Freda Barber, BSc (Hons), RN, RM.
Senior Nurse, Graingerville Clinic, Newcastle Contraception and Sexual Health ServiceA wide range of highly effective contraceptive methods is available today, yet a recent survey of over 5000 British women revealed that 29% of them had had an unplanned pregnancy (National Opinion Poll, 2003). Of these, 48% put it down to difficulties with their contraception. In a French study of unplanned pregnancies (Bajos et al, 2003) 65% of women were using some form of contraceptive. UK abortion rates among women in their 20s and 30s are also very high (Department of Health, 2001).
A wide range of highly effective contraceptive methods is available today, yet a recent survey of over 5000 British women revealed that 29% of them had had an unplanned pregnancy (National Opinion Poll, 2003). Of these, 48% put it down to difficulties with their contraception. In a French study of unplanned pregnancies (Bajos et al, 2003) 65% of women were using some form of contraceptive. UK abortion rates among women in their 20s and 30s are also very high (Department of Health, 2001).
So why are women having problems with their contraception? One of the major issues is regimen concordance, and this paper aims to outline the fact that by ensuring that the patient is involved as much as possible in the decision-making process she will be much more likely to take responsibility for using her method correctly.
Real-life usage of hormonal options
Of the three-quarters of British women aged between 16 and 49 who are using some form of contraception, 28% are using the contraceptive pill (Office for National Statistics, 2001) But although many of today's contraceptive options are extremely effective when used correctly, failure rates of combined oral contraceptives (COCs) are approximately 5% during the first year of use compared to failure rates of 0.1% reported in clinical trials where COCs are used correctly and consistently (Trussell, 1998).
Concordance can be affected by a variety of factors, including the following:
- Younger women may have an ambivalent attitude to Pill-taking or lead an unstructured lifestyle not well suited to remembering a Pill every day
- Older women leading busy lives involving full-time work and raising a family might also forget to take the Pill
- Women may lack understanding of how the body or contraception works; many women may be reluctant to ask for advice or do not know who to go to for help
- Real or perceived side-effects with their chosen method may also affect concordance and create a negative association in the mind of the user.
To help patients make an informed choice it is important to gain a thorough understanding of their lifestyle, their needs and any preconceptions they may have about contraception.
What to ask the patient
The consultation gives the nurse an excellent opportunity to encourage women to consider what they want from their contraception to help them become knowledgeable about the contraceptive option that is most suitable for them.
Health-care professionals may want to discuss the following when it comes to helping a woman make a decision on contraception:
- Whether she knows all the options available to her
- If she has any idea of what method she would like to use
- Any medical conditions (or history) that might influence what options are suitable
- Special consideration that may need to be given, such as age and/or weight and/or whether she is a smoker
- Whether it would be a disaster, or just an inconvenience, if she got pregnant now
- Whether she has any reservations about any particular methods
- Whether she wants something that gives her contraception cover all the time or just as and when she needs it
- Whether she is nervous or worried about using contraception
- The real need to protect herself from sexually transmitted infections (STIs) as well as preventing pregnancy, preferably by using a condom with a hormonal method.
What the patient may ask
Women may want to ask the nurse some of their own questions, such as:
- What options are currently available?
- What types are suitable for their life stage? Requirements may differ between women who:
- Are in a regular long-term relationship versus those likely to be having more than one sexual partner
- Want children in the near or distant future, compared to those who are between children, or have completed their family or who do not want children at all
- How effective the different types are - in real-life situations - and how easy they are to use
- The benefits or risks to health from the different contraceptive options.
There is already a wide range of contraceptive options, but the ongoing high rate of unplanned pregnancies indicates the need for greater choice, education and patient involvement in the decision-making process. Fortunately, the choice is set to increase further over the next few months, with the introduction of a vaginal ring, monthly injections and new formulations of the contraceptive pill. For the future, research is under way to develop low-dose androgens in combination with gestogens or gonadotrophin-releasing hormone antagonists for male contraceptive pills.
The most recent addition to the range of contraceptive choices now available for prescription in the UK is the transdermal patch, Evra (Janssen-Cilag), which releases the hormones oestrogen (ethinyl estradiol 20mcg) and progesterone (norelgestromin 150mcg) directly through the skin each day over the seven-day wear period. Each patch lasts for one week and is replaced every week for three weeks, followed by a fourth 'patch-free' week. The patch should be worn on hairless skin such as the buttock, abdomen, upper arm or upper torso and consecutive patches should be applied at a different place. Care must be taken with disposal of the patches to prevent harmful environmental effects. They should be sealed in a disposable pouch and thrown away or returned to the pharmacy. They should not be flushed down the toilet.
A study comparing the patch with the Pill showed similar efficacy in preventing pregnancy but better concordance. Average concordance was 88.7% for women using patches compared with 79.2% for those taking the Pill. Concordance with the patch was consistent across all age groups, with 87.8% of patch users aged under 20 achieving perfect concordance compared to 67.7% with Pill users (Archer et al, 2002).
With the wide range of contraceptive options currently available and further developments on the horizon there is an opportunity for nurses to make a measurable impact on the lives of women considering birth control. This can be achieved by working with them to find a method that matches their lifestyle and preferences, educating them about contraception and their bodies and ensuring they know where they can access further information.
CONTRACEPTIVE OPTIONS AVAILABLE
Hormonal: All have one or more actions on the body to prevent pregnancy, either via inhibiting ovulation and/or thickening the mucus in the cervical canal to help prevent sperm meeting the egg and/or thinning the womb lining to prevent eggs implanting. Options include:
- Combined oral contraceptives
- The mini-pill
- The patch
- Intrauterine system
Advantages: over 99% effective if used correctly (Trussell, 1998). These methods can improve the symptoms of premenstrual syndrome, protect against some cancers - particularly the ovaries and womb, and all are reversible and do not cause infertility (Guillebaud, 1999).
Disadvantages: although there are few absolute contraindications, a medical history should be taken before prescribing these methods. They do not protect against STIs.
Non-hormonal options include:
- Condoms (male and female)
- Diaphragm and caps
- Intrauterine devices
- Natural family planning
- Sterilisation (male and female).
Condoms and the diaphragm act as barriers to prevent sperm entering the vagina or cervix, although only male and female condoms can protect against STIs, and for many woman diaphragms have an unacceptably high failure rate of 4-8%. Natural family planning relies on the patient avoiding intercourse during the most fertile times of the menstrual cycle. This may need modification of sexual behaviour and commitment from both sexual partners.
Advantages: these can be an effective means of contraception for those who do not want to or cannot use hormonal contraception. They are reversible and do not cause infertility.
Disadvantages: can be susceptible to user error. IUDs are thought to create an inflammatory response, which destroys the sperm and egg. Can be a very effective long-term method (98-99%) but not suitable for all women.
- Male: sealing of vas deferens to eliminate sperm from semen.
- Female: sealing of fallopian tubes to prevent egg meeting sperm.
Advantages: over 99% effective (Trussell, 1998), no long-term health risks.
Disadvantages: difficult to reverse, do not protect against STIs, minor surgical procedure required.
- Emergency Pill - progestogen-only pill that can be effective up to three days after unprotected sex
- Emergency IUD - device inserted into the womb up to five days after unprotected sex to stop fertilisation of egg, or egg implanting.
Advantages: can be very effective in reducing chances of pregnancy after unprotected sex.
Disadvantages: no STI protection; not a long-term solution to birth control.
ADVICE FOR WOMEN CHOOSING CONTRACEPTION
- Always advise 'doubling up' - a condom plus a more reliable method if the woman requires STI protection
- Point out the gap between perfect use and typical use failure rates of main methods
- Dispel myths and misconceptions about hormonal and other methods of contraception
- Ensure patient understands that side-effects of hormonal contraception are generally transient, but there can be rare but serious adverse effects
- Always put risks of contraception in context and explain benefits first
- Discuss emergency contraception in the event of user error
- Provide information both verbally and in writing
Archer, D.F., Bigrigg, A., Smallwood, G.H. et al. (2002)Assessment of compliance with a weekly contraceptive patch (Ortho Evra/Evra) among North American women. Fertility and Sterility 77: 2, (suppl 2), S27-S31.
Bajos, N., Leridon, H., Goulard, H. et al, (2003)Contraception: from accessibility to efficiency. Human Reproduction 18: 5, 994-999.
Department of Health (2001)Legal abortions carried out under the 1967 Abortion Act in England and Wales, 2001. Abortion Statistics Series AB 28. London: The Stationery Office.
Guillebaud, J. (1999)Contraception: Your questions answered. London: Churchill Livingstone.
National Opinion Poll (2003)Sexsensus 2003. London: NOP.
Office for National Statistics (2003)Contraception and Sexual Health 2001. London: Office for National Statistics.
Trussell, J. (1998)Contraceptive efficacy. In: Hatcher, R.A., Trussell, J., Stewart, R. et al. Contraceptive Technology. New York, NY: Ardent Media.