Extended from antenatal care, preconception health is targeted for a planned pregnancy and a healthier pre-pregnancy status, by the approach of folic acid supplement, treatment of chronic and infectious disease, etc. Abundant studies have reported preconception care (PCC) is beneficial for the health of women and children. For example, pre-pregnancy diagnosis and treatment of congenital heart disease are useful for avoiding maternal death; folic acid supplement is recommended for eliminating risk of offspring's neural tube defects. However, PCC practice is not that satisfactory, and moreover, different health system and cultural background lead to diverse PCC model worldwide. In this issue of the Journal, we will discuss about current practice model and related diversity of (PCC) worldwide. Most outline the prenatal care system that has successfully been established in China and then contrast it prenatal care as it is developing in urban Western societies
In China, PCC has become more important than ever. First, according to the Birth Defect Report in China, neonatal and maternal mortality has decreased from 1.9% and 47.7/100,000 in 2005 to 1.21% and 26.1/100,000 in 2011, but birth defects are increasing with a 5.6% annual prevalence1 despite recent advances in prenatal diagnosis and political transformation regarding childbearing policies in China. Therefore, birth defects are becoming much more attributed to neonatal death. Second, since compulsory premarital medical examination was canceled for married couples in 2003, subsequent voluntary examination has decreased to approximately 50%.2 Thus, couples in rural China did not received PCC leading to unclear reproductive health status and some potentially unidentified risks before pregnancy. Concerns have been expressed by politicians and medical experts as to whether the prevalence of birth defect in rural areas might increase due to the lack of effective comprehensive pre-pregnancy checkups and counseling. Moreover, in 2015, China shifted from one-child policy to a two-child policy as a countermeasure to aging population, skewed sex ratio, and a shrinking labor supply.3 Not surprisingly, a greater proportion of high-risk pregnancy (including advanced age and previous history of Cesarean Section) is expected. Therefore, China has built up its own PCC model. In 2010, Chinese government launched National Free Preconception Health Examination Project on community base in 220 pilot counties, and expanded it to all rural areas nationwide since 2013.4 It provides free PCC married couples planning a pregnancy within 6 months, aiming to achieve healthier pre-pregnancy condition and improve maternal and infant outcome. The program is unique for its nationwide coverage, graded preventive strategy, intervention-based risk classification system, and prospective follow up of the cohort. First, well-trained community staff and local hospital are responsible for ensuring high coverage of more than 85%. Second, primary, secondary, and tertiary strategies are in place for health promotion and examination of the couples to identify and avoid exposure harmful substances/environment, ensure adequate nutrition screen for potential health problems, diagnose and treat diseases to achieve a healthier pre-pregnancy status and make appropriate pregnancy follow-up plans.4 Third, a novel risk classification system was introduced that is based on the amenability of pre-pregnancy risk factors to intervention.5 In addition, a real-time database is built up for a continuous follow-up and data collection from preconception, early pregnancy to postpartum period.6
China is one of the leaders in PCC worldwide. The National Free Preconception Health Examination Project is an ambitious welfare project providing a comprehensive PCC in community level for all married couples living in rural areas and mostly benefiting those of younger age and lower education level.4,7 As we previously reported, universal PCC is indicated especially in rural areas as almost half of the participating couples have pre-pregnancy risk factors, and the majority of the risk factors are avoidable, preventable or treatable.5 Also, an integrated approach to PCC including both women and men is justified as more than half of the male partners planning to father a child, were exposed to risk factors during the preconception period.7
So far, some articles have been published based on the data collected from this program indicating the benefit of universal preconception screening for hyperglycemia,8 hepatitis virus B,9 Rubella,10 and Toxoplasma.11 Liu et al.12 reported the association between maternal pre-pregnancy hepatitis virus B infection and preterm birth. In addition, this government-led project appears to be effective in promoting positive lifestyle and behavioral changes in couples of childbearing age in a retrospective study on the couples’ knowledge toward PCC in Shanghai.13 Thus, PCC can be expected to improve pregnancy outcomes, and the follow-up data from this prospective cohort would be gold mine for exploring the impact of PCC on maternal and neonatal health.
Ideally, PCC should be universally recommended for each couple based on the idea of “prevention is priority.” However, in real-world, the necessity is the prerequisite for care and the efficacy is the key of a successful care. The question is what is a “perfect” PCC and is it really worthwhile. To accomplish a good PCC, identifying targeted population, supporting planned pregnancy, recognizing amenable risk factors, and providing appropriate pre-pregnancy, prenatal, and post-pregnancy care are important. Before implementing any universal PCC, we should re-think about the difficulties related to limited medical investment, unbalanced economic resources, population size and cultural diversity, potential for overdiagnosis and treatment, and impact on decision-making regarding the plan for conception and childbearing. The community-based strategy and amenability-based risk classification system used in China provide an optional model for other countries, to promote preconception health with high coverage and personalized management. Its generalizability should be accessed further considering increasing urbanization and immigration. Current PCC is mainly focused on advising couples on healthy life-style, nutrition, screening and diagnosis and treatment of some infectious, genetic and systemic diseases. Whether including screening for other factors, such as work environment, psychological stress, and mental health, would be beneficial needs further evaluation.
In the West, the principles and practice of antenatal care have become vastly different. Many of our routine practices are being called into question. In Canada, according to choosing wisely we are now instructed that there is no benefit to testing urine for proteinuria or glycosuria.14 Routine symphyseal fundal height measurement has been supposed in many places by routine ultrasound, and debates are more frequently related to the most appropriate fetal growth curve as opposed to discussions on healthy lifestyle and nutrition. This is not to say that there are many populations within the West in whom these factors still apply-indeed in Canada we can take a lesson from our East and colleagues in the application of prenatal care to our indigenous population, in whom the basic infrastructure and outcomes achieved in China are desperately required.
Apart from rural areas, access to Vitamin and iron supplementation in pregnancy in the West are routinely available, and, healthy nutrition is available and smoking rates are, at least in the urban areas of Canada extremely low and falling in the pregnant population.15 While new challenges arise, eg, the legalization of Cannabis in Canada and it's uncertain effect on the mother and unborn baby, generally, the population in urban Western society is healthy if not aging. Thus the challenge and focus of prenatal care in the West differs significantly.
Our population demographics has largely shifted so that currently more than one-third of our patients are over the age of 3516 and our prenatal care evolved from that described above to these days a focus on genetic screening. More recently prenatal genetic screening has been replaced by the concept of, first-trimester screen for the prevention of her preeclampsia and preterm birth as espoused by Nikolaides et al. and his inverted pyramid.17
That is not to say we are without problems. Maternal mortality rate in Canada has increased over the last years as result of increasing rates of placenta accreta occasioned by our high cesarean section rate.18 Our prenatal care rather than focusing on population health social determinants of health, and basic clinical antenatal care now focuses on detection of high-risk pregnancies older and sicker mothers, who require more sophisticated screening and tests in order to improve pregnancy outcome.
In other western countries, the concept of PCC is also not new. According to the Public Health Outcomes Framework in the United Kingdom,19 PCC is thought to be relevant to provide across the whole reproductive life span of couples, in all relevant health and social care pathways. The Preconception Service in Hungary20,21 is mainly targeted at prevention of congenital abnormalities and preterm birth from 3 months before the planned pregnancy until the 12th week of pregnancy, including preconception reproductive health check-up, a 3-month preparation for conception and achievement of optimal conception and better protection in early pregnancy. There is a general consensus that PCC is beneficial not only for achieving better pregnancy outcome, but also healthier life of the offspring. It is also important to emphasize that both women's, as well as men's health before conception, contribute to the health of the offspring.
The challenge and opportunity presented by this journal is that I believe both systems can learn from each other. In the West the exceptional data participation and collaboration in the comprehensive antenatal screening programs of China have lessons that we must learn to impart to our urban and vulnerable populations, perhaps for our East and colleagues, we provide a window to the future of the challenge of prenatal care in the next millennium.
Conflicts of Interest
. Ministry of Health of People's Republic of China. The report on the prevention of birth defects in China. 2012. Available at: www.gov.cn/gzdt/
. Gu Y, Li L, Zhou C, et al Factors influencing voluntary premarital medical examination in Zhejiang province, China: a culturally-tailored health behavioral model analysis. BMC Public Health 2014;14:659. doi: 10.1186/1471-2458-14-659.
. Schwank SE, Gu C, Cao Z, et al China's child policy shift and its impact on Shanghai and Hangzhou women's decision-making. Int J Womens Health 2018;10:639–648. doi: 10.2147/IJWH.S172804.
. Zhou Q, Acharya G, Zhang S, et al A new perspective on universal preconception care in China. Acta Obstet Gynecol Scand 2016;95(4):377–381. doi: 10.1111/aogs.12865.
. Zhang S, Wang Q, Sheng H. Design of the National Free Preconception Health Examination Project in China [in Chinese]. Zhonghua Yi Xue Za Zhi 2015;95(3):162–165. doi: 10.3760/cma.j.issn.0376-2491.2015.03.002.
. Wang Q, Zhang M, Zhang S, et al Establishment of quality assurance system of the National Free Preconception Health Care Project in China [in Chinese]. Zhonghua Yi Xue Za Zhi 2015;95(3):166–168. doi.10.3760/cma.j.issn.0376-2491.2015.03.003.
. Zhou Q, Zhang S, Wang Q, et al China's community-based strategy of universal preconception care in rural areas at a population level using a novel risk classification system for stratifying couples’ preconception health status. BMC Health Serv Res 2016;16(1):689. doi: 10.1186/s12913-016-1930-4.
. Zhou Q, Wang Q, Shen H, et al Prevalence of diabetes and regional differences in chinese women planning pregnancy: a nationwide population-based cross-sectional study. Diabetes Care 2017;40(2):e16–e18. doi: 10.2337/dc16-2188.
. Liu J, Zhang S, Wang Q, et al Seroepidemiology of hepatitis B virus infection in 2 million men aged 21–49 years in rural China: a population-based, cross-sectional study. Lancet Infect Dis 2016;16(1):80–86. doi: 10.1016/S1473-3099(15)00218-2.
. Zhou Q, Wang Q, Shen H, et al Rubella virus immunization status in preconception period among Chinese women of reproductive age: a nation-wide, cross-sectional study. Vaccine 2017;35(23):3076–3081. doi: 10.1016/j.vaccine.2017.04.044.
. Zhou Q, Wang Q, Shen H, et al Seroepidemiological map of Toxoplasma gondii infection and associated risk factors in preconception period in China: a nationwide cross-sectional study. J Obstet Gynaecol Res 2018;44(6):1134–1139. doi: 10.1111/jog.13638.
. Liu J, Zhang S, Liu M, et al Maternal pre-pregnancy infection with hepatitis B virus and the risk of preterm birth: a population-based cohort study. Lancet Glob Health 2017;5(6):e624–e632. doi: 10.1016/S2214-109X(17)30142-0.
. Ding Y, Li XT, Xie F, et al Survey on the implementation of preconception care in Shanghai, China. Paediatr Perinat Epidemiol 2015;29(6):492–500. doi: 10.1111/ppe.12218.
. Cui Y, Shooshtari S, Forget EL, et al Smoking during pregnancy: findings from the 2009–2010 Canadian Community Health Survey. PLoS One 2014;9(1):e84640. doi: 10.1371/journal.pone.0084640.
. Nicolaides KH. Turning the pyramid of prenatal care. Fetal Diagn Ther 2011;29(3):183–196. doi: 10.1159/000324320.
. Rosen T. Placenta accreta and cesarean scar pregnancy: overlooked costs of the rising cesarean section rate. Clin Perinatol 2008;35(3):519–529. doi: 10.1016/j.clp.2008.07.003.
. Robertson L, Knight H, Prosser Snelling E, et al Each baby counts: national quality improvement programme to reduce intrapartum-related deaths and brain injuries in term babies. Semin Fetal Neonatal Med 2017;22(3):193–198. doi: 10.1016/j.siny.2017.02.001.
. Czeizel AE. Experience of the Hungarian preconception service between 1984 and 2010. Eur J Obstet Gynecol Reprod Biol 2012;161(1):18–25. doi: 10.1016/j.ejogrb.2011.12.019.
. Czeizel AE. Ten years of experience in periconceptional care. Eur J Obstet Gynecol Reprod Biol 1999;84(1):43–49.