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

Authors: Natazcza Abdul Rahim, Mizanur Rahman, Mohd Taha Arif

Affiliations: Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak (UNIMAS), Kota Samarahan, Sarawak

Published: Malaysian Journal of Public Health Medicine, 2018, Vol. 18(1): 149–157

Last reviewed: March 2026

Background and Context

Preconception care—also known as pre-pregnancy care—is a preventive health strategy aimed at identifying and modifying biomedical, behavioural, and social risks before conception occurs. The rationale for preconception care is straightforward: many adverse pregnancy outcomes, including neural tube defects, gestational diabetes complications, and preterm birth, can be mitigated or prevented through interventions initiated before pregnancy. The major components of preconception care include risk assessment, health promotion, and the provision of appropriate medical and psychosocial interventions for women and couples planning a pregnancy.

In Malaysia, pre-pregnancy clinic (PPC) services were formally established as part of the public health clinic system, with implementation beginning in various states at different times. In Sarawak, the programme was introduced in 2011, targeting women of reproductive age, particularly those with chronic conditions such as diabetes, hypertension, or obesity, as well as women who had experienced previous adverse pregnancy outcomes. Despite the evidence supporting preconception care as a means of improving maternal and child health outcomes, the implementation and uptake of PPC services in Malaysia have faced significant challenges.

This study, published in MJPHM in 2018, sought to explore these challenges from the perspective of the healthcare providers responsible for delivering PPC services in Sarawak—one of Malaysia’s largest and most geographically diverse states.

Study Design and Methodology

The study employed a cross-sectional design with a qualitative analytical approach. Nine healthcare facilities across Sarawak were selected using a multistage sampling procedure to ensure representation of different administrative divisions and levels of healthcare infrastructure. A total of 322 healthcare providers—including medical officers, nurses, midwives, and community health workers—participated by responding to an unstructured open-ended questionnaire designed to elicit their in-depth views on the barriers, strengths, and weaknesses of PPC services in their respective facilities.

The qualitative data were analysed using manual thematic analysis. Responses were coded and categorised into themes and sub-themes, which were then organised into the three main domains of investigation: barriers, strengths, and weaknesses. This approach ensured that the voices of frontline providers were captured systematically while allowing for the emergence of unexpected themes.

Barriers to Pre-Pregnancy Care

The thematic analysis identified several categories of barriers that hindered the effective delivery and uptake of PPC services. The most prominent barrier theme related to perception, attitude, and acceptance of PPC services among clients. Providers reported that many women and their partners were unaware of the existence of PPC services or did not perceive them as necessary, particularly among those who had not experienced complications in previous pregnancies. This lack of awareness was exacerbated by insufficient promotional activities and health education efforts within the community.

Socioeconomic barriers constituted a second major theme. Providers noted that financial limitations, transportation difficulties, and competing demands on women’s time—including work obligations and childcare responsibilities—prevented many eligible women from attending PPC clinics. These barriers were particularly acute in rural and remote areas of Sarawak, where healthcare facilities may be geographically distant and public transportation limited.

Service and client factors formed the third barrier theme. Providers identified issues such as inadequate staffing, limited clinic operating hours, and insufficient training for healthcare workers delivering PPC services. Some providers expressed a lack of confidence in their ability to provide comprehensive preconception counselling, particularly on topics such as family planning, chronic disease management, and medication safety in pregnancy.

Strengths of PPC Services

Despite the identified barriers, healthcare providers also recognised important strengths of the PPC programme. The most frequently cited strength was the service’s role in preparing women for pregnancy by identifying and addressing risk factors before conception. Providers valued the opportunity to screen for and optimise the management of chronic conditions such as diabetes and hypertension, to ensure adequate folic acid supplementation, and to counsel women on lifestyle modifications that could improve pregnancy outcomes.

The preventive potential of PPC services was another widely acknowledged strength. Providers recognised that by intervening before pregnancy, PPC services could contribute to reducing maternal mortality and morbidity—a key national health objective aligned with the Sustainable Development Goals. The comprehensive nature of the services, encompassing physical health screening, mental health assessment, nutritional counselling, and family planning advice, was viewed as a significant advantage over more fragmented approaches to preconception care.

Weaknesses of PPC Services

The perceived weaknesses of PPC services were organised under two main themes: working environment and service factors. Working environment challenges included inadequate physical space for conducting confidential consultations, limited availability of essential equipment and educational materials, and heavy workloads that left insufficient time for thorough preconception assessments. Several providers noted that PPC services were treated as an add-on to existing clinic activities rather than being allocated dedicated time and resources.

Service-related weaknesses centred on gaps in training and capacity building. Untrained or inadequately trained staff, poor delegation of responsibilities, and a lack of confidence among some providers were identified as factors affecting the quality of PPC services and the trust placed in them by the public. The absence of standardised protocols and clinical guidelines specific to PPC services in some facilities further contributed to inconsistencies in service delivery.

Implications for Maternal Health Policy

The findings of this study have direct implications for the strengthening of pre-pregnancy care services in Sarawak and across Malaysia. Addressing the identified barriers will require a multi-pronged approach that combines public awareness campaigns, targeted health education, improved training for healthcare providers, and investment in clinic infrastructure and staffing. Promotional activities should leverage multiple channels, including antenatal care visits, community health programmes, and social media, to reach women of reproductive age and their partners.

The importance of addressing geographic and socioeconomic barriers in Sarawak, with its vast territory and dispersed population, cannot be overstated. Innovative approaches such as mobile PPC clinics, telehealth consultations, and community health worker outreach may be needed to extend services to remote and underserved communities. Partnerships with non-governmental organisations and community leaders could also help bridge the gap between formal health services and the communities they serve.

Limitations

The study has several limitations. The reliance on written open-ended questionnaires, rather than face-to-face interviews or focus group discussions, may have limited the depth and richness of some responses. The participating facilities were predominantly Type I and Type II clinics with relatively good accessibility and equipment; the perspectives of providers in more remote and under-resourced facilities may differ substantially. The study focused exclusively on provider perspectives; the views and experiences of clients—the women targeted by PPC services—were not captured and represent an important area for complementary research.

Conclusion

This qualitative study provides valuable insights into the challenges and strengths of pre-pregnancy clinic services in Sarawak from the perspective of healthcare providers. The findings highlight the need for sustained investment in awareness-raising, provider training, and service infrastructure to realise the full potential of preconception care as a strategy for improving maternal and child health outcomes. As Malaysia continues to strengthen its primary healthcare system, ensuring that PPC services are accessible, effective, and responsive to the needs of women and communities will be essential for achieving national health objectives and contributing to the global Sustainable Development Goals.

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