Preconception Health Assessment in China, Lebanon and the Philippines: Applicability to Other Countries
To test the utility of a preconception checklist tool in identifying preconception health needs of women in three countries; China, Lebanon and the Philippines. An academic medical center within each country participated in the development and testing of a preconception checklist tool, which was administered over a 6 month period to selected target groups in each country. The checklist provided valuable data on the preconception health of 6,530 women. Aggregated data identified common preconception health needs across all countries, including provision of modern contraceptives and adequate immunization coverage; HIV and STI screening; treatment for anemia; and counseling for maintenance of a healthy weight. A preconception checklist tool was found to be useful in distinct cultural settings. The study was a pilot. Future steps include validation and standardization of the checklist, data from which could be used to help shape preconception care policies and implementation strategies.
KeywordsPreconception health assessmentPreconception careGlobal maternal and child healthMiddle-income countries
In much of the world, women seek antenatal care once they recognize they are pregnant; a time at which prevention of certain outcomes may be too late. Without public policies and programs for provision of preconception care, countries are missing an important opportunity to improve the women’s, maternal and neonatal health of their populations [1–10].
The CDC defines preconception health as “…the health of women and men during their reproductive years. [Preconception health] focuses on steps that women, men and health professionals can take to reduce risks, promote healthy lifestyles, and increase readiness for pregnancy. Although preconception health care emphasizes preparing for pregnancy, all women and men of reproductive age can benefit, whether or not they plan to have a baby one day.”.
Over the past decade, preconception health research, policy and program efforts have been initiated in the US and Western Europe [6, 11–19]. Recently, policy and program efforts have contributed to development of consensus at the global level of the importance of preconception care for prevention of maternal and child mortality and morbidity and, importantly, to improve the health of women and adolescents . In tandem, research is leading to the development of a package of interventions for lower and middle income countries [20–22]. Top research priorities include development of strategies to improve nutrition, reduce harmful environmental smoke exposure, prevent adolescent pregnancy, increase contraception usage, screen for chronic conditions such as hypertension and anemia, manage infections and improve immunization coverage . Strategies to improve preconception health should be added to existing maternal health intervention packages. Preconception health education and clinical services for adolescents are also critical needs .
Screening tools to assess preconception health are needed for target groups of women and for adolescents in lower and middle income countries. Efforts are underway in the US to develop and implement preconception health assessment tools. In support of this work, the US Centers for Disease Control and Prevention has made available a report on preconception clinical screening tools and interventions evaluated in the US . The checklist tool presented here contributes to the growing number of preconception checklist tools. Additionally, to our knowledge, we have developed the first common preconception health checklist tool for use in a study carried out simultaneously in several middle income countries.
In 2010–2011, the March of Dimes Foundation, Global Programs engaged with its Global Network for Maternal and Infant Health (GNMIH) academic medical center partners in China (Peking University), Lebanon (the American University of Beirut) and the Philippines (University of the Philippines-Manila) to collect baseline data on the preconception health status of selected groups of women. The study was a pilot aimed at testing the utility of a preconception checklist tool for identifying preconception health needs of selected target groups in three middle income countries. A common preconception health checklist tool was implemented by clinicians in all three countries. The tool has provided data on preconception health needs shared by all groups and needs found to be significant within specific target groups of women. The data fill a gap in our understanding of preventable preconception (and interconception) health risks for the groups of women and girls included in the study, and will be useful in formulating preconception care policy and programs in the three countries.
Materials and Methods
Collaboration on the project required several steps: (1) development of a common (shared) preconception health checklist tool; (2) selection of target groups and implementation sites in each country; (3) submission for IRB review or to the appropriate authorities in each country for approval; (4) training of clinicians to implement the tool at the selected sites; (5) data collection and (6) analysis of the data and write-up of results.
The Preconception Checklist Tool
The tool was developed in a collaborative process between the principal investigators in the three countries and March of Dimes Global Programs staff. A key resource was the birth defects surveillance tool in use by the Lebanese National Collaborative Perinatal Neonatal Network, from which questions on reproductive health history and pre-existing medical conditions were developed. Several additional sources on preconception health needs and interventions were used to develop the other questions [12, 13]. March of Dimes staff completed a draft, which was then circulated to all PIs until consensus was reached on the content and form of the checklist tool.
Selection of Target Groups
The selection of target groups was based on three factors: women at higher risk of poor preconception health; inclusion of two or more distinct population groups within each country (e.g. rural/urban; poor/wealthier groups) and/or, the practical consideration of which sites were amenable to carrying out the project. In China, the project was carried out in an eastern region, JiangSu Province, and included three clinics and three worksites in an underdeveloped county (Xuzhou) and three each in an urban county (Wuxi), allowing for a rural/urban comparison. The target age range was women aged 17–35 years. In Lebanon the project was carried out in a homogenous group of women in seven outpatient clinics. The clinics are located in relatively modest sections of greater Beirut. The target was women aged 17–40 years presenting for routine obstetrical or family medicine care. Due to practical limitations on access to rural areas, the research in Lebanon focused on an urban population having a need for improved health services. In the Philippines, the project was carried out in Batangas Province, specifically in its capital, Lipa City, which is located 85 km from Manila. Lipa City was chosen as the target research site because of the willingness of the local government health staff (city health officers and staff) and local officials (the mayor, barangay captain and others) to participate in the project. Lipa has a good mix of rural and urban workplaces and clinics reaching the target groups of women and adolescents, aged 15–45 years.
Institutional Review Board Approvals
The projects in Lebanon and the Philippines were submitted to institutional review boards for review and approval. In Lebanon, the title of the project was “Preconception Check-list—Lebanon”, reviewed by the Institutional Review Board of the American University of Beirut, which granted Approval of Research for a duration of 1 year (July 2011–July 2012). In the Philippines, the title of the project was “A Model Implementation for Preconception Health Care Services in an Urban and Rural Setting”, reviewed by the National Institutes of Health, University of the Philippines—Manila, Ethics Review Board, which granted approval for Research and Experimental Development for the period May 2011–November 2011. In China, the project was classified as a health questionnaire survey, a category that in China does not require institutional review board submission and review. Instead, the project was submitted for approval to the Provincial Department of Health of JiangSu Province and then to the directorate of each of the participating sites. Approval was granted for a preconception health questionnaire survey. Approval was obtained for 1 year (March 2011–March 2012) from the sites and the Provincial Department of Health.
Site Preparation and Training of Health Care Providers
Following selection of the sites and completion of approval processes, project directors and staff in each country carried out consultations, orientations and training of clinicians to administer the tool. Existing staff at each of the sites were trained in the purpose and administration of the tool. In the Philippines, staff included nurses and midwives, in Lebanon obstetricians and clinic assistants, and in China physicians, community health workers and village doctors.
Administration of the Tool
Data collection took place between March and November of 2011. In each site, women coming into the clinic who fit the selection criteria were interviewed by the trained staff. In the Philippines, the selection criteria included all patients coming in for prenatal consultation and all parents accompanying children for vaccination. It also included women attending pre-marriage seminars. At workplaces in the Philippines, all available women of reproductive age were interviewed. In Lebanon, primarily middle-income women were interviewed at obstetrics clinics when they came in for care, and obstetricians with high patient loads were preferentially selected to participate in the study. Prior to the interview, informed consent was obtained from the woman and positive response rates were high. The tool was administered as a separate component of the clinic visit. Each interview took approximately 10 min. Data were self-reported by the women being interviewed, with the exception of BMI, which was calculated by the interviewing clinician.
Analysis of the Data
Development of aggregated data sets took place at the end of 2011 and early 2012. At project initiation, we agreed that the completed questionnaires and aggregated data from each of the clinics and workplaces would be proprietary information to be retained by the participating medical university (GNMIH site). Researchers at each of the GNMIH sites developed data sets comparing preconception health risk factors between the different target groups within their country. Additionally, each GNMIH site developed an aggregated data set that combined the information from all clinics and workplaces. The aggregated data provided a composite view of preconception health risk factors across several distinct groups of women. The three aggregated data sets (one each for China, Lebanon and the Philippines) were then combined by March of Dimes Global Programs to develop an overview of common preconception risk factors found in all countries.
During the study period, a total of 1,733 women were interviewed in JiangSu Province, China. In Lebanon, a total of 1,248 women were interviewed in the greater Beirut area; and in the Philippines, a total of 3,549 women were interviewed in Batangas Province.
China—The median age of women was 27 years. Approximately half resided in a developed/urban setting while half resided in an undeveloped rural area. A high percentage of the total group of women (42.5 %) had attained an educational level above secondary school.
Lebanon—The median age of women was 29 years. The Lebanese group was more urban that the other two, with nearly 83 % of women living in greater Beirut. A high percentage of the women (49 %) had attained an educational level above secondary school.
Philippines—The median age of women was 26 years. In contrast to the Lebanese and Chinese groups, the majority of women in the Philippines study (62 %) were living in rural areas. Nevertheless, as with both other groups, a high percentage (54 %) had attained an educational level above secondary school.
The preconception health checklist covered 10 topics: family planning; reproductive health history; genetic conditions and consanguinity; immunizations; micronutrients; lifestyle; infectious diseases; chronic medical conditions; psycho-social factors; and socio-economic factors. Results of the study for each topic are as follows:
Approximately half of the study population (China 59 % and Lebanon 46 %) were planning to get pregnant. Of these women, 45 % in China and 52.9 % in Lebanon planned a pregnancy within the next 6 months. We found that questions on contraception and family planning were sensitive matters for the Philippines group, as the target group, and the country, are Roman Catholic. Approximately 30 % of the Chinese and Lebanon groups reported using modern contraceptives, in contrast to 14 % of women in the Philippines group. The most common methods in use within these countries where: condoms (China) and oral contraceptive pills (Lebanon and the Philippines). Second most common methods included the IUD (Lebanon) the safety period (China) and condoms (Philippines). The women interviewed in all three countries reported having an average of 1–2 living children. Within China the range was 1–3, however in Lebanon and the Philippines a much greater range was found: 0–8 and 0–14, respectively.
Reproductive Health History
Data on reproductive outcomes were useful on a case by case basis for provision of interconception care and counseling. Data were aggregated by women in the study. We found variation among country groups in terms of abortion and C-section: 18 % of Chinese women in the study reported having had an abortion, in contrast to only 2 % of Lebanese women and 1.5 % of women in the Philippines. In Lebanon, nearly 30 % of women had delivered by C-section, versus 10 % in the Philippines and 3 % in China. The C-section data are important because decreasing C-section rates, especially due to a lower number of elective C-sections, decreases the late preterm birth rate. Approximately 8 % of women in the Chinese and Philippines groups reported a prior miscarriage, while 18 % of Lebanese women reported a prior miscarriage.
With regard to consanguinity, we found a higher percentage of Lebanese women in consanguineous marriages (14.5 %), versus 0 % in the Chinese and Philippines groups. 1.5 % of the Lebanese women had thalassemia, with less than 1 % of their relatives having either thalassemia or sickle cell disease.
MMR, tetanus and Hepatitis B immunization status was assessed. Approximately half of the women in the Chinese and Philippines groups and over 80 % of women in Lebanon group had received MMR vaccination. Over 75 % of women in the Lebanon and Philippines groups reported having had tetanus vaccination, while only 25 % in Chinese group had received tetanus vaccination. Over 80 % of Lebanese women, 65 % of women in the Philippines and 42 % of Chinese women in the study reported having received the Hepatitis B vaccine.
A significant disparity was found between the data from Lebanon and that from China and the Philippines with regard to micronutrient intake. 56 % of the Lebanese women took folic acid supplements (400 mcg/day) versus 26 % of the Chinese and 14 % of Philippines groups. Within Lebanon, almost 20 % took a multivitamin (9 % of Chinese and 18 % of Philippines groups); 38 % took iron tablets, (1.5 % of Chinese and 26 % of Philippines groups); and 39 % took calcium tablets (5 % of Chinese and 1.5 % of Philippines). Half of the women in China and the Philippines groups reported using iodized salt. The question on consumption of iodized salt was not asked in Lebanon as iodized salt is universally available to the target group.
The BMI range for Lebanon was 15–45, for the Philippines 12–41 and for the Chinese group 13–57. Very few women in the Philippines and China used tobacco (1.8 and 0.7 % respectively) while in Lebanon, almost 13 % used cigarettes and over 25 % used shisha (hubble-bubble). However, with regard to alcohol, 17 % of Chinese women and 9 % of Philippines women in the study reported consuming alcohol, versus only 0.2 % of the Lebanese women. The Lebanese study population does not customarily consume alcohol.
Fewer than 3 % of all women had been screened for HIV or other STIs; 5 % of Chinese, 6 % of Lebanese and 15 % of Philippines women reported intestinal parasites; 4 % of Lebanese and 9 % of Philippines groups had periodontal disease. Less than 1 % of Chinese and Philippines women and 2 % of Lebanese women reported any other infectious disease.
Chronic Medical Conditions
In the Chinese and Philippines groups 1–2 % of women had diabetes, hypothyroidism, seizure disorder, rheumatoid arthritis, heart disease, blood disorders or other chronic medical conditions. Approximately 4 % the Lebanese group had diabetes, hypertension, or hypothyroidism and approximately 5 % of women in the Philippines group had hypertension. However, over 9 % in the Lebanese, 6 % in the Philippines and 4 % in the Chinese group suffered from anemia.
About 1 % of the Chinese group reported experiencing a stressful family life and fewer yet reported treatment for depression, or a stressful family life that included physical violence. In Lebanon, approximately 3 % of the women were being treated for depression and reported a stressful family life; less than 0.5 % reported physical violence in the family. For the Philippines group, less than 0.3 % of women were being treated for depression. However, almost 21 % reported a stressful family life, with 2 % reporting physical violence. The higher reporting rate for stress among these women correlates with higher rates of physical violence and also with larger households.
As noted earlier, the women included in the study had attained a high level of education. Approximately 50 % had an educational level above secondary school; of the remainder, approximately 30 % had completed secondary school, and fewer than 1 % were illiterate. The Lebanese group was predominately urban (83 %) while 52 % of the Chinese and 37 % of the Philippines women lived in an urban setting. The median number of people in the household ranged from 3 in Lebanon to 5 in China and the Philippines. However the range was 2–8 in China, 1–10 in Lebanon and 1–25 in the Philippines.
A gap existed between the percentage of women not contemplating a pregnancy in the next year and the percentage (lower) using modern contraceptives, yet the size of the gap varied between countries, being in China 9.9 % and in Lebanon 23.3 %. For the Philippines the gap is likely considerably higher, as only 14.3 % of the women reported using modern contraceptives. However, for reasons noted above, we were unable to collect data on pregnancy planning for the Philippines groups.
With the exception of data from Lebanon, immunization coverage averaged <70 % for MMR, Tetanus and Hepatitis B vaccination. Micronutrient supplementation usage, and use of iodized salt, averaged lower than 60 %.
Levels of screening for HIV were low, as were reported STI prevalence rates.
While the burden of chronic conditions was low in the study population, data indicate that anemia is an important problem.
Following global trends, we found evidence of both under- and over-weight within the populations in all three countries.
The data also point to differences in health care access, attitudes and practice in women’s health and childbearing, and policies regarding health care provision between the Chinese, Lebanese and Philippines groups. Specifically, the differences include the variation in modern contraception use, with relatively low uptake in the Philippines; the differences between Chinese and other women in terms of numbers of children and numbers of abortions; the difference between Lebanese and other women in percentage of consanguineous marriages and also in use of tobacco; and the higher levels of stress reportedly experienced by women in the Philippines group. Any application of a preconception checklist tool would need to be sensitive to cultural variation and differing social realities among groups of women across countries, and also in many cases, within a single country.
The study helped to raise awareness in each of the three countries regarding the importance of preconception care and women’s and preconception health risk factors. Preconception health education projects were carried out in all three countries in tandem with the study. In Lebanon, project collaborators implemented school-based education of adolescents about healthy behaviors and preconception health. This project reached approximately 7,000 students in 2011–2012. In China and the Philippines, youth groups affiliated with the project held a number of health fairs and education sessions for groups of young adults.
The study was a pilot limited in scope and funding, with the result that the preconception checklist tool was implemented with minimal pre-testing. We found that the tool had several limitations. Suggestions for modifications are included in Table 1. Specifically, the tool included a question allowing for calculation of reproductive spacing. However, the question needs to be reformulated. Rather than ask for the birthdate of each child, as was done in the study, a simple and reliable method would be to ask for each child’s age. To facilitate analysis of reproductive outcomes by total births, a question should have been added to the tool asking total parity for each woman. A question on total parity would allow for the creation of a denominator with which to measure reproductive outcomes such as birth defects per number of births for the study group. Finally, interviewing clinicians in some cases found the tool difficult and/or time consuming to administer.
The data represent the preconception health of particular groups of women and cannot be generalized to the country level. A much larger and more diverse sample of women would be necessary to produce country-level data. Weaknesses notwithstanding, the results of the pilot study indicate that the use of a preconception checklist tool is a promising approach to developing data on preconception health that is applicable to other countries. The checklist presented here can serve as a sample tool for lower and middle income countries. Specific questions, such as those on genetics, can be modified to address genetic conditions of concern for a particular target group. One significant challenge is to reach women with the tool during the preconception or interconception period. The study aimed to overcome this challenge through implementation of the tool in workplaces and in clinics were women brought their children in for care.
As attention to recommendations for preconception health interventions in lower and middle income countries increases, better data on the health of specific groups of women and adolescents is needed. The study demonstrates the usefulness of one approach to collection of data on the preconception health of target groups of women. The tool can be adapted for use in a variety of settings and target groups as defined by standard public health criteria such as age, residence, and socio-economic status; and for specific high-risk groups. The tool is likely to be particularly useful for adolescent girls and for women with poor nutritional status, lack of access to preventive care, and/or with behavioral risk factors. It may be especially useful for women between pregnancies who have had a poor prior pregnancy outcome. Applied at the country or provincial level, aggregated data from the checklist tool could be used to raise awareness among policymakers and health care planners of the need to improve preconception health care, and to identify specific interventions that should be included in programs to improve the health of women and adolescent girls.
The authors would like to acknowledge the financial support of the March of Dimes Foundation for the project. Dr. Padilla would like to acknowledge the contribution of Aster Lynn Sur and Ariel Lescano in data collection and analysis in the Philippines. Dr. Zhong would like to acknowledge the contribution of Drs. Lixia Zhang, Fengying Ma and Xiaoyan He for their role in data collection and analysis in China. Each was supported through funding from the March of Dimes Foundation grant for the project. Dr Yunis acknowledges the assistance of his team at the National Collaborative Perinatal Neonatal Network and the Lebanese Obstetrics Society.