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| Journal of the New Zealand Medical Association,
10-August-2012, Vol 125 No 1359
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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.
MethodsStudy population—The study
population consisted of:
Data
collection—
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.
ResultsWomen attending for termination of pregnancy (ToP)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.
Lead Maternity Carers (LMCs)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? DiscussionThe 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
References:
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