Preconception counseling (PC) is defined as the process of recognizing and attempting to modify where possible medical, behavioral, and environmental factors that lead to increased risk for an adverse pregnancy outcome before conception. In 2006, the CDC released recommendations on improving preconception health and included a focus on ‘Preventative Visits’ 1. As healthcare policy has placed additional emphasis on preventative medicine, the interest in PC has grown. The American Congress of Obstetricians and Gynecologists as well as the American Academy of Family Physicians are just two of the many organizations that have come out with position papers emphasizing the importance of PC 2,3. Current guidelines state that any woman of reproductive age should be offered PC at their regular health examinations. Additional opportunities for healthcare providers to provide PC are available, such as STD screenings or contraception counseling sessions 4,5.
With nearly half of pregnancies in the USA being unintended, it is important that healthcare providers offer PC to all female patients of reproductive age and not just to those attempting to become pregnant 6. Prenatal care plays a vital and well-recognized role in patient care during pregnancy; however, it often begins after most fetal organ systems begin to develop, and therefore is not helpful for the prevention of congenital anomalies or other factors influencing morbidity and mortality. In some instances, early patient education and intervention before pregnancy would prevent these anomalies and other adverse outcomes. The most obvious example of this is the utilization of folic acid before conception to prevent neural tube defects 7–9.
PC has been shown to have benefits across a wide range issues that arise, or take on increased importance, during pregnancy. Maternal cessation of alcohol consumption prevents fetal alcohol syndrome while, along with smoking cessation, also decreasing the risk for miscarriage, premature delivery, and low birth weight 8,10. Ensuring maternal immunization is also strongly recommended 1,11. Vaccines that should be included are measles, mumps, rubella, varicella, diphtheria, tetanus, pertussis, and influenza 12. The need to ensure appropriate vaccination has brought on a new sense of urgency in light of the increasing prevalence of several of these diseases including pertussis and measles 13,14. Dietary advice and counseling that focuses on appropriate weight gain decreases the risks for malnutrition, obesity, and diabetes 10,15,16.
Despite the many advantages and relatively low cost of PC, only 30–40% of women report having received this care 8,17,18. Attempts to examine why the participation rate in PC was so low have identified several barriers both from the clinician and patient standpoint. Many clinicians cite lack of time and reimbursement as reasons for not providing PC 19. A study from the Netherlands showed that patients often decline PC due to perceived knowledge, perceived lack of risk, and a fundamental misunderstanding of what PC is 20. Patient hesitancy also plays a role; one study suggested that a vast majority of women feel uniformed about congenital disorders but often have no intention of asking for information about the risks 21,22. In light of these barriers and the known benefits of PC, our research study examined patient perceptions of PC in an effort to see whether patients themselves deemed the experience useful.
Patients and methods
Consecutive postpartum patients recuperating in an inpatient setting at a tertiary care academic teaching hospital were invited to participate in this study. Eligible patients were at least 18 years of age. Informed consent was obtained. The study was approved by the Penn State Hershey Medical Center ethics committee. Patients who participated in the study were asked to complete a short questionnaire. The questionnaire asked demographic characteristics. It additionally surveyed patient knowledge regarding areas focused on in PC. Eight areas of PC were examined with each question beginning as ‘Prior to my pregnancy I was aware of …’. These eight areas assessed knowledge about the use of folic acid, the recommendations for exercise/nutrition, the importance of vaccinations, the effects pre-existing medical conditions and medications may have on pregnancy, the risk for inherited diseases, the risks of tobacco/alcohol/radiation, and the effect of pregnancy on maternal mental health. Following the knowledge assessment questions, it was inquired whether the patient felt PC was helpful in that area or, if the patient did not receive PC, whether they thought PC would have been beneficial. Finally, patients were asked to rate their overall satisfaction with their medical care during pregnancy on a 1–5 scale. The surveys were distributed and collected by the first author of this paper. Questionnaires were returned the same day they were received. Participants in this study were recruited over a 3-month (92 days) period from 1 October 2013 to 31 December 2013. On the basis of the volume of deliveries performed at the institution where this research took place and the timeframe allotted, it was anticipated that over 250 patients could be recruited into this study. In addition, it was expected that the number of patients being exposed to PC would be similar to those in previous studies (30–40%) 8,17,18.
In our study, we compared the demographics between the group of patients who had received PC and those who had not. We then proceeded to evaluate self-attested patient knowledge on eight facets of patient care that ACOG recommends review of during PC. Patient perceptions of the usefulness of PC in covering these areas were compared between the population who received PC and the patients who did not. We explored these patient perceptions regarding PC by computing unadjusted prevalence odds ratios and 95% confidence intervals. Patient overall satisfaction with care during their pregnancy was examined utilizing the Mann–Whitney test due to the ordinal properties of the data set. A P value less than 0.05 was considered statistically significant. All analyses were performed using medcalc.org or elegans.som.vcu.edu.
In this study on 103 patients, only 12 (12%) reported receiving PC. For the majority of patients surveyed, this pregnancy was not their first. In all, 39 (43%) patients who did not receive PC and five (42%) patients who did receive PC reported this as their first pregnancy. In both groups, the majority of the patients were young (<25 years of age), White, had a family income of less than $40 000, and had either a high school diploma or college degree. Of the 91 patients who did not receive PC, 10 (11%) reported wishing they had received it. The full demographic breakdown of the population surveyed for this study is shown in Table 1. When comparing patient perceptions of their knowledge regarding PC and the benefits thereof, we found no statistical difference between family income levels. We compared each income bracket individually and also compared patients whose family income was less than $80 000 and those whose family income was over this threshold.
As previously noted, PC encompasses a wide range of topics, of which we surveyed eight that ACOG recommends review of. In all eight topics, patients who experienced PC were at an increased likelihood to attest to awareness of the guidelines and recommendations before the initiation of their pregnancy. Despite this trend, none of these were found to be statistically significant expect for patient awareness regarding the risks that pre-existing medical conditions may have on their pregnancy (odds ratio=13.41, 95% confidence interval=1.66–108.28).
Patient perceptions regarding PC followed a similar pattern. In all eight facets of counseling, examined patients who did not receive PC were less likely to think PC would be beneficial for that issue than patients who did. The difference between the two populations, however, was not significant in any of the analyses. These results can be seen below in Table 2. Finally, patients who received PC were more likely to be satisfied with their medical care during pregnancy (4.6 vs. 4.9, P<0.14).
To investigate patient perceptions of PC, we analyzed data from a survey of postpartum patients collected over a 3-month period. Overall, few patients (12%) who took part in our survey reported having any kind of PC. This is a lower percentage than other survey research, which suggested a level of 30–40% being the norm 8,17,18. This may in part due to the low patient desire for PC, as only 10% of patients who did not receive PC wish they had.
Overall, patients who underwent PC were more likely to self-report knowledge regarding the areas of focus in PC. They were more likely to be aware of folic acid recommendations, the importance of exercise and vaccinations, the risks of inherited diseases, medications, tobacco, alcohol, and radiation as well as the mental health risks of pregnancy. These trends all pointed toward the benefits of PC; however, none of these differences between those receiving PC and those who did not were statistically significant. In one case, knowledge of pre-existing medical conditions and the elevated knowledge of those who underwent PC were statistically greater than those who did not. Despite the lack of statistical significance in most categories, the uniform trend of patients who had PC reporting higher knowledge certainly suggests that patients who undergo PC feel better prepared entering their pregnancy.
Patients who failed to undergo PC were less likely to perceive PC as beneficial than those who underwent exposure to it. In a similar outcome to patient knowledge in all eight categories examined, patients who did not receive PC were less likely to think that PC would be beneficial. Patients who did undergo PC were more likely to say PC was helpful in each section. In addition, each subsection was not statistically significant; however, the uniform trend across all eight categories points to patients who underwent PC perceiving a benefit of that additional counseling. Finally, patients who did receive PC were more likely to be satisfied with their overall medical care during pregnancy, although, again, this result was not statistically significant (P<0.14).
Previous studies had examined barriers to PC and PC effects on maternal behavior; however, to our knowledge, this is the first study to examine patient perceptions of the benefit of PC. There were several limitations to our study. As previously noted, our small sample size limited our ability to discern statistically significant results. This is in part due to patients being less receptive than anticipated to partaking in this study. Hesitation on the part of patients was likely due in part to the researcher being unable to approach patients about participation except during peak family visiting hours because of scheduling constraints. Similar scheduling limitations precluded extending the length of time for recruitment into the study as well. Second, our question to measure patient reception of PC was broad and we were not able to discern the depth or specific content of the PC that the patients received. In addition, if the patient herself brought up PC, she would likely already be motivated to increase her own knowledge of the sections we measured regardless of the quality of the PC she had.
In conclusion, our findings suggest that patients perceive a benefit to PC. Patients who underwent PC were more likely to feel more knowledgeable about a wide range of pregnancy topics than those patients who did not. They were also more likely to view PC as helpful and be satisfied overall with their care in pregnancy. Additional study with a larger sample size is needed to ensure that these trends are statistically significant, but our study points to patients finding PC valuable in preparing them for pregnancy.
Conflicts of interest
There are no conflicts of interest.
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