Women’s experiences of, and preferences for, postpartum contraception counselling

Keywords: family planning, general practice, long-acting reversible contraception, postpartum care, postpartum contraception, primary care, reproductive health, women’s health.

The use of contraception during the postpartum period is an important element for preventing unintended pregnancies and short interpregnancy intervals and associated complications (Pridham et al. 1991; Guttmacher Institute 2021). An interpregnancy interval of at least 24 months is recommended to reduce the risk of adverse maternal, perinatal and infant outcomes (World Health Organization 2007; Faculty of Sexual & Reproductive Healthcare 2017). Most contraceptive options are suitable following birth, according to their safety profiles for individual women and their family planning needs (World Health Organization 2013); however, globally, about two-thirds of postpartum women may have unmet contraceptive needs (Ross and Winfrey 2001; Lopez et al. 2010; Dev et al. 2019). Despite a variety of contraceptive options available, uptake of postpartum contraception remains relatively low, ranging from 2% to 40% in different countries and regions (World Health Organization 2013; Cleland et al. 2015; Sok et al. 2016; Bearak et al. 2020). In addition to personal and social factors, women’s use of postpartum contraception can be influenced by: their access to contraception information and services, awareness of options, costs and access to healthcare providers (Cleland et al. 2015; Sok et al. 2016; Dev et al. 2019).

In Australia, it is estimated that one-quarter of women have experienced an unintended pregnancy, with 30% ending in abortion (Taft et al. 2018). Yet, provision of contraceptive counselling (i.e. provision of information and education to support decision-making) during the postpartum period is inconsistent across maternity settings, including among obstetricians, general practitioners (GPs), midwives and maternal and child health nurses (Piejko 2006). Although the Royal Australian College of General Practitioners (RACGP) recommend a 6-week postpartum check for well-woman and well-baby review after birth in the GP setting, there is no guidance as to when, how or by whom contraceptive counselling should be provided (Piejko 2006; Bessett et al. 2015; Bearak et al. 2020). Further to this, research on contraceptive counselling and women’s preferences for postpartum contraception is scarce in Australia. We therefore undertook a study to explore Australian women’s experiences of, and preferences for, accessing postpartum contraceptive counselling.

In 2020, in this qualitative study, we recruited women from Melbourne, Victoria, Australia, via a local parenting group on Facebook (Melbourne Mums Group, with over 46 000 followers as of June 2020) to participate in a semi-structured telephone interview to discuss their experiences of, and preferences for, postpartum contraception. Interested women accessed the explanatory statement (which outlined eligibility criteria) and consent form online through Qualtrics (Qualtrics XM). English-speaking women aged 18–40 years old who had at least one child under the age of 5 years were able to participate.

Interviews were conducted via telephone as Melbourne was under social isolation restrictions during the coronavirus disease 2019 (COVID-19) pandemic, where residents were required to stay at home and reduce social contact at the time of the study. The first 20 eligible women who expressed interest were contacted. Participants received an SMS reminder 1 hour prior to the agreed time to ensure that they were in a comfortable and quiet location for the interview. An interview guide was used, developed using Andersen’s model of healthcare utilisation (Andersen 1995), with questions focussing on women’s experiences of, and preferences for, postpartum contraception. Each participant was remunerated with a A$50 shopping voucher for their time after completion of the interview.

Each interview ran for approximately 30–60 min. Interviews were recorded by an audio recorder and the files were electronically transferred to a secure drive at Monash University and subsequently deleted from the audio-recorder. Professional transcription of the recordings was used for data analysis based on Braun and Clarke’s reflexive thematic analysis, including data familiarisation, coding and categorisation, theme generation and review, redefining and theme reporting (Braun and Clarke 2006). NVivo 12 software (QSR International Pty Ltd) was used for data coding, with themes identified by the primary researcher, with secondary researchers’ assistance to refine the themes.

The Monash University Human Research Ethics Committee, Project ID 23951, approved this study.

Twenty women from age 30 to 39 years, with one to three children under the age of 5 years, and interpregnancy intervals of 2–24 months participated in the study. All participants were partnered (i.e. married or in a de facto relationship) and resided in the greater Melbourne area. Participant characteristics are described in Table 1.

Table 1.  Demographics of study participants.

Participants reported that their busy personal schedules caring for their newborns and other children were a key barrier to accessing contraceptive counselling. They tended to regard their own health as a low priority, including consideration of contraception, and were usually ‘too busy’ to think about it.

Look, to be honest, I probably needed it (contraception) earlier… I sort of waited a while just because… having a newborn, going to the doctors to get the contraception just didn’t seem like a priority at the time… it was just about having time to be able to do it. (Participant 2 (39 years old))

Most participants reported that they had not received detailed contraception information before or immediately after they gave birth. Approximately half the women reported receiving very brief information about contraception while they were in hospital, from a midwife or obstetric doctor, with some receiving suggestions only after birth from a maternal and child health nurse; however, none received formal counselling where detailed contraceptive information was discussed.

I feel like it seems like they (hospital staff) were very busy… they will just give you a booklet or piece of paper telling you about all these things. (Participant 14 (36 years old))

Most women had some discussion regarding contraception at 6 weeks postpartum when they presented to their GPs or obstetricians with their newborns for a designated postpartum assessment; however, they reported that it was usually ‘short’, ‘rushed’ and ‘limited’. Women commented: ‘the doctor is not that invested in my health’ (Participant 7), ‘I was just there for my kids’ (Participant 6) and ‘I was taking too much of the doctor’s time’ (Participant 14). Participants felt that these appointments did not adequately cover postpartum care and the well-baby check, let alone comprehensive counselling on postpartum contraception. For most participants, follow-up appointments were not made to further discuss contraception, commonly because the healthcare provider did not suggest this, and women were not aware of the need for such.

The doctors are so busy and so rushed and I always feel really guilty taking up the doctor’s time in appointments. (Participant 10 (39 years old))

Nearly three-quarters of women interviewed had resumed sex within the first 3 months postpartum, with all resuming this by 6 months. However, only three were aware of safe interpregnancy intervals, which they had learned about through self-directed reading. None could recall this topic being mentioned by any healthcare providers.

Not exactly (sure) but I think I know that you are supposed to wait for the body to heal and replenish… not everyone follows, but I know there’s some recommended time, but I’m not sure. (Participant 4 (30 years old))

Most participants felt that the 6-week postpartum check with their GPs or obstetricians was the ideal time to receive postpartum contraception counselling and provision, although they were also interested in receiving information on contraception throughout their maternity journey, including antenatally and immediately postpartum. More than half considered it helpful to have a follow-up appointment with their GP or obstetrician to further discuss contraception if needed; for example, an initial discussion and then another several months later.

I think six weeks is probably the right time to have the first conversation, but I think there needs to be another one six to eight months down the track, because that’s sort of when you are out of that initial newborn ‘bubble’ most likely… (My) sleep (at around six months) was starting to get a little bit better and I was feeling a bit more mentally clear. (Participant 11 (32 years old))

Those who had experienced medical complications during or after their pregnancy felt having immediate postpartum counselling and provision was particularly important, including those who had experienced gestational diabetes, eclampsia, premature babies and postnatal depression.

(With the previous pregnancy of gestational anxiety,) I think because I would want to make sure that I was on contraception as soon as possible after the birth, like that was my priority. (Participant 9 (31 years old))

When asked which healthcare provider they would prefer to provide postpartum contraceptive counselling, most participants expressed a general preference for their GPs or a midwife, followed by obstetricians and maternal and child health nurses. The gender of the provider was not considered important to most participants, with only three participants expressing preference for a female provider for contraceptive care. The more important characteristics identified by participants included their healthcare provider being ‘compassionate’, ‘trustworthy’ and ‘caring and knowledgeable’.

I must admit I had a great GP where I was able to call up before an appointment… to get the Implanon… we would just make a long appointment and then she had a good chat with me beforehand and checked how I was and my mental health. (Participant 2 (39 years old))

Most women in this study were not aware of safe interpregnancy intervals and could not recall this being discussed by healthcare providers. Further, most did not receive in-depth contraceptive counselling antenatally or postnatally, although had brief discussions with their GPs or obstetricians at the 6-week postnatal check. Participants felt some counselling throughout their maternity care would have been useful, particularly those who experienced complications during their pregnancy or birth. Many women in our study also expressed a general preference for their GPs or midwives to provide contraceptive counselling, rather than an obstetrician or nurse, and they noted that characteristics such as compassion, trust and care are particularly important.

The international literature has comparable findings regarding when and who should provide postpartum contraception to meet women’s needs. Overseas guidelines recommend postpartum contraception information and services be integrated into maternity care pathways, including by GPs, midwives and other clinicians (World Health Organization 2013; American College of Obstetricians and Gynecologists 2016). In a systematic review conducted in 2015, Zapata et al. found that postpartum contraception use has been shown to be highest when contraceptive counselling is provided during both antenatal and postpartum time periods (Zapata et al. 2015). Although the RACGP in Australia recommends that the 6-week postnatal check is an ideal time to discuss contraception (Piejko 2006), this is currently not routine practice by all GPs in Australia, and no postpartum contraception policy is available to guide maternity carers (Brodribb et al. 2013; Cheney et al. 2021). Although the 6-week check may be a suitable time to discuss contraception, such discussions must also occur earlier in the pregnancy and postpartum period. Pregnancy can occur as early as 21 days after delivery and not all women attend the 6-week appointment (and for those who do, contraception is not always discussed in detail), as was also reflected in our study (Brodribb et al. 2013; Zapata et al. 2015; Dev et al. 2019).

Similar to some women’s preference in our study, other international studies also suggested that antenatal counselling and follow-up counselling after 6–12 months after birth may promote postpartum contraception uptake (Akman et al. 2010; Reyes-Lacalle et al. 2020). The development of a national postpartum contraception policy would provide necessary guidance for maternity carers in Australia, as would better engagement by relevant professional bodies and education programs to promote this aspect of care.

Contraceptive counselling and provision are particularly critical for women who experience complications during their pregnancy or birth. This has also been reported in other studies, as these women may be at higher risk of complications with a subsequent unintended pregnancy or short interpregnancy interval (Chor et al. 2011; Perritt et al. 2013). Women who may be at higher risk should be identified by their healthcare providers and receive contraception counselling antenatally and postnatally to ensure timely and comprehensive access to contraception information and services in ways appropriate for them.

Overall, it is important for all women in Australia to have access to postpartum contraception information throughout their maternity journey and be aware of safe interpregnancy intervals, as access to postpartum contraception can help to avoid unintended pregnancies and promote longer interpregnancy intervals to optimise maternal and infant health (Lewis et al. 2010; Tocce et al. 2012; American College of Obstetricians and Gynecologists 2016). This should be facilitated by women’s main maternity carer(s) and could be supported by the use of resources to increase awareness of interpregnancy intervals and the range of contraception options available, including credible websites, social media, smartphone applications and text reminders.

Our study highlighted that women experienced a lack of consistent maternity care providers designated to offer postpartum contraception advice. In our study and others, GPs and midwives were often identified as preferred, reliable sources of such information, with the added benefit of their availability and flexibility to offer continuity of care around perinatal and general health issues (Fanello et al. 2007; McCance and Cameron 2014). Who provides postpartum contraception counselling may play a major role in influencing women’s contraceptive uptake, follow up of subsequent postpartum outcomes and decisions around an unintended pregnancy; without consistent and standardised practice, over half of women may have missed opportunities for contraceptive access (Glasier et al. 1996; Fanello et al. 2007).

We wish to note that our study has several limitations, including a relatively small sample size of women. Additional research with maternity carers, as well as with women that is inclusive of wider demographics in Australia, including Indigenous women, women from culturally and linguistically diverse backgrounds, and those living in rural and remote areas, would be valuable to better understand and identify opportunities to inform policy and practice change, and increase use of postpartum contraception.

The provision of postpartum contraceptive counselling could be enhanced in Australia through consistent and routine provision antenatally and postnatally by maternity carers. Findings from our study suggest postpartum contraception counselling is not consistently provided, although women are interested in receiving this both antenatally and postnatally from GPs and midwives. Contraceptive uptake in the postpartum period may be promoted by ensuring provision of contraceptive counselling during pregnancy, after birth and at 6-weeks postpartum, as well as continued follow up some months after birth, if required. This may be supported by the use of resources to increase awareness of optimal interpregnancy intervals and contraception options. The development of a national postpartum contraception policy to guide maternity carers would further support these endeavours.

The data that support this study cannot be publicly shared due to ethical or privacy reasons, and may be shared upon reasonable request to the corresponding author, if appropriate.

Danielle Mazza and Jessica Botfield are guest editors of the Australian Journal of Primary Health, but were blinded from the peer-review process for this paper.

The Australian Government supported this study under the Australian General Practice Training Program.