Journal of the New Zealand Medical Association, 10-August-2012, Vol 125 No 1359
Unintended pregnancy and therapeutic abortion in the postpartum period. Is an opportunity to intervene being missed?
With perfect use of contraception in the postnatal period the rate of unintended pregnancy can be reduced to less than 1%.1,2 During pregnancy and the postnatal period women have regular contact with healthcare providers who are trained in the provision of contraceptive advice, and are likely to be receptive to this advice.3 Rates far higher than this however are seen in practice,4,5 suggesting that less than adequate contraceptive practices may be being used.
There are over 2000 abortions performed in Waikato District Health Board (DHB) clinics each year. A number of these women have recently given birth and cite the inability to cope with another baby within a year of the last one, as a reason for requesting the abortion.
In order to introduce an effective intervention to address the current situation, the barriers to successful contraceptive use and reasons behind them need to be identified.
A study has not been carried out previously in this specific group of women. The aims of this study are to identify barriers and facilitators; and to make recommendations on intervention strategies to overcome them as the current provisions appear to be failing a number of women. By identifying the barriers to achieving adequate contraception it is hoped that recommendations can be made on interventions to facilitate this.
Study population—The study population consisted of:
In this clinic women with unintended pregnancies of less than 13 weeks gestation are seen by Certifying Consultants - doctors appointed by the Abortion Supervisory Committee.
From 1 January 2009 to 31 December 2009 all women attending the First Trimester Termination of Pregnancy Clinics at Waikato Hospital, who had given birth to a live infant less than 6 months before the date of their scheduled abortion, were invited to take part in the study by the Certifying Consultant.
Women were excluded if they were unable to give informed consent to the study or if the multidisciplinary team assessed her to be at risk of harm from taking part in the study.
Women who gave informed consent to the study undertook a self-complete questionnaire on the day of their termination of pregnancy.
The questionnaire obtained information on: The preceding pregnancy, and the woman’s recollection of contraceptive counselling and prescription provision following it; the barriers which the woman identified as contributing to her unintended pregnancy; and interventions which she feels would have helped prevent it.
The questionnaires asked for demographic data and then used four closed multi-choice questions and three open questions allowing free text answers. Ethnicity was determined by self selection using the abortion supervisory commission categories or allowing free text if ‘other’ was chosen. Data is presented in Tables 1–5.
Questionnaires asked LMCs about: their contraceptive prescribing practices; barriers that LMCs identify in its provision, and in women’s uptake; and suggestions as to how these could be overcome. Demographic data was collected and six closed multi-choice questions were asked followed by the same three open questions as asked to the women. Data is shown in Tables 6–11.
Analysis—Quantitative data is presented in numerical format.
Participants’ free-text comments were analysed by thematic analysis: Themes in the data were identified independently by both researchers and themes were collated and presented in Table 12.
Twenty-six women who were identified as eligible agreed to enrol in the study. Four women enrolled but subsequently felt they did not have time to complete the questionnaire; 22 women then completed the questionnaire.
Demographic data is presented in Table 1
Table 1. Demographics of the study population
N/A = data not available; ToP = termination of pregnancy; NZE = NZ European; MELAA = Middle Eastern/Latin American/African.
All 22 of the women reported that their lead maternity carer for the preceding pregnancy was a midwife.
Almost all the women (20/22) remember discussing contraception with someone during their pregnancy, many with multiple professionals.
Only six women reported being provided with a prescription for contraception four of these prescriptions were for the PoP and were filled, and two were for condoms which were not then taken to a pharmacy—leaving the majority of the women with no contraceptive provision.
All of the women reported previously accessing contraception; with eighteen reporting multiple previous methods used and from a variety of sources. No women identified lack knowledge about contraception as being a barrier to their accessing contraception. There was however quite a low reported previous access to the emergency contraceptive pill (ECP). The most common reason cited as a barrier to accessing contraception was cost.
Table 2. (Q) Do you remember talking about contraception (birth control) while pregnant or after you had your youngest baby with:
Table 3. (Q) Have you ever accessed contraception (birth control) before?
If yes, what have you accessed?
IUCD= Intrauterine contraceptive device
Table 4. (Q) If yes, where have you accessed contraception (birth control) from?
Table 5. (Q) What, if any, barriers/problems have you met to accessing contraception (birth control)?
When asked for the ‘main reasons for conceiving so soon after having their last baby; what and who could have prevented this from happening’ the women identified a number of factors which have been analysed by theme and listed in table 15 and include: financial and time constraints; problems accessing healthcare; lack of information or knowledge; and a strong theme of ‘self blame’ for the pregnancy.
Fifty-nine LMCs responded to the questionnaire. All but one of the LMCs who responded were midwives—at present there are no General Practitioners undertaking LMC work in the region.
Almost all of the LMCs who responded to the questionnaire identified as NZ European ethnicity.
All LMCs reported discussing contraception with every one of their women, however this is often left until after the baby is born, or even until the 6-week discharge.
The vast majority of the prescriptions given are reported to be for progesterone only pills or for condoms, with only 2 reporting prescribing the emergency contraceptive pill.
Twenty-four of the 59 LMCs reported holding a postgraduate qualification in contraception, or having attended any specialist training courses.
Table 6. (Q) Do you identify as:
Respondents gave more than one ethnicity.
Table 7. (Q) Approximately what percentage of your women do you discuss contraception with:
Table 8. (Q) Approximately what percentage of your women do you provide with contraceptive supplies or a prescription?
Table 9. (Q) What do you routinely supply/ prescribe?
LAM= Lactational amenorrhoea method; NFP=Natural Family Planning,
COCP=Combined Oral contraceptive pill.
Table 10. (Q) At what time would you usually give these supplies/prescription?
Table 11. Q. Do you routinely refer women to other contraceptive providers?
In analysing the qualitative data in addition to supporting many of the same barriers and suggestions that the women provided two strong themes emerged from the qualitative data from the LMC questionnaires: Lack of LMC Knowledge and LMC attitudes.
Table 12. Themes identified from qualitative data.
Questions asked with free text allowed for response: Women:
What would help you accessing contraception? And why?
What do you think was the main reason/reasons that you became pregnant again so soon after having your last baby?
What do you think could, or should, have been done to prevent this happening?
And who would have been best to do that? And why?
Questions asked with free text allowed for response: LMCs:
What, if any barriers do you meet in providing women with contraceptive advice/provisions?
What do you think would help overcome these?
What, if any, barriers do you identify that women experience in accessing postnatal contraception?
What do you think would help overcome these?
The current maternity care provisions in New Zealand are that pregnant women are required to choose one Lead Maternity Carer (LMC) who coordinates their maternity care. Lead Maternity Carers are contracted through the Ministry of Health to provide a complete maternity service. The majority of women choose a midwife as their LMC, and will have their care provided free through the LMC system.
Each woman signs a contract with her LMC which stipulates the care that she should expect. One of these provisions is advice regarding contraception.6
Only 19 of the women reported recalling their LMC discussing contraception with them during or after their preceding pregnancy. All of the LMCs reported discussing contraception with all of their women, however the majority leave this until after the baby is born, when the woman is likely to be less able to make arrangements for contraception while caring for her infant; or even until the 6-week discharge appointment—by which time a number of women in this study had already conceived.
The majority of prescriptions and counselling by LMCs was towards methods which require significant ‘user compliance’ such as the progestogen only pill (PoP) or condoms, the success of which relies heavily upon the correct usage – at a busy time in a woman’s life this is likely to be lower. Recent international guidance 8 is advising a move toward longer acting and ‘intercourse independent’ methods. Only six of the women reported being provided with a prescription, and this was for either a PoP or condoms and only the four prescriptions for the PoP were filled.
The most common barrier identified by the women to accessing contraception was financial. Under current maternity funding women can only access a funded consultation for postnatal contraception from their Lead Maternity Carer, and many women in the study group expressed preference to seek consultation elsewhere. The majority of the LMCs also report regularly referring their women on to other providers such as the Family Planning Clinic or a General Practitioner for further contraceptive advice or prescription.
As more than half the women reported being in a low income group they may not be able to afford a consultation with an alternative provider at a time when they may have other financial pressures. There was also a discrepancy in the ethnicities of the women and LMCs: with the majority of LMCs being European while the majority of the women identify as non-European. Women may prefer to choose a health provider who she feels is more culturally appropriate for her.
Both the women and the LMCs identified: time pressure on new mums, waiting lists at healthcare facilities and the centralisation of healthcare resources in urban areas as a barrier to women accessing these facilities.
While women did not directly identify lack of knowledge as a reason for the unintended pregnancy their responses do suggest a need for further education as their pregnancy was often explained by forgotten or missed pills, inability to negotiate condom use, being unaware that they could conceive while breastfeeding and not being aware of all the options option to them.
The majority of the women report breast feeding until at least six weeks postpartum and even up until the time of the ToP, indicating that this has not provided adequate contraception to prevent the unintended pregnancy.
Ability to give contraceptive advice is a required competency for registration with the New Zealand Midwifery Council7 Less than half of the LMCs admitted to having attended any postgraduate training in contraception or Family Planning – and many of those added a footnote that this was quite a while ago.
While some of the LMCs showed high levels of understanding and knowledge through their answers others freely admitted their ignorance.
“Because I do not feel very confident with my knowledge base...or prescribing pills or inj(ection)”
“I do not feel I should be prescribing pills, only condoms”
“Need more updates”
“I feel out of my depth prescribing”
“lack of knowledge & understanding to be able to prescribe safely”
“Not comfortable prescribing more than minipill or condoms”
“I only prescribe mini pill or condom”
Through the answers there was also evidence of what has been described by educationalists as unconscious incompetence (i.e. “you don't know that you don't know something”),9—with evidence of inappropriate prescribing practices including prescribing diaphragms and the use of ‘natural family planning’ –which would be considered contraindicated during the puerperium;1,8 and also a lack of knowledge regarding the rapid return of fertility following birth.
In addition there was evidence of somewhat derogatory attitudes towards the task of educating the women, or addressing the issue of preventing unintended pregnancy.
“Women’s laziness to attend appointments or get script filled”
“Can’t get their act together to do some self care”
“Cant be bothered”
“Next baby = WINZ will pay, no incentive to stop”
“Women who sometimes have a blazé (sic) approach to contraceptive”
“I think women are their own worst enemies—they are conditioned not to take responsibility”
“Too busy, too poor, too unmotivated”
A strong theme throughout the women’s answers was that of self blame – with the women taking the culpability for the pregnancy—apparently unaware of the responsibility which should be held by their care givers.
For example: four women state that the provision of contraceptive counselling, as stated within the LMC contract and stipulated within midwifery training could have prevented their pregnancies:
“I think it would be good if midwifes (sic) made sure their clients were on contraception before they sign off” “Whether you asked for it or not” as they are the “Last person to see women before fertile”. And in asking to “Hav(e) contraception come around to your door and people explaining each one to you to make it easier for you”.
A weakness of this study is the small numbers recruited and by only capturing the information of women actively recruited during a busy clinic it is not possible to quantify the number of women affected each year, as women who were eligible may have been unintentionally omitted.
The response rate from the LMCs was also low. Also of note, the women recruited were not necessarily cared for by the LMCs who responded and in order to preserve anonymity this could not be tracked.
In addition to the women who have abortions there can also be expected to be a significant number of women who conceive an unintended pregnancy in the postnatal period and continue the pregnancy, who are also not represented in this study.
Women with unintended pregnancies are less likely to access early pregnancy care and more likely to be exposed to teratogens during pregnancy. Unintended pregnancies are more likely to result in a preterm birth, infant of low birth weight or a perinatal death. In addition short inter-pregnancy interval are at increased risk of adverse outcomes: intervals of less than 6 months have been associated with increased risk of preterm birth, perinatal death, maternal death, third trimester bleeding, premature rupture of membranes and puerperal endometritis. 11,12
Children that are the result of an unintended pregnancy are more likely to suffer abuse or neglect and to have weaker relationships with their parents and to have delayed early childhood development. Mothers of unintended pregnancies are more likely to suffer from depression and to experience domestic violence. 13
Thus interventions to reduce both ‘unwanted’ and ‘mistimed’ pregnancies 10 can be expected to have positive effects on the woman, her family and her subsequent children.
Competing interests: None known.
Author information: Karen Joseph, Gynaecology Registrar Christchurch Women’s Hospital. Anna Whitehead, Family Planning Locality Medical Advisor, Hamilton
Acknowledgements: This study was supported by a grant from the Margaret Sparrow Research Fund. We thank the first certifying consultants at the termination of pregnancy clinic; and the women and LMCs who took the time to complete the questionnaires.
Correspondence: Karen Joseph, Christchurch Women’s Hospital., Private Bag 4711 Christchurch, New Zealand. Email: Karen.Joseph@cdhb.govt.nz
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