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Title: Improving choice and use of contraception
Author: Lakha, Fatim
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 2013
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Background: Almost all women are at risk of unintended pregnancy throughout their reproductive years. In the UK alone, more than 200,000 pregnancies were terminated by induced abortion in 2010. Additionally, a substantial number of births result from unintended pregnancy. Family planning is achieved through use of contraceptive methods. Contraceptive prevalence is increasing worldwide, however, some need for contraception remains unmet. Even in industrialised countries where contraception is readily available and use is high, many unintended pregnancies occur. The reason for this is that existing methods are not perfect, and their acceptability is limited by side effects and inconvenience leading to either non-use or incorrect and inconsistent use. Preventing unintended pregnancy requires the number of successful contraceptive users to increase. This, at a minimum, requires the availability of safe, acceptable and effective methods of contraception; access to information, supplies and services; and the motivation and ability (including recognition of risk) to initiate and use contraceptives correctly and consistently. Currently available methods need to be reviewed and where necessary adapted to address users' concerns and preferences in an effort to increase acceptability and hence uptake and adherence. And, most importantly, new methods need to be developed which do not cause the systemic side-effects linked to existing methods and offer additional non-contraceptive health benefits. Methodology: Using a variety of methodologies we explored three areas. Firstly we sought to establish via a questionnaire survey how many pregnancies ending in either childbirth or abortion are unintended, and what proportion of women use emergency contraception (EC) to try to prevent pregnancy. Secondly we explored the issue of acceptability of adapted methods of contraception (Implanon® and Depo-provera®) via questionnaire survey. And thirdly we further developed a novel contraceptive, mifepristone by exploring both its effectiveness and its potential non-contraceptive health benefits (amenorrhoea and protection against STI's including HIV). Results: Ninety percent of pregnancies which end in induced abortion were clearly unintended, however, of these women only 12% recognised their risk and used EC to try and prevent a pregnancy. Additionally one third of pregnancies which resulted in a birth were not clearly intended. Both Implanon®, in practice, and subcutaneous depo-provera®, in theory, were found to be acceptable methods of contraception to women. Approximately half (47%) of those who used Implanon® continued to use it for the full duration ( > 2years 9/12) and one third of all users chose to have another implant when the first one expired. Regarding subcutaneous depo-provera® 67% of current users, 26% of never users and 40% of exusers said they would seriously consider self-administration of depo-provera® if it were to be licensed. In investigating mifepristone it was found that there were no pregnancies in 356 months of exposure to mifepristone and more women were amenorrhoic whilst taking mifepristone than POP (49% vs 0% p < 0.001) and no mifepristone users discontinued for reasons related to bleeding profiles. Additionally no significant changes were found in vaginal thickness or content with use of mifepristone. Discussion: Unintended pregnancy is common, even among women who choose to continue pregnancy. EC use is low indicating that women are often not aware of their risk. Thus EC is unlikely to reduce unintended pregnancy. Rather, we need to encourage improved use of regular contraception. Long acting reversible contraceptives are particularly beneficial as they do not require daily intake and hence can be 'forgotten'. Our findings suggest that the long acting reversible methods of contraception (LARC) Implanon® is acceptable to women and its continuation rates justify its widespread provision. Similarly, the advent of subcutaneous self-administrable Depo-provera® would likely be beneficial and popular with women. Alongside adapting existing methods of contraception there is a need to develop novel methods of contraception such as antigestogens. Our studies of mifepristone show that mifepristone is an effective oral contraceptive pill with a better pattern of menstrual bleeding than an existing POP (levenorgestrel). We also found that in contrast to other oestrogen-free contraceptives, mifepristone is unlikely to be associated with an increased risk of transmission of HIV and other sexually transmitted infections.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available