It's complicated: Why free contraception is not a simple solution
In the run-up to the referendum, the Government committed to consider the introduction of free contraception in the event of a repeal of the Eighth Amendment, writes
Now, in the context of the overwhelming yes vote on May 25, the health minister is examining the funding of free contraception as part of its package of measures to reduce crisis pregnancies.
But this is no simple solution — contraception is a deeply complex subject, involving planning, negotiation, trust, and a solid understanding of the different forms of birth control, how they work, and how their effectiveness can vary.
Given our hook-up, Tinder-driven culture where unplanned sex is so often the norm, will free contraception make a significant difference?
Dr Mary Short, president of the European Society of Contraception and Reproductive Health, says the availability of free contraception has the potential to make a significant difference to the number of crisis pregnancies which occur in this country, but realistically only if two issues are effectively tackled:
The Irish Family Planning Association and Well Woman Centre emphasise the need for the Government to prioritise inclusion of LARCs — known as “fit and forget” because once in place, they require little to no management from the user — in any free contraceptives programme.
In real terms, say the experts, LARCs are more dependable than certain other popular forms of contraception such as the pill or condom, whose effectiveness depends on rigorously compliant use. Implants and injections are, for example, more than 99% effective.
LARCs have an extremely high rate of success, and thus are our best chance of reducing the incidence of unintended pregnancy, says Dr Shirley McQuade, medical director of the Well Woman Centre in Dublin.
Free condoms might reduce the STI rate, but the failure rate for contraception with condoms is quite high, she warns — when used correctly, the effectiveness of condoms is 98%, but in reality and when human error is taken into account, they have found to be only about 85% effective.
The usage of older forms of birth control such as barrier methods like diaphragms and cervical caps — research has shown they are similar to condoms in terms of effectiveness — has fallen away, according to Dr McQuade.
The Well Woman Centre has fewer than 20 consultations about diaphragms — a shallow latex cup left in place for at least six hours after sex and it does not supply the cervical cap, a silicone cup that can be used for up to 48 hours.
Diaphragms and caps are not very effective as forms of contraception and have a high failure rate, says Dr McQuade.
In contrast, LARCs are increasingly acknowledged to be among the most highly effective forms of birth control on the market — a 2013 Choice study in the US, conducted by researchers at Washington University, found that the teen pregnancy rates plummeted among girls who participated in the use of LARCs.
Pregnancy, for example, was just 34 per 1,000 of the girls in the study, compared to a US national average of 160 per 1,000.
According to Dr Short and other experts in the birth control area, LARCs are increasingly in demand in Ireland.
Things have changed significantly since the most recent Irish Contraception and Crisis Pregnancy Study, conducted in 2010 and published in 2012. It found that while 43% of women used the oral contraceptive pill and 62% of respondents used condoms as contraception, just 19% of women used LARCs.
But this low take-up is changing — a 2015 study by the IFPA showed 39% of its contraceptive services were related to LARCs, up from 19% three years earlier.
According to Dr McQuade, the Well Woman Centre has registered a 50% rise in the uptake of coils and implants since 2012.
There is a steady demand for the copper coil (a LARC and non-hormonal form of birth control), says Dr Short — it’s effective and, because it lasts for 10 years, works out quite cheap at €30 a year.
It is in demand among younger women who do not wish to have a hormonal form of birth control or who have found they have a sensitivity to progesterone. The Irish Family Planning Association gets regular referrals from GPs for this form of contraception, according to medical director Dr Catriona Henchion.
“I would see more demand for LARC prescriptions in my practice than I would have for the pill — this has changed immensely in the last 15 years or so,” says Dr Short.
While the Irish Pharmacy Union does not have statistics on the uptake of LARCs, secretary general Darragh O’Loughlin says that, anecdotally, there has been a definite increase in the demand for LARCs across its 1,740 pharmacies around the country.
Emergency contraception, also known as the morning-after pill, for women at risk of an unplanned pregnancy after unprotected sex, has been available at the pharmacy on an over-the-counter basis since 2015.
The IPU is now strongly advocating that access to free contraception should also be through pharmacists without prescription.
O’Loughlin points to the US, where, in many states, women can now access hormonal birth control without the need for a prescription. Similarly, in New Zealand and Canada, contraceptives can be bought from a chemist without prescription.
However, if a State-run programme offering free contraception is to impact on unplanned pregnancy levels, the importance of effective sex education must be recognised and prioritised, say experts.
“If we don’t tackle the education part of it, we don’t tackle it,” says Dr Henchion, warning that people must be aware of, and fully understand, the different birth control options in order to avoid unplanned pregnancy.
Any difference that the availability of free contraception could make to crisis pregnancy levels will be restricted if Ireland doesn’t improve its education around sex, she says.
Education is the key and we have to make sure people are getting good quality information.
Dr Henchion is aware of cases where people with “very limited education on reproduction”, were still attempting to use old-fashioned birth control methods based around the time of the month, or withdrawal of a man’s penis prior to ejaculation.
“They are taking chances based on that faulty education,” she points out, adding that it is also not just about sex education, but overall education. Research has repeatedly shown early school leavers have a higher risk of an unplanned pregnancy.
Good quality sex education must take in not just the biological facts around sex but the whole gamut of issues around relationships and self-esteem, explains Dr Short.
“A lot of younger people are currently getting sex education from porn,” she says, adding that a holistic programme of education, such as that being implemented in Norway and Finland, has been “shown to reduce the abortion rate in Scandinavian countries”.
Such programmes take in everything from self-esteem to sex education, and not just the biological information about how sex and pregnancy works, says Dr Short.
It’s very much about educating earlier and having well-thought-out programmes. If it’s done in a holistic way, and parents are brought on board, children will inform parents and vice versa, so it’s about education, personal integrity about sexually transmitted infections, contraceptive options.
She says these programmes also emphasise the need for a sense of responsibility in terms of “a person’s place in society.”
The approach to sex education in these Nordic countries is well thought out, she says.
“They take the holistic approach from primary school onwards — it’s an ongoing part of the curriculum that begins at primary level and is not just a session in sixth class.”
Children aged 16 and over can consent to medical treatment without needing parental approval.
“In practice [girls] often come in with mum who may just sit in the waiting room but is there for support — and also because few people know whether or not parental consent will be needed,” says Dr Shirley McQuade. “However the age for consent to sex is 17.”
Dr Short warns that the increasing incidence of sexually transmitted infections also needs to be taken into account in terms of improved sex education.
The latest HSE figures on STI rates among teens show that in 2016, there was an 8% year-on-year rise
of more than 8% from 2015 in the incidence of STIs in 15-19-year-olds.
"There needs to be more awareness that condoms provide protection against STIs — the message of double indemnity needs to be brought home," says Dr Short.
In recent decades, the area of contraception has increasingly been the responsibility of women — primarily because there are still no good reversible methods of contraception for men (there is no guarantee that a vasectomy can be reversed) and because condoms are not particularly effective, says Dr McQuade.
Yet, says Dr Henchion, even today some women can be reluctant to carry condoms, despite their proven protectiveness against STIs because they fear that carrying them may result in their being perceived as ‘permissive’:.
That same anxiety doesn’t seem to happen with the pill — after all, nobody but the woman and her doctor need to know whether she’s taking the pill.
Dr Henchion says there appears to be a feeling that women who pull a condom out of their handbag, might give the impression they are ‘ready to do it.’
Definitely there are some young women who will not carry a condom themselves and if the man says he doesn’t like to use one they think this is ‘out’ as an option. There’s no real logic to it.
If there is one thing all the experts agree on, it’s the importance of recognising the need for LARCs to be a major part of any free contraception programme.
“Long-acting reversible contraception has the best chance of reducing unintended pregnancy,” says Dr McQuad.
“These are intrauterine coils or the implant under the skin of the upper arm. Once in place, they last three to 10 years depending on the device so unplanned sex would then simply not be an issue.”
Condoms
Used perfectly, the effectiveness of condoms is 98%, but in practice, they have found to be about 85% effective.
A pack of 12 costs €7.99 and upwards
The pill
Used correctly, it can be more than 99%
Doctor consultation, €50 - €60. Pill costs between €3 and €14 per month depending on the brand.
IUDs
These are small T-shaped copper devices that must be inserted into your womb by a trained doctor.
The copper coil is slightly less effective than the Mirena but its failure rate is still significantly lower than the contraceptive pill, which can be forgotten or not absorbed due to a stomach upset.
GP consultation €50-€60. Fitting of device is €230
Implants (Implanon)
More than 99%
GP consultation €50-€60.Implanon (fitting only) €125
Injectable contraception (Depo-Provera)
More than 99%
GP consultation and first injection €80. Second and subsequent injections €66
IUS
The Mirena intrauterine system provides effective contraception for five years. The Jaydess intrauterine system lasts for three years, while the Kyleena intrauterine system lasts for five years. All are small T-shaped devices that must be inserted into your womb by a trained doctor.
More than 99%.
Initial consultation €60; Mirena, Kyleena and Jaydess (fitting only) €195.
Vaginal ring
99%.
Doctor consultation €50 to €60 plus cost of ring, €18 per month.
Emergency contraception (morning-after pill)
99% plus, depending on the pill
Free to medical card holders. For other patients, the cost includes GP consultation €50-€60; Prevenelle (up to 3 days) costs €45. Alternatively, GP consultation €50-€60 plus ellaOne (up to 5 days), €70.
