Ellie Blasse on Immediate Postpartum Contraception: A Lite Course for Midwives?
Date: 28 Jun 2018
Author: Ellie Blasse
Ellie Blasse's blog explores a pilot postpartum contraception course for midwives.
Between December 2016 and July 2017 a pilot postpartum contraception course was run at St Thomas’ Hospital to be able to provide midwives with the knowledge base and skills needed to develop this public health initiative and deliver contraceptive services on the postnatal ward. I had the opportunity to deliver a short oral presentation of this pilot at the FSRH ASM in May 2018 and this is what our work was all about.
The SHRINE Charity initiative approached Guys and St Thomas’ NHS Foundation Trust (GSTT) Maternity Safeguarding Team to discuss training the midwives to provide postpartum contraception to target vulnerable groups. There had always been a lack of services in this area of postnatal maternity care; midwives regularly accompanied clients to the on-site sexual health clinics for contraception and sexual health screening but as services moved out of the trust site to community health clinics this became more challenging. As a result the matron was calling on the services of a sexual health consultant (on bicycle!) to provide the most vulnerable mothers with immediate postpartum contraception to be able to give this group of women the choice for their reproductive health; utilising a small window of opportunity that maternity services have to improve the health and wellbeing of mothers and babies.
Between 2013-2017 a weekly consultant led SRH clinic on the site of two specialist addiction services, various homeless hostels and the continued targeted service on the postnatal ward showed a statistically significant decrease in the number of opioid dependant women on the postnatal ward at St Thomas’ Hospital. This demonstrated the value of targeted contraception services to vulnerable women supporting the case for midwives being trained to provide postpartum contraception.
Midwives are perfectly placed to provide public health information; pregnancy and the postpartum period gives healthcare access to women who at other times in their life may be hard to reach or struggle to access clinic settings. NICE recommends that midwives should have the knowledge to provide women with advice regarding all contraceptives within seven days of delivery. Additionally, the FRSH supports that there should be a provision for contraception to be provided to women immediately postpartum and prior to discharge if appropriate. Midwives are autonomous practitioners; they are able to facilitate antenatal, intrapartum and postnatal care in a range of settings; they hold additional clinical skills such as venepuncture, cannulation, and perineal suturing to name a few; therefore giving midwives the skills to provide women with contraception could be an ideal way to improve maternal healthcare without having to invest a large budget in new service provision.
What is the Moral and Economic Perspective?
It is key to gain the support of the stakeholders in being able to license a training course specifically for midwives and be able to deliver that course in maternity units. The long term health costs include reducing maternal and neonatal morbidity associated with short birth spacing or complications associated with medically complex pregnancy. Reducing the social care costs associated with babies being removed into foster care which includes the ongoing costs of court hearings, placements and lifetime costs associated with education, therapy services, housing, welfare benefits, criminal justice system and poor health such as cardiac disease, obesity and diabetes. BPAS reported that 10% of the patients seen in their clinic in one year were women who had delivered less than a year before suggesting that SRH services are not currently meeting the need of immediately postpartum women.
What does this course look like?
Specific FRSH e-learning modules were completed prior to SHRINE delivered a comprehensive interactive study day. Midwives were given the knowledge base with regards to all methods of contraception and then a more detailed understanding of progestogen only methods suitable for immediate administration and safe with lactation as well as the role of PGD’s and human rights in contraceptive choice.
Undertaking Practical Clinical Training in the sexual health clinics enabled us to be able to counsel women who were not immediately postpartum – understanding pregnancy risk assessment. It also exposed us to observation of the administration and removal of the SDI in the clinical setting as well as insertion if the IUS. SRH clinical settings supported us to understand women of all ages accessing sexual and reproductive health services; this foundation then led to being able to complete training on the postnatal ward with our target groups.
How do we rate the success of our pilot course?
I am coming up to a year post course and have implanted 30 women and have had the opportunity to counsel many more. The most satisfying part is seeing the genuine shock women display when informing them they will ovulate around day 28 postnatal. A number of women have accepted barrier methods and the myth busting around contraception and breastfeeding has been beneficial to the patients and to the midwives who are finding more confidence in having the contraceptive discussion. I would like to see these discussions beginning in the antenatal period the same way that breastfeeding, BCG and pertussis vaccination are part of the antenatal public health initiative.
I envisage that contraceptive courses will be embedded into the midwifery curriculum; a basic foundation pre-registration and development of the clinical skills as a post registration qualification. Midwifery practice should be hand in hand with sexual and reproductive health; maternal health and violence against women and girls should be high on the agenda for healthcare services. Providing these women with access to contraceptive information and choice in the immediate postpartum period means their basic human right to choose when to have a baby is enshrined.
Ellie is a FSRH short paper prize winner and presented her paper at the FSRH's Annual Scientific Meeting in May 2018.