Reproductive Health

 

Key Facts

The World Health Organisation (WHO)1 defines reproductive health as a “state of physical, mental, and social well-being in all matters relating to the reproductive system. It addresses the reproductive processes, functions and system at all stages of life and implies that people are able to have a satisfying and safe sex life, and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so”.

For the majority of  women in their reproductive years, contraception and preconception care are important aspects of their daily lives that require individualised support. 

At any point an estimated 78%2 of women aged 16-44 are sexually active and either wanting to prevent or to achieve an unassisted pregnancy.

Of these:

  • 12% are using no contraception
  • 45% need ongoing contraception according to need
  • 20% need preconception and postnatal care.

A planned pregnancy is likely to be a healthier one, as unplanned pregnancies represent a missed opportunity to optimise pre-pregnancy health. Currently, 45% of pregnancies and one third of births in England are unplanned or associated with feelings of ambivalence3.

Although pregnancies continuing to term mostly lead to positive outcomes, some unplanned pregnancies can have adverse health impacts for mother, baby and children into later in life. 

General practice remains the preferred place for women to access their contraception3.  

References

  1. WHO Pacific Regional Office. Reproductive Health
  2. PHE: Health matters: reproductive health and pregnancy planning
  3. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3);  Wellings K et al. The Lancet. 2013:  382; 1807-16. 
  4. PHE: What do women say? Reproductive health is a public health issue

General

Most women of reproductive age are at any point either wanting to become pregnant or to prevent pregnancy.  Contraception and pregnancy planning care should be integrated to enable optimization of health and wellbeing of the woman and her family for when the decision is made to try for a pregnancy. 

There are many opportunities in primary care to offer preconception advise including appointments for contraception, cervical screening, management of long-term conditions and medication review.

Public Health England (PHE) have produced a series of resources for professionals working with women and men that may have children in the future focusing on reproductive choice and ensuring that pregnancy, if desired, occurs at the right time and when health is optimised. Effective contraception and planning for pregnancy mean that women and men stay healthy throughout life and take steps to improve the health of the baby.

Resources: 

  1. What do women say? Reproductive health is a public health issue
  2. Health matters: reproductive health and pregnancy planning: A resource focusing on reproductive choice and ensuring that pregnancy, if desired, occurs at the right time and when health is optimised.

Resources for training and appraisal

The majority of contraception is provided from primary care.  There are many resources available for training in counselling and provision of contraception including the resources listed below.

A 60 minute RCGP contraception e-learning course has been produced to upskill professionals so that they can provide accurate information about the contraceptive options available to women. The course is useful for those providing contraception at a basic level in primary care; including contraceptive choices counselling, emergency contraception, risk/benefit assessment and information about sexual health screening.

This  course was developed in partnership with Public Health England and The Faculty of Sexual and Reproductive Healthcare (FSRH)

This free two-hour contraceptive counselling online course designed to support healthcare professionals to develop:

  • Key concepts in contraceptive counselling
  • Key skills for effective contraceptive counselling
  • Understanding good and bad consultations 
  • Action planning to improve contraceptive consultations

The comprehensive curriculum for Sexual and reproductive healthcare e-learning (e-SRH) was developed to reflect the level of knowledge and competence required by a doctor or nurse delivering non-specialist sexual and reproductive healthcare in a community setting.  The learning is also useful as theoretical training towards FSRH qualifications.

It includes:

  • Contraception
  • Sexually transmitted infections
  • Early pregnancy assessment and referral
  • Recognising psychosexual problems
  • The law relating to confidentiality, sexual activity and young people

The Faculty of Sexual and Reproductive Healthcare offers additional training, either as a Diploma in Sexual and Reproductive Healthcare (DFSRH) or as Letters of Competence in Intrauterine insertion and Sub-dermal insertion and removal techniques.

Guidelines and Pathways

NICE Long-acting Reversible Contraception (CG30, Oct 2005, updated 2019)

This guideline covers long-acting reversible contraception (LARC). It aims to reduce the number of unintended pregnancies by improving the information provided to women about contraceptive choices and increasing the use of the more effective ‘fit and forget’ LARC methods.

LARC methods of contraception are defined in this guideline as contraceptive methods that require administration less than once per cycle or month. Included in the category of LARC are:

  • copper intrauterine devices
  • progestogen-only intrauterine systems
  • progestogen-only injectable contraceptives
  • progestogen-only subdermal implants

The NICE CG30 guideline includes pathways for improving contraception counselling and LARC provision:

The Faculty of Sexual and Reproductive Health's current clinical guidance lists a number of resources to help improve the safety and use of different methods of contraception in a range of clinical scenarios. These resources are produced by the FSRH Clinical Effectiveness Unit and are free to access by all.

Including :

The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) offers guidance on contraceptive safety. The evidence-based recommendations allow a safety assessment for use of a contraceptive method by women with particular medical conditions or personal characteristics. This is an essential resource for use by any clinician providing contraception consultations. The summary document can be downloaded onto the clinical system for easy reference.

Other guidance includes evidence-based information for contraceptive use that are:

  • Method specific:
    • Intra-uterine contraception
    • Progestogen-only implant
    • Combined Hormonal Contraception
    • Progestogen-only pills
    • Progestogen-only injectable
  • For specific consultations
    • Emergency contraception
    • Quick starting contraception
  • For specific populations:
    • Contraception for women aged over 40
    • Contraception after pregnancy
    • Overweight, obesity and contraception
    • Contraceptive choices for young people

Top tips and useful resources

Contraceptive CHOICE project round up: what we did and what we learned

The US Contraceptive CHOICE Project was a prospective cohort study of 9,256 women in the St. Louis area. The project provided no-cost reversible contraception to participants for 2-3 years with the goal of increasing uptake of long-acting reversible contraception and decreasing unintended pregnancy in the area.

Results from this project found that when barriers to contraception (cost, access and knowledge) were removed women choose the most effective and user-independent methods, method satisfaction and continuation rates were higher and unintended pregnancy and abortion rates were reduced.

Primary Care Women’s Health Forum: 10 top tips for intrauterine contraception

Useful evidence-based tips to improve counselling and increase awareness of the advantages of intrauterine methods of contraception.

Guidelines in Practice: Top Tips: sexual and reproductive health

Excellent top tips summary on providing sexual and reproductive health in general practice, including recommendations on:

  • Screening patients for sexually transmitted infections and HIV
  • Contraception methods and recommendations
  • Providing care for different communities including people who identify as LGBT.

Commissioning

Commissioning fragmentation in England as a result of the 2012 Health and Social Care Act alongside difficulties with accessing training in the UK has resulted in fewer trained primary care clinicians providing Long Acting Reversible Contraceptives.

Resources

  1. The Faculty of Sexual and Reproductive Health's report 'Opportunities to embed sexual and reproductive healthcare services into new models of care.  A practical guide for commissioner and service providers', sets out case studies demonstrating the potential for new models of care to embed SRH services.
  2. The Health and Social Care Committee: Sexual Health Inquiry report has results and recommendations from the Government Select Committee Inquiry into sexual health.
  3. Public Health England's Making it work. A guide to whole system commissioning for sexual health, reproductive health and HIV contains recommendations for local government, clinical commissioning groups (CCGs) and NHS England. The guide focuses on establishing seamless, integrated care pathways through taking a whole system approach, and describes how this can be made to work in practice.
  4. The RCGP's report, Sexual and Reproductive Health; Time to Act' is a response to funding and training cuts and reduction in provision of LARC in primary care.  The report includes comments from GPs about the impact of the cuts in their local areas.The RCGP recommendations include the requirement for oversight of the fragmented commissioning system in England and improved funding and training for LARC provision in primary care.
  5. The Sexual and Reproductive Health Profiles have been developed by Public Health England to support local authorities, public health leads and other interested parties to monitor the sexual and reproductive health of their population and the contribution of local public health related systems.

 Interactive maps, charts and tables provide a snapshot and trends across a range of topics including teenage pregnancy, abortions, contraception, HIV, sexually transmitted infections and sexual  offences. Wider influences on sexual health such as alcohol use, and other topics particularly relating to teenage conceptions such as education and deprivation level, are also included.

Patient resources

  1. Brook, the national charity offers clinical sexual health services and education and wellbeing services for young people including, resources for young people and clinicians.
  2. The Contraception Choices website providing information to help weigh up the pros and cons of the different methods available.  Includes an easy to use tool to determine how effective each method is at preventing pregnancy plus access to NHS Choices youtube video explaining each method.
  3. The NHS UK: Your contraception Guide provides information about contraception aiming to answer questions about different contraception choices and about the method they are using if there are concerns.
  4. The Sexwise website provides information about all contraceptive methods plus an option to compare methods allowing the user to determine which method is right for them. 

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