STRENGTHS AND LIMITATIONS OF THIS STUDY

The review provided the first meta-analysis of association of preconception care with previous use of family planning and prior adverse birth outcomes.

This review provides insight to policymakers and other stakeholders to consider expanding and integrating preconception care with family planning services areas.

The findings of this review could not ensure the certainty of evidence due to the cross-sectional nature of the included studies.

The study did not conduct subgroup analysis due to lack of possibility to split the data into subgroups, or for subsets of studies.

Introduction

Preconception care is the provision of behavioural, social and biomedical health interventions to women and couples between pregnancies and before conception that aims at reducing poor maternal and child health outcomes.1–3 The recommended package of interventions for preconception care includes maternal nutrition such as iron, folic acids and other micronutrient supplementation, vaccination, sexuality education, prevention of interpersonal violence, support for mental health, cessation of tobacco and excessive alcohol use and protection from environmental hazards.4–6 Preconception care is recognised as an important strategy to improve both maternal and child health outcomes and create an opportunity for promoting appropriate preparation for pregnancy and practice healthy pregnancy.7–9

Though the WHO acknowledges the feasibility of preconception care in low-income and middle-income countries,2 10 it has not been effectively implemented in African countries. For instance, a recent systematic review and meta-analysis showed that the overall utilisation of preconception care in Africa was low at 18.72%.11 Similarly, a recent review in sub-Saharan Africa (SSA) found that the pooled utilisation of preconception care was low at 24.05%.12 Furthermore, a systematic review and meta-analysis in Ethiopia has found that the utilisation of preconception care among reproductive-age women was 16.27%.13

Despite the existence of recommendations, the provision of preconception care has not been effectively integrated into the existing healthcare system.14 Recent evidence highlights the need for system-level support and training for healthcare professionals who can provide the service for effective implementation of preconception care.15 A systematic scoping review in SSA indicated that HIV testing, counselling and family planning, while preconception folic acid supplementation were most identified preconception care interventions; but still underused.16

Short pregnancy and birth intervals are associated with high levels of adverse birth outcomes and infant mortality.17 18 Hence, addressing adverse birth outcomes necessitates an approach that includes preconception care and the utilisation of family planning.18 19 Furthermore, using family planning can reduce the effects of both short interpregnancy intervals and long intervals on the occurrence of adverse birth outcomes.20 21 Moreover, evidence has been identified that clinical interventions offered before conception could prevent adverse pregnancy outcomes.22 Preconception care provides women an opportunity for family planning or reducing the risk of adverse health outcomes for the woman, fetus and neonates.23 24 While women are expected to receive information about preconception care during family planning services,15 25 there is a lack of conclusive evidence regarding the association between previous family planning use and the utilisation of preconception care in Ethiopia. Furthermore, there is limited strong evidence indicating whether women who have experienced adverse birth outcomes in their last pregnancy would use preconception care to prevent complications in their future pregnancies in Ethiopia.

Existing reviews have shown that women’s knowledge of preconception care, pregnancy intention and pre-existing medical condition was found to be significantly associated with increased utilisation of preconception care.11 12 In addition, a recent meta-analysis conducted in Ethiopia has found that utilisation of family planning had a positive impact on women’s knowledge of preconception care.26 However, inconsistent findings on the associations of preconception care with utilisation of family planning and previous adverse birth outcomes have not been systematically reviewed in Ethiopia. Thus, this review aims to estimate the pooled association of preconception care with utilisation of family planning and previous adverse birth outcomes in Ethiopia. Routine implementation of evidence-based interventions will be fully realised the intended benefits of the preconception care in promoting optimal pregnancies.22 27 Hence, this review will provide strong evidence on the integration of preconception care with other existing maternal healthcare interventions mainly family planning.

Methods

The review has been published with the International Prospective Register of Systematic Reviews (PROSPERO) with registration Identifier CRD42023443855. The updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist28 is used to prepare and report the review (online supplemental file 1).

Eligibility criteria

Observational studies that reported preconception care as an outcome variable and the use of family planning before pregnancy or previous adverse birth outcomes as exposure variables were considered. Studies that reported the ORs with 95% CIs or available raw data to calculate the ORs with 95% CIs for the explanatory variables were also included. Furthermore, studies conducted among reproductive-aged women in Ethiopia were considered. Moreover, articles written or published in English without publication date restriction were included.

Studies that did not report the OR for explanatory variables or had no data to calculate the ORs with 95% CIs were excluded. In addition, qualitative studies, reviews, conference abstracts, commentaries and editorial reports were excluded from the study.

Information sources and search strategy

The searching keywords were prepared based on the following concepts: preconception care, family planning, birth outcome and Ethiopia. The Medical Subject Headings and free text keywords with Boolean operators, truncation and phrases were used during literature searching. Articles search was conducted in MEDLINE Complete, CINAHL Complete, Scopus and Global Health from inception to 28 July 2023. Furthermore, bibliographies of identified articles were reviewed in Google Scholar for additional potentially relevant studies. Initially, the search plan was established in EBSCOhost MEDLINE and then used for other databases with modification. The searching strategy for each database is provided as online supplemental file 2.

Study selection

All identified records were exported to Covidence (Veritas Health Innovation, Melbourne, VIC, Australia) systematic review software to manage the screening process. Two reviewers (BDM and SST) conducted article screening based on title and abstract following the removal of duplicates. Then full-text review was done for those studies deemed relevant to full-text screening.28 The PRISMA 2020 flow diagram is used for study screening and selection processes.

Data extraction

Two reviewers (BDM and SST) separately extracted important data from each selected study using Microsoft Excel spreadsheet. From each primary study, first author, study period, year of publication, study population, study setting and design, sample size, number of women who received preconception care with respect to each explanatory variable and OR or raw data to calculate OR for previous use of family planning and prior adverse birth outcome were extracted.

Assessment of risk of bias

The Joanna Briggs Institute critical appraisal checklist adapted for analytical cross-sectional studies was used for assessing the quality of included studies.29 Two reviewers (BDM and SST) individually evaluated the quality of each study with any disagreements or unclear information was resolved through discussion. Studies were evaluated mainly on the following elements: study objectives, adequacy of sample size, addressing the target population, data collection methods, data collection tools, definition of the variables, adequacy of response rate and appropriateness of statistical analysis. Studies were rated from 0 to an overall score of 8 (online supplemental file 3).

Outcome

The main outcome of this review was to determine the associations of preconception care with use of family planning and prior adverse birth outcome in Ethiopia. In the primary studies, the preconception care utilisation was considered if women received any of the components of preconception care interventions either lifestyle modification, advice or treatment at least once before being pregnant. In the original studies, women have asked “Have you ever used any contraceptive prior to your last pregnancy?” Use of family planning was considered if women’s response was ‘Yes’ or no history of family planning if the response was ‘No’. In the primary studies, prior adverse birth outcome was considered when a woman reported at least one of the following: stillbirth, preterm birth, low birth weight and congenital malformation.

Data analysis

The ORs with the 95% CIs for each explanatory variable were extracted from the included original studies. The ORs with the 95% CIs were also calculated from available raw data by creating a 2 by 2 table for those studies which did not report. We executed the meta-analysis using Stata V.18 statistical software with all statistical significance level considered at p value ≤0.05. Cochran’s Q-statistic was used to assess potential heterogeneity to be quantified with the I2 value. A fixed-effects model was used to estimate the association between preconception care and prior adverse birth outcomes. Similarly, a fixed-effects model was used to determine the pooled association between preconception care and previous use of family planning though significant heterogeneity was detected across the included studies. In this analysis, a fixed-effects model was chosen over a random-effects model due to the small sample size, making it inappropriate to perform the random-effects model. Although heterogeneity was detected, the precision in estimating variability in studies is limited.30 31 Sensitivity analysis was done to detect the influence of a single study on the overall meta-analysis estimates.

Patient and public involvement

None.

ResultsStudy selection

The databases and other sources produced a total of 179 records. After removing 66 duplicates, 88 articles were removed during titles and abstracts screening. Eight studies were included in the review after the exclusion of 17 articles in the full-text review (figure 1).

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the studies screening process.

Studies characteristics

In this review, five community-based cross-sectional and three facility-based cross-sectional studies published between 2019 and 2022 were included. From an estimated 3911 sample size, a total of 3829 participants were involved in the included studies. All the included studies collected data via face-to-face interview using simple random sampling,32 systematic random sampling,33–35 multistage random sampling36–38 and convenience sampling39 methods. In terms of study region, two studies were done in Amhara, two in Southern Nations, Nationalities and Peoples, two in Addis Ababa, one in Oromia and one in the Tigray region. Of the included studies in the review, four studies were scored 8 out of 8 points (table 1).

Table 1

Summary of included studies for the review of the associations between preconception care and family planning and previous adverse birth outcomes in Ethiopia, 202339

The association between preconception care and previous family planning use

Six studies involving 2724 participants assessed the associations between preconception care and previous family planning use. The pooled analysis found that use of family planning before current pregnancy had a positive statistical association with increased utilisation of preconception care. Women who had a history of family planning use were 2.09 times (OR 2.67, 95% CI 1.74 to 2.52) more likely to use preconception care than their counterparts (figure 2).

Figure 2

Forest plot of the association between previous use of family planning and preconception care in Ethiopia, 2023.39

The association between preconception care and prior adverse birth outcomes

Six studies involving 2838 participants assessed the associations between preconception care and prior adverse birth outcomes. The pooled analysis found that prior adverse birth outcomes had a positive association with the utilisation of preconception care. Women who had prior adverse birth outcome were 3.38 times (OR 3.38, 95% CI 1.06 to 10.74) more likely to use preconception care than their counterparts (figure 3).

Figure 3

Forest plot of the association between prior adverse birth outcome and preconception care in Ethiopia, 2023.39

Sensitivity analysis

Leave-one-out meta-analysis was done for the analysis of the association between previous use of family planning and preconception care using a fixed-effects model. Accordingly, the result indicated no influence of one study on the overall meta-analysis estimates (online supplemental table 1). Further sensitivity analysis was conducted by excluding one study with a particularly large observation. The analysis results indicated that the study with a particularly large observation did not significantly influence the overall statistical significance of the effect size (online supplemental figure 1). Although there were some differences in the effect size, we chose not to exclude the study with a large observation as it did not impact the overall statistical significance of the effect size.

Discussion

This review evaluated the associations between preconception care and previous use of family planning and prior adverse birth outcomes using available data in Ethiopia. Some of the studies included in the review reported statistically significant associations between preconception care and previous use of family planning and between preconception care and prior adverse birth outcomes. Further, the pooled estimate of the meta-analysis showed that previous use of family planning and prior adverse birth outcomes had a significant positive association with preconception care. The findings could imply the importance of integrating preconception care with other maternity care services.

The results of this review showed that women with a history of family planning use had a higher likelihood of using preconception care than those women who did not use family planning before their current pregnancy. This finding infers the need of strengthening preconception care services integration with other maternal healthcare services including family planning to improve the utilisation of preconception care. The WHO recommendation and other preconception care strategies supported this implication that family planning services could be included in the selected preconception care interventions that are currently being implemented to reach specific groups in the population.40–42

The review also showed that women with prior adverse birth outcome had a higher chance of using preconception care than women with no history of prior adverse birth outcomes. The reason could be that women who experienced prior adverse birth outcomes may tend to seek healthcare professional support before being pregnant to avoid further adverse birth outcomes in their subsequent pregnancies. This could create an opportunity for woman to get psychological support and medical treatment to minimise further risk of adverse birth outcomes in their subsequent pregnancies. Evidence has shown that the preconception period is a window of opportunity where interventions could have a significant impact on reducing adverse birth and health outcomes.43 44

The positive association of preconception care with previous use of family planning and prior adverse birth outcomes has public health implications. These results provide insight to policymakers and other relevant stakeholders to consider expanding and integrating preconception care with all family planning services areas including private clinics and community pharmacies. Literature has shown that community pharmacists have demonstrated provision of preconception care contraceptive services.45 46 In Ethiopia, healthcare facilities do not have well-established preconception care units, which are designated spaces for women to receive care before becoming pregnant. Hence, integrating preconception care with other service units, such as family planning, antenatal care, postabortion care and adolescent and youth-friendly services, would be more beneficial. The findings also would indicate healthcare providers to give emphasis for early screening and treatment support for women who had prior adverse birth outcomes to minimise further adverse pregnancy outcomes.

Limitation

The review provided the first meta-analysis of the association of preconception care with previous use of family planning and prior adverse birth outcomes. The first limitation of the review is lack of certainty in causal conclusion on the association of preconception care with previous use of family planning and prior adverse birth outcomes due to the cross-sectional nature of included studies. Second, though heterogeneity was observed in the analysis of the association between previous use of family planning and preconception care, meta-regression was not conducted due to fewer number of included studies. Furthermore, subgroup analysis was not conducted due to lack of possibility to split the data into subgroups, or for subsets of studies. Third, publication bias assessment was not conducted due to the limited number of studies included in the meta-analysis, which may compromise the reliability of the results.47 Finally, we could not discuss the findings compared with existing evidence because of the lack of comparable studies in the study country and worldwide.

Conclusions

This review indicated that utilisation of preconception care had positive association with previous use of family planning and prior adverse birth outcomes. Thus, policymakers and other relevant stakeholders should strengthen the integration of preconception care with family planning and other maternal healthcare services. Moreover, healthcare providers should prioritise women who have had prior adverse birth outcomes to minimise further adverse pregnancy outcomes.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

Not applicable.