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www.thelancet.com Published online April 16, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30313-1
1
Series
Preconception health 3
Intervention strategies to improve nutrition and health
behaviours before conception
Mary Barker, Stephan U Dombrowski, Tim Colbourn, Caroline H D Fall, Natasha M Kriznik, Wendy T Lawrence, Shane A Norris, Gloria Ngaiza,
Dilisha Patel, Jolene Skordis-Worrall, Falko F Sniehotta, Régine Steegers-Theunissen, Christina Vogel, Kathryn Woods-Townsend, Judith Stephenson
The nutritional status of both women and men before conception has profound implications for the growth,
development, and long-term health of their ospring. Evidence of the eectiveness of preconception interventions for
improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively
low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies
for intervention that are likely to be scalable and have positive eects on a range of health outcomes: supplementation
and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies,
we suggest a model specifying pathways to eect. Pathways are incorporated into a life-course framework using
individual motivation and receptiveness at dierent preconception action phases, to guide design and targeting of
preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of
settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be
engaged with maternal health services. Interventions to improve women’s nutritional status and health behaviours at
all preconception action phases should consider social and environmental determinants, to avoid exacerbating health
and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a
dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population
more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and
symbolic connection between improved preconception maternal health and nutrition, and ospring health. We
suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the
private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception
health, to harness the political will and leadership necessary to turn high-level policy into eective coordinated action.
Introduction
In 2016, the UN committed to “end all forms of
malnutrition, including achieving, by 2025, the
internationally agreed targets on stunting and wasting
in children under 5 years of age, and address the
nutritional needs of adolescent girls, pregnant and
lactating women, and older persons” in target 2·2 of
Sustainable Development Goal 2.1 Growth and
development targets for children, and the consequent
reduction in their risk of non-communicable disease in
adulthood, could be achieved through improving
women’s nutritional status and health behaviour before
conception.2 Two previous Lancet Series have called for
innovation in the design and delivery of aordable,
scalable nutrition interventions to improve maternal
and child health.3,4 In this Series paper, we review what
is known about the eectiveness of preconception
nutritional and behavioural interventions, and propose
a strategy for aligning interventions with individual
motivation and receptiveness at dierent preconception
action phases during the life course. We propose a
dual strategy targeting health improvement in men
and women planning a pregnancy, and in the general
population, on the basis that improvements in pre-
conception health require a supportive environment
(under pinned by a social movement and policy
initiatives), and on the engagement of the private sector.
Intervention strategies
We conducted a quasi-systematic review of trials of
preconception nutrition and health behaviour inter-
ventions, to identify eective interventions and specify
pathways to eect (appendix). We included interventions
assessing nutritional status and body composition
outcomes, excluding other clinical outcomes such as
improved glycaemic control. Pathways to eect were
Published Online
April 16, 2018
http://dx.doi.org/10.1016/
S0140-6736(18)30313-1
This is the third in a Series of
three papers about
preconception health
MRC Lifecourse Epidemiology
Unit, University of
Southampton, Southampton
General Hospital,
Southampton, UK
(M Barker PhD,
Prof C H D Fall DM,
W T Lawrence PhD, C Vogel PhD);
NIHR Southampton Biomedical
Research Centre, Southampton
General Hospital,
Southampton, UK
(M Barker, W T Lawrence, C Vogel,
K Woods-Townsend PhD);
Faculty of Natural Sciences,
Division of Psychology,
University of Stirling, Stirling,
UK (S U Dombrowski PhD); UCL
Institute for Global Health
(T Colbourn PhD, G Ngaiza PhD,
J Skordis-Worrall PhD), and UCL
EGA Institute for Women’s
Health, Faculty of Population
Health Sciences (D Patel MSc,
Prof J Stephenson FFPH),
University College London,
London, UK; The Healthcare
Key messages
• Epidemiological data, and findings from developmental biology, suggest that
intervening to improve men’s and women’s nutritional status before pregnancy
improves long-term outcomes for mothers and babies
• Trials of interventions to improve nutritional status before conception and birth
outcomes are scarce, but new trials are underway
• Effective preconception nutritional interventions include supplementation or food
fortification to provide micronutrients, particularly folic acid and iodine
• To maximise benefit and achieve health growth trajectories in the next generation,
preconception strategies should be broader than supplementation or fortification,
and address wider determinants of health
• Motivations to engage with preconception nutrition differ according to age and life
phase; understanding and harnessing these motivations is key to successful intervention
• Interventions should be context-specific and make use of existing platforms for delivery
• Preconception interventions need to be supported by a social movement and political
will, both of which require skilful engagement with powerful commercial interests
Series
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www.thelancet.com Published online April 16, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30313-1
then incorporated into a life-course framework to aid the
targeting of interventions. Preconception interventions
were reviewed using the reach, eectiveness, adoption,
implementation, and main tenance (REAIM) framework.5
Finally, we applied a consumer-marketing approach to
the challenge of creating a social movement to strengthen
political resolve for wide-scale intervention.
We identified 14 controlled primary studies evaluating
three strategies: supplementation and fortification, cash
transfers or incentives, and behaviour change intervention.
We did not identify enough good quality studies conducted
in the preconception period to enable us to perform
a meta-analysis or draw firm conclusions about eective-
ness; however, epidemiological and biological evidence
points to the value of intervening prior to conception.
Intervention strategies were selected for review on the
basis of being scalable, low risk, and of likely benefit to
nutritional outcomes in the preconception period. We
developed a model describing the key pathways to be
quantified once more high quality data from randomised
trials become available (figure 1).
Supplementation and food fortification
Most evidence for the benefits of improving precon-
ception nutrition and health comes from trials examining
the eects of micronutrient and energy supplementation.
The Bacon Chow study,6 done in Taiwan, found that
supplementing the diets of women who were under-
nourished with 800 kcal and 40 g protein per day after the
birth of their first baby increased birthweight of the
second baby when compared with a control group given
just 80 kcal extra per day. A similar study in the USA7
also found increased birthweight of subsequent babies
among women given supplements for 5–7 months
following the birth of their first baby, compared with
those given supplements for up to 2 months. The
Mumbai Maternal Nutrition Project8,9 showed that a
locally sourced, micronutrient-rich snack, given daily
before conception and during pregnancy, reduced the
likelihood of gestational diabetes and increased
birthweight in a high-risk Indian population (but only
among mothers who were not underweight). These
studies represent the best available evidence for the
benefits of preconception nutritional supplemen tation.
Eective strategies to improve access to additional
calories before conception still need to be identified in
contexts where maternal undernutrition is common.
Supplementation interventions are generally accept-
able to women, but uptake is often hampered by poor
adherence. Several solutions have been proposed, in-
cluding a contraceptive pill containing folic acid available
in the USA;10,11 however, the impact of this solution
depends on contraceptive pill use, which varies widely
between countries. Fortifying foods such as flour or rice
has wide potential reach, and is currently mandated in
87 countries.12 The WHO has also issued a guideline for
the fortification of salt with iodine, which can prevent
irreversible mental impairment of the fetus.13 In
addition, reductions in the prevalence of neural tube
defects have been observed following mandatory folic
acid fortification in Canada, Chile, Costa Rica, South
Africa, and the USA.14,15 However, folic acid forti-
fication is not mandatory in Europe; in the UK,
there are concerns about increasing cancer risk in
older populations, potential masking of anaemia
caused by vitamin B12 deficiency, and removal of
individual choice.14 Despite these concerns, there is
little evidence of negative eects from folic acid
fortification.16 The UK’s Scientific Advisory Committee
on Nutrition continues to recommend mandatory folic
Improvement Studies Institute,
University of Cambridge,
Cambridge, UK
(N M Kriznik PhD); MRC
Developmental Pathways for
Health Research Unit,
Department of Paediatrics,
School of Clinical Medicine,
Faculty of Health Sciences,
University of the
Witwatersrand, Johannesburg,
South Africa
(Prof S A Norris PhD); Institute
of Health and Society,
Newcastle University and Fuse,
the UK Clinical Research
Collaboration Centre of
Excellence for Translational
Research in Public Health,
Newcastle upon Tyne, UK
(Prof F F Sniehotta PhD);
Department of Obstetrics and
Gynaecology, and Department
of Pediatrics, Division of
Neonatology, Erasmus MC,
University Medical Center,
Rotterdam, Netherlands
(Prof R Steegers-Theunissen PhD);
and Southampton Education
School, Faculty of Social and
Human Sciences, University of
Southampton, Southampton,
UK (K Woods-Townsend)
Correspondence to:
Prof Judith Stephenson, UCL EGA
Institute for Women’s Health,
Faculty of Population Health
Sciences, University College
London, Medical School
Building, 74 Huntley Street,
London WC1E 6AU, UK
judith.stephenson@ucl.ac.uk
See Online for appendix
Preconception
Previous
pregnancy/
birth
2
years
1
year
3
months
Pregnancy trimester
First Second Third
Postbirth
1 month 6 months 12 months 24
months
60
months
Conception Birth
Risk factors
Maternal nutrition
Underweight
(BMI <18)
Normal
(BMI 18–25)
Overweight
(BMI 25–30)
Obese
(BMI >30)
Interventions Mechanisms Outcomes
Increased calorie
consumption
Increased micronutrient
consumption (including
fruit and vegetables)
Decreased calorie
consumption
Food/fortification and
supplementation
Cash transfers or
incentives
Confounders
Socioeconomic status
Education
Behaviour change
interventions
Increased
gestation
Increased
birthweight
Increased
maternal BMI
Decreased
macrosomia
Decreased
maternal BMI
Decreased
stillbirth
Decreased neonatal
mortality
Increased WAZ, HAZ, WHZ
Improved early childhood
development
Addresses undernutrition
Addresses overnutrition
Confounders
Income
Occupation
Figure 1: Conceptual model of pathways between interventions to improve maternal nutritional status and maternal and infant outcomes
BMI=body-mass index. WAZ=weight-for-age Z score. HAZ=height-for-age Z score. WHZ=weight-for-height Z score.
Series
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3
acid fortification to improve the folate status of women
most at risk of neural tube defect-aected pregnancies.16
Cash transfers and incentives
None of the studies identified investigated the eects of
preconception cash transfers on birth or nutritional
outcomes. However, this strategy was included in the
model because cash transfers are eective in improving
school enrolment and attendance among girls, access to
preventive health care, and household food consumption
in low-income settings.17–19 These factors are risks for
poor birth and nutritional outcomes, suggesting that
preconception cash transfers could be useful.20,21 In high-
income settings, further work is needed to demonstrate
the eectiveness and acceptability of combating over-
weight and obesity through incentivising the purchase of
healthy foods.
Behaviour change interventions
Two systematic reviews22,23 examining 12 preconception
trials identified possible improvements in health
behaviours (including alcohol consumption and smok-
ing), and psychological mediators of intervention eects
(such as maternal self-ecacy and perceived control).
Neither review reported maternal nutritional status as an
outcome. Two studies tested the eect of preconception
nutritional or behavioural interventions on birth
outcomes: no eect on pregnancy outcomes was found
in a Dutch study24 when general practitioners counselled
couples on health behaviours; and a negative eect on
birthweight of counselling on risk factors including diet,
timing of next pregnancy, and specialist referrals was
noted in an Australian study.25 The authors of the latter
study speculated that improved preconception health
meant that previously unsustainable pregnancies were
sustained for longer, resulting in increased preterm
births and decreased birthweights. If true, this would
be an unexpected and adverse eect of preconception
intervention.
Addressing preconception undernutrition in low-income
settings could require broader behavioural strategies than
tackling overnutrition in high-income settings. Low-
resource households cannot simply change their behaviour
if food is unavailable, and so strategies must combine
behaviour change with food access, as was done in the
CARING Trial26,27 in eastern India. A health-care approach
was used that successfully engaged women and reduced
maternal and neonatal mortality in rural, low-resource
settings, known as participatory learning and action
through women’s groups.28 Facilitated by a trained health-
care professional, this group-based, problem-solving
approach involves women of all ages, and tackles a variety
of maternal and newborn problems including nutrition.
Although the original trials testing this approach did not
report on nutritional outcomes, the CARING trial found
that the approach improved key secondary outcomes,
including dietary diversity and handwashing (although no
significant increase in child length was measured).
Interventions in high-resource contexts can focus on
individual choice, but multilevel interventions might be
more eective.29 Intervention trials developed as part of the
Canadian Government’s Healthy Life Trajectories Initiative
are good examples of multilevel interventions that aim to
address precon ception nutrition and health behaviour, but
also wider health and social determinants. These trials
will provide gold standard evidence of the eectiveness,
and cost-eectiveness, of multicomponent preconception
interventions in improving outcomes for children.
Preconception interventions often require engagement
from individuals who are not thinking about becoming
pregnant in the near future, and are unlikely to be using
maternal health services. Interventions to improve health
behaviours in adolescents and young adults might,
therefore, have to be placed outside maternal and child
health services and appeal to motivations unrelated to
health, such as self-image.30–32
Motivation and engagement
The complexities involved in changing individual and
population health behaviours are well recognised. It is
usually not enough to simply educate or give advice, as
knowing something is good for you is rarely sucient to
change behaviour. Successful behaviour change requires
the target population to engage with the need to change,
sustain the motivation to maintain the change, and be
supported by contexts that facilitate change (service
providers, society, social networks, and environments).33
Figure 2 shows a model of preconception action phases,
adapted from the Rubicon model of action phases and the
Action phase model of developmental regulation, and
applied to preconception motivations and interventions.34,35
The model is based on five assumptions: first, most
young adults intend to become parents at some point,
and this goal begins to form in childhood; second, young
adults have the adaptive capacity to pursue this goal
among their other developmental life-course goals, and to
translate it into action; third, the goal to become a parent
is nested within other facilitating and conflicting develop-
mental life-course goals, which are pursued as oppor-
tunities evolve over time; fourth, motivation to become a
parent is the driver that translates that goal into relevant
preconception behaviours; and fifth, translating the goal
to become a parent into conception and pre gnancy
outcomes is imperfect.
The model distinguishes four phases, characterised by
overarching biological or psychological agendas and
motives, in relation to the goal to become a parent. As an
individual moves through the phases, interventions
become less general and more targeted towards specific
populations (in keeping with the dual strategy for
promoting preconception health proposed here). In the
early phases of the model, intervention reach will be
increased, although eect sizes are likely to be small due
to low intensity. The benefits of interventions in these
For the Healthy Life Trajectories
Initiative see http://www.cihr-
irsc.gc.ca/e/49511.html
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early phases will be general; healthy diets will benefit
both the individual and society, and enhance motivation
in those not planning imminent pregnancy. Creating a
social movement could raise awareness of the importance
of preconception nutrition, and generate a supportive
social environment for preconception health. It could also
help build engagement at each phase, and facilitate
preparation for pregnancy as a normal part of having a
baby within standard health-care practice.36
Intervening with children and adolescents
In the first phase of preconception action, motivation to
become a parent forms without any physical capability
for childbearing, which changes as children develop into
adolescents. Laying foundations for a healthy life is
essential for reasons independent of any preconception
health agenda, and there is a need to raise awareness of
healthy preparation for pregnancy as a concept from an
early age.
Recent recognition of the triple benefit from investment
in adolescent health—their health now, their health in the
future, and the health of the next generation—has
focused attention on this life-course phase.37–39 90% of the
world’s 1·8 billion adolescents live in low-income and
middle-income countries (LMICs); up to half experience
stunted growth and pregnancy is common.40 For this
group, a key intervention in improving outcomes for
mothers and babies is to delay first pregnancy beyond
18 years, when nutrients are no longer needed to support
maternal growth.40 In high-income countries, adolescents
have the poorest diets of any age group.41 Physiological
responses and health behaviours established during
adolescence continue into adulthood, and neurological
and epigenetic changes in adolescence suggest that it is a
crucial period for establishing long-term health risk.42,43
Adolescents typically disengage with traditional health
messages, prioritising the immediate over the long-term,
and having a strong desire for autonomy causes them to
reject instructive health education.44,45 Eective inter-
ventions with adolescents need to empower and
encourage by giving, rather than taking away,
responsibility.
The LifeLab programme is an example of a school-
based intervention, aimed at developing adolescents’
motivations for improving their diets and physical
activity levels through engagement with science, with an
emphasis on their health but with reference to benefits
for their future children (appendix).46,47 The students
report that being good parents in the future is important
to them; learning about preconception health motivates
Goal to
become parent Forming
• Developing biological
capacity to become
pregnant
• Family role modelling
to influence
parenthood expectations
• Learning of lifestyle habits
Activated
• Increased investment of
thought, time, and effort
into becoming pregnant
• Receptive to pre-
pregnancy input
• Reflecting on lifestyle
habits and contemplating
change
Reactivated
• Previous experience of
pre-pregnancy phase and
outcome
• Activation of previous
habits and behaviours
• Lower receptiveness for
pre-pregnancy input
Refining
• Pregnancy physically
possible, but other life
goals more importatant
• Consolidation of
lifestyle habits
• Loss of capacity to have a
healthy child in future may
be motivating factor for
some (loss aversion)
• Consideration of personal,
normative, economic,
and social context
• Foster healthy lifestyle
independent of
preconception agenda
• Teach why and how
lifestyle is important for
preconception health
• Raise public awareness of
preconception health
• Signpost to available
evidence-based
information resources and
support tools, eg, online
information platforms
• Support foundations for
independent living
• Actively support
preconception health,
eg, text messaging
intervention
• Provide practical tools and
stratagies in an engaging
way
• For subgroups, provide
intense direct and tailored
individual support, eg,
one-to-one counselling
• Actively support
preconception health
tailored to parents
• Provide practical tools and
strategies in an engaging
way and relevant to parents
taking previous pregnancy
experience into account
Features
Intervention
opportunities
Children and
adolescents
Adults with no immediate
intention to become
pregnant
Adults with intention to
become pregnant
Adults with intention to
become pregnant again
Maturation and socialisation
Intention formation
Intention prioritisation
Intention reactivisation
Figure 2: Model of preconception action phases
The model outlines four phases individuals move through in relation to the goal to become a parent, highlighting features and intervention opportunities for each
phase (adapted from the Rubicon model of action phases and the Action phase model of developmental regulation).34,35
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5
them to improve their diets and physical activity. LifeLab
has potential to help children and adolescents develop a
concept of preconception and parenthood, but this
concept alone might not motivate change because it is
not an immediate imperative. Motivation is a necessary
but not sucient condition for behaviour change.48 The
addition of an in-person intervention to LifeLab
would support students’ capabilities (ie, “you can do
this! I believe in you!”), and opportunities for behaviour
change (ie, “how are you going to exercise more and
what is your plan for eating healthily?”). Where female
participation in formal schooling is low, alternative
approaches are needed to ensure engagement of
adolescent boys and girls.
In rural South Africa, where there are high rates of
adolescent overweight and obesity, the Ntshembo (Hope)
intervention49 aims to achieve a healthy body-mass index in
14–19 year-olds through a 2-year programme of behaviour
change support. Working with adolescents, their carers,
and village leaders, Ntshembo is explicitly designed to
address individual and community motiva tions and
capabilities, and to provide opportunities for adolescents to
eat well and exercise more. It harnesses the power of social
influence on adolescent behaviour through peer support,
and employs community health workers trained to support
problem-solving and capitalise on adolescents’ need
for autonomy; the development of an adolescent-friendly
health service to deliver gender and context-specific
interventions is widely supported.50 As in LifeLab, the
preconception agenda in Ntshembo is largely that of
the intervention developers, who will need to engage
with adolescents’ own imperatives for the intervention
to succeed.
Interventions with adults not immediately intending to
become pregnant
In this second phase, the goal to become a parent is
refined and shaped by the individual’s psychological,
social, economic, and biological status.51–53 As young
adults mature, developmental goals such as completing
education, obtaining employment, and forming intimate
relationships generally take priority over becoming a
parent. Consequently, preconception health will have
little motivational currency during this phase. Eective
methods of engagement at this stage will be highly
context-specific.
In some cultures, marriage oers an opportunity to
engage couples in thinking about their nutrition and
health before conception, particularly in countries
where premarital testing aimed at reducing transmission
of inherited disorders is mandatory. The Jom Mama
project,54 supported by the Malaysian Government, uses
an existing premarital HIV screening and wellness
programme to provide preconception nutrition support
to couples, using a combination of an online platform
and in-person behaviour change support (appendix).
Newly married Malaysian women said that having a
healthy baby in the future was a major motivation for
improving their diets and physical activity (panel).
However, other life-course goals, such as work, were a
barrier to eating well and being active. The eectiveness
of this intervention might be constrained by its focus on
individual responsibility, and the fact that it does not
directly address the challenge of social influences or an
obesogenic environment.
The absence of dedicated preconception health care in
many countries means interventions to improve pre-
conception nutritional status need to take advantage of
routine contact between young adults and health-
care professionals.55 For example, oering support in
reproductive health clinics has the potential to improve the
preconception nutritional status of women who might or
might not be actively planning pregnancies. This requires
health-care professionals to be aware of the importance of
preconception nutrition, have the skills to intervene, and
see oering nutritional support as part of their job. To help
raise awareness, the USA’s Centers for Disease Control
and Prevention promotes a Reproductive Life Plan56
intended to encourage people of child-bearing age to
prepare for pregnancy, and maximise the preconception
benefit of interactions with health-care professionals.
Training for health-care professionals in skills to
support behaviour change is available in the form of
Healthy Conversation Skills;57 this set of easily acquired,
theory-based skills for practitioners is designed to
engage and motivate patients and clients during brief
consultations. Unlike giving information and advice,
the Healthy Conversation Skills training promotes the
use of open discovery questions, listening, reflecting,
and goal-setting to enable a woman or couple to prepare
for pregnancy, and support them in finding their own
solutions to challenges. The skills have been used in
maternal and child health contexts around the world, and
their use is both acceptable and feasible.58,59
Armed with these skills, practice and community
nurses, sexual and reproductive health clinic sta, those
working in early pregnancy units (who treat women who
have miscarried), and sta providing weight management
services are all potential agents for delivering appropriate,
timely, and culturally sensitive support to improve
preconception nutritional status at scale. Extending this
skills training to community health workers, with support
from local and national policies, has the potential for
widespread impact on preconception health; in other
contexts this approach can improve health outcomes in a
range of public health and primary care settings.60,61
An approach such as Healthy Conversation Skills enables
health-care professionals to provide care that is responsive
to women’s personal, social, and cultural environments.55
In contexts outside health care, supermarkets represent
an unexploited opportunity for promoting preconception
nutrition. Supermarkets have an unparalleled reach into
communities and expertise in customer engagement.
Women do most of the family food shopping, and in
For USA’s Centers for Disease
Control and Prevention
preconception health guidance
see https://www.cdc.gov/
preconception/index.html
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high-income countries, these choices are made in super-
markets.62 The food choices of disadvantaged women are
particularly susceptible to the supermarket environment,
suggesting that modifications which encourage the
purchasing of healthy foods, might have greatest impact
on women with poor diets.63 In LMICs, the role of
supermarkets as food purveyors is rapidly expanding,
although not necessarily in remote and rural areas where
increasing the accessibility of nutrient-dense food
remains a priority.64,65 A model whereby supermarkets
oer precon ception nutritional support alongside sales of
folic acid and other supplements is one that could be
developed in high-income countries and, if successful,
translated to LMICs as supermarkets become more
widespread.
Interventions with adults intending to become pregnant
In the third phase, the goal to become a parent has been
activated through a combination of social (eg, subjective
norms), situational (eg, marriage), and biological (eg, age)
Panel: Motivations for engagement in interventions to improve preconception health
In the development of the Jom Mama intervention, 18 couples
were interviewed about their motivations to engage with the
intervention programme, and to improve their health before
conception. Having a healthy pregnancy and a healthy child
were clear motives for improving diet and lifestyle:
• “Because I want to conceive as I’ve never conceived before.
So getting pregnant will motivate us.” (Respondent 12)
• “I wanted to be healthy for myself and for my child…I think
my commitment as a wife and mother is important.”
(Respondent 10)
Interviewees suggested that a range of incentives, including
financial and personalised support from health-care staff,
would sustain their engagement in a programme of diet and
lifestyle improvement, as would stories from others at the same
stage of life. They also proposed that programme content
should be simple, attractive, and specifically targeted to them,
and that it should not interfere with their working hours,
suggesting that delivery should be on a digital platform,
accessible at their convenience.
Participants described features of their lives as young, working
people that acted as barriers to improving their diets and
physical activity levels in preparation for pregnancy.
• Working patterns: “I usually don’t take breakfast…and then I
start work, rest at 12.30 pm, but if I’m too busy I don’t rest
until the evenings, sometimes at 6 pm, sometimes until
8, 9 pm only then I go home.” (Respondent 8)
• Eating habits: “Sometimes I have lunch at 12 noon…
sometimes at 3 pm…it’s uncertain.” (Respondent 13)
• Exercise: “Not after marriage…can’t make it in the evening.
No time.” (Respondent 1)
In the UK, women who had recently had a child attending
routine appointments with health visitors were approached
and asked whether they would be planning another
pregnancy in the following 12 months. Those who indicated
they would be interested were invited to participate in a pilot
study of the effectiveness of the Smarter Pregnancy
intervention and subsequently provide an in-depth interview.
15 women were interviewed and their views of preconception
care were sought.
Women felt that just because they had already had a baby did not
mean they were aware of what was required for a healthy
conception and pregnancy. Because of their involvement in the
interconception study, they accepted that preconception care was
important, something they might not have considered before:
• “We’ve not had something like this before and I felt like, at
that time when I wanted to get pregnant…you don’t know,
even though you’ve had three kids already before. You just
forget everything.” (Woman 31, married with three children
aged 14 years, 8 years, and 4 years)
• “I know [now] that our body has to be ready before we get
pregnant. You need to be prepared. Everything has to be
enough. Since then, I know, I start to understand you have
to eat enough vitamins to get pregnant.” (Woman 31,
married with two children—a baby and a 10-year-old)
When they discussed the implications of their new
understanding, women highlighted the importance of
improving their health prior to conceiving, with specific focus
on improving their diet and being a healthy weight:
• “In terms of...sometimes, you lose track of what is healthy.
So that is when I had to relook at my diet in terms of having
more vegetables and then taking my folic acid and looking
at all of these healthy things.” (Woman 40, previous
stillbirth, currently pregnant)
Key sources of information for preconception care were the
internet and friends and family. There was a desire for reliable
and accredited sources of information to put couples’ minds at
ease. What the women said suggests there is a gap in current
provision of preconception health information:
• “I think the problem is if people don’t know, they go to
Google. And you go to Google, and you get some chat on
Mumsnet. And it’s a load of women feeding other women
garbage... there’s so much false information out there. But if
you don’t know that, you go ‘This is what it means.’ Stuff
like this [the intervention material] just keeping people on
the straight and narrow is quite helpful.” (Woman 32,
one child aged 1 year, recent miscarriage)
There was agreement among women that healthier lifestyles can
contribute to healthier pregnancies, a reflection that they had
not considered this for their previous pregnancy, and an
intention to improve their nutritional status in preparation for
the next pregnancy. Therefore, the inter-partum period might be
a fruitful time to engage women in preconception health care.
In the UK, women are under the care of the community health visiting services from
pregnancy up to 5 years of age of the child.
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7
factors, and is now actively pursued. This phase is
characterised by an increased investment of thought,
time, and eort into becoming pregnant. Willingness
to engage in interventions increases, and behaviours
can range from passive (eg, reduced investment in
contraception), to active. With appropriate support, pre-
conception interventions are likely to be translated into
behaviour change. Interventions need to allow for swift
and discrete implementation, given the sensitive nature
of couples’ plans for conception, and active promotion
through channels such as contraception counselling.
Since this group is likely to be engaged and seeking
information, preconception health services in primary
care, with a focus on nutrition, could be appropriate.
Interventions oered in this setting can improve pre-
conception health behaviours in women who are planning
to become pregnant.23,66,67 Screening for pregnancy
intention, as outlined in the first paper in this Series,
would enable practitioners in sexual and reproductive
health clinics to oer preconception support, for example,
to women attending for removal of implants and
intrauterine devices.
Digital interventions (online or smartphone-based)
oer privacy and easy access for disadvantaged or
disenfranchised groups less likely to engage with more
formal services. Smarter Pregnancy is a rare example of a
digital intervention designed specifically to support
improvements in preconception nutrition and health
behaviours, and has had some success with couples
who are actively preparing for pregnancy (appendix).68,69
Mobile phone interventions to improve maternal and
child health in LMICs have delivered tailored information
and supported improved infant feeding outcomes.70
Combining digital interventions with motivational
human interaction increases engagement with, and the
eectiveness of, behaviour change interventions.71 An
accessible, population-wide preconception health-care
service could be oered to women via a digital
intervention, and combined with face-to-face or
telephone contact with health-care sta trained in a
motivational approach, such as Healthy Conversation
Skills.
Interventions with adults intending to become
pregnant again
In the fourth phase, the goal to become a parent is
reactivated. Preparation for pregnancy is likely to be influ-
enced by couples’ previous preconception experiences.
Previously uncomplicated pregnancies might decrease
receptiveness for preconception input; if their first baby
was healthy why would couples change their preparations?
However, women and their families have intensive
contact with health services and health-care professionals
during pregnancy, and are motivated to make dietary
changes. Therefore, interventions can support maternal
dietary behaviour change and reduce postnatal weight
gain.72–76
In LMICs, interest has focused mainly on maternal
underweight and micronutrient deficiencies. Women are
willing to take nutritional supplements during pregnancy,
with con sequent reductions in low birthweight,77
however, few studies have focused on supporting change
in habitual dietary behaviour, likely because choices tend
to be limited in undernourished settings. Exceptions
include qualitative studies78 that have sug gested
modifiable dietary behaviours in populations in LMICs.
Young, rural Indian women report avoiding specific
nutritious foods because of fears they could harm a
pregnancy, undereat in the belief that this will make
delivery easier, consume the least nutritious foods after
other family members have eaten because of household
hierarchies, and observe women’s cultural fasting days
(eating predominantly low-nutrient foods).79,80 These data
provide further evidence for extending initiatives that
support wider social and cultural change to include
preconception nutritional interventions.
Maternal and child health-care systems oer post-
partum or interpartum opportunities for working with
women to support dietary behaviour change. Women
interviewed following an interpartum inter vention at a
health visitor clinic in London, UK, had a new awareness
that their nutritional status during and between
pregnancies had an impact on the baby (panel). In high-
income countries, post-partum studies have mainly
focused on limiting weight retention among normal or
overweight women, and improving glucose tolerance
among women with a history of gestational diabetes.81,82
Interventions to address both diet and physical activity
that include self-monitoring of progress, could be more
eective than interventions that focus on only one
behaviour or that do not support monitoring of weight.83,84
Some studies have successfully used education
programmes, or financial incentives, to improve dietary
quality by reducing energy intake and increasing fruit,
vegetable, and whole grain intake.85,86
Many post-partum randomised studies report low
recruitment or retention rates; post-partum mothers
report multiple barriers to participation, including little
spare time, stress, and sleep deprivation.87 Interventions
might need to take a supportive approach involving home
visits, and provision of foods, child care, and
self-monitoring facilities such as weighing scales.87 One
solution could be to integrate in-person support for
interpartum behaviour change with a digital service. Post-
partum weight retention is associated with lifetime obesity
risk and adverse outcomes in the next pregnancy.88 A
cluster randomised trial89 of an internet-based weight loss
programme, coupled with face-to-face support
(Fit Moms/Mamás Activas) in low-income women in
California, USA, found that women in the intervention
group maintained significantly greater weight loss at
12 months than did women who did not receive the
intervention (3·2 kg vs 0·9 kg; dierence 2·3 kg [95% CI
1·1–3·5]).
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Creation of a social movement
A social movement to optimise preconception health,
nutritional status, and health behaviours needs to involve
the whole population and harness political will and
leadership. A social movement in Brazil led to significant
improvements in preconception nutrition for women,
and virtual eradication of undernutrition and wasting
among children younger than 5 years, between 1994
and 2006.90,91 The movement involved, first, a national
cam paign against hunger that raised public aware-
ness of the need to tackle malnutrition, and, second,
development of an advocacy coalition with political
anities that created a critical mass of activists, and
monitored the government’s progress in reducing
malnutrition. Eradicating mal nutrition became a high-
profile social responsibility, prompting strong leadership
from central government in addressing food security.
Under pinning Brazil’s approach was an appreciation
that how women feed themselves and their children is
not solely an individual responsibility, but involves
wider determinants.
Social movements are distinct from social marketing
campaigns. The latter would traditionally attempt to
improve nutrition and health behaviour through providing
information and recommending behaviour change, but
could fail to reach the neediest groups and inadvertently
widen inequalities.92,93 The UK’s Change4Life intervention
adopted this approach, with little evidence of eective-
ness.94 Social practice theory provides some insight as
to why such campaigns are insucient; individuals
and communities require, not only knowledge, but also
resources to enact change, and a purpose or meaning to
provide motivation.95 A social movement providing these
factors might best be founded in socially constructed ideas
of human action, and allied to the field of consumer
marketing and brand creation.
Consumer marketing recognises that individual
behaviour and choices are a function of self-image,
and brands must develop an emotional and symbolic
connection with consumers, making the brand a form of
self-expression.96 A campaign using brand development
practice would target emotions that are central to an
individual’s identity. This approach is epitomised in such
campaigns as the handwashing with soap social move-
ment, which applied brand marketing practices and an
advocacy campaign to address infant mortality under the
tag-line Help a Child Reach 5. The media campaign
followed the principles of being personally relevant,
emotionally engaging, and easy to understand.97 The
evidence-based rationale for handwashing is given only
after the other appeals have been made. The campaign
was driven by a multinational company (Unilever),
supported by an alliance of public health activists and
academics. It has received strong endorsement by the
inclusion of handwashing with soap as an indicator in
the UN’s sustainable development goals, and government
policy initiatives to improve washing facilities.
The handwashing movement is an example of mutual
benefit for public health and for private sector profit that
can come from a joint social purpose. Companies are
more likely to do the right thing in a sustainable way if
public health benefit is accompanied by commercial gain.97
In 2013, Black and colleagues3 declared that “the private
sector is an important force in shaping nutrition outcomes
and has the potential to do more” to improve maternal and
child nutrition. Engaging with the food industry is crucial
because of their reach and power to shape consumer
behaviour. A major diculty with applying the mutual
benefit approach to improving preconception nutrition
and lifestyle through a relationship with the food industry
is their history of malpractice in respect to infant feeding,98
and their role in generating and sustaining an obesogenic
environment. Whether commercial and public health
interests can be aligned in the way they have been for
handwashing remains to be seen. One attempt is
Unilever’s campaign to market iron-fortified stock cubes
to reduce iron-deficiency anaemia in women in Nigeria.99
However, lobbying by some members of the food industry
against sugar-sweetened beverage taxes suggests that
caution is required to ensure the legitimacy of campaigns
and health actions from the food industry. Independent
monitoring of food industry activities by academia and the
public is crucial to building societal support that will
catalyse government and industry actions in respect of
preconception health.100
Marketing principles suggest that a preconception
social movement should be emotionally engaging and
positively framed, appealing to positive emotions, such as
love, as opposed to campaigns that call on personal
responsibility or fear. The call to action would target the
whole population and would ask people to, for example,
support young women or couples to achieve an optimal
pre-pregnancy weight, or eat a variety of fruits and
vegetables. The challenge is to identify simple actions
around which the campaign could be built.
Advocacy coalitions
Political science suggests that a strong advocacy coalition
within international, national, and local policy subsystems
should be developed to place preconception nutrition
firmly on government agendas to incite global policy
action.101 International organisations are already engaged
in advocacy to promote improved preconception health
care. In 2012, WHO coordinated a global consensus on
Preconception Care to Reduce Maternal and Childhood
Mortality and Morbidity, and provided a package of
evidence-based interventions, including nutritional inter-
ventions.102 Pre conception nutrition was then integrated
into a number of transnational organisation initiatives.
With the notable exception of the Netherlands, only
LMICs have shown political support for the adoption of
strategies to address social, environmental, and economic
determinants of maternal and child malnutrition.90,103
Political debate in the Netherlands was sparked by
For Help a Child Reach 5 see
http://www.lifebuoy.com/article/
category/1102088/help-a-child-
reach-5
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9
academics drawing attention to high national perinatal
mortality rates, especially among poor immigrant
communities. The promotion of preconception health to
reach the poorest in the Netherlands has since become a
priority, and includes addressing social deprivation and
broad determinants of maternal ill-health.
Policy change is more likely if advocacy coalitions are
developed to focus on a specific policy subsystem and
engage multiple participants (ie, government agencies,
research institutions, non-government organisations, the
media, commercial interests, and influential individuals)
to build critical mass.101 Strong leadership, adequate
resources, and a coordinated infrastructure are required
to ensure advocacy coalitions sustain engagement over
the potentially lengthy period of time necessary to achieve
high-level, coordinated policy action, particularly in
competitive policy subsystems with opposing advocacy
coalitions. Initiatives such as sugar taxes or marketing
restrictions to curb sugar intake have gained policy
traction in some countries following decades of increasing
evidence, advocacy, and public awareness, in spite of
strong opposition from food companies.104 A major
advantage of campaigning for better preconception
nutrition is that the focus is building stronger mothers
and babies and reducing non-communicable disease
burden in the next generation; these are uncontroversial
messages, easy for the public to engage with emotionally.
Conclusion
A dual strategy targeting women and couples planning a
pregnancy, coupled with promoting the health of all
women of child-bearing age, could be the most eective
approach to improving preconception health. Sparse
evidence from robust and context-relevant trials of
preconception nutrition and health behaviour inter-
ventions, makes it hard to draw firm conclusions about
their eectiveness in improving outcomes for mothers
and babies on a large scale. Trials of preconception
interventions are far fewer than those conducted during
pregnancy, because recruitment is more dicult and
Study design Participants Estimated
completion
Sites
Nutritional Intervention Preconception
and During Pregnancy to Maintain Healthy
Glucose Metabolism and Offspring Health
(NiPPeR study, NCT02509988)
The aim is to assess whether a nutritional drink taken before conception and
continuing through pregnancy, assists in the maintenance of healthy glucose
metabolism in the mother and promotes offspring health
1800 women October, 2018 New Zealand,
Singapore, and UK
Inter-pregnAncy Coaching for a Healthy
fuTure (Inter-ACT, NCT02989142)
The intervention targets women with excessive weight gain in their first pregnancy,
and attempts to reduce complications in the second pregnancy through an
interpartum programme of coaching, combining face-to-face counselling with the use
of a mobile application connected to medical devices (scale and pedometer)
1100 women September, 2020 Belgium
Women First: Preconception Maternal
Nutrition (WF, NCT01883193)
Multicountry three-arm, individually randomised, non-masked, controlled trial to
ascertain the benefits of ensuring optimal maternal nutrition before conception,
and providing an evidence-base for programmatic priority to minimise the risk of
malnutrition in females of reproductive age. Women are required to take a lipid-based
micronutrient supplement. Run from University of Colorado, Denver, CO, USA
7374 women October, 2019 Democratic
Republic of the
Congo, Guatemala,
India, and Pakistan
Development of Pre-pregnancy
Intervention to Reduce the Risk of
Diabetes and Prediabetes (Jom Mama,
NCT02617693)
The aim is to assess the efficacy of a pre-pregnancy intervention to reduce the risk of
diabetes and prediabetes. A lifestyle intervention combines behaviour change
counselling from community health promoters trained to support behaviour change,
and utilisation of an eHealth platform providing preconception information and support
660 women November, 2017 Malaysia
Erasmus MC Care Innovation for a healthy
pregnancy (NTR4150)
To test whether use of the Smarter Pregnant intervention (a mobile application
comprising an interactive food and lifestyle coaching programme) leads to an
improvement in unhealthy food habits (intake of fruits and vegetables, and folic acid
use) after 6 months, measured as a decrease in the Food Risk Score of women and men
considering pregnancy
3000 men and
women
January, 2017* The Netherlands
Healthy Lifestyles Trajectory Initiative
(HeLTI)
Four interlinked preconception nutrition intervention trials planned by a consortium
of the Canadian Institute for Health Research, the WHO, the governments of Canada,
China, India, and South Africa, and academic partners in each country. These
randomised controlled trials aim to test the effect of a package of nutritional and
lifestyle interventions before conception on offspring body composition
Not applicable October, 2017
(start date)
Canada, China,
India, and South
Africa
The Low Birth Weight in South Asia Trial
(LBWSAT)105†
This cluster randomised controlled trial aims to identify the most cost-effective means
of increasing birthweight by comparing birthweight in current programme areas with
birthweight in areas where one of three combinations of interventions is conducted:
first, a behaviour change strategy involving working with participatory women’s groups
and other community members, to change pregnant women’s eating behaviour and to
increase their intake of nutritious food; second and third combine this strategy with
provision of a food supplement or a cash payment, respectively. The primary outcome
of the trial is birthweight, accurate to 10 g, measured within 72 h of birth
17 000 pregnant
women,
13 000 babies
Unknown Nepal (80 study
areas)
*This study has been extended as recruitment was slower than anticipated. †This trial is not a preconception trial, but will have implications for understanding the value of cash transfers and participatory
women’s groups in improving the nutritional status of women of childbearing age.
Table: Ongoing trials of preconception nutrition interventions
Series
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5 Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework:
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7 Caan B, Horgen DM, Margen S, King JC, Jewell NP.
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18 Fenn B, Colbourn T, Dolan C, Pietzsch S, Sangrasi M, Shoham J.
Impact evaluation of dierent cash-based intervention modalities on
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22: 42–52.
24 Elsinga J, de Jong-Potjer LC, van der Pal-de Bruin KM, le Cessie S,
Assendelft WJ, Buitendijk SE. The eect of preconception
counselling on lifestyle and other behaviour before and during
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outcomes can be assessed only in women who sub-
sequently become pregnant. Fortunately, several such
trials are underway (table). Meanwhile, public health
strategies to improve nutritional status in children and
in adults of reproductive age should be strengthened
without delay.
Interventions could be more eective for longer if they
use existing delivery platforms within a systems approach.
System-wide changes to accommodate preconception
health care will need support from a social movement
that establishes its importance for the health of the next
generation, stresses societal responsibility, and requires
strong local, national, and international leadership. The
strength of this social movement, and the capacity to
deliver eective nutrition and behavioural interventions,
could be enhanced through carefully negotiated engage-
ment with commercial interests.
Contributors
MB conceptualised the paper in consultation with all authors and wrote
the first draft with substantial inputs from TC, JS-W, GN, SUD, FFS,
CHDF, SAN, CV, NMK, WTL, and JS. TC, JS-W, and GN carried out the
review and produced the pathways model of intervention eects.
The analysis of preconception action phases was developed by SUD and
FFS. SAN, RS-T, DP, and KW-T provided data and wrote descriptions of
exemplar intervention studies. CHDF wrote the first draft of the section on
interventions with adults intending to become pregnant again. Sections on
the creation of a social movement and advocacy coalitions were produced
by CV and NMK. JS oversaw and advised on all aspects of producing and
editing the paper. All authors saw successive drafts of the paper and
provided input. MB finalised the paper and is the overall guarantor.
Declaration of interests
We declare no competing interests.
Acknowledgments
The idea for this Series was conceived by JS and developed during a
4-day symposium, led by MB and JS and funded by The Rank Prize
Funds, on Preconception Nutrition and Lifelong Health in Grasmere,
UK, February, 2016. We thank a number of individuals who have
contributed their thoughts and time to this paper: Nicola Heslehurst
(Newcastle University, Newcastle,UK) for her contribution to an early
draft of the paper; Zulfi Bhutta (Aga Khan University, Karachi, Pakistan)
for his perspectives on interventions in LMICs; Chandni Jacob and
Mark Hanson (University of Southampton, Southampton, UK) for their
contribution to the review; Jayne Hutchinson and Janet Cade (University
of Leeds, Leeds, UK) for advice on fortification; Matthijs van Dijk
(Erasmus MC, Rotterdam, Netherlands) for data from Smarter
Pregnancy; Julius Cheah and the Jom Mama project partners comprised
of the Ministry of Health of Malaysia (Putrajaya, Malaysia), University of
Southampton (Southampton, UK), University of Witwatersrand
(Johannesburg, South Africa), Steno Diabetes Center (Gentofte,
Denmark), and Novo Nordisk (Gentofte, Denmark); Mike Kelly
(University of Cambridge, Cambridge, UK) for discussions on the value
of social practices; and Andy Last (MullenLowe salt, London, UK) for his
insights into how a social movement might be created around
preconception health.
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