Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Contraception and safeguarding in abortion care
Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Act on immediate danger without removing agency
Threats, sexual violence, trafficking, child exploitation, forced abortion or forced continuation of pregnancy can place the patient at imminent risk during travel, communication, medicine use or discharge.
Action: Consult privately, establish immediate safety, involve named safeguarding and emergency services when necessary, share only information justified by law or serious-harm prevention, and maintain access to the patient's chosen lawful care.
Role and principles
Offer immediate voluntary contraception while identifying reproductive coercion, abuse and exploitation through confidential, proportionate safeguarding that preserves access and autonomy.
Abortion care is an effective opportunity to provide contraception because the patient is already in contact with a trained service, but opportunity must not become pressure. Ask permission to discuss methods and accept a decision for no contraception. Explore priorities such as effectiveness, bleeding pattern, hormones, privacy, control, future fertility and ease of discontinuation. Present long-acting and shorter-acting methods fairly, include condoms for STI protection and make the chosen option genuinely available rather than giving information without access.
NICE recommends that the full range of reversible methods is available on the same day as medical or surgical abortion. After surgical care, implant, injection and intrauterine contraception can usually be provided during the same visit. During medical abortion, the implant can be inserted when mifepristone is taken, and oral progestogen-only or combined methods and patch can start according to eligibility. The vaginal ring and intrauterine methods are used after expulsion. Immediate provision improves uptake and avoids loss between referral and a later appointment.
Assessment and patient selection
Autonomous method choice
The patient can describe benefits and drawbacks important to them and selects or declines contraception without pressure from staff, partner or family.
Reproductive coercion
Another person controls pregnancy outcome, sabotages contraception, monitors care or threatens harm if the patient uses or refuses a method.
Child exploitation indicators
Partner power, payment, gifts, secrecy, substances, trafficking, online grooming or a position of trust raises concern beyond consensual adolescent activity.
Method privacy risk
Bleeding change, palpable implant, device strings, packaging, appointments or electronic messages may disclose contraception or abortion in an unsafe household.
Need for additional support
Communication difficulty, insecure housing, disability or lack of transport can undermine informed choice, medicine use and follow-up unless practical adjustments are arranged.
Red flags requiring action
An accompanying person answering questions, controlling the phone or medicines, refusing private consultation or threatening consequences suggests coercive control and requires a safe private assessment.
Pregnancy in a child under 13 always requires urgent safeguarding escalation; a marked age or power gap, payment, exploitation, trafficking, assault or a partner in a position of trust also requires an immediate proportionate response.
Baseline assessment
01Contraceptive eligibility assessmentFirst step
Why
Identify medical conditions, medicines and preferences that change safe method options.
Interpretation and limitations
Use current UK medical eligibility and product guidance. Current or previous meningioma contraindicates DMPA and needs expert review before any hormonal method; do not otherwise create unnecessary tests for methods that can safely start immediately.
02Pregnancy completion check
Why
Confirm medical abortion success before intrauterine insertion and after immediate DMPA when ongoing-pregnancy risk was discussed.
Interpretation and limitations
Use the abortion service's timed low-sensitivity or multi-level test and review positivity, persistent symptoms or little bleeding promptly.
03Private safeguarding assessment
Why
Explore coercion, abuse, exploitation, trafficking and practical safety without an accompanying person hearing or influencing answers.
Interpretation and limitations
Findings guide proportionate protection and communication planning while the patient's autonomous pregnancy and contraception choices remain central.
04Competence assessment
Why
Establish whether a young person understands each proposed reproductive-health decision and its consequences.
Interpretation and limitations
Interventions
01Contraceptive offerTurn preference into same-day accessFirst stepThe patient wants to discuss contraception during abortion care.+
1Ask about effectiveness, bleeding, hormones, privacy, fertility timing and method control, then check medical eligibility without steering toward long-acting contraception.
2Provide the chosen method on the abortion day or at the earliest safe post-expulsion time, using bridging contraception when an intrauterine appointment is delayed.
3Explain onset of protection, side effects, completion follow-up, STI prevention and how to switch or remove the method without needing to justify the request.
02Medical abortion timingStart methods without losing completion follow-upA patient choosing medical abortion also wants immediate contraception.+
1Offer implant or appropriate oral, patch or injectable methods at the mifepristone visit, including the specific DMPA ongoing-pregnancy discussion.
Medicines and treatment safety
Provides highly effective reversible contraception without relying on daily adherence after abortion.
Etonogestrel contraceptive implant
Insert one 68 mg subdermal implant on the day of mifepristone or surgical abortion; the current UK licensed duration is five years.
Check enzyme-inducing medicines and insertion eligibility, explain irregular bleeding and palpability, and seek expert advice before use with current or previous meningioma because it may be inappropriate; use safe records and remove promptly when requested.
Offers discreet medium-acting contraception when regular injections and delayed fertility return are acceptable.
Depot medroxyprogesterone acetate
Give 150 mg by intramuscular injection every 13 weeks; it may start at the mifepristone visit after the specific effectiveness discussion.
Contraindicated with current or previous meningioma. Immediate use with mifepristone may slightly raise ongoing-pregnancy risk; discuss bleeding, bone health, repeat timing and delayed return to fertility and ensure abortion completion follow-up.
Targets, monitoring and follow-up
Confirm that the chosen method was actually supplied or inserted and that delayed intrauterine appointments, transport and bridging contraception are documented and tracked.
Review the timed abortion completion test after immediate hormonal contraception because amenorrhoea or altered bleeding cannot confirm that pregnancy ended.
Provide a low-barrier route for adverse effects, missing implant, suspected IUD expulsion, method switching and removal without requiring continuation against the patient's wishes.
Check that safeguarding referrals reached the appropriate team and that contact attempts do not expose the patient to an abusive or controlling person.
Revisit STI results, vaccination, condom needs and emotional wellbeing through the safe channel agreed with the patient, sharing only necessary information.
Special situations
Two decisions need two consents
Consent to abortion does not imply consent to contraception, and choosing a method never proves the pregnancy decision was voluntary.
Immediate access prevents attrition
Offering the selected method before discharge avoids transport, childcare, cost and coercive barriers that often defeat a later referral.
Bleeding can hide completion clues
Hormonal contraception changes bleeding, so the specified pregnancy test remains necessary after home medical treatment even when a method starts immediately.
Discretion is method-specific
A hidden injection may protect one patient, while irregular bleeding or missed appointments exposes another; privacy requires individual risk assessment.
Safeguarding is not surveillance
Private questions and proportionate sharing should make the patient safer, not turn confidential reproductive care into routine reporting of all adolescent sex.
Common pitfalls
01
Making long-acting contraception the price of timely abortion care or presenting declining a method as irresponsible.
02
Delaying implant provision until after medical expulsion despite the option to insert it with mifepristone.
03
Giving DMPA with mifepristone without explaining the small possible rise in ongoing pregnancy risk.
04
Inserting an intrauterine method before medical expulsion is confirmed or when pelvic infection is suspected.
05
Conducting safeguarding questions while a controlling partner remains in the room or controls interpretation.
06
Sharing an entire record, sending unsafe messages or assuming every under-16 consultation automatically requires parental disclosure.
Practice
Two practice questions
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Question 1 of 2
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Obstetrics and gynaecologyOriginal SBA
Timing of intrauterine contraception
A patient choosing medical abortion also wants a levonorgestrel intrauterine system. When should the service offer insertion according to NICE principles?
Sources and review status9 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Intrauterine contraception can be placed immediately after a completed surgical abortion when there is no sepsis, or as soon as practical after confirmed medical expulsion. Discuss the slightly higher expulsion risk with later-gestation immediate insertion and the advantage of guaranteed access. If insertion is delayed, supply a bridging method if desired and book a definite appointment. The copper IUD also provides hormone-free long-term contraception, while a levonorgestrel intrauterine system may reduce later menstrual bleeding.
Depot medroxyprogesterone acetate deserves specific counselling. NICE allows consideration of the intramuscular injection at the mifepristone appointment, but evidence suggests a small increase in ongoing pregnancy when given at that point; absolute risk remains low. The patient can choose immediate convenience or delayed administration after expulsion. Ensure the standard abortion completion check occurs. Discuss bleeding change, delayed return to fertility, bone-health considerations and repeat-injection timing without overstating any one risk. Current or previous meningioma is a DMPA contraindication; seek expert advice before any hormonal alternative because tumour type matters and some other methods may also be inappropriate.
Safeguarding and contraception intersect through reproductive coercion. An abusive person may sabotage condoms or pills, remove an implant, prevent clinic attendance, force a visible method or monitor bleeding and records. Ask privately who controls sex, pregnancy decisions and healthcare access and whether a method's discoverability creates risk. A covert method may feel safer for some patients, while recommending concealment without understanding the household can increase danger. Build a personalised contact, packaging and follow-up plan with domestic-abuse or safeguarding specialists.
Young people deserve confidential, developmentally appropriate care. Assess competence for the abortion and contraception decisions separately, since understanding can differ by intervention. Encourage a safe supportive adult but do not require one from a competent young person. Explore partner identity, age difference, authority, force, threats, payment, substance use and online exploitation. Sexual activity involving a child under 13 always requires a safeguarding response; pregnancy in an under-13 requires urgent social-care referral and prompt in-person assessment in an appropriate inpatient setting without delaying care. For older teenagers, judge risk individually and consult the named professional when uncertain.
Information sharing should be purposeful and minimal. Explain confidentiality and its limits before sensitive questions. Seek consent to share where appropriate, unless asking would increase danger or a decision to disclose for serious-harm prevention has already been made. Tell the patient what will be shared and with whom when safe, record the reasoning and avoid copying whole records. Safeguarding referral should run alongside abortion and contraceptive care, not create a separate obstacle that leaves the patient pregnant or without protection.
Offer STI and HIV testing according to national recommendations, vaccination and treatment pathways and condoms where wanted. A positive result should not usually delay abortion or contraception. Discuss emergency contraception for any new unprotected sex after the abortion and explain when a chosen method becomes effective. Arrange a reliable route for method problems, implant or IUD checks when clinically needed and switching or removal. Autonomy includes the right to stop a method as well as to start it.
Key points
Ask whether contraception information is wanted and offer the full reversible range on the same day; accepting a method is never a condition for receiving abortion care.
Fertility can return rapidly, so methods started at the abortion or within five days generally provide immediate protection under current guidance.
An implant can be inserted on the day of surgical abortion or when mifepristone is taken; oral, patch and most other hormonal methods can also start immediately.
Insert an intrauterine method at surgical abortion or as soon as possible after medical expulsion when completion is confirmed and infection is not suspected.
Intramuscular DMPA may be given with mifepristone, but explain the small possible increase in ongoing-pregnancy risk and ensure completion follow-up.
Do not use depot medroxyprogesterone in a patient with current or previous meningioma. Seek expert individualised advice before any hormonal method because tumour type and evidence differ; an implant or another hormonal method may also be inappropriate.
Discuss effectiveness, bleeding, side effects, privacy, contraindications, return to fertility and STI protection in a non-directive way that supports the patient's priorities.
See every patient alone for part of the assessment and ask about safety, coercion, partner age and power, assault, exploitation and control of reproductive decisions.
Confidentiality applies to young people, but share information proportionately when law or serious-harm prevention requires it; explain and document the decision when safe.
The patient appears to be forced either to terminate or continue the pregnancy; both are forms of reproductive coercion and can invalidate apparent voluntariness.
A method that can be discovered or controlled by an abusive partner may increase danger, so confidentiality, packaging, records and follow-up contact must be planned explicitly.
Homelessness, unsafe housing, learning disability, language barriers or lack of phone access can make home treatment or later contraception follow-up unsafe without additional support.
Assess abortion and contraceptive choices separately, document functional understanding and seek specialist support when competence or protection is uncertain.
05STI and HIV testing offer
Why
Detect infection, arrange treatment and provide prevention without making testing compulsory.
Interpretation and limitations
Take appropriate samples based on risk and consent; results generally need not postpone abortion or most contraceptive methods.
06Safe-contact review
Why
Identify secure ways to send results, reminders, prescriptions and safeguarding information.
Interpretation and limitations
Use the patient's stated channel and timing, suppress unsafe correspondence where systems allow and document who may receive information.
2Arrange IUD, IUS or vaginal-ring initiation after expulsion using a reliable early appointment and an optional interim method.
3EscalationComplete the planned abortion pregnancy test regardless of contraception-related bleeding changes, escalating a positive result or continuing symptoms.
03Safeguarding concernProtect while preserving reproductive choicePrivate enquiry identifies coercion, violence, assault, exploitation, trafficking or immediate danger.+
1Clarify the patient's own wishes, immediate safety, safe contacts and control of transport and medicines, involving an advocate or interpreter independent of family.
2Consult the named safeguarding professional and share minimum necessary information with consent where possible or under lawful serious-harm justification.
3Coordinate a safety plan and timely abortion and contraception, documenting why information was or was not shared and avoiding unsafe messages or packaging.
04Young personCombine competence, confidentiality and protectionA patient under 18 seeks abortion care and contraception.+
1Assess competence separately for each intervention, give developmentally appropriate information and encourage safe adult support without making it a condition.
2Explore partner age, authority, force, payment, substances, online contact and home safety and discuss concerns with the child-protection lead.
3Provide confidential care when appropriate, or make proportionate disclosure when required, telling the young person what will happen unless that increases danger.