There have been a number of articles looking at this subject. For healthcare professionals providing contraception, understanding how and why women make contraceptive choices is important. Minimising unintended pregnancy depends on maximising a woman's satisfaction with a method, by providing a method that is truly her method of choice at that time.
Barriers to contraception may include:
As health care professionals it is important for us to address a woman's medical suitability for all different methods and then to present these methods with particular reference to what is important to her. The Family Planning Association (fpa) leaflet 'Your guide to contraception' is a very useful overview to use when talking to women about contraceptive choices. Women should have enough information to make a considered choice.
The World Health Organization (WHO) Medical Eligibility Criteria (WHOMEC) aim to remove medical barriers to different methods of contraception, by providing guidance as to which women can use which methods safely. The WHO has also produced a decision making aid with corresponding pages for women and professionals to support health care professionals providing contraception to assist women in choosing and using a contraceptive method.
The published National Institute for Health and Clinical Excellence (NICE) guidelines for long-acting reversible contraception (LARC) reminded us that LARC is more cost-effective than the combined pill, even at one year of use, and encouraged us as practitioners to consider LARC more widely. If you do not provide LARC within your own practice, have an agreed mechanism in place for referring women on. It is thought this would also help to reduce the rate of unintended pregnancy.
Particularly for young women worries about confidentiality may be the most important determinant of all, and these fears may lead to non-use of contraception. This was examined in a study looking at contraceptive non-use at first sex and the most important reason was found to be concern about parents finding out, followed by problems accessing contraception.
There has been some discussion as to whether hormonal contraceptives should require a prescription at all. One paper this month suggests women can adequately screen themselves for contraindications, manage side effects, and determine an appropriate start date, leaving little for us to do? Of course our role is not just in screening for potential problems but also to discuss health promotion, safe sex advice etc. One other paper from South Africa though looked at whether affluent, well-educated, career-orientated women are knowledgeable users of the oral contraceptive pill. The study involved 51 women completing a questionnaire.
The results showed:
This reinforces the importance of providing the same unbiased comprehensive information to all, leaving our assumptions behind.
A study has addressed the question "Is a doctor really aware of women's expectations and needs when choosing their contraceptive?" Many women's choices are based on what friends and family members have told them about their own experiences. As professionals we should not make assumptions about what is important for any individual woman, we should explore her ideas, concerns and expectations. One woman's priority may be good cycle control, another may be looking for improvement in acne, whilst another may be looking for a long-lasting forgettable method.
A professional who has little knowledge or experience of the subdermal implant, for example, will introduce an element of bias if they are not able to discuss the implant in the context of other methods and should refer the woman on to a professional who can discuss the full range of contraceptive methods. All methods should be placed in the context of alternative methods during discussion about pros and cons.
The information available to women can also be misleading. The NHS Direct website, for example, says of hormonal methods: "It may be taken orally (by mouth) in the form of the combined or progestogen-only pill or in the form of an injection every two to three months". Six paragraphs on it mentions that women can also have an implant. Regarding intra-uterine devices (IUDs) NHS Direct says: "They are useful for women who have already had children and want to defer or prevent future pregnancies". This may be taken as a negative message for a young nulliparous woman interested in using the IUD.
References:
Iuliano A et al. Reasons for contraceptive nonuse at first sex and unintended pregnancy. Am J Health Behav 2006; 30: 92-102.
Welsh, M et al. Access to modern contraception. Best Pract Res Clin Obstet Gynaecol 2006; 25 Jan [Epub ahead of print].
Grossman, D. Do product labelling and practice guidelines deter contraceptive use? Am J Public Health, 2006; 31 Jan [Epub ahead of print].
van der Westhuizen, M et al. Are affluent, well-educated, career-orientated women knowledgeable users of the oral contraceptive pill? J Fam Plann Reprod Health Care 2005; 31: 307-309.
P van de Weijer. What women want and what their doctors need - how do women evaluate the quality of contraceptive methods and products introduced by their gynaecologist? A different perspective. Eur J Contracept Reprod Health Care, 2005; 10: 2-6.
Walsh, J. Contraceptive Choices: Supporting Effective Use of Methods. WHO. 2006. (This paper is adapted and developed from: Joan Walsh and Helen Lythgoe with Stephen Peckham, Contraceptive Choices: Supporting Effective Use of Methods. Contraceptive Education Service, Family Planning Association 1996.)