29
clinical review
talking women
Gaps in good birth control
DR DEBORAH BATESON
MA (Oxon), MSc (LSHTM), MBBS
Medical Director & Director, Clinical
Services, Family Planning NSW
Contraceptive use varies
by age and culture. Here
is an update on women’s
choices in Australia.
dreamstime.com
TWO-thirds of Australian women
of reproductive age report currently using contraception.
The recently published Reproductive and Sexual Health in
Australia report 1 highlights that
oral contraception remains the
most common method (up to
34%), followed by condoms (23%),
vasectomy (11%) and tubal ligation (8.6%).
By contrast, the least used
are intrauterine methods (3%)
and the contraceptive implant
(3%). Withdrawal is reported by
2.4% of women and the proportion reporting they had ever used
emergency contraception is 27%.
While limitations to the data
are acknowledged, it is notable
that Australia lags behind similar high-income countries in the
uptake of long-acting reversible
contraception (LARC).
This is an effective and safe
choice for women across the
reproductive life course, including young nulliparous women.
LARC, including contraceptive
implants, intrauterine devices
(IUDs) and the contraceptive
injection, provides highly effective contraception and does not
require user input.
Despite these proven benefits,
LARC uptake remains low with
barriers existing at the level of the
healthcare system, providers and
the community. Lack of awareness, misinformation, concerns
about side effects, lack of access
to trained providers and relatively
high upfront costs may contribute
to the low uptake.
Increasing uptake of LARC has
been identified as a public health
priority to decrease unintended
pregnancy and abortion in many
countries, including the UK and
the US.
Contraceptive use by age group:
Contraceptive use increases from
teenage years into the 20s and
declines at ages 30—35 years prior
to another increase. The dip most
likely reflects a desire to conceive
given that the average maternal
age in Australia is 30 years.
Practice points
• A ustralia has relatively low LARC uptake despite proven advantages of it.
• Dual protection against unintended pregnancy and STIs can be achieved through the use of condoms
and an effective contraceptive method.
• K nowledge that emergency contraception can be obtained without a doctor’s visit and is effective up
to 96 hours after unprotected intercourse remains low.
• Older women need evidence-based information, both in relation to declining fertility and the chance of
a successful pregnancy through ART, and the need for contraception to prevent unintended pregnancy.
• T he lower uptake of contraception by Aboriginal women and by women from non-English speaking
countries is likely to be related to sociocultural factors, access barriers and affordability.
Young women, who have
the highest fertility, tend to use
the least effective contraceptive
methods, including condoms and
oral contraception, while women
approaching menopause have a
higher uptake of intrauterine and
permanent methods.
While evidence points to insufficient awareness of age-related
infertility, an underestimation of
fertility may also contribute to
unintended pregnancy in women
in their 40s. LARC will likely
replace permanent methods for
this group in the future.
Dual protection: Condoms are
highly effective at preventing STIs
but have a high failure rate in preventing unintended pregnancy.
Promoting dual use of condoms
and other effective methods of
contraception is important for
women of all ages who are at risk
of contracting an STI.
Emergency contraception: Des­
pite increased accessibility to
the emergency contraception pill
(ECP), there has not been a reduction in unintended pregnancy or
abortion rates.
This failure may be attributable to lack of knowledge that
ECP is available without a prescription and that its effectiveness extends beyond 24 hours to
up to 96 hours after unprotected
intercourse.
Improved access to the copper
IUD, which provides highly effective post-coital contraception
and can be continued in the long
term, is likely to have an impact
on reproductive health outcomes.
as factors limiting contraceptive
uptake.
Contraceptive use in Aboriginal communities: Contraceptive
use among Aboriginal women is
lower than among non-Aboriginal women (64% vs 71% ), with
higher rates of tubal ligation (14%
vs 4.1%) and lower uptake of oral
contraception (23% vs 35%).
Both the implant and injection are used more commonly by
Aboriginal women (7% and 8%
respectively) than the national
average (less than 2% for both
methods).
Lack of access to culturally
sensitive services, transport and
affordability as well as a positive attitude to pregnancy at a
young age have been identified
Contraceptive use among women
from non-English speaking backgrounds:
Contraceptive
use
among this group of women is
much lower than among women
from Australia or other Englishspeaking countries (50% vs 71%),
which is likely to be related to
sociocultural factors in relation to
family size as well as issues of
access to culturally and linguistically appropriate information and
services, and affordability.
Reference at medobs.com.au
Jean Hailes for Women’s Health
is a national, not-for-profit organisation focusing on clinical care, innovative research and practical educational
opportunities for health professionals and
women. www.jeanhailes.org.au
1 august 2014