Knowledge And Practice of Preconception Care Among Women of Reproductive-Age in Bheerkot Municipality, Nepal

The research design used in this study was descriptive cross-sectional, using a quantitative data approach. The study mainly focused on women between the ages of 15 and 49 who are part of the reproductive age group and reside in the Bheerkot Municipality, Syangja District of Nepal.

We calculated a sample size of 215 participants using the total population of Bheerkot Municipality (N) = 6981, with a 95 % confidence interval (CI).

Total number of reproductive age group (15-49) women in all wards of Bheerkot Municipality (N) = 6981 (NDHS report, 2022)

Z= Standard normal variable at 95% confidence interval (1.96)

P= Estimated proportion = 15.42% so, p =0.154 ^7,9,13

q = (1-p) = 1- 0.154 = 0.846

d = 0.05 (5% margin of error)

Using the formula for calculating sample size,

Now, putting the value, we get

n = 195

Non-response rate is 10%

Final sample size = n + 0.1*n =195+ 0.1*195 =215

Thus, the final sample size is 215.

We randomly selected three wards using the simple random sampling technique (lottery method) from among nine wards of the Bheerkot Municipality in Syangja District. We calculated the number of samples from each ward (Ward One = 100 samples, Ward Six = 56 samples, and Ward Seven = 59 samples) to ensure equal representation using proportionate sampling.

A face-to-face interview was conducted for data collection using a structured questionnaire designed in the Nepali language. The questionnaire comprised three sections: Socio-demographic, knowledge-related information, and practice-related information on preconception care. A literature review ^{13, 15} was used to develop tools and categorize knowledge and practice levels.

The data collection tool (questionnaire) and techniques were cross-checked and verified by the supervisor and pretested on a 10% similar target group of homogeneous settings at Walling Municipality. The content validity ratio (CVR = 0.83) and content validity index (CVI = 0.75) confirmed the content validity of the questionnaire. The research was conducted under the close guidance of the research supervisor.

The data collected were reviewed carefully for completeness, coding, and editing and combined into a single dataset. The data was entered into Epi-data V3.1 and exported to IBM SPSS V21 for analysis. In a statistical analysis, we employed the Chi-squared test and logistic regression analysis to identify possible predictors using the odds ratio and considered variables with p<0.05 statistically significant at a 95% confidence interval.

Women of the reproductive age group of 15–49 years in Bheerkot Municipality were included. Women who refused to participate or could not answer the questionnaire are exclusive criteria. 

The study period was from April 2022 to November 2022 (8 months). This period was for developing the research design, preparing the data collection tools, analyzing the data, and submitting the final report to the concerned authority.

1. Preconception care: Preconception care refers to a set of interventions aimed at identifying and modifying biomedical, behavioral, and social risks to women's health or pregnancy outcomes through prevention and management before conception.

2. Reproductive-aged women: Reproductive women are those between the ages of 15 and 49, ranging from menarche to menopause.

3. Knowledge of preconception care: The level of knowledge of preconception care is determined by the correct responses to questions provided by the women. A literature review ^{13, 15} was used to categorize knowledge levels. Women's knowledge was measured using 16 questions, with each correct answer earning one point and each incorrect answer earning zero points. The total score ranged from 0 to 16 points.

4. Good Knowledge and Poor Knowledge: Those scoring ≥9 were labeled as having "good knowledge," while those scoring ≤8 were labeled as having "poor knowledge” to preconception care knowledge questions.

5. Practice of preconception care: The practice of preconception care is evaluated based on the respondent's actions towards the services used. A set of 16 questions were scored either '1' (correct) or '0' (incorrect) to determine the minimum and maximum possible total practice scores for each participant, which were '0' and '16,' respectively.

6. Good Practice and Poor Practice: The preconception care practice was categorized as "good practice" (≥9) or "poor practice" (≤8) using the mean practice score as a cutoff point for preconception care practice questions. ^{13, 15}

This study of 215 respondents showed that most were aged 35-49 (63.7%) and had completed secondary education (59.5%). The majority were from nuclear families (78.1%) and earned income from foreign employment (35.8%) or agriculture (28.4%). Over half (54.9%) reported a monthly income of NPR 30000-60000. About 63.7% of the respondents were unemployed. Similarly, of those with pregnancy experience (161 respondents), 64% had one pregnancy, and 36% had two or more. Of those who have ever been pregnant, 6.9% of the respondents experienced their pregnancy under the age of 20 years. However, 62.8% of respondents have access to health facilities less than one hour (on foot) from their residence. (Table 1)

All (100%) respondents had prior knowledge about preconception care, but 25.6% were unsure of its exact meaning or purpose. Among the components of preconception care, most respondents knew about having a balanced diet, avoiding self-medication, testing for STIs, HIV counseling and testing, monitoring weight and blood pressure, and intake of iron tablets. More than half of the respondents (86.5%) got this information from their family/friends. However, they had the least knowledge about Immunization (JE, Rubella, and Hepatitis B) and Prophylaxis (Filariasis, Typhoid, Malaria, and Cholera) with 5.6% and 9.3%, respectively. About 62.8% of the respondents did not have a general understanding of the health problems during pregnancy. (Table 2)

Only 121 (56.3%) of the respondents have practiced preconception, and the majority of the respondents (93.4%) took preconception services from government health institutions. Regarding the reasons for not taking preconception care, 40.4% lacked proper knowledge, and nearly half of the respondents also mentioned not prioritizing preconception care (46.8%) in their families and communities. Among the mentioned components of preconception care, most respondents practiced a Balanced Diet, Avoided self-medication, testing for STIs, HIV Counseling and testing, Monitoring Weight and Blood Pressure, and Intake of Iron Tablets. (Table 3)

Out of the 215 women who participated in the study, only 46.9% (101) had a good knowledge of preconception care. Shockingly, 43.7% (94) of the respondents never practiced preconception care, even a single component. Among the respondents who had practiced preconception care before, only 47.9% (58) reported good practice, while 52.1% (63) reported poor practice. (Table 3, Table 4)

Age of the respondent (χ²=14.2063, P=0.000823), marital status (χ²=17.9851, P=0.000022), time to reach a health facility (χ²=30.1371, P=0.00001), and also age at first pregnancy (χ²=4.7975, P=0.0285) were statistically associated (p<0.05) with knowledge about preconception care. Similarly, the number of previous pregnancies (χ² = 18.406, P = 0.000018), age of the respondent (χ² = 8.337, P = 0.015476), and source of family income (χ² = 10.8392, P = 0.028432) were statistically associated (p<0.05) with preconception care practice. Further, women who have foreign employment as a major source of family income and whose age is from 25 to 34 years were more likely to have a better practice of preconception care than their counterparts (COR 3.5000, CI 1.3343 to 9.1805, P = 0.0109) and (COR 3.4000, CI 1.1646 to 9.9265, P = 0.0252), respectively. (Table 5)

Our study revealed that all (100%) respondents heard about preconception care, which is higher than the previous study (28.63%) conducted in Nepal by Prashansa Gautam and Rojana Dhakal ⁹. The reason could be that the education status at the secondary level in our recent study is higher (59.5%) than in the comparing study (46.62%). However, only 46.9% had good knowledge of preconception care, while 53.1% had poor knowledge in our recent study. This study contradicts the findings of a previous study where the majority (84.58%) had an average level, and only 15.42% had a good level of knowledge ¹³, which is less than our study. The overall preconception care knowledge of reproductive age group women in our study (46.9%) was also higher than studies carried out in Sudan (11.1%) ¹⁷, Iran (10.4%), and Nepal (15.6%) ^{16, 9}. Likewise, in another study from Nigeria, about 65.3% of respondents had an 'average level of knowledge, and only 15.42% had good knowledge of preconception care. ¹⁰ It may be because only married women were chosen ⁹, whereas both married and unmarried women were selected for our recent study, and because the participants' educational levels were also varied. A previous study also showed that the percentage of individuals with PCC knowledge in Japan significantly increased three months after the health education seminar among female workers of reproductive age, and it remained at this level even six months after the education seminar ¹⁴.

Regarding the meaning of preconception care, 35.4% of the respondents mentioned physical examination as the meaning or purpose of preconception care, and 17.2% mentioned health promotion and prevention (immunization), where all options were multiple choice. About 25.6% were unsure of the exact meaning or purpose of preconception care in our study. However, in another study conducted in Kathmandu, 94.5% of the respondents mentioned health promotion as the meaning of preconception care. ⁸ This result also contradicts another study done in Nepal in 2016, where 90.3% of respondents mentioned health promotion as the component or meaning of preconception care, 33.9% mentioned that preconception care is beneficial to promote the health of future children, 80.18% mentioned that preconception care is needed to have a safe pregnancy, 47.15% suggested that preconception care should focus on both married and unmarried people, and 55.94% mentioned the correct answer of preconception care, which is care provided to a couple before conception. ⁹ It clearly shows that there is still some confusion, and rural women are unsure about the meaning and components of preconception care.

Most respondents (73%) mentioned that the preconception period is between pregnancy (after the onset of pregnancy and delivery), and only 43.3 of the respondents mentioned it before pregnancy in our recent study. However, in a previous study, most respondents (81%) said the preconception period is between plans and the onset of pregnancy (about three months before pregnancy), which is the correct answer in our study too. ⁸ This difference might be because the previous study was carried out in urban areas, where social media is widely utilized, but the current study was done in rural areas, where social media is less used. It also clearly shows that the meaning or purpose of preconception care is not clear among reproductive-aged women.

Furthermore, in our study, regarding the benefits of preconception care, 90.7% of respondents mentioned reduced child and maternal mortality, and only 60.9% mentioned it prevented pregnancy complications. However, in a previous study, most respondents (98.4%) mentioned that preconception care is needed for a safe pregnancy, delivery, and healthy newborn, followed by improving the couple's and child's health (83.9%). ⁸ Additionally, more than half of the respondents (86.5%) got this information from their family/friends. In a similar study conducted in the Kaski district by Krishma Giri, less than one-quarter of the respondents (20.5%) got information from the radio/television, whereas 5.5% were from family/friends. ¹³ Thus, we can claim that sensitizing family members regarding preconception care would help to increase maternal and child health promotion in rural Nepal.

Only 56.3% of respondents have practiced preconception care, and almost 43.7% have never practiced it, not even a single component. It is higher than a similar previous study, which revealed that 46.6% of Iranian women who intended to become pregnant followed preconception care. ¹¹ Among the respondents who reported practicing preconception care before, only 47.9% reported good practice, while 52.1% had poor practice in our recent study. This result is also supported by a study conducted in Kelantan, Malaysia, in which 45.2% of women had poor preconception care practices. ¹² In another study on the utilization of preconception care, nearly all (98%) respondents had low utilization, and 2% had high utilization levels of preconception care. ⁸ This is probably because the educational status, employment, and family income levels were higher in our recent study.

Regarding the reasons for not taking preconception care, about 40.4% lacked proper knowledge about it, and nearly half (46.8%) of the respondents also mentioned prioritizing less preconception care in their families and community. It is similar to results from a study conducted among reproductive-aged women in Kaski, Nepal, that showed approximately one-third (37.3%) of respondents mentioned a barrier to preconception care was a lack of awareness, and one-fourth (25%) of respondents mentioned limited access to health services ¹³, which supports the present study. In our recent study, most respondents (93.4%) took preconception services from government health institutions. Most rural people in Nepal cannot afford private health institutions to practice PCC services as needed, where the service cost is relatively higher than that of government health institutions. Unfortunately, government health institutions do not provide a complete package of PCC to reproductive-aged women, and it is difficult to practice as they require it at the local level.

Among the 16 components of preconception care, most (90.1%) of the respondents practiced a proper balanced diet, about 86.8% tested for STIs, 81.8% avoided medicine without a medical prescription, and 80.2% regularly monitored blood pressure as part of preconception care. Moreover, the majority of the respondents (76.9%) used deworming tablets, checked blood sugar levels (65.3%), and supplemented with iron tablets (57.9%), despite only 13.3% having immunization (JE, Rubella, and Hepatitis B) and 11.6% having prophylaxis (Filariasis, Typhoid, Malaria, and Cholera) before pregnancy. This result is supported by the findings of a previous study conducted among women attending appointments at a rural clinic in Kelantan, in which only 7.4% of the respondents consumed drugs without doctors’ advice. ¹² However, in contrast to a study by Khanal et al. conducted among women in Kathmandu, only 19% monitored blood pressure, followed by deworming (18%), checking blood sugar levels (14%), iron tablet supplementation (4.0%), and testing for STI (1.5%). ⁸

The respondent's age, marital status, time to reach a health facility, and age at first pregnancy were statistically highly associated (p<0.05) with knowledge about preconception care. However, it contradicts a previous study, where there was a statistically significant association between the level of knowledge of preconception care and education, occupation, number of children, hearing previously about preconception care, and source of information. ¹³ However, time to reach a health facility was statistically associated with knowledge of PCC in another study. ¹⁵ Similarly, in this study, the number of previous pregnancies, respondent's age, and family income source were statistically associated (p<0.05) with preconception care practice. Furthermore, knowledge and practice of preconception care were also significantly associated with understanding possible health problems during pregnancy.

As it is a new concept in Nepal, there are no specific national policies and protocols to support and emphasize preconception care packages. However, some of the PCC services (checkups or counseling) are freely available (including reproductive planning, folic acid, contraception, family and genetic history, weight monitoring, chronic disease management, social and behavioral history, immunizations, medication, STIs, and physical, sexual, and emotional abuse) in the government health institutions in Nepal. ¹⁸ Somehow, it also tried to address the safe motherhood program (under the birth preparedness package), but not specifically for the PCC. ¹⁹ It is also mentioned in the Right to Safe Motherhood and Reproductive Health Act, 2075 (2018), under chapter 2, " Every woman and teenager shall have the right to obtain an education, information, counseling, and service relating to sexual and reproductive health." ²⁰ However, it also could not address the issue and importance of PCC specifically. There are also some government tools (standard protocols and job aids on a balanced diet, deworming use, avoiding self-medication, checking blood sugar, iron tablet supplementation, etc.) for counseling on PCC components to the targeted reproductive-aged women and their utilization; however, it seems they are not being used properly or prioritized due to not having a specific package or policy in PCC at local levels in government health institutions. PCC is still taken as an optional choice of service or care in the reproductive health care system in Nepal.

DNA: Deoxyribonucleic acid

HIV: Human immunodeficiency virus

JE: Japanese Encephalitis

MM: Maternal Mortality

NPR: Nepalese rupee

PCC: Preconception care

PRAMS: Pregnancy Risk Assessment Monitoring System

STD: Sexually transmitted disease

STI: Sexually transmitted infection

SBA: Skilled Birth Attendant

SPSS: Statistical Package for Social Science

WHO: World Health Organization

Before collecting data, we diligently sought permission from the Department of Public Health at LA GRANDEE International College, Bheerkot Municipality (Ref. 209), and the selected ward office. Furthermore, the participants (legal guardians or next of kin) provided written informed consent to participate in this study. We also reassured the respondents to keep their information confidential and to be free to opt out of the study at any time.

Datasets used in the current study are available from the corresponding author upon reasonable request.

None

MG contributed significantly to the research concept and design, data gathering, acquiring, analyzing, interpreting, and drafting of the article. KS made a central contribution to drafting the research article, critically revised it for important intellectual content, acquired, analyzed, or interpreted data, and approved the version to be published. KRA supervised and suggested all the activities throughout the research period, including proposal writing, tool development, data collection, analysis, and report writing.

Firstly, our most profound gratitude goes to La Grandee International College, Pokhara University, Nepal. We also want to express our appreciation to Mr. Sandip Pahari and Mr. Prabin Sharma for their assistance during this research.