Background and objectives
Clinical guidelines advocate using long-acting reversible contraceptives (LARC) to reduce unintended pregnancy, but LARC use in Australia is poor. Additionally, little is known about contraceptive practices of women with a history of unintended pregnancy. The aim of this study was to describe current contraception use according to a history of unintended pregnancy.
Methods
Data were analysed from women recruited into The Australian Contraceptive ChOice pRoject (ACCORd) trial.
Results
Approximately 47% (128/275) of women aged 16–45 years reported unintended pregnancies, and 30% had an abortion (83/275). Contraceptive data available from 117 women showed that condoms (24%, n = 28/117) and the oral contraceptive pill (22%, n = 26/117) were most commonly used among women reporting one unintended pregnancy or more.
Discussion
These findings support implementing interventions to increase the uptake of effective contraception, as successfully demonstrated in the ACCORd trial, in general practice.
Approximately one-quarter of Australian women experience an unintended pregnancy in their lifetime,1 with rates of unintended pregnancy disproportionately greater among socioeconomically disadvantaged women.1 Approximately 30% of unintended pregnancies end in abortion,2 and those resulting in a live birth have poorer outcomes for mother and child, adversely affecting the social and financial wellbeing of women and their families.3 Additionally, women experiencing violence and abuse are at an increased risk of unintended pregnancy.4
While national and international clinical guidelines recommend increasing the use of long-acting reversible contraceptives (LARC),5,6 within the context of informed choice,7–9 current contraceptive use and management in Australia do not reflect these recommendations. Only 7% of general practice consultations with female patients aged 12–54 years that involved contraception included discussion of LARC.10,11 Evidence from the Contraceptive Use, Pregnancy Intention and Decisions study shows that young women presenting with an unintended pregnancy commonly use the oral contraceptive pill (OCP; 39.1%), followed by condoms (29.4%) or no contraception at all (26.6%).12 Similarly, in a recent national survey of unintended pregnancy,2 most women were not using contraception at the time of conception, and those who were reported using suboptimal, user-dependent methods (OCP or condoms), with few (6%) using LARC. However, there are limited data on the contraceptive choices of women who have experienced an unintended pregnancy/abortion, and who do not intend to become pregnant in the near future.
Given that unintended pregnancy is a risk factor for repeat unplanned pregnancy and general practitioners (GPs) have an integral role in counselling women regarding their contraceptive needs,13 the aim of the study was to investigate current contraceptive practices of women with a history of unintended pregnancy, who were interested in contraceptive counselling and attending general practice in Melbourne, Australia.
Methods
Study design and setting
The researchers analysed data collected from The Australian Contraceptive ChOice pRoject (ACCORd) study, a cluster randomised controlled trial in Australian general practice.14 The ACCORd research team investigated the impact of a complex intervention involving a combination of GP training on contraceptive counselling and rapid access to LARC insertions on the uptake of LARC.14 Data were collected between April 2016 and July 2018 from 740 women attending 56 general practices in metropolitan Melbourne.
Participants
Women aged between 16 and 45 years, requiring contraception, not pregnant or planning a pregnancy in the subsequent 12 months, proficient in English and interested in discussing contraception with their GP were included. Potential participants were recruited by either GPs or reception staff and completed an eligibility form. For the purpose of this study, the researchers used data available from the eligible women who also reported a history of unintended pregnancy.
Data
All eligible women were contacted by ACCORd researchers, and those interested in participating in the study completed a 30-minute telephone interview. Women were asked how many pregnancies they had ever had, the number (if any) that were unintended and the outcome of each pregnancy. Women were also asked about current use of all contraceptive methods.
Ethics
This trial is registered with the Australian New Zealand Trials Registry (ACTRN12615001346561). The ACCORd study was approved by the Monash University Human Research Ethics Committee (CF14/3990-2014002066 and CF16/188-2016000080) on 16 March 2016.
Data analysis
Descriptive statistics were used to describe current contraception use according to a woman’s history of unintended pregnancy.
Results
Of the 740 women recruited into the ACCORd study, 37% (275/740) had ever been pregnant. Of these, approximately 47% (128/275) reported having at least one unintended pregnancy. Thirty per cent reported having had an abortion (83/275), of whom 19% (16/83) reported more than one abortion.
The majority of the 128 women with a history of unintended pregnancy were born in Australia (91%) and had completed high school (95%). Approximately 51% were aged ≥35 years, and 36% had never been married (Table 1).
| Table 1. Sociodemographic characteristics of women with a history of unintended pregnancy (n = 128) |
| Characteristic |
n (%) |
| Age (years) |
|
| 16–24 |
18 (14) |
| 25–34 |
45 (35) |
| ≥35 |
65 (51) |
| Highest education level |
| Completed <Year 12 |
6 (5) |
| Completed ≥Year 12 |
122 (95) |
| Born in Australia* |
| Yes |
91 (72) |
| No |
35 (28) |
| Marital status |
| Never married |
46 (36) |
| Married |
51 (40) |
| In a relationship |
23 (18) |
| Separated/divorced |
8 (6) |
| Socioeconomic status |
| Middle/high |
89 (70) |
| Low |
39 (30) |
| Health insurance |
| Medicare only |
51 (40) |
| Private health insurance |
75 (59) |
| Refused to answer/did not know |
2 (2) |
| Number of unintended pregnancies* |
| 1 |
84 (66) |
| 2 |
27 (21) |
| 3 |
9 (7) |
| 4 |
5 (4) |
| 5 |
1 (1) |
| 10 |
1 (1) |
| *Data available from 127 participants |
Approximately 27% reported using LARC; fewer than 1% were using LARC in combination with other methods (Table 2). A significant minority of women reported using condoms (24%) and the OCP (22%) as their current form of contraception.
| Table 2. Current contraception used among women who reported previously experiencing an unintended pregnancy |
| Type of contraception* |
n (%) |
| Discrete |
| Oral contraceptive pill (OCP) |
26 (22) |
| Long-acting reversible contraception |
25 (21) |
| Condoms |
28 (24) |
| Withdrawal |
7 (6) |
| Combination |
| OCP and other non-hormonal methods |
13 (11) |
| Long-acting reversible contraception with other method |
7 (6) |
| Condoms and withdrawal |
6 (5) |
| Other non-hormonal and hormonal contraception combinations |
5 (4) |
| Total |
117 |
| *Data available for 117 women |
Discussion
In this study, of the women attending general practice not intending to become pregnant in the next 12 months, three of four who had experienced an unintended pregnancy were not using the most effective forms of contraception (LARC). These findings demonstrate that there are opportunities in the primary care setting to increase the uptake of LARC in women who do not plan to become pregnant in the near future.
An interesting finding from this study is that, despite the abortion rates reported in ACCORd being similar to previous studies,2 the proportion of women reporting currently using a LARC is substantially higher than in a recent study of women with unintended pregnancies (27% versus 6%),10 and is similar to LARC being used in ACCORd as a whole (20%).
Given the success of the ACCORd study increasing LARC uptake in general practice by more than 20% among women (at six and 12 months post-baseline), this analysis provides additional impetus for the implementation of similar interventions shown to be effective in Australian general practice. Long-term follow up (currently underway) will confirm whether the ACCORd intervention, which consisted of an educational intervention for GPs and rapid LARC insertion clinics,11 results in fewer unplanned pregnancies in this cohort.
Strengths and limitations
In this study, the authors provide novel data on current contraceptive use by women of reproductive age with a history of unintended pregnancy, attending general practices in Melbourne, Australia. These findings are likely to be generalisable to Australian general practices. However, the sample was small and contraceptive data were missing for approximately 9% of women, although no significant differences in participant characteristics were detected between those providing contraceptive data and those not providing these data.
Conclusion
User-dependent contraceptive methods are used by three out of four women attending general practices in Melbourne, who have a history of unintended pregnancy and who do not plan to become pregnant in the near future. The present findings support the implementation of effective interventions in primary care, similar to those studied in the ACCORd trial, designed to increase the uptake of LARC among these women and reduce the burden of unintended pregnancy.