Improving the counselling and delivery of postnatal contraception

Dr Anu Ajakaiye, ST3 Doctor O&G

Dr Noreen Haque, ST6 Doctor O&G

Dr Maria Kaloudi, ST5 Doctor O&G

Dr Ruth Roberts, Consultant Obstetrician & Gynaecologist

Betsi Cadwaladr University Health Board

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Background

Cartoon image of three women in a line. The first woman is pink in colour whilst the other two are navy.

1 in 3 pregnancies in the UK end in termination. Obtaining contraception during the pandemic has been challenging and recent government figures show that termination rates have increased during this time [1]. Having a termination is a difficult decision to make and can have a negative impact on an individual’s mental health, increasing risk of depression, anxiety, drug and alcohol abuse, and suicidal behaviours [2].

Pregnancies that continue are unplanned or unintended. This leads to concerns of high-risk women not having vital preconceptive care.

1 in 13 women who fall pregnant have conceived within a year of a previous birth. Evidence shows an interpregnancy interval of less than 12 months is associated with increased antenatal risks.

Risks associated with <12 month interpregnancy interval

Image: Risks associated with short inter-pregnancy interval

Prior to implementing any changes to our current hospital policy, we carried out patient and staff surveys to assess the current understanding and prescribing of postnatal contraception. The staff survey showed that 97% of staff felt they would benefit from formal training on contraception. The patient survey showed that 50% of antenatal and 50% of postnatal women did not recall discussing contraception.

We also carried out an audit looking at contraception provided to postnatal women and documentation in antenatal and postnatal notes. This showed that only 1 woman left the unit with contraception and documentation was poor.

Project Aims

Provide formal standardised training to all clinical staff with the help of contraception champions

Headshots of Contraception Champions — *Image: Contraception Champions*

This includes doctors, midwives of all grades and healthcare assistants.

This has helped improve the counselling skills of staff which in turn has resulted in an increase in the uptake of postnatal contraception.

Education is an essential part of providing and delivering better and safer care to patients.

Image of Dr Anu Ajakaiye at a training session for the Contraception Champions — *Image: Dr Anu Ajakaiye at a training session for the Contraception Champions*

Provide staff with tools to ensure safe prescribing of contraception.

Following the delivery of a baby not all forms of contraception are safe to be used straight away.

There are a number of conditions where some forms of contraception are contraindicated.

To help the staff feel safe about prescribing contraception, we developed proformas that should highlight any safety issues. These proformas were also sent to pharmacy with the prescription to ensure safe prescribing. GPs received a copy of the proforma with the birth summary to allow for continuity of care and chosen contraceptive method.

‘Contraception Files’ were created so all the necessary information needed to counsel and prescribe was easily accessible. The colour of the file was purposefully different to other files found on the ward so that it could be seen easily.

Images of contraception files — *Image: Contraception files*

Image of lapel pin worn by Contraception Champions — *Image: Lapel pin worn by Contraception Champions*

Provide patients with reliable and more accessible information on contraception choices.

A poster was developed which directed patients to reliable, up to date information on contraception online. This was placed in waiting areas within the unit as well as in community clinics

Poster directing patients to up to date information on contraception online

Patient information leaflets were designed following feedback from both staff and patients. A total of 8 leaflets were created, they were all translated into Welsh and Polish (next most common language spoken in Wales). Each information leaflet had links to further information online if needed.

Patient information leaflets advising on post-pregnancy contraception

Smartphone Application – Still in progress. When completed, this will provide patients with all necessary information to make an informed choice.

Screenshot of Contraception in Post natal Period smartphone application, which is still in development

4. Improve the availability of contraception postnatally

All forms of contraception that are suitable after the birth of a baby were made available.

Challenges

Keeping the momentum of the project going. Having a team of 30 enthusiastic champions helped push progress forward and emphasise that this work was intended to be a permanent change and not temporary during the pandemic. A WhatsApp group was set up for troubleshooting, and for sharing updates and statistics.

Difficulties with breast feeding and contraception. All forms of contraception offered at the unit are suitable for women who are breastfeeding. There is some anecdotal evidence that some forms of contraception can potentially reduce the production of breast milk. To ensure that women are given the correct information, this was added to the counselling and proforma.

Insertion of long acting reversible contraception (LARC – contraceptive implant and intrauterine contraception). The insertion of implant requires specific training and a certificate of competence. Unfortunately, we were not able to access this training during the pandemic. Gynaecologists are trained in routine coil insertion. However, inserting a coil immediately after vaginal delivery is not the same as routine insertion and requires training. A programme has been developed and will be implemented soon. In the meantime, women requiring LARC are referred to the sexual health team. They are counselled and all relevant paperwork completed so that women only need one appointment rather than the routine two.

APP. Developing a mobile application requires expertise and resources so we utilised the different skill mix in the team to facilitate this without incurring costs.

Key Outcomes

Increase in uptake of postnatal contraception. Prior to implementing any changes an audit showed that only one woman left the hospital with postnatal contraception in the form of sterilisation. In the month of April 2021 47% of women were discharged with a suitable form of postnatal contraception. A patient survey also showed that 86% of women recalled discussing contraception postnatally compared to 50% in an earlier survey.

Line graph showing contraception uptake from June 2020-April 2021

The Faculty of Sexual and Reproductive Health (FSRH) offer a course ‘Essential Contraception for Midwives’ at an average cost of £100 per person. Our training programme covers the same topics and objectives and was delivered with little cost to the department and no cost to the staff. During a 4 month period 90% (n=160) of clinical staff attended a training session, saving the trust approximately £16,000. Further to this, 99% of staff who attended a training session felt more confident about counselling women about contraception compared to 31% in a previous survey.

Eight different leaflets on contraception can be purchased at a cost of approximately £20 per 100 leaflets. We have produced our own version which have also been translated into Welsh and Polish. The leaflets are available as a printed copy as well as a digital version. We estimate this has saved the unit approximately £1000 per year. There is potential for further savings when we roll out the project in other units within the health board.

Our project has also saved valuable time for both patients and staff within primary and secondary care. A number of guidelines recommend that contraception should be discussed during pregnancy and following the birth of a baby. By following the recommendations and implementing changes we have saved women time as well as removing some of the barriers to accessing suitable contraception during the pandemic. The 6 week postnatal check carried out in primary care is usually a double appointment, to allow time to discuss contraception. Our changes potentially mean that this visit can be reduced to a single GP slot – this will lead to significant time and cost savings in primary care.

Feedback from staff training sessions

‘Tammy made it very interesting and easy to understand. It was a very good session and I now feel more confident in being able to help support women make contraceptive choices’

‘In depth information – I thought I was quite knowledgeable but I learnt lots!’

‘I feel much more informed now, lots of interesting information regarding contraindications that I didn’t previously know.

‘Brilliant teaching session, full of information and clear information giving me confidence

‘Informative and clear information relevant to practice. Now feel more confident to discuss in the postnatal period’

Feedback from postnatal patients

‘No improvement needed, very good advice given’

‘I think to just keep as you’re doing its perfect’

‘It’s already good enough’

Next Steps

Roll out the training programme to the other sites within BCUHB – we have presented our work to the Womens Service Board and are having discussions with our Director of Midwifery and Women’s Services on how to implement the same training programme at Ysbyty Gwynedd and Ysbyty Glan Clwyd.

Implementing training for insertion of coils following a vaginal delivery.

Image of MamuU Trainer — Image: ‘MamaU’ Trainer

Our Exemplar Experience

As part of the Bevan Exemplar experience, we felt very supported as a team. The knowledge from the sessions was important in giving us direction in how we developed and evaluated our work.

All round a great experience.

Showcase

We have a number of poster presentations accepted for National and International Conferences:

Ajakaiye A., Haque N., Kaloudi M., Roberts R. Postnatal Contraception: Using Technology for service development, poster presented at Health Technology Assessment International (HTAi) Virtual Annual Meeting, Virtual, June 2021
Ajakaiye A., Haque N., Kaloudi M., Roberts R. Development of A Training Programme to Improve Counselling and Uptake of Postnatal Contraception, poster presented at 2021 Welsh Annual Audit & Quality Improvement Event, June 2021 Virtually.
Haque N., Ajakaiye A., Kaloudi M. Roberts R. Development & Delivery of A Training Programme To Help Improve Postnatal Contraception Counselling poster presented at RCOG Virtual World Congress 2021, June 2021, Virtual https://rcog2021.ipostersessions.com/default.aspx?s=D6-A7-8C-2C-58-CE-60-21-7C-C7-C5-D7-3F-10-DF-EC
Ajakaiye A., Haque N., Kaloudi M., Roberts R. The use of the Quick Response (QR) code within the NHS, poster presented at RCOG World Congress 2021, June 2021 Virtual. Abstract published in the BJOG RCOG Virtual World Congress – Top 500 abstracts, Quality improvement; 216. https://rcog2021.ipostersessions.com/default.aspx?s=CF-59-DC-23-D4-2B-64-D6-66-F2-20-21-12-4B-CC-8C&guestview=true
Ajakaiye A., Haque N., Kaloudi M., Roberts R. Development of A Training Programme To Improve Counselling and Uptake of Postnatal Contraception, poster presented at RCOG National Trainees Conference 2021, virtual, May 2021. Abstract published in BJOG; The Authors;134;527 https://az659834.vo.msecnd.net/eventsairwesteuprod/production-rcog-public/08965e3cfc98466da981bab7ff41b1bc
Ajakaiye A., Haque N., Kaloudi M., Roberts R. Accessing Surveys and Patient Information via Quick Response (QR) codes to evaluate and improve the delivery of postnatal contraception, poster presentation at RCOG National Trainees Conference 2021, Virtual, May 2021. Abstract published in BJOG; The Authors;117;477 https://az659834.vo.msecnd.net/eventsairwesteuprod/production-rcog-public/9954010ad2814cb481aa03936ddd4fc4
Ajakaiye A., Haque N., Kaloudi M., Roberts R. Improving access to postnatal contraception during COVID pandemic, oral presentation in Welsh Obstetrics and Gynaecology Meeting Spring 2021, Virtual, March 2021 https://wisdom.nhs.wales/welsh-o-g-society/conference/welsh-o-g-society-general-conference-section/welsh-o-g-society-conference-spring-2021/posters-presentations/improving-access-to-postnatal-contraception-n-haque21-pdf/

Thank you to Mr Maraj, Mrs Upadhyay and Fiona Giraud, our senior management team for their support throughout the project.

A special thank you to our champions: