{"paper_id":"edfe0e74-c948-4faa-9149-f1ff327bdee9","body_text":"What support is needed for preconception health improvement, and by \nwhom? A qualitative study of women’s views \n \nMichael P Dalya*, Ruth R Kippinga, James Whiteb, Julia Sandersc \naDepartment of Population Health Sciences, Bristol Medical School, University of Bristol, UK \nbCentre for Trials Research, DECIPHer, School of Medicine, Cardiff University, UK \ncSchool of Healthcare Sciences, Cardiff University, UK \n*Corresponding author \n \nABSTRACT \nBackground: Systematic review s suggest preconception health interventions may be effective in \nimproving maternal and infant outcomes. However, few studies have explored women’s views on the \ntypes of support required for preconception health improvement, nor when and to whom this support \nshould be provided.  \nMethods: We purposively sampled  women aged 18 -48 years  in the West of England  from \nrespondents to a survey, and conducted semi-structured in-depth interviews to explore their views on \nsupport needs in the preconception period  and target populations for this support . We analyzed the \ndata using a data-driven framework analysis. \nResults: The women we interviewed (N= 20) broadly supported promoting greater awareness of \npreconception health and felt the limited focus on health before pregnancy downplays its importance \nrelative to  antenatal health. Some women opposed support services and structural interventions to \nimprove preconception health, due to concerns these are less impactful than encouraging individual \nresponsibility for health.  Women who supported  structural interventions highlighted broader \ndeterminants of health and socioeconomic barriers to preconception health improvement . Men were \nconsidered a  key target population for preconception support, to help share the burden for \npreconception health improvement . Women broadly supported ‘age-appropriate’, school-based \npreconception health education , highlighting young women as a n under -served group in need of  \nadditional preconception education.  \nConclusion: Our findings indicate a need to deliver early preventive support ahead of first pregnancy \nthrough services, interventions and polic ies co-produced with women and women’s partners. Future \nresearch should explore how to increase public understanding of the socioeconomic, environmental \nand commercial determinants of preconception health.  \n \nKEYWORDS: Preconception Care, Preconception health, Women’s Health, Intervention \ndevelopment, Qualitative \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n \n2  \nHIGHLIGHTS: \n1. Women broadly supported promoting greater awareness of preconception health \n2. Neoliberal views on responsibility underlay opposition to structural interventions \n3. Awareness of wider health determinants underlay support for structural interventions \n4. Suggested support included preconception health checks and community support groups \n5. Young women were considered an under-served group in terms of preconception support \n \n1 Introduction  \nGlobally, around 23 million miscarriages (Quenby et al., 2021) , 2.4 million neonatal deaths \n(UNICEF, 2020), and 260,000 neural tube defect -affected pregnancies occur annually (Blencowe et \nal., 2018) . High- and moderate -certainty evidence indicates that maternal  exposures before \nconception, including inadequate dietary folate, physical inactivity, high body mass index (BMI) and \ninterpregnancy weight gain, increase the risk of these and other adverse perinatal outcomes (Daly et \nal., 2021) . However, two-thirds of  women do not  take folate supplement s before pregnancy  \n(Toivonen et al., 2018) , a third are not sufficiently active (Guthold et al., 2018)  and in high-income \ncountries, one in two are living with obesity or an overweight BMI (Flegal et al., 2012; Public Health \nEngland, 2019). These risk factors are  more prevalent among some minoritized ethnic groups and \nsocioeconomically disadvantaged women (Public Health England, 2019; Stephenson et al., 2014). \nSystematic reviews suggest preconception interventions may help to improve infant birth weight and \nwomen’s diets, physical activity  and pre-pregnancy weight, and reduc e the risk of congenital \nanomalies and alcohol-exposed pregnancies (Lassi et al., 2020; Temel et al., 2014; Withanage et al., \n2022). National health organizations have called for further research on these interventions, \nemphasizing the importance of  incorporating public perspectives  to ensure interventions are \nacceptable to their target populations and address their needs  (Department of Health and Social Care, \n2022a, 2022b) . Yet, f ew studies have explored women’s views on whether preconception support \nshould be provided to women or couples, what this support should involve, and to whom it should be \nprovided.  \nIn qualitative studies  describing women’s preconception support needs to date , women have \nexpressed a desire for partners to be involved , noting the disproportionate responsibility placed on \nmothers-to-be for ensuring a healthy pregnancy (McGowan et al., 2020) , and that partners can \nsupport health improvement (Kretowicz et al., 2018; Scott et al., 2020; Squiers et al., 2013) . These \nstudies have highlighted that economically disadvantaged women  may require support to improve \ntheir intake of folate supplements and nutritious foods as these are less affordable and accessible to  \nthem (Mazza & Chapman, 2010; Scott et al., 2020; Squiers et al., 2013) , and  that women with  \nexisting children may face barriers to improving their health before pregnancy due to the competing \ndemands they face (Scott et al., 2020; Tuomainen et al., 2013). Women have also expressed that they \nhave low knowledge of how to improve their  preconception health and would value being better \ninformed about this, in early life or when planning a pre gnancy (Lang et al., 2020; McGowan et al., \n2020; Tuomainen et al., 2013) .  In the few studies that reported  women’s views on existing \npreconception support, some indicated they would only seek support from healthcare services if they \nencountered difficulty conceiving (Bortolus et al., 2017; McGowan et al., 2020)  and that it is \nwomen’s responsibility to prepare for pregnancy  (M’hamdi et al., 2018) . Others spoke more \nfavorably of receiving preconception counselling from health professionals with dedicated time for \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n3 \nthis, or during clinically-relevant appointments such as cervical s mear tests  (M’hamdi et al., 2018; \nTuomainen et al., 2013; van der Zee et al., 2013) . Beyond this, w omen’s views on preconception \nsupport services, interventions and policie s, which may be needed to address the environmental and \nsocioeconomic determinants of preconception health (Beauchamp et al., 2014; Lorenc et al., 2013) , \nare absent from the literature . To address th is gap, we conducted a qualitative study to explore \nreproductive-age women’s views on preconception support needs and who they feel should be \nprioritized for this support. \n \n2 Materials and Methods  \n2.1 Study design  \nThis qualitative study was the second phase of a mixed methods project exploring women’s views on \ncandidate preconception intervention designs. It involved semi-structured, in -depth interviews with \nwomen aged 18 -48 years  and was undertaken from a critical realis t position (Collier, 1994) . \nComplementing this position, we iteratively collected and analyzed data using a  data-driven \nframework analysis approach (Gale et al., 2013) . We gained ethical approval from the South West -\nFrenchay Research Ethics Committee before conducting the study (19/SW/0235) and report the study \nfollowing Standards for Reporting Qualitative Research guidelines (O’Brien et al., 2014). \n2.2 Study population and participant selection \n2.2.1 Eligibility criteria \nParticipants were eligible to participate if they took part in our prior survey of women aged 18-48 \nyears registered with  seven primary care centres  in the West of England  (Daly et al., 2022)  and \nconveyed interest in being interviewed. To minimize distress, women with conditions causing \npermanent infertility and those who were pregnant o r had ever experienced perinatal mortality  (or \nearlier-stage pregnancy loss in the previous three month s) were excluded from the survey. Only \nwomen who had English as their main spoken language were included as funding for translation was \nunavailable.  \n2.2.2 Participant sampling \nOf the 835 survey respondents, 313 (37.5%) were interested in being interviewed. We used a \nmaximum variation purposive sampling approach to increase participant diversity (Mason, 2017) and \nthe transferability of our findings  (Braun & Clarke, 2021) . Our survey findings (Daly et al., 2022)  \ninformed our sampling criteria (Appendix A). As age, pregnancy history, and household income were \nassociated with preconception health knowledge and attitudes , we aimed to achieve a n even split in \ninterviewees for these  primary criteria. Secondary criteria  included ethnicity , country of birth , \npregnancy intentions and attitudes toward preconception health  and candidate intervention delivery \nmethods. We monitored these criteria during recruitment to ensure diversity in their coverage.  \n2.2.3 Participant recruitment \nWe invited f orty-six women with the aim of recruiting 10 participants for each grouping of our  \nbinary primary criteria (20 overall) (Braun & Clarke, 2021) . We continuously monitored the dataset \nduring data collection to ensure the sample supported claims of validity, patterned meaning  and \ninformation power (Braun & Clarke, 2021). \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n4  \n2.3 Data collection  \n2.3.1 Interview schedule \nWe conducted in-depth, semi-structured interviews to enable probing and reduce the risk of socially \ndesirable responding  (Bergen & Labonté, 2020) . Our interview topic guide  (Appendix B ) was \ninformed by our survey findings, a literature review and feedback from academic experts. It included \nquestions to evoke participants’ views on  preconception support needs , target populations for this \nsupport, and seven candidate delivery options for preconception health interventions found to be \nacceptable to women in our survey . The delivery options were: social media, personal texts and \nemails, pregnancy tests, health education in schools , general practitioners (GPs), nurse practitioners  \nand pharmacists (the specific points participants made about these delivery options are reported in a \nseparate journal article which explored women’s views on potential content and delivery methods for \npreconception interventions  (Daly et al., 2024) ). P rompt questions on different forms of \npreconception support were informed by Frieden’s health impact pyramid and included education , \npreconception care and other support services, and structural interventions such as folate fortification \nwhich aim to “change the environmental context to make healthy options the default choice ” \n(Frieden, 2010) . We piloted the  topic guide  with five women and re phrased commonly \nmisunderstood terms. The topic guide was updated as new areas of interest arose from the interviews.  \n2.3.2 Interviews \nAll participants chose a telephone interview (N=20; September-December 2021 ), which  lasted an \naverage of 57 minutes (range: 37-79 minutes). MD conducted 19 (95%) interviews . JS interviewed \none participant who requested a female interviewer. We used an encrypted audio -recorder to record \ninterviews after consent was confirmed. We gave participants £20 shopping vouchers to thank them. \n2.4 Ethical considerations  \nParticipants gave consent for their anonymized information to be  published and shared. Recognizing \nthat pregnancy could be  a distressing topic for those who had difficult pregnancy experiences , we \nstated in the information sheet and interview pre-briefing that participants could skip questions , stop \nthe interview or withdraw at any point. \n2.5 Data analysis  \nData were analyzed following the framework method (Gale et al., 2013). Interviews were transcribed \nverbatim, transcripts were anonymized and uploaded to  the NVivo 11 software package , and \nfamiliarization was undertaken . Deductive code labels  (Appendix C ) were added to all  relevant \nexcerpts. I nductive codes were developed from  the first three transcripts , which we coded in \nduplicate. We agreed on a preliminary analytical framework which MD used to index the remaining \ntranscripts, and discussed potential amendments. We charted t he data into matrices  using Microsoft \nExcel. E ach code’s data  were paraphrased  and added to relevant participants’ matrix cells with \nillustrative quotations. We developed candidate themes through identifying data patterns within and \nacross matrices. Themes were selected based on prevalence, the study’s aims , deductive codes, and \ninductively-derived concepts, and elaborated through a nalytical memos (Gale et al., 2013) . We re-\nread the transcripts to ensure candidate themes formed a coherent narrative of the data  and answered \nthe research questions . We  reported the final ised themes and subthemes as an analytic narrative , \nreporting participants’ age and gravidity alongside their quotations as contextual information. \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n5 \n2.6 Data quality \nWe incorporated the concept of data trustworthiness , operationalised as credibility, dependability, \ntransferability and confirmability of findings, in our  analysis (Lincoln & Guba, 1986) . Appendix D \nsummarises our quality-assurance measures for each data trustworthiness criterion.  \n \n3 Results \n3.1 Participant characteristics \nWe interviewed 20 women (43.5% of invitees). Table 1 shows there were equal numbers of women \nwho had and had not been pregnant and 18-29 and 30-48-year-olds. Half (45%) reported at least one \nlive birth and a fifth (20%) had experienced miscarriage. Two-thirds (65%) reported a desire  for a \nfuture pregnancy. The proportion s of participants who had household incomes  below £32,000 and \nwere born outside the UK aligned with the national average , and a greater proportion had a minority \nethnicity and were university graduates than the national average (Office for National Statistics, \n2017, 2021a, 2021b, 2021c) . There w ere broadly e qual numbers of participants with ‘ low’ \nknowledge of preconception health (n=9; liste d ≤2 of the  preconception risk factors  our survey  \nassessed (Daly et al., 2022)) and ‘high’ knowledge (n=11; listed ≥3 assessed risk factors).  \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n6  \nTable 1. Characteristics of the interview participants* \nVariable Response categories Study \nsample \nN (%) \nAge (years) 18-19 \n20-24 \n25-29 \n30-34 \n35-39 \n45-48 \n1 \n2 \n7 \n4 \n5 \n1 \n5 \n10 \n35 \n20 \n25 \n5 \nHousehold income  Less than £13,000 \n£13,000-18,999  \n£19,000-25,999 \n£26,000-31,999  \n£32,000-47,999  \n£48,000-63,999  \n£64,000-95,999  \nMore than £96,000 \n1 \n2 \n1 \n5 \n4 \n1 \n2 \n4 \n5 \n10 \n5 \n25 \n20 \n5 \n10 \n20 \nEthnicity White \nMixed/Multiple ethnic groups \nAsian/Asian British \nBlack/African/Caribbean/Black British \nOther ethnic group \n15 \n1 \n1 \n2 \n1 \n75 \n5 \n5 \n10 \n5 \nEducation University \nIntermediate \nSecondary school \nStill in education \n11 \n4 \n4 \n1 \n65 \n20 \n20 \n5 \nCountry of birth UK \nOther† \n17 \n3 \n85 \n15 \nGravidity Previously pregnant \nNever pregnant \n10 \n10 \n50 \n50 \nPrevious livebirth(s) Yes \nNo \n9 \n11 \n45 \n55 \nAdverse pregnancy outcome(s) Yes ‡ \nNo \n4 \n16 \n20 \n80 \nPrevious infertility § Yes \nNo \n5 \n15 \n25 \n75 \nPregnancy desire Currently trying to become pregnant \nWould like to get pregnant in the next 1-2 years \nWould like to get pregnant in the next 3+ years \nNot sure/Don’t know \nWould definitely not like to get pregnant  \n3 \n3 \n7 \n6 \n1 \n15 \n15 \n35 \n30 \n5 \nLegend: *These correspond to the interview participants’ questionnaire responses in our prior survey \nstudy (Daly et al., 2022). †African and South American countries. ‡All four participants had \nexperienced miscarriage. §Participants who were unable to become pregnant after ≥12 months of \ntrying and/or had sought professional help for infertility. \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n7 \n3.2 Themes \nTable 2 shows t he themes and sub -themes developed from the data ;  these are the focus of the \nanalytic narrative presented below. \nTable 2. Thematic map of study findings \nTheme Sub-themes  \nTheme 1: \nReaching \nthe right \npeople at \nthe right \ntime \n• Limited ways of providing universal or targeted preconception interventions - \ncomplicated by the sensitivities of pregnancy and lack of a  clear go-to source of \nsupport \n \n1.1 Reaching the right people \n• Broad support for ‘age-appropriate’ school-based preconception health education \n• Some concerns that providing younger children with ‘too much’ information may \nencourage teenage pregnancy \n• Health professionals are overfocused on preventing pregnancies in young women \n• Women with fertility -related conditions, low socioeconomic status and same -sex \npartners have additional or unique support needs  \n• Nulliparous women have support needs relating to their lack of knowledge, \nwhereas previously pregnan t women face barriers relating to their competing \ndemands  \n• Men should be included in interventions, as their preconception health is important \nand this would help to share the ‘burden’ for preconception health improvement  \n \n1.2 Reaching people at the right time \n• Distinction between methods likely to reach more people at a less relevant time \nand those likely to reach fewer people at a more relevant time \n• Broad reach and mandatory nature of school health education is advantageous, \ndespite recipients not being the ‘ideal’ target population \n• Ovulation kits considered more appropriate than pregnancy tests for reaching the \nright people at the right time (those actively trying to conceive) \n \nTheme 2: \nPre-\nconception \nsupport \nneeds \n• Mixed views on whether poor preconception health  is enough of a problem to \nwarrant additional preconception support \n• Perceived need for different forms of preconception support related to views on \nwho is responsible for preconception health improvement \n \n2.1 Need to increase awareness of preconception health \n• Broad support for promoting greater awareness of preconception health (‘most’ \npeople would follow preconception health guidelines if they ‘knew the benefits’) \n• Limited focus on preconception health, relative to ante natal and postnatal health, \ndownplays its importance \n• Topics meriting greater awareness include  safe drinking limits , where to source \nfolic acid, and the potential for exposure to harms before pregnancy is known   \n \n2.2 Need for support services \n• Some felt health professionals should offer more preconception support and that \npregnancy services are delivered too late in the pregnancy journey  \n• Others felt spending public funds on support services that only benefit  (some) \nwomen may be ‘unfair’  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n8  \n• Common service suggestions included community-based preconception support \ngroups, classes, preconception health checks and midwife appointments \n \n2.3 Need for structural interventions \n• Women in favour of these interventions highlighted the broader determinants of \nhealth (e.g., environmental influences)  and socioeconomic barriers to \npreconception health improvement  \n• Those opposed felt it is more impactful to encourage individual responsibility for \nhealth and questioned if policies focused exclusively on women’s health are ‘fair’ \n• Structural intervention suggestions included making healthier, fortified foods more \naccessible to all, addressing poverty, and improving women’s occupational health  \n \n \n3.2.1 Theme 1: Reaching the right people at the right time \nParticipants commonly acknowledged the challenge of determining when and how to inform the \n“right” (P.02) people about preconception health. This rel ated to views that there are limited ways of \nproviding this information to ‘everyone’ or to people who intend to become pregnant. Participants \nfelt there is currently no clear ‘go-to’ place for information about preconception health:  \n“…pre-pregnancy is difficult... once you are pregnant you get all this advice … when you go \nto see the midwife… but beforehand, where do you go to find this information? ” (P.05, 35-39 \nyears, previously pregnant)  \nParticipants felt the challenge of delivering preconception support to the ‘right’ people is complicated \nby the need to be “sensitive” (P.02) to the wishes and experiences of a range of people, including \nthose who have had “ really negative experiences” of pregnancy (P.18), those struggling to conceive, \nand those who “don’t want to get pregnant” (P.02):  \n“Some women are having extremely difficult times with their conception. And they don't want \nto be told what they need to be doing… Some women will want to have children but their \npartners won't. So them getting messages about what they should be doing is just so not \nuseful.” (P.03, 25-29 years, nulligravid)  \nThe desire experienced by “most people” (P.17) to conceal their pregnancy intentions until pregnancy \nconfirmation was seen to add further complexity to this challenge:  \n“You can’t do a real public thing, because I think most people wouldn't want people to know \nthat they're pre -trying. And people are only happy to share that information when they're \npregnant…” (P.17, 35-39 years, previously pregnant) \n3.2.1.1 Reaching the right people \nThrough their descriptions of suitable ways of delivering preconception health support, participants \noften expressed a view of who the ‘right’ people to receive this support were. This was most strongly \nrelated to age. Participants broadly agreed that this support should be targeted at people during the \nreproductive years when pregnancy is most likely:  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n9 \n“If you're getting to a certain age, I think it'd probably be quite apt to say ‘is that something \nthat's on the cards? Would you like to have a family?’” (P.01, 35 -39 years, previously \npregnant)  \nViews on the appropriateness of providing information about preconception health  to children and \nyoung people were more complex. All participants felt that providing at least some information \nthrough schools would be appropriate. Some highlighted that thi s would come at a relevant time for \nwomen who become pregnant during or soon after school , who have an enhanced  need for this \ninformation but may lack other means of receiving it:  \n“If I imagine people that would be less informed, it would be younger mothers … they don't \nhave friends who know anything about it.” (P.10, 20-24 years, nulligravid)  \n“[At school] It was a lot of: ‘oh , here's a bag of condoms’… but there's nothing to keep you \naware of… if it [pregnancy] does happen.” (P.15, 25-29 years, previously pregnant)   \nOthers suggested it would be more appropriate to only provide this information - or provide “more \ninformation” (P.03)  - to older teenagers, with some suggesting that further and higher education \nsettings may be more appropriate than schools, as recipients may be more “ receptive” (P.03). For \nyounger teenagers and children, it was widely expressed that providing less information and avoiding \n“heavy” (P.01) topics such as risk factors for miscarriage may be more appropriate. This related to \nconcerns that these pupils are not mature enough “ to take things on balance ” (P.01), and that this \ninformation may give them the impression that they are well-equipped to “handle a baby” (P.01):  \n“You don't want to give too much information that it sparks an interest at too young an age… \nGoing to the extent of what mums need to do to look after themselves or… avoid \nmiscarriages.” (P.01, 35-39 years, previously pregnant)  \nParticipants commonly framed young women as a population in need  of preconception health \nsupport. In contrast to the above concerns about encouraging teenage pregnancy, they felt that health \nprofessionals are too focused on preventi ng pregnancies  in young women, relative to pregnancy \neducation: \n“…healthcare professionals are very quick to chuck contraception at young women but not \nquick enough to educate young women… about if you get pregnant and things like that.” \n(P.15, 25-29 years, previously pregnant)  \nThey spoke favorably of shifting this focus and opportunistically delivering preconception health \nsupport to young women during smear tests and contraception removal appointments, noting that \nmany young women “want children young” but “don't get a lot of information” relating to pregnancy \n(P.04): \n“…potentially that [cervical screening] is a good opportunity - you've got young women \ncoming in - just to say ‘are you thinking about getting pregnant any time soon? Are you \ncomfortable with preconception health...?” (P.16, 30-34 years, previously pregnant)  \nWomen with conditions affecting their fertility were also highlighted as an important target \npopulation. Additionally, some participants felt women from low-income households  receive \n“problematic” information on topics such as  nutrition and that making healthier foods and \ninformation more “readily available” to them would help to tackle health inequalities:  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n10  \n“…it’s just because they may be from a poorer income famil y… they’re not taught the right \nways to nourish themselves.” (P.03, 25-29 years, nulligravid)  \n“…I can see the benefit of that [banning ‘harmful’ ingredients] because… poor, more \nuneducated people will then have that as standard when they may not consider it.” (P.10, 20-\n24 years, nulligravid) \nMen were also considered a key target population. Justifications for this view included the \nimportance of men’s preconception health and the disproportionate burden placed on women to \nimprove their health around pregnancy:  \n“…it affects them [men] as well… how they treat their body and their pre-pregnancy health… \na lot of it can feel -, not like a burden on people with uteruses but it's like: ‘oh you've got to … \ntake medication not to get pregnant’ and then when you do want to get pregnant you've got to \nworry about your health.” (P.09, 20-24 years, nulligravid)  \nA further justification for involving men was that “ a lot of people don't … identify with one specific \ngender” (P.13, 18 -19 years, nulligravid) , so segregating target populations by gender may be \ninappropriate. It was also felt that this would help to support “everyone involved in pregnancies ” as \nboth birth parents are “equally responsible for a child ” (P.13) and this would help to strengthen \nrelationships between opposite-sex pregnancy partners:  \n“If men are educated as well then they can pass information onto partners … that can also \ngive them a closer connection while they're going through pregnancy together.” (P.15, 25-29 \nyears, previously pregnant)  \nSome participants noted it can be “ tricky” to find information that specifically relates to “ pregnancy \nas a same-sex couple” (P.10). It was also felt that women preparing for their first pregnancy can feel \n“overwhelmed by all the information ” they receive  (P.19), but are usually  “really aware of what to \ndo by their second pregnancy” (P.19). However, it was noted that women with children sometimes \nlet their health take a “bit of a backseat ” ( P.15) due to their competing demands and limited \navailability, so support that addresses these barriers to preconception health improvement would be \nbeneficial. \n3.2.1.2 Reaching people at the right time \nParticipants commonly framed the relative merits of different methods of delivering preconception \nsupport in terms of the point in people’s reproductive lives at which they would receive it. In doing \nso, they often evoked a distinction between methods likely to reach more people at a less relevant \ntime and those likely to reach fewer people at a more relevant time. This was evident in views that \nthe broad reach and mandatory nature of school health education would be advantageous:  \n“…people only care about things when they become relevant to them, unless people are in an \nenvironment where it's mandatory, which is school.” (P.11, 30-34 years, nulligravid)  \nThis was seen to address the issue that, in adulthood, opportunities for wide -reaching information \nprovision are relatively lacking:  \n“The tricky bit when you're an adult is having less places to get information from… you don't \nalways have a chance to sit in a room and listen to a person talk ...” (P.10, 20 -24 years, \nnulligravid)  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n11 \nWhilst some participants felt preconception health information provided through schools would come \nat a relevant time for women who become pregnant during or soon after school , others framed this \napproach as a trade -off. These participants felt that the teenage years are not the optimal time to \nreceive this information,  but this issue is outweighed by the advantage of reach ing more people \nsimultaneously:  \n“Your ideal age … [would be] twenty-four-year-olds to twenty -eight. But you're not going to \nbe able to catch them, so this is where you have to make the compromise , go with the \neighteen-year-olds in sixth form and in college” (P.17, 35-39 years, previously pregnant)  \nOthers felt  the timing of information receipt at school, when most recipients are unlikely to be \nplanning a pregnancy, was not a problem, as information learnt in school “stays with you” (P.09), and \nmay even be advantageous:  \n“…if at least it's being raised in that school environment, then later on those children are \ngoing to think about it and look into it.” (P.16, 30-34 years, previously pregnant)  \n“…once women are already at the age where they're having children they might have already \nhad really negative experiences.” (P.18, 25-29 years, nulligravid)  \nConversely, the importance of reaching the right people at the right time was evoked in participants’ \nviews on pregnancy tests as an i nformation medium. Some felt this was an “ ideal” (P.02) way of \ngetting preconception health information to people who have an immediate need for it:  \n“For somebody that is doing a [pregnancy] test, maybe the person is trying to conceive… it’s \nvery, very important to have the information then” (P.02, 25-29 years, previously pregnant)  \nHowever, others also felt this approach would mean  reaching some people at the wrong time. They \nnoted that this information is not \"really of benefit\" (P.02) if the recipient is already pregnant and that \n\"ideally you'd want to have it before[hand]\" (P.14). Some took issue with the apparent assumption of \npregnancy desire:  \n“…would you have some information about things to do to prevent you getting pregnant in \nthat? Because then you're assuming that people who are taking pregnancy tests are wanting \nto conceive, and it's quite an assumption.” (P.08, 25-29 years, nulligravid)  \nAcknowledging this issue, ovulation kits were suggested as a more appropriate information medium, \nas these are exclusively used by the right people at the right time (i.e. people actively “trying to \nconceive” (P.08)) meaning the provided preconception health information may be better received:  \n“Everyone reads those [instructions provided with ovulation tests]… because they want to get \npregnant… the user need is there.” (P.11, 30-34 years, nulligravid) \n3.2.2 Theme 2: Need for preconception support \nParticipants expressed a range of views on whether and how to support people to improve their \npreconception health. Some felt there was a need to provide  more preconception support whereas \nothers questioned \"how much of a problem \" poor preconception health is  (P.18). Adding further \ncomplexity, participants’ views on various forms of  preconception support were interlinked with \ntheir views on who should be considered  responsible for  preconception health improvement , as \nexplored in the below sub-themes. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n12  \n3.2.2.1 Need for promotion of preconception health awareness  \nParticipants commonly highlighted a need to make information about preconception health more \n“readily available\" (P.14), as \"not everybody” (P.15) has friends or family members who can provide \nreliable guidance. It was therefore felt there is “a whole generation of people ” aged “twenty-eight \nto… forty” in need of education on how to optimize their health before pregnancy (P.17). A common \nview was that  preconception health is  not \"spoken about enough ” (P.17) and that, for women and \ncouples without health conditions, the focus is “ mostly” on health during and after pregnancy (P.17). \nWomen also felt the limited focus on the preconception period mainly relates to potential fertility \nissues rather than general health improvement: \n\"…the emphasis goes on if you can conceive or not… There's not much talk about what you \ncan do to feel at your best before conception.\" (P.06, 35-39 years, previously pregnant) \nIt was thus felt that people “are more aware ” (P.02) of the importance of ante natal and postnatal \nhealth, leading them to believe they do not  need to make changes or seek support  before conception \nunless they experience fertility issues:  \n“that bit  [preconception] you just DIY. And then you look for the assistance once you are \nactually pregnant.” (P.02, 25-29 years, previously pregnant) \nA related view was that women's health issues typically receive little attention, relative to other \nhealth issues, so \"you only get real knowledge ” about these issues  “if you go out of your way to find \nit\" (P.15). A perceived benefit of promoting greater awareness of the importance of preconception \nhealth was that this could improve people's health behaviours , as “most” (P.02) people would follow \npreconception guidelines if they “know the benefits\" (P.02):  \n“…it's about the motivation to do it. And knowing how to… there are some people who just \ndon't understand the ramifications of their lifestyle on their health …” (P.19, 45 -48 years, \npreviously pregnant) \nIt was also felt that improved knowledge of preconception health may help to address health \ninequalities, and enable people to make “informed decision(s)\" (P.20) and avoid preconception risks: \n“…there's a lot of people who don't have access to health care or health information. And \nsometimes they lose a child… out of not knowing.” (P.01, 35-39 years, previously pregnant) \n“…many people buy multivitamins but don't look at the dose… So yay, they're taking vitamin \nD, but 0.1 per cent of your daily requirement.” (P.17, 35-39 years, previously pregnant) \nSome felt the responsibility for acting on preconception recommendations lies with mothers -to-be, \nmeaning information provision is the only required form of support:  \n“…as long as you make the information available … in a timely way, the rest of it is down to \nthe mum and what they do with that information.” (P.01, 35-39 years, previously pregnant) \nParticipants highlighted several preconception-relevant topics they felt merited greater awareness. \nThese included preconception diet and exercise, safe drinking limits, and “clear guidance” (P.12) on \nfolic acid, including where to buy supplements and alternative dietary sources for women who cannot \nafford these. Participants also called for greater awareness that women are “unlikely to find out [they \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n13 \nare pregnant] for X amount of weeks\" (P.16) and that women “don’t have to spend loads of money” or \n“make massive changes” to meaningfully improve their preconception health (P.19).  \nParticipants suggested a range of settings  for disseminating preconception health  information. \nHealthcare-related suggestions included providing information in general practice waiting rooms, \nsexual health clinics and  pharmacies, through the N ational Health Service ( NHS) app and website, \nand providing enhanced training to healthcare professionals . Participants also suggested providing \ninformation to patients by post, at check -up appointments, and with contraceptive prescriptions. \nMedia-related suggestions included television and radio programmes, documentaries and \nadvertisements, and a soap opera storyline involving “a character that wants to get pregnant\" (P.20). \nThey further included online forums and seminars advertised through social media, and adding \ninformation to period track er and calendar  apps. Retail -related suggestions included providing \ninformation in shopping centre  toilets and making preconception supplements more visible where \nthese are sold . Further suggestions included children’s centres and an awareness month involving a \n\"national advertising campaign” (P.16) and collaborations with relevant charities.  \n3.2.2.2 Need for support services \nViews on whether there is a need for preconception support services were more mixed. Some felt \nthere is currently a \"lack of support\" (P.04) from health professionals in this area and that pregnancy \nservices are delivered too late in the pregnancy journey.  These participants highlighted that many \nhealth promotion services are free to access during pregnancy, but not beforehand, and criticized the \nlack of funding for \"early intervention\" (P.15). Participants with opposing views argued it may not be \n\"fair\" to spend public funds on health promotion services that only benefit women before pregnancy, \nas men may also want free access to these services and many women would not have time to attend \nthem. Others questioned the need for these services, as they felt women planning a pregnancy will \nalready research “what they need to do \" and there is “enough” information online (P.11). Some felt \nadditional support would primarily be needed by people with chronic  health conditions rather than \nthose who are \"already fit and healthy\" (P.05). \nParticipants suggested a range of preconception support services for women. A common suggestion \nwas to provide “community-based” support groups with a \" social aspect\" (P.03) to enable women to \nshare experiences, learn from each other and find \" fellowship\" ( P.19), and address the issue that \nwomen often “ feel isolated and alone \" ( P.15) in their reproductive experiences. Preconception \nclasses were another common suggestion, as it was considered “very helpful” (P.10) to receive advice \nfrom an expert, especially in group settings where attendees benefit from hearing others ask relevant \nquestions:   \n“…another benefit to a class is if the woman across the room asks a question that maybe you \ndidn't think of…\" (P.10, 20-24 years, nulligravid)  \nAnother common service suggestion was a preconception consultation or health check. This included \nsuggestions to normalize seeing a doctor before pregnancy, general practices hosting a monthly  \npreconception care clinic, and having \" your first midwife appointment ” ( P.16) when trying to \nconceive. It was suggested that \" something like\" the NHS Health Check (for patients aged 40 years \nand over) would be a \" really good tool \" (P.17) to assess factors such as weight, blood pressure and \ndiet before pregnancy, and pre -emptively identify conditions affecting fertility, including \nendometriosis. It was also suggested there should be a protocol for health professionals providing \nthese consultations. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n14  \nFurther suggestions for preconception services included access to a nutritionist and one -to-one health \ncoaching. Participants also suggested providing free or subsided  fruit and veg etables, dentistry care, \nvitamin supplements and  exercise classes, particularly to single parents and  those with child tax \ncredits to address the \"class disparity on who gets to have a healthy pregnancy \" (P.10). They further \nsuggested providing additional funding for weight management services, transforming primary care \ncentres into “health-promoting hubs\" (P.12), and making preconception services \"disproportionately \navailable” (P.12) in deprived areas, to address the link between poverty and risk factors such as \nobesity.  \n3.2.2.3 Need for structural interventions \nViews on the need for structural interventions  to support preconception health improvement were \neven more mixed. Participants in favour of these interventions argued it  is \" in the greater good ” \n(P.03) to have better policies relating to factors such as nutrition, as people’s behaviour s are largely \n\"driven by” their environment s (P.03). They spoke favourably of government investment to address \nthe \"massive gap[s] in health inequality\" (P.19). Conversely, others questioned whether such policies \nwould work, as they felt real change begins with an individual seeking out, and acting on, \ninformation about “what is good for [them] ” (P.07) and that “timely” information provision is \ntherefore sufficient (P.01). Others questioned whether it is fair to have policies that exclusively focus \non women’s health as \"men's health, also, isn't great\" (P.12). \nRegarding fortifying foods with folate, some participants felt this would  “help everyone and not \nhinder anyone\" (P.16). These participants considered folate fortification to be \" really positive\" as it \nimproves all women’s dietary folate intake and “negates the need\" (P.19) for women to source folate \nsupplements. They noted that women may be uncomfortable buying these supplements in case this \nreveals their pregnancy plans, and felt it is \" unfair\" ( P.11) that some women cannot afford the m.  \nOthers disagreed with this suggestion; they felt it is not the government’s responsibility  “to dictate \nwhat people can and can't afford \" (P.05) and questioned how someone who cannot afford folic acid \nsupplements could afford a future child. Some questioned the effectiveness of folate fortification, \nwhether eating folate -fortified foods is sufficient without supplements, and whether companies \nimplementing this  policy will increase retail prices  for customers . Others considered folate \nfortification \"a marketing ploy \" to lure people from \"more natural” (P.06) sources of dietary folate , \nand that policies of this nature may complicate individuals' efforts to improve their preconception \nhealth: \n\"…you wouldn't want people being frightened also that they hadn't realised it was in their \ncereal and they've also taken a supplement... it's much easier to say: ‘okay I need to be taking \nthis much folic acid a day’.\" (P.05, 35-39 years, previously pregnant) \nA view that people “should be educated ” (P.11) to  take action themselves  underpinned much of the \nopposition to mandatory folate fortification. This related to views that this “government interference\" \n(P.10) forgoes an opportunity to  encourage individual responsibility for health , which can be  more \nimpactful:   \n\"...while it might solve a very simple problem of 'we need to have women getting more folic \nacid', does it really encourage people to take responsibility for their own health?... when it \ncomes from the person themselves, it tends to be more long -lasting, and it tends to have a \nwider impact across their whole health.” (P.12, 35-39 years, nulligravid) \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n15 \n\"I think it's much easier to say: ‘okay, I need to be taking this much folic acid a day’... people \nneed to be responsible for themselves which includes their finance and their health… \" (P.05, \n35-39 years, previously pregnant) \nThese participants also expressed that they found it \"hard to empathize with\", and support policies \ndesigned to benefit, women who do not plan their pregnancies:  \n\"...we spent twelve thousand pounds having our daughter…we did everything we could. And \nit's sometimes quite difficult … to separate the accidental pregnancies who don't want the \nchildren and then have no interest in trying to find out how to keep them well …\" (P.11, 30-34 \nyears, nulligravid) \nOther participants questioned the need to “foie gras” (P.11) the majority of the population with folic \nacid without their \" knowledge or consent \" ( P.10) when more targeted approaches are available to \ndeliver folate supplements to women planning a pregnancy:   \n“…[folate fortification] just seems an odd approach, because you've got a ready market of \npeople who want this stuff…  If people go to the NHS and say: ‘I'm trying to get pregnant’. \nAnd they hand over a couple of pills when you’re really needing it, then that's brilliant .” \n(P.11, 30-34 years, nulligravid) \nThese participants felt  folate fortification would be \" forcing\" all men and some women to consume \nsomething “of no benefit to them\" and questioned whether women “would like that if it was the other \nway around” (P.20). They were more supportive of more universally -relevant policies, such as those \ntargeting alcohol, as it is “healthy, generally, for people to drink less” (P.20). \nParticipants’ s uggestions for structural interventions  included making healthier foods cheaper and \nmore accessible than unhealthy foods and alcohol, banning harmful ingredients from food, and \nfortifying more foods with key nutrients. Further suggestions included having a greater focus on \naddressing poverty as the \"biggest risk factor for poor health\" (P.12), having “more joined-up\" health \nagendas (P.12), and funding more health promotion work  in primary care. It was also suggested that \nemployers should be required to safeguard women from occupational risks and enable them to attend \npreconception healthcare appointments during working hours. \n4 Discussion \nNational health organizations have called for more research with women to develop acceptable \nstrategies to address their preconception health support needs (Department of Health and Social Care, \n2022a, 2022b) . This is the first qualitative study  to explore views on  what preconception support \nshould involve and who it should target , with purposively-sampled women to capture a diversity of \nperspectives and experiences. Women highlighted a need to deliver preventive interventions ahead of \nfirst pregnancy. There was broad support for promoting greater awareness of preconception health , \nbut v iews on the need for preconception support services and  structural interventions were more \nmixed. Women who supported these services and interventions highlighted broader influences on \nhealth and ‘unfair’ socioeconomic barriers to preconception health  improvement. Those opposed \ncited neoliberal arguments  that encouraging individual responsibility for health may be more \nimpactful and that spending public funds on  interventions that only benefit women’s health may be \nunfair.  \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n16  \n4.1 Integration with prior research \nParticipants considered the provision of  preconception health support to the ‘right’ people at the \n‘right’ time to  be a challenging task  and noted a lack of a clear go -to place for this support. This \nechoes health professionals’ concerns that no one profession has taken responsibility for delivering \npreconception care (Goossens et al., 2018; Steel et al., 2016) . Participants noted that the importance \nof preconception health receives limited attention  relative to ante natal and postnatal health , which \nconveys the impression that preconception support is only relevant to those with subfertility. Prior \nqualitative studies have also reported limited public understanding of the benefits of good \npreconception health , despite broad understanding of the importance of good health in pregnancy \n(Bortolus et al., 2017; M’hamdi et al., 2018; Mazza & Chapman, 2010) . Collectively, these findings \noffer an explanation as to why women have previously indicated they would only seek preconception \nhealthcare support if they encountered difficulty conceiving (Bortolus et al., 2017; McGowan et al., \n2020). Some participants highlighted a need for additional preconception support from healthcare \nservices, including preconception health checks and midwife appointments. This aligns with prior \nqualitative findings  that women would value  receiving preconception counselling from healthcare \nprofessionals with dedicated time for this (Tuomainen et al., 2013; van der Zee et al., 2013). \nSome participants reported a desire for preconception support to include men. This contrasts with the \nlack of  epidemiological evidence for paternal preconception risk fact ors relative to maternal risk \nfactors (Daly et al., 2021). Participants’ justifications for this view included the importance of men’s \npreconception health  and support needs , and that this would help to address the disproportionate \nburden placed on women to improve their health around pregnancy . These views have been reported \nin prior qualitative studies (McGowan et al., 2020; Tuomainen et al., 2013) , but some participants in \nthis study additionally felt it would be inappropriate to segregate target populations by gender, noting \nthe discordance between  some people’s gender identit ies and assigned sex at birth . They also  \nhighlighted a need to provide tailored preconception support to same-sex couples. Whilst women in \nprior studies have reported the importance of a partner ’s support in facilitating women’s \npreconception health improvement efforts  (Kretowicz et al., 2018; Scott et al., 2020; Squiers et al., \n2013), women in this study  also reported that they would value receiving mutual preconception \nsupport from other w omen planning a pregnancy . Collectively, these findings highlight the \nimportance of different forms of social and peer support before pregnancy.  \nEchoing prior qualitative findings , some p articipants highlighted that socioeconomically \ndisadvantaged women may require additional support to improve their preconception health, as folate \nsupplements and nutritious foods may be less accessible to them (Mazza & Chapman, 2010; Scott et \nal., 2020; Squiers et al., 2013) . However, other participants expressed opposition to structural \ninterventions including folate fortification, that may help to address these preconception inequalities \n(Sumar & McLaren, 2011) . They felt encouraging individual responsibility for preconception health \nimprovement would be  more impactful  and questioned the fairness of spending public funds on \nservices and policies that benefit only select groups of women . Conversely, there was broad support \nfor promoting greater knowledge of preconception health, particularly in early life and during  \npregnancy planning, as per previous qualitative studies  (Lang et al., 2020; McGowan et al., 2020; \nTuomainen et al., 2013) .  This mirrors findings that  support involving advice  and guidance is \ngenerally more acceptable to the public than structural interventions, as this is considered to cost less \nand enable individual choice  (Adams et al., 2016; Diepeveen et al., 2013) . Conversely, this type of \nsupport can be less effective and more likely to exacerbate health inequalities, as marginalized groups \nmay lack the capability and resources required to act on and benefit from the provided information  \n(Adams et al., 2016; Beauchamp et al., 2014; Lorenc et al., 2013). \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n17 \n4.2 Implications for policy, practice and future research \nOur findings highlight a range of unmet preconception support needs that policymakers, \ncommissioners, healthcare providers and public health professionals should seek to address through \npreconception services, interventions and policies . They also highlight complexities for these \ninterventions and trade -offs that may be needed to tackl e these. One such challenge relates to the \nview expressed by some participants that it would be unacceptable to deliver preconception \ninterventions to particular groups of women , including those struggling with infertility and women \nwho do not want children. This suggests that some broad-reach, universal support may either be \ninappropriate or require careful consideration of how to reflect and respect the circumstances of these \ngroups. Relatedly, participants highlighted that delivering preventive support ahead of first \npregnancy, such as  school-based preconception health education, could have unique benefits  \nincluding a reduced risk of distress . However, some participants were concerned that providing ‘too \nmuch’ information at ‘too young’ an age may encourage teenage pregnancy. Future research should \nexplore how to ensure ‘age-appropriate’ tailoring of  preconception education for different age \ncohorts, to allay these concerns.   \nA further challenge relates to the negative views expressed by some participants toward the provision \nof services and structural interventions to improve preconception health , including folate \nfortification, despite broad support for promoting greater awareness of preconception health.  This \nrelated to concerns these  services and interventions would require public funding but only benefit \nparticular groups of women . This highlights a tension between the public ’s preferences and the \nimperative to improve preconception health using the most effective and equitable methods (Adams \net al., 2016; Beauchamp et al., 2014; Lorenc et al., 2013) . It also highlights a need to communicate \nthe wider benefits of preventive public health policies such as folate fortification to the public (Finch \net al., 2024; Rodrigues et al., 2021) . Some participants framed structural interventions as \n‘government interference’ and placed responsibility for improving preconception health squarely on \nwomen planning a pregnancy. This highlights the importance of improving public understanding of \nthe impacts of the social and commercial determinants of health and structural inequalities relating to \npoverty (Graham et al., 2010; Singh -Manoux & Marmot, 2005; The Food Foundation, 2023) . This \nmay help to improve the public acceptability of these interventions (Grunseit et al., 2023), which can \nincrease governments’ willingness to implement them (Diepeveen et al., 2013) . Providing the public \nwith  opportunities to engage in the development of these interventions and express their concerns  \nmay also facilitate this (Sunstein et al., 2019).  \n4.3 Limitations \nOur study has limitations concerning its sample and design. We achieved a balanced sample in terms \nof age and pregnancy history and the proportions of participants who were born outside the UK and \nhad below-average household incomes aligned with  the national average (Office for National \nStatistics, 2021a, 2021b). However, the actual participant numbers from these groups were small and \nuniversity graduates were overrepresented . Additionally, we excluded  pregnant women and women \nwho reported certain adverse reproductive outcomes in our survey, to minimize distress . Women in \nthis study felt preconception support should be sensitive to the se women’s circumstances , but these \nwomen’s views on how to achieve this were not captured.   \nOur sequential explanatory mixed methods desig n involved analyzing our quantitative data before \ncollecting our qualitative data. This  enabled us to purposively recruit a diverse sample of  women, \nthereby avoiding  the potential bias of previous studies (McGowan et al., 2020; Tuomainen et al., \n2013). However, a  sequential exploratory design would have enabled us to quantitatively determine \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n18  \nhow representative participants’ views were  and the suitability of transferring our findings to other \nsamples (Spencer et al., 2004). This is a potential direction for future research. \nFurther, the  first author ’s positioning as an outsider researcher  may have influenced the study’s \nknowledge production . This likely helped  to avoid challenges relating to  insider research, such as  \ntaken‐for‐granted assumptions, over‐familiarity, and participants omitting details because of assumed \nshared experience and understanding (Hockey, 1993) . Putting participants in a relatively expert \nposition can also be an ‘empowering experience’ and beneficial in research with marginalized groups \n(Berger, 2015). However, MD’s positioning as a male, outsider researcher may have meant some of \nthe interviewed women did not feel comfortable sharing particular details of  their reproductive \nexperiences and omitted these (Berger, 2015).   \n5 Conclusion  \nWomen highlighted a need to provide preventive support ahead of first pregnancy  and broadly \nsupported promoting greater awareness of preconception health. However, some oppose d the \nprovision of preconception support services and structural interventions, due to concerns these would \nbe less impactful than encouraging individual responsibility for health and have limited benefits for \nthe wider population. Future research should aim to co-produce preconception health interventions \ninformed by these findings and explore how to increase public understanding of the soci oeconomic, \nenvironmental and commercial determinants of preconception health. \n \nAcknowledgements: The authors thank the women who participated in this study. We would also \nlike to thank Mike Bell at NIHR ARC West, who supported the study’s public involvement, and \nJudith Stephenson, Jennifer Hall and Geraldine Barrett, who reviewed the study’s protocol and topic \nguide before its conduct.  \n \nFunding s tatement: This work was supported in part by grant MR/N0137941/1 for the GW4 \nBIOMED DTP, awarded to the Universities of Bath, Bristol, Cardiff and Exeter from the Medical \nResearch Council (MRC)/UKRI.  This included funding for open access publication fees.  The \nfunding body had no role in the design of the study and collection, analysis, and interpretation of data \nand in writing the manuscript. \n \nCompeting interests statement: The authors declare that the research was conducted in the absence \nof any commercial, financial or personal relationships that could be construed as a potential conflict \nof interest. \n \nAbbreviations: BMI: Body Mass Index; GP: General Practitioner; NHS: National Health Service \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n19 \nReferences \nAdams, J., Mytton, O., White, M., & Monsivais, P. (2016). 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CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint \n\n \n23 \nWithanage, N. N., Botfield, J. R., Srinivasan, S., Black, K. I., & Mazza, D. (2022). Effectiveness of \npreconception interventions in primary care: a systematic review. British Journal of General \nPractice, 72, e865-e872. https://doi.org/10.3399/BJGP.2022.0040  \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 11, 2024. ; https://doi.org/10.1101/2024.12.04.24318497doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}