Beyond Barriers: A Guide for Best Practice

Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception – A Guide for Best Practice showcases proven, replicable models of local service delivery.

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

“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

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

“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.” 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.” Post-pregnancy contraception (PPC)

“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

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.

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

Contents

Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception

A Best Practice Guide

Foreword

Dr Sue Mann, National Clinical Director in Women’s Health for NHS England

Foreword: The Importance of a Universal Offer of Post-Pregnancy Contraception

Dr Malcolm Moffat

Introduction

By Dr Janet Barter, CoSRH President, and Prof Ranee Thakar, RCOG President

Key Statistics

Best Practice In Post-Pregnancy Contraception: The Lessons Learnt 1. The Importance of Supportive Commissioning and Leadership Locally

13 14 14 15 17 19 21 22 23

2. The Importance of a Contraceptive Champion

3. The Role of the Nurse or Midwife as a Conduit for PPC Provision

4. Fostering Collaboration Across Disciplines, and Establishing Clear Care Pathways to Support

5. The Importance of Contraceptive Counselling During Pregnancy 6. The Importance of Robust Workforce Training and Education

7. The Importance of Access to Evidence-Based, Accurate Information on Contraception 8. The Importance of Efficient Digital Infrastructure for Guiding, Recording, Monitoring

and Evaluating PPC Services

PPC in Scotland and Wales

25 25

A View from Scotland A View from Wales

Acknowledgements

Appendices and Resources

Appendix 1: Contraceptive Options Post-Pregnancy 28 Appendix 2: Setting Out the Evidence, Research and Data on Post-Pregnancy Contraception 29 to Enable Women’s Reproductive Choices by Dr Annette Thwaites, Dr Edward Mullins, and Dr Patricia A. Lohr Appendix 3: The Importance of Sensitive Contraception Counselling after Pregnancy Loss and the Death of a Baby: a View of Those Supporting Bereaved Parents 34 Appendix 4: Accessing Contraception after Abortion by Dr Annette Thwaites, Dr Edward Mullins, and Dr Patricia A. Lohr 35 Appendix 5: The View from Scotland by Professor Anna Glasier and Dr Michelle Cooper 38 Appendix 6: The View from Wales by Dr Helen Munro and Aimee Burgess 41 Appendix 7: Equipping the Workforce with the Education and Training They Need: The View from the CoSRH 44 Resources 47

A Guide for Best Practice 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 offers best practice approaches for local and regional delivery, aimed at Integrated Care Board (ICB) leaders, managers in hospital Trusts, and other healthcare commissioners. The companion report: Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception - The Case for Change outlines the strategic, policy, and funding actions needed to drive system- wide improvement in PPC provision. The report audience is aimed at parliamentarians, ICB leaders, and national policymakers. The report outlines the case for change from the current situation of a ‘postcode lottery’ where high-quality PPC services – although present in regions across the UK – are not standard practice. 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, as shown by the following statistics: • 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 supporting women to have all necessary information and 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. Opportunities Many regions across the UK have set up successful PPC services, many of which have provided case studies for this report. However, these exemplary services are not standard, and many potential providers struggle to set up a PPC service due to the barriers of existing commissioning structures.

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.

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

Dr Sue Mann, National Clinical Director in Women’s Health for NHS England Foreword England and a Consultant in Women’s Health I know how valuable access to post-pregnancy contraception (PPC) is for women. Most women who have recently experienced pregnancy do not wish to become pregnant again straight away, whether in maternity, early pregnancy or abortion settings. However, we know that a woman’s fertility returns within 21 days of birth and that almost half of women resume sexual activity within 8 weeks of birth. Furthermore, a study conducted in Scotland found almost 1 in 13 women presenting for an abortion or delivery had conceived within 1 year of a previous birth. This evidence, and this report, demonstrates a clear need for access to contraception in the post-pregnancy period, to facilitate choice and enable women to plan or prevent any further pregnancies as they wish. As women are already in frequent contact with the health system during pregnancy, there are several opportunities to have discussions with known, and often familiar, healthcare professionals about their options. This allows women to choose the contraception that’s right for them, at a time and place that suits them best after pregnancy. Crucially, PPC is also an effective public-health intervention – it takes an upstream approach to prevention and looks to avoid the harms which can come from an unintended or unwanted pregnancy. It reaches women who may typically struggle to engage with services outside of the pregnancy journey and therefore has the potential to greatly reduce reproductive health inequalities in a local area.

Dr Sue Mann FFPHM MRCOG MFSRH is the National Clinical Director in Women’s Health for NHS England. She has previously held national roles at Public Health England and Department of Health and Social Care and in all these roles she has consistently driven a population, integrated and outcome-based approach to delivery of women’s healthcare across the system. She currently leads a programme of work at NHS England to tackle

Gynaecology elective waiting lists through both improving efficiencies but also challenging current models of care to drive transformation. She is passionate about improving experience for women in healthcare and committed, following her appearance at the Women and Equalities Select Committee, to making this a priority for NHS England. She has also led the development of a Women’s Health Equity Framework to drive a reduction of inequalities in care received for menopause and heavy menstrual bleeding. She is a clinical Consultant in Women’s Health and Clinical Lead for Women’s Health in City and Hackney where she leads a specialist neighbourhood service for delivery of women’s healthcare. As part of this service she has pioneered the delivery of group consultations for delivering women’s healthcare particularly in menopause and seen more than 3,000 women in this way over the last 5 years. Working national to local, secondary to primary and integrating across specialties has enabled an integrated vision of how women’s healthcare in the future can be delivered. Alongside these significant benefits to the woman, there is compelling evidence which demonstrates PPC as a highly cost- effective intervention for the NHS and wider society. PPC has a return on investment of £32 to the public sector for every £1 invested. This is significant at a time of financial restraint in the NHS. Local authorities would also save costs on public health expenditure by avoiding unintended pregnancies and reduced costs of children in care. The savings are greatest for other wider government departments who do not invest in contraception directly but will make savings for example in education and welfare. This is why I welcome this report and applaud the best practice outlined within it – from South Tees, Bristol, London, and Derby – demonstrating how important this service is to women and the empowering impact it can have on their life. I want to sincerely thank all who continue to work hard to deliver PPC services for women across England and very much look forward to working with them on this crucial aspect of women’s reproductive care.

Dr Malcolm Moffat Foreword: The Importance of a Universal Offer of Post-Pregnancy Contraception

Post-pregnancy contraception (PPC) should be a key part of a core public health offer. At its heart, it is about prevention, about taking an upstream approach to tackling the psychosocial and physical harms that we know occur downstream when pregnancies are unwanted and/or unplanned, particularly those conceptions that arise during the postpartum period. 7 This not only benefits individuals but also strengthens family and community networks, leading to impressive economic savings for health and social care services, which are currently under huge financial pressure. And, as with everything we do in public health, it is fundamentally about reducing inequalities.

Dr Malcolm Moffat is an Honorary Consultant in Public Health with a clinical background in women’s health, based at Newcastle University. His ongoing work on an NIHR Doctoral Fellowship is looking to determine a consensus approach to the delivery of PPC services in England.

Improving PPC provision across England represents an opportunity to address the deep disparities in unplanned pregnancies that currently exist.

receive less comprehensive care — we found that women who might be considered at higher risk of having a rapid repeat pregnancy were more likely to use PPC. 9 This included younger women and girls, especially those of teen age, women in households with a lower household income, women with multiple children, non-breastfeeding women, and women who reported that their pregnancy had been unplanned – all groups perceived to be at a higher risk of experiencing a short interpregnancy interval. Overall, it revealed that the targeted PPC provision in the Northeast and North Cumbria fell a long way short of reaching the whole local population and all the women who needed it. It can be persuasively argued that a universal approach to PPC provision is needed. PPC care must reach further into our communities and meet the needs of the larger group of all women, or we continue to fail to reap the public health benefits. Importantly, we have not adequately considered how a truly universal PPC offer might also involve male partners. Expanding our PPC offer to make services accessible not only to all women but also to all men represents an important

However, the current provision of PPC in the UK falls short of meeting the needs of our population, and remains patchy and uneven. This is despite the numerous examples of great PPC care being delivered by innovative and ambitious services across the country, many of which are represented in this report. As we reflect on these case studies, there is an opportunity to make the case for a PPC service that moves away from being a targeted offer to one that is truly universal. The Northeast and North Cumbria Postnatal Contraception (PoCo) Study was the first UK-based study to examine PPC provision across a whole UK region (the Northeast and North Cumbria Integrated Care System (NENC ICS), the largest Integrated Care System (ICS) in England) and across the whole pregnancy and postnatal pathway. 8 The study surveyed 2,500 women who had a term pregnancy in the preceding three years and asked them to describe their postnatal contraception experiences at multiple points in their maternity/postnatal pathways. Analysis of the results was surprising. Contrary to what is more typically seen in health research that reflects the ‘inverse care law’ — where people belonging to the most marginalised and underserved social groups typically

7 For more on the evidential basis for post-pregnancy contraception, see Appendix 2. 8 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;00:1–8. https://doi. org/10.1111/1471-0528.17821.

9 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;00:1–8. https://doi. org/10.1111/1471-0528.17821. 10 Boydell V, Smith RD, Global LARC Collaborative (GLC). Hidden in plain sight: A systematic review of coercion and Long-Acting Reversible Contraceptive methods (LARC). PLOS Glob Public Health. 2023:3(8): e0002131. https://doi.org/10.1371/ journal.pgph.0002131.

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

opportunity to address gendered attitudes to PPC care that may perpetuate outdated views around who is responsible for pregnancy prevention. A key theme of PPC research is whether targeted, ‘high risk’ models of PPC provision might also result in care that could be considered prejudiced or coercive. Historical abuses of reproductive autonomy have cast a long shadow over attitudes to contraception provision, and the international literature still points to differential experiences of PPC care in which marginalised women report feeling pressured to accept particular methods. 10 What we need is person-centred provision that helps women to make informed, considered decisions about what works for them. Making our PPC offer universal and giving everyone access to culturally appropriate, evidence-based information

and services, helps to address any danger that new parents feel directed towards a particular model of PPC care due to perceived fitness for parenthood. With this Government’s shift in focus to prevention in the NHS and their commitment that “never again will women’s health be neglected”, the time is ripe for an ambitious reset in terms of our approach to PPC care.

If realised, the benefits are likely to be significant. As the Government’s Women’s Health Ambassador, Dame Lesley Regan says, “when we get it right for women, everybody in society benefits.” As we look forward, let’s aim to get it right for all women.

By Dr Janet Barter and Prof Ranee Thakar Introduction

We firmly believe that abortion is an essential aspect of healthcare and women’s reproductive autonomy. Yet, these statistics suggest an unmet need for effective contraception, including just after a 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 to avoid future unintended pregnancies. 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 (PPC) refers to the methods used to plan and prevent pregnancy after childbirth, and crucially after miscarriage, 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.

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 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 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, 11 Abortion statistics are at a record high, with the latest data recording a 17% increase in procedures in comparison to the previous year. 12 Data also shows that more than half of women accessing abortion care have children, and 41% have had one or more previous abortions. 13

Fertility returns soon after pregnancy, as early as three weeks after birth, even before the return of menstruation. 14 Additionally, more than half of women resume sexual activity within two weeks of a termination of pregnancy. 15

11 The National Survey of Sexual Attitudes and Lifestyles (Natsal-3). 12 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022. 13 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022. 14 NHS.uk. Sex and contraception after birth.

15 Boesen HC, RØrbye C, NØrgaard M and Nilas L, Sexual behaviour during the first eight weeks after legal termination of pregnancy; Acta Obstetricia et Gynecologica Scandinavica, 83: 1189-1192. 16 Heller R, Cameron S, Briggs R, et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short-inter pregnancy intervals. Journal of Family Planning and Reproductive Health Care 2016;42:93-98.

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

Importantly, improved provision of PPC helps to tackle common myths and misconceptions around women, pregnancy, contraception, and fertility. Moreover, individuals who experience outcomes such as miscarriage, abortion, or ectopic pregnancy may not encounter maternity or midwifery services. Therefore, it is essential that PPC is delivered through a coordinated, whole- system approach that integrates services and commissioning structures to prevent gaps in care, information provision and ensure equitable access for all post-pregnancy outcomes. PPC is integral to supporting safe maternity care by supporting women to have all necessary information and informed choice. Importantly, 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.” 17 National statistics support this need for improved access to accurate knowledge and counselling on contraception. Meanwhile, 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. 18 It is crucial that women are able to make informed choices about contraception and access the support they need post-pregnancy. Yet, too many health services are not set up to facilitate this, and women face a postcode lottery of provision across England. That is why since 2023 we have led a working group of the CoSRH Hatfield Vision on post-pregnancy access to contraception and the importance of collaborative commissioning to make this a reality. We would like to 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.

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

17 Contribution from provider to the report. 18 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.

Key Statistics

FERTILITY RETURNS POST-BIRTH WITHIN

ABORTION STATS ARE AT A RECORD HIGH, WITH

IN BRITAIN 45 % 21 around

17 %

DAYS 20

1 IN 8 parous women conceive and continue another pregnancy WITHIN A YEAR OF A PREVIOUS BIRTH 21

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 22 SAVINGS OF £32 PROVIDING CONTRACEPTION SERVICE in maternity settings has an estimated to the public sector for every £1 invested 28 OF A PREVIOUS BIRTH 25

of pregnancies are unplanned or ambivalent 19

ALMOST HALF of women resumed some form of sexual activity within 8 WEEKS of delivery 24

An increasing proportion of abortions in women who already have children 23

1 /

Miscarriage is the most adverse pregnancy outcome IN THE UK 10 % TO 15 % OF ALL PREGNANCIES END IN MISCARRIAGE 26

ALMOST of women are unable to

access their preferred method of postnatal contraception 27

19 The National Survey of Sexual Attitudes and Lifestyles (Natsal-3). 20 NHS.uk. Sex and contraception after birth

25 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. 26 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. 27 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. 28 Public Health England. PHE Women’s Reproductive Health Programme 2020 to 2021.

21 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. 22 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022. 23 Office for Health Improvement and Disparities. Abortion statistics for England and Wales: 2022. 24 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.

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

Best Practice In Post-Pregnancy Contraception: The Lessons Learnt

The following is imperative: 1 . The Importance of Supportive Commissioning and Leadership Locally 2 . The Importance of a Contraceptive Champion 3 . The Role of the Nurse or Midwife as a Conduit for PPC Provision 4 . Fostering Collaboration Across Disciplines, and Establishing Clear Care Pathways to Support 5 . The Importance of Contraceptive Counselling During Pregnancy 6 . The Importance of Robust Workforce Training and Education 7 . The Importance of Access to Evidence-Based, Accurate Information on Contraception 8 . The Importance of Efficient Digital Infrastructure for Guiding, Recording, Monitoring and Evaluating PPC Services

In compiling this report on best practice of PPC, the CoSRH heard from an array of contributors that many commissioners and service providers are going above and beyond what is set out in existing guidance to ensure that women receive the necessary high quality contraceptive care throughout their maternity journey. We know that professionals want to do this, and they want to get it right. From analysis of the dozens of case studies submitted to us from PPC providers across England, clear themes of best practice emerged providing valuable lessons to aid the improvement of existing services and for those considering establishing a PPC service. This report set out that effective commissioning and delivery of PPC is possible, necessary and financially efficient, and most importantly how it can be set up to meet the needs of women at this important stage in their lives.

ACCESS TO EVIDENCE- BASED CULTURALLY

SUPPORTIVE LEADERSHIP

APPROPRIATE INFORMATION

ONGOING WORKFORCE EDUCATION & TRAINING

MIDWIFE OR NURSES AS CHAMPIONS

PATIENT-LED ANTENATAL COUNSELLING

COLLABORATIVE MULTI-DISCIPLINARY WORKING

The Importance of Supportive Commissioning and Leadership Locally

Recommendation 1 Foster Supportive Leadership at ICB and Trust-level Supportive leadership from both Commissioners and Trust managers is vital to mitigate barriers to setting up and maintaining a consistent service, and to ensure that the necessary resource and capacity is secured. It is important to demonstrate how essential a PPC service is via a strong business case to obtain leadership buy-in. This report aims to provide resource for the business case, and the companion report will be helpful in influencing policy makers Services must be supported through effective commissioning and provider training to ensure all methods, including LARC, are available. 29

“Strong leadership is essential to drive service improvements and advocate for necessary resources. Obstacles include limited budget, staff capacity, and the need for continuous advocacy to maintain support for the service” Public Health Principal, Portsmouth The strong consensus from contributors is that ICB and hospital Trust-level senior leadership is essential when developing and sustaining a PPC service, particularly to mitigate the various barriers involved with setting up and maintaining an offer of PPC consistently to women. The PPC service in South Tees emphasised how strong top-down leadership is vital for culture change to happen: “…we need top-down passion for post-natal contraception, in addition to the few of us that are passionate on the floor”. Consultant Obstetrician, South Tees In Liverpool, PPC was supported by leaders locally through the inclusion of the integration of contraception provision into the maternity pathway as a key action in the Liverpool Sexual & Reproductive Health Strategy (2024-2030) : “The local authority supported and funded the LARC pathway and devices, with the ICB/NHS picking up the cost of routine

The Importance of a Contraceptive Champion

Contributors spoke about the importance of a Contraception Champion within the service to drive forward progress locally. This is often on a maternity ward, as discovered by research in NHS Lothian, Scotland: “Contraceptive Champions are hospital and community midwives in NHS Lothian trained to advise women on postnatal contraceptive methods.” 30 In Greater Manchester, the Public Health Matron within the midwifery team has played a pivotal role in facilitating the PPC pilot project: “The dedicated time and input from this position [of the Public Health Matron] have been essential to its progress, and the work would have been significantly more challenging without it. And it is recognised, that not all Trusts have access to this role.” Public Health Strategy Manager, Salford City Council In addition to midwifery staff, it is also vital to have other staff championing PPC, as services in South Tees and Bedfordshire outlined: “Clinical leadership and advocacy within midwifery and consultant level is key. We had consultant leads in both of our Trusts championing the pathways and developing the standard operating protocols which helped with leadership within the Trusts.” Commissioner, Bedfordshire, Luton and Milton Keynes ICB Due to their passion to provide PPC, many staff were doing this work in addition to their already demanding workloads. However,

contraception.” Commissioner, Liverpool

Gloucestershire also secured local authority funding for PPC, which proved vital to establishing a sustainable service: “This funding mechanism has ensured sustainability post-pilot and allowed the service to grow in reach and consistency

across Gloucestershire.” Specialist Midwife, Gloucestershire

The importance of supportive leadership ‘from higher up’ was clear from contributions to this report and suggests that Government providing this support nationally could deliver huge transformational change to PPC provision across the country.

29 NHS England. Principles for commissioning abortion services. 30 Gallimore A, Craig A, Cameron S, et al. Developing the role of midwives as ‘contraceptive champions’ to support early access to effective postnatal contraception for women. BMJ Sex Reprod Health 2019; 45:309-312.

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

“Women were unanimously open to midwife involvement in counselling and provision of contraception[..] Women found midwives ‘very relatable’, in established relationships, and ‘more convenient and comfortable’ than doctors. Women felt midwives were knowledgeable regarding contraception.” Freeman-Spratt et al. 31 Leading the way for best practice in this area is Gloucestershire, whose service is led by Specialist Midwife Vicki Pirie. In one of her contributions to this report, Vicki outlined that recognising and expanding the role of the midwife in this space is a vital step toward equitable, effective, and prevention-focused reproductive healthcare across the UK: “When we listen to women, it becomes clear that they want timely, honest, and compassionate conversations about their options delivered by people they know and trust. Midwives are ideally positioned to have these conversations, and when supported appropriately, they can make a lasting difference in the lives of the families they serve.” Vicki and her team in the Gloucestershire PPC pilot found having a lead specialist midwife dedicated to PPC was a vital component of the programme’s success. The specialist midwife supported ongoing staff training, ensured adherence to best practice, embedded PPC within the wider maternity model, and acted as a conduit – a central point of contact for troubleshooting, service development, and mentoring. Since embedding the service: “Early data from the neonatal unit has shown high engagement from mothers who may otherwise have missed the opportunity due to extended hospital stays, reinforcing the importance of flexible access points in ensuring equitable contraceptive care.” Specialist Midwife, Gloucestershire “[Audit] results astonished all those involved in the pilot, particularly regarding the high acceptance rates of contraception when it was offered proactively and sensitively by trusted midwives.” Specialist Midwife, Gloucestershire The Post-Birth Contraception Network UK was jointly developed by teams in Gloucestershire and Northwest London, led by specialist Midwifes Gillian Matthews, Vicki Pirie, and Dr Edward Mullins, to support national collaboration and innovation in PPC. Overall, the majority of successful PPC services have midwives or nurses acting as conduits including East Sussex, Bristol, North

relying upon the dedication, goodwill, and commitment of individual professionals is not sustainable, and as Greater Manchester recognise above, many areas do not have the adequate resource for a dedicated role. Overall, contributors, including a Consultant Obstetrician in South Tees, argued strongly for the importance of having a Champion in each unit whose job it is to promote PPC with sufficient time and resource allocated for delivery: “[..] to get a culture change within a unit requires someone to regularly be promoting it and discussing it and providing it as well Recommendation 2 Establish a Contraceptive Champion within your Service Services should appoint a ‘Contraceptive Champion’ within their service who will hold oversee, monitor, and advocate for the provision of PPC on the maternity ward, as well as ongoing staff development to ensure all maternity staff are equipped to deliver PPC. In many successful PPC services this is a midwife or nurse. 3. The Role of the Nurse or Midwife as a Conduit for PPC Provision All contributions outlined the important role of the nurse or midwife as essential to delivering a PPC offer successfully. Several areas spoke of them as conduit in their service, crucial for its efficiency, providing an important link across services: “The motivation of the Midwifery team is essential to the continued forward motion.” East Sussex PPC service as formal staff training.” Consultant Obstetrician, South Tees Importantly, women have been found to have positive experiences of midwives as conduits for PPC care, as many develop strong and trusting relationships with their midwife during pregnancy, providing a safe space to discuss sensitive topics such as contraception: “Midwives help women explore which options align with their personal values, medical history, and future family plans. These early conversations can continue throughout the antenatal journey, building knowledge and confidence.” Specialist Nurse, Bristol, North Somerset and South Gloucestershire 3

31 Freeman-Spratt GJ, Botfield JR, Lee GS, et al. Understanding women’s views of and preferences for accessing postpartum contraception: a qualitative evidence synthesis. BMJ Sex Reprod Health 2023;49:129–141.

The Royal College of Midwives (RCM), who represent and support over 50,000 midwives, student midwives and maternity support workers have expressed valid concerns about embedding PPC as a midwifery responsibility considering their crucial role in much of the pregnancy journey and current workload pressures. These worries are reasonable and justified, demonstrating the acute need for resource and capacity to alleviate pressure on midwives and ensure they can continue to deliver PPC alongside other aspects of their vital role: “We should be making it as easy as possible for women to get suitable contraception after childbirth, using the existing points of contact with the NHS. In some areas, contraceptive services are embedded within maternity services and midwives are trained and confident in providing it. I applaud the fantastic midwives who are going the extra mile to meet the needs of women and their families by doing this.”

Somerset and South Gloucestershire, Greater Manchester, The Wirral, Derbyshire and South Tees. In each the PPC service is delivered chiefly by midwives or nurses and are crucially supported by other disciplines, and by obstetricians and SRH professionals on the maternity ward, efficiently embedding contraception provision into routine maternity care: “Embedding contraception into routine maternity care is both effective and well- received.” Specialist Nurse, Bristol, North Somerset and South Gloucestershire Additionally, midwives and nurses often provide care in community or clinic settings, making access to advice more convenient, especially for women in rural or underserved areas. Whilst meeting the needs of women locally, shifting more midwifery care into the community will also ease mounting pressures on primary care.

In focus: the Royal College of Midwives Midwives see everyday the benefits of post childbirth contraception: mothers’ bodies are more rested and recovered before starting another pregnancy, families are stabilised, health risks are reduced. The postnatal period is often a turbulent time, as sleep is disrupted, routines are established and everyone in the household adjusts to the new arrival. It’s not usually a time when mothers’ self-care is given priority, and that includes taking care of their reproductive health needs. We should be making it as easy as possible for women to get suitable contraception after childbirth, using the existing points of contact with the NHS. In some areas, contraceptive services are embedded within maternity services and midwives are trained and confident in providing it. I applaud the fantastic midwives who are going the extra mile to meet the needs of women and their families by doing this. They are part of an army of midwives across the UK who are committed to maximising the public health potential of the first 1000 days of life. There are so many ways in which midwives are unsung heroes of public health – not just by providing post birth contraception, but also extended support with breastfeeding, mental wellbeing and more. It is impressive what can be achieved when midwives are resourced and supported to fulfil their contribution, and deeply disappointing that current workforce and resource shortages prevent this being realised everywhere. At a time when resources are so stretched that commissioners are focusing on the basics of safe clinical care, and when what happens in labour ward must be prioritised over what comes after, the public health potential of midwifery care is curtailed. Let’s hope this won’t always be so, and that the inspiring midwives and doctors cited in this report will one day become the norm, not the pioneers.

Fiona Gibb, Director of Professional Midwifery, Royal College of Midwives (RCM)

BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE

4. Fostering Collaboration Across Disciplines, and Establishing Clear Care Pathways to Support While nurses and midwives are the best suited role as conduits for PPC, they should be supported collaboratively by colleagues across maternity services, primary care, sexual health services, particularly in terms of administering contraceptives such as the coil and implant with leadership from local SRH professionals. This emerged strongly as a requisite for delivering effective PPC provision: “PPC services need to be fully multidisciplinary, not just midwifery and sexual health, they must also include medical staff – many of the women for whom pregnancy planning and spacing is the most important come under consultant led care and it is important that doctors also take an interest in contraception choices and not just leave it to someone else.” Public Health Midwife, South Tees This shared multidisciplinary approach avoids responsibility for PPC provision sitting with one individual: The roll out of the Service relied heavily on a passionate individual who had to take on and drive much of the work in isolation.” PPC provider, Hertfordshire In East Sussex the PPC service was supported by: “An enthusiastic and collaborative working group. The training reflected a joint Maternity, Public Health and Sexual Health approach to the planning and delivery of training, working across traditional boundaries.” This was also evident in Portsmouth, where setting up the PPC service involved significant collaboration across local public health, maternity services, sexual health services, and family nurse partnership health visitors. By creating strong partnerships outside of traditional boundaries, services can be established and maintained: “Some services, like the Family Nurse Partnership within the health visitor provision have also been really key to support ongoing contraception for our vulnerable parents under 25 years old.” Public Health Principal, Portsmouth Bedfordshire also utilised existing pathways to involve health visitors in the provision of PPC, and this resulted in improved uptake amongst the most vulnerable women, too: 4

The contributions to this report demonstrated that, with sufficient support, training, and resources, it is possible for midwives to be conduits for PPC. For example, results from a survey of midwifery staff delivering PPC in Gloucestershire revealed that 93% of respondents believed the model to be sustainable in the medium to long term: “With additional support from specialist midwives, it is achievable even with our current workload. The training gave me the confidence to have these conversations.” Midwife, Gloucestershire This is echoed across other services, including Northwest (NW) London: “We need to encourage and increase professional development options for midwives in areas that they want to pursue, to help avoid burnout and losing even more midwives from the profession. I see development in contraception and sexual health as a complementary specialism for midwives who want to maintain their midwifery skills and remain in the maternity workforce whilst creating more variety in their day to day working lives.” Gillian Matthews, Specialist Midwife, NW London Post-birth Contraception Service It is important to note additionally that individuals who experience outcomes such as miscarriage, abortion, or ectopic pregnancy may not encounter maternity or midwifery services. This is another reason why it is essential that PPC is delivered through a coordinated, whole-system approach that integrates services and commissioning structures to prevent gaps in care, information provision and ensure equitable access for all post- pregnancy outcomes. Recommendation 3 Establish Nurse or Midwife as a Conduit for PPC Provision A nurse or midwife should be the conduit for PPC provision. Due to their unique position, they can support women throughout their pregnancy journey, allowing opportunity to build trust, normalise discussion about contraceptive options and give pregnant people the space they need to consider what works best for them.

“We did awareness session with health visiting leads around existing pathways and signposting women to the existing community based sexual and reproductive health services where postnatal contraception is required. This pathway is well utilised for women who have comorbidities and vulnerabilities.” Commissioner, Bedfordshire, Luton and Milton Keynes ICB This is backed up by research by Gilroy et al. which showed that health visitors can play a vital role in providing PPC postnatally in the community and that interpregnancy care is a core part of the health visiting offer. 32 Following this, a bespoke training package on postnatal contraception was designed and developed for health visitors. Since its launch in March 2022, these tailored training resources has been delivered to over 80 health visitors and midwives and are available to read in the resources section of this report. “The statistics made it really hit home and made me realise how important it was as part of my role” 33 Health Visitor quoted in Gilroy et al. Contributors outlined specifically how collaboration with SRH professionals was essential to successfully deliver contraceptive provision post-pregnancy. For example, in Liverpool, the PPC service collaborated with a local sexual health provider - Axess Sexual Health. Axess plays an important role in supporting the delivery of PPC through its expertise in sexual and reproductive health, and providing additional resources and services, to ensure that women have continued support in accessing contraception post-pregnancy. A pathway for Intrauterine Devices (IUD) check in the Axess Specialist Integrated Urgent Care clinic at 6 weeks post insertion at caesarean has been established and early evaluation shows it to be working well. Similarly, in Greater Manchester: “Strengthening links with primary care, sexual health, and gynaecology services would ensure smoother continuity of care and clearer referral pathways to access wider services.” PPC provider, Greater Manchester In South Tees, clear referral pathways with the local sexual health services proved vital to providing women with the contraception they wanted, when worked for them, for example after leaving the hospital ward:

“If we are unable to provide the right contraception to women prior to discharge or, if women would prefer to wait for LARC or, for women who require specialised input regarding contraception we have worked together with our local sexual health services to create a referral form. We refer these women directly and they are then fast tracked into their local service.” Public Health Midwife, South Tees Overall, contributors stressed the need for this integration with other health or community services, and how establishing these robust care pathways should be a priority and must be set up as early as possible. Similarly, this emphasis on collaboration and integration is also important to facilitate women accessing wider public health services in their local community. For example, in Portsmouth, women could be referred through their PPC service to sheltered housing, substance misuse services or Project W for women who experience substance misuse and/or homelessness. The service has also worked with the weight management and stop smoking teams working with pregnant people to support these healthy conversations and access to information. In Cambridge an approach was piloted by the team at the antenatal diabetes clinic within Cambridge Community Trust: “Women are offered contraception discussions around at 20–24 weeks of their pregnancy. Many of these women, who often require planned caesarean sections around 38 weeks, found it helpful to plan their contraception in advance.” PPC provider, Cambridge Community Trust Examples of best practice such as these demonstrate the value and potential of PPC services to deliver better outcomes for the health of the mother and child, alleviate wider public health concerns, and improve health literacy of the population. Importantly, given that ICB geography doesn’t match that of a local authority,

32 Gilroy V, Gilmore KL, Thwaites A. Better way of working, Exploring and promoting the role of health visitors in postnatal contraception: a ‘test and learn’ project, BMJ Sex Reprod Health 2023;49:219–221.

33 Gilroy V, Gilmore KL, Thwaites A. Better way of working, Exploring and promoting the role of health visitors in postnatal contraception: a ‘test and learn’ project, BMJ Sex Reprod Health 2023;49:219–221.

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