Expanding access to postpartum contraception

PURPOSE OF REVIEW

Women are particularly vulnerable to unintended pregnancy in the 12 months following a birth. Improving access to postpartum contraception within maternity settings can prevent unintended and closely spaced births, improving the health of mother and child. This review will summarize the recent research in postpartum contraception (PPC), building on existing knowledge and developments in this field.

RECENT FINDINGS

Current models of postpartum contraceptive provision may not adequately meet women's needs. The COVID-19 pandemic led to changes in postpartum contraceptive provision, with an increasing emphasis placed on maternity services. Antenatal contraceptive discussion is associated with increased postpartum contraceptive planning and uptake of methods after birth. Digital health interventions may be a useful tool to support information about contraception. The most effective long-acting reversible contraceptive (LARC) methods, such as the intrauterine device (IUD) and implant, can be challenging to provide in the maternity setting because of availability of trained providers. Postpartum IUD insertion remains relatively under-utilized, despite evidence supporting its safety, efficacy and cost-effectiveness.

SUMMARY

Antenatal information needs to be partnered with access to the full range of methods immediately after birth to reduce barriers to PPC uptake. Training and education of maternity providers is central to successful implementation of PPC services.

A Scoping Review of Patient-Centered Perinatal Contraceptive Counseling

INTRODUCTION

Contraceptive counseling during the perinatal period is an important component of comprehensive perinatal care. We synthesized research about contraceptive counseling during the perinatal period, which has not previously been systematically compiled.

METHODS

We developed search criteria to identify articles listed in PubMed, Embase, and Popline databases published between 1992 and July 2022 that address patients' preferences for, and experiences of, perinatal contraceptive counseling, as well as health outcomes associated with this counseling. Search results were independently reviewed by multiple reviewers to assess relevance for the present review. Methods were conducted in accordance with PRISMA guidelines.

RESULTS

Thirty-four articles were included in the final full text review. Of the included articles, 10 included implementation and evaluation of a contraceptive counseling method or protocol, and 24 evaluated preferences for or experiences of existing contraceptive counseling in the perinatal period. Common themes included the acceptability of contraceptive counseling in the peripartum and postpartum periods, and a preference for contraceptive counseling at some point during the antenatal period and before the inpatient hospital experience, and direct provider-patient discussion instead of video or written material. Multiple studies suggest that timing, content, and modality should be individualized. In general, avoiding actual or perceived directiveness and providing multi-modal counseling that includes both written educational materials and patient-provider conversations was desired.

DISCUSSION

The perinatal period constitutes a critical opportunity to provide contraceptive counseling that can support pregnant and postpartum people's management of their reproductive futures. The reviewed studies highlight the importance of patient-centered approach to providing this care, including flexibility of timing, content, and modality to accommodate individual preferences.

Postpartum contraception provision across Europe: preliminary findings from a multi country survey

INTRODUCTION

Looking after a baby and recovering from birth pose barriers to accessing and initiating effective contraception in the postpartum period. Another pregnancy at this time can end in abortion or a short interbirth interval. These are preventable if contraception is provided immediately from maternity settings. Our aim was to survey contraceptive experts across Europe about provision of postpartum contraception (PPC) in their country to develop a greater understanding of availability of and delivery of PPC services within the region.

MATERIALS AND METHODS

Contraceptive experts across Europe were invited to participate in an anonymous mixed-methods online survey consisting of free text and fixed-response questions focusing on: (1) national guidelines/policy (2) antenatal contraceptive discussion and (3) immediate postpartum provision of methods. Respondents were asked to rate PPC provision in their region and detail perceived facilitators or barriers.

RESULTS

Experts from 28 countries completed the survey. Fifteen (40%) reported their country had national guidelines for PPC provision, 40% reported that some antenatal contraceptive counselling was offered and 51% reported that contraceptive methods were provided in some (43%) or all (8%) maternity settings. Country-level PPC provision was reported as 'poor' or 'very poor' by 54% of respondents. Reported barriers to PPC provision included: cost, lack of policy/government support, awareness and training of maternity staff.

CONCLUSIONS

There is significant variation in PPC provision across Europe. Few countries offer antenatal contraceptive counselling or provide contraception from maternity settings. Introduction of supportive PPC policies, funding and training for staff could improve outcomes for mothers and babies.

Women's experiences of postpartum contraceptive services when elective caesarean section is the method of birth: a qualitative study

BACKGROUND

The unmet need for postpartum contraception is a global challenge. Postpartum placement of an intrauterine device (IUD) within 48 hours of vaginal delivery is available in many settings worldwide, but is not routinely practised in Sweden. To improve contraceptive services and facilitate the informed choice of IUD placement at the time of a caesarean section (CS), we performed this study to identify and describe women's experiences of contraceptive services before, during and after an elective CS.

METHODS

A qualitative design and methodology was used. We interviewed 20 women aged 28-42 years who underwent elective CS in Sweden. Interviews were analysed using reflexive thematic analysis.

RESULTS

The three main themes found were (1) receptivity to contraceptive counselling in the context of CS, (2) communication and decision-making about postpartum contraception before CS and (3) lack of support and guidance to receive contraceptive services before and after CS. The participants described readiness and interest regarding postpartum contraception. They prefered counselling from around 25 weeks of gestation. Despite this finding, antenatal communication and contraceptive decision-making seemed rare. Participants reported a lack of support and guidance which necessitated a need by women to navigate the contraceptive services themselves in order to receive information about contraception before CS and to receive postpartum support.

CONCLUSIONS

Antenatal contraceptive counselling including information about IUD placement during CS was appreciated and welcomed by women with elective CS as their birth method. Most of the women whom we interviewed would prefer to receive contraception counselling on postpartum use during the second half of their pregnancy.

An exploration of the contraceptive counselling practices of midwives who provide postpartum care in Australia

OBJECTIVE

We sought to explore and describe midwives' attitudes and practices relating to their provision of postpartum contraception counselling.

DESIGN

We used an exploratory cross-sectional design. Recruitment used an anonymous online survey using electronic communication platforms of professional, and special-interest organisations, over six months . Descriptive and quantitative analysis was used.

SETTING AND PARTICIPANTS

Australian Midwives who provide postpartum care.

MEANING AND FINDINGS

A total of 289 complete responses were included. Findings from this national survey of midwives showed that almost 75% of Australian midwives reported providing some contraceptive advice to women. Those working in continuity of care models were significantly more likely to fulfil this responsibility. More than half (67%) indicated they had not received any formal contraception education or training. Those working in private obstetric-led settings were significantly less likely to have received education compared to midwives in community settings. Systems barriers preventing the provision of contraceptive counselling included: clinical workload; lack of management support; lack of education; and models of care.

KEY CONCLUSIONS

Most midwives (82%) wanted to provide postpartum contraception counselling as part of their role. They cited barriers from within the health system, ambiguity about roles and responsibilities and offered solutions to improve the provision of postnatal contraception counselling.

IMPLICATIONS FOR PRACTICE

Recommendations include the development of education programs for midwives. Continuity of care models provided the time, autonomy and opportunity for midwives to undertake contraceptive counselling and fulfil this part of their professional scope. Consideration should be given to expanding access and provision of continuity of midwifery care. An urgent investment in the education and skills of midwives is recommended to ensure all women across acute and community services benefit from improved outcomes associated with pregnancy spacing.

Postpartum contraception in Australia: opportunities for increasing access in the primary care setting

In Australia, 20% of pregnancies occur within the first year after birth and most are unintended. Both unintended pregnancies and short interpregnancy intervals (<12-18months) can have adverse effects on maternal, infant, and child health. Access to postpartum contraception reduces the risk of unintended pregnancies and short interpregnancy intervals, and supports women in pregnancy planning and birth spacing. In this forum article, we describe how postpartum contraception is currently provided in Australia and highlight opportunities for improving access in the primary care setting.

Scoping review protocol: exploration of the barriers and facilitators to the uptake of early postnatal contraception

INTRODUCTION

It is well documented that many women do not desire a short interpregnancy interval. Medical societies, government agencies and leaders in the field recommend that contraception should be part of maternity care. Short spaced and unplanned pregnancies increase the chances of mortality and morbidity in the mother and child. The WHO recommends a 24-month interpregnancy interval; however, short pregnancy intervals remain common. The goal of this scoping review will be to explore barriers and facilitators to the uptake of early postnatal contraception. A review of globally published literature relating to the implementation of a postnatal contraception service provision globally will be carried out which will highlight evidence gaps, strengths and weaknesses of studies associated with uptake and known barriers and facilitators to the uptake of early postnatal contraception.

METHODS AND ANALYSIS

This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The search strategy aims to locate both published and unpublished studies. An initial limited search of PubMed and CINAHL was undertaken to identify articles on the provision of postnatal contraception. The search strategy will be adapted for each included database CINAHL, SCOPUS, MEDLINE, PROSPERO and COCHRANE from 1 January 1993 to 1 January 2023 and reviewed by two reviewers. The data will be analysed and presented in tables, diagrams and text.

ETHICS AND DISSEMINATION

Ethical approval is not required. This review is a retrospective review of widely and publicly available evidence. The review findings will be disseminated via publication in peer-reviewed journals, as part of a PhD thesis and conference presentation.

SCOPING REVIEW QUESTION

What are the barriers and facilitators to early postnatal contraception provision and uptake?

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation

BACKGROUND

Immigrant women's challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women's possibility to choose and initiate effective contraceptive methods post-partum.

METHODS

This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study's intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women's choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women's experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project's primary outcome involving women's choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents.

DISCUSSION

The intervention's co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services.

TRIAL REGISTRATION

NCT05521646, August 30, 2022.

Factors associated with postpartum contraceptive planning in New Zealand

OBJECTIVE

To identify factors associated with contraceptive planning in the immediate postpartum period.

STUDY DESIGN

Survey of those receiving inpatient postpartum care in two tertiary hospitals/associated birthing units (Auckland, New Zealand). Multivariable analyses using logistic regression examined independent predictors of contraceptive planning.

RESULTS

Of 571 participants, those who recalled both antenatal and postpartum contraception discussions were more likely to have a contraceptive plan than those who recalled neither (aOR 5.6(2.8-11.5)).

CONCLUSION

Both antenatal and postpartum contraceptive discussions are associated with postpartum contraceptive planning.

IMPLICATIONS

Both antenatal and postpartum discussions around contraception were independently associated with increased rates of established contraceptive plan postpartum, however patients who recalled both were more likely to have made a plan. Clinicians should provide multiple opportunities for discussing contraception throughout pregnancy and post-pregnancy to facilitate informed decision making.

Improving Access to and Quality of Postpartum Contraception Provision

Sexual activity and fertility can resume shortly after childbirth, but there are barriers to contraceptive access in the postpartum period. Unintended pregnancy and short interpregnancy intervals (of less than one year) can increase the risk of obstetric and neonatal complications. The antenatal period presents an opportunity to discuss contraceptive options, many of which can be safely initiated immediately after childbirth. Successful delivery of a postpartum contraception program requires an adequate number of maternity staff trained to provide the full range of methods.

Opportunities for Increasing Access to Effective Contraception in Australia

Effective contraception can prevent unintended pregnancies, however there is an unmet need for effective contraception in Australia. Despite their being a range of contraceptive methods available, access to these remains equitable and uptake of the most effective methods is low. There is an opportunity to reduce the rate of unintended pregnancies in Australia by improving the uptake of effective contraception for those who desire this. Improving access will require increasing consumer health literacy about contraception, as well as the option of telehealth as a mode of service delivery, and stronger investment in contraceptive services through appropriate reimbursement for providers. There is also a need to test new models of care to increase access to and use of effective contraception in Australia, including nurse and midwifery-led models of contraceptive care and pharmacy involvement in contraceptive counseling.

Developing contraceptive services for immigrant women postpartum - a case study of a quality improvement collaborative in Sweden

Background

Immigrant women use less effective contraceptive methods and have a higher risk of unintended pregnancies. Maternal health care services offer a central opportunity to strengthen contraceptive services, especially among immigrants. This study aimed to evaluate a Quality Improvement Collaborative QIC. Its objective was to improve contraceptive services for immigrant women postpartum, through health care professionals’ (HCPs) counselling and a more effective choice of contraceptive methods.

Methods

The pilot study was designed as an organisational case study including both qualitative and quantitative data collection and analysis. Midwives at three maternal health clinics (MHCs) in Stockholm, Sweden participated in a QIC during 2018–2019. In addition, two recently pregnant women and a couple contributed user feedback. Data on women’s choice of contraceptive method at the postpartum visit were registered in the Swedish Pregnancy Register over 1 year.

Results

The participating midwives decided that increasing the proportion of immigrant women choosing a more effective contraceptive method postpartum would be the goal of the QIC. Evidence-based changes in contraceptive services, supported by user feedback, were tested in clinical practice during three action periods. During the QIC, the proportion of women choosing a more effective contraceptive method postpartum increased at an early stage of the QIC. Among immigrant women, the choice of a more effective contraception increased from 30 to 47% during the study period. Midwives reported that their counselling skills had developed due to participation in the QIC, and they found using a register beneficial for evaluating women’s choice of contraceptive methods.

Conclusions

The QIC, supported by a register and user feedback, helped midwives to improve their contraceptive services during the pregnancy and postpartum periods. Immigrant women’s choice of a more effective contraceptive method postpartum increased during the QIC. This implies that a QIC could increase the choice of a more effective contraception of postpartum contraception among immigrants.

Perspectives of obstetricians and midwives on the provision of immediate postpartum intrauterine devices: a qualitative service evaluation

BACKGROUND

Immediate postpartum intrauterine device (PPIUD) insertion is safe and effective but largely unavailable in Europe. Data on maternity staff views on the provision and implementation of PPIUD services are limited. The objective of this qualitative evaluation was to explore the views and experiences of obstetricians and midwives providing PPIUD within a UK maternity setting, in order to identify areas for improvement and inform service provision in other areas.

METHODS

Qualitative health services research within two public maternity hospitals in Lothian (Edinburgh and surrounding region), UK. Interviews with 30 maternity staff (obstetricians n=8; midwives n=22) involved in PPIUD provision. Data were analysed thematically.

RESULTS

Maternity staff were positive about the benefits of PPIUD for women. Midwives reported initial concerns about PPIUD safety, and the impact on workload; these views shifted following training, and as PPIUD was embedded into practice. Having a large pool of PPIUD-trained staff was identified as an important factor in successful service implementation. Having PPIUD 'champions' was important to address staff concerns, encourage training uptake, and advocate for the service to ensure continued resourcing.

CONCLUSIONS

PPIUD in maternity services can help address unmet need for effective contraception in the immediate postpartum period. We emphasise the importance of widespread engagement around PPIUD among all healthcare professionals involved in the care of women, to ensure staff are informed and supported. Clinical champions and leaders play a key role in amplifying the benefits of PPIUD, and advancing organisational learning.

Short interpregnancy interval: circumstance or choice?

INTRODUCTION

Despite the knowledge of pregnancy risks attributable to inadequate birth spacing, over one-third of pregnancies occur within 18 months of a preceding birth. In this qualitative study we sought to interview women with a short interpregnancy interval (sIPI) to explore their knowledge of contraception and birth spacing and their experience of counselling on these themes.

METHODS

We conducted in-depth interviews with women with a sIPI (live-birth less than 18 months prior to conception of current pregnancy) at Royal Prince Alfred Hospital and Canterbury Hospital in Sydney, Australia. Women were recruited at the second antenatal visit or day 3 postpartum. Interviews were recorded and transcribed. The six-phase thematic analysis framework described by Braun and Clarke was used to perform qualitative data analysis.

RESULTS

Twenty women were interviewed (IPI range: 3-18 months). The three central themes that arose were that perceptions of IPIs are shaped by individual circumstances, a lack of information from healthcare providers (HCPs) on IPI and contraception limited women's ability to make informed decisions, and that reproductive life planning is an important element of pregnancy care.

CONCLUSIONS

In this study, women with a sIPI did not feel informed about birth spacing, had poor knowledge of reliable contraceptives, and remained at risk of further closely spaced pregnancies. There was a desire among women with a sIPI to receive clear and consistent education on these topics. HCPs need to do more to educate women in the antenatal and postnatal period to help them space their pregnancies appropriately.

Feasibility, acceptability and sustainability of postpartum contraceptive implant provision by midwives in NSW public hospitals

BACKGROUND

Repeat pregnancy in the first year after a birth is common. Many of these conceptions are unintended and may be prevented by providing access to contraception in the immediate postpartum period. Midwives in the hospital setting could potentially play a greater role in improving postnatal contraception information and provision.

AIM

We sought to implement and examine the success of a program training hospital-based midwives in immediate postpartum implant insertion.

METHODS

This mixed methods study in two hospitals in New South Wales sought to explore the feasibility, acceptability and sustainability of a program that provided competency-based implant insertion training for midwives. The study documented training completion, implant insertion numbers and experience, and conducted end of study interviews with midwives and stakeholders.

FINDINGS

Twenty-seven midwives undertook training and inserted 265 implants during the study period. Interviews with 13 midwives and 11 stakeholders concluded the program to be feasible and acceptable with midwives reporting high satisfaction from their involvement. All interviewees felt that midwives were well placed to insert implants, and reported that challenges around workload and opportunities for practice were generally manageable. It was recognised that sustainability of the program would require supportive policy and regular insertion opportunities.

CONCLUSIONS

Midwives successfully upskilled in implant insertions and there was widespread support for the program with expectations it would be sustained. Provision of contraceptive information and implant insertion by midwives in the immediate postpartum period is likely to increase contraceptive choice and access for women and contribute to reducing rapid repeat pregnancies.

The views of postnatal women and midwives on midwives providing contraceptive advice and methods: a mixed method concurrent study

BACKGROUND

Provision of contraception to women in the immediate postnatal period has been endorsed by professional bodies, to reduce the incidence of short inter-pregnancy intervals. This study examined the views of postnatal women and practising midwives regarding provision of contraceptive advice and contraceptive methods by midwives, in a region of the United Kingdom.

METHODS

A mixed-method approach using qualitative interviews with midwives, and a postnatal survey followed by qualitative interviews with postnatal women, in five hospitals in the East of England. Twenty-one practising midwives and ten women were interviewed. Two hundred and twenty-seven women returned a survey. Survey data was analysed descriptively, augmented by Student's t-tests and Chi-squared tests to examine associations within the data. Interviews were recorded, transcribed and analysed guided by the phases of thematic analysis.

RESULTS

Midwives and women supported the concept of increased midwifery provision of contraceptive advice, and provision of contraceptive methods in the postnatal period. Convenience and an established trusting relationship were reasons for preferring midwifery provision over visiting a doctor for contraception. The best time for detailed discussion was reported to be antenatal and community visits. The Progesterone-only-pill (POP) was the method, in which women indicated most interest postnatally. Concerns for midwives included the need for increased education on contraceptive methods and training in supplying these. Structural barriers to such provision were time pressures, low prioritisation of contraceptive training and disputes over funding.

CONCLUSIONS

Women reported interest in midwives supplying contraceptive methods and expressed the view that this would be convenient and highly acceptable. Midwives are supportive of the concept of providing enhanced contraceptive advice and methods to women in their care, and believe that it would be advantageous for women. Institutional support is required to overcome structural barriers such as poor access to continuous professional development, and to allow contraceptive provision to be fully recognised as integral to the midwifery role, rather than a marginalised addition.

Norwegian women's experiences and opinions on contraceptive counselling: A systematic textcondensation study

INTRODUCTION

Contraception plays a pivotal role in most women's lives, from teenage years to the menopause. Contraception and sexual wellbeing are closely related. Ideally, women should be able to access contraception and discuss issues concerning their sexual life during a contraceptive counselling session. Previously, only doctors conducted contraceptive consultations. Increasingly, other healthcare workers are providing contraceptive care. The aim of this study is to explore women's experiences and opinions related to contraceptive counselling.

METHODS

An electronic questionnaire was distributed in 2017-2018. The texts of 308 women's written responses to open-ended questions were analyzed using systematic text-condensation.

RESULTS

The analysis resulted in four themes: 1) Women-centered care, 2) Side-effects of hormonal contraceptives, 3) Non-hormonal methods and male involvement, and 4) Counsellors' professional background. Women wished for a consultation that would lead to the best choice of contraception for them, taking into account their medical history, personal preference and living circumstances. Side-effects of hormonal products were under-communicated, as were non-hormonal methods. Respondents had contradicting opinions about midwives as contraceptive counsellors and were unfamiliar with them in this role.

CONCLUSIONS

The quality of contraceptive counselling in Norway needs to be improved. Women require individualized follow-up, sufficient information and a choice of methods to find the most suitable alternative for them. A good relationship with a health provider they trust could improve contraceptive consultation. Midwives' knowledge and competence in this area need to be made more widely known.

Influence of culture, religion and experience on the decision of Pakistani women in Lothian, Scotland to use postnatal contraception: a qualitative study

INTRODUCTION

Evidence suggests that Pakistani women may experience difficulty accessing postnatal contraceptive (PNC) services. The study aimed to identify experience and decision-making around PNC provision for Pakistani women in Lothian, and to explore the views and experience of maternity staff who provide PNC counselling.

METHODS

Qualitative research including focus groups and 1:1 semi-structured interviews with women and staff. Participants were first- and second-generation Pakistani women with a child/children aged up to 5 years, or pregnant; community and hospital midwives, obstetric doctors who counsel or provide PNC. Data were coded and categorised using QSR NVIVO10. Inductive thematic analysis was carried out.

RESULTS

Women were receptive to discussion of contraception, including antenatally, and welcomed translated information. Some said the decision on PNC was theirs or made jointly with their husband; however, they acknowledged that in some marriages the husband will take the decision. Women stated they may face family expectation to have a baby early in marriage. Language was identified as a challenge by maternity staff, who utilised translation services to ensure women received the information they needed on contraception.

CONCLUSIONS

Pakistani women value antenatal discussion about PNC. Maternity staff have an important role in providing quality information on contraception and should be supported with translated resources in a range of formats. Most importantly, staff should adopt a tailored approach to identify the individual woman's needs and preferences.

Contraception provision in the postpartum period: Knowledge, views and practices of midwives

BACKGROUND

Women are susceptible to unintended pregnancies in the first year after giving birth, particularly as consideration of contraception may be a low priority during this time. Discussing and providing contraception before women leave hospital after giving birth may prevent rapid repeat pregnancy and its associated risks. Midwives are well placed to assist with contraceptive decision-making and provision; however, this is not routinely undertaken by midwives in the Australian hospital setting and little is known regarding their views and experiences in relation to contraception.

METHODS

An anonymous survey was conducted with midwives at two urban hospitals in New South Wales to better understand their contraceptive knowledge, views and practices regarding midwifery-led contraception provision in the postpartum period.

FINDINGS

The survey was completed by 128 midwives. Most agreed that information about contraception provided in the postpartum period is valuable to women, although their knowledge about different methods was variable. The majority (88%) believed that midwives have a role in providing contraceptive information, and 79% reported currently providing contraceptive counselling. However, only 14% had received formal training in this area.

CONCLUSION

Findings demonstrate that most midwives provide some contraception information and believe this is an important part of a midwife's role. Yet most have not undertaken formal training in contraception. Additional research is needed to explore the content and quality of midwives' contraception discussions with women. Training midwives in contraceptive counselling would ensure women receive accurate information about available options. Upskilling midwives in contraception provision may increase postpartum uptake and reduce rapid repeat pregnancies.

A cross-sectional study exploring obesity and pregnancy planning among women attending an antenatal clinic in Suva, Fiji

BACKGROUND

Pregnancy planning enables maternal health optimisation which is particularly important for women who have obesity and are at increased risk of adverse perinatal outcomes.

AIMS

The prevalence of pregnancy planning and its relationship to body mass index (BMI) was investigated in a cohort of women attending antenatal clinics in the main referral hospital in Suva, Fiji.

MATERIALS AND METHODS

The questionnaire captured health and socio-demographic data, anthropometry and asked about pregnancy planning.

RESULTS

Two thousand, two hundred and three pregnant women presenting for their first booking at the antenatal clinic were enrolled; 721 (37.4%) out of 1926 women with complete data reported they did not plan their pregnancy. A third of women (n = 633, 32.8%) had overweight and 805 (41.7%) had obesity. In multivariable analyses parity, employment status, marital status, and BMI were significantly associated with pregnancy planning. Compared to women of a healthy weight or underweight, women who have obesity were less likely to plan their pregnancy (adjusted odds ratio 0.742; 95% CI 0.569-0.967).

CONCLUSION

Tackling the cycle of obesity will require attention to preconception care and optimising weight before pregnancy.

Risk of abortion within 1-2 years after childbirth in relation to contraceptive choice: a retrospective cohort study

Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period.Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum.Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p =  .005). Smoking, age <25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk.Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.

Provision of immediate postpartum intrauterine contraception after vaginal birth within a public maternity setting: Health services research evaluation

Introduction

Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter‐pregnancy intervals; however, provision across Europe is limited. Our aim was to determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model.

Material and methods

Phased introduction of PPIUC across two Lothian maternity hospitals; all women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or a copper intrauterine device within 48 hours of vaginal birth. Follow‐up was conducted in‐person at 6 weeks postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion‐related variables.

Results

Uptake of PPIUC was 4.6% of all vaginal births; 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose a levonorgestrel intrauterine system (73%). At 6 weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n = 113) and most had symptoms (n = 79). Of the additional 121 devices removed, 118 were because of partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared with those by doctors. The re‐insertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%.

Conclusions

Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Re‐insertion and therefore longer‐term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely spaced pregnancies.

Developing the role of midwives as 'contraceptive champions' to support early access to effective postnatal contraception for women

OBJECTIVE

To evaluate the acceptability of the new contraceptive champion role to the first hospital and community midwives in NHS Lothian trained in this role.

DESIGN

Health service evaluation.

POPULATION

Hospital and community midwives trained as contraceptive champions, NHS Lothian, Scotland, UK.

METHODS

Qualitative research: 1:1 semi-structured interviews (baseline and follow-up) with five contraceptive champions.

MAIN OUTCOME MEASURE

Qualitative data on views of the new contraceptive champions on the first 6 months of the role.

RESULTS

All contraceptive champions stated increased confidence in their knowledge of postnatal contraception. They reported that women had not questioned the role of midwives in inserting contraceptive implants postnatally in hospital and at home. Midwife colleagues and hospital doctors had been supportive.

CONCLUSION

The new role of contraceptive champion is reported by midwives to have been well received in its first year by women, the midwives themselves and their healthcare colleagues.

Antenatal contraception counselling and provision of contraception after delivery for first-time young mothers enrolled with a Family Nurse Partnership programme

OBJECTIVE

To evaluate antenatal contraceptive counselling and provision of postpartum contraception on contraceptive choices of first-time teenage mothers enrolled with a Family Nurse Partnership (FNP) programme.

DESIGN

Health service research evaluation.

POPULATION

Cohort of FNP clients (n=195), Scotland, UK.

METHODS

Antenatal contraceptive counselling and provision of chosen method from the hospital. Evaluation consisted of (i) self-administered questionnaires of FNP clients and (ii) interviews with FNP clients and FNP nurses.

MAIN OUTCOME MEASURES

FNP client views on intervention. Secondary outcomes included: contraceptive choice antenatally, at day 10 postpartum, 3 and 12 months after delivery, and views of FNP nurses on the intervention.

RESULTS

Antenatal questionnaires were completed by 118/195 (61%) clients. 96/118 (81%) agreed that it was very or quite helpful to receive antenatal contraceptive counselling and 80/118 (68%) were planning to use a long-acting reversible method of contraception (LARC). 97/121 (80%) wished to receive contraception before leaving the hospital. 104/195 (53%) completed a questionnaire at day 10 postpartum, of which 33 (32%) indicated that they had received contraception from the hospital. FNP nurses expressed frustration when contraception was not provided; this was usually attributed to the busy workload of the maternity department.

CONCLUSIONS

Antenatal contraceptive counselling was appreciated by FNP clients and they expressed a preference for contraception provision following delivery. Over two-thirds planned to use a LARC method but many did not receive this from the hospital. Further interventions are required to ensure that the provision of postpartum contraception is prioritised for this group of young women.

Contraception after pregnancy

Whatever the outcome, pregnancy provides the opportunity to offer effective contraception to couples motivated to avoid another pregnancy. This narrative review summarizes the evidence for health providers, drawing attention to current guidelines on which contraceptive methods can be used, and when they should be started after pregnancy, whatever its outcome. Fertility returns within 1 month of the end of pregnancy unless breastfeeding occurs. Breastfeeding, which itself suppresses fertility after childbirth, influences both when contraception should start and what methods can be used. Without breastfeeding, effective contraception should be started as soon as possible if another pregnancy is to be avoided. Interpregnancy intervals of at least 6 months after miscarriage and 1-2 years after childbirth have long been recommended by the World Health Organization in order to reduce the chance of adverse pregnancy outcome. Recent research suggests that this may not be necessary, at least for healthy women <35 years old. Most contraceptive methods can be used after pregnancy regardless of the outcome. Because of an increased risk of venous thromboembolism associated with estrogen-containing contraceptives, initiation of these methods should be delayed until 6 weeks after childbirth. More research is required to settle the questions over the use of combined hormonal contraception during breastfeeding, the use of injectable progestin-only contraceptives before 6 weeks after childbirth, and the use of both hormonal and intrauterine contraception after gestational trophoblastic disease. The potential impact on the risk of ectopic pregnancy of certain contraceptive methods often confuses healthcare providers. The challenges involved in providing effective, seamless service provision of contraception after pregnancy are numerous, even in industrialized countries. Nevertheless, the clear benefits demonstrate that it is worth the effort.

Women's and healthcare professionals' views on immediate postnatal contraception provision: a literature review

OBJECTIVES

Provision of immediate postnatal contraception, including long-acting reversible contraceptive (LARC) methods, is increasingly identified and endorsed as a key strategy for reducing unplanned and rapid repeat pregnancies. This literature review aims to evaluatethe views of women and healthcare professionals regarding the receipt, initiation or delivery of these services.

METHODS

Databases (Embase, Medline, CINAHL, HMIC) were searched for relevant English language studies, from January2003 to December 2017. In addition, Evidence Search, Google Scholar and Scopus (citation search) were used to identify further literature. Other relevant websites were accessed for policies, guidance and supplementary grey literature.

RESULTS

There is clear guidance on how to deliver good-quality postnatal contraception to women, but the reality of service delivery in the UK does not currently meet these aspirations, and guidance on implementation is lacking. The available evidence on the provision of immediate postnatal contraception focuses more on clinical rather than patient-centred outcomes. Research on postnatal women's views is limited to receptivity to LARC and contraception counselling rather than what influences their decision-making process at this time. Research on views of healthcare professionals highlights a range of key systemic barriers to implementation.

CONCLUSIONS

While views of postnatal women and healthcare professionals are largely in support of immediate postnatal contraception provision, important challenges have been raised and present a need for national sharing of service commissioning and delivery models, resources and evaluation data. Provider attitudes and training needs across multidisciplinary groups also need to be assessed and addressed as collaborative working across a motivated, skilled and up-to-date network of healthcare professionals is viewed as key to successful service implementation.

Successful implementation of immediate postpartum intrauterine contraception services in Edinburgh and framework for wider dissemination

Provision of immediate postpartum intrauterine device (PPIUD) insertion within maternity settings can overcome many of the barriers faced by women in accessing this method after childbirth. Uptake of PPIUD can help reduce the risk of a subsequent unintended pregnancy and improve spacing between births. PPIUD insertion is not yet routinely available in the UK and evidence to support the practical implementation of the service in this setting is lacking. Shared learning and experience of providers may assist in the wider availability of PPIUD. A routine PPIUD service has been successfully established within a public maternity setting in Edinburgh (UK) and this article utilizes an implementation framework to discuss the approach.

Quality and Cost Interventions During the Extended Perinatal Period to Increase Family Planning Use in Kinshasa, DRC: Results From an Initial Study

The combined intervention of free contraceptives plus a set of quality inputs for family planning during the extended perinatal period, including provision of long-acting methods immediately postpartum, had the strongest effect on use of modern contraceptives, especially long-acting methods.

Background:

Most women worldwide do not desire another pregnancy within a year after giving birth, but uptake of modern contraception during this time period is low. We independently tested 2 approaches to increasing contraceptive uptake and the 2 approaches combined using a quasi-experimental study design in Kinshasa, the Democratic Republic of the Congo.

Methods:

The primary analytic data came from client exit interviews conducted post-intervention (N=563) from 4 study groups. The first arm (n=150) received free family planning, and the second arm (n=113) a quality inputs intervention involving systematic screening, referral, and immediate provision of long-acting reversible contraceptives (LARCs) after labor and delivery. The third arm (n=150) received a combination of the 2 interventions, and the fourth (n=150) no intervention. Family planning service statistics were also collected throughout the intervention period.

Results:

Women in the quality arm (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.8 to 10.9) and free/quality arm (OR=6.7; 95% CI, 2.8 to 16.1) were more likely to be properly screened for family planning than women in the control group, but paper referral was seldom implemented in any group. Women in the free arm (OR=3.8; 95% CI, 1.6 to 9.0) and in the free/quality arm (OR=11.0; 95% CI, 4.3 to 27.9) were more likely than the control group to report being properly counseled on family planning. Clients were more likely to be modern contraceptive users (excluding condoms) in the free arm (OR=3.2; 95% CI, 1.4 to 7.2) and in the free/quality arm (OR=8.6; 95% CI, 3.9 to 19.0) than in the control group. Clients in all study arms were more likely to use a LARC compared with the control group (Quality arm: OR=2.9; 95% CI, 1.1 to 7.9. Free arm: OR=5.6; 95% CI, 2.3 to 13.7. Free/quality arm: OR=8.4; 95% CI, 3.4 to 20.6). Service statistics from the combined intervention arm showed that a significantly greater proportion of family planning adoption occurred within the immediate postpartum period (0 to 2 days) in the quality arm (P<.001) and free/quality arm (P<.001) than in the control arm. Quality inputs, free contraceptives, and the combined intervention had positive impacts on aspects of screening and contraceptive uptake. The combined intervention performed best by all measures.

Conclusion:

Providing family planning, including LARCs, in the immediate postpartum period, implementing a systematic screening and referral system, and providing free methods may improve family planning access and uptake in the extended perinatal period in this environment.

Community sexual health providers' views on immediate postpartum provision of intrauterine contraception

BACKGROUND

Increasing access to effective postpartum contraceptive methods can reduce the risk of unintended pregnancy and short inter-birth intervals. The need for an additional postpartum visit can be a barrier to women accessing intrauterine contraception after childbirth. Immediate postpartum intrauterine contraception (PPIUC) provision is known to be safe, but is not routinely available in the UK. Establishing this service requires multidisciplinary support, including from community and maternity stakeholders. The aim of this study was to determine the views of community sexual health providers towards PPIUC implementation.

METHODS

A questionnaire was distributed to attendees at two UK sexual health conferences. Research questions focused on (1) views on PPIUC (2) perceived role of the sexual health provider in PPIUC service and (3) potential challenges anticipated in providing PPIUC aftercare. Free-text boxes were provided for further comment. Analysis was by a mixed methods approach.

RESULTS

A total of 240 questionnaires were distributed with 156 completed (response rate 65%). Some 128 respondents (82%) felt 'positive' towards the PPIUC implementation. Most respondents (67.9%) indicated they would be happy to promote PPIUC and provide thread checks. Perceived challenges in providing PPIUC aftercare included staff time, experience in managing clinical issues, and access to ultrasound.

CONCLUSIONS

Community sexual health providers were positive towards PPIUC implementation, and perceived their role predominantly in the aftercare of women. Several clinical and practical challenges were identified, some of which differ from those previously expressed by other groups. Stakeholder involvement is key to successful implementation of PPIUC, and wider recognition of potential barriers can assist in developing strategies to overcome these.