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Dr Sue Mann on Public Health England's holistic focus on women's reproductive health
Date: 13 Jun 2017
Author: Dr Sue Mann
Dr Sue Mann is a Consultant in Sexual and Reproductive Health (SRH) and Medical Expert in Reproductive Health at Public Health England. She has worked for many years in SRH in a clinical, academic and teaching capacity and has an interest in the wider public health role of sexual health services and methodologies for effectively translating research evidence into clinical practice. In this month’s blog, Sue outlines the holistic focus on women’s reproductive health currently underpinning PHE work in this area. She stresses the importance of meeting women’s reproductive health needs and providing accessible and individualised care across the life-course. She also highlights the need for services to work across boundaries to the same outcomes regardless of whether point of entry into care is through general practice, sexual health services, maternity services, pharmacy or elsewhere.
It has been a busy year since taking up post as Medical Expert in Reproductive Health at PHE. Much of the early focus has been on increasing the visibility of reproductive health within the overall sexual health, reproductive health and HIV agenda at PHE. Three main principles have been at the forefront of the work:
(i) a focus on the whole life-course;
(ii) women’s journeys at the centre of care and
(iii) contraception care as part of a holistic and comprehensive approach to reproductive wellbeing. The response to this reassures us that there is a need for this work, not to mention a huge appetite amongst a dynamic group of stakeholders to move the sector forwards and together.
Importantly, publication of the National Maternity Review (2016) and particularly its work stream on prevention has given momentum to this area in the health and wellbeing agenda. Maternity care is a gateway to health improvement and reaches 10% of women of reproductive age per year. It is a key time and opportunity to provide contraception and other aspects of care for many who may be less well provided for by services at other times in their lives. The most recent NATSAL survey (1) showed us that 46% of pregnancies are unplanned or ambivalent of which only just over half (57%) lead to abortion.
Women who continue with their unplanned pregnancies may be sub-optimally prepared having missed out on preconception care. Unplanned pregnancies are associated with a greater likelihood of poor maternal and neonatal outcomes which begs a question about how we should tackle the issue of pregnancy planning and preparation in a more integrated way.
The data tells us we are some way from women achieving control over when and if they have pregnancies. However, pregnancy is an opportunity to improve contraceptive choices going forward and be better prepared for the future. Rapid repeat pregnancy (pregnancy within a year of delivery) is also associated with poor life outcomes, and contraception supports effective spacing.
In overall population terms, the 51% who are women need contraception for around 30 years of their lives in order to retain control over their fertility. Contraception has largely been seen as a medical issue since it often requires medical supervision for its provision. This is a huge challenge when meeting the needs of half the population over such a long period of their lives, whilst retaining access to the full range of choice. We know that contraception is one of the most effective and cost-effective public health interventions particularly the Longer Acting Methods (2). Cost effectiveness data shows that for every £1 spent on LARC, £11 can be saved (3). Increasing access to long-acting reversible contraception (LARC) by suggesting women switch from their shorter acting methods in primary care, and implementing post pregnancy contraception feature as one of the recommended cost-saving interventions for Sustainability and Transformation Partnerships (STPs) to implement (4).
Maintaining real access at every stage of the pathway is the only thing that will provide real method choice for women. Universal access to discussions associated with straightforward rapid choice of method, regardless of point of entry into care, is needed – whether general practice, sexual health services, maternity services, pharmacy or elsewhere. There are good resources available for non-specialists to learn basic skills needed for an opportunistic contraceptive choices discussion. This year the Royal College of General Practitioners (RCGP) led the development (co-badged with PHE and Faculty of Sexual and Reproductive Healthcare) of a free online learning resource.
There is still some progress to be made in ensuring the offer of contraception is embedded as part of a Making Every Contact Count approach and that onward pathways are robust. This is always particularly challenging for offering or receiving an IUD provision where time, capacity, training and governance are needed but at a time when these are not always available. Local specialist provision for the complex parts of contraceptive care, such as deeply inserted implants or lost IUD threads is also a vital part of this pathway, which requires particular gynaecological skills and for which the need will increase as access improves. For good access, services must work across boundaries to the same outcomes regardless of point of entry into the system.
Local Authority commissioning presents an opportunity to address place and person-based rather than service-led approaches. Much can be learned from the system-wide approach of the Teenage Pregnancy Strategy where contraceptive service quality and access were improved but also so much more, leading to the impressive reductions in teenage pregnancy rates that have been seen. By recognising the multi-faceted elements that contribute to pregnancy amongst young people the Strategy highlighted a “10 key factor” approach for success. Many of these factors translate to care of women across the whole life-course of pregnancy, planning and prevention. Moving commissioning of services out of health is an opportunity to recognise and address some of these wider determinants of reproductive wellbeing and to harness the players across the non-healthcare sector to add value to what is already provided through healthcare.
Of course, reproductive health is not just about preventing or achieving pregnancy for women but is important as a determinant of overall wellbeing (5). Enhancing and reframing the narrative around reproductive wellbeing is needed so that we can start to think more about what success looks like in terms of population-level choice, control and empowerment. Learning from women about their concept of good reproductive health is the first step in doing this.
Here at PHE we are analysing data we have gathered from focus groups, the literature and the search threads to the most frequently used online resources to understand about the things that women perceive as important to their reproductive wellbeing. As a companion to this we will also be publishing a consensus statement amongst stakeholders about how they visualise the scope of provision in reproductive healthcare for the future. Lastly, we are developing a summary of the data about what we know about the nation’s reproductive health and these together will form the basis of the reproductive health part of the Sexual Health, Reproductive Health and HIV Action Plan going forward. Whilst being mindful of current constraints we hope that this will provide a roadmap for action for the future about what the system should and is able to deliver - and one that is firmly rooted in women’s needs and desires for care.
(1) Wellings, K et al The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) The Lancet 2013; 382 ( 9907): 1807-1816
(2) The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline. Hum Reprod. 2008 Jun;23 (6):1338-45.
(3) Bayer HealthCare, Contraception Atlas 2013, November 2013
(4) Public Health England (2016) Local Health and Care Planning: Menu of Interventions https://www.gov.uk/government/publications/local-health-and-care-planning-menu-of-preventative-interventions
(5) Department of Health (2012) The relationship between wellbeing and health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/295474/The_relationship_between_wellbeing_and_health.pdf