Unintended Pregnancy Rates Astonishing

Increased GP rebates for insertion of long-acting reversible contraceptives (LARCs) as well as the provision of free contraception to women who have undergone abortions are key measures that may help reduce the proportion of unplanned pregnancies in Australia, says a leading general practice researcher.

Professor Danielle Mazza, Head of the Department of General Practice at Monash University, was commenting on a national population survey, of which she is co-author, that found that one in four women (25%) reported an unintended pregnancy in the previous decade, and more than half of these women (56.6%) were not using contraception at the time.

The national population survey of 2013 women aged 18–45 years, published in this week’s MJA, also found that almost one in five women (18.8%) who had been pregnant in the past 10 years had had an abortion.

“These are astonishing [findings] in this day and age, given the relative prevalence of contraception in Australia,” Professor Mazza told MJA InSight. “It highlights some very important policy issues that need to be addressed.”

Professor Mazza said the publication of the research was timely as it coincided with the Medicare Benefits Schedule (MBS) review, which had the capacity to address some of the barriers to contraception.

“There are real barriers around practitioners not offering the most effective forms of contraception, which we know are long-acting methods like IUDs [intrauterine devices] and implants,” she said.

She said many health practitioners had “profound misconceptions” about IUDs and were reluctant to offer these options to young women due to fears of pelvic infection. Even when women were offered LARCs and wanted to use this type of contraception, there were “huge access barriers”, Professor Mazza said.

“It’s often very difficult to get an insertion done locally in a timely way. With few GPs undertaking IUD insertions and hospital contraceptive clinics decreasing in number, women often need to bear the cost of a private gynaecologist inserting an IUD and that is quite prohibitive,” she said.

“We need to try to increase the delivery of IUDs in primary care in a very concerted way and the MBS review is very timely to look at this issue and perhaps to provide some better incentives for GPs.”

The current rebate for IUD insertion in primary care was inadequate to cover staffing time, nursing support, equipment and sterilisation costs, Professor Mazza said. Opportunities and clinic locations for GPs to undertake training in inserting implants and IUDs was also lacking, she said.

Professor Mazza said there were also patient-level barriers to accessing appropriate contraception, including a lack of knowledge.

“Women are guided by their peers, and younger women by their mothers, who may not be across the range of contraception that is available to them.”

In the MJA article, the authors said clinicians should focus their attention on women who were at highest risk of unplanned pregnancy, including those who have had three or more pregnancies. They said the immediate post-partum and post-abortion periods were “opportune times for intervening to avert unintended pregnancies”.

Professor Mazza said providing free contraception to women after an abortion should also be considered.

“I put out a challenge to the government to consider some policy initiatives such as the provision of free contraception to women at these particular points in their lives,” she said, adding that some states in Canada provided free medical abortions as well as free contraception afterwards to assist women.

Dr Deborah Bateson, Medical Director at Family Planning NSW, welcomed the survey findings.

"The findings of this important Australian study are line with international data and highlight that despite the wide range of contraceptive options potentially available to women and their partners, most unintended pregnancies result from either the non-use of contraception or from use of a less reliable methods," she said.

Dr Bateson said it was important that women were made aware of not only the effectiveness of the various contraceptive options, but also about the advantages and disadvantages of each method. "Efficacy is an important consideration in choosing a contraceptive method but only one of many. If a woman experiences troublesome side effects and then stops using the method as a result, then that’s not a good choice for her,” she said.

Dr Bateson said there had been increases in the uptake of LARCs, but there was still room for improved awareness and access.

"If we are to increase access to the highly effective LARC methods, we need to increase the number of GPs who can insert IUDs and make sure that women can access these easily and locally. We currently face challenges in meeting demand, particularly for IUD insertion, with very long waiting lists at family planning clinics.”

Professor Caroline Homer, Co-Program Director, Maternal and Child Health, at the Burnet Institute, said changes to the health care landscape could be contributing to the rate of unplanned pregnancies in Australia.

“There were once a number of family planning clinics and bulk-billing GPs who young women in particular could go to, but now there are fewer, particularly in rural areas, so perhaps that is part of it,” Professor Homer said.

While acknowledging GPs’ already overwhelming workload, Professor Homer said primary care was an ideal place for opportunistic questioning of young women about their reproductive health and contraceptive needs.

“Young women will be going to GPs or health providers for all sorts of issues, but they may not actually say ‘I need contraception’,” Professor Homer said. “These are opportune moments to have conversations with women. It’s one of those questions that can be asked as a matter of course – ‘can I do anything to help you in terms of contraception?’”

She said it was also important that women were counselled about the potential side effects of the various contraceptive options.

“It’s important that women understand that side effects may start, then go away over time, particularly for LARCs. Some women will find they have side effects and remove it quite early, whereas if they understand that some of these methods may take a couple of months to settle down, it will more often than not be fine,” Professor Homer said.

Professor Mazza said the recent funding by the National Health and Medical Research Council of a Centre of Research Excellence, called SPHERE, would seek to improve sexual and reproductive health outcomes for women through primary care.