General Practice and Reproductive Health:

 The Lived Experience, Part 1

Listening Sessions are a key part of QNIS’ Healthier Pregnancies, Better Lives programme. Lorna Dhami QN and I have been ‘testing the water’ on how prospective parents feel about their reproductive health care, and how General Practice Nurses feel about providing information, services and support in this area. Our focus was specifically on preconception and interconception health care. This included screening to identify risks and either eliminate or mitigate those risks prior to conception.

I had a wonderful advantage working with Lorna, one of Scotland’s extraordinary Queen’s Nurses: https://www.qnis.org.uk/queens-nurses/contemporary-queens-nurses/. She is a force of nature, who orchestrated three Listening Sessions; two with practitioners and one with patients. Her context, her lived experience, and her perspective fit the definition of a patients’ champion.

We are excited to share what we heard from her colleagues in Glasgow. But first, Lorna’s story:

As a practice nurse, I know there are actions we could take to improve pregnancy and birth outcomes.

Every colleague I have spoken to has been genuinely keen to consider taking on the role of preconception care prior to a first pregnancy, as well as interconception health care between pregnancies. This is unlikely to happen automatically, especially given the normal demands of the role plus the extra pressures from the pandemic. We need CPD and support to effectively add pre-pregnancy work to our practices.

A year ago, as a Queen’s Nurse; the NES GPN Education Advisor for NHS GG&C; and a representative for the NE Glasgow Practice Nurse Forum, I was invited to be involved with a fascinating new QNIS initiative, the Healthier Pregnancies, Better Lives programme, and I remain a member of the Steering Group. I started with curiosity about what preconception and interconception counselling and care actually meant. My training and initial experience was as a midwife for 11 years. However, the last 27 years have been spent as a practice nurse in a busy Deep End, single-handed, primary care practice in the East End of Glasgow.

By the end of the first HPBL Steering Group meeting, perhaps because of my midwifery background, I was struck to realise how very little attention I pay to patients’ reproductive health. In part, this is due to fewer regular smear test visits since HPV testing was introduced. It made me realise how frequently ‘health during the time before pregnancy’ falls through the cracks between General Practice and Sexual & Reproductive Health (which primarily focuses on pregnancy prevention or termination).

I must admit, I knew better. I knew the importance of reproductive health to overall health. But this is not routinely part of a GP Nurse’s role. Of course, a woman’s health at the time of conception is the single greatest predictor of the success of that pregnancy and positive birth outcomes. Obviously, some other health practitioners should already be taking advantage of this golden opportunity for primary prevention and health promotion. They are . . . aren’t they? Too often, the answer is no.

Our role is to support the patient in minimizing risk and improving wellbeing. The time between avoiding pregnancy and being pregnant seems to have become a lost opportunity. What possible harm could we cause by asking what patients want in relation to pregnancy; and then offering appropriate information and person-centred advice? Whether or not pregnancy was desired or likely, wouldn’t everyone benefit by reducing, if not eliminating, such health risk behaviours as smoking, drinking, recreational drug use, obesity and lack of physical activity?

Sitting there in that first HPBL Steering Group meeting, I had to ask – what about considering General Practice taking on pre-pregnancy care? Before I knew it, I had raised my hand volunteering to recruit peers and patients for virtual Listening Sessions to discuss ‘preconception health and care’.

Practice Nurses’ Voices

We facilitated two different sessions with practice nurses. We asked key questions, listened well, and learned a great deal from the lived experience of these front-line clinicians.

The community nurses realised there is a considerable gap in services for reproductive age women (and men). They reported that only very occasionally do they actually have contraception or pre-pregnancy conversations. Practitioners also pointed out they are supposed to talk with men having diabetes about erectile dysfunction and yet rarely discuss reproductive health consequences for reproductive age women with diabetes. Why is that?

As one participant noted: “We really seem to have ignored the connections between chronic disease management and pregnancy. Practice nurses were not taught about reproductive health beyond contraception. There has been no guidance to talk with women about preconception risks.”

Some expressed concern that the conversation might be too private or intrusive. They discussed the need to be sensitive to how patients react to questions or information. And yet the reality is, when they do not at least attempt to initiate such conversations, these adults are on their own. People not under specialist care for major long-term conditions (such as epilepsy) usually have no place to go if seeking preconception information, assessments and counselling other than primary care or general practice. These HPBL Listening Session participants concluded amongst themselves that primary care or general practice should be the place where pre-pregnancy topics are routinely discussed and acted upon either directly or by meaningful signposting.

Practitioners made clear they are not up to date on the most effective contraception choices. They also expressed the need for detailed CPD and guidance on what exactly is meant by preconception and interconception care.  What are the screening and risk assessments to be done? What do they need to know to competently and confidently share advice and offer bespoke assistance regarding medications, weight, or risk behaviours that impact pregnancy and birth outcomes?

To implement this change in practice, they wanted these questions addressed in standardised practice protocols, developed for both preconception and interconception care. They asked for guidance that will help them ensure reproductive age patients receive pre-pregnancy services equitably and efficiently.

Time is always a major constraint and we heard that a prompted template in the electronic health record would be extremely helpful. Assuming it would be approved by their practice physicians (with a nod from their Health Boards) these community clinicians felt practice change is both doable and desirable.

The bottom-line is that practitioners were very open to a potential change in practice, provided they have sufficient training and time. Time is also dictated by what services are covered in their remit. These HPBL Listening Sessions ended with an expressed interest in continuing the conversation and making these changes happen.

Listening Sessions are one method to assess what people know and think about preconception health. Surveys are another, and the results of the QNIS/HPBL survey on preconception health and care reinforced the learnings of the Listening Sessions (read our blogs here].

But what do reproductive age patients want?

Next, we convened a group of reproductive aged women whose primary care provider was a general practice. Part 2 of this joint blog focuses on their lived experience and the advice flowing from it.

Please share your reactions with us via @HPBL@qnis.org.uk or @HPBL_Scot.

This is the fourth blog in a series of five, you can read the other blogs here:

1. The Best Answers Come From Asking the Right Questions (qnis.org.uk)
2. Nothing About Us Without Us (qnis.org.uk)
3. They Spoke, We Listened (qnis.org.uk)
4. General Practice and Reproductive Health: (qnis.org.uk) Part 1 – Greater Glasgow & Clyde (you’re already here)
5. General Practice and Reproductive Health: (qnis.org.uk) Part 2 – Greater Glasgow & Clyde

Click here to see Lorna’s article in the NES GPN Connect Journal