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Implementation of reproductive life planning (RLP)in primary health care supported by an evidence-based website

Melinda Koo Andersson & Tanja Tydén

To cite this article: Melinda Koo Andersson & Tanja Tydén (2020) Implementation ofreproductive life planning (RLP) in primary health care supported by an evidence-basedwebsite, The European Journal of Contraception & Reproductive Health Care, 25:1, 1-7, DOI:10.1080/13625187.2019.1695117

To link to this article: https://doi.org/10.1080/13625187.2019.1695117

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Published online: 28 Nov 2019.

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CLINICAL STUDY

Implementation of reproductive life planning (RLP) in primary health caresupported by an evidence-based website

Melinda Koo Andersson and Tanja Tyd�en

Department of Women’s and Children’s Health, Uppsala University Hospital, Uppsala, Sweden

ABSTRACTObjectives: The aims of the study were to evaluate how well the reproductive life plan (RLP) toolwas implemented in practice and explore the utility of the website www.reproduktivlivsplan.se forpatient counselling.Methods: A cross-sectional study was conducted in 2018, in which 73 midwives in primary healthcare were asked to use the RLP tool and the website in their daily practice. Three months later,participants answered a questionnaire, based on normalisation process theory (NPT), about theirimplementation experience.Results: The response rate was 73% (n¼ 53). The mean length of midwifery experience was15 years. Almost all respondents (89%) reported a positive attitude towards the tool and the web-site and their ability to use them in practice. The majority agreed to all statements about imple-mentation of the RLP, according to NPT. Use of the RLP also made it easier for midwives tosupport clients in forming reproductive goals (85%, n¼ 45), give family planning advice (81%,n¼ 43), give advice about how to improve health before pregnancy (85%, n¼ 45) and give adviceabout how to preserve fertility (89%, n¼ 47). Nine out of ten respondents said they would recom-mend the website to other midwives.Conclusion: The RLP was well implemented among the respondents and the majority consideredthe website to be a useful tool. Long-term studies are needed to further elucidate the effects ofthe RLP on changes in health behaviour and pregnancy outcomes.

ARTICLE HISTORYReceived 26 June 2019Revised 22 September 2019Accepted 15 November 2019

KEYWORDSFamily planning; fertility;implementation; preconcep-tion health; pregnancy;reproductive life plan

Introduction

Unintended pregnancies remain a public health problem. Itis estimated that, between 2010 and 2014, 44% of all preg-nancies worldwide were unintended, about half of whichended in abortion [1]. Sweden has the highest abortionrate in Western Europe [2], in spite of subsidised contracep-tives for young women and contraceptive counselling avail-able free of charge for all women. In a nationwide study[3], the unmet need for contraception was estimated to be15%. Skogsdal et al. [4] found that in Sweden 23% ofparous women and 10% of nulliparous women did not useany contraception.

The Centres for Disease Control and Prevention (CDC)recommends a tool named the reproductive life plan (RLP)to increase awareness of unintended pregnancies and pro-mote reproductive health. Files et al. [5] explored ways toincorporate the CDC guidelines into clinical practice in orderto give clinicians an opportunity to help reproductive-agedwomen and men reflect on whether to have children, toincrease preconception health and to avoid unintendedpregnancies. The authors suggested that midwives werestrategically well placed to engage women in a discussionabout reproductive life planning. The American College ofObstetricians and Gynaecologists encourages health careproviders to assess women’s RLPs at every encounter, toimprove a woman’s health before conception [6]; but in

Europe preconception recommendations for healthy womenand men are fragmented and inconsistent [7].

A review of publications between 2000 and 2014 aboutthe RLP concept suggested that reproductive life planningwas integral to preconception care and family planningand could serve as a framework for promoting reproduct-ive health across the lifespan of both men and women [8].The RLP concept has been tested in interventions amongmen in Sweden [9] and among women in Sweden [10,11]and Iran [12]. Men and women appreciated the RLP coun-selling and it increased their fertility awareness. Some mensuggested that a homepage or mobile phone applicationabout fertility would be useful. The intervention had lim-ited impact, however, on reproductive plans [9–12].

Swedish national contraceptive guidelines state that theaims of contraceptive counselling are to prevent unplannedpregnancies and to preserve women’s fertility by promot-ing sexual and reproductive health until pregnancy isdesired [13]. A structured approach to achieve these goalscan potentially be offered by the RLP, but its value in dif-ferent settings needs to be evaluated.

In Sweden, midwives are licenced to provide contracep-tive counselling to healthy women; most contraceptives areprescribed by midwives. Midwives who used the RLP toolfound it feasible for promoting preconception health andthey had the impression that many women had notreflected on their reproductive plans. The midwives

CONTACT Melinda Koo Andersson [email protected] Department of Women’s and Children’s Health, Uppsala University Hospital,Uppsala, SE-751 85, Sweden� 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE2020, VOL. 25, NO. 1, 1–7https://doi.org/10.1080/13625187.2019.1695117

http://www.reproduktivlivsplan.se


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http://orcid.org/0000-0002-2172-6527

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emphasised the importance of tactfulness in individualcounselling sessions [14]. As the results were promising, amobile-friendly RLP website (www.reproduktivlivsplan.se) indifferent languages was developed for health care pro-viders and their clients [15]. As further information wasdeemed necessary on how to implement the RLP in con-junction with a mobile-friendly website, we set out toinvestigate midwives’ adoption of the RLP tool and theirexperiences of using the website in their consultations.

Methods

A cross-sectional study was conducted in Uppsala County,Sweden. Uppsala County has a population of almost400,000 and the educational level and proportion of immi-grants are similar to the Swedish average. Some of thecounty’s midwives had used the RLP concept in 2014 [14].It was therefore natural to return to this population of mid-wives in the next step of adopting the RLP and using themobile-friendly website for further support. The study wassupported by a senior gynaecology consultant and a coor-dinating midwife in antenatal care. The project leader(MKA) informed all midwives (n¼ 73) about the projectduring a staff meeting in August 2018 and 1 month latervisited each clinic to follow up on the previous meeting.

The website

The website consists of questions about the desire to havechildren or not, and, if yes, when and how many. The ques-tions were constructed with an understanding that somewomen are unsure whether they want a baby and that theRLP may change over the lifespan. The information coversconception, eggs, sperms, fertilisation and the menstrualcycle, as well as fertility and health, age and fertility, life-style prior to conception, health and environment, diet andexercise, calculation of body mass index, sexually transmit-ted infections, getting help to become pregnant, andcontraception. There is also a quiz about fertility and linksto official information sites such as 1177.se and umo.se,which is a virtual adolescent clinic about sex, health andrelationships for ages 13–25. These sites are only inSwedish. The RLP website is in Swedish, English, French,Spanish, Arabic, Greek and Somali.

The questionnaire

To better evaluate participants’ perceptions of the RLP andthe website, the questionnaire used was a modified versionof the NoMAD instrument [16], which is theoreticallyderived from and based on normalisation process theory(NPT; www.normalizationprocess.org). NPT is a social theoryto understand the dynamics of implementing new technol-ogy or complex interventions in health care. NPT has fourkey constructs: (1) coherence, (2) cognitive participation, (3)collective action and (4) reflexive monitoring [17].Implementation of new practices requires the involvementof participants through those constructs: ‘coherence’, con-cerning the shared and individual understanding of aimsand expected benefits of a practice; ‘cognitive participa-tion’, concerning the relational work that people collect-ively do to build and sustain the practice; ‘collective

action’, concerning the enacting of a practice by its users;and ‘reflexive monitoring’, concerning the comprehensionof the effects of a practice [18]. The NoMAD instrumentcan be used as a structured assessment of implementationprocesses such as that of the RLP [17].

The questions were grouped into four parts. Part A con-sisted of five questions on how many years the midwifehad worked and whether s/he was experienced with RLPand the information booklet. Part B consisted of three gen-eral questions about the RLP method. Respondents wereasked to identify their level of familiarity on a rating scalefrom 0 to 10, where 0 was ‘not at all/still feels very new’and 10 was ‘completely/feels completely familiar’. Part Ccovered 13 detailed statements about the implementationof the RLP method answered on a five-point Likert scaleranging from ‘strongly agree’ to ‘strongly disagree’. Thefirst nine questions mirrored the four NPT constructs.

� Coherence (two statements): ‘staff in this organisationhave a shared understanding of the purpose of the RLPmethod’ and ‘I can see the potential value of the RLPmethod for my work’.

� Cognitive participation (two statements): ‘I believe thatparticipating in the RLP method is a legitimate part ofmy role’ and ‘I will continue to support the RLP method’.

� Collective action (three statements): ‘I can easily inte-grate the RLP method into my existing work’, ‘sufficienttraining is provided to enable midwives to implementthe RLP method’ and ‘management adequately supportsthe RLP method’.

� Reflexive monitoring (two statements): ‘we midwives,i.e., me and my colleagues, agree that the RLP methodis worthwhile’ and ‘I can modify how I work with theRLP method’.

Part D consisted of questions, designed by the researchgroup, to measure the midwives’ attitudes towards imple-menting new working methods and assess their perceptionsof the website. The last four questions were open-ended ques-tions about the usefulness of the website, how it could beimproved, how to facilitate the use of it, and reasons for notusing it. The final questionnaire consisted of 33 questions.

The questionnaires were posted to the clinics 8 weeksafter giving out the information at a staff meeting. The pro-ject leader (MKA) collected the questionnaires during visitsto the clinics 1 month later. Respondents placed their com-pleted questionnaire into a sealed envelope.

Data analysis

Descriptive statistics were used. Spearman correlation ana-lysis was used for working experience and attitude towardsimplementing new working methods, to test whether therewas a connection between the variables; a p-value <0.05was considered significant. Statistical analysis was performedusing IBM SPSS Statistics for Windows, version 25.0 (IBM,Armonk, NY). Answers to the open-ended questions are illus-trated with a few representative quotes, and some typicalstatements are shown. We did not use any qualitative ana-lysis methods as we had only four open-ended questions.The authors selected direct quotes for each answer.

2 M. KOO ANDERSSON AND T. TYDÉN

http://www.reproduktivlivsplan.se

http://www.normalizationprocess.org

Ethical considerations

Participation in the study was voluntary and anonymous.According to current Swedish legislation, formal approvalby the regional ethics review board was not required. Theonly personal data collected were how many years partici-pants had worked as a midwife. Throughout the project,the ethical principles outlined in the Declaration of Helsinkiwere followed. Midwives were included in the study onlyafter giving their informed consent; verbal and writteninformation on the study was given. Permission for con-ducting the study in primary health care was approved byUppsala County Council.

Results

Of 73 midwives who received information about the pro-ject, 53 (73%) filled in the questionnaire. Midwives hadbeen working an average of 15 years (range 2–42 years),9 years (range 3 months to 36 years) of which were in pri-mary health care.

Previous experience with the RLP

Almost all (96.2%, n¼ 51) had heard about the RLP methodbefore the project started, 77.4% (n¼ 41) had previouslyused the RLP method in their work and 73.6%, (n¼ 39) hadexperience of working with the booklet. The midwives

rated their general experiences of using the RLP on a scalefrom 1 to 10 (best option) as follows:

� ‘How familiar does it feel when using the RLP method?’(median 8, range 1–10).

� ‘Do you feel that the RLP method will continue to be orotherwise become a standard part of your work?’(median 7, range 1–10).

� ‘Do you feel that the RLP method is already an inte-grated part of your counselling?’ (median 6,range 1–10).

The midwives’ opinions on the RLP method are pre-sented in Table 1. The majority agreed to all statementsaccording to the NPT constructs. No one disagreed, but40% (n¼ 21) expressed doubt about the support of man-agement since they answered ‘neither agree nor disagree’.

As shown in Table 2, the majority agreed that the RLPmethod made it easier for them to support clients to formreproductive goals (84.9%, n¼ 45), to deliver family planningadvice (81.1%, n¼ 43), to improve health before pregnancy(84.9%, n¼ 45) and to preserve fertility (88.7%, n¼ 47).

Perceptions about the website and attitudes towardsimplementing new working methods

As shown in Table 3, almost all respondents (88.7%, n¼ 47)had an optimistic attitude towards implementing new

Table 1. Midwives’ (n¼ 53) opinions about the RLP method, according to the NPT constructs.

NPT construct and item Response Frequency Percent

CoherenceStaff in this organisation have ashared understanding of thepurpose of the RLP method

Strongly agree 14 26.4Agree 24 45.3Neither agree nor disagree 8 15.1Strongly disagree/disagree/no response 7 13.2

I can see the potential value of theRLP method for my work

Strongly agree 22 41.5Agree 28 52.8Neither agree nor disagree 3 5.7Strongly disagree/disagree/no response 0 0

Cognitive participationI believe that participating in the RLPmethod is a legitimate part of

my role


I will continue to support theRLP method


Collective actionI can easily integrate the RLP methodinto my existing work


Sufficient training is provided toenable midwives to implement theRLP method


Management adequately supports theRLP method


Reflexive monitoringWe midwives, i.e., me and mycolleagues, agree that the RLPmethod is worthwhile


I can modify how I work with theRLP method


THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 3

working methods and tools. There was no significant cor-relation between working experience as a midwife(r¼ 0.014, n¼ 50, p¼ 0.924), or between working experi-ence as a midwife in primary health care, and attitudetowards implementing new working methods and tools(r¼�0.090, n¼ 50, p¼ 0.535).

Open-ended questionsThe response rate to the open-ended questions was 87%and in total we received 94 quotes. Some representativequotes, corresponding to the majority opinion, are illus-trated below.

In what way has the website been a useful tool for you?The majority answered that they could refer clients toinformation on the website and encourage them to read

more on their own. They also found the website to be ahelpful tool to inform clients about preconception health.One midwife wrote:

It is easy to display, easy to understand and easy torecommend the woman to look into and read on her own.

Some thought the website was helpful as a conversationstarter about the RLP:

It is easier to get into the subject of reproductive health.It is a good way to start the conversation; it clarifies for theclient what is being discussed.[It has] good pictures to talk about.

Some midwives thought that the website was a goodsource of information for both clients and midwives:

[It is] a knowledge support; [it is] good that information isequal for everyone.

Table 2. Midwives’ responses (n¼ 53) to detailed questions (self-designed) about the RLP method.

Item Response Frequency Percent

The RLP method makes it easier forme to support clients formingreproductive goals


The RLP method makes it easier forme to give family planningadvice to clients


The RLP method makes it easier forme to give advice about how toimprove health before pregnancy


The RLP method makes it easier forme to give advice about how topreserve fertility


Table 3. Midwives’ (n¼ 53) statements about the website.

Item Response Frequency Percent

My general estimation of the website Very positive 8 15.1Positive 36 67.9Neither agree nor disagree 5 9.4Very negative/negative/no response 4 7.5

I have an optimistic attitude towardsimplementing new working methodsand tools


I can see the potential value of the use of thewebsite for my work


I will continue to use the website Strongly agree 5 9.4Agree 32 60.4Neither agree nor disagree 10 18.9Strongly disagree/disagree/no response 6 11.3

I can easily integrate using the website into myexisting work


I can modify how I work with the website Strongly agree 9 17.0Agree 30 56.6Neither agree nor disagree 10 18.9Strongly disagree/disagree/no response 4 7.5

I recommend other midwives to use the websitein their work


Do you consider the website to be auseful tool?

Yes 39 73.6No 7 13.2No response 7 13.2


[It] helped me with information to give patients.

One of the midwives who did not consider the websiteuseful wrote:

[It is] useful to refer the website to clients but [it is] not a toolfor me.

Could the website be improved in any way? The major-ity suggested that the website should be translated intoseveral languages, especially Arabic, Somali and Dari. Onemidwife wrote:

[It should] clarify on the website that it is not about ‘anti-feminist’ propaganda; [it is] easy to read negatively by womenwho for career or other reasons choose to wait.

Some thought that the name of the website was toolong and complicated:

[I suggest to] have an easier name of the website; the currentone is long and complicated.

What could facilitate the use of the website? The major-ity would like to have some kind of business card to handout or to link the website to the website 1177.se. One mid-wife wrote:

The website should be available on 1177.

Another wrote:

[I] wish there were business cards with the name of thewebsite to hand out to patients.

Some midwives gave examples of how to remind them-selves to use the website. One midwife wrote:

[I like] to place it as ‘favourite’ or add [it] to ‘my links’.

What was the foremost reason for not using the website?The most common reasons were lack of time or simpleforgetfulness:

Lack of time; sometimes it feels ‘overbearing’ to receive newinformation on everything we have to offer patients,considering the time we have.

Another wrote:

[I] have used it very little, mostly because I forgot.

Discussion

Findings and interpretation

We investigated the implementation of the RLP conceptamong midwives working in primary health care andwhether they considered the RLP website to be a usefultool in their consultations.

The majority of the respondents stated that they agreedor agreed strongly with the RLP statements across the fourNPT constructs. It is noteworthy that no one disagreed.Generally, the more a respondent agrees to the statements,the more an innovation is implemented according to therespondent�s perceptions [17,18]. The midwives agreed thatsufficient training was provided to implement the RLPmethod. Only on one item were almost half ambivalentabout the lack of adequate support from management. Areason may be that the midwives worked at 15 clinics withdifferent managers, which emphasises the importance ofcommunication between different stakeholders to ensuresupport from an entire organisation. This requirement of

support from managers and sufficient training before start-ing to use the RLP has been pointed out previously [19].

Health care providers should have an understandingabout the sensitivity of questions concerning having or nothaving children in the future and must ask those questionswith interest, using a patient-centred approach. An open-ended question, ‘What is your attitude to having children/more children?’ is a better approach than ‘Do you wish tohave children?’ Health care providers must also have timeto have a discussion with a client, as the subject can besensitive. In a previous Swedish study, the midwives wereaware of the importance of tactfulness and professionalism,since individual and societal factors influenced the RLP[14]. In Sweden, many midwives are used to motivationalinterviewing when discussing lifestyle changes, which canexplain their positive experiences of the RLP.

Interestingly, as many as 89% of respondents either‘agreed’ or ‘strongly agreed’ that they had an optimisticattitude towards implementing new working methods andtools. According to the Diffusion of Innovation Theory,about half of a population are early adopters and half arelate adopters [20]. The respondents in our study maybelong to the early adopters.

The majority considered the website to be a useful toolfor both clients and midwives. It was easy to display andunderstand, and women could be recommended to readthe information further on their own. In the study by Sternet al. [14], the midwives had an RLP booklet to assist themin counselling, which was appreciated. Complementaryinformation can easily be added to the website; midwivessuggested that it could be linked to the existing Swedishplatform for health care counselling, 1177.se.

A few midwives commented that lack of time was theirreason for non-use of the website. The booked consultationwith the midwives in our study varied from 15 to 45min;referring women to the website prior to the visit couldtherefore be a time-saving strategy and facilitate counsel-ling. The internet has become one of the most popularsources of health information; worldwide 5% of all internetsearches are health-related [21]. Many women use theinternet for issues related to their pregnancies but they donot discuss the information with their health care provider[22,23]. Health care providers could initiate a discussion onwhat their clients have learnt from the internet, asalthough some information is evidence-based there is alsoa flow of misleading information.

The RLP website is publicly available and has beentranslated into several languages, as one out of fourwomen attending antenatal care in Sweden was bornabroad [24]. Health care providers can emphasise differentitems depending on cultural and social aspects.

Exploring experiences of new technology among profes-sionals is important for further development of differentkinds of health applications. The website can be a startingpoint for reproductive-aged women and men to developan RLP and learn more about fertility and preconcep-tion health.

Similarities and differences in relation to other studies

Implementation of the RLP in primary health care wasaccepted by the study respondents. Primary health care


providers in the US perceived time constraints in conduct-ing pregnancy intention screening [25,26]. Baldwin et al.[26] evaluated two pregnancy intention screening toolsand found that half of providers thought either tool to behelpful. Furthermore, two-thirds of the respondentsreported that the tools helped them to communicate theirreproductive goals to their providers.

The importance of having a patient-centred consultationthat allows women to express ambivalence about preg-nancy has been previously discussed [27,28]. Amongwomen attending antenatal care in Sweden, 14% of thepregnancies were neither planned nor unplanned and 12%were fairly or very unplanned [29]. One out of 10 femaleuniversity students in Sweden did not wish to have chil-dren and considered the possibility of freezing eggs.Furthermore, the students were not sufficiently aware ofthe age-related decline in female fecundity and 13% hadan unmet need for contraception [30]. Female universitystudents would have benefited from information aboutreproductive age-related risks and contraceptive methodscompatible with their needs. We hope that the RLP websitewill be particularly useful for this group, to enable them tomake well-informed decisions concerning reproductiveplanning. There is ongoing research on the effectiveness ofusing mobile applications in promoting preconceptionhealth [31].

Strengths and weaknesses

The 73% participation rate was felt to be acceptable, as ithas gradually become harder to recruit people to answerquestionnaires. Implementation of new working methodsin health care is important and necessary to improve thequality of health care delivery. For the same reason it isalso important to use new evaluation instruments. Ourswas a quantitative study containing some open-endedquestions, contributing qualitative data. This added a depthof understanding and valuable opinions of the participants,which is strength.

The study had, however, some limitations. It was con-ducted in one of 20 counties in Sweden. A university towndominates the county, and health care providers are oftenasked to participate in different kinds of research projects.The participants were probably interested in research anddevelopment, and three out of four had used the RLP in aresearch project 5 years earlier [10].

One limitation concerns the NoMAD questionnaire,which is a fairly new instrument. The NPT has been widelyused to analyse the implementation of complex healthcare interventions and has proven to be useful and benefi-cial [17]. Although it is a new approach to assess an imple-mentation process using NoMAD, the instrument has beentested in a Swedish version [32].

Conclusion

This study showed that the RLP method, based on NPT, iswell implemented among midwives working in primaryhealth care and that a majority thought that the RLP web-site was a useful tool. We have informed coordinating mid-wives in all Swedish counties about the present projectand some have already contacted us for more information.

Long-term studies will be needed to further elucidate theeffects of the RLP on changes in health behaviour andpregnancy outcomes, in randomised trials or regis-try studies.

Acknowledgements

The authors acknowledge L. Ax�en, coordinating midwife, and B.Segeblad, consulting gynaecologist, for supporting this study. Theauthors also thank T. L. Finch, for sharing her excellent knowledgeand work about the NoMAD instrument, and J. Hultstrand, for assistingin the survey design.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Melinda Koo Andersson http://orcid.org/0000-0002-5805-7582Tanja Tyd�en http://orcid.org/0000-0002-2172-6527

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