REVIEW OF LITERATURE

Review of literature is an important source for Development of research project. It helps to gain
insight into the research problem and provide information of what has been done previously. It
helps the researcher to be familiar with the existing studies, provides basis future investigations
and helps to develop the methodology, tools data collection and research design.
The review of literature will be discussed based on the following headings:

1. Review of Literature related to preconception care.

 Related to folic acid and iron supplementation.
 Related to smoking and alcohol.
 Related to medical illness.
 Related to work place hazards and noxious substances.
 Related to genetic counseling.
2. Review of Literature to effectiveness of structured teaching programme on
preconception care.

1. Review of Literature related to preconception care.

 Related to folic acid and iron supplementation.

A study was conducted in Hungary, to determine demographic, obstetrics and

pregnancy care related factors of folic acid intake during preconception care and
prenatal period of pregnancy. A questionnaire based retrospective study conducted
among 349 pregnant women. The results showed that taking folic acid during
pregnancy increased with age and decreased with gestational age. Prenatal folic acid
intake significantly related to the earlier intake of folic acid and prenatal multivitamin
medication. So, the research concluded that it is important to target women who are
less likely to take periconceptional folic acid as well as to increase awareness among
women of childbearing age in general through an intensive campaign and improved
education.18
 A study was conducted on folate intake and food related behaviors in non-pregnant,
low income women of childbearing age, study reported that 157 non-pregnant, low
income(< or = 185% federal poverty level) women of child bearing age(18 to 45years)
were evaluated for usual intake of natural food folate and synthetic folic acid as well
as specific food related behaviors. 85% met the recommended dietary allowance for
folate, but, only 37% met the current synthetic folic acid recommendation for reducing
the risk of neural tube defects. Nutrition education that includes information about
folic acid may be one way to improve folate intake and other health food behaviors
among low income women of childbearing age.19

A study was conducted on pregnancy intendedness and use of preconceptional folic

acid. The finding shows that preconceptional use of folic acid can prevent 50% of
neural tube defects. The importance of fertile women’s taking daily multivitamins that
contain 400 microgram (0.4mg) of folic acid should be stressed who are not
contemplating pregnancy, especially adolescents and low income women.20

A study was conducted in Bangladesh, to determine whether periconceptional iron

supplementation reduces anemia during pregnancy. A randomized, double-blind,
controlled trial was done. Married, nulliparous women were randomly assigned to
receive daily iron and folic acid (n=134) in the form of a powdered supplement added
to food. Results showed that among 88 pregnant women, periconceptional iron and
folic acid in comparison with folic acid did not affect anemia or iron status at 15 week
gestation. Among 146 non-pregnant women, IFA decreased anemia (odds ratio: 0.19%;
CI:0.04,0.95) and improved iron stores (P=0.001) more than did FA. The study
concluded that there is good adherence and initiation of supplementation before
conception is needed to reduce anemia during early pregnancy.21

 Related to smoking and alcohol.

A study conducted in Kentucky among reproductive age group women, reveals that the
proportion of pregnant women who smokes in Kentucky is twice that of the nation’s
proportion and babies born to smokers are more likely to be premature, low birth
weight, develop asthma, and be more susceptible to Sudden Infant Death Syndrome.
Another risk factor causing low birth weight, preterm births, birth defects and
developmental disorders is due to alcohol use during pregnancy.22
 More children and young people are starting to smoke; the prevalence of regular
smoking of those aged 11 to 15 has increased in England from 8% in 1988 to 13% in
1996. Over this period the proportion of 15 years old girls who smoke regularly has
increased from just one in five to one in three.23

A study was conducted among reproductive age group women who consume alcohol.
The study reveals that, the fetal alcohol syndrome occurs in the babies of 2.5 to 10%
mother’s who are heavy drinker’s. 3 to 4% of babies delivered at will have a major
congenital abnormality. 5% of these abnormalities are chromosomal, 10% due to
teratogens and 20% are genetic.24

A recent review by the Royal college of Obstetricians and Gynecologists found no

conclusive evidence of adverse effects in either growth or IQ at levels of consumption
below 15 units (120g) per week. Even so, the recommendations are that women should
remain cautious and limit alcohol consumption in pregnancy to no more than 1
standard unit of drink/day.23

 Related to medical illness.

A study was conducted on preconception care among women with diabetes mellitus
reduces the risk of spontaneous abortion and congenital malformations. The main
purpose is to provide nurses with current clinical assessment and management
strategies of women with diabetes in order to implement a comprehensive
individualized preconception plan of care.25

A study was conducted on effect of preconceptional care and the risk of congenital
anomalies in the offspring of women with diabetes mellitus: a meta-analysis. A meta-
analysis of published studies of preconceptional care in women with diabetes mellitus
was done. In 14 cohort studies, major congenital malformations were assessed among
1192 offspring of mothers who had received preconceptional care, and 1459 offspring
of women who had not .In nine studies, the risk for major and minor anomalies was
also lower among women who received preconceptional care. The study revealed that
the pooled rate of major anomalies was lower among preconceptional care recipients
(2.1%) than non-recipients (6.5%) and. Out-patient preconceptional care probably
reduces the risk of major congenital anomalies among the offspring of women with
presentational diabetes mellitus.26
 A study was conducted on preconception counseling for women with epilepsy to
reduce adverse pregnancy outcome, revealed that the value of counseling to women
with epilepsy prior to conception reduce the risk of adverse outcome and change in
both maternal and infant outcome.27

A study conducted on preconception counseling, data were collected from the medical
records of women who were seen at the outpatient’s clinic for preconceptional
counseling. The result indicates that the outpatient’s clinic for preconceptional
counseling helped to minimize risk factors for adverse pregnancy outcome amongst
high risk women by providing extensive advice as well as by means of the early
detection and treatment of diagnosed abnormalities.28

 Work place hazards and radiation.

Humans are exposed to many environmental agents that may be hazardous to their
reproductive capacity and much exposure may occur in the work place. Some
occupational exposure to hazards can reduce male or female fertility although the
Health and Safety Executive (2006) require employers to ensure that exposure to
substances that can cause occupational asthma, cancer or damage to genes that can be
passed from one generation to another, is reduced as low as is reasonably practicable.
Reports of miscarriages or birth defects among workers using visual display units
(VDUs) have not been borne out.29

Exposure to radiation is a positive danger to the developing fetus. The most common
source of radiation is abdominal X-ray during pregnancy. Studies have shown that
mortality rates from leukemia and other neoplasms were significantly greater among
children exposed to intrauterine X-ray. Congenital malformation such as microcephaly
is known to occur due to radiation. Hence, X-ray examination in pregnancy should be
carried out only for definite indications.30

 Genetic counseling.

A study was conducted on prevalence of beta thalassaemia and sickle cell traits in
premarital screening, totally 38,153 individuals were screened during the study period.
The prevalence rate of beta thalassaemia and sickle cell traits were 0.165% (63/38/153)
and 0.252% (96/38/153) respectively. Screening for the both of beta thalassaemia and
sickle cell traits is important to prevent at risk marriage through genetic counseling. 31
 Chromosome aberrations include the trisomies, such as trisomy 21 (Down syndrome)
and the rarer trisomy 13 and 18. Age factors are significant particularly in Down
syndrome, for which the risk is 1% for a women around 40 years of age. Monosomies
are usually lethal and non-viable autosomal trisomies are extremely common in
spontaneous abortions. Sex chromosome abnormalities, such as Turner’s syndrome
(XO) and Klinefelter’s syndrome (XXY) have a rare recurrence rate in families.
Translocation is where genetic material is transferred from one chromosome to another
and is regarded as reciprocal where there is exchange of chromosome material but no
change in chromosomal number. The incidence of reciprocal translocations is
approximately 1 in 500 in the general population.32

2. Review of literature to effectiveness of structured teaching programme on

preconception care.

A study done to evaluate the effectiveness of structured teaching programme on

preconception care among women age group of 18 to 45 years in a selected rural area,
Chennai, India. The experimental design was selected for the study. Data were collected
from 80 randomly selected samples by using the structured interview schedule. 40
samples were allocated for experimental group and remaining 40 samples for the control
group. The overall knowledge mean value in experimental design was 48.69 with the
standard deviation of 17.41 where as in the control group the mean value was only 5.36
with the standard deviation of 11.94. After structured teaching programme the paired‘t’
value was 17.69 with the p<0.001 which is highly significant. So, there is an
improvement in knowledge on preconception care among women. There is an
association of level of knowledge with that of age and education of women.33

A well established structured teaching programme can help to improve the knowledge
on particular aspects. A study to evaluate the effectiveness of structured teaching
programme in improving knowledge and attitude of school going adolescents on
reproductive health in Dharan town of Nepal. A total of 200 adolescent school students
were included in this study. The mean (±SD) pretest score of the experimental group on
knowledge of reproductive health was 39.83(± 16.89) and of the control group was
39.47(±0.08). The same of the experimental group after administration of the structured
teaching programme (84.60±10.60) and of the control group with conventional teaching
method (43.93±10.08) was statistically significant (p<0.001). Similarly, the posttest
scores of knowledge of the groups on responsible sexual behavior and their attitude
towards reproductive health were better in the experimental group than in the control
group (p<0.001). The knowledge of adolescent school students on reproductive health is
inadequate. The use of structured teaching programme is effective in improving
knowledge and attitude of the adolescents on reproductive health.34

A study was conducted to assess the effectiveness of structured teaching programme

regarding preconception care among women in selected hospital of Erode, Tamilnadu.
Sixty women were selected for this study using a convenient sampling technique. A
structured interview was conducted. The majority of primigravida mothers have
inadequate knowledge regarding preconception care. Significant difference was seen in
the pretest mean score value 44.10% and posttest mean score value 58.89% and
obtained‘t’ value was10.79. This indicates that structured teaching programme was
effective.35

A study was conducted among preconceptional women ages 18 to 35years to determine

the effectiveness of structured teaching programme. Women were randomized in a ratio
of 2-to-1 to intervention and control groups; participants received baseline information
regarding preconception care and health risk assessment at 14 weeks and completed
questionnaire to assess behavioral variables. The result shows that women in the
intervention group were significantly more knowledge (57%) than the controls group
(36%). It reports that higher self-efficacy for eating healthy food and to perceive higher
preconception care of birth outcomes; greater intent to eat healthy foods and be more
physically active; and greater frequency of reading food labels, physical activity
consistent with recommended level, and daily use of a multivitamin with folic acid. 36

To determine the effectiveness of planned teaching programme, a study was conducted

in Government hospital, Tumkur, among women of age group 15 to 40 years regarding
preconception care. 50 women participated in the study. Non probability purposive
sampling technique was used. Findings of the study indicated that in experimental
group, the mean posttest knowledge score (61.17) is higher than the mean posttest
knowledge score of (16.13) of control group with‘t’ value 33.01P>0.001 level of
significance. This study indicates that planned teaching programme is effective in
improving the knowledge of women regarding preconception care.37
Preconception care recognizes that many adolescent girls and young women will plunge
into parenthood without the knowledge, skills or support that they need in order to
become mothers. Preconception care is any intervention provided to women and couples
of reproductive age regardless of pregnancy status or desire before pregnancy so as to
improve the health outcomes for the women, newborns and children. Provision of care
throughout the life stages from childhood through adolescence to adulthood ensures that
gains at every stage enhance the transition of boys and girls from adolescent to becoming
adults and potential parents (Dean, Zohra, Ayesha, & Bhutta, 2014)

Health workers should encourage women of reproductive age to have a reproductive life
plan which includes preconception care. This can be made possible by initiating the
communication by asking a simple question like "Are you considering pregnancy in the
near future, or could you possibly become pregnant soon?". This in itself can initiate
several preconception care interventions such as a dialogue regarding the patient's
readiness for pregnancy, an evaluation of her overall health and opportunities for
improving her health and preventive measures put in place. If the woman does not desire
pregnancy, current contraceptive use and options should be discussed to assist her in
identifying the most appropriate and effective method (ACOG, 2005).
2.1 Preconception care practices across the world

Worldwide, low and middle-income countries where Kenya falls carry a

disproportionately heavy burden of maternal and neonatal mortality and morbidity. Many
women bleed profusely to death peripartum, develop acute stroke, renal failure, or
pulmonary edema from uncontrolled hypertension, or are affected by severe sepsis,
including after unsafe abortion. A negative outcome to an expectant mother directly
affects the fetus or the newborn which may result in neonatal sepsis or preterm delivery
and in which most of these countries lack the facilities to take care of the preterm baby
whose organs are immature. In these countries preconception care would greatly help to
reduce maternal and neonatal mortalities if utilized by the adolescents and women of
reproductive age and yet it has been neglected by many women of child bearing age to
date (Young, Arquia, & Ray, 2013).

In Sri Lanka, preconception care has yielded benefits and now all eligible couples should
be registered in the eligible couple register and all the women who are getting pregnant
are assumed to have pre-conception care that is; Rubella immunization, preconception
folic acid supplementation, screening for medical condition and nutritional assessment.
Throughout the preconception care, couples are educated regarding pregnancy symptoms
and the importance of early initiation of antenatal care. They are also educated on when
and how to get the health practioners informed once they get pregnant. In Sri Lanka,
preconception care and antenatal care is provided through clinic care and domiciliary
care. Upon registration at the clinic or at home, pregnant mother should receive the clinic
antenatal care as early as possible, preferably around 6-8 weeks of gestation so that the
growth of the fetus is monitored and the health of the mother is also monitored
throughout pregnancy (MOH, 2011).