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Abstract
Background Unhealthy lifestyle is responsible for many chronic conditions, and antenatal engagement with women about lifestyle behaviours can be too late to prevent some adverse pregnancy outcomes and subsequent childhood risks. To reduce the risk of future adverse outcomes, the interconception period is an opportunity to implement positive health changes. The aim of this scoping review was to explore women’s needs for lifestyle risk reduction engagement during the interconception period.
Methods The JBI methodology guided our scoping review. Six databases were searched for peer-reviewed, English-language research papers published between 2010 and 2021 on topics including perceptions, attitudes, lifestyle, postpartum, preconception and interconception. Title-abstract and full text screening was independently undertaken by two authors. Included papers’ reference lists were searched to find additional papers. The main concepts were then identified using a descriptive and tabular approach.
Results A total of 1734 papers were screened and 33 met our inclusion criteria. Most included papers (82%, n=27) reported on nutrition and/or physical activity. Papers identified interconception through postpartum and/or preconception. Women’s self-management needs for lifestyle risk reduction engagement during interconception included: informational needs, managing competing priorities, physical and mental health, self-perception and motivation, access to services and professional support, and family and peer networks.
Conclusions There is a range of challenges for women to engage in lifestyle risk reduction during interconception. To enable women’s preferences for how lifestyle risk reduction activities can be enacted, issues including childcare, ongoing and tailored health professional support, domestic support, cost and health literacy need to be addressed.
- patient preference
- patient participation
- reproductive health
- reproductive health services
- reproductive behavior
Data availability statement
No data are available.
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- patient preference
- patient participation
- reproductive health
- reproductive health services
- reproductive behavior
WHAT IS ALREADY KNOWN ON THIS TOPIC
Antenatal and preconception lifestyle risk reduction can be too late for outcomes related to behaviour change to occur.
WHAT THIS STUDY ADDS
Initiatives targeting lifestyle risk reduction activities during interconception need to consider life stage demands to support engagement. Health professionals, family and peer networks are important for the enablement of lifestyle risk reduction participation.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Women preferred knowledgeable and supportive sources of information about lifestyle risk reduction enhanced engagement. Discussions and opportunities for self-management in lifestyle risk reduction need to be ongoing, person-centred and consider women’s social determinants of health, autonomy, and family needs.
Introduction
To support the reduction of adverse outcomes on mother and child, lifestyle risk reduction measures are integrated into international preconception and pregnancy care recommendations.1 2 However, women’s awareness of preconception health optimisation is low3 and antenatal engagement about lifestyle risk reduction can be too late to prevent some outcomes such as low birth weight associated with smoking, or fetal alcohol syndrome associated with harmful alcohol intake.4 The interconception period, applying to those who have previously been pregnant and could be so in the future,5 provides an opportunity for the prevention of lifestyle risks. However, it is also a time when there are challenges for dedicated engagement in lifestyle risk reduction due to factors such as balancing work and caring responsibilities.6
As maternal age and parity increase, so too does the potential impact of lifestyle risks.7 Increased maternal age can negatively impact maternal and fetal health during pregnancy due to the physiological changes that occur and the risk of adverse outcomes from conditions such as pre-existing or gestational hypertension and weight gain.8 Lifestyle risk factors such as tobacco use, unhealthy diet, harmful alcohol intake, and inadequate physical activity are modifiable and can lead to non-communicable disease (NCD) morbidity and mortality if left unchecked.9 For example, an increased body mass index is a substantial risk factor for the recurrence of gestational diabetes mellitus (GDM), enhancing risks for maternal pre-eclampsia and neonatal hypoglycaemia.10 There are also increased risks of birth defects from nutritional deficits secondary to short pregnancy intervals.11 In addition, smoking is responsible for NCDs such as emphysema and cardiovascular disease,12 where exposure during pregnancy can have childhood impacts including asthma and obesity.13
A life course approach, or the prevention and control of NCDs at many stages of life,14 can be supported by ‘teachable moments’ for behaviour change15 before and beyond antenatal care. The integration of interconception care into routine practice is recommended by the international literature but is known only to occur opportunistically, for example, as part of post-partum or child health visits.16 17 In the context of the appreciation of barriers to behaviour change and not stigmatising women about lifestyle risks, clinician involvement can create opportunity for lifestyle risk reduction discussions. However, access to care is often geared to the needs of the child(ren) and is affected by perceived need, and social and demographic factors.5 18
Understanding women’s preferences for engagement in lifestyle risk reduction is therefore necessary to improve self-management, quality of care and the capacity of services to support lifestyle risk reduction during the interconception period. Indeed, self-management requires problem solving, decision making, the utilisation of resources, partnership with healthcare providers, and self-tailoring actions.19 While there is evidence of the barriers, enablers and importance of understanding the determinants of lifestyle change on preconception health,20 we undertook a scoping review focused on understanding women’s perceptions of how lifestyle risk reduction could occur during interconception.
Methods
This review was reported against the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.21 While a protocol for the review was not registered, the JBI (formerly Joanna Briggs Institute) approach was used to inform the scoping review process.22
Search strategy
Research question: What are women’s needs for lifestyle risk reduction engagement during the interconception period?
The review aimed to:
Understand women’s needs for lifestyle risk reduction during the interconception period
Understand how women engage in lifestyle risk reduction during the interconception period.
Given the complexity of identifying interconception literature as a distinctive lifestage, we undertook a preliminary search of the literature in Prospero, Figshare and Open Science Framework to inform our search strategy. This resulted in a comprehensive search strategy to capture women’s experiences during this time period and included search terms such as postpartum, preconception and interpregnancy (online supplemental table S1). Although particular lifestyle topics were not searched, we were interested in identifying relevant topics from a breadth of literature that included smoking, nutrition, alcohol and physical activity. Following librarian consultation, search term piloting and finalisation, we searched six databases: Cinahl, Cochrane interventions, Embase, MEDLNE, PsycInfo, and Scopus. We identified English-language, peer-reviewed international literature about women of reproductive age, who had at least one pregnancy, about their needs for lifestyle risk reduction. Changes to the search strategy were made based on database-specific keywords. Given the research focused on women’s perceived needs for lifestyle risk reduction during interconception, we felt peer-reviewed studies would provide richer data, so the searching of grey literature was not undertaken. Studies relating to lifestyle risk reduction during pregnancy, or where data from postpartum participants could not be extracted, were excluded from the review. To reflect contemporary challenges for women engaging in lifestyle risk reduction, only papers published between 1 January 2010 and 29 September 2021 were included.
Supplemental material
Source of evidence screening and selection
We collected search results in EndNote X9 and uploaded to Covidence (online screening tool) for duplicate removal and screening. Title-abstract and full text screening was independently undertaken by two authors (SJ, JM). The discussion of conflicts was done at each screening stage and there was no need for third author review. Following review of papers in full text, we then undertook hand searching of included papers’ reference lists to find additional papers. In keeping with the scoping review approach, that is, to map available evidence,23 a critical appraisal of included papers was not undertaken.
Data extraction
A data extraction form was developed and piloted by the screening authors. Data from each paper were extracted and we summarised these based on the research aim and inclusion and exclusion criteria.
Analysis and presentation of results
Results have been presented visually as a map of extracted data, in a table and through descriptive summaries. Following upload to NVivo 1.3, the descriptive summarisation of included papers’ key findings relating to the review’s aims was done by SJ. JM and SJ independently coded concepts from five papers. Concepts derived from descriptive summarisation of all papers were then verified by JM.
Results
Database searching yielded 1734 papers for screening. Following screening, 33 papers were included in the review (figure 1). Most papers were from high-income countries (n=31; 94%), such as the USA (n=12, 36%), followed by Australia (n=7, 21%) and the UK (n=5, 15%). Only two papers were from middle-income countries such as Turkey (n=1, 3%) and Egypt (n=1, 3%). Of the included papers, 28 (85%) were qualitative (interviews or focus groups), and five (15%) were mixed-methods studies (interviews and surveys or physical, mental health or behavioural assessment tools) (online supplemental table S2).
Supplemental material
PRISMA diagram showing the literature screening process. PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.|
Study characteristics
Most included studies addressed aspects of interconception through the preconception or postpartum periods. Only one paper addressed both the preconception and postpartum periods. No papers discussed interconception lifestyle risk reduction as a concept. While most papers discussed postpartum lifestyle risk/s (n=30, 91%), few addressed the needs of multiparous women during preconception (n=2, 6%).
Most papers reported on nutrition and/or physical activity (n=27, 82%). Of these, findings primarily focused on weight management and GDM or type 2 diabetes mellitis (T2DM). Only three (9%) papers addressed smoking, with a focus on the postpartum stage of interconception. No papers discussed women’s perceptions of alcohol risk reduction during interconception.
From participant responses and outcomes identified in the included papers, factors affecting engagement in lifestyle risk reduction during interconception included: informational needs, managing competing priorities, physical and mental health, self-perception and motivation, access to services and professional support, and family and peer networks (figure 2). Family and peer networks, and access to services and professional support, were the most frequently identified self-management need for lifestyle risk reduction (figure 3).
Factors affecting engagement in lifestyle risk reduction during interconception.
Number of papers addressing lifestyle risk and women’s perceived engagement need.
Informational needs
Included papers identified the need for additional and targeted information for women to support lifestyle change.24–26 Participants in included papers wanted to understand the benefits of lifestyle risk reduction,27–30 and ongoing risks of lifestyle habits24 31–33 and chronic conditions6 28 32–35 on mother and child, and guidance about when and how lifestyle risk reduction should occur following birth.27 31 Examples of this related to culturally appropriate information,33 education or advice about meal planning,29 36 37 healthy meals,29 30 33 and physical activity.32 33 The way information was conveyed to participants was found to be important. For example, information can be unclear32 or perceived to be rushed and relate to pregnancy, rather than maternal or childhood long-term outcomes.33
Managing competing priorities
The ability to undertake lifestyle risk reduction related to competing priorities, largely around time6 24–26 28 29 36–44 and finances.24 29 36 37 40 43 Time and finances also had an impact on decisions relating to food access,36 44 choices36–39 44 and preparation,28 36 39 44 and engagement in physical activity.28 32 37 42 Strategies to overcome these challenges included organisational tips for meal planning and exercise29 as well as replacement activities instead of smoking.45 46 The ability to balance lifestyle risk reduction with demands such as caring or family responsibilities,25 37 38 40 43 47 48 accessing health care,6 25 33 40 43 46 and work6 38 also had an impact on prioritisation. The extent of these impacts varied, depending on postpartum stage.32
Physical and mental health
Participants’ postpartum mental and physical health was perceived to be worse than pre-pregnancy.25 Challenges included depression,26 38 healing or managing pregnancy complications,25 49 caesarean section,26 38 child ill-health,41 46 processing being a mother,41 46 49 and loneliness (for overseas-born women).33 Recovery time after delivery31 44 and support was deemed necessary to address these issues.35 41 42 46 Recovery after having a baby affected the woman’s ability to participate in lifestyle risk reduction activities.31 47 Cultural practices of rest were found to support this recovery time in the postpartum period, but also had an impact on opportunities for weight loss.26
Papers identified the mental health benefits of lifestyle risk reduction, particularly regarding diet and physical activity improvement. This included improvements in energy levels,36 37 42 mood,42 48 stress42 48 and motivation.42 However, perceived capabilities in initiating and maintaining behaviour change were also related to fatigue29 32 33 36 37 40 42 50 and stress39 49 50 as well as pelvic floor dysfunction40 42 and breastfeeding needs.39 41 42 51 For overseas-born women, consuming culturally valued high calorie foods assisted in the promotion of breastfeeding, recovery and homesickness.33 However, this created challenges when following dietary recommendations following GDM.33
Self-perception and motivation
Women’s concerns about body image post-pregnancy were identified in some papers.40 50 Following the birth of a child and change in body shape, there was a loss of confidence and self-esteem25 38 40 41 compounded by perceptions of societal expectations about how women should look.37 Many papers described a lack of motivation as having an impact on lifestyle risk reduction engagement.26 28 39 40 42 However, engaging in weight loss activities was encouraged by positive reinforcement,50 compliments38 as well as gains in self-esteem.26 42 47 Women wanted to improve their health or prevent future health conditions such as T2DM.25 26 28 29 47 While returning to a pre-baby body size44 or looking healthier32 47 served as a motivator for lifestyle risk reduction, so too did social and family support,26 34 44 returning to work39 and accountability or goal setting.26 29 40 48 52 A mother’s motivation to enact a healthy lifestyle to benefit family health was seen in papers identifying benefits to lactation and infant health25 46 51 and through a desire to role model healthy lifestyle behaviours.25 26 28 29 32
Access to services and professional support
Transport access to clinical support, food or exercise opportunities affected engagement in lifestyle risk reduction.29 44 46 To tackle obstacles such as work or caring responsibilities, the included papers presented options for addressing lifestyle risk reduction service issues of flexibility and engagement. This included home-based programmes,27 36 42 face-to-face,6 29 31 34 or a mixture of both31 that considered family routines, were in close proximity to other services such as the family doctor,31 involved children,30 or where childcare arrangements were available27–30 32 34 36 40 48 and affordable.30 32
Ongoing support for lifestyle risk reduction was valued but the timing of commencement varied from 2 to 12 months postnatally.30 32 53 Consultations about lifestyle risk reduction could occur in conjunction with, or separate to, postpartum visits.29 31 However, a lack of health professional or lifestyle coach support after delivery,25 40 health system fragmentation33 43 and communication approaches about lifestyle risk impacted women’s engagement. These communication approaches about lifestyle risk reduction were found to require discussions that were tailored,26 30 32 35 non-judgemental,30 36 honest30 and culturally appropriate,6 33 41 and considered the use of medical terminology.30 One-on-one support33 40 and communication from clinicians who had experience working with women who have had lifestyle risks and pregnancy complications was deemed beneficial.31 Adjunctive roles of technology6 26 29 32 36 42 48 52 such as text messaging,29 phone-calls52 and apps49 were also suggested, provided communication was tailored31 and on a secure platform.31 However, technology could be less motivating and personal than face-to-face advice.31
Family and peer networks
Women wanted access to peer and family support to engage and sustain lifestyle risk reduction. This was found to occur socially or as part of coordinated activities for lifestyle risk reduction such as group physical activity or support groups for physical activity, smoking cessation, weight reduction, and diabetes and cancer prevention.26 27 29 32 35–37 40 46 49 52 54–56 Online peer networks were valued,6 provided these were supportive environments and content was evidence-based or moderated by health professionals.42 49
Family and partner support were also necessary for childcare, encouragement for and the creation of environments that enabled smoking cessation, as well as diet and exercise modifications.32 36 38–41 43 45 46 55 56 For example, one study in Australia revealed that overseas-born women were less likely to receive domestic chore support from partners to enable them to engage with lifestyle risk reduction activities.33 Environments that supported lifestyle risk reduction also occurred where behaviour change ‘with’ peers, family or partners was undertaken.6 36 38 Removing the emotional burden of leaving children with others outside of the family supported lifestyle risk reduction activities.28
Discussion
This scoping review explored women’s needs for lifestyle risk reduction and their engagement in this during the interconception period. Most included studies in our review involved participant views of interconception lifestyle reduction through the preconception and/or postpartum periods, and none discussed ‘interconception’ as a concept. The language is made particularly complex as a range of terms and definitions may be used to describe these periods of time, and some definitions of interconception care also use the term preconception.57 However, to realise fully population health, there is a need for consistent preventive services across the life course,57 including during the interconception period. While we know the interconception period presents an opportunity to provide education regarding optimal pregnancy spacing, provide postpartum contraception and consider lifestyle risk factors, implementation of this in reality can be challenging17 and therefore requires a multifaceted approach.
Income (influencing food insecurity and physical activity engagement), health literacy, and access to healthcare were social determinants of health affecting the interconception period found in this review. Social determinants of health account for 30–55% of health outcomes.58 NCDs occur as a result of behaviours (such as lifestyle), and environmental, physiological and genetic factors.59 It is estimated that 86% of deaths attributed to NCDs occur in low- and middle-income countries where increases in NCDs are compounded by the social determinants of health through the impact of illness on loss of income, poverty, and limited access to affordable health care.59 Broader public policy initiatives are also needed to support lifestyle risk reduction such as through the impact of unplanned urbanisation on active transport and the aggressive marketing of products such as tobacco and unhealthy foods.
Papers included in this review suggest that family and peer networks can create opportunities for lifestyle risk reduction through family/peer involvement in the lifestyle risk reduction activities, caring responsibilities and domestic support. Enabling environments at home and/or work do form part of the solution of how women reduce lifestyle risk, provided that competing priorities such as time and cost are also considered. Traditional gender roles can fragment women’s opportunities for a healthy lifestyle, particularly where there is little partner or family support, paid work occurs in the home alongside domestic and caring responsibilities, or in roles where there is low decisional latitude.60 While returning to work after having a baby was found to be one motivator to lifestyle risk reduction, this may not occur for all women. Enabling commercial determinants of health established through the workplace, such as encouraging physical activity interventions, improve a woman’s physical activity and their weight-related outcomes.61 For example, organisational support for physical activity could mitigate cost and time concerns through appropriate living wages, and the allocation of time and financial incentives to attend places where physical activity can occur.
This study highlighted the value women placed on person-centred approaches by health professionals to supporting women’s health literacy and capacity for engagement in lifestyle risk reduction. Lifestyle interventions that are culturally tailored can be effective in supporting behaviour change.62 However, a lack of organisational and funding support and role clarity can lead to hesitancy in initiating lifestyle risk conversations.63 To develop health professional confidence in non-judgemental lifestyle risk reduction discussions, a concerted approach to tertiary training, health policy, and workplace support is required to facilitate the time needed for behaviour change interventions in practice.64 65 This includes the skills and resources necessary for behaviour change consultation opportunities to occur across the life course, supporting women’s autonomy, and developing the trust, rapport, and the relational and temporal continuity needed between health professionals and patients for discussions about lifestyle risk reduction.63
Our search strategy for this review included papers from 2010, reflecting the contemporary challenges for women to engage in lifestyle risk reduction including balancing employment and family responsibilities. However, it is possible that key literature before this time may have been excluded. The challenges conceptualising interconception terminology in the literature could be perceived as a limitation to conducting this review. A breadth of study designs and interconception stage key words were used to mitigate this. While there was also an absence of papers about alcohol consumption, the study sought to understand broadly women’s perceptions of reducing lifestyle risk during interconception. In addition, when trying to capture papers focusing on the postpartum stage where changes to chronic disease risk affected by age and parity can occur, it is possible that participants who did not have further children may have been included.
In keeping with the JBI approach to scoping reviews,22 included papers were not appraised for strength or quality. Instead, a descriptive summarisation of current literature is presented. The exclusion of grey literature may be a limitation and it is possible that while international primary literature was included in the search strategy, content from low socioeconomic status countries may have been included from grey literature sources. However, given the focus of the review on women’s preferences, we feel that the availability of grey literature would be limited.
Conclusions
Addressing population-based needs for lifestyle risk reduction requires a multifaceted approach throughout the mother’s lifespan. Lifestyle risk reduction support during interconception is needed with additional and targeted information, time and finances, postpartum physical and mental health, self-perception and motivation, access to services such as transport and health professionals, and family and peer networks. Our review found that enabling networks and services that support self-management are key to how women engage in lifestyle risk reduction activities during interconception. For example, family and peers enable lifestyle risk reduction through childcare, encouragement and domestic support. In addition, healthcare professionals can support women’s decision making and capabilities for lifestyle risk reduction through the incorporation of knowledgeable, supportive and tailored information and communication techniques. Future research should consider the ongoing opportunities health professionals can have to enact person-centred lifestyle risk reduction across the interconception period.
Additional educational resources
Kandel P, Lim S, Pirotta S, et al. Enablers and barriers to women’s lifestyle behaviour change during the preconception period: a systematic review. Obesity Reviews 2021.
World Health Organization. Preconception care. 2014. https://apps.who.int/iris/handle/10665/205637 [Accessed 21 July 2022].
World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva, Switzerland, 2016.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @Sharon_MJames, @jessicamoulton_, @anisaassifi, @jess_botfield, @MarkHansonUoS, @Danielle_Mazza
Contributors SJ conceived, planned and carried out this review and took part in all stages from planning to submission. SJ and JEM conducted the the screening of papers and analysis for the review. SJ, JEM, JB, AA, KB, MH, DM contributed to the interpretation of findings and writing of the manuscript. All authors proofread and signed off on the article prior to submission.
Funding Funding for this scoping review was received from a National Health and Medical Research Council SPHERE Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care seeding grant, within the Department of General Practice, Monash University, Australia.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.