How should you advise a young woman with diabetes who is reluctant to use contraception?

Advanced nurse practitioner Callum Metcalfe-O’Shea advises on how to manage this tricky case of a female diabetes patient of childbearing age who is reluctant to use contraception

The dilemma: You are conducting a regular diabetes review with a 30-year-old female patient with type 2 diabetes. You open up a discussion about contraception and she explains she is in a long-term relationship with a male partner but is not using regular contraception, partly because of concern about risks associated with the contraceptive pill, although she is not planning to get pregnant.

Nurses in primary care play an important role in counselling women with diabetes of childbearing age about contraception and the need for pre-pregnancy planning. This includes those with type 2 diabetes, which is increasingly affecting younger people.

In a case like this of a woman with diabetes who says she is not planning a pregnancy but is not using contraception, the clinical conversation can be particularly complex and sensitive.

The aim is not to pressurise, but to provide clear, compassionate, evidence-based information that enables informed decision-making.

If a patient is not seeking pregnancy, the discussion should focus on risk awareness, safety planning and freedom of choice.

Establish rapport and explore beliefs

Start by building rapport and exploring her reasoning. A question like, ‘Can I ask what’s important to you when it comes to contraception or planning for pregnancy?’ allows her to express her views without feeling judged.

She may have personal, cultural, religious or past health reasons that influence her reluctance.

Understanding her perspective first helps shape a patient-centred, non-confrontational discussion.

Frame it as safety planning, not persuasion

It’s helpful to reframe the conversation from ‘you need to use contraception’ to ‘let’s talk about how to keep you safe and well, now and in the future’.

Unplanned pregnancy carries significant risks – particularly in the first 6-8 weeks, before many women realise they are pregnant.¹ Poor glycaemic control during early pregnancy increases the risks of complications for both mother (eg, miscarriage, eye and kidney disease and having a large baby which can cause problems during labour) and baby (eg, congenital defects including spina bifida, preterm birth and stillbirth).^2,3

Pre-pregnancy planning, including measures to optimise HbA1c and folic acid supplementation (5mg daily), is strongly associated with improved outcomes for both mother and child.^1,4 Women with diabetes are encouraged to let their GP or nurse know soon as possible if they are planning to conceive, so they can be referred to a specialist clinic for a comprehensive care plan.^1,4Many medications used in T2DM are contraindicated in pregnancy and patients are usually switched to insulin therapy under specialist care.⁴

Making her aware of these time-sensitive risks doesn’t mean suggesting she must use contraception, but it gives her the context for why it matters.

A phrase like, ‘Because many pregnancy complications happen very early, before a woman even knows she’s pregnant, we usually try to support planning and preparation in advance. So even though you’re not planning a pregnancy now, it’s worth thinking ahead in case anything changes.’

Explore the full range of options – including natural and barrier methods

She may believe that not using hormonal contraception is safer for her health. If that’s the case, reassure her that a wide range of contraceptive options exist and use patient literature to help support any decision-making processes. In terms of contraceptive choices, this may include long-acting reversible contraceptive (LARC) choices such as the coil or implant, or oral contraceptives including progesterone-only pills (POP) and the combined pill (COP). Alternatively, barrier methods like condoms may be acceptable to her. Information on the different choices are available from the Family Planning Association. Nurses should refer to the Faculty of Sexual and Reproductive Health (FSRH) UK Medical Eligibility Criteria regarding the suitability of different contraceptive choices,⁵ in particular for use of hormonal contraception if the patient has a high BMI or other comorbidities putting them at increased risk of cardiovascular disease. A full assessment will need to take place to ensure any method is safe and suitable for the patient.

It’s also worth checking whether she is open to use of emergency contraception in the event of unprotected sex, and explaining the copper intrauterine device (IUD) is a highly effective emergency option when used up to 5 days after the first unprotected sexual intercourse, or up to 5 days after the earliest estimated date of ovulation (ie, within minimum period before implantation), whichever is later.⁶

Shared decision-making and future planning

Use the principles of shared decision-making to align care with her preferences. If she is strongly opposed to contraception now, and thinking of future pregnancy, this can be an opportunity to plan preconception care in advance.

You could make it a question to encourage the shared approach and build trust: ‘If you ever do start thinking about pregnancy, would you feel able to let us know early, so we can make sure everything’s in place to give you the healthiest start?’

You might also ask whether she’d be open to a review of her diabetes control and management in line with preconception advice – by referring to a preconception clinic, the specialist will ensure optimised HbA1c levels, discuss folic acid use, and review her medications that may harm an unborn child (eg, ACE inhibitors or statins, which are contraindicated in pregnancy).³

Use of structured preconception counselling tools

Evidence shows that structured education around preconception health improves outcomes. The READY model,⁶ DAFNE (for women with type 1 diabetes)⁷ and preconception leaflets from organisations like Diabetes UK⁸ can support conversations. A brief offer to follow up later may also allow her time to reflect without pressure.

Key points

A woman with diabetes of childbearing age who is not planning pregnancy but does not want to use contraception should be counselled about the potential risk this poses.
Avoid judgement and focus on respectful dialogue, informed choice and safety.
Explain the risks of unplanned pregnancy in the context of diabetes to both mother and baby.
Explore the options without coercion, and offer follow-up or signposting to preconception care if she reconsiders in future.
Ensure she feels supported and informed and that she can access care and guidance when needed.

Callum Metcalfe O’Shea is an advanced nurse practitioner with diabetes specialist interest

References

Diabetes UK. Planning for a pregnancy when you have diabetes.
Diabetes UK. Complications of gestational diabetes.
Nakshine V, Jogdand S. A comprehensive review of gestational diabetes mellitus: impacts on maternal health, fetal development, childhood outcomes, and long-term treatment strategies. Cureus 2023 Oct 23;15(10)
NICE. Diabetes in pregnancy: management from preconception to the postnatal period. [NG3] 2020
FSRH. UK Medical Eligibility Criteria for Contraceptive Use. 2016
FSRH. Clinical guideline: Emergency contraception. Amended July 2013
Royal College of Obstetricians and Gynaecologists, 2024. READY Model. Available at: Logic model | RCOG. (Accessed: 13 May 2025)
DAFNE, 2025. What is DAFNE? Available at: Home – DAFNE. (Accessed: 13 May 2025)