Scoping review into models of interconception care delivered at well-child visits for the Australian context

Keywords: health promotion, interconception care, maternal and child health care, maternal screening, postpartum care, preconception care, scoping review, well-child visits.

The interconception period is a chance for women and clinicians to focus on a woman’s health behaviours and medical history, assess her mental and physical wellbeing, and optimise birth spacing prior to the next pregnancy (Louis et al. 2019). Interconception care (ICC) involves screening for risk factors such as overweight/obesity and tobacco use, and offering advice and information on folic acid supplementation and contraception (Frayne et al. 2021). ICC models also consider the woman’s previous pregnancies, examining any genetic conditions that may impact future pregnancies, or conditions that arose in past pregnancies, such as gestational diabetes, providing support to manage these into the next pregnancy and beyond (DeCesare et al. 2015).

Regarding birth spacing, there is quality evidence, although the data are beset with issues of confounding, that intervals of 6 months from the birth of one baby to the conception of the next increases the risk of adverse perinatal outcomes including small in size for gestational age, low birthweight, autism, and maternal obesity (Conde-Agudelo et al. 2007; Ball et al. 2014; Cheslack-Postava et al. 2014; Hanley et al. 2017). Consequently, ICC should be offered to women in between their pregnancies to improve their own health outcomes, along with the health of their future pregnancies and future children (Rosener et al. 2016; Louis et al. 2019; Frayne et al. 2021).

Researchers and clinicians have identified that well-child visits (WCVs) (the term we will use in this review) are a potential time for ICC. WCVs focus primarily on health promotion, developmental screening of children, parenting advice and referrals to specialist health services where required (Rossiter et al. 2019). Women are more likely to attend their child’s healthcare appointment than attend to their own postpartum health needs (Rosener et al. 2016; Hartman et al. 2020). WCVs do not routinely provide scheduled or routine assessments of women beyond an initial 6-week postpartum check (Rossiter et al. 2019). Thus, many women do not receive a life-cycle approach to maternal health care and continue to have their healthcare needs siloed (Bell et al. 2018).

The aim of this review is to examine models of ICC delivered at WCVs around the world, looking at the impact ICC has on women’s health and health behaviours, and the acceptability and feasibility of delivering ICC at WCVs as perceived by women and clinicians.

This review followed a scoping review methodology, as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P), which focuses on how to report literature that evaluates healthcare interventions (PRISMA 2021). The review process was informed by guidance from the Joanna Briggs Institute (Peters et al. 2015) and examined the literature around what types of care were included in ICC. The authors searched for cohort studies, randomised control trials and cross-sectional studies examining models of ICC delivered at WCVs published over a 20-year period, between January 2002 and January 2022, in the following academic databases: Medline (OVID); CINAHL (EBSCO); PubMed; and Embase (OVID). We used the following medical subject headings (MeSH) search terms to guide our search: interconception care; women, maternal and child health services; well-child visits; health promotion; and healthy behaviours – see Table 1 for the full list of terms used. Additionally, we conducted key word searches within these databases, and searched the reference lists of relevant articles by hand. All peer-reviewed articles published in English that examined or evaluated a model of ICC delivered at WCVs were imported into Covidence (Veritas Health Innovation Ltd), an online tool to systematically screen citations, abstracts, and full texts for reviews.

Table 1.  Summary of search terms.

Eligible studies for the review had to meet the inclusion criteria. Peer-reviewed publications that conducted clinical studies, such as randomised control trials (RCTs), cohort studies, and cross-sectional studies, were included. Studies were also included if they examined a model of ICC that supported behavioural change in postpartum women; were conducted by registered nurses, registered midwives, or medical doctors; and examined women who had given birth within the last 24 months. Studies were excluded if published >20 years ago; focused only on models of preconception care as we were interested solely in models that addressed care given to women after giving birth, while also considering their family planning needs; were a retrospective study looking at past pregnancies; or were literature reviews, policy papers, commentaries, or qualitative studies.

The titles and abstracts, followed by the full-texts, were screened independently by two authors (MT and KC) in reference to the inclusion and exclusion criteria. If there were any conflicts regarding the eligibility of an article for inclusion, MT and KC would discuss with a third reviewer (KB), who would make the final decision.

As the criterion of a scoping review is to assess the scope of available literature, we did not provide a quality assessment of the research (PRISMA 2021). Instead, once we had determined the relevant articles as per the inclusion and exclusion criteria, we systematically read the articles, applying a narrative analysis to identify key themes from the reviewed manuscripts.

A total of 97 studies were imported into Covidence, with 13 duplicates removed. Eighty-four titles and abstracts were screened in reference to the inclusion and exclusion criteria. Forty-nine studies were excluded. Thirty-five studies were then assessed for full-text eligibility, and from the full-text screen, 15 studies were included in the final review, the details of which can be found in Table 2. Ten studies focused on the impacts of ICC delivered at WCVs, four examined women’s perceptions of co-locating ICC at WCVs, and two examined perceptions of health professionals delivering ICC at WCVs. The included studies were made up of cohort studies, cross-sectional studies, randomised control studies and comparative studies, were all based in either the USA or the Netherlands, and were solely delivered by medical doctors. A PRISMA flow diagram detailing the review process can be found in Fig. 1.

Table 2.  Summary of included study characteristics.

Fig. 1.  Flow diagram for the scoping review.

A narrative analysis was applied to the studies, and the following themes were identified: impact of ICC interventions delivered at WCVs; postpartum women’s perceptions on the acceptability of receiving ICC at WCVs; and health professionals’ perceptions of delivering interconception care at well-child visits.

A total of 11 studies focused on the implementation of interconception models of care at WCVs. Four studies examined the uptake of long-acting reversible contraception (LARC). Two of these found that LARC uptake and use was significantly higher for women who had a co-located visit compared with the control group (Haider et al. 2020; Smith et al. 2021). Women who completed a self-administered Postpartum Questionnaire prior to their WCV were more likely to use a LARC than those in the control group (Caskey et al. 2021). And family planning counselling was provided more frequently when ICC was co-located with WCVs (Frayne et al. 2021). Four studies examined the use of WCVs to deliver postnatal depression (PND) screening, and all found that PND was more frequently detected in women who received repetitive screenings and follow-up care at the WCVs (Chaudron et al. 2004; Sheeder et al. 2009; van der Zee-van den Berg et al. 2017; Frayne et al. 2021). Four studies focused on the effect of education on maternal folic acid use when delivered at WCVs. Two of the studies found that women who received ICC had higher rates of taking multivitamins by their next WCV (Upadhya et al. 2020; DeMarco et al. 2021). Frayne et al. (2021) found an increase in multivitamin counselling delivered by clinicians, whereas de Smit et al. (2015) found little difference in uptake between the intervention and control groups. One study examined the benefits of screening for maternal health risks at WCVs, determining that identifying modifiable risk factors for subsequent pregnancies was feasible during WCVs (Srinivasan et al. 2018). Overall, the 11 studies found that ICC interventions and screening were positive for postpartum women’s health outcomes and health behaviours.

Four studies examined the perceptions of women receiving maternal care at their child’s WCV (Fagan et al. 2009; Kumaraswami et al. 2018; Sijpkens et al. 2019; Haider et al. 2020). All four of these studies found the majority of participants were comfortable discussing contraception at their child’s WCV; were likely to accept the advice given by the child’s health professional; would use a prescription for contraception provided by the health professional; and felt the merging of ICC at their child’s WCV was convenient for their family planning (Fagan et al. 2009; Kumaraswami et al. 2018; Sijpkens et al. 2019; Haider et al. 2020). Sijpkens et al. (2019), however, also found that women were unclear on the benefits ICC would have for them or their child.

Two studies examined the perceptions of WCV health professionals delivering ICC and assessed their attitudes on the feasibility of doing so (Caskey et al. 2016; Sijpkens et al. 2019). The health professionals reported that ICC was important for prevention, family planning and ensuring all women were cared for appropriately (Sijpkens et al. 2019). Clinicians in the study by Caskey et al. (2016) reported they felt comfortable discussing and providing family planning counselling; however, few had done it before. Both studies reported that health professionals working in WCVs did not find it feasible to include models of ICC while already being stretched for time, and reported they feared it would detract time from the child, who remained their top priority (Caskey et al. 2016; Sijpkens et al. 2019).

This scoping review was conducted to assess the current models of ICC delivered in WCVs around the world. Fifteen relevant studies were found to highlight the benefits and possibilities of delivering ICC at WCVs. The research identifies the benefits of ICC on women’s health outcomes and preparation for subsequent pregnancies, specifically the uptake of contraception and prenatal folic acid use. It also shows that women respond positively to the idea of receiving health advice from their child’s health practitioner. The challenges to implementing ICC include clinicians’ lack of time to incorporate the delivery of regular ICC at WCVs; women’s lack of understanding on the benefits of ICC; and disagreement among clinicians about what is involved in ICC. This review highlights that to introduce an in-depth ICC model into WCVs would require additional funding, training, and time for clinicians, but if done effectively, would benefit postpartum women and their future pregnancies and children.

Much research has been conducted on the benefits and importance of preconception health care for women as they prepare for their first or subsequent pregnancy journey. Preconception care is vital for pregnancy success and a key step in improving generational health through a life cycle approach to health and health care (Stephenson et al. 2018). Preconception health care has been found to improve health literacy on risk factors in pregnancy (Mittal et al. 2014; Toivonen et al. 2018; Kandel et al. 2021); improve risky health behaviours, such as tobacco and alcohol use during pregnancy (Shannon et al. 2014); increase folic acid use (Elsinga et al. 2008; Stephenson et al. 2018); and provide counselling on weight loss (Mazza et al. 2013). Despite the multitude of benefits preconception care can provide women, women have low understanding of its benefits, and are unlikely to alter their health behaviours prior to conception or initiate preconception healthcare checks (Barker et al. 2018; Toivonen et al. 2018). The research recommends that preconception care is best provided in routine primary healthcare settings (Johnson et al. 2006; Barker et al. 2018); however, the challenge is that most women do not attend regular primary health care until they are pregnant or have had their child (Stephenson et al. 2018). As a consequence, ICC, delivered at routine WCVs, can align with this recommendation and be used to improve women’s access to models of preconception health care, providing them with interventions to improve their health and health behaviours in preparation for subsequent pregnancies.

However, as identified in this scoping review, there are challenges to the integration of preconception care into WCVs, including a lack of clinician’s time and their perceived capacity to deliver models of ICC to women while also conducting a WCV (Caskey et al. 2016; Sijpkens et al. 2019). WCVs are usually delivered by GPs or specialised child health nurses. In this scoping review, all studies included examined models where the practitioner was a doctor. Additional research examining benefits of task sharing offer a solution to this barrier. Task sharing offers a method to address staff shortages, time constraints faced by clinicians and improve access to care (WHO 2017). Task sharing is intended to create a more equitable distribution of labour between health workers, and thus suits the delivery of ICC and WCVs, as it can broaden the scope of who delivers the model of care to women (WHO 2017). Providing training on ICC to a wider scope of clinicians, such as nurses and midwives, would see benefits for both women and clinician’s interconception health literacy, reduce the chances of women continuing to practice risky health behaviours in future pregnancies, and address the barrier of time for current clinicians delivering ICC (Kizirian et al. 2019; Dorney et al. 2021; Walker et al. 2021). The key to successfully introducing task sharing into the interconception period is providing education and training to clinicians (Price and Reichert 2017). Ensuring the health literacy of the clinical workforce will aid in improving the health literacy of women and men preparing for conception.

The findings from this review show ICC co-located and delivered at WCVs improves the uptake of healthy behaviours in women, and it shows that women are comfortable to receive co-located care; however, time, funding and social attitudes challenge the delivery and uptake of the service. Johnson et al. (2006) published their recommendations to improve the delivery of preconception health care, which is closely linked to the delivery of ICC, and they suggested 10 recommendations to address the gap between need and delivery. Primarily their recommendations point to enhancing the health literacy of all people on the importance of pre-pregnancy health checks; promoting the idea that the responsibility lies with individuals; utilising postpartum visits to deliver ICC; and creating public health programs and strategies to promote the importance and means to access it (Johnson et al. 2006).

The recommendations from both this review and that of broader literature, and the importance of preconception and interconception health care on women and children’s life cycle of health, reinforces the importance of finding a method to make this model of care accessible to all women and deliverable by clinicians. In implementing this, it would be crucial to increase health literacy around interconception care. Practice change may be enabled with incentives for clinicians delivering the care.

This scoping review was guided by PRISMA-P guidelines and a protocol reviewed by the whole research team. Each publication was reviewed by two independent reviewers who met regularly with a third independent reviewer to resolve conflicts. This review used a bibliographic manager (EndNote 2.0; Clarivate) to ensure that all articles were accounted for during the process. This scoping review has some limitations that need to be acknowledged. First, it only included papers published in English, which may have excluded some relevant studies. Second, due to the nature of scoping reviews, the quality of the individual studies was not assessed. Third, the studies included in this review were from high-income countries; therefore, findings cannot be extrapolated to all economic experiences. Finally, the studies examined provided little evidence into long-term impacts of ICC on women and children, and did not address health behaviours such as obesity and tobacco use. Despite these limitations, this scoping review highlights the benefits of delivering ICC at WCVs on maternal outcomes and explored the barriers to implementation and how these may be addressed.

ICC is associated with improving maternal and infant health outcomes in the peri- and post-partum periods and beyond. Co-locating ICC services with WCVs offers an opportunity for healthcare providers to deliver holistic care that will impact positively on a woman, her child, and any future pregnancies and children she may have. This review identified that ICC can increase use of contraception, increase folic acid use, and improve detection of postpartum depression symptoms; it also determined that women were happy to receive co-located care with their children, but that clinicians did not have the capacity to deliver it successfully. Any ICC model developed should consider the barriers of time and scope of practice and responsibility, so targeted training, resource and time allocation will enable implementation.

Data sharing is not applicable as no new data were generated or analysed during this study.

The authors declare no conflicts of interest.

This research did not receive any specific funding.