Promoting the use of long-acting reversible contraceptives to reduce unplanned pregnancies
Intended for healthcare professionals
Evidence and practice    

Promoting the use of long-acting reversible contraceptives to reduce unplanned pregnancies

Emma Louise Jones General practice nurse, Hereford Road Surgery, Abergavenny, Wales

Why you should read this article:
  • To recognise why it is important to reduce the number of unplanned pregnancies

  • To enhance your knowledge of the benefits and risks associated with long-acting reversible contraceptives

  • To understand the role of general practice nurses in discussing contraception with patients

Contraception is a highly cost-effective public health intervention because it reduces the number of unplanned pregnancies. However, the provision of contraception is variable, funding for publicly provided contraception has declined and unplanned pregnancies continue to be a public health issue in the UK. Long-acting reversible contraceptives (LARCs) are deemed to be the most effective methods of contraception and increasing their uptake could reduce unplanned pregnancies. This article provides information to support general practice nurses in reducing unplanned pregnancies by promoting the use of LARCs. It explores the benefits and risks of LARCs, existing barriers to their uptake and the role of nurses in discussing contraception with patients in general practice settings.

Primary Health Care. doi: 10.7748/phc.2023.e1800

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@gpn_emma

Correspondence

Emma.Jones78@wales.nhs.uk

Conflict of interest

None declared

Jones EL (2023) Promoting the use of long-acting reversible contraceptives to reduce unplanned pregnancies. Primary Health Care. doi: 10.7748/phc.2023.e1800

Published online: 16 August 2023

Unplanned pregnancies continue to be a public health issue in the UK and worldwide. In England, 45% of pregnancies and one third of births are ‘unplanned or associated with feelings of ambivalence’ (Public Health England 2018a). In a large-scale probability sample survey, Wellings et al (2013) found that approximately one in six pregnancies in Britain (England, Scotland and Wales) were unplanned. Bearak et al (2020) estimated that in 2015-2019 the rate of unplanned pregnancy in Europe was 35 per 1,000 women aged between 15 years and 49 years. This represented a 47% decline from 1990-1994, when the rate was estimated to be 67 per 1,000 women (Bearak et al 2020), but nonetheless the figure was still high.

In its guidance on reproductive health and pregnancy planning, Public Health England (2018a) recognised that planned pregnancies are likely to be healthier, since in unplanned pregnancies there is no opportunity to optimise pre-pregnancy health, and that some unplanned pregnancies can have adverse health effects on the mother and the child. Public Health England (2018a) further emphasised that women should have control over reproduction so that as many pregnancies as possible are planned and wanted, women’s health is optimised before a first pregnancy and during the inter-pregnancy interval (the time between one pregnancy and the next), and women who do not wish to have children can avoid becoming pregnant.

General practice nurses have an important role in women’s health which includes the provision of cervical screening, menopause support, family planning advice and contraception services. Since unplanned pregnancies are common reproductive health events, it is important that general practice nurses know how to care for women presenting with them. Their responsibilities in this area include appropriate assessment, advising women on their options, providing or referring them for care and support, coordinating care, and providing education and advice to decrease the risk of further unplanned pregnancies (Simmonds and Likis 2011).

It is equally important that general practice nurses can contribute to wider efforts aimed at avoiding unplanned pregnancies in the first place. Long-acting reversible contraceptives (LARCs) are the most effective methods of contraception available at present (National Institute for Health and Care Excellence (NICE) 2019), so this article discusses how general practice nurses can help reduce unplanned pregnancies by promoting the use of LARCs.

Effectiveness of contraception methods

According to Wellings et al (2013), heterosexually active women in Britain spend approximately 30 years of their lives needing to prevent unplanned pregnancies. During those 30 years, most women are highly likely to become pregnant if they do not proactively seek to avoid it – that is, if they do not use a contraception method. Therefore, contraception is a daily reality for the vast majority of women in England for most of their reproductive years (Public Health England 2018a).

Contraception methods are generally less effective when they are not used correctly and consistently. However, effectiveness varies considerably between methods. For example, the effectiveness of oral contraceptive pills relies on daily concordance, whereas LARCs require administration less than once per menstrual cycle or per month to be effective (NICE 2019). Table 1 shows the percentage of women who experience an unplanned pregnancy with different contraception methods in the first year of use, comparing between ‘typical use’ (when the method is not always used correctly or consistently) and ‘perfect use’ (when the method is always used correctly and consistently).

Table 1.

Percentage of women who experience an unplanned pregnancy with different contraception methods in the first year of use

Type of contraception methodSpecific contraception methodTypical usePerfect use
Natural methodsFertility awareness24%1% to 9%
Lactational amenorrhoea (exclusively breastfeeding)2%0.5%
Withdrawal22%4%
Oral contraceptive pillsCombined hormonal pill and progesterone-only pill9%0.3%
Barrier methodsMale condom18%2%
Female condom21%5%
Diaphragm plus spermicide12%6%
Combined vaginal ring9%0.3%
Combined transdermal patch9%0.3%
Long-acting reversible contraceptivesProgesterone-only subdermal implant0.05%0.05%
Progesterone-only injectable contraceptive6%0.2%
Progesterone-only (levonorgestrel) intrauterine system (IUS)0.2%0.2%
Copper intrauterine device (IUD)0.8%0.6%
Permanent contraceptionFemale sterilisation0.5%0.5%
Male sterilisation0.15%0.1%

Types of LARCs include intrauterine devices (IUDs) (non-hormonal contraceptives) and subdermal implants, injectable contraceptives and intrauterine systems (IUSs) (progesterone-only contraceptives). According to expert clinical opinion, increasing the uptake of LARCs could reduce the number of unplanned pregnancies (NICE 2019). However, their use is still lower than that of user-dependent methods such as oral contraceptive pills and barriers methods.

In England in 2019-2020, 46% of women in contact with sexual and reproductive health services were using a LARC, compared with 54% who were using user-dependent methods (NHS Digital 2020). The method most commonly used was the oral contraceptive pill (38%) in all age groups except for those aged 45 years or over, among whom the most commonly used method was the IUS. Subdermal implants were the main method used by 18%, with younger age groups more likely to use them. Intrauterine contraceptives (IUCs) – that is, IUSs and IUDs – were the main method used by 19%, with 11% using an IUS and 8% using an IUD. The use of IUCs increased with age, with 42% of those aged 45 years or over using either an IUS or IUD as their main method of contraception. Injectable contraceptives were the main method used by 9% (NHS Digital 2020).

Return on investment

Contraception is recognised as a highly cost-effective public health intervention, notably because it reduces the number of unplanned pregnancies, which generate high financial costs for individuals, healthcare services and public services in general (Public Health England 2018b). In a report on the progress made towards reducing the number of teenage pregnancies in England, the Teenage Pregnancy Independent Advisory Group (2010) emphasised the need to show that investment in contraception is cost-effective, citing the estimated figure of £11 saved by the NHS for every £1 invested in contraception.

Public Health England (2018b) conducted an economic analysis of publicly funded contraception in England. It found that when considering total cost savings for the public sector as a whole there was a £9 return on investment (ROI) after ten years – that is, a £9 cost saving for every £1 invested in publicly funded contraception. Public Health England (2021) applied its contraception ROI tool to two scenarios: the provision of contraception in maternity settings during the immediate postnatal period, and the provision of LARCs in primary care. It showed that providing LARCs in primary care produced a £48 ROI – that is, a total cost saving of £48 for every £1 invested for the public sector as a whole (Public Health England 2021).

Gaps in service provision

As a result of ongoing public spending cuts, funding for sexual health services in England has declined, with a corresponding reduction in funding for publicly provided contraception (Public Health England 2018b).

Key points

  • The role of general practice nurses in women’s health includes the provision of cervical screening, menopause support, family planning advice and contraception services

  • It is important that as many pregnancies as possible are planned and wanted, that women’s health is optimised before pregnancy, and that women who do not wish to have children can avoid becoming pregnant

  • Increasing the uptake of long-acting reversible contraceptives (LARCs) could reduce the number of unplanned pregnancies; however, their use is still lower than that of user-dependent methods such as oral contraceptive pills

  • General practice nurses are well-placed to help prevent unplanned pregnancies by ensuring that women have access to comprehensive information and advice on contraception methods, including LARCs

The Family Planning Association (FPA) (2021) reported ‘worrying gaps’ in the provision of contraception based on the results of a survey of 1,023 GPs from 914 practices in England. They found that the combined hormonal pill and progestogen-only pill were the only contraception methods prescribed by all respondents and only 2% said they offered the full range of available methods to patients. While 99% of respondents said they offered the injectable contraceptive, the provision of other LARCs was variable: one fifth of respondents said they did not offer the IUD, one fifth said they did not offer the IUS, and almost one quarter said they did not offer the subdermal implant. Reasons cited for LARCs not being offered included lack of training and lack of funding. Provision was also variable for all other remaining methods. These findings led the FPA to call for increased awareness of the different options available and greater choice offered to patients in general practice to help them to avoid unplanned pregnancies.

The Women’s Health Strategy for England is a ten-year strategy that adopts a life-course approach, whereby the focus is on understanding the changing health and care needs of women across their lives (Department of Health and Social Care (DHSC) 2022a). It was informed by a survey of women on their health issues and their experience of the healthcare system – which received almost 100,000 responses – and by feedback from 436 individuals and organisations with expertise in women’s health (DHSC 2022b). The survey found that 84% of respondents felt there were times when women were not listened to by healthcare professionals (DHSC 2022b). The strategy identified that the ‘male as default’ approach traditionally used in the UK healthcare system has meant that healthcare policies and services have been designed without considering women’s health issues. This has resulted in inefficiencies in service delivery, including challenges in accessing reproductive health services and contraception (DHSC 2022a).

Barriers to uptake

In addition to lack of funding and gaps in service provision, further barriers to the uptake of LARCs have been noted. Research into what could make LARCs more appealing to patients is scarce, but Coombe et al’s (2016) systematic review explored what qualities of LARCs women perceive as desirable or undesirable, while Hoggart et al’s (2015) mixed methods study investigated barriers to the uptake of IUCs.

Based on the 30 studies they reviewed, Coombe et al (2016) found that women perceive that LARCs have:

  • Desirable qualities including high effectiveness and long-term protection, and that they are ‘fit and forget’ methods.

  • Undesirable qualities including uncertain effects on the menstrual cycle and weight gain. In the case of IUCs, additional undesirable qualities included location in the body and the painful insertion and removal procedure.

In their mixed-method study, Hoggart et al (2015) identified the following barriers to the uptake of IUCs:

  • Barriers for women – for example IUCs not being viewed as their first-choice contraception method, concerns that the device may move inside the body, and the need for the device to be inserted and removed by a healthcare professional.

  • Practitioner barriers – for example lack of knowledge about IUCs, the inaccurate belief that IUCs are not suitable for nulliparous women (women who have never given birth), difficulties arranging training to learn to fit IUCs, and cost of training.

Shoupe (2016) acknowledged that the knowledge and experience of healthcare professionals are important factors in how well LARCs are promoted in clinical practice. Furthermore, to be able to provide IUCs and subdermal implants, healthcare professionals need additional training. The Faculty of Sexual and Reproductive Healthcare (FSRH) (2023) stated that healthcare professionals who insert or remove such methods should be appropriately trained, maintain their competence and attend regular updates. Some GPs and general practice nurses undertake training to be able to provide these contraception methods to patients, but Hoggart et al (2015) noted that training can be challenging to arrange and/or too costly.

Furthermore, in the FPA’s (2021) survey of 1,023 GPs in England, more than half of the respondents said they lacked time to discuss contraception with patients during a standard appointment. General practice nurses are likely facing a similar issue, considering that an appointment with a nurse lasts approximately ten minutes on average (NHS England 2023) and women will need a considerable amount of information to be able to make an informed decision about contraception.

Discussing contraception with patients

Advice about and provision of contraception is mainly offered to patients in primary care, usually in a GP surgery or a sexual and reproductive health clinic. An online survey of 7,367 women aged over 16 years conducted by Public Health England (2018c) identified that most women prefer to obtain their contraception method from a GP surgery. Therefore, general practice nurses are well-placed to inform women of their options, explain to them the risks and benefits of each contraception method, and address their concerns.

Increasing patients’ awareness and knowledge of the different contraception methods can, in time, contribute towards preventing unplanned pregnancies (NICE 2019, FPA 2021). NICE (2019) states that women requiring contraception should be given information about, and offered a choice of, all methods of contraception including LARCs. The role of general practice nurses typically entails discussing contraception with patients to support them to make an informed decision about it, undertaking routine checks and providing advice to patients.

Having open and honest discussions about contraception can increase the uptake of LARCs (Glasier et al 2008). Each woman will have their own needs and preferences, so the discussion and subsequent provision of contraception need to be tailored to the individual. Some women may be reluctant to discuss contraception because sexuality is still a taboo subject and/or because they fear judgement, humiliation or stigmatisation. Therefore, the positive aspects of sexual healthcare should be promoted to reduce stigma (Fennell and Grant 2019), and general practice nurses need to demonstrate empathy and use a non-judgemental approach. They also need to reassure patients that their privacy and confidentiality will be respected, as stated in the Code: Professional Standards of Practice and Behaviour for Nurses, Midwives, and Nursing Associates (Nursing and Midwifery Council (NMC) 2018a).

When discussing contraception with patients, general practice nurses also need to encourage them to participate in the decision-making process and to ensure that the care they provide is person centred (Coulter and Collins 2011, NMC 2018b). When providing health promotion interventions such as contraception care, nurses have a crucial role not only in educating patients, but also in empowering them to make decisions about their care (Chilton and Bain 2018).

Making Every Contact Count (Public Health England et al 2016) is an evidence-based approach founded on the premise that health promotion can be carried out in almost every encounter with patients. At its two most basic levels, the Making Every Contact Count approach can be implemented using very brief and brief interventions (Public Health England et al 2016). Such interventions can be valuable tools for general practice nurses to start a discussion with patients about contraception.

When discussing contraception with patients, general practice nurses need to:

  • Be aware of the risk factors for unplanned pregnancy.

  • Consider the eligibility criteria for the different contraception methods.

  • Be able to explain the mechanisms of action, advantages and disadvantages of LARCs.

Risk factors for unplanned pregnancy

According to Public Health England (2018a) there are many risk factors for unplanned pregnancy, including lower educational attainment, younger age, smoking and substance misuse. Public Health England (2018a) also noted that abortion rates are higher among some black and Asian minority ethnic (BAME) groups, which may indicate either higher rates of total unplanned pregnancies and/or greater proportions of unplanned pregnancies resulting in abortion.

Unplanned pregnancy is also an issue for women between the age of 35 years and the menopause, because that group may be the least likely to use adequate contraception even if they are sexually active but do not want to conceive. This is supported by rising abortion rates in that age group in 2010-2020 in England and Wales, a period during which abortion rates decreased among girls under the age of 18 years (DHSC 2022c).

Eligibility criteria for contraception methods

The FSRH (2019a) publishes guidance on patient eligibility criteria for the different contraception methods, based on the UK Medical Eligibility Criteria (UKMEC) and according to various patient characteristics. There are four UKMEC categories:

  • Category 1 – a condition for which there is no restriction for the use of the method.

  • Category 2 – a condition where the advantages of using the method generally outweigh the theoretical or proven risks.

  • Category 3 – a condition where the theoretical or proven risks usually outweigh the advantages of using the method. Since the use of the method is not usually recommended, its provision requires expert clinical judgement and/or referral to a specialist contraception provider.

  • Category 4 – a condition which represents an unacceptable health risk if the method is used.

Patient characteristics considered in the FSRH (2019a) guidance encompass personal characteristics, reproductive history, smoking, obesity, cardiovascular disease, neurological conditions, depressive disorders, breast and reproductive tract conditions, infections, endocrine conditions, gastrointestinal conditions, anaemias, rheumatic diseases and drug interactions. The FSRH (2019a) guidance is an invaluable tool that enables healthcare professionals to safely advise patients on, and prescribe, contraception methods.

Mechanisms of action of long-acting reversible contraceptives

The mechanism of action of LARCs differs depending on whether the method is hormonal or non-hormonal. The IUD is the only non-hormonal method available, while the hormonal methods are the IUS, subdermal implant and injectable contraceptive.

The IUD is inserted into the uterus and can last between five years and ten years, depending on the device (Joint Formulary Committee 2023). The IUD contains a copper component that acts as a spermicide, damaging the sperm and consequently preventing it from fertilising the egg (World Health Organization (WHO) 2020).

Similar to the IUD, the IUS is inserted into the uterus. The IUS contains progesterone and works by mimicking the menstrual cycle, thickening the cervical mucous to prevent sperm from meeting the egg (WHO 2020). It can last between three and five years, depending on the system (Joint Formulary Committee 2023).

The subdermal implant is a small rod containing long-acting progesterone that is inserted into the subdermal layer of the upper arm. It slowly releases progesterone, which inhibits ovulation and thickens the cervical mucous, thus preventing sperm from meeting the egg (WHO 2020). It is licensed in the UK for three years of use (FSRH 2021).

The injectable contraceptive also contains long-acting progesterone and works by inhibiting ovulation and thickening the cervical mucous to prevent sperm from meeting the egg (WHO 2020). The injectable contraceptive available in the UK contains depot medroxyprogesterone acetate (DMPA), which is formulated for deep intramuscular injection (brand name Depo-Provera) and for subcutaneous injection (brand name Sayana Press) (FSRH 2020). The FSRH (2020) recommends a dosing interval of 13 weeks for both intramuscular and subcutaneous DMPA.

Advantages of long-acting reversible contraceptives

LARCs are safe and highly effective in preventing pregnancy, with effectiveness rates being higher than 99% with perfect use (Table 1). They can be described as ‘fit and forget’ methods, since users do not need to remember to take them daily or use them at the time of sexual activity. They also have been shown to be highly cost-effective methods of contraception (Mavranezouli 2008, Public Health England 2021). LARCs are all available free of charge on the NHS but are only available with a prescription, meaning that they cannot be bought over the counter (Terrence Higgins Trust 2021).

IUCs are well-suited to women who want longer-term contraception, with fertility anticipated to return to normal levels shortly after their removal (FSRH 2023). The IUS has an additional benefit for women aged 45 years or over, in whom it can be used first as a contraception method and then as a hormone replacement therapy to alleviate symptoms of the menopause (FSRH 2019b).

The injectable contraceptive is a short-term method that can be helpful for couples who are awaiting a more permanent contraception method such as sterilisation. Moreover, in its formulation for subcutaneous injection, the injectable contraceptive can be self-administered by the user after they receive appropriate training and guidance (FSRH 2021).

Disadvantages of long-acting reversible contraceptives

One of the main disadvantages of LARCs is that they do not protect users against sexually transmitted infections (STIs). It is necessary to also use a barrier method to protect against potential STIs, and frequent testing for STIs between sexual partners is recommended (FSRH 2023). Another disadvantage is that the IUS, the IUD and subdermal implants have to be inserted and removed by a specially trained healthcare professional (NICE 2019, FSRH 2023).

Another disadvantage is that each LARC has associated side effects. Among the hormonal (progesterone-only) LARCs, side effects include changes to the menstrual cycle, pelvic pain, acne and weight changes. A systematic review undertaken by NICE concluded that the injectable contraceptive is associated with a small loss of bone mineral density, which is largely recovered after the method is discontinued (FSRH 2020). However, in its guideline on LARCs, NICE (2019) states that ‘the effect of injectable contraceptives on bone mineral density in women who have used DMPA for longer than two years is uncertain’ and calls for research into bone mineral density recovery after DMPA has been discontinued following long-term use. The side effects of the IUD include lower abdominal pain, potential changes to menstrual bleeding and pelvic inflammatory disease (Joint Formulary Committee 2023). The British National Formulary (bnf.nice.org.uk) and the Electronic Medicines Compendium (medicines.org.uk/emc) provide further information on the side effects associated with each LARC.

The causes of the side effects associated with LARCs are not well understood, despite extensive research (Edwards et al 2020). There are options available to mitigate these side effects, for example introducing a combined oral contraceptive pill or antifibrinolytic agents (such as mefenamic acid or tranexamic acid) to reduce problematic bleeding (FSRH 2015b), but counselling on side effects is essential when discussing contraception with women (Edwards et al 2020). The FSRH (2020) recommends that the risks and benefits of DMPA are re-evaluated every two years.

Training

GPs cited a lack of training as one reason why not all LARCs were being consistently offered to patients (FPA 2021). General practice nurses may also lack training on LARCs, notably on the insertion and removal of IUCs and subdermal implants. Ensuring that general practice nurses receive training on LARCs would benefit patients, who would receive more comprehensive information, advice and contraception provision, and the nurses themselves, who would increase their knowledge, skills and competence. Professional development opportunities may be available for general practice nurses to train to become providers of IUCs and subdermal implants. GP surgeries should consider offering nurses training, while nurses should request training from their employer. The FSRH offers training on LARCs (see further resources).

Conclusion

Unplanned pregnancies remain a public health issue, accounting for approximately one in six pregnancies in Britain. Increasing the uptake of LARCs, which are the most effective methods of contraception, could help reduce unplanned pregnancies. Advising women on contraception is part of the health promotion role of general practice nurses, who are well placed to help prevent unplanned pregnancies by ensuring that women have access to comprehensive information and advice on contraception methods, including LARCs. Training general practice nurses to become providers of IUCs and subdermal implants would have benefits for patients, for nurses themselves and for the healthcare system generally.

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