Abstract
Preconception care (PCC) is an important prevention strategy in primary health care to optimize maternal and fetal health outcomes by addressing pre-pregnancy risks. Although it is beneficial, utilization rates remain very low among women of reproductive age (WRA) in low- and middle-income countries (LMICs), including Indonesia. This qualitative study aims to explore perceptions, knowledge, barriers, and implementation strategies related to pre-pregnancy health screening among WRA who utilize PHC. In-depth interviews were conducted on 21 informants recruited by the purposive method from the Primary Health Center (PHC) in Denpasar City, Bali, Indonesia. Thematic analysis is used to identify the main themes of the transcribed data. Four main themes emerged that are (1) perceptions of pre-pregnancy screening vary from WRA, (2) knowledge levels that tend to be low about PCC, (3) the existence of barriers to access to services, social stigma and screening time constraints, and (4) the integration of screening services as a strategy to increase service coverage. These findings conclude that negative perceptions, low levels of knowledge and access barriers, social stigma and time constraints are related to the low utilization of preconception health screening. These findings contribute to the improvement of global health status. Future policies are implemented to prioritize stigma reduction, knowledge enhancement and expand access through the integration of pre-pregnancy health screening services with Community Clinic to increase the coverage of PCC.
Introduction
Preconception care is an essential strategic intervention in primary health services to identify and address modifiable risk factors before pregnancy, thereby optimizing maternal and fetal health outcomes. 1 PCC includes health screening, nutritional counseling, management of chronic conditions, as well as the promotion of healthy behaviors such as avoiding tobacco and alcohol, which have been shown to reduce maternal and fetal morbidity and mortality, including a reduced risk of birth defects, premature birth, and stunted fetal growth. Pre-pregnancy health screening is carried out by targeting the critical period before conception, where up to 50% of pregnancies occur unplanned, thus limiting the chances of intervention during the pregnancy itself. 2
Although the benefits of PCC have been proven, Women of reproductive age who visit preconception health screening services in low- and middle-income countries (LMICs) are still low, including Indonesia.3 -5 In LMICs, only a small percentage of WRA access these services, with participation rates varying from 6% to 50%.6 -10 Meanwhile, in Indonesia, until now, there has been no publication of national data that specifically measures the percentage of women who receive PCC. However, based on the results of a preliminary study conducted at one of the CHC, it was found that only about 10% of women received preconception counseling.
Low female participation in PCC contributes to the burden of adverse pregnancy outcomes such as babies with low birth weight, complications during pregnancy, poor maternal health, and negative neonatal outcomes. 9 The groups most affected by low participation often include those with lower socioeconomic status and marginalized populations, who also need such care the most. 11 This exacerbates reproductive health disparities, especially in poor urban communities, where maternal mortality is still high compared to the Sustainable Development Goals (SDGs) targets.
Several factors were identified as related to the low coverage of PCC in Indonesia, namely a combination of individual, systemic, and sociocultural factors.11 -13 In Indonesia, where PHC serves as a frontline for community-based reproductive health, these gaps are exacerbated by limited awareness and resources, leading to missed opportunities to prevent adverse events that burden families and the health care system. Based on the results of the researcher’s interview with midwives who serve as maternal and child health service providers at one of the PHCs, it was found that preconception visits are rare. Consumers who use PCC services are limited to brides-to-be to get a health certificate as a condition for taking care of marriage certificates.
Studies related to the use of PCC services are still relatively little published, especially studies that explore the perception of service use, namely, women of childbearing age. The available studies mostly use observational methods with a Hospital-based cross-sectional study design, such as the one conducted in Ethiopia.14,15 Another study used secondary data using a retrospective method in San Diego 16 and in the US from 2010 to 2018. 17 Meanwhile, studies with published qualitative methods were conducted in Indonesia, with the subject of the study being health workers. 18 Therefore, it is very important to look at the perception from the user aspect, so that balanced information is available about health screening before pregnancy.
This qualitative study aims to explore perceptions, knowledge, barriers, and implementation strategies related to pre-pregnancy health screening among women of reproductive age who utilize CHC. By understanding women’s perspectives in the context of primary services, this study is expected to provide insights into the development of evidence-based interventions that improve access to and utilization of PCCs.
Methods
Study Design
This study uses a qualitative exploration design with WRA research subjects who are domiciled in Denpasar City Bali, Indonesia. This exploration method is used to obtain views from informants as a basis for developing interventions. 19 This study aims to explore the perceptions, knowledge, barriers, and implementation strategies related to pre-pregnancy health screening services of WRA in PHC.
The study is supported by a social ecology model, which recognizes the interaction of individual, interpersonal, community, and systemic factors in the utilization of PCCs. This framework guides the exploration of perceptions and barriers in primary health care (PHCs), in line with public health principles.
Setting
The research was conducted at one of the Public Health Centers in Denpasar City, Bali Province, Indonesia. The location of the research was chosen purposively with the consideration that this health center has been providing pre-pregnancy screening services since 2015. In addition, the socio-demographic characteristics of the population in Denpasar City are more varied than other districts so that they can describe the general condition of the population. Interviews are conducted in a private room at CHC to ensure familiarity and accessibility for participants. This arrangement was chosen because it represents a frontline primary care facility where PCCs are integrated into public health services. No non-participants were present during the interview to maintain confidentiality.
Participants
The research participants consisted of 16 main informants and 5 supporting informants, namely 1 obstetrician and gynecologist informant, a general practitioner, a nutritionist, a village midwife, and an independent midwife. The main informants are WRAs who visit the Primary Health Center, whether they have visited preconception services or have never visited the health center. Table 1 shows the characteristics of WRA as the main informant. Further information about the informant is conveyed as follows.
Informant Characteristics.
Participant Selection
The participants in this study were WRA who were selected using the purposive method. Women of reproductive age who visited the Primary Health Care facilities were selected with the purpose of obtaining information regarding their experiences in utilizing preconception health screening services. The criteria for informants involved in this study are willing to participate by filling out a participation consent form. The exclusion criteria are participants who do not complete the required interviews. All informants were explained by the background, objectives, benefits, and procedures of the research. Furthermore, each informant was required to provide a signed consent form prior to the commencement of the interview. In this study, the triangulation technique was used to provide credibility. Triangulation brings together many different sources to provide evidence that supports a phenomenon or case. 19 A variety of sources are grouped based on education level, occupation, marital status, and experience in getting health screening services before pregnancy.
Research Instruments
The measuring tool in this study is an in-depth interview guideline. Interview guidelines that have been tested to assess the accuracy of the content of the questions and the ease of understanding the sentences of the questions that are prepared. The questions listed in the interview guidelines were developed by the researchers based on the concept of preconception care. The questionnaire is differentiated based on the type of informant, namely, a questionnaire for health workers and women of reproductive ages. The interview guidelines for preconception healthcare providers consist of 2 questions. The interview guidelines for the WRA consist of 4 questions.
Validation of research instruments with instrument trials was carried out simultaneously during data collection. Instrument is corrected when questions are found that are not well understood by the informant. In addition, triangulation of information sources was carried out in this study to compare the results. To ensure that the interview results are appropriate, the researcher conducts member checking by returning a summary of the results to the informant to ensure that the researcher’s interpretation is appropriate.
Data Collection
Data was collected by the in-depth interview method in June to August 2023. The interviewer is a researcher his self. Researcher is a female doctor an expert an expert in the field of public health and has experience in conducting in-depth interviews. The face-to-face interview is conducted at a place agreed upon between the informant and the interviewer. No additional individuals were involved in the interview process. The interviewer and the informant had no prior acquaintance before the interview was conducted. The interview process begins with an introduction between the interviewer and the informant. Then the interviewer conveys the purpose and benefits of the research, the estimated length of the interview time and expectations for the informant to give honest answers to the questions received. Before the interview began, the interviewer again confirmed the informant’s willingness to voluntarily participate in the study by asking the informant to sign the informant’s consent.
Interviews are conducted between 45 and 60 min per informant. The Q&A during the interview was recorded using a recorder. The interview process ends by conveying the conclusion of the interview results to the informant to ensure the correctness of the answers given by the informant. Data collection was stopped after considering that no new information was obtained.
Data Analysis
Thematic methods were used to analyze the data from the interview results. The interview recordings of each informant were copied into transcripts. Furthermore, the interview script was read to find themes and sub-themes based on WRA’s perception of pre-pregnancy health screening. The preparation of themes and sub-sub-themes is done manually. The results of the categorization of themes and sub-themes are arranged in tables and narratives.
Results
The perception and barriers of WRA about pre-pregnancy health screening consist of 4 themes: perception, knowledge, barriers and implementation of pre-pregnancy health screening. Each theme consists of 1 or more sub-themes. Table 2 showing themes and sub-themes about the perception and barriers of WRA to conduct health screening before pregnancy.
Themes About Perceptions and Barriers to WRA Health Screening Pre-Pregnancy.
Women’s Perceptions on Health Screening Pre-pregnancy
Based on the results of the interviews, it was found that WRA informants had varying perceptions of pre-pregnancy health screening. According to the informant, health screening is an important step to ensure the body is in optimal condition before pregnancy and provides a sense of calm because it can detect potential health problems early, such as the following quote: “I think screening is like a general health check, but it focuses more on things that can affect pregnancy, such as sugar levels, blood pressure, or maybe fertility checks” (W2, Private Employee, Married).
At that time, the doctor suggested a blood check, ultrasound, and a family history check. I feel more confident because I know my body is ready (W1, Housewife, Married).
Negative and limited perceptions are obtained from informants that screening is something that is only done by couples who are married or planning to get pregnant soon, as the following quote. “I think it's only for people who want to get pregnant as soon as possible. For me, it feels like it's still a long way off.” (W3, female student, unmarried)
I know screening is important, but I'm confused about where to start. Is it just to go to the obstetrician, or do I have to go to another doctor as well? (W6, Merchant, Married)
Women’s Knowledge of Screening Pre-pregnancy
The level of knowledge about pre-pregnancy health in this study was found to be limited among unemployed and married informants, as quoted below.
I know I have to take care of my diet, exercise, and maybe vitamin consumption, but I don't know the details, like what vitamins or what checks are necessary. (W5, Private Employee, Unmarried). I only knew from biology lessons at school, if you want a healthy body, I didn't know that getting pregnant requires special preparation, and I also rarely heard about health before pregnancy, so I didn't think it was important. (W15, Female Student, Unmarried)
Meanwhile, informants who already have experience of pregnancy and have children tend to have sufficient knowledge about pre-pregnancy health, as the following quote shows.
The doctor at that time said I had to check my hemoglobin, take folic acid three months before getting pregnant, and make sure there were no infections like toxoplasma" (W12, Housewife, Married)
Obstacles in Conducting Screening Pre-pregnancy
Based on the results of the interview, it was found that obstacles in conducting pre-pregnancy screening include lack of urgency and clear information, limited access to health facilities, social stigma, and time constraints. Unmarried informants acknowledged that the primary obstacles to undergoing pre-pregnancy health screening were the perceived lack of urgency and the presence of social stigma, as illustrated in the following excerpts.
I'm not married yet, so I don't think there's any need to check now. After all, I don't know where to start or what doctor, (W9, private employee, unmarried). If I go to the doctor for a health check before getting pregnant, people might think I'm pregnant, even though I'm not married. It is taboo for young women who want to consult about reproductive health, so they tend to avoid this topic, (W13, not working, unmarried)
Meanwhile, married informants acknowledged that the obstacles to preconception health screening included limited access to information, time constraints, and the need for coordination with their partners, as reflected in the following quotation.
At first, I was confused about what to check, because not all health centers have complete information about preconception screening, (W8, housewife, married) My husband and I are both busy, so it's hard to find a schedule to go to the doctor together. Sometimes I also must wait in line for a long time at the clinic, (W10, entrepreneur, married).
Implementation of Pre-pregnancy Health Screening
The interviewed obstetricians and gynecologists recommended a team approach involving obstetricians, general practitioners, and nutritionists to assess nutritional status and mental health in the implementation of pre-pregnancy health screening. Meanwhile, the village midwives interviewed argued that the implementation of screening must be standardized and affordable and integrated with primary health services at health centers, as the following quote.
In the village, many women don't know about preconception screening. So, we have to start with basic counseling about the importance of health checks before pregnancy. We must have a special program for education and preconception screening at the community level, for example, through Community Clinic or bride-to-be classes.
The General Practitioner stated that the implementation of health screening before pregnancy must be individual and tailored to the patient’s condition.
Every patient has different risks, so screening should include relevant screenings, such as diabetes screening for those with a family history.
Nutritionist Informant views that the implementation of health screening before pregnancy must include nutritional aspects, as the following quote.
Nutritional screening is very important, such as checking iron status, measuring height, weight and arm circumference, as this affects the health of the mother and fetus,
Discussion
Perceptions of Pre-pregnancy Health Screening
In this study, it was found that the perception of pre-pregnancy screening includes positive and negative views. Positive perceptions center on the recognition of screening as a proactive measure to ensure a healthy pregnancy, aligned with benefits such as early detection of health risks and improved mother-fetal outcomes. Instead, negative perceptions often stem from misconceptions, viewing screening as unnecessary, especially when a pregnancy is not immediately planned. Negative perceptions tend to be related to the low utilization of health screening services before pregnancy. An exploratory study of women of childbearing age in the KwaZulu-Natal province of South Africa also found that the use of the preconception care services was inadequate in relation to low awareness. 20 Relatively similar results were obtained from a systematic review of PCC service needs and found that the majority of WRAs believed in the positive impact of PCC but received less preconception health care. 21 They tend to prioritize lifestyle changes over screening or communicating directly with doctors/health workers.22 -24
Women who are married or planning to become pregnant tend to be more proactive, while unmarried women still view screening as irrelevant. These findings are supported by other studies that found that married WRAs illustrate the importance of PCCs to address the adverse effects of exposure on pregnancy and ensure positive pregnancy outcomes. 25 However, based on studies in Malawi, it was found that PCC use tends to be lower in WRA with marriage status compared to WRA with single status, even though they both have a positive perception. 26 There may be a role of socio-economic, cultural, and health system factors in the use of PCC, especially in low- and middle-income countries (LMICs). 27
Knowledge Levels
Knowledge of PCC among women of childbearing age is categorized as good or poor based on the limitations of the information received. Poor knowledge was interpreted based on the results of the interview, which stated that the informant admitted that he did not know about PCC and its benefits, and did not understand the medical examination that should be carried out before pregnancy. These results are supported by a study in Malawi that found that only about 54% of WRAs have heard of PCC. 26 Further systematic reviews highlight globally limited preconception knowledge, often limited to pregnancy-related behaviors rather than holistic preconception health.24,28 In the context of primary health care, this knowledge gap underscores the need for integrated education in routine visits, as inadequate understanding perpetuates low service utilization in community settings. 26
Barriers to Utilization
The barriers identified were a lack of urgency and information, limited access to information, social stigma, and incompatible consultation times. These findings are in line with the results of other studies that identified a lack of knowledge and shyness/culture hindering WRA visits to PCC services. 29 Another study found that the preference to seek information on their own through internet media reduced initial contact with health workers for screening. 23 In addition, limited time and capacity, low service integration, and limited availability of standard screening tools/screenings were also reported as barriers to the provision of PCC services by primary health workers.30,31 Addressing this in a public health framework requires multifaceted interventions, such as flexible scheduling tailored to the needs of women of childbearing age and stigma reduction campaigns, to improve equity in access to primary care. 32
Implementation of Pre-pregnancy Screening Services
The results of the study indicate the implementation of PCC services through service integration, individualized approaches, simplicity and affordability, and nutritional inclusion. The results of the interviews suggest that education on PCC services, especially pre-pregnancy health screening, also involves couples from WRA. This is in line with the recommendations of qualitative studies that found that partner involvement is the main facilitator in receiving education on WRA in lower-middle-income countries. 33 In addition, an individualized approach to PCC service implementation is more recommended than a community-based approach. The same was obtained from a study on women at a tertiary hospital in Rotterdam stated that 71% of women admitted that they preferred private PCC consultations with health workers, especially with obstetricians. 34
The results of this study also indicate that pre-pregnancy health screening services are integrated with maternal and child health services to increase the uptake of PCC services. The same is conveyed from a study in women in Iran that found that efforts to overcome the low absorption rate of PCC were carried out with a preconception care integration program. 35 In addition to service integration, PCC’s service implementation strategy is expected to include preconception nutrition programs to improve the preconception nutritional status of women planning a pregnancy. This requires preconception health care professionals to be aware of the importance of preconception nutrition. 36 And finally, the simplicity and affordability of the service also get attention in the implementation of PCC services. A study of women in Hardin County found that they did not get health care because there were barriers to health care access, affordability, and insurance coverage.
Implications for Primary Care and Community Health
This study has significant implications for primary care and public health, especially in resource-constrained environments such as Indonesia. By addressing perceptions and knowledge gaps through targeted education, PHC can improve the uptake of PCC, reduce maternal and neonatal morbidity. Overcoming barriers through flexible, stigma-free services and integrating PCCs into family planning or routine health checkups can improve equity and accessibility. Implementation suggestions offer actionable pathways, such as partner-focused programs and nutrition counseling, aligned with the journal’s focus on community-oriented primary care. Ultimately, these efforts can contribute to sustainable development goals by improving reproductive health outcomes at the grassroots level.
Limitations
This research has limitations in the instrument validation process. Validation is only carried out through member checking, limited questionnaire tests, and source triangulation. This approach does provide a basis for credibility, but it does not include more comprehensive validation strategies such as expert judgment, peer debriefing, and triangulation methods. The limited questionnaire test also involved only a small number of informants so that it did not fully represent the diversity of perspectives. In addition, this study is limited by its qualitative nature and focus on specific Indonesian contexts, which has the potential to reduce generalizations. Reliance on self-reported data can lead to memory bias, and samples may not be fully representative of diverse socioeconomic groups. Therefore, the results of this study still need to be read by considering the potential for interpretation bias and the limitations of the scope of instrument validation.
Future research may incorporate quantitative measures or a broader geographic scope. Further studies should evaluate the effectiveness of interventions, such as pilot programs that integrate PCCs into PHCs, and explore male perspectives more deeply to encourage inclusive approaches. Policy advocacy for national PCC guidelines can reinforce these findings, ensuring primary care evolves to meet the needs of communities.
Conclusion
These findings underscore the various challenges that hinder the uptake of PCC in primary care, emphasizing the role of public health interventions to address knowledge gaps and barriers. By integrating couple-focused education and flexible services into PHCs, utilization can be improved, ultimately improving reproductive health equity in community settings. Future policies must prioritize stigma reduction and holistic implementation to align with global health goals.
Supplemental Material
sj-pdf-1-inq-10.1177_00469580261434470 – Supplemental material for Negative Perceptions, Low Knowledge, and Social Stigma as Barriers to Preconception Care in Primary Health Care
Supplemental material, sj-pdf-1-inq-10.1177_00469580261434470 for Negative Perceptions, Low Knowledge, and Social Stigma as Barriers to Preconception Care in Primary Health Care by Luh Seri Ani, Luh Mertasari and I Gede Gawandhi Arrya in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Acknowledgements
We want to thank all participants in this research.
Ethical Considerations
Ethical approval was obtained from the Institutional Review Board of Udayana University, Indonesia (Approval No. 2094/UN 14.2.2.V11.14/LT/2023).
Consent to Participate
All informants were explained by the background, objectives, benefits, and procedures of the research. Furthermore, each informant was required to provide a signed consent form prior to the commencement of the interview. The study is in line with ethical standards for public health research, ensuring cultural sensitivity in the context of primary care.
Author Contributions
LSA: led conceptualization, methodology, investigation, formal analysis, data curation, software, supervision, original draft writing, review and editing, and funding raising. LM: has supporting roles in investigation, formal analysis, writing – original draft and writing – review and editing. IGGA: has a supporting role in data collection, review writing, and editing.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.
Supplemental Material
Supplemental material for this article is available online.