The Lived Experience, Part 2
In the companion blog to this one (read here) Lorna Dhami QN and I described General Practice Nurses’ reactions to the possibility of routinely adding reproductive health information and conversation to their practices. These community clinicians realised prospective parents do not have basic information about how to prepare for a healthy pregnancy, or even why it’s such a good idea!
Primary care’s potential for pre-pregnancy counselling, assessments and services is a golden opportunity to prevent harm and promote health. It arose from their understanding that people of reproductive age are rarely getting the information and assistance they need from other health professionals. They understand that primary care providers are usually best placed within Scotland’s healthcare system to play this new role.
When I started similar work 12 years ago in the USA, the seemingly reasonable place to start would have been with family planning clinics. But we had already learned that dramatically expanded access to contraception did not decrease the proportion of ‘unintended’ pregnancies. The reality is that roughly half of all pregnancies in the USA, Scotland, the rest of the UK are still unplanned, mistimed or accidental. Moreover, even ‘intentional’ or ‘planned’ does not always mean well prepared.
The most obvious place to which people of reproductive age might go to receive pre-pregnancy health care is their GP practice or primary care provider. Community clinical care may seem obvious, but it is dramatically underused for pre-pregnancy health information, advice and assistance. There is a de facto ‘Don’t ask. Don’t tell’ tradition in which neither patients nor practitioners are likely to initiate a conversation about reproductive desires/goals. Therefore, these goals are left off the table – and preventable problems are not prevented.
Although patients may be attending primary care or GP appointments for other matters, there is no reason why these community clinicians cannot raise the topic and seek patients’ views about what they want and need to avoid, or prepare for, pregnancy. Since community nurses and their colleagues often have a longstanding relationship of trust with their patients, they are well-placed (sometimes uniquely so) to normalise ‘sensitive’ conversations.
It has always confounded me how an individual’s health can be assessed without the inclusion of their reproductive health. I admit I have never understood why women in the States had to go to two different providers for basic healthcare. As a patient, I could not fully trust my primary care treatment plan, if I had to leave my reproductive health (and organs!) at the door.
Primary care is not only the most logical place for this to happen, but also where patients and clients across the States want it to happen! I listened to hundreds of women who wanted to have this conversation with their trusted primary care provider.
The same is proving true in Scotland. GP nurses affirmed the value of having this conversation but wondered how patients would react to them asking directly about pregnancy desires and reproductive health needs. Would the conversation be too personal or be seen as too intrusive?
What we heard during these three Greater Glasgow & Clyde Sessions left us very excited and optimistic that change can happen. The core lesson learned is that patients want to have this conversation within their GP practice and GP nurses want to have this conversation with their patients.
Patients in General Practice: What are their views?
To get answers from the source, we asked reproductive aged women who were General Practice patients. It was fascinating! We wish you could have heard them talk about pre-pregnancy issues.
It was so helpful to be able to check practitioners’ assumptions with the people directly affected. We asked them to see themselves as the experts of their own lives. What was their lived experience, in terms of needing and receiving reproductive health and pre-pregnancy information, advice and care?
I have facilitated many Listening Sessions with clients and patients around reproductive health. These young women from the Glasgow area were crystal clear about what they needed and how they needed it to be delivered.
“We receive too little sexual health information. We have to rely on friends or some random internet source that we don’t even know for sure is factual.”
“People ask us all the time if we are pregnant, why would we be upset when we are asked by someone who cares about the answer”?
“We know assumptions are being made. Please don’t assume I ever want to have a child or that I’m looking forward to being pregnant! Ask me!
Importantly, we discussed our concerns around discussing personalised preconception health risks, such as smoking, drinking, or weight management. Our intention was to not communicate shame, blame, or fault by words, tone or body language. In return, patients offered sound advice.
Patients want personalised risk information from a General Practice Nurse or GP that is factual, not judgmental or biased.
Patients want accurate information, personalised during a GP visit, based on their individual desire to avoid, delay or become pregnant. They want to be supported regardless of their choices. They would like to be offered appropriate reading material, brochures, written guidance, or signposting to trusted information sources and internet links, as well as referrals to other professionals, as needed.
These patients were unanimous in their desire to hear risks to pregnancy and birth outcomes associated with smoking, drinking, weight or other concerns. All of them wanted to know about their specific risks, as long as this is delivered in a strictly fact-based manner – without any judgment or bias. “Tell it straight up. Be polite but it’s got to be factual.”
Regarding which words to use that would not communicate shame or blame, these women advised:
“There are no magic words to prevent shame or blame when discussing weight, smoking, drinking and recreational drug use”.
“Shame is communicated by their tone, not just words. Words can be neutral.”
“Words can be benign, but the way words are said is clear this is judgement, disapproval, assumptions and bias!”
“Non-verbal cues can also feel negative even if the words are neutral. What does their face say?”
This group also asked for pertinent information from General Practice before looking for additional preconception care information from other sources. They did not want to try to discern what was factual (or a good source for accurate information) by looking to the internet or social media without practitioner guidance.
Patients with lived experience were specific about the reproductive health and pre-pregnancy information they need; who they wish to provide it; and, how they would like it to be delivered.
We repeat: Patients want to have this conversation with their most trusted health professionals, i.e., their GP practices or primary care practitioners. The participating community clinicians agree and want to play that new role, as soon as they have the training, guidance and support to provide this dimension of quality care effectively within their overall practice.
Based upon my experience working with hundreds of primary care practitioners in a wide range of practices across the USA, I can assure you that practitioners find it does not “take too much time”. They do not feel it derails the purpose of the visit and that it is feasible in a busy practice. They found patients welcomed it and that it positively altered the treatment plan about 20% of the time. Because of these new conversations, preconception and interconception care increases. In fact, is so valuable that professional have adopted it as part of the primary care protocol. These are the American equivalents of the NMC and Royal Colleges.
Scotland and America have different cultures, health systems, training and policies. I am not suggesting Scotland simply accept and adopt examples from the other side of the Atlantic.
Nonetheless, there are great similarities and common ground upon which to build. In both nations, people of reproductive age need and want to feel (and be) empowered and informed to make the best possible decisions about their health and futures. That includes decisions about whether, when, and how best, to ensure positive pregnancy and birth outcomes.
Community nurses and primary care providers in Scotland and the USA want to help the people coming to them achieve those reproductive goals as effectively, compassionately and fully as possible. Creating a bespoke Scottish pathway to Healthier Pregnancies, Better Lives is why HPBL exists.
What do you think? Willing to share your reactions? We’d love to hear from you! You can always reach us at HPBL@qnis.org.uk or @HPBL_Scot.
This is the fifth blog in a series of five currently, you can read the other blogs here:
- The Best Answers Come From Asking the Right Questions (qnis.org.uk)
- Nothing About Us Without Us (qnis.org.uk)
- They Spoke, We Listened (qnis.org.uk)
- General Practice and Reproductive Health: (qnis.org.uk)Part 1 – Greater Glasgow & Clyde
- General Practice and Reproductive Health: (qnis.org.uk) Part 2 – Greater Glasgow & Clyde (you’re already here)
Click here to see Lorna’s article in the NES GPN Connect Journal