Veronique Maas

Despite major advances in clinical research and medical technology, the prevalence of adverse maternal and neonatal health outcomes in the Netherlands has only moderately decreased over the past decade. While the majority of antenatal care starts between 8 and 10 weeks of gestation, the foundation of most critical organs is initiated earlier, thus, preventive efforts should be initiated as early as possible, preferably prior to conception. Considering the high incidence of unhealthy lifestyle behaviours among the reproductive population and the low awareness regarding these risk factors for adverse pregnancy outcomes, the periconception period provides a window of opportunity to intervene. Hence, preconception care (PCC) has been introduced as a means to enable prospective parents to improve unhealthy lifestyle behaviours and offers an opportunity for timely reproductive choices regarding genetic risks before pregnancy. Evidence on the effectiveness of PCC is necessary to affirm the urgency to structurally embed PCC within Dutch healthcare. In Chapter 1, PCC is introduced as an instrument to encourage prospective parents to actively prepare for pregnancy and to change unhealthy preconceptional lifestyle behaviours. It also states the overall aim of this thesis to explore and evaluate 1) the implementation of a new and innovative PCC-approach within multiple municipalities and 2) its effect on preconceptional lifestyle behaviours and reach among prospective parents and healthcare providers.

This thesis was based on research performed within the APROPOS-II study, a stepped wedge cluster randomised controlled trial. This study was conducted between 2018 and 2021 within six municipalities in the Netherlands. This thesis reported on both the pre-implementation research (Part I; Chapters 2 – 5) as well as the development and evaluation of the PCC-approach (Part II; Chapters 6-8).

Part I – Pre-implementation research
The study presented in Chapter 2 evaluated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle behaviours. In this secondary analysis of a prospective multicentre cohort study in the Netherlands, 3,684 pregnant women were included. Results of this study showed that women who are overweight, and especially those who are obese, have the highest odds of developing any adverse pregnancy outcome (adjusted odds ratio (aOR) 1.61 (95% Confidence Interval (CI) 1.31-1.99) and aOR 2.85 (95% CI 2.20-3.68), respectively), particularly gestational hypertensive disorders and diabetes. These results also indicated that smoking cessation, having a normal body mass index (BMI) and initiating folic acid supplements preconceptionally may decrease the risk of adverse pregnancy outcomes.

Research in Chapter 3 explored how preconceptional lifestyle behaviours and actively preparing for pregnancy were associated with planned pregnancies and health beliefs. A total of 1,077 pregnant women from midwifery practices within six municipalities in the Netherlands participated in this study by administering a single questionnaire in the first trimester of their pregnancy. Based on the London Measure of Unplanned Pregnancies, over 85% of women in our cohort experienced a planned pregnancy. However, despite consciously planning their pregnancy, most women did not adhere to preconceptional lifestyle behaviour recommendations; 69.5% of women with planned pregnancies adequately used folic acid supplements and 50.5% of women consumed alcohol at any point during pregnancy. We demonstrated some interchangeable associations between preconceptional lifestyle behaviour change, planned pregnancies and health beliefs (based on 14 statements e.g. ‘there are too many rules for a healthy pregnancy’). We also showed that the pregnant women in our study tended to overestimate their own health status, since most women who agreed with the health belief that they are ‘healthy enough and don’t need PCC’ still exhibited many preconceptional risk factors. Therefore, women’s health beliefs and overestimation of their health status seemed to interfere with actively preparing for pregnancy.

While most PCC-interventions are aimed at women, men are also in need of PCC to reduce risk factors affecting their sperm quality, since enhancing men’s biological and genetic contributions to the conception can lead to improved pregnancy outcomes. The objective of Chapter 4 was to explore male perceptions regarding the need to engage in PCC. Using a mixed-methods study design, 229 men were included in our study by filling out a questionnaire and 14 of these men were interviewed to gain more insights into their motives to actively prepare for pregnancy. The majority of men (59.0%) did not retrieve any PCC-information before conception nor visited a health care provider for a PCC-consultation (79.5%), hence they expressed a low need for PCC. While several interviewed men expressed their fear for infertility, this did not lead to increased uptake of PCC as men felt they were healthy enough already. Finally, men proposed several channels (e.g. podcasts, radio ads or social media) to reach prospective fathers with PCC-information. Tailoring preconceptional information towards male needs was suggested to provide a window of opportunity to improve men’s reproductive health and possibly the health of future generations.

Despite the development of several national guidelines, risk assessment tools, and recommendations by the Dutch government, no programmatic PCC-program has yet been implemented and only a few healthcare providers currently provide PCC. The study in Chapter 5 explored healthcare providers’ views on improving PCC in their municipality. A total of 10 working conferences were hosted, aimed to educate healthcare providers on preconceptional risk factors and conduct a local analysis of barriers and facilitators for implementing PCC. This resulted in a cohort of 250 multidisciplinary healthcare providers who filled out a questionnaire and participated in workshops. While almost all healthcare providers agreed that general practitioners and midwives are best positioned to provide PCC-consultations, many other professions (e.g. preventive child healthcare professionals) were also suggested to contribute to improved PCC-awareness. Still, approximately 1 in 7 midwives (strongly) disagreed with the statement that it is part of their job to provide PCC-information to couples with a wish to conceive. During the regional bottleneck analyses, healthcare providers expressed their desire to share the responsibility to provide PCC-consultations among multiple disciplines related to women’s healthcare.

Part II – Development, implementation and evaluation of a locally tailored preconception care intervention.
Social marketing is an emerging discipline since the 1970s when marketing strategies - then successful in selling products and services to consumers - were also started to be used to promote socially beneficial ideas, attitudes and behaviours. Social marketing strategies are suggested to potentially improve preconceptional lifestyle behaviours. The aim of Chapter 6 was to describe the development of a PCC social marketing strategy based on eight benchmark criteria of the National Social Marketing Centre for effective social marketing. In-depth insights of all benchmarks were analysed and incorporated during the development process of a new PCC social marketing strategy. With a special focus on the application of the ‘Health Belief Model’ (benchmark 3) and ‘the Four-P framework’ (benchmark 8), this formative research resulted in the development of the Woke Women® strategy, empowering women to actively prepare for pregnancy.

A previous feasibility study (APROPOS) conducted by our group in a single municipality of the Netherlands demonstrated that a locally tailored PCC-intervention could potentially improve preconceptional lifestyle behaviours and increase the use of PCC among prospective parents. Therefore, we designed a second study (APROPOS-II) with implementation in more municipalities, a larger group of respondents, randomization, assessment of a more comprehensive set of (clinical) outcomes and the implementation of a social marketing strategy (Woke Women®). Chapter 7 extensively describes the protocol of the APROPOS-II study, a stepped-wedge cluster-randomized controlled trial in four municipalities in the Netherlands, which aimed to assess the effectiveness and the implementation process of a local PCC-intervention on preconceptional lifestyle behaviours and the reach of PCC among prospective parents and healthcare providers. The intervention contained a dual-track approach and focused on both the uptake of PCC (the prospective parents) and on the provision of PCC (healthcare providers). The target population was reached through a large campaign week during which the Woke Women® campaign was launched with lots of media attention and innovative channels e.g. social media and local ambassadors. To improve interdisciplinary collaboration among healthcare providers, a working conference was organised, followed by the formation of a local stakeholder coalition that tailored the local care pathway including interdisciplinary arrangements for collaboration to their own municipality.

The results of the APROPOS-II study are presented in Chapter 8. The primary outcome for women was adherence to ≥3 preconceptional lifestyle recommendations, i.e. early initiation of folic acid supplements, no smoking nor alcohol use, and healthy nutrition (adequate vegetable, fruit and caffeine intake). Results showed some positive effects as prospective parents in the intervention phase were more prone to actively prepare for pregnancy and change preconceptional behaviours, especially vegetable intake (Relative Risk (RR) of 1.82 (95% CI 1.14 - 2.91)). The primary outcome only showed a statistical difference among women participating in the municipality where the awareness of the intervention was highest (RR 1.57; 95% CI 1.11–2.22). In the intervention phase, more men made a preconceptional lifestyle behaviour change compared to men in the control phase (RR 1.89; 95% CI 0.94–3.78). Not only data on preconceptional (lifestyle) behaviours among prospective parents was collected through questionnaires, implementation outcomes were likewise collected through healthcare providers and data from our online platforms. While the increased website visits in the intervention phase were closely associated with the campaign weeks, social media showed to be a more consistent medium to reach the target population in all municipalities simultaneously. Finally, healthcare providers in the intervention phase were significantly more aware of the recent