An exploration of preconception care for people with health conditions using realist methodology: what works, for whom, and in what circumstances?

Abstract

Background: People living with pre-existing physical or mental health conditions are over-represented in audits and confidential enquiries regarding maternal morbidity and mortality and thus often advised to stabilise or optimise their health prior to becoming pregnant. Preconception care may include medication or behaviour change, which can be effective but not always accessed by those who need it, and there is a lack of evidence demonstrating how this can be achieved. The aim of this study was therefore to explore what form of preconception care for people living with health conditions works, for whom, how do these approaches work, and in what circumstances. Design: Realist methodology was used to identify causal explanations, involving consideration of unobservable processes or powers that can only be identified by their effects but may still have relevant impact on the outcomes of an intervention or programme. A realist review of literature was followed by a realist evaluation, which involved qualitative interviews with relevant stakeholders: women living with health conditions, their partners or supporting family members, and healthcare professionals. Results: Thirteen refined middle-range theories, providing causal explanations of what works for whom, and how, were identified. These focused on information, knowledge and beliefs, therapeutic relationships, and social structures and healthcare services. Theories were identified as relevant different points of a person’s journey. Since pregnancy planning was identified as important for people living with health conditions, theories providing a causal explanation of how this can be enabled are important, in addition to theories that apply within the context of pregnancy planning. Discussion: This is the first study of preconception care for people living with health conditions using a realist approach. A realist review followed by a realist evaluation has resulted in new knowledge about causal factors that promote access to preconception care and support for people in this group to improve their preconception health. Focusing on causality has identified important recommendations for health care professionals, public health messaging, and the organisation of healthcare. Implementation in practice will lead to a greater chance of pregnancy planning and support to optimise preconception health for people living with health conditions.