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21/576 HSDR Improving choice, access and uptake of contraception for women - supporting information

Contents

Background

Women constitute more than half of the UK population (51%) and most of these women at any one time want to either prevent or achieve pregnancy, making contraceptive care crucial for women in their reproductive years. In the UK nearly 45% of pregnancies are unplanned and can have a negative impact on the physical and mental wellbeing of both mother and child. Two groups that are particularly at high risk of unplanned pregnancies are women over 35 years of age and teenagers. Teenage pregnancies are also associated with higher risk of infant death, decreased infant health and poor mental health of the mother.

Access to sexual and reproductive health services

Women may contact sexual and reproductive health services for several reasons, including but not exclusively:

  • provision of main method of contraception
  • contraception advice
  • provision of emergency contraception
  • removal of contraception devices
  • sexual health advice

Most women in England access contraception from general practice while younger women and women from marginalised groups tend to access them from sexual and reproductive health clinics. However, one third of women are unable to access contraception from their preferred source, and women who are already disadvantaged are less likely to access contraception services. Women who are not reached by existing contraception services may receive opportunistic contraception advice, such as after taking emergency hormonal contraception (EHC), after having an abortion or a baby, or when they are in contact with health services for other issues.

Types of contraception

Although contraceptive use is high in the UK, the most popular methods are oral contraceptives and male condoms that are user-dependent contraceptives. Long-acting reversible contraceptives (LARC) include intrauterine methods [intrauterine device (IUD)/intrauterine system (IUS)], progestogen subdermal implants and progestogen injectable contraceptives. Long-acting reversible contraceptive is the most effective and cost-effective form of contraception and women should be able to access it through either general practice or sexual and reproductive health services, depending on their personal preference and service availability.

The National Institute for Health and Care Excellence (NICE) guideline on long-acting reversible contraceptives concluded that increased long-acting reversible contraceptive uptake would reduce unintended pregnancies and be a cost-effective method. Long-acting reversible contraceptive is more commonly used in older women compared to younger women. Fifty eight percent of women in 2019/20 aged 35-44 years in England were in contact with sexual and reproductive services using a long-acting reversible contraceptive, compared to 42% who were using user dependent contraception.

Impact during COVID-19 pandemic

Contraception provision in community sexual and reproductive health services (excluding general practices and pharmacists) shows a steep fall in access to emergency contraception (53%) and uptake of long-acting reversible contraceptive (43%) during April to September 2020 (see previous link).  During the pandemic, some services in the UK, including removal and re-insertion of long-acting reversible contraceptive and drop-in services for young people, either completely ceased or operated with limited capacity and continue to do so. In addition, there has recently been greater awareness and reporting of pain experienced by some women during and post-insertion of an IUD. Issues relating to access and uptake of contraception has the potential to have both medium and long-term effects on women’s choice and uptake of contraception, as well as decisions to discontinue contraception, subsequently leading to implications for not only the individual (unintended pregnancies and abortions, fertility), but also future service and intervention development.

A recently published King's Fund Report reiterated that limited access to contraception could be a potential factor for increased abortion rates among older women aged over 30 years of age. In recent years, rates of abortion have increased amongst women aged 30-34 and peaked during 2019 since the Abortion Act in 1968.

During the COVID-19 pandemic, a drop in the uptake of contraception services by young and ethnic minority people accessing them has been reported. Whilst most women in England can access some form of contraception, deprived and marginalised groups are less likely to be able to access these services, especially when the provision of these services became online. Those without private internet access, for example, find themselves further marginalised as in-person appointments become scarce. The Women’s Health Strategy and the Sexual and Reproductive Health Strategy represent a unique opportunity for the NHS and its partners, including non-governmental organizations or companies under contract to the local government, to tackle long-standing barriers to the delivery of women’s reproductive health. Understanding women’s experiences of access and choice of contraception, along with the impact of sexual and reproductive health services with either joined or fragmented care, are crucial in shaping these strategies.

Relevant on-going and published studies

During the development of the brief the following completed and ongoing NIHR studies were reviewed that applicants may find useful.

(Please note that the studies identified in no way represent a full literature review and applicants should ensure that they review the completed and ongoing research in this area and explain how their proposal addresses a research gap).

Completed/published

Active/on-going