Emergency contraception and pre-conception advice are important elements of everyday family medicine, says Dr Chris Barclay
Sexual encounters are not always planned and contraceptive precautions are not always dependable. One survey from Scotland found that over 90% of women presenting for termination of pregnancy knew about emergency contraception, but only 3% of those presenting for termination for the first time had used it.1
A large US study of women requesting termination of pregnancy found that 46% had taken no precautions against pregnancy in the conception cycle and 76% of those taking the contraceptive pill had used it inconsistently.2
Contraceptive services fall under the additional services section of the new GMS contract. There are just two indicators: one relates to emergency contraception and the other to preconception advice (Table 1, below).
|Table 1: Contraceptive services indicators|
|CON 1: The team has a written policy for responding to requests for emergency contraception||1|
|CON 2: The team has a written policy for providing pre-conceptual advice||1|
CON 1 – Emergency contraception
In the UK there are two options for emergency contraception, the oral progestogen levonorgestrel and the copper intra-uterine contraceptive device (IUD). Ease of access to emergency contraception when needed was an important aspect to consider when formulating our practice policy for this indicator.
‘Front of house’ policy
Over half of occurrences of first intercourse in teenagers are unprotected.3 The earlier after intercourse oral emergency contraception is taken the more likely it is to be effective. Nine out of 10 pregnancies will be prevented if emergency contraception is taken within 24 hours. The proportion falls to 5 out of 10 by 72 hours.4
The first contact patients have with the practice is with a receptionist. We plan to spend time educating our staff on the true emergency nature of this type of contraception at our next practice learning initiative afternoon. This will include acting out different situations involving, for example, shy or embarrassed patients and judgemental staff.
The practice emergency contraception policy will be covered in the introductory programme for new staff and in staff appraisals.
Weekends seem to be the time when contraceptive mishaps occur most.5 Our practice is closed on Saturdays so we have confirmed that our out-of-hours provider regards emergency contraception as an emergency. One study showed that Monday and Tuesday are peak days for emergency contraception need.5
When it is too late for oral emergency contraception
Oral emergency contraception has almost no contraindications;6 however, some women present after the 72- hour window during which it is effective. Fitting a copper IUD, not later than 5 days after unprotected intercourse and the expected date of ovulation, is an option.
Fitting an IUD at short notice requires a high degree of organisation and flexibility, which is difficult for us to achieve in the practice. Therefore we have started to use the ‘advanced access’ 7 approach to managing demand, which may enable us to fit emergency IUDs. Meanwhile, our policy is to refer women to the community family planning service when we cannot offer the service.
The overall pregnancy rate among women using emergency contraception is around 3%.4 Even in women who do not become pregnant, the need for emergency contraception implies that a review of contraceptive provision may be advantageous. Our protocol stipulates that patients should be advised that emergency contraception is not 100% reliable and that oral emergency contraception does not provide contraceptive cover for subsequent sexual activity.
A follow up appointment must be given at the time emergency contraception is prescribed and patients are advised to return immediately if they develop abdominal pain.
Stand-by emergency contraception
Women who are given emergency contraception to use in case contraception fails are no more likely to abuse the medication than those obtaining supplies at the time of need.8 Provision of stand-by emergency contraception depends on the local level of need and supply arrangements. Our practice is located in an affluent area of a large city, so our situation does not at present warrant this.
A Swedish study that looked at the demographic features of emergency contraception users concluded that they "could be anyone”.9 Our practice policy is therefore to reinforce emergency contraception advice at all well-woman and contraception advice consultations including postnatal follow up visits.
Although teenagers are more likely to take contraceptive risks than older women our policy states that value judgements must not be made about who does and who does not need emergency contraception advice and information.
As well as giving verbal advice, we offer information leaflets and we are also considering putting up posters and providing information leaflets in the waiting room.
CON 2 – Preconceptual advice
Consultations by couples planning for a baby provide opportunities to build relationships and give health promotion advice. Certain areas are important to cover; our policy specifies giving advice on folic acid, pre-existing medical conditions, medication use and smoking, alcohol and other drug use.
The incidence of neural tube defects is reduced in women who take a small folate supplement in the months before, and for the first few weeks during pregnancy. The recommended dose is 400 mcg per day.10 Women with a personal or family history of neural tube defect or who are taking folate antagonists (most commonly antiepileptic medication) should take 5 mg per day.
Before pregnancy most women simply need advice about a balanced diet. Recently, there have been concerns about the levels of methylmercury in fish. Our policy is to advise women to adhere to the Food Standards Agency’s advice not to eat swordfish, shark and marlin before or during pregnancy and to limit fresh or tinned tuna to two portions per week.11
Most women wanting to conceive are fit and well but some will have significant medical conditions. Our policy covers four specific conditions:
- Diabetes: We refer all such women with type 1 diabetes to a pre-pregnancy multidisciplinary team for advice and to optimise their diabetes control before conception as this has been shown to reduce the risk of the feto-maternal complication of poor diabetes control. 12 The need for pre-conception planning should be stressed at general medical reviews.
- Epilepsy: Most women with epilepsy will be taking an anticonvulsant drug. Several of these are teratogenic.13 We refer all women with epilepsy to a pre-pregnancy multidisciplinary team for advice and to optimise their medication regimen before they conceive. Women taking anticonvulsants are advised to take high dose folic acid before conception. Our policy is to prescribe 5 mg per day. Prescriptions are for a 90-day supply, equating to the over-the-counter 400 mcg dose pack size. Again, the need for pre-conception planning must be stressed at general medical reviews.
- Depression: Depression can develop for the first time or relapse during pregnancy and the puerperium.14 Our policy document specifies that we enquire about the woman’s current and previous mental health. SSRIs can be used with caution during pregnancy. However, women taking SSRIs should not be advised routinely to withdraw from treatment before or during pregnancy.15 In cases where the potential benefit outweighs the risks, the best option may be to continue with SSRIs before, during and after pregnancy.
- Asthma: Asthma medications are not teratogenic. Poorly controlled asthma is a risk situation for pregnant women and their pregnancies. Our policy therefore is to manage asthma no differently before or during pregnancy than at any other time.16
Almost all women are anxious about taking prescription drugs in early pregnancy. Some medications have a teratogenic potential and should be stopped before trying to conceive. Our policy document does not address every drug in the formulary but medication review is required as part of the pre-conception consultation. We also enquire about any nonprescription drugs the patient may be taking.
Tobacco and alcohol use
We advise all women to try to stop smoking. All women who smoke are offered an appointment with the local smoking cessation group.
We advise women who drink alcohol to abstain during pregnancy,17,18 and to consume alcohol only in moderation during the pre-conception phase.
We ask about occupation even though it will only very occasionally be relevant, for example oncology nurses handling teratogenic drugs or sheep farmers exposed to ovine chlamydia.
If the file does not contain an up to date smear test result, we arrange for the woman to have a smear test.
We enquire about rubella status, and a pre-pregnancy vaccination is administered to those who are nonimmune. Our policy requires us to give consideration to hepatitis B and chicken pox antibody status, although testing and vaccination is rarely indicated.
This part of the new contract contains just two sections and has little potential for increasing practice income; however the areas it covers are integral to everyday family medicine. Our practice policy document provides an aide memoire to ensuring that opportunities to give advice about emergency contraception and pre-conception are not overlooked.
- Tewan SK, Diaz-Morales O, Urquhart DR, Mahmood TA. Understanding factors influencing request for a repeat termination of pregnancy. Health Bull (Edinb) 2001; 59(3): 193-7.
- Jones RK, Darroch JE, Henshaw SK. Contraceptive use among U.S. women having abortions in 2000-2001. Persp Sex Reprod Health 2002; 34(6); 294-303.
- Rowlands S, Devalia H, Lawrenson R, Logie J et al. Repeated use of hormonal emergency contraception by younger women in the UK. Br J Fam Plann 2000; 26(3): 138-43.
- Rowlands S, Dakin L, Booth M. Deregulating emergency contraception. Service should reflect greater demand after the weekend. Br Med J 1993; 307: 1143 (letter).
- British National Formulary No 47 pp. 393 and 677-8.
- Oldham J. Advanced access in primary care. Manchester: National Primary Care Development Team, 2001. www.npdt.org/scripts/default.asp?site_id=1&id=1626
- Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med 1998; 339: 1-4.
- Tyden T, Wetterholm M, Odlind V. Emergency contraception: the user profile. Adv Contracept 1998; 14(4): 171-8.
- Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet 1991; 338: 131-7.
- American Diabetes Association. Pre-conception care of women with diabetes. Diabetes Care 2000; 23: S65-8.
- British National Formulary No 47, p. 713.
- Simon GE, Cunningham ML, Davis RL. Outcomes of prenatal antidepressant exposure. Am J Psychiatry 2002; 159(12): 2055-61.
- Use of psychoactive medication during pregnancy and possible effects on the fetus and newborn. Committee on Drugs. American Academy of Pediatrics. Pediatrics 2000; 105:880-7.
- British National Formulary No 47, p. 131.
- Guerri C, Riley E, Stromland K. Commentary on the recommendation of the Royal College of Obstetricians and Gynaecologists concerning alcohol consumption in pregnancy. Alcohol Alcohol 1999; 34(4): 497-501.
- Sood B, Delaney-Black V, Covington C et al. Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect. Paediatrics 2001; 108(2):E34.