Contraception and Contraceptive Use - study group statement

Consensus views arising from the 49th Study Group: Contraception and Contraceptive Use

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• Consensus views arising from the 49th Study Group: Contraception and contraceptive Use

Introduction

The focus of this meeting was on contraception and contraceptive use in developed countries, particularly in the UK. Other issues relating to fertility control, such as abortion, were addressed tangentially. Only passing reference was made to other partsof the world, including resource-poor countries. This summary of consensus views records briefly the key points made during the course of the meeting, followed by their implications for action. It reflects the views of the members of the Study Group and is not a comprehensive review.

Demographic and lifestyle trends

Population is still a vitally important policy area in both developed and developing countries. Patterns of and trends in fertility are now as important a focus in public health terms as absolute fertility rates have been to date. The so-called 'second demographic transition', characterised by declining age at first intercourse (to an average age of 16 years for today's teenagers) and increasing age at first childbirth (average age 27 years for women and 29 years for men), creates an extended interval during which people are at risk of unintended pregnancy and sexually transmitted infection. Increasing proportions of women are delaying childbearing until their fourth decade. The trend towards later marriage and the greater prevalence of cohabitation, delayed pregnancy and smaller families has major implications for contraceptive useand the demand for abortion. Condom use at first intercourse has increased dramatically over the past two decades. Comparative studies, however, show the prevalence of intercourse before ag e16 years in England to be the second highest, and recent condom use among young people to be the fifth lowest, in Europe. Abortion rates in the UK are comparable to those in other Western European countries in which contraceptive prevalence is high. Abortion ratios (the proportion of all pregnancies which are terminated) have been increasing, especially among teenage women. However, the figures for the UK remain considerably lower than those in other European countries.

Teenage conception rates in the UK have remained relatively stable over recent decades unlike those in some Western European countries, where rates have fallen. Rates in the UK remain amongst the highest in developed countries.

Implications for action

Health policy/education

1. Sexual health strategies need to continue to take account of our persistently unfavourable situation with regard to teenage pregnancy in comparison with other European countries.
2. Contraception and abortion elements of the National Sexual Health Strategies need to be prioritised by UK Government, the Department of Health and Commissioners, by establishing a National Service Framework or its equivalent

Contraceptive use

Given the increasing interval between the onset of sexual activity and the start of childbearing, considerable achievements have been made in helping people to regulate their fertility.

Men and women take into account a number of criteria when choosing a contraceptive method (from a list which might include effectiveness, safety, positive and negative side effects and acceptability of use) according to their health and situation in life. Couples in the UK who have completed their families still tend to choose sterilisation, despite the availability of long-acting methods that are easy to use and reversible in the event of wishing to resume childbearing with a new partner.

Most women need to use contraception for over 30 years. During the perimen-pause, declining fertility, an increasing tendency towards menstrual irregularity and increasing background risks of both cardiovascular disease and breast cancer influence contraceptive choice and eligibility.

Contraceptive continuation rates, in common with other health behaviours, increase with age and experience. With reversible methods, continuation rates have been shown to be highest with long-acting methods of contraception. Evidence from the USA suggests that increasing the uptake of injections and implants has contributed to a reduction in teenage pregnancy. The causes of discontinuation are not well understood but side effects, perceived or real, play a major part. Evidence is emerging of a beneficial effect on continuation rates of high quality information and advice.

Failure to use contraception at all, or to use it effectively and consistently, is often used as an indicator of unplanned pregnancy. Research has shown pregnancy intentions to be complex and so a simple measurement strategy is likely to provide poor estimates of the prevalence of unplanned pregnancy. Moreover, the value attached to the outcome of pregnancy varies with life stage and situation. Although a new evidence-based measure of unintended pregnancy has been developed, taking account of these factors, it has not yet been used to estimate prevalence. Furthermore, there is almost no detailed research on how women experience pregnancy, make decisions on outcomes and seek and use abortion services.

In the context of the need for prevention of sexually transmitted infections, there is an increasing necessity to ensure that protection against both pregnancy and infection are practised in tandem.

Implications for action

Policy

1. The RCOG guidelines on offering the full range of contraceptive methods to women after abortion should be reaffirmed.
2. Efforts should be made to educate the public about the safety and convenience of modern, long-term, reversible methods of contraception as an alternative to sterilisation.

Clinical practice

1. Given their relatively high continuation rates, long-acting non-user-dependent methods of contraception should be promoted among women likely to benefit most from their use.
2. Counselling for male and female sterilisation should be provided in services that can offer all contraceptive methods on site.
3. Contraceptive method counselling should include sexually transmitted infection prevention messages and discussion of the effective use of condoms for all women not in an exclusive sexual relationship.
4. There is a need for the development and use of a simple tool, for use in clinical practice, which will identify women at high risk of unintended pregnancy.
5. The newly available, validated British measure of unintended pregnancy should be used in research and in clinical practice to provide data that will inform the development and effective targeting of contraceptive services.

Research

1. More research is urgently needed in the UK to understand patterns of contraceptive use, the reasons for these patterns and the effectiveness of interventions designed to enhance use.
2. Further research is needed on premature discontinuation, with particular attention to the meaning for men and women of side effects of specific methods and how this interacts with ambivalence towards use of the method.
3. Research is needed to generate an understanding of why women seek abortion and their experience of doing so (including at later gestational stages).
4. Research is needed to examine and increase understanding of the interface between combined hormonal contraception and hormone replacement therapy relating to providing ongoing contraception, cycle control and relief of menopausal symptoms in older women.
5. Research should be undertaken into the biochemistry of the perimenopause to identify factors which might predict with greater precision the likelihood of further ovulation and hence the need for use of ongoing contraception.

Contraceptive methods risks, benefits and new developments

A variety of different methods of contraception are available. All are generally extremely safe compared with the risks associated with pregnancy and childbirth. Not all methods are suitable for everyone. Combined hormonal methods, in particular, are contraindicated for women with certain medical conditions.

Summaries of product characteristics and patient information leaflets produced b ythe manufacturers of contraceptives are often at odds with evidence and with national guidance and can cause confusion.

While there is evidence for an increased relative risk of breast and cervical cance rand cardiovascular disease in association with hormonal contraception, particularly the combined pill, the absolute risk is very small.

Since most cardiovascular events among oral contraceptive users occur in women with well-recognised risk factors (including smoking, hypertension and adverse lipid profiles), the most important preventive strategy in reducing cardiovascular risk among women of reproductive age is to reduce these risk factors.

Concern persists about the effect hormonal contraception may have on the risk of sexually transmitted infections and HIV infection acquisition and transmission.

The noncontraceptive health benefits of different methods (such as the reduction in menstrual dysfunction and ovarian, colorectal and endometrial cancer associated with the combined pill) have potentially enormous consequences for public health. These benefits may also increase uptake and continuation rates.

The prospect of new systemic methods of contraception, which depart from the theme of steroid hormones, remains distant. While antiprogestogens have been shown to have a wide range of contraceptive effects, their development has been hampered by their association with abortion.

Important advances have been made in the last decade in the development of hormonal methods for men.

Implications for action

Policy

1. Discussion on the content of summaries of product characteristics and patient information leaflets should involve the Medicines and Healthcare products Regulatory Agency, European regulatory authorities and consumer representatives and should reflect national guidance.

Clinical practice

1. Users of combined oral contraceptives should be told that they may have an increased relative risk of having breast and cervical cancer (particularly after prolonged periods of use) diagnosed while using hormonal methods of contraception.
2. When discussing the harmful effects of hormonal contraception, however, absolute as well as relative risks should be discussed and any beneficial effects highlighted.
3. Women should be informed of the risk factors associated with specific adverse health outcomes (such as smoking) and encouraged to reduce them.
4. Evidence-based guidelines, such as the World Health Organization's Medical Eligibility Criteria, the UK Faculty of Family Planning and Reproductive Health Care (FFPRHC) Guidance and the American College of Obstetricians and Gynecologists Practice Bulletin, should include recommendations based on different levels and combinations of risk factors.
5. Women with conditions that may be exacerbated by oestrogen should useprogestogen-only rather than combined methods.

Research

1. Additional high-quality prospective studies are needed to evaluate the effect of intrauterine contraception, oral and injectable contraceptives and newer hormonal methods on the risk of acquisition of sexually transmitted infections.
2. Continued research is needed regarding the combined effects of hormonal contraception and cardiovascular risk factors, especially for newer combined formulations and for progestogen-only formulations.
3. The development of new methods should take account of the need for contraceptives which have added health benefits, such as the prevention of breast or prostate cancer. Ideally, future developments in contraception should offerprotection against both pregnancy and sexually transmitted infections.
4. The development of hormonal methods for men should continue as a priority.

Provision of contraceptive education

Broad-spectrum dedicated campaigns, using the mass media, have been shown to be of value in raising awareness of the need for safer sex and contraception. By contrast, routine coverage in the print and broadcast media has contributed greatly to successive sensationalised 'pill scares', which have hindered progress in terms of preventing unplanned pregnancy.

Research has shown benefits of personal and sex education in schools in terms of increased likelihood of contraceptive use at first intercourse.

Implications for action

Policy

1. Sex and relationships education should be made a statutory component of personal, social and health education and citizenship within schools and efforts should continue to be made to incorporate it into teacher training.
2. Sex and relationship education needs to take account of the wider social context in which it takes place.

Clinical practice

1. Efforts should be made to use the media to educate contraceptive users and to influence the ways in which contraceptive issues are presented in the press.
2. Thought needs to be given to ways of presenting risk in a way that is easily understood by both professionals and the public, particularly with regard to relative and absolute risk.
3. Efforts should be made to increase awareness and knowledge of long-acting methods of contraception among both healthcare professionals and the public.

Research

1. Future research should focus on those at highest risk, with the aim of developing and evaluating interventions, including specifically parental involvement, to improve sexual health education.
2. Methods of developing and evaluating promising interventions in schools should be explored.
3. Research is needed on how healthcare professionals communicate risk and harm and on how this may influence uptake, adherence and continuation of contraceptives.

Provision of contraceptive services

Despite the many potential interventions for improving service delivery, there are few good data demonstrating that they improve contraceptive uptake, compliance or continuation rates, and none showing an effect on rates of unintended pregnancy. There is disappointingly little evidence, as yet, of any impact of protocols and guidelines on effectiveness of service provision. There is, however, evidence that contraceptive access is improved by provision of services in a range of settings, including nonclinical venues. There is also evidence from other countries, most notably the Netherlands, that the dismantling of services is quickly followed by a deterioration of sexual and reproductive health status.

Research shows confidentiality to be paramount in young people's decision to choose and use a service.

Implications for action

Policy

1. Consideration should be given to the more frequent and widespread use of independent and supplementary prescribing and Patient Group Directions so as to improve access to contraceptive and sexual health services.
2. Given the strength of the evidence of young people's need to access confidential services, members of the Study Group oppose any changes that would jeopardise this.

Clinical practice

1. Access to all forms of fertility control should be increased by optimising opening hours and broadening the range of outlets, including those in innovative settings such as schools.
2. Training should address clinical skills and knowledge, attitudes, values and communication in contraception and sexual health.
3. Sexual health training in relevant healthcare subjects needs to start in the undergraduate years and continue throughout postgraduate careers.
4. All professionals providing contraceptive services should be appropriately trained.
5. Every health policy maker, head of service and clinical team should routinely have a system in place to draw attention to recently published guidelines, standards, consensus statements (such as these Study Group proceedings) and policy documents relevant to their area of practice.
6. Policy makers, heads of services and clinical teams should compare their own practice with the recommendations in these identified documents. If necessary, local audits should be undertaken to assess the extent to which practice measuresup to recommendations.
7. For each aspect of practice for which a need for change is identified,a three-point action plan for change should be adopted
   • What are we going to do?
   • Who is going to make it happen?
   • When will it be done