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Clinical: Providing contraceptive care

Key learning points:

General practice is often the first access point for those who have contraceptive concerns or needs.

The most effective methods are long-acting reversible contraceptives (LARC).

Practice nurses can only be expected to deliver a sexual health service if they are adequately skilled and familiar with the most up-to-date clinical guidelines and national standards.

It is estimated that between 75-80% of the nation’s contraceptive care is provided in general practice and it is often the first access point for individuals who have contraceptive concerns or needs. Practice nurses are therefore ideally placed to take a prominent role in advising clients and providing them with their chosen method. Practice nurses often lead on contraception as well as other aspects of care – for example, asthma, diabetes, chronic disease management and travel health. Contraception needs are often raised by patients during consultations that are unrelated to contraception and there is an assumption that practice nurses will know all the answers.

Playing a role in contraception

According to the Government’s Sexual Health Framework, published in 2013, around 50% of all pregnancies are unplanned or unintended [1]. The ambition of the Government at the time of that publication was to reduce unintended pregnancies among all women of childbearing age through better knowledge and awareness of all methods of contraception and improved access to emergency contraception in a timely manner.

Women in Britain now spend about 30 years of their lives averting unintended or unwanted pregnancy. The third national survey of attitudes and lifestyles (NATSAL) study in 2013 stated that 16.2% of women scored their pregnancy as unplanned and 29.0% as ambivalent. The study showed that the highest risk of unplanned pregnancy was in women at the beginning and end of the family building cycle [2].

Any investment in contraception makes economic sense. Health and social outcomes are worse for women and their babies with unplanned or short-interval pregnancies and any effort to reduce unintended pregnancy supports Public Health England’s Best Start in Life priority [3]. It has been estimated that for every £1 invested in contraception, a saving of £11.09 is made to the national health purse.

To address concerns about restriction to services in some areas, a paper was published by Brook and the FPA in 2013 titled The Unprotected Nation and this highlighted that between £3.7 billion and £5.1 billion could be saved by improving access to contraceptive and sexual health services [4].

Any opportunity to raise awareness among women about all the methods of contraception and having nurses skilled to address questions and expel myths may go some way to reducing the large numbers of unintentended pregnancies. Good sexual and reproductive advice is key to protecting and improving the health and wellbeing of the nation.

Current commissioning arrangements that have been in place since 2013 for contraception are somewhat fragmented. The local authority (Public Health England) is responsible for commissioning contraception provided by community services. NHS England is responsible for commissioning contraceptive services provided under the GP contract and abortion services are commissioned by clinical commissioning groups (CCGs). Not all CCGs commission contraception as part of abortion care. This is a missed opportunity and without clear pathways women may not access advice on contraception for some time following abortion.

Abortion rates

The latest data from the Office of National Statistics shows that while conception rates have reduced among some age groups between 1990 and 2014, clearly more work is needed to further reduce unplanned rates of pregnancy, with numbers still rising across all age groups.

The Department of Health statistics show that in 2014, the highest rate of abortion was among women aged 22 years at 28 per 1,000 pregnancies. Additionally, in 2014, 37% of abortions were among women who had had at least one other abortion.

Having access to contraception after abortion is vital; some women may not be using their chosen method correctly and part of any abortion discussion and advice should be a conversation around contraception options.

For some women this may be the first real opportunity to have a discussion with an expert about all methods of contraception, discuss effects and failure rates as well as the non-contraceptive benefits of some methods.

Methods of contraception

There are at least 15 methods of contraception available for women to choose from. These include:

  • Combined methods (pill, ring and patch).
  • Progestogen-only pills (POPs).
  • Intrauterine devices (copper-bearing devices).
  • Intrauterine systems (Mirena, Jaydesse and Levosert).
  • Sub-dermal implants (Nexplanon).
  • Condoms (male and female).
  • Sterilisation (male and female).
  • Diaphragms.
  • Natural fertility awareness.
  • Lactation amenorrhea.

The most effective methods of contraception are known as long-acting reversible contraceptives (LARC). The National Institute of Healthcare Excellence (NICE) [7] published the first ever guidance on long-acting reversible contraception in 2005. The four methods are intrauterine devices (IUDs), intrauterine systems (IUS), sub-dermal implants (SDI) and injectables. NICE highlighted in the guidance that:

  • All currently available LARC methods are more cost effective than the combined oral contraceptive pill even at one year of use.
  • The IUS and implants are more cost-effective than the injectable contraceptives.
  • Increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies.

In September 2016 NICE [8] published a new quality standard that set out the key areas where advice to women on contraception needs to improve. It is estimated by NICE that in 2014/15 some 95% of emergency contraception supplied by sexual and reproductive health services was the emergency pill, despite the fact that the IUD is more effective and women may wish to continue using it as their chosen method.

Despite the recommendations of NICE in 2005 and again in 2016 that LARCs are more effective, many women still experience restrictions in accessing the full range of contraceptive methods and the most effective emergency contraceptive method.

For example, intrauterine contraception is safe, highly effective and in line with all other methods of contraception and is free to women in the United Kingdom. It is estimated by Walker et al in 2016that only 9% of women attending community contraceptive clinics during 2014-2015 were using IUC methods (4% were using the IUD and 5% using the IUS) [9].

The reasons for low use of LARC are varied and may include the following:

  • Lack of awareness of LARC among women, which means they do not ask about them.
  • Lack of knowledge about LARC among health professionals.
  • Lack of training opportunities for nurses to provide LARC, therefore LARC is not mentioned to patients.
  • Time needed to train and gain competency to fit IUDs and insert SDIs may prohibit practice nurses from advancing their practice.

Training and education

It must be acknowledged that practice nurses cannot be expected to deliver a service if they are not adequately skilled and familiar with the most up-to-date clinical guidelines and national standards on contraception and sexual health. The current pressure on reduced budgets for training makes it more difficult for nurses to access training. Traditionally, universities provide programmes in contraception and sexual health, but these involve time away from work and can be costly.

Education and training must be viewed as a fundamental aspect of effective and sustainable health service planning and delivery, thus ensuring that patients continue to receive the highest standards of care. Education and training should be a mandatory inclusion in all commissioned contracts. The local education and training boards (LETBs) could take a lead on ensuring that local training needs assessments are done to ensure that staff with the right knowledge and skills are in place to deliver the service.

Many nurses miss the opportunity for contraception and sexual health skills acquisition during the nurse pre-registration programme because there may be a lack of experts on sexual health to deliver the programmes.

Once qualified, some nurses may have difficulty in accessing programmes due to cost and time away from work.

More recently, the Faculty of Sexual and Reproductive Healthcare (FSRH) has opened its programmes to nurses, with doctors and nurses undertaking the same training. The FSRH recently developed an essential skills programme, known as SRH essentials. This is a one-day interactive course for nurses working in primary care. The programme has been rolled out across the four countries and for venues, dates and contact details see link to the FSRH training programme [10].

Practice nurses who would like to develop skills in the insertion of SDIs and IUDs and IUSs are now able to gain competencies through the FSRH. The FSRH provides an online course for skills acquisition related to sexual and reproductive healthcare, which is available for a modest fee. Nurses considering this route should in the first instance read all the FSRH guidelines related to each method of contraception including the United Kingdom Medical Eligibility Criteria (UKMEC) [11]. The UKMEC has been updated in 2016 and gives clear guidance on which method should not be used by women with specific conditions. Nurses can apply to undertake the FSRH Electronic Knowledge Assessment (eKA) test, which must be completed before any clinical training can take place.

The key to success with the eKA is to spend time reading all the guidelines before considering taking the test, as the questions from the random eKA test will be covered in the guidance. They should not undertake the eKA until they feel confident they will pass. They can retake the test but will need to pay each time. Colleagues recommend good preparation and then a quiet time to do the test without interruption.

Nurses who complete the electronic module can then apply to be trained by a FSRH trainer who holds the Letter of Competence (LoC) and once competent the nurse will be awarded an LoC for either SDIs or intrauterine techniques. This is the national old standard for training and most commissioners now insist on it when they commission services.

The FSRH guidance on training stipulates ongoing maintenance of competency and updating.

Any nurse, regardless of place of practice, who has a role in contraception advice and provision should be familiar with the UKMEC. The UKMEC was updated in May 2016 and there are some changes to all methods of contraception. All the guidelines are available at fsrh.org [12].

In conclusion, nurses working in general practice can make a real difference to empowering women about all contraceptive methods. Women generally appreciate being able to get all their contraceptive needs met in one place. Practice nurses should be supported to advance their skills and given time to undertake the necessary training and where nurses are unable to offer LARC in their practice, a clear pathway to other providers should be in place.

References

1. Department of Health (2013). A framework for sexual health improvement in England 2013 gov.uk/government/uploads/system/uploads/attachment_data/file/142592/9287-2900714-TSO-SexualHealthPolicyNW_ACCESSIBLE.pdf

2. National Survey of Sexual Attitudes and Lifestyles (NATSAL) (2013). One in six pregnancies are unplanned. thelancet.com/journals/lancet/issue/vol382no9907/PIIS0140-6736(13)X6059-3

3. Public Health England (2016). Best start in life and beyond: Improving public health outcomes for children, young people and families. gov.uk/government/uploads/system/uploads/attachment_data/file/554499/Service_specification_0-19_commissioning_guide_1.pdf

4. Brook and FPA (2013). The unprotected nation: The Financial and economic Impact of restricted contraceptive and sexual health services. fpa.org.uk/sites/default/files/unprotected-nation-sexual-healthfull-report.pdf

5. Office of National Statistics (2016). ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates

6. Office of National Statistics (2016). gov.uk/government/uploads/system/uploads/attachment_data/file/433437/2014_Commentary__5_.pdf

7. National Institute of Clinical and Health Excellence (2005). Long acting reversible contraception nice.org.uk/guidance/cg30/chapter/1-recommendations

8. National Institute of Clinical and Health Excellence (2016). Coil is more effective than the pill as emergency contraceptionnice.org.uk/news/article/coil-is-more-effective-than-pill-as-emergency-contraception-saysnice

9. Walker S, Newton V, Hoggart L et al. Predictors of non-use of intrauterine contraception among women aged 18-49 years in a general practice setting in the UK. Open Access Journal of Contraception 2016;7:155-6010. Faculty of Sexual and Reproductive Healthcare fsrh.org/careers-andtraining/srh-essentials

11. Faculty of Sexual and Reproductive Health Care fsrh.otg/careers-and-training/e-knolwedge-assessemnt-eka/

12. Faculty of Sexual and Reproductive Health Care (2016). United Kingdom Medical Eligibility Criteria fsrh.org/standards-and-guidance/uk-medicaleligibility-criteria-for-contraceptive-use