Guidance

Women’s reproductive health programme: progress, products and next steps

Published 14 July 2021

A note on scope

The work of the Public Health England (PHE) reproductive health programme aims to address the needs of all women regardless of their sexual orientation or ‘trans’ status. (Trans is an inclusive term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth.)

However, it is recognised that people with gender identities that do not align with the sex they were assigned at birth have unique and specific reproductive health needs that are not addressed in this update report.

To address this gap, PHE and leaders and representatives of the lesbian, gay, bisexual, and transgender (LGBT) sector have undertaken research to gain insight into the specific needs of trans and non-binary people. The report ‘Trans people’s reproductive health’ will be published in 2021.

Summary of new products and resources

Return on investment tool

The return on investment (ROI) of:
a) providing contraception to women in a maternity setting, and
b) providing additional LARC fitting capacity within General Practice
has been modelled by the PHE health economics team and is available to download.

This model builds on the existing contraception ROI tool published in 2018. A strong ROI is demonstrated in both settings. For every £1 invested on the maternity intervention, there is a saving of £32 for the public sector. Investment in the provision of additional LARC by GPs has even greater potential cost savings, with an ROI of £48 for every £1 invested.

Reproductive health behavioural insights (BI) tool

An evidence review of the barriers and facilitators to women seeking help across 3 main areas of reproductive health (RH) was commissioned by PHE and translated into a user-friendly tool to help commissioners and providers plan and design services.

Delphi process for RH indicators

A new suite of RH indicators were developed via a consensus process in 2020. An accompanying document provides an overview of the new indicator list and the process used to reach consensus among a steering group of experts.

PHE resources

Many SRH providers reacted innovatively to the challenges of the coronavirus (COVID- 19) pandemic. To encourage shared learning and resilience, good-practice examples and relevant policy and guidance are available.

Telemedicine resources

PHE has worked with the British Association for Sexual Health and HIV (BASHH), the Faculty of Sexual and Reproductive Healthcare (FSRH) and Brook to produce a range of resources supporting practitioners working in telemedicine during the pandemic, including:

• triage integration to prioritise vulnerable groups
• homeworking considerations
• a resource directory for telehealth services
• triage design guidance
• call handling tips for risk identification

Introduction

Women make up 51% of the population and 47% of the workforce. They have multiple and changing health needs throughout their lives, from puberty, through to menopause, and beyond. Reproductive health (RH) shapes not only the overall wellbeing of women, but also of families, communities and wider society, extending far beyond the important experiences of pregnancy and childbirth. Women should be able to enjoy their lives without being affected by reproductive symptoms and lack of choice.

We know that women want information to inform their own decisions. They want RH issues to be normalised and destigmatised so they can be discussed openly, and information and care can be accessed easily and with confidence. (Reproductive Health – What Women Say 2018.) Embarrassment should never be a barrier for better reproductive health.

We also need to do better to meet the needs of all women. This means improving the universal reach of service provision for reproductive healthcare, informed by an improved understanding of the factors that might make reproductive issues more common, or more difficult for some women than others.

The PHE reproductive health programme provides leadership to drive this work forward across the system, placing women at the centre and considering their needs across the life course.

PHE reproductive health programme

The PHE reproductive health programme takes a life-course approach from menstruation to menopause and provides a national framework to support regionally and locally-led action.

The planned publication of the ‘women’s reproductive health action plan’ in March 2020 was paused due to the COVID-19 pandemic. The work of the programme has not, however, been paused. Many of the planned actions are already complete or are underway. Some that were planned for the future have been expedited or revised, and others have been approached in innovative new ways, in light of the pandemic.

This document provides an update on progress to date against main workstreams within the programme, with signposts and links to new resources and guidance for providers, commissioners, and policy makers.

Ongoing and outstanding actions from the PHE women’s reproductive health programme will be integrated into the Department of Health and Social Care (DHSC) sexual and reproductive health (SRH) and women’s health strategies scheduled for publication in 2021.

Programme development

Developing the evidence base

PHE conducted and analysed a one-off survey of over 7,500 women in 2018, supported by focus group discussions. The survey found high levels of reproductive healthcare need in England, and illustrated the physical, mental, and economic consequences of poor RH for women, their children, and wider society.

An accompanying document What does the data tell us? provided a national overview of the current status of RH based on both routine and survey data.

Building a consensus statement

A 2018 stakeholder consensus process brought main RH stakeholders together to establish an agreed scope and vision for RH as a public health issue in the UK. The process resulted in the publication of a consensus statement centred around the definition of 6 pillars of RH and a set of shared values on which to base the work of the programme and future actions to improve the RH of the population.

The Reproductive Health Systems Leadership Forum

In 2018 PHE established a National Reproductive Health Systems Leadership Forum (RHSLF) including representation from professional, statutory, local government, voluntary and academic sectors with a stake in RH. The RHSLF continues to meet to oversee the development and implementation of the Women’s reproductive health programme and national level actions.

Programme ambitions

Improving reproductive health-related quality of life

Debilitating symptoms relating to periods and the menopause are commonly associated with normal reproductive function but can significantly impact on the daily lives of women. There are many barriers to women getting the support they need for these issues, including perceptions about whether their symptoms are ‘normal’ and the absence of supportive contexts to share their experiences more widely.

Fulfilment of reproductive choice

Currently nearly half of pregnancies are unplanned whilst around 1 in 7 couples who wish to be pregnant report difficulties conceiving. Throughout their reproductive lives, women must navigate avoiding pregnancy when and if they do not wish to have children, and becoming pregnant if and at a time they choose to.

Early identification of reproductive morbidity

Some reproductive issues that influence future health and wellbeing may remain concealed or not be taken seriously by women themselves or the professionals they come into contact with. The cervical screening programme and the chlamydia screening programme are designed to identify asymptomatic disease at an early stage.

A system-wide approach

The PHE women’s reproductive health programme has been developed around 6 main workstreams, taking a system-wide approach, similar to that taken by the Teenage Pregnancy Strategy, which ran to 2010.

The following sections outline a selection of some of the main actions to date, including work responding to the COVID-19 pandemic, and planned next steps within each of the workstreams.

Figure: a graphic outlining the 6 workstreams for the PHE women’s reproductive health programme

Reproductive health during COVID-19

Intelligence from across the system indicates that RH services have been adversely affected by the impacts of the pandemic, particularly with respect to the fitting and removal of long-acting reversible contraceptives (LARC).

Primary care LARC prescriptions in May 2020 were 85% lower than in May 2019, with declines across all regions following the national lockdown in March 2020. Regional recoveries were mixed across the summer, but by autumn 2020 volumes of total LARC prescriptions had recovered to pre-pandemic levels. The cumulative impact of the decline in LARC fittings in the first half of the year will have likely contributed to a significant backlog in demand that will need to be addressed in the coming months.

Data from the PHE-funded sexual health helpline has indicated that women, particularly in rural areas, have experienced difficulties in accessing contraception, especially LARC, from their normal providers. Calls to the helpline relating to free emergency contraception (EC) and all aspects of reproductive wellbeing, including access to LARC rose quickly on announcement of lockdown in March 2020.

By autumn 2020 access to free EC and unintended pregnancy calls stabilised, although free EC access remained an issue dependent on local tier levels. LARC fitting, removal and renewal showed some minor signs of recovery by late autumn, however this fragile recovery showed signs of slowing into the winter lockdown period.

Responding to, and learning from the ongoing impact of COVID-19 on access to RH services, particularly LARC, will be a priority for the PHE RH team and the upcoming SRH strategy.

Workstream 1: strategic leadership and accountability

Context

Whilst regional, national and local strategic leadership at the highest level is needed for policies to have the greatest impact, there is no obvious structure that cross-cuts all the areas of RH. The split commissioning and provisioning landscape means there is a particularly acute need for collaborative working and creative thinking across the health system to improve RH access and outcomes.

Work to date

The Reproductive Health Systems Leadership Forum (RHSLF), established by PHE in 2018, has overseen the development and implementation of PHE’s RH programme.

A workshop held in the North East region in October 2020 was the first in a series of local events to explore how the national system-wide approach to RH can be translated to the regional level.

The COVID-19 pandemic response has resulted in more frequent senior stakeholder engagement, leading to greater transparency and clarity about changes and challenges, and more opportunities for cross-system working.

Next steps

It is essential to recognise that RH stakeholders are overlapping but not identical to those in sexual health. This highlights the importance of maintaining the RHSLF’s RH specific membership and scope. The work of the RHSLF will be continued as part of the development and implementation of the planned SRH strategy.

Workstream 2: data and evidence

Aim

The data and evidence workstream is focused on the development and implementation of a new set of core indicators to monitor RH at a regional, local, and national level. The workstream also supports whole population-based improvement and local decision making across the full scope of RH by developing new tools and resources.

Context

RH data is derived from multiple sources and is currently not collected in one place. Some indicators may be available but are not currently part of routine analyses and reporting. In other areas such as General Practice there is a lack of good RH data altogether. Improved data is needed to measure population need and evaluate the delivery of new policy.

Work to date

A new core set of RH indicators were chosen via a Delphi consensus process that will enable progress against the ambitions of the RH programme to be monitored.

A new tool developed by the PHE health economics team estimates the return on investment (ROI) of:
a) provision of contraception in maternity settings, and
b) increased primary care LARC provision.
This work follows an original ROI tool that estimated the ROI of publicly funded contraception to be £9 for every £1 spent.

Next steps

Oversee the implementation of the new set of RH indicators across PHE reporting platforms, including a focus on improving health inequalities data.

PHE have commissioned the design of an online survey instrument to capture women’s experiences of RH issues, services and support, including development of validated questions and a social media strategy for survey dissemination.

Reliable evidence regarding the impact of COVID-19 on RH access remains limited. PHE commissioned NHS Digital to publish an extra Sexual and Reproductive Health Activity Dataset (SRHAD), to cover the 6-month period from April to September 2020.

Workstream 3: information and messaging

Aim

This workstream aims to improve understanding of how behaviours and experience influence a woman’s ability to consume, understand, and act upon RH information and messaging. This knowledge can then be used to design balanced and accessible messaging, empowering women to self-manage their RH choices however suits them best.

Context

Appropriate messaging throughout the life course should enable women to know how and where to access accurate information on their RH choices, free from stigma. High-quality information provision should start at school. However, the ways in which knowledge drives behaviours are not well understood, limiting the efficacy and reach of existing RH policies.

Main work to date

Academics at the University of Warwick were commissioned to conduct an evidence review of the barriers and facilitators to women’s help-seeking across 3 main areas of RH using behavioural insights (BI). This has been translated into a user-friendly tool for commissioners and providers.

The new statutory RSHE curriculum is now compulsory in all schools and must be delivered in full no later than summer term 2021. A SRH training module is included in the Department for Education training programme for teachers.

PHE has been working with stakeholders to provide information to the public about accessing SRH advice during COVID-19 via the PHE-funded Sexwise website.

Next steps

PHE will review existing information sources (for example, Sexwise) to ensure they address the barriers and facilitators identified by the Warwick BI research.

PHE will be working with local teams to ensure schools have access to evidence-based information on SRH and can link students to local services.

Workstream 4: workforce

Aim

Over the next 5 years, Health Education England (HEE), FSRH and other stakeholders have committed to ensuring that the distribution of the specialist and generalist workforce for delivery of universal and targeted RH is fit for purpose. PHE will work alongside these partners to develop a sustainable RH workforce model that meets the needs of the population.

Context

The RH workforce cuts across sexual health, General Practice, maternity and gynaecology. A sustainable workforce model will be one that balances universal provision for the whole population and targeted provision for more complex patients. The COVID-19 pandemic has further highlighted workforce capacity and training limitations and geographical inequities. A future workforce that is fit for purpose will not only address capacity but also consistency of knowledge, awareness, and communication amongst providers.

Work to date

PHE has established a framework for the delivery of digital contraception, (and STI and BBV testing) to increase accessibility of low-risk contraception methods for low-risk populations that aims to free up time in the clinic for more complex cases.

Work is underway to better understand the barriers and facilitators to the provision of the full range of contraception, including longer-acting methods of contraception, in primary care.

The BI research and tool highlights how providers can facilitate, or may unintentionally hinder, women’s help-seeking behaviours.

Next steps

As part of development work for the upcoming SRH strategy, DHSC, PHE, RCGP, FSRH, and HEE will review the RH workforce’s capacity to meet population need and new models of care (for example, integrated care systems).

Promote the inclusion of BI findings within workforce training materials.

Workstreams 5: inequalities and access for inclusion populations

Aim

This workstream aims to ensure high-quality RH care can be accessed by all women, taking a more targeted approach for those least well served and/or with the poorest outcomes.

Context

Significant inequalities in RH access and outcomes exist both geographically and across different demographic groups within the UK. For example, young people under 25, women from a BAME background, and those from socially disadvantaged backgrounds are all more likely to have abortions than other populations, suggesting an unmet need for contraception among these groups. Additionally, evidence suggests that the impact of COVID-19 on contraception service provision is likely to have exacerbated existing inequalities.

Work to date

PHE brought together a network of professionals working with inclusion populations (ISHIN) to develop a strategic approach to ensure the interests of those most poorly served are protected, now and in the future.

PHE has worked with BASHH, FSRH and Brook to produce 5 documents to address safeguarding issues relevant to the expanded use of telemedicine by sexual and reproductive health services during the COVID-19 pandemic.

An ‘Ask, advise and assist’ message was developed and disseminated to local system partners such as drug and alcohol services and homelessness services to increase reach of RH services during the COVID-19 pandemic.

Next steps

Development of post-pregnancy contraception guidance, including support to the system on implementing different payment models in order to increase opportunistic access for those least well served.

The recommendations of ISHIN will inform the upcoming SRH and women’s health strategies.

Workstream 6: universal access

Aim

This workstream aims to ensure high-quality RH care can be accessed by all women, taking a more targeted approach for those least well served and/or with the poorest outcomes.

Context

Fifty-one per cent of the population are female, with the vast majority requiring contraception, cervical screening, preconception, and menopause care at some point in their lives. This provides a major challenge to the system in terms of access and equitable reach. Restrictions imposed during the pandemic have galvanised areas into rapid innovation and implementation of new ways of working to improve access. This has both changed the landscape and set the scene for scaling some local developments more widely.

Work to date

Many SRH providers reacted innovatively to the challenges of COVID-19, ensuring they could continue to meet the diverse needs of their service users. Relevant case studies, policy, and guidance have been shared by PHE to encourage shared learning and resilience.

PHE have developed a digital framework for delivery of contraception, which will provide better access to some sections of the population.

Development of the ROI tool for postnatal contraception and GP LARC supports the case for universal access at a local level.

Next steps

PHE and partners to develop a women’s hub, commissioning specifications to enable women to meet their holistic RH needs through a single point of access.

The PHE RH programme team have plans to increase the focus on the ‘improving reproductive wellbeing’ ambition of the RH programme in 2021, beginning with a webinar focusing on menstrual wellbeing in the workplace.

Recognise and provide the necessary support to those with additional RH needs or those with limited digital access.

Next steps for PHE reproductive health during 2021 to 2021

We will:

• support DHSC to develop the SRH and women’s health strategies, ensuring RH aspects address our 3 ambitions:
  • fulfilment of reproductive choice
  • reproductive wellbeing
  • early identification of reproductive morbidity
• continue to provide support to the system around COVID-19 pandemic recovery work following the impact of the pandemic on core RH services such as the provision of LARC in primary care
• ensure recommendations of the ISHIN report are embedded in the future across the PHE RH programme and the wider SRH strategy, to ensure continued focus on inequalities in RH access and outcomes
• provide support to local public health teams to implement RSHE at a local level
• continue the RH data improvement work including developing the new indicators and RH experiences survey
• provide leadership across the system to encourage improved integration of commissioning structures
• ensure information for the public and professionals is shaped by learnings from the behavioural insights research.

The PHE RH programme will continue to be delivered during the forthcoming transition of PHE functions to other organisations. This programme will be reviewed once these changes have become established.