An audit of the contraception service offered to teenagers attending Scottish genitourinary medicine clinics in 2007

Introduction

Getting pregnant as a teenager can be bad for the mother, the child and society. ¹ Traditionally, genitourinary (GU) medicine clinics were seen as primarily involved in the management of sexually transmitted infections (STIs), and contraception took secondary importance. Scotland has one of the highest teenage conception rates in the western world and the reduction of unintended pregnancies is a key goal in the Scottish sexual health strategy. ² GU medicine clinics are ideally placed to address the contraception needs of young women.

We audited the contraception service offered to teenagers attending Scottish GU medicine clinics in 2007 against various standards.^3–5

The main outcomes audited were the proportion of women who had an assessment of their need for contraception (target 100%) and the proportion of women in need of contraceptive advice who received it at that attendance (target 100%).

Method

The case record numbers of up to 100 new female patients aged less than 18 years who attended the main clinic of 11 Scottish health boards (Ayrshire and Arran, Grampian, Borders, Dumfries and Galloway, Lothian, Fife, Greater Glasgow and Clyde, Highland, Lanarkshire, Forth Valley and Tayside) between January and June 2007 were identified using the Scottish STI Surveillance System. The notes were audited by three independent auditors (VN, CO or SR).

Data were entered directly into Microsoft Excel and analysed using either Excel or Stata 8.1 where appropriate.

Results

The case notes of 579 women aged less than 18 years were reviewed. The nature and relationship of the most recent sexual contact was recorded in 564 (97.4%) cases.

Documentation as to whether or not an additional method of contraception was used was noted in 555 (96%) cases. Of these, 253 (46%) used an additional method and the method used was recorded for 248. The combined oral contraceptive (COC) was used by 196 (79%) women; the contraceptive implant, Implanon^® by 24 (9.7%); Depo Provera^® by 23 (9.3%); the progesterone only pill by four (1.6%) and one woman (0.4%) used a Mirena^® Intrauterine System (IUS).

Whether a condom was used for the last vaginal sex was noted in 485 (84.8%) cases. For the purpose of this audit, the authors did not consider condom use alone as a reliable method of contraception.

The auditors assessed whether the women needed advice on adopting a reliable method of contraception. In most cases, 553 (95.5%), sufficient data were available to make a judgement. Of these, 280 women (50.6%) were assessed as needing advice. Other than being a current user, reasons for not needing advice were: ‘pregnancy not a problem’ in 14 cases (5.6%) and ‘only female partners’ in one case (0.4%).

Of the 280 women who needed advice, 156 (56%) (confidence interval [CI] 50–62%) received it. The percentage advised varied from 0% in one health board to 84% in another (Figure 1). OPEN IN VIEWER

The likelihood of being given contraception advice was strongly related to age. Women aged less than 17 years were significantly more likely to receive advice than those aged 17 years or over (P < 0.001).

Fifteen women (5.4% of 280) were started on a contraceptive method during that consultation; five on the COC, two on Implanon^® and seven on Depo Provera^®. In addition, 22 women were given Levonelle^®.

Discussion

In 2007, there were 4436 episodes of care involving women under 18 years old at Scottish GU medicine clinics (ISD Scotland, personal communication). This audit has shown that almost all those women are likely to have had an assessment made of their need for contraception. About half (2245 if we extrapolate from national figures) did not want to get pregnant, but were not using a reliable method of contraception, and approximately 1100 appear to have left the clinic without being given any advice about reducing their risk of pregnancy. Staff should ensure they document that they have given advice on preventing unwanted pregnancy.

Fifteen percent of case records did not document whether a condom was used or not. This is an essential part of risk assessment and should be done in all cases.

It is unclear as to why women over the age of 17 years old were less likely to be given advice than younger adolescents. Perhaps they were regarded as more capable of finding information for themselves.

GU medicine departments should see provision of contraception for teenagers as a priority and address gaps in contraception when they become apparent, ideally by supplying long-acting reversible methods. To this end, sufficient staff should be trained in Implanon^® insertion and clinic schedules should allow flexibility so that a method can be supplied at a woman's first visit. Clearly these changes would require an increase in resources.