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

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.

Perceived barriers and opportunities of providing quality family planning services among Palestinian midwives, physicians and nurses in the West Bank: a qualitative study

BACKGROUND

Despite advancements in family planning (FP) services, several barriers persist in the Occupied Palestinian territory (oPt), blocking women's access to suitable, high-quality and equitable FP services. The aim of this study was to understand how healthcare providers perceive their abilities, barriers and opportunities in providing good quality FP services. Furthermore, it seeks to explore knowledge and training regarding FP among healthcare providers engaged in providing FP services.

METHODS

A qualitative study was undertaken from August to September 2022 in seven Primary Health Care (PHC) clinics distributed in three governorates and operating under the Palestinian Ministry of Health (MoH) in the West Bank. Semi-structured, in-depth face-to-face interviews were conducted with 13 health providers (Physicians, midwives and nurses), using an interview guide in Arabic language. Transcripts were subsequently analyzed using the six phases of reflexive thematic analysis.

RESULTS

FP services face various challenges, including shortages in resources such as staff, supplies, infrastructures and FP methods. Midwives possess significant potentials to offer accessible, high-quality, efficient and equitable FP services, yet, their capacities remain underutilized, representing a missed opportunity for a country like Palestine. The study provided a current overview of FP services while illustrating the need for quality FP services and the need for an updated continuous education and training, updated standardized guidelines and protocols and supportive supervision are needed across all levels of healthcare providers. Finally, providers reported a wide range of structural barriers to FP services.

CONCLUSIONS

It is crucial to meticulously address both community-related and health system factors to enhance the fulfillment of FP needs and reduce unintended and closely spaced pregnancies. Policymakers should invest in the development of laws and regulations regarding FP services, promoting a comprehensive and holistic approach to FP services. This includes formulating supportive policies, capacity building of human resources and maintaining security of FP commodities.

Prescriptive Authority for Direct Entry Midwives in Washington State: Increasing Client Access to Contraception

Improving health and achieving health equity includes access to sexual and reproductive health care for all populations, especially those most in need. However, access to life-saving and life-affirming contraception with an individual's chosen perinatal provider can be impeded by restrictive regulations that limit scope and practice authority. This is especially true for the majority of community and direct entry midwives in the United States who have historically been unable to legally provide effective contraceptive methods. Recently, licensed midwives in Washington state were the first in the nation to achieve prescriptive authority, enabling their clients to directly obtain contraception and access to medications for common prenatal and postpartum conditions. Sustained advocacy efforts in the state's capitol enabled the Midwives' Association of Washington State to build relationships over time with legislators and government agencies to achieve this long-term goal. We present a successful midwifery-led innovation that achieved scope expansion for licensed midwives whose practice authority was limited by restrictive laws. Lessons learned are described and strategies offered to aid midwives and their advocates in other locales who want to improve health equity and access to contraception. Midwives are well positioned to provide this essential care to individuals living in underserved rural and urban areas and those from historically marginalized communities, but their ability to do so is limited by restrictive legislation.

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.

Early removal of the etonogestrel contraceptive implant in Spanish women: a prospective cohort study

Purpose

To know the discontinuation rate and characterize predictors and reasons of contraceptive implant removal within 12 months of insertion in our community setting.

Methods

This prospective cohort study included women receiving the etonogestrel contraceptive implant at sexual and reproductive health centers between September 2019 and September 2020. The variables collected were implanted insertion timing, reproductive and demographic characteristics, medical conditions, sexual activity and counseling. Our primary outcome was implant discontinuation. Kaplan-Meier survival curves were used to show the cumulative discontinuation rate of implants contraceptive within the first year of insertion. We also identified factors that increased the risk of implant removal using the log-rank test and the Cox regression model. Reasons for discontinuation were documented.

Results

199 women were followed up. Implant discontinuation was documented in 17.1% of implant users prior to 12 months. Factors that increase the risk of implant removal are living with a partner, being aged 25-34 years and not receiving comprehensive and structured counseling from the midwife. The main reason for removal was unsatisfactory bleeding (97.1%), but this was combined with other reasons such as cessation of sexual intercourse (58.8%), worsening mood (58.8%), weight gain (55.9%) or decreased libido (50.0%).

Conclusion

The rate of discontinuous implant uses in the first year is relevant in relation to cost-effectiveness, there is room for improvement that should not be overlooked. Comprehensive and structured midwife-led counseling can reduce early implant abandonment removal. The development in different countries of the role of midwives in the management of contraceptives can contribute to the economic benefit of health services and the satisfaction of women.

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.

Introduction of the London Measure of Unplanned Pregnancy at the booking visit and the midwives' perspective

BACKGROUND

Pregnancy planning and preconception care benefit women, their children, and future generations. The London Measure of Unplanned Pregnancy (LMUP) is a tool that can be used in antenatal care to identify women with unintended pregnancies who require improved access to such services. This tool was recently implemented into routine antenatal care in two maternity centres in New South Wales, Australia. This study explores midwives' attitudes to the LMUP 12 months after it was introduced into the booking visit and their understanding of its application to their scope of practice.

METHODS

This is a qualitative study using in-depth semi-structured interviews with midwives from two maternity care centres in Australia. All midwives performing antenatal booking visits were eligible to take part. Interviews were transcribed, analysed, and coded to define key themes. Recruitment ceased when thematic saturation was reached.

RESULTS

Ten midwives from two maternity centres were interviewed. Midwives support the inclusion of the LMUP into the booking visit and felt it was in their scope of practice to be using the tool. Time constraints, the impact of COVID-19 and the lack of structured referral pathways were identified as barriers to the implementation of the LMUP in routine care.

CONCLUSIONS

Midwives support the inclusion of the LMUP into the antenatal booking visit and see that it falls within their scope of practice. Service barriers were identified at the individual, organisational and external context levels. These need to be addressed to enhance the potential of this tool.

Understanding women's views of and preferences for accessing postpartum contraception: a qualitative evidence synthesis

BACKGROUND

Nearly half of women experience unintended pregnancies. These are associated with increased risk of poor maternal physical and psychosocial health outcomes. Many pregnancies in the first year postpartum are unintended, further increasing risks of poor outcomes and complications. We undertook a qualitative evidence synthesis to evaluate qualitative research on women's views and preferences for accessing postpartum contraception, and identify evidence gaps and opportunities for postpartum contraception provision.

METHODS

Five databases were searched to identify relevant qualitative studies. Included studies focused on views of, and preferences for, accessing postpartum contraception for women of reproductive age in high-income countries.

RESULTS

Of 1854 studies identified, 28 full texts were assessed and 19 studies included. These were critically appraised using Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) and analysed using thematic synthesis. Included studies indicated the majority of women desire postpartum contraception, but face a range of financial, health system and personal barriers. Women felt unclear about the ideal interpregnancy interval (IPI) and the rationale for this. Women preferred contraceptive counselling at varying times both antenatally and postnatally, and commonly preferred to receive contraception in the immediate postpartum period before hospital discharge. Women commonly saw their obstetrician or general practitioner for contraceptive counselling, but welcomed midwifery involvement.

CONCLUSIONS

Most women were interested in postpartum contraception and pregnancy spacing, but felt unclear about the optimal IPI, highlighting the need for further education and support around this issue. Contraceptive counselling was viewed as valuable antenatally and postnatally, and by varying maternal health providers, as was the provision of immediate postpartum contraception.

Profiles of copper intrauterine devices and levonorgestrel intrauterine systems users in France in 2019: A national observational population-based study

OBJECTIVE

To assess the user profiles of copper intrauterine devices (Cu-IUD) and levonorgestrel intrauterine systems (LNG-IUS) in France in 2019 and the rates of continuation 1 year later.

METHODS

A population-based study was conducted of all French women aged 13-49 years for whom an IUD was dispensed in 2019. Information was collected from the French National Health Data System about their characteristics at the time of dispensation and indicators of continued use 1 year later. Associations between these characteristics and the type of IUD were analyzed using multivariate regressions.

RESULTS

A total of 477 705 Cu-IUDs and 355 242 LNG-IUSs (mean age 32.5 ± 7.3 and 36.4 ± 7.7 years, respectively) were dispensed in 2019. After adjustment, having a LNG-IUS rather than a Cu-IUD was associated with being aged 35-44 years compared to 25-35 years (odds ratio [OR_35-44 ] 2.03, 95% confidence interval [CI] 2.01-2.05), having a prescription by a gynecologist rather than a general practitioner (OR_35-44 1.09, 95% CI 1.08-1.11), and having a gynecological history (OR_35-44 2.28, 95% CI 2.20-2.36). The continuation rates 1 year after dispensation were 86.4% for Cu-IUD versus 85.7% for LNG-IUS. A Cu-IUD dispensation rather than a LNG-IUS one was associated with a higher chance of continued use 1 year later.

CONCLUSION

Two different patterns of use of Cu-IUDs and LNG-IUSs in France are highlighted.

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.

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.