This edition of Health Matters focuses on an integrated approach to pregnancy planning and reproductive health, where preconception care and contraception are two sides of the same coin. This approach will better enable populations to be healthier at an earlier stage in preparation for a pregnancy if they choose to have one, and avoid unintended pregnancies if they do not.
The life-course approach
Women make up 51% of England’s population. Of these, more than three quarters at any one time want to either prevent or achieve pregnancy. Contraception and preconception care are therefore a day-to-day reality for the vast majority of women for most of their reproductive years.
Women having control over reproduction is imperative, as it ensures that:
- as many pregnancies are planned and wanted
- health is optimised both before a first pregnancy and in the interpregnancy period
- women who do not wish to have children can effectively prevent becoming pregnant
A planned pregnancy is likely to be a healthier one, as unplanned pregnancies represent a missed opportunity to optimise pre-pregnancy health. This can lead to adverse health impacts for the mother, including obstetric complications and antenatal and postnatal depression, as well as for the child, including low birthweight and developmental abnormalities.
Whilst traditionally, preconception care has focused on women planning a pregnancy, with 45% of pregnancies in England being unplanned at the time of conception, the timing of addressing preconception risks poses a challenge.
There are multiple risk factors for unplanned pregnancy, including lower educational attainment, younger age, smoking and substance misuse.
In 2016, the under-18 conception rate in England was 18.8 conceptions per thousand women aged 15 to 17. Although this was the lowest rate recorded since comparable statistics were first produced in 1969, teenagers remain the group at highest risk of unplanned pregnancy.
Contraception is important for all heterosexual women of reproductive age, regardless of whether they are planning a pregnancy, as it enables them to effectively control if and when they desire to conceive. The contraceptive consultation also offers an opportunity for optimising health and a longer time period to address risk factors in advance of pregnancy, if this is a desired goal.
78% of women of childbearing age want to either prevent or achieve an unassisted pregnancy at any one time. Therefore, taking a population approach to contraception alongside addressing other aspects of health improvement is likely to be an effective way to address health needs in preparation for pregnancy at a later date.
A total of 12% of women who are at risk of pregnancy but not wanting to conceive are not using contraception. One third of women are unable to access contraception from their preferred source, and women who are already disadvantaged are less likely to access contraception and preconception care altogether.
Women who do not reach contraceptive services proactively can benefit from opportunistic contraceptive and preconception advice. After taking emergency hormonal contraception, after having a baby or an abortion, or when they are in contact with health services for other issues or conditions all provide ideal opportunities.
Preconception health and care
The preconception period presents an opportunity for intervention, when women and men can adopt healthier behaviours in preparation for a successful pregnancy and positive health outcomes. This includes:
- ensuring you are up to date with vaccinations
- ensuring sexual health checks and cervical screening are up to date
- taking vitamin D and folic acid supplements
- eating a healthy balanced diet
- undertaking regular moderate intensity physical activity
- reducing alcohol consumption
- giving up smoking
- using contraception for family spacing
By not addressing these risk factors, women and their children are at greater risk of poor outcomes. However, only a minority of future parents make changes in preparation for pregnancy, and most only start thinking about preconception care once pregnant.
Maternal and paternal obesity is one example where there is an increased risk of many major adverse maternal and perinatal outcomes. 19% of women of reproductive age in England are obese, 3.6% are severely obese, and of these obese women 5.3% will become pregnant each year.
Achieving weight loss requires a longer period of time to address adequately before pregnancy, and is therefore an area where changes could be made earlier than the traditional preconception period of 3 months.
There is also increasing evidence for the impacts of a global increase in male obesity on outcomes. Paternal obesity has been linked to impaired fertility by affecting sperm quality and quantity, as well as an increased risk of chronic disease in future generations.
Making reproductive health and pregnancy planning everyday business
Reproductive health needs to be part of day-to-day business for many key services, and support for healthy behaviour change must be important for all. There are both universal and targeted approaches to achieving this, with higher risk groups with multiple vulnerabilities requiring a more intensive and multidisciplinary approach.
Read this edition of Health Matters to find out what local authorities, NHS commissioners and health professionals can do at different stages of the life course to apply these approaches and make reproductive health and pregnancy planning everyday business.
Health Matters is a resource for professionals which brings together the latest data and evidence, makes the case for effective public health interventions and highlights tools and resources that can facilitate local or national action. Visit the Health Matters area of GOV.UK or sign up to receive the latest updates through our e-bulletin. If you found this blog helpful, please view other Health Matters blogs.