A wake-up call for preconception health: a clinical review

Preparing for a healthy pregnancy, preconception care, should be the norm and a more actively managed step in primary care.Decades of improvement in the quality of maternity care have greatly reduced the risks associated with pregnancy and childbirth, but improvements in preconception care have lagged behind.The health of women as they enter pregnancy remains a major challenge to maternity services, and two-thirds of maternal deaths in the UK are now in women with pre-existing medical conditions. 1 Animal and human research show clear links between preconception influences and offspring health extending across two or more generations.2 In the UK and most other countries, preconception health is frequently compromised by maternal and paternal obesity, dietary deficiencies, smoking, excessive alcohol consumption, mental health issues, and recreational drug use, all of which are associated with poorer pregnancy outcomes and frequently rooted in social and economic deprivation.The rise in obesity among women of reproductive age has been the most pressing 'wake-up call' to improve preconception health.Obesity (body mass index [BMI] ≥30 kg/ m 2 ), which affects over one in five (21.6%) pregnant women in the UK, 3 is strongly linked to almost all adverse pregnancy and birth outcomes, notably pre-eclampsia, gestational diabetes, and stillbirth, and has lasting consequences for the health of the offspring. 4nfortunately, attempts to tackle the problem through diet and physical activity interventions starting in pregnancy have had negligible effect on immediate and later outcomes.5,6 Together, these findings call for a new focus on improving health before conception. REVIEW OF EVIDENCEThis article draws on comprehensive recent reviews of clinical care from the National Institute for Health and Care Excellence (NICE), 7 research evidence from the National Institute for Health Research (NIHR), 8 the scientific rationale, 9 the 2018 Lancet series on preconception health, 2,5,10 and a suite of resources produced by Public Health England 'making the case for preconception care'.11 In addition, this article illustrates the implications of preconception care guidance for a typical general practice. HOW CAN PRECONCEPTION CARE BE NORMALISED?A common objection to normalising preconception care is that around 40% of pregnancies are not planned.Leaving aside the counter-response that 60% of pregnancies are planned (although the intention to conceive is often not declared), this objection merely points to the need for dual action at both individual and population level -a proposal that is emphasised in the Lancet series.5,10 Action at the population level offers the opportunity to optimise preconception health to those not planning a pregnancy.It is needed not only because of unplanned pregnancies but also because many risk factors are set in train well before pregnancy.Changing established patterns of behaviour, such as smoking or diet, and removing barriers to achieving a healthy preconception status, can take months or years.5,10 Public health, system-wide interventions avoid some of the limitations of individually targeted interventions, which include burdening women with responsibility for preconception health, widening health inequalities, poor compliance, feelings of blame or shame, and limited impact.These features are well illustrated by prevention of neural tube defects with folic acid: in England in 2017, <30% of women took folic acid supplements before a first or subsequent pregnancy, and <15% of women aged <25 years where social deprivation is greater.12 The alternative approach, mandatory fortification of food with folic acid, is still under consideration by the UK Government, but has been implemented in 82 countries including the US, Canada, and most of South America.