“I’m pleased to introduce a second, thought provoking blog from Research Fellow, Keira Lowther, in our “FNP: What next?” series. Keira outlines some of the evidence around the impact of subsequent pregnancies, the spacing between births, and the differences in effectiveness of different forms of contraception. She then sets out some issues and challenges, based on her conversations with FNP teams around the country – I’m really grateful to them for sharing their experiences and helping us move our thinking on.
"It looks as if the evidence is mixed around the impact of subsequent pregnancies, that most subsequent pregnancies in FNP mums may be unplanned, and that where they are planned the reasons are complex to unpick. We are committed to addressing this issue better. We think we will want to look more at how family nurses can support increased access to outreach contraceptive services, and we may want to differentiate more between planned and unplanned pregnancies, and on the spacing between pregnancies, in our monitoring and clinical focus. As ever, we are keen to learn and to improve outcomes for mothers and babies and welcome your thoughts. Join the conversation on Twitter: @FNPNationalUnit."
Ailsa Swarbrick, FNP National Unit Director
The Building Blocks trial showed that 66% of mothers in both the FNP group and the control group had another pregnancy within 24 months. In a similar way to our approach to understanding the FNP RCT findings for stopping smoking, we looked to the research on the effects and consequences of rapid subsequent pregnancies and into interventions with strong evidence of effectiveness. We also asked the FNP community about their experiences and why they thought this was a difficult outcome to change.
There is strong evidence that an interval of less than one year between the birth of one child and the conception of the next is associated with premature birth . This link remains strong in adolescents , although more recent evidence suggests that the link might not be straightforward. A study from Australia found that when pregnancy intervals were explored in the same mother (their sample was 40,441 mothers), the link between short interval and premature birth was weaker . They suggested that the link seen previously might be due to other unmeasured maternal characteristics, rather than the short interval itself. In addition, according to a recent systematic review of 58 studies, the understanding of specifically how a short pregnancy interval might affect preterm birth is currently weak (although growing) . Therefore, the evidence is not conclusive about the association between rapid subsequent pregnancy and premature birth.
For children’s outcomes, there is some evidence that an interpregnancy interval of less than 24 months is associated with neglectful parenting and poor warmth toward the first child (5). The first child is also more likely to have more behavioural problems (especially internalising) and lower cognitive functioning in first grade .
Research has shown that for adolescents, use of a long-acting reversible contraceptive (LARC) method (intrauterine device or contraceptive implant) is associated with better spacing of pregnancies (Odds Ratio 3.89) compared with hormonal control (OR 1.89) or no contraception at all (OR of 0.66), using barrier contraceptives as reference . LARCs are also most effective when initiated earlier after an abortion or within the postpartum period . Another study reported that leaving the hospital postpartum without initiating any contraception was associated with 2.5 times increased risk of repeat pregnancy within the next two years . Ethnographic research with young mums who had had a repeat pregnancy found that sexual activity was often spontaneous, unplanned, and sometimes involuntary and recommended that choice of contraceptive should be informed by this .
We spoke to eight FNP teams, who varied in their success at preventing rapid subsequent pregnancy, about their experiences.
We found that the reasons for having a planned pregnancy can be complex and varied.
Family nurses told us that when young mothers had a planned pregnancy, this was mostly affected by the presence of a new partner. New couples felt a baby would cement their relationship or at times the new partner wanted to have a baby of their own.
Mothers reportedly felt pressure to create the impression of a traditional family unit, and did this in several ways. To avoid the stigma of multiple children by multiple fathers, some would get pregnant if they felt their partner was thinking of leaving. Others might get pregnant again intentionally so social workers would see their family as a stable unit, particularly if there was a risk that the first child might be taken into care.
Family nurses felt that some women who had not been told they were good at anything before their experience of FNP would go on to have more children, especially if they enjoyed being a mother. This role also gave mothers a sense of purpose in their lives, especially when their economic opportunities were few.
Some mothers planned rapid subsequent pregnancies to have their children close in age, whilst others wanted to complete their family before they then returned to work or training.
In some cultures rapid pregnancies are planned and expected, and are encouraged as a sign of health. In other cases a subsequent pregnancy could be a replacement for a child taken into care, or born with a disability. One team in particular described how women who gave birth to a disabled child would become pregnant again to have the ‘perfect baby’, sometimes to prove that they could, to their extended family.
Subsequent unplanned pregnancy was more common for a number of reasons. Some women didn’t realise how fertile they were and fell pregnant while changing contraceptive methods, leaving them unprotected. Some were in denial about whether or not they could get pregnant, particularly those in unstable relationships. In some cases, rapid second pregnancy was the result of domestic violence, especially when there was a risk of the mother leaving. This would be more difficult with two children, rather than one.
Access to contraceptive outreach services was extremely effective in reducing unplanned pregnancies, with the FNP teams experiencing the fewest subsequent pregnancies all referring mothers to these services. Contraceptive decisions were also affected by peer support and experience. If mothers heard a negative story about a particular contraceptive option, they'd be much less likely to choose it for themselves. For example serious side effects experienced by a peer or family member would carry more weight than the minimal side effects professionals might advise them they could expect. Mixed messages were also sometimes received from professionals, which undermined their trust.
FNP practice focusses on supporting the young mother and her partner through the decision-making process and helping them both to think about what they would like for their future. They concentrate on building self-efficacy, with the view that “ambition is the best contraceptive”. Building self-efficacy is a slow process with a long trajectory, and obviously did not happen quickly enough for some mothers. Family nurses felt strongly that they should ultimately respect the decision of the mother after accompanying them through the decision making process.
Addressing the goal to reduce subsequent pregnancies will clearly be a complex process. Our early thinking is that we should look at how family nurses can support increased access to other services, such as outreach contraception. In addition, we think that it may be sensible to differentiate between planned and unplanned pregnancies in our monitoring and clinical focus, and to think further about spacing between pregnancies, as there appear to be quite different underlying causes and consequences. At the FNP National Unit, we’re taking these findings seriously to plan what our next steps should be. If you would like to work with us in this, please forward your interest to KLowther@fnp.nhs.uk or contact me on Twitter @keira_lowther