The journey from fertility to maternity care by Carmel Bagness

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Becoming pregnant following fertility treatment is both joyous and challenging for the person concerned and their partner, support network and family. The Royal College of Nursing (RCN) became aware of the concerns raised by fertility nurses, midwives and patient groups that the journey from fertility to maternity care is not always easy or smooth, and that guidance was needed.

As a result, the RCN invited a wide range of stakeholders (including Progress Educational Trust, Fertility Network, British Fertility Society and others), to collaborate and create guidance addressing the needs families may have as they move from fertility care to maternity services. In September 2022, the RCN published Transitions from Fertility to Maternity Care as a result of this work.

The stress of becoming pregnant and keeping a pregnancy causes anxiety for many, not just those who have been through fertility treatment. Regardless of where the woman is in that journey, the reality of being pregnant and what that means for the future can be difficult to comprehend. For those who have had fertility treatment, this emotional turmoil is further compounded by the difficulties sometimes experienced when moving from fertility to maternity services, at a time when good continuity of care is critical to physical and emotional well-being.

The time taken for people to access fertility care varies, and it often takes a number of years to achieve a successful pregnancy, especially if fertility treatment is due to a medical condition. If the treatment has been for non-medical reasons, the journey can be quicker, but is still challenging for those involved in it. NHS funding for fertility care remains a major issue in some areas.

Once a pregnancy has been confirmed, the patient will be discharged from the fertility services, usually at less than six to eight weeks into the pregnancy. They are advised to book an appointment with the local midwife, but that can take several weeks to materialise as the first booking in appointment normally occurs at around 12 weeks. They can be left between professional support, moving from what has often been an intensive service to possibly nothing – not knowing who to contact if they are anxious, ill or concerned. This gap in service provision will vary from service to service, and across the UK. Consequently, it is important that when women are discharged from fertility care they are given written information about their local services.

Most people will move from fertility to maternity care with relative ease, even with a gap in services, however, others may experience problems, including vaginal bleeding, abdominal pain, pregnancy-related nausea and vomiting, hyperemesis, ectopic pregnancy, molar pregnancy and miscarriage, and some will also require support at:

early pregnancy care (EPC) units,
emergency care, including out-of-hours/GP services and walk-in centres,
termination of pregnancy services.
Any potential problem may be distressing, consequently, access to a local EPC unit is important for the mental and physical well-being of the woman (and her partner). EPC units are well established in a number of NHS trusts across the UK and should be the first point of contact to support needs during this time. The Association of Early Pregnancy Units lists over 200 EPC units across the UK.

It is important to acknowledge that there is a wide variation in the fertility journey, which may have involved lengthy treatment and patients will have different emotional needs. Those who have had IVF or treatment with donated gametes to become pregnant should have been offered counselling, which may or may not continue once a pregnancy has been confirmed.

During this time, some women may also have had changes in their personal circumstances with physical or mental health, or socioeconomic issues arising. Even though they have had fertility treatment to achieve a pregnancy, they may consider/choose termination of pregnancy. Anyone who chooses this option must be supported to make decisions about their pregnancies according to their own circumstances, free of judgement, regardless of the process they have experienced to become pregnant, acknowledging that this decision can be complex.

Maternity care is very much about understanding the person who is pregnant, what their needs and expectations are, and this should take account of the journey they have been on. This also requires consideration of differing family structures, and not making assumptions about the person. This guidance acknowledges and identifies details for care that may be considered for patients and their families from the LGBTQIA+ communities, who may have different needs. Equally not all those who become pregnant will identify as women. Some women will come with a surrogacy arrangement in place, and there are care pathways identified to best support the woman and intended parents, which can be found in the guidance. It is always best to ask about the journey, and plan care accordingly. Several potentially useful contacts are listed in the guidance.

The quality of care provided to pregnant women is really important and all services try to achieve that high standard, however service configuration can challenge this, in particular the need for good continuity of care between the three services, and there is always room for improvements. Fertility care, EPC and maternity services need to work collaboratively to reduce the gap in services that some women experience. This could take the form of more formal links and service-level agreements, which would require more integration of the service. It is imperative that fertility nurses understand the onward journey, while midwives have confidence in their understanding of the individual's history.

Overall a greater awareness of the gap in services requires an understanding of EPC services in the local area. Healthcare professionals need to work together to ensure that women have continuity of care and know who the first point of contact ought to be, should an issue arise. The RCN guidance provides information and ideas on how this can be better achieved.