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
- HTA 13/79/09 Increasing uptake and adherence to long-acting reversible contraceptive (LARC) methods in young women. CI – Judith Stephenson. Completed September 2018.
- HTA 15/113/01 A randomised controlled trial to determine the effectiveness of bridging from emergency to regular contraception: The 'Bridge-it' study. CI – Sharon Cameron. Completed March 2020.
- HTA 17/130/05 The feasibility and acceptability of a planned pre-pregnancy weight loss intervention: The Plan-it study. CI – Susan Channon. Completed February 2021.
- RfPB PB-PG-0815-20009 A mixed methods evaluation of online provision of oral contraceptives to measure: validity of self-reported biometric data; essential information transfer and user experience of self-measurement and submission of biometric data. CI – Paula Baraitser. Completed September 2019.
- NIHR Fellowship DRF-2017-10-033 Models of maternity care for women living socially complex lives: What works, for whom, and in what circumstances? CI – Hannah Rayment-Jones. Completed October 2020.
Active/on-going
- NIHR Fellowship DRF-2017-10-181 Improving the effectiveness and equity of contraception provision in general practice. CI – Richard Ma. Start date September 2019; End date August 2022.
- NIHR Fellowship PDF-2017-10-021 Planning for pregnancy: an integrated pathway to plan or prevent pregnancy and mitigate the adverse health effects of unplanned pregnancy to improve outcomes for women and their families. CI – Jennifer Hall. Start date January 2018; End date April 2023.
- HSDR NIHR129529 Evidence base to inform health service configuration for abortion provision. CI – Kaye Wellings. Start date September 2020; End date August 2022.