LARC and postpartum contraception in focus

Alongside the new UK Medical Eligibility Criteria (UKMEC) criteria, which give long-acting reversible contraceptive (LARC) methods even greater prominence, this journal issue presents UK and international data related to both intrauterine device (IUD) and other LARC use. Not all of it is optimistic. Given that short inter-pregnancy interval is associated with adverse outcomes, the immediate postpartum period ought to be an ideal time to establish effective contraception. But quantitative and qualitative studies from the UK, India and Guyana identify barriers to the discussion about and fitting of LARC, postpartum. Opportunities to discuss it are frequently missed both in the third trimester and before discharge, in both India and Scotland. Data from an Edinburgh obstetric unit also point to gaps between women's plans for inter-pregnancy interval and the observed reality. Limited access to LARC insertion before discharge from the obstetric use appears to hinder some women otherwise interested in using these methods. Meanwhile at the 6-week postpartum check, qualitative research identifies further, often organisational, barriers to LARC fitting; these include making time for counselling and extra appointments for fitting.

Sandy Goldbeck-Wood

Editor-in-Chief

Revised UKMEC place LARC first and are UK focused

The new UKMEC begin with a noticeable change of order, and hence emphasis, with LARC methods presented first, followed by medium- and then shorter-acting methods, with sterilisation and barrier methods removed altogether. Similarly, for emergency contraception, the IUD is presented before ulipristal acetate, with levonorgestrel in third place. The categorisation of diseases such as viral hepatitis or diabetes has been reordered to allow a more patient-centred judgement about the applicability of a method to a given individual, while schistosomiasis and malaria, uncommon in the UK, have been removed. Raynaud's phenomenon, whose risk relates to the underlying disease, has also gone, and advice regarding systemic lupus erythematosus has been simplified and clarified. Conversely, increasingly prevalent conditions such as bariatric surgery, organ transplant, cardiomyopathy, arrhythmias and rheumatoid arthritis are given more space, while asymptomatic chlamydia has been reclassified as UKMEC 3 rather than 4. Finally, combined hormonal contraception for breastfeeding women has been deemed safe from 6 weeks postpartum, and reclassified from UKMEC 3 to 2. Finally, a resource on the diagnosis of migraine offers welcome clarification for an important condition that many struggle to classify in practice. See page 81

Randomised data suggest 10% lidocaine spray reduces pain in IUD insertion

Prevention of pain during IUD insertion has been a longstanding topic in this journal. A randomised, placebo-controlled study trial in parous women from Turkey reports on on the use of 10% lidocaine for analgesia. Sprayed on to the cervical surface and os prior to the application of a tenaculum and insertion of an IUD, its use was associated with a significant reduction in pain scores in the treatment group. This appears to be an effective, simple and safe addition to the range of analgesic treatments available for IUD insertion, but very reasonably the authors suggest that confirmatory studies are needed. See page 83

Retrospective data from Buenos Aires demonstrate that IUDs are well tolerated

Interest in increasing the use of IUDs has been great, internationally. A retrospective study of 1047 IUD insertions in an Argentinian public hospital over a 5-year period demonstrates how well IUDs are tolerated. Despite the acknowledged limitations of this observational study, it delivers the reassuring message that fewer than one in five women will discontinue an IUD within 5 years. In fact, the majority in this study were discontinued for personal or involuntary reasons, including wanted pregnancy, no current sexual partner, IUD expulsion or replacement. Pain and bleeding, both common concerns, figured less strongly in this evaluation than elsewhere. See page 88

Postpartum contraception is a missed opportunity to prevent harms

Because both unintended pregnancy and short inter-pregnancy interval are associated with adverse outcomes, the immediate postpartum period is an ideal time to discuss effective contraception. But at a time when there is much else to think about, this is easily forgotten. A 6-month database analysis from Edinburgh, UK looked both at the proportion of women´s future pregnancy plans on discharge from the obstetric unit, and at the number giving birth after an inter-pregnancy interval of 12 months or less. While most were not planning a further pregnancy within a year, at the time of discharge, 1 in 13 women gave birth following an inter-pregnancy interval of 12 months or less. And while only a minority was planning to use LARC, just under half indicated they would choose these methods if they could be inserted before hospital discharge. Postpartum LARC provision could thus be an important initiative. See page 93

GPs report challenges in providing LARC at the 6-week postnatal visit

Prescriptions for oral contraception remain firmly embedded in the UK's 6-week general practitioner (GP) postnatal visit. But despite the National Institute for Health and Care Excellence (NICE) encouraging increased access to LARC in 2005, GP provision of LARC remains poor, for poorly understood reasons. This qualitative study explores in depth and summarises the challenges that GPs face when considering the provision of LARC. These include the need for detailed counselling, and up to two further appointments for IUD/intrauterine system insertion. The article also explores alternative models of providing LARC in the postnatal period. See page 99

Third trimester and postpartum advice increases contraceptive uptake, but is often omitted

Maternal health services provide an invaluable opportunity to inform and educate women about family planning. As part of a survey of women who had delivered a live baby between 2010 and 2012 in Uttar Pradesh, India, where a National Urban Health Mission integrates family planning into obstetric settings, questions were asked about information on, and use of, contraception. Having received contraceptive information as part of third-trimester antenatal care and during the postpartum period were positively associated with postpartum use of effective contraception, but these opportunities were often missed by healthcare providers. See page 107

Pregnant teenagers in Guyana lack reproductive health knowledge

One of the serious issues affecting maternal health globally is teenage pregnancy. In this study from Guyana, 50 girls aged 11–19 years attending a maternity unit were interviewed. As well as overall poor sexual and reproductive health (SRH) knowledge and high-risk sexual health practices, the study revealed high rates of rape and sexual coercion, with 80% stating that there was a lack of power in their sexual relationships. The authors conclude that teenagers need more targeted SRH services and that there should be more research into sexual violence amongst young women. They report that their findings prompted the establishment of a screening and referral system for those at risk, as well as a clinic targeted specifically towards teenage pregnancy. These are clearly interventions that could be valuable in many other settings. See page 116

Daughters' HPV vaccination invitations may motivate their mothers to consider cervical screening

Does the invitation to a girl to receive human papillomavirus (HPV) vaccination prompt a change in her mother's attitude if the mother herself has had inadequate cervical screening? In this study, questionnaires identified under-screened mothers whose screening intentions had or had not changed following their daughters' receipt of invitations to participate in the UK National Health Service HPV vaccination programme. The questionnaires were followed up with semi-structured interviews. The authors found that in some cases mothers' attitudes did change, but concluded that information provided in both the HPV vaccination and cervical screening programmes should do more to incorporate both the cause of cervical cancer and the methods to prevent it. One very valuable additional finding was that the information provided with the HPV vaccination programme does promote mother–daughter communication, which must surely be classed as an unexpected benefit of the programme. See page 119

Medical abortion is safe in community settings

In the past, medical abortion was seen as a hospital-based procedure, a view which has lingered despite the increase in frequency and different nature of this procedure. This large-scale retrospective study suggests that early medical abortion (EMA) is just as safe if performed in the community (SRH clinics) as in a hospital gynaecological department. Whilst this finding is perhaps not in itself remarkable (as similar trained personnel work in both settings), this study enforces the view that EMA can be safely performed in community settings, which will hopefully increase community provision and offer women greater choice and hopefully quicker access to medical abortion. See page 127

Identification of factors associated with having more than one abortion

This very large Scottish registry-based study found that almost a quarter of women who had one abortion had a further abortion at a later date. The authors analysed registry data to search for factors associated with having more than one abortion and found that age under 20 years at initial abortion, severe social deprivation, and having had two or more previous livebirths or miscarriages all increased the risk. Interestingly there was also an association between the use of contraceptive implants or medroxyprogesterone acetate after the initial abortion and an increased chance of further unwanted pregnancy and abortion over 2 years later, presumably because these methods were discontinued because of unwanted effects with no adequate contraception being substituted. The study results point to groups that might benefit from targeted intervention to reduce the chances of further unplanned pregnancy, and to alternative LARC methods, such as IUDs, that could help to achieve this. See page 133

Brief intervention for alcohol misuse may be appropriate in sexual health settings

Excessive drinking is a major issue in the UK, and alcohol use and sexual behaviour are closely linked. Brief intervention (BI) has been validated as a cost-effective strategy to address problem drinking. This article assesses the feasibility and acceptability of screening attendees in a sexual health clinic for alcohol misuse and the delivery of a BI, in a cohort with high rates of alcohol use. Although the study was not powered to detect outcome differences, the team report a suggestion that simple measures such as BI may be effective as a low-cost approach to addressing this significant sexual and general health risk, in a time-pressured setting. See page 143

SRH provision in a drug and alcohol service offers tangible benefits

This ‘Better Way of Working’ article focuses on the delivery of services in a hard-to-reach group, within a drug and alcohol clinic, to women highly vulnerable to the consequences of unplanned pregnancies. Previously women were signposted to sexual health services, which despite being local, were rarely taken up. This new service was delivered within the drug and alcohol clinic, using mainly local staff, but with Level 3 services delivered by a sexual health consultant doctor. Interestingly, financial incentives were offered to patients and, with the caveat that only small numbers have been seen so far, these appear to increase LARC uptake. The authors also outline the importance of involving relevant commissioners in the design of the service; despite controlling different budgets, they were able to collaborate to fund this project, in anticipation of savings made by avoiding unintended pregnancies. See page 152

Film reviews on transgender issues and FGM

Two film reviews focus on what are currently high-profile topics, namely female genital mutilation (FGM) (page 163) and transgender issues (page 162), a theme that is also picked up in this issue's Organisational Factfile article on ‘Gendered Intelligence’ (page 155).