Michele Stranger Hunter was the Founder and National Program Director for One Key Question in the USA. Her work on reproductive and preconception health is respected internationally. OKQ has become ‘best practice’ and successfully implemented in more than thirty states. Scotland must create its own approach and solutions based upon our cultural, policy, and professional contexts. As a consultant to QNIS’ new Healthier Pregnancies, Better Lives programme, Michele will share lessons from decades of experience, as well as her insights, to help create a bespoke Scottish strategy.
Growing up in an American town where the norm was ‘another year, another baby’, questions about pregnancy were always in the air, even if not openly discussed. It was transformational to come of age as birth control made sexual activity without becoming pregnant a viable option. And yet, a large proportion of pregnancies continued to be unintended or mistimed.
My first job was as a counselor to pregnant teenagers. The primary reason I was hired was my proximity in age and the assumption the girls would be comfortable talking with me. Over six years, I listened and heard the stories of 600 pregnant teens.
From that experience, I jumped at the chance to work for the newly minted National Family Planning Program and to focus on pregnancy prevention. Using lessons learned from the ‘school-age mothers’, I developed a comprehensive health approach to adolescent pregnancy prevention, as well as outreach and education programs for anyone who could become pregnant.
I had the opportunity to accumulate a great deal of experience developing reproductive health service programs, approaches, policy, messaging, and protocols. I spent years working on pregnancy prevention education; service delivery models for increasing access in a country lacking an NHS, and supporting practitioners with training to deliver contraception services.
In 2010, while raising the alarm among primary care organizations that “Half of all pregnancies are unintended!”, I was startled to hear the echo of my voice saying the very same thing in 1970. With decades of increasing access to reproductive health services and massive amounts of contraception information available, how could this be?
It was truly humbling. Reproductive health experts focused on pregnancy prevention had not gotten it right. I chose to see opportunity and embark on a ‘journey of the blank paper’.
Through an extensive process using surveys, questionnaires, discussion sessions and focus groups, we listened – and then listened more – in order to fill our blank paper with answers from both women of childbearing potential and primary care practitioners.
At the end of that respectful, candid, iterative process, I created a model that improves individual satisfaction and changes clinical practice based on each woman’s desire, or lack of desire or ambivalence about becoming pregnant in the next year called One Key Question® (OKQ). Within the past decade, this model became nationally-known as best practice for asking about and then responding well to, pregnancy intentions across America.
In 2017, as I entered ‘retirement’, OKQ was adopted by Power to Decide, a national organization committed to reproductive well-being and providing women with the encouragement, information and services they need to decide if, when and under what circumstances to become pregnant.
On both sides of the Atlantic, most people neither plan nor prepare for pregnancy. It remains the case that about 50% of the time, it ‘just happens’. The general assumption is that early, high quality, antenatal care will ensure a healthy pregnancy and good birth outcomes. Unfortunately, that is too often wishful thinking.
Both evidence and common sense reveal that the health and well-being of a woman at the beginning of her pregnancy is the most accurate predictor of pregnancy and birth outcomes. Unintended pregnancies – and even intended, but poorly prepared for, pregnancies – are more likely to lead to terminations, miscarriages, stillbirths, and birth defects.
Promotion of health and prevention of harm can best occur, and sometimes can only happen, before conception. For instance, additional amounts of folic acid (vitamin B9) are required for months before pregnancy in order to prevent neural tube defects. That opportunity is lost when a pregnancy is unintentional or happens without conscious preparation.
I recently became a consultant to the Queens Nursing Institute Scotland. I was thrilled to be asked. Helping plan and develop Healthier Pregnancies, Better Lives feels like the capstone of my long career. My work has been devoted to women gaining a sense of agency in relation to their reproductive health and any potential pregnancy. That can now continue here.
One focus has been listening to women and supporting them to make their own well-informed choices about whether, when and under what circumstances to become a mother (or avoid becoming one). I have learned how effective and essential it is to listen to what the people most affected say about how they see their own situations and view their options. It is critical to hear and heed the voices of people who can become pregnant in order to provide the assistance they want and need to meet their reproductive life goals.
My efforts have also emphasized the importance of listening to and engaging in conversations with, primary care practitioners, midwives, other relevant clinicians and health educators. The diversity and extensive reach of Scotland’s community nurses make QNIS an ideal organization to address the long-standing personal, societal and professional ‘blind spots’ in relation to preconception health, education and care.
Scotland’s solutions, framework, approach, policy, strategies, and communications must be unique to Scotland. Because the success of preconception health, education and care depends on Scotland’s cultural, political, institutional and professional context, what makes sense and will work to Scotland’s benefit must be created within Scotland.
Considering the COVID-19 pandemic, there are many conversations underway about creating a better, healthier, ‘new normal’. QNIS’ Healthier Pregnancies, Better Lives initiative seeks to bring people together to create a new normal in Scotland in which old blind spots become visible; preparing well for pregnancy is the norm; and achieving the positive pregnancy and birth outcomes everyone desires becomes a reality.
As a consultant, my goal is to help QNIS, community nurses/midwives and other Scottish allies develop that process of listening and strategy for acting. I look forward to meeting, sharing with, and learning from many of you. I am feeling excited, and honored, to have this opportunity.
To share your thoughts with Michele, or for further information on the evidence undergirding this new QNIS programme, please contact Dr Jonathan Sher: firstname.lastname@example.org