Making a case for preconception care—the pregnancy experiences of women with pre-existing medical conditions in Ibadan, Nigeria

Background Factors that predispose to poor maternal and child health outcomes in most low and middle income countries include the presence of pre-existing medical conditions that are amenable to preconception care (PCC). Nigeria has an increasing pool of women of reproductive age with pre-existing medical conditions but PCC services are not provided routinely in the maternal and child health framework. This study explores the pregnancy experiences of women with pre-existing medical conditions to make a case for PCC as a routine service. Methods Nine women purposively selected because they has pre-existing medical conditions participated in in-depth interviews (IDIs) in this qualitative study. The IDIs were held in the obstetric outpatient clinics and lying-in wards of two referral hospitals for maternal and child health services in Ibadan North LGA of Oyo State, southwest Nigeria. The interviews lasted an average of 30 minutes, were digitally recorded and transcribed verbatim. Thematic analysis using a hybrid of inductive and deductive coding was done using MAXQDA 2018. preconception care. Also includes opinions on whether or not participants believe preconception care is necessary for them as individuals.


Introduction
Preconception care (PCC) is defined as any intervention provided to women, men and couples of childbearing age, regardless of pregnancy status or desire, before pregnancy, to improve health outcomes for women, newborns and children [1,2]. PCC services aim to detect, treat or counsel about pre-existing medical social and behavioural conditions that may impede positive reproductive outcomes [3]. Medical conditions that are amenable to PCC include non-communicable diseases like hypertension and diabetes, genetic disorders including sickle cell and thalassaemia, infectious disease including Hepatitis B and C, sexually transmitted infections including HIV [4,5]. Also included within the coverage of PCC are lifestyle modifications such as reduction of alcohol intake, and cessation smoking and other substance use, encouraging a healthy diet and exercise [6,7].
Addressing these conditions in the preconception period ensures optimal health before pregnancy occurs and improves the chances of a positive outcome for the mother and child [8,9].
Low and middle income countries (LMIC) particularly in Asia and sub-Saharan Africa have the poorest maternal and child health indices globally [10]. Many of the predisposing factors to poor maternal and child health outcomes are due to diseases amenable to PCC. However, PCC services are either nonexistent or weak in many LMICs. Studies from Jordan, Iran, Sudan, Ethiopia and Nigeria show low awareness and utilisation of PCC services [11][12][13][14][15][16][17][18][19]. In these studies, utilisation of PCC was influenced by health care providers' provision of PCC information, presence of chronic medical conditions and sociodemographic factors including educational and wealth status .
In Nigeria, there is an increasing pool of women with pre-existing medical conditions that require PCC [3,20,21]. Hypertension, which had a prevalence of 25.2% among women is the most common noncommunicable disease in Nigeria [22]. Diabetes mellitus has a prevalence ranging from 8 to 10% in the country [21] while the reported prevalence of gestational diabetes is 13.9% among urban women [23]. About a quarter of the Nigerian population have the sickle cell trait while the estimated 4 prevalence of sickle cell disease is 2% [22]. The maternal mortality ratio in the 2018 demographic and health survey is 512/100,000; 67% of pregnant women received antenatal care and only 43% had skilled birth attendants at delivery [24]. The use of PCC has been shown to be significantly associated with timely antenatal care which is linked with improved birth preparedness and better maternal and child health outcomes [25]. PCC is identified as a primary prevention strategy for prevention of mother to child transmission of HIV in the Nigerian National Guidelines for the Prevention of Maternal to Child Transmission of HIV [26]. The guidelines however do not state any implementation strategy and the country has no specific PCC guidelines [26]. PCC services are therefore provided in an opportunistic manner when health care providers see the need for it [15,27]. This explores the pregnancy experiences of women with pre-existing conditions to make a case for PCC services.

Study design and setting
This exploratory qualitative study used multiple case studies to make a case for PCC through the pregnancy experiences of women with pre-existing medical conditions. The study was conducted in the obstetric and gynaecological clinics and lying-in ward of two hospitals in Ibadan North LGA of Oyo State, southwest Nigeria. The first, Adeoyo Maternity Hospital is a secondary health facility while the second, University College Hospital (UCH), Ibadan is a tertiary health facility. Both facilities are referral centres for maternal and child health services in the state while the UCH also provides referral services in maternal and child health for most of the southwestern region of the country and beyond.

Participant characteristics and sampling
The study participants were women aged 18 to 49 years who were purposively selected from the obstetric or gynaecological clinic or the lying-in ward because they had pre-existing medical conditions that had affected their previous or current pregnancy. Pre-existing medical conditions commonly occurring among women of reproductive age in southwest Nigeria include hypertension, diabetes mellitus and sickle cell disorder [20][21][22]. These were represented among the study sample along with chronic hepatitis, HIV, previous pregnancy loss of unknown cause and secondary 5 infertility.

Data collection
Data collection, held between June and December 2019 was through one on one in-depth interviews conducted by three research assistants supervised by the first author. The research assistants were female resident doctors in Community Medicine in the UCH who were familiar with qualitative data collection and were trained for the purpose of the study. Neither the first author nor the research assistants had any prior engagement with the participants before the interviews. The participants were identified with the assistance of chief nursing officers, also females, in the obstetrics and gynaecology department of the hospitals. They were then approached by the research assistants and invited to participate in the study. Everyone who was invited accepted to participate in the study. The plan was to conduct a minimum of five interviews and for the data collection to continue until saturation was reached. After nine interviews, responses to interview questions were similar in spite of the differences in pre-existing medical conditions among the participants and the interviews were discontinued. The interviews held in the obstetric or gynaecological clinic or the lying-in ward of the two hospitals.
Interview guides based on literature were used for the interviews. The interview guides were pretested and the questions that were unclear to the participants or generated ambiguous responses were rephrased. The main interview questions are shown in Table 1. All the interviews were digitally recorded and lasted an average of 30 minutes. The interviewers made field notes during the interviews.

Data management and analysis
6 The audio recordings were transcribed verbatim by the first author and integrated with the field notes to ensure all information was adequately captured. Thematic analysis was done by the first author using a hybrid of deductive and inductive coding [28,29]. Analyst triangulation was done to improve credibility with an independent researcher who was not a part of the research team coding 20% of the transcripts (2 out of 9) [30,31]. A total of 26 codes were derived from the data which were merged into six themes. Both coders met to review the codes, reached intercoder agreement and merged codes into themes. All the data analysis was done using MAXQDA 2018 qualitative data analysis software [32]. The study themes are shown in Table 2. The Consolidated criteria for reporting qualitative studies (COREQ) guided the development of this article [33].

Ethical consideration
The participants were provided with information sheets containing the details of the study and provided consent for the interview and audio recording before each interview.

Participants' sociodemographic characteristics
Nine transcripts were analysed with the mean age of the participants being 36.2 ± 3.7 years. All the participants were married, completed secondary education and were employed. Seven of the women were pregnant at the time of the interview. The mean number of previous pregnancies was 2.4 ± 1.0 while the modal number of living children was one with three women having no living child at the time of the interview. Further details of the participants' characteristics are shown in Table 2.

Study themes
An initial set of 20 codes were identified from recurring patterns in the data which were merged into six themes through discussion to arrive at a consensus. The six themes identified in the study as shown in Table 3. In support of their desire for pregnancy, two of the participants had discontinued the family planning method they had been using in anticipation.
I had been using family planning for seven years, but I stopped a year ago because we wanted another baby. -PW2 Although they desired and planned to have another pregnancy, two of the participants stated that timing was not in keeping with their desire. They had given up on their expectation for pregnancy when they finally became pregnant.

Discussion
This study describes the need for preconception care services as part of maternal and child health care within the Nigerian health system using multiple case studies of women who had medical problems in pregnancy. The medical conditions experienced by the women in this study included hypertension, diabetes, HIV, chronic hepatitis, sickle cell disorder, teenage pregnancy and secondary infertility. These are all conditions that have been shown to be amenable to interventions available through PCC [5,34,35]. Most of the participants were unaware of PCC or its potential benefits to them at the time of their pregnancy. No participant informed their health provider about their intention to conceive and so did not have their medications adjusted where necessary until they were pregnant.
Only one of the nine participants in this study was aware of PCC and she had heard about the concept in the hospital during a previous pregnancy. Previous studies across Africa and Nigeria have shown that many women who are aware of PCC often receive their information from health facilities or health care providers [13-15, 19, 36, 37]. All the participants in this study had been diagnosed with different medical conditions before their pregnancy and had routine clinic visits for follow up. That they were unaware of the concept of PCC and its potential benefit for them implies a possible lack of awareness of the need among their health care providers. A study among health care workers in northern Nigeria showed that less than half of the participants had ever provided PCC [27]. PCC is recognised in the Nigerian National Guidelines for the Prevention of Maternal to Child Transmission of HIV as a primary prevention strategy [26]. However, the participant who was HIV positive was unaware of PCC, suggesting that the service had not been offered to her at any of her routine clinic visits before she became pregnant. By implication, there is a gap in the care of women of reproductive age who have chronic medical illnesses that should be filled by PCC services. There is a need for increased awareness among health care providers as an important source of information to this group of women. The health care providers' role includes informing women about the risks associated with pre-existing conditions, screening for those who are unaware of their health risks and treatment modification for those who are receiving medications [38,39]. Thus all health workers need to encourage their clients to discuss their pregnancy plans in order to begin or adjust treatment plans where necessary.
Although all the participants in the study stated their desire for pregnancy, the specific efforts by two participants was discontinuing their contraceptive methods, which is intuitive for anyone who desires pregnancy. Research on pregnancy intentions have shown that women with intended pregnancies are more likely to engage in positive health behaviours like use of vitamin supplements, including folic acid and avoiding alcohol and tobacco use [40,41]. They are also more likely to seek medical interventions and use PCC services in order to avoid potential complications [11,13], a fact that was prominent among the participants in this study who had experienced complications in their previous pregnancies. However, none of the participants told their health providers about their desire for pregnancy, thus missing out on the opportunity to adjust their medications or receive necessary counsel on lifestyle modifications before pregnancy. By implication, health care providers who care for women of reproductive age with chronic medical conditions should ask them about their desire for pregnancy routinely in order to counsel and adjust medications in a timely manner. Beyond addressing known health problems, PCC also includes identification of pre-existing conditions [8,42] and should therefore not be restricted to women who have known complications. The experiences of two of the study participants buttresses this point -one who had chronic hepatitis was only diagnosed in the current pregnancy while another was diagnosed with diabetes in her previous pregnancy.
Optimising health in the preconception period through medical screening would have been beneficial in both instances.
The participants expressed different opinions about the possible benefits of PCC to the general population and to themselves with respect to their medical conditions. While most believed that PCC services as described in the interviews would benefit anyone who used it irrespective of pre-existing medical conditions, one of the participants who had sickle cell disorder dissented. She believed that only those who had difficulty with conceiving would need such care. She also stated that in spite of her pre-existing medical condition, PCC would not have helped her in any way. Such dissenting voices 14 need to be identified and targeted information provided on the potential benefits. For instance, in the case of this participant, sickle cell disorder would benefit from premarital counselling and screening [43], as well as optimising the health of the mother in the preconception period because of the documented higher risk of maternal and foetal complications [44,45]. In addition, having preconception care followed by effective antenatal care has been shown to be associated with a reduction in the occurrence of complications among women with sickle cell disorder [45].

Conclusion
This study showed a lack of awareness of PCC among a group of women with pre-existing medical conditions who would have benefited from the use of the service. While they all desired pregnancy, none of the participants' preparations included seeking information from their health care providers on what adjustments they may have needed to make to their treatment regimen. This implies a need for health care providers to include specific preconception information in their packages of care for women of reproductive age. There is also a need to improve awareness of the need for PCC among health care providers as they are an important source of information for women in the reproductive age group who have pre-existing medical conditions that can affect pregnancy negatively.