1. Contraception; the role of the midwife
Dr Catherine Angell

2. Aims of this session Discuss the midwife and public health
Debate the importance of contraception discussions with women
Identify the issues relating to discussing contraception with women at this time
Consider important considerations for women relating to contraception 
Discuss breastfeeding and contraception
Use a series of case studies to consider role of midwife and the appropriateness of different methods for different women  

3. The midwife and public health
‘You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support’
(NMC, The Code, 2007)
‘More than ever it is essential that midwives understand their pivotal and life enhancing role in public health’
(Edwards and Byrom, 2007)

4. Contraception as a personal and a public health issue
Personal issues:
Family size - money, housing, etc
Age gap between children
Recovery from last pregnancy and birth
Family and relationship changes
Public health issues:
Population growth
Infant feeding behaviours
Child health
Woman’s long term health
Sexual health

5. ‘To make choices women need information’
Critical thinking
Get into groups of 4-5. Discuss one of these statements in relation to the midwife’s role and contraception.
‘To make choices women need information’
(Evans, 2005)
‘Discussing contraceptive choices is a matter of finding the ‘least worst’ option’
(Belfield et al., 2009)
‘During pregnancy and the postpartum period women may be more receptive to different methods of contraception’
(Cwiak et al, 2004)

6. What happens in practice
Only 4% of women had opportunity to discuss contraception antenatally
Hospital postnatal discussions before discharge often very brief
Few women leave hospital with contraceptive supplies
Most definitive advice given at ‘6 week check’
Missed opportunity, especially for young or vulnerable women with limited previous use of contraception
(Evans, 2005)

7. Issues relating to contraceptive discussions
What barriers can you think of for women when seeking contraceptive advice?
Time, energy, embarrassment
Lack of understanding of fertility and reproduction
Social, cultural, religious issues
Changes in body and sex life after child birth
Gap between knowing about and acting on
Lack of continuity of care/interprofessional working

8. Fertility after birth
It is impossible to predict the return of fertility
Ovulation occurs before the first period in most women
For non breastfeeding women the earliest time women are likely to ovulate again is 25 days after birth...the average is 45 days
Feeding method is the most important determinant of return of fertility
50% of couples have had penetrative
sex within 6 weeks of birth...

9. What are the options?
Get into groups of 4 or 5. List as many contraceptive methods as you can in 2 minutes....

10. What did you find? Combined pill Progesterone only pill
Emergency contraception
Contraceptive injection
Contraceptive patch
Contraceptive implant
Intrauterine system (IUS) or Mirena
Vaginal ring
Male/female condoms
Intrauterine device (IUD)
Diaphragm
Cap
Sterilisation – male/female
Natural method
Breastfeeding

11. Knowledge grid
Each group has an information sheet from NHS website, FPA or Brook on one method. Read the sheet.
Note key points to feed back to the class and put onto our knowledge grid
Look at issues of
Reliability
STI protection
When to use after childbirth
Combining with breastfeeding
A major advantage
A major disadvantage

12. An extra note about breastfeeding
Breastfeeding is the most widely used form of contraception in the world
Breastfeeding can be up to 98% effective in preventing pregnancy
BUT breastfeeding must be
Exclusive
Regular
Baby under 6 months old

13. Important considerations for women
What do you think is important for women when choosing contraceptive methods? What and who influences their decisions? Are some issues more important than others? Are everyone’s priorities the same? In your groups write down as many considerations as you can

14. Influences on women’s choices
Pregnancy prevention
STI prevention
Health considerations
Breastfeeding
Mechanical v. Hormonal
Previous infertility
Future plans
Ease of use
Cost
Lifestyle
Remembering
Embarrassment
Partner’s views
Health care providers
Religious views ?

15. Contraception for individuals... everyone is different
Get into groups of 4 or 5
Read the scenario you have been given
Discuss the scenario. You may want to focus on:
What is important to that woman?
What health needs does she have?
What methods might be appropriate for her?
What care can you offer her?

16. Fiona
Fiona has just had a normal birth. This was her 4th baby in 6 years. She had a PPH and is anaemic and very tired. She is breastfeeding. She is in a stable relationship with a long term partner. They have not decided whether their family is complete yet.

17. Geraldine
Geraldine met her partner when she was 38 and he was 49. She is now 42. She has some difficulty conceiving and had IVF for this pregnancy. Geraldine has just had her first baby by LSCS. She is breastfeeding but wants to combine this with formula as soon as possible. She and her partner do not anticipate having another child.

18. Helen
Helen is 22. She has just had her first baby at home. She is breastfeeding. She conceived her baby whilst on a year working in the Caribbean. She was taking the pill at the time. She came home to stay with her parents for the birth but plans to go abroad again with her baby to live and work in the surf shop that she left prior to coming home. She has no partner there but lots of friends who can support her.

19. Izzy
Izzy has just had her 2nd child. She is 19 and lives in temporary council accommodation. She took the pill for a while when she had a regular partner but didn’t like going to see her GP and her prescription ran out. She sometimes uses condoms. She has no partner at present and has no plans to start a relationship.

20. Jennifer
Jennifer has just had her 3rd baby, and her 3rd LSCS. She has had pre-eclampsia twice, which was worse on this occasion. She is very keen not to have more children. She and her husband are both 40 and are in a stable and long term relationship.

21. Karen
Karen has just had her second baby. She is breastfeeding at present and hopes to continue for a while. She and her partner did not use contraceptives between pregnancies and they have not thought about contraception yet. Although they might want another baby Karen wants something fairly reliable for the time being. She thinks that she gets side effects, such as weight gain, from hormone based methods.

22. Feedback
Did you end up with a single choice or a range of choices for each woman?
Was there one or numerous factors that might influence her choice?
Do you think your own views or experiences influenced the choices you thought would be suitable?

23. What do you think is the midwife’s role...
The role of the midwife
What do you think is the midwife’s role...
Encouraging planning of contraception?
Discussion of the options?
Referral?

24. A note about folic acid...
Taking folic acid prior to conception is beneficial in reducing neural tube defects
Discussing this with women may encourage use of folic acid when they plan next pregnancy
This is an important aspect of family planning

25. Final thought...safe sex in pregnancy
Women may not worry about the risk of pregnancy in the antenatal period... BUT for some having unprotected sex in pregnancy may leave them at risk from STIs

26. Thank you!
Dr Catherine Angell