Michele Stranger Hunter
Dr Jonathan Sher
Lisa Lyte
QNIS’ Healthier Pregnancies, Better Lives programme (@HPBL_Scot) began in 2021 with support from the National Lottery Community Fund and Cattanach. Two surveys were conducted during Year 1, providing responses from an illustrative sample of Scotland’s community nurses and midwives.
The results of the first survey about FASD were shared across four blogs on the QNIS website, which you can read HERE. The second survey took place in April 2022 and focused on preconception and interconception health, education and care. It sought to understand what community nurses and midwives throughout Scotland know and do during the time before a first or subsequent pregnancy, which is the opportunity for preconception assistance.
This is the second blog in the series, you can read the other blogs here:
- Mind the Gap
- Preconception Health Risks and Realities (you’re already here)
- Your Views and Experiences
- What Respondents Want to Happen Next
Our society tends to think and act as if there are only two phases in reproductive health – avoiding pregnancy or being pregnant. Yet, there is a crucial middle period between contraception and conception. It is at this point that preparing well for pregnancy can best occur.
This committed community of Scottish healthcare professionals took time to help us learn from their knowledge and lived experience of providing information, advice and services to people of reproductive age. We are grateful to them.
An overview of the characteristics of the 212 respondents can be found HERE.
Knowledge about Preconception Health
The primary goal of the Healthier Pregnancies, Better Lives programme is to help those who hope to become parents to achieve what every birth parent wants; a safe pregnancy, a healthy baby and a thriving family.
The first set of questions in the survey explored the most important factors that contribute to a healthy pregnancy and delivery. Taken together, the answers reflected a knowledge base, illuminating what is known, and not known, among these practitioners.
Although the invitation to participate in this survey highlighted practitioners who work with people of reproductive age, any community nurse or midwife in Scotland could have responded. Health visitors and midwives were the two most common professions to respond.
Nonetheless, it became clear that having reproductive age people in one’s practice did not automatically translate into extensive knowledge about key issues in preconception/interconception health, education and care.
The survey results revealed significant gaps in preconception and interconception training and misconceptions around some core realties. This reflects the fact that preconception/interconception topics are generally not emphasised in pre-service education or continuing professional development. The findings revealed the need for a preconception and interconception education campaign across the board. This would include relevant courses for students, changes in curricula, in-service opportunities, and media coverage of topics essential to help prepare for pregnancy.
For instance, Question 5 in this survey asked whether the following statement is true or false: “As long as folic acid (vitamin B9) supplements are started daily after the first antenatal appointment, most Neural Tube Defects (NTDs) can be prevented.” The correct answer is ‘False’.
And yet, 45% of survey respondents answered the question about the timing of folic acid supplementation incorrectly. An additional 17% were unsure, leaving only 38% of survey respondents answering correctly.
The neural tube (which becomes the brain, spinal cord and central nervous system) is formed, or malformed, by the end of the fourth week of pregnancy. Most individuals don’t even know they are pregnant that early. Research has consistently shown that reproductive age women have low blood folate levels prior to pregnancy – too low to prevent NTDs.
Starting to take folic acid supplements after the first antenatal appointment (‘first booking’ usually at 8-12 weeks) has no benefit in preventing life-long, disabilities caused by NTDs, e.g., Spina Bifida. Worse are the even more common consequences of low blood folate levels at conception. These include: miscarriages, stillbirths, neonatal deaths and therapeutic terminations (when an early pregnancy screening reveals an NTD-affected foetus).
Neural Tube Defects represent a classic, compelling example of the necessity to introduce preconception/interconception information, education and care. Blood folate levels cannot be increased overnight. Until fully effective fortification of staple foods is a reality in Scotland and the rest of the UK (as it already is in almost 90 other countries), taking adequate folic acid supplements daily is required for at least a month before conception and continuing during the first trimester.
The connection between folic acid and the prevention of NTDs is not headline news. It was first proven thirty years ago in MRC-funded international research. This MRC Vitamin Study was led by Professor Sir Nicholas Wald (an HPBL Advisor).
Happily, wrong answers to this question and another regarding teratogenic medications (a cause of birth defects) were outliers. Still, they make an important point. Community nurses and midwives can only provide the best possible information, advice and care to individuals/couples prior to pregnancy when they are up-to-date and well-informed themselves.
Clearly, that happens in some areas, but not others. The survey confirmed a solid knowledge base among respondents on other risk factors that are ideally assessed and addressed prior to conception.
What is concerning is that 12% of respondents did not indicate that smoking tobacco, drinking alcohol, and taking illegal drugs present serious risks to a healthy pregnancy and developing fetus. These risks cannot be retroactively eliminated during antenatal care.
Scotland’s community nurses and midwives are dedicated, caring health professionals with high standards for person-centred service delivery. This commitment shows in their candid responses and identifies a lack of updated training in contraception. It also illustrated a widespread absence of adequate education and professional development on preconception and interconception health, education and care.
Through the Healthier Pregnancies, Better Lives programme, QNIS will continue to honour the commitment of these health professionals by hearing and heeding their voices, views and lived experiences. Our aim is to co-develop future resources to provide them with the information and opportunities they want and need to close the gap in understanding of preconception/interconception health, education and care.
In our next blog in this series, we will share the responses to the section of this survey: About Your Views and Your Experiences. Your comments and advice are always welcome.
