Appendix 5: The View from Scotland By Professor Anna Glasier and Dr Michelle Cooper
Anna is a world expert on emergency contraception. Retired from clinical practice, she remains active in research, with her work focused on reproductive health, particularly contraceptive development and the delivery of contraceptive services. She was previously on the Board of Professor Anna Glasier, Women’s Health Champion for Scotland & Honorary professor at the London School of Hygiene and Tropical Medicine and the University of Edinburgh.
Dr Michelle Cooper, Consultant in Gynaecology & Sexual Health, NHS Lothian & Senior Clinical Lecturer, University of Edinburgh.
Michelle is Chair of the Scottish Postpartum Contraception Network and as a clinician-researcher, leads several projects on improving access to postpartum contraception, which also formed the subject of her PhD. She has also contributed to national policy, guidelines and educational resources in this field and is a member of the Scottish Committees of the RCOG and FSRH, and Speciality Advisor to the Scottish Government for Women’s Health.
Trustee and International Committee for Contraceptive Research at the Population Council for over 10 years. With the Human Reproduction Programme of the World Health Organisation, she served on the scientific advisory committee and the research proposal review panel.
Much of the UK’s early formative research demonstrating the need for and feasibility of expanding access to PPC was conducted in the Lothian region of Scotland. In 2013, the first feasibility study of routine antenatal contraception counselling in an NHS maternity setting was conducted, known as the “APPLES” study. 123 This demonstrated that women valued the opportunity to discuss contraception during pregnancy with their midwife or obstetrician. Following this landmark study, antenatal contraception discussion was embedded into routine care within the region and, along with growing evidence at the time, featured as a key recommendation in several subsequent UK clinical guidelines and policy. Routine antenatal contraceptive discussion now features in most regional pregnancy care pathways in Scotland, although there are still inter-and intra-regional disparities in the timing, consistency and quality of information provided. The APPLES study highlighted the gap between provision of contraceptive advice and actual uptake of methods, with the ability to offer methods directly from maternity services being to overcoming barriers women can face in accessing methods after leaving the birth unit. Despite 44% of women indicating a preference for LARC during pregnancy, only 9% of those in the study left the birth unit with a LARC method. 124 These included the early introduction of midwife contraceptive ‘champions’, with specialist knowledge and skills in contraceptive provision including implant insertion; 125 innovative approaches to PPC delivery such as a pilot study evaluating home implant insertion using local anaesthetic. 126 Many of these novel approaches to PPC service provision have since been adopted into routine practice both in the region and beyond and influenced national policy direction.
Contraception is one of the most cost-effective preventive interventions we have. It is simple, cheap, and cost-effective. 117 There are currently over 18,000 induced abortions every year in Scotland, and we know that almost one third of pregnancies which end in childbirth are unplanned or mistimed. 118 Access to contraception has declined markedly since the COVID-19 pandemic. Scotland’s Women’s Health Plan (2021- 2024) 119 recognised the need to restore and improve upon that access – particularly access to long-acting reversible contraceptives (LARC) which have been shown to reduce unintended pregnancy at a population level. 120 Globally, contraception is recognised as a key life-saving intervention for mothers and their children. 121 However, even in the UK, postpartum women often do not receive the services they need to support longer birth intervals or reduce unintended pregnancy and its consequences. The Women’s Health Plan for Scotland (2021-2024) included a specific priority to: “Ensure that discussions on contraception take place during pregnancy. Women should be given adequate and appropriate information on their options, as well as rapid access to their preferred method where applicable to ensure rapid and easily accessible postnatal contraception as a priority.” 122 Although much work has been done in Scotland to try to achieve this end, there is still much to do, particularly in ensuring access to immediate postpartum LARC. Postpartum contraception will continue to be a priority in the next phase of the Women’s Health Plan to be published in 2025. 117 Mavranezouli I, Wilkinson C. Long-acting reversible contraceptives: not only effective, but also a cost-effective option for the NHS. JFPRHC 2006;32 (1): 3-5. 118 Lakha F, Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Lancet 2006; 368: 1782-7. 119 Scottish Government, Women’s Health Plan. 120 Harper CC, Rocca CH, Thompson KM et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial. Lancet 2015; 386: 562-8.
121 World Health Organisation, Family planning: a health and development issue, a key intervention for the survival of women and children, 2012. 122 Scottish Government, Women’s Health Plan. 123 Cameron ST, Craig A, Sim J, Gallimore A, Cowan S, Dundas K, Heller R, Milne D, Lakha F. Feasibility and acceptability of introducing routine antenatal contraceptive counselling and provision of contraception after delivery: the APPLES pilot evaluation. BJOG: An International Journal of Obstetrics & Gynaecology. 2017 Dec;124(13):2009-15. 124 Cameron ST, Craig A, Sim J, Gallimore A, Cowan S, Dundas K, Heller R, Milne D, Lakha F.
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