postnatal ward found that almost half of women would prefer contraception provision before discharge. 98 Following services such as NHS Lothian who have led the way in developing universal offers of PPC in the UK, North-West London currently has a universal offer of antenatal contraception education during pregnancy and availability of a range of post- birth contraception. This has resulted in annual proportions of between 5 and 28% of women going home with contraception from 2020-2025. Assessing whether this is effective implies that there is a certain proportion of women who should take home contraception. Setting a target rate is unlikely to be helpful as it risks pursuing a number of women taking home contraception rather than a number of women making an informed choice about what works for them personally. In reality, women’s contraceptive preferences and choices are individual, diverse and dynamic shaped by a range of personal, relational, and contextual factors that evolve over time. 99 Access to a wide variety of methods and supportive, individualised counselling are therefore key to meeting women’s reproductive goals. Enabling women to exercise their own informed choices must be the central aim of PPC services. Overall, PPC represents a critical but often overlooked component of comprehensive pregnancy healthcare and a life course approach to addressing sexual and reproductive health needs of women. The rapid return of fertility after pregnancy, combined with knowledge gaps and misconceptions and current barriers to contraceptive education and provision, leave women at high risk of unintended pregnancies with potential associated health risks and far-reaching impact on their lives. Evidence suggests that waiting 6-12 months to conceive after livebirth may optimise maternal recovery and infant outcomes, making effective contraception important during this period. Improving PPC services requires addressing both knowledge gaps through enhanced education and tackling systemic barriers through integration of contraceptive provision into routine maternity care. Women accessing care for miscarriage or abortion have consistently been seen to be receptive to contraception counselling with high uptake of contraceptive methods when offered, emphasising the importance of 95 Cooper M, Cameron S. Successful implementation of immediate postpartum intrauterine contraception services in Edinburgh and framework for wider dissemination. Int J Gynecol Obstet 2018. 96 Hu D, Tang Y, Pei K. Strategies for Improving Postpartum Contraception Compared With Routine Maternal Care: A Systematic Review and Meta-Analysis. Int J Public Health. 2023 Apr 13; 68:1605564; Cooper M, Black K, Cameron S. Expanding access to postpartum contraception. Curr Opin Obstet Gynecol. 2024 Oct 1. 97 Kavanaugh ML, Carlin EE, Jones RK. Patient’s attitudes and experiences related to receiving contraception during abortion care. Contraception. 2011; 84:585–593; Purcell C, Cameron S, Lawton J, Glasier A, Harden J. Contraceptive care at the time of medical abortion: experiences of women and health professionals in a hospital or community sexual and reproductive health context. Contraception. 2016 Feb;93(2):170-7;Aiken A, Lohr PA, Aiken CE, Forsyth T, Trussell J. Contraceptive method preferences and provision after termination of pregnancy: a population- based analysis of women obtaining care with the British Pregnancy Advisory Service. BJOG. 2017 Apr;124(5):815-824; Lichtenstein Liljeblad KA-O, Kopp Kallner HA-O, Brynhildsen J, Kilander H. Women’s experiences of postpartum contraceptive services when elective caesarean section is the method of birth: a qualitative study. BMJ Sexual & Reproductive Health. 2024;5; Henderson, V., Stumbras, K., Caskey, R. et al. Understanding Factors Associated with Postpartum Visit Attendance and Contraception Choices: Listening to Low-Income Postpartum Women and Health Care Providers. Matern Child Health J 20 (Suppl 1). 98 Thwaites A, Logan L, Nardone A, et al. Immediate postnatal contraception: what women know and think BMJ Sex Reprod Health 2019. 99 Dam A, Yeh PT, Burke AE, Kennedy CE. Contraceptive values and preferences of pregnant women, postpartum women, women seeking emergency contraceptives, and women seeking abortion services: A systematic review. Contraception. 2022 Jul.
Furthermore, only 18% of postnatal women recalled a health professional speaking to them about contraception at any point during their pregnancy, indicating a significant gap in prenatal education about postnatal contraceptive needs. 91 This lack of information leaves many women unprepared to make informed contraceptive choices after pregnancy. Mistakenly relying on breastfeeding, delaying initiation, limiting contraception choice or avoiding the most effective methods places them at risk of rapid repeat, unintended pregnancies. At a national level, there is also an important lack of data on unintended pregnancy with validated measures such as the London Measure of Unplanned Pregnancy being introduced but not yet in routine use across all pregnancy health care settings. 92 This makes it challenging to quantify unmet need to post- pregnancy contraception at a population level and evaluate the impact of contraception initiatives.
Effectiveness of Post-Pregnancy Contraceptive Services
There is significant UK and global evidence of post pregnancy contraception delivery initiatives resulting in increased uptake and continued use of contraceptive methods, including the most effective, long-acting reversible methods and associated decrease in rapid repeat pregnancies. 93 A 2023 systematic review reported high 6-month and 12-month continuation rates of postnatal IUDs (over 80%) amongst the 133 included studies. 94 A recent meta-analysis found postnatal interventions were associated with a statistically significant decrease in repeat pregnancy rates during the first 6 months postpartum, highlighting the potential impact of well-designed universal contraception services at the place of delivery. 95 The timing of contraceptive interventions appears critical to their effectiveness. Results indicate that early intervention, beginning with counselling during pregnancy and continuing through the immediate postnatal period, may be most effective for establishing postnatal contraception planning and optimising uptake. 96 Moreover, the evidence invariably supports the desirability by women for contraception services in early pregnancy, maternity and abortion settings. 97 A UK survey of women on a 91 Thwaites A, Logan L, Nardone A, et al. Immediate postnatal contraception: what women know and think BMJ Sex Reprod Health 2019;45:111–117. 92 Hall JA, Stewart C, Stoneman B, Bicknell T, Lovell H, Duncan H, Stephenson J, Barrett G. Implementation of the London Measure of Unplanned Pregnancy in routine antenatal care: A mixed-methods evaluation in three London NHS Trusts. Eur J Midwifery. 2024 Jun. 93 Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine device insertion in postpartum women. Contraception 2005; Increasing the use of effective postpartum contraception: urgent and possible. Morroni, Chelsea et al., The Lancet Global Health, Volume 8, Issue 3, e316 - e317; Roe AH, Fortin J, Janiak E, Maurer R, Goldberg AB. Prevalence and predictors of 275 initiation of intrauterine devices and subdermal implants immediately after surgical 276 abortion. Contraception 2019; Langston AM, Joslin-Roher SL, Westhoff CL. Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice. Contraception 2014;89; Waidee T, Kaewrudee S, Wattanakamolchai P, Sothornwit J. Use of contraceptive implants at 12 months in women who intended to undergo immediate versus delayed postpartum insertion following high-risk pregnancy. Obstet Gynecol Sci. 2023 May; Blazer C, Prata N. Postpartum family planning: current evidence on successful interventions. Open Access J Contracept. 2016; Brunson MR, Klein DA, Olsen CH, et al. Postpartum contraception: initiation and effectiveness in a large universal healthcare system. Am J Obstet Gynecol 2017; Cohen R, Sheeder J, Arango N, et al. Twelve- month contraceptive continuation and repeat pregnancy among young mothers choosing post delivery contraceptive implants or postplacental intrauterine devices. Contraception 2016; Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012. 94 Lopez LM, Bernholc A, Hubacher D, Stuart G, Van Vliet HA. Immediate postpartum insertion of intrauterine device for contraception. Cochrane Database Syst Rev 2015(6).
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