By Rebecca H. Allen, MD, MPH, Editor
Synopsis: In this cross-sectional study of 88,550 patients presenting for abortion services in England and Wales in 2018 and 2023, the use of effective methods of contraception decreased over time (hormonal methods: 18.8% vs. 11.3%, P < 0.001; long-acting reversible contraceptives: 3% vs. 0.6%, P < 0.001), while fertility awareness-based methods increased from 0.4% to 2.5% (P < 0.001).
Source: McNee R, McCulloch H, Lohr PA, Glasier A. Self-reported contraceptive method use at conception among patients presenting for abortion in England: A cross-sectional analysis comparing 2018 and 2023. BMJ Sex Reprod Health. 2025; Jan 13. doi: 10.1136/bmjsrh-2024-202573. [Online ahead of print].
The authors of this study sought to describe trends in contraceptive use among patients presenting for abortion services in England and Wales. The authors hypothesized that patients today were less likely to want to take hormonal methods of contraception and more likely to want to use “natural” methods, such as fertility awareness-based methods.
The study used data from the British Pregnancy Advisory Service, which is a network of independent clinics that provide abortion and contraceptive care as well as screening and treatment for sexually transmitted infections. When patients present for abortion care, the contraceptive used at the time of conception is documented. Contraceptive methods were grouped into fertility awareness-based methods (FABM), hormonal contraceptive methods (pills, patch, vaginal ring, emergency contraception), long-acting reversible contraception (LARC; intrauterine device, injectable), other (condom, sterilization), and none. Two periods of time were compared, Jan. 1, 2018, to June 30, 2018, and Jan. 1, 2023, to June 30, 2023.
The 2018 group comprised 33,495 patients and the 2023 group comprised 55,055 patients. In 2018, 69% of abortions were medication abortions. This rose to 85.6% in 2023. The majority of patients were in the first trimester of pregnancy, with patients presenting earlier in gestation in 2023 compared to 2018 (gestational age ≤ 7 weeks 59.4% vs. 35.6%, respectively). The percentage of patients using FABM increased from 0.4% in 2018 to 2.5% in 2023 (P < 0.001). Hormonal contraceptive use decreased from 18.8% to 11.3% (P < 0.001) and LARC use decreased from 3% to 0.6% (P < 0.001) over the same time period. Additionally, in 2018, 55.8% of patients reported using no method of contraception compared to 69.6% of patients in 2023 (P < 0.001).
Commentary
This study demonstrated that abortion patients in England and Wales currently are less likely to use highly effective contraceptive methods in favor of using no method or FABM. There has been research documenting more patients gravitating toward “natural” methods of contraception.1 With the advent of the smartphone, period tracking applications can facilitate the use of FABM.
There is one U.S. Food and Drug Administration-approved application called Natural Cycles for contraceptive use in premenopausal females aged 18 years and older.2 The app requires the patient to track their basal body temperature and menstrual cycle. The clinical trial showed a perfect use failure rate of 1.8% and a typical use failure rate of 6.5%. Apps that do not incorporate temperature tracking are less effective.
The authors also noted that the abortion rate had increased in England and Wales during the same period. Although they could not assume causation, there may be a correlation with these study findings. Additionally, they noted that access to more effective methods of contraception has been more difficult for patients during and after the COVID-19 pandemic for a variety of reasons. Clearly, easy access to all types of contraceptives is critical in reducing unintended pregnancies.
Interestingly, based on service delivery changes allowing the use of mifepristone and misoprostol at home in England and Wales, the number of medication abortions increased over the study period, as well as abortions at ≤ 7 weeks’ gestation. Although telehealth medication abortion and home delivery of medications are more convenient for patients, they then only interact with the healthcare system with a single phone call. Therefore, post-abortion contraception counseling and access may be hindered. It will be important for these changes to be investigated further. Although this study only examined England and Wales, these trends may be predictive of what will happen in the United States in the future.
Rebecca H. Allen, MD, MPH, is Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.
References
1. Le Guen M, Schantz C, Regnier-Lolier A, de la Rochebrochard E. Reasons for rejecting hormonal contraception in Western countries: A systematic review. Soc Sci Med. 2021;284:114247.
2. U.S. Food and Drug Administration. FDA allows marketing of first direct-to-consumer app for contraceptive use to prevent pregnancy. Published Aug. 10, 2018. https://www.fda.gov/news-events/press-announcements/fda-allows-marketing-first-direct-consumer-app-contraceptive-use-prevent-pregnancy
In this cross-sectional study of 88,550 patients presenting for abortion services in England and Wales in 2018 and 2023, the use of effective methods of contraception decreased over time (hormonal methods: 18.8% vs. 11.3%, P < 0.001; long-acting reversible contraceptives: 3% vs. 0.6%, P < 0.001), while fertility awareness-based methods increased from 0.4% to 2.5% (P < 0.001).
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