Assessment of contraceptive services in a maternity unit of a district general hospital in the UK

A survey was undertaken to assess the quality of contraceptive services provided to women delivering in a District General Hospital. Separate questionnaires were given to the women and the midwives giving the contraceptive advice. Response rate of the survey was 87%. Thirty eight per cent of women reported having some discussion on contraception during antenatal period. All the women had received contraceptive advises during the postpartum period. Eighty one per cent of women felt that sufficient information and enough time was given to discuss contraception. However analysis of questionnaires indicated that most received information only on short-term contraceptive methods. Out of 64 midwives surveyed, 52 had attended a family planning course. However 37 of them had attended the course at least 3 years earlier. Thirty eight midwives felt that they have adequate knowledge to give advice but all of them reported that they should receive further training. There should be provision for comprehensive discussion regarding contraceptive options during both antenatal and postpartum periods. Midwives require regular training in family planning.

Expulsions following 1000 GyneFix insertions

CONTEXT

The GyneFix intra-uterine device has been used in our family planning service since 1997. One of the perceived advantages is its low expulsion rate, as reported by clinical trials.

OBJECTIVE

To calculate expulsion rates in routine clinical use and to look at possible reasons for expulsion.

DESIGN

Retrospective casenote analysis and opportunistic client consultation.

SETTING

A city centre family planning clinic.

PARTICIPANTS

The first 1000 GyneFix insertions.

MAIN OUTCOME MEASURES

Parity of client, experience of clinician carrying out insertion, time from device insertion to expulsion.

RESULTS

Overall expulsion rate was 7.6%. There was no significant difference in parity of clients experiencing expulsion. Most (4.7%) expulsions were early, occurring within 3 months of insertion. There was considerable variation in early expulsion rate from one clinician to another. Later expulsions also occurred, up to 28 months after insertion. Increasing experience of the inserting clinician led to lower rates of late expulsion. Unnoticed expulsion led to four unplanned pregnancies.

CONCLUSIONS

The GyneFix expulsion rate in our service is higher than quoted in clinical trials. Early expulsions may be related to insertion technique, representing insufficient implantation of the anchoring knot into the fundal myometrium. Late expulsions also occur, often many months after insertion; the reason for these is unclear. Users should be taught to check for the presence of the thread after each menstrual period and unnoticed expulsion should be confirmed by ultrasound and abdomino-pelvic plain X-ray.

Introduction of the GyneFix intra-uterine device into the UK: client satisfaction survey and casenotes review

OBJECTIVE

To assess the first year's use with the GyneFix intra-uterine device. This has been used in Liverpool since early 1997. It is offered mainly to nulliparous women wishing to use an effective non-hormonal method and parous women who have had pain with, or expulsion of, a framed device previously. It is also used as emergency contraception.

DESIGN

Retrospective study, by means of casenote review and client questionnaire.

PARTICIPANTS

All GyneFix users from February 1997 to January 1998; 215 women in total.

MAIN OUTCOME MEASURES

Data were extracted from casenotes to determine reasons for choice of GyneFix, parity, whether the insertion was planned or as an emergency measure, problems reported at follow-up and reasons for removal. Users were asked by questionnaire to comment on insertion procedure, menstrual or other changes since insertion and to state their overall satisfaction.

RESULTS

Over half of the users (57%) were nulliparous and a quarter of insertions were for emergency contraceptive use. A third reported that insertion was 'very painful'. Half reported that their periods had become heavier since insertion, but only 8% said that they were now unmanageable. Unacceptable bleeding was the most common reason for removal. Some reported intermenstrual bleeding and dysmenorrhoea. Satisfaction with the GyneFix was high; 86% of questionnaire responders said that they would recommend it to a friend.

CONCLUSION

The GyneFix is well accepted in Liverpool inappropriately selected clients, and is an effective non-hormonal method for nulliparous as well as parous women.

Provision of emergency contraception by nurses: a way forward to increased access

OBJECTIVES

The objectives of the study were to assess the suitability of a service for provision of emergency hormonal contraception by nurses.

METHODS

Retrospective analysis was carried out of data obtained from the case records of 500 consecutive women who attended ABACUS (a city center-based family planning clinic in Liverpool, UK) for emergency contraception during the 7th and 9th months of the first year (1994) of the service. Similar data were collected for 100 consecutive women during 1 month of the third year (June 1996). The number of women who received emergency hormonal contraception was noted. In particular, details pertaining to the reasons for referral to the doctor and the trend of referrals were noted.

RESULTS

The results indicate that during the first year the nurses independently issued emergency hormonal contraception to 37% of the women. They referred the remaining 63% to the medical staff. One-third of referrals were for ongoing contraception, especially oral contraception. Another third of referrals appeared to be due to 'nurse anxiety', as no medical or other cause was found for these referrals. During the third year, nurses dispensed emergency hormonal contraception to 64% of women. Among the remaining 36% of women who were referred to the doctor, 19% needed hormonal contraception. Referral reflecting 'nurse anxiety' significantly declined (1%) compared to the first year of service.

CONCLUSIONS

Ongoing contraception, particularly initiation of oral contraception, was one of the main reasons for referral during the first year. Referral due to 'nurse anxiety' significantly declined with continued experience and may have reflected initial anxiety and the learning curve. With increased experience over the first 2 years, the outcome of this service showed encouraging improvement. The nurses now dispense emergency hormonal contraception to a majority of women.

Impact of patient counseling on acceptance of the levonorgestrel implant contraceptive in the United Kingdom

Patient counseling is an important aspect of family planning. Patient choice, compliance, and satisfaction with a contraceptive method depend heavily on the counseling experience. This is especially true in the United Kingdom where contraceptives are provided to patients at no direct cost to them. Women are therefore more likely to choose a contraceptive option based on perceived desirability as opposed to cost. We surveyed physicians from six family planning centers in the United Kingdom who have extensive experience with levonorgestrel contraceptive implants with respect to counseling issues and patient acceptability of levonorgestrel implants. The physicians reported on their experience with 521 women. They acknowledged the need for and importance of counseling, and these centers provided preinsertion counseling 100% of the time. Primary responsibility for counseling was handled by the physician who spent, on average, 19 minutes per patient discussing the advantages and risks of levonorgestrel implants. Physicians felt that the majority of women (82%) accepting levonorgestrel implants had a positive experience. The incidence of bleeding irregularities was consistent with that reported in clinical trials, and this did not substantially affect the postinsertion acceptability of the product. Effective counseling is no doubt responsible for the high level of patient acceptance of these side effects. In a review of the literature, we found counseling to be a significant factor in a woman's tolerance of contraceptive-induced bleeding irregularities, which are frequently experienced with levonorgestrel implants. The results of our survey support the literature findings.