Unplanned, unwanted pregnancies have adverse health and economic costs for the mother, child, and society, particularly for young women under 25 years. Reducing these and therapeutic abortions are major goals of reproductive health programmes globally. The UK have high abortion rates compared with other European countries and low prevalence of long-acting reversible contraception (LARC) use. Together, these suggest significant room for improvement in contraceptive programmes.

I used a feminist orientation and mixed-methods approach for this thesis. I conducted five studies for my PhD which examined what could be done to improve the contraceptive care in general practice; not only to address the unmet need for contraception, but also to improve the effectiveness, equity and experience of contraceptive care women receive when they attend general practice.

Using contraceptive prescriptions (including LARC) and abortion rates as outcomes, a pay-for-performance (P4P) scheme to give LARC advice to women attending for contraceptive care was associated with more LARC prescriptions, with greater impact for younger women and those from deprived backgrounds, but it had uncertain impact on abortion rates. A survey of contraceptive access during COVID-19 lockdown reported the struggles some women had to get the contraception they needed. A focus group study of young women’s experiences of contraceptive care offered insight into what young women needed to make choices about contraceptives, and some of the barriers that made it difficult for them to exercise their choice, some of these included gender inequality and societal attitudes to young women. Women who attend primary care might have conditions and circumstances which made them more likely to have abortions. Improving access to effective contraception will not necessarily change the circumstances associated with abortions but managing some upstream factors might change women’s lives and improve reproductive health outcomes.