This article describes the development and audit of a nurse-led contraceptive and sexual health drop-in clinic for young parents
Mansey, J. (2009) Setting up a nurse-led contraceptive clinic for young parents. Nursing Times; 105: 11.
This article describes the development of a nurse-led contraceptive and sexual health drop-in clinic, which runs alongside an existing young parents’ drop-in service provided by a charity called Key to the Door.
The clinic provides young parents, whose average age is 16–25, with access to a variety of first-issue contraceptive methods and screening for sexually transmitted infections (STIs). The article explains how the service was developed and provides information from an audit, which shows the clinic’s effectiveness and positive outcomes for service users.
Keywords: Sexual health, Contraception, Health promotion
This article has been double-blind peer reviewed
Jackie Mansey, MSc, BSc, RM, SCPHN (HV), RGN, is clinical outreach nurse, contraceptive and sexual health service, Oldham Community Health Services, part of Oldham PCT.
Implications for practice
- Partnership working between healthcare professionals, clients and existing non-NHS services is crucial to developing successful projects.
- Using different communication methods is necessary, as appropriate for the client group.
- Young parents prefer to access services that are designed following consultation and which aim to meet their expressed needs.
- Further work is necessary to meet young fathers’ and young men’s sexual health needs.
- Increasing access to contraceptive and sexual health services for young parents also increases access to general health promotion advice and provides an opportunity to identify other health needs.
- One in five babies conceived by under-18s are by young women who are already mothers (Department of Health and Department for Children, Schools and Families, 2007).
- Smith et al (2003) identified that women who are most likely to have short interpregnancy intervals are those who have lost a baby and young parents.
- The risks involved with short intervals include anaemia, maternal haemorrhage and maternal death, intrauterine growth retardation and neonatal death (Smith et al, 2003; Conde-Agudelo, 2000).
Since young mothers are among those most likely to have short interpregnancy intervals, it is vital they have access to up-to-date information and knowledge to allow them to plan their families safely.
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The Department of Health and the Department for Children, Schools and Families (2007) highlighted that many young mothers are unaware of how easy it is to become pregnant after having a baby and are ill-informed about the range of contraception available.
The report identified the difficulties that teenage parents have in accessing mainstream contraceptive services and recommended proactive support to help them avoid repeat pregnancies.
Supporting families from disadvantaged groups is key to tackling health inequalities (DH, 2003). The DH (2007) outlined a vision for providing personalised care for the most vulnerable and those in greatest need, providing access to services at a time and place of their choice.
Developing the service
Part of my role as a clinical outreach nurse with the contraceptive and sexual health (CASH) service in Oldham is networking and building sustainable working partnerships with community services and voluntary groups. The aim is to improve access to these services for clients who are vulnerable or from hard-to-reach groups.
Key to the Door is a local charity that provides projects for young parents including a new weekly drop-in service at a residents’ centre. The drop-in provides crèche facilities, arts and crafts, computer skills training, physical activities such as dance and exercise, cooking skills training, and advice on issues such as employment, benefits and housing. This service brings young parents together to share experiences and helps to counter feelings of isolation.
The charity approached me when it acquired funding for the young parents’ drop-in session, asking what I could offer as a clinical outreach nurse. I consulted the young parents and agreed to attend the drop-in on a weekly basis, as long as this was what clients wanted.
The service started in January 2008. Sessions take place every Wednesday, apart from school holidays, at 11am–2pm at a tenants hall quite close to Oldham town centre. Crèche places are provided on a first come, first served basis with places for 20 children.
There was no formal publicity and the majority of young parents heard about the drop-in through word of mouth. They choose to access the Key to the Door service regularly and come from a wide variety of areas in the borough, despite the fact that transport is not provided. This proves that parents are choosing this service rather than accessing those available in their own areas. There is no age limit but the majority of clients are aged 16–25 years.
The Key to the Door drop-in is provided for young mothers and the nurse-led CASH service runs alongside it. However, any partners of young mothers or any young fathers would not be refused a CASH consultation if they did choose to access the service.
The nurse-led drop-in clinic operates in a lockable side room which ensures privacy, and confidential consultation and assessment. It offers a range of services:
- Full sexual health needs assessment;
- Screening for asymptomatic STIs;
- First-issue contraception using patient group directions;
- Improved access to long-acting reversible contraception (LARC) (NICE, 2005);
- Condom provision;
- Emergency contraception;
- Pregnancy testing;
- Counselling and referral for termination of pregnancy;
- General health promotion advice.
The drop-in clinic aims to:
- Improve overall access to contraceptive and sexual health services;
- Prevent STIs and unplanned pregnancies;
- Research young parents’ needs in terms of accessing universal services;
- Support young parents’ emotional well-being.
The CASH drop-in clinic was audited from the start of the service in January until the start of July 2008. In total, 19 sessions were held, with 78 consultations plus informal chats around the table. For more details on the types of consultation and services provided, see Table 1.
Nurses working in primary care are now able to undertake screening for asymptomatic chlamydia and gonorrhoea using a simple urine test or vulvovaginal swab as part of the Greater Manchester chlamydia screening programme, known as RU CLEAR. This service aims to increase access to screening for clients aged under 25. However, those attending the drop-in clinic over 25 can also be screened as part of mainstream arrangements with the PCT.
Facilities are limited at the tenants’ centre and, because there is no formal medical/treatment room, I am unable to examine clients with STI symptoms such as genital warts or genital herpes. Any clients with STI symptoms are referred to the genitourinary medicine (GUM) clinic at the hospital by a fast- track arrangement. The drop-in clinic then provides young parents with an opportunity to discuss their experience and any treatments needed, and for further discussion about safer sex advice and preventing infection.
|Table 1. Type of consultation|
|RU CLEAR tests||15|
|Combined oral contraceptive pill||3|
|Progesterone-only contraceptive pill||3|
|Progesterone-only emergency contraception||2|
|Implant insertion consultation and appointment||4|
|Implant removal consultation and appointment||7|
|Intrauterine device consultation and appointment||3|
|Termination of pregnancy counselling and referral||3|
|Referral to others||3|
Sometimes the drop-in clinic can be busy, with as many as 10 clients seen in one session, but, at other times, fewer parents attend. This provides an opportunity for me to sit around the table and join in general discussions with young women, which helps to build positive relationships. There is much informal discussion about sex and STIs around the table.
While I always endeavour to ensure absolute client confidentiality, I have been surprised by the openness and information-sharing that takes place between the women. These discussions have also revealed a clear lack of understanding and basic knowledge of sex, relationships and contraception.
Some young parents were slow to engage at first but, as we have developed a rapport, numbers attending the drop-in clinic are steadily increasing. I have developed trusting relationships with clients, leading to the identification of young women with high alcohol consumption, substance misuse, risky sexual behaviours, urogynaecological symptoms and sexual difficulties. Other clients have disclosed domestic violence problems and emotional difficulties.
Referrals have been made to other services as appropriate, and clients have reported very positive outcomes from these.
Advising young parents
As shown in Table 1, a large number of consultations are for advice. Much of this is around the different methods of contraception that clients use, especially in relation to missed pill advice and side-effects. Much of my time is spent dispelling myths about various aspects of sex and contraception. Some clients have completely misunderstood how to use the combined pill or patches and have needed the information explaining repeatedly. Others have been worried about weight gain and bleeding problems caused by various contraceptive methods.
Providing this opportunity for young parents to discuss their concerns has helped to improve compliance with different methods, especially with contraceptive injections and implants. In addition, while some weight gain is a recognised side-effect of a number of hormonal contraceptives (Guillebaud, 2007), anecdotal evidence has shown that sometimes it is caused by young mothers’ change in lifestyle and by their own poor diet and lack of exercise. The drop-in clinic helps to address such issues and provides general health promotion advice.
Some 45% of all teenage mothers smoke throughout their pregnancy, compared with 17% of older mothers (DH and DCSF, 2007). Many mothers attending the drop-in clinic are smokers and have repeatedly asked for my help in quitting. In response to this request I have enlisted the support of the PCT’s smoking cessation specialists. As a result, a number of parents have stopped smoking and others are working closely with the smoking cessation team regularly as they now also attend the Key to the Door drop-in.
|Box 1. Key outcomes for service users|
|Improved awareness of contraception and STIs|
|Increased access to contraception and sexual heath services, especially LARC|
|Development of a good rapport and trusting relationship between young parents and the clinical outreach nurse has led to the identification of a number of clients with high alcohol consumption, risky sexual behaviour, urogynaecological symptoms and sexual difficulties|
|Provision of appropriate support and referrals to other healthcare providers|
|Signposting to other NHS and non-NHS services and agencies|
One possible explanation for the drop-in service’s success is the crèche facilities. Young mothers have said these allow them to have discussions with a nurse away from interruptions from children. The drop-in means that clinic consultations do not have to be rushed, and parents are given time to explain and discuss their concerns fully.
Some are embarrassed to talk about sexual health issues and choose to reveal a little more information at each subsequent consultation. Nurses working in such situations need to use all their experience and knowledge of appropriate communication skills to ensure accurate history-taking and risk assessment.
Another possible reason for the service’s success is its informal and positive approach to young parents. All staff are experienced in working with young people and have developed appropriate communication skills.
I provide my work mobile phone number to parents, who often choose to communicate with me by text messaging. Almost all the messages I have received have been relevant to the outreach service provided and, on rare occasions when the client has been unable to access the drop-in clinic, I have supported them at home as a wider part of the CASH outreach service provision. This aspect of the service has never been abused. The clients and I have worked in partnership to identify and meet their needs.
Some young parents have moved on from the Key to the Door projects and returned to college or back to work, but still choose to access the drop-in clinic rather than attend mainstream services. This further demonstrates the service’s success.
Further work is planned with this group to develop a sexual health fun day and to work with the group to identify the best way to develop contraceptive and sexual health services for all young people in the borough of Oldham.
There are also plans to develop services targeted at young mothers’ partners and to address young men’s sexual health needs. A drop-in service operating from the Key to the Door office is planned to start early in 2009, to reach out to young men who call in for condoms. This will also increase access to screening for STIs and, hopefully, create an arena for further research into the needs of this client group.
I am also undertaking training to fit contraceptive implants, which will further increase access to LARC methods for clients from hard-to-reach groups. As my role develops and the CASH service expands in Oldham, I may be trained to fit intrauterine methods of contraception.
Patient group directions are now being written to allow treatment for positive STI results identified by any screening conducted at the drop-in clinic, which ensures continuity of care and also enhances job satisfaction.
When the CASH drop-in clinic was agreed, I envisaged that it would start on a weekly basis and then move to being fortnightly or even monthly as clients’ needs were addressed. However, the clinic has continued on a weekly basis because different parents access it at different times and bring their friends along.
The future for this initiative is uncertain because Key to the Door is funded by different streams and funding for future projects is a difficult issue. At the moment, there is no specific funding for the drop-in service for young parents but it continues to run on the charity’s reserves. The charity continues to apply for funding from different streams including the National Lottery, and feels optimistic that some applications will be successful. The CASH drop-in clinic will continue for as long as funding allows.
The positive outcomes for service users demonstrate the effectiveness of the nurse-led CASH drop-in clinic. This initiative also shows how services can be successfully developed if they are taken to the places where young people already meet.
Such developments would not be possible without daily support from the contraceptive and sexual health team members, the nurse manager and an NHS organisation that promotes best practice and supports initiative.
Conde-Agudelo, A. (2000) Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ; 321: 1255–1259.
Department of Health (2007) Our NHS Our Future: NHS Next Stage Review – Interim Report. London: DH.
Department of Health (2003) Tackling Health Inequalities: a Programme for Action. London: DH.
Department of Health, Department for Children, Schools and Families (2007) Teenage Parents Next Steps: Guidance for Local Authorities and Primary Care Trusts. London: DCSF.
Guillebaud, J. (2007) Contraception Today. London: Informa Healthcare.
NICE (2005) Long-acting Reversible Contraception. London: NICE.
Smith, G.C.S. et al (2003) Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. BMJ; 327: 313–320.