Addressing the key uncertainties of improving preconception health in the UK

Preconception exposures have been associated with adverse pregnancy, birth and postpartum outcomes, which continue to have a substantial impact on morbidity and mortality. This mixed methods thesis comprises three studies intended to address key uncertainties of improving preconception health in the UK. The first study was an umbrella review that used the GRADE framework to assess the evidence certainty of 205 unique associations for preconception exposures contained in 53 systematic reviews. I identified high- and moderate-certainty evidence that maternal preconception folate supplementation, weight, interpregnancy weight change and physical inactivity, and advanced paternal age, are associated with adverse pregnancy, birth and postpartum outcomes. The second study was a cross-sectional survey of 835 women registered with primary care in the West of England, which assessed their knowledge, attitudes and views of preconception health and intervention methods. I identified a need to promote awareness of preconception risk factors and motivation for preconception health changes, particularly among younger and nulligravid women and women with lower incomes. Intervention methods involving communication from healthcare professionals, schools, family members, and digital media were reported to be acceptable. The third study involved in-depth interviews with 20 of the cross-sectional survey participants, purposively sampled using a maximum variation approach. A framework analysis of their views on interventions to improve preconception health highlighted a multitude of factors that can enhance the acceptability and appeal of these interventions. These included enabling discretion and access, seeking consent, ensuring sensitivity, including details of the 'why', 'how' and 'how much' of preconception recommendations, and the use of visual media and personalisation. In line with national policy recommendations, a need to deliver preventive interventions ahead of first pregnancy was highlighted. This thesis contributes to the growing literature on improving preconception health. Future research should seek to develop interventions informed by the findings of this research.