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Contraception

Contraception. Romford GP VTS Dr Sylvia Bond 17/02/2010. Overview of issues related to contraception Revision of methods available Case discussion. Preventative Health Care. Cost service vs health and social cost of unplanned pregnancy Cf Immunisations Part of health service since 1974

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Contraception

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  1. Contraception Romford GP VTS Dr Sylvia Bond 17/02/2010

  2. Overview of issues related to contraception • Revision of methods available • Case discussion

  3. Preventative Health Care • Cost service vs health and social cost of unplanned pregnancy • Cf Immunisations • Part of health service since 1974 • All services FREE including prescription charges

  4. DOH 1992 Health of Nation “Planned parenthood provides benefits for the health of individuals, families and communities. Family planning services aim to promote this by providing access to contraception, sterilisation and advice on unplanned pregnancy. Additionally, education, counselling and health promotion can enable prospective parents to choose healthy lifestyles and increase the chances that their children will be wanted and healthy. Delaying and spacing pregnancies and limiting family size contributes to the physical and mental health of mothers and children and general family well-being.”

  5. Choice • Primary care-GPs, PNs,midwifes,HV • Community Clinics • Young peoples services eg Brook Advisory, school nurses • Hospital, GUM,Gyane • Private/Voluntary Marie Stopes ,BPAS • Pharmacists

  6. QOF • “LARC” new 2009/10 QOF points • Long Acting Reversible Contraception • IUS/IUCD/Depo-Provera/Implanon • Low risk and low cost • All women prescribed oral contraceptives and MAP should be advised of LARC benefits.

  7. Training DFRSH New training from January 2010 On-line theory course www.frsh.org Faculty of sexual and Reproductive Health, 27 Sussex Place. Regents park. London. NW1 4RG £50 Approx 20 hours Practical sessions Letter of competence in IUD

  8. Recommended reading • Fpa contraceptive handbook • RCGP Handbook of Sexual Health in primary care • Family Planning Masterclass RCOG Press

  9. Patient inoformation • Leaflets from fpa • FREE delivery to GPs ( order form) • Keep up to date versions • Record what you have given as evidence of advice given/risks explained.

  10. Confidentiality statement “We will not discuss any information about you with anyone else, unless you ask us to do so, except in very exceptional circumstances – if you or any other person’s safety is at risk.” Consider notice in waiting room and in practice leaflet.

  11. Chlamydia screening programme • Uses text to mobile phones to avoid letters home.

  12. Minors • By 1995-6 10% of 14-15 yrs were attending FP clinics • Social services define as child as < 18yrs for sexual abuse purposes • Under 13yrs should consider disclosure to social services • Ask advice before breaking confidentiality • Children’s Act 1989- Can give consent < 16 yrs

  13. Fraser guidelines • A doctor would be justified in giving advice and treatment without parental knowledge or consent, provided he is satisfied: • That the young person could understand his advice and had sufficient maturity to understand what was involved in terms of the moral, social and emotional implications • That he could neither persuade the young person to inform the parents, nor to allow him to inform them, that contraceptive advice was being sought

  14. That the young person would be very likely to begin or to continue having sexual intercourse with or without contraceptive treatment • That, without contraceptive advice or treatment, the young person’s physical or mental health would be likely to suffer • That the young person’s best interests required him to give contraceptive advice, treatment or both without parental consent.

  15. YOUNG PERSON IS ACCOMPANIED BY AN ADULT or TWO ADULTS • Establish the wishes of the patient “ I realise you may well prefer to have your mum with you, but I’d like to give you a chance in case there's anything you’d like to ask?” “ Come on in. I don’t think we have met?... And your relationship is?” “To find out the reasons for this sort of problem some of the questions I should ask you are quite personal. Would it be best if .... Waited outside?” “ I don’t wish to make any assumptions; could I check if you are friends or partners?”

  16. Abortion • Abortion Act 1967, before only to save life of mother. ( Not N. Ireland) • Estimated 70,000 lives saved per year • 1 in 5 pregnancies end in abortion now • 2 doctors sign to grounds clauses a-e • All doctors have duty to refer to a colleague if object on personal grounds • Amended 1991 to upper limit of 24 weeks, except to save mother’s life, risk of grave permanent injury to mother or risk of serious fetal handicap.

  17. Multicultural issues 50% first born babies in UK are to unmarried parents, many planned and wanted Method specific religious/cultural issues Sexual practice does not always match religious teachings

  18. Sexual health in Gay and Lesbians • STI screening/safe sex • Ask about “partner” • Do not assume ocpill for contraception • Advice cervical smears still • Non judgemental questions. “Could I check is your partner a man or a woman?” “ Do you have any other partners?” “ Are there any other time you have had sexual intercourse we need to consider?”

  19. Methods of contraception • PoP/”morning after pill” • LARC-IUS/IUCD/injection/implant • Non-hormonal-Barrier methods/sterilisation/ rhythm • Ocpill/patches/ring Compare each group to the ideal contraceptive.......

  20. The ideal contraceptive • Effective- stops pregnancy 100% • Reversible • Non-user dependent ( male pill??) • Does not interfere with sex • No side effects/long-term risks • Accessible – otc vs specialist Dr training to fit • Cheap ( especially relevant worldwide) • Method does not rely on non-implantation (religion)

  21. Cases group 1 • When would the desgrestrel-only pill be considered a suitable method of contraception? • How would you advise a woman who is 48 years old and taking the progestogen-only pill about her ongoing need for contraception

  22. Cases group 2 • A 15 year old girl wishes to consider depot medroxyprogesterone acetate ( DMPA). What would you specifically counsel her about at her age? • Discuss the management of a 45 year old smoker who wishes to continue with DMPA in the foreseeable future • How would you assess a woman who appears 4 weeks late for her next DMPA injection and is requesting a further injection?

  23. Case group 3 • A woman asks for an intrauterine system to be fitted 21 days after her caesarean section. She is fully breastfeeding. She had “unprotected “ intercourse with her husband 2 nights previously. How would you advise this woman. • How would you counsel a pregnant woamn who requests sterilisation? • Discuss the potential benefits to women of choosing a long-acting reversible contraception method.

  24. Cases group 4 • Discuss and consider the evidence-based advice a clinician would give a 36 year old client considering combined oral contraception (COC) use with a BMI of 29, BP > 130/90 on last 2 occasions. • In deciding which COC to use a woman needs to think about risks and benefits carefully. Discuss how best to explain “risk” to a patient • In helping women feel comfortable with COC use, discuss any health benefits COC may offer.

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