Focus on Women Physiotherapy - Gold Coast

GPs play a critical role in ensuring that women in Australia can access the most effective forms of contraception available to them. Yet uptake of the most effective contraception remains low.

Long-acting reversible contraception (LARC), such as intrauterine devices (IUDs) and implants, is the most effective form of contraception. It has a failure rate of less than 1% due to its ‘set and forget’ nature and long duration. It is suitable for all women of reproductive age (including teenagers) and has high rates of acceptability and continuation. However, the uptake of LARCs in Australia continues to be low – only around 11% of women aged 15-44 years use this form of contraception[1].

Some of the reasons for low uptake include lack of awareness of these methods, myths and misconceptions about the side effects and risks, and limited access to or lack of knowledge of health care providers who are trained to insert IUDs and/or implants.

However, a trial conducted by the SPHERE Centre of Research Excellence in Sexual and Reproductive Health in Primary Care has found that training GPs to deliver effectiveness-based contraceptive counselling, in which they first talk to their patients about the most effective contraceptive methods – in this case, LARC – and providing GPs with a rapid referral pathway for their patients to quickly access a LARC insertion, increases LARC uptake by women.

Role of GPs

GPs are the first point of contact for most women when it comes to their contraception needs. Therefore, GPs play an important role in ensuring that women are fully informed of their contraceptive options, including the availability of LARCs. However, GPs continue to recommend the oral contraceptive pill over other more effective methods.[2]

This may be due to lack of familiarity with, or knowledge of, other contraceptive methods. In the case of LARCs, some GPs may wrongly believe that they are inappropriate for women who have not given birth, or that they should only be offered when other methods are unsuitable[3]. Moreover, GPs who are not trained to insert IUDs or implants are less likely to recommend these methods to their patients[4].

The Australian Contraceptive Choice Project (ACCORd) ^_[5]

To address the low uptake of LARCs, GPs from general practices in Melbourne participated in a clinical trial, in which they were trained to deliver effectiveness-based contraception counselling to women and were provided referral pathways to LARC insertion clinics to see if this would increase LARC uptake. The ACCORd intervention was adapted from the US Contraceptive CHOICE study[6], which reported an increase in LARC uptake when women were provided with information about all reversible contraceptive options through structured effectiveness-based counselling and offered free contraception.

The impact of the ACCORd intervention on LARC uptake was almost immediate. Of the women who received contraceptive counselling, 19.3% had a LARC inserted within four weeks compared to 12.9% of women who received usual care. This increased further at 12 months, with 46.6% of women who received contraceptive counselling choosing to have a LARC inserted compared to 32.8% of women who received usual care.

Also, a survey conducted with women who participated in the trial showed that those who chose a hormonal LARC method had the highest continuation rates (levonorgestrel intrauterine system – 93%; levonorgestrel implant – 73%) compared with those who chose the oral contraceptive pill (58%).

Satisfaction rates were also highest among women who were using the levonorgestrel intrauterine system (86%) and the implant (75%) compared with those who were using the oral contraceptive pill (61%). [7]

How can GPs help women to become more aware of their contraceptive choices?

The ACCORd trial demonstrated that helping women become more aware of their contraceptive options and the effectiveness of each method can increase LARC uptake.

“It’s really important that women get the opportunity to hear about all the contraceptive methods available to them. Many women who are taking the pill may not know that there are other more effective methods available to them,” said Professor Danielle Mazza, lead investigator of the ACCORd trial and Director of SPHERE.

Prof Mazza said GPs could start providing effectiveness-based contraceptive counselling by simply informing their patient that IUDs and implants are more effective than other methods. “Resources such as a counselling card produced by Family Planning Alliance Australia can help GPs explain the differences in the effectiveness of different contraceptive methods,” she said.

The availability of referral pathways for LARC insertion services is also important as it addresses the issue of access in instances where a woman’s regular GP is not trained to insert LARCs.

“Once a woman decides she wants an IUD or an implant, she should be assisted to have it inserted as soon as practicable,” said Prof Mazza. “Sometimes it’s hard to find a clinician who does insertions. Rapid referral pathways to local provision of LARC insertion help facilitate this and reduce the barriers to her starting on a LARC method.”

Further support for GPs

In response to the need to improve access to contraception and medical abortion in Australia, SPHERE has established the Australian Contraception and Abortion Primary Care Practitioner Support (AusCAPPS) Network. This online community of practice provides support for GPs, pharmacists and nurses working in primary care to deliver LARC and medical abortion services.

Professor Mazza said that one of the barriers to LARC provision for many GPs is the limited opportunities to access training in this area. Similarly, some GPs feel that medical abortion is beyond their scope of practice or that they need additional support and resources to help integrate this service into their practice.

“The AusCAPPS Network has been developed to fill this gap so that we can have more GPs providing LARC and medical abortion services, particularly in rural and regional areas where access to these services is severely restricted,” she said.

The AusCAPPS Network, a Partnerships Project funded by the National Health and Medical Research Council, is open to GPs, pharmacists and practice nurses working in primary care. Members of this network will have access to:

• a peer support network comprising other GPs, pharmacists and nurses around Australia who also provide LARC and medical abortion services
• training and education opportunities relating to LARC insertion and medical abortion provision
• information on local referral pathways for LARC insertion
• resources, guidelines, referral forms and patient handouts
• the latest news and research related to LARC and medical abortion.

 

Published with the permission of Jean Hailes for Women's Health

jeanhailes.org.au – tollfree number 1800 JEAN HAILES (532 642) for women seeking further health information.