Dr Annette Thwaites on - 'Immediate Postnatal Contraception – why bother?'

Posted 10 Jul 2018

Date: 10 Jul 2018

Author: Annette Thwaites

Annette Thwaites reflects on her 5 years of specialty training in Community Sexual and Reproductive Health (CSRH) and what sparked and sustained her interest in immediate postnatal contraception.

Community Sexual and Reproductive Health is a young, small specialty and can be a difficult one to define and communicate to those working in medicine and more widely. At the beginning of my training, when asked socially “what kind of doctor are you?” it became clear that people often only hear the “sex” in CSRH and conversations could take an unpredictable turn - even prompting some unsolicited disclosures. Throughout my rotations, I have been mistaken by other health care professionals for a trainee in general practice, genito-urinary medicine, obstetrics & gynaecology, public health and a variety of clinical nurse specialists. During my yearlong clinical fellowship at Public Health England I witnessed firsthand the challenges associated with achieving a consensus across a diverse national stakeholder group as to the scope of ‘reproductive health’.

However, I believe these blurred boundaries and close overlaps with other specialties provide CSRH Trainees with a unique and valuable perspective. Throughout the course of my training, I have been continually struck by unmet need for immediate postnatal contraception and its impact on women and families in a wide variety of settings. In early pregnancy and abortion care, I met women surprised and shocked at finding themselves pregnant again soon after a delivery. In community contraception clinics I was diagnosing pregnancy in postnatal women attending for fitting of long acting reversible methods. In obstetrics, on the postnatal ward I met women who expressed their desire for contraception on the ward, O&G trainees who were surprised we still don’t offer this and experienced health care professionals who remembered when we did (albeit before the advent of most modern LARC).

My early attempts to initiate this service locally included an “InReach” service offering implants on the postnatal ward for women with high safeguarding risk or medically dangerous pregnancies: The woman with 11 children, younger than me, who held my hand in gratitude; the woman in theatre recovery who pushed her surgeon out of the way to allow me space at the trolleyside; the woman post septic miscarriage, suicidal at the possibility of another pregnancy; the woman who had delivered at home but whose baby had been admitted for toxicology testing; the teen who had delivered twice previously in our hospital and whose children were all in care; the woman who had very nearly died in ITU post delivery. These women taught me the value of immediate postnatal contraception and it is their stories that moved and motivated me to begin research in this field.

This first service was largely carried out during breaks around my rota and, whilst unsustainable without dedicated staffing and a funding stream, it provided me with a great opportunity to identify and learn more about the many and diverse challenges faced in the implementation of a consistent comprehensive contraceptive service to postnatal women. I also found myself asking lots of questions: What are other services doing? What are other countries doing? Why aren’t women demanding this? What are the barriers? What are the costs? What are the benefits? How can we quantify these? What data do we hold? What do women know about postnatal contraception? What do they plan to do currently? What do they do currently? What are their preferences?

Sponsored by Public Health England, I began to work on some of these and conducted a cross-sectional survey of women on the postnatal ward in Lewisham hospital, which has been a great opportunity to collaborate with research scientists, epidemiologists and other specialists. Our findings suggest that women on the postnatal ward currently lack key knowledge to enable them to make informed decisions regarding their use and choice of contraceptive method. The majority of women were also not aware that LARC methods are safe in the immediate postnatal period and when breastfeeding and also had low levels of knowledge of the safety of hormonal methods generally. Despite this, women expressed a preference for postnatal contraception provision on the postnatal ward and a likelihood to choose LARC in this setting.

There is now a pressing need to pilot a dedicated and fully funded service in England to offer all methods of contraception, including LARC, to all women on a postnatal ward. This needs to include effective, tailored contraceptive choices discussions with every woman during pregnancy as well as integrated planning for postnatal provision of her chosen method.

So plenty to do but I am constantly reminded in my clinical roles that getting this service right benefits individual families and wider public health over generations and may well save the public purse billions also.

Annette’s poster on immediate postnatal contraception – what women know and want - won first prize at the FSRH's Annual Scientific Meeting in May 2018.  This work, sponsored by Public Health England, has been submitted to BMJ SRH for publication.