Women’s access to emergency contraception ‘critical’

Anastasia Tsirtsakis

28/08/2020 12:54:54 PM

With demand expected to rise as the pandemic continues, GPs can help to inform patients of their options – and dispel common myths.

Copper IUDs
Despite their effectiveness, just 1.3% of Australian women aged 15–49 use IUDs.

A higher prevalence of unprotected sex, reproductive coercion, and restricted access to regular contraceptive methods during the COVID-19 pandemic are all factors experts anticipate will result in increased demand for emergency contraceptives.
To help promote access and address barriers, the NHMRC Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care’s (SPHERE)’ COVID-19 Coalition (the Coalition) has released a consensus statement with recommendations for primary care, pharmacy, and policy.
For primary care, it is recommended that:

  • women be advised of all available emergency contraception methods at the point of contact, and that the copper intrauterine device (Cu-IUD) is the most effective form, followed by the ulipristal acetate emergency contraceptive pill (UPA-ECP) and then the levonorgestrel emergency contraceptive pill (LNG-ECP)
  • telephone or video consultations should be provided for the provision of oral emergency contraception where social distancing needs to be maintained, with the option of a delivery or pick-up service of the product to limit face-to-face contact
  • interdisciplinary collaborations and rapid referral pathways should be established by primary health networks to facilitate emergency Cu-IUD insertion for emergency contraception.
Inserted up to 120 hours after unprotected sex, the copper IUD is the most effective form of emergency contraception, and as a long-acting reversible contraceptive (LARC) can offer protection for up to 10 years.
Yet despite this effectiveness, just 1.3% of Australian women aged 15–49 use IUDs.
Dr Safeera Hussainy, a pharmacist and SPHERE chief investigator, said research has shown that upskilling GPs, as well as public messaging, can help to better inform women about LARCs.
‘There’s no doubt that GPs play a critical role in educating and informing women about all of their options,’ she told newsGP.
‘GPs, when doing a telehealth consultation or face-to-face consultation for a woman’s health issue, can touch on this topic. So if she’s sexually active and looking at contraceptive options, then promoting LARC.’
But with many women bypassing their GP and heading straight to the pharmacy for over-the-counter oral contraceptives, Dr Hussainy says pharmacists also have a responsibility.
‘Pharmacists who do see women at that critical point, when women are requesting emergency contraception, should be promoting LARC as well, and know who those skilled providers are to insert a copper IUD,’ Dr Hussainy said.
‘And then referring back to the GP so that everyone is kept in the loop.’
Dr Amy Moten, GP and Chair of the RACGP Specific Interests Sexual Health network, agrees. She says GPs can also help to dispel myths around LARCs.
‘People have an idea that all contraceptions can impair their fertility, and this is because they often are using them for many years, and if delaying fertility till their mid-to-late 30s, then of course your natural fertility will be different compared to when you were 25,’ she told newsGP.
‘But it’s not actually caused by any of the contraceptives, and in particular the copper IUD, because it doesn’t have any hormones at all.
‘You can monitor your natural fertility; you’ll have the cycle that you would have regardless of the copper IUD in most cases versus the pill or the other progestogen containing contraceptions, which can artificially suppress or otherwise alter your natural cycle.’
Other myths about IUDs include that they are not suitable for nulliparous women, they are painful, and they carry a risk of infection and pelvic inflammatory disease.
‘That’s absolutely not the case,’ Dr Moten said.
‘Anyone, outside of a few medical contraindications, can have an IUD and they can have it pretty much at any age.’

Dr Amy Moten, GP and Chair of the RACGP Specific Interests Sexual Health network, says GPs can help to dispel myths around long-acting reversible contraceptives.

While the International Consortium for Emergency Contraception Guidelines state that all women should have access to emergency contraception, regardless of age, Dr Houssainy says the guidance is not always adhered to.
‘We know in Australia girls start being sexually active from the age of 12. So there should not be a bias or discrimination to accessing emergency contraception,’ she said.
‘Pharmacists have denied access based on a history of using it. But the emergency contraceptive levonorgestrel was actually developed initially as a post-coital method of contraception. So there is no data to show harm to a woman who is 14 years and above, or using it repeatedly.’
For women not using a LARC, the Coalition recommends advanced provision of emergency contraception to ensure timely access.
Dr Moten suggests GPs discuss this with patients during discussions about contraception.
‘Someone that has an emergency contraceptive pill at home as back up, rather than having to get up and go to the pharmacy or go and get a prescription, they’re more likely to take it quickly,’ she said.
‘So it’s worth having a quick mention of emergency contraception to say, “This is what you should do if you forget to take your pill or the condom breaks”, or any other reason that you might be at risk of pregnancy.’
There can be initial barriers to accessing a copper IUD, including the need to order one in and making a booking with a qualified inserter.  
Cost can also be a factor, given the IUD itself is not covered by the Pharmaceutical Benefit Scheme; while more cost effective long-term, the initial outlay for a patient can be up to $120.
‘It’s a lot cheaper than the pill over time,’ Dr Moten points out. ‘But cost shouldn’t come into a choice of emergency contraception – it should be about the one that suits you the most.
‘So if people are having to make a choice between buying some groceries and getting the more effective emergency contraception, that shouldn’t be happening.’
Among its policy recommendations, the Coalition proposes that all emergency contraception should be made available free and that cost of insertion should be publicly funded during the pandemic and beyond. 
‘In the UK, emergency contraception is freely available to women,’ Dr Houssainy said. ‘Their model is based on looking at the number of unwanted pregnancies averted, and it’s a cost–benefit thing as well.’
The Coalition also recommends that a national hotline based on the 1800MyOptions service should be funded to allow women to access information on the locations of pro-choice pharmacies and IUD insertion providers.
‘GPs and pharmacists, like all other primary healthcare professionals, should be working together in this pandemic, and triaging where the need is,’ Dr Houssainy said.
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