Setting research priorities for preconception care in low- and middle -income countries: Aiming to reduce maternal and child mortality and morbidity

Preconception care means providing care before pregnancy is established. Women and couples of reproductive age are generally unaware of the effects that their own health conditions and health-related behaviors may have on the fetus during pregnancy. Although antenatal care is set in the maternal, newborn, and child health (MNCH) continuum [1], it neglects the most critical time of embryonic development, which often occurs before a woman even knows she is pregnant [2]. The evidence increasingly points to earlier care before pregnancy to improve women's health, and better pregnancy outcomes for the mother and newborn [3]–[5]. Preconception care may be defined as “any intervention provided to women and couples of childbearing age, regardless of pregnancy status or desire, before pregnancy, to improve health outcomes for women, newborns and children” [3] or “a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management” [4]. For instance, education and awareness about nutritional anemia and congenital malformations can increase receptiveness to and uptake of iron and folic acid supplementation even before pregnancy. The specific aim of preconception care is to improve pregnancy outcomes for mothers and newborns, by optimizing health before a possible pregnancy occurs. Under strict terms, the preconception period may be defined as a minimum of three menstrual cycles prior to the initiation of sexual intercourse, the intent of which is to achieve a wanted and viable pregnancy. An exact “preconception period” has not been standardized by the evidence base; however, since many pregnancies are unplanned, and time to conception for couples varies greatly. We propose that the preconception period be defined as a minimum of one year prior to the initiation of any unprotected sexual intercourse that could possibly result in a pregnancy, reflecting the broader scope of preconception care that extends to adolescents and all women and couples of reproductive age. A systematic review [3] established that there are currently three levels of evidence within the area of preconception care. For some preconception interventions, such as folic acid supplementation to prevent neural tube defects, the evidence base is strong [6], yet even in developed countries less than half of all women regularly consume folic acid supplements around the time of conception [7]. In other areas, such as intervals between pregnancies, the data shows significant risk in terms of excess maternal deaths, higher rates of prematurity and stillbirths, with short inter-pregnancy intervals 8,9; however, strategies to optimize birth spacing and increase contraceptive uptake are lacking [10]. Finally in women's health, violence against girls and women; unsafe abortions; alcohol and tobacco use; and harmful environmental exposures require further substantiation of magnitude of pre-pregnancy risk, and proof that prevention and management as part of preconception care will have greater impact than prenatal care alone. Preconception care has the potential to positively impact 208 million pregnancies worldwide each year [11]. Unfortunately, many adolescent girls and women in low- and middle-income countries (LMICs), which have the highest burden of maternal and childhood mortality (map of global infant mortality [World Bank 2011] http://data.worldbank.org/indicator/SP.DYN.IMRT.IN/countries?display=map and map of maternal mortality worldwide [WHO 2010] http://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html) [12],[13], do not receive the benefits of these interventions, either because they lack access to care or because it is not routinely offered to them before pregnancy. Critical appraisal of the literature review in light of the current global MNCH picture suggests that the greatest benefit would be in these resource-poor countries, and emphasizes the need for implementation strategies and increasing coverage of existing cost-effective preconception interventions. Although present-day funding for global health is previously unparalleled [14] and a substantial proportion of maternal and child deaths in LMICs are preventable with existing interventions [15]–[17], progress in reducing these deaths is far too slow. Perhaps one contributing factor is the bias that remains in health care and research investment—for example, worldwide 7.6 million children died in 2010, equivalent to global deaths due to cancer and slightly higher than deaths due to heart disease [18],[19], yet funding favors breakthrough research for cancer and heart disease, which have high media interest, while implementation research and delivery for maternal and child health is sidelined. The persisting high mortality for mothers and children in LMICs [20],[21], with its repercussions on global MNCH and overall population health and development, represents a continuing failure and challenge. We assembled a group of maternal and child health professionals whose specific goal was to identify and prioritize evidence-based, equitable research investment opportunities for development and increased delivery of effective preconception interventions in LMIC, with the intent of reducing maternal, fetal, newborn, and childhood mortality and severe morbidity.