Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception – The Case for Change sets out the strategic, funding, and policy levers needed to ensure system-wide progress.
BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
“It would have been a lifeline to me.” Service User
“Making appointments or finding the time to go to the GP whilst having two [children] is daunting – this makes the process so much easier and less stressful.” Service User
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
“The discussion of contraception was helpful as I was unaware of the scheme – general feeling of relief.” Service User
“The sheer volume of uptake, especially among groups historically facing barriers to access such as young parents, women in care, and those with substance misuse or language highlights the critical value of integrating contraceptive care into the maternity pathway.” Post-pregnancy contraception (PPC) Provider
“I’ve seen how it empowers women – we’re offering something practical and important at exactly the right time.” PPC Provider
“…at no point in my life was I more scared of getting pregnant than when I just had a baby. I just couldn’t think of anything more traumatic” BMA Women’s Health Report
“It is very difficult to understand why postnatal contraception is not prioritised across the UK, and instead left to a small group of motivated staff to try to establish a service.” PPC Provider
“Providing contraception in maternity settings has an even greater ROI – at £32 savings to the public sector for every £1 invested – and, for many women, will offer greater convenience as it saves women from needing to arrange an appointment with their GP or other healthcare provider.” Women’s Health Strategy
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Disclaimers Language: Within this report we use the terms ‘woman’ and ‘women’s health’. However, it is important to acknowledge that it is not only people who identify as women (or girls) who access women’s health and reproductive services in order to maintain their sexual and reproductive health (SRH) and wellbeing. The terms ‘woman’ and ‘women’s health’ are used for brevity, on the understanding and recognition that sexual and reproductive healthcare services will be accessed by women, gender diverse individuals, and people whose gender identity does not align with the sex recorded at birth. Delivery of care must therefore be appropriate, inclusive, and sensitive to the needs of those individuals whose gender identity does not align with the sex they were recorded as at birth. Funders: The College of Sexual and Reproductive Healthcare (CoSRH) Hatfield Vision is a national programme of advocacy work supported by a wide range of organisations, including charities, professional bodies, and industry leaders. Some collaborators provide funding to support the running of the programme. The monies received help the CoSRH to resource the programme in line with the CoSRH’s charitable objectives and attainment of the Vision goals. The CoSRH engages with all organisations working on the programme equally and collaboratively regardless of funding. Organisations who provide funding cannot influence the direction of the Vision, nor will the CoSRH preferentially advance the aims of one supporter over any other. All monies received are used to equitably advance the work of the Vision.
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
Contents
Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception
6
The Case for Change
Recommendations
8 8
Recommendations for Government
Recommendations for the NHS, ICBs and the wider health system
9
Recommendations for Workforce and Training
10
Foreword: Experience of a Consultant Obstetrician after Birth
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How the System Works Against You: The personal experience of a consultant obstetrician trying to access contraception after birth Introduction By Dr Janet Barter, CoSRH President, and Prof Ranee Thakar, RCOG President
12
Key Statistics
16
Why is Post-Pregnancy Contraception Important? The Clear Case for Action
17
The Postcode Lottery of PPC and Commissioning Barriers across England
20
The Existing Barriers Caused by Commissioning Arrangements
Conclusion
26
Acknowledgements
27
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The Case for Change Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception
“I’ve seen how it empowers women – we’re offering something practical and important at exactly the right time.” – PPC Provider Overview This report outlines the strategic, policy, and funding actions needed to drive system-wide improvement in the provision of post-pregnancy contraception (PPC). The report audience is aimed at parliamentarians, Integrated Care Board (ICB) leaders, and national policymakers. It outlines the case for change and articulates the need to end the postcode lottery, with high- quality PPC services easily available in some parts of the country while in others, provision is scant or non-existent. The companion report Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception - A Guide for Best Practice offers best practice approaches for local and regional delivery, targeting ICB leaders, PPC providers, and commissioners. While each report stands alone, they are designed to be read together, offering a comprehensive framework for advancing PPC policy and practice across the UK. What is post-pregnancy contraception (PPC)? Post-pregnancy contraception includes provision of contraception to women after childbirth, abortion, ectopic pregnancy, miscarriage, or gestational trophoblastic disease (GTD). In this report, post-pregnancy contraception also refers to the provision of contraception following stillbirth and baby loss. Background Access to post-pregnancy contraception remains a luxury for many women in the UK, and in some regions, access is virtually non-existent. The statistics show: • In Britain, around 45% of pregnancies are unplanned or ambivalent. 1 • Almost 1 in 13 women presenting for an abortion or birth had conceived within a year of a previous birth. 2 • 1 in 8 women who have delivered one or more children conceive and continue another pregnancy within a year of a previous birth. 3
• Abortions are at a record high, with a 17% increase in comparison to the previous year in 2022. 4 • Almost a fifth of women are unable to access their preferred method of postnatal contraception. 5 Despite a clear incentive for PPC provision, many women face significant barriers to access. Access to PPC is currently a ‘postcode lottery’ due to existing commissioning structures, which mean that there is no clarity of responsibility in terms of who should provide post-pregnancy contraception. Why is access to post-pregnancy contraception important? 1. Women want PPC Providing information about contraception options during pregnancy allows women to make informed decisions about if and when they wish to get pregnant again. 2. PPC produces significant cost savings Providing contraception service in maternity settings has an estimated ROI of £32 savings to the public sector for every £1 invested. 6 3. PPC supports safe maternity care PPC is integral to supporting safe maternity care by ensuring women have all necessary information and can make an informed choice. Importantly, improved provision of PPC helps to tackle common myths and misconceptions around women, pregnancy, contraception and fertility. 4. Access to PPC reduces health inequalities Contributors to this report demonstrated the positive impact of PPC in tackling health inequalities in their local area. By flexibly providing contraception to women post-pregnancy in circumstances that suited them, they are improving women’s outcomes, particularly those who may find it harder to access SRH services.
1 The National Survey of Sexual Attitudes and Lifestyles (Natsal-3). 2 Heller R, Cameron S, Briggs R et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care. 2016;42(2):93-8. 3 Heller R, Cameron S, Briggs R et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care. 2016;42(2):93-8.
4 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022. 5 Moffat M, Jackowich R, Möller-Christensen C et al. Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study. 2024; 131(10): 1360–1367. 6 Public Health England. PHE Women’s Reproductive Health Programme 2020 to 2021.
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
7
Recommendations Recommendations for Government:
1
Support for post-pregnancy contraception should be clearly articulated and embedded into Government’s national health plans, including a reiterated commitment in any future updates or phases of the Women’s Health Strategy, and future work on maternity and neonatal safety, such as the national action plan. a. This should include support for developing a ‘Once for England’ approach to PPC provision, reflecting the efforts in other UK nations to help standardise the PPC offer and facilitate local areas meeting the needs of their local communities. We know that newer PPC services may need to target specific patients at first, to build a strong business case for wider funding and coverage. However, universal access and the standardisation of PPC should be the ultimate objective, so that every woman can access this crucial service no matter where they live. The merging of NHS England (NHSE) and the Department of Health and Social Care (DHSC) and the Government’s focus on integration, accountability and clarity in the health system, presents an ideal opportunity to fix the fragmented commissioning of women’s health and contraception: a. The DHSC should ensure that each ICB has a named individual who is accountable for the joined-up commissioning of contraception and women’s health services, including post-pregnancy contraception, in collaboration with local authority partners. This role should carry clear responsibility and authority to coordinate service delivery. This accountability is essential to empower ICBs to plan and deliver the services women need. b. The DHSC should support and promote co-commissioning of PPC services, and create a national forum to share examples of best practice with ICBs. c. Local Women’s Health Champions and the Women’s Health Ambassador/National Clinical Director for Women’s Health should maintain national oversight of commissioning decisions to ensure the needs of women are met throughout the life course. d. Merging NHSE and The DHSC creates an opportunity to bring together the expertise of the women’s health and reproductive health policy teams which currently sit separately. This will enable joined-up policy around the holistic needs of women across the life course. e. In conjunction with these changes at national level, local commissioning bodies should share budgets and contractual mechanisms to improve outcomes and facilitate simple solutions where capacity, priority, timing and relationships enable this to happen. i. Local Authority Health and Wellbeing boards or Overview and Scrutiny boards should hold parties to account for local decisions and any potential risks or issues.
2
3
The Government should consider conducting an audit of the current gaps in PPC provision across England.
4
The Government should work closely with the CoSRH and local PPC champions to establish a national resource database on PPC to share best practice of provision centrally. a. This should include the national counselling framework with scripts, and resource packs to support midwives and nurses in delivering high-quality and timely information. This should start in the antenatal period for those in maternity care and, where possible, prior to the end of pregnancy for those who need contraception after other pregnancy outcomes. The Government should build a repository of information to enable healthcare practitioners and all birthing people and their support networks to improve health literacy of the population around fertility, pregnancy, maternity and reproductive health. a. The NHS website and NHS app should be updated to include information about all PPC options.
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
6
In line with their commitment to shift to digital NHS systems and the introduction of the Single Patient Record in 10 Year Health Plan, the Government should oversee the improvement of electronic notes systems to ensure adequate, timely documentation of contraceptive discussions with women throughout the pregnancy journey. This should include digital alerts of previous PPC discussions when admitted for delivery. Maternity is rightly being prioritised in the Single Patient Record roll-out and the Government should ensure PPC is included in this . Better data is crucial to improving the quality and coverage of PPC services in England. National data sets should be amended to collect and record essential data related to PPC. For example, healthcare professionals delivering post-pregnancy care are currently asked to record previous pregnancies of the patient but not when they were. We recommend that: a. At a minimum, routine SRH and abortion data should include the date of the end of the last pregnancy. b. Additionally, routine maternity datasets should be modified to include fields on the London Measure of Unplanned Pregnancy, women’s antenatal choice of postnatal contraception and what contraception was provided post-pregnancy. c. This will allow the better monitoring of pregnancy planning and PPC at a national level to understand the choices and services available to women at this important time of their reproductive life.
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Recommendations for the NHS, ICBs and the wider health system:
1
National Institute for Health and Care Excellence (NICE) guidance on Contraception after Childbirth should be renamed Contraception after Pregnancy to reflect the importance of women’s access to the full range of contraceptive methods in all pregnancy outcomes. This guidance has not been updated since 2016 and trends in contraception along with best practice of PPC provision have changed considerably since then.
2
NHS England should publish its delayed guidance on women’s postnatal care, giving clear direction and recommendations for best practice including the provision of PPC.
3
NHS guidance should be made clearer to support information pathways at a local level. Women in the local community should know where, when and how they can access contraceptive services, either via physical or electronic guidance. a. Information outreach to pregnant women should be improved via promotion of the NHS digital inclusion framework. 7 ICBs should meet their responsibilities to commission maternity services that enable safe, equitable, and personalised maternity care for local populations and commission care in line with NICE guidelines. a. As per the NICE guideline Contraception after childbirth , commissioners should ‘ensure that maternity services give women information about and offer them a choice of all contraceptive methods as soon as possible and within 7 days of delivery, and refer them to a contraceptive service if contraception cannot be provided immediately.’ b. Commissioners should establish integrated pathways of care to make sure women are provided with their preferred method of contraception in a place of their choosing, in line with the Hatfield Vision: Goal 3/Action 4.
4
7 Inclusive digital healthcare: a framework for NHS action on digital inclusion
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Information should be provided in different formats for women to access when they feel ready, and healthcare professionals should practice compassion, empathy and sensitivity and understand why women may want to wait to receive certain information on contraception, including following pregnancy and baby loss. a. Ensure that guidance on contraception after pregnancy is available in accessible formats for all women and birthing partners (including male methods). This information must also be culturally sensitive and available in different languages. b. Ensure that providers adhere to the National Bereavement Care Pathway Guidance and Sands guidance when discussing contraceptive plans with women who have experienced pregnancy or baby loss. c. Ensure that contraception is discussed but never imposed on women who have needed an abortion, and that individuals are supported in selecting and using the method that best aligns with their needs and values. A non-directive, person-centred approach is essential to uphold reproductive autonomy and deliver respectful, high-quality care.
6
The College of Sexual and Reproductive Healthcare should develop a service standard on post-pregnancy contraception, which aligns with the CoSRH guidance on Contraception after Pregnancy , and these standards should be used to audit PPC services annually .
Recommendations for Workforce and Training:
1
The NHS should continue to review the need for more resources and capacity for professionals working in maternity services, including investing in and expanding the workforce so that staff have adequate time for education and training on contraception, and more time for contraceptive counselling and provision.
2
The NHS and higher education institutions should launch a review of future investment in education and training, including undergraduate and postgraduate curriculums to ensure that midwives and other healthcare professionals are equipped with the knowledge and skills to provide PPC.
3
The RCOG should embed Contraception including PPC into their O&G curriculum, recognising the need for obstetricians as well as all other maternity staff to provide advice and, where possible, postnatal contraceptive care.
4
Assessments should be made of the current contraceptive training opportunities for the maternity workforce and those working in abortion-care services. Consideration should be made to embedding specific skills into training pathways, including Long-Acting Reversible Contraception (LARC) competencies (Sub-Dermal Implant (SDI), Postpartum Intrauterine Contraceptive (PPIUC)).
5
Employers should reserve time in job plans of healthcare professionals involved in delivering PPC services for training, peer support, and mentorship.
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
HOW THE SYSTEM WORKS AGAINST YOU: The personal experience of a consultant obstetrician trying to access contraception after birth Foreword: Experience of a Consultant Obstetrician after Birth
I had my second baby by planned caesarean section at 39 weeks in March 2021, just as the first Covid restrictions were being lifted. Despite working in the Trust and being the Lead for Postnatal Contraception at the same hospital where I was having my caesarean section, I was unable to have a coil fitted at the same time, even though I knew that I didn’t want further children. This was because the service was not funded to provide this, nor did we have the community set up to support follow-up. This is despite experiencing two high-risk pregnancies and a scar opening during surgery. This would have been a clinically logical and convenient opportunity for this procedure, which only takes a few minutes, preventing repeat appointments and wasting NHS resources. Coils are safe to be inserted during or after the surgery and a convenient option for postpartum contraception. Research shows it is a highly effective method, with a very low failure rate. 8 Six weeks after my caesarean section, I contacted my GP for a coil fitting. I was told I was unable to book this appointment without a GP consultation first. I explained I didn’t think I needed to waste a GP’s time on this, having had coils since 2011, and being a Consultant Obstetrician. However, they still refused and could not tell me when they would be re-instating their LARC provision. Instead, I contacted my local Sexual Health service. They were happy to support a coil fit, but did not have their diary planned yet for the next month and would get back to me. They didn’t. So, I chased, two weeks later, and they still hadn’t confirmed their diaries, and couldn’t give me a timescale, even though it is standard NHS practice of giving six weeks’ notice for annual leave. I then contacted the next nearest Sexual Health clinic in the north of my county as I am lucky enough to have my own transport to enable me to attend this appointment. They could fit me in but there was a four week wait. When I attended this long-awaited appointment, they weren’t happy that I had brought my four- month old baby with me despite him being asleep in his car seat for the entire appointment. Unfortunately, this was unavoidable as I could not secure local childcare provision.
The clinician then said they were not happy to fit the coil as I was breastfeeding and advised me to come back when I had finished feeding. This is despite NHS guidance clearly outlining the safety of an Intra Uterine Device (IUD) during breastfeeding:
“ It’s safe to have an IUD when you’re breastfeeding, and it will not affect your baby or your milk supply .” 9
I finally had my coil fitted in November at the clinic further away from my home when my baby was eight months old. As a Consultant Obstetrician, I see patients everyday who face multiple barriers in trying to access contraception they need. If I had this kind of struggle – with my extensive knowledge of the health system, of the contraceptive options available to me plus the advantage of having transport, and having English as my first language – what chance do other women have of navigating this system and accessing the contraception while juggling the pressures of raising a newborn child? I can only imagine what other patients go through. What is the cost of this illogical system, both to the women themselves and to the health system? I see it too often in my line of work. For example, very recently in my termination of pregnancy service, I saw a 14+5 weeks pregnant woman, with her six-month-old baby in the clinic. This is not unusual – 20% of all women in termination of pregnancy service had a baby under one years old. We need policymakers to read stories like mine and understand the importance of action to get this right, to ensure women can easily access the contraception they need in the post-delivery period.
8 Goldstuck ND, Steyn PS. Insertion of intrauterine devices after caesarean section: a systematic review update. Int J Womens Health. 2017 Apr 18;9:205-212.
9 NHS.uk, Who can get the IUD (coil)?
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By Dr Janet Barter and Prof Ranee Thakar Introduction
Fertility also returns quickly after an abortion, with ovulation occurring as soon as 8 to 10 days and typically within three weeks of the procedure, regardless of the method of abortion. 14 Additionally, more than half of women resume sexual activity within two weeks of a termination of pregnancy. 15 A UK study reported that almost 1 in 13 women presenting for an abortion or birth had conceived within a year of a previous birth, and 1 in 8 women with children conceive and continue another pregnancy within the same time frame. 16 Without access to timely information and a method of choice, women may be at risk of an unplanned pregnancy soon after birth, abortion, or baby loss. Post-pregnancy contraception refers to the methods used to plan and prevent pregnancy after childbirth, and crucially after miscarriage, pregnancy loss, abortion, ectopic pregnancy, or gestational trophoblastic disease. It is integral to supporting women to have all necessary information and informed choice of methods no matter the pregnancy outcome. Importantly, the experiences of bereaved mothers must also be considered in this discussion. Miscarriage is the most common adverse pregnancy outcome with estimates rates of 10-15% in the UK. The NHS advises women that they “will need to use contraception from day 5 after a miscarriage or ectopic pregnancy” if they do not wish to conceive immediately. 17 Yet, it is rare for units managing early pregnancy loss to be able to provide this contraception. 18 Additionally, improved provision of PPC helps to tackle common myths and misconceptions around women, pregnancy, contraception, and fertility. For example, providers of PPC in Greater Manchester (Manchester, Trafford and Salford (SSCMS)) found that in asking women on the postnatal ward when they thought they could get pregnant again after birth, answers varied from “straight away” to “150 days” to “2 years.” 19 National statistics support this need for improved access to accurate knowledge and counselling on contraception. It is therefore crucial that women are able to make informed choices about contraception and access the support they need post-pregnancy. We also know that this is what women want. One study of women on postnatal wards found nearly 97% of the women stated that they were not planning a baby in the next year. 20 Furthermore, providing PPC offers a significant opportunity to reduce health inequalities by enabling access to contraception for women who may not engage with sexual health services. Yet, despite these opportunities and demand for PPC, too many health services are not set up to facilitate this, and women face a postcode lottery of provision across England. We strongly welcome the recognition of the importance of PPC in the Women’s Health Strategy and the opportunity the strategy presents to adopt a life-course approach to women’s health: “Information about contraception after childbirth should be offered in the antenatal period to support informed decision-making.
As Presidents of the College of Sexual and Reproductive Health and Royal College of Obstetricians and Gynaecologists (RCOG) we are deeply committed to ensuring every woman has access to contraception and can make informed choices about when and if to have a child. This is fundamental for women to be able to live well and pursue ambitions in every aspect of their lives. Today, women across the UK are becoming sexually active earlier and are having children later in comparison to previous generations. With a preference for having fewer children, women now spend decades of their reproductive life trying to prevent or plan pregnancy. However, despite this, we also know from our own experience as clinicians and from the thousands of members delivering front-line services across the UK that we represent, that too many women still face obstacles in accessing the contraception they need. In Britain, it is estimated that around 45% of pregnancies are unplanned or ambivalent, 10 abortion statistics are at a record high, with the latest data recording a 17% increase in procedures in comparison to the previous year. 11 Data also shows that more than half of women accessing abortion care have children, and 41% have had one or more previous abortions. 12 We firmly believe that abortion is an essential component of healthcare and a vital aspect of women’s reproductive rights and autonomy. Yet, these statistics suggest an unmet need for effective contraception, including after pregnancy. The Importance of Access to Post-Pregnancy Contraception (PPC) Pregnancy is a significant reproductive event during which women are in regular contact with healthcare services, creating an opportunity to discuss contraceptive choice with women and their partners and to provide contraception to help them plan or avoid future pregnancies. Fertility returns soon after pregnancy, as early as three weeks after birth, even before the return of menstruation. 13
10 The National Survey of Sexual Attitudes and Lifestyles (Natsal-3). 11 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022 12 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022 13 NHS.uk. Sex and contraception after birth. 14 Boyd EF, Jr, Holmstrom EG. Ovulation following therapeutic abortion. Am J Obstet Gynecol. 1972;113:469–473. Lähteenmäki P, Luukkainen T. Return of ovarian function after
abortion. Clin Endocrinol (Oxf) 1978; 8: 123–32. Schreiber CA, Sober S, Ratcliffe S, Creinin MD. Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception 2011; 84: 230–3. 15 Boesen HC, Rørbye C, Nørgaard M, Nilas L. Sexual behavior during the first eight weeks after legal termination of pregnancy. Acta Obstet Gynecol Scand. 2004 Dec;83(12):1189–92. 16 Heller R, Cameron S, Briggs R, et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
We are encouraged to see examples of local areas providing contraception in maternity settings and encourage local commissioners and providers to consider implementing this service.” 21 We also know that there is a significant cost benefit to PPC, which is largely returned to the healthcare service itself. In a financial climate where NHS budgets are under pressure to find savings, the cost efficiency of PPC cannot be overstated. Providing contraceptive counselling and methods at this crucial stage of women’s reproductive life ensures that women have timely access to the contraception they want, while they are already in contact with the health system. As it stands, too many opportunities are missed, to the detriment of women, their families and the health system as a whole. The CoSRH Hatfield Vision and our Work to Improve PPC Provision: Since 2023 we have led a working group of the CoSRH Hatfield Vision on post-pregnancy access to contraception; emphasising the importance of collaborative commissioning to make this a reality. The Hatfield Vision is the CoSRH’s blueprint outlining what needs to be achieved to improve the health of 51% of the UK’s population and tackle the inequalities that women and girls face across their lifetime. The Vision sets out goals and actions endorsed by 70 leading organisations in areas such as contraception, abortion,
menopause, menstrual health, cervical screening, and maternal health outcomes in Black women and women of colour. It is a legacy to the late Jane Hatfield, the first CEO of the Faculty of Sexual and Reproductive Healthcare (now the CoSRH), who worked tirelessly to improve the quality of reproductive healthcare that every woman and girl receives. Goal 8 of the Hatfield Vision focuses on improving access to PPC: “Integrated Care Systems (ICSs) should ensure that all methods of contraception are discussed with women during pregnancy and, where possible, their method of choice should be initiated prior to discharge from maternity services. Rapid follow-up pathways for LARC should be in place when needed.” 22 A wide range of experts and organisations have come together to work on improving PPC, including researchers, obstetricians, midwives, nurses, and commissioners, all of whom are driven and passionate about improving this pathway, including Dr Ed Mullins, Obstetrician and Clinical Lecturer at Imperial College London; Dr Annette Thwaites, Honorary Research Fellow in Sexual and Reproductive Health at The Institute for Women’s Heath at University College London; Vicki Pirie, Lead Contraception Midwife in Gloucestershire, and Fiona Gibb, Director of Midwifery at the Royal College of Midwives. This report is the culmination of the expertise and experiences shared during the meetings of this group since its inception two years ago. It contains invaluable insights from multidisciplinary professionals working tirelessly to research, commission, lead on, and deliver PPC to women across the UK, as well as from women themselves who have accessed this vital service or have faced barriers in doing so.
Health Care 2016;42:93–8. 17 Government UK, Government response to the independent pregnancy loss review: Care and support when baby loss occurs before 24 weeks’ gestation. 18 Government UK, Government response to the independent pregnancy loss review: Care and support when baby loss occurs before 24 weeks’ gestation. 19 Contribution from provider to the report.
20 Heller R, Cameron S, Briggs R, et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care 2016;42:93–8. 21 Government UK, Women’s health strategy for England: Fertility, pregnancy, pregnancy loss, and postnatal support. 22 CoSRH, Hatfield Vision: Two Years in: Progressing our Sector’s Consensus Ambitions for Reproductive Health Outcomes (2024).
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The provision of PPC perfectly exemplifies the consequences of this fragmentation as clinicians and patients are forced to fight siloed arrangements to be able to deliver the essential care regarded as ‘common sense’ by many. The Government now has an opportunity to introduce the clarity, accountability and collaboration into PPC provision that is urgently needed. This will be implemented alongside the welcome shifting of services towards preventative, efficient care in the community that will improve outcomes and tackle health inequalities - all goals that are central to PPC provision. We strongly believe that ensuring access to contraception should be a key priority for this Government, including a focused effort to improve the provision of PPC. The Government’s key stated ambitions for the health service, to strategically shift services towards preventative, efficient care in the community that will improve outcomes and tackle health inequalities, are all goals that are central to PPC. We sincerely thank all individuals, professionals and organisations who have given their time and expertise to contribute to this report and to the delivery of PPC services across the UK. We warmly welcome the report’s recommendations and very much look forward to working with colleagues in the health sector and policymakers across the country to ensure that all women and their partners are able to access the contraceptive care they need post-pregnancy.
It is women and their experiences who are central to this report. Their testimonies show us the barriers women still face in accessing contraceptive care during and after pregnancy. It is for this reason we came together, as Presidents of the CoSRH and RCOG to show how SRH and maternity professionals are united in consensus for this report’s ambition and recommendations. We both warmly welcomed the Government’s commitment in its Manifesto: “Never again will women’s health be neglected. Labour will prioritise women’s health as we reform the NHS” 23 as well as the intention to strategically rebuild the NHS so it is fit for future generations. Specifically, in its 10 Year Plan for the NHS, the Government recognises the longstanding issue of fragmented commissioning and the detrimental impact of this particularly has on women’s experiences of health services.
Dr Janet Barter is President of the College of Sexual and Reproductive Healthcare and a Consultant in Sexual and Reproductive Healthcare in East London. After medical training in Sheffield, and time as a GP trainee, she embarked on a career in Obstetrics and Gynaecology, driven by a strong interest in women’s health shaped by experiences in the UK and West Africa. As the specialty of SRH developed she became embedded in the Specialty as a Consultant, Educator and Leader and has worked clinically across the whole sphere of SRH.
Dr Janet Barter President, The College of Sexual and Reproductive Healthcare
Prof Ranee Thakar MD FRCOG is the President of the Royal College of Obstetricians and Gynaecologists, a Consultant Obstetrician and Urogynaecologist at Croydon University Hospital, an Honorary Senior Lecturer at St George’s University of London, and Honorary Professor of Women’s Health at the University of Liverpool.
Prof Ranee Thakar President, The Royal College of Obstetricians and Gynaecologists
23 The Labour Party, Change Labour Party Manifesto 2024.
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
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Key Statistics
FERTILITY RETURNS POST-BIRTH WITHIN
ABORTION STATS ARE AT A RECORD HIGH, WITH
IN BRITAIN 45 % 21 around
17 %
DAYS 25
1 IN 8 parous women conceive and continue another pregnancy WITHIN A YEAR OF A PREVIOUS BIRTH 26
WITHIN 1 YEAR women presenting for an abortion or delivery had conceived 1 IN 13 – ALMOST – INCREASE IN COMPARISON TO THE PREVIOUS YEAR IN 2022 27 SAVINGS OF £32 PROVIDING CONTRACEPTION SERVICE in maternity settings has an estimated to the public sector for every £1 invested 33 OF A PREVIOUS BIRTH 30
of pregnancies are unplanned or ambivalent 24
ALMOST HALF of women resumed some form of sexual activity within 8 WEEKS of delivery 29
An increasing proportion of abortions in women who already have children 28
1 /
Miscarriage is the most adverse pregnancy outcome IN THE UK 10 % TO 15 % OF ALL PREGNANCIES END IN MISCARRIAGE 31
ALMOST of women are unable to
5
access their preferred method of postnatal contraception 32
24 The National Survey of Sexual Attitudes and Lifestyles (Natsal-3). 25 NHS.uk. Sex and contraception after birth
30 Heller R, Cameron S, Briggs R, et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care 2016;42:93–8. 31 Glasier A, Bhattacharya S, Evers H, Gemzell-Danielsson K, Hardman S, Heikinheimo O, La Vecchia C, Somigliana E; Annual Capri Workshop Group. Contraception after pregnancy. Acta Obstet Gynecol Scand. 2019 Nov;98(11):1378-1385. doi: 10.1111/aogs.13627. Epub 2019 May 13. PMID: 31001809. 32 Moffat M, Jackowich R, Möller-Christensen C, Sullivan C, Rankin J. Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study. BJOG. 2024; 131(10): 1360–1367. 33 Public Health England. PHE Women’s Reproductive Health Programme 2020 to 2021.
26 Heller R, Cameron S, Briggs R, et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care 2016;42:93–8. 27 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022. 28 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022. 29 Moffat M, Jackowich R, Möller-Christensen C, Sullivan C, Rankin J. Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study. 2024; 131(10): 1360–1367.
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
Why is Post-Pregnancy Contraception Important? The Clear Case for Action:
It’s what women want:
The case for improved PPC is clear to providers who see how with a new baby, accessing contraception can be understandably even more difficult to access or prioritise. “PPC is an essential aspect to empower women who are often under significant pressures to support a newborn and or other children.” York and North Yorkshire PPC service “PPC is important to us, because contraception is important to us, and the health of women and their families now and moving forwards is important to us. I find it frustrating that we are able to do many, many complex things for women and their babies without even thinking about it, but we are unable to easily provide one of the most basic forms of healthcare, one that has very valuable benefits to women and their families.” South Tees PPC service PPC Can Help Tackle Health Inequalities: The Government has made clear that reducing health inequalities is at the heart of its vision for the future of the NHS. Several contributors to this report outlined how PPC has successfully reduced health inequalities in their local area by facilitating access to essential services and engaging with typically ‘easy to ignore’ groups. By flexibly providing contraception to women post-pregnancy in circumstances that suited them, they are improving women’s outcomes, particularly those who may find it harder to access SRH services:
“ I had to ask about contraception myself, and then I was told I could have it at the same time as my caesarean. ” “ I wanted to talk about the coil and implant [before birth] .” “ Obviously, [...] we had, we had to speak about these kind of things. Because, obviously, I dinnae want to be falling pregnant, straight after, [...] And, yeah, it kind of helped me a lot [...] I didn’t know that, like, I could get it [the implant] put in straightaway after [...] I thought I had to wait, like, a couple of weeks .” Guidelines recommend that individuals wait 12-24 months after giving birth before trying to get pregnant again to optimise maternal recovery, reproductive autonomy and improve health outcomes for future pregnancies. 34 The CoSRH and The National Institute for Health and Care Excellence (NICE) guidance state that service providers should ensure all women have access to the full range of effective contraceptive methods immediately after childbirth and all other pregnancy outcomes such as miscarriage, stillbirth, neonatal death, molar or ectopic pregnancy, or abortion. 35 Additionally, Sands, the UK’s leading pregnancy and baby loss charity, guidance advises healthcare professionals to approach these conversations with compassion, empathy and sensitivity, recognising emotional context and individual needs, as outlined in the National Bereavement Care Pathway (NBCP). However, access to contraception is highly variable to women across the UK. While all women and service users should be able to access contraception from primary care and sexual health services, in reality, women can face huge barriers in doing so, as shown in a recent report from the British Pregnancy Advisory Service (BPAS) which surveyed over 1,000 women aged 18-45 and found that nearly half of women face barriers to accessing contraception. 36 Consensus from contributors to this report is that these barriers are often intensified, worsened or exacerbated with a newborn baby.
34 World Health Organization. Birth spacing: A policy brief, 2005; College of Sexual and Reproductive Healthcare. Contraception after pregnancy: Guideline, January 2017; National Institute for Health and Care Excellence. Quality statement 4: Contraception after childbirth, 2016. 35 College of Sexual and Reproductive Healthcare. Contraception after pregnancy: Guideline, January 2017; National Institute for Health and Care Excellence. Quality statement 4: Contraception after childbirth, 2016; UK Parliament. CDP-2025-0038: Women’s Health.
36 British Pregnancy Advisory Service, Contraception Re-Imagined: The Unfinished Revolution, March 2025.
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“In one instance, a 15-year-old planned to have an implant fitted postnatally but was too distressed on the ward due to a transfer to a mother-and-baby foster placement. A follow-up home visit enabled timely contraception.” “Another woman with learning difficulties was supported over multiple appointments using simplified resources, while a mother with mental health challenges accessed a virtual consultation and felt empowered by the process.” Quotes from Gloucestershire PPC service “By embedding contraception provision into routine maternity care, the service ensures women are supported with timely, effective options that align with their needs and circumstances, ultimately promoting reproductive autonomy and reducing health inequalities across Greater Manchester.” Greater Manchester PPC service
“Women from Black and ethnic minority backgrounds and lower socioeconomic groups are at greater risk of physical and psychiatric conditions of pregnancy when compared to white British women. Without appropriate education about risk factors, such as obesity and smoking, as well as effective and robust mechanisms for follow-up beyond the traditional postpartum period of 6 weeks, these inequalities are reinforced.” Commissioner, Bedfordshire, Luton and Milton Keynes ICB Contributors agreed that providing PPC helps to address wider public health inequalities and improve health outcomes for mothers in the most deprived areas while they are already in contact with health service. This echoes academic research into PPC: “Our [research] results also highlight the potential for contraception provision on the postnatal ward to reduce inequalities in access to contraceptive services as 10% of our sample had never used any contraception.” Thwaites A, Logan L, Nardone A et al.’s study. 37 Importantly, echoing existing research, contributors were keen to stress that a universal approach to providing PPC was essential to tackling inequalities. Only by ensuring that all pregnant people and their partners, regardless of their background or circumstances, receive an offer of contraception can a service can address the needs of all vulnerable populations and reduce disparities. 38 PPC Can Provide Huge Cost-Benefits to the NHS: A strong argument in favour of improving the provision of PPC is its huge potential for cost-saving benefits to the NHS and wider health system. The cost of training and initial contraceptive supply is offset by public health and financial savings including on: • Reduced rates of unplanned and high-risk pregnancies • Decreased demand on primary care, abortion and maternity services • Prevention of complications associated with short birth intervals
37 Thwaites A, Logan L, Nardone A, et al. Immediate postnatal contraception: What women know and think BMJ Sex Reprod Health 2019;45:111–117. 38 Heller R, Cameron S, Briggs R, et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care 2016;42:93–8.
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BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
Government analysis of the return of investment of contraception found that it could lead to savings of £32 over a 10 year period for the system as a whole, for every additional £1 invested. 39
“Contraception also has an important wider role in women’s lives – for example, managing symptoms of menstrual problems, gynaecological conditions and perimenopause. Through management of gynaecological conditions, contraception also supports women and girls to reach their full potential in education or the workplace.” 42 The better management of such conditions through PPC would undoubtedly help ease pressure on other primary and community services in the health service. This is particularly welcome as absenteeism from work due to heavy and painful periods, endometriosis, fibroids and ovarian cysts costs the UK economy nearly £11 billion every year. 43 Improving PPC access may help reduce health-related work absences and deliver savings in both healthcare costs and lost productivity. Improved PPC Provision Can Empower Women and Improve Their Health Literacy: Contributors were in consensus that in addition to reducing pressure on other healthcare services across contraception, sexual health and women’s health, PPC educates and empowers women and their partners to make informed decisions about their families – improving health literacy and maternal and child health outcomes: “Better public awareness of these issues would also help women make an informed choice as to when to have their next pregnancy and whether to access immediate post-natal contraception.” Dr Georgina Forbes, Specialist Doctor in SRH and the CoSRH Wales Committee Chair PPC is a Global Maternal Health Priority: This domestic progress echoes a growing global consensus from countries such as Australia and the US that PPC is not only a matter of women’s autonomy but a key strategic tool to address reproductive health inequalities. The UK has an opportunity to become a world leader in providing PPC, tackling reproductive health inequalities while also bringing financial savings to the NHS.
In relation to post-pregnancy contraception in particular, the cost savings are stark: “Over 10 years, based on an estimated 64% uptake of postnatal contraception on maternity wards, total cost savings to the NHS and wider system would amount to £150 million, comprising £59 million for the NHS, £9 million for local authorities, and £82 million for other government departments.” 40 These estimated savings compare highly favourably with other public health interventions such as childhood vaccinations or HIV Prevention (PrEP) which have been implemented. 41 This is critically important in the current financial context and the significant reductions facing Integrated Care Board (ICB) budgets. Importantly, in areas such as York and North Yorkshire, contributors for this report set out how improving PPC provision allowed them to optimise efficiency of their resources, and become more operationally cost-effective: “Allowing new mums the access to a safe and inexpensive contraception in their own home at a time when they were juggling a new baby [..] the POP [progestogen-only pill] six-month supply cost was £2.62 this is a cost-effective bridging method which allowed women an opportunity to consider their next contraception plan without having to rush a decision.” York and North Yorkshire PPC service Many contributors noted how providing contraception at this point, when women are already in contact with the health system, is resource efficient and eases pressure on other services in primary or community care where women would have had to make additional appointments to access contraception – which then become avoidable and unnecessary. It is crucial to note that PPC also provides valuable non- contraceptive uses to many women. For example, it can support the management of menstrual disorders or heavy menstrual bleeding, as acknowledged in the Women’s Health Strategy:
39 Public Health England. PHE Women’s Reproductive Health Programme 2020 to 2021. Cost effectiveness analysis has also demonstrated that immediate contraception provision at the time of a medical abortion is more cost-effective than delayed provision. 40 Public Health England, Extending Public Health England’s contraception return on investment tool, maternity and primary care settings. 41 Ong KJ, Desai S, Field N, Desai M, Nardone A, van Hoek AJ, Gill ON. Economic evaluation
of HIV pre-exposure prophylaxis among men-who-have-sex-with-men in England in 2016. Euro Surveill. 2017 Oct;22(42):17-00192. 42 Government UK. Women’s health strategy for England: Fertility, pregnancy, pregnancy loss, and postnatal support. 43 NHS Confederation. Women’s health economics, 2024.
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