Dr Anne Connolly explains how the number of unplanned pregnancies can be reduced by improving access to, and uptake of long-acting reversible contraception
- LARC methods have superior efficacy and cost-effectiveness in reducing unplanned pregnancy compared with traditional user-dependent methods, such as pills and condoms
- Many generalists are not up to date with contraceptive advances because of the wide variety of other educational requirements
- 75% of contraceptive care is provided in primary care, but the majority of LARC provision is by community contraceptive clinics
- There needs to be improvements to LARC fitting services particularly those for young women
- There are insufficient LARC ‘fitters’ and ongoing training issues
- Additional points have been added to the 2009/10 QOF indicators, but it is too early to assess whether this has improved contraceptive choices
At least 30% of all pregnancies in the UK are unplanned;1 in 2008, there were nearly 200,000 abortions in England and Wales, a four-fold increase since 1969.2 Moreover, 62% of women who attend for abortion report that they were using a method of contraception at the time of becoming pregnant.3 It is estimated that in the future, at least half of all women will have had an abortion,4 although this is not a true reflection of the present abortion rates.
The Government target to reduce under-18 conceptions by 50% (from the 1998 baseline) by 2010 is a long way off track: in 2007, a reduction of only 10.7% was achieved.5 Indeed, the UK still has the highest rate of teenage pregnancy in Europe.6
These shocking statistics reflect changing sexual behaviours7 and inadequate provision of reliable contraceptive options. Long-acting reversible contraception (LARC) has been proven to be very reliable at preventing unplanned pregnancy and also more cost effective than traditional methods.1 Despite this, many women continue to be offered mainly ‘last-century’ methods, such as pills and barrier methods, which are in practice user dependent and therefore far less reliable.
This article highlights a number of key areas related to LARCs including: guidance from both NICE and the quality and outcomes framework (QOF); the cost–benefit analysis of these contraceptive methods; and what steps should be taken to help women control their fertility more consistently in the future.
Long-acting reversible contraceptive methods
All LARC methods achieve superior contraceptive efficacy by reducing user-error: typical failure rates in LARC become close-to-perfect failure rates (0.05–2.00%) in comparison with the user-dependent pills and barrier methods (8%).8 The 2005 NICE guideline on the use of LARC highlighted the advantages both for women and for the health economy of promoting the use of these user-independent methods, which demonstrate superior efficacy (compared to non-LARC methods) and are cost effective, even after only 1 year of use.1 There are five different LARC methods available, namely copper intrauterine devices (IUDs), the intrauterine system (IUS), the contraceptive implant, progestogen-only injectable contraceptives, and the combined vaginal ring. These are discussed in more detail below.
Copper intrauterine devices
Copper-containing IUDs are still a popular contraceptive method, especially for women requesting a non-hormonal method. A Cochrane review recommends the use of the T-Safe 380A QL because of its superior efficacy, a failure rate of fewer than 2 in 100 women over 5 years for 380 mm2 copper devices; and its longer (10 year) duration of action,9 which minimises the complications associated with insertion.10
The IUS is an extremely reliable method of contraception, with a failure rate of fewer than 1 in 100 women over 5 years. It is also recommended by NICE as the first-line treatment for heavy menstrual bleeding.11 This contraceptive system also offers endometrial protection for women using oestrogen therapy for menopausal symptoms. Despite its advantages, many women stop using the IUS because of irregular bleeding and spotting, which is common in the first 6 months. Oligo-amenorrhoea is likely by the end of the first year,10 but continuation rates can be improved if good pre-insertion counselling is offered.
The contraceptive implant is now accepted as the most reliable contraceptive available with a failure rate of fewer than 0.1 in 100 women over 3 years.1 It is a safe method with very few contraindications for use12 and results in no delay in return to fertility after removal. Irregular vaginal bleeding affects nearly 50% of users and is the commonest cause of discontinuation,1 which affects cost effectiveness. The addition of a combined hormonal contraceptive, unless contraindicated, often helps to reduce irregular bleeding and improve continuation rates.13
Progestogen-only injectable contraceptives
Progestogen-only injectable contraceptives have a pregnancy rate of below 0.4 in 100 women over two years. They have reduced efficacy and cost effectiveness when compared with other LARCs as they depend on the woman returning at the correct intervals for subsequent injections. The majority of users become amenorrhoeic after the first year of use and there is a delay in return to fertility upon discontinuation.14 Other concerns regarding this method include the effect of hypo-oestrogenism and the theoretical adverse consequence that this may have on reducing bone density.1 The Committee on Safety of Medicines recommends that this treatment should only be used in adolescents after other methods have been discussed and declined. Prescribers should re-evaluate the suitability of treatment for individuals continuing to use the method for more than 2 years.15
Combined vaginal ring
The hormonal vaginal ring is a recent addition to contraception methods available in the UK. There is some debate as to whether this is considered a LARC method but, as it was mentioned in the original NICE recommendations,1 it is discussed here for the sake of completeness. It consists of a soft, flexible, transparent (one-sized) ring, which is inserted by the user into the vagina and releases a steady, low-dose, combination of ethinylestradiol and etonorgestrel. Each ring lasts for 3 weeks and is followed by a 1-week break, which causes a withdrawal bleed before a new ring is inserted.16 The contraindications for use of this method are the same as for any combined hormonal method.12 This contraceptive requires regular user involvement and is relatively expensive at £9 per month, but is an excellent choice for women who want regular withdrawal bleeds.16
The NICE guideline emphasises that information about LARC methods should be offered to all women as part of their contraceptive choices. This should include information on:1
- contraceptive efficacy
- duration of use
- risks and possible side-effects
- non-contraceptive benefits
- the procedure for initiation and removal/discontinuation
- when to seek help while using the method.
Unfortunately there are still many myths that adversely influence women’s choices. These are perpetuated by both the media and those healthcare professionals who are uninformed about more recent evidence regarding contraceptive developments. Healthcare professionals and patients should be aware that:
- IUDs/IUS can be used in women of all ages and in nulliparous women
- modern IUDs/IUS do not increase infection rates or ectopic pregnancy (the IUS reduces these)
- neither the IUS nor the contraceptive implant cause weight gain
- LARC methods are cost effective and become more so the longer that they are used. Although adverse effects can be problematic during the first few months, discontinuation can be avoided through careful management
- with the exception of the combined hormonal vaginal ring, all LARC methods can be used in women who are unable to use oestrogen-containing products because of contraindications, or conditions such as obesity, breastfeeding, migraine, or diabetes.12
For healthcare professionals to be able to provide accurate information on LARC methods they need appropriate training. This requirement is highlighted in the NICE guideline,1 which states that individuals:
- advising women about contraceptive choices should be competent to:
- help women consider and compare the risks and benefits of all methods relevant to their individual needs
- manage common side-effects and problems
- be appropriately trained to develop and maintain their skills when providing intrauterine and implant contraceptives.
In primary care—where 75% of women continue to go for their contraception17—there is a shortage of healthcare providers who are trained in inserting contraceptive implants, IUDs, and the IUS. Latest reports confirm this problem, as LARC prescribing in primary care comprises 13.5% of total contraceptive-related attendances compared with 24% of women attending contraception and sexual health services (CaSH).18 Unfortunately, many generalist primary care healthcare professionals struggle to prioritise the need to keep up to date with contraceptive developments against the wide variety of other educational needs. In addition, there are reduced training opportunities because of changing roles and increased workload pressures for the main workforce responsible for training, which is chiefly employed by the CaSH services. Solutions that aim to increase the numbers of ‘fitters’ include:
- training nurses to fit LARC methods19
- using accredited nurses to train doctors and nurses in contraceptive implant fitting
- the restructured Diploma of the Faculty of Sexual and Reproductive Healthcare, which should address some of the problems of long training lists.20 The electronic-learning aspects of the diploma facilitate distance learning and the shortened theory course and learner-centred practical training should reduce the time commitments required for each trainee
- developing locally agreed training mechanisms for accreditation by some PCTs after ensuring appropriate governance requirements are in place.
The NICE guideline recommends that providers of contraceptive services who do not provide LARC within their own practice or service should have an agreed referral mechanism.
Cost effectiveness of LARCs
In addition to their efficacy, LARCs are cost-effective options. A recent (unpublished) economic evaluation of contraceptive methods (excluding the combined hormonal vaginal ring)21 suggests that LARC methods (used typically) are highly cost-effective options compared to oral contraceptives.21 Long-acting reversible contraceptives are perceived to have initial high costs, but all incremental cost-effectiveness ratios—as early as in the first year of use—were found to be well below the cost-effectiveness threshold (conservatively estimated as £1811, the weighted average cost of an unintended pregnancy). In the first year of LARC use, the NHS will save:21
- £28 per woman and reduce the risk of unintended pregnancy by 68% for every woman who is switched from oral contraception (pers. comm)
- £1261 and reduce the risk of unintended pregnancy by 97% for every woman who is started on a LARC after using no contraceptive method (pers. comm).
These financial benefits become increasingly significant the longer the method is used and confirm the need to improve compliance with LARC methods as discontinuation is a key determinant of cost-effectiveness.8
Funds to improve access to contraception have been allocated by the Department of Health for 3 years (2008–11) to increase the numbers and accessibility of services offering LARC methods and to improve services for young people.22 These funds have been allocated to PCTs that have successfully bid to improve access by developing training opportunities or improving service delivery either in community or primary care, under service level agreements or by practice-based consortia developing services under practice-based commissioning arrangements.
Quality and outcomes framework
In the 2009/10 update of the QOF, the previously allocated two points under contraception were increased to 10 points (see Table 1).1,23 The rationale for this inclusion was to:
- complete a register of attendees
- ensure that all women are informed of advances in contraceptive choices and recognise that a woman’s contraceptive needs change over her reproductive lifespan
- offer contraceptive choices to women who present in an ‘emergency’ situation having failed to use a contraceptive method or who recognise that their method has not been used correctly.
It is too early to assess the impact of the contraception indicators in the QOF. However, there are concerns about the QOF indicators for contraception and many experts feel that they have not fully addressed the issues. It is currently impossible to determine the quality of the counselling and information given, which will be dependent on the knowledge and enthusiasm of the healthcare professional giving the advice. Practices in which there are trained accredited ‘fitters’ or good pathways of referral are more likely to offer the full range of contraceptive options consistently. Although there are limitations with the QOF indicators, they do raise the profile of LARC for healthcare professionals who are not up to date with contraceptive developments.
In the 2008 review of the National strategy for sexual health and HIV,24 which proposed sexual health indicators for local and national use, the authors advised the collection of baseline data and monitoring of trends in prescribing of LARC rather than setting a specific target for uptake. This was because there were concerns that setting specific targets may eventually reduce patient choice by adding pressure within services for inappropriate over-prescribing of LARC methods. From a low starting point, an increase in provision of LARC can be used as a proxy measure for the quality of information supplied and improved access to a range of methods.
|Table 1: Quality and outcomes framework clinical indicators 2009/10 for contraception23|
|SH 1||The practice can produce a register of women who have been prescribed any method of contraception at least once in the last year, or other appropriate interval (e.g. last 5 years for an intrauterine system)||4|
|SH 2||The percentage of women prescribed an oral or patch contraceptive method in the last year who have also received information from the practice about long-acting reversible methods of contraception in the previous 15 months||3||40–90%|
|SH 3||The percentage of women prescribed emergency hormonal contraception at least once in the year by the practice who have received information from the practice about long-acting reversible methods of contraception at the time of, or within one month of, the prescription||3||40–90%|
Uptake of LARC use
A report on the uptake of LARC has been published by NICE. There has been a 54% increase in volume of implants in the 12 months to March 2007 compared with the previous 12 months and this increased use is continuing. Prescriptions of the IUS increased by 8% over the same time period. The number of IUDs used is relatively static and injectable contraceptive use is decreasing slowly, a trend that was not anticipated. Overall LARC prescribing is at a similar rate but the more reliable methods such as the implant and IUS have increased.25
Oral contraception continues to be the primary contraceptive method of 44% or women who attend community contraceptive clinics, but LARC methods are now accounting for 24% of primary methods of contraception (an increase from 18% in 2003/4). The percentage of women choosing LARC as their primary method increases with age (9% of those aged under 16 years compared with 37% of those aged over 35 years).26
There remains an urgent need to prevent unplanned pregnancy in communities throughout the UK. This need is particularly relevant among the sexually active young women in society, but women at all stages of their reproductive life will benefit from modern, individualised contraceptive care. The NICE guidance transformed the attitude of providers and commissioners on the use of LARC as a first-line choice because they are financially viable even if only used for 12 months. The QOF promotes best practice as it ensures that the care provided to patients is both of high quality and evidence based.
The launch of the social marketing campaign ‘Sex worth talking about’ will raise awareness of better contraceptive options available to women.27 If successful, this campaign will empower women to demand streamlined access to services that promote a full range of LARC methods.
The expansion of contraceptive options, including the LARC method, heralds the opportunity to address the need for acceptable and reliable ways of fertility control; without this the inexorable rise in demand for termination of pregnancy services as a last-ditch ‘solution’ to failed contraception will continue. Women making choices in the 21st century should no longer be restricted to the choices their mothers were offered in the 1960s and 1970s, but this is unlikely to be achieved without a pragmatic and well-resourced strategy to re-educate healthcare professionals about the role of LARC methods. There should be particular focus on the training needs of primary care clinicians and strengthening of incentives to encourage evidence-based practice.
‘Contraception use is like recycling: it needs to be made easy and accessible.’28
- There is no doubt that LARC methods are effective, but they are not as widely used as they could be
- The QOF incentive (3 points) for offering LARC to all women receiving contraceptives amounts to just £1 per patient (Dr Jenner's practice) and practices often have no financial incentive to insert them
- PBC collectives and PCTs would be wise to consider offering adequate incentives for GP practices (possibly as an LES or item of service payment) to train in contraception, and offer IUDs, the IUS, and implants
- Young adults are often wary of attending local GP practices where their parents are registered so alternative, confidential CaSH should be commissioned so patients have a choice of service
- CaSH services delivered outside the context of an acute hospital do not attract a mandatory payment-by-results tariff
- National Institute for Health and Care Excellence. Long-acting reversible contraception. Clinical Guideline 30. London: NICE, 2005. Available at: www.nice.org.uk/guidance/CG30
- Department of Health. Statistical bulletin—abortion statistics, England and Wales: 2008. DH, 2009. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_099285
- Bury L, Tony Kerridge. "The condom broke!” Why do women in the UK have unintended pregnancies? London: Marie Stopes International, 2009.
- Chamberlain J, Corbin T. Trends in reproductive epidemiology and women’s health. In: Lewis G editor. Why mothers die 2000–2002. The sixth report of the confidential enquiries into maternal deaths in the United Kingdom. London: RCOG Press, 2004. p282. Available at: www.cemach.org.uk/Publications/Saving-Mothers-Lives-Report-2000-2002.aspx
- Department of Health. More cash for contraception. nds.coi.gov.uk/content/Detail.aspx?ReleaseID=393819&NewsAreaID=2 (accessed 9 December 2009).
- World Health Organization. What are the most effective strategies for reducing the rate of teenage pregnancies? www.euro.who.int/HEN/Syntheses/short/20040423_6 (accessed 5 January 2010).
- Erens B, McManus S, Field J et al. National survey of sexual attitudes and lifestyles II: Technical report. London: National Centre for Social Research, 2001. Available at: www.data-archive.ac.uk/findingData/publicationListForSN.asp?sn=5223
- National Collaborating Centre for Women’s and Children’s Health. Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception. London: RCOG Press, 2005. Available at: www.nice.org.uk/guidance/CG30
- Kulier R, Helmerhorst F, O’Brien P et al. Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev 2006; 3: CD005347.
- Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Intrauterine contraception. London: FSRH CEU, 2007.
- National Institute for Health and Care Excellence. Heavy menstrual bleeding. Clinical Guideline 44. London: NICE, 2007. Available at: www.nice.org.uk/guidance/CG44/NiceGuidance/pdf/English
- Faculty of Sexual and Reproductive Healthcare. UK medical eligibility criteria for contraceptive use (UKMEC 2009). London: FSRH, 2009.
- Lakha F, Glasier A. Continuation rates of Implanon in the UK: data from an observational study in a clinical setting. Contraception 2006; 74 (4): 287–289.
- Fraser I. Systemic hormonal contraception by non-oral routes. In: Filshie M, Guillebaud J editors. Contraception: Science and practice. London: Butterworths, 1989.
- Medicines and Healthcare Products Regulatory Agency. Updated summary of the committee on safety of medicines meeting held on November 2004. MHRA, 2007.
- Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. New product review: combined vaginal ring. FSRH, 2009.
- Wellings K, Zhihong Z, Krentel A et al. Attitudes to long acting reversible methods of contraception in general practice in the UK. Contraception 2007; 76 (3): 208–214.
- CSD Patient Data, Cegedim Strategic Data UK Ltd, October 2009 MAT.
- Royal College of Nursing. Intrauterine techniques: RCN accreditation and training guidance for nurses and midwives. London: RCN, 2008.
- Faculty of Sexual and Reproductive Healthcare. Introducing the new DFSRH training package. www.ffprhc.org.uk/Default.asp?Section=ExamsTraining&Subsection=DFSRHJan10 (accessed 2 December 2009).
- Cost effectiveness analysis by Schering-Plough (unpublished data).
- Independent Advisory Group on Sexual Health and HIV. The time is now: Achieving world class contraceptive and abortion services. Independent Advisory Group on Sexual Health and HIV, 2009.
- British Medical Association, NHS Employers. Quality and outcomes framework guidance for GMS contract 2009/10. London: BMA, NHS Employers, 2009. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qof0309.jsp?page=1
- Medical Foundation for AIDS and Sexual Health. Progress and priorities—working together for high quality sexual health. London: MedFASH, 2008.
- National Institute for Health and Care Excellence. NICE implementation uptake report: long acting reversible contraception. London: NICE, 2009. Available at: www.nice.org.uk/media/207/D2/ImplUptakeReportLARCs.pdf
- The NHS Information Centre. NHS contraceptive services—England 2008/09. The Health and Social Care Information Centre, 2009.
- NHS website. Sex worth talking about. www.nhs.uk/worthtalkingabout/Pages/sex-worth-talking-about.aspx (accessed 4 December 2009).
- Senanayake P, Potts M. Atlas of contraception. London: Informa Healthcare, 2008.G