Background
Methods
Setting
Study design
Design of Quality Improvement Collaborative (QIC)
Learning Seminars (LS) | Themes for the seminar | Activities at the seminar Discussions/teamwork | Homework and activities after the seminar |
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LS 1 (Dec 2018) | Why do we need to improve contraceptive services? Update relevant research from the field regarding: Risk-factors for unintended pregnancy Best practice contraceptive counselling postpartum Local data from the SPR regarding women’s choice of contraceptive methods postpartum Improvement in health care and theory. Introduction of driver diagram Introduction to the tool Plan-Do-Study-Act How to work in a team in a QIC | Identify obstacles in; -providing contraceptives services postpartum -registering women’s choice of contraceptive method postpartum in the SPR Introduction to visual tool illustrating the effectiveness of contraceptive methods Discuss and set goals for the QIC: What do we want to accomplish? | Continue to identify possible obstacles and possibilities at each MHC Continue to register women’s choice of contraceptives postpartum in the SPR Test visual tool illustrating the effectiveness of different contraceptive methods Test offer information about contraceptive methods during gestational weeks 36–38 Test book the postpartum visit during pregnancy. |
LS 2 (March 2019) | Analyse results in SPR. RLP, a tool for person-centred counselling Midwives’ experiences of improvement activities Clarify the goals of the work. What changes are we planning to make? | Share experiences of registering women’s choice of contraceptive method in the SPR Reflect on how to use RLP in the conversation about contraception Share experiences of improvement activities Choose future testing areas | Continue to register women’s choice of contraceptives postpartum Continue using the visual tool Continue offering information about contraceptive methods and offer prescriptions during gestational weeks 36–38 Test book appointments for contraceptive services postpartum Test to develop a stock of LARC |
LS 3 (June 2019) | Analyse results regarding women’s choice of contraceptive method in the SPR Lecture in best practice contraceptive methods postpartum, including natural family planning User feedback: Immigrant women’s and Swedish-born women’s views on teams’ improvement activities Midwives’ experiences of improvement activities | Share experiences of register women’s choice of contraceptive method postpartum Share experiences of improvement activities Reflect on users’ views in the QIC | Continue to register women’s choice of contraceptives postpartum Continue using the visual tool Continue offering information about contraceptive methods and prescription during gestational weeks 36–38 Continue to book appointments for contraceptive services postpartum Maintain the stock of LARC |
LS 4 (Oct 2019) | Analyse the results so far from the SPR User feedback: Immigrant women’s and Swedish-born women’s views on teams’ actions Future work | Reflect on users’ views in the QIC How to keep on reaching the goal? How can we create sustainability? | Continue to register women’s choice of contraceptives postpartum Continue using the visual tool Continue offering information about Contraceptive methods during gestational weeks 36–38 Continue to book appointments for contraceptive counselling postpartum Maintain the stock of LARC |
Qualitative data collection and analysis
Quantitative data collection and analysis
Ethical considerations
Results
Activities decided upon for the learning seminars and action periods
Quantitative results
Immigrant women’s choice of more effective contraceptive methods
Characteristic | Number of women (%) |
---|---|
Clinic | |
MHC a | 346 (61) |
MHC b | 129 (23) |
MHC c | 92 (16) |
Para | |
0 | 234 (41) |
1 | 188 (33) |
2 | 114 (20) |
3+ | 31 (6) |
Level of education | |
No education/less than 9 years | 6 (1) |
Primary school (9 years) | 34 (6) |
Secondary school (12 years) | 230 (41) |
University | 251 (44) |
Missing | 46 (8) |
Country of birth | |
Sweden | 271 (48) |
Middle-East/North-Africa | 152 (27) |
Other | 144 (25) |
Baseline/LS1 Pre-QIC 1st Sep-12th Dec 2018 | LS2 (13th Dec 2018-5th March 2019) | LS3 (6th March-4th June 2019) | LS4 (5th June-31st Aug 2019) | Increase in more effective method in % | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Less effective/ no methodb n (%) | More effective methodsa n (%) | Less effective/ No methodb n (%) | More effective methodsa n (%) | Less effective/ no methodb n (%) | More effective methodsa n (%) | Less effective/ no methodb n (%) | More effective methodsa n (%) | LS4 vs. LS1 | LS3 vs. LS1 | LS2 vs. LS1 | |
Immigrants | 51 (70) | 22 (30) | 30 (48) | 33 (52) | 34 (45) | 41 (55) | 45 (53) | 40 (47) | + 16.9 (0.03)c | + 24.5 | + 22.2 |
TOTAL | 98 (64) | 55 (36) | 49 (45) | 59 (55) | 66 (46) | 78 (54) | 80 (49) | 82 (51) | + 14.7 (0.008)c | + 18.2 | + 18.7 |
Qualitative results
Development of contraceptive counselling – conveying information and relational aspects
Regarding the relational aspects of counselling, midwives described an increased use of open-ended questions after the QIC. Several midwives were positive about the experience of using a person-centred approach inspired by reproductive life planning, and had started asking questions such as “How many children would you like to have?, and “How long would you like to wait until you become pregnant again?”“I think it’s natural to talk about ovulation and the need for contraception postpartum …it feels better to initiate the topic at the end of pregnancy… I didn’t do it before; now it feels strange to exclude it …..the talk seems to prepare women …and I think it motivates attendance at the postpartum visit” (Midwife MHC A)
Increasing attendance and access to contraceptive services postpartum
“I have offered and inserted more intrauterine devices and systems at the first visit six weeks postpartum, as women expressed the wish to resume sexual activity” (Midwife MHC B)
Experiences of registering women’s choice of contraceptive method
“I did not systematically ask about women’s contraceptive needs… before we started to collect the data. It is a more natural part of the postpartum visit now compared to before” (Midwife MHC C)
Midwives’ experiences of participating in the QIC
In the written evaluation after the QIC was finalised, almost all midwives reported that the tested improvement activities (secondary drivers, Fig. 2) would continue as implemented activities in contraceptive services during pregnancy and postpartum.“In consultations where women previously declined contraceptive methods… I have started to offer a conversation, which I didn’t before… I have also changed my approach to how I provide information and talk about contraception…. I include positive health effects nowadays and I believe that more women decide to use a method compared to before (this project)….” (Midwife MHC A)