Providing general practitioners (GPs) with financial incentives to offer information about long-acting contraceptives, such as the hormonal implant, is associated with an increase in their use, and a fall in the number of abortions .
This is the finding of researchers from Imperial College London, who conducted the first large-scale analysis of an incentive scheme for GPs to provide women with information about long-acting reversible contraceptives, termed LARCs. The team analysed data from the anonymised health records of over three million women in England, Wales and Scotland between financial years 2004/2005 to 2013/2014.
The study, funded by the National Institute for Health Research, and published in the journal PLOS Medicine found that the scheme was associated with a 13 percent increase in LARC prescriptions (or absolute increase of 4.5 prescriptions per 1,000 women), above what would have been expected, four years after the scheme was introduced.
This was accompanied by a fall of nearly 17% in number of prescriptions for non-LARC contraception (or absolute decrease of 42 prescriptions per 1,000 women) in the same four-year period, suggesting a major switch in the choice of contraceptive method used.
The findings also showed a 38 percent more than expected reduction in abortions (or absolute reduction of 5.3 per 1,000 women) four years after the incentive was introduced. This is the equivalent of 95,170 fewer abortions than expected, if the results were extrapolated across the whole UK population.
Most of the impact on LARC prescriptions and abortions were among women under 25 years old, and those from poorer areas.
Dr. Richard Ma, a GP and lead researcher on the study from Imperial’s School of Public Health said: “Our study suggests if women were better informed about more effective and reliable methods such as long-acting contraceptives, they might choose these over less reliable methods. This could reduce the number of unplanned and unwanted pregnancies. We expected this study would show the incentive had led to some change in behaviour—but we never expected it to reveal such a profound effect, especially for a simple intervention and a relatively modest incentive.”
The UK government introduced a financial incentive scheme called the Quality and Outcomes Framework (QOF) in 2004/05 which rewarded primary care practices for improving the quality of care. A new target was introduced under this pay for performance (P4P) scheme in 2009/10 for GPs to provide information about LARC to any female patient between the ages of 13-54 who had previously received a prescription for contraceptives, including emergency hormonal contraception. This advice was given in person, as a text message or leaflet. This target was worth about £700 (US$900 or €760) per year for an average sized practice of 6,000 patients. The GPs were not paid for the number of LARC prescriptions issued, only for reaching a target (50% to 90%) of women given information about LARCs.
LARCs include the contraceptive injection which is effective for 3 months, contraceptive implant (effective for 3 years), intrauterine system (IUS, effective for 5 years), and intrauterine device (IUD or “coil”, effective for up to 10 years).
The scheme was introduced in 2009, and the study examined the number of LARCs prescribed for five years before, and four years after the scheme, while giving the scheme one full year to take effect. The study also examined the number of prescriptions for non-LARC contraceptives, such as the contraceptive pill, in this time period. Abortions were examined as a proxy marker for unplanned and unwanted pregnancies, as these could not be reliably measured.
The data was from the Clinical Practice Research Datalink, a database which contains the anonymised health records of 17 million patients in England, Scotland and Wales from over 600 GP practices.
The study authors stress the research does not show a direct link between the information being provided to women, and the number of LARC prescriptions and abortions—but simply an association. Furthermore, this study looked at outcomes at the population level, and therefore cannot say conclusively that providing a specific individual with information about LARC will result in a reduced likelihood of an unplanned and unwanted pregnancy. Other awareness campaigns and improved access to contraceptive methods might explain the findings, but to a smaller extent.
Professor Sonia Saxena, GP and co-author of the study from the School of Public Health added: “There are two important points to make clear about this scheme. The first is the aim of the incentive was not to nudge women to choose LARC methods, but to consider the best options available to match their needs. The second point is that as women’s circumstances change, regular review of contraceptive needs from primary care professionals, such as their GP or practice nurse, may help women to make better decisions about contraceptive methods that are appropriate for their life stage”