Improving secondary prevention and integrated primary care for unwanted pregnancies: Insights from general practitioners, midwives, unwanted pregnant women and their significant others in the Netherlands

BACKGROUND Unwanted pregnancy (UWP) has been defined as a pregnancy occurring when no (more) children were desired. In 2016, approx. 37,000 to 57,000 Dutch women had UWPs. In international research, UWPs were related to maternal and offspring psychosocial and health problems. Primary care providers (general practitioners (GP) and midwives) provide care, UWP options counselling and support for women and their significant others once confronted with an UWP. They monitor outcomes and provide aftercare and secondary prevention, e.g. contraceptive care to reduce repeat UWP. Yet, knowledge is scarce on Dutch rates of UWPs and groups at risk attending primary care (GP and midwifery care). It has been estimated that each GP sees 2-3 Dutch UWP-women per year indicating a low frequency of UWPs in daily practice. Thus, primary care providers may not have much experience in counseling, supporting, and providing secondary prevention for UWP-women, especially when these women stem from high risk groups, e.g. migrants, possibly having specific care needs. This may affect the care providers’ ability to adequately consider care needs and psychosocial problems and to provide appropriate care. A Dutch review indicated that there is a lack of coherence and cooperation among Dutch (primary) care providers and organizations involved in UWP care. Vulnerable (young) women with UWPs often have to find their own way in receiving adequate care. Thus, cooperation among primary care providers offering Integrated Primary Care (IPC) and quality of IPC concerning UWP needs improvement. AIMS Our project aims to improve IPC for and secondary prevention of UWPs, by: (a) Generating new insights into rates of (repeat) UWP in primary care, groups highly at risk of UWPs, and care pathways concerning UWPs; (b) Exploring care needs regarding IPC, from perspectives of UWP-women, significant others, and primary care providers; (c) Examining feasibility and potential effectiveness of a strategy, i.e. an adjusted intervention to improve IPC for and secondary prevention of UWP, particularly in high risk groups. METHODS Within a period of 48 months we will conduct three interconnected studies using quantitative, qualitative and participatory action research methods. Study I will examine: (a) rates of (repeat) UWPs and contraceptive use, care pathways and UWP outcomes among pregnant clients and (b) identify groups at high risk of (repeat) UWP using quantitative epidemiological methods, e.g. descriptive statistics and multilevel multivariable logistic regression analyses. Data will be derived from Dutch GP databases, and a large midwifery database (VeCas). These databases jointly consist of about 270 GP and midwifery practices with anonymous routine data of about one million people. UWPs will be identified via standardized codes used in the databases and open text field analyses of electronic medical files filled in by GPs. Study II will explore experiences and needs for IPC care provided by primary care providers in case of UWPs. Approx. 45 women, significant others, and primary care providers (midwives and GPs) will be interviewed. Study III will examine the feasibility and potential effectiveness of strategies and an adjusted intervention to improve IPC for and secondary prevention of UWPs, by using the ‘ACTion toolkit for implementation’ in a participatory action research study. A Learning Community (LC) will be formed consisting of approx. 9 members involved in UWPs: Experts by Experience (UWP-women), enrolled via Fiom, Zorgbelang, or Sterk uit Armoede, primary care providers, two medical or midwifery students from AVAG and UMCG, (primary care) researchers, and a facilitator. The LC will conduct four steps: (1) Identifying an intervention to improve IPC for and secondary prevention of UWP; (2) Adjusting this intervention for high risk groups using findings from Study I & II; (3) Implementing the adjusted intervention and conducting a single-arm pilot study to examine its feasibility using self-reported contraception use and interviews assessing experiences of participating UWP-women; and (4) Dissemination of results. DELIVERABLES Project deliverables will include: First, we will depict rates of UWPs, care pathways and outcomes regarding UWPs in Dutch primary care. Second, high risk groups of UWP will be identified. Third, experiences of and needs for IPC, from perspectives of women, significant others and primary care providers will be revealed. Finally, for implementation and dissemination purposes, strategies, communication plans and scientific publications will be generated. Deliverables will comprise factsheets, a final report, additional tools to guide UWP-women, and recommendations for education programs and guidelines for GPs and midwives. The feasibility level of an adjusted intervention to improve IPC and secondary prevention of UWP, will be reported. Our project will contribute to the improvement of IPC for and secondary prevention of UWP.