Sex and

contraception

after

Supporting women’s choices in the postnatal period

Sex and they feel they cannot carry to term. We regularly see contraception women experiencing an unplanned pregnancy in the year after childbirth after giving birth. Our experience is mirrored elsewhere: recent Introduction research presented at the European Society of Contraception The World Health Organisation and found recognises the importance of that around 10% of women pleasurable and safe sexual presenting with unplanned experiences, and the ability to pregnancy at one NHS clinic had control the number, timing and given birth in the last 12 months. spacing of one’s children.1 In the In this study, unplanned UK, there has been much focus on pregnancy within a year of birth developing sexual health policies was significantly more prevalent and services for younger age than after within the groups which has led to a same space of time.2 welcome fall in rates of After an initial shock, for many . However women the news that they are the needs of other groups at other expecting again can be a source of life stages have sometimes not real joy, but for others the received the attention they should, discovery can cause considerable including women in the postnatal distress. Experiencing an period. In 2012, the last year for unplanned pregnancy can be which figures are available, emotionally and physically around 800,000 women in the UK challenging at any stage of a gave birth. There has been woman’s life, but it may be relatively little research on the particularly difficult while coping sexual health needs of this group with a baby and the upheavals of women. that in itself brings. While the The British Pregnancy Advisory risks of having 2 children close Service is a charity which counsels together should never be over- more than 60,000 women a year stated, shorter inter-pregnancy with unplanned pregnancy or a intervals are associated with an

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increased risk of adverse again with their partner within a outcomes for both mother and short period. baby.3 However it should be With the welcome support of acknowledged that some women, Bounty, we are now able to ensure particularly as more couples delay most new mothers in the country childbearing into their late 30s, receive our guide to contraception may seek to become pregnant after a baby, which provides again relatively quickly before information on the return of fertility further declines, while fertility, when others may feel there are protects against pregnancy, and economic advantages associated which methods can safely be used with closer . Their whether a mum is breastfeeding choices should absolutely be or not. We have also undertaken respected. research with Bounty’s Word of The reasons for unplanned Mum panel, surveying 1,323 pregnancy within a year of women who had given birth at maternity may be diverse. More least once within the last 4 years, women are initiating to better understand women’s breastfeeding than previously, and choices about resuming sex after may believe that breastfeeding childbirth, providing the first either provides full contraceptive modern UK data in this area. The cover or do not know what research also looked at their effective contraception can safely knowledge of contraception and be used while breastfeeding. Live ease of obtaining what they births increased by 22% between needed, when they needed it. This 2002 and 20124, and builds on research undertaken in say they do not always have the conjunction with the time and resources to provide the site Mumsnet in late 2012 and our information and support about guide has been produced in direct contraception they believe women response to their calls for better need.5 Women may not always written information on know how rapidly fertility can contraception choices after having return, but particularly if they a baby. Unless otherwise stated, have had a straightforward birth, all survey results in this report are may feel ready to start having sex from the Bounty panel and

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exclude those who answered “prefer not to say” (the base is Those who are least likely to have stated in each graph). Quotations, started having sex again before 6 unless otherwise stated, are from weeks are those who underwent users of Mumsnet who had given an emergency caesarean (13% birth in the last 3 years. resumed before 6 weeks) followed Resuming sex by those who experienced tearing or an , with little By 4 weeks postpartum, one in 5 difference in whether the birth women (20%) who have had a was assisted (forceps or ventouse) vaginal delivery without tearing or or non-assisted. (20% and 21% an episiotomy have started having respectively). Contrary to sex again. By 6 weeks, a third of previous studies, our survey women (35%) who had deliveries suggests it is perineal trauma without perineal trauma have rather than whether the birth is resumed sex, and a quarter of assisted or not which leads to a women who have undergone differences in the timing of the planned caesarean sections resumption of sex.6 In our survey (25%). around 85% of first time mothers delivering vaginally experienced Resumed sex before 6 weeks Base: 1,169 tearing or an episiotomy, 45% compared to 58% of women with 40% subsequent vaginal deliveries. 35% 30% Overall around a quarter of 25% women (23%) will have started 20% having sex again before 6 weeks, 15% which is before a postnatal check 10% 5% is scheduled where contraception 0% is generally discussed. There is absolutely no reason why women who wish to start having sex again should delay until this appointment, but they should be informed that in non-

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breastfeeding women When did you resume sex contraception is needed from 3 after childbirth? weeks after the birth and offered Base: 1,169 their choice of contraception if 87% they want to avoid pregnancy.

“I think being advised of how 60% quickly you can fall pregnant again after the birth of a baby (I fell pregnant again when my 10% 3% eldest was 2 months old).7 By 3 By 6 Between 6 Longer By 3 months, around 60% of months months months than a year women have resumed sex, but this and a year ranges from 50% of women who underwent an emergency Our survey shows little difference to 73% of in resumption of sex between first women with a vaginal delivery time and second time mothers, with no tearing or episiotomy. By however it does show some 6 months 87% of women had difference by age. resumed sex, with very little variation by mode of delivery. Resumed sex by 3 months 10% waited between 6 months Base: 1,169 and a year, and a further 3% 70% longer than a year. 60% 50% 61% 40% 57% 30% 20% 10% 0% First time Subsequent mum mum

Nearly 3/4 of mothers (73%) under 25 have resumed sex by 3 months, compared to just over half of women aged 35-44. bpas |Sex and contraception after childbirth 5

“pressured by my partner into it” Resumed sex by 3 months (8%) or that they had felt they

Base: 1,169 should do it because “other couples were probably doing it”. 80%

70% How did you feel about resuming 73% sex again? 60% 60% Base: 1,164 50% 60% 52% 40% 50% 30% 40% 20% 30% 10% 20% 0% 16-24 25-34 35-44 10%

0% The survey shows therefore a wide timetable for resumption of sex, which means that sexual and reproductive health services need to be flexible to the individual needs of women in the postnatal period – needs which may well in the initial months at least be Pain and exhaustion were the influenced by their mode of principle barriers to women delivery. resuming sex, and worryingly nearly half of women (45%) When asked to describe how they women said feeling uncomfortable felt about resuming sex, women about their own body was a were more likely to respond that it barrier. Research has shown that was “important for me and my body image – and weight loss – are partner” (50%) than “I felt like some of the most prevalent it/it felt right” (48%). concerns for women in the Reassuringly relatively few postnatal period.8 A survey women replied that they felt conducted by the Royal College of

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Midwives (RCM) and the While guidance from the Faculty parenting site Netmums in 2010 of Sexual and Reproductive found 6 in 10 new mothers felt Healthcare (FSRH) says health “celebrity culture” put more professionals should create pressure on them to lose their opportunities for women to raise pregnancy weight quickly. 9 issues relating to postnatal sexual health and body image,10nearly What put you off having sex after half of women (47%) in our childbirth? survey did not feel they could Base: 1,244 speak to a 60% about any concerns they had with

50% regards to resuming sex, if they needed to, compared to 37% who 40% said they could, with the 30% remainder unsure. A study

20% published in 2000, found around 80% of women reported a 10% postnatal sexual problem (eg pain, 0% vaginal tightness, difficulty reaching orgasm), but only 15% of those said they discussed it with a healthcare professional.11

“What I would have liked was further discussion about sexual health in general, after I had a second degree tear – no-one asked about it save when I was getting my stitches checked, and it took such a long time to re- establish a sex life with my More than one in five also worried partner. I would really have about contraception and getting appreciated someone talking pregnant again when they that over with me, but never felt resumed sex, including a third of quite able to ask especially as mothers under 25.

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check-ups with baby are so breastfeeding and using focused on baby.”12 , no one ever suggested I use an implant.”14 Did you feel you could speak to a health professional about any According to the RCM, there were concerns about resuming sex? 128,996 more births in 2012 than Base: 1,323 the service was designed to cope 60% with. 15 Midwives, as is widely reported, are stretched. A recent 50% report by the RCM found that fewer than half of these 40% professionals believed they had

30% the time and resources to provide the information they felt women 20% needed on contraception. 16

10% In addition, a qualitative study of midwives’ experiences and views 0% of giving postpartum Yes No Don't know contraceptive advice, published in 2014, found that while all “Sex was a difficult issue for us discussed the return of fertility, as a couple after pregnancy and most found it a job of lesser birth and I felt embarrassed to importance which they felt 17 speak to someone face-to-face” inadequately trained for. In this (mother who wished more help study, no made a firm was available over the phone) 13 contraceptive plan with women, the only plan being that they Discussing contraception: should see another healthcare providing women with professional to obtain further information information and advice.

“I know most women laugh when a) Breastfeeding as this comes up, but it would have contraception been v helpful to have a fuller discussion of the options. DS 2 The proportion of women was conceived when I was initiating breastfeeding has

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increased steadily in recent years Lactational Amenorrhoea Method as a result of public health policies – or LAM. Fairly strict criteria to promote this as the optimal need to be met for it to work form of feeding, with effectively, including the baby not exclusive breastfeeding using a dummy, and like all recommended for the first 6 contraception, it is not fail-safe. months. In 2012/2013, the most Research suggests relatively few recent year for which healthcare professionals suggest it comprehensive figures are as a form of contraception in the available, around 74% of mothers knowledge that even if they intend started breastfeeding their babies. to, few women exclusively By 6-8 weeks, just under half of breastfeed for long periods. Just babies are receiving some breast- under a third of women are milk.18 exclusively breastfeeding by 6 weeks19but fewer than 1% of Prevalence of breastfeeding at 6 women follow official guidance to to 8 weeks exclusively breastfeed for 6 50% months.20 45% 40% “They shouldn’t push 35% breastfeeding as a safe 30% contraceptive, it wasn’t in my 25% 20% case and I had an unplanned 15% pregnancy at 6 months followed 21 10% by a .” 5% However other women say they 0% Exclusive + Exclusive Partially resent being told flat out that it Partially will not work, and argue that Source: NHS England Breastfeeding Statistics women should be trusted with the 2012/2013 information to assess their own levels of risk.

Exclusive, regular breastfeeding [referring to advice that can act as an effective breastfeeding could not be relied contraceptive as it supresses on as contraception] “It felt to ovulation. This is known as the me that women were not trusted

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to assess whether the level of coils and the mini-pill could safely risk was acceptable to them and be used. Just 17% thought the the blanket advice was that it could not be relied on.”22 (Nexplanon) was safe while breastfeeding, and only one in 10 a) Contraception while thought injections were safe. breastfeeding Worryingly, just 5% of mothers surveyed thought Levonelle There are however several forms emergency contraception could be of contraception with can safely be used while breastfeeding. Infact used as a back-up to LAM or when the progestogen-only morning a mother decides to introduce after pill can be used while formula milk (mixed feeding), breastfeeding without the need to which do not impact upon either express and discard the milk, and her milk supply or the growth of can be an extremely useful back her baby. These include non- up for women relying on condoms hormonal methods such as the or who have not yet chosen a copper coil, but also progestogen- regular method of contraception. only methods including the implant, mini-pill, injections and Which contraceptives can safely be Mirena coils, as well as Levonelle used whilst breastfeeding emergency contraception (but not Base: 1,323 EllaOne). 90% Our work with Mumsnet 80% suggested that only a third of 70% 60% mothers who were breastfeeding 50% discussed safe forms of 40% contraception with a healthcare 30% professional.23 The survey with 20% the Bounty panel meanwhile 10% found the majority of mums think 0% that condoms are the only safe contraceptives which can be used while breastfeeding. Only around a third of those surveyed thought

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“I have found the information on used contraception if the what hormonal contraception is pregnancy was planned, as it may suitable while breastfeeding have taken some time to conceive. extremely muddled.” In addition, it is estimated that “More advice on what to use only half of are while breastfeeding, and more formally planned, with the rest info about using breastfeeding either classed as ambivalent or as a contraceptive.” unplanned. 25 Whatever the case, her contraception may have let “I raised the issue with my GP at her down or she may have my 6 week check. I specifically abandoned it after deciding she asked for contraception as I was not suited to it, in which case didn’t want to rely on information about the range of breastfeeding alone as it’s not options now available could help failsafe. I was then told that I her find a more suitable method. didn’t need it as I was breastfeeding and we just went “An overview of all contraceptive round in circles. Needless to say types might have been helpful as other than condoms I have no [it was a] a long time since I last and am highly chose new contraception.”26 p***** off.”24 Life with a new baby disrupts b) Information about women’s normal routine, and a contraception for women woman who has previously and who are not/no longer successfully relied on the pill may breastfeeding find remembering to take her

contraception daily no longer All forms of contraception are feasible now that her life has suitable for a woman who decides changed. breastfeeding is not the right “Although I’m 37, I’m actually feeding method for her and her pretty ignorant about most baby. forms of contraception. The pill It should be remembered that it no longer suits me, but I don’t may be considerably more than really know enough about other nine months since a woman last

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forms and haven’t the time or “You are in a four-bedded bay energy to find out.” and you don’t want to get too personal with people…because “More options should be offered here obviously everyone listens and discussed. Nobody spoke to through the curtains.”29 me about contraception, I suspect because it was my But many women are happy not second baby and they assumed I just with the information they knew what I was doing. I asked received but the time it was for the mini-pill but I’ve since delivered, and speak in glowing found out about other methods terms about their caregivers. that I would have preferred if “My midwife was excellent, she someone had taken the time to raised the question early and in discuss them with me.” an informed way.” “It would have been nice to have “I had amazing contraceptive been given more options, the advice. They were very thorough approach did seem to be ‘you and discussed in detail.” 30 were on the pill before and got on ok with it, so we’ll prescribe It is also clear that some women that again’. I was on the pill for find the discussion, both content over 10 years, and I do wonder and timing, inappropriate and whether there would be intrusive, whenever it is delivered. anything better suited to me.”27 “Every single health professional Timing of discussion I talked to in the hours, days and weeks after my children were “I wanted to say to them that born mentioned contraception. there is no risk of sex soon, let This was true for all my three alone pregnancy!”28 children. I probably had Discussions in the immediate contraception mentioned to me aftermath of giving birth about more than I had sex in the six resuming sex and contraception months following the birth of my are understandably viewed as kids.” inappropriate by many women “Don’t go on and on about and their caregivers. As one contraception to a woman who midwife noted: bpas |Sex and contraception after childbirth 12

had trouble conceiving and who pregnancy, I had to ring my GP lost one baby by miscarriage.” 31 when my daughter was 4 weeks, when I stopped breastfeeding Yet equally for another woman and wanted to begin taking who had experienced problems contraception as had no idea conceiving, the opposite was true: what to do about starting – I’d “As someone who has 2 children not discussed it with anyone up 51 weeks apart it would have until this point.” been helpful if someone could “Perhaps if more information have pointed out that a first given DURING pregnancy, not pregnancy achieved via immediately after birth.” clomiphene does not mean that would continue.”32 “It should be discussed before the birth so that something is in Clearly, setting the right tone with place more quickly.”35 the level of information and getting the timing right, is This would have the advantage of challenging for those providing giving women more time to think women’s care, something which about their options so they know mothers themselves recognise. what they want when the time comes. “It’s a hard balance between too early and not soon enough!”33 “Having time, I felt very rushed. It was assumed I’d go on the Many women suggested that it mini-pill.”36 would be more useful to have a discussion before the baby was Many women also commented on born, and indeed this is in keeping how “baby-focused”37 postnatal with guidance from the Faculty of care could be, and how they would Sexual and Reproductive have appreciated an appointment, Healthcare,34 although our preferably with a midwife, entirely research with Mumsnet found less devoted to their needs and than a third of mothers were concerns – including offered this. contraception.

“I would have preferred to have “Very quickly post birth discussed it towards the end of everything becomes about the

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baby, weight gain, jabs etc and a would be midwives who would be bit more time after the newborn interested in being trained to euphoria fades could be directly provide contraceptives dedicated to mums.”38 including long acting reversible forms.40 And many mothers commented on wanting written information that In addition many women they could take away and read at a commented that they wished they time that suited them about could have organised what they contraception choices, and in needed through their midwife or particular what methods can be health visitor without needing to used while breastfeeding. make an appointment with their GP. Obtaining chosen contraception “It would be handy if you could Even if a woman has the arrange the fitting of a coil information she needs to choose through the midwife/health her contraceptive, fewer than a visitor rather than having to go quarter of women said they found to the GP.” it easy to obtain it. This was highest for younger women (32%) “I feel that contraception could and lowest for older women be more easily available after (17%). having a baby. Making an appointment at my GP isn’t easy More than one in ten women and the local would have preferred to have left clinic is full of teenagers getting hospital with contraception free condoms.” “Would help if hospitals could “Personally I would like to go on provide an initial supply of the pill or coil now but I have to contraception on leaving rather go to a clinic between 5 and 7 than women having to make GP once a week to do this. With a or family planning clinic toddler and a newborn baby, this appointment in the early weeks is not really possible right of having a baby.”39 now!”41 Some hospitals do provide this, and research suggests that there

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Conclusions and However while healthcare professionals need to respond to policy implications the individual needs of each mother, postnatal sexual health The postnatal period is a busy and and contraception is an important sometimes difficult time. As component of care that feeds into previously noted, midwives are broader issues of maternal stretched and say they do not wellbeing. For many women, the always have the time to provide midwife is the one best placed to the information and support they provide advice in a way that takes feel women need across a number into account how she may be of issues - maternal emotional feeling post-birth. wellbeing, normal infant behaviour, and how to prepare “I think the midwives often have bottle feeds, as well as a better manner and approach contraception.42 to such discussions and have a better understanding of how you Also for women, particularly those might be feeling about having who are struggling to breastfeed sex and considering and/or who have had a traumatic contraception so soon after your birth, contraception is unlikely to body has given birth.”44 be high on their list of priorities. Resuming sex “Wasn’t the main thing on my mind. (problems breastfeeding, Our data shows there is a wide wound healing, pnd/ptsd timetable among women when it [postnatal depression, post comes to resuming sex, and that traumatic stress disorder], mode of delivery may well affect would have been annoyed if it timing. Women may well was made a big issue of.” appreciate knowing that there is no set time to resume sex, and that “Annoying that it was one thing it will vary widely from couple to consistently mentioned when I couple. felt I had so many other pressing concerns with a newborn - eg “I felt it would have been nice for lack of help with them to say you might be breastfeeding.”43

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gagging for it or don’t worry if let her down, and that a method you don’t get there yet.”45 which may have suited her then may not suit her with a new baby. It is troubling that for many This means it is important that she women body image was a barrier has access to comprehensive to doing so. Those involved in information about all the methods women’s postnatal care could available – including rings and consider how reassurance could patches, which could be a good be provided about post-pregnancy option for women in between body shape, and provide babies who do not want a daily pill opportunities for women to but are reluctant for take on a long discuss their concerns about acting form. issues relating to body image, and sexual health and wellbeing. Timing of advice about contraceptives Information about contraceptives Discussion and provision of information in the antenatal Women should be informed that if period when women have more they are not breastfeeding time to think about their options contraceptive protection is may be useful. required from day 21 after the birth if pregnancy is to be avoided Greater understanding of how and provided with information mode of delivery influences about all contraceptive options resumption of sex may enable available, including when healthcare professionals to time breastfeeding provides the provision of contraception contraceptive cover and the information and support more criteria that should be met for it to effectively, while recognising that work effectively, as well as what every woman will have her own contraception can be used while personal needs. breastfeeding. The last midwife home visit at 10 It should be recalled that it may be days, when the health visitor takes more than a year since a woman over care, may be a particularly last used contraception, that the opportune moment, but it also method she was using may have appears many women would value

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the offer of a discussion during has not been to hand. The various interactions with Levonelle morning-after-pill can, healthcare professionals in the as noted, be safely used by first year. breastfeeding women up to 72 hours after an episode of Access to contraceptives unprotected sex. While young If women have made their mind women can often obtain it free of up about their contraception in charge from their local pharmacy, the antenatal period, it would be older women either have to pay in ideal if these could be provided the region of £30 or visit their GP, before she leaves hospital. local sexual health service or A&E, with all the inconvenience that Midwives who wish to take on a entails. Consideration should be role in the provision of given to the advance provision of contraception, and in particular EHC to new mothers in order that long acting reversible forms, women have it at home if and would require on going training when they should need it. and support. This would necessitate closer links between maternity services and sexual and July 2014 reproductive health services, which at the very least might also make it easier for midwives to refer women directly for 1 World Health Organisation. Developing sexual health programmes. contraception appointments, http://whqlibdoc.who.int/hq/2010/WHO_RHR_ which many women would HRP_10.22_eng.pdf appreciate. 2 Mullin N. “What are the contraceptive issues of women conceiving too soon after their last Attention could also be paid to pregnancy.” PowerPoint presentation. ESC Congress. Lisbon. 2014. providing more specific contraception clinic sessions for 3 DeFranco E et al . Influence of interpregnancy interval on birth timing. BJOG 2014; DOI mothers. 10.1111/1471-0528.1289.Influence of interpregnancy interval on birth timing - Emergency Hormonal DeFranco - 2014 - BJOG: An International Journal of & - Wiley Contraception (EHC) is a safe and Online Library effective back-up for women when 4 ONS. Birth Summary Tables- England and their regular contraception fails or Wales, 2012. bpas |Sex and contraception after childbirth 17

http://www.ons.gov.uk/ons/publications/re- reference-tables.html?edition=tcm%3A77- 16 RCM. Maternal mental health: Improving 314475 emotional wellbeing in postnatal care. 2014. https://www.rcm.org.uk/sites/default/files/Pre 5 RCM. Maternal mental health: Improving ssure%20Points%20- emotional wellbeing in postnatal care. 2014. %20Mental%20Health%20-%20Final.pdf https://www.rcm.org.uk/sites/default/files/Pre ssure%20Points%20- 17 McCance K, et al. Journal of Family Planning %20Mental%20Health%20-%20Final.pdf and Reproductive . 2014;0:1–7. doi:10.1136/jfprhc-2013-100770 Midwives’ 6 Hicks T L et al. Postpartum sexual functioning experiences and views of giving postpartum and method of delivery: summary of the contraceptive advice and providing long-acting evidence. J Womens Health. 2004 reversible contraception: a qualitative study -- Sep-Oct;49(5):430-6. McCance and Cameron -- Journal of Family http://www.ncbi.nlm.nih.gov/pubmed/153513 Planning and Reproductive Health Care 33 18 Breastfeeding 13/14 Q3. NHS England 7 Mumsnet. Post Natal Contraception Survey for Maternity and Breastfeeding. Statistics » BPAS. 2012 Maternity and Breastfeeding

8 Wray J. Bouncing back? An ethnographic study 19 ibid exploring the context of care and recovery after birth through the experiences and voices of mothers.RCN.2011.http://www.rcn.org.uk/__dat 20 The Information Centre for Health and Social a/assets/pdf_file/0008/459035/Wray_Julie_co Care. Infant Feeding Survey - UK, 2010. 2012 mplete_thesis_2011.pdf Find data - Health & Social Care Information Centre 21 Mumsnet. Post Natal Contraception Survey for 9 RCM & Netmums. A Growing Problem: Does BPAS. 2012 weight matter in pregnancy? 2010 http://cdn.netmums.com/assets/images/2012/ 22 ibid A_Growing_Problem_Nov2010.pdf 23 ibid 24 ibid 10 Faculty of Sexual and Reproductive Healthcare Clinical Guidance. Postnatal Sexual 25 National Survey of Sexual Attitudes and and Reproductive Health. 2009. Lifestyles. 2013.National Survey of Sexual http://www.fsrh.org/pdfs/CEUGuidancePostnat Attitudes and Lifestyles. Natsal-3 al09.pdf

26Mumsnet. Post Natal Contraception Survey for 11 Barrett G et al. Women’s sexual health after BPAS. 2012 childbirth. BJOG. 2000 Feb;107(2):186- 95.Women's sexual health after childbirth. [BJOG. 27 ibid 2000] - PubMed - NCBI 28 Ibid

12 Mumsnet. Post Natal Contraception Survey for 29 McCance K, et al. J Journal of Family Planning BPAS. 2012 and Reproductive Health Care 2014;0:1–7. doi:10.1136/jfprhc-2013-100770Midwives’ 13 ibid experiences and views of giving postpartum 14 ibid contraceptive advice and providing long-acting reversible contraception: a qualitative study -- 15 RCM. State of Maternity Services Report 2013. McCance and Cameron -- Journal of Family https://www.rcm.org.uk/sites/default/files/Sta Planning and Reproductive Health Care te%20of%20Maternity%20Services%20report %202013.pdf

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30Mumsnet. Post Natal Contraception Survey for BPAS. 2012

31 ibid 32 ibid 33 Ibid

34 Faculty of Sexual and Reproductive Healthcare Clinical Guidance. Postnatal Sexual and Reproductive Health. 2009. http://www.fsrh.org/pdfs/CEUGuidancePostnat al09.pdf

35Mumsnet. Post Natal Contraception Survey for BPAS. 2012

36 ibid 37 ibid 38 ibid 39 Ibid

40 McCance K, et al. Journal of Family Planning and Reproductive Health Care. 2014;0:1–7. doi:10.1136/jfprhc-2013-100770 Midwives’ experiences and views of giving postpartum contraceptive advice and providing long-acting reversible contraception: a qualitative study -- McCance and Cameron -- Journal of Family Planning and Reproductive Health Care

41 Mumsnet. Post Natal Contraception Survey for BPAS. 2012

42 RCM. Maternal mental health: Improving emotional wellbeing in postnatal care. 2014. https://www.rcm.org.uk/sites/default/files/Pre ssure%20Points%20- %20Mental%20Health%20-%20Final.pdf

43 Mumsnet. Post Natal Contraception Survey for BPAS. 2012

44 ibid 45 Ibid

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