Setting up post birth contraception services in NW London

In this month’s eFeature, Dr Edward Mullins, together with midwifery, obstetrics and SRH colleagues, describes the process of setting up a new clinical service to introduce post birth contraception for all women in North West London. They outline the considerations and requirements at each stage of developing the service, including staffing and other resources, building a business case for a sustaining the service and using routine clinical datasets to support service evaluation and improvement.

With the onset of COVID-19 restrictions in late March 2020, the difficulties facing women in accessing effective contraception after birth rose rapidly. In order to prevent a crisis in unplanned pregnancy for the 29,000 women having babies in North West (NW) London annually, a collaboration of NW London obstetricians, midwives, sexual and reproductive healthcare (SRH) doctors and commissioners championed the provision of contraceptive options, compatible with breast-feeding, before women left maternity services.

With the support of our clinical director to utilise COVID response funding, we started practical training and arranged pharmacy supplies to our labour and postnatal wards. Midwives and obstetricians were trained together face-to-face and online in contraception counselling and fitting sub-dermal implants. We telephoned women at 6 weeks and 6 months after birth for feedback to refine our service.

Our aim was simply to provide women access to contraception post birth. We knew from 2019 commissioning data that without support to avoid unplanned pregnancy, within 12 months 3% of women would terminate a pregnancy and 1 in 13 women would deliver another baby. Our local data tallied with national surveys which indicated that more than 40% of women wanted to access reliable contraception immediately after delivery but most had failed to 6 months postnatally.

Providing women with effective contraception after having a baby is not a new idea and has been implemented successfully in many global settings. Lesley Regan had successfully introduced services in Tanzania and South Africa but was unable to do so in Paddington!

Our initial service was planned and delivered by a band 7 midwife who had self-funded her training in the FSRH diploma, two obstetric registrars, a SRH consultant and a former president of the Royal College of Obstetricians and Gynaecologists (RCOG). As we discussed implementing and building the service, it became clear that all of us had individually tried and failed to do so previously. Commissioning silos had made it nearly impossible to bring together funding and resources to provide reliable family planning into maternity services because funding followed the provider not the woman.

Within acute NHS trusts, this service could not show an in-year return on investment. SRH services with resources and expertise to provide long-acting reversible contraception (LARC) were unable to deliver contraception within maternity services. Before COVID hit we had all met bureaucratic brick walls, but the pandemic provided a highly disruptive influence which for us to overcome previously insurmountable administrative obstacles. 

As the pandemic progressed, we refined our original aim: to form a regional, midwife-led post birth contraception service with obstetric support and SRH input for women with complex contraception needs. We followed the excellent service models from West Lothian and the RCOG Leading Safe Choices projects. We set up online conferences to disseminate our experience and learnt of other successful initiatives across England, the majority unfunded and so at risk of being dropped after the pandemic. Our innovative midwives utilised the SRH LARC backlog to set up training lists for midwives and obstetricians to become skilled in sub-dermal implants (SDI) insertion, fast-tracking their experience which would have taken many weeks to achieve on postnatal wards.

Public Health England provided a return on investment (ROI) tool that demonstrated post birth contraception ROI was £16 for every £1 spent with NHS costs being recouped within two years. We worked with a superb commissioner to build a business case for the 9 NW London Clinical Commissioning Groups (CCGs), soon to morph into an Integrated Care System (ICS). This incorporated potential cost savings from reduction in abortion, maternity services and the service costs of staff training, contraception and provision.

In this plan for a future sustainable service, we also included costs for a full-time senior midwifery trainer, band 6/7 midwives for each maternity centre, administrative time and O&G consultant time to deliver staff training and support more complex contraception provision.

Evaluation is key in justifying the ongoing service. We audit our hospital electronic patient records system (EPRs) to assess counselling and contraception provision and are setting up automated surveys via the NW London Care Information Exchange to deliver information antenatally and collect patient experiences. To assess longer-term impact of the service, we will seek to use routine clinical datasets to support service evaluation and improvement in this and many other maternity services.

We hope to emulate the admirable West Lothian PPIUD service. Our experience to date is that we have found intra-uterine devices require the most training to provide and have observed unexpected complications when inserted after caesarean section. Providing intra-uterine contraception after vaginal birth is our next goal.

Providing this postpartum contraception service is highly rewarding but not easy to start or maintain. We believe the key is to empower midwives, who deliver the vast majority of care to low-risk women, to provide post birth contraception counselling and chosen method. Contraception training for midwives and obstetricians is highly variable and needs to be addressed nationally to ensure that women receive high quality information to make their decisions. The FSRH has been hugely supportive in providing subsidised certification, and allowing colleagues with the IO LOC competencies to act as secondary trainers removes a major barrier in maternity provision.

Facilitators and barriers vary across geographical regions, some services being led by maternity and others by SRH colleagues. It is essential to embed a regional service within the Local Maternity System and ICS, so that benefits are seen more widely, rather than by individual trusts.

We welcome inquiries from those wishing to set this service up in their area. Our business case, standard operating procedures (SOPs), guidelines, leaflets and training materials are available to all on request from Edward.mullins@imperial.ac.uk. We look forward to working with colleagues across the country to make this service available for the thousands of women a year who will benefit from it.

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This eFeature was written by Dr Edward Mullins (Clinical Lecturer at Imperial College, London and the George Institute for Global Health and Locum Consultant in Obstetrics and Gynaecology at Queen Charlotte’s and Chelsea Hospital, London) together with Claire Cousins (Midwife, Imperial College NHS Trust), Gillian Matthews (Midwife, St Mary’s Hospital, Imperial College NHS Trust), Dr Naomi Hampton (SRH Consultant, London Northwest NHS Trust), Dr Yasmin Mulji, (Imperial College NHS Trust) and Professor Lesley Regan (Professor of Obstetrics and Gynaecology at Imperial College's St Mary's Hospital Campus, and Honorary Consultant at the Imperial College NHS Trust).

Published in the October 2021 edition of the Sexual Health, Reproductive Health and HIV Policy eBulletin.  The content of all eFeatures represents the views and opinions of the authors. FSRH and coalition partners do not necessarily share or endorse the views expressed within them.