was developed to amalgamate the three data sources [24]. Overlapping pregnancy records were grouped together and reduced to one record per pregnancy. Additional cleaning removed records that were likely to be non-contemporaneous or partial records erroneously identified as a separate unique pregnancy by the original PR algorithm.

Deriving variables

Records from the CPRD clinical, referral, therapy and test files and linked indices of multiple deprivation (IMD) data were used to derive sociodemographic and health-related variables, using code lists (see Table听1 and Additional file 1 for details of variables and categorisation). Code lists were adapted from previously published lists, using the CPRD GOLD code browser (version 3.0.0) and clinical input (Additional file 1). The selected pre-existing health conditions are recognised risk factors for poor pregnancy, perinatal and longer-term outcomes, particularly if severe or poorly managed. Women鈥檚 interaction with the GP services, including face-to-face contact with general practitioners and/or nurses and cervical screening appointments were derived to explore opportunities for GPs to optimise women鈥檚 health before pregnancy.

Table 1 Characteristics of study population, and subset of women who became pregnant during follow up

Identification of pre-pregnancy care

To capture PPC, records were restricted to the year before the baseline date (01/01/2017), for all eligible women of reproductive age (to include those who did not go on to conceive), and the year prior to pregnancy for those who became pregnant, respectively. Diagnostic and symptom codes relating to PPC were extracted from the women鈥檚 clinical and referral records in CPRD using pre-specified code lists (Additional file 2) to explore the feasibility of identifying women receiving PPC. Two types of care were considered: specific PPC (folic acid advice, fertility discussions, general PPC and advice) and general health promotion (nutrition, smoking cessation, weight management, alcohol advice, contraception).

Analysis

Summary statistics were used to describe sociodemographic characteristics, health behaviours and pre-existing conditions among the eligible women, and among those with a pregnancy recorded in 2017- 2018. We then described the PPC women received, for all women, all pregnant women and in those with recognised risk factors for poor pregnancy, perinatal and longer-term outcomes. For women with more than one pregnancy in the study period, the first pregnancy was included. Additionally, we explored PPC by women鈥檚 characteristics among those with a pregnancy recorded in 2017- 2018.

To explore opportunities for GPs to optimise women鈥檚 health before pregnancy starts, we calculated the percentage of women who had any engagement with the GP service in the year prior to pregnancy for all women with a pregnancy in 2017鈥�2018, and for those with pre-existing conditions. We additionally described any evidence of active management of their pre-existing condition (Additional file 3).

All analyses were performed with Stata 17 [25].

Results

Characteristics of women

The characteristics of women of reproductive age and the prevalence of pre-existing health conditions are shown in Table听1. The mean age (SD) of the 193,578 women of reproductive age included in our analysis was 34.4听years (8.8). White British was the most frequently recorded ethnicity (68.8%), 14.3% were recorded as White other, and 16.9% were from other ethnic groups. More than a quarter (28.6%) of women were registered with practices in the most deprived IMD quintile.

Almost half of the women of reproductive age were overweight or obese (Table听1). More than half had never smoked (55.8%), 25.4% were former smokers and 18.8% current smokers. The prevalence of ever diagnosed asthma was 17.1% and common mental disorders was 33.9%. Records indicated that 4.8% of women had a diagnosis of PCOS, 2.9% of women were living with hypertension and 1.6% with diabetes. Between 2017 and 2018, 14,326 women had a recorded pregnancy (Table听1). The pregnant women were, on average, younger and healthier than the general population of women of reproductive age. However, of the women who became pregnant, about two thirds (n鈥�=鈥�9,528, 66.5%) still had had at least one pre-existing health condition placing them at higher risk of poorer outcomes.

Pre-pregnancy care

PPC was rarely recorded; only 2,640 women had specific PPC codes (1.4% of women of reproductive age, Table听2). Of the women with PPC records, less than half had evidence of a pregnancy in the following 24听months (n鈥�=鈥�1,093, Table听2). On average, women aged 30鈥�44听years, Asian or Asian British women, nulliparous women and those from less deprived areas were more likely to have records of PPC (Additional file 4, Supplementary Table).

Table 2 Provision of pre-pregnancy care in all women, women who became pregnant in 2017鈥�2018, and higher risk women who became pregnant in 2017鈥�2018

Of the 14,326 women who subsequently became pregnant in the study period, 7.6% had PPC recorded in the preceding 12听months, and the prevalence remained low in the sub-groups of women with pre-existing conditions (4.7% to 14.9%, Table听2).

Around 41.5% of all women of reproductive age and a similar proportion (41.0%) of those who became pregnant had general health promotion records in the previous year (Table听2). Overall, more women with pre-existing conditions received general health promotion (between 46.0% and 83.9% for various risk groups) compared with all pregnant women.

Opportunities for PPC or discussion of pregnancy intentions

Almost all pregnant women had contact with GP services in the year prior to the start of pregnancy (96.9%, Table听3). Just under four fifths (79.7%) had one or more face-to-face appointments with a general practitioner, and 44.2% with a nurse. About one fifth had records for cervical screening appointments in the year prior to pregnancy. The proportions of women with pre-existing conditions who engaged with GP services in the year prior to the pregnancy were generally higher (between 97.7% and 100.0%, Table听3). Evidence of active management of a pre-existing condition in the year prior to pregnancy varied by diagnosis (Table听3).

Table 3 Opportunities for pre-pregnancy care in women who became pregnant in 2017鈥�2018, and higher risk women who became pregnant in 2017鈥�2018

Discussion

Summary

PPC is rarely recorded in coded electronic health record (EHR) data. Among pregnant women, only 7.6% had records of pre-pregnancy care, including folic acid advice, in the year prior to pregnancy; 41.0% had general health promotion records. While women with pre-existing conditions generally received higher levels of general health promotion than the overall population of pregnant women, the levels of PPC were similar or only slightly higher on average. Despite the low prevalence of recorded PPC, most of women interacted with their GP services in the year prior to the start of pregnancy, presenting opportunities for GPs to support women to improve their health and wellbeing before pregnancy.

Strengths and limitations

CPRD GOLD is broadly representative of England鈥檚 population, identifies pregnancy and those at higher risk, and therefore allows us to describe consultations before pregnancy, and explore PPC in those with pre-existing conditions. Augmentation of primary care data using hospital maternity records allows the identification of pregnancies that were omitted in GP coded data. As such, we can describe PPC in women who subsequently have a pregnancy. However, pregnancies ending in termination or miscarriage may still be underestimated as GPs are not be informed in all cases. As these pregnancies may be excluded from the denominator, this may overestimate PPC provision among those who became pregnant. Data on pregnancy intention was not available, and therefore we cannot specifically explore the provision of PPC within those hoping to conceive.

The use of detailed code lists, drawing on diagnosis, symptoms, prescriptions and referrals maximises the opportunity to identify the variables of interest in EHRs. However, data quality is dependent on recording by GPs. For example, free-text notes regarding PPC would be missed, and some non-specific codes such as 鈥榟ad a chat to patient鈥� may encompass PPC but would not have been recognised as such. Women with the pre-existing conditions that place them at higher risk of poorer outcomes, particularly epilepsy, may be managed in a hospital setting. The GP EHRs may not reflect these, as hospital letters are not always coded and available for quantitative research. Using coded GP data may therefore underestimate the provision of some aspects of care.

Comparison with existing literature

Despite the growing recognition of PPC as a crucial component of maternal health care [26], research on its current provision or uptake is limited and often only conducted in higher risk population [27]. Research often focuses on antenatal interventions, with fewer studies shedding light on the proactive health measures taken by women before pregnancy [28, 29]. There is also a lack of available effective pre-pregnancy interventions, for example, for weight loss in the pre-pregnancy period [30]. This evidence gap poses a challenge to policymakers and healthcare providers striving to implement effective strategies for PPC.

Historically, PPC has focused on women actively planning a pregnancy [1]. Yet, given that nearly half of all pregnancies are not planned [5], timely delivery of PPC presents a considerable challenge. Our finding adds to the evidence that a substantial proportion of women in their childbearing years only seek care after becoming pregnant [1], emphasising the need to broaden the scope and timing of preconception health initiatives and the importance of a focus on improvements in the public health of the population in general.

Implications for research and/or practice

The responsibility for PPC currently falls largely on women, who are expected to seek appropriate medical guidance [31]. However, our study indicates that the majority of women do not engage in PPC via primary care services in the year prior to pregnancy, despite having contact with their GP for other health issues during the same period. Those who do may be either proactive planners or women who have faced challenges in conceiving and are now seeking fertility assistance [32]. This suggests that although primary care represents a highly accessible channel for reaching women, both healthy and at higher risk, it is not being fully utilised for delivering PPC. While guidelines for healthcare professionals on delivering PPC do exist [17, 18, 33], there is a need for greater clarity regarding the responsibilities and the most effective methods for delivering PPC. Specifically, it is crucial to define the roles of GPs and health services in promoting PPC. This process should engage all stakeholders, including GPs, women, and other health services.

Identifying and addressing barriers to PPC is a crucial step in improving PPC, both from the perspective of women seeking care and GPs providing it. Known challenges for GPs include inadequate training and proficiency in delivering health guidance [34], time constraints within consultations, the low prevalence of women proactively seeking preconception care, multiple competing preventive care priorities in general practice, concerns regarding the affordability and accessibility of preconception care, and insufficient resources for supporting the implementation of preconception care guidelines [35, 36]. Barriers for women include, but are not limited to, a lack of understanding regarding the importance and benefits for planning a pregnancy [32, 37], quicker-than-expected conception, logistical challenges in attendance [38], unsupportive staff and overly busy clinics [37]. Although PPC has shown effectiveness for women with serious health conditions, its broader impact on improving pregnancy outcomes appears limited [39], which may affect the motivation of both GPs and women to engage. Furthermore, the COVID-19 pandemic generally led to reduced access to healthcare services, which may have disproportionately affected certain population groups who were already less likely to use primary care before the pandemic [40, 41].

Addressing these barriers requires a multifaceted approach, including enhanced GP training, better resource allocation, public education campaigns to raise awareness, and systemic changes to improve accessibility and integration of preconception care into routine general practice [36]. Further research is warranted to assess the wider benefits of PPC and to develop evidence-based strategies for overcoming these challenges.

While considerable efforts are made to prevent unwanted pregnancy, there is a notable lack of public health emphasis on considering the optimal timing for conception and improving overall health for pregnancy. By integrating PPC into general health promotion initiatives for women's health, we can ensure that women, whether or not they are actively planning, are informed and empowered to make healthier choices [32].

High-risk groups, particularly those with pre-existing health conditions, represent an easily identifiable demographic for PPC. On the other hand, women in the highest risk groups may choose termination of pregnancy if they have not received appropriate PPC. However, our results suggest that even within this group, there is insufficient awareness and engagement. Research indicates that high-risk women, their healthcare professionals, and the healthcare system may not prioritise planning for pregnancy [42], and women may not be aware of the need to do so [27]. Coordinating care between primary and consultant-led services poses additional challenges, necessitating clear guidelines on communication, responsibility and jurisdiction. Addressing these challenges is essential to ensuring that those at increased risk receive the most beneficial PPC.

General practices could employ various methods to promote PPC, including providing information on practice websites, signposting via text messages or social media, and distributing physical posters and leaflets within the surgery. However, these messages will not reach all women and are more likely to be noticed by women actively planning to conceive or who have a higher level of health awareness. A conversation with a trained health care professional, particularly for women who have existing health concerns or risk factors, is more likely to ensure that women engage with the information provided. Improving the coding of PPC within EHRs, particularly by including detailed information about discussions between healthcare providers and patients, as well as the information or guidance given to women, is imperative, as monitoring and evaluating the effectiveness of PPC interventions rely on accurate data coding.

While the findings of this study are most relevant to England and may have limited generalisability to other countries and healthcare settings, they offer insights with global relevance. In countries with similar health systems, clarifying roles and improving the coding and monitoring of routine health data [29] could contribute to enhancing PPC. For countries with weaker health infrastructures, prioritising the identification of barriers and reallocating resources to address them might take precedence. Regardless of the healthcare context, raising awareness about the importance and advantages for planning a pregnancy could play a key role in reducing unplanned pregnancies and improving preconception health. Moreover, integrating PPC into broader health promotion strategies in an equitable way could help address missed opportunities across all healthcare systems.

Conclusions

Pre-pregnancy care is rarely recorded in primary care in England, likely reflecting low levels of consultations for pregnancy planning, even among those with pre-existing recognised health conditions that place them at higher risk for poorer pregnancy and health outcomes. This represents a missed opportunity for promoting pre-pregnancy and subsequent health. The current state of pre-pregnancy care calls for a shift towards a more proactive and collaborative approach to meet the policy ambition of the Women鈥檚 Health Strategy. It is necessary to clarify responsibilities, address barriers, and integrate appropriate pre-pregnancy care into broader health promotion initiatives, alongside enhanced coding of routine health data and monitoring.