NICE: 'schools should provide morning-after pill'
New guidelines on contraceptive services for young people issued by the National Institute for Health and Care Excellence (NICE) have prompted widespread coverage.
The headlines have focused on a number of elements, with The Daily Telegraph reporting that, “Schools are told to give free morning-after pills and condoms to teenage girls to cut unwanted pregnancies”, while The Daily Express claims that there is “Outrage as NHS says ‘give pupils the morning-after pill’.”
The media coverage largely focuses on recommendations to:
- provide free emergency contraception such as the morning-after pill (which includes provision by suitably qualified nurses, including school nurses, and pharmacists)
- provide school and education-based contraceptive services
- provide condoms in addition to other methods of contraception
NICE is the body that advises on best practice for healthcare in England. These new guidelines aim to improve access to high-quality contraceptive services for young people.
The guidance is targeted at professionals who may have a role in contraceptive services. The wide-ranging recommendations advise on how to assess local need for contraceptive services, and offer culturally appropriate and non-judgemental services to young people.
Why do we need to help young people get contraception?
NICE states that although conception rates for under-18s have fallen to the lowest levels since 1969, England still has one of the highest teen pregnancy rates in Europe. There were 27,834 conceptions among women aged under 18 in England in 2012.
The new guidance sets out to reduce the number of unwanted pregnancies among young people through providing improved contraceptive services.
How did the media report the news?
The publication of the new NICE guidelines was covered very reasonably by the Mail Online website.
The Daily Telegraph also took an initially balanced view. However, it chose to cite only two independent comments, both in opposition to the advice.
Patient Concern described the guidance as “like a way of promoting promiscuity”, while a spokesperson for Comment on Reproductive Ethics, known for its links to religious groups, said: “Having a stockpile of the morning-after pill on hand is a licence for unprotected sex”. Neither of these statements is backed by the evidence.
What are the NICE recommendations on contraceptive services?
The new young people’s contraceptive guidance advises those in charge of health-related services in England to give all young people access to contraception. Advice should also be provided at convenient locations so that everyone can get contraceptive services, regardless of where they live.
The recommendations emphasise the need to offer additional tailored support to meet the particular needs and choices of those who are socially disadvantaged or who may find it difficult to use contraceptive services.
There are 12 recommendations set out in the guidelines. The recommendations that have been the main focus of the media attention include:
- providing contraceptive services for young people – doctors, nurses and pharmacists should provide information about the full range of contraceptives available
- providing contraceptive services after a pregnancy
- providing contraceptive services after an abortion – the guidelines point out that it is important to dispel the myth that there is no need for contraception after an abortion and to explain that women are fertile immediately after an abortion
- providing school and education-based contraceptive services – information on the location and hours of local services should be available
- providing emergency contraception – suitably qualified nurses (including school nurses) should be given the ability through “patient group directions” (PDGs) to give free oral emergency contraception to young women and ensure that young people know where to obtain free emergency contraception
- young women should be informed that an intrauterine device is a more effective form of emergency contraception than the oral method and can be used on an ongoing basis
- providing condoms as well as other methods of contraception – condoms should always be made accessible along with other contraception, as they help prevent the transmission of sexually transmitted infections (STIs)
PDGs are a legal framework established in 2000 that allows some registered health professionals to provide a specified treatment to a predefined group of people without them having to see a doctor.
Treatment provided under PDGs should be reserved for situations in which this offers an advantage for patient care without compromising patient safety.
How do contraceptive pills work?
There are quite a lot of contraceptive methods to choose from. One of the most popular forms of contraception is the combined oral contraceptive pill – usually just called “the Pill” – which contains synthetic versions of the hormones oestrogen and progesterone. When taken correctly, it is more than 99% effective at preventing pregnancy.
Women need to follow the guidance of healthcare professionals on how to use the Pill prescribed for them, including advice on what to do if a combined pill is missed.
The combined pill is not suitable for everyone – there are various groups of women who cannot take it or should take it with caution. Other kinds of contraceptive pill or devices are available.
Read more about the 15 methods of contraception.
What are the methods of emergency contraception?
A woman can use emergency contraception to prevent pregnancy after having unprotected sex or if a method of contraception has failed. There are two methods of emergency contraception:
- the emergency contraceptive pill (the morning-after pill) – either Levonelle or ellaOne
- the copper intrauterine device (IUD) – a small plastic and copper device that can be fitted into your womb by a doctor or nurse within five days of having unprotected sex or up to five days after ovulation
Both of these methods are effective at preventing pregnancy if they are used soon after unprotected sex. However, the IUD is always 99.9% effective, whereas Levonelle is very slightly less effective.
The emergency contraceptive pill should not be used as a regular method of contraception. However, if the copper IUD is fitted, this can be used as an ongoing form of contraception.
Are there any side effects or risks of complications of contraceptive pills?
The combined pill (the Pill)
There are some risks associated with using the combined contraceptive pill. However, these risks are small, and the benefits outweigh the risks for most women.
Oestrogen in the pill may cause your blood to clot more readily. If a blood clot develops, it could cause a deep vein thrombosis (clot in your leg), pulmonary embolus (clot in your lung), stroke or heart attack.
The risk of getting a blood clot is very small, but your doctor will check if you have certain risk factors that make you more vulnerable before they will prescribe the Pill. These risk factors include being a smoker, being overweight, having high blood pressure, or having a personal or close family history of blood clots.
Research is ongoing into the link between breast cancer and the Pill. Research suggests that users of all types of hormonal contraception have a slightly higher chance of being diagnosed with breast cancer compared with women who do not use them. However, your risk of breast cancer returns to normal 10 years after you stop taking the Pill.
Research has also suggested a link between the Pill and the risk of developing cervical cancer and a rare form of liver cancer. However, the Pill does offer some protection against developing endometrium (lining of the womb) cancer, ovarian cancer and colon cancer.
The emergency pill
Taking the emergency contraceptive pill has not been shown to cause any serious or long-term health problems. However, it can sometimes have side effects. Common side effects include:
- abdominal (tummy) pain
- irregular menstrual bleeding (spotting or heavy bleeding) before your next period
- nausea (feeling sick)
Less common side effects include:
- breast tenderness
- vomiting – seek medical advice if you vomit within two hours of taking Levonelle or three hours of taking ellaOne, as you will need to take another dose or have an IUD fitted
When the copper IUD is inserted, it needs to be ensured that there is no current sexually transmitted infection, as an existing infection can be worsened by inserting the IUD.
Pain or discomfort is the most common side effect immediately after inserting the copper IUD. In the longer term, side effects include the possibility of heavier or more painful periods.
Everyone makes mistakes, but if you find yourself relying on the morning-after pill as a regular method of contraception, you may want to speak to a healthcare professional about what would be the most suitable form of ongoing contraception for you to use. This could include methods that do not involve needing to take a daily pill, such as contraceptive patches, injections or an implant.
However, none of these methods will protect you against sexually transmitted infections (STIs). Condoms are cheap, free of side effects and they will protect you against STIs such as chlamydia.
For more information about your contraception options, visit the Contraception guide. If you have any health questions and want to speak to someone in confidence, call:
- the Sexual Health Line on 0300 123 7123
- Brook on 0808 802 1234
- the fpa on 0845 122 8690
- NHS 111