Preconception education, counselling and care – prior to a first or subsequent pregnancy – are the missing links in supporting healthier women, healthier pregnancies and improved birth outcomes.
In my first blog for this series, I talked about increased access to affordable, effective contraception and how this was not the ‘magic bullet’ I thought it would be in significantly reducing a high level of unintended pregnancies. This realisation forced me to rethink the situation from scratch.
My reassessment led me, first and foremost, to ask people of reproductive age for their insights and advice. That included both people with the capacity to become pregnant and the practitioners who offer services to support them. Through a robust process of surveys, interviews, and listening sessions, One Key Question® (OKQ) evolved.
Both potential parents and their health professionals welcome a simple, straightforward ‘pregnancy desire’ screening question. This is especially true when integrated into existing services and – depending upon their answers – followed by contraception advice and assistance and/or preconception education, counselling and care.
“No one ever asked me that before.”
“Thank you for asking!”
“I’m kinda conflicted. I didn’t think I could talk about this here.”
These are just some of the oft-repeated comments from patients after attending a general practice health visit that included the use of the OKQ framework.
Before the current version was published, the OKQ tool was piloted, evaluated, retested, and refined. Over the past five years, it has been adopted as best practice and implemented in 30 American states. For me, this was the evidence that solving the problem of unintended pregnancy was best tackled by asking potential parents what they think the “problem” actually is. I then asked, what would address this in meaningful and effective ways for them?
When I was invited to become a consultant to QNIS’ Healthier Pregnancies and Better Lives programme, it was because of the process I had used to create OKQ, rather than any interest in transplanting this American initiative to Scotland ‘as is. My role is to help HPBL develop a bespoke Scottish tool and pathway that reflects the goals and preferences of patients, their GP staff members and their sexual reproductive practitioners. All have lived experiences that must be taken into account to effectively guide the Healthier Pregnancies, Better Lives programme.
So, we planned a series of Listening Sessions during Year 1 of HPBL, and it was obvious what to do next. We listened!
Listening Sessions – The Process
Hearing directly from those with first-hand experience of receiving or providing reproductive health services is an essential part of developing effective solutions. I have successfully used this Listening Session approach for the last 12 years, and it has proven to be the guiding light toward effective system change. Here in Scotland, the Listening Sessions have been similarly enlightening. Even at this early stage, we are confident in HPBL’s process.
Conducting these sessions is HPBL’s primary strategy for unravelling the complex barriers to effective pre/interconception health, education, counselling and care.
The narratives shared during Listening Sessions sometimes affirm and sometimes dispute the favoured assumptions and current policies and practices. While challenges to the accepted systems are not uncommon, we have found that both the patients and the practitioners offering them direct services, hold critical information and recognise the need for improvement.
Community nurses and midwives are overwhelmingly women, many of them also have their own lived experience as reproductive health patients. Their own lives as women influence their own attitudes, conversations and actions with the people of reproductive age in their practices. Yet, these crucial factors are often overlooked, left unexamined or can introduce an element of unintentional bias.
Those who are served, and those who serve, are too often voiceless and marginalised. Neither of these groups are the policymakers who design and control the systems affecting them. Listening to them, we are being led by what we hear, not by what we want to hear and, above all, not by what is generally assumed to be true. Listening Sessions are one hallmark of HPBL’s work.
Our ethos embraces the maxim: “Nothing about us without us”. The expression applies equally to those receiving health services and those providing them. Both perspectives and sets of personal understanding matter when it comes to promoting Healthier Pregnancies, Better Lives.
During this initial year of planning and development, HPBL looked to one of QNIS’ greatest resources; its network of 110 remarkable community nurses and midwives who have earned the title of Queen’s Nurse (QN). QNs from four different areas volunteered to recruit participants and co-facilitate one Listening Session with patients and one with direct service practitioners in their areas.
Even amid the COVID-19 pandemic, whilst patients and practitioners alike struggled with staff shortages and sickness, we held eight Listening Sessions in four different specialty areas in four locations. A diligent, highly skilled QN and I co-facilitated each one. We used questions developed and tested over the years to unearth their stories of each reproductive health care encounter.
We held the following HPBL Listening Sessions:
- One with Family Nurses and two with young, single, first-time mothers in NHS Forth Valley’s Family Nurse Practitioner programme.
- Two with General Practice Nurses and one with reproductive-age women patients in NHS Greater Glasgow & Clyde; specifically, within the Deep End service network of Easterhouse Clinic.
- One with practitioners from Chalmers Sexual Health Centre – NHS Lothian’s sexual/reproductive health care clinic.
- One at Edinburgh Access Project’s weekly general practice clinic for homeless women.
The core principle is to ask those people who can become pregnant and the people who provide direct services to them – sensitively, compassionately and non-judgmentally – about this aspect of their lived experience.
What happens when we ask what they know, feel and want?
We learned that patients perceive those services considered women’s health services as fragmented silos. Practitioners told us they experience little or no control over the design of the systems supporting their clients, nor the requirements, policies, regulations, measurement criteria, or time constraints.
The Groups Have Much in Common
Patients welcomed the unfamiliar opportunity to be considered, and treated, as the experts about their own lives! In response, they were clear, candid and comfortable sharing their opinions and stories. They had never heard that much could, and should, be done prior to conception to support the safest pregnancy and healthiest baby possible. And they want to know!
Consistently, they expressed frustration with the often-disconnected healthcare silos that kept them from getting what would have been welcome reproductive health information, advice and assistance. Helping them prepare for pregnancy didn’t seem to be anybody’s business. No one reported having received preconception education, counselling or care.
They want to have a pregnancy-related conversation initiated by their most trusted health care practitioner. They want to be offered personalised reproductive health information and services tailored to their specific health conditions/risks – whether they want to avoid, delay, or become pregnant.
FNP clients discussed the difference between their less satisfying interactions with antenatal services versus their positive post-partum care from Family Nurses with whom they had developed a good, two-way relationship.
Similarly, very few practitioners knew what was meant by pre/interconception care. Most assess contraception use and offer pregnancy prevention services. The practitioners’ lack of exposure to the distinct elements of pre/interconception health assessments and treatments was nearly as great as their clients.
Both patients and practitioners want more preconception and interconception health information, counselling and care to be available.
Practitioners agreed that patients should have access to better information and assistance to prepare for pregnancy and to prevent or mitigate risks. Presently, these community nurses do not feel adequately equipped or well-supported to provide such help themselves. There was an assumption amongst those at the sessions that other providers were already doing this work.
Patients and practitioners alike require more support to explore these issues. Neither group has a clear and accurate understanding of preconception or interconception education and care. This means that discussions around preparing for a healthy pregnancy are missing some vitally important information. Some nurses expressed concern about the potential disruption of otherwise routine visits or suggested that introducing this work could overburden their already stretched workloads.
Despite these reservations, these community nurses all expressed an interest in providing meaningful, person-centred preconception screening, counselling and care. Practitioners and their patients all agreed; let’s add preconception and interconception care for reproductive-age people!
Of course, if it were that simple, then it would have already happened. We heard from everyone in the HPBL Listening Sessions about the barriers to introducing this type of care and the importance of not creating another silo when doing it.
We need to deepen our understanding of the individual, institutional, systemic and cultural barriers that mean access to information about adequate preparation for pregnancy is still lacking.
We also need to identify the strengths and opportunities that do exist. These can eventually change the reality that comprehensive Scottish health provision between contraception and conception is needed, but still missing.
By listening, we learned that preparing well for pregnancy is a shared goal among both people of reproductive age and community nurses.
Look for our next blog in the series: They Spoke, We Listened, Now What? Where we will share what was learned during the Listening Sessions and the implications those lessons have as we move together toward Healthier Pregnancies, Better Lives.
We are still Listening!
This is the second 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 (you’re already here)
- 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