New research exploring women’s attitudes to contraception suggests some ways to boost the uptake of long-acting reversible methods. Nerys Hairon finds out more
Hairon, N. (2008) Increasing use of long-acting reversible contraception. Nursing Times; 104: 42, 23–24.
Many women are worried about the effects of contraceptives on future fertility (Glasier et al, 2008). This research, which aimed to inform a campaign to increase the use of long-acting reversible contraception (LARC), suggested that practitioners should stop describing these methods as ‘long-acting’ and stress their lasting protection instead.
The study, published in the Journal of Family Planning and Reproductive Health Care, found concerns about side-effects such as weight gain deterred women, outweighing even the fear of unwanted pregnancy.
In spite of NICE (2005) guidance on the use of LARC, its uptake in the UK is low. The study authors conclude that, while some barriers to its use cannot be overcome, giving more information on ease of use, reversibility, effects on weight and other women’s positive experiences may help improve acceptability.
The term LARC encompasses intrauterine devices/intrauterine system (IUDs/IUS), implants and injectables. In 2005–2006, only 10% of women aged 16–49 years in the UK had used any LARC in the previous year, compared with 23% who had used oral contraception and 21% condoms (Taylor et al, 2006).
Glasier et al (2008) say increasing uptake of LARC is one measure being used to monitor implementation of the national sexual health strategy in Scotland.
The Department of Health (2008) launched an initiative to promote LARC use and improve access to contraception for young people (Hairon, 2008). The DH says that 11% of sexually active women do not use any form of contraception. It pledged that local health teams would be given extra money to work with women of all ages to promote all methods of contraception, including LARC.
Glasier et al (2008) aimed to improve the understanding of attitudes to contraception and unintended pregnancy, the reasons for choosing the popular methods, and knowledge of and potential interest in LARC.
Eight focus groups were held with 55 women in two cities in Scotland. The researchers recruited women with lifestyles that might increase the desirability of long-term contraception (students, young mothers and those who did not want more children). Discussions covered unintended pregnancy and contraception in general, condoms and contraceptive pills in particular, and attitudes towards healthcare professionals giving advice. Attitudes to LARC were discussed before and after women were given detailed information about these methods.
The researchers found that contraceptive choice was based on perceptions of safety, efficacy and reliability of protection against pregnancy and disease, ease of use, sideeffects, reversibility and accessibility.
All women stressed the importance of contraception. Despite strong belief in the need for it, all participants indicated they had taken or were prepared to take risks.
In discussions about healthcare professionals, many women wanted to avoid seeing a doctor, citing embarrassment, concern about confidentiality and difficult/inconvenient access as reasons. They expressed a preference for consulting female healthcare professionals but had limited awareness of nurses’ role. While they praised GPs in managing contraceptive problems or side-effects, there was an overall perception that primary care consultations by GPs failed to provide the education and information on which to base decisions. The focus groups revealed that women disliked starting discussions about contraception with healthcare professionals.
The authors argue that women want to be offered contraceptive choices and to feel they have sufficient knowledge to make informed decisions. Participants felt healthcare staff should ask the right questions, be proactive and questioning, avoid assumptions and present information in an open manner.
Participants perceived contraceptive pills and condoms to be effective and protective, and considered them ‘normal’.
Pills were perceived as effective, known, convenient and easy to ask for; to result in lighter, more regular periods; and more effective and less ‘messy’ than condoms. However, women acknowledged that pills had to be taken regularly and many admitted to forgetting to take up to three pills each month.
Discussions on LARC revealed that while most participants were aware of long-acting methods, they had limited knowledge of individual methods, and relied on ‘negative, second-hand stories’ from friends and the media. After being given detailed information about LARC, women accepted their knowledge was limited.
However, the authors stress that concerns about these methods were still evident, especially in relation to intrauterine methods. While there were positive responses to ease of use, efficacy and side-effects, women continued to express concern about duration of action and were unhappy with the term ‘long-acting’, with its implications of a possible negative effect on return of fertility. As a result, they preferred the idea of methods being ‘lasting’. Participants also had concerns regarding insertion and removal. When asked directly, 25% – particularly university students and young mothers – said they might be interested in LARC in the future.
The authors argue that, to increase consideration of LARC methods, women want help from healthcare professionals to make informed choices.
Glasier et al (2008) say that well-recognised factors such as effectiveness, ease of use and safety are important considerations in choosing a contraceptive method. They stress that familiarity is also clearly important, which may explain why it seems to take a long time for new methods to become widely used. For women in their study, taking oral contraceptives was seen as the norm, and they were nervous about using a method they perceived as ‘unusual’.
The authors argue that healthcare professionals need to be aware of this when outlining methods that are ‘new’ to patients – it may be important to emphasise that lots of women use and are happy with them.
The study also revealed the strong influence of other people’s experiences. The authors say it is ‘disappointing’ that providing correct information appears to do little to change prejudices. The research also confirmed that myths and misconceptions about contraception are common and fear of side-effects is an important factor in their acceptability. Fear of visible side-effects has an impact on both uptake and continuation and outweighs the fear of pregnancy, even when unwanted.
In addition, all women were ‘extremely anxious’ to avoid any method that might jeopardise their fertility. The researchers found the term ‘lasting’ had a positive meaning, implying reliability and quality. They say that while some barriers to LARC cannot easily be overcome, terms used to describe these methods and fears about infertility could be overcome. Their reversibility and lack of effect on weight should be stressed.
Glasier et al (2008) conclude that positive, open consultations with healthcare professionals, focusing on concerns including insertion/removal and return of fertility could help overcome some barriers.
The box below outlines some of the study’s key messages for nurses. NICE (2005) guidance recommends that women requiring contraception should be given information about and offered a choice of all methods, including LARC methods. It also covers counselling, provision of information and training healthcare professionals, and outlines the care pathway.
Practice nurses are vital in ensuring that women are provided with the necessary information to make informed choices.
Key points for nurses
Department of Health (2008) £26.8 Million to Improve Access to Contraception. Press release, 6 February 2008. www.dh.gov.uk
Glasier, A. et al (2008) Attitudes of women in Scotland to contraception: a qualitative study to explore the acceptability of longacting methods. Journal of Family Planning and Reproductive Health Care; 34: 4, 213–217.
Hairon, N. (2008) Drive to increase contraceptive service use among young people. Nursing Times; 104: 7, 21–22.
NICE (2005) Long-acting Reversible Contraception. Quick Reference Guide. www.nice.org.uk
Taylor, T. et al (2006) Contraception and Sexual Health 2005/06. Omnibus Survey Report No 30. www.statistics.gov.uk