by Dr Jo Burgin, Centre for Academic Primary Care, University of Bristol
Over a third of all pregnancies in women over 40 result in therapeutic abortion. This is one of the highest rates of abortion compared to live births in any age group. This suggests an unmet need for contraception. I interviewed women over 40 about their views and experience with contraception to find out more.
“I couldn’t do another child”
Previous studies have attributed the relatively low use of reliable contraception in women over 40 to women’s perceptions of themselves as low risk of pregnancy. However, participants in this study felt pregnancy was a real possibility and that an unplanned pregnancy would have a significant negative impact on their lives. Some had completed their families or had other caring responsibilities. While others knew they did not want any children and did not want to be faced with the difficult decisions an unplanned pregnancy would bring.
“You’re at the age now”
However, the need to avoid pregnancy occurred at the same time as a narrowing of contraception options. As women get older the risks associated with using certain types of contraception, mainly those that contain oestrogen, can increase. Some women will switch from combined contraception (two hormones) to progestogen-only contraception (one hormone) because of health conditions.
But many participants in this study reported being switched to progestogen-only contraception due to age alone. This is not supported by clinical guidelines which suggests that for most women over 40 the benefits of combined contraception outweigh the risks. This switch also occurs at a time when women may benefit most from combined contraception to help treat perimenopausal symptoms.
“I wasn’t keen to go through that again”
On average, women over 40 will try three different contraceptive methods over the course of their lifetimes. We may think that this experience with contraception increases women’s knowledge and leads to higher uptake and satisfaction with methods later in life but, crucially, much of this experience is not positive experience. Indeed, women in this study had reported a lot of negative experiences with both contraception and women’s healthcare in general.
Women cited contraceptive side effects, painful smears or IUD fittings and traumatic births among the experiences that put them off using certain types of contraception. Worryingly, several women recounted negative interactions with healthcare providers, from dismissal to coercion, as reasons they would not consider some contraception methods in the future. Inevitably, these negative interactions increased hesitancy around contraception methods that need to be fitted by a clinician, like the implant or the coil.
So what do women (over 40) want?
Contraception remains a priority for women over 40. This group has distinct motivators and barriers to choosing and using contraception. A tailored approach is important to address women’s changing health needs, including perimenopausal symptoms, to ensure contraception choices are not narrowed arbitrarily.
Importantly, clinicians need the time to approach women holistically, to be able to ask about past experiences, and to address the concerns women may have over contraception that requires fitting.
It’s over 50 years since contraception became widely available to women through the NHS. There is still work to do to realise the health and wellbeing benefits for women across all age groups.
Today is International Women’s Day, “a global day celebrating the social, economic, cultural and political achievements of women. The day also marks a call to action for accelerating gender parity.”
About the author
Dr Jo Burgin is a GP Academic Clinical Fellow with over 15 years working in Sexual and Reproductive Health, both clinically and as a part of a non-governmental organisation. She has worked in developing training materials for dissemination in multiple countries and languages and has used her skills to deliver training in Africa and Asia. She has a Masters in Sexual and Reproductive Health research and has postgraduate diplomas in Obstetrics and Gynaecology and Sexual and Reproductive Health.
Dr Burgin is clinical editor of the Contraception Choices website and has developed a specific section for women over 40s in the FAQ section. She has recently completed a qualitative study on Contraception for Women over 40 which highlighted the need for further information perimenopausal symptoms.