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BJOG: An International Journal of Obstetrics & Gynaecology, 2025; 0:1–12
https://doi.org/10.1111/1471-0528.18133
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BJOG: An International Journal of Obstetrics & Gynaecology
RESEARCH ARTICLE OPEN ACCESS
The Burden of Poor Reproductive Health in England:
Results From a Cross- Sectional Survey
MelissaJ.Palmer | OnaL.McCarthy | RebeccaS.French
Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine,
London,UK
Correspondence: Melissa J. Palmer (melissa.palmer@lshtm.ac.uk)
Received: 22 October 2024 | Revised: 19 Februar y 2025 | Accepted: 2 March 2025
Funding: The Reproductive Health Survey for England 2023 was funded by the Department of Health and Social Care (DHSC). The DHSC published a call
for expressions of interest to conduct this commissioned survey, and the authors of this paper applied. Representatives of the DHSC reviewed the draft ques-
tionnaire and fed in to whether additional questions were required to ensure policy- relevance of the information collected. The funding provided covered
the time- period for the development and implementation of the survey. No specific f unding was acquired for the analyses and write- up presented in this
paper, and the DHSC had no role in writing this article. The views expressed are those of the authors and not necessarily those of the DHSC.
Keywords: England| inequalities| reproductive health
ABSTRACT
Objective: To quantify the burden of poor reproductive health in England by age, ethnicity, and financial security.
Design: Cross- sectional survey.
Setting: England.
Sample: 59 332 women and people assigned female at birth aged 16–55 years.
Methods: The Reproductive Health Survey for England 2023 (RHSE2023) used an online convenience sampling strategy and a
self- completion questionnaire.
Main Outcome Measures: 13 indicators of reproductive health organised into three domains: reproductive morbidities (includ-
ing endometriosis, fibroids); menstrual health (severely painful and/or heavy periods; menopausal symptoms); and pregnancy-
related adverse experiences (pregnancy loss, infertility, unplanned pregnancy) in the last year.
Results: Compared to the general population, our sample over- represented those with higher education levels and under-
represented minority ethnic groups. 28.0% of participants reported at least one reproductive morbidity; 61.9% reported menstrual-
related issue(s); and 5.5% reported pregnancy- related adverse experience(s) in the last year, with considerable variation by age.
Compiling the three domains, 73.7% reported at least one indicator of poor reproductive health. Inequalities were observed:
Black British, Caribbean, and African women had increased odds of reporting reproductive morbidity (aOR: 1.69); heavy and/
or severely painful periods (aOR: 1.28); and pregnancy- related adverse experience (aOR: 1.50). Financial insecurity was also
associated with poor reproductive health.
Conclusions: As the first study to simultaneously examine this broad range of indicators of reproductive health within a
single sample, we highlight the substantial burden of poor reproductive health in England, with evident ethnic and financial
inequalities.
This is a n open access ar ticle under the terms of t he Creative Commons Attr ibution License, which p ermits use, dis tribution and repro duction in any medium, p rovided the orig inal work is
properly cited.
© 2025 T he Author(s). BJOG: An Inter national Jour nal of Obstetr ics and Gynae cology publis hed by John Wiley & Sons L td.
2 of 12 BJOG: An International Journal of Obstetrics & Gynaecology, 2025
1 | Introduction
Reproductive health is central to overall health and wellbeing.
A multitude of conditions and experiences can impact a person's
reproductive health, and needs and priorities change according
to age and life- stage. Understanding the range and prevalence
of reproductive health issues across the life course is crucial so
that efforts to improve reproductive health can be appropriately
targeted.
Inequalities in reproductive health are well documented; for ex-
ample, deprivation has been shown to be associated with higher
sexually transmitted infection and abortion rates [1], risk of se-
vere maternal morbidity [2] and adverse pregnancy outcomes
[3]. There is also considerable evidence for ethnic disparities in
maternal and pregnancy outcomes, with Black and South Asian
women at increased risk of experiencing stillbirth, preterm
birth, foetal growth restriction [3], maternal morbidity [2] and
mortality [4].
Despite the widely accepted definition of reproductive health
referring to “all matters relating to the reproductive system and
to its functions and processes” [5] there has been a tendency in
research to examine different aspects of reproductive health in
isolation from one another. Commonly reported prevalence es-
timates of individual reproductive health conditions (e.g., “1 in
10 women suffer from endometriosis”) imply that such issues
are only experienced by the (albeit substantial) minority. To
estimate the proportion of people who experience any facet of
poor reproductive health, detailed data collection focusing on
the range of potential health issues experienced across the re-
productive life course is required within a single sample.
In 2022, the UK Government launched the Women's Health
Strategy for England, with reproductive health issues identi-
fied as priority areas [6]. As a commitment of this strategy, the
Department of Health and Social Care (DHSC) commissioned
the Women's Reproductive Health Survey for England 2023
(RHSE2023). This was the first population- based survey carried
out in Britain to cover such a wide range of questions relating to
many aspects of reproductive health. Using this data, this paper
aims to quantify the burden of poor reproductive health at the
population- level, broadly defined, by age, ethnicity, and finan-
cial secur ity.
2 | Methods
2.1 | Recruitment
Based on the pilot study carried out in 2021 (see McCarthy etal.
[7] for detail), we used online methods to recruit participants
for the RHSE2023, resulting in a non- probability convenience
sample, with the aim of achieving a sample broadly ref lective
of the population in terms of age, ethnicity, education level, and
region of residence. Participants were eligible to complete the
survey if they were assigned female at birth, aged 16–55 years,
and resident in England.
The sample achieved in the pilot study had an under-
representation of those from Black, A sian, and minority ethnic
groups, those aged 24 and under, and those without a degree or
equivalent education. Due to resource limits, we were unable
to employ alternative sampling methodologies for this main
survey. Therefore, we revised the recruitment materials and
strategy with the aim of increasing recruitment among these
groups. The recruitment strategy involved three strands: paid-
for advertising on social media (Instagram and Facebook); so-
cial media posting and dissemination to networks by partner
organisations (LGBT Foundation; Race Equality Foundation;
Brook; and Birth Companions); and press releases issued by
DHSC and LSHTM at the survey launch to increase news
coverage.
The survey advertisements and promotional materials fea-
tured newly developed illustrations (as opposed to the stock
images used in the pilot survey) created by a graphic design
company, and with input from our partner organisations, to
reflect diversity in terms of age, ethnicity, and socio- economic
status. We used the Meta Ads Manager to create and deliver
paid- for adverts on Facebook and Instagram, and employed
the same targeting strategies as in the pilot study [7], but
implemented them from survey launch instead of waiting
for the under- representation of certain groups to be evident
in the data collected, as in the pilot. For example, additional
funds were directed to ensure more adverts were displayed to
those living in local authority areas with a higher proportion
of people from minority ethnic groups, to people aged 16–24,
and to those who recorded lower levels of education on their
social media profiles. All adverts featured one of the newly-
developed images alongside the same generic wording, (“Are
you a woman aged 16- 55 years? Complete the Reproductive
Health Survey for England 2023”; “Complete the Reproductive
Health Survey for England 2023”). The word ‘woman’ was
omitted from adverts designed to appeal to other gender iden-
tities who could be affected by the survey topics. Targeted
language highlighting the groups of people at risk of under-
representation and emphasising the importance of their en-
gagement was used in social media posts and outreach efforts
delivered by our partner organisations.
The survey ran for 6 weeks, from 7th September to 19th October
2023. The sample was monitored once a week to assess how the
digital marketing and communications strategy was working
through comparison of the sample with Census 2021 data and to
identify when additional efforts were needed to improve uptake
among specific demographic groups.
2.2 | Data Collection
On clicking the survey link, participants were taken to the
information sheet, consent form, and self- completion ques-
tionnaire hosted by Snap Surveys (https:// www. snaps urveys.
com/ ), an online survey platform. The survey was designed
to be completed within 20 min, and filter questions ensured
participants were only presented with questions of relevance
to them.
Topics covered in the questionnaire included menstruation
and menopause, family planning, pregnancy outcomes, re-
productive morbidities, and experiences of care and support.
3 of 12
The questionnaire was originally developed for the pilot sur-
vey based on the creation of a matrix of reproductive health
stages and thematic concepts relating to the fulfilment of re-
productive intentions, supporting reproductive wellness, and
identification of reproductive morbidities. Existing survey
instruments were mapped onto this matrix, and where gaps
remained, new questions were designed and underwent cog-
nitive testing [7]. Patient and Public Involvement Volunteers
helped us to develop the questionnaire for the pilot study, en-
suring that it was easy to understand and navigate, and cov-
ered topics relevant to people's lives. Further refinements were
made to the questionnaire for the RHSE2023 based on learn-
ings from the pilot study. Additional questions were added to
the questionnaire based on our review of the topics covered in
the recently published policy document, the Women's Health
Strategy for England [6].
2.3 | Measures
In this analysis, we report on 13 indicators of reproductive
health organised into three domains: reproductive morbidi-
ties (diagnosed conditions which affect the reproductive or-
gans of those assigned female at birth), poor menstrual health
(potentially problematic symptoms directly related to the
menstrual cycle), and pregnancy- related adverse experiences
(experiences that are relevant for fulfilment of reproductive
intentions).
Within reproductive morbidities, we examined the propor-
tion of participants who reported currently having: polycystic
ovary syndrome (PCOS); endometriosis; uterine fibroids; uter-
ine or cervical polyps; pelvic organ prolapse; cervical, ovar-
ian, uterine, or breast cancer; or another reproductive health
condition.
For poor menstrual health, we looked at the proportion of par-
ticipants who reported having experienced heavy menstrual
bleeding in the last year, severely painful periods in the last year,
and for those aged 40 or over, the proportion reporting having
experienced hot flushes and/or night sweats in the last year as
potential peri- menopausal or menopausal symptoms.
In relation to pregnancy- related adverse experiences, we fo-
cused on the experience of pregnancy loss in the last year (in-
cluding miscarriage, ectopic pregnancy, or stillbirth); infertility
(as indicated by having sought NHS treatment for infertility in
the last year); and whether participants had an unplanned preg-
nancy in the last year (measured using the London Measure of
Unplanned Pregnancy, categorised as unplanned based on a
score of 0–3) [8].
For details of the survey questions used for each indicator, see
TableS1.
To ask about the participants' ethnicity, we used the same ques-
tion and ethnic group categorisations as in the UK Census 2021
[9]. To capture financial security, we use a question designed to
capture the participant's subjective financial situation, “How
well would you say you yourself are managing financially these
days?” with response options: ‘finding it very difficult’, ‘finding
it quite difficult’, ‘just about getting by’, ‘doing alright’ and ‘liv-
ing comfortably’ [10].
2.4 | Analysis
We provide the demographic characteristics of the sample
recruited, alongside the equivalent estimates from the 2021
Census. We present the percentages of par ticipants who reported
experiencing each indicator of reproductive health, followed
by the percentage who reported at least one of these indicators
within each domain and across all three combined. In order that
our estimates could be used to indicate population- level burden,
the denominators of each percentage included all participants.
For example, the question about heavy menstrual bleeding was
only asked of those who reported having had a period in the last
year, but our denominator also includes those who had not had
a period in the last year.
Results are presented by five- year age group and overall.
Logistic regression analysis was used to examine differences in
the burden of poor reproductive health by ethnic group and sub-
jective financial situation while adjusting for age group. Due to
the over- representation of younger participants in our sample,
particularly those aged 20 –34 years, we applied weights based
on the Census 2021 [9] age distribution for females. All analyses
were carried out using Stata 18 [11].
3 | Results
In the 6 weeks the sur vey was live, 59,332 eligible participants
responded. A description of the socio- demographics of the sam-
ple is provided in Table1. In comparison to data from the 2021
Census, our sample had an over- representation of younger age
groups and those with higher levels of education, and an under-
representation of those from minority ethnic groups. However,
the regional distribution of participants was broadly consistent
with the 2021 Census.
Tables2a and 2b present the percentage of participants reporting
each indicator of reproductive health by age group and overall.
Polycystic ovary syndrome was the most commonly reported re-
productive morbidity (10.5%) followed by endometriosis (8.8%).
Uterine fibroids, uterine or cervical polyps, pelvic organ pro-
lapse, and reproductive- cancers were less commonly reported
but increased with advancing age. Over a quarter of participants
reported at least one reproductive morbidity (28.0%); this was
12.9% among the 16–19- year- olds and ranged from 29.2% to
33.9% among those aged 30 and over.
Overall, 18.7% of participants reported experiencing severe
period pain in the last year, but this varied considerably by
age, peaking among 16–19- year- olds and 20–24- year- olds
at 36.5% and 32%, respectively, and falling to 5.5% among
50–55- year- olds. Heavy menstrual bleeding was reported by
40% of the sample and also peaked at younger ages (62.4% of
16–19 year olds and 53.6% of 20 –24 year olds). Among those
aged 40 or over, two- thirds reported experiencing hot flushes
4 of 12 BJOG: An International Journal of Obstetrics & Gynaecology, 2025
and/or night sweats. Looking across these indicators of men-
strual health, 61.9% of participants had experienced at least
one issue in the last year, with the highest menstrual health
burden among the youngest (68.7%) and oldest (81.5%) age
groups.
In relation to our indicators of pregnancy- related adverse experi-
ences, just under 1% of the sample had an unplanned pregnancy
in the last year, with the highest among those aged 20–24 years,
at 2.5%. Pregnancy loss was most commonly reported by partic-
ipants in their thirties (5.7%), and the proportion seeking NHS
fertility treatment followed a similar pattern, peaking at around
7% in this age group. Overall, 1 in 20 participants (5.5%) reported
at least one of these pregnancy- related adverse experiences in
the last year, and this proportion reached 12% among those
aged 30 –39.
Looking across all three domains, the overall proportion re-
porting any reproductive, menstrual, or pregnancy- related issue
was 73.7%, ranging from 61.5% among 30–34- year- olds to 87.3%
among participants aged 50–55- years.
Table 3 presents the proportion of participants reporting
any reproductive morbidity and any pregnancy- related ad-
verse experience by ethnic group and by financial situation,
and the corresponding age- adjusted odds ratios. Within the
menstrual health domain, the indicators of heavy and/or se-
verely painful periods are presented separately to the meno-
pausal symptoms. Compared with White participants, those
from minority ethnic groups had significantly greater odds
of reporting a reproductive morbidity, peaking among Black,
Black British, Caribbean or African participants (aOR: 1.69,
95% CI: 1.43–1.98). Further analyses found this to be driven
by a large difference in the percentage reporting uterine fi-
broids: 19.8% (95% CI: 16.7–23.2) among Black ethnic groups
and 9.8% (95% CI: 6.4, 14.7) among other ethnic groups, com-
pared with 4.9% (95% CI: 4.7–5.1) among White ethnic groups.
TABLE | Description of RHSE2023 participants and England
census data.
RHSE 2023
N (%) Census 2021
Age
16 to 19 3995 (6.7%) 8.4%
20 to 24 9159 (15.4%) 11.4%
25 to 29 9931 (16.7%) 12.7%
30 to 34 9904 (16.7%) 13.7%
35 to 39 7954 (13.4%) 13.1%
40 to 44 670 8 (11. 3%) 12.3%
45 to 49 5147 (8.7%) 12.3%
50 to 55 653 4 (11.0%) 16.0%
Ethnicity
White 53 687 (92.3%) 77. 9%
Mixed/multiple
ethnic groups
1931 (3.3%) 2.9%
Asian/Asian British 1457 (2.5%) 11.6%
Black/Black British/
Carib./African
795 (1.4%) 5.1%
Other ethnic group 311 (0.5%) 2.6%
Has degree or equivalent
No 15 738 (27.4%) 58.6%
Yes 41 639 (72.6%) 41.4%
Government Region
North East 2056 (3 .9 %) 4.5%
North West 6333 (12.1%) 12.9%
Yorkshire and
Humber
5512 (10.5%) 9.5%
East Midlands 4313 (8.2%) 8.4%
West Midlands 4307 (8.2%) 10.3%
East 55 62 (10.6%) 10.9%
London 9342 (17.8 %) 18.2%
South East 8687 (16.6%) 16.0%
South West 63 64 (12.1%) 9.4%
Gendera
Woman/gi rl 56 8 22 (96.2%)
Non- binary 102 6 (1.7%)
Woman/gi rl/
non- binary
277 (0.5%)
Think of myself in
another way
293 (0.5%)
(Continues)
RHSE 2023
N (%) Census 2021
Non- binary/Trans 167 (0.3%)
Man/boy/Trans 100 (0.2%)
All other responses 397 (0.7%)
Index Multiple Deprivation (IMD) 2019 quintiles
1 (most deprived) 6751 (12 .9%)
210 664 (20.3%)
311 592 (22.1%)
411 710 (22 .3%)
5 (least deprived) 11 759 (22.4%)
Note: Census 2 021 estimates are based on census data from women, resident in
England, a ged- 16- 55 only.
aParticipants were asked "Which of the options describes how you think of
yourself ?" and could select all answer options that apply. We present the 6 most
common responses, followed by all other responses together.
TABLE | (Continued)
5 of 12
TABLE A | Reproductive morbidities by age group and overall.
16 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 55 Total
Reproductive morbidities
PCOS 5.93 10.95 14.74 13.89 12.72 10.98 8.50 5.33 10.47
[5.18, 6 .79] [10.2 8, 11. 65] [14.01, 15.5] [13.18, 14 .64] [11.96, 13.53] [10.2, 11.82] [7.71, 9.35] [4.77, 5.94] [10.21, 10.74]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Endometriosis 5.36 7.59 9.87 9.95 10.55 10.36 9.41 6.30 8.77
[4.65, 6.18] [7.0 2 , 8.19] [9.26, 10.52] [9.33, 10.6] [9.85, 11.3] [9.60 , 11.17] [8.59, 10.3] [5.69, 6 .9 6] [8 .53, 9.03]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Uterine fibroids 0.21 0.45 1.07 2.65 4.71 7.54 9.03 11.61 5.09
[0.10, 0.44] [0.33, 0.63] [0. 87, 1.31] [2.33, 3.01] [4.23, 5.2 4] [6.89, 8.25] [8.23, 9.91] [10.80 , 12 .47] [4.88, 5.30]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Uterine or cervical polyps 0.06 0.42 0.77 1.08 1.42 2.40 2.35 3.31 1.60
[0.02, 0.24] [0.30, 0.59] [0.61, 0.98] [0.88, 1.32] [1.17, 1.73] [2.04, 2.83] [1.94, 2.84] [2.87, 3.81] [1.49, 1.73]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Pelvic organ prolapse 00.14 0.32 1.55 3.52 4.20 4.70 4.23 2.50
—[0.08, 0.25] [0.22, 0.47] [1.31, 1.83] [3.11, 3.98] [3.72, 4.75] [4.11, 5.36] [3.73, 4.79] [2.36, 2.66]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Cervical, ovarian, uterine, or
breast cancer
0.06 0.03 0.14 0.12 0.39 0.57 1.01 1.47 0.52
[0.02, 0.24] [0.01, 0.10] [0.08, 0.24] [0.06, 0.22] [0.27, 0.57] [0.41, 0.80] [0.75, 1.35] [1.19, 1.82] [0.46, 0.60]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Other reproductive health
condition
2.91 4.53 6.21 6.91 8.17 8.04 6.04 5.45 6.19
[2.39, 3.53] [4 .10, 5.01] [5.72, 6.74] [6.39, 7.47] [7.55, 8 .84] [7.37, 8.77] [5.38, 6.77] [4.89, 6.07] [5.98, 6.4 0]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Any of the above 12.86 20.57 27. 23 29.31 33.01 33.85 31.59 29.18 28.0
[11.76 , 14.03] [19.69, 21.47] [26.31, 28.18] [28.35, 30.28] [31.91, 34.13] [32 .64, 35.0 8] [30.24, 32.97] [28 .0, 30.37] [27.6 , 28 .41]
3337 7921 8692 8595 6901 5781 4473 5652 51 352
Note: Table presents: % [95% confidence interval] N. In order that our estimates can be used to indicate population- level burden, the denominators of each percentage included all participants.
6 of 12 BJOG: An International Journal of Obstetrics & Gynaecology, 2025
TABLE B | Menstrual health, and adverse- pregnancy related experiences, by age group and overall.
16 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 55 Total
Menstrual Health
Severe period
paina
36.49 31.96 25.51 18.93 15.98 14.12 11.33 5.49 18.65
[34 .96, 38.0 4] [31.0 , 32 .95] [24.65, 26. 4] [18.16 , 19.73] [15.17, 16. 81] [13.29, 15.0] [10.47, 1 2.24] [4.95, 6.08] [18.33, 18.97]
3774 8763 9572 9533 7674 6429 4962 6268 56 975
Heavy
menstrual
bleedinga
62.44 53.58 42.68 37.4 8 3 7.9 3 40.96 37. 3 4 21.97 40.04
[60.89, 63.9 8] [52.53, 54. 62] [41.69, 43.68] [36.51, 38.46] [36 .85, 39.02] [39.76, 42 .16] [36.0, 38.7] [20.96, 23.01] [39. 62, 40.45]
3773 8754 9564 9525 7673 6424 4952 6267 56 932
Hot flushes or
night sweatsb
52.5 67.97 76.15 66.57
[51.26, 53.74] [66.64, 69.27] [75 .07, 77.2 0] [65.86, 67.27]
6215 4824 6118 17 15 7
Any of the
above
68.74 59.84 49.17 42.5 41.77 71.74 80.86 81.49 61.86
[67.24, 70.2] [58.81, 60.86] [48 .17, 50.17] [41.51, 43.49] [40 .67, 42 .88] [70.61, 72.84] [79.73, 81.94] [80.5, 82.43] [61.45, 62.2 6]
3775 8757 9563 9523 7665 6302 4885 6179 5 6 649
Pregnancy- related adverse experiences
Unplanned
pregnancyc
2.31 2.54 1.52 0.94 0.60 0.39 0.11 0.03 0.95
[1.86, 2.86] [2.22, 2.91] [1.28, 1.79] [0.76, 1.16] [0.45, 0.81] [0.26, 0.58] [0.05, 0.26] [0.01, 0.14] [0.8 8, 1. 03]
3510 8217 8963 8856 7159 5958 4624 5837 53 124
Pregnancy loss
in last yearc
1.48 1.60 2.68 5.69 5.66 2.78 0.45 0.09 2.59
[1.13, 1.93] [1.35, 1.90] [2.37, 3.04] [5.23, 6.19] [5.15, 6. 22] [2.40, 3.23] [0.29, 0.69] [0.04, 0.20] [2.47, 2.72]
3523 8247 9020 8975 7262 6034 4669 5904 53 63 4
Sought NHS
fertility
treatment in
last yeard
0.06 0.59 2.74 6.61 7.01 3.05 0.20 0.05 2.67
[0.014, 0.28] [0.44, 0.78] [2.42, 3.10] [6.11, 7.14] [6 .44, 7.63] [2 .6 4, 3. 52] [0.10, 0.38] [0.02, 0.16] [2.54, 2.80]
3477 8141 8884 8795 7114 5936 4591 5761 52 69 9
Any of the
above
2.83 4.03 6.11 12.06 12.0 5.53 0.66 0.14 5.52
[2. 33, 3.4 4] [3.62, 4 .48] [5.63, 6.63] [11.39, 12.76] [11.26, 12.77] [4.98, 6.15] [0.46, 0.94] [0.07, 0.28] [5.33, 5.71]
3461 8122 8865 8765 7077 5874 4538 5685 52 3 87
(Continues)
7 of 12
Participants from minority ethnic groups were also signifi-
cantly more likely to report heav y and/or severely painful
periods, while little variation was observed in relation to hot
flushes and/or night sweats. Finally, pregnancy- related ad-
verse experiences were most commonly reported by Black,
Black British, Caribbean or African participants (aOR: 1.50,
95% CI: 1.14–1.99) and those from other ethnic groups (aOR:
1.91, 95% CI: 1.25–2.90). The odds of reporting any reproduc-
tive morbidity, heavy and/or severely painful periods, and
menopausal symptoms, increased with declining financial se-
curity. While no statistically significant pattern was observed
for the adverse pregnancy experiences domain overall, further
analyses indicated a strong association between increasing
financial insecurity and odds of having had an unplanned
pregnancy in the last year; those who reported that they were
‘finding it very difficult’ had almost five- times greater odds of
an unplanned pregnancy in the last year compared to those
who were ‘living comfortably’ (aOR: 4.96, 95% CI: 3.23–7.41).
4 | Discussion
4.1 | Main Findings
This is the first study to simultaneously examine this com-
bination of indicators of reproductive health within a single
sample. Our findings indicate there is a substantial burden of
poor reproductive health and that the nature of this burden var-
ies by age group. Reproductive morbidities tended to increase
with advancing age, while menstrual- related issues followed a
u- shaped curve peaking at both younger and older ages, with
pregnancy- related adverse experiences most commonly experi-
enced between the ages of 30 and 39 years. We found evidence
of inequalities in reproductive health according to ethnicity
and financial security. Minority ethnic groups, and particularly
those identifying as Black, Black British, Caribbean, or African,
experienced a higher burden of poor reproductive health across
the three domains investigated, while greater financial insecu-
rity was associated with poor reproductive health across two
domains.
4.2 | Strengths and Limitations
The main streng th of this study is the collection of data relating
to a wide range of indicators relevant to reproductive health
within a single large population- based sample. Several limita-
tions should also be noted in the interpretation of our findings.
Having used a non- probability convenience approach to sam-
pling, we cannot be certain of the extent to which our findings
are representative of the wider population of women and those
assigned female at birth aged 16–55 living in England. In
comparing the characteristics of the RHSE participants to UK
census data, our sample has an under- representation of Black,
Asian, and other minority ethnic groups and those without
degree- level education. Therefore, the sample achieved is
likely to under- represent those at greater risk of having poorer
reproductive health and outcomes. Comparingour individual
estimates for each of the reproductive conditions/experiences
to published literature (see next section) provides reassur-
anceagainst concerns of over- estimating the burden of poor
16 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 55 Total
Any reproductive, menstrual, or pregnancy issue
Any
reproductive,
menstrual,
or pregnancy
issue
74.19 69.07 63.33 61.4 8 63.14 81.83 86.79 87. 3 73.72
[72.75, 75.59] [68.07, 70.05] [62.34, 64.32] [60.47, 62.49] [62.02, 64.25] [80.85, 82.78] [85.81, 87.72] [86 .4 4, 88.12] [73.34, 74.09]
3631 8402 9071 8965 7171 6148 4801 6073 5 4 262
Note: Table presents: % [95% confidence interval] N. In order that our estimates can be used to indicate population- level burden, the denominators of each percentage included all participants. Denominators vary due to item
non- response.
aDenominator includes all participants regardless of whether they have had a period in the last year.
bDenominator includes all participants a ged 40 to 55 years.
cDenominator includes all participants regardless of whether they have had a pregnancy in the last year.
dDenominator includes all participants regardless of whether they have ever experienced infertility.
TABLE B | (Continued)
8 of 12 BJOG: An International Journal of Obstetrics & Gynaecology, 2025
TABLE | Age- adjusted associations between ethnicity, financial situation, and reproductive health.
Any reproductive morbidity
Heavy and/or severely
painful periods Hot flushes and/or night sweats
Any pregnancy- related
adverse experience
% aOR (95% CI) N% aOR (95% CI) N% aOR (95% CI) N% aOR (95% CI) N
Ethnic group
White 27.7 1 (ref ) 47 205 43.6 1 (ref ) 52 251 66.7 1 (ref) 16 1 36 5.4 1 (ref) 48 196
Mixed or multiple
ethnic groups
28.8 1.14* 1698 50.8 1.14** 1874 67.6 1.15 352 6.2 1.04 1733
(1.02, 1.27) (1.03, 1.26) (0.91, 1.45) (0.85, 1.27)
Asian or Asian
British
31.6 1.27*** 1230 49.1 1.12* 1406 60.2 0.82 332 6.7 1.15 1235
(1.1 2, 1.4 4) (1.00, 1.25) (0.65, 1.03) (0.92 , 1.43)
Black, Black British,
Caribbean or
African
38. 1 1.69* 650 52.7 1.28** 749 64.1 0.97 145 9.0 1.50** 655
(1.43, 1.98) (1.10, 1.50) (0.6 8, 1.38) (1.14, 1.99)
Other ethnic group 34.2 1.36* 259 50.5 1.36* 295 62.2 0.79 82 10.5 1.91** 257
(1.04, 1.78) (1.06, 1.75) (0.50, 1.25) (1. 25, 2.90)
Financial situation
Living comfortably 26.0 1 (ref) 10 9 24 34.9 1 (ref) 12 2 02 63.3 1 (r ef ) 4800 5.7 1 (r ef ) 11 191
Doing alright 27. 2 1.13* 2 2 752 42.4 1.23*** 25 2 45 66.0 1.17*** 7526 5.4 0.91 23 223
(1.07, 1.20) (1.18, 1.29) (1.08, 1.27) (0.83, 1.0 0)
Just getting by 29.9 1.38* 1068 50.5 1.60*** 13 350 70.1 1.46*** 3414 5.5 0.96 12 285
(1.30, 1.47) (1.52, 1.69) (1.32, 1.60) (0.86, 1.07)
Finding it quite
difficult
30.0 1.46*** 4076 56.3 1.91** 4460 71.7 1.58*** 945 5.7 1.03 4148
(1.34, 1.59) (1.77, 2.0 5) (1.35, 1.86) (0.88, 1.20)
Finding it very
difficult
36.1 1.87*** 1396 60.1 2.39*** 1508 74.0 1.77*** 401 6.2 1.18 1408
(1.65, 2.12) (2.13, 2.68) (1.40, 2. 24) (0.94, 1.49)
*p≤0.05.
**p≤0.01.
***p≤0.001.
9 of 12
reproductive health. Due to resource constraints, the sample
was limited to those aged 16 to 55 years; however, our find-
ings provide clear evidence that reproductive health issues
show no sign of declining with advancing age, meaning an
important segment of the population is missed in this anal-
ysis. Furthermore, although broad, the measures included in
our study fail to include important experiences relevant to re-
productive health; for example, we do not include indicators
relating to recent birth- related issues such as psychological
trauma and obstetric injury, ante- and post- natal poor mental
health, menstrual- related mood disorders, other gynaecolog-
ical symptoms such as vulval pain and non- menstrual pelvic
pain, and broader symptoms of peri- menopause and meno-
pause, such as brain fog. We also do not report the psycho-
logical, relational, and economic impacts of the reproductive
health experiences considered, thereby capturing only their
occurrence, but not their broader costs. While our analyses
focused on age, ethnicity, and financial security, other factors
are likely to relate to reproductive health status, such as ac-
cess to care and general health status. For those conditions
included, we necessarily rely on participants' self- report, but
it is possible that certain experiences and conditions may be
over or under- reported according to their recent salience, the
time taken to diagnosis, and whether treatment or strategies
to control symptoms have been effective. As a proxy for recent
experience of infertility, we relied on a question asking partic-
ipants whether they had tried to access free fertility treatment
on the NHS in the last year, which will not capture those who
proceeded directly to private providers. However, given that
private treatment is only accessible to those who can afford
it, its inclusion as an indicator may have biased our results,
particularly when examining experiences by financial status.
Finally, while useful for examining burden at a population
level, we have combined clinically- distinct conditions and ex-
periences into three domains. The inequalities observed for
each domain according to ethnicity and financial status may
not be reflected for each individual indicator separately.
4.3 | Interpretation
Due to our sampling strategy, we cannot claim the sample
is necessarily representative of the wider population, and
the comparison of our data with the 2021 Census shows that
particular sociodemographic groups were under- represented
in the sample achieved. In considering the impact that our
sample make- up may have on the estimates reported, those
who are under- represented (minority ethnic groups, lower
education, living in more deprived areas) are generally the
same groups who are likely to have poorer reproductive health
and outcomes. On this basis, our findings may be an under-
estimate of the true burden of poor reproductive health in the
wider population. However, we would argue that having an
indicative lower bound is more useful than a potential over-
estimate. Additionally, those over- represented in our sample
may be more likely than the general population to access
healthcare services and receive a diagnosis of certain gynae-
cological conditions, which can take many years and visits
before adequate investigations are carried out. In compar-
ing our estimated prevalences of each individual indicator of
reproductive health to previously published figures, we do not
find evidence to suggest an over- representation of any aspect
of poor reproductive health. Our estimates for PCOS and en-
dometriosis were consistent with previously reported preva-
lence rates [12, 13], however, those for fibroids, polyps, and
prolapse were considerably lower than those reported in other
studies, potentially due to the under- diagnosis of these condi-
tions [14–16].
Published estimates of heavy menstrual bleeding and pain
vary widely due to differences in measurement and sampling
approaches, making comparisons difficult; however, a sur-
vey of European respondents found 27% reported at least two
symptoms of heavy menstrual bleeding [17]; while a cross-
sectional study across 10 low- and middle- income countries re-
ported prevalences of heavy menstrual bleeding ranging from
38.3% to 77.6%, as measured by the multi- item SAMANTA
scale [18]. In a postal survey conducted in Scotland, 35% of
participants reported ‘heavy’ or ‘very heav y’ periods, and 15%
reported ‘severe’ or ‘very severe’ period pain [19]. In relation
to menopausal symptoms, another online survey among 35
to 70- year- olds living in the UK found that 80.7% of partic-
ipants reported recently experiencing hot flushes or night
sweats [20].
Our estimate of unplanned pregnancy in the last year is
slightly lower than the 1.5% among 16–44 years old in the third
National Survey of Sexual Attitudes and Lifestyles [21], even
when restrictions are made to calculate this among the same
age range. In relation to pregnancy loss, it is estimated that
around 15% of all recognised pregnancies end in miscarriage
[22], though the true rate is likely to be higher. Our results
show a peak in the proportion of women reporting pregnancy
loss in the last year among those aged 30 to 39, as would be
expected given that conception rates are highest among the
30–34- year- old age group in England and Wales [23], and the
risk of miscarriage increases with maternal age [24]. In line
with these findings, the proportion of participants reporting
having sought fertility treatment from the NHS in the last year
follows a similar pattern across the age groups, reflective of
when people may be most likely to attempt to have children
and the increased risk of infertility that comes with advanc-
ing age.
Our findings of disparities in reproductive health accord-
ing to ethnicity and financial status are consistent with the
large body of literature concerned with socio- economic in-
equalities in health. Driving the ethnic inequality observed
for the reproductive morbidity domain was a stark difference
in the proportion of Black respondents reporting uterine fi-
broids compared to other ethnicities. This pattern has been
repeatedly demonstrated in US- based studies with a two- to
three- fold increase in the risk of uterine fibroids among Black
women compared to White women [25–27], though the rel-
ative contribution of social, environmental, and biological
factors is not well understood [28–30]. In interpreting the asso-
ciation between self- rated financial security and reproductive
health, various mechanisms should be considered; for exam-
ple, those with greater financial insecurity may face barriers
in accessing effective care for the management of menstrual
10 of 12 BJOG: An International Journal of Obstetrics & Gynaecology, 2025
symptoms; poor reproductive health itself may be disruptive
to a person's ability to work and maintain financial security;
or the potential impact of poor reproductive health on health
more generally may in turn contribute to the way in which
one interprets their own financial security (e.g., prior research
using the same measure of financial status found evidence for
causal effects of general and mental health status on self- rated
financial security) [31].
4.4 | Implications
Our findings indicate that reproductive health issues are expe-
rienced by the majority of women and those assigned female at
birth. W hile increased risks of poor maternal health among Black
women and other minority ethnic groups are well documented
[32], this analysis demonstrates that ethnic inequalities are evi-
dent across multiple aspects of reproductive health. Furthermore,
previous research has often relied on area- level indicators of
deprivation as a proxy for individual- level disadvantage in ex-
amining socio- economic disparities in reproductive health; our
findings show that inequalities exist according to person- level
self- rated financial security. These findings are set in a context
where women's experiences of health and reproductive condi-
tions are often ignored, dismissed or simply considered within
the norm of what one should expect [33]. Funding and meaning-
ful action to promote and support women's health has histori-
cally being lacking, and according to the UK Clinical Research
Collaboration, just 2.4% of health and biomedical research fund-
ing was spent on ‘Reproductive Health and Childbirth’ in 2022
[34]. Women's health services are under increasing pressure,
with an estimated 591 000 people in England currently on a wait-
ing list for gynaecology hospital care [35], and a series of public
inquiries highlighting serious failings in the provision of mater-
nity services [36]. Further implications of our findings for policy
and future research are presented in Box1.
Recently there has been increasing interest in supportive
workplace policies for specific issues such as pregnancy loss
[39] and menopause [40], though these only relate to two re-
productive health issues and fail to recognise that the most
salient and disruptive reproductive experiences will differ ac-
cording to age and life stage. Our findings reinforce the value
of taking a life- course approach to reproductive health and
the importance of support and healthcare being delivered as
a continuum [41].
5 | Conclusion
Examining multiple indicators simultaneously has exposed
a substantial burden of poor reproductive health experienced
by women and those assigned female at birth, the nature of
which varies considerably by age. Ethnic and financial in-
equalities exist across multiple facets of reproductive health.
Investment and innovation in health services and support
strategies are urgently needed to mitigate the impact of poor
reproductive health on the lives of women and those assigned
female at birth.
BOX | Implications for policy and future research.
• Given the sampling strategy employed, we cannot
claim to have produced perfect prevalence estimates,
and it is likely that our results provide an indicative
lower bound of the population- level burden of poor
reproductive health. This extent of poor reproductive
health may not seem surprising to those providing spe-
cialised clinical care. However, our data provide the
first population- based estimates for a wide range of re-
productive health issues simultaneously, which can in-
form investment, commissioning, and policy- making,
and increase awareness among non- specialist health-
care providers.
• Reproductive health is underfunded and under-
researched. A recent report by the UK House of
Commons Women and Equalities Committee high-
lighted the neglect of reproductive health in policy,
the provision of healthcare, and in medical research
[37]. Our findings highlight that there is no empirical
basis for reproductive health to be treated as niche and
unimportant.
• With the change of UK government last year, the policy
steer for women's reproductive health in England is not
yet clear. The Women's Health Strategy for England of
the former government was backed up with inadequate
levels of funding for Integrated Care Boards to estab-
lish and sustainably expand the proposed ‘Women's
Health Hubs’, despite economic analyses indicating
that for every £1 spent on implementing a Primary Care
Network- sized hub, there would be an estimated £5 of
benefits in return [36, 38]. A grasp of reproductive health
indicators at a population level are important to priori-
tise this key area of health.
• Poor reproductive health impacts other aspects of health
and general wellbeing, and threatens the extent to which
those affected are able to engage in education and work,
meaning the costs extend beyond the individual to
societ y.
• Primary care will most often be the first port of call
for reproductive healthcare. It is important that those
working in primary care appreciate how common re-
productive health issues are, as well as how their dis-
tribution varies according to age, so that referrals to
the appropriate specialised services are not delayed
unnecessarily.
• Our findings highlight the need for greater investment
in the conduct of high- quality research focused on re-
productive health in the population, ensuring adequate
representation from those groups at risk of poorer
health and outcomes and who may be better reached
by more resource- intensive offline community-
based methods of recruitment and the opportunity to
contribute to such research in languages other than
English.
• In addition to public health research, our findings also
underscore the need for genuine investment in clinical
medical research so that the huge number of people af-
fected by poor reproductive health can benefit from im-
proved diagnostics and new treatment options.
11 of 12
Author Contributions
R.S.F., M.J.P., and O.L.M. designed the study, including questionnaire
development, recruitment strategy, and data collection. M.J.P. carried
out the data analysis for this article, with input from O.M. and R.S.F.,
M.J.P., wrote the first draft of the article, and all authors were responsi-
ble for reviewing and editing it. All authors have read and approved the
final version for publication.
Acknowledgements
We thank the Sta keholder Reference Group for their guidance and a dvice
throughout the project, including reviewing questionnaire drafts, pro-
viding feedback on recruitment strategies and materials, and support-
ing survey dissemination: Tracey Bignall (Race Equality Foundation),
Kate Chivers (Birth Companions), Finn Grice (LGBT Foundation),
Isabel Inman (Brook), Kirsty Kitchen (Birth Companions), Sue Mann
(NHSE), Catherine Mercer (UCL), Eva Morrison (Race Equality
Foundation), Neha Pathak (UCL & G STT), Sophie Patterson (University
of Lancaster), Peter Weatherburn (LSHTM), Kaye Wellings (LSHTM),
Ellie White (LGBT Foundation), Jessica Winters (Brook). We thank the
thousands of people who completed the questionnaire and shared their
experiences of reproductive health with us.
Ethics Statement
Approval for this study was granted by the London School of Hygiene
and Tropical Medicine Ethics Committee (LSHTM Ethics Ref: 29389)
on 25th July 2023.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available from
Department of Health and Social Care. Restrictions apply to the avail-
ability of these data, which were used under license for this study. Data
are available from the author(s) with the permission of Department of
Health and Social Care.
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Supporting Information
Additional supporting information can be found online in the
Supporting Information section.
