Who is using emergency contraception in Wales and why? Reflections on 5-years of the service

By Efi Mantzourani, Andrew Evans, and Cheryl Way

 

The bigger picture in the Welsh strategy

Access to Emergency Contraception (EC) has been a core component of attempts to address high teenage pregnancy rates in Wales. In 2011, the Welsh Government directed local health boards to commission a national EC service from community pharmacies (CPs) allowing levonorgestrel to be obtained by women and girls from the age of 13 free of charge under a patient group direction. In April 2015, the service was extended to allow ulipristal acetate to be supplied between 72 and 120 hours after unprotected sexual intercourse (UPSI). The arrangements aimed to widen access to EC and increase the provision of sexual health advice amongst sexually active women. By 2017, 76% of CPs in Wales (544/716) were providing the service.

What we did and why

We investigated five years of the EC service, to describe its use and explore changes in the pattern of use over time. We conducted secondary analyses of data from all NHS funded EC consultations taking place in CPs in Wales between 1 August 2012 and 31 July 2017 (n = 181,359). We obtained data from the NHS Wales Shared Services Partnership from details of EC service consultations, submitted by CPs for reimbursement. Data contained standardised clinical and demographic information, in the form of pre-defined service user responses, submitted for reimbursement by CPs.

Who used the service?

Overall service provision remained relatively consistent over the study period, with women between 13 and 59 years of age accessing the service. Most EC consultations took place with 20-24-year-olds, however use in this group represented less than 30% of all EC consultations with the service accessed by large numbers of service users of all ages. This suggests the service is helping meet the sexual health needs of many women regardless of age. Despite a lower number and proportion of consultations amongst 16-19-year-olds, age standardized rates using data for estimated population in Wales demonstrate this group were the most frequent users of the CP service over the study period.  This finding supports the role of the CP EC service as part of a wider teenage pregnancy strategy.  Access to free of charge EC, which is especially relevant to young users, may have contributed to uptake.

When was the service accessed most?

In the 5-year period, more than two thirds of requests made through the EC service took place within 24 hours of UPSI (67.5%). Around 25% of all EC consultations occurred on a Monday, with Tuesday and Saturday (at ~15%) the next most popular days.  The lowest proportion of consultations was observed on Sunday (9.5%).  Additionally, an association was observed between the time since unprotected sexual intercourse and the day on which the service was accessed. Consultations within 25-48 hours of UPSI were more likely to happen on Mondays and Tuesdays, and for 49-120 hours since UPSI on Mondays, Tuesdays and Wednesdays. These findings combined suggest poorer access to EC over the weekend. A focussed review of accessibility of EC service on Sunday would be beneficial for service commissioners, to explore whether other determinants, for example the absence of a pharmacist accredited to provide the EC service, contributed to this finding.

Links between different life-course patterns

Almost half (47.9%) of requests were because no contraception had been used; EC requests resulting from barrier contraception failure decreased from 45.8% to 37.9% over the study period. A statistically significant association was found between EC request reasons and the age group of EC service users.

Barrier contraception failure was significant among women over 24 years old, but less common among women under 24. Teenagers were more likely to not use either contraception during sex nor regular contraception. Women between 20-29 years old were more likely to report missed contraceptive pills when using regular contraception, whilst women over 40 were more likely to not use regular contraception.

What does this all mean for patient care?

Further sexual health and contraception counselling was provided in 79.2% and referral to another agency in 31.3% of EC consultations; both increased with time. Access to EC from CPs has coincided with decreased rates of abortion and live births to teenage mothers in Wales. Whilst the rate of abortions in the 20-24-year-old age group has decreased, it remains higher than in other age groups, following the same pattern as the number of EC consultations during the study period. This may suggest this group who would have been teenagers at the start of the study period and were the target of measures to improve availability of EC, continue to use EC as a means of contraception in later life. Further work may be required to promote routine contraception amongst this age group.

This study suggests improved access to EC, as part of the multifaceted approach set out in Wales’ sexual health action plan of 2010 is contributing to a positive and sustained effect towards the root causes of teenage pregnancy. The finding that provision of further sexual health and contraception counselling by pharmacists increased over the study period, in line with the original aims of the EC service, adds further support for extending the role of CPs.  Our findings support CP extended roles, for example in the provision of routine oral contraception, as described in the 2017-18 report on sexual health in Wales.

 

A 5-year evaluation of the emergency contraception enhanced community pharmacy service provided in Wales, by Mantzourani E, Hodson K, Evans A, et al, was published in

 

(Visited 313 times, 1 visits today)