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Contraception Choices?

October 26th, 2005

Dr Petra

Today there’s been a launch of new guidelines on contraception from NICE (National Institute for Health and Clinical Excellence). These new guidelines are promoting long acting reversible contraception (LARC) as a means of increasing women’s contraception choices. Examples of LARC include the intrauterine methods, injection or implant. These can last for several months through to up to ten years depending on method chosen.

In theory this is a good idea – over the past century there have been great efforts to both improve the range, quality and availability of contraceptives. There are fourteen different types of birth control, although not all are available to all women globally.

Other Department of Health guidelines are clear that not only should there be a range of contraceptives available, but access to these should be easy, and women should be offered a choice of contraception that suits their lifestyle.

The NICE guidelines (with the support of the National Collaborating Centre for Women’s and Children’s Health) recommend:
“• To improve services, women requiring contraception should be given information about and offered a choice of all methods, including long-acting reversible contraception (LARC) methods.
• Contraceptive service providers should be aware that:
- increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies and therefore offer cost savings to the NHS.
- all LARC methods are more cost effective than the combined oral contraceptive pill because they reduce the likelihood of unplanned pregnancy.
- all types of intrauterine methods and implants are more cost effective than the injectable contraceptives”

NICE also recommends that healthcare practitioners are trained to include LARC in their discussions with patients about contraception.

Evidence suggests that 25% women use the pill and 23% use condoms, whilst only 8% use LARC methods.

Whilst I support the idea of offering women contraception choices, I think there needs to be some caution over the NICE guidelines. They argue promoting LARC will reduce unplanned pregnancies. Yet many unplanned pregnancies happen in women who aren’t using any contraception. Under the new guidelines are these women to be pressured into using LARC?

There’s also the issue of conflicting health information. Department of Health guidelines suggest a wide range of choices to suit a woman. They also strongly recommend the use of condoms to overcome our rising sexually transmitted infection rate. The NICE guidelines suggest promoting LARC increases choice (or at least helps women consider options they hadn’t previously). Yet it may be this is interpreted as making LARC methods seem like the main or ‘best’ choice of contraception – thereby restricting women’s choices.

The press coverage of this story also hasn’t really focused on these complex and often contradictory issues. And they’ve definitely missed the point about LARC increasing choice. Instead they’ve led with stories like:

Women urged to use contraceptive jabs and implants
– The Telegraph
Call for long-acting contraception – The Mail
Pill is history after NHS offers new choice of contraceptives
– Times Online
Doctors urged to offer Pill alternatives – UIP
Freeing women from the daily pill
– The Herald
New methods as pill is on way out
– Australian

Whilst some media coverage has accurately discussed contraception choices, most have presented LARC as either a ‘new’ method of contraception (long acting reversible contraceptives are not new), or that the availability of LARC is a ‘license for promiscuity’. The majority interpreted the guidelines as an instruction that women should give up the pill.

If I were a young woman faced with all this information I’d be hard pressed to know if I should stay on the pill if I was taking it. I might think there were dangers in taking it, or perhaps that the ‘best’ or ‘newest’ contraception on the block was a LARC. It wouldn’t for a minute remind me that these methods would only protect against pregnancy and not STIs.

If I were a young man reading this I’d again assume contraception was a woman’s issue (most young men when surveyed assume contraception is a female thing, and also often only link STIs as a women’s problem). Again I’d not be encouraged to think about condoms.

If I were a busy GP or nurse I’d be also a bit confused. Earlier this year I’d have been told that choice was important, and to stress condom use. Now I’m being told both to increase choice but also to promote LARC. I may be very confused how to do this.

LARC can help if you don’t plan to have a baby for a while and some forms may help with heavy periods. Injections need repeating every two to three months, intrauterine methods can stay in place for several years. Some women enjoy the freedom these methods provide. However others like a more self-controlled method of the pill. And of course the only way to protect against STIs is using a condom.

I’ve no problem with recommending LARC. I just hope it can be done in relation to other methods of contraception and with greater education offered so whatever means of contraception a woman chooses, she can use it successfully. And I really hope the promotion of LARC isn’t just to save money.

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