BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE
The proportion of those presenting for abortion in the UK over 35 years old is increasing and recent data from the Northeast of England showed younger women were significantly more likely to access prescribed contraception within 8 weeks post birth. 84 This suggests an increasing unmet need for PPC among older women who are at higher risk of pregnancy complications which is likely to be replicated across other areas of the country. 85 Particularly for women with existing chronic medical conditions, the interpregnancy period also provides an important opportunity to optimise health before getting pregnant again, to stabilise health conditions, adjust medications, and implement lifestyle changes that may improve outcomes in future pregnancies. Knowledge Gaps and Misconceptions Women in the UK and other high-income countries lack vital knowledge about their return to fertility and contraception options after pregnancy, perpetuated by myths and misconceptions, inconsistent counselling and systemic barriers. 86 For example, a survey of women on a postnatal ward in London who had just given birth found that approximately one-third either did not know or significantly overestimated the earliest time period it is possible to get pregnant after having a baby and 43% were unaware of recommended interpregnancy intervals or thought it was less than a year. 87 Similar knowledge gaps have been reported in other high-income settings. 88 Women also have misconceptions or lack accurate information regarding the effectiveness of breast feeding as contraception or incorrectly believe that they cannot conceive until their menstrual cycle returns. 89 Breastfeeding is only an effective method in the first 6 months post birth if a woman is exclusively breastfeeding with no long gaps between food, day or night and their periods haven’t restarted. 90 Significant knowledge gaps also exist amongst women regarding their contraceptive options post-pregnancy. More than half of women surveyed in a London postnatal ward survey did not think LARC methods were safe immediately after childbirth. 81 Smith GCS, Pell JP, Dobbie R. Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. BMJ. 2003;327(7410):313. 82 Hutcheon JA, Nelson HD, Stidd R, Moskosky S, Ahrens KA. Short interpregnancy intervals and adverse maternal outcomes in high-resource settings: An updated systematic review. Paediatr Perinat Epidemiol 2019; Mühlrad, H., Björkegren, E., Haraldson, P. et al. Interpregnancy interval and maternal and neonatal morbidity: a nationwide cohort study. Sci Rep 12, 17402 (2022). 83 Schummers L, Hutcheon JA, Hernandez-Diaz S, et al. Association of short interpregnancy interval with pregnancy outcomes according to maternal age. JAMA Intern Med 2018;178(12):1661–70. 84 Malcolm Moffat, Robyn Jackowich, Christine Möller-Christensen et al. BJOG Published online: Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study 2 April 2024. 85 Pinheiro RL, Areia AL, Mota Pinto A, Donato H. Advanced Maternal Age: Adverse Outcomes of Pregnancy, A Meta-Analysis. Acta Med Port. 86 BPAS. Contraception Re-Imagined: The Unfinished Revolution; Cooper M, Black K, Cameron S. Expanding access to postpartum contraception. Curr Opin Obstet Gynecol. 2024; Cooper M, Free CJ, Cameron S. Contraception after childbirth in the UK: beyond the COVID-19 pandemic. BMJ Sexual & Reproductive Health. 87 Thwaites A, Logan L, Nardone A, et al. Immediate postnatal contraception: what women know and think BMJ Sex Reprod Health 2019. 88 Yang JM, Cheney K, Taylor R, Black K. Interpregnancy intervals and women’s knowledge of the ideal timing between birth and conception. BMJ Sex Reprod Health 2019; Taylor RAM, Yang JM, Cheney K, Black K. Short interpregnancy interval: circumstance or choice? BMJ Sex Reprod Health. 2022 Apr;48(2). 89 Thwaites A, Logan L, Nardone A, et al. Immediate postnatal contraception: what women know and think BMJ Sex Reprod Health 2019;45:111–117; Hoyt-Austin A, Chen MJ, Iwuagwu C, et al. Understanding of lactational amenorrhea as a contraceptive method among U.S. pregnant women. Breastfeed Med 2023; 18:621–625. 90 CoSRH Guideline: Contraception After Pregnancy; Taylor RAM, Yang JM, Cheney K, Black K. Short interpregnancy interval: circumstance or choice? BMJ Sex Reprod Health. 2022 Apr;48(2):110-116.
and capacity to provide optimal care for their existing children. Planned pregnancies enable families to manage financial resources more effectively and potentially reduce dependence on social support systems. Additionally, it may improve women’s ability to return to education or employment as desired, enhancing long-term family economic stability and maternal career development, as well as local communities, society and the economy. 78 Adequate spacing between pregnancies may potentially also confer health benefits for both women and babies. However, any mechanisms by which interpregnancy intervals may affect specific birth outcomes are not well understood. Studies have reported that interpregnancy intervals of more than 12 months may reduce maternal risks of anaemia, third-trimester bleeding, premature rupture of membranes, and maternal mortality and morbidity. 79 For infants, potential benefits include reduced risks of preterm birth, low birth weight, small size for gestational age, and infant mortality in the subsequent pregnancy. 80 However, there is a range of opinion on whether the interval from the end of pregnancy to the next conception is a cause of or is associated with increased risk of adverse outcomes. A key early study by Smith et al. reports that the rates of preterm birth, low birth weight, small size for gestational age are all higher in the first pregnancies of women with short interpregnancy intervals as well as their subsequent rapid repeat pregnancies. 81 Some studies have since suggested that there may be a lesser effect in high income settings or confounding factors responsible. 82 A large population-based Canadian cohort study reported that very short interpregnancy intervals of less than 6 months were associated with an increased risk of adverse outcomes when compared to interpregnancy intervals of 18 months, and that the profile of these outcomes changes correspond to maternal age with younger women (aged 20–34 years) having higher rates of preterm birth, and women aged over 35 years having higher rates of maternal mortality and morbidity. 83 and healthcare professionals’ views on immediate postnatal contraception provision: a literature review. BMJ Sex Reprod Health. 2019 Apr;45(2):88-94; Moniz MH, Spector- Bagdady K, Perritt JB, Heisler M, Loder CM, Wetmore MK, Harris LH. Balancing enhanced contraceptive access with risk of reproductive injustice: A United States comparative case study. Contraception. 2022 Sep;113:88-94. 78 Mahdi Shahraki Sara Emamgholipour, The Effect of Child Spacing on Mothers’ Labor Force Participation in Urban Households of Iran. Middle East J Rehabil Health, 2022;9 (4). 79 Wendt A, Gibbs CM, Peters S, Hogue CJ. Impact of increasing inter-pregnancy interval on maternal and infant health. Paediatr Perinat Epidemiol. 2012;26(1)(suppl 1):239-258. 80 Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006; Merklinger-Gruchala A, Jasienska G, Kapiszewska M. Short interpregnancy interval and low birth weight: a role of parity. Am J Hum Biol. 2015; McKinney D, House M, Chen A, Muglia L, DeFranco E. The influence of interpregnancy interval on infant mortality. Am J Obstet Gynecol. 2017; Smith GCS, Pell JP, Dobbie R. Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. BMJ. 2003; Zhang L, Shen S, He J, et al. Effect of interpregnancy interval on adverse perinatal outcomes in southern China: a retrospective cohort study, 2000-2015. Paediatr Perinat Epidemiol; Rutstein, S.O., 2005. Effects of preceding birth intervals on neonatal, infant and under‐five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. International Journal of Gynecology & Obstetrics; Basso O, Olsen J, Knudsen LB, Christensen K. Low birth weight and preterm birth after short interpregnancy intervals. Am J Obstet Gynecol 1998; Fuentes-Afflick E, Hessol NA. Interpregnancy interval and the risk of premature infants. Obstet Gynecol 2000; Zhu BP, Le T. Effect of interpregnancy interval on infant low birth weight: A retrospective cohort study using the Michigan maternally linked birth database. Matern Child Health J 2003; Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and Health. Lancet (2012); Hutcheon JA, Nelson HD, Stidd R, Moskosky S, Ahrens KA. Short interpregnancy intervals and adverse maternal outcomes in high-resource settings: An updated systematic review. Paediatr Perinat Epidemiol 2019; Mühlrad, H., Björkegren, E., Haraldson, P. et al. Interpregnancy interval and maternal and neonatal morbidity: a nationwide cohort study. Sci Rep 12, 17402 (2022); Schummers L, Hutcheon JA, Hernandez-Diaz S, et al. Association of short interpregnancy interval with pregnancy outcomes according to maternal age. JAMA Intern Med 2018;178(12):1661–70.
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