THEORY OF HEALTH PROMOTION MODEL

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CHAPTER 3 LITERATURE REVIEW

INTRODUCTION

The chapter discusses the literature reviewed on the studies that have been done in other countries about the provision of preconception health care that is one of the essential interventions in an effort to improve maternal and newborn health. The literature review focused on what is the package that is provided to men and women of the childbearing age to promote awareness related to healthy pre-pregnancy and pregnancy interventions that would yield improved maternal and newborn outcomes. The literature map will discuss preconception health care, inter-natal care, benefits of PCC, and interventions in PCC like nutrition supplements, health screening, behavioural change, family planning, HTSP and health planning of pregnancy. Some studies have indicated the adverse effects that would happen if couples have unplanned pregnancy. Frey and Files (2006:73) assert that the goal of PCC is done to identify medical and social conditions that may put the mother or foetus at risk. Lack of PCC and late entry into prenatal care are contributing factors to infant mortality and the literature review will examine how the concept of PCC has been adopted into the health care setting, barriers to developing and using PCC.

Purpose of literature review

A thorough literature review was done to gain insight on what are the recommended interventions and strategies that other places have used to ensure quality provision of PCC that improve maternal and newborn outcome. Polit and Beck (2012:120) argue that a good literature review requires thorough familiarity with available evidence to gain confidence to prepare a state of the art review so that the researcher can determine how best to make a contribution to existing evidence. In this study, the researcher needs to generate enough evidence that PCC has done to improve maternal and newborn outcomes in other settings. The best practices done in other settings can influence the developing countries like Malawi to consolidate interventions that are relevant to Malawi setting to have standardised quality PCC that would improve maternal and newborn outcomes. The information gathered was used by the researcher to make sense of the findings.
It is important to synthesise and evaluate what other researchers have done on PCC and the benefits to learn on what has been done and implement in Malawi to assist to improve maternal and newborn outcome (Moule & Goodman 2009:137).

THE CONCEPT OF PRECONCEPTION CARE

PCC is maintenance of women’s and men’s health before conception so that some of the detrimental effects on pregnancy, maternal and neonatal health are prevented to have a health outcome. PCC includes any intervention to optimise a woman’s health before pregnancy with the aim to improve maternal, newborn health outcomes (Dean et al 2014c:1; Dean, Rudan, Althabe, Webb Girard et al 2013:1). PCC has the potential to positively impact 208 million pregnancies worldwide each year but the challenge is that women in low and middle – income countries that have the highest burden of maternal and neonatal mortality do not access benefits of interventions (Dean et al 2013:2). Maternal health behaviours have had an impact to improve the health of the mother and the infant if done before pregnancy, whether it be a first pregnancy or between consecutive pregnancies (Steel et al 2015:2). Whitworth and Dowswell (2014:2) further report about a study conducted in Hungary that provided evidence that PCC assisted to identify infertile couples that were treated sooner, treatment of genito-urinary infections, genetic counselling, positive maternal behavioural modification which was associated with increased infant morbidity and mortality improved birth outcomes of infants. Weisman, Hillemenier, Downs, Feinberg, Chuang, Botti and Dyer (2011:2) further provide evidence that behavioural change interventions are effective in changing adverse pregnancy outcomes during pre-pregnancy period. There is increased evidence that PCC is effective in improving pregnancy outcome, especially if women and men of the childbearing age practice health behaviours.
The aim of PCC is to ensure that men and women of childbearing age have optimal state of physical and emotional health at the onset of pregnancy to ensure a healthy mother and baby after birth. Lynch, Squiers, Lewis, Moultrie, Kish-Doto, Boudewyns, Bann, Levis, and Mitchell (2014:149) suggest that preconception health and health care address risk factors, promote health and manage potential chronic health conditions that could affect maternal health, conception and foetal development. Appropriate health behaviours practised by men and women who intend to get pregnant will reduce risks of having a baby with birth defect and low birth weight that is so common in Malawi now. The findings on a social campaign revealed that despite the knowledge of what a woman knows on what to do to have a healthy pregnancy, very few take action to engage in specific preconception health behaviours that would improve the outcome of pregnancy (Lynch et al 2014:154). The health benefits to mothers and babies if preconception health is practised are numerous despite some countries that have no guidelines to promote preconception health.
Preconception stress increased risk for preterm birth and small for gestation age status (Class, Khashan, Lichtenstein, Langstrom & D’Onofrio 2013:1311). PCC is essential as the results in Class et al (2013:1314) revealed that maternal preconception stress increases the risk for infant mortality and adverse birth outcomes in offsprings, as there was increase in infant mortality to women that experienced severe stress before conception. Therefore, Malawi should take an initiative to develop guidelines for the health workers and community interventions to impart relevant information to women and men intending to get pregnant to improve knowledge on PCC that will improve the outcome of mothers and babies. It is important to identify opportunities where health care workers like doctors, nurses, clinicians, dieticians and counsellors can engage in providing relevant information on PCC to prevent complications that would affect the mother and the baby at birth. There should be a shift to put more emphasis on pre-pregnancy intervention from prenatal care that is too late to reduce risk for foetal development (Weisman et al 2011:20), Whitworth and Doswell (2014:10; Waggoner 2013:1).
Thus far, findings suggest that there is convincing evidence that health problems like nutritional deficiencies like anaemia, obesity, vaccine preventable diseases like tetanus and mental health problems such as depression contribute to poor maternal and child health outcomes (Mason, Chandra-Mouli, Baltag, Christiansen, Lassi & Bhutta 2014:2). In addition, Mason et al (2014:2) also conclude that in low and middle-income countries, there is a need for public health care that would include PCC as a priority intervention to improve maternal and newborn outcome. There is evidence that tobacco, alcohol use, individual genetic condition, and environmental exposure to chemicals and radiation would affect maternal and child health outcome. Furthermore, Mason et al (2014:2) argue that if the problems outlined are addressed early before conception occurs, that could improve health outcome of the mothers and babies. Congenital problems, neural tube defects, partner violence, and unintended pregnancies could be minimised if interventions like counselling, vaccinations and treatment are done on time before conception occurs. Several studies found that the research priorities for PCC have identified the following strategies to increase coverage of basic interventions to low and middle income countries like Malawi to address the basic intervention that would improve maternal and newborn income, namely, nutrition; reproductive planning for adolescents; contraception that is provided according to health timing and spacing of pregnancy; prevention; detection; and treatment of chronic conditions that affect maternal health, immunisation, diagnosis and treatment of infectious diseases and reducing harmful environmental smoke exposure. Mason (2014:3) highlights that the benefit of PCC could improve the health and social well-being of families as there is evidence that there could be reduction of maternal and childhood mortality and morbidity. PCC should incorporate male involvement that would support to address the priority interventions that would contribute to the health outcome of the mother and the baby. Frey, Navarro, Kotelchuck and Lu (2008:389) argue that male involvement in PCC can result in improved reproductive health practices and outcomes for women. In addition, Kabagenyi, Jennings, Reid, Nalwadda, Ntozi and Atuyambe (2014:2) note that despite the growing evidence that male involvement improves reproductive health decision making, there are still some gaps in sub-Saharan African countries on use of family planning services.
It is a fact that maternal health before and during pregnancy impacts the health of the child long after infacncy (Goodfellow, Frank, Mcfreer and Rankin 2017:1). There are potential barriers to developing and using PCC and policy implications related to nursing and midwifery practice like health literacy. Goodfellow et al (2017:7) highlight the importance of training of health care providers and non-health professions on PCC. Despite the literacy challenge, there is evidence that an encounter with a health professional prior to conception may positively affect the health of the developing foetus once pregnancy occurs. Education and implementation of health lifestyles during PCC would improve the health outcome of the mothers and the babies. Belizan, Hofmeyr, Buekens, and Salaria et al (2013:2) point out that all women of reproductive age should have access to PCC like preventing adolescent pregnancy, preventing unintended pregnancy, promoting optimal birth spacing, adequate nutrition during pregnancy, screening for health problems, and appropriate treatment prior to pregnancy. According to state of the midwifery report, it is said that comprehensive midwifery care should include pre-pregnancy through to pregnancy, childbirth and postnatal (Day-stirk, McConville, Campbell, Laski, Gueerra-Arias, Hoope-Bender, Michel-Schuldt & De Bernis 2014:2).

BENEFITS OF PRACTICING PRECONCEPTION CARE:

The maternal, neonatal and child health interventions have a great impact in accelerating progress to achieve MDGs 4 and 5 which Malawi is still creeping behind to achieve. Achievement of the targets need interventions to be implemented across the reproductive life span starting from the pre-pregnancy period that is very crucial to yield a health outcome of the mother, the baby and the child (Lassi, Imam, Dean & Bhutta 2014a:1). There is evidence that PCC provided to men and women of the reproductive age would yield effective results to have healthy pregnancy outcomes that will instil families to be physically, socially, economically and psychologically stable. De Jong-Potjer, Elsinga, le Cessie, Van der Pal-de Bruin, Neven, Buitendijk, and Assendelft (2006:7) highlighted the importance of infoming all women of childbearing age to be knowledgable on PCC so that they can prepare for their pregnancy. There is evidence that health promotion interventions are associated with providing health outcomes of the women and infants after birth. Day-strick et al (2014) recommend that PCC will support the 10 pillars of midwifery 2030 whereby one of the pillars is that all women of reproductive age including adolescents have universal access to midwifery care across the birth continuum including pre-pregnancy phase. Blencowe, Cousens, Chou, Oestergaard, Say, Moller, Kinney and Lawn (2013:33) report that many women are unaware of how health before conception many influence their risk of having an adverse outcome of pregnancy. Women of the reproductive age and adolescents need to practice PCC that includes appropriate preconception weight, adequate nutrition, optimal birth spacing, prevention, and treatment of sexually transmitted diseases and HIV/AIDS, screening for chronic diseases that will prevent risks of having premature births, low birth weight on newborns and congenital abnormalities. Lassi, Kumar, Mansoor, Salam, Das and Bhutta (2014c:15) highlight the importance of family planning, and spacing pregnancy at appropriate interval, screening for chronic diseases and infections and preconception folic acid supplementation which have shown significant impact in reducing maternal and neonatal morbidity and mortality.
The current research priorities for PCC in low and middle-income countries are to focus on development and delivery of existing interventions during preconception period such us improving nutrition, contraception screening and treatment of chronic diseases and infections and reducing harmful environmental smoke exposures (Dean et al 2013:7). Salihu, Salinas and Mogos (2013:3) recommend that comparative effectiveness research should be done to identify interventions that would improve preconception health care in different settings of the people. Therefore, Malawi should have guidelines that will direct the provision of PCC to assist the reduction of maternal and infant morbidity and mortality so that interventions are relevant to the Malawian setting. PCC should be a priority strategy to improve maternal and child health in Malawi. In a review of some studies, Dean et al (2014b:31) found that if PCC is provided on time, it would promote women to have reproductive health plan, encourage use of exclusive breast-feeding and uptake of modern contraceptives.

Reproductive planning as an intervention during preconception care

Reproductive planning is one of the strategies to improve maternal and health outcome after birth as mothers conceive when it is the right time to carry a pregnancy that will facilitate the baby to grow well. Healthy Timing and Spacing of Pregnancy (HTSP) is an intervention to help women and families delay or space their pregnancies to achieve the healthiest outcomes for women, newborns, infants, and children. Schwandt, Skinner, Hebert, Cobb, Saad and Odeku (2017:1) highlighted that inadequate birth spacing is rated as riskier that all contraceptive methods. According to WHO (2014), there is a recommendation that women of childbearing age should ensure to have a period of 24 months passed in order to reduce the risk of adverse maternal, perinatal and infant outcomes. Lassi et al (2014b:2) contend that the short interval of less than six months is associated with higher risk of preterm births, low birth rate, foetal death, and small for gestation age compared to inter-pregnancy interval of 18 to 23 months and the risks were also higher in pregnancy conceived at more than 60 months. Optimally, spaced births have economic, social and demography significance and could potentially reduce foetal and maternal morbidity and mortality (Yakoob, Menezes, Soomro, Haws, Darmstadt & Bhutta 2009:3). A report on perinatal risk factors suggests that pregnancies should be well spaced as unintended pregnancies result in short-and long-term negative outcomes for both the mother and the baby. The developed countries, as some literature suggest, put emphasis on PCC that ensure that men and women of childbearing age have to conceive when one is ready to get pregnant at the recommended time. Faye, Speizer, Fotso, Corroon and Koumtigue (2013:1) provide evidence that 14.3% of pregnant women reported having a recent unintended pregnancy that is associated with low participation of women in their reproductive goals and lack of discussion on family planning with their spouses.
Family planning is fundamental to prevent unplanned pregnancy that contributes to a lot of adverse effects of maternal and newborn outcome at birth. Tamang, Raynes-Greenow, McGeechan, and Black (2017:8) highlighted that reproductive health messages should be introduced to the youth as early as possible to prevent detrimental effects like teenage pregnancies. Unfortunately, a study done in Kenya, Uganda and Senegal revealed that only about 60% of the women of the childbearing age had unmet need for modern contraceptives due to social cultural barriers like male partner opposition (Okigbo, Speizer, Corroon & Gueye 2015:2). Media like radios, televisions outreach activities and religious leaders should target the men for increase uptake of modern family planning methods. Use of contraception during preconception period assist couples to have pregnancy when one is ready to conceive (Salam, Mansoor, Mallick, Lassi, Das & Bhutta 2014:10). Family planning messages should include preconception messages that would inform men and women of childbearing age to use contraceptives and have pregnancies when one is physically, socially and psychologically prepared to have a healthy outcome of pregnancy.
Advice should be provided to postpartum patients soon after birth to utilise family planning services that would assist them during internatal period. Bazile, Rigodon, Berman, Boulanger, Maistrellis, Kausiwa and Yamin (2015:9) conclude that for Malawi to improve maternal and neonatal mortality, one of the strategies to put in place to achieve the MDG goal 5 is by ensuring provision of contraceptive options to all women and men of reproductive age, including those residing in remote areas. A study conducted in Uganda showed that maternal and neonatal health care services were at 75% for antenatal services and 75% utilising postnatal services. However, there was only 50% utilisation of family planning services indicating that people of the reproductive age group do not fully use contraception options that would improve the mothers’ and babies’ health (Wilunda, Oyerinde, Putoto, Lochoro, Dall’Oglio, Manenti, Sagafredo, Atzori, Criel, Panza & Quaglio 2015:5).
A report written by Johnson, Posner, Biermann et al (2006) recommends that couples and individuals should reflect their personal intentions regarding the number and timing of pregnancies in the context of personal values and life goals to increase the number of planned pregnancies. Studies reviewed by Dean et al (2014b:23) showed that women who receive PCC may be more likely to plan and space their pregnancies. Closely spaced pregnancies predispose mothers to deplete their nutritional reserves and lead to anaemia, and increased chances of having stillbirths, premature rupture of membranes (PROM) and puerperal endometritis. The women that have closely spaced pregnancies have about 66% more chance to die during pregnancy than women that have pregnancies at recommended intervals. Children have the high chance to be born premature, low birth weight (LBW) and small for gestation age (SGA) (Dean et al 2014b:29). It is a risk as almost 1/3 of the pregnancies are intended and 1/5 end in abortion. Another risk factors associated with short intervals in between pregnancies include uterine rupture during trial of labour. Dean et al (2014b:31) provide the necessary period that women of the childbearing age should follow to have a healthy outcome. There should be 18 to 24 months in between the two pregnancies and women should not exceed five years long between pregnancies. Al-Akour, Sou’Ub, Mohammad and Zayed (2014:246) provided evidence that in Jordan half of the population of the respondents under study were aware that men and women need to have good health before conception to improve pregnancy outcomes.
Use of contraceptives assist couples to plan for pregnancy during preconception period as couples and individuals conceive when it is safe to carry pregnancy. Mustafa, Azmat, Hameed, Ali, Ishaque, Hussain, Ahmed, and Munroe (2015:8) reported that couple were accessing contraceptive very late due to lack of information for health care facilities. More importantly, family planning services should be available, accessible, affordable, and acceptable to couples of the reproductive age. Men should be aware of use of modern contraceptive to support their families to have healthy pregnancies as using PCC methods increase male involvement. Mohammed, Woldeyohannes, Feleke, and Megabiaw (2014:4) recommend that male involvement has an important role to support the use of modern contraceptives in a study done in Ethiopia. Women who discussed with their husbands about use of family planning methods were seven times more likely to use modern contraceptives than women that did not involve their spouses. Modern contraceptive use prevents preterm births, low birth weight, foetal death, and small for gestation age that occur owing to short inter-pregnancy interval if family planning is not done. Exaggerated long intervals between pregnancies that come after 60 months or more are also associated with the outcome of pregnancy (Lassi et al 2014a:7). Pregnancies that are planned at appropriate intervals are expected to have minimal risks. It is therefore important to avoid unplanned pregnancies by promoting use of family planning during PCC. Arambepola and Rajapaska (2014:3) caution that many women are at risk of terminating their pregnancies that predispose them to more risk. Moreover, they do that for a number of reasons, namely, lack of income and social support, and psychological factors as some think are too old to carry a pregnancy or ashamed of a very short last birth interval. Dean et al (2014b:31) found that 90% of the childbearing women that receive post-abortion counselling used family planning services.
Family planning use is high if there is male involvement. Therefore, couples should be encouraged through proper communication to have better birth outcome if pregnancies come at the recommended time. Mason et al (2014:4) assert that both men and women should be targeted to access PCC as men’s health and their health behaviours have important implications for the health of the partners and children. Families, couples and communities would plan their pregnancies if their male counterparts were involved in family planning. The women would participate in issues that affect them as they would make well-informed and well-considered decisions about fertility and health (Mason et al 2014:3). There is a worldwide problem of infertility problems that are affecting couples at present. Blaževičienė, Jakušovaitė and Vaškelytė (2014:1) found that women are assisted with new reproductive technologies for them to conceive. Screening for reproductive health problems would be provided in family planning clinic during preconception period for couples to identify and find assistance that need specialised care. PCC is an entry point where family planning methods can be provided and if there were challenges in conception, other ways would be instituted. Dean (2012:7) highlighted that there is ument need of contraceptive use in Sub Saharan Africa that would hinder adolescents and women of childbearing age to access PCC.

TABLE OF CONTENTS
CHAPTER 1  OVERVIEW OF THE RESEARCH
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION ABOUT THE RESEARCH PROBLEM
1.3 RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITIONS OF TERMS
1.7 THEORETICAL FOUNDATIONS OF THE STUDY
1.8 RESEARCH DESIGN AND METHOD
1.9 DATA MANAGEMENT AND ANALYSIS
1.10 SCOPE OF THE STUDY
1.11 STRUCTURE OF THE DISSERTATION
1.12 CONCLUSION
CHAPTER 2  CONCEPTUAL FRAMEWORK
2.1 THEORETICAL FOUNDATION OF THE STUDY
2.2 THEORY OF HEALTH PROMOTION MODEL
2.3 COMPONENTS OF THE HPM
2.4 CONCLUSION
CHAPTER 3 LITERATURE REVIEW
3.1 INTRODUCTION
3.2 The concept of preconception care
3.3 Benefits of practicing preconception care:
3.4 CONCLUSION
CHAPTER 4 RESEARCH METHODOLOGY
4.1 INTRODUCTION
4.2 Research objectives
4.3 RESEARCH DESIGN
4.4 RESEARCH METHOD
4.5 CONCLUSION
CHAPTER 5  DISCUSSION OF RESULTS ON THE INFORMATION ON PRECONCEPTION CARE ON CHILDBEARING AGE GROUP
5.1 INTRODUCTION
5.2 PRESENTATION OF FINDINGS ON INFORMATION AND CARE PROVIDED TO MEN AND WOMEN
5.3 RELATIONSHIP OF VARIABLES
5.4 CROSS TABULATIONS OF VARIABLES TO INDICATE RELATIONSHIPS
5.5 CONCLUSION
CHAPTER 6 GUIDELINES ON PRECONCEPTION CARE IN BLANTYRE URBAN MALAWI
6.1 INTRODUCTION
6.2 SUMMARY OF FINDING FROM THE STUDY
6.3 CONCLUSION
6.4 RELEVANT INTERVENTIONS TO PROVIDE PRECONCEPTION CARE THAT WOULD IMPROVE MATERNAL AND NEWBORN HEALTH IN BLANTYRE DISTRICT IN MALAWI
6.5 SECTION 2: TECHNICAL GUIDELINES ON PRECONCEPTION HEALTH CARE
6.6 CONCLUSION
CHAPTER 7 CONCLUSIONS AND RECOMMENDATIONS
7.1 INTRODUCTION
7.2 RESEARCH DESIGN AND METHOD
7.3 SUMMARY AND INTERPRETATION OF THE RESEARCH FINDINGS
7.4 CONCLUSIONS
7.5 RECOMMENDATIONS
7.6 CONTRIBUTIONS OF THE STUDY
7.7 LIMITATIONS OF THE STUDY
7.8 CONCLUDING REMARKS
LIST OF REFERENCES
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