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Abstract
Background Access to post-abortion contraception (PAC) is critical for reducing unintended pregnancies and supporting reproductive decision-making. Patients often face challenges in identifying, accessing and initiating their preferred contraceptive methods post-abortion. This may be particularly so with telemedicine models of care with absence of in-person appointments, and reduced opportunities to provide some contraceptive methods. This qualitative service evaluation explored patients' perspectives on PAC consultations and decision-making to inform future PAC service models in the era of telemedicine.
Methods Qualitative interviews with 15 patients who had telemedicine medical abortion at home up to 12 weeks’ gestation. Data were analysed using reflexive thematic analysis.
Results Contraceptive discussions during pre-abortion consultations were valued for supporting informed choices about future contraceptive use. Decision-making was influenced by previous contraception experiences, emotional state at the time of abortion and concerns about contraceptive ‘failure’. Some preferred non-hormonal methods due to past negative experiences with hormonal contraceptives. However, limited information about 'natural' contraceptive methods and concerns about discussing these with healthcare professionals were described. Barriers to accessing preferred methods, particularly long-acting reversible contraception (LARC), included reduced availability of appointments and caring responsibilities. Fast-tracked appointments for LARC fitting post-abortion were valued. The need for flexible PAC consultations and access after abortion, for example, remote consultations complemented by personalised interactions with sexual and reproductive health experts, was emphasised.
Conclusion The findings highlight the need for flexible and more accessible PAC service models in the era of telemedicine care to ensure timely access to preferred contraceptive methods.
- Abortion, Therapeutic
- abortion, induced
- contraception behavior
- Counseling
- Health Services Research
- qualitative research
Data availability statement
Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Abortion, Therapeutic
- abortion, induced
- contraception behavior
- Counseling
- Health Services Research
- qualitative research
WHAT IS ALREADY KNOWN ON THIS TOPIC
Patients often face challenges in identifying, accessing and starting their preferred contraceptive method after medical abortion. This may be particularly an issue with telemedicine models of care.
WHAT THIS STUDY ADDS
Supporting patients in making informed choices about post-abortion contraception (PAC) and ensuring timely access to a comprehensive range of contraceptive options is critical.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
With telemedicine-delivered abortion care, there is a need for more adaptable PAC service models to enhance the availability of contraceptive options and facilitate informed decision-making, access and initiation.
Introduction
Improving access to post-abortion contraception (PAC) is a central recommendation of United Kingdom (UK) and international policy frameworks and evidence-based guidelines.1–4 UK guidelines recommend that abortion services offer the complete range of reversible contraceptive options to patients at the time of their abortion.3 4 In the context of telemedicine-delivered medical abortion care, this typically equates to the same day as a patient’s telemedicine pre-abortion consultation. Ensuring rapid access to contraception after abortion reduces the likelihood of subsequent unintended conceptions.3 4 This underscores the value of contraceptive counselling at the pre-abortion consultation, as it can enhance reproductive autonomy by supporting informed reproductive and contraceptive decision-making and help to prevent future unintended conceptions.4–7
Many patients encounter challenges in identifying, accessing and initiating their preferred contraceptive method after abortion.8 9 Previous research has highlighted the complexity patients (see online supplemental file 1) experience in navigating and making decisions about contraception during abortion treatment, including identifying referrals and access, processing a high volume of information, and managing competing emotional, physical and logistical priorities .8–10 Consequently, contraceptive counselling at the time of abortion can be challenging, potentially raising tensions for both patients and providers.6 9 10 Existing research highlights the importance of providing contraceptive counselling in a non-judgmental and person-centred way to avoid the potential for coercion, whether implicit or explicit.9–12
Supplemental material
Over the past three decades, the landscape of abortion care has undergone significant change, driven in part by advancements in medical abortion.13–16 Since the COVID-19 pandemic, the delivery of early medical abortion throughout Great Britain has largely transitioned to telemedicine.17 While telemedicine consultations offer advantages such as enhanced flexibility, accessibility and privacy,18 as well as presenting opportunities for tailored discussions on PAC,19 20 they also present limitations.19 21 22 Although patients can readily obtain short-acting contraception (eg, progestogen-only pill) in abortion medication packs with this model of care, evidence suggests that accessing long-acting reversible contraception (LARC) is more challenging.23 24 This can be exacerbated by the need for extra in-person appointments and reduced availability of these effective contraceptive methods in primary care settings.23 25 Furthermore, accessing other short-acting contraceptives, such as the combined oral contraceptive pill, may present additional challenges like blood pressure monitoring,26 while access to the medium-acting, self-injectable contraceptives may present the challenge of providing self-injection training.
Given these changes in service delivery, further research is needed to understand patients' experiences with contraceptive consultations at the time of telemedicine abortion, and to explore new models of PAC counselling and provision.17 25 This article presents findings from a qualitative service evaluation study that explored patients' perspectives on contraceptive counselling and decision-making during telemedicine-delivered medical abortion. The qualitative evaluation addressed three questions: (1) What were patients' experiences with contraceptive counselling during abortion care? (2) What barriers did patients encounter in accessing their preferred contraceptive method? (3) What elements of PAC services do patients value for future service models?
Methods
This qualitative evaluation took place between May and September 2022 in NHS Lothian, the exclusive provider of abortion care in Edinburgh and the surrounding region, offering approximately 3000 abortions annually. As is typical within the National Health Service (NHS), all aspects of abortion care, including PAC, are provided to patients free of charge. For patients accessing telemedicine abortion, standard care includes an option for discussion of contraception during a pre-abortion telephone consultation with an offer to provide the chosen contraception.19 Immediate short- and medium-acting methods can be dispensed, rapid access appointments for LARC offered, and 'bridging' methods provided until LARC can be initiated, if preferred.
We used purposive sampling to select participants from the service. During the recruitment period, in addition to standard care, some patients were offered an enhanced PAC service, including an additional telephone follow-up contraceptive consultation with a nurse.27 Our sample included both those who did and did not participate in the pilot PAC consultations. Inclusion criteria included individuals obtaining early medical abortion under Ground C of the 1967 Abortion Act (excluding medical conditions or fetal abnormality), aged 18 years or over and proficient in speaking, reading and understanding English. The principle of information power28 guided decisions on sample size, and sample characteristics were reviewed during data collection to ensure a diverse range of experiences were captured.
To recruit, participant information sheets with study contact details were provided to all patients having a medical abortion at home. Patients who used the pilot PAC service were made a further offer of the qualitative study by the nurse consulting with them. A researcher called approximately 3 weeks later to arrange an interview, if agreed.
Individual semi-structured interviews, following a topic guide (online supplemental file 2), explored contraceptive counselling during abortion care, pre- and post-abortion contraceptive methods, factors influencing method choices, barriers to accessing contraception, and perspectives on future PAC service models. Interviews were conducted by social scientists (SB and NB), both cisgender women with experience in sexual and reproductive health (SRH) research. Interviews took place on Microsoft Teams or by telephone and lasted an average of 50 min. They were recorded and then transcribed by a specialist company. Informed consent was obtained verbally, and participants received a £15 voucher in appreciation of their time.
Supplemental material
Qualitative data analysis was conducted by NB, SB and JH, following principles of reflexive thematic analysis,29 and using NVIVO30 for data management. Analysis was iterative and involved repeated readings and comparisons of interview transcripts, which informed the development of a coding framework applied to the entire dataset. During analysis, we drew on sensitising concepts from research literature on PAC and unanticipated issues that emerged during interviews. To ensure analytic rigour, the wider study team engaged in collaborative discussions, drawing on their diverse disciplinary perspectives to interpret the data and develop findings.
The evaluation was reviewed and approved by the NHS Lothian SRH Quality Improvement Team and Edinburgh Medical School Research Ethics Committee (Ref.: 22-EMREC-008).
Patient and public involvement
Patients and the public were not involved in the planning of this study; however, the interview guide was refined based on participant feedback.
Results
Of the 54 potential participants who agreed to be contacted, the final sample comprised 15 patients who accessed post-abortion contraceptive counselling following medical abortion treatment. Participant characteristics are outlined in table 1. We present thematic areas from our qualitative analysis of patients' accounts: (1) considering temporal dimensions of contraceptive counselling; (2) balancing interconnected factors in contraceptive decision-making; (3) situating approaches to contraceptive decision support; and (4) navigating access to post-abortion contraception. Illustrative quotes are presented in tables 2 and 3.
Characteristics of study participants (N=15)
Illustrative quotes: considering temporal dimensions of contraceptive counselling and balancing interconnected factors in contraceptive decision-making
Illustrative quotes: situating approaches to contraceptive decision support and navigating access to post-abortion contraception
Considering temporal dimensions of contraceptive counselling
Participants acknowledged the value of discussing contraception during the pre-abortion consultation. Although some had not expected to discuss contraception at that time, it was generally understood as an appropriate point to consider future contraceptive options (Quote #1).
However, some participants noted that their emotional state influenced their level of engagement about ongoing contraception. They emphasised that their primary focus was on abortion treatment rather than PAC decisions (Quote #2). This led some to suggest that they would be more open to discussing contraception after, rather than before, the abortion (Quote #3). Nevertheless, some noted that there may only be one consultation, and if contraception is not discussed at that point, there was a risk that some people may ‘fall between the cracks’ (Quote #4).
Although there was general agreement about the value of discussing contraception pre-abortion, some participants described feeling that they ought to, rather than wanted to, discuss contraception because they were presenting for abortion (Quote #5).
Balancing interconnected factors in contraceptive decision-making
Our analysis suggests that, in general, participants did not feel pressure to choose or initiate a specific contraceptive method (Quote #6). However, some perceived an implicit preference for LARC methods among healthcare professionals (HCPs) (Quote #7). Concerns about 'contraceptive failure' motivated some participants to seek different contraceptive methods, including LARC (Quote #8).
Previous negative experiences with hormonal contraceptives, including mood changes, anxiety and reduced libido, influenced contraceptive decision-making, with some participants articulating a preference for non-hormonal methods. Those who had used or considered using 'natural' contraception methods, such as fertility awareness and fertility tracking mobile health applications, described challenges in discussing these options with HCPs due to perceived stigma, doubts expressed about their effectiveness (interpreted as delegitimisation), and an apparent lack of knowledge among HCPs about these methods (Quote #9).
Situating approaches to contraceptive decision support
Expressing a desire for support in identifying the 'best option' for them, participants valued decision aids and tools, including online contraceptive decision-making tools that synthesise and personalise information. Videos explaining the pros and cons of contraceptive methods were seen as useful and visually engaging (Quote #10). Nevertheless, participants noted the benefit of opportunities for personalised interaction and information from supportive, ‘expert’ HCPs to identify preferences, address concerns about autonomy and control over contraception, and provide further guidance where needed (Quote #11). Several patients expressed a preference for receiving expert advice via telephone due to its convenience and because they felt less judged (Quote #12). However, others, especially those who had experienced a problem related to the medical abortion and therefore had to attend a clinic, highlighted the advantages of receiving contraceptive counselling in person (Quote #13).
Navigating access to post-abortion contraception
The reduced availability of contraceptive consultations, both within primary care and specialist SRH services, was emphasised by participants, widely attributed to the lasting impact of the COVID-19 pandemic on UK health services. Barriers to accessing contraception were particularly evident in the accounts of those attempting to access LARC methods, such as intrauterine devices (IUDs), prior to the current pregnancy (Quote #14). In contrast, some participants reported finding it ‘easier’ or being ‘fast-tracked’ for an appointment to fit LARC following abortion (Quote #15).
Participants who accepted the offer of receiving text messages offering a contraceptive consultation with a nurse, as part of the pilot programme for enhanced PAC consultations, emphasised the benefits. These messages served as reminders to further consider and access contraception (Quote #16). Continuity of care for contraception from the abortion service was highly valued and identified as a facilitator for contraceptive initiation. Maintaining a relationship with the same HCP was seen as offering benefits, including knowledge of their abortion, contributing to a sense of provider trust and personalised support (Quote #17). In addition, some preferred to remain under the care of community-based SRH services because they were viewed as ‘experts’ in contraception and adept at discussing sensitive issues around reproductive health. General practitioners were widely perceived as less experienced in contraceptive counselling and LARC fitting (Quote #18).
Discussion
This study provides insights into abortion patients’ experiences of contraceptive decision-making and contraceptive counselling. Our key findings indicate the importance of integrating different approaches to contraceptive decision-making support and challenges in navigating access to PAC, highlighting the diverse needs and preferences of patients for flexible and accessible models of PAC provision.
Participants understood contraceptive counselling as an appropriate aspect of abortion care whether at the time of the pre-abortion assessment consultation or after an interval, enabling informed choices about future contraceptive use. The introduction of telemedicine abortion has increased the volume of information provided remotely, with patients reporting finding it challenging to focus beyond their immediate abortion treatment.31 Therefore, providers of telemedicine abortion could consider offering follow-up contraceptive counselling for those who prefer this.31
Openness to contraceptive counselling varied among participants and was shaped by previous contraceptive experiences, personal perspectives and abortion experiences, illustrating the recursive nature of decision-making in this context.6 8–10 32 33 Concerns about ‘contraceptive failure’ and a desire to avoid another abortion influenced some participants’ decisions to choose long-acting methods like IUDs. This finding is consistent with qualitative studies from Scotland10 and Sweden,9 where patients experiencing ‘contraceptive failure’ often sought more effective methods after weighing up the perceived advantages.
Not all patients opted to change their contraceptive method post-abortion. Some reported a preference for 'natural' contraception methods, such as fertility tracking apps, both before and after the abortion. This finding echoes research on women’s perceptions of hormonal contraception, including broader concerns about physical side effects (and delegitimisation of these), mental health, sexual function or satisfaction, menstrual changes, distrust of synthetic hormones and concerns about future fertility.9 32 34 Some participants described being uncomfortable discussing ‘natural’ methods with HCPs due to perceived knowledge gaps of HCPs on these methods, and stigmatisation of these methods. This aligns with a recent review on fertility awareness-based methods (FABMs), highlighting challenges in accessing accurate information due to the proliferation of period tracking and fertility applications, and insufficient evidence on their effectiveness.34 Concerns among providers about effectiveness, and the scarcity of formal training on FABMs, may hinder discussions with patients.34–36 Further research into concerns about hormonal contraception and patients' perspectives on discussing these with HCPs could offer insights into approaches to supporting contraceptive decision-making.33
Barriers to accessing preferred contraceptive methods, especially LARC methods such as IUDs, were identified. Although the COVID-19 pandemic may have exacerbated these issues, difficult access to contraception has been a longstanding issue in the UK.10 Timely access to preferred methods is critical, particularly for those facing additional obstacles to making and attending appointments.22 37
The importance of convenience, flexibility and accessibility in future PAC service models was emphasised by participants. Remote delivery of contraceptive counselling, supported by decision aids, was acceptable, with the option for in-person consultations when needed, and pre-abortion consultations, highlighting the need for flexibility in timing. This suggests the potential value in offering a separate pre-abortion telephone contraceptive consultation, as suggested by earlier studies.31
Specialist SRH services for contraception were often preferred by participants, who perceived HCPs in these settings as more knowledgeable and experienced in counselling and fitting, aligning with past research.10 Participants appreciated support during pre-abortion contraceptive consultations, which allowed them to explore contraceptive options and make decisions best suited to their needs. Participants valued a supportive and non-judgmental atmosphere during these discussions because it fostered open dialogue, reduced anxiety and allayed concerns about feeling pressured or coerced into specific contraceptive choices. This is consistent with existing literature that highlights the significance of relational contraceptive counselling and trust, as a lack of trust can negatively impact future contraceptive use.9 10 32
Fast-tracked appointments for LARC fitting and same-day appointments for rapid initiation of other methods were viewed by participants as supporting timely access to contraception. This is particularly important given the challenges for patients in accessing contraception in primary care, specialist SRH services, and at the time of abortion, as highlighted by research in the UK during and since the pandemic.23 25 37 As such, our findings emphasise the need for flexible post-abortion service models within telemedicine-delivered abortion care to ensure timely access to a range of contraceptive options.
Strengths and limitations
This study provides rich qualitative insights into patients' experiences with PAC care, which can inform service improvements. However, several limitations should be considered when interpreting the findings. The relatively small sample size recruited from a single region19 may limit the applicability of the findings to other contexts. Additionally, the study was conducted in an NHS setting where contraception is provided at no cost, which may affect the transferability of the findings to different service delivery models or geographic contexts where contraception incurs a cost.
Conclusions
Future research and practice should focus on developing flexible and accessible models of PAC service provision that address patient needs and preferences in the era of telemedicine abortion care. By addressing these findings, services can better meet the needs of patients and improve reproductive health outcomes.
Data availability statement
Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and the evaluation was reviewed and approved by the NHS Lothian SRH Quality Improvement Team and Edinburgh Medical School Research Ethics Committee (Ref.: 22-EMREC-008). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors wish to thank the patients who kindly agreed to take part in the study. The authors also wish to acknowledge the contributions of Anne Johnstone and Karen McCabe to project study recruitment.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @NBW80, @doctorjjrw, @jeniharden
Contributors The original idea and overall study design were conceived by JH, NB, JJR-W and STC. Qualitative study design, data collection and analysis were conducted by JH, NB and SB, with input from JJR-W and STC. NB prepared the initial manuscript with contributions from, and edits by, JH, SB, JJR-W and STC. NB is responsible for the overall content as guarantor. All authors jointly approved the version to be published and are accountable for the accuracy and integrity of the work.
Funding The study was funded by the NHS Lothian Sexual Health and Blood Borne Virus Programme Fund (Project No. 12312504). NB is supported by the Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies Institute (Project No. 8538504_8538623). The study was conducted by staff at the Centre for Reproductive Health (JJRW and STC), which is funded by Grant MR/N022556/1.
Disclaimer The study funders were not involved in research conduct or manuscript preparation.
Competing interests JH and JJR-W are Associate Editors of BMJ SRH. STC is Editor-in-Chief of BMJ SRH. JJR-W has received an educational grant from Gedeon Richter.
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.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.