Preconception, Interconception, and reproductive health screening tools: A systematic review

Abstract Objective To identify and describe the standardized interconception and preconception screening tools for reproductive health needs that are applicable in general outpatient clinical practice. Data Sources and Study Setting This systematic review identifies research on pregnancy intention screening and counseling tools, and standardized approaches to preconception and interconception care. We focus on tools designed for clinical settings, but also include research tools with potential for clinical implementation. These tools may include a component of contraceptive counseling, but those focusing solely on contraceptive counseling were excluded. Data were collected from studies done in the United States between January 2000 and March 2022. Study Design We performed a systematic literature search to generate a list of unique tools, assessed the quality of evidence supporting each tool, and described the peer‐reviewed clinical applications of each. We used the Mixed Methods Appraisal Tool to appraise the quality of individual studies. Data Collection/Extraction Methods We searched PubMed, Web of Science, and CINAHL databases for standardized preconception and interconception health screening tools published in English from January 2000 through March 2022. We used keywords “preconception care,” “interconception care,” “family planning,” “contraception,” “reproductive health services,” and “counseling.” Utilizing the Preferred Reporting Items for Systematic Reviews guidelines, we screened titles and abstracts to identify studies for full text review. Principal Findings The search resulted in 15,399 studies. After removing 4172 duplicates, we screened 11,227 titles/abstracts and advanced 207 for full‐text review. From these, we identified 53 eligible studies representing 22 tools/standardized approaches, of which 10 had evidence from randomized clinical trials. These ranged widely in design, setting, and population of study. Conclusions Clinicians have a choice of tools when implementing standard reproductive screening services. A growing body of research can inform the selection of an appropriate tool, and more study is needed to establish effects on long‐term patient outcomes.

appropriate tool, and more study is needed to establish effects on long-term patient outcomes.

K E Y W O R D S
interconception care, preconception care, pregnancy intention screening, primary care, reproductive counseling, reproductive life plan, systematic review What is known on this topic • A barrier to preconception and interconception health screening in general outpatient practices is the number of competing clinical needs • Many standardized tools exist that proactively screen for these reproductive health needs • Clinicians seeking guidance on these tools lack a structured review of different approaches

What this study adds
• This study provides a structured review of different approaches to preconception and interconception health screening  Among women at particular risk of increased pregnancy-related morbidity, including those with a recent birth who had diabetes, hypertension, or both prior to becoming pregnant, fewer than half report receiving preconception health counseling. 3,4 Additionally, low-income women are more likely to receive reproductive health services in primary care (vs. dedicated women's health settings) and are disproportionately cared for in federally qualified health centers (FQHCs). 5,6 Women who have Medicaid insurance or are uninsured have been shown to have increased rates of adverse birth outcomes, 7 hence, it is particularly important that general outpatient practices have a means of identifying those that need preconception/interconception care. In this paper, we use "general outpatient practice" to include primary care and other outpatient practices not specifically designed for family planning.
Patients have expressed interest in receiving preconception/ interconception health screening and counseling from their primary care provider (PCP). 8,9 However, numerous competing demands, lack of preconception health knowledge by both patients and clinicians, and lack of ownership in delivery of preconception care are well-documented barriers. 10,11 Often, clinicians do not even recognize that a patient would be eligible for preconception care. 12 Despite the routine use of screening tools to identify other health needs such as depression, screening for preconception and interconception health needs is not widely adopted and there is a lack of consensus on the best approach. 13 To help clinicians in overcoming barriers to incorporating preconception counseling, we conducted this systematic review of preconception, interconception, and pregnancy intention screening tools and standardized (i.e., replicable) approaches relevant to general outpatient practice in the United States. Many of these standardized approaches involved the use of a specific tool, such as a screening question or form, but any study adopting a standardized approach (with or without a specific tool) was included in this review. In describing specific studies, we mirrored the language authors chose for framing their research (i.e., "interconception counseling" vs. "reproductive counseling", "pregnant person" vs. "woman"); however, we recognize that people of all genders, including nonbinary and transgender individuals, can become pregnant and give birth. The study's objective is to describe these standardized approaches and tools, the settings in which they have been studied, and the published findings about their uses and limitations.
found in (Table S1). To maintain a high degree of search sensitivity, no additional database filters were applied. Studies with titles clearly indicating that they were conducted outside the United States were removed from the results to be screened. The search process was conducted from March to April 2022 and resulted in a total of 15,399 studies. After removing 4172 duplicates, we reviewed the remaining 11,227 ( Figure 1).
Our inclusion criteria centered on standardized approaches or tools with potential for implementation within clinical settings in the United States. Tools tested in family planning clinics were accepted if they were also applicable in general outpatient settings. To ensure included studies outline tools with potential for clinical implementation, we excluded approaches that required resources beyond the typical clinical setting and those that focused solely on skills development for clinical staff or students. We considered contraceptive needs assessment and counseling a component of preconception and interconception care. Given our study's objective, we excluded studies that focused exclusively on contraceptive use, continuation, or method choice, unless the tool had clear applicability for preconception care more broadly defined. Table 1 provides the full list of inclusion and exclusion criteria used.
Using the Covidence platform to manage and track our screening process, each title/abstract was reviewed by two study team members to determine whether the study could be eligible for inclusion. 14,15 If the first two reviewers' eligibility decisions conflicted, a separate reviewer performed a third screening to determine inclusion eligibility.
Once initial eligibility was assessed, full text manuscripts were reviewed to determine final inclusion. Full text review was similarly conducted by F I G U R E 1 PRISMA diagram of included studies. Flow diagram of our literature search from three databases (PubMed, Web of Science, CINAHL). One-session motivational alcoholexposed pregnancy prevention intervention One-session alcohol-exposed pregnancy prevention intervention Two cities in central Virginia

T A B L E 1 Inclusion and exclusion criteria
The one-session EARLY intervention had less powerful effects than multisession alcohol-exposed pregnancy prevention interventions among community women, but may provide a new option in a continuum of preventive care.

| Data abstraction
We exported the included studies from Covidence to Excel and identified the following characteristics of each: the study objectives, the setting and/or population studied, the primary methods, and the key findings.

| Quality assessment
To assess the methodological quality of included studies, we used  indicate that the study sample was representative of the target population. Overall, the quantitative descriptive studies utilized appropriate sampling strategies (11/11), measurements (10/11), and statistical analysis (10/11) but only one provided enough information to determine that the sample was representative of the target population.

| Specific tools and other standardized approaches
We found 17 specific tools, and an additional five standardized approaches not associated with a specific tool. Many of the specific tools incorporated a combination of approaches. For example, the  For specific health conditions and behaviors, where there is strong evidence that providing preconception care improves pregnancy outcomes, such as preconception glycemic control in patients with diabetes reducing the risk of major and minor congenital anomalies, and preconception use of folic acid reducing the risk of neural tube defects and related anomalies, 18,19 it is important to use validated tools and approaches found to be effective in clinical practice.
Interventions such as READY-Girls for adolescents with diabetes, or the IMPLICIT model for embedding interconception care within well-child visits, provide evidence-based strategies for implementing these practices.
For many other approaches, the evidence indicates that implementing a standardized prompt or screening tool leads to higher rates of screening and counseling, but these have yet to demonstrate changes in patient behavior or clinical outcomes. Similar to our findings, prior systematic reviews have found insufficient evidence on the effectiveness of pregnancy intention screening to change patient outcomes, although with our updated review we add multiple recent studies that indicate pregnancy intention screening leads to changes in counseling rates or patient satisfaction. 20 Future research will ideally follow patients longitudinally and track multiple outcomes, including prevention of undesired pregnancy, better pre-pregnancy health, and improved perinatal outcomes.
Our approach had several limitations that clinicians should consider when applying these tools: First, we only reviewed studies in English that tested tools in the United States. It is possible that tools developed in other languages and countries could be adapted and prove clinically useful in the United States. Our strategy may have disproportionately excluded tools that would be useful in U.S.-based patient populations for whom English is not the primary language. A second limitation is the exclusion of studies that only looked at contraceptive use (including method selection, continuation, etc.), unless it was clear the tool would also be applicable for preconception counseling. In applying this exclusion criterion, it is possible we inadvertently excluded tools that could be useful for interconception/ preconception care.
Nonetheless, the findings of this systematic review are significant in summarizing a diverse and growing body of research: the implementation of clinical tools for preconception and interconception care, and pregnancy intention screening. Using our findings, clinicians will be able to identify applicable tools based on their practice setting and patient population and understand the existing research about each tool. Researchers wishing to build on existing evidence, and those interested in adapting known tools to new settings, may also find this review useful. Routine use of evidence-based preconception tools has the potential to help patients control the timing of conditions of future pregnancies and improve perinatal outcomesespecially for those with pre-pregnancy chronic conditions or other risk factors for adverse outcomes. To achieve this potential benefit, ongoing research is needed to further assess the use of tools in everyday clinical practice.

ACKNOWLEDGMENTS
Funded by NIH R21HD104086. Dr. Bello's time is supported by NIH K23DA053433.