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Objective: To evaluate the effect of structured contraceptive counselling on the uptake of long‐acting reversible contraceptives (LARCs) and pregnancy rates. Design: Cluster randomised trial. Setting: Abortion, youth and maternal health clinics in Stockholm, Sweden. Population: Sexually active women aged ≥18 years without a wish for pregnancy seeking abortion and/or contraceptive counselling. Methods: For participants in clinics randomised to intervention, trained healthcare providers implemented a study‐specific intervention package designed for structured contraceptive counselling. Participants in the control clinics received routine counselling. Main outcome measures: The primary outcome was choice of LARCs at first visit. Secondary outcomes were LARC initiation at 3 months and pregnancy rates at 3 and 12 months. We used logistic mixed‐effects models with random intercept for clinic to account for clustering. Results: From September 2017 to May 2019, 28 randomised clinics enrolled 1364 participants. Analyses including 1338 subjects showed that more participants in the intervention group compared with the control group chose LARCs: 267/658 (40.6%) versus 206/680 (30.3%) (OR 2.77, 95% CI 1.99–3.86). LARC initiation was higher in the intervention group compared with the control group: 213/528 (40.3%) versus 153/531 (28.8%) (OR 1.74, 95% CI 1.22–2.49). At the abortion clinics, the pregnancy rate was significantly lower at 12 months in the intervention group compared with the control group: 13/101 (12.9%) versus 28/103 (27.2%) (OR 0.39, 95% CI 0.18–0.88). Conclusions: Structured contraceptive counselling increased LARC uptake in all clinics and significantly reduced unintended pregnancy rates in abortion clinics at the 12 months follow‐up. Structured contraceptive counselling increased LARC uptake and reduced pregnancy rates at 12 months. Structured contraceptive counselling increased LARC uptake and reduced pregnancy rates at 12 months. [ABSTRACT FROM AUTHOR]