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International Journal of Nursing Studies

journal homepage: www.elsevier.com/locate/ijns

Barriers and facilitators to the provision of preconception care by healthcare providers: A systematic review

Joline Goossensa,1, Marjon De Roosea,1, Ann Van Heckea,b, Régine Goemaesa, Sofie Verhaeghea,c,2, Dimitri Beeckmana,d,⁎,2

aUniversity Centre for Nursing & Midwifery, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, UZ 5K3, De Pintelaan 185, B-9000 Ghent, Belgium bNursing Science, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium c VIVES University College, Department Health Care, Wilgenstraat 32, B-8800 Roeselare, Belgium d School of Health Sciences, Faculty of Health & Medical Sciences, Duke of Kent Building, University of Surrey Guildford Surrey, GU2 7XH, United Kingdom

A R T I C L E I N F O

Keywords: Health knowledge, attitudes, practice Health personnel Preconception care Review Socio-Ecological Model (SEM)

A B S T R A C T

Background: Healthcare providers play an important role in providing preconception care to women and men of childbearing age. Yet, the provision of preconception care by healthcare providers remains low. Objectives: To provide an overview of barriers and facilitators at multiple levels that influence the provision of preconception care by healthcare providers. Design: A mixed-methods systematic review. Data sources: PubMed, Web of Science, CINAHL, The Cochrane Library, and EMBASE were systematically searched up to April 27, 2017. The search strategy contained MeSH terms and key words related to pre- conception care and healthcare providers. Reference lists of included studies and systematic reviews on pre- conception care were screened. Review methods: Publications were eligible if they reported on barriers and facilitators influencing the provision of preconception care by healthcare providers. Data were extracted by two independent reviewers using a data extraction form. Barriers and facilitators were organized based on the social ecological model. The methodo- logical quality of included studies was evaluated using the Critical Appraisal Skills Programme Qualitative checklist for qualitative studies, the Quality Assessment Tool for quantitative studies, and the Mixed Methods Appraisal Tool for mixed methods studies. Results: Thirty-one articles were included. Barriers were more reported than facilitators. These were situated at provider level (unfavourable attitude and lack of knowledge of preconception care, not working in the field of obstetrics and gynaecology, lack of clarity on the responsibility for providing preconception care) and client level (not contacting a healthcare provider in the preconception stage, negative attitude, and lack of knowledge of preconception care). Limited resources (lack of time, tools, guidelines, and reimbursement) were frequently reported at the organizational and societal level. Conclusions: Healthcare providers reported more barriers than facilitators to provide preconception care, which might explain why the provision of preconception care is low. To overcome the different client, provider, or- ganizational, and societal barriers, it is necessary to develop and implement multilevel interventions.

What is already known about the topic?

• Healthcare providers play an important role in the uptake of pre- conception care.

• The provision of preconception care is low and offered on an ad hoc basis.

What this paper adds

• There are several barriers and facilitators at client, provider, orga- nizational, and societal level that influence the provision of pre- conception care by healthcare providers.

https://doi.org/10.1016/j.ijnurstu.2018.06.009 Received 8 January 2018; Received in revised form 8 June 2018; Accepted 15 June 2018

⁎ Corresponding author at: De Pintelaan 185, B-9000 Ghent, Belgium.

1 These authors contributed equally to this work and shared the first authorship. 2 These authors contributed equally to this work and shared the last authorship.

E-mail address: [email protected] (D. Beeckman).

International Journal of Nursing Studies 87 (2018) 113–130

0020-7489/ © 2018 Elsevier Ltd. All rights reserved.

T

• Most barriers were situated at client and provider level.

• Lack of clarity on the responsibility for the provision of PCC was one of the most reported barriers in the provision of PCC.

1. Introduction

The improvement of maternal health and the reduction of child mortality remain global health objectives, and are two health targets of the Sustainable Development Goals for 2030 that build on the Millennium Development Goals (United Nations, 2015). Despite a substantial reduction of the global maternal and child mortality be- tween 1990 and 2015, efforts remain necessary to further improve maternal and newborn health, and reduce maternal mortality and preventable deaths of newborns (United Nations, 2015). One strategy towards ending preventable maternal and child mortality could be fo- cusing on preconception care (PCC) as many adverse reproductive outcomes including pregnancy losses, congenital disorders, and low birth weight are associated with preventable preconception risk factors (Johnson et al., 2006; World Health Organization, 2012). Preconcep- tion care can be defined as “the provision of biomedical, behavioural and social health interventions to women and couples before concep- tion occurs, aimed at improving maternal and child health outcomes in both the short and long term” (World Health Organization, 2012, p. 36). PCC is an umbrella term that refers to health promotion, risk as- sessment, and the initiation of interventions to target risk factors with a potential influence on pregnancy outcomes (Johnson et al., 2006). Key domains of PCC include family planning; nutrition and physical ac- tivity; tobacco, alcohol and substance use; occupational and environ- mental exposures; family history and genetic risks; infectious diseases and immunization; medical and psychosocial conditions; and medica- tions (Johnson et al., 2006). Given the potential benefits of PCC to improve pregnancy outcomes, several prominent international organi- zations including the Centers for Disease Control and Prevention (CDC), American College of Obstetricians and Gynecologists (ACOG), and World Health Organization (WHO), recommend PCC for all women and men of childbearing age (Jack et al., 2008; Johnson et al., 2006; World Health Organization, 2012). Nevertheless, the use of PCC remains low in couples who are planning a pregnancy (Stephenson et al., 2014). To illustrate, a UK study of Stephenson et al. (2014) found that 63% of the pregnant women with a planned pregnancy reported to take folic acid before pregnancy, and 48% of the smokers and 41% of the drinkers reduced or stopped before conceiving. In addition, research suggests that only 25%–39% of the couples consulted a healthcare professional before conception (Poels et al., 2017a, 2017b). A systematic review of Poels et al. (2016) revealed several barriers to women’s use of PCC, including lack of awareness and unfamiliarity with the concept of PCC, not fully planning their pregnancy, women’s wish for secrecy, perceived absence of risks, and perceived sufficient knowledge. In addition, sev- eral provider characteristics were identified as possible influencing factors for PCC use, such as provider attitudes and communication with providers (Poels et al., 2016). This suggests that healthcare providers (HCPs) may have an important influence on couples’ use of PCC. Yet, the provision of PCC by HCPs is low with mainly providing PCC on an opportunistically rather than on a routine basis (Shawe et al., 2014).

Given the role of HCPs in promoting and providing PCC, an ex- ploration of associated factors and underlying processes of the provi- sion of PCC is needed. Factors influencing the provision of PCC are often complex due to the multifactorial and multilevel character (Eldredge et al., 2016; McLeroy et al., 1988). Understanding facilitators and barriers to providing PCC is essential as it can inform intervention development and strategies to improve PCC uptake and delivery (Eldredge et al., 2016). A literature review is one of the first steps in the development of these interventions and strategies (Eldredge et al., 2016).

To the authors’ knowledge, only few systematic reviews were con- ducted on the topic of PCC, including a literature review on the

effectiveness of preconception care (Korenbrot et al., 2002), research regarding preconception health behaviours (Toivonen et al., 2017), and factors related to the use of preconception care by women (Delissaint and McKyer, 2011; Poels et al., 2016). Curtis et al. (2006) and Steel et al. (2016) performed a systematic review on clinical practice of HCPs with regard to PCC guidelines, and healthcare professionals’ attitudes and experience of preconception care service delivery, respectively. Our study built on this previous work (Curtis et al., 2006; Steel et al., 2016), and aimed to provide an overview of factors identified as barriers and facilitators at multiple levels that influence the provision of PCC by HCPs.

2. Methods

A mixed-methods systematic review was conducted based on PRISMA guidelines (Moher et al., 2010).

2.1. Search strategy

Five electronic databases were searched for studies published up to April 27, 2017: PubMed, Web of Science (WoS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, and EMBASE. The search strategy was developed based on literature scoping preconception care, and several discussions with methodolo- gical experts. The search strategy consisted of combining MeSH terms and key words for two concepts: “preconception care” AND “healthcare provider” (See Table 1). In order to improve the sensitivity of the search strategy, terms referring to nurses/midwives and physicians (physi- cians, GPs, Obstetricians, gynecologists) were added as synonyms of the concept “healthcare provider”. Reference lists of included studies and systematic reviews on preconception care (Curtis et al., 2006; Steel et al., 2016) were also screened to identify additional studies. Authors of relevant conference abstracts were also contacted to identify addi- tional studies.

Table 1 Search strategy with MeSH terms and key words.

Boolean operator ‘OR’1 Boolean operator ‘OR’1

MeSH Terms Preconception Care AND Health Personnel Nurses Midwifery General Practitioners Physicians

Key words Pre conception* Healthcare Provider* Preconception* Health care Provider* Prepregnan* Healthcare professional* Pre pregnancy Health care professional* Pre-pregnancy Nurse* Periconception* Midwife* Peri conception* Midwives Peri-conception Physician* Before pregnancy Obstetrician* Internatal* Gynaecologist* Interpregnan* Gynecologist* Inter pregnancy General practitioner* Inter-pregnancy Interconception* Inter conception* Inter-conception Pregestation* Pre gestation* Pre-gestation* Intergestation*

1 All the MeSH terms and key words in this column were combined with Boolean operator 'OR'.

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114

2.2. Eligibility criteria

Studies written in English, French, German, and Dutch were in- cluded if they met the following eligibility criteria: (1) Participants: all healthcare providers including physicians, midwives, and nurses; (2) Outcomes: perceived barriers and facilitators to provide PCC in general or one aspect of PCC, such as folic acid supplementation or genetic carrier screening; (3) Design: quantitative, qualitative, and mixed methods research. Quantitative studies were excluded if only de- scriptive statistics were performed. Studies were also excluded if they

only focused on barriers and enablers to implementing a nationwide PCC program, because these might be different from factors related to direct care provision.

2.3. Study selection

Three reviewers (JG, RG, and MD) independently screened a se- lection of titles and abstracts. Differences in assessment were discussed between the reviewers until consensus was reached. In case of dis- agreement between reviewers, a fourth independent reviewer (DB) was

Fig. 1. Decision flowchart for identified studies.

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

115

involved. An interrater agreement of 99.7% between the reviewers on title and abstract screening was obtained. Two reviewers (JG and MD) screened the remaining references and full texts.

2.4. Quality assessment

To assess the methodological quality of the included studies, we used the Critical Appraisal Skills Programme (CASP) Qualitative checklist developed by the Public Health team in Oxford for qualitative studies (Critical Appraisal Skills Programme, 2017; Milne et al., 1995), the Quality Assessment Tool developed by Vyncke et al. (2013) for quantitative studies, and the Mixed Methods Appraisal Tool (MMAT) – version 2011 developed by Pluye et al. (2009) for mixed methods studies. The methodological quality was assessed by one reviewer (MD) and 10% of the articles were double checked by a second reviewer (JG). Differences in assessment between the two reviewers were discussed until consensus was reached. No studies were excluded based on the methodological quality.

2.5. Data extraction and synthesis

Data from each study was extracted by two independent reviewers (MD and JG). A data extraction form was used to extract data, which included study aim, content of PCC provision, study design, country and health setting, data collection methods, study population char- acteristics, and factors associated with providing PCC. The associated factors were classified into barriers (-) and facilitators (+) for the provision of preconception care, and were organized based on the social ecological model (SEM) (McLeroy et al., 1988). The SEM is a theory- based framework for understanding the dynamic and multifaceted in- terplay between individual and environmental factors that impact be- haviours (McLeroy et al., 1988). The SEM acknowledges that individual behaviour is shaped through multilevel factors including the individual, interpersonal, organizational, community, and societal level (McLeroy et al., 1988). In the present study we included four levels of influence: provider (individual characteristics and biologically determined fac- tors), client (women’s and couples’ characteristics, and the character- istics of the provider-client relationship), organizational (policies, formal and informal structures, and rules in healthcare organizations), and societal (local and national laws and policies). Due to heterogeneity in methodology and content of PCC, results were synthesized descrip- tively and no meta-analysis was performed.

3. Results

3.1. Selection of articles

A total of 14,003 records were identified through database searching. Duplicates (n=1969) were excluded. The remaining articles (n=12,034) were screened on title, abstract, and full text respectively, and assessed for eligibility according to the pre-determined selection criteria (n= 117). Twenty-eight articles met all inclusion criteria, and the snowball method added three more articles (Fig. 1).

3.2. Study characteristics

Table 2 presents an overview of the study characteristics, barriers and facilitators influencing the provision of PCC.

All included research articles (n=31) were published in English between 2003 and 2017. This review discussed 17 quantitative studies (including 16 cross-sectional study designs (Abu-Hammad et al., 2008; Baars et al., 2004; Bonham et al., 2010; Burris and Werler, 2011; Heyes et al., 2004; Morgan et al., 2004, 2006; Parker et al., 2010; Poppelaars et al., 2004; Power et al., 2013; Tough et al., 2007, 2004; Tough et al., 2008, 2006; van Voorst et al., 2016; Williams et al., 2006), one trans- verse correlational study design (Miranda et al., 2003), 13 qualitative

studies (Archibald et al., 2016; Bortolus et al., 2017; Chuang et al., 2012; Coll et al., 2016; M’Hamdi et al., 2017; Mazza et al., 2013; McClaren et al., 2008; McPhie et al., 2016; Mortagy et al., 2010; Ojukwu et al., 2016; Poels et al., 2017a, 2017b; Schwarz et al., 2009; Stephenson et al., 2014), and one mixed method design (Fieldwick et al., 2017). The studies were conducted in a variety of settings, in- cluding general / university / public / private hospitals, private prac- tices, and primary care settings in the field of obstetrics and gynae- cology, paediatrics, midwifery, and family practice in particular. The majority of the studies were conducted in the USA (n=10) (Bonham et al., 2010; Burris and Werler, 2011; Chuang et al., 2012; Coll et al., 2016; Morgan et al., 2004, 2006; Parker et al., 2010; Power et al., 2013; Schwarz et al., 2009; Williams et al., 2006), the Netherlands (n=5) (Baars et al., 2004; M’Hamdi et al., 2017; Poels et al., 2017a, 2017b; Poppelaars et al., 2004; van Voorst et al., 2016), Canada (n=4) (Tough et al., 2007, 2004; Tough et al., 2008, 2006), the UK (n=4) (Heyes et al., 2004; Mortagy et al., 2010; Ojukwu et al., 2016; Stephenson et al., 2014), and Australia (n= 4) (Archibald et al., 2016; Mazza et al., 2013; McClaren et al., 2008; McPhie et al., 2016). Sample size, referring to the total number of healthcare providers included, ranged from small-scale studies (n=7) to large-scale studies (n= 2101).

Thirteen publications focused on general PCC (Bortolus et al., 2017; Chuang et al., 2012; Heyes et al., 2004; M’Hamdi et al., 2017; Mazza et al., 2013; Morgan et al., 2006; Ojukwu et al., 2016; Parker et al., 2010; Poels et al., 2017a, 2017b; Power et al., 2013; Stephenson et al., 2014; Tough et al., 2006; van Voorst et al., 2016), six studies on pre- conception genetic screening (e.g. cystic fibrosis carrier screening, fragile X syndrome) (Archibald et al., 2016; Baars et al., 2004; Bonham et al., 2010; McClaren et al., 2008; Morgan et al., 2004; Poppelaars et al., 2004), four studies on preconception folic acid supplementation (and multivitamins) (Abu-Hammad et al., 2008; Burris and Werler, 2011; Miranda et al., 2003; Williams et al., 2006), three studies on preconception alcohol use (e.g. abstinence, foetal alcohol spectrum disorder prevention) (Tough et al., 2007, 2004, 2008; Williams et al., 2006), one study on weight management (McPhie et al., 2016), and one study on teratogenic medications (Schwarz et al., 2009). Few publica- tions focused on PCC in specific subpopulations e.g. women with dia- betes (n=1) (Mortagy et al., 2010), HIV-infected women (n= 1) (Coll et al., 2016), and women suffering from overweight or obesity (n=1) (Fieldwick et al., 2017).

3.3. Methodological quality of the studies included

A summary of the quality assessment of the included quantitative studies is displayed in Supplementary file 1, in Supplementary file 2 for studies with a qualitative approach, and in Supplementary file 3 for mixed methods studies. In general, the overall methodological quality of the quantitative studies was weak to moderate. A considerable risk of selection bias was present in half of these studies. Five studies men- tioned the potential influence of confounding factors (Baars et al., 2004; Bonham et al., 2010; Burris and Werler, 2011; Morgan et al., 2006; Tough et al., 2004). Data collection methods were evaluated as mod- erately valid and/or reliable in only two studies (Baars et al., 2004; Miranda et al., 2003). Few studies reported on power calculation (n= 4), and nine articles did not report on how they handled missing data (Baars et al., 2004; Heyes et al., 2004; Miranda et al., 2003; Morgan et al., 2004, 2006; Poppelaars et al., 2004; Power et al., 2013; Tough et al., 2007; van Voorst et al., 2016). However, in all studies, the main results of statistical analysis were unambiguously reported, the statistical methods were appropriate, and the results-section reported on all outcomes measures mentioned in the method-section.

With regard to the qualitative studies, the articles generally showed good methodological quality. All qualitative studies had a clear state- ment of aims, an appropriate methodology and data collection, an ap- propriate recruitment strategy, a clear statement of findings, and were considered to be valuable research. Nevertheless, in one study (McPhie

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

116

Ta bl e 2

St ud

y ch

ar ac te ri st ic s,

ba rr ie rs

an d fa ci lit at or s in fl ue

nc in g th e pr ov

is io n of

pr ec on

ce pt io n ca re .

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

M ir an

da et

al .

(2 00

3) (1 ) To

ev al ua

te th e kn

ow le dg

e of

pr im

ar y ph

ys ic ia ns

ab ou

t FA

su pp

le m en

ta ti on

fo r th e pr ev

en ti on

of N TD

(2 ) PC

FA su pp

le m en

ta ti on

Tr an

sv er se -

co rr el at io na

l, qu

an ti ta ti ve

(1 ) Pu

er to

R ic o (2 ) O ne

pr iv at e an

d on

e pu

bl ic

ho sp it al

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

66 pr im

ar y ph

ys ic ia ns ;4

2. 2%

fe m al e

A ge :4

6y ±

9. 3

Y ea rs

in pr ac tic

e: /

C li en

t: /

Pr ov

id er :

•L ev

el of

kn ow

le dg

e (+

-) O rg an

iz at io na

l: /

So ci et al : /

Ba ar s et

al .

(2 00

4) (1 ) To

ex am

in e th e op

in io n of

ph ys ic ia ns

on PC

ge ne

ti c te st in g &

to ex am

in e w hi ch

fa ct or s ar e as so ci at ed

w it h a po

si ti ve

op in io n (2 ) PC

C ys ti c

fi br os is

ca rr ie r sc re en

in g

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) th e N et he

rl an

ds (2 )

G en

er al

or un

iv er si ty

ho sp it al

Se lf -a dm

in is te re d va

lid at ed

qu es ti on

na ir e

n =

49 7 pa

ed ia tr ic ia ns , G Ps

gy na

ec ol og

is ts ; 28

% fe m al e

A ge :6

8% ag

ed 40

-5 4y

Y ea rs

in pr ac tic

e: 14

y

C li en

t: /

Pr ov

id er :

•C on

si de

ri ng

th e te st

se ns it iv it y le ss

im po

rt an

t (+

)

•H ig h pe

rc ei ve

d ri sk

of ha

vi ng

a ch

ild w it h C F (+

)

•R ea ss ur an

ce w he

n bo

th pa

rt ne

rs te st

ne ga

ti ve

(+ )

O rg an

iz at io na

l:

•P ro vi di ng

ge ne

ti c co

un se lli ng

in ow

n pr ac ti ce

(+ )

So ci et al : /

H ey

es et

al .

(2 00

4) (1 ) To

de sc ri be

th e cu

rr en

t pr ac ti ce

of PC

C in

Ba rn sl ey

an d to

as se ss

th e

be lie

fs an

d at ti tu de

s of

pr im

ar y

he al th ca re

pr ac ti ti on

er s (2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U K

(2 ) Pr im

ar y ca re

se tt in g

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

), co

ns is ti ng

of cl os ed

- an

d op

en - en

de d qu

es ti on

s

n =

16 3 G Ps ,p

ra ct ic e nu

rs es ,h

ea lt h

vi si to rs

an d m id w iv es ;/

A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•C lie

nt ’s pe

rc ep

ti on

of th e im

po rt an

ce of

PC C (+

-)

•C on

ta ct

w it h pr im

ar y ca re

te am

s af te r co

nc ep

ti on

(- ): un

pl an

ne d pr eg

na nc

ie s (- ), no

co m m un

ic at io n

ab ou

t pr eg

na nc

y pl an

s (- )

Pr ov

id er :

•A tt it ud

e: pr io ri ty

gi ve

n to

PC C (+

-)

•P ro fe ss io na

l re sp on

si bi lit y/

ro le : co

nf us io n ov

er w ho

sh ou

ld de

liv er

PC C (- )

•L ac k of

tr ai ni ng

(- )

O rg an

iz at io na

l:

•L ac k of

re so ur ce s (- ): m on

ey ,s

pa ce ,m

an po

w er ,

ti m e

•A dd

ed w or kl oa

d (- )

So ci et al :

•N ee d fo r ev

id en

ce -b as ed

gu id el in es

•N ee d fo r cl ie nt

in fo rm

at io n

M or ga

n et

al .

(2 00

4) (1 ) To

as se ss

pr ac ti ce s of

O bG

yn s

re ga

rd in g ca rr ie r sc re en

in g fo r C ys ti c

Fi br os is

(2 ) PC

cy st ic

fi br os is

ca rr ie r sc re en

in g

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U SA

(2 ) O bG

yn pr ac ti ce s

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

63 2 O bG

yn s;

42 .4 %

fe m al e

A ge :4 7. 1y

± 0. 39

Y ea rs

in pr ac tic

e: /

Y ea rs

si nc e re si de nc y:

15 .4 y ±

0. 38

C li en

t:

•A tt em

pt in g pr eg

na nc

y (+

) (d es cr ip ti ve

re su lt )

•H ea lt h st at us :f am

ily hi st or y of

C F,

ha vi ng

pa rt ne

r w ho

ha s C F or

is kn

ow n ca rr ie r (+

) (d es cr ip ti ve

re su lt )

•C lie

nt re qu

es t (d es cr ip ti ve

re su lt )

Pr ov

id er :

•M or e ex pe

ri en

ce (+

)

•P ro fe ss io n/

sp ec ia lt y:

O bG

yn s >

G yn

s O nl y (+

) O rg an

iz at io na

l: /

So ci et al : /

Po pp

el aa

rs et

al .

(2 00

4)

(1 ) To

de te rm

in e th e at ti tu de

s of

po te nt ia l pr ov

id er s to w ar ds

PC cy st ic

fi br os is

ca rr ie r sc re en

in g (2 ) PC

cy st ic

fi br os is

ca rr ie r sc re en

in g

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) th e N et he

rl an

ds (2 ) C om

m un

it y H ea lt h

Se rv ic e (C

H S) ,G

en er al

pr ac ti ce

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

21 5 G Ps

an d C H S w or ke

rs ;4

3% fe m al e

A ge :4

5y (2 9–

63 )

Y ea rs

in pr ac tic

e: /

C li en

t: /

Pr ov

id er :

•H ig h pe

rc ei ve

d se ve

ri ty

of cy st ic

fi br os is

(+ )

•b ei ng

no nr el ig io us

co m pa

re d to

re fo rm

ed (+

)

•L ow

pe rc ei ve

d ba

rr ie rs

(+ )

•H ig h pe

rc ei ve

d te st

se ns it iv it y (+

) O rg an

iz at io na

l: /

So ci et al : /

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

117

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

To ug

h et

al .

(2 00

4) (1 ) To

de sc ri be

ch ar ac te ri st ic s of

ph ys ic ia ns

w ho

re co

m m en

d al co

ho l

ab st in en

ce du

ri ng

pr eg

na nc

y w it h

re ga

rd to

kn ow

le dg

e of

FA S an

d PC

co un

se lli ng

st ra te gi es

(2 ) PC

al co

ho l ab

st in en

ce

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) C an

ad a

(2 ) Fa

m ily

pr ac ti ce ,

ob st et ri cs / gy

na ec ol og

y pr ac ti ce s,

m id w if er y

na ti on

w id e

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

10 90

O bG

yn s,

fa m ily

ph ys ic ia ns

an d m id w iv es ;5

18 %

fe m al e

A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•P er ce iv ed

la ck

of cl ie nt

in te re st

(- )

•B el ie vi ng

th at

cl ie nt s ar e in te re st ed

in di sc us si ng

al co

ho l us e (+

) Pr

ov id er :

•P ro fe ss io n/

sp ec ia lit y:

Fa m Ph

ys (+

) >

m id w iv es

an d ob

st et ri ci an

s

•R ol e:

be lie

vi ng

in ha

vi ng

a ro le

to m an

ag e cl ie nt s in

th e ar ea

of al co

ho l us e (+

-)

•K no

w le dg

e (+

)

•O bt ai ni ng

in fo rm

at io n fr om

m ed

ic al

jo ur na

ls (+

)

•A w ar en

es s: be

lie vi ng

th at

th er e is so lid

in fo rm

at io n

ab ou

t al co

ho l us e (+

) O rg an

iz at io na

l: /

So ci et al : /

M or ga

n et

al .

(2 00

6) (1 ) To

de sc ri be

O bG

yn s’ op

in io ns

of PC

C (2 ) PC

C in

ge ne

ra l

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U SA

(2 ) O bG

yn pr ac ti ce s

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

57 9 O bG

yn s;

46 .1 %

fe m al e

A ge

:4 7. 3y

± 0. 39

Y ea rs

in pr ac tic

e: 15

.2 2y

± 0. 41

C li en

t:

•F re qu

en cy

w it h w hi ch

cl ie nt s re po

rt ed

ly pr es en

t fo r PC

C (+

) Pr

ov id er :

•O pi ni on

s re ga

rd in g PC

C :d

efi ni ng

PC C as

ro ut in e

(+ ) ⬄

de fi ni ng

PC C as

sp ec ia liz

ed (- ), ag

re e th at

PC C is

im po

rt an

t/ po

si ti ve

/ hi gh

pr io ri ty

(+ )

O rg an

iz at io na

l: /

So ci et al : /

To ug

h et

al .

(2 00

6) (1 ) To

de te rm

in e th e PC

pr ac ti ce s

am on

g O bG

yn s an

d fa m ily

ph ys ic ia ns

in C an

ad a

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) C an

ad a

(2 ) Fa

m ily

pr ac ti ce ,

ob st et ri cs

& gy

na ec ol og

y na

ti on

w id e

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

96 5 fa m ily

ph ys ic ia ns

& O bG

yn s;

50 .6 %

fe m al e Y ea rs

in pr ac tic

e: /

Y ea rs

gr ad

ua te d:

≥ 22

y: 27

.4 % ,1

2 –

21 y:

31 .6 % ,≤

11 y:

41 .0 %

C li en

t: /

Pr ov

id er :

•P ro fe ss io n/

sp ec ia lit y:

O bG

yn s (+

) >

Fa m Ph

ys fo r

di sc us si ng

Pa p te st in g &

pr eg

na nc

y re la te d is su es

in cl ud

in g fo lic

ac id ,s

m ok

in g,

dr ug

us e,

se xu

al ab

us e) ;F

am Ph

ys >

O bG

yn s to

di sc us s m en

ta l

he al th ,d

ep re ss io n,

w or kp

la ce

st re ss

•G en

de r:

fe m al e (+

) >

m al e ph

ys ic ia ns

to di sc us s

9 or

m or e PC

an d he

al th

pr om

ot io n to pi cs

O rg an

iz at io na

l: /

So ci et al : /

W ill ia m s et

al .

(2 00

6) (1 ) To

as se ss

he al th ca re

pr ov

id er s

kn ow

le dg

e an

d pr ac ti ce s re ga

rd in g FA

us e fo r ne

ur al

tu be

de fe ct

pr ev

en ti on

(2 ) PC

FA us e

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U SA

(2 ) O bG

yn an

d Fa

m /G

en pr ac ti ce

se tt in gs

Te le ph

on e su rv ey

(n ot

va lid

at ed

) n =

11 11

ph ys ic ia ns

(O bG

yn s an

d Fa

m /G

en ) an

d no

n- ph

ys ic ia ns

(p hy

si ci an

as si st an

ts , nu

rs e

pr ac ti ti on

er ,c

er ti fi ed

nu rs e m id w iv es

an d re gi st er ed

nu rs es ); 60

% fe m al e

A ge :7

6% <

55 y

Y ea rs

in pr ac tic

e: 39

% ov

er 20

y in

pr ac ti ce

C li en

t: /

Pr ov

id er :

•P ro fe ss io n/

sp ec ia lit y:

pr ov

id er s in

O bG

yn se tt in gs

(+ ) >

Fa m /G

en se tt in gs ;n

ur se

pr ac ti ti on

er s in

O bG

yn se tt in g (+

) w er e m os t lik

el y to

ta lk

ab ou

t FA

an d fa m /g

en ph

ys ic ia ns

le as t lik

el y

•P ro vi de

r pe

rs on

al ly

to ok

m ul ti vi ta m in

(+ )

•L ow

er in co

m e cl ie nt s (+

)

•P ra ct ic es

co ns is te d of

at le as t 10

% m in or it ie s (+

)

•G en

de r:

fe m al e pr ov

id er

(+ )

O rg an

iz at io na

l: /

So ci et al : /

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

118

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

To ug

h et

al .

(2 00

7) (1 ) To

ex am

in e if ph

ys ic ia n kn

ow le dg

e an

d pr ac ti ce s re la te d to

FA SD

an d it s

pr ev

en ti on

va ry

ba se d on

th e

pr op

or ti on

of N at iv e/

A bo

ri gi na

l pa

ti en

ts se rv ed

(2 ) PC

FA SD

pr ev

en ti on

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) C an

ad a

(2 ) Fa

m ily

pr ac ti ce ,O

bG yn

pr ac ti ce s,

pa ed

ia tr ic s

na ti on

w id e

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

17 00

O bG

yn s,

fa m ily

ph ys ic ia ns ,

pa ed

ia tr ic ia n;

/ A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•E th ni ci ty

(+ -) :p

hy si ci an

s ca ri ng

fo r a gr ea te r

pr op

or ti on

of N at iv e/ A bo

ri gi na

l cl ie nt s w er e le ss

lik el y to

di sc us s fo lic

ac id ,b

ut m or e lik

el y to

ro ut in el y in qu

ir e ab

ou td

ri nk

in g pr io r to

pr eg

na nc

y aw

ar en

es s

Pr ov

id er : /

O rg an

iz at io na

l:

•L ac k of

ti m e (- ) (d es cr ip ti ve

re su lt )

•P oo

rl y fo rm

at te d in fo rm

at io n (- ) (d es cr ip ti ve

re su lt )

So ci et al :/

A bu

-H am

m ad

et al .

(2 00

8)

(1 ) To

ev al ua

te pr im

ar y ca re

ph ys ic ia ns ’k

no w le dg

e an

d at ti tu de

s re ga

rd in g FA

su pp

le m en

ta ti on

fo r

ch ild

be ar in g w om

en (2 ) PC

FA su pp

le m en

ta ti on

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) Is ra el

(2 ) Th

e la rg es t he

al th ca re

pr ov

id er

or ga

ni za ti on

in Is ra el

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

87 pr im

ar y ca re

ph ys ic ia ns ;6

1. 5%

A ge :4

7. 3y

± 7. 8y

Y ea rs

in pr ac tic

e: 18

.7 y ±

8. 7

C li en

t:

•E th ni ci ty :J

ew is h >

Be do

ui n (+

-) Pr

ov id er :

•C er ti fi ca ti on

:u nc

er ti fi ed

> bo

ar d- ce rt ifi ed

(+ -)

O rg an

iz at io na

l: /

So ci et al : /

M cC

la re n et

al .

(2 00

8) (1 ) To

ex pl or e pe

rs pe

ct iv es

of th e

V ic to ri an

co m m un

it y re ga

rd in g ca rr ie r

sc re en

in g fo r cy st ic

fi br os is

pr io r to

off er in g sc re en

in g

(2 ) PC

ge ne

ti c ca rr ie r sc re en

in g fo r

cy st ic

fi br os is

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) A us tr al ia

(2 ) G Ps

of pr ac ti ce s in

th e

lo ca l m et ro po

lit an

M el bo

ur ne

ar ea ,h

os pi ta l,

pr en

at al

cl in ic s,

U ni ve

rs it y

of M el bo

ur ne

Se m i- st ru ct ur ed

fo cu

s gr ou

p in te rv ie w s &

in di vi du

al in te rv ie w s

n =

12 he

al th

pr ov

id er s

(m id w iv es ,s

oc ia l w or ke

r ph

ys io th er ap

is ts , ge

ne ti c co

un se llo

r, ob

st et ri ci an

s G Ps ); /

A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•T he

po te nt ia l ps yc ho

so ci al

im pa

ct fo r cl ie nt s:

st ig m a an

d st re ss

on re la ti on

sh ip s (- )

•N ot

th in ki ng

ab ou

t ha

vi ng

ch ild

re n (- )

Pr ov

id er :

•P er so na

la tt it ud

e to w ar ds

off er in g ca rr ie r sc re en

in g

to cl ie nt s (+

-)

•H av

in g ex pe

ri en

ce w it h di sc us si ng

po te nt ia li m pa

ct an

d ac ce pt ab

ili ty

of a sc re en

in g pr og

ra m m e fo r

th ei r cl ie nt s (+

) O rg an

iz at io na

l:

•T im

e co

ns tr ai nt s al re ad

y pr es en

t in

co ns ul ta ti on

s (- )

So ci et al : /

To ug

h et

al .

(2 00

8) (1 ) To

de te rm

in e w he

th er

di ff er en

ce s

ex is t be

tw ee n ru ra l an

d ur ba

n he

al th ca re

pr ov

id er s in

kn ow

le dg

e of ,

at ti tu de

s ab

ou ta

nd aw

ar en

es s of

FA SD

di so rd er s an

d PC

co un

se lli ng

(2 ) FA

SD pr ev

en ti on

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) C an

ad a

(2 ) Fa

m ily

pr ac ti ce ,

ob st et ri cs

& gy

na ec ol og

y, pa

ed ia tr ic s,

ps yc hi at ry ,

m id w if er y na

ti on

w id e

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

21 01

O bG

yn s,

fa m ily

ph ys ic ia ns ,

ps yc hi at ri st s pa

ed ia tr ic ia ns , m id w iv es ;

49 .0 %

fe m al e

A ge : <

40 y:

31 % , 40

-4 9y

:3 4%

, 50

- 57

y: 25

% , ≥ 60

y: 10

% Y ea rs

in pr ac tic

e: /

Y ea rs

gr ad

ua te d:

≥ 42

y: 2%

;2 2–

41 y:

39 % ; 12

–2 1y

: 31

% ;≤

11 y:

28 %

C li en

t: /

Pr ov

id er :

•B el ie ft ha

t cl ie nt s al re ad

y ha

d go

od in fo rm

at io n on

al co

ho l us e (- ) (d es cr ip ti ve

re su lt )

•P ro fe ss io n/

sp ec ia lit y:

ur ba

n pr ov

id er s w er e m or e

lik el y to

di sc us s fo lic

ac id

(+ ) >

ru ra l pr ov

id er s;

no di ff er en

ce s re ga

rd in g ot he

r PC

to pi cs

O rg an

iz at io na

l:

•L ac k of

ti m e (- ) (d es cr ip ti ve

re su lt )

•I nf or m at io n no

t in

a us ef ul

fo rm

at (- ) (d es cr ip ti ve

re su lt )

So ci et al :/

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

119

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

Sc hw

ar z et

al .

(2 00

9) (1 ) To

id en

ti fy

w ha

t pr im

ar y ca re

pr ov

id er s pe

rc ei ve

as ba

rr ie rs

to an

d po

te nt ia l fa ci lit at or s of

pr ov

id in g

co un

se lli ng

to w om

en of

ch ild

be ar in g

ag e w he

n te ra to ge

ni c m ed

ic at io ns

ar e

pr es cr ib ed

(2 )T

er at og

en ic

m ed

ic at io ns

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) U SA

(2 ) 4 cl in ic al

se tt in gs

in Pi tt sb ur gh

, Pe

nn sy lv an

ia

Fo cu

s gr ou

p in te rv ie w s

n =

48 pr im

ar y ca re

pr ov

id er s

(a ca de

m ic

an d co

m m un

it y- ba

se d

cl in ic ia ns , ph

ar m ac is ts , nu

rs es ,

ph ys ic ia ns ,c

lin ic al

fa cu

lt y an

d tr ai ne

es ); 88

% fe m al e

A ge :4

9y ±

9 Y ea rs

in pr ac tic

e: /

C li en

t:

•C on

ce rn

th at

cl ie nt s an

xi et y re la te d to

in fo rm

at io n

ab ou

t te ra to ge

ni c ri sk

w ill

le ad

to m ed

ic at io n no

n- us e (- )

•W om

en ha

vi ng

di ffi cu

lt y of

vo lu nt ee ri ng

in fo rm

at io n ab

ou t th ei r pr eg

na nc

y in te nt io n (- )

Pr ov

id er :

•P ro fe ss io na

l re sp on

si bi lit y/

ro le

(+ )

•D iffi

cu lt y id en

ti fy in g cl ie nt s’ pr eg

na nc

y in te nt io ns

/ no

t ro ut in el y as ki ng

cl ie nt s’ pr eg

na nc

y in te nt io ns

(- )

O rg an

iz at io na

l:

•L im

it ed

cl in ic al

ti m e &

co m pe

ti ng

m ed

ic al

pr io ri ti es .D

is cu

ss io ns

ab ou

t te ra to ge

ni c ri sk s of

m ed

ic at io n ar e co

m pl ex ,a

nd th us ,t im

e co

ns um

in g

(- )

•D iffi

cu lt y fi nd

in g cl in ic al ly

re le va

nt in fo rm

at io n on

m ed

ic at io ns ’t er at og

en ic it y (- )

•A ss is ta nc

e in

id en

ti fy in g m ed

ic at io ns

th at

po se

te ra to ge

ni c ri sk s (+

) (e .g .o

nl in e re fe re nc

es ,

co m pu

te ri ze d de

ci si on

su pp

or t)

•A ss is ta nc

e in

id en

ti fy in g w om

en ’s pr eg

na nc

y in te nt io ns

(+ )

So ci et al :

•L ac k of

re im

bu rs em

en t fo r ti m e sp en

t co

un se lli ng

(- )

•A cc es s to

ed uc

at io na

l m at er ia ls

fo r cl ie nt s (+

) Bo

nh am

et al .

(2 01

0) (1 ) To

as se ss

th e in fl ue

nc e of

pa ti en

t ch

ar ac te ri st ic s on

de ci si on

s to

off er

pr ec on

ce pt io n ge

ne ti c sc re en

in g

(2 ) PC

ge ne

ti c sc re en

in g

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U SA

(2 ) G en

er al

pr ac ti ce

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

96 8 fa m ily

ph ys ic ia ns ;3

2. 7%

fe m al e

A ge :4

5. 6y

Y ea rs

in pr ac tic

e: /

Y ea rs

si nc e re si de nc y co m pl et io n:

< 5y

: 19

% , 5y

-1 5y

:3 6%

, >

15 y:

45 %

C li en

t:

•R ac e:

be in g bl ac k (+

)

•F em

al e ge

nd er

(+ ) (b la ck

cl ie nt )

•A ge

(+ ) (d es cr ip ti ve

re su lt )

Pr ov

id er :

•W or k ex pe

ri en

ce :c

om pl et in g re si de

nc y le ss

th an

15 ye

ar s ea rl ie r (+

) (b la ck

cl ie nt )

•W or ki ng

in a un

iv er si ty ,t ea ch

in g,

or re si de

nc y

tr ai ni ng

en vi ro nm

en t (+

) (b la ck

cl ie nt )

O rg an

iz at io na

l: /

So ci et al : /

Pa rk er

et al .

(2 01

0) (1 ) To

as se ss

pe rc ep

ti on

s of

th e

im po

rt an

ce of

PC C an

d fa ct or s

aff ec ti ng

th e w ill in gn

es s of

ST D

co un

se llo

rs to

in te gr at e PC

C in

ST D

cl in ic s.

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U SA

(2 ) ST

D cl in ic s

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

14 0 ST

D co

un se llo

rs ; /

A ge

:/ Y ea rs

in pr ac tic

e: 2- 5y

:2 1%

, 6- 10

y: 48

% ,

≥ 10

y: 31

%

C li en

t: /

Pr ov

id er :

•G oo

d or

ex ce lle

nt kn

ow le dg

e of

PC C (+

)

•H ig he

r le ve

l of

re sp on

si bi lit y (+

)

•M or e ye

ar s of

w or k ex pe

ri en

ce (+

)

•C om

in g fr om

ar ea s w it h hi gh

le ve

ls of

m or bi di ty

(+ )

O rg an

iz at io na

l: /

So ci et al : /

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

120

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

M or ta gy

et al .

(2 01

0) (1 ) To

ex pl or e th e pe

rs pe

ct iv e of

G Ps

an d se co

nd ar y ca re

he al th

pr of es si on

al s on

th e ro le

of G Ps

in de

liv er in g PC

to w om

en w it h di ab

et es

(2 )G

en er al

PC to

w om

en w it h di ab

et es

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) U K

(2 ) D iv er se

se t of

G P

pr ac ti ce s an

d 1 Lo

nd on

te ac hi ng

ho sp it al

Se m i- st ru ct ur ed

in te rv ie w s

n =

15 G Ps

an d se co

nd ar y he

al th ca re

pr of es si on

al s;

/ A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t: /

Pr ov

id er :

•I nt er es t in

di ab

et es

ca re

(+ )

•P ro fe ss io na

l re sp on

si bi lit y/

ro le : la ck

of a de

fi ne

d G P ro le

in PC

C (- )

•A w ar en

es s th ro ug

h on

go in g ed

uc at io n an

d tr ai ni ng

(+ )

O rg an

iz at io na

l:

•L ac k of

cl ea r di vi si on

of re sp on

si bi lit y an

d -la

bo ur

re ga

rd in g di ab

et es

ca re

pr ac ti ce s be

tw ee n pr im

ar y

an d se co

nd ar y ca re

(- )

•P ra ct ic e pr ot oc

ol s re ga

rd in g PC

C (+

) So

ci et al :

•L ac k of

cl ea r gu

id el in es

on ho

w to

pr ov

id e PC

C an

d w he

n to

m ak

e re fe rr al s (- )

•E vi de

nc e- ba

se d in fo rm

at io n on

PC be

ne fi ts

(+ )

•A cc es s to

cl ie nt

in fo rm

at io n le afl

et s (+

) Bu

rr is

an d

W er le r

(2 01

1)

(1 ) To

de te rm

in e w he

th er

m ed

ic al

pr ov

id er s or de

r fo lic

ac id

or fo lic

ac id -

co nt ai ni ng

m ul ti vi ta m in s fo r th ei r no

n- pr eg

na nt

fe m al e pa

ti en

ts of

ch ild

be ar in g ag

e (2 ) PC

FA an

d m ul ti vi ta m in s

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U SA

(2 ) N on

-f ed

er al ly

offi ce

ba se d ph

ys ic ia n pr ac ti ce

an d no

n- fe de

ra l ho

sp it al s

A na

ly si s of

da ta

fr om

tw o da

ta so ur ce s N A M C S an

d N H A M C S

n =

46 34

pr ev

en ti ve

vi si ts

of no

n- pr eg

na nt

w om

en A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•A ge

(+ ); w om

en ag

es 30

-3 4

> w om

en ag

ed 15

-1 9

or 40

-4 4

•R ac e/ et hn

ic it y (+

): ra ce

ot he

r th an

w hi te ,b

la ck

or H is pa

ni c

•I ns ur an

ce st at us

(+ ): M ed

ic ai d >

pr iv at e

in su ra nc

e or

ot he

r Pr

ov id er :

•P ro fe ss io n/

sp ec ia lit y:

(+ ):

O bG

yn s >

no n- O bG

yn s

O rg an

iz at io na

l: /

So ci et al : /

C hu

an g et

al .

(2 01

2) (1 ) To

ex am

in e pr im

ar y ca re

ph ys ic ia ns ’p

er ce pt io ns

of ba

rr ie rs

to pr ev

en ti ve

re pr od

uc ti ve

he al th ca re

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) U SA

(2 ) So

lo pr iv at e pr ac ti ce s

an d ho

sp it al -o w ne

d m ul ti sp ec ia lt y gr ou

ps in

ru ra l ce nt ra l Pe

nn sy lv an

ia

Se m i- st ru ct ur ed

te le ph

on e

an d fa ce -t o- fa ce

in te rv ie w s

n =

19 ru ra l pr im

ar y ca re

ph ys ic ia ns ;

47 .4 %

fe m al e

A ge :/

Y ea rs

in pr ac tic

e: 21

y (1 –3

8)

C li en

t:

•N ot

in it ia ti ng

di sc us si on

s ab

ou t pr eg

na nc

y pl an

ni ng

be ca us e of

in di ff er en

ce to

fa m ily

pl an

ni ng

(- )

Pr ov

id er :

•P ro fe ss io na

lr es po

ns ib ili ty /r ol e:

be lie

f th at

it is

no t

th e pr im

ar y ca re

ph ys ic ia n’ s ro le

to in it ia te

an d

di sc us s pr eg

na nc

y pl an

ni ng

an d PC

C (- )

•P C C is

no pr io ri ty

(- )

•F ee lin

g un

ce rt ai n w ha

t th ey

co ul d off

er (- )

O rg an

iz at io na

l:

•L ac k of

ti m e (- )

•A la ck

of lo ca l sp ec ia lis ts :l ac k of

ac ce ss

to ob

st et ri ci an

s w it h tr ai ni ng

in m an

ag in g hi gh

-r is k

pr eg

na nc

ie s w ho

m ay

as si st

PC C ,o

r en

do cr in ol og

is ts

w ho

m ay

as si st

w it h m an

ag em

en t

of di ab

et es

(- )

So ci et al

•R ur al

co m m un

it y no

rm s (- ): e. g.

ac ce pt in g

un in te nd

ed pr eg

na nc

ie s,

ea rl y ch

ild be

ar in g,

la rg e

fa m ili es …

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

121

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

M az za

et al .

(2 01

3) (1 ) To

ex am

in e th e ba

rr ie rs

an d

en ab

le rs

to th e de

liv er y an

d up

ta ke

of PC

C gu

id el in es

fr om

G Ps ’p

er sp ec ti ve

us in g th eo

re ti ca l do

m ai ns

re la te d to

be ha

vi ou

r ch

an ge

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) A us tr al ia

(2 ) D iv er se

pr ac ti ce

se tt in gs

Fo cu

s gr ou

p in te rv ie w s

n =

22 G Ps ;5

9. 1%

fe m al e A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•N ot

pr es en

ti ng

at PC

st ag

e (- ): un

aw ar e of

av ai la bi lit y an

d im

po rt an

ce of

PC C (- )

•N ot

w ill in g to

sp en

d m or e ti m e an

d m on

ey fo r

m ul ti pl e co

ns ul ta ti on

s (- )

Pr ov

id er :

•P er ce pt io n of

ha vi ng

no op

po rt un

it y to

de liv

er PC

C (- )

•B el ie fs

ab ou

t eff

ec ti ve

ne ss

PC C :d

ou bt s re ga

rd in g

eff ec ti ve

ne ss

of fo lic

ac id

in pr ev

en ti ng

N TD

’s (- )

•O th er

co m pe

ti ng

pr ev

en ti ve

ca re

pr io ri ti es

(b el ie vi ng

in a po

te nt ia l in cr ea se

in bu

rd en

on cl in ic s if th e nu

m be

r of

PC C co

ns ul ta ti on

s w as

in cr ea se d (- )

O rg an

iz at io na

l:

•T im

e lim

it s on

co ns ul ta ti on

(- )

•G P an

d cl ie nt

re so ur ce s fo r PC

C :L

ac k of

re so ur ce s

(- ); av

ai la bi lit y of

PC C re so ur ce s (e .g .c

he ck lis ts /

cl ie nt

br oc

hu re s/

ha nd

ou ts / w ai ti ng

ro om

po st er s)

(+ )

•L im

it ed

ac ce ss

to in di vi du

al G Ps

(e .g .l on

g w ai ti ng

lis t)

(- )

•L im

it ed

nu m be

r of

G Ps

w ill in g to

de liv

er PC

C (- ):

po te nt ia l de

la y fo r cl ie nt s

•P ot en

ti al

bu rd en

on cl in ic s if PC

C co

ns ul ta ti on

s in cr ea se d (- )

So ci et al :

•L ac k of

G P &

cl ie nt

re so ur ce s (e .g .e

vi de

nc e ba

se d

w eb

si te s)

fo r PC

C (- )

Po w er

et al .

(2 01

3) (1 ) To

as se ss

ba rr ie rs

to an

d qu

al it y of

pr ec on

ce pt io n,

pr en

at al

an d po

st na

ta l

ca re

fo r di ab

et ic

w om

en by

ob st et ri ci an

-g yn

ae co

lo gi st s

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) U SA

(2 ) Pr iv at e gr ou

p, pr iv at e

so lo , ac ad

em ic ,h

os pi ta l-

ow ne

d se tt in gs

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

51 0 O bG

yn s,

/ A ge :/

Y ea rs

in pr ac tic

e: 17

.5 ±

1. 5 y.

C li en

t:

•H ea lt h st at us :i f a cl ie nt

ha d di ab

et es , ph

ys ic ia ns

w er e m or e lik

el y to

as k ab

ou tp

re gn

an cy

pl an

s (+

) (d es cr ip ti ve

re su lt )

•A ct iv e de

si re

fo r ch

ild re n (+

) (d es cr ip ti ve

re su lt )

Pr ov

id er :

•P ro fe ss io n/

sp ec ia lit y:

M at er na

l-f oe

ta l m ed

ic in e

sp ec ia lis t (+

) >

no n- M at er na

l-f oe

ta l m ed

ic in e

sp ec ia lis t

O rg an

iz at io na

l: /

So ci et al :/

St ep

he ns on

et al .

(2 01

4)

(1 ) To

as se ss

th e vi ew

s an

d en

ga ge

m en

t of

he al th

pr of es si on

al s

w it h PC

C (2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) U K

(2 ) A ll se tt in gs

re la te d to

ge ne

ra l pr ac ti ce , ob

st et ri cs

& gy

na ec ol og

y, m id w if er y,

se xu

al &

re pr od

uc ti ve

he al th

Te le ph

on e in te rv ie w s

n =

21 co

ns ul ta nt s in

O bG

yn ,

m id w iv es ,G

Ps ,c

om m un

it y ba

se d

co ns ul ta nt s (o r cl in ic al

le ad

s) in

se xu

al an

d re pr od

uc ti ve

he al th ,s

ex ua

l he

al th

sp ec ia lis t nu

rs e;

/ A ge : <

30 y:

28 % ,3

0- 34

y: 41

% ,3

5+ y:

31 %

Y ea rs

in pr ac tic

e: /

C li en

t:

•U np

la nn

ed pr eg

na nc

ie s (- )

•A w ar en

es s (+

) Pr

ov id er :

•P ro fe ss io na

l re sp on

si bi lit y/

ro le : PC

C is

so m eo

ne el se ’s re sp on

si bi lit y (- )

•K no

w le dg

e (+

-)

•C on

fi de

nc e (+

)

•L ac k of

in te re st

(- )

O rg an

iz at io na

l: /

So ci et al :

•C on

st ra in ed

re so ur ce s (- )

•F in an

ci al

in ce nt iv es

fo r de

liv er y of

PC C (+

)

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

122

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

A rc hi ba

ld et

al .

(2 01

6) (1 ) To

ex pl or e st ak

eh ol de

r vi ew

s ab

ou t

off er in g po

pu la ti on

-b as ed

ge ne

ti c

ca rr ie r sc re en

in g fo r fr ag

ile X

sy nd

ro m e

(2 ) PC

ge ne

ti c ca rr ie r sc re en

in g fo r

fr ag

ile X sy nd

ro m e

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) A us tr al ia

(2 ) /

Se m i- st ru ct ur ed

in te rv ie w s &

fo cu

s gr ou

ps n =

81 he

al th

pr ov

id er s (G

Ps ,

ph ys io th er ap

is ts

nu rs es ,m

id w iv es ,

sp ee ch

pa th ol og

is ts ,O

bG yn

s, ps yc ho

lo gi st s,

su pp

or t w or ke

rs ,

pa ed

ia tr ic ia ns ,

cl in ic al

ge ne

ti ci st s an

d co

un se llo

rs ,

m ed

ic al

sc ie nt is ts ,o

cc up

at io na

l th er ap

is ts ); /

A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•L ac k of

kn ow

le dg

e an

d aw

ar en

es s (- )

•T he

po te nt ia lt o in cr ea se

an xi et y at

a st re ss fu lt im

e (- )

Pr ov

id er :

•L ac k of

kn ow

le dg

e an

d aw

ar en

es s (- )

•S up

po rt

fr om

he al th ca re

pr ov

id er s (+

) O rg an

iz at io na

l:

•R ed

uc ed

ti m e fo r de

ci si on

-m ak

in g (- )

•L im

it ed

re pr od

uc ti ve

op ti on

s (- )

•L im

it ed

ti m e av

ai la bl e to

pr ov

id e pr et es t

co un

se lli ng

(- )

•A se le ct iv e ap

pr oa

ch to

off er in g sc re en

in g (- )

•T ra in ed

an d qu

al ifi ed

ca re

pr ov

id er s to

off er

th e

te st

(+ )

•S uffi

ci en

t re so ur ce s fo r m an

ag in g te st -p os it iv e

re su lt s (+

) So

ci et al :

•D ev

el op

m en

t of

pr ot oc

ol s an

d gu

id el in es

(+ )

•E co

no m ic

ev al ua

ti on

s (+

) C ol l et

al .

(2 01

6) (1 ) Ex

pl or in g kn

ow le dg

e, at ti tu de

an d

pr ac ti ce s am

on g he

al th ca re

pr ov

id er s

re ga

rd in g PC

C , sa fe r co

nc ep

ti on

an d

pr eg

na nc

y am

on g H IV -i nf ec te d w om

en (2 ) PC

C am

on g H IV -i nf ec te d w om

en

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) U SA

(2 ) U rb an

So ut h Fl or id a –

pu bl ic

an d pr iv at e ho

sp it al s

K ey

in fo rm

an t in te rv ie w s

n =

14 nu

rs e pr ac ti ti on

er s ph

ys ic ia ns ,

ph ys ic ia n as si st an

ts , an

d pr ov

id in g

O bG

yn an

d H IV

ca re ;/

A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•L ac k of

kn ow

le dg

e (- )

•W om

en do

no t br in g up

th e to pi c du

e to

st ig m as

su rr ou

nd H IV -i nf ec te d w om

en ’s de

si re s fo r ch

ild re n

(- ) an

d un

pl an

ne d pr eg

na nc

y (- )

Pr ov

id er :

•C om

pe ti ng

m ed

ic al

pr io ri ti es

(- )

•F ai lu re

to ad

dr es s fe rt ili ty

de si re s (- )

•L im

it ed

kn ow

le dg

e/ un

de rs ta nd

in g of

PC is su es

(- )

O rg an

iz at io na

l:

•T im

e co

ns tr ai nt s (- )

•L ac k of

pr ov

id er

re so ur ce s fo r H IV -in

fe ct ed

w om

en (- )

So ci et al : /

M cP

hi e et

al .

(2 01

6) (1 ) To

id en

ti fy

ba rr ie rs

to pr ov

id in g

pr ec on

ce pt io n w ei gh

t m an

ag em

en t

(2 ) PC

w ei gh

t m an

ag em

en t

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) A us tr al ia

(2 ) /

Se m i- st ru ct ur ed

ph on

e in te rv ie w

n =

20 he

al th

pr ov

id er s w it h ex pe

rt is e

in m at er na

l an

d ch

ild he

al th

(p ri m ar y

he al th

pr ac ti ti on

er s,

m id w iv es ,

st ak

eh ol de

rs w or ki ng

in he

al th

po lic

y, he

al th ca re

m an

ag em

en t, pr ev

en ti ve

he al th ); /

A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•L ac k of

aw ar en

es s of

th e im

po rt an

ce of

PC he

al th

an d w ei gh

t: es pe

ci al ly

w om

en w ho

ar e no

t pl an

ni ng

on be

co m in g pr eg

na nt

(- )

•U np

la nn

ed pr eg

na nc

ie s (- )

Pr ov

id er :

•P ro fe ss io na

lr es po

ns ib ili ty /r ol e:

co nfl

ic tin

g id ea s

ab ou

tw ho

sh ou

ld be

re sp on

si bl e fo rp

ro vi di ng

PC C (- )

•S en

si ti ve

na tu re

of th e to pi c (- )

•L ac k of

co nfi

de nc

e to

ha nd

le se ns it iv e

co nv

er sa ti on

s (- )

•L im

ite d ac ce ss to

w om

en of

ch ild

be ar in g ag e w ho

pl an

to co nc ei ve :m

is co nc ep tio

n ab

ou t pr ev al en

ce of

un pl an

ne d pr eg na

nc ie s an

d im

po ss ib le

to de te rm

in e

w hi ch

w om

en w ill

be co m e pr eg na

nt an

d w he

n (- )

O rg an

iz at io na

l:

•N o sc op

e in

th ei r ro le

or th e cu

rr en

t he

al th ca re

sy st em

(e .g .d

ue to

ti m e co

ns tr ai nt s)

(- )

So ci et al :

•N o sc op

e in

th ei r ro le

or th e cu

rr en

t he

al th ca re

sy st em

(e .g .d

ue to

ti m e co

ns tr ai nt s)

(- )

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

123

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

O ju kw

u et

al .

(2 01

6) (1 ) To

ex am

in e G Ps

kn ow

le dg

e, at ti tu de

s, an

d vi ew

s to w ar ds

pr ec on

ce pt io n he

al th

an d ca re

in th e

ge ne

ra l pr ac ti ce

se tt in g

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) U K

(2 ) G en

er al

pr ac ti ce s

In di vi du

al se m i- st ru ct ur ed

in te rv ie w s

N =

7 G Ps ;4

2. 8%

fe m al e

A ge :/

ye ar s in

pr ac tic

e: 13

.7 y

C li en

t:

•L ac k of

at te nd

an ce

fo r he

al th ca re

be fo re

pr eg

na nc

y (- ): un

pl an

ne d pr eg

na nc

ie s,

et hn

ic po

pu la ti on

s

•L ac k of

kn ow

le dg

e (- )

•L ac k of

pe rc ei ve

d ne

ed (- )

Pr ov

id er :

•L ac k of

m ot iv at io n (- )

•‘N an

ny st at e’

in di ca ti ng

pe rs on

al be

ha vi ou

r (- )

O rg an

iz at io na

l:

•L ac k of

ti m e (- )

•F in an

ci al

co ns tr ai nt s (- )

So ci et al :/

va n V oo

rs t

et al .

(2 01

6)

(1 ) To

as se ss

cu rr en

t ac ti vi ti es ,

pe rc ep

ti on

s an

d pr er eq

ui si te s fo r

de liv

er y of

PC C

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu an

ti ta ti ve

(1 ) th e N et he

rl an

ds (2 ) pr im

ar y ca re

se tt in g

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

) n =

69 9 G Ps

an d m id w iv es ;6

9. 6%

fe m al e

A ge :4

1y (2 3–

66 )

Y ea rs

in pr ac tic

e: /

C li en

t:

•M en

ti on

in g de

si re

to be

co m e pr eg

na nt

(+ )

(d es cr ip ti ve

re su lt )

•A ft er

m is ca rr ia ge

(+ ) (d es cr ip ti ve

re su lt )

•A pp

ar en

t ri sk

fo r ad

ve rs e re pr od

uc ti ve

ou tc om

es (+

) (d es cr ip ti ve

re su lt )

•P os tn at al

ch ec k- up

(+ ) (m

id w iv es

– de

sc ri pt iv e

re su lt )

•P re sc ri pt io n m ed

ic at io n,

di sc us si ng

co nt ra ce pt io n

an d fo llo

w -u p ch

ro ni c di se as e (+

) (G

Ps –

de sc ri pt iv e re su lt )

Pr ov

id er

:

•P ro fe ss io n/

sp ec ia lit y:

G Ps

(+ ) >

m id w iv es

in pe

rf or m in g PC

C co

ns ul ta ti on

; m id w iv es

> G Ps

in as se ss in g PC

C ri sk

fa ct or s

•P er ce pt io ns

(- ): PC

C on

ly fo r w om

en w it h hi gh

ri sk s,

PC C m ed

ic al is ed

pr ec on

ce pt io n pe

ri od

,P C C

w it ho

ut w om

en as ki ng

fo r it w as

ob je ct io na

bl e

(d es cr ip ti ve

re su lt s)

O rg an

iz at io na

l: /

So ci et al :/

Fi el dw

ic k et

al .

(2 01

7) (1 ) To

ex pl or e th e kn

ow le dg

e an

d pr ac ti ce

of G Ps

re ga

rd in g PC

an d

ge st at io na

l w ei gh

t m an

ag em

en t

(2 ) PC

w ei gh

t m an

ag em

en t (i n w om

en ha

vi ng

ov er w ei gh

t, ob

es it y or

w om

en w ho

ex ce ss

ge st at io na

l w ei gh

t ga

in )

C ro ss -s ec ti on

al ,

m ix ed

m et ho

ds (1 ) N ew

Ze al an

d (2 ) /

Se lf -a dm

in is te re d

qu es ti on

na ir e (n ot

va lid

at ed

), co

ns is ti ng

of cl os ed

-e nd

ed qu

es ti on

s (q ua

nt it at iv e)

an d

an op

en qu

es ti on

(q ua

lit at iv e)

n =

20 0 G Ps ;/

A ge : <

30 y:

2% ,3

0- 39

y: 26

% ,4

0- 49

y: 23

% , 50

-5 9y

:3 5%

, 60

+ y:

15 %

Y ea rs

in pr ac tic

e: <

4y :1

1% ,4

-9 y:

20 % , 10

-1 5y

:1 7%

, >

15 y:

52 %

C li en

t:

•H ea lt h st at us :G

Ps m or e of te n di sc us s w ei gh

t m an

ag em

en tw

it h ov

er w ei gh

to r ob

es e w om

en (+

) (d es cr ip ti ve

re su lt ); if w om

en pr es en

t pr ec on

ce pt io n,

it is

of te n re la te d to

in fe rt ili ty

(+ )

•R ar el y pr es en

ti ng

fo r PC

C (- )

Pr ov

id er :

•L ac k of

op po

rt un

it y to

pr ov

id e PC

C (- )

•L ac k of

aw ar en

es s: no

tk no

w in g w ha

t PC

C in vo

lv es

an d th e be

ne fi ts

of PC

in te rv en

ti on

s in

ov er w ei gh

t an

d ob

es e w om

en (- )

O rg an

iz at io na

l: /

So ci et al : /

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

124

Ta bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

M ’H am

di et

al .

(2 01

7) (1 ) To

ex am

in e he

al th ca re

pr of es si on

al s' vi ew

s of

th ei r ro le

an d

re sp on

si bi lit ie s in

pr ov

id in g PC

C an

d id en

ti fy

ba rr ie rs

th at

aff ec t th e

de liv

er y an

d up

ta ke

of PC

C (2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) Th

e N et he

rl an

ds (2 ) O ne

un iv er si ty

ho sp it al

(s pe

ci al is ts ), G P an

d m id w if er y pr ac ti ce s

Se m i- st ru ct ur ed

in te rv ie w s

n =

20 m id w iv es ,G

Ps ,s

pe ci al is ts ;/

A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•U nf am

ili ar it y w it h PC

C (- )

•L im

it ed

aw ar en

es s ab

ou t im

po rt an

ce of

PC C (- )

•L ow

so ci oe

co no

m ic

w om

en ar e ha

rd es t to

re ac h (- )

•N ot

w ill in g to

in ve

st ti m e an

d eff

or t (- )

Pr ov

id er :

•U nf am

ili ar it y w it h PC

C (- )

•L ac k of

kn ow

le dg

e of

PC C (- )

•E th ic al

ba rr ie rs

(- ): te ns io n be

tw ee n pe

rs on

al be

lie fs

ab ou

t pr eg

na nc

y an

d th e w el lb ei ng

of th e

fu tu re

ch ild

on th e on

e ha

nd ⬄

th e pr of es si on

al re sp on

si bi lit y to

pr ov

id e th e be

st ca re

po ss ib le

fo r

cl ie nt s w hi le

re sp ec ti ng

th e re pr od

uc ti ve

au to no

m y

of th e fu tu re

pa re nt s on

th e ot he

r ha

nd O rg an

iz at io na

l:

•T im

e co

ns um

in g (- ): PC

C is

a ne

w fo rm

of ca re ,a

su bs ta nt ia l am

ou nt

of ri sk

fa ct or s sh ou

ld be

ad dr es se d,

co m pe

ti ng

pr ev

en ti ve

ca re

w hi ch

al so

ne ed

s to

be de

liv er ed

•P oo

r or

la ck

of co

m m un

ic at io n be

tw ee n di ff er en

t he

al th ca re

di sc ip lin

es th at

off er

PC C (- )

So ci et al :

•N o fi na

nc ia l co

m pe

ns at io n (- ): la ck

of a fe e in

co m bi na

ti on

w it h la bo

ur in te ns iv en

es s

Po el s et

al .

(2 01

7a ,

20 17

b)

(1 ) To

id en

ti fy

bo tt le ne

ck s an

d so lu ti on

s fo r th e de

liv er y of

PC C fr om

a H C pr ov

id er s’ pe

rs pe

ct iv e

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) Th

e N et he

rl an

ds (2 ) /

Pa ra lle

l gr ou

p se ss io ns

n =

30 he

al th

pr ov

id er s

(g yn

ae co

lo gi st s,

m id w iv es ,p

re ve

nt iv e

ch ild

he al th ca re ,f er ti lit y sp ec ia lis ts ,

m at er ni ty

ca re ,G

Ps ,d

ie ti ci an

, ph

ys io th er ap

is ts , pa

ti en

t ad

vo ca cy ,

m un

ic ip al

po lic

y offi

ce r;

/ A ge :/

Y ea rs

in pr ac tic

e: /

C li en

t:

•L ac k of

at te nd

an ce

fo r he

al th ca re

be fo re

pr eg

na nc

y du

e to

un aw

ar en

es s (- ) an

d po

or un

de rs ta nd

in g of

pe rs on

al ri sk s (- )

•H ig h- ri sk

gr ou

ps (l ow

so ci oe

co no

m ic

st at us ,n

on -

w es te rn

et hn

ic it y or

liv in g in

de pr iv ed

ar ea s)

du e

to ig no

ra nc

e, la ck

of se lf -k no

w le dg

e an

d in ad

m is si bi lit y fo r PC

in fo rm

at io n (- )

Pr ov

id er :

•R ol e/ re sp on

si bi lit y:

un cl ea r w ho

sh ou

ld be

th e

en ti tl ed

pr ov

id er

fo r PC

C (- )

•P ro fe ss io n/

sp ec ia lit y:

m id w iv es

le ss

ac ce ss

to w om

en w it h ch

ild be

ar in g pl an

s, bu

tm os tw

ill in g to

pr ov

id e PC

C ;G

Ps ha

ve m or e ac ce ss

to w om

en w it h

ch ild

be ar in g pl an

s, bu

t le ss

in te re st ed

in pr ov

id in g

PC C

•L ac k of

aw ar en

es s an

d kn

ow le dg

e (- )

•N ot

be in g co

nv in ce d of

th e im

po rt an

ce , ne

ed ,

be ne

fi ts

an d effi

ca cy

of PC

C (- )

•L ac k of

ex pe

ri en

ce (- )

O rg an

iz at io na

l:

•R ol e/ re sp on

si bi lit y:

un cl ea r w ho

sh ou

ld be

th e

en ti tl ed

pr ov

id er

fo r PC

C (- )

•P C C co

ns ul ts ar e ti m e co

ns um

in g (t im

e co

ns tr ai nt s)

(- )

•L im

it ed

co lla

bo ra ti on

an d re fe rr al s be

tw ee n

he al th ca re

pr ov

id er s w it h re ga

rd to

PC C du

e to

la ck

of aw

ar en

es s of

PC C an

d ex is ti ng

te ns io n be

tw ee n

di ff er en

t he

al th ca re

di sc ip lin

es (- )

(c on

tin ue d on

ne xt

pa ge )

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

125

et al., 2016), the presence of an appropriate design could not be eval- uated. Three articles did not sufficiently report on rigorousness of the data analysis (Bortolus et al., 2017; McClaren et al., 2008; Stephenson et al., 2014). Only two research articles clearly considered the re- lationship between the researcher and the participants (McPhie et al., 2016; Poels et al., 2017a, 2017b). Ethical issues were inadequately discussed in four qualitative studies (Chuang et al., 2012; McClaren et al., 2008; Mortagy et al., 2010; Stephenson et al., 2014).

One article with a relevant mixed method design, integrating both qualitative and quantitative data, was included (Fieldwick et al., 2017). Nevertheless, the study inappropriately considered the limitations of this integration. The qualitative part was based on relevant data sources, and an adequate data analysis process. The relation between the findings and the context as well as the researchers’ influence were, however, inadequately considered. The quantitative part was char- acterized by inappropriate measurements, and the absence of an ac- ceptable response rate. The sampling strategy was found to be relevant, and the presence of a representative sample could not be evaluated.

3.4. Provider factors as facilitators or barriers to the provision of PCC

Most provider facilitators and barriers were related to the profes- sional responsibility. Being confused about who should (be the entitled provider to) deliver PCC was a frequently reported barrier (Bortolus et al., 2017; Chuang et al., 2012; Heyes et al., 2004; Mortagy et al., 2010; Poels et al., 2017a, 2017b; Stephenson et al., 2014; Tough et al., 2004). Conversely, the belief that having a responsibility in PCC fa- cilitated the provision of PCC (Parker et al., 2010; Tough et al., 2004).

The intention to provide PCC appeared to depend on the HCPs’ profession or specialty, although research findings were often incon- sistent. HCPs in obstetrics and gynaecology (ob/gyn) practice settings, including obstetrician–gynaecologists (Burris and Werler, 2011; Morgan et al., 2004; Williams et al., 2006), maternal-foetal medicine specialists (Power et al., 2013), and midwives (Poels et al., 2017a, 2017b) tended to be more involved in PCC compared with HCPs in non–ob/gyn practice settings such as gynaecologists only (Burris and Werler, 2011; Morgan et al., 2004) and general practitioners (Poels et al., 2017a, 2017b; Williams et al., 2006). Some studies, however, observed a greater PCC–engagement among family physicians in com- parison with midwives and obstetricians (Tough et al., 2004; van Voorst et al., 2016). In addition, the intention to provide PCC seemed to de- pend on which PCC aspect was dealt with. Obstetrician-gynaecologists seemed to discuss Pap testing and pregnancy related issues (including folic acid, smoking, drug use, sexual abuse) more frequently than family physicians, while family physicians tended to handle mental health, depression, and workplace stress related topics more often (Tough et al., 2006). Midwives seemed to assess PCC risk factors more regularly compared with general practitioners (Poels et al., 2017a, 2017b). Moreover, nurse practitioners in ob/gyn settings were most likely to talk about folic acid while family physicians were least likely to discuss the topic (Williams et al., 2006).

Having good knowledge on PCC was also identified as one of the main facilitators to provide PCC (Archibald et al., 2016; Coll et al., 2016; M’Hamdi et al., 2017; Miranda et al., 2003; Parker et al., 2010; Poels et al., 2017a, 2017b; Stephenson et al., 2014; Tough et al., 2004). By contrast, lack of awareness of PCC and unfamiliarity with PCC (e.g. not knowing what PCC involves and what the benefits of PC interven- tions are) were identified as barriers to the provision of PCC (Archibald et al., 2016; Fieldwick et al., 2017; M’Hamdi et al., 2017; Poels et al., 2017a, 2017b).

Another influencing factor seemed to be a HCP’s personal attitude; those considering PCC as a high priority more frequently provided PCC (Heyes et al., 2004; Morgan et al., 2006) than those having negative perceptions and not being convinced of the importance, need, benefits and efficacy of PCC (Chuang et al., 2012; Mazza et al., 2013; Poels et al., 2017a, 2017b; van Voorst et al., 2016). Perceiving PCC asTa

bl e 2 (c on

tin ue d)

St ud

y (1 ) St ud

y ai m

(2 ) C on

te nt

of PC

C St ud

y de

si gn

(1 ) C ou

nt ry

(2 ) H ea lt h se tt in g

D at a co

lle ct io n m et ho

ds St ud

y po

pu la ti on

M ea n ±

SD Fa

ct or s as so ci at ed

w it h pr ov

id in g (+

) or

no t

pr ov

id in g (- ) PC

C in

re la ti on

to le ve

l w it hi n so ci o-

ec ol og

ic al

m od

el

So ci et al :

•L ac k of

to ol s/ gu

id el in es

fo r PC

C (- )

•L ac k of

ov er vi ew

of co

lla bo

ra ti on

pa rt ne

rs (- )

•E du

ca ti on

:f or m al

pr of es si on

al ed

uc at io n on

PC C

fa lls

sh or t (m

id w iv es ) (- )

•A bs en

ce of

a co

st in g st ru ct ur e (fi

na nc

ia l

co ns tr ai nt s)

(- )

Bo rt ol us

et al .

(2 01

7) (1 ) To

in ve

st ig at e at ti tu de

s an

d be

ha vi ou

rs of

It al ia n w om

en of

ch ild

be ar in g ag

e an

d he

al th ca re

pr of es si on

al s re ga

rd in g pr ec on

ce pt io n

he al th

(2 ) G en

er al

PC C

C ro ss -s ec ti on

al ,

qu al it at iv e

(1 ) It al y

(2 ) H os pi ta l se tt in g

Fo cu

s gr ou

p in te rv ie w s

n= 12

he al th

pr ov

id er s w it h ex pe

rt is e

in a m ot he

r an

d ch

ild he

al th

fi el d

(n eo

na ta l nu

rs es ,h

os pi ta l m id w iv es ,

O bG

yn s,

pa ed

ia tr ic ia n) ; 10

0% fe m al e

A ge :3

8. 4y

(2 9- 52

) Y ea rs

in pr ac tic

e: 13

.9 y (4 -3 2)

C li en

t:

•N ot

in it ia ti ng

di sc us si on

s ab

ou t pr ec on

ce pt io n

he al th

(- )

Pr ov

id er :

•R ol e/ re sp on

si bi lit y:

un cl ea r w ho

sh ou

ld be

th e

en ti tl ed

pr ov

id er

fo r PC

C (- )

O rg an

iz at io na

l:

•P C C co

ns ul ts ar e ti m e co

ns um

in g (t im

e co

ns tr ai nt s)

(- )

So ci et al : /

A bb

re vi at io ns :P

C :p

re co

nc ep

ti on

;P C C :p

re co

nc ep

ti on

ca re ;C

F: cy st ic

fi br os is ;F

A :f ol ic

ac id ;f am

/g en

:f am

ily /g

en er al ;F

am Ph

ys :f am

ily ph

ys ic ia n;

FA S:

fo et al

al co

ho ls yn

dr om

e; FA

SD :f oe

ta la

lc oh

ol sp ec tr um

di so rd er s;

G P:

ge ne

ra l pr ac ti ti on

er ;N

TD :n

eu ra l tu be

de fe ct s;

O bG

yn s:

O bs te tr ic ia n- gy

na ec ol og

is ts ; ST

D :s

ex ua

lly tr an

sm it te d di se as es .

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

126

specialized rather than routine care was also a barrier for the provision of PCC (Morgan et al., 2006). One study identified lack of motivation as a barrier (Ojukwu et al., 2016). Being interested or not might have a stimulating (Mortagy et al., 2010) or restraining influence (Stephenson et al., 2014) on the provision of PCC.

The HCP’s perception of having no opportunity to deliver PCC was also found to be a considerable barrier for the provision of PCC (Fieldwick et al., 2017; Mazza et al., 2013). Some professionals experienced a limited access to women of childbearing age who plan to conceive (McPhie et al., 2016). Competing priorities (e.g. medical, preventive) might also discourage professionals to engage in PCC (Coll et al., 2016; Mazza et al., 2013).

Some studies cited communication problems as a barrier. HCPs might experience some difficulties in addressing the topic of pregnancy in- tentions or fertility desires (Coll et al., 2016; Schwarz et al., 2009), or did not routinely ask clients for it (Schwarz et al., 2009). The sensitive nature of the topic also seemed to prevent professionals in beginning a PC-conversation with their clients (McPhie et al., 2016), which may be attended by a lack of confidence (McPhie et al., 2016). Having good or a lack of confidence (Chuang et al., 2012; Stephenson et al., 2014), as well as having more or less (years of work) experience in providing PCC (Bonham et al., 2010; McClaren et al., 2008; Morgan et al., 2004; Poels et al., 2017a, 2017b) were also found to be either a facilitator or bar- rier. Moreover, lack of training seemed to hamper HCPs (Heyes et al., 2004).

Several articles mentioned that a HCP’s workplace influences the provision of PCC; those working in a university, teaching, or residency training environment (Bonham et al., 2010), and coming from areas with high levels of morbidity (Parker et al., 2010) were more likely to engage in PCC. Urban providers tended to discuss folic acid more often than providers in rural areas (Tough et al., 2008). Another facilitating factor was having clients of high risk groups; healthcare providers seeing lower income clients, and whose practice consisted of at least 10% minorities tended to be more inclined to provide PCC (Williams et al., 2006). Two studies found a positive association between female pro- fessionals and the provision of PCC (Heyes et al., 2004; Tough et al., 2006).

The following facilitating HCP factors were mentioned in only one study: provider who personally took multivitamin (Williams et al., 2006); being nonreligious compared to reformed (Poppelaars et al., 2004); obtaining information from medical journals (Tough et al., 2004); support from other healthcare providers (Archibald et al., 2016); and being uncertified (Abu-Hammad et al., 2008). Experiencing ethical barriers (M’Hamdi et al., 2017) was considered to be an additional barrier related to the provision of PCC.

3.5. Client factors as facilitators or barriers to the provision of PCC

A total of 14 studies identified contact with clients only after con- ception as the main barrier for HCPs to deliver PCC. This implies clients who do not present (whether consciously or not e.g. due to being unaware of availability and importance of PCC) at preconception stage (Fieldwick et al., 2017; Mazza et al., 2013; Ojukwu et al., 2016; Poels et al., 2017a, 2017b), and those having unplanned pregnancies (Coll et al., 2016; Heyes et al., 2004; McPhie et al., 2016; Ojukwu et al., 2016; Stephenson et al., 2014). The aforementioned barrier also implies communication difficulties; the perception that clients are not thinking about having children (McClaren et al., 2008) or do not (want to) in- itiate discussions about pregnancy planning or preconception health, dissuaded HCPs from providing PCC (Bortolus et al., 2017; Chuang et al., 2012; Heyes et al., 2004; Schwarz et al., 2009). By contrast, client request (Morgan et al., 2004, 2006), and mentioning the desire to be- come pregnant (Morgan et al., 2004; Power et al., 2013; van Voorst et al., 2016) incited HCPs to offer PCC.

Several barriers related to the client’s personal attitude, seemed to negatively influence the degree to which HCPs are willing to provide

PCC, including clients who are not willing to invest time, money, and effort in preconception consultations (M’Hamdi et al., 2017; Mazza et al., 2013), not interested in discussing PCC-related topics (Tough et al., 2004), perceiving PCC as less needed (Ojukwu et al., 2016) or important (Heyes et al., 2004), and less attending for healthcare before pregnancy due to poor understanding of personal risks (Poels et al., 2017a, 2017b).

The client’s lack of knowledge on PCC was considered as another impeding factor (Archibald et al., 2016; Coll et al., 2016; Ojukwu et al., 2016). Healthcare providers also seemed to be susceptible to the extent to which clients are aware of PCC or otherwise. While awareness can be seen as a facilitating factor (Stephenson et al., 2014), the client’s lack of or limited awareness about the availability and importance of PCC were identified as discouraging factors in the provision of PCC (Archibald et al., 2016; M’Hamdi et al., 2017; Mazza et al., 2013; McPhie et al., 2016; Poels et al., 2017a, 2017b).

Furthermore, HCPs mentioned the negative influence of the client’s status, especially those belonging to high risk groups (e.g. low socio- economic status, living in deprived areas) (M’Hamdi et al., 2017). Those clients might be hardest to reach due to lack of self-knowledge, ignorance, and inadmissibility for preconception information (M’Hamdi et al., 2017; Poels et al., 2017a, 2017b). The client’s ethnicity or race might either hamper or stimulate HCPs to provide PCC. Healthcare providers were more likely to discuss preconception-related topics if their clients were Jewish (Abu-Hammad et al., 2008), if the client’s race was black (Bonham et al., 2010), or other than white, black or Hispanic (Burris and Werler, 2011). Physicians caring for Indigenous clients were more likely to inform their clients about drinking prior to pregnancy (Tough et al., 2007). One study identified a non-western ethnicity as a possible barrier for HCPs (Poels et al., 2017a, 2017b).

Several studies named the potential psychosocial impact for clients as a discouraging factor for HCPs to provide PCC, including the potential to increase anxiety (related to specific information, e.g. teratogenic risk of certain medications) (Archibald et al., 2016; Schwarz et al., 2009), as well as the potential to cause stress on relationships (McClaren et al., 2008). Existing stigmas among clients might also hamper HCPs to in- itiate PCC (Coll et al., 2016; McClaren et al., 2008). However, other articles found that the client’s health status may trigger HCPs to discuss PCC-related topics. A family history of cystic fibrosis, having a partner who has cystic fibrosis or is a known carrier (Morgan et al., 2004), suffering from diabetes (Power et al., 2013) or a chronic disease (van Voorst et al., 2016), having experienced a miscarriage (van Voorst et al., 2016), having infertility problems (Fieldwick et al., 2017), taking medicines (e.g. contraception) (van Voorst et al., 2016), or having overweight or obesity (Fieldwick et al., 2017) were mentioned as fa- cilitating factors.

The following facilitating client factors were mentioned in only one or two studies: the client’s insurance status (Burris and Werler, 2011), gender (i.e. female clients) (Bonham et al., 2010), and age (Bonham et al., 2010; Burris and Werler, 2011).

3.6. Organizational factors as facilitators or barriers to the provision of PCC

The main organizational factors were related to resources. Especially lack of time was found to be a major barrier for HCPs to provide PCC (Archibald et al., 2016; Bortolus et al., 2017; Chuang et al., 2012; Coll et al., 2016; Heyes et al., 2004; M’Hamdi et al., 2017; Mazza et al., 2013; McClaren et al., 2008; McPhie et al., 2016; Ojukwu et al., 2016; Poels et al., 2017a, 2017b; Schwarz et al., 2009; Tough et al., 2007, 2008). Those time constraints refer to e.g. the decision-making process (Archibald et al., 2016), the provision of pretest counselling (Archibald et al., 2016), and other competing preventive care which also needs to be delivered (M’Hamdi et al., 2017). HCPs in the study of McPhie et al. (2016) considered limited available time as the reason why there is no scope for PCC in both their role and the current healthcare system. Other resource-related barriers were lack of money (Heyes et al., 2004;

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Ojukwu et al., 2016), lack of space (Heyes et al., 2004), lack of client / provider resources for PCC (Coll et al., 2016; Mazza et al., 2013), and lack of manpower (Heyes et al., 2004). The latter includes a limited number of general practitioners (willing) to deliver PCC (Mazza et al., 2013), and a lack of (access to) local specialists or general practitioners (e.g. long waiting list) (Chuang et al., 2012; Mazza et al., 2013). Con- versely, the availability of PCC resources (e.g. checklists, client bro- chures, handouts, waiting room posters), as well as trained and quali- fied care providers were identified as organizational facilitators (Archibald et al., 2016; Mazza et al., 2013; Schwarz et al., 2009).

HCPs tended to be less inclined to provide PCC if there was poorly formatted information (Tough et al., 2007, 2008), or if they experienced difficulties in finding clinically relevant information (e.g. on medica- tions’ teratogenicity) (Schwarz et al., 2009). Disposing of the necessary aids regarding PCC (e.g. online references, computerized decision support, practice protocols), however, stimulated HCPs to engage in PCC (Mortagy et al., 2010; Schwarz et al., 2009).

Besides the potential negative influence of resource- and informa- tion-related factors, a lack of clear division of responsibility concerning PCC was regarded as another barrier; some HCPs still found it unclear who should be the entitled provider for PCC (Mortagy et al., 2010; Poels et al., 2017a, 2017b). HCPs also mentioned that PCC (consultations) might cause burden on organizational level owing to e.g. an added workload (Heyes et al., 2004; Mazza et al., 2013).

Only Baars et al. (2004) identified the provision of genetic coun- selling in an HCP’s own practice as an facilitating factor on organiza- tional level. Limited reproductive options, a selective approach to of- fering screening (Archibald et al., 2016), limited collaboration and referrals between HCPs regarding PCC, and existing tension between different healthcare disciplines (Poels et al., 2017a, 2017b) were identified once as organizational factors that discourage HCPs to pro- vide PCC.

3.7. Societal factors as facilitators or barriers to the provision of PCC

Societal barriers and facilitators were particularly related to the availability of resources, guidelines, and reimbursement. The degree to which HCPs are triggered to deliver PCC seemed to depend on having access to educational materials for clients (e.g. information leaflets) and professional resources (e.g. evidence based websites) or not (Mazza et al., 2013; Mortagy et al., 2010; Schwarz et al., 2009; Stephenson et al., 2014). HCPs need a society in which client information and evidence-based guidelines for PCC are available (Heyes et al., 2004; Mortagy et al., 2010) and being developed (Archibald et al., 2016). A lack of PCC-related tools and guidelines were seen as discouraging factors to provide PCC (Mortagy et al., 2010; Poels et al., 2017a, 2017b). Being reluctant to provide PCC can also be attributed to fi- nancial constraints, including the absence of a costing structure (Poels et al., 2017a, 2017b), and the lack of a financial compensation for PCC (M’Hamdi et al., 2017; Schwarz et al., 2009). A society that equips fi- nancial incentives, by contrast, might entice HCPs into providing PCC to their clients (Stephenson et al., 2014). In the study of Archibald et al. (2016) HCPs also identified the performance of economic evaluations of PCC as a facilitating factor.

The following additional societal barriers were mentioned in only one study: rural community norms (e.g. accepting early childbearing, unintended pregnancies) (Chuang et al., 2012), poor or lack of com- munication between different healthcare disciplines that offer PCC (M’Hamdi et al., 2017), lack of formal professional education on PCC (Poels et al., 2017a, 2017b), lack of overview of collaboration partners (Poels et al., 2017a, 2017b), and the organization of the current healthcare system (e.g. time constraints) (McPhie et al., 2016).

4. Discussion

The aim of this review was to provide an overview of barriers and

facilitators that could influence the provision of PCC by HCPs. Thirty- one studies were included in this review. Findings of this review suggest that the provision of PCC is influenced by several client, provider, or- ganizational, and societal factors. Most of the factors influencing the provision of PCC were identified as barriers, which might explain why the provision of PCC is low. The majority of the reported barriers were situated at client level (e.g. not contacting a HCP in the preconception stage, negative attitude and lack of knowledge of PCC), and HCP level (e.g. unfavourable attitude and lack of knowledge of PCC, not working in the field of obstetrics and gynaecology, and lack of clarity on the responsibility for the provision of PCC). The aforementioned barrier was one of the most reported barriers in the provision of PCC (Bortolus et al., 2017; Chuang et al., 2012; Heyes et al., 2004; M’Hamdi et al., 2017; McPhie et al., 2016; Mortagy et al., 2010; Poels et al., 2017a, 2017b; Schwarz et al., 2009; Stephenson et al., 2014; Tough et al., 2004). Several studies found that HCPs perceive PCC as the responsi- bility of other HCPs rather than their own responsibility. This lack of clarity of responsibility can be explained by the fact that PCC is still an emerging topic. In 2006, the Centers for Disease Control and Prevention (CDC) were one of the first to develop recommendations to improve preconception health and care (Johnson et al., 2006). Since then, more attention has been given to PCC with an increased research activity and development of national and global guidelines (Jack et al., 2008; Shawe et al., 2014; World Health Organization, 2012). However, there is still a lack of clarity regarding who should provide PCC. Most studies and guidelines recommend a shared responsibility between all healthcare providers who have contact with women, from obstetricians/gynae- cologists to general practitioners, paediatricians, family practice phy- sicians, midwives, nurses, (advanced) midwife/nurse practitioners, and so on, which may reduce the sense of individual responsibility and ef- forts (Johnson et al., 2006; Shawe et al., 2014).

Another frequently reported barrier was the lack of client initiative in the preconception stage to discuss pregnancy planning or pre- conception health due to unplanned pregnancies and lack of awareness (Bortolus et al., 2017; Chuang et al., 2012; Coll et al., 2016; Fieldwick et al., 2017; Heyes et al., 2004; Mazza et al., 2013; McPhie et al., 2016; Morgan et al., 2004; Ojukwu et al., 2016; Poels et al., 2017a, 2017b; Schwarz et al., 2009; Stephenson et al., 2014; van Voorst et al., 2016). The perception of women as main initiators of a dialogue about preg- nancy planning and preconception health may result from the belief that PCC is the responsibility of others, including women’s responsi- bility (Goossens et al., 2014). Another explanation is that HCPs hesitate to pose personal questions about women’s reproductive plans because they belief these questions are sensitive or embarrassing. Yet, literature suggests that the majority of clients appreciate a discussion about their reproductive plans and health (Stern et al., 2013). In addition, the re- search of Wendt and colleagues suggests that women may experience difficulties in raising a conversation about sexual health issues them- selves, and therefore, would find it easier if a HCP would initiate a dialogue about these matters (Wendt et al., 2007).

Limited resources were frequently reported barriers at the organi- zational and societal level. At the organizational level, lack of time was found to be a major barrier for the provision of PCC. Previous research also identified lack of time and heavy workload as one of the most important factors that prevented HCPs from providing health promo- tion and prevention (Luquis and Paz, 2015). A study in six European countries found that mean consultation length in general practices was 10.7 min (Deveugele et al., 2002). Given the restricted amount of time, the opportunities to discuss preconception health promotion may be limited, as physicians need to spend their time discussing more urgent care issues. A possible solution to lack of physician time is to use a team-based PCC approach in which midwives and nurses, and health educators are responsible for general preconception health promotion, and advanced nurse/midwife practitioners and physicians address the more complicated cases.

Lack of reimbursement for PCC, tools and guidelines were the main

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societal barriers for the provision of PCC. These barriers were also frequently reported in other studies on factors influencing the provision of preventive health services and health promotion (Luquis and Paz, 2015). Clear evidence-based guidelines, and education materials and tools might support the provision of PCC.

This systematic review has some limitations. First, a number of methodological issues and potential biases were identified in the in- cluded studies. More than half of the quantitative studies had a con- siderable risk of selection bias due to low response rates (Bonham et al., 2010; Fieldwick et al., 2017; Tough et al., 2007, 2004; Tough et al., 2008, 2006; van Voorst et al., 2016) and convenience sampling (Miranda et al., 2003). Furthermore, only two quantitative studies used a validated and reliable data collection method (Baars et al., 2004; Miranda et al., 2003), and only Morgan et al. (2004, 2006) and Tough et al. (2006, 2008) performed a sample size or power calculation. Some of the qualitative studies had a relatively small and heterogeneous sample of HCPs (Bortolus et al., 2017; Coll et al., 2016; Mortagy et al., 2010; Ojukwu et al., 2016), and a rather short interview duration (Coll et al., 2016; McPhie et al., 2016). In addition, the authors critically considered their role as researcher and the potential bias and influence during the data collection in only two qualitative studies (McPhie et al., 2016; Poels et al., 2017a, 2017b). The aforementioned methodological concerns may affect the validity of the study findings. Second, physi- cians (e.g. GPs and obstetricians-gynaecologist) were overrepresented in this review with 14 studies focusing on physicians only (Abu- Hammad et al., 2008; Baars et al., 2004; Bonham et al., 2010; Burris and Werler, 2011; Chuang et al., 2012; Fieldwick et al., 2017; Mazza et al., 2013; Miranda et al., 2003; Morgan et al., 2004, 2006; Ojukwu et al., 2016; Power et al., 2013; Tough et al., 2007, 2006), and 16 studies included both physicians and non-physicians healthcare provi- ders (e.g. midwives and nurses) (Archibald et al., 2016; Bortolus et al., 2017; Coll et al., 2016; Heyes et al., 2004; M’ Hamdi et al., 2017; McClaren et al., 2008; McPhie et al., 2016; Mortagy et al., 2010; Poels et al., 2017a, 2017b; Poppelaars et al., 2004; Schwarz et al., 2009; Stephenson et al., 2014; Tough et al., 2004, 2008; van Voorst et al., 2016; Williams et al., 2006). Because most findings relate to physicians, findings might be less generalizable to non-physician healthcare pro- viders including midwives and nurses. It is possible that nurses and midwives experience other barriers and facilitators influencing the provision of preconception care. In addition, due to heterogeneity in study characteristics, including content of PCC (PCC in general or a specific care domain), target population (general population or sub- groups of the population), study country, and healthcare setting, find- ings may be less generalizable to a broader context. Third, this het- erogeneity in methodology and content of PCC made it impossible to perform a meta-analysis, which would have allowed us to learn more about associated factors of the provision of PCC. Finally, we did not search for grey literature. Therefore, it is possible that some studies might have been missed due to publication bias.

To overcome the different client, provider, organizational, and so- cietal barriers, it is necessary to develop and implement multilevel in- terventions (Eldredge et al., 2016). At the client level, developing and implementing preconception mass media campaigns with e.g. posters, leaflets, TV spots, mobile applications, and evidence-based websites could improve people’s attitude, awareness, and knowledge about preconception health (Poels et al., 2017a, 2017b; Toivonen et al., 2017). However, this does not guarantee a preconception lifestyle change (Delissaint and McKyer, 2011; Toivonen et al., 2017). There- fore, it is important to gain insight in which determinants are associated with the intention to prepare for pregnancy (Toivonen et al., 2017). The study of intentions to prepare for pregnancy may also be more en- lightening than measuring knowledge or attitude alone to assess the effectiveness of a preconception campaign (Toivonen et al., 2017). In addition, most preconception interventions focus on women only (Toivonen et al., 2017). Yet, preconception health is considered as a shared responsibility between women and men, therefore, future

research should target both future parents (Toivonen et al., 2017). At provider level, there is a need to define the role and responsibility of the different HCPs in providing PCC. A team-based PCC approach with general PCC provided by nurses and midwives, and specialized in- dividual PCC provided by advanced nurse/midwife practitioners and physicians should be further explored. In addition, further research should be undertaken to investigate barriers and enablers to provide PCC among non-physician HCPs (e.g. midwives, nurses, health educa- tors) as none of the included studies focused solely on factors influen- cing the provision of PCC by these HCPs. At organizational level, our findings suggest that the development of education materials and tools could facilitate the provision of PCC. The Reproductive Life Plan (RLP), a tool for reproductive health promotion across the life span, might be a feasible tool for promoting reproductive and preconception health in primary care settings, such as student health centres, STD clinics, and community health centres (Stern et al., 2013). Preconception inter- ventions should also be delivered through non-medical channels, for example, through school-based education programs. By integrating preconception health and care in existing sexual health education, the vast majority of the population could be reached. At societal level, the provision of preconception care can be encouraged by developing clear evidence-based guidelines and reimbursing PCC.

Funding

This work was supported by The Research Foundation – “Flanders (FWO) (grant number G058113N)”.

Appendix A. Supplementary data

Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.ijnurstu.2018.06.009.

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