With perfect use of contraception in the postnatal period the rate of unintended pregnancy can be reduced to less than 1%.1,2 During pregnancy and the postnatal period women have regular contact with healthcare providers who are trained in the provision of contraceptive advice, and are likely to be receptive to this advice.3 Rates far higher than this however are seen in practice,4,5 suggesting that less than adequate contraceptive practices may be being used.There are over 2000 abortions performed in Waikato District Health Board (DHB) clinics each year. A number of these women have recently given birth and cite the inability to cope with another baby within a year of the last one, as a reason for requesting the abortion.In order to introduce an effective intervention to address the current situation, the barriers to successful contraceptive use and reasons behind them need to be identified.A study has not been carried out previously in this specific group of women. The aims of this study are to identify barriers and facilitators; and to make recommendations on intervention strategies to overcome them as the current provisions appear to be failing a number of women. By identifying the barriers to achieving adequate contraception it is hoped that recommendations can be made on interventions to facilitate this.Methods Study population—The study population consisted of: 22 women attending Waikato Hospital (Hamilton, New Zealand) for a first trimester termination of pregnancy between January and December 2009 who had delivered a live-born infant within the preceding 6 months. 100 randomly selected LMCs (Lead Maternity Carers) in the Waikato region. Data collection— Following approval by the Northern Regional Ethics Committee, data collection was undertaken through the first trimester termination of pregnancy clinic at Waikato Hospital. In this clinic women with unintended pregnancies of less than 13 weeks gestation are seen by Certifying Consultants - doctors appointed by the Abortion Supervisory Committee. From 1 January 2009 to 31 December 2009 all women attending the First Trimester Termination of Pregnancy Clinics at Waikato Hospital, who had given birth to a live infant less than 6 months before the date of their scheduled abortion, were invited to take part in the study by the Certifying Consultant. Women were excluded if they were unable to give informed consent to the study or if the multidisciplinary team assessed her to be at risk of harm from taking part in the study. Women who gave informed consent to the study undertook a self-complete questionnaire on the day of their termination of pregnancy. The questionnaire obtained information on: The preceding pregnancy, and the woman's recollection of contraceptive counselling and prescription provision following it; the barriers which the woman identified as contributing to her unintended pregnancy; and interventions which she feels would have helped prevent it. The questionnaires asked for demographic data and then used four closed multi-choice questions and three open questions allowing free text answers. Ethnicity was determined by self selection using the abortion supervisory commission categories or allowing free text if ‘other' was chosen. Data is presented in Tables 1-5. Anonymous self-complete questionnaires were also mailed to 100 LMCs, randomly selected from those who have listed a contact address with the Waikato District Health Board; using a random number generator. Questionnaires asked LMCs about: their contraceptive prescribing practices; barriers that LMCs identify in its provision, and in women's uptake; and suggestions as to how these could be overcome. Demographic data was collected and six closed multi-choice questions were asked followed by the same three open questions as asked to the women. Data is shown in Tables 6-11. Analysis—Quantitative data is presented in numerical format. Participants' free-text comments were analysed by thematic analysis: Themes in the data were identified independently by both researchers and themes were collated and presented in Table 12. Results Women attending for termination of pregnancy (ToP) Twenty-six women who were identified as eligible agreed to enrol in the study. Four women enrolled but subsequently felt they did not have time to complete the questionnaire; 22 women then completed the questionnaire. Demographic data is presented in Table 1 Table 1. Demographics of the study population Variable Values Age Mean Range 22.9 years 17-35 years Ethnicity Māori European Pacific Islander NZE/Māori Asian MELAA N/A Number (N) 8 6 2 2 1 1 2 Breastfeeding nil <6weeks 6 weeks-6 months current N/A N 1 4 7 6 4 Age of baby at time of ToP 4 months 5 months 6 months N/A N 4 9 6 3 Community Service Card holder yes no N/A N 13 1 8 Rural location yes no N/A N 6 12 4 N/A = data not available; ToP = termination of pregnancy; NZE = NZ European; MELAA = Middle Eastern/Latin American/African. All 22 of the women reported that their lead maternity carer for the preceding pregnancy was a midwife. Almost all the women (20/22) remember discussing contraception with someone during their pregnancy, many with multiple professionals. Only six women reported being provided with a prescription for contraception four of these prescriptions were for the PoP and were filled, and two were for condoms which were not then taken to a pharmacy—leaving the majority of the women with no contraceptive provision. All of the women reported previously accessing contraception; with eighteen reporting multiple previous methods used and from a variety of sources. No women identified lack knowledge about contraception as being a barrier to their accessing contraception. There was however quite a low reported previous access to the emergency contraceptive pill (ECP). The most common reason cited as a barrier to accessing contraception was cost. Table 2. (Q) Do you remember talking about contraception (birth control) while pregnant or after you had your youngest baby with: Variable N LMC GP Family Planning Antenatal class Plunket Nurse Mother No-one 19 5 1 2 2 1 2 Table 3. (Q) Have you ever accessed contraception (birth control) before? If yes, what have you accessed? IUCD= Intrauterine contraceptive device Table 4. (Q) If yes, where have you accessed contraception (birth control) from? Table 5. (Q) What, if any, barriers/problems have you met to accessing contraception (birth control)? When asked for the ‘main reasons for conceiving so soon after having their last baby; what and who could have prevented this from happening' the women identified a number of factors which have been analysed by theme and listed in table 15 and include: financial and time constraints; problems accessing healthcare; lack of information or knowledge; and a strong theme of ‘self blame' for the pregnancy. Lead Maternity Carers (LMCs) Fifty-nine LMCs responded to the questionnaire. All but one of the LMCs who responded were midwives—at present there are no General Practitioners undertaking LMC work in the region. Almost all of the LMCs who responded to the questionnaire identified as NZ European ethnicity. All LMCs reported discussing contraception with every one of their women, however this is often left until after the baby is born, or even until the 6-week discharge. The vast majority of the prescriptions given are reported to be for progesterone only pills or for condoms, with only 2 reporting prescribing the emergency contraceptive pill. Twenty-four of the 59 LMCs reported holding a postgraduate qualification in contraception, or having attended any specialist training courses. Table 6. (Q) Do you identify as: Variable N Independent midwife Caseload midwife GP Specialist NZ European Māori Other 55 3 0 1 50 4 7 Respondents gave more than one ethnicity. Table 7. (Q) Approximately what percentage of your women do you discuss contraception with: Time No. No. No. No. No. No. At booking? Antenatally Postnatally At discharge In total 0% 0% 0% 0% 0% 29 6 - - - 10% 10% 10% 10% 10% 14 7 1 - - 25% 25% 25% 25% 25% 1 6 3 - - 50% 50% 50% 50% 50% 1 8 1 2 - 75% 75% 75% 75% 75% 7 2 1 - 100% 100% 100% 100% 100% 5 23 49 50 59 Table 8. (Q) Approximately what percentage of your women do y