Four major barriers to the uptake of preconception care were found and one barrier to the uptake of periconceptional folate supplementation was consistently identified. With the exception of service provider issues, all barriers identified were consistent across groups.
Degree of receptivity
There was a strong sense that women had to be receptive to the information in order to act upon it. This receptivity was dependent on their life stage and whether they were thinking about getting pregnant soon.
"You have to be in the zone." (Rural, 29 years)
Women who had already had a child felt they already knew about preconception care issues and didn't need to access preconception care.
"Because you think you know it. I don't have a child with spina bifida, so why should I take the folate? And I don't need to go the doctor because I've done it all before." (Low SES, 34 years)
Conception is a normal event
Because conception is perceived as an event that most women go through, women felt that it was normal and that there was no need for medical attention or intervention prior to it occurring.
"Some women also think it's a natural thing; that we should just go ahead and get pregnant and all have healthy babies because that is the norm and is what's expected." (Low SES, 34 years)
Interestingly this contrasted with women's sense that it was important to present to a general practitioner (GP) as soon as they knew they were pregnant as they felt medical attention then became necessary.
"I thought the importance [of presenting to a GP] was more on when you were pregnant. When you think about going [to a GP], it's once you have fallen pregnant." (Rural, 29 years)
Perceived risk and lack of awareness of the need for preconception care
Most women were unaware of the need for preconception care in general and said that their GPs did not offer preconception care or inform them of its availability. They were surprised at the breadth of issues that could comprise a preconception care consultation.
"It's a bit daunting when you get all this [preconception care information]. It's a lot to take in, but this is what I would like to have gotten from my GP. The thing is - I never had the concept of preconception care in my mind." (Rural, 26 years)
"Unless you actually go and pursue it [preconception care consultation] nothing will happen. (Low SES, 21 years)
Service Provider Issues
Service provider issues were a major theme elicited in the focus groups and the theme most related to socioeconomic status and rurality. Women living in high socioeconomic areas described attending alternative health practitioners such as naturopaths and Chinese medical practitioners for preconception advice. This was particularly the case for women who had experienced trouble conceiving or who were currently accessing assisted reproductive technologies such as in-vitro fertilisation. Many women had been given specially prepared supplements by their naturopath but were unaware of the contents of these supplements. They nevertheless had implicit trust that they contained 'all that was needed' to optimise conception and pregnancy outcomes.
"I don't have a GP; I have a naturopath, and have a really close relationship. She's been my guiding force behind all the information." (High SES, 33 years)
"If I was looking at information from a dietary perspective I would go to a naturopath. I would ask a GP but that's not their area of specialty and they're not so keen on supplements and vitamins." (High SES, 24 years)
"I am trying lots of things. I'm seeing a Chinese medicine specialist and he knows all the medications - more than my GP. I'm impressed about what he knows."(High SES, 40 years)
For a number of women the GP was not initially thought of as a major provider of preconception care. The reasons given for this were many. In rural areas there was difficulty accessing GPs, cost was a barrier for some women and women across all groups felt that as they were young and healthy, and in some cases yet to have children, they had not established an ongoing relationship with any particular GP and did not identify anyone as 'their GP'. Women also perceived the role of the GP to be one of 'acute care' and did not consider that GPs could or should deliver preventive care. Many felt that other patients who were unwell should have priority in a stretched system.
"You go to a GP because you're sick, not to discuss family planning." (High SES, 40 years)
"If I went in there to have a chat about planning pregnancy, would I be wasting their time?"(Rural, 26 years)
Women also felt that because there wasn't a procedure to carry out (in contrast to having a pap smear), they didn't feel they had to attend their GP to obtain preconception care advice.
"Because it's not active, with your pap smear and breast check you get something done, but for preconception care it's an appointment to go and talk, it's not actually a procedure." (Rural, 35 years)
Women's main source of information regarding preconception care was from friends and family and increasingly from the internet. Broadcast and printed media were not raised by participants.
"If I wanted information like that [preconception care] I would probably just go to an internet source...I wouldn't think of necessarily going to the GP if I can read it elsewhere." (Rural 26 years)
The most widely named internet sites being accessed for preconception related information were sites run by commercial for profit companies (media companies, companies producing nappies and those producing preconception supplements).
Nature and symbolism of folate supplements
Most women expressed confusion about periconceptional folate supplementation: the dose, timing and benefits. There was particular confusion about the nature and efficacy of branded 'preconception' products and how these compared to supermarket brand products. They also voiced concern about the cost of vitamins. The purchase of folate supplements was for many women a clear marker of intent to conceive and they felt that keeping them on a shelf at home was an indication or sign to their partners that they were intending to conceive.
"That was one of the things; I just bought them [supplements] from the supermarket and they all had different milligrams. Do you have a multivitamin or just straight folate? I didn't know which one was better." (Rural, 29 years)
"I've always bought them [folate supplements] and had them ready to go but never really knew why." (Low SES, 36 years)
Two major thematic areas were identified in relation to enablers to the uptake of preconception care and periconceptional folate supplementation.
High motivation to optimise pregnancy outcome
In relation to enablers of delivery and uptake of preconception care and periconceptional folate supplementation, there was universal agreement that women had a strong desire to achieve the best outcome possible for their baby and as such were very motivated to access information and engage in preventive care.
"I was really concerned; I wanted to do everything that I could for its [the baby's] welfare." (Rural, 32 years)
Proactive promotion by GPs
While there was general agreement that public health campaigns and the media had a large role to play in raising awareness of folate supplementation and other preconception issues, there was strong support for GPs to be more proactive in making known the availability and need for preconception care.
"If they said to me if you think you might ever want to start planning a family these are some of the things we can discuss with you...I would file that away and when I'd made my decision I would come to talk to them about it." (Rural, 35 years)
Suggestions made were that during consultations for other matters GPs should discuss the availability and need for preconception care and suggest that women make another appointment to return. There were other suggestions made such as sending women of reproductive age a letter from the GP inviting attendance for preconception care, running preconception classes similar to 'antenatal classes', having preconception appointments available with a nurse, having posters in the waiting room to advertise preconception care and having information and patient brochures in waiting rooms.