Australian women need increased access to long-acting reversible contraception

In November 2012, an emergent theme at the first National Sexual and Reproductive Health Conference, convened by the Public Health Association of Australia and Sexual Health and Family Planning Australia, was the need to increase access to and uptake of long-acting reversible contraception (LARC) methods, particularly by younger, highly fertile women. Compared with countries in northern Europe, Australia has a relatively high rate of unintended pregnancy and abortion (19.7 per 1000 women aged 15–44 years in Australia versus 17 per 1000 in northern Europe)1,2 yet a low uptake of the most effective methods of contraception — the LARC methods (used by 6.5% of women using contraception in Australia versus 14.8% in northern Europe).3,4 These methods include: 3-monthly progestogen injections (depot medroxy-progesterone acetate); a progestogen-only (etonogestrel) subdermal implant with a duration of action of up to 3 years; and intrauterine contraceptive (IUC) methods — the hormonal levonorgestrel intrauterine system and copper intrauterine devices, which provide highly effective contraception for up to 5 and 10 years, respectively. Although data are lacking in Australia, we can learn from the situation in the United States. Population surveys have found that half of unintended pregnancies in the US are attributable to failure of contraceptive methods that, to optimise success, require women to make a daily decision to use them.5 Interventions such as enhanced counselling and instituting immediate start of the contraceptive pill have not consistently improved regularity of use and continuation rates or reduced the occurrence of unintended pregnancies. Adolescents and young women are especially vulnerable to unintended pregnancy, as they are highly fertile and may be less reliable in their contraceptive use.6

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. Although we do not have an Australian estimate, in the US it is estimated that taxpayers spend US$9.6–12.6 billion annually on care for women experiencing an unintended pregnancy.7

One of the key strategies promoted by international public health bodies to reduce the number of unintended pregnancies is the increased uptake of LARC methods. LARCs are known to be the most effective reversible methods of pregnancy prevention (Box 1).8 Studies in the US and United Kingdom have also found LARC methods to be highly cost-effective.9,10 Although associated with a relatively high initial cost, all LARC methods are more cost-effective than the combined oral contraceptive pill, largely through prevention of unintended pregnancy.8,10 The UK study reported that if 5% of women of reproductive age in Britain using the combined oral contraceptive pill as “typical” users were to change to using one of the LARC methods, there would be 7500 fewer unintended pregnancies each year, resulting in an annual net cost saving of £9.5 million.10

LARCs are also highly acceptable to women of all reproductive ages. For example, the Contraceptive CHOICE Project in the US found that young women, when provided with balanced information about contraceptive options, will choose a LARC method in preference to user-dependent methods such as the oral contraceptive pill, the transdermal patch or vaginal ring. Among the 14–45-year-old women enrolled in the study, 67% chose a LARC method (implant or IUC)11 and their risk of unintended pregnancy within 3 years was reduced 20-fold compared with those who used other methods.12

Currently, LARC methods are not commonly provided in Australia. Data from the 2005 Household, Income and Labour Dynamics in Australia survey showed that, of the women at risk of pregnancy, 1.6% were using an IUC method, 2.1% an injectable agent and 2.8% an implant.3 Recently published data on 114 000 Australian general practice consultations indicated that 6% of consultations were for contraception; and only 15.4% of these related to LARC methods.13

Why is the uptake of LARCs so low in Australia? Despite availability of evidence-based guidance,14 studies in Australia and elsewhere have identified a lag in accurate knowledge among providers, as well as insufficient training in LARC insertion.13,15,16 In general, women have little awareness of the benefits of LARCs.16,17 Misperceptions about IUC methods focus on the risks of infection and infertility based on the memory of older devices. Community concern over coercive prescribing with depot medroxyprogesterone acetate and the reputation for unacceptable side effects from implants potentially limits uptake of these methods. Evidence suggests these reputations are undeserved: modern IUC methods are not associated with infertility and are suitable for use in young women.18 Continuity and satisfaction rates with all LARC methods are high, indicating that their side effects are acceptable for most women (Box 2).19

Expanding access to LARCs has been supported by the National Institute for Health and Care Excellence (NICE; formerly the National Institute for Health and Clinical Excellence) in the UK since 200520 and was declared a national public health priority in the US in 2009.21 Evidence from NICE and from cost-effectiveness studies has driven a UK-based program whereby general practitioners are provided with incentives to provide information about LARCs. We believe a similar national coordinated effort to enhance the use of LARC methods within the context of comprehensive contraception provision is now needed in Australia. Research into the barriers and enablers of LARC use in the Australian context will be essential to inform programs for health professional and community education. We believe that there is already a convincing health argument as well as a strong economic argument for investigating strategies to increase LARC uptake in Australia, especially among young women.