The vast majority of women in the UK spend more than 30 years of their lives trying to avoid becoming pregnant. Contraception has been available free from the NHS since 1974 and today there is a choice of 15 methods, so it would seem that avoiding pregnancy should be straightforward. Yet the evidence demonstrates otherwise, with about one in five conceptions ending in abortion.
An understandable preoccupation with the UK's high levels of teenage pregnancy has had the unfortunate consequence of diverting attention from the importance of contraceptive services for women throughout their reproductive years. Yet women in their 20s have the highest abortion rates and perimenopausal women are among those who are most likely to choose an abortion if they become pregnant.
Public health campaigns at national and local level have inadvertently given the message that condoms and emergency hormonal contraception alongside the pill are the main answers: EHC and the pill to prevent pregnancy, condoms to prevent the spread of sexually transmitted infections and to prevent pregnancy.
The information provided has often been simplistic and inadequate. EHC is a valuable fallback when continuing contraception has not been used or has failed, but it is much less effective than other methods of contraception. Similarly, the increase in STIs has led to an emphasis on the use of condoms to the exclusion of other much more effective contraceptive methods.
The lack of comprehensive national awareness-raising campaigns about contraception is compounded by the fragmented nature of the services that women are offered. Very few primary care trusts have undertaken a review of their services or made any assessment of hidden needs. The majority of women obtain their contraception from their doctor, and GPs mostly prescribe the combined pill, which again is not the most effective method. In 2005, guidance from the National Institute for Clinical Excellence recommended that long-acting reversible contraception – the implant, injection and inter-uterine methods, (LARC) – were more cost-effective, and since then LARC use has increased slowly. However, provision is still patchy, and many women are being denied these very effective methods.
Sadly, there is a complete lack of research evidence about women's contraceptive preferences and many women are unable to exercise an informed choice because they do not know what is available and where.
From 2001 women have been able to buy EHC in community pharmacies, and today they are the main source of this method. This provision has greatly increased access but it is not known whether women actually prefer to pay £25, or whether difficulty in accessing free NHS provision is forcing them to do so.
Last year the government announced three years' funding for PCTs to improve services. Unfortunately, the additional funding to trusts is not ring-fenced and at the end of the first year, little progress had been seen at local level.
While most of the money is to be spent by PCTs, there will be a national campaign aimed at young people to raise awareness of LARC. Alas, the vital needs of the majority of women are again being ignored, which is not only bad for them but very shortsighted. Young people get much of their information from their mothers, sisters, aunts and friends. If older women are ignored by the campaign, enduring myths about contraception may prove more powerful than the national campaign's messages.
Another significant change is that, since April this year, doctors receive payment for telling women seeking advice about contraception about all the methods. Some are already seeing an increased take-up of LARC.
This is a complex area and women need comprehensive and sophisticated information so that they can make the right choice for them, taking into account the pros and cons of different methods of contraception, their relative effectiveness and how best to reduce the risk of pregnancy and of contracting an STI. Strategic health authorities and PCTs must recognise that contraception is central to public health and wellbeing, and give it priority. The government needs to put in place a national workforce plan to ensure that the professionals are in place to provide the service when and where it is needed. Women in 2009 should expect no less.
