I came of age just as birth control made it possible to be sexually active without becoming pregnant. Quite by serendipity, this was when I was hired to coordinate an alternative education program for pregnant teens. Six years, and six hundred pregnant teens later, my feelings, experiences and values coalesced into a lifelong commitment to supporting people’s choice to avoid, delay, or become pregnant. My view for many years was that the most important work I could do was to help women prevent unintended pregnancy. For decades, I focused my efforts on increased access to contraception and termination.
Women should not die from childbirth when it is preventable, but too many do. Babies should not be born with major birth defects and lifelong disabilities that were preventable, but too many are. Almost all women start antenatal care during their first trimester; so, isn’t that soon enough?
The problem is unintended pregnancy…or maybe it isn’t!
With few exceptions, our collective approach to preventing unintended pregnancy has been to encourage consistent use of contraceptives by anyone sexually active. Decades were focused on increasing access to effective contraception services. However, what has not changed is the fact that approximately half of all pregnancies carried to term are still unintended. After 50 years of increasing access to effective contraception, the proportion of unintended pregnancies has not dramatically decreased!
The proportion of low birth weight and premature babies is significantly higher among identified unintended pregnancies. Yet, the proportion of miscarriages, stillbirths, terminations, birth defects and developmental delays is high even when the pregnancy was intended. How can this be?
Intending (trying) to become pregnant is not the same thing as preparing to become pregnant. Birth outcomes would improve if those thinking they might like to become pregnant understand what preparation should entail and take the specific steps that maximise the chances of a safe, healthy pregnancy. Intention is not action. Yet, the concept of intention remains the cornerstone of policy.
Planning a pregnancy is not the same thing as preparing to become pregnant. Planning usually amounts to deciding you are ready; financially stable; and, primed to eat nutritiously. Unfortunately, even most of those who plan for pregnancy do not: seek a preconception physical examination; take enough folic acid early and consistently enough to prevent neural tube defects; or understand the nature and seriousness of their specific, individual risks.
It is not generally realised by those who can become pregnant that their health and wellbeing at the time of conception is the best predictor of pregnancy and birth outcomes. There is even less emphasis on the roles (positive or negative) of prospective fathers in sexual and reproductive health; let alone, how men’s health and genetic material contribute to these outcomes.
Practitioners also tend to see the people of reproductive age in their practice as either: A) not pregnant; or, B) pregnant. Those in category A need contraception when sexually active, but not keen to conceive. Those in category B need antenatal care. The missing piece, the ‘blind spot’, the gap can be found between A and B. This is the golden opportunity when practitioners could be asking questions and offering advice/assistance about preparing for pregnancy.
Everyone wants a safe pregnancy and a healthy baby. Such outcomes do not have to be left to good luck. Yet, too often, without even realising it, they become a matter of chance, not a choice. There is little emphasis on how best to prepare for pregnancy or on the fact that taking the time to prepare is worthwhile. The time between contraception and conception is crucial. However, too few practitioners and services take advantage of this time/space to teach people how to prepare adequately for a potential pregnancy.
The answer is simple when you redefine the problem
Twelve years ago, I had an epiphany! We, the experts focused on pregnancy intentions, had not gotten it right. Quitting was tempting, but I am tenacious. Instead, I began the ‘journey of the blank page’.
Through an extensive process using surveys and listening sessions, I filled that blank page with answers from those with lived experience. That included people who can become pregnant, primary care practitioners and sexual/reproductive health providers.
At the end of a year-long process, I created a model that improves patient satisfaction and changes clinical practice based on the patient’s/client’s desire, ambivalence or neutrality about becoming pregnant in the next year. It was called One Key Question® (OKQ). Over the past 12 years, OKQ became a nationally designated screening tool in the USA for asking whether a patient/client desires to become pregnant. This replaced the traditional yes/no question about using contraception. Asking the broader question allows the practitioner to make the best recommendations for contraception or preconception services based on the response. Yes, No, Unsure and Okay Either Way were all acceptable answers.
When I was asked to be a consultant to QNIS to help plan and develop Healthier Pregnancies, Better Lives (HPBL), it felt like the capstone of my career. My work in Scotland is devoted to hearing from those with lived experience about what they want and need to meet their own goals regarding whether to become pregnant at all (and, if so, when); as well as to help them gain a sense of agency about their reproductive health and wellbeing.
It is critical to listen deeply to the voices of people who can become pregnant in order to provide the assistance they want and need. It is also vital to understand the perspective and lived experiences – personal and professional – of the community nurses working with people of reproductive age. Like their patients/clients, they have their own valuable stories and insights about policies, practices and systems that impact their decision-making, but which they neither created nor control. Examining two sides of the same coin offers a deeper, truer understanding of the strengths, weaknesses and opportunities surrounding preconception (and interconception) health, education, counselling and care.
I was recruited by QNIS to consult on their HPBL programme because of my particular expertise in developing a model for reproductive health screening in the United States. To be clear, my assignment is not to ‘sell the OKQ franchise’ in Scotland. That is not a possibility anyway. Rather, my job is to assist in finding and developing Scotland’s bespoke solutions, framework, and approach to what could, and should, happen prior to pregnancy. The success of uniquely Scottish preconception health, education, and care initiatives depends on translating into action Scotland’s cultural, political, institutional and professional contexts.
The New Questions
How would the right approach change if unintended pregnancy no longer defines the challenge? What would it mean if the core concern is the lack of preparation to become pregnant? What could and should everyone involved do differently?
Practitioners need updated training on which preconception screenings are the most essential in preventing or mitigating problems. They would also benefit from heightened education and support for improving two-way, non-judgmental, person-centred, compassionate communications with the people of reproductive age in their practices. Avoiding blaming and shaming should be a given in such communications, but there are also subtle, non-verbal messages to be aware of. Some might inadvertently discourage trust and prevent a candid dialogue. Not every practitioner has already mastered these skills.
Can we change the status quo? How do the people most affected feel about this? Do those who can become pregnant want to receive preconception information and services? What do general practice and sexual/reproductive health practitioners think are the best ways to add or more fully integrate pre/interconception care conversations and services into their practices?
What systemic supports are, or should be, in place to facilitate effective preconception health, education and care? What are the systemic barriers? What would have to happen routinely at the policy and systems levels to encourage and enable the integration of preparing well for pregnancy into mainstream health services and care? How can that transformation be accomplished?
Ask those who can become pregnant what they want! Ask practitioners what they need in order to offer clients and patients what they want! Both have critical lived experiences to inform the nature of the problem and possible solutions. They are the experts.
HPBL will continue to be led by those with lived experience; that is, reproductive age people and their direct service practitioners. Through eight structured Listening Sessions co-facilitated by four Queen’s Nurses, a Sexual Health Researcher and me, we heard from clients/patients and direct service practitioners from four different specialties and four different locations.
Given the relatively small sample, we are not declaring their responses are representative. We are declaring that the responses we heard will guide our implementation strategies and direct our future research. Many concerns were shared among patients from different backgrounds with varying experiences. Many practitioner reactions and suggestions were also shared, regardless of geography or specialism.
In addition, there has just been a QNIS/HPBL preconception health survey open to all community nurses and midwives anywhere in Scotland. That, too, will reveal vital information and insights about the lived experiences and reflections of frontline community-based practitioners.
We are excited to open this dialogue to all of you as we share the responses we gathered and the suggestions for change that were made. There were surprises!
The next blog in this series will describe the surprising, the disappointing, and the inspiring answers to our open-ended questions. Look for Listening Session Blog #2: Are You Listening?
We invite you to respond to this blog series with your comments. Please feel welcome to weigh in with your views at HPBL@qnis.org.uk.
We want to hear about your lived experiences and journeys while accessing, receiving, and/or providing reproductive health information and services.