“Now what?” I asked when, despite increasing access to reliable contraception, we had not been successful in decreasing the proportion of unintended pregnancies in the United States.
In looking internationally for answers 12 years ago, I realised policies and practices in reproductive health and pregnancy are not universal. Instead, they are deeply embedded in cultural and societal norms. That is why a strategy and tool developed in the U.S. cannot simply be franchised and remain effective in Scotland.
A bespoke Scottish strategy and set of resources are required but do not yet exist. They must address preconception information and services prior to a first pregnancy – and interconception health and wellbeing quickly following every pregnancy (whether or not that pregnancy resulted in a healthy baby).
Expertise matters and evidence-based recommendations deserve to be respected. However, guidance based upon the lived reproductive health, pre-pregnancy and antenatal/childbirth experiences of both clients/patients and their frontline healthcare providers, such as community nurses and midwives, is of equal importance.
Neither patients nor providers are policymakers, but both groups are profoundly influenced by the systems and policies surrounding them. Each have vital knowledge and advice that goes unsolicited or disregarded far too often. One of the fundamental commitments of QNIS’ Healthier Pregnancies, Better Lives programme is giving priority to correcting the imbalance over whose voices count.
From the practitioner’s perspective: We are talking about one person with one reproductive life cycle. Sometimes that one person needs support for menstruation; sometimes guidance on how to prevent becoming pregnant; sometimes for pregnancy preparation and pre-conception care; and, sometimes for antenatal and then post-partum care. We are talking about one person divided among several service silos.
Wouldn’t it make more sense to retire the silos in favour of coordinated services based upon each person’s unique health history and current needs?
And no, no one is already doing that.
Not primary care or general practice. Not sexual and reproductive health. Not specialists for prospective parents with chronic health conditions. After all, people are far less likely to fall through the gaps, if those gaps in service no longer exist.
We all want healthy birth parents, healthy babies, and thriving families. Many of us say we support the full range of reproductive options, including prevention and termination. If we support the full range of options, then why is it that preparing for a possible pregnancy isn’t routine?
Scottish women of reproductive age say they want to know about the individual risks they face. They want to know about those risks that might arise from pre-existing conditions, their personal pregnancy history, medications and social behaviours, such as smoking, drinking and diet. They stated:
“We are on our own to try to figure it all out. Don’t get an STI and don’t get pregnant. You can’t trust the internet or social media because you can’t trust it is factual. What are we supposed to do?”
Practitioners genuinely want their clients/patients to be satisfied with their service. They worry about offending them by being too personal and coming across as intrusive. They make assumptions about what patients want, as well as assumptions about what they may find too personal. They do not want patients to feel blamed or shamed and so, largely out of kindness, they avoid talking about their underlying health risks and behaviours that could negatively affect a potential pregnancy.
The HPBL Listening Sessions illuminate a perception gap between practitioners and patients. Significant needs and major opportunities were expressed from each perspective. Still, the common denominator was their interest in increasing their own reproductive and preconception health education.
Our eight Listening Sessions revealed that these reproductive age women do not know about the benefits of pregnancy preparation or understand what is meant by ‘preconception information and services’. But they do want to know.
- These reproductive-age patients/clients do not have access to much sexual health information and rarely understand why it is especially important to be as healthy as possible before conception. So, they don’t even know how to begin preparing well for a possible pregnancy.
It continues to surprise me, given how long “sex education” has been part of the school curriculum, that young people have not been well educated about reproductive health and the middle stage between contraception and conception i.e., preparing for a safe and healthy pregnancy.
People of reproductive age repeatedly told us that the education they received at school was painfully co-ed and minimal. They do not know what to expect from their bodies throughout the reproductive life cycle, including menstrual health, pre-pregnancy health and how health risks and behaviours affect the outcomes of a pregnancy.
I assumed that even if they were not taught in school, there were many ways to access the information online. But as the women pointed out to us, they do not feel like they know enough to “just Google it”.
“Who do we believe? What sites should we trust?”
“We are not at all confident we can discern what are the facts versus falsehoods.”
“We want to talk with our practitioner and have them tell us where to go for information they can trust.”
Yes, these are actual client/patient quotes.
- The wait is too long for the first antenatal visit with a midwife. While waiting up to 12 weeks into a pregnancy may be acceptable for low-risk pregnant people, it becomes problematic for many, especially those at higher risk.
“The wait from the time you find out your pregnant until you get seen, is weeks! I needed to see someone at six weeks but was told I had to wait until I was 10 weeks for my first antenatal visit.”
This comment from a young first-time mum reflects the time gap between primary care of some kind, and the first antenatal visit.
People who can become pregnant are fertile for an average of 39 years. On average, they have 2 children and spend 5 years pregnant or postpartum. That leaves 34 years to prevent an ‘unintended’ pregnancy! What support is offered to help them in between primary care and antenatal care?
Those with lived experience are telling us what they need. Our collective response should consider how to increase the knowledge base and meet the needs of both patients and providers in relation to counselling, services and support before any and every pregnancy. Serious consideration, followed by effective action, is also necessary to influence systems and policies that have kept preconception and interconception, health, education and care ‘under the radar’ for far too long.
The next blogs will be co-written by the Queen’s Nurses in four Scottish locations who recruited participants and co-facilitated the eight HPBL Listening Sessions conducted during Year 1 of this QNIS programme. We will share what we learned thanks to the voices of those having lived experiences of seeking, receiving, and providing sexual and reproductive health services. What they know is crucial to what we do and how we do it.
This is the third 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) (you’re already here)
- 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