Unintended and unwanted pregnancy in Australia: a cross‐sectional, national random telephone survey of prevalence and outcomes

To the Editor: We note with interest the research letter by Taft and colleagues regarding unplanned pregnancy in Australia.1 An audit of terminations of pregnancy in our Australian metropolitan hospital service (Austin Health, Melbourne) supports the findings of the national survey while highlighting additional areas of educational need.

Of 309 women (aged 15–46 years) who underwent terminations for unwanted pregnancy from January 2016 to October 2018, 145 chose surgical termination and 164 women chose medical termination. Compared with the national survey, our cohort had similar rates of not using contraception (48.2% v 56.5%) and contraception failure (51.8% v 41.4%).1 Failed barrier and oral contraception respectively accounted for 52.1% and 29.3% of contraception failures. This differs from the survey findings, where the most common contraception failure was oral contraception, followed by condoms.1

There is a paucity of Australian literature reporting long‐acting reversible contraception (LARC) usage following termination; however, a Swedish study found a rate of 34%2 and a New Zealand public hospital service reported a rate of 44.5%.3 Our post‐termination LARC rate was 58.2% (72.5% following surgical termination and 43.2% following medical termination). We attribute the higher rate to our conscientious use of tiered counselling4 (ie, presenting the most efficacious method first) to enable women to make informed decisions regarding contraception. The most common choice of contraception following surgical termination was a levonorgestrel‐releasing intrauterine device (Mirena [Bayer]) (56.0%); however, oral contraception was more popular (38.8%) following medical termination, followed by Mirena (25.9%). A British study also found that women more often chose an intrauterine device or implant after surgical termination,5 suggesting that ease of insertion under anaesthetic influences choice.

Of the 134 women documented as not using contraception in our audit, three had received inaccurate medical advice regarding contraception, or had been inappropriately labelled as infertile due to age, endometriosis or polycystic ovary syndrome. A further three pregnancies occurred as a result of removing LARC without arranging alternative contraception.

We support the researchers’ conclusion regarding the need to explore reasons for poor contraception uptake and determine where education would be most helpful.1 In addition to increasing access to and promoting informed choice of LARC in primary health care settings,6 greater efforts to improve practitioner knowledge of contraception management, as well as common gynaecological conditions to aid appropriate diagnosis and evaluation of fertility impact, are vitally important.