FIGO-ICM Joint statement on contraception

Contraception provision* is fundamental to the basic human right of women to decide whether and when to have a child or children.¹ It is a key component required to achieve gender equality. It is also vital to support informed decision making on timing, number and spacing of any pregnancies. The provision of comprehensive contraception services and care is therefore critical to the health and wellbeing of women, adolescents and children. In contrast, contraceptive inaccessibility carries devastating personal, social, economic and public health consequences.

Ensuring access to contraceptive information and services should be addressed at all stages of the life course. Only through the protection and provision of individual choice and empowerment can contraception contribute to improving health and economic outcomes for people of reproductive age worldwide. Contraception provision is also a key strategy to reduce maternal deaths and disabilities. Studies suggest that addressing the unmet need for contraception as a single intervention could reduce global maternal deaths by as much as 30%.² Furthermore, short 
inter-pregnancy intervals have been associated with maternal anaemia, small-for-gestational age infants, preterm birth, and increased infant mortality and malnutrition.^3–7

Strategic priorities

The International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives urgently call upon obstetrician-gynaecologists (OBGYNs) and midwives at all levels of practice, in hospitals and communities – whether in government (public), non-profit or private sectors – to prioritise and actively engage in the following ways to ensure the provision of contraception to all.

• Integrate person-centred and respectful contraception provision into sexual, reproductive, maternal and adolescent care services, and emergency obstetric and neonatal care.
• Prioritise equitable postpartum and post-abortion contraception provision.
• Provide education and access to contraceptives for marginalised and underserved populations, including migrants, refugees and displaced people, adolescents, members of the LGBTQ+ community, people with disabilities, racial and ethnic minorities, and people living in extreme poverty.

Integrating services 

The World Health Organization (WHO) recommends beginning contraceptive counselling during initial facility based antenatal care visits or at community based pregnancy screenings.⁸ This is crucial, as 75% of women see a midwife or OBGYN at least once during their pregnancies and often for subsequent postpartum visits.⁹ Integrating contraception into antenatal, intrapartum, postpartum, post-abortion, and maternal and newborn health services is a key strategy for improving maternal and newborn health indicators in future pregnancies. This strategy could also increase postpartum contraceptive uptake by as much as 14%.^5,9–12

There may be additional opportunities to integrate contraception provision into basic and comprehensive emergency obstetric and neonatal care (EmONC) services. These include provision of modern contraceptive methods including long-acting reversible methods (intrauterine devices, implants) after obstetrical emergencies. This includes contraception after vaginal birth, caesarean section, abortion or miscarriage.

Prioritising postpartum care

The greatest unmet need for contraception is among postpartum women and initiating antenatal discussions around contraception is critical if we are to realise this need.^5,13,14 In many settings, intrapartum and post-pregnancy care may be the only time a healthy woman comes into contact with an OBGYN or midwife. This provides an ideal opportunity for contraceptive advice, especially as many women are unlikely to seek subsequent care specifically for contraceptive advice.¹⁵ Studies have found that women who receive contraceptive counselling postpartum or post-abortion were more likely to accept a contraceptive method and use it long-term.^10,16,17 As such, the postpartum period presents both a particular challenge and a crucial touchpoint for healthcare professionals to offer contraception and optimise advice and care within the healthcare system. Pivoting to immediate postpartum contraception, as opposed to contraception in the extended postpartum period, may reap greater rewards.

Supporting marginalised and underserved populations

Adolescent girls and young women represent a crucial demographic for contraception provision: they face an unmet need for contraception of 43%.⁴ If addressed, this could reduce unintended pregnancies by at least 6 million annually.¹⁸ Doing so requires holistic, comprehensive sexuality education, integration of contraceptive needs assessments into primary care visits, and updated training for healthcare professionals.^{19, 20} Other marginalised populations – including women who are displaced or living in conflict zones and climate-affected areas, members of the LGBTQ+ community, and those with disabilities – may require tailored counselling and contraceptive methods based on the WHO medical eligibility criteria and their specific needs. Contraceptive provision is critical in humanitarian settings. All contraceptive counselling and provision should be accessible in a variety of languages and formats. It must emphasise the universal and basic human right to contraception free from coercion.⁸

The strength of OBGYNs and midwives together: symbiosis
for the best care and outcomes

ICM and FIGO are committed to supporting the increase of inclusive, equitable, accessible and high-quality comprehensive reproductive health services, including contraceptive care. Collaboration between OBGYNs and midwives is essential for providing the best care and outcomes for women.

OBGYNs and midwives play a key role in educating women and their families about the benefits and side effects of contraceptive methods, dispelling myths and addressing taboos. They are ideally positioned to offer the necessary information, support and care to prevent unintended or mistimed pregnancies. Additionally, they are equipped to support women in making informed choices about contraception and providing the appropriate contraceptive service across the life course, including anticipatory guidance during the antenatal, intrapartum and postpartum periods. Effective communication with women and their families – considering factors such as religious beliefs, cultural norms and gender inequalities – is key to facilitating informed choices.

ICM and FIGO jointly recommend that appropriate contraceptive methods be discussed and made available immediately postpartum, including lactational amenorrhea methods, intrauterine devices, condoms and sterilisation.²¹ Importantly, they highlight the need for healthcare professionals to be aware of specific WHO Medical Eligibility Criteria for postpartum and breastfeeding populations.²² 

Actions for OBGYN societies and midwives’ associations 

FIGO and ICM commit, promote and advocate for post-pregnancy contraception provision as a critical means of addressing and decreasing maternal and child mortality worldwide. Together, our organisations call attention to the following key opportunities for midwives and OBGYNs to work collaboratively to address contraceptive needs comprehensively and holistically:

• Educate and build capacity at all levels of care provision, including in facilities and communities, with an emphasis on pre-service and in-service education and training for OBGYNs and midwives. It is critical to highlight the importance of competency-based continuing education and training.
• Disseminate and implement recommendations on postpartum and post-abortion contraception, ensuring women receive appropriate knowledge and resources.
• Advocate for universal access to contraceptive methods and services that are appropriate, accessible, inclusive, equitable, affordable and cost-effective. Advocate for information about contraception and preconception health to be included in adolescent health education and promotion programmes.  
• Amplify one another’s voices in the field through respect and inter-professional collaboration. It is crucial that midwives and OBGYNs recognise the importance and value of contributions by both professions in providing optimal care.

Participate in efforts to influence national regulation, strategic planning, policy evaluation and clinical guideline revision. Acknowledge the importance of improved referral pathways for contraception provision that benefit services provided by both midwives and OBGYNs, with the ultimate goal of improving ease of access and positive outcomes for women.

** The provision of contraceptive methods and services for the purposes of birth control or family planning.