A total of 1228 articles were initially identified. Of these, 54 articles were duplicates, 1152 articles were excluded during the title and abstract screening process, and another 11 were excluded after a full-text review as they were ineligible. A total of 11 studies published between 2012 and 2022 (involving 2580 participants) across six countries were included in this review (Fig. 1). Of the studies included, nine were cross-sectional, and two were retrospective cohort studies. Seven studies were conducted in the USA (one of them conducted throughout North America), and two were from the UK. All eleven studies were conducted in facility-based settings (e.g., hospitals) [25,26,27,28,29,30,31,32,33,34, 36]. Participants in all studies were women aged 15 years and older (Table 2).

The risk of bias of studies was assessed by the JBI checklist quality appraisal tool. The quality appraisal of the included studies, including both cross-sectional and longitudinal designs, showed methodological strengths and weaknesses. Among the nine cross-sectional studies, variations were observed in appraisal scores. One study [26] received the highest methodological rigour with a score of 8. Two other studies [25, 28] had an appraisal of 6. However, five studies [29,30,31, 33, 34] received lower appraisals ranging from 3 to 5, suggesting limitations. In contrast, both retrospective longitudinal studies [32, 36] had similar appraisal scores of 6. Overall, the studies showed limitations in specific areas such as a lack of describing study subjects and settings [34], measuring exposure [27, 29,30,31, 33], identifying and dealing with confounding factors [25, 28, 29, 31, 33, 34], and reporting follow-up time and completeness [32, 36] (Supplementary Tables 1 and 2).

Eleven studies reported on CVD classification either through medical classification or self-report. A German cross-sectional study at two tertiary care centres involving women with congenital health diseases (CHD) aged 18 years or older classified CVD severity using the American College of Cardiology (ACC) recommendations. Of these participants, 52% had moderate CHD, and 25% had severe CHD. However, the treating physician classified 41% of the women as class II and 8% as class III–IV [26]. A cross-sectional study from the USA reported CVD classification based solely on self-report. Of the 77 women, 38% reported severely complex CHD, and 51% reported moderately complex CHD [34].

Five studies included disease severity as part of CVD classification [24, 25, 29, 31, 33], with three using the modified World Health Organization (mWHO) classification [24, 25, 29]. Using mWHO, a study from the UK reported a significant percentage of women with CVD were at moderate level [24]. A cross-sectional survey of nine Adult Congenital Heart Disease (ACHD) centres throughout North America found that women with CHD (aged 18 years or older) primarily had moderate (45%) or great complexity (36%) [31]. Another cross-sectional survey from the USA involving 54 female patients aged 18 years and older with CHD also reported rates of disease severity, although in this sample, almost half of the participants reported severe disease [29]. A study from the USA involving 83 women aged 19 or older with CHD noted that 29% of participants were classified as having class 3 and 11% class 4 disease severity [25].

Finally, one study from the UK documented CVD severity among two groups of participants surveyed three years apart. In Group 1, using the mWHO classification, 14% of the participants were in stage II–III, and 14% in stage III. In Group 2, 31% were stage II–III and 14% were stage III. In total, 3% of the women were classified as WHO IV, in which pregnancy would be contraindicated [32]. In another study, 78% of participants had documentation regarding significant increased risk for an adverse pregnancy outcome. Interestingly, less than half of these women were able to self-report the risk correctly. Of all patients surveyed, 72% did not know that having CVD placed them at increased risk for having a child with CVD [29].

The pooled prevalence of contraceptive counselling was assessed using 11 studies. From these, the pooled prevalence was estimated at 63% (95% CI, 49–76%); however, there was significant evidence of heterogeneity (Q (10) = 818.19, ɽ2 = 0.05, I2 = 98.76%, p < 0.001) (Fig. 2).

Contraceptive counselling among women with cardiovascular diseases

Subgroup analyses by study design showed that contraceptive counselling prevalence was 65% (95% CI, 48–81%) (Q (8) = 792.13, I2 = 99.11, p < 0.001) among cross-sectional studies and 54% (95% CI, 38–71%) (Q = 5.49, I2 = 81.78%, p < 0.001) among retrospective studies (Fig. 3). In US-based studies, the pooled contraceptive counselling prevalence was 67% (95% CI, 45–89%) (Q (5) = 509.00, I2 = 99.06, p < 0.001). In other countries, on pooling, 57% of participants received contraceptive counselling (95% CI, 42 to 73%) (Q (4) = 297.75, I2 = 97.75, p < 0.001) (Fig. 4). The pooled contraceptive counselling prevalence for CHD studies was 66% (95% CI, 47 to 86%) (Q (6) = 684.79, I2 = 99.31, p < 0.001) while in studies unrelated to CHD, the pooled contraceptive counselling prevalence was 56% (95% CI, 41–72%) (Q (3) = 61.48, I2 = 93.81, p < 0.001) (Fig. 5). In studies focusing on contraception provision, the contraceptive counselling prevalence was 64% (95% CI, 45–84%) (Q (6) = 593.16, I2 = 99.18, p < 0.001), while within the preconception focus studies, the contraceptive counselling prevalence was 74% (95% CI, 53–96% [Q (1) = 10.25, I2 = 90.24, p < 0.001]) (Fig. 6). Given the heterogeneity among these studies (I2 > 75%), a narrative review is provided below.

Contraceptive counselling by study design among women with cardiovascular diseases

Contraceptive counselling by country among women with cardiovascular diseases

Contraceptive counselling by cardiovascular disease type

Contraceptive counselling by focus of the study

Furthemore, two studies found that about half of the participants did not receive contraceptive counselling inline with their specific heart conditions. A cross-sectional survey from the USA at a single tertiary adult CHD clinic showed 54% of women with CHD reported that a healthcare professional had never discussed their options for birth control with respect to their heart condition. Of the 38 participants who did report receiving contraceptive counselling that specifically addressed their heart condition, only 47% received such counselling prior to their first sexual intercourse [25]. A retrospective cohort study from the UK also highlighted that 63% of women with cardiac disease attended preconception counseling (PCC). Of the 14 that did not attend PCC, 5 referred to their service from another unit without PCC and 2 previously defaulted from follow-up [24].

Women with CVD however were more likely to receive counselling than women with alternative medical diagnoses. For instance, a retrospective comparative audit from the UK at a single tertiary maternity unit showed that nearly half of the women with an underlying cardiac condition had received counselling [32]. The same study compared two groups of participants. In Group 1 (conducted in 2015), this study highlighted those women with CHD were more likely to receive counselling compared to women with alternative diagnoses (64% vs. 29% (p < 0.01)). In Group 2 (conducted in 2018–2019), 46% received counselling (68% of the women with CHD vs. 15% of women with an alternative diagnosis (p < 0.001)) [32].

Four studies reported contraceptive counselling in relation to WHO’s risk of pregnancy classification (see Supplementary Table 3 for definition). A study among 88 women with CVD showed that women in higher pregnancy WHO classes were more likely to have received counselling than those in lower WHO classes (P < 0.002) [25]. In a UK retrospective study, in Group 1 (conducted in 2015), 69% of participants classified as high-risk received contraceptive counselling compared with 35% who were deemed low-risk (p < 0.05). In Group 2 (conducted in 2018–2019), 69% of the participants classified as high-risk (WHO II–III, III, or IV) received counselling compared with nine (26%) at low risk (p < 0.0001) [32]. Another study highlighted that women with complex CHD (according to the 2008 American College of Cardiology Guidelines for the Management of Adults with Congenital Heart Disease) were more likely to receive contraceptive counselling compared to those with less complex CHD (56.0% vs. 45%, p = 0.036) [31].

Furthermore, two studies documented a knowledge gap between actual and self-perceived disease severity among women with CHD. For example, a cross-sectional study from the USA [28], which applied the WHO Pregnancy Risk Classification to assess pregnancy complication risk, reported that only 51% of the study population accurately assessed their cardiovascular pregnancy risk score, with 22% underestimating and 27% overestimating the risk score [28]. In a cross-sectional study conducted across multiple centres in three countries (Germany, Hungary, and Japan), 45.7% (n = 290) of participants considered themselves to be inadequately informed, while 30.6% (n = 194) felt moderately informed, and less than one-fifth (n = 113) rated their level of information as very high [27].

Finally, there was a gap in knowledge regarding contraceptive choices, with many not having conversations with providers. A cross-sectional survey (n = 54) in an outpatient clinic of a large paediatric hospital in the USA indicated that less than half (46%) identified their contraceptive options correctly for their health conditions [29].

Eight studies identified that for women of reproductive age with CVD, their main sources of information were often obstetricians and gynaecologists, healthcare teams, and cardiologists [26,27,28,29,30,31, 33, 34]. Another study supported the findings that gynaecologists were the primary source of information. Only 43% indicated receiving counselling from their ACHD provider (physician, nurse practitioner, or physician assistant), 55% from gynaecologists, and 11% from primary care physicians [31]. A cross-sectional study from the USA reported that among participants who reported discussing contraception with a healthcare provider, 92.9% were with an obstetrician-gynaecologist, and less than 50% were with their cardiologist [28].

Two studies from the USA and the UK also showed that cardiologists were the primary source of heart-specific counselling for contraception among CHD patients, with some patients also receiving counselling from primary care physicians and obstetricians/gynaecologists [24, 25]. A cross-sectional survey from the USA at a single tertiary adult CHD clinic showed that a paediatric cardiologist was involved with 42% for their first contraceptive counselling and 13% for their most recent counselling. A cardiac specialist (paediatric cardiologist, adult cardiologist, or cardiothoracic surgeon) provided contraceptive counselling at least once for 57%, and only 25% of all study participants received heart-specific contraceptive counselling from a cardiac specialist. Others reported that heart-specific counselling first came from a primary care physician (26%) or an obstetrician/gynaecologist (24%). Regarding the most recent counselling, 29% received counselling from a primary care physician and 24% from an obstetrician/gynaecologist [25]. A UK retrospective cohort study also showed that combined ACHD cardiologist and obstetrician, as well as a follow-up from the cardiology team, were the source of contraceptive counselling [24]. Participants reported receiving counselling that did not include a discussion of their heart condition most frequently from a family medicine physician (73%) or an obstetrician/gynaecologist (55%) [25].

Finally, three studies from the USA and North America reported that ACHD providers and healthcare teams provided contraceptive counselling for more than a quarter of the participants. A cross-sectional survey in North America showed that 84% of ACHD reported receiving contraceptive counselling, but only 43% reported receiving counselling from an ACHD provider [31]. A USA cross-sectional study from registry also showed that the healthcare team provided information regarding the potential risks of subsequent pregnancies to 75.1% of patients [33]. While treating physicians were the primary source of contraceptive information, younger participants (aged 18–34 years) also turned to friends and the internet for information, with less than half discussing contraception with their cardiologist [26].

Among eleven studies included in this review, five assessed the prevalence of contraceptive uptake among women with CVD. The pooled contraceptive prevalence was 64% (95% CI, 45–82%); however, significant evidence of heterogeneity was identified (Q (4) = 318.73, r2 < 0.01, I2 = 98.06%, p < 0.001) (Fig. 7).

Contraceptive use among women with cardiovascular disorders

We found 64% of women with CVD were using some form of contraception. A cross-sectional study from the USA reported that approximately 76% of sexually active women with CHD were using contraceptives [28]. Only just over one-third of participants were using very effective contraceptive methods, with 11% using LARC methods (failure rate < 1% per year) [28]. In another US cross-sectional study, the commonly used LARC methods were tubal ligation (24.3%) and IUDs (16.4%) [33].

Some women were using less effective methods as well as methods where the risks of using the method outweighed the benefits. A cross-sectional study from the USA reported that only 24% of sexually active women with CHD were using effective methods (failure rate 6–12% a year), and 16% were using less-effective methods (failure rate 18–24% per year). This study found that 10% of participants with absolute or relative contraindications to combined hormonal methods were using them, with 53% reporting a history of use [28]. Three more studies reported many women with CVD, particularly those with CHD, were using less effective contraception (e.g., condoms) and often irregularly. A cross-sectional study from the USA showed that 15% of participants reported using contraception at least half or most of the time. The most common le