Introduction

This quality standard covers advice about all methods of contraception for women, including emergency contraception. It applies to young people (under 25) and adults. This includes all women of childbearing potential, and young people under 16 who are competent to consent to contraceptive treatment under the Department of Health's Reference guide to consent for examination or treatment.

It does not cover sexual health or reducing sexually transmitted infections. For more information see the contraceptive services topic overview.

NICE quality standards focus on aspects of health and social care that are commissioned locally. Areas of national policy, such as the Department of Health's Commissioning sexual health services and interventions: best practice for local authorities, are therefore not covered, but should be read alongside this quality standard.

Why this quality standard is needed

An estimated 19% of pregnancies are unplanned[1]. Some groups are at a greater risk of unplanned pregnancy, including young people. According to the 2010/12 'National survey of sexual attitudes and lifestyles'[2], the median age of first intercourse was 17 for both sexes, but it was 16 in those aged 16–24 at interview. Between one‑quarter and one‑third of all young people are thought to have sex before 16.

Since 1998, the under‑18 conception rate for England and Wales has dropped by 51%. The estimated number of under‑18 conceptions in England and Wales fell from 24,306 in 2013 to 22,653 in 2014, a decrease of 6.8%. In women aged 15–17 the rate was 22.9 conceptions per 1,000 in 2014, the lowest since statistics were first recorded in 1969.

Current contraceptive methods

Current contraceptive methods include long-acting reversible contraception (also known as LARC), hormonal methods, oral and barrier methods.

Oral contraceptives are the most common form of contraception used by women (NHS contraceptive services: England, community contraceptive clinics. Statistics for 2013–14 Health and Social Care information Centre). The male condom is another commonly used method in the UK.

In a 2008/09 survey, less than 1% of women reported using diaphragms and caps (Contraception and sexual health Office for National Statistics).

The uptake of long-acting reversible contraception has been slowly increasing. In 2013/14, 31% of all women who made contact with sexual and reproductive health services were enquiring about long-acting reversible contraception.

The effectiveness of oral contraceptive pills and barrier methods depend on their correct use every day or each time the person has sex. The effectiveness of long-acting reversible contraception does not rely on correct everyday use.

Abortion rates

Although 88% of women aged 15–44 in a heterosexual relationship report using at least 1 method of contraception, 184,571 abortions still took place in 2014 (Abortion statistics, England and Wales: 2014 Department of Health). The Department of Health statistics also show that, in 2014, the highest abortion rate was among women aged 22, at 28 per 1,000 pregnancies. The rate for those aged under 16 was 2.5 per 1,000, and for those aged under 18 it was 11.1 per 1,000. In 2014, 37% of abortions were among women who had already had 1 or more abortions.

Contraceptive services

Contraceptive services aim to help men and women choose a method that best suits their individual needs and lifestyle, making it more likely that contraception will be used effectively.

In this quality standard 'contraceptive services' refers to the whole range of contraceptive, sexual and reproductive health services for all ages. It includes:

  • primary care

  • services offered by community, education and pharmacy outlets (commissioned by local authorities from the NHS, the private or voluntary sectors)

  • services commissioned by clinical commissioning groups (such as termination of pregnancy [abortion] services)

  • services commissioned by NHS England (for example, contraceptive services provided as an 'additional service' under the GP contract).

[Adapted from NICE's guideline on contraceptive services for under 25s and Making it work: a guide to whole system commissioning for sexual health, reproductive health and HIV Public Health England]

The quality standard is expected to contribute to improvements in the following outcomes:

  • under‑18 conceptions

  • abortion rate

  • women having more than 1 abortion

  • accessibility of contraceptive services

  • provision of information about contraception

  • use of long-acting reversible contraception.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS outcomes framework 2016–17

Domain

Overarching indicators and improvement areas

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

ii GP Out-of-hours services

4d Patient experience characterised as poor or worse

i Primary care

Improvement areas

Improving women and their families' experience of maternity services

4.5 Women's experience of maternity services

Improving people's experience of integrated care

4.9 People's experience of integrated care**

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

** Indicator is complementary

Indicators in italics in development

Table 2 Public health outcomes framework for England 2016–19

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors which affect health and wellbeing and health inequalities

Indicators

1.01 Children in low income families

1.05 16–18 year olds not in education, employment or training

1.11 Domestic abuse

1.12 Violent crime (including sexual violence)

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.04 Under 18 conceptions

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering services relevant to contraception.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and people who use services.

Quality statements on these aspects of patient experience are not usually included in topic-specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience, and are specific to the topic, are considered during quality statement development.

Coordinated services

The quality standard for contraception specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole contraception care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to people accessing contraception.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality contraceptive service are listed in related NICE quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in supporting access to contraception should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers may have in supporting people to access contraception. If appropriate, healthcare practitioners should ensure that family members and carers are involved in the decision-making process.



[1] Wellings K, Jones KG, Mercer CH et al. (2013) The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). The Lancet 382: 1807–16

[2] Mercer CH, Tanton C, Prah P et al. (2013) Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). The Lancet 382. 1781–94