Perceptions and practice of preconception care by healthcare workers and high-risk women in south africa: A qualitative study

Preconception care is biomedical, behavioural, and social health interventions provided to women and couples before conception. This service is sometimes prioritised for women at high risk for adverse pregnancy outcomes. Evidence revealed that only very few women in Africa with severe chronic conditions receive or seek preconception care advice and assessment for future pregnancy. Thus, this study aimed to explore the perceptions and practice of preconception care by healthcare workers and high-risk women in Kwa-Zulu-Natal, South Africa. This exploratory, descriptive qualitative study utilised individual in-depth interviews to collect data from 24 women at high risk of adverse pregnancy outcomes and five healthcare workers. Thematic analysis was conducted using Nvivo version 12. Five main themes that emerged from the study include participants’ views, patients’ access to information, practices, and perceived benefits of preconception care. The healthcare workers were well acquainted with the preconception care concept, but the women had inconsistent acquaintance. Both groups acknowledge the role preconception care can play in the reduction of maternal and child mortality. A recommendation is made for the healthcare workers to use the ‘One key’ reproductive life plan question as an entry point for the provision of preconception care.

This study was conducted in a tertiary hospital with a dedicated preconception care clinic at eThekwini Metropolitan Municipality in KwaZulu-Natal province of South Africa. This tertiary hospital carters and gets referrals from the entire population of Kwazulu-Natal and parts of Eastern Cape province. eThekwini Metropolitan Municipality is the third most populated Municipality in South Africa after Gauteng and Cape Town, with 3.4 million inhabitants [36]. The Municipality has one tertiary and many district hospitals, including clinics. The province has the highest maternal and child mortality rate among women aged 10 to 24 years in South Africa [37]. This study is part of a mixed-method multiple case study conducted in a tertiary hospital and a higher education institution that trains nurses in the province. The study was conducted in the obstetric and gynaecological unit, which comprises preconception care, genetic, obstetrics, and gynaecology, feto-maternal medicine clinics. The selected tertiary hospital is a referral hospital, and the selected obstetric unit gets referrals of women with high-risk conditions. A qualitative descriptive design was used in this study to enable an in-depth [38] exploration of the perceptions of patients and healthcare workers (HCWs) regarding preconception care provision. This design was deemed vital in having a rich and diverse insight of the patient’s perspective and that of the health care workers to answer the questions of how and why regarding preconception care provision. Data were purposively collected from two different groups of participants to obtain rich data. The participants included women at high risk of adverse pregnancy outcomes attending services in the obstetric and gynaecological unit and all health care workers attending to these patients. These health care workers were the providers of PCC in the unit and are a good representation of healthcare workers that high-risk patients would encounter for PCC because of their various clinical specialties. The participants were deemed appropriate for the study because they would be able to provide the necessary information regarding their PCC care provision. Patients must have received at least one preconception care counselling or be at risk of adverse pregnancy outcomes, and health care workers must be employed permanently in the unit for at least one year to be eligible to participate in the study. Participants must be 18 years and older. The table below (Table 1) reveals the characteristics of the participants and the number of years they have been working or visiting the unit. Among the patients, ten are being investigated and managed for cardiac diseases/surgery, eight are being treated and investigated for infertility, and two each are being managed for hypertensive disorders, diabetes, and chromosomal abnormalities. The healthcare workers comprised of an obstetric and gynaecological and a feto-maternal medicine specialist. Two genetic nurses and a midwife specialist who is also a family planning nurse. Participants’ characteristics. A non-probability purposive sampling method was used to recruit a sample of patients and healthcare workers for this study. Twenty-four women at high risk of adverse pregnancy outcomes (n = 24) and specialist healthcare workers (n = 5) made up the sample size. The sample size was based on data redundancy. Potential participants were identified and approached through the assistance of the nurses in the unit. All women at high risk of adverse pregnancy outcomes that were attending various clinics in the obstetric and gynaecological unit during the data collection period and health care workers who attended to these women were approached for data collection. The managers of the hospital granted permission to access the unit and participant. The researchers visited the clinics on days when potential participants will be available to introduce the researcher, explain the study aims and objectives, and request their participation. Appointments for interviews were then made for data collection based on participants’ preferences. Ethical clearance for the study was obtained from the University of KwaZulu-Natal Human and Social Sciences Research Ethics Committee and the KwaZulu-Natal Health Research (HSSREC/00001069/2020) and Knowledge Management directorate reference number (KZ-202003-009). All the necessary institutional permission was obtained from the tertiary hospital prior to data collection. All protocols stipulated in the Helsinki declaration regarding voluntary participation, confidentiality, and anonymity were observed during data collection and reporting of findings. The study data were collected using a semi-structured interview guide to conduct an in-depth interview between October and December 2020. There were open-ended qualitative items based on the participant’s perceptions and practice of PCC. Each group of participants was asked the same main questions with varying probing questions based on their responses. The main questions asked were as follows: “Please share with me your understanding of PCC? (What is this all about, what does it mean to you, and who and what does it involve).” “Tell me what you understand by reproductive life plan?” “Share with me your perceptions and views regarding PCC provision?” “Please share with me the aspect of PCC provided here.” The researchers visited the unit twice before resuming the interview to get familiar with the environment and establish relationships with the participants. Interview appointments and participants preferred venues were established, and data were collected after obtaining voluntary informed consent. The interviews lasted between 25 to 60 min with few individual variations. Data were collected in English, with participants given the option to have the interviews in other preferred local languages. The individual in-depth interviews were deemed appropriate because they enabled the exploration of individual opinions that would have been hampered by focus group discussion. All interviews were audio-recorded, and field notes were made on each interview. Data collection and analysis co-occurred with transcription and were saved in a password-protected file using pseudonyms to maintain anonymity. Interviews were conducted by the first author and another doctorate student with experience in qualitative study after two days of training to acquaint her with the interview questions. Interviews were audio-recorded with permission from participants then transcribed verbatim while quotes were edited for clarity. Recorded interviews were transcribed verbatim. The authenticity of the transcripts was ensured by reading the transcripts while listening to the audio recording. Transcripts were sent to participants for correction to maintain the accuracy and credibility of the findings. Transcripts were then exported to Nvivo version 12 (QSR International, Doncaster, Australia) for organisation, coding, and analysis. The thematic analysis approach was used for data analysis following the six steps proposed by Braun and Clarke [39,40]. The six steps used include (a) reading through the data several times to enable immersion, (b) producing initial codes from the data, (c) sorting different codes to form themes, (d) reviewing and refining themes, (e) defining and naming themes (f) producing a report using data extracts in a concise, coherent, logical way. Data were coded by two independent coders and verified by the co-author. Modifications were made where necessary to provide clarity or to remove redundant words such as em and ehm. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was followed to report findings [41]. The trustworthiness criteria proposed by Guba and Lincoln [42] were followed to ensure the quality of the study’s results. This includes credibility, dependability, confirmability, and transferability. All four aspects of trustworthiness were ensured as follows. Credibility relates to how the study analysis was conducted to ensure that no pertinent information was excluded [43]. Credibility was achieved through member checking with some research participants and with the co-investigators to confirm research findings and interpretation. Dependability, the extent to which data can be depended on over time, was ensured using an inquiry audit and using participant’s verbatim quotes to support findings interpretation. The use of two groups of participants and women with varying medical and surgical conditions helped the generalization of findings. At the same time, confirmability was ensured by involving two independent coders in the coding process to exclude subjectivity [44]. Four main themes and 14 subthemes were generated concerning the provision of, and perceptions about PCC emerged from the data. They are views about PCC, services provided, patient’s access to PCC information, and perceived benefits of PCC and reproductive life plan (RLP). The summary of the emerged themes and subthemes is presented in Table 2. Summary of the emerged themes and sub-themes. PCC: preconception care; RLP: reproductive life plan. Four subthemes emerged with regards to participant’s perceptions about PCC. This includes preconception care as preventive care, which involves screening services, who PCC should be prioritised, and setting for PCC provision. Participants reported that PCC should be about providing services to women that will prevent complications that may contribute to adverse pregnancy outcomes and genetic disorders. PCC involves interventions to avert adverse pregnancy outcomes, especially for women with underlying conditions. It involves stabilising the conditions of the women before conception, advising, and educating them about their conditions so that they are aware of the implications of their medical and surgical conditions. “PCC focuses more on preventing genetic disorders and defects…it is about giving optimum care to a woman of childbearing age… a woman with medical conditions such as diabetes, cardiac, epileptic. What does it mean to her to have optimal control before she conceives? It is about giving advice, educating, and creating awareness.” “Is the preventive care that we offer to women that are planning to fall pregnant… specifically here, we focus on women with high-risk conditions either from a previous history or family history or a condition that the patient themselves indeed have. We advise on whether it is safe or probably not safe to undertake a future pregnancy.” It also includes investigative services to identify risk factors in a woman, family, or environment that may affect the pregnancy outcome. After this investigation, women are advised about the safety of future pregnancy and what they need to do if they are planning pregnancy. “This is a service provided to women before they fall pregnant so that they can have a planned pregnancy. Any questions about the pregnancy can be answered. If there are modifiable risk factors like drugs, alcohol, smoking, the weight, they can also be modified before they fall pregnant…” “It is an opportunity to investigate them without the pregnancy because you can do much more without the concern about the pregnancy and then to advise them appropriately about the safety of falling pregnant both for the woman and for the fetus.” All the HCWs reiterated that they prioritise women with chronic medical or surgical conditions for PCC. Although PCC is meant for everyone in the childbearing age, priority is given to those above 35 years and those at high risk of adverse pregnancy outcomes. This priority group is due to the shortage of human resources prevalent in the healthcare system and the number of women and men in the childbearing age bracket that should be seen. “Maternal age is considered—the very young and over 35. Women with prior medical conditions, like diabetes, hypertension, cardiac diseases, multiple miscarriages. People with epilepsy because we worry about control for them…and we worry about the medication they are taking, its effects on them and the outcomes on their babies.” “…all women should have access to the PCC service, including women with medical and surgical disorders. Family history of certain genetic disorders…couples who have previous children with problems… those women attending contraception clinics and who have underlying problems. At the moment, we can’t offer it to all women because of the numbers…” Participants stressed that PCC should be every healthcare worker’s business. All HCWs that attend to people of childbearing age should assume the PCC role. They should be able to ask them about their reproductive life plan then advise them accordingly. This is the same for HCWs that prescribe different teratogenic medications to people of the reproductive age. They should counsel them and ensure that they are using a reliable contraceptive method to avoid unplanned pregnancies that can be detrimental to both the mother and child. “It is every nurse’s job to be a health educator…it does not have to be only a designated genetic nurse or genetic counsellor.” “…the family planning sister, youth, and adolescent Primary Health Care, and all HCWs should advise women about PCC.” “Clinics are issuing Epilem to young patients, but no one is asking them which contraception they are on. If you take Epilem, you must be on very reliable contraception. You shouldn’t fall pregnant while on it, so all HCWs, including cardiology, rheumatology even dermatologists, should give PCC advice.” The participants further stated that PCC should ideally start from home with good nutrition and be part of every primary health care clinic. It should also be provided in hospitals, family planning clinics, every specialist care that manages women at risk of adverse pregnancy outcomes. It should be included in the school curriculum. “PCC should start right from home…preconceptionally, people must be healthy and eat well.” “PCC services should be done at the clinics because there are so many people. I have seen nurses in the waiting area talking to patients. Also, it should be provided at every regional hospital that has obstetrics and gynaecology service.” “PCC service should actually start at the base hospital and the local clinics…the other place where this service should be part of family planning. I don’t think family planning is only about contraception; I think it should also have an element of women’s health. If you do stop your contraception, then you are planning to fall pregnant and should go and seek prenatal counselling.” “It is quite okay for women who have had one pregnancy. Then maybe health care workers can counsel them about future pregnancies. However, the issue also comes about with first-time people who have not fallen pregnant before. Another issue will be the growing number of teenage pregnancies so it might be something that should be put into the school curriculum to inform them about these things.” The HCWs stated that their PCC services include genetic counselling, PCC counselling and screening, preventive care, and contraceptive services. Participants confirmed that women with or suspected genetic issues are counselled in the unit for future pregnancies. In confirmed cases of a genetic disorder, this service is also provided for the children as premarital counselling and screening. “In genetics, the mothers are counselled about the birth defects that the babies can have…. We do test for the parents if there are chromosomal abnormalities or there are multiple miscarriages. I am opportune to see some of my clients as children and then as adults for genetic counselling.” “Women who have had fetal anomalies, multiple miscarriages…I think miscarriages are under-recorded and under-scored in our health services. Any four five six first trimester miscarriages should be considered for PCC…you can then counsel them about prenatal supplements.” Participants also provided PCC services as investigations and screenings, which are carried out to determine future pregnancy risks, including folic acid supplementation. “I would advise them firstly checking to see if they have any medical issues so that we can get it under control. We do the regular screening. We do pap smears…we make sure they are at an ideal weight…If they are on any medication, they should continue taking it, but you need to check that they are safe before they conceive and also start folic acid at least three months prior to conception.” “For women with a previous baby with abnormality, we test both parents for reoccurrence and advise.” They reported that they also attend and control any modifiable risk factors such as weight control and tobacco or alcohol/drug cessation. They also try to improve pregnancy outcomes by stabilising the patient’s condition and providing curative care before pregnancy. They also provide access to supplements and immunisations for women and educate them about the importance of those interventions. “During PCC, we would say don’t fall pregnant, or we would say fix this then fall pregnant or change this then fall pregnant or stop smoking and then fall pregnant…lose weight then fall pregnant……diabetic, control your sugars better and then fall pregnant the chances of having abnormalities are less.” “PCC not only prevent women who are high-risk falling pregnant, but you also going to try and improve the outcomes of pregnancy by fixing things; for example, women with cardiac conditions should get surgery before they fall pregnant… a woman come to this clinic they can be examined.” “We provide access to vitamins like folic acids, immunisations, alcohol, smoking, and recreational drugs…we educate them.” The participants provide contraceptive services for pregnancy planning among women. “Here we also provide family planning services to women who are delivered here. We educate them about child spacing and to visit our pre-pregnancy clinic whenever they want to fall pregnant for further assessment. We encourage spacing of planned pregnancy.” Two themes emerged regarding women’s access to PCC information. This includes varying PCC awareness levels among women and poor reproductive life plan knowledge. There was varying awareness level among participants about PCC. Almost all the participants with cardiac conditions were aware of PCC. They were informed about what to do while planning pregnancy and immediately after conception, but that is not the case for other patients with other conditions, especially those treated for infertility. Most women have never heard about PCC, and even after the concept was explained to them, they confirmed that no one has ever informed them about it. “I knew about PCC; I was told about it when I had my first baby. I was given PCC counselling about my condition.” “I haven’t heard about PCC anywhere before…. we just go to antenatal visits, and they check our blood pressure and others.” “It is the first time I hear the word, so I am not sure what it means. It sounds like the care given to women.” All the participants were not aware of the Reproductive Life Planning concept. A RLP tool involves one key question that HCWs should use to screen women’s reproductive plan and advise accordingly. However, that tool is not available or common among HCWs. “I have never heard about the reproductive life plan concept.” “What does reproductive life plan mean? It is my first time to hear about it….” The perceived advantage of PCC and RLP emerged as a theme with four subthemes of reduction in maternal and child mortality, prevention of birth defects, prevention of teenage pregnancy and pregnancy planning, and empowerment. The HCWs acknowledged the importance of PCC and RLP in reducing maternal and child morbidity and mortality. “PCC can save women’s life you may not see the benefits now. If you go through the system, you might find out that there are patients who may not want to fall pregnant because they realise that the risks are too high or maybe women where you can change the drug they are taking, and you prevent the abnormal babies, for example, women who are taking Epilem.” “We are going to see better outcomes both mother and baby, and we probably will save a lot of mothers, or we would save mothers who are not supposed to be falling pregnant but are falling pregnant.” “PCC will help us know what we are falling into and save our lives and the baby. If you know that you will be pregnant, you have to check your body every time to know what is going on in your body. Do you have BP and all the stuff…no woman will die. PCC service is good.” Most participants perceived PCC to assist in preventing congenital abnormalities through early screening, testing, and counselling. “PCC will assist in the prevention of fetal alcohol syndrome, which is the commonest quiet form of mental retardation…South Africa is number one in the world for fetal alcohol syndrome, and we will have a healthier, happier society.” “Working in genetics, we can see the number of birth defects that could have been prevented if mothers were advised properly when they were planning their pregnancies…the preconception folic acid that can be given to prevent neural tube defects. All this will lead to better outcomes both for the mother and baby.” The participants perceived PCC and RLP as a valuable tool in preventing teenage pregnancy and in assisting with pregnancy planning. Although both the HCWs and women are not well acquainted with the concept of RLP, with a short explanation of the concept, they could perceive it as the ideal thing for the patients and HCWs. “PCC and reproductive planning are important because you can’t do anything without planning. Why do we fall pregnant without planning to? I think if you pre-plan your pregnancy, it will go well. With PCC, women are gaining information which is better because most of the time you get pregnant, which you don’t understand.” “It is always best to know information before you go through anything. If the pregnancy is planned, you can never go wrong because you will have understanding.” “PCC is very important, and there will be a reduction in child pregnancies and mishaps like disabilities…If they are educated my opinion is that it will be way better for them, for an older person is fine but for a young child pregnancy will be a burden… is so sad to see a teenager pregnant, if no one is there teaching them they just gonna be in trouble and continue falling pregnant.” “RLP sounds nice…the ideal would be RLP because, unfortunately, the challenges that we are still facing in KwaZulu-Natal and many parts of the country is that patients don’t have a plan.” PCC was perceived as essential in equipping women with knowledge and empowering them to handle their conditions. This empowerment can be in inform of educational resources and knowledge that will enable them to take charge of their life and reproduction. “PCC rewards to the patients are more empowered to control their condition and their lives.” “It will make me act better as I plan to begin my family. it will give women power because even if you are pregnant, you can be able to save your baby, understand better and feel equipped.” “…they are more aware of their condition, and patients will be more prepared for the future.”

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