Special Report – Permanent Contraception by The Magazine Production Company

Special Report

SPECIAL REPORT

SPECIAL REPORT: PERMANENT CONTRACEPTION

Contents Permanent Foreword Contraception Life Course Approach to Contraceptive Choice:

Contents Permanent Contraception John Hancock, Editor

Delivering Access for All Women

Mr Ali Kubba, Chairman International Affairs Committee, Faculty of Sexual and Reproductive Healthcare and Community Gynaecologist at Guy’s & St Thomas’ NHS Foundation Trust

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Why Birth Control?

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The Best Contraceptive is One That is Used Reasons to Delay or Avoid Pregnancy Health Risks Age Related Summary

Business Development Director Marie-Anne Brooks

Making the Right Choice

Editor John Hancock

For further information visit: www.globalbusinessmedia.org

Foreword

What is Contraception? Different Methods Pros and Cons Changing Live: Changing Priorities

Life Course Approach to Contraceptive Choice: Outcomes and Values 11 Access for All Women John Hancock, Delivering Editor

The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

© 2012. The entire contents of this publication are protected by copyright. Full details are Sponsored by All rights reserved. available from the Publishers. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Human Benefits Avoiding Unintended Pregnancies Age Issues Health Issues Healthcare System Benefits

Life Course Approach to Contraceptive Choice: Delivering Access for All Women 3

Why Birth Control?

Making the Right Choice Outcomes and Values 13

Mr Ali Kubba, Chairman International Affairs Committee, Faculty of Sexual and Reproductive Healthcare and Community Gynaecologist at Guy’s & St Thomas’ NHS Foundation Trust

Getting to the Right Answer Camilla Slade, Staff Writer

Getting to the Right Answer

Who Can Help Decide? What Works for Each Person? Wants and Needs Where to Go

References

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Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom

The Best Contraceptive is One That is Used Reasons to Delay or Avoid Pregnancy Health Risks Age Related Summary

Business Development Director Marie-Anne Brooks

Making the Right Choice

Editor John Hancock

What is Contraception? Different Methods Pros and Cons Changing Live: Changing Priorities

Life Course Approach to Contraceptive Choice: Outcomes and Values 11 Access for All Women John Hancock, Delivering Editor

© 2012. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

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Peter Dunwell, Medical Correspondent

Senior Project Manager Steve Banks

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Camilla Slade, Staff Writer

Publisher Kevin Bell

Production Manager Paul Davies

Restrictions on Access to Contraceptive Choice Commitment to Access to Contraceptive Choice Across the Life Course Trends in Contraception for Older Age Groups Permanent Contraception – Adoption of the Latest Technology by NHS Conclusion

Why Birth Control?

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Advertising Executives Michael McCarthy Abigail Coombes

John Hancock, Editor

Peter Dunwell, Medical Correspondent

Senior Project Manager Steve Banks

Production Manager Paul Davies

Camilla Slade, Staff Writer

Publisher Kevin Bell

Advertising Executives Michael McCarthy Abigail Coombes

Human Benefits Avoiding Unintended Pregnancies Age Issues Health Issues Healthcare System Benefits

Why Birth Control?

Making the Right Choice Outcomes and Values 13

Getting to the Right Answer Camilla Slade, Staff Writer

Getting to the Right Answer

Who Can Help Decide? What Works for Each Person? Wants and Needs Where to Go

References 15

Published by Global Business Media

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SPECIAL REPORT

Contents Permanent Foreword Contraception Life Course Approach to Contraceptive Choice:

John Hancock, Editor

Delivering Access for All Women

Mr Ali Kubba, Chairman International Affairs Committee, Faculty of Sexual and Reproductive Healthcare and Community Gynaecologist at Guy’s & St Thomas’ NHS Foundation Trust

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom

Making the Right Choice

Editor John Hancock

Peter Dunwell, Medical Correspondent

Senior Project Manager Steve Banks

For further information visit: www.globalbusinessmedia.org

The Best Contraceptive is One That is Used Reasons to Delay or Avoid Pregnancy Health Risks Age Related Summary

Business Development Director Marie-Anne Brooks

Production Manager Paul Davies

Contents

Camilla Slade, Staff Writer

Publisher Kevin Bell

Advertising Executives Michael McCarthy Abigail Coombes

Why Birth Control?

Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org

SPECIAL REPORT: PERMANENT CONTRACEPTION

What is Contraception? Different Methods Pros and Cons Changing Live: Changing Priorities

Life Course Approach to Contraceptive Choice: Outcomes and Values 11 Access for All Women John Hancock, Delivering Editor

Human Benefits Avoiding Unintended Pregnancies Age Issues Health Issues Healthcare System Benefits

Why Birth Control?

Making the Right Choice Outcomes and Values 13

Getting to the Right Answer Camilla Slade, Staff Writer

Getting to the Right Answer

Who Can Help Decide? What Works for Each Person? Wants and Needs Where to Go

References

Published by Global Business Media

WWW.PRIMARYCAREREPORTS.CO.UK | 1

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor John Hancock Senior Project Manager Steve Banks

Foreword

Life Course Approach to Contraceptive Choice: Delivering Access for All Women 3 Mr Ali Kubba, Chairman International Affairs Committee, Faculty of Sexual and Reproductive Healthcare and Community Gynaecologist at Guy’s & St Thomas’ NHS Foundation Trust

Why Birth Control? The Best Contraceptive is One That is Used Reasons to Delay or Avoid Pregnancy Health Risks Age Related Summary

Making the Right Choice

Production Manager Paul Davies

Outcomes and Values

Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

Peter Dunwell, Medical Correspondent

Advertising Executives Michael McCarthy Abigail Coombes

Camilla Slade, Staff Writer

What is Contraception? Different Methods Pros and Cons Changing Live: Changing Priorities

For further information visit: www.globalbusinessmedia.org

John Hancock, Editor

Human Benefits Avoiding Unintended Pregnancies Age Issues Health Issues Healthcare System Benefits

Getting to the Right Answer

Camilla Slade, Staff Writer

Who Can Help Decide? What Works for Each Person? Wants and Needs Where to Go

References 15

www.primarycarereports.co.uk | 1

SPECIAL REPORT: PERMANENT CONTRACEPTION

Foreword E

ven in our ‘enlightened’ times, contraception

behaviour or in the same light as abortion. Others

arouses passionate and conflicting views. To

regard contraception as a sensible way to manage

understand why, we need first to understand the

pregnancy, health and family size. Certain societies

societal baggage that contraception carries with it.

do not accord women equality with men and

Even on a global level there are tensions between

consider it wrong for a woman not to wish, even for

the right to parenthood and the problems for a

a limited period, to give her husband a child: and

population growing faster than the planet’s ability

there may be stigma attached to contraception

to shelter, employ or feed it.

from, confusingly, the same quarters who attach

This Special Report on Permanent Contraception

stigma to unmarried pregnancy.

opens with an article that looks at the choices of

There are concerns about the age at which

contraception available to women and the results of

contraceptive advice should be given and the

an inquiry carried out by the All-Party Parliamentary

context in which it should be placed, although there

Group on Sexual and Reproductive Health (APPG).

is welcome agreement on the view that it should

Among the most important recommendations

be in the context of a caring or loving relationship.

set out by the inquiry is that all women must have

But to dwell too much on global and societal issues

access to a full choice of contraceptives and

risks missing a really important point and that is that

contraceptive services including comprehensive

pregnancy changes people’s lives and, most often,

information and advice that enables them to

women’s lives. Contraception offers a safe and

choose the method which is best for them. In an

organised means with which women can exercise

announcement earlier this year, the Department

control over what is generally regarded as the most

of Health added hysteroscopic sterilisation in

natural but most demanding of women’s roles, the

an outpatient setting as a Best Practice Tarriff,

gestation, birth and upbringing of children.

making this option available to all women in the

Whatever individual views there might be, women

newly announced Payment by Results (PbR).

deserve for the subject to be discussed in a calm

This has been demonstrated to be the most

and rational manner and for all views to be equally

effective of all permanent contraceptive options

available to them when deciding to bear children at

(including vasectomies in men) in preventing

the time or ever.

unintended pregnancy. There are social taboos and pressures associated with pregnancy and contraception. Some religions look unfavourably on contraception either as defiance against God, as incentive to immoral

John Hancock Editor

John Hancock has been Editor of Primary Care Reports since its launch. A journalist for nearly 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

2 | www.primarycarereports.co.uk

SPECIAL REPORT: PERMANENT CONTRACEPTION

Life Course Approach to Contraceptive Choice: Delivering Access for All Women Mr Ali Kubba, Chairman International Affairs Committee, Faculty of Sexual and Reproductive Healthcare and Community Gynaecologist at Guy’s & St Thomas’ NHS Foundation Trust

Mr ali kubba, chairman International Affairs Committee

recent inquiry by the All-Party Parliamentary Group on Sexual and Reproductive Health (APPG) into restrictions in access to contraception services in England, produced some interesting points for debate, especially concerning the relationship between user-centered contractive choices and effective use (see box 1). The inquiry highlighted women aged 24 years and upwards as a group that is currently at risk of poor and worsening access to contraceptive choice. This contradicts the life course approach across all stages of a woman’s life recommended by the RCOG.2 – http://www.rcog.org.uk/files/rcog-corp/14.10.11SACLifecourse.pdf This article outlines the restrictions in access to contraceptive choices, discusses how contraception needs change throughout a woman’s life course and reviews current contraceptive options for the older age groups.

BOX 1: APPG Inquiry following the AGC Audit into Contraception Earlier this year the Advisory Group on Contraception (AGC) – a coalition of leading experts and advocacy groups interested in sexual and reproductive health – conducted an audit into contraception across Primary Care Trusts (PCTs) in England through Freedom of Information (FOI) requests.1 Concerns from this audit by the All-Party Parliamentary Group of Sexual and Reproductive Health in the UK (APPG) prompted an Inquiry into restrictions in access to contraception services.2 The APPG’s Inquiry found that there is a correlation between when women are happy with their choice of contraception and using it effectively. When women have access to contraception alternatives it enables them to make informed choices and take control of their sexual and reproductive health. Ultimately, this results in fewer unintended pregnancies and consequent negative outcomes for women, and thereby reduces costs for the NHS.2

Restrictions on Access to Contraceptive Choice The Advisory Group on Contraception’s (AGC’s) audit found that as many as 3.2 million women of reproductive age (15-44), or one third of women in England, are living in areas where fully comprehensive contraceptive services, through community and/ or primary care www.primarycarereports.co.uk | 3

SPECIAL REPORT: PERMANENT CONTRACEPTION

Restrictions based on costs are detrimental to choice and quality, are false economies and run against the NICE guidelines.

services, are not provided.1 34 per cent of PCTs reported they have a restriction on the prescribing or availability of contraceptives, and furthermore, in those PCTs where restrictions to access were evident, a higher abortion rate than the national average was seen.1 However, over a quarter (28%) of PCTs responding to the audit did not have a strategy in place or under development to address unintended pregnancy. Inevitably, cost is a major consideration in restricting access to contraceptives and contraceptive services, with current economic pressures causing the NHS to make unprecedented cuts. However, restrictions based on costs are detrimental to choice and quality, are false economies and run against the NICE guidelines.3 PCTs reported restrictions in access to services based on geographical boundaries, the age of the women, type of contraceptive method offered, and GP contact/ referral barriers. The Family Planning Association (FPA) found evidence of similar practices.1, 4 The publication of this AGC’s audit generated much discussion. Baroness Gould of Potternewton, Chair of the All-Party Parliamentary Group on Sexual and Reproductive Health in the UK, said with regards to issues raised:2 ‘Choice and access to contraception is an essential for most women. It enables them to control their reproduction, plan their lives and avoid unplanned pregnancy. Access to contraception services and contraception choice is a necessity, not a luxury. Women’s reproductive health needs to be given much greater priority.’ The APPG’s Inquiry in turn sets out a series of recommendations, which include first and foremost:2 4 | www.primarycarereports.co.uk

‘All women must have access to a full choice of contraceptives and contraceptive services, including comprehensive information and advice that enables them to choose the method which is best for them. Any restrictions on access on the basis of age, residence or method should be removed as a matter of urgency.’

Commitment to Access to Contraceptive Choice Across the Life Course In all areas of public health it is recognised that people’s health needs change at different times of their lives, and this is particularly significant for women with regards to their sexual and reproductive health as lifestyle and personal relationships impact on their contraceptive choices. To address changing health needs throughout people’s lives, the Department of Health’s public health white paper, Healthy Lives, Healthy People: Our strategy for public health in England gave a commitment to adopt a life stage approach to public health.5 From the APPG’s Inquiry, it is apparent that such has been the Government’s focus on addressing unintended pregnancies among young people that this has been to the detriment of older women’s contraceptive needs. The majority (79%) of all abortions are for women aged over 20 years; 16% of women having abortions are married; and 48% have already given birth to one or more children.6, 7 The APPG recommends the Government’s sexual health policy ‘should take a life course approach, including addressing the needs of people over the age of 20 years old’ and that ‘the Department of Health, working with Public Health

SPECIAL REPORT: PERMANENT CONTRACEPTION

England, should establish what national levers can be put in place to ensure local commissioning decisions do not have a perverse impact on a group of people in their area.’2

Trends in Contraception for Older Age Groups The use of Long Acting Reversible Contraceptives (LARCs) – implant, injection, intrauterine device, and intrauterine systems – continues to increase for older age groups. Prescriptions for LARCs have increased from 0.7 million in 1997/98 to 1.3 million in 2010/11 and account for 28% of primary methods of contraception among women who attended NHS community contraceptive clinics, compared to 18% in 2003/04.8 During the same period, prescriptions for user dependant methods have remained stable, varying between 7.5 and 7.8 million.8 Traditional sterilisation (permanent contraception) has fallen from 40,500 in 1997/98 to 9,700 in 2010/11, or 15,900 when combined with a main or secondary procedure, in part due to non-funding in specific PCTs where the procedure is deemed ‘low priority’.9

Permanent Contraception – Adoption of the Latest Technology by NHS Permanent contraception, however, has had a recent turning point with the Department of Health’s announcement earlier this year that it would now include hysteroscopic sterilisation in an outpatient setting as a Best Practice Tariff in the newly announced Payment by Results (PbR).10 The decision to introduce this tariff, thereby making hysteroscopic sterilisation a contraceptive option available to all women, has been seen as

a sensible way of removing the funding problems which have previously limited availability in the UK. Hysteroscopic sterilisation brings a new choice for women and offers greater safety, efficacy advantages and value for money over traditional laparoscopic techniques to achieve tubal occlusion. Performed in an outpatient clinic, the soft, flexible inserts are placed into the fallopian tubes via a vaginal route into the uterine cavity and then work to create a natural barrier that provides permanent contraception. The procedure requires no general anaesthetic, scarring, cutting or associated risks of the traditional method of sterilisation, tubal ligation. Hysteroscopic sterilisation has been demonstrated to be the most effective of all permanent contraception options (including vasectomies for men) in preventing unintended pregnancy.11 It is useful to identify women who will benefit from a permanent method of contraception, particularly the minimally invasive procedure of hysteroscopic sterilisation – key factors may include: • Those who ask for it • Those with medical disorders –R estricting choice of non-permanent contraceptive –T hose deemed poor risks for general anaesthesia or for laparoscopy –T he obese who have one or the other of the above 2 factors •T hose with risk factors for reversible methods •T hose dissatisfied/non-compliant with their current methods of contraception Permanent contraception offers women who have decided their family unit is complete or www.primarycarereports.co.uk | 5

SPECIAL REPORT: PERMANENT CONTRACEPTION

Hysteroscopic

that they do not want children, an option to prevent further pregnancies. This is an important contraceptive choice to deliver to women at this stage of their life course, and it is significant that women can now have access to the minimally invasive procedure of hysteroscopic sterilisation to achieve this contraceptive choice.

sterilisation brings a new choice for women and

Conclusion Though choice and access to contraception is a necessity for women, one third, are living in areas where not all contraceptive choices are provided. With nearly 40% of all abortions being for women aged over 20 years of age who have already had children, it seems the older age group have been particularly neglected. Womenâ&#x20AC;&#x2122;s contraceptive needs change throughout their life-course. To address this and prevent unwanted pregnancies, healthcare professionals need to review womenâ&#x20AC;&#x2122;s contraception on a regular basis and offer them access to a full choice of services, including all relevant reversible and permanent options.

offers greater safety, efficacy advantages and value for money over traditional laparoscopic techniques to achieve tubal occlusion.

References 1. Advisory Group on Contraception (2012) Sex, Lives and Commissioning: An Audit by the Advisory Group on Contraception of the Commissioning of Contraceptive and Abortion Services in England. April 2012. 2. All-Party Parliamentary Group of Sexual and Reproductive Health in the UK (2012) Healthy women, healthy lives? The cost of curbing access to contraception services. May 2012. 3. NICE guidelines http://www.nice.org.uk/nicemedia/live/10974/29916/29916.pdf 4. FPA research [Page 16/17 APPG Healthy women, healthy lives etc; no reference for FPA listed] 5. Department of Health (2010) Healthy Lives, Healthy People: our strategy for public health in England. November 2010. Last accessed September 2012: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127424.pdf 6. Department of Health (2011) Abortion Statistics England and Wales. May 2011. 7. Abortion statistics 1.ONS & DH (May 2009), Statistical Bulletin, Abortion Statistics: 2008, England and Wales. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_099285 2. ONS & DH (June 2008), Statistical Bulletin, Abortion Statistics: 2007, England and Wales. Available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_085508 3. ONS & DH (June 2007), Statistical Bulletin, Abortion Statistics: 2006, England and Wales. Available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_075697 4.ONS & DH (June 2006), Statistical Bulletin, Abortion Statistics: 2005, England and Wales. Available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4136852 8. LARC statistics NHS Contraceptive services England 2010-11 9. HES Sterilisation statistics 2010-11 10. Department of Health Best Practice Tariff (2012)

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SPECIAL REPORT: PERMANENT CONTRACEPTION

Why Birth Control? Camilla Slade, Staff Writer

Or why not? It is not so much about choosing to use contraception as being properly informed to make the choice

to avoid, it is of little practical use. The importance of a birth control method being acceptable to use can best be illustrated by a statistic from the Guttmacher Institute used in the About.com article, ‘Why use contraception?’2 “Women who choose not to use any birth control and who are sexually active for one year have an 85% chance of becoming pregnant in that year (depending on variables such as age and frequency of intercourse).” Great if that’s what they want; not so good to disastrous if it’s not.

Reasons to Delay or Avoid Pregnancy

irth control or contraception fulfils a number of roles in society although they all stem from just two reasons: the prevention of pregnancy and, for some barrier methods of contraception, the avoidance of sexually transmitted diseases (STDs). All of the other outcomes (positive or negative) from contraception flow from these two.

The Best Contraceptive is One That is Used As long ago as the 1950s, statistician Christopher Tietze, working with the National Committee for Maternal Health (NCMH) in New York, wrote that “any contraceptive approach succeeds only if it is ‘use-effective’—one which individual women (and men) find appropriate for use within their own lives.”1 Tietze was engaged on a programme to evaluate different contraceptive methods then available, not only for efficacy but also for acceptability and likelihood that they would get used when needed. This latter point is very important because, no matter how scientifically ‘good’ a solution might be, if its use doesn’t fit the lifestyle of those whose pregnancy it is intended

Access to practical contraception is important whatever the reason and further on in the same About.com article, the broad reasons why a woman or a couple might not want children are set out… “Choosing the birth control that is right for you is a personal decision and should be an informed one. •Y ou may have decided that you don’t wish to have children or would love them – just at a later point in your life. • You may choose to use birth control to help space the timing of the births of your children. • You may be feeling like your family is complete, so you wish to guard against the possibility of becoming pregnant again. Because we are all individuals and have our own unique needs, so too, we may prefer a particular contraceptive method over another – depending on our sexual, moral, or reproductive needs.” Why people choose birth control is usually for family planning – either to manage the rate at which additions join the family, enable both parents to continue to make an economic contribution to the family by delaying the time to have children or simply because they feel that the family is large enough already.

Health Risks But there are even more basic reasons why birth control might be a woman’s or couple’s choice, if available to them. Over the six years between 1995 and 2000 there were an estimated 338 www.primarycarereports.co.uk | 7

SPECIAL REPORT: PERMANENT CONTRACEPTION

Most unintended pregnancies occur as a result of not using contraception that is available or using contraceptives inconsistently or incorrectly so there is a case for longer acting solutions that do not require the user to be organised or to gain the consent of the other party.

million pregnancies that were unintended and unwanted worldwide (28% of the total 1.2 billion pregnancies during that period). These unwanted pregnancies resulted in nearly 700,000 maternal deaths (approximately one-fifth of maternal deaths during that period). More than one-third of the deaths were from problems associated with pregnancy or childbirth, but the majority (64%) were from complications [after] unsafe or unsanitary abortion. Most of the deaths occurred in less developed parts of the world, where family planning and reproductive health services were less available3 which puts into perspective, but doesn’t invalidate, some of the ‘lifestyle’ considerations that exercise us in the developed world. Health is an important consideration for all women. Midwives will screen women during pregnancy to identify those at risk of suffering poor outcomes4 due to conditions such as the potential to develop venous thromboembolism, current overweight or obesity, poorly managed diabetes, substance abuse or others. Often, in such cases, it would be better to delay the likelihood of pregnancy at least until a better outcome can be anticipated.

Age Related And there are some contradictions between the age at which a woman is best physically able to carry, deliver and bring up a baby and her maturity to cope with parenthood at that time. “Young mums are more likely to go into labour prematurely and to have a low birth weight baby, 8 | www.primarycarereports.co.uk

which can be associated with medical problems. It’s not yet clear if this relates to other factors, such as teenage mums being more likely to smoke, or whether teenage mothers just may not always be physically mature enough to give their baby all the nutrients they need. They’re also more likely to develop preeclampsia – a condition connected to high blood pressure, which can cause serious health complications for mother and baby. And without the support they need, they’re less likely to breast-feed, with all the benefits that brings their baby.”5 This from Dr Sarah Jarvis’ ‘health & wellness’ blog on Patient.co.uk. Also, while contraception might be used to defer pregnancy until later in life, that choice itself is not without challenges. In the same blog from Dr Sarah Jarvis, “… these women [late 30s early 40s] are more likely to have problems with pregnancy, in addition to finding it harder to get pregnant in the first place and having a higher rate of miscarriage. They’re more likely to have health problems like high blood pressure or diabetes, either dating from before they get pregnant or developing during pregnancy. Like young mums, they are also at higher risk of pre-eclampsia. They are also more likely to have problems in labour, to need a Caesarean section or to have a stillbirth. And there’s no getting round the fact that the risk of having a baby with a genetic condition like Down’s syndrome rises steadily with age.”

Summary Most unintended pregnancies occur as a result of not using contraception that is available or using contraceptives inconsistently or incorrectly so there is a case for longer acting solutions that do not require the user to be organised or to gain the consent of the other party. All in all, there are strong moral arguments both for and against contraception and, while there would not be the space to air them fully here, they have both been neatly summarised in two BBC Ethics Guides, ‘Moral case for contraception’6 and ‘Moral case against contraception’7 None of this should be read as saying that women must use a contraceptive, nor should the setting out of potential risks and problems resulting from pregnancy be read as an outof-proportion argument against child bearing and rearing. It should, though, be seen in the context of pregnancy and contraception being issues where decisions will undoubtedly impact massively on the lives of those concerned and, especially, women and mothers. In that context, it is right to set out all the factors that a potential parent should take into account when making an informed decision on what remains one of life’s biggest decisions.

SPECIAL REPORT: PERMANENT CONTRACEPTION

Making the Right Choice Peter Dunwell, Medical Correspondent

With up to 15 types of contraceptive available, choosing which might be right is not easy

have access to the services of two excellent services in Brook and FPA who have developed an interactive tool ‘My Contraception Tool’9 & 10 to assist in the process of choosing which family planning method is best for them. There is a short version of the tool which takes about five minutes to complete or a longer version that asks about the user’s medical history which might be important.

Different Methods

ike so many other issues today, as Marcia Meldrum’s Lancet article, ‘Women making contraceptive choices in 20th century America’, concluded; “Many women’s responses to contraception in the 21st century are clearly interwoven with feminism, concerns about pharmaceutical marketing, and the rising consciousness of women about their own health... Where they have options, women will make choices...” The important thing is; from what can they choose?

What is Contraception? It is also important that they don’t lose sight of what lies at the heart of all this… A woman can get pregnant if a man’s sperm reaches one of her eggs (ova). Contraception tries to stop this happening by keeping the egg and sperm apart or by stopping egg production8. The NHS offers a pretty comprehensive summation of what anybody considering contraception should bear in mind and lists the different methods. In the UK, women are fortunate to

At its least controversial, contraception doesn’t have to involve any pill or physical device. There is a method called Natural Family Planning11 based on a woman observing and recording her monthly cycle from fertility to safe times when no egg will be present to be fertilised. Clearly, with its absence of chemical or other intervention and properly applied, this method can enable a woman to manage her body wholly within its natural processes. But it does require a level of organisation and commitment to the process that would not suit all lifestyles or abilities. For instance, it would not do for groups likely to engage in promiscuous sexual activity, especially if accompanied by alcohol or drug use and would certainly not work for those with chaotic lifestyles. Neither would it work for those with learning difficulties or mental conditions. For those who might not be able to or wish to manage Natural Family Planning, there is a range of options to give, mainly, women and, sometimes, men control over their fertility or likelihood of becoming/making pregnant. Other methods that require varying degrees of organisation are known as ‘methods with user failure’ – in which users have to employ and think about them regularly or each time they have sex12. These are also called non-permanent methods and would include: • Contraceptive patch; • Vaginal ring; •P ill (Combined or Progestogen-only) or Oral Contraceptive; • Condom (male or female); • Diaphragm/cap. www.primarycarereports.co.uk | 9

SPECIAL REPORT: PERMANENT CONTRACEPTION

The NHS offers a pretty comprehensive summation of what anybody considering contraception should bear in mind and lists the different methods.

Perhaps the strongest methods are those categorised as ‘methods with no user failure’ which do not depend on anybody remembering to take or use them. These are sometimes known as permanent methods (whether reversible or not) and would include: • Injection; • Implant • Intrauterine system (IUS); • Intrauterine device (IUD); • Female and male sterilisation. Most of the above methods have a reliability rate between 92% (diaphragm or cap), 95% (female condom) and 98-99% (the rest): all percentages assume correct application or use. There is also a more recent and less invasive development in female sterilisation in which small implants are placed in the fallopian tubes using a hysteroscope passed through the vagina and cervix (hysteroscopic sterilisation by tubal cannulation and placement of intrafallopian implants And, for those who have had sex without protection, there is emergency contraception which some would equate with very early stage abortion.

Pros and Cons When oral contraceptives, in particular, became available, most women welcomed the freedom and personal control offered them but it was not an unalloyed boon. In less than a year after its introduction, there were six reported deaths and 20 other non-fatal cases of women who had suffered a thrombosis as a result of the chemical changes that the pill wrought in their bodies. For a while, the IUD came back into fashion with a variant from A H Robins Company called the Dalkon Shield. This, however, soon became associated with severe pelvic inflammatory disease, miscarriages, birth defects, infertility and even death: manufacture stopped in 1976. An implantable device called Norplant that

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released progesterone over a five year period came and had gone by 2000. Also, a number of methods can change women’s periods; making them lighter or heavier, less frequent or irregular. There would not be space here to list all of the pros and cons of the various methods but the Center for Young Women’s Health at the Boston Children’s Hospital has put together an excellent and comprehensive table, ‘The Pros and Cons of different Contraceptive Methods’13. Whatever contraceptive value these devices might have possessed, they were clearly not always good for women to one degree or another, and understandably women began to distrust the industry that made them and the clinicians who prescribed them. Yet, they still hankered after that level of control over their own bodies and actions that a well matched usable contraceptive should offer.

Changing Live: Changing Priorities Nothing is fixed in this area. As women progress through different stages of their lives, their contraceptive needs also change. For teenagers, contraception is sometimes seen as a bulwark between hormone rich, promiscuous lifestyles and pregnancy; although it is also argued that provision of contraception makes promiscuity more likely – not a debate for these pages. Young adults often need to avoid pregnancy while they are building a career or are endeavouring to get financially established; while family makers might wish to control the rate at which their family grows. Finally, there are older people and people who have decided not to have children. The changing priorities that accompany these life stages will also call for at least a revisiting of contraception choices to ensure that the method being used is still appropriate to the purpose for which it is being applied.

SPECIAL REPORT: PERMANENT CONTRACEPTION

Outcomes and Values John Hancock

Not only can family planning bring immense benefits to the lives of woman who can access it, contraception also delivers real economic value

ccording to the United Nations Population Fund (UNFPA) in its 2012 annual ‘State of World Population’ report, as covered by Health24, “The world economy would be boosted by billions of dollars if all women had access to contraception...”14 The report said inadequate family planning in developing countries contributed significantly to poverty and ill health, and that $5.7 billion (4.5 billion euros) could be saved by preventing unintended pregnancies and unsafe abortions. “Family planning is not a privilege, but a right. Yet, too many women – and men – are denied this human right,” said Babatunde Osotimehin, executive director of (UNFPA). While this macro-economic start to an article about the values of family planning and contraception may seem a little hard headed, it has to be remembered that every life makes additional demands on finite resources and it is in those areas of the world least able to realise or fairly distribute resources where most population growth takes place. Any method that could successfully manage that conundrum would generate immense value and very positive

outcomes for us all. But we mustn’t forget the people directly affected in all this.

Human Benefits Mr Osotimehin went on to say that women who use contraception are generally healthier, better educated, more empowered in their households and communities and more economically productive. But the macroeconomic values of population control and, at a more human level, family planning and contraception, cannot be ignored. There are a number of benefits that result from family planning including the ability for women to work and contribute more income to what are smaller and, therefore, per capita wealthier families. This is a positive outcome at the family level, but an increased use of contraceptives has also been cited as one element in the success of Asian ‘Tiger’ economies with fewer mouths to feed enabling parents to work more and earn more. Also, on a more human level, the UN estimates that the extension of contraception to a further 120 million women worldwide by 2020 would mean three million less babies dying in their first www.primarycarereports.co.uk | 11

SPECIAL REPORT: PERMANENT CONTRACEPTION

The head of Britain’s largest abortion provider said many young women were living chaotic lives that meant they could not organise contraception…

year of life. As well as, on a global scale, family planning would deliver, “immeasurable rewards to women, families, and communities around the world,” the UNFPA report said.

Avoiding Unintended Pregnancies The reason that contraception can deliver all this lies in its prime outcome; the avoidance of unplanned, unintended or unwanted (sometimes called mistimed) pregnancies. While not entirely without risks, contraceptives have been refined to a high level of quality and will almost certainly offer a better outcome than the main alternatives, abortion or miscarriage, both of which (especially miscarriage) carry considerable health risks. And unintended pregnancies are linked to numerous maternal and child health problems15. So, in one sense, the beneficial outcomes from contraceptive use are marked as much by the absence of poor outcomes. Some of the problems that unintended pregnancies bring for mothers can be seen in the UK’s profoundly depressing rates of teenage conception and abortion. Laura Donnelly, Health Correspondent on the Telegraph, wrote on 12 June 2010, “Government data have disclosed that 89 girls aged 17 or under who terminated a pregnancy last year had had at least two abortions previously. The head of Britain’s largest abortion provider said many young women were living chaotic lives that meant they could not organise contraception… The Department of Health figures for 2009 show that, for the first time, more than a third (34 per cent) of abortions were performed on women who had already ended one or more pregnancies. Across all ages, more than 1,000 women or girls were on at least their fifth termination, including 214 on their sixth, 70 on their seventh and 48 who underwent the procedure for at least the eighth time.”16 Doctors will say that the more abortion procedures to which a woman or girl subjects her womb, the greater the risk that she will become either infertile or unable to sustain a full-term pregnancy when she really wants to.

Age Issues At the other end of the age spectrum, there are specific risks associated with pregnancy in older

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women and, while some women will deliberately choose to delay parenthood for career or other reasons, others who may have completed their families will not wish to expose themselves to unnecessary risk of17… • High blood pressure; • Increased risk of birth defects; • Miscarriage; • Diabetes; • Fertility Problems; • Carrying more than one fetus; • Genetic disorders; • Placenta previa; • Increased rate of C-Section. …or to risk giving birth to a child with a higher risk of genetic disorders such as Down’s Syndrome18. For these women who have decided to manage the end of their fertility, it may well be that a permanent contraception solution will be the one most likely to deliver the outcome that they seek.

Health Issues Other cases where poor outcomes might be avoided by contraception would be where the woman is overweight (risk of diabetes and/ or pre-eclampsia), drinks, smokes or is a user of recreational drugs: all can adversely affect a woman’s health during pregnancy and endanger the unborn child’s health or even, in extreme cases, life. Contraception can avoid these outcomes either permanently or until the woman has taken steps to improve her chances of a good outcome.

Healthcare System Benefits And last, but by no means least, properly and appropriately applied contraception can reduce costs for healthcare systems. A study in the US by NCBI (National Center for Biotechnology Information)19 concluded that, “Contraceptives save health care resources by preventing unintended pregnancies. Up-front acquisition costs are inaccurate predictors of the total economic costs of competing contraceptive methods.” In the UK, Martin Beckford and Simon Caldwell, writing in The Telegraph20, reported that the 2010 cost to the public purse was £118 million for 173,000 abortions. Contraception has to be a more economically viable solution than that.

SPECIAL REPORT: PERMANENT CONTRACEPTION

Getting to the Right Answer Camilla Slade, Staff Writer

here is no shortage of choices for people who want or need to access contraception: however, they do need guidance on how to choose the solution that is right for them and to determine that their reasons for wanting contraception are sound and healthy.

Who Can Help Decide? One person well placed to assist in this is a GP. “If a young person under the age of legal consent is having sex then this should be treated as a safeguarding issue, and health professionals will always bear this in mind first and foremost in their approach to providing contraception or other sexual health services. The GP will, through careful skill, ensure the young person understands, is competent to make these decisions, and is not being coerced into having a sexual relationship.”21 This opening statement in the Royal College of General Practitioners (RCGP) April 2012 response to the NHS

report suggesting that the contraceptive pill should be available at pharmacies without a GP prescription, including to some under-16s, makes an important point. There are occasions when partners who are violent or abusive will seek to disrupt a contraceptive programme or where religion will intervene – some religions do not think contraception should be a woman’s choice as they don’t agree with the empowerment of women. The RCGP approach considers the contraceptive decision in the context of the whole person as do other services such as Brook and FPA (Family Planning Association). People, usually women, who need contraception, will present in a variety of ways and clinicians or advisers should be trained to analyse what is really required and then discuss it with the user. That even extends to emergency contraception, “if [the woman] had sex without using contraception. Or, if [she] had sex but there was a mistake with contraception. For example, www.primarycarereports.co.uk | 13

SPECIAL REPORT: PERMANENT CONTRACEPTION

There are also groups

life whereas all too many women who present at GP surgeries or family planning centres are not in control of much, if any, of their chaotic lives. For them, a more permanent solution might be appropriate but even people in chaos have the right to make their own decision as to how they would wish to proceed; advisers can only advise. As Marcia Meldrum put it in her Lancet article ‘Women making contraceptive choices in 20th century America’25 “[Media] now shifted emphasis from discussing the risks of the pill to comparing and contrasting various contraceptive methods available and describing the ‘lifestyle’ that each would best fit...”

of women who need to consider contraception because pregnancy will either add a burden to a

Wants and Needs

current health problem or mental condition, or for whom some types of contraception could be harmful.

a split condom or if [she] missed taking [her] usual contraceptive pills.” Such a situation might also offer a clue as to the woman’s lifestyle and whether a different, perhaps more permanent, method of contraception might be appropriate to discuss with her. There are now less invasive methods for permanent sterilisation available. In particular, a method known as ‘female sterilisation using implants (inserted through the vagina) to block the fallopian tubes’ and using a procedure known in medical terms as ‘hysteroscopic sterilisation by tubal cannulation and placement of intrafallopian implants’ was approved in early 2012 for use in the NHS. More can be learned about about this method from the UK’s National Institute for Health and Clinical Excellence (NICE)22. Most types of contraception don’t protect against sexually transmitted infections (STIs). The male condom is the only form of contraception that protects against STIs as well as preventing pregnancy. Therefore, if, particularly a woman, is using another type of contraception, such as the contraceptive pill, she should also use a condom to protect herself against STI transmission23. This sensible advice from NHS Choices alludes to some of the complexities around this area that is so intertwined with human nature.

What Works for Each Person? One problem is that, often, the women who most need contraception are the ones with least access to it or at the highest risk. NHS Choices, again24, points out that if you’re a well-organised person with a reasonably regular routine, then you have a wide choice of contraception. This is because you’re less likely to forget about your contraception – for example, forgetting to take a pill or to reapply a patch. But someone who is organised is also likely to be in control of all of their 14 | www.primarycarereports.co.uk

But all of the above examples are about women who want to use contraceptives to plan their lives better. There are also groups of women who need to consider contraception because pregnancy will either add a burden to a current health problem or mental condition, or for whom some types of contraception could be harmful. While there may be permanent cases in this category for whom a permanent solution would be appropriate, most will need to use contraception to delay conception until their bodies (or mental health) are better able to cope. Some of the more obvious cases would be where a woman smokes, drinks, uses recreational drugs or has a long term condition such as diabetes or cancer. But there are many more and more complex reasons listed by NHS Choices (see 23 above).

Where to Go For women (or men) who need unbiased information with which to make a choice, FPA has devised a Contraceptive Choices leaflet26 that sets out the main contraceptive methods with a brief summary of each one’s effectiveness, advantages and disadvantages. And of course, NHS Choices (see 23 above) offers a guide as to where contraceptive advice can be accessed. For a summary of choosing a method of contraception, Patient.co.uk produces a leaflet ‘Contraceptive Choices’27 which includes; ‘When you choose a method of contraception you need to think about: • How effective it is. • Possible risks and side-effects. • Plans for future pregnancies. • Personal preference. • I f you have a medical condition, or take medicines that interact with the method.’ For contraception to be effective and useful it needs to be the right method for the person using it and accessible to whoever wants or needs it. Then it will be able to contribute to the improvement of women’s lives, in particular, and, who knows, to the improvement of society overall.

SPECIAL REPORT: PERMANENT CONTRACEPTION

References: 1

The Lancet, ‘Women making contraceptive choices in 20th-century America’ http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961166-0/fulltext

About.com article, ‘Why use contraception?’ http://contraception.about.com/od/contraceptionoverview/f/Purposes.htm

Wikipedia http://en.wikipedia.org/wiki/Unwanted_pregnancy

British Journal of Midwifery http://info.britishjournalofmidwifery.com/downloads/antenatal_screening

Patient.co.uk, Dr Sarah Jarvis’ ‘health & wellness’ blog http://www.patient.co.uk/blogs/sarah-says/2012/10/getting-pregnant---what-age-is-best

BBC ‘Moral case for contraception’ http://www.bbc.co.uk/ethics/contraception/in_favour.shtml

BBC ‘Moral case against contraception’ http://www.bbc.co.uk/ethics/contraception/against_1.shtml

NHS, ‘Contraception: what’s right for me?’ http://www.nhs.uk/Livewell/Contraception/Pages/Whichmethodsuitsme.aspx

Brook, ‘My Contraception Tool’ http://brook.org.uk/contraception/my-contraception-tool

FPA, ‘My Contraception Tool’ http://www.fpa.org.uk/helpandadvice/mycontraceptiontool

Natural Family Planning http://www.fpa.org.uk/helpandadvice/contraception/naturalfamilyplanning

FPA ‘Your Contraceptive Choices’ http://www.fpa.org.uk/media/uploads/professionals/yourcontraceptivechoicessept09.pdf

Boston Children’s Hospital, The Pros and Cons of different Contraceptive Methods’ http://www.youngwomenshealth.org/prosandcons.html

Health24 http://www.health24.com/news/Contraception/1-900,77857.asp

Wikipedia http://en.wikipedia.org/wiki/Unwanted_pregnancy

The Telegraph http://www.telegraph.co.uk/health/women_shealth/7823317/Dozens-of-teenage-girls-have-had-three-abortions-or-more.html

Amazing Pregnancy.com http://www.amazingpregnancy.com/pregnancy-articles/544.html

Amazing Pregnancy.com http://www.amazingpregnancy.com/pregnancy-articles/543.html

NCBI, ‘The economic value of contraception: a comparison of 15 methods’ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615115/

The Telegraph http://www.telegraph.co.uk/health/women_shealth/8904455/Abortion-costs-30m-higher-than-previously-thought.html#

RCGP statement on contraceptive pill availability http://www.rcgp.org.uk/news/2012/april/rcgp-statement-on-contraceptive-pill-availability.aspx

NICE, Female sterilisation using implants (inserted through the vagina) to block the fallopian tubes http://www.nice.org.uk/nicemedia/live/11118/45504/45504.pdf

NHS Choices http://www.nhs.uk/Conditions/Contraception/Pages/Introduction.aspx

NHS Choices http://www.nhs.uk/Livewell/Contraception/Pages/Whichmethodsuitsme.aspx

The Lancet, ‘Women making contraceptive choices in 20th-century America’

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961166-0/fulltext 26

FPA ‘Your Contraceptive Choices’ http://www.fpa.org.uk/media/uploads/professionals/yourcontraceptivechoicessept09.pdf

Patient.co.uk ‘Contraceptive Choices’ http://www.patient.co.uk/health/Contraceptive-Choices www.primarycarereports.co.uk | 15

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