New funding has been made available to improve uptake of contraceptive services by young people. Nerys Hairon explains how nurses can help to cut teenage pregnancies.
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The government has announced a 26.8m drive to improve access to contraception for young people, and to help reduce the teenage pregnancy rate (Department of Health, 2008).
While teenage pregnancy rates in England are at their lowest for over 20 years, latest figures show that 11% of sexually active women do not use contraception. Most (80%) teenage pregnancies are in 16 to 17-year-olds, and the highest rates of termination are among 20 to 24-year-olds (DH, 2008). Local health teams are therefore to be given extra funding to work with women of all ages to promote the full range of methods of contraception, including long-acting reversible contraception (LARC).
The effectiveness of condoms and oral contraceptives depends on their correct use. NICE (2005) published guidance on LARC, which highlighted that LARC methods do not depend on daily concordance. NICE (2007) guidance on preventing sexually transmitted infections and unwanted teenage pregnancies outlined recommendations for practice nurses, school nurses, midwives and health visitors to improve use of contraception among young people.
Some 14m will be available to fund innovative new ways of helping young people to access sexual health advice and contraception. Strategic health authorities will be asked to produce proposals and, if agreed, they could be granted funding to run pilots. Examples of ways in which the money could be used are:
Offering contraception and more information at termination of pregnancy (ToP) clinics to prevent repeat procedures;
Working with health visitors to target vulnerable young women – particularly teenage mothers;
Providing condom kiosks in pharmacies.
This funding is in addition to the 130m invested in sexual health clinics and services over the past two years. A total of 12.8m of the new funding will be distributed to PCTs in their main allocations.
The DH says the Teenage Pregnancy Strategy has reversed the previous upward trend and reduced the under-18 conception rate by 11.4% and the under-16 conception rate by 12.1%.
However, NICE (2007) guidance stressed that the UK still has the highest rate of teenage pregnancy in western Europe. In 2004, there were 39,545 under-18 conceptions in England, of which 41% ended in termination. In the same year, there were 7,179 under-16 conceptions, of which 58% were terminated (NICE, 2007).
LONG-ACTING REVERSIBLE METHODS
NICE (2005) guidance on LARC outlined a number of key priorities for implementation for healthcare professionals, to improve contraception choices for women. These priorities focus on: contraceptive provision; counselling and provision of information; and training healthcare professionals in contraceptive care.
The guidance emphasised that women needing contraception should be given information about and offered a choice of all methods, including LARC. Contraceptive service providers should be aware that:
All currently available LARC methods (intrauterine devices (IUDs), the intrauterine system (IUS), injectable contraceptives and implants) are more cost-effective than the combined oral contraceptive pill even at one year of use;
IUDs, the IUS and implants are more cost-effective than injectable contraceptives;
Increasing the uptake of LARC methods will reduce the number of unintended pregnancies.
Under counselling and provision of information, NICE recommended that women considering LARC should receive detailed information – both verbal and written – to enable them to choose a method and use it effectively. This information should take into account their individual needs and should include:
Duration of use;
Risks and possible side-effects;
The procedure for initiation and removal/discontinuation;
When to seek help while using the chosen method.
In addition, NICE emphasised the importance of training for healthcare professionals. Practitioners advising women about contraceptive choices should be competent to:
Help women to consider and compare the risks and benefits of all methods relevant to their individual needs;
Manage common side-effects and problems related to contraceptives
Service providers who do not provide LARC within their own practice or service should have an agreed mechanism in place for referring women for this contraception. Healthcare staff providing intrauterine or subdermal contraceptives should receive training to develop and maintain the relevant skills to provide these methods.
The guidance (NICE, 2005) also contains a useful diagram illustrating the recommended care pathway for women requesting contraception, and a table outlining the features of different LARC methods to discuss with them. Another section contains information on appropriate choices and those not recommended for different groups of women according to age, childbirth, medication, medical history and STI risk (see www.nice.org.uk for details on these factors). The women for whom all LARC methods are suitable are listed in the guidance (see box), and it contains practical details related to LARC, including fitting or administering the contraceptives.
PREVENTING TEENAGE PREGNANCIES
NICE (2007) guidance on sexual health contains two recommendations that focus on reducing the rate of conceptions in women under the age of 18.
The first recommendation on preventing unwanted pregnancies is aimed at nurses working in primary care, community contraceptive services, antenatal and postnatal care, ToP and GUM services, and school nurses. Where appropriate, these nurses should provide one-to-one sexual health advice on a range of issues to vulnerable young people under 18. Topics should include:
How to prevent unwanted pregnancies and STIs;
All methods of reversible contraception including LARC in line with NICE (2005) guidance;
How to obtain and use emergency contraception.
Nurses should also provide supporting information in an appropriate format.
The second recommendation in the guidance is aimed at midwives and health visitors who provide antenatal, postnatal and child development services. These practitioners should regularly visit vulnerable young women under 18 years of age who are pregnant or already mothers, and should discuss with them how to prevent unwanted pregnancies and STIs. This discussion should cover:
All methods of reversible contraception, including LARC, and how to obtain and use emergency contraception;
Health promotion advice, in line with NICE (2006) guidance on postnatal care;
Opportunities for returning to education, training and employment in the future.
Again, practitioners should provide supporting information in an appropriate format and, where appropriate, they should also refer young women to relevant agencies, including services concerned with reintegration into education and work.
It is clear that practice nurses, school nurses, midwives and health visitors can play a significant role in increasing contraceptive use among young people and promoting wider choice of methods. Increasing the use of LARC will reduce unwanted pregnancies. Nurses can also take the lead in setting up innovative new projects to improve access to contraception for young and vulnerable people.
All LARC methods are suitable for:
Choices for adolescents:
Source: NICE (2005)
Department of Health (2008) 26.8m to Improve Access to Contraception. Press release, Wednesday, 6 February.
NICE (2007) Reducing the Transmission of Sexually Transmitted Infections (STIs) Including HIV, and to Reduce the Rate of Under-18 Conceptions, Especially Among Vulnerable and At-Risk Groups. London: NICE. www.nice.org.uk
NICE (2006) Routine Postnatal Care of Women and Their Babies. London: NICE. www.nice.org.uk
NICE (2005) Long-acting Reversible Contraception. Quick Reference Guide. London: NICE. www.nice.org.uk