Health prior to conception can significantly impact offspring health, however, a clear definition of the attributes of the preconception population is currently lacking. We aimed to use existing literature to explore the concept and attributes of a preconception population by: [1] identifying characteristics and research recruitment methods; and [2] generating an attribute-based working definition of a preconception population.
Adopting these perspectives may allow researchers to accurately define, identify and recruit preconception populations and to develop interventions that are appropriately broad or tailored depending on population needs. We hope the definitions will facilitate research with this population and will subsequently improve the wellbeing of preconception men and women, which is essential to ensuring the health of future generations.
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Preconception health is critically important to promote favourable maternal and infant outcomes in both the short- and long-term. Adverse lifestyle factors and unhealthy weight status prior to pregnancy are now recognised as important factors associated with reduced fertility [1], excessive gestational weight gain [2], postpartum weight retention, and high long-term weight status in both mothers and offspring [3]. Furthermore, the preconception period is considered a unique opportunity for the reduction of risk factors linked with non-communicable diseases in offspring [4]. Mechanisms by which maternal preconception health can impact offspring health include epigenetic alterations to gene expression occurring soon after conception [5], via poorer pregnancy outcomes associated with maternal over- or undernutrition [5], or via environmental and social impacts [6].
With this issue in mind, the 2018 Lancet series on preconception health posited three perspectives upon which to conceptualise the preconception period [15]. These were: [1] the biological perspective, encompassing the days to weeks before embryo development [2]; the individual perspective, which includes a conscious intention to conceive, and is typically weeks to months before pregnancy; and [3] the public health perspective, which occurs over the longer period of months to years with the goal to address preconception risk factors. These definitions provide a useful, evidence-based framework to identify critical preconception time points, as well as upon which to target various individual and public health initiatives to improve preconception health outcomes. However, they do not go so far as to identify the specific attributes of potential preconception populations.
Studies were required to: [1] recruit participants (men and/or women) for primary research during the preconception period (not pregnant at recruitment) [2]; refer to the population as preconception (or related term e.g. pregnancy planning) in the title or abstract [3]; provide clear detail about the characteristics of the recruited population [4]; involve humans; and [5] be peer-reviewed and published in English between 2008 and 2018.
Data were extracted by two authors (BH and SC) using a piloted data extraction form which included study aim, explicit and implicit definitions of preconception, participant inclusion and exclusion criteria, participant characteristics, and recruitment methods. Where available, protocol papers or other publications relating to the same study were checked for additional recruitment information. The findings summarised in the data extraction tables were synthesised narratively to create a profile of the characteristics of preconception populations and recruitment methods employed in the included studies.
Two authors (BH and SC) independently extracted data relating to the eight steps from all papers identified as eligible in Stages 1 and 2. Subsequently, the authors collaboratively generated a summary of the concept analysis findings, and using the concept analysis methodology, developed a reflective, literature-informed definition of a preconception population.
Three defining attributes were present for all cases of preconception participants. These were (1) reproductive age; (2) man or woman; (3) woman or partner were not pregnant. These attributes were encompassed across the literaturee.g.,11,40 and include the majority of the adult population, therefore we broke this down into four definitions where more specific attributes could be applied (see Fig. 2). Firstly, the public health preconception perspective includes the three defining attributes described above, but includes only individuals who are not sexually active. The potential preconception perspective includes three of the four defining attributes in the public health perspective (reproductive age, man/woman, not pregnant), however, the criteria for not being sexually active is changed to include only individuals who are sexually active, including those who partake in intercourse without using effective contraception or who experience contraceptive failure. This encompasses men or women who may go on to experience unplanned pregnancies. The intentional preconception perspective includes the four potential preconception population defining attributes, plus a conscious decision to conceive and/or an element of pregnancy planning. In this way, the intentional perspective focuses on women or men with pregnancy intentions, whether or not specific behavioural changes have been made towards preparing for pregnancy. The life course perspective recognises that preconception health can be addressed throughout the life course by targeting populations that do not meet the criteria for the other definitions, for example adolescents or pregnant women. One final approach should be considered that is cross-cutting across the other perspectives; a systems approach to addressing preconception health is essential to support activities across all other perspectives and includes adequate policies and guidelines regarding lifestyle and health; these were reflected in many of the included documents. All of these perspectives apply equally to men and women, to same sex couples and to solo mothers by choice.
The public health preconception perspective provides a broad and encompassing definition of a preconception population, which would be most suited to population wide research. Despite variation in participant demographic characteristics and recruitment methods, the majority of included studies defined their preconception populations as reproductive-aged. Interestingly, there was little consideration of males. This is noteworthy given the biological and psychological influence men can have on the health of a pregnancy and child [47, 48]. Furthermore, while the literature was focused on women, and to a lesser extent men, this definition can include other gender identities that are capable of supporting reproduction through provision or donation of egg or sperm. The public health preconception definition would facilitate large, population level research and subsequent, long-term health promotion interventions that captures individuals who do not consider preconception an important life phase to them [15]. We decided to limit our public health perspective to the four defining attributes of reproductive age, man or woman, not being pregnant, and not sexually active. This differs from Stephenson et al. [15] who posit that the public health perspective captures other sensitive phases of the life course such as adolescence. Our life course perspective captures these populations.
The intentional preconception perspective is identifiable by the addition of the conscious decision to conceive and/or pregnancy planning activities. This is perhaps the most recognisable definition of a preconception population, as was evident in the types of studies that were identified in the search. In many cases, individuals planning pregnancy seek out preconception care of their own volition and may be more likely to engage in healthy behaviours or cessation of unhealthy behaviours (e.g., smoking [54]). Pregnancy planners may be easier to target for research and intervention.
The life course preconception perspective is also important to consider. Specifically, the other three perspectives do not fully capture the breadth of preconception populations and the strategies needed to reach individuals on the periphery. The primary studies included in this concept analysis did not address this broader perspective, which incorporates a systems approach to addressing preconception health, as well as targeting individual behaviour change at life phases that are not captured elsewhere. Systems approaches are widely recognised as essential to achieving reductions in adverse public health problems such as smoking and obesity [55, 56] and have also been applied to obesity prevention across the preconception, pregnancy, postpartum, and early life phases [57]. Stephenson et al. highlight that health behaviours may become established before reproductive age and thus one of the challenges of improving preconception health is to reach women and men across the life course [15]. For example, reaching adolescents or those who are newly sexually active will ensure that individuals are targeted as they transition into a preconception population. We also acknowledge that the systems approach can and should be applied across all of the preconception definitions identified.
An important limitation to consider is that this concept analysis is the first attempt to ascribe attributes to preconception populations. Consequently, these definitions require refinement and attention to additional perspectives beyond what are available in the published literature. This includes the views of experts in the field, including researchers, practitioners, policy makers, and consumers/public. The next planned step is to conduct a consensus development exercise to make sense of these definitions in the real world.
We propose definitions of preconception populations across life course, public health, potential, and intentional preconception perspectives. They consider the attributes of men and women who may be classified as being preconception, e.g. planning pregnancy, as well as those who may not identify as preconception, e.g. those using contraception. Adopting these definitions will allow researchers to accurately identify and recruit their target preconception populations and to develop interventions that are appropriately broad or tailored depending on population needs. In addition to using these proposed attribute-based definitions to recruit appropriate preconception research populations, they can be considered alongside the definitions proposed by Stephenson et al. for broader public health and health promotion purposes [15]. Governing bodies should ensure that appropriate policies, guidelines and directives consider all preconception perspectives to ensure that key or vulnerable populations are not missed. Importantly, reaching preconception populations may require approaches that overlap across these perspectives. The definitions of preconception populations described will make it easier to understand, reach and improve the wellbeing of preconception individuals, which is essential to promoting general health, facilitating healthy pregnancies, and ensuring the health and wellbeing of future generations. 2ff7e9595c
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