Why is Australia still in the Dark Ages when it comes to contraception?
This is one of the questions being asked by Dr Kirsten Black, joint head of obstetrics, gynaecology and neonatology from the University of Sydney, who is frustrated at Australia’s low take up of modern contraception.
Rates of unintended pregnancies and abortion are relatively high in Australia (19.7 per 1,000 women aged 15-44) compared to northern Europe (17 per 1,000).
This fact was highlighted by Black when she was discovered that a third of the women from an antenatal class she was taking reported they had become pregnant accidentally.
This wasn’t a group of teenagers forgetting to take the pill or being too caught up in a moment of passion to slip on a condom. It was a group of well-educated women in inner city Sydney. And reports from the US found that almost half of all unintended pregnancies come about because, basically, women forgot to take the pill.
In a paper for the Medical Journal of Australia, Black and two co-authors, wrote: “The implications of unintended pregnancies are enormous; they have a heavy impact on the economic, social, psychological and physical aspects of women’s lives as well as having repercussions for subsequent maternal and child health.”
There’s an easy solution to all this, however, says Black, and it’s called long acting reversible contraceptive (LARCs) methods.
“The evidence is that modern devices don’t increase risk of infection in the long term, there is no impact on fertility and it is easily reversible,” she says.
And best of all, “With long acting methods, you just leave it in and forget about it.” No more remembering to take the pill every day, which is especially difficult for teenagers and young women.
The US and UK have run major national health campaigns to encourage doctors to talk about LARCs with their patients, which has seen a much higher uptake of these contraceptive methods there.
In the UK, where contraception is free for everybody, the National Institute for Health and Care Excellence (NICE) found that an increase in the uptake of LARCs reduced unintended pregnancies – including teenage pregnancies, which is a major issue for the UK’s National Health Service (NHS). In fact, the study found that if 5 per cent of women currently on the pill in Britain switched to a LARC method, there would be 7,500 fewer unintended pregnancies each year and the NHS would save £9.5 million ($16.3 million) annually.
Kirsten also points to a US study that followed women after their abortions.
“If you send women home with a long acting method, they’re significantly less likely to have a repeat abortion within two years than those who were sent home with the pill or condoms,” she says.
Another study showed that on a trial in which women could choose whatever form of contraception they liked, women who chose an implant or hormonal IUD were 20 times less likely to get pregnant compared with those who chose another method.
All this got us thinking: why don’t we know more about this LARC malarkey? With the help of Dr Black, we’ve produced
A GUIDE TO 21ST CENTURY CONTRACEPTION
What are the main types of long acting contraceptive methods?
There are four main types of long acting contraceptive methods available in Australia. They can all be administered by your GP or a family planning clinic and are all more than 99 per cent effective in preventing pregnancy when used properly. And best of all, none of them requires you to think about contraception EVERY DAY or even every time you have sex.
Injection – This is a three-monthly injection of progestogen. Progestogen is a synthetic version of the body’s natural progesterone hormone, which is released by the ovaries when a woman menstruates. It is also used in implants and the hormonal IUD (see below) and is beneficial for women who don’t tolerate oestrogen-based contraception, such as the pill.
Progestogen prevents pregnancy by thickening the mucus in the cervix, which stops sperm reaching an egg. It can also thin the lining of the uterus and prevent the release of an egg in some instances. The injection lasts three months and can’t be reversed during this time.
Implant: A “subdermal implant” is a flexible tube about 40mm long that is inserted under the skin of a women’s upper arm. It can last up to three years and works by continuously releasing progestogen into the bloodstream. You can have the implant taken out at any time and return to natural fertility within a week. It can be inserted and removed by your GP or a family planning clinic.
Hormonal IUD or IUS: An IUD, or intrauterine device, is inserted into a woman’s uterus. The hormonal IUD, or intrauterine system as it is often known, is a small plastic T-shaped contraceptive device that releases progesterone into the uterus to prevent pregnancy. It can last for up to five years and can be removed at any time with a quick return to natural fertility.
Copper IUD: The copper intrauterine device (IUD) is a small plastic device with copper wire wrapped around it. It is inserted into the uterus and releases copper there, which stops sperm surviving. Depending on the amount of copper in the device, it can last from five to 10 years. You can have it removed by a doctor or a trained health care professional at any time with a quick return to natural fertility.
Aren’t there side effects?
There are some side effects for some women, and some of these contraceptive methods may not be right for every woman, just as the pill isn’t.
Some of the side effects include heavier or more painful periods, in the case of the copper IUD. On the other hand, the implant and hormonal IUD can make a woman’s period lighter, less frequent and less painful.
Other side effects include headaches, mood changes, breast tenderness, nausea, loss of sex drive and irregular or unpredictable bleeding.
There is a risk of infection for 21 days following the insertion of an IUD, which should be managed by you and your doctor, but there is no long term risk of infection.
Is it safe for young women?
Most definitely. In fact, one of the reasons the NHS in Britain incentivised doctors to discuss LARCs with their patients was to reduce teenage pregnancies.
All the international research shows that the use of long acting reversible contraceptive methods does not reduce fertility in young women or in women who have not yet had a baby, says Black.
What if I change my mind and want to get pregnant?
Let’s put the emphasis on the R in LARCs – long acting REVERSIBLE contraception. All the devices listed above are reversible with a quick return to natural fertility, with a small exception in the case of the injection.
The contraceptive injection lasts a full three months and can’t be reversed in that time. Some reports suggest that natural fertility may take a year to return after injections stop.
What about STIs?
Condoms are the only way to prevent contracting sexually transmitted infections such as HIV, chlamydia, gonorrhea, herpes and hepatitis B. Black recommends that women with multiple sexual partners go “double Dutch”, which means using condoms as well as a long acting method.
“The only way to prevent sexually transmitted infections is condoms, but condoms alone aren’t a great way to protect against pregnancy,” she says.
Isn’t this going to be expensive?
Administering LARCs is a procedure – healthcare professionals must be trained and accredited to insert an IUD and an implant – and these procedures obviously take longer than typing up a prescription for the pill. Evidence from overseas shows, however, that it is cheaper for health services to encourage women onto long acting contraception because it reduces costs involved with abortions and unintended pregnancies.
Continuity is also higher with LARCs. About 55 per cent of women prescribed the pill are still taking it after one year, compared with 85 per cent with an implant.
Also, it’s just easier not to have to remember to take a pill at the same time every day.
“You just leave it in and forget about contraception,” says Black.
Why hasn’t my doctor told me about this?
The US and UK have both launched national public health campaigns designed to encourage doctors to talk about LARCs with their patients. The main reason for this is because of the overwhelming evidence that long acting reversible contraceptive methods are the best way to prevent unintended pregnancies, reduce the need for abortions and save the health system money in the long run.
While Australia does have a problem with unintended pregnancies, no government has made contraception a high priority.
Many healthcare professionals are haunted by the memory of the Dalkon Shield, which was an IUD available in the 1970s that caused high rates of infection and infertility in some women.
There is ample evidence available now that shows no such risks are apparent in the LARCs listed above.
There is a “lack of accurate knowledge among providers as well as insufficient training in LARC insertion” in Australia, according to Black and the other authors of the MJA report.