Nursing Issues in the Emergency Contraceptive Pill

A ten year Strategy was launched in 1999, by the government with an objective to halve the under 18 Teenage Pregnancy conception rate by 2010. Research has shown that the increased availability and accessibility of the emergency contraceptive pill, (EC) has not had an impact on the new found reduction in the rate of unplanned pregnancy. Using a problem solving approach the author will examine how the nurse should influence and raise awareness of the availability of the emergency contraception pill, levonorgestrel 1. mg, during consultation with young teenagers, for long acting reversible contraception. For the purpose of this assignment a young person shall be classified as with the FFPHC (2004) Guidance that states that a ‘young person’ as anyone aged less than 18 years. In England, Wales and Northern Ireland a child is ‘a person who has not reached the age of 18 years’ DoH, (1997) and in Scotland is ‘a person below the age of 16 years’ (The Stationary Office, 1995) Some reference related to contraceptive advice and treatment will be specific to young people aged less than 16 years.

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The sexual health needs assessment will be discussed as an indicator that there is a dilemma with the use of the emergency pill. Reference will relate to trends in abortions and how the nurse should work towards the increased demands of those individuals who are changing their behaviour to reduce risks of unplanned pregnancy and sexually transmitted diseases (STI). This work will explore a number of issues to support the author’s view that in relation to the current abortion statistics, assessments for good practice in providing emergency contraception and sexual health to young people are not being collectively addressed.

Emergency contraception is an intervention aimed at preventing pregnancy after unprotected sexual intercourse or potential contraceptive failure. Less preferred terms for ’emergency contraception’ include ‘post-coital contraception’ and ‘the morning-after pill’ [FFPRHC, 2006b]. Emergency contraceptives have been available for more than 30 years and are a safe and effective method of contraception. For the purpose of discussing informed choices, the IUD which is a emergency contraception shall be referred to.

A Judicial Review in 2002 ruled that pregnancy begins at implantation, not at fertilization; therefore the use of emergency contraception is not to be considered as an abortion. The emergency contraceptive pill is a tablet containing progesterone, a hormone which is similar to the natural progesterone women produce in their ovaries. The emergency pill mode of action is to stop an egg being released (ovulation), or delay ovulation, depending on cycle at time of use. It may also stop a fertilised egg settling in the womb (implanting). Fpa 2006) The teenage pregnancy strategy was launched based on a report from the social exclusion unit in 1998. The report aim to improve the number of teenage parents in, employment, education and training, reducing the long term risk of social exclusion that in return contributes to the rate of conception of young women under the age of 16. an independent advisory group set up in 2002 has been monitoring the strategy and providing advice to the government, as a result the teenage conception rate has seen a decline between 1998 and 2005 by 41% in under 18s and 12. 1% in under 16s.

Although it does not directly mention the importance of the EC in reducing the rate of unintended pregnancies, the Department for Education and Skills suggest that the provision of emergency contraceptive services has a small but important role to play in reducing teenage pregnancies. It has been concluded that the key factors in reducing teenage pregnancy rates include ‘the availability of a well publicised young people-centred contraceptive and sexual health advice service, with a strong remit to undertake health promotion work, as well as delivering reactive services’ [DfES, 2006].

The statistics in abortion is an important indicator that that the emergency contraceptive pill does not prevent unwanted pregnancies. Glaiser & Lakha (2006) state that emergency contraception use is low even among women with no intention of conceiving, and is thus unlikely to reduce unintended pregnancy rates. The study showed that even with an advance supply of emergency contraception the women did not recognize or acknowledge that they were at risk (Glaiser et al 2004).

This statement suggests that there has been no change in education towards known barriers of usage of emergency contraception such as lack of knowledge of how and when to use emergency contraception, difficulties with getting hold of it and reservations about using it. Researchers, from Scotland who surveyed 907 women requesting an abortion from one hospital in Edinburgh, found that ninety per cent (814/907) of the women indicated clearly that they had not meant to get pregnant, but only 12% (113/907) said they had tried to prevent the pregnancy with emergency contraception.

Similar low rates of uptake have been reported repeatedly over the past two decades, and the authors say it’s becoming clear that promoting emergency contraception is an ineffective way to prevent unwanted pregnancies. Health professionals and policy makers should focus more on long term regular contraception instead. (Lakha and Glasier 2006) Abortions, one of the most commonly performed gynaecological procedures in Great Britain, with 198. 500 terminations performed in 2007 compared to 193. 00 in 2007 a rise of 2. 5 per cent, in England and Wales (DOH 2005). A report in 1996 showed that the costs of terminations of pregnancy to the NHS are as follows. Medical management costs ? 346 per patient and surgical management ? 397 per patient, (Waller & McPherson 2003). More than 100 teenagers are undergoing an abortion for the second time in England and Wales Department of Health (DOH). Statistics from the DOH also show that 44 women had their 8th abortion last year with 20 of these under 30.

A total of 186416 abortions were performed in 2005 including more than 60000 on women who had already had at least one (Daily Mail 2006 pg 9). The figures also show that 90% of abortions were carried out at less than 13 weeks of the pregnancy. About 70% were carried out at under 10 weeks’ gestation. Only 1% of the abortions, 1,900 in total, were carried out under ground E of the Abortion Act – stating that the child would be born disabled. DoH 2008) Statistics show that the number of occasions on which emergency contraceptives were prescribed by NHS community contraception clinics and Brook services rose from about 196,000 in 1996-97 to 240,000 in 1999-2000. This fell back to about 158,000 in 2006-07 following the reclassification in 2001 of EHC, making it available for women aged 16 and over to buy at pharmacies. (However, there is no indication that the pill was been purchased from this source).

The requirement for switching a medication from prescription to over-the-counter status includes making sure the drug is safe and has a low potential for abuse or misuse. In addition, the young person must be able to recognize the condition on their own and require minimal health care provider intervention in order to use it correctly. The option of rapid availability from a pharmacist or a walk in centre, without the need for attendance at clinic or GP, is therefore a welcome addition to responsible family planning measures.

A recent study has shown that there are additional barriers such as, a lack of information and misperceptions about contraception. The survey conducted by the Kaiser Family Foundation and Seventeen magazines revealed considerable gaps in knowledge about newer methods and emergency contraception. For example, nearly 20% of surveyed teens underestimated the contraceptive efficacy of the contraceptive patch or ring, and more than 25% believed that emergency contraception causes abortion.

A reluctance to acknowledge sexual activity and denial of the associated risks are among the issues that may prevent adolescents from seeking contraceptive services. Young people need to gather knowledge and develop the skills necessary to enable them to avoid unplanned pregnancies and to protect them against sexually transmitted infections (STI’s) most teenagers who became pregnant attended general practice in the year before pregnancy, and many had sought contraceptive advice. (Glasier & Gebbie 2000). ore than 25% of the teens did not know that oral contraception provides no protection against sexually transmitted disease. Importantly, many adolescents may harbor unfounded fears, including beliefs that contraception may cause infertility or birth defects. Clinical competence is a major component for the nurse, when providing contraceptive and reproductive sexual health care service. In order to maintain safe practice, theoretical knowledge on which to base care and the practical application skills required to implement that knowledge, must be developed.

The nurse’s role in provision of advice and treatment on contraception, sexual and reproductive health including abortion is supported by the department of health best practice guidance, (2004). The contraceptive nurse working with young people should be able to provide confidential advice to ensure that each young person is not discouraged from seeking the help they need about contraception for fear of their parents finding out. (FFPRHC 2004) The nurse must adhere to the NMC code of practice, (2002) remembering that the duty of confidentiality is not absolute.

Where there is a risk to health, safety or welfare of a young person or others, which is so serious as to outweigh the young persons right to privacy, the protocols outlined in ‘working together to safeguard children’(2006) need to be followed. The sexual offenders Act (2003) will protect the nurse against, being found guilty of aiding and abetting or counselling a sexual offence against a child where they are acting for the purpose of protecting a child from pregnancy or sexually transmitted infection, protecting the physical safety of a child or promoting a child’s emotional well being by the giving of advice.

The nurse will discuss and identify the indications for emergency contraception, and inform young persons about the methods of emergency contraception available. All nursing staff should work using a patient group direction(PGD). (FFPRHC 2004). to provide safe evaluation of the client taking into account issues relating to persons under the age of 16(Fraser guidelines), STIs and future contraceptive use. The use of the Fraser guidelines allows the nurse to provide contraceptive advice and treatment to young people under the age of 16 years without parental consent.

Within the guidelines the nurse must ensure that the young person understands the advice she receives, for example in the case of emergency contraception understands when the pill is indicated. The nurse needs to be assured by the young person that they cannot be persuaded to inform her parents of to allow the clinician to inform them. There must be some indication that with or without contraception the young person will continue to have sex which will put them at risk of pregnancy and cause physical and mental suffering, as a result of withholding treatment.

The nurse also needs to ensure that it is in the best interests of the young person for the clinician to provide contraceptive advice, treatment or both, without parental consent. If a young person is assessed competent this should be documented in case notes as her being ‘Fraser ruling competent’ (advice understood, will have or continue to have sex, advised to inform her parents, in her best interest) (Grade C. FFPRHC Guidance (October 2004)). Young persons should be aware that the efficacy of the emergency contraception depends on its correct and consistent use.

They should also know that both the IUD and the emergency hormonal contraceptive method may fail, even with appropriate use. Patients should be counselled about the comparable efficacy rates. The Emergency contraception pill can be given to a woman who has had unprotected intercourse up to 72 hours regardless of time in the menstrual cycle. 84% of expected pregnancies are prevented if Emergency Contraception (EC) is used within 72 hours of UPSI. Von Hertzen. (2002).

Indications for emergency contraception include a contraceptive mishap, sexual assault, or exposure to such teratogens as a live vaccine, cytoxic drug, or extensive radiation. The copper IUD is used as a long acting reversible contraception, preferably for a woman at low risk of sexually transmitted disease who desires long-term contraception. However insertion can be done up to 5 days after unprotected sexual intercourse (upsi)to prevent pregnancy. Based on 8,400 post-coital insertions, Trussell et al estimated the failure rate of the copper IUD for emergency contraception as

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