Barriers, Strength and Weakness of Pre-Pregnancy Clinic Services in Sarawak: A Qualitative Analysis from Provider Perspectives

Last reviewed: March 2026

Background and Rationale

Pre-pregnancy care (also known as preconception care) is a critical but often underutilised component of the maternal health continuum. By identifying and addressing biomedical, behavioural, and social risks before conception, pre-pregnancy care can significantly reduce adverse pregnancy outcomes including maternal mortality, neonatal mortality, and congenital anomalies. In Malaysia, Pre-Pregnancy Clinic (PPC) services were introduced as part of the government’s commitment to achieving the Millennium Development Goals (subsequently the Sustainable Development Goals) related to maternal and child health.

In Sarawak—Malaysia’s largest state by land area, characterised by geographic challenges, diverse ethnic communities, and dispersed rural populations—PPC services were implemented from 2011 onward. However, the uptake and effectiveness of these services had not been systematically evaluated. Understanding the perspectives of healthcare providers—who are responsible for delivering PPC services on the ground—is essential for identifying barriers, recognising strengths, and addressing weaknesses in service delivery.

Study Design and Methodology

This cross-sectional study was conducted across nine selected healthcare facilities throughout Sarawak, chosen using a multistage cluster sampling technique. A total of 322 healthcare providers from various professional grades participated in the study. An unstructured open-ended questionnaire was administered to gather in-depth qualitative data on providers’ perceived views about barriers, strengths, and weaknesses of PPC services.

The qualitative data were analysed using thematic analysis, with themes being identified manually from the textual responses. This approach allowed the researchers to capture the nuanced perspectives of frontline providers in a way that structured quantitative measures alone could not achieve.

Barriers to Service Delivery

The thematic analysis identified several major categories of barriers to effective PPC service delivery. Client-side barriers included low awareness of PPC services among the target population, negative attitudes towards preconception health screening, and poor acceptance of family planning counselling as a component of pre-pregnancy care. Many providers reported that potential clients were unfamiliar with the concept of pre-pregnancy preparation and did not perceive a need for health optimisation before conception.

Socioeconomic barriers also featured prominently. Transportation difficulties—particularly relevant in Sarawak’s vast rural interior—limited access to healthcare facilities offering PPC services. Financial constraints, competing work obligations, and childcare responsibilities created additional obstacles for women seeking pre-pregnancy care.

Service-related barriers included insufficient staffing, inadequate training on PPC protocols, and competing clinical demands that left providers with limited time to devote to preconception counselling. Perceptions towards family planning discussions proved particularly challenging, as cultural and religious sensitivities in some communities made providers reluctant to initiate conversations about contraception and birth spacing.

Identified Weaknesses

The perceived weaknesses of existing PPC services fell under two main themes: working environment factors and service delivery factors. Staffing challenges were a consistent concern, with providers citing understaffing, poor delegation of duties, and lack of confidence among staff as factors that undermined service quality. Insufficient training left many providers feeling inadequately prepared to deliver comprehensive preconception care, particularly in areas requiring specialised knowledge such as genetic counselling, chronic disease management in the pre-pregnancy context, and nutritional assessment.

Organisational barriers within the healthcare system—including unclear referral pathways, inadequate documentation systems, and insufficient integration between PPC services and other maternal health programmes—further hampered effective service delivery.

Recognised Strengths

Despite the identified barriers and weaknesses, providers also recognised several important strengths of PPC services. Three major thematic areas of strength were identified: preparation for pregnancy, prevention of mortality and morbidity, and the comprehensive nature of the service package. Providers valued the PPC framework for its holistic approach to pre-pregnancy health assessment, which encompassed physical health screening, nutritional counselling, chronic disease optimisation, mental health assessment, and family planning guidance.

The preventive potential of PPC services was widely recognised, with providers acknowledging that identifying and addressing risk factors before conception could significantly reduce adverse pregnancy outcomes. This preventive orientation was seen as an important complement to the existing focus on antenatal care, which begins only after conception has occurred.

Implications for Policy and Practice

The study’s findings suggest several actionable recommendations for strengthening PPC services in Sarawak and beyond. Community awareness campaigns are needed to educate the target population about the availability and benefits of pre-pregnancy care. These campaigns should be culturally sensitive and delivered through channels that reach diverse communities, including rural and indigenous populations.

Investment in staff training is essential. Providers need both the clinical knowledge and the communication skills to deliver effective preconception counselling, particularly in areas involving sensitive topics such as family planning and reproductive health. Adequate staffing levels must be ensured so that providers have sufficient time to devote to PPC consultations without compromising other clinical responsibilities.

Improved integration of PPC services within the broader maternal health care framework—including clear referral pathways, standardised protocols, and shared documentation systems—would enhance service continuity and efficiency. Finally, mobile and outreach-based service delivery models should be explored to address the geographic barriers that are particularly salient in Sarawak’s rural interior.

Limitations

The study focused exclusively on provider perspectives, and the views of clients and community members may differ. The participating healthcare facilities were primarily Type I and Type II clinics with relatively good accessibility, and inclusion of more remote facilities might have revealed additional barriers. The qualitative methodology, while providing rich descriptive data, limits the generalisability of findings to specific prevalence rates of identified barriers and weaknesses.

Significance of This Research

This study provides valuable qualitative evidence on the implementation challenges facing PPC services in Sarawak, a state with unique geographic and demographic characteristics that present distinct healthcare delivery challenges. The findings are relevant not only to Sarawak but to other Malaysian states and developing countries seeking to establish or strengthen pre-pregnancy care programmes. By giving voice to the perspectives of frontline providers, the study identifies practical priorities for service improvement that can inform both policy and practice.

← Return to Homepage