Individuals, Professionals and the ‘System’
Women have been having babies throughout human history. But very familiar doesn’t mean ‘easy’ or always successful. In fact, pregnancy was often dangerous for both women and foetuses. The maternal and infant mortality rates were unimaginably high by modern standards. Beyond improvements in public health and general medicine, the game changer in modern times has been in antenatal/perinatal care.
Over the last 50 years, data relating to pregnancy and delivery experiences have been analysed to identify and respond well to the many risks to a healthy pregnancy and baby which can be mitigated with antenatal care. Antenatal health and care were the hallmark of progress during the 20th century. Although the accomplishments in this field have been very impressive, there is always more to learn and improve.
We now also know that such measures as taking folic acid, weaning off teratogenic medications, and stopping drinking alcohol, smoking and other risks can only prevent harm to women and their babies if engaged in before conception.
Unfortunately, we are not yet seeing the full benefits, or dramatically improved outcomes, despite the existence of this hard-earned knowledge about preconception health. There continue to be major awareness and implementation gaps when it comes to recognising the essential benefits of preparing to become pregnant (and what healthy preparation entails). This needs to become more widely understood and embraced as the ‘new normal’ in the 21st century.
We could know better and do better. We could and should design all-encompassing community reproductive health education campaigns, which are gender inclusive and culturally appropriate for the diverse, reproductive age population. Most of the focus so far, has been on changing the behaviour of each individual woman or practitioner.
Of course, individual decisions and behaviours do truly matter, but they are not the only major influences upon pregnancy and birth outcomes. Far from it. Neither patients nor front-line practitioners are in complete control of the factors that so often determine what happens (or fails to happen) during pregnancy.
Sometimes for the better, often for the worse, practitioners and patient/client services are limited by the ‘system’; its design, regulations and stipulations in contracts and remits. Fragmentation of approach, lack of coordination between disciplines and siloed services in general practice, sexual and reproductive health clinics, and midwifery/obstetrics are all barriers.
In my experience, initiatives and interventions primarily aimed at changing individuals’ behaviours ignore the reality that even if individual behaviour changes, system barriers still won’t disappear. Siloed services that fail to coordinate and ensure compassionate, person-centred care, almost inevitably deliver splintered, far from ideal, services. Fragmentation has proven to be counterproductive in meeting the reproductive health needs and desires of the intended beneficiaries.
Silos create unintentional barriers to individualised reproductive health care, whether the individual’s goal is avoiding, delaying or preparing for pregnancy. To date, the ‘system’ has rarely been there to help individuals/couples prepare well for pregnancy prior to conception. In fact, the focus on individual risks and behaviours, coupled with the tendency to overlook the fundamental role of the system, inadvertently puts the responsibility on the individual whilst insisting that procedures were followed.
Historically, Primary Care justified separating Reproductive Health in the belief that pregnancy was the province of generally young, healthy people who do not require a general health assessment prior to a healthy pregnancy. The assumption was that, when there are reproductive health issues, they would be best dealt with by specialists, not primary care practitioners.
Over recent decades, however, important factors have changed with an adverse effect on the health of a pregnancy and birth:
- The average age of women, when they become pregnant, has increased significantly.
- In part because of this increase in age, many, if not most, of those becoming pregnant have at least one pre-existing condition – and are prescribed one or more medications – that could affect the pregnancy.
- The minimal proportion of pregnancies when sufficiently strong folic acid (Vitamin B9) supplements were taken early enough (i.e., months before conception) to prevent Neural Tube can result in miscarriages, stillbirth, therapeutic terminations and neonatal deaths, as well as major birth defects.
- The increased prevalence of depression/anxiety diagnoses has led to a rise in people who are routinely taking medications not recommended during pregnancy, and, for undiagnosed cases, increased self-medication with alcohol and/or street drugs.
- A rise in the proportion of pregnancies at risk due to smoking, drinking and obesity.
- The decreased proportion of women being seen for a general health assessment prior to becoming pregnant; particularly since the protocol regarding smear tests increased from annually to 3-5 years.
While the risks have clearly grown, the delivery system for ‘women’s health services’ has not yet caught up. Mainstream health care must reconsider its approach. The existing women’s health silos are leaving us with substantial gaps in reproductive health care and, although inadvertently, are contributing to poorer outcomes.
Scotland deserves praise for creating the UK’s first Women’s Health Plan, which includes recommendations about reproductive and pre-pregnancy health, education and care. Sadly, funding and implementation of that Plan has officially been delayed for another year.
Recommendations for System Change
System change is needed to improve pregnancy and birth outcomes by improving preconception and interconception health, education and care.
The QNIS/HPBL Listening Sessions [read the blogs here] suggest that even when individual behaviour changes, this alone will not be enough. There are systemic barriers that must also be addressed. Otherwise, access to preventive health actions will be too limited, and come too late, to stand any chance of improving outcomes.
There were two major barriers identified in our QNIS/HPBL Listening Sessions:
- Women’s health care services are fragmented and uncoordinated. Practitioners and women prefer General Practice to be responsible for reproductive health concerns, including preconception/interconception information, counselling and care.
Women in our Listening Sessions repeatedly expressed frustration that, “We have to see a lot of different professionals for different things (health care services). No one knows me!”
Practitioners also complained in the QNIS/HPBL Listening Sessions about the silos in women’s healthcare. Patients usually go from a GP to a Midwife, and then on to a Health Visitor for antenatal then post-partum care. Her reproductive health history often does not follow her. Information and services received from Midwifery or Sexual Reproductive Health (SRH) clinics are not automatically coordinated with other specialties or primary care providers.
In our sessions, both patients/clients and front-line practitioners expressed the view that General Practice is the preferable service for discussion of pre-pregnancy health matters.
Women want a trusted practitioner who they can go to, and count on, for reproductive health information, advice and services that are person-centred, i.e., tailored to them as individuals. They often said, “Give us one place to go! My General Practice is the place I trust the most to ask my (reproductive health) questions and talk about what is worrying me”.
The Practice Nurses in our surveys and Listening Sessions also saw General Practice as having the most opportunity to offer effective, easily accessible reproductive health services (i.e., contraception and preconception), with the possibility of referrals to an SRH clinic for specialty care.
Sexual and Reproductive Health practitioners also see General Practice as the place these services should be made available. The SRH role is focused on pregnancy prevention, e.g., Long-Acting Reversible Contraception (LARCs), as well as on STIs and terminations. They do not routinely deal with potential pregnancies that are wanted.
- The greatest barrier discovered, however, is that no single part of the system is accountable for reproductive and preconception health. Everyone says: ‘It’s not my remit.’
Everyone in the ‘system’ is potentially responsible for preconception health, education and care. Yet, the common chorus is, “Someone else (a different type of practitioner) already does that.” This is widely asserted and believed, but rarely true. Clear accountability for preconception and reproductive health within our health systems is lacking. Reference is made to NHS contracts, but these contracts do not explicitly include preconception and contraception care.
Does one part of the system need to officially ‘own’ primary responsibility for preconception and interconception health, education and care? If so, then there is a need to identify the other health care professionals involved and to designate their responsibilities within the process.
Should primary care have primary responsibility for primary prevention in this arena? What do you think? We are still listening!
Please let us know your thoughts, concerns, questions, and always, suggestions using either HPBL@qnis.org.uk or @HPBL_Scot.