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Contraception: are you aware of all available methods?

Kathy French
RN BSC (Hons) PhD Phil Cert Ed PGDip NT
Clinical Director, Brook

Nurses, midwives and health visitors are often approached by their patients about contraception, but without sufficient training many are unable to advise competently. This article signposts nurses to current information on all methods of contraception, as well as means of acquiring knowledge about sexual health.

The benefits of contraception to women worldwide should not be underestimated because of the high maternal morbidity and mortality. There are one or more maternal deaths for every 100 births in 17 of the 36 countries in West, Middle and East Africa.1

While this is not an issue in the developed world and there are some 14 methods of contraception available in the UK, women and their partners, and indeed some healthcare professionals, may not know about all of them. This lack of knowledge can lead to unplanned pregnancies. Around 30% of pregnancies are unplanned and about 50% of those end in abortion.2

When considering contraception, the user should be the chooser; however, some methods may be contraindicated for some women, and clinicians should be familiar with the Faculty of Sexual and Reproductive Healthcare (FSRH) UK Medical Eligibility Criteria for contraceptive use, which is adapted from the World Health Organization. This guidance is currently being updated.3 The UK category definitions for use of hormonal contraception, intrauterine devices and barrier methods provide the clinician with four specific categories which should assist them when prescribing (see Box 1).

[[Box 1 contrac]]

In 2005, the National Institute for Health and Clinical Excellence (NICE) published a guide on the effectiveness of long-acting reversible contraception (LARC). LARC is defined as contraceptive methods that require administration less than once per cycle or month.2

Which women are suitable for LARC?

  • Women who have not had children.
  • Women who are breastfeeding.
  • Women who have had an abortion.
  • Women with a body mass index (BMI) >30.
  • Women with HIV.
  • Women with diabetes.
  • Women with migraine, with or without aura.
  • Women with contraindications to oestrogen.

LARC is not only a very effective method of contraception but it is also cost-effective.4 Table 1 shows the types of LARC methods available.

[[Tab 1 contrac]]

[[Tab 1b contrac]]

[[Tab 1c contrac]]

Case scenario 1
A 43-year-old married woman with three children has used the combined oral contraceptive (COC) for many years and does not want any more children. She and her husband discussed sterilisation for one of them. They did have some concerns about the permanency of this option. On discussion with the contraceptive doctor, she had not heard of LARC and following counselling/managing expectations, she decided on the intrauterine system (IUS).

Case scenario 2
An 18-year-girl had taken the progestrogen-only pill (POP) for some time. She had a BMI of 32 and smoked 20 a day, but was cutting down on smoking as she understood the health risks. She had a recent abortion, which she felt would not have happened had she taken her pills correctly. She was about to start a two-year course at college and did not want to be pregnant again. After a session with the nurse she felt she would like the subdermal implant. She was given written information and time to consider her options. She returned two days later for the insertion of the implant. She was advised about condom use.

Emergency contraception
Emergency contraception provides women with a safe means of preventing a pregnancy and is used after unprotected sexual intercourse (UPSI). Currently, there are two methods of emergency contraception  available to women: emergency hormonal contraception and emergency intrauterine contraception (IUD).

Emergency hormonal contraception
Levonelle 1500® is licensed for 72 hours after UPSI and is also available over the counter as Levonelle One Stop®. Levonelle 1500® can be given up to 120 hours after UPSI, but this is outside the product licence.

Ulipristal Acetate® (ellaOne) was launched in October 2009 and is licensed for up to five days (120 hours) after UPSI.
These methods do not cause abortion, and pregnancy, or suspected pregnancy, is the main contraindication to use.

Emergency IUD
An emergency IUD can be fitted up to 120 hours (five days) after UPSI and the woman must be referred to a service where the trained clinician can assess and insert the IUD. The IUS is not licensed as an emergency method of contraception.

Training options
There are several routes into training in contraception/sexual health for nurses, some delivered by e-learning and others through the universities/higher education institutes. Many universities offer courses in contraception/sexual health, but these are not standardised throughout the UK where cost and content vary. Check the GU Nurses Association (see Resources). From January 2010, FSRH will offer an e-learning option, which will comprise:

  • e-SRH (electronic learning package).
  • Course of five sessions.
  • Clinical experience.

Following successful completion of the e-SRH, students will move to the "Course of 5" which comprises five one-hour sessions with fixed content and clinical experience will take place in a variety of locations (see Resources).
Greenwich University in south-east London offers an e-learning option, which runs over an academic term with an assignment at the end. This would be useful for nurses and others. Nurses wanting to gain skills in the insertion of IUD/IUS/implants should check the Royal College of Nursing (RCN) website (see Resources).

Conclusion
This brief article intended to help nurses without training to understand all methods of contraception, where to gain additional information and access training opportunities. Nurses should be able to signpost their clients/patients to services locally in order that they get the most appropriate method of contraception in a timely manner. Emergency contraception is especially important if the number of unwanted pregnancies and abortions are to be reduced.

References
1. French K. Essential Clinical Skills for Nurses: Sexual Health. Oxford: Wiley-Blackwell; 2009.
2. National Institute for Health and Clinical Excellence (NICE). Long acting reversible contraception. London: NICE; 2005. Available from: www.nice.org.uk/CG030
3. Faculty of Sexual and Reproductive Healthcare. UK Medical Eligibility Criteria for Contraceptive use. Available from: www.cks.nhs.uk/contraception/management/detailed_answers/uk_medical_elig...
4. Marvranezouli I, Wilkinson C. Long -acting reversible contraceptives: not only effective, but a cost effective option for the National Health Service. J Fam Plann Reprod Health Care 2006; 32(1):3-5.
5. Royal College of Nursing (RCN). Fitting intrauterine devices: RCN training guidance for nurses and midwives. London: RCN; 2008.
6. Royal College of Nursing (RCN) Inserting and removing subdermal contraceptive implants. London: RCN; 2008. Available from: www.rcn.org.uk/__data/assets/pdf_file/0004/199381/002_240.pdf

Resources
Brook
W: www.brook.org.uk

Family Planning Association
W: www.fpa.org.uk 

Genito-Urinary Nurses Association
W: www.guna.org.uk

Greenwich University
W: www.gre.ac.uk/schools/health
T: 020 8331 8692

Healthcare A2Z
W: www.healthcarea2z.org

Medical Foundation for AIDS & Sexual Health
W: www.medfash.org.uk

Royal College of Obstetricians and Gynaecologists Faculty of Family Planning and Reproductive
Health Care
W: www.fsrh.org

Royal College of Nursing
W: www.rcn.org.uk

talkchoice4nurses
W: www.talkchoice4nurses.co.uk