Mazza and Chapman BMC Public Health 2010, 10:786 http://www.biomedcentral.com/1471-2458/10/786 companies producing nappies and those producing pre- conception supplements). Nature and symbolism of folate supplements Most women expressed confusion about periconcep- tional folate supplementation: the dose, timing and ben- efits. 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 indica- tion or sign to their partners that they were intending to conceive. “That was one of the things; I just bought them [sup- plements] from the supermarket and they all had differ- ent 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) Enablers Two major thematic areas were identified in relation to enablers to the uptake of preconception care and peri- conceptional folate supplementation. High motivation to optimise pregnancy outcome In relation to enablers of delivery and uptake of precon- ception care and periconceptional folate supplementa- tion, 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 Page 4 of 6 make another appointment to return. There were other suggestions made such as sending women of reproduc- tive age a letter from the GP inviting attendance for pre- conception care, running preconception classes similar to ‘antenatal classes’, having preconception appoint- ments available with a nurse, having posters in the wait- ing room to advertise preconception care and having information and patient brochures in waiting rooms. Discussion This qualitative study provides new insights into the views of women of reproductive age regarding the bar- riers and enablers to the delivery and uptake preconcep- tion care and periconceptional folate supplementation, taking into account the significant variables of socioeco- nomic status and rurality. Although a relatively small sample of women was recruited to this study, the find- ings may give future direction to strategies for the implementation of preconception care guidelines in gen- eral practice. Our findings, consistent with other studies [16] indi- cate a great willingness on the part of women to opti- mise their health in preparation for pregnancy; however several factors are acting as barriers. Major amongst these are the lack of GP ‘push’ for preconception care, with women reporting that GPs do not inform women of either the need for preconception care or its availabil- ity. Additionally, there is lack of patient ‘pull’ for these services because of a lack of familiarity with the concept of preconception care, the breadth of issues to be cov- ered as part of preconception care or of its availability through general practice. Furthermore, whilst most women felt obligated to present to a GP once pregnant, a number of women stated that the concept of precon- ception care over-medicalised a natural human event. This dissonance of resisting the medicalisation of plan- ning the occurrence of pregnancy whilst supporting it once pregnancy occurs may comprise a barrier that, if not more fully understood, will continue to impede the success of efforts to promote family planning and pre- conception care. In contrast to our results, a small study exploring why women did not respond to an invitation to attend for preconception care found that despite generally subscribing to the value of preventive behaviours and a healthy lifestyle, women perceived themselves as hav- ing sufficient knowledge of preconception care issues and/or not being at risk. Some also misunderstood the aim of preconception care as being advice about infer- tility [17]. This perception of sufficient knowledge was only consistent for women in our study who had pre- viously had children. For these reasons, asking women to complete existing screening tools for preconception risk factors may assist in overcoming these barriers