This is the third blog presenting the results of the spring 2022 QNIS/Healthier Pregnancies, Better Lives survey of an illustrative sample of Scotland’s community nurses and midwives.
The takeaway from Your Views and Experiences is the overwhelming willingness among respondents to engage with these issues. They want to enhance their current knowledge base and practices to improve pregnancy and birth outcomes.
We were excited by the sheer strength of the response when we asked if preconception/interconception health, education and care should be a routine part of your work and training. Eighty percent responded ‘YES!’ and thought it should be routine. It should also be noted that half of the 20% who said ‘no’ did so because they work with post-menopausal women.
The insightful replies to the Views and Experience section of this survey offer a great deal more contextual information about the perspectives of respondents within all specialties.
Community nurses and midwives are dedicated, highly-skilled professionals who often develop and maintain close relationships through their patient-centered practices. In this way, they are the best positioned to have a conversation about pregnancy with their reproductive age patients.
With this in mind, we asked about their current confidence levels in providing assistance and/or referrals relating to pregnancy.
Given the relatively close relationships between practitioners and their clients, it is perhaps unsurprising that 84% of respondents felt confident reacting to enquiries about delaying, avoiding or becoming pregnant from their clients. Once again, of the 16% who did not feel confident, most are not working with reproductive age people.
In question 15, we asked if respondents would ever initiate a discussion about pregnancy, as well as what inhibits or encourages that conversation. On one end of the spectrum, a full 43% answered that they usually (or always) initiate conversations about pregnancy, which is to be applauded. The 19% who only occasionally initiate a conversation showed a willingness to have such a discussion but said they hesitate to do so regularly because of a lack of confidence. These respondents indicated they would increase this practice, if they had more training in how best to conduct and follow up on this conversation, as well as more experience in doing so.
It is most important to note that only 27% felt they had sufficient training and knowledge to ask a pregnancy desire question, facilitate that conversation and assist in the next steps. More respondents (31%) were fairly confident but only 19% felt competent in this area.
These figures affirm our position that there is currently insufficient training in preconception/interconception care. In particular, this inadequacy exists around initiating conversations about pregnancy desire or supporting clients to create an informal reproductive life plan.
While 74% were confident talking about contraception and avoiding pregnancy, only 54% felt confident assessing preconception/interconception health risks.
These comments underscored the theme that a lack of training inhibits many practitioners from doing more.
“My conversations are limited to the knowledge I have so far. Would like to become more comfortable and confident with these discussions.”
“I feel like we had no training on anything ‘preconception’, but I’ve found my way on the job.”
“WE ARE NEVER GIVEN TRAINING OR UPDATES ON THIS SUBJECT, SEEN AS VERY SPECIALISED”.
“I am confident in preparing parents for parenthood as part of my job, but do not feel I have had any decent/in depth training on contraception and/or reproductive decisions prior to becoming or choosing to become a parent.”
Other inhibitors in addition to training were noted:
“I have only very rarely been approached by women for preconception advice. Women in many areas do not have access to (or do not know) how to directly refer themselves to midwife services and that this can include preconception advice”.
“I am not sure that there are sufficient effective referral pathways”.
“It’s not my remit.”
Generally, community nurses and midwives dealing with reproductive age clients and patients expressed an understanding of why preconception and interconception care are so important. Yet, we repeatedly heard how they felt limited by their lack of training and opportunities, plus their perceived limited scope to do it within their remit/role.
More than half of the respondents’ comments suggested that they thought it was ‘someone else’s job’; i.e., the territory of another type of specialist. Midwives assume it’s Health Visitors; Health Visitors assume it’s Midwives; Sexual and Reproductive Health nurses point to GP nurses and GP nurses point to Midwives or SRH nurses. There is a genuine assumption that other groups are already embedding preconception health into their practice. Therefore, it simply isn’t their responsibility and preconception care is falling between the silos.
“Health visitors do not see clients before she becomes pregnant. It’s the role of specialists like midwives.”
“I feel like I do not have much training on preconception counseling because, as a midwife, my first contact is post-conception”.
“I’m a midwife and I don’t see women until they are pregnant and two weeks post- natal. The timing is inappropriate to discuss the next pregnancy”.
But the division of specialties within the health care system does not explain why some of those within the same specialty see their role and relevance differently:
“Yes, of course I do, I’m a midwife”.
“No, I don’t, I’m a midwife, I only see women when they are actually pregnant”.
Similarly, Health Visitors differ in how they see the way in which pre-pregnancy health fits with their role:
“We see clients in their homes over time; so, Health Visitors are able to have a broader conversation about interconception care”.
“I only see women after they become pregnant, and my care focuses on the baby”.
Specifically, 6% pointed to the limits of their remit role as the primary inhibitor.
The 38% who were confident offering advice and referral, reported very few barriers that prevent or inhibit discussions of reproductive health. They felt able to help but wanted training to be on-going.
“I’m confident to some extent, but I am normally worried that I might be missing some information.”
There was a strong correlation between the 37% reporting they were not confident and needed training, and those who identified a lack of knowledge and training as the primary reason for this aspect of practice being missed. These respondents are the most likely group to add a preconception and interconception care conversation, providing they have training, and their practice remit allows it.
“As a midwife seeing the woman two weeks post-natal there is limited opportunity to discuss interconception health”.
“WE ARE NEVER GIVEN TRAINING OR UPDATES ON THIS SUBJECT – SEEN AS VERY SPECIALISED”.
“I answer questions when asked but would not initiate conversations about reproductive health or attitudes towards pregnancy”.
“Feedback from patients state that they are glad that this was discussed as part of their counselling for their treatment at a time when maybe pregnancy was not on their radar. It allows informed choice and planning.”
Overall, the survey participants expressed an interest and willingness to address the missing discussions, services and support that should be taking place, before and between pregnancies. Scotland’s Coalition for Healthier Pregnancies, Better Lives would recommend prioritising this group for additional training and assistance.
A midwife usually sees the parents for two weeks post-natal, which offers limited opportunity to discuss interconception health. However, it is important that the patient and the Health Visitor understand any post-partum risks, as well as any other risks that may affect any subsequent pregnancy. It is a golden opportunity to plant the seeds of interconception care.
If Health Visitors were supported to provide interconception care to the birth parents they see post-partum, then they could directly support the client’s desire to avoid, delay or prepare for the next pregnancy. The Health Visitor would be able to follow-up on any health risks post-partum, as well as educate them about having a healthy future pregnancy. It would improve care coordination and be in alignment with interconception care discussions, which include contraceptives to enable healthy birth spacing.
The next blog will focus on the final section: What You Want to Happen Next. Clearly, community nurses and midwives are the most appropriately positioned to become agents for change in preconception health, education and care. They know what works now, what is missing and have provided great suggestions about what to do about the gaps.
The prospects for progress are bright. We will pursue the next steps based upon what we have learned. Please feel very welcome to contribute to this work by contacting us at HPBL@qnis.org.uk and/or by following us at @HPBL_Scot.
This is the third blog in the series, you can read the other blogs here: