Co-designed counseling raises postpartum contraception choices to 48.9%

At the 16-week postpartum follow-up, the share of women choosing effective contraception had risen from 45.2% to 48.9% in the Swedish clinics testing a new counseling approach. Led by Karolinska Institutet and published in The Lancet Obstetrics, Gynaecology & Women's Health, the study followed nearly 14,000 women across Stockholm, Västra Götaland and Jönköping.

Closely spaced pregnancies are associated with risks for both mother and child, but postpartum counseling is not always clear, individualized or easy to access. The problem is particularly evident among women with migration backgrounds in high-income countries, who may be less likely to receive counseling or prescriptions and may encounter language barriers, health literacy challenges, costs and difficulty navigating a new health care system.

The IMPROVE-it project tested a quality-improvement collaborative — a clinic-based effort to change working practices — in which midwives and women with migration experience developed contraceptive services together. Half of the 28 clinics implemented the approach, with midwives receiving training and using practical tools and new ways of working; the remaining clinics continued standard care. Helena Kilander of Jönköping University was assistant research leader on the project.

The result came with a sharp qualification. The increase was mainly observed among women born in Sweden. Among women born outside Sweden, the change was small and not statistically significant, and the effects varied between regions. Elin C. Larsson, associate professor and senior researcher at Karolinska Institutet, pointed to a lack of interpreters, limited time during appointments and an organization’s readiness to allow changes as barriers to equitable care.

Concretely, the study gives maternity services a two-part lesson: involving women in designing counseling can improve the choice of effective contraception, but co-design alone cannot remove the practical barriers that shape access. The researchers will continue analyzing why the approach worked better in some regions and have launched IMPROVE-it 2.0 to investigate those organizational factors.