Title: Improving the effectiveness and equity of contraception provision in general practice
Funder: Department of Health and Social Care

Abstract: Background Unplanned pregnancies have costs for mother, baby and society. Teenage Pregnancy Strategy, National Institute for Health and Care Excellence (NICE) guidelines on long acting reversible contraception (LARC), and financial incentives for general practitioners (GPs) to give advice to women about LARCs are examples of policy initiatives to prevent unplanned pregnancies and abortions. Assuming most unplanned pregnancies end in abortions, abortion rates have not reduced by much since then, particularly for women in their 20s.We do not know if financial incentives for GPs to give LARC advice had equitable impact on LARC use and reduced abortions. Women at risk of abortions might benefit from early interventions but we do not know how to identify them in general practice. Contraception consultations might not be effective because some women have problems expressing needs and clinicians sometimes make assumptions about what is best for their patients.I will explore how general practice can support women to get the contraception they want and when they need it to prevent unplanned pregnancies.Aim To assess the effectiveness and equity of contraception provision in general practice and explore how best to support women to make informed choices for contraceptive careResearch questions 1.Do financial incentives in general practice to offer LARC advice increase LARC use and reduce abortion rates in the population? 2.Does offering LARC advice reduce risk of abortion in women of reproductive age? 3.Which women registered in general practice are at a higher risk of abortion? 4.How can primary care professionals improve women decision making for contraception, especially for vulnerable women?Plan of investigation I will use Clinical Practice Research Datalink (CPRD) which is a database of anonymised medical records from general practice. It has coverage of 6.9% and broadly representative of UK population.Using a before-and-after study design on CPRD, I will measure the impact of financial incentives given to GPs to give LARC advice to women since its introduction in 2009. I will use interrupted time series analysis to examine impact using LARC use and abortion rates, and equity by demographics such as age, deprivation, and practice areas.To examine the effectiveness of LARC advice on LARC use and risk of abortions, I will follow up thee cohorts of women: those eligible for LARC advice if they were using non-LARC contraception, those who attended for emergency contraception; and women not using any contraception who were not eligible for advice which will be the control group. I will analyse effects with regression methods, using LARC advice as predictor variable and risk of abortion as outcome.Using a cohort of women of reproductive age in the CPRD, I will compare women who had abortions with those who didn't, employing regression models to create risk profiles based on age, deprivation, lifestyles, consultation patterns and contraceptive use.Lastly, I will conduct focus group studies of women from different backgrounds to explore their experiences of contraceptive care in general practice, and what support they want to help them choose the right contraception.Potential benefits Unplanned pregnancies and abortions have costs to both the individuals and society, some of these are quantifiable and others not. Switching women from using oral contraception to LARC might save over 100 million for the NHS but many factors affect women's decisions to use a contraceptive method to prevent pregnancies and control their fertility.My proposal will help us understand what works, in whom and where the missed opportunities might be. The findings from the studies will help primary care professionals to support women to make informed choices about contraceptive care that works for them.

Lay abstract: Title Improving the effectiveness and equity of contraceptive provision in general practiceAim To find out what works in general practice to give the right contraception to the right women and how best to support women to make informed choicesBackground Unplanned pregnancies have costs for mother, baby and society. Teenage Pregnancy Strategy helped young people get sex education and contraception. National Institute for Health and Care Excellence (NICE) guidelines recommend using long acting reversible contraception (LARC) including injections and implants because they work better than other methods. General practitioners (GPs) have been given financial incentives to give advice to women about LARC. These are some solutions, but if we assume unwanted pregnancies end in abortions, the number carried out each year has not reduced by much, particularly for women in their 20s.Research shows financial incentives for GPs to give LARC advice increased LARC prescriptions but we don't know if the right women benefited. Women with certain risk factors are more likely to have an abortion but some risk factors are not recorded routinely in GP notes for GPs to acted earlier to prevent abortions. When women get to see their GPs, some find it hard to ask what they want, such as those with learning disabilities and mental health problems; they also make assumptions about what is best for their patients.In this study, I want to know what we can do in general practice to support all women to get the contraception they want and when they need it to prevent unplanned pregnancies.Design and methods I will use Clinical Practice Research Datalink CPRD - a database of anonymised electronic patient health records from over 600 GP practices in the UK, where clinical information is recorded as codes used for research.My aim is to answer these questions: Do financial incentives for GPs to give LARC advice increase its use and reduce abortion rates? Using information from GP records, I will look at whether the number of prescriptions for LARCs and the abortion rates changed when the financial incentive was introduced in 2009. I will also investigate whether prescribing and abortion rates were different for women from different areas, age groups and social backgrounds. Did giving LARC advice stop women from having abortions? LARC advice given by GPs might make women use LARC and prevent unplanned pregnancies. Using CPRD, I will compare women who were given LARC advice with those who weren't and measure differences in LARC prescription, use, and abortion rates. Which women on GP lists are more likely to have abortions? We want to know if information in GP records can accurately identify women at risk of abortion to offer contraception advice earlier. Information that could be used might include: history of abortion, younger age, repeated use of emergency contraception and history of depression. We can compare women who had abortions with women who did not and see which group is more likely to have these risk factors. How can GPs help women choose the contraception that is best for them? Not all women want or need contraception. Getting advice unexpectedly based on profiling could be insensitive and annoying. On the other hand, some might welcome the chance to talk about it. Some women find it harder to talk to their doctor or nurse for contraceptive advice, such as teenagers, those with learning disabilities and mental health difficulties.I will use four focus groups of between 8 to 15 women each from different backgrounds (e.g. young women, women with mental health problems or learning difficulties) to talk about their experiences of getting contraception, if they welcome unsolicited advice and what they want from their doctor or nurse to help them make choices. The findings will help to produce guidelines for clinicians to discuss contraceptive choices.Public and patient involvement I sought feedback using Twitter and online forums, from a range of women including: under 25s, women with mental health problems and learning disabilities. Their feedback resulted in changes to study proposal, the language used and this summary. Some of them will join the Project Advisory Group (PAG) to help oversee this study throughout the fellowship.Outputs from research I will promote research findings in medical journals and present at conferences to the wider community. With the PAG, we will create materials such as: posters, YouTube videos, infographics, and use social media to spread the message.My research will transform the way doctors and nurses work with women to make informed contraceptive choices.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH