Targeting healthy pregnancies

05 July 2018

Journalist Helen Bird looks at the gap in preconception health support and knowledge, and considers a three-part solution.


New research has found that 92% of couples attempting pregnancy who ate seafood more than twice a week conceived within a year, compared with those who consumed fewer servings (Gaskins et al, 2018). But surely optimising preconception health is far more complex than upping the number of fish suppers you have? A series of studies recently published in The Lancet appears to confirm this (Barker et al, 2018; Fleming et al, 2018; Stephenson et al, 2018).

The authors identify three different concepts of preconception health, each of which would require a different intervention approach. The biological perspective ranges from weeks to days before embryo development, while the individual view links to the intention to conceive with a timeframe of weeks to months before pregnancy. The more holistic public health perspective should target all women of childbearing age and their partners, the studies propose.

So with these three ideas in play, when should we start focusing on preconception health? And what is the community practitioner’s role in all this?


Mind the gap

To answer these questions, it’s best to start with the current state of preconception healthcare in the UK.

Preliminary research funded by a Department of Health and Social Care grant exposed a chasm in knowledge about this period, says Judith Stephenson, lead author of the series’ first study and co-author of the other two. ‘Traditionally, it’s a private matter to plan a pregnancy – you might not even tell your friends or relatives until you’re 12 weeks pregnant,’ she says. ‘I’m not suggesting we over-medicalise it, but the scoping review showed that there’s not much going on – people don’t know what to say, and they’re not sure whose responsibility it is.’

The lack of targeted advice and support for preconception health is a blind spot, Judith suggests. ‘Women engage with health services at lots of points when they are probably planning a pregnancy but it’s not discussed,’ she says. ‘We did a study in east London where women come for routine baby checks – at nine months and then two-and-a-half years – and we knew from cohort studies that around one in four or five women would have another pregnancy within the next year, and yet that’s not really talked about.

‘So we asked health visitors to recruit women to a study of online advice about preconception health. When the women were recruited they said: “How come we didn’t get this information before the first baby?”’


Key findings

In addition to looking at existing evidence on preconception health, Judith’s studies involved two new analyses of UK and Australian women aged between 18 and 42.

The researchers assessed the nutrition of 509 women, concluding that 77% had insufficient iodine and 96% not enough iron or folic acid in their diet (Stephenson, 2018). The second paper in the series looked at the importance of paternal – as well as maternal – metabolism, physiology, diet and body composition, linking these factors to an increased risk of chronic disease in offspring through evidence from both human and animal research (Fleming et al, 2018).

The series also highlighted the correlation shown by previous research between smoking, high alcohol intake, poor diet, obesity and malnutrition during the preconception period and the risk of children developing cardiovascular, metabolic, immune and neurological diseases.

Judith admits she was surprised by the apparent lack of understanding of the influence parental diet and weight can have on conception and health outcomes for future children.

‘The message from the media was: “We knew that smoking and alcohol were bad for pregnancy and babies, but we didn’t know this about obesity and nutrition,”’ she says. ‘So it is something that needs discussing, and the challenge is to find clear, succinct ways of doing that.’

Based on the proportion of women who are likely to be nutritionally unprepared for pregnancy, it’s clear that early intervention is needed.


What can be done?

Estimates suggest that 40% of global pregnancies are unplanned (Sedgh et al, 2014), so the authors recommend efforts to improve nutrition and health behaviour on a general level, as well as more targeted support for those planning to start a family.

Schools form a key part of the solution, they suggest, to help young people prepare for future parenthood. It tends to be adolescent girls and women in their early 20s who have the worst diets, Judith observes, while recent research shows that teenage girls who diet are more likely than others to make decisions that could compromise their health (Raffoul et al, 2018).

Victoria Button, a school nurse in the North East and school nurse chair for the CPHVA Executive Committee and Expert Reference Group, agrees these years are crucial for intervention. ‘School nurses are ideally placed to promote positive health messages, ensuring [young people] are able to make informed decisions regarding their health and lifestyle,’ she says.

‘School nurse commissioning is now so wide and varied due to funding being held by local authorities, [so] the service level can differ greatly,’ she says. ‘But pupils have reported previously that they would like health information delivered by qualified health professionals rather than teaching staff. I feel this is an important point to consider during the planning of PHSE [personal, social and health education] and school-based health promotion strategies.’

Public Health England (PHE) has commissioned the charity Tommy’s and the Royal College of Obstetricians and Gynaecologists to deliver a ‘planning for pregnancy’ tool and campaign to raise awareness of preconception health, which is due to launch at the time of going to press. 

Neil Waterman at PHE’s chief nurse directorate says: ‘In addition, PHE are soon to publish a preconception care animation and documents that make the case for preconception care by highlighting the impact of poor preconception health, as well as pathways for how preconception care can be embedded into existing models of care.’

Local authority budget restraints also affect sexual health services, which are being cut in many areas. More sexually transmitted infections (STIs) could go undiagnosed or untreated, with consequent risks to preconception health. ‘Untreated STIs could impact significantly on the ability to conceive, through an association with tubal infertility,’ says Neil.

Judith believes opportunities to have preconception health conversations also exist – and are being missed – in early pregnancy assessment units, to which women at risk of miscarriage or ectopic pregnancy can self-refer. ‘Many of them will be going straight on to try and conceive again, and yet it’s not a place where preconception health is discussed,’ she says. ‘The clinical staff will say to them: “Don’t stop taking folic acid”, but if the woman’s obese, they won’t have a conversation about that.’


Starting the discussion

Conversation is surely at the heart of the public health approach, Judith suggests. ‘If you just give people a leaflet, it doesn’t have that much effect. So we’ve been doing some research about “healthy conversation skills”. It’s about finding out what helps the woman change behaviour, because these are difficult behaviours to shift – eating differently, losing weight, stopping smoking. It’s about recognising those things are tough, and exploring with the woman how she might seek help and change behaviours in the way that would help her most.’

Such conversations should also be extended to the male population, Judith acknowledges, adding that she’s working on newer studies focusing on men. But what about young lesbian, gay, bisexual and trans (LGBT) men and women, who are vulnerable to falling through the net when it comes to healthcare advice and support, and could therefore miss out on the preconception health chat?

Victoria agrees these groups are ‘often missed or not targeted for preconception and general health promotion’ but adds that, thanks to the ‘You’re welcome’ quality criteria standards that underpin most healthcare services (Department of Health, 2011), school nurses ‘offer equal access to all’.

The long view

The studies’ authors state that taking ‘a life-course view’ to preconception health will benefit both current and future generations, while the first paper concludes that health professionals ‘should be alerted to ways of identifying women who are planning a pregnancy’.

Although this approach is a challenge in health-visiting practice, particularly in identifying prospective first-time parents, for school nurses there are undeniably opportunities – in spite of the difficulties the profession faces. A three-year project funded by the Burdett Trust for Nursing for instance aims to reduce maternal obesity ‘through working with adolescents and aiming to break this cycle prior to them becoming parents’.

While The Lancet series’ authors acknowledge that ‘interventions at a public health level will usually take months to years to have an effect’, given the positive health outcomes that are likely to arise among the next generations, it’s surely an investment worth making.

The studies’ key recommendations

  • Improved awareness of preconception health, particularly regarding diet and nutrition
  • Health professionals to be alerted to ways of identifying women who are planning a pregnancy
  • New guidance for parents on preparing for pregnancy, to protect the health of offspring
  • Three methods of intervention: supplementation and fortification; cash transfers and incentives; and behaviour change
  • A three-pronged approach taking into account the different preconception phases and definitions: biological, individual and public health
  • A strategy targeting specific groups actively planning a pregnancy while improving the health of the population more broadly
  • The development of an advocacy coalition of groups interested in preconception health to turn policy into action
  • That there should be no obesity strategy, no undernutrition strategy, no non-communicable diseases strategy and no adolescent health strategy without including preconception health.

Barker et al, 2018; Fleming et al, 2018; Stephenson et al, 2018.




Picture Credit | NHS


Barker M, Dombrowski SU, Colbourn T, Fall CHD, Kriznik NM, Lawrence WT, Norris SA, Ngaiza G, Patel D, Skordis-Worrall J, Sniehotta FF, Steegers-Theunissen R, Vogel C, Woods-Townsend K, Stephenson J. (2018) Intervention strategies to improve nutrition and health behaviours before conception. The Lancet 391: 1853-64. See: thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30313-1.pdf (accessed 9 June 2018).

Department of Health. (2011) Quality criteria for young people friendly health services. See: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216350/dh_127632.pdf (accessed 9 June 2018).

Fleming TP, Watkins AJ, Velazquez MA, Mathers JC, Prentice AM, Stephenson J, Barker M, Saffery R, Yajnik CS, Eckert JJ, Hanson MA, Forrester T, Gluckman PD, Godfrey KM. (2018) Origins of lifetime health around the time of conception: causes and consequences. The Lancet 391: 1842-52. See: thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30312-X.pdf (accessed 9 June 2018).

Gaskins AJ, Sundaram R, Buck Louis GM, Chavarro JE. (2018) Seafood intake, sexual activity, and time to pregnancy. Journal of Clinical Endocrinology & Metabolism 103(5). See: doi.org/10.1210/jc.2018-00385 (accessed 9 June 2018).

NHS. (2017) Vitamins and minerals. See: nhs.uk/conditions/vitamins-and-minerals (accessed 18 June 2018).

Raffoul A, Leatherdale ST, Kirkpatrick SI. (2018) Dieting predicts engagement in multiple risky behaviours among adolescent Canadian girls: a longitudinal analysis. Canadian Journal of Public Health 109(1): 66-9. See: link.springer.com/article/10.17269%2Fs41997-018-0025-x (accessed 9 June 2018).

Sedgh G, Singh S, Hussain R. (2014) Intended and unintended pregnancies worldwide in 2012 and recent trends. Studies in Family Planning, 45(3): 301-314. See: ncbi.nlm.nih.gov/pmc/articles/PMC4727534/ (accessed 9 June 2018).

Stephenson J, Heslehurst N, Hall J, Schoenaker DAJM, Hutchinson J, Cade JE, Poston L, Barrett G, Crozier SR, Barker M, Kumaran K, Yajnik CS, Baird J, Mishra GD. (2018) Before the beginning: nutrition and lifestyle in the preconception period and its importance for future health. The Lancet 391: 1830-41. See: thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30311-8.pdf (accessed 9 June 2018).

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