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- COVID-19
- family planning services
- health policy
- health services research
- long-acting reversible contraception
- reproductive health
Due to the rapid return of fertility and sexual activity after delivery combined with increased difficulty accessing services, the postpartum period presents a particular risk for unintended pregnancy.1 Fractured commissioning of sexual and reproductive health (SRH) services in some regions of the UK, and more recently the COVID-19 pandemic, have further reduced community-based contraceptive access.
The impact of this unmet contraceptive need can be seen in a number of ways. Studies indicate that up to 97% of women do not wish to become pregnant again in the year following childbirth.1 2 However, many women are unaware of how quickly they can conceive, and which contraceptive methods are safe to use at this time.2 Data from the UK suggests that at least 1 in 13 women access abortion services within the year after childbirth, and one in eight parous women conceive and continue another pregnancy within the same time frame.1 The resulting short interpregnancy interval (defined as less than 12 months between birth and subsequent conception) is an independent risk factor for almost all pregnancy-related complications.3
Despite no-cost contraception in the UK, access to effective methods during the postpartum period is challenging. The need to attend multiple appointments can be difficult for new mothers balancing newborn care and childbirth recovery. Although a dedicated six-week postpartum health check for mothers has been introduced in England, this may be too late for some as at least 50% of women will have resumed sexual activity by this time.4 Furthermore, for women considering long-acting reversible methods of contraception (LARC), attending further appointments for fitting may still be required. With primary care services under significant pressure in the post-COVID era, LARC provision is one of many competing clinical priorities and there are considerable challenges in restoring these services to pre-pandemic levels. This places additional pressure on SRH services, many of which are already battling service cuts. These issues serve to further compound the difficulties for women trying to access contraception, and particularly LARC.
Integrating contraception into maternity care
Although contraception is not required before day 21 postpartum,5 earlier initiation is a highly convenient option for women and overcomes many of the barriers described. This was recognised in the Faculty of Sexual & Reproductive Healthcare (FSRH) ‘Contraception After Pregnancy’ guideline which recommends that women should have access to their chosen method of contraception before leaving the delivery unit.5
While initial progress towards achieving this goal in the UK has been slow, the COVID-19 pandemic has provided a catalyst to increase awareness and provision of contraception within maternity services. There have been examples of innovative service developments, such as the mobilisation of SRH staff to maternity centres to provide postpartum contraception ‘at the bedside’.6 Such developments have been positively received by women but are still largely confined to regional centres. Furthermore, many of these new initiatives have been bolstered by the temporary ‘emergency’ funding and redistribution of staff during the COVID-19 pandemic, raising concerns about the future sustainability of these services.
Planning for successful provision in maternity services
There is still much work to be done to make universal access to postpartum contraception a reality in the UK. Discussions around fertility aspirations and future contraception should ideally begin in the antenatal period, when women and couples have time to fully consider their options. A routine antenatal contraceptive discussion can be successfully incorporated into pregnancy care pathways.7 Women should have access to reliable information in a range of formats to suit their needs, reinforced by discussion with their maternity care provider, and be supported to include an individualised plan for postpartum contraception in their birth plan. In order to support informed choice, and to ensure women do not feel pressured towards choosing any particular method, a full range of contraceptive methods should be available in the maternity setting (including LARC).
Training and education is central to expanding the provision of contraception within maternity services. The FSRH have introduced an ‘insertion only’ qualification in implant insertion, recognising the specific training needs of these professionals. For newer techniques such as postpartum intrauterine device (IUD) insertion, a formal training qualification is yet to be developed. However, this has been successfully introduced in some regions using tailored versions of existing Royal College of Obstetricians & Gynaecologists’ resources and could be replicated elsewhere.8 Recognising the challenges of ‘scaling up’ these interventions, there are an increasing number of implementation-based strategies proposed to support expansion of these services.9
While maternity services are absolutely integral to the success of postpartum contraception initiatives, the role of community-based providers should not be overlooked. SRH clinicians and general practitioners have an important role in training and championing postpartum contraception services.10 In addition, for women who have had a postpartum IUD insertion, the follow-up thread check can be managed in a community setting.
What next for postpartum contraception?
As we emerge from the COVID-19 pandemic, there is an opportunity to review how postpartum contraceptive services are delivered and adapt these to meet the needs of women.
To support informed and universal access, a systems-wide approach should be adopted to facilitate contraceptive discussion between maternity care providers and women. Consideration should also be given to how digital technology can supplement these discussions, including providing remote support for women who remain undecided about their future contraceptive use or assisting them in accessing their chosen method.
This should be coupled with innovative models of method provision in the postpartum setting. Delivering contraception in women’s homes or training midwives to insert LARC while they are in the maternity unit can reduce access barriers and allow expanded and equitable contraceptive choice.11 Access to practical training in implant and IUD insertion should be improved to encourage maternity care providers to offer these services, and contraception should form part of the core curriculum for midwifery and obstetric trainees.
There are undeniable benefits of improved access to postpartum contraception. Investing in these services supports the ‘life course’ approach to women’s health (as advocated by many public health strategies in the UK) and can lead to improved outcomes for women and their babies.
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Contributors MC researched and prepared the manuscript. All authors reviewed, amended and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.