A systematic review of the effectiveness of preconception interventions in primary care

Problem

Preconception care (PCC) refers to interventions delivered prior to conception that aim to optimise the health of reproductive-aged women and men, in order to improve pregnancy outcomes. As the first point of health care contact, primary care settings have the potential to improve pregnancy outcomes, however the effectiveness of primary care-based PCC is still unclear and has not recently been reviewed. We aimed to evaluate the effectiveness of primary care-based PCC interventions delivered to reproductive-aged women and men on improving health knowledge, reducing preconception risk factors and improving pregnancy outcomes.

Approach

We undertook a systematic review of OVID Medline, Cochrane CENTRAL, EMBASE, Web of Science, Scopus and CINAHL. Updating the findings of a review published in 2016, we included randomized controlled trials (RCTs) conducted in primary care settings, that included reproductive-aged women and/or men published between July 1999 and May 2021. Two reviewers independently assessed article eligibility and quality, the latter using the Cochrane risk of bias tool. We followed the Preferred Reproting for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines and registered our review with PROSPERO (CRD42021235499).

Findings

Twenty-eight articles reporting on 22 RCTs were included. All but one of the articles focussed on women. Articles were from USA (n=8), Iran (n=8), Vietnam (n=5), China (n=2), Netherlands (n=2), Australia (n=1), India (n=1) and Sweden (n=1). Interventions focused on: brief education (single session) (n=9), intensive education (multiple sessions) (n=9), folate supplementation (n=7) and/or dietary modification (n=4). Brief education improved health knowledge (n=4), reduced alcohol/tobacco consumption (n=2) and increased folate intake (n=3), while intensive education reduced spontaneous pregnancy loss (n=1), maternal stress (n=2) and alcohol-exposed pregnancies (n=2), and increased physical activity (n=2). Supplementary medication increased self-reported folate intake (n=4), and diet modification reduced pre-eclampsia (n=1) and increased birthweight (n=1). Only eight articles reported on pregnancy outcomes, with a range of interventions used, and four of these reported improvements in pregnancy outcomes. The majority of the RCTs were determined to be of low quality (n=13).

Consequences

Primary care-based PCC interventions including brief and intensive education, supplementary medication and diet modification are effective in improving health knowledge and reducing preconception risk factors in women, although there is limited evidence for men. However, given the limited number of studies reporting an improvement in pregnancy outcomes, across a variety of interventions, further research is required to determine the whether primary-care based PCC can improve pregnancy outcomes.