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IMPROVING PRE-PREGNANCY CARE (PPC) AMONG PATIENTS WITH DIABETES AND HYPERTENSION AT HEALTH CLINICS IN KUALA MUDA DISTRICT, KEDAH.

DISTRICT SPECIFIC APPROACH

PKD KUALA MUDA 2016/2017

Facilitator:

Dr Hasniza Bt Hasim

Group Members:

Dr Azira Bt Azmi

Dr Norliza Bt Mohd Sabri

Dr Nur Mahfuzah Bt Mohamed Fauzi

KJK Che Zaiton Bt Yahaya

KJK Rosmiza Bt Khazaid

JK Norazdliza Bt Azmi

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PROBLEMS IDENTIFICATION:

Increasing trend of anaemia cases among pregnant mothers at 36/52 POA.
Low percentages of intervention among reproductive age women registered under Pregnancy Care Clinic (PPC) at health clinics in PKD Kuala Muda.
Decreasing numbers of child attendance between age 5 to 6 years.
High rates of severe neonatal jaundice.
High rates of absence T-zone in pap smear samples.
Low percentages of diabetes patient with proteinuria started on Ace-inhibitor.
Low percentages of diabetes patient with HbA1C <6.5%. (SIQ Diabetes).
Small numbers of kospen screening among locality in pkd kuala muda.
Low percentages of case detection rate (CDR) for pulmonary tuberculosis among high risk patients.

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PROBLEMS VERIFICATION:

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PROBLEMS PRIORITISATION (SMART criteria):

Bil	Problems	CRITERIA
		S	M	A	R	T	TOTAL	RANKS
1	Increasing trend of anaemia cases among pregnant mothers at 36/52 POA.	31	30	29	31	28	149	2
2	Low percentages of intervention among reproductive age women registered under Pregnancy Care Clinic (PPC) at health clinics in PKD Kuala Muda.	32	31	29	30	29	151	1
3	High rates of severe neonatal jaundice (target 50/10000).	35	26	28	26	27	142	4
4	Low percentages of diabetes patient with proteinuria started on Ace-inhibitor.	24	24	24	24	22	118	5
5	Low percentages of case detection rate (CDR) for pulmonary tuberculosis among high risk patients.	33	31	30	27	27	148	3
		No of Voters: 7 (program leader)

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RE-DEFINE TOPIC

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RATIONALE SELECTION OF TOPIC

SERIOUSNESS	In PKD Kuala Muda, Pre-pregnancy care (PPC) has been implemented since 2011. The numbers of women in reproductive age group with chronic illness such as diabetes and hypertension showed increment. However, percentages of client given interventions was very low and reducing from 18% to 14% in 2013 to 2015 respectively. High risk clients on contraception was also low with average of 19% over 3 years.
MEASURABLE	% of PPC clients with diabetes and hypertension given interventions such as referral to appropriate personal for optimisation of illness. % of PPC clients with diabetes and hypertension given advise on contraception. % of PPC clients given health education for lifestyle modifications.
APPROPRIATENESS	All staffs in health clinics must follow “standard PPC guidelines” in implementing PPC at their clinics. Standardisation in methods of screening and registration, planning of appropriate interventions, traceability of clients card and reassessment in 6 months will be implemented.
REMEDIABLE	Standardisation of procedure will start with educating the staff and adherence to proper guidelines will be monitored by monitoring the indicators as above.
TIMELINESS	Reassessment of PPC client’s intervention will be done within 3 and 6 months

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STUDY VERIFICATION:

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LITERATURE REVIEW

Mahmud M et.al⁷, stated that ¾ of people with diabetes in developing country including Malaysia has age less than 65 years old and 25% of these adults is younger than 44 years old. Adverse pregnancy outcome in women with diabetes is 3-5 times higher than other maternal population.

Murphy HR et.al⁵ has identified women with diabetes barriers to accessing PPC in UK is mainly due to poor knowledge of diabetes control, poor relationship with health professionals and desire for a less medicated pregnancy. Therefore, failure to improve PPC provision leaves majority of women at increase risk of potentially preventable poor pregnancy outcome.

To increase quality of PPC services in public health, Mason et.al.⁴ stated we need to have a system based approach that tailored to the woman individual needs. The acceptance, application and full realisation of the benefits of PPC will depends on the contribution s of many individuals, group and institution.

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PROBLEM STATEMENT

Low percentages of intervention among reproductive age women registered under PPC at health clinics in PKD Kuala Muda

Pre Pregnancy Care (PPC) focuses on specific group of women in the reproductive age group with a set of interventions that must be done before conception to have beneficial impact of optimal maternal health and improved fetal outcome.

Failure in planning of pregnancy and optimising medical illness prior to conception will lead to increase incidence of maternal and neonatal complications in these women.

Possible causes of low percentages of PPC clients given interventions are poor management of PPC service, poor PPC clients involvement, limited human resources and poor traceability of PPC clients card.

Availability of standardized PPC guidelines will increase the percentages of interventions given to PPC clients.

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CAUSE-EFFECT ANALYSIS

Low percentage of intervention among reproductive age women registered under

PPC

Poor management of PPC

Poor identification and registration of PPC clients

Inadequate advice to clients – poor practice of PPC.

Inadequate knowledge of staff

HCW attitudes towards PPC

Human resources

No specific staff incharge

High numbers of patients

High workload

Shortage of staf

Poor community

involvement

Inadequate knowledge of clients

Attitude

Poor identification of PPC card

No registration number

No tagging

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No standardised PPC guideline

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CAUSE-EFFECT ANALYSIS

Low percentage of intervention among reproductive age women registered under

PPC

Poor management of PPC

Poor registration of PPC clients

Inadequate advice to clients – poor practice of PPC.

Inadequate knowledge of staff

HCW attitudes towards PPC

Poor identification of PPC card

No registration number

No tagging

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No standardised PPC guideline

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Perinatal Manual Care 3^rd Edition, MOH, 2013

IMPROVISATION

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PROCESS OF CARE

NCD

Diabetes
Hypertension

Screening of reproductive age women between age 15-49yo with BSSK form

Registered?

Yes

No

Referral to MO

Registration

JK/JM at screening counter

Fill up PPC 1/2010 form

Entry point to PPC

Tagging?

Yes

No

Tagging process

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CONSULTATION

History taking

Physical examination

Laboratory investigation

Identification of Appropriate Interventions

Optimization of illness

Advice lifestyle modifications

Optimization of Treatment

Referral to appropriate personal

Stamp PPC on OPD card, use PPC 2010 OPD card

Advice and Initiation of contraception

Update PPC registration book on every TCA

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MODEL OF GOOD CARE

Step	Process of Care	Criteria	Standard
1	Screening of diabetes and hypertension patient.	Diabetes and hypertension women within reproductive age of 15 to 49 years old excluding patient that has menopause or had undergone BTL/ hysterectomy. - BSSK form.	100%
2	Registration	All patient eligible registered in PPC Registration Book and tag with pink tag with written registration number at the side of DM/HPT book.	100%
3	Refer client to Medical Officer (MO)	MOs in health clinics	100%
4	History taking, physical examinations and Laboratory investigations	- Filling of PPC form by MO Full physical examinations Ordering appropriate investigations eg FLP/RP/LFT/FBS	100%

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Step	Process of Care	Criteria	Standard
5	Identification of appropriate interventions	Depending on examinations findings Optimise DM and HPT control Initiation of contraception Lifestyle modifications	100 %
5.1	Optimisation of Illness	E1.1: Optimisation of treatment to achieve optimal control according to DM and HPT CPG DM with HbA1C <6.5% HPT with BP < 140/90mmHg	DM 30% HPT 50%
5.1	Optimisation of Illness	E1.2: Referral to other personal to achieve good DM and HPT control BMI > 25kg/m2 and poor diet control refer PSP Poorly controlled DM/HPT refer FMS Clients admitted to having stress with high DASS score refer Clinical Psychologist/Counsellor Uncontrolled DM and HPT with optimum treatment at Health Clinic – refer MOPD	50%
5.2	Advice on contraception	Client is advise on suitable contraception according to medical eligibility criteria (MEC) and contraception is prescribed according to client’s preferences. Priority given to CODE 1 contraception.	100%

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Step	Process of Care	Criteria	Standard
5.3	Advice lifestyle modifications	Client is advise on healthy lifestyle which includes: Achieving appropriate BMI Healthy eating Regular exercises Stress management	100%
6	Update PPC registration book on every TCA	All clients undergoing follow-up must be updated on any intervention given during consultation in PPC registration book.	100%

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QA STUDY

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INDICATOR & STANDARD OF �QA STUDY

No	Indicator	Formula	Standard
1	% of diabetes and hypertension patient registered	No. of patients with DM/HPT registered -------------------------------------------------------------- X100 No of with patients with DM/HPT audited	100%

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INDICATOR & STANDARD OF QA STUDY

No	Indicator	Formula	Standard
2	% of PPC clients given intervention	No. of PPC clients with DM/HPT given intervention -------------------------------------------------------------------- X100 No of PPC clients with DM/HPT	100%
3	% of PPC clients received optimisation of illness	Clients received optimisation of illness: No of PPC clients with DM/HPT being optimised ------------------------------------------------------------------------------------- X100 No of PPC clients with DM/HPT	100%
	% of PPC clients received optimisation of illness	(2) PPC clients achived target: No of PPC clients with HbA1C ≤ 6.5% or BP <140/90mmHg ----------------------------------------------------------------------------------------- X 100 No of PPC client with DM/HPT	30% DM 50% HPT
	% of Referral to other specialties.	(3) Referral to other personal/specialties for optimisation of illness: No of PPC clients referred to other specialties for optimisation of illness ------------------------------------------------------------------------------------------- X 100 No of PPC clients with DM/HPT	50%

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INDICATOR & STANDARD OF QA STUDY

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No	Indicator	Formula	Standard
4	% of PPC clients given advice on contraception	No. of PPC clients with DM/HPT given advice on contraception --------------------------------------------------------------------------------- X 100 No of PPC clients with DM/HPT	100%
5	% of PPC clients given advice on lifestyle modification: Achieving appropriate BMI Healthy eating Regular exercises Stress management	No of PPC clients with DM/HPT given advice on lifestyle modification --------------------------------------------------------------------------- X 100 No of PPC clients with DM/HPT	100%

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KEYWORD DEFINITION OF QA STUDY

KEYWORD	DEFINITION
PPC INTERVENTIONS	A set of intervention that aim to identify and reduce risk for women in reproductive age with chronic illnesses to achieve safe and successful pregnancy. It includes optimisation of illness, advice on appropriate contraception and lifestyle modification. Optimisation of illness is define as improving clients health to achieve optimal control of the illness. (HbA1C <6.5% for DM and BP <140/90mmHg for HPT or optimising medications). It also includes referral to other specialties to achieve optimum control. Advice on appropriate contraception means giving advice to clients regarding appropriate birth control method to achieve a planned pregnancy. Lifestyle modification means advising clients on life changing behavior that includes achieving appropriate BMI, healthy eating, regular exercises and stress management.

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MAIN OBJECTIVE OF QA STUDY

To increase percentages of interventions given to PPC clients in with diabetes and hypertension by means of optimisation of illness, advice on contraception and lifestyle modifications.

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SPECIFIC OBJECTIVES OF QA STUDY

To determine percentages of PPC clients given intervention in 2015.
To analyse the possible causes of low percentages of PPC clients given interventions.
To formulate remedial action in order to increase percentage of PPC clients given at least one of intervention.
To evaluate the effectiveness of remedial measures taken to increase percentage of PPC clients given intervention.
To re-evaluate effectiveness of measures taken to increase percentage of PPC clients given intervention

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METHODOLOGY OF QA STUDY

There are 2 studies in this project:

1

2

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METHODOLOGY OF QA STUDY

Type of Study	Cross-sectional/Card Audit
Study Population	Women in reproductive age of 15 to 49 years old with DM and HPT
Sampling Method	Simple Random Sampling of DM and HPT card. Sample size = approx. 370 cards (calculated via sample size calculator with CI = 95%)
Study Period	22^nd to 26^th May 2016 (5 days)
Data Collection Techniques	Tools: Checklist and PPC Assessment form All cards selected will be screened whether it has been registered under PPC or not. All cards will be assessed using assessment form provided to determine intervention given to client.

Type of Study	Cross sectional
Study Population	Doctors, Staff Nurses, PPP and JM from NCD/OPD/MCH (as control sample)
Sampling Method	Purposive sampling
Study Period	22^nd to 26^th May 2016
Data Collection Techniques	Tools: Knowledge, Attitude and Practice (KAP) Questionnaire regarding PPC

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PROCESS OF GATHERING INFORMATION �(DATA COLLECTION TOOLS)

FACTOR	VARIABLE	METHOD OF COLLECTION	SOURCE	SAMPLE UNIT	SAMPLE SIZE	STANDARD
Verify DM/HPT clients registered under PPC	% of DM/HPT clients registered under PPC	PPC Assessment Form	DM and HPT cards for woman within 15-49 years old	Client’s card	DM = 334 cards HPT = 315 cards	100%
Verify PPC clients with DM/HPT received interventions	% of PPC clients with DM/HPT received interventions	PPC Assessment Form	DM and HPT cards for woman within 15-49 years old	Client’s card	DM = 334 cards HPT = 315 cards	100%
Verify PPC clients with DM/HPT received either optimisation of illness OR Advice on contraception OR Lifestyle modification	% of PPC clients with DM/HPT received interventions	PPC Assessment Form	DM and HPT cards for woman within 15-49 years old	Client’s card	DM = 334 cards HPT = 315 cards	100%

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PROCESS OF GATHERING INFORMATION �(DATA COLLECTION TOOLS)

FACTOR	VARIABLE	METHOD OF COLLECTION	SOURCE	SAMPLE UNIT	SAMPLE SIZE	STANDARD
Proper PPC registration by Health Care Workers (HCWs)	5 steps of complete process of registration	PPC Assessment Form	DM and HPT cards for woman within 15-49 years old	Client’s card	DM = 334 cards HPT = 315 cards	100%
Proper management by Health Care Workers	a) Knowledge	Questionnaire	Self administered KAP questionnaire	Doctors PPP JK JM	157 HCW
	b) Attitude	Questionnaire	Self administered KAP questionnaire	Doctors PPP JK JM	157 HCW
	c) Practice	Questionnaire	Self administered KAP questionnaire	Doctors PPP JK JM	157 HCW

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STUDY

RESULTS

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STUDY 1: MAGNITUDE OF PPC INTERVENTIONS IN PKD KUALA MUDA 2016/2017

N = 649	Registered PPC (n = 344) 53%	No PPC (n = 305) 47%	P value
Interventions (Overall = 77.5%) Received 1 intervention Received 2 interventions Received 3 interventions	298 (86.6%) 139 (15.4%) 104 (30.2%) 48 (14.0%)	205 (57.2%) 176 (57.7%) 16 (5.2%) 7 (2.3%)	<0.01
Optimisation of illness (Overall = 61.5%) Achieved target HbA1C (≤ 6.5%) Controlled BP Referral to other specialties	224 (65.1%) 87 (31.6%) 8 (2.3%) 135 (39.2%) 41 (11.9%)	175 (57.4%) 94 (36.7%) 13 (4.3%) 127 (41.6%) 25 (8.2%)	0.04 0.22 0.12
Advice on contraception (Overall = 27.7%)	165 (48%)	15 (4.9%)	<0.01
Advice on lifestyle modifications (Overall = 22.0%)	104 (30.2%)	39 (12.8%)	<0.01

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STUDY 2: PPC KAP STUDY AMONG HCW IN PKD KUALA MUDA 2016/2017

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RESULT SUMMARY

86.6% PPC clients with diabetes/hypertension has received interventions.
Comparing between clients registered under PPC and those who don’t, clients under PPC received more interventions. This prove our points that registering NCD patients into PPC improve their chances to receive more interventions.
Analysis of KAP questionnaires among HCW showed that those who attended PPC course performed better in terms of knowledge, practice and attitude. Therefore, strengthening PPC course to our HCW is important in delivering high quality PPC service to our high risk clients.

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REMEDIAL MEASURES

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REMEDIAL MEASURES 1:�DEVELOPED STANDARDISED GUIDELINE FOR PPC MANAGEMENT

To ensure all 7 health clinics follow the same guideline in managing PPC.
BEFORE	AFTER
Every health clinic has its own way of managing PPC. No standardised method in: Selection of high risk patient and exclusion criteria (some clinic still register menopause/patient undergone BTL in PPC) Tagging PPC client card. Proper referral to MO Proper history taking in PPC card by MO Continuation of follow-up for PPC client.

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REMEDIAL MEASURE 2:�STRENGTHENING PPC REGISTRATION: TAGGING

For easy identification of PPC card. HCW can recognised PPC client’s card during encounter, ensuring proper history taking and follow up.
BEFORE	AFTER
No specification for tagging PPC card. Some clinic has no tagging system and some clinic use purple coloured thread.	Tagging is done using a pink coloured sticker with PPC registration number attached to the side of the card for easy recognition. PPC registration number stamp is optional.

Write on PPC pink sticker

- PPC registration number

Attach sticker to the side of NCD booklet and cover with selefon tape

Stamp PPC at top right corner of NCD booklet.

INNOVATION 1

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REMEDIAL MEASURE 3:�STRENGTHENING PPC REGISTRATION: BSSK

For screening of other health related problem among PPC clients.
BEFORE	AFTER
BSSK screening was done but no further action taken including no evaluation from medical officers. BSSK form was removed from the client’s card for registration under BSSK screening.	BSSK screening was incorporated under PPC guideline in PKD Kuala Muda and all BSSK form must be reviewed and evaluated by medical officers. BSSK form will remain in client’s card for future reference.

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REMEDIAL MEASURE 4:�STRENGTHENING PPC REGISTRATION: BOOKING FORM

Simplified form for a quick history taking by medical officer. It covers essential background of PPC clients, other risk factors and initial examination of the client.
BEFORE	AFTER
No proper history taking by medical officer in PPC card. Sometimes the PPC form was left blank and no useful information available in the card.	PPC Booking Form:

INNOVATION 2

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REMEDIAL MEASURE 4:�STRENGTHENING PPC REGISTRATION: BOOKING FORM

Simplified form for a quick history taking by medical officer. It covers essential background of PPC clients, other risk factors and initial examination of the client.
BEFORE	AFTER
No proper history taking by medical officer in PPC card. Sometimes the PPC form was left blank and no useful information available in the card.	Client’s detail was completed in the PPC card. Then PPC booking form was completed by medical officer with appropriate plan. The form was attached to the PPC card which was then attached to the first page of client’s booklet.

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REMEDIAL MEASURE 5:�STRENGTHENING PPC FOLLOW-UP: PPC STAMP

Created for yearly follow-up. It contains information needed in keeping with JKN Kedah Plan of Action 2016.
BEFORE	AFTER
Small numbers of follow-up done for PPC client on yearly basis.	Stamped PPC Components at the back/new page of PPC card during registration and then yearly (at the start of a new year). Medical officer must fill in all the information required on yearly basis but it can also be filled from time to time.

INNOVATION 3

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REMEDIAL MEASURE 6:�STRENGTHENING PPC FOLLOW-UP: UPDATE PPC BOOK

PPC book need to be updated on every TCA to avoid defaulter.
BEFORE	AFTER
PPC book was not updated on regular basis by person in-charge.	Update PPC 101 and record next TCA date

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QA STUDY

POST REMEDIAL ACTION

CYCLE 1: DISEMBER 2016

CYCLE 2: EARLY MAC 2017

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PERCENTAGES OF PPC REGISTRATION IN PKD KUALA MUDA

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79.2%

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COMPARISON OF COMPLETENESS IN PPC REGISTRATION BETWEEN 1^ST AND 2^ND CYCLE

	CYCLE 1	CYCLE 2
	N = 140	N = 618
Completeness of Registration 0/5 complete 1/5 complete 2/5 complete 3/5 complete 4/5 complete 5/5 complete	1 (0.7%) 0 (0%) 79 (56.4%) 45 (32.1%) 13 (9.3%) 2 (1.4%)	0 (0%) 36 (5.8%) 242 (39.1%) 162 (26.2%) 74 (12.0%) 104 (16.8%)

1

2

3

4

5

PPC registration with complete 5 components has increased post remedial actions.

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ABNA OF INTERVENTION GIVEN TO PPC CLIENTS BETWEEN QA & POST STUDY

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70

13.4

4.7

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POST CYCLE 1 REMEDIAL ACTION:�“PPC ROADSHOW” TO ALL 7 HEALTH CLINICS

All medical officers and PPC in-charge was given personalise teaching regarding PPC flowchart and the importance to be actively involved in PPC.

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ABNA OF INTERVENTION GIVEN TO PPC CLIENTS BETWEEN QA & POST STUDY

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TABLE OF PERCENTAGES OF INTERVENTIONS GIVEN IN QA & POST STUDY

	QA	CYCLE 1	CYCLE 2
	N = 344	N = 140	N = 618
Interventions 1 intervention 2 interventions 3 interventions	298 (86.6%) 139 (15.4%) 104 (30.2%) 48 (14.0%)	98 (70%)* 47 (38.2%)* 34 (27.5%)* 5 (4.1%)*	589 (95.3%) 243 (39.3%) 155 (25.1%) 191 (30.9%)

* Minus missing data

PPC clients received interventions and all 3 modalities of intervention has increased after remedial action taken.

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TABLE OF PPC CLIENTS RECEIVED OPTIMISATION OF ILLNESS BETWEEN QA & POST STUDY

	QA	CYCLE 1	CYCLE 2
	N = 344	N = 140	N = 618
Optimisation of illness Achieved target HbA1C (≤ 6.5%) Controlled BP Referral to other specialties	224 (65.1%) 87 (25.3%) 8 (2.3%) 135 (39.2%) 41 (11.9%)	44 (31.4%) 3 (2.1%) 3 (2.1%) 63 (45%) 8 (5.7%)	529 (85.6%) 186 (30.1%) 25 (4.0%) 321 (52.1%) 40 (6.5%)

Percentages of PPC clients received optimisation of illness increased post remedial actions but there was not much difference for clients that achieved target. Referral to other specialties was also reduce.

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TABLE OF PERCENTAGES OF PPC CLIENTS RECEIVED ADVICE FOR CONTRACEPTION AND LIFESTYLE MODIFICATION BETWEEN QA & POST STUDY

	QA	CYCLE 1	CYCLE 2
	N = 344	N = 140	N = 618
Advice/Initiation/Maintainance of contraception	165 (48%)	55 (39.3%)	325 (52.6%)
Advice on lifestyle modifications	104 (30.2%)	48 (34.3%)	272 (44%)

Percentages of PPC clients received advice for both contraception and lifestyle modifications has increased post remedial actions.

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CONCLUSION

Percentages of diabetes and hypertension reproductive age patients registered into PPC increased from 53% to 79.2%
Percentage of PPC clients received interventions increased from 86.5% to 95.3%.
Optimisation of illness among PPC clients showed increment from 65.1% to 85.6%.
Advice/use of contraception increased from 48% to 52.6%.
Advice on lifestyle modifications showed increment from 30.2% to 44%.
Implementation of remedial actions has successfully increased percentages of interventions given to PPC clients with diabetes and hypertension and also reducing ABNA to 4.7% in this QA Study.

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LIMITATIONS

Small scale audit for the first cycle study which has impact on the results. However, the 1^st cycle study aim is to identify flaw in our process of care and the problems faced by person in-charge of PPC so that further remedial actions can be taken.

The QA study started near the end of the year. No further provision for PPC course to improve our healthcare workers awareness towards PPC.

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WHAT ARE OUR NEXT STEPS?

To incorporate PPC model of good care (MOGC) in PPC course to further enlighten our health care workers regarding the importance of PPC.
To further strengthen BSSK screening among PPC clients
To extend the new PPC guideline for other non-communicable diseases.
Regular assessment every 6 months to maintain continuity of PPC in all 7 health clinics in PKD Kuala Muda
Being a centre of excellence in PPC management and actively involved in improving PPC at national level.

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GANTT’S CHART

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REFERENCES

Perinatal Care Manual, 3^rd edition. Ministry of Health, Malaysia 2013.
Seshadri S, Oakshott P, Nelson-Piercy C, Chappell LC. Clinical review: Pre-pregnancy Care. BMJ. 2012;344-e3467.
Mazza D, Chapman A, Michie S. Barriers to the implementation of preconception care guidelines as perceived by general practitioners: a qualitative study. BMC Health Service Research. 2013; 13:36
Mason E, Chandra-Mouli V, Baltag V, et.al. Preconception care: advancing from ‘important to do and can be done’ to is being done and is making a difference’. Reproductive Health. 2014;11(suppl 3):58
Murphy HR, Roland JM, Skinner TC et.al. Effectiveness of a Regional Prepregnancy Care Program in women with type 1 and type 2 diabetes. Diabetes Care. 2010; Vol33(Number 12):2514-2520.

6. Tuomainen H, Cross-Bardell L, Bhoday M, et.al. Opportunities and challenges for enhancing preconception health in primary care: qualitative study with women from ethnically diverse communities. BMJ Open. 2013;3:e002977.
7. Mahmud M and Mazza D. Preconception care of women with diabetes: a review of current guideline recommendations. BMC Women’s Health. 2010; 10:5.
8. Cragan JD, Friedman JM, Holmes LB, et.al. Ensuring the safe and effective use of medications during pregnancy: Planning and prevention through preconception care. Maternal Child Health Journal. 2006;10:S129-S135.
9. Barrett G, Shawe J, Howden B, et.al. Why do women invest in pre-pregnancy health and care? A qualitative investigation with women attending maternity services. BMC Pregnancy and Childbirth. 2015; 15:236.

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THANK YOU