BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION A GUIDE FOR BEST PRACTICE
Appendix 4: Accessing Contraception after Abortion By Dr Annette Thwaites, Dr Edward Mullins, and Dr Patricia A. Lohr
Summary of NICE and the CoSRH PPC guideline recommendations
Evidence-based clinical guidelines strongly endorse the integration of timely contraception into abortion care. 101 They recommend offering contraceptive counselling to all individuals seeking abortion, ensuring they can discuss and choose from a full range of options. Where medically appropriate, methods and desires should be discussed at the time of the abortion or as soon as possible afterwards. To make this possible, services must be supported through effective commissioning and provider training to ensure all methods, including LARC, are available. 102 These practices are linked to improved outcomes including higher patient satisfaction, higher contraceptive receipt and continuation, greater cost-effectiveness, and fewer unintended pregnancies. 103 Many individuals consider the time of abortion an appropriate moment to reflect on and initiate contraception, and a substantial proportion opt for both counselling and a method when these are routinely offered. 104 Alternatively, some individuals may decline counselling yet still want to receive a method - a US study found that while 71% of participants wished to leave their abortion appointment with a contraceptive method in place, only 31% wanted to engage in contraceptive counselling. 105 Among those who declined, many already knew which method they wanted. Overall, not all individuals want or need contraception at the time of abortion. Some may prefer to make decisions about contraception separately, at a different time, or may not wish to use a method at all. 106 The contraceptive methods used by individuals at the time of conception appear to be changing, with some data indicating a growing reluctance to use hormonal methods and increased interest in fertility awareness-based approaches. 107 Abortion care should respond to shifting preferences by ensuring that contraception is available but never imposed, 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. This includes providing clear, evidence-based information on all contraceptive options, free from bias or misinformation, so individuals can make informed choices that are right for them.
Contraceptive counselling should be offered to all individuals requesting abortion, with services structured to support timely initiation of the chosen method – ideally immediately following the procedure, or within five days where immediate provision is not practicable. All methods of contraception are considered safe to start immediately after an uncomplicated abortion, except for IUD insertion in the presence of sepsis. Counselling should be non-directive and support informed decision-making, without pressure to choose a method or any specific method. LARC • IUDs can be inserted immediately after surgical abortion or following confirmation of complete expulsion during medical abortion at any gestational age. • Progestogen-only implants can be safely placed at the time of surgical abortion or at the administration of mifepristone during medical abortion without impacting abortion success. Hormonal methods • POPs and combined hormonal contraception (CHC) can be initiated immediately after either surgical or medical abortion. POPs may be particularly suitable for remote prescribing and require no in-person assessment. • DMPA may also be initiated at the time of mifepristone for medical abortion; however, women should be advised that this may slightly increase the risk of abortion failure. Confirmation of abortion completion is essential when initiating at this stage. • If hormonal methods are started five or more days after the abortion, additional contraceptive precautions (e.g. condoms or abstinence) should be used until efficacy is established. No additional precautions are needed if initiation occurs immediately or within five days. Other methods • Sterilisation is a valid option but should ideally not be performed concurrently with abortion due to higher rates of regret and increased procedural risk.
101 National Institute for Health and Care Excellence. Long-acting reversible contraception: NG140, 2019; CoSRH Guideline: Contraception After Pregnancy. 102 NHS England. Principles for commissioning abortion services. 103 National Guideline Alliance (UK). Contraception after abortion: Abortion care: Evidence review 104 Kavanaugh ML, Carlin EE, Jones RK. Patients’ attitudes and experiences related to receiving contraception during abortion care. Contraception. 2011 Dec;84(6):585-93; 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. 105 Cansino C, Lichtenberg ES, Perriera LK, Hou MY, Melo J, Creinin MD. Do women want to talk about birth control at the time of a first-trimester abortion? Contraception 2018; 98: 535– 40.
106 Boydell N, Buijsen S, Reynolds-Wright JJ, Cameron ST, Harden J. Abortion patients’ perspectives on enhancing a telemedicine model of post-abortion contraception: a qualitative study. BMJ Sex Reprod Health. 2024 Dec 30: bmjsrh-2024-202428; Lohr PA, Aiken ARA, Forsyth T, Trussell J. Telephone or integrated contraception counselling before abortion: impact on method choice and receipt. BMJ Sex Reprod Health. 2018 Apr;44(2):114-121; Bury L, Hoggart L, Newton VL. “I thought I was protected”: abortion, contraceptive uptake and use among young women: a quantitative survey. Milton Keynes: The Open University; 2014. 107 Boydell N, Buijsen S, Reynolds-Wright JJ, Cameron ST, Harden J. Abortion patients’ perspectives on enhancing a telemedicine model of post-abortion contraception: a qualitative study. BMJ Sex Reprod Health. 2024 Dec 30: bmjsrh-2024-202428; McNee R, McCulloch H, Lohr PA, Glasier A. Self-reported contraceptive method use at conception among patients presenting for abortion in England: a cross-sectional analysis comparing 2018 and 2023. BMJ Sex Reprod Health. 2025 Jan 13: bmjsrh-2024-202573.
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