Improving young people's access to emergency contraception
VOL: 99, ISSUE: 33, PAGE NO: 24
Claire Flowerdew, BSc, RN, is clinical team leader in school nursing, Mid Sussex Primary Care TrustThe UK has the highest teenage pregnancy rate in western Europe (Social Exclusion Unit, 1999) and various action plans have been identified to achieve the government's target of reducing this rate by 50 per cent by 2010. These plans include better prevention so that young people are better informed and prepared to deal with the pressure to have a sexual relationship and are better able to access contraceptive advice and services (SEU, 1999).
In 2000 a progesterone-only postcoital contraceptive, Levonelle-2 (two tablets of levonorgestrel 750µg), was licensed as a prescription-only medicine. Its legal status was then changed in 2001 to a pharmacy medicine available for women over the age of 16 years and was sold as Levonelle (McQuarrie, 2001). The term Levonelle is used in this article because both products (Levonelle and Levonelle-2) contain levonorgestrel. It remains available on prescription to all women, including girls under 16 years without parental consent if the Fraser guidelines are followed (Box 1). Efficacy of Levonelle
Levonelle is a safe and effective contraceptive (95 per cent efficacy) if taken up to 24 hours after unprotected sex (Schering, 2001). It can be used up to 72 hours after unprotected sex, but its efficacy falls to 85 per cent if taken 25-48 hours afterwards and to 58 per cent if 49-72 hours have elapsed (Schering, 2001). The exact efficacy is difficult to ascertain because a percentage of women taking it would not have become pregnant anyway. Levonelle works by preventing or delaying ovulation and reducing the thickening of the endometrium. It reduces the likelihood of implantation of a fertilised egg and adversely affects the tubal transportation of the egg and sperm. It does not have an abortive effect because an implanted egg would be unaffected (Schering, 2001). Certain medications, such as St John's Wort, phenytoin, rifampicin (for tuberculosis), ritonavir (for HIV) and griseofulvin (for fungal infections), will reduce its absorption and its effect, as will some medical conditions, for example Crohn's disease (Schering, 2001). Side-effects
Levonelle causes nausea in 23 per cent and vomiting in six per cent of women. Other possible side-effects include breast tenderness, headaches, lower abdominal pain, tiredness and spotting until their next period (Schering, 2001). As the name 'emergency contraception' suggests, it is only intended for use in an emergency when another method of contraception fails, for example a condom splits, or when passion or alcohol compromise rational thinking. High teenage pregnancy rate
The UK has a high rate of alcohol use among teenagers (Alcohol Concern, 2002) and a high teenage pregnancy rate. Young people are not only more likely to have unprotected sex when using alcohol, but those who drink are also more likely to take other risks, including having unprotected sex, even when sober (Alcohol Concern, 2002). Alcohol use in UK teenagers impacts on the teenage pregnancy rate, as does the fact that 30 per cent of those under 16 are sexually active and half of these did not use contraception when they first had sexual intercourse. The teenage pregnancy rate is a concern because of the effect on both the teenage mother and her child if she chooses to proceed with the pregnancy (SEU, 1999). Half of those under 16 who become pregnant have terminations, as do a third of 16 to 17-year-olds. Teenage parents are more likely to live in poverty because they have been unable to complete their education or secure a good job. Their babies tend to have lower birth weights and the mortality rate of babies born to this group is 60 per cent higher than those born to older mothers. Daughters born to teenage mothers are also more likely to become teenage parents themselves (SEU, 1999). The SEU (1999) identified several contributory factors to teenage pregnancy, including poor access to contraceptive services and lack of knowledge about contraception. School nurses are ideally placed to participate in interventions to reduce these gaps. Their expertise in delivering sex education in a relaxed and informative way has been recognised for some time (Sex Education Forum, 1996). This, together with their promotion as public health practitioners (DoH, 1999), may encourage schools to invite them to participate in delivering the personal, social and health education curriculum as well as developing the school's sex and relationship education policy (DoH, 2001). The NHS Plan (DoH, 2000) sets a clear agenda for nurses to extend their roles, for example by taking on prescribing. Until this is realised, they can issue emergency contraception under a patient group direction (PGD). Access to family planning services
Although emergency contraceptive pills are available on prescription from GPs, family planning clinics and some A&E departments, access remains a problem because: - Young people are often reluctant to attend GP surgeries (Sherman-Jones, 2003); - Family planning clinics may not be easily accessible; - Not all family planning clinics run dedicated young people's sessions. Because efficacy decreases as the coitus-to-treatment time increases, easy access to family planning services is essential to reducing the number of teenage pregnancies. Community pharmacy schemes are being introduced to improve availability, particularly at weekends. The more anonymous nature of such services means clients are less likely to be recognised and may encourage uptake (SEU, 1999). Pharmacists are being trained to dispense Levonelle to young people, including those under 16 years old, via a PGD (McQuarrie, 2001). The upper age limit is decided by the primary care trust funding the project. The young women who obtain their pills by this route are not offered a follow-up appointment but are referred to another professional, such as a family planning clinic, GP or school nurse. Follow-up is particularly important if a normal period has not occurred within three weeks of treatment so that pregnancy can be excluded. One of the advantages of young people obtaining emergency contraception from family planning clinics, GPs or school nurses is their ability to follow up each person. They can also keep a record of the number of requests. Repeated requests indicate a need for more sexual health promotion. Health promotion
Some degree of sexual health promotion is essential when prescribing emergency contraception because this method is only for use in an emergency. If another method has failed then some instruction may be required to reduce the chance of another occurrence. If no contraceptive was used then an appropriate professional should discuss various methods for future use or a referral to local services should be made. The risk of sexually transmitted infections (STIs) should also be explained and patients should be referred on or advised to attend a sexual health clinic for screening. Chlamydia, an STI that is often asymptomatic but can cause ectopic pregnancy and may lead to infertility if left untreated, affects more teenage girls than any other age group (SEU, 1999). The highest incidence of gonorrhoea is also seen in young people aged 16-19 years (SEU, 1999). Both these infections respond well to antibiotics but need to be detected for treatment to be commenced. Legal issues
Whenever treatment for young people is discussed the issue of parental consent is raised. Section 8 of the Family Law Reform Act 1964 set the age of medical majority at 16 years, allowing those of this age to consent to medical or surgical procedures. In 1985, Mrs Gillick attempted to prevent any doctor supplying contraceptives to her five daughters without her consent before they were 16 years old. The high court case failed (Gillick v West Norfolk and Wisbech Area Health Authority and the DHSS, 1985) and the resulting Fraser guidelines (Box 1) are followed when a minor presents requesting advice or contraception. The Children Act 1989 upholds this by insisting that the welfare of the child is paramount and indicates that minors can consent or refuse treatment if they have the capacity to understand what is involved. The NMC (2002) reflects this sentiment by acknowledging that parental consent is usually necessary but this does depend on the age and cognitive ability of the child. Nurses must also abide by the Code of Professional Conduct (NMC, 2002) and ensure that their actions or omissions do not harm a patient, in this case a young person requesting emergency contraception. Although it is good practice to encourage young people to discuss their contraceptive needs with a parent or carer, if they refuse and treatment is withheld then a pregnancy could arise. Any professional working with children and young people must take child protection issues into account. It is important to satisfy yourself that sex has been consensual and is not occurring in an incestuous relationship. If professionals feel that coercion or force have been used or that any sexual abuse has occurred they have a duty to follow national and local child protection procedures; for nurses this is clearly stated by the NMC (2002). Conclusion
Improving access to emergency contraception is only one issue that needs to be addressed to achieve the government's target reduction in the teenage pregnancy rate by 2010. Sex education in schools needs to include information not only about contraception and where services are located but also needs to build skills to help young people deal with the pressure to have sex (SEU, 1999).