Examining the pace of change in contraceptive practices in abortion services - a follow-up case study of a quality improvement collaborative

Abstract

Background: Among all women who experienced an abortion in Sweden 2017, 45% had previously underwent at least one abortion. This phenomenon of increasing rates of repeat abortions stimulated efforts to improve contraceptive services through a Quality Improvement Collaborative (QIC) with user involvement. The participating teams had difficulty in coordinating access post-abortion to the most effective contraception, Long-acting reversible contraception (LARC), during the eight-month QIC. This prompted questions about the pace of change in contraceptive services post-abortion. The aim of the study is to evaluate the evolution and impact of QIC changes regarding patient outcomes, system performance and professional development over 12 months after a QIC designed to enhance contraceptive services in the context of abortion.

Methods: This follow-up case study involves three multi-professional teams from abortion services at three hospitals in Sweden, which participated in a QIC during 2017. We integrated qualitative data on the evolution of changes and quantitative data regarding the monthly proportion of women initiating LARC, analysed in statistical control charts from before the QIC up until 12 months after its conclusion.

Results: Teams A and B increased the average proportion of women who initiated LARC within 30 days post abortion in the 12 months after the QIC; Team A 16-25%; Team B 20-34%. Team C achieved more than 50% in individual months but not consistently in the Post-QIC period. Elusive during the QIC, they now could offer timely appointments for women to initiate LARC more frequently. Team members reported continued focus on how to create trustful relationships when counseling women. They described improved teamwork, leadership support and impact on organizing appointments for initiating LARC following the QIC.

Conclusions: QIC teams further improved women's timely access to LARC post abortion through continued changes in services 12 months after the QIC, demonstrating that the 8-month QIC was too short for all changes to materialize. Teams simultaneously improved women's reproductive health, health services, and professional development.

Keywords: Contraceptive counselling; Health services accessibility; Long- acting reversible contraception; Professional development and pregnancy termination; Quality improvement; System performance.

Fig. 1

P-charts for teams A, B and C showing the monthly proportion (%, on the y-axis) of women who initiated LARC within 30 days post-abortion. For team B, the data recording was of uncertain reliability before the QIC. Data for teams A and B was extracted from existing electronic health information systems. For team C, data was manually collected from records prior to the QIC. Note the signs of special cause variation, highlighted in red, signalling an improvement in the proportion of women starting LARC in a timely manner. LARC = Long-acting reversible contraception. QIC = Quality Improvement Collaboratives. LS = Learning sessions. p-bar = the average of all observations. LCLp = Lower control limit (for proportions). UCLp = Upper control limit (for proportions)

Fig. 2

P-charts for teams A and B showing the monthly proportion (%, on the y-axis) of women who initiated LARC within 30 days post-abortion, with a re-calculated average for the Post-QIC period. This indicates the shifts (i.e. improvement) in the proportions of women who started use of LARC after the conclusion of the QIC, compared to before and during the QIC, for these teams. LARC = Long-acting reversible contraception. QIC = Quality Improvement Collaboratives. POST-QIC = The follow-up period 12 months after the conclusion of the QIC. LS = Learning sessions. p-bar = the average of all observations. LCLp = Lower control limit (for proportions). UCLp = Upper control limit (for proportions)