Becoming pregnant again soon after giving birth is associated with risks for both mother and child. A study led by Karolinska Institutet and published in The Lancet Obstetrics, Gynaecology & Women's Health shows that approaches and guidance developed jointly by midwives and mothers can increase the proportion of women who choose effective contraception after childbirth, but also that organisational barriers limit opportunities for equitable care.
The period after childbirth is important for preventing closely spaced pregnancies, which can pose risks to both mother and child. Despite this, many women do not receive sufficiently good contraceptive counseling and services. The problem is particularly evident among women with a migration background in high-income countries. They are less likely to receive counselling or prescriptions and may encounter challenges such as language barriers, health literacy, costs, and difficulties navigating a new healthcare system.
Quality improvement with women and midwives
Previous research shows that women want clear, individualized information that respects their autonomy, but this is not always achieved in practice. Quality improvement collaborative and co-design has been proposed as a method to address this gap, yet many such initiatives have lacked involvement from the women they are intended to support.
In a recently published study within the IMPROVE-it project, researchers examined a quality improvement collaborative in which women with migration experience and midwives worked together to develop contraceptive services. The aim was to investigate whether such an approach could support women in choosing effective contraception after giving birth. .
The study was conducted at 28 antenatal care clinics across three Swedish regions: Stockholm, Västra Götaland, and Jönköping. Half of the clinics implemented the new approach in which midwives received training and, together with women with migration experience developed practical tools and new ways of working. The remaining clinics continued with standard care. In total, nearly 14,000 women were included and followed up at the post-partum visit 16 weeks after childbirth.
Organisational barriers remain
The results show that the proportion of women choosing an effective contraceptive method after childbirth increased from 45.2 to 48.9 per cent in the group that tested the new approach. The increase was mainly observed among women born in Sweden. Among women born outside Sweden, the change was small and not statistically significant.
However, the effects varied between regions, indicating differences in the conditions and opportunities available to midwives for implementing improvement initiatives.
"The results suggest that identifying problems and changing working methods are not enough to achieve equitable healthcare. Organisational barriers, such as a lack of interpreters and limited time during appointments, can play a major role. The organisation's readiness to allow changes to their way of working is crucial", says Elin C. Larsson , Associate Professor and Senior Researcher at the Department of Global Public Health and the last author of the article.
The findings provide important insights for efforts to enhance equity and effectiveness in contraceptive services and in maternity care more broadly.
"The IMPROVE-it project is unique since women with migrant background together with health care professionals and researcher, design services to make them relevant", continues Helena Kilander , Associate Professor and Senior Lecturer at the Department for Quality Improvement and Leadership, Jönköping University, and the assistant research leader.
Next steps
The research group will continue analyzing the data to better understand why the intervention was more effective in some regions than in others, and which factors facilitated or hindered its implementation.
The researchers have also launched a follow-up study, IMPROVE-it 2.0, to investigate the organisational factors that the study showed may constitute a barrier to equitable contraceptive services.
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The study was carried out in collaboration between Karolinska Institutet, Jönköping University, Uppsala University, Jönköping Region, Västra Götaland Region and Stockholm Region. It was funded by Forte and the Swedish Research Council.
Publication
About IMPROVE-it
The study was part of the research project Implementing best practice postpartum contraceptive services through a quality improvement initiative (IMPROVE-it) , which aims to improve access to effective contraceptive methods after childbirth for women with a migrant background in Sweden.
The project explores how women and men view contraception, reproductive decisions and partner involvement. It also evaluates whether quality improvement programs within maternal care can increase the use of effective contraceptive methods after childbirth.
The project combines interviews and focus group discussions with a large clinical trial in Swedish healthcare settings.
The findings will help develop better and more equitable contraceptive service that meet the needs of women with migration experience and their partners.
The goal is to support informed choices about family planning, reduce unintended pregnancies, and promote equitable sexual and reproductive health for all women.
