Published 23 December 2008, doi:10.1136/bmj.a3056
Cite this as: BMJ 2008;337:a3056

Head to Head

Should the contraceptive pill be available without prescription? No

¹ Royal College of General Practitioners, London SW7 1PU

Two areas in London are piloting over the counter oral contraceptives. Daniel Grossman (doi:10.1136/bmj.a3044) argues that the policy should be widely adopted but Sarah Jarvis believes it is the wrong approach to reducing unwanted pregnancy

The United Kingdom is top of a league in western Europe—and a very undesirable first place it is, too. The league table is that for teenage pregnancies, with rates of teenage motherhood in the UK, at 15%, around twice those of Germany (8%), three times those of France (6%), and almost four times those of Sweden (4%).^{1 2}

The implementation of a national teenage pregnancy strategy in 1999 has gone some way to reversing the rising trend of teenage pregnancies, but only by about 2% a year in the first five years after it was implemented.³ As with other lifestyle diseases such as diabetes, however, the UK still ranks far behind the United States, where 22% of women have a child before the age of 20.²

Nevertheless, action still needs to be taken to address the underlying causes. The Department of Health Social Exclusion Unit has highlighted complex reasons for the high rates of teenage pregnancy in the UK, including lack of education and mixed messages in the media.¹ Societal attitudes, government housing policy for teenage mothers, and media messages are largely beyond the remit of primary care’s influence. Education about contraception, however, is not. And it is contraceptive use, rather than sexual activity, which correlates most closely with rates of unplanned pregnancy.²

Wrong method

In 2005, the National Institute for Health and Clinical Excellence (NICE) guidance highlighted low use of long acting reversible contraception (intrauterine contraceptive devices, intrauterine system, progestogen-only subdermal implants, and progestogen-only injectable contraceptives) compared with user dependent methods such as the contraceptive pill as one of the reasons for high rates of unwanted pregnancy. This claim certainly fits with the evidence—about 8% of women of childbearing age in the UK (with a 15% teenage motherhood rate) use long acting contraceptives compared with about 20% in Sweden, where the rate of teenage motherhood is 4%.

Although making the combined oral contraceptive pill available without prescription may be safe, it would not help. Those using the service would not, as the NICE guidance recommends, be offered a full range of contraception on every occasion. Oral contraceptives require daily compliance on the part of the patient, whereas all long acting contraceptives are effective for at least three months, are at least as cost effective at one year as the oral contraceptives, and have similar satisfaction rates.⁴

The major difference between long acting and oral contraceptives is their reliability in practice. Compliance is low with oral contraceptives. In one study of women using oral contraception, 47% missed one or more pills per cycle, and 22% missed two or more.⁵ These women have almost a threefold increase in unintended pregnancy compared with women who take the pill consistently, and teenagers are the group with the highest non-compliance.⁶

Long acting contraceptives such as the intrauterine contraceptive device, intrauterine system, and the progesterone-only subdermal implant, are effective for at least three years.⁴ Even the progestogen-only injectable contraceptive (depot contraception), which requires attendance for repeat injection every three months, is significantly more reliable than oral contraceptives. In a US study of teenagers offered contraception after termination, repeat pregnancy rate was 29.7% for girls given the oral contraceptive compared with 14.2% for those given depot contraception.⁷

Availability

Access to primary care services is less of a problem in the UK than in some other countries, particularly the United States. Over 99% of the UK population is registered with a general practitioner, and 85% of the population see a general practitioner at least once a year.⁸ Although 16-19 year olds are more likely than other groups to use family planning clinics (rather than general practitioners) for contraception,⁹ 72% of teenagers still express a preference for attending the general practitioner for contraceptive services.¹⁰

There is great untapped opportunity for general practitioners to encourage young women to use long acting contraceptives—an analysis of the general practice records of 13-19 year olds who had had a termination showed that half had sought contraceptive advice from the general practitioner in the previous year and that 40% of these had been prescribed oral contraception. In addition, compared with matched controls, girls who had become pregnant were significantly more likely to have requested emergency contraception.¹¹ This does not include the many chances for opportunistic discussion during attendances for other reasons.

The availability of emergency contraception without prescription has done little to change the rate of teenage pregnancies. This is hardly surprising, when among under 25s, only 37% use emergency contraception on every occasion that they have unprotected intercourse.¹² Increased uptake of reliable, non user-dependent methods has to be the key. Rather than making a potentially unreliable method of contraception more easily available, our best avenue for reducing unplanned pregnancies is to encourage general practitioners to help their patients to make the best choices.

Cite this as: BMJ 2008;337:a3056

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Competing interests: SJ has been paid by Bayer for speaking at symposiums and writing educational articles.

References

1. Social Exclusion Unit. Teenage pregnancy report.London: HMSO, 1999.
2. Darroch JE, Singh S, Frost JJ. Differences in teenage pregnancy rates among five developed countries: the roles of sexual activity and contraceptive use. Fam Plann Perspect 2001;33:244-50.[CrossRef][Web of Science][Medline]
3. Wilkinson P. Teenage conceptions, abortions, and births in England, 1994-2003, and the national teenage pregnancy strategy. Lancet 2006;368:1879-86.[CrossRef][Web of Science][Medline]
4. National Institute of Clinical Excellence. Long acting reversible contraception. Clinical guideline 30. 2005. www.nice.org.uk/Guidance/CG30.
5. Rosenberg MJ, Waugh MS, Burnhill MS. Compliance, counseling and satisfaction with oral contraceptives: a prospective evaluation. Fam Plann Perspect 1998;30:89-92.[CrossRef][Web of Science][Medline]
6. Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation. Contraception 1995;51:283-8.[CrossRef][Web of Science][Medline]
7. Thurman AR. Preventing repeat teen pregnancy: postpartum depot medroxyprogesterone acetate, oral contraceptive pills, or the patch? J Pediatr Adolesc Gynecol 2007;20:61-5.[CrossRef][Web of Science][Medline]
8. Department of Health. National survey of local health services 2006. www.dh.gov.uk/en/Publicationsandstatistics/Statistics/StatisticalWorkAreas/Statisticalhealthcare/DH_073494.
9. Botting B, Dunnell K. Trends in fertility and contraception in the last quarter of the 20th century. www.statistics.gov.uk/articles/population_trends/fertconttrends_pt100.pdf.
10. McMillan HM. Spotlight on teenage pregnancy—defining the demographics and the family planning requirements. Ir Med J 2004;97:276-7.[Medline]
11. Churchill D. Teenagers at risk of unintended pregnancy: identification of practical risk markers for use in general practice from a retrospective analysis of case records in the United Kingdom. Int J Adolesc Med Health 2002;14:153-60.[Medline]
12. Free C. Contraceptive risk and compensatory behaviour in young people in education post 16 years: a cross-sectional study. J Fam Plann Reprod Health 2004;3:91-4.

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