Low fertility awareness and associated factors - a multi-centre cross-sectional study among abortion-seeking women in Sweden

The Swedish model for contraceptive counselling is well developed, with free and easily accessible services, and contraceptives that are free or subsidised. Despite this, many women have an unmet need for contraception. The aim of this study was to investigate the reasons for not using contraceptive methods at the time of conception among abortion-seeking women, and to identify factors associated with unawareness of their potential to become pregnant at that time. A multi-centre cross-sectional survey was conducted among 623 abortion-seeking women at seven family planning clinics in Sweden in 2021. The questionnaire comprised 39 items, one of which explicitly addressed the reasons for not using contraception at the time of conception. Bivariate and multivariate analyses were conducted using odds ratios (ORs) and confidence intervals (CIs). Of the 623 women, 387 reported not using contraception at the time of conception. The most common reason was unawareness of their potential to become pregnant at that time, considered as low fertility awareness (LFA), reported by 142 (37%) women. No significant sociodemographic or lifestyle differences were found between women with LFA and those reporting other reasons for not using contraception. However, LFA was more common among women who had not used contraception in the previous 12 months (OR = 2.912, CI: 1.844–4.601), and previous abortion experience was a protective factor (OR = 0.617, CI: 0.398–0.958). A significantly lower proportion of women reported contraceptive use at the time of conception compared to the preceding year. LFA is common and linked to no contraceptive use in the previous year and no prior abortion history, and contraceptive use at conception is lower than over the preceding year indicating gaps in continuity and adherence. These findings support service models that turn counselling into timely initiation with verified uptake and sustained use.