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There is also a commitment to spending £50 million on a sexual health advertising campaign for under-25s and further financial support to upgrade prevention services including contraceptive services.
If this strategy is adequately supported, it will go some way to halting the worryingly high levels of poor sexual health; but the financial and political commitment by the government and the commitment to implement at the local level must be real. Already some PCTs are being accused of not allocating Choosing Health monies towards improvements in sexual health and instead are using the monies to maintain financial balance at year-end. A recent report in Public Health News (2006) reported that 64 GUM providers have had difficulty in getting any of their Choosing Healthfunds allocated to develop services and in other areas, plans to develop chlamydia screening programmes have been halted.
Sexual Health 107 be liaising with relevant professional bodies for midwives and health visitors, including the Royal Colleges, to build contra- ception training into preregistration and CPD programmes
(DfES 2006) In October 2005, NICE published guidance on long-acting reversible contraception (LARC). The guidance aims to assist clini- cians and patients in making decisions about the most appropriate treatment for specific conditions.
LARC is taken up by an estimated 8% of women aged 16–49 years (2003–2004). Oral contraceptives and male condoms are the most commonly used methods of contraception, with uptake of 25% and 23% respectively. Uptake of LARC is fairly low when compared with other contraceptive methods (NICE 2005).
It is vital that midwives are up-to-date with recommendations such as those in the NICE guidance. Midwives are well placed to discuss future contraceptive use. The option of using LARC may be of particular benefit to women who have more difficulty in complying with a contraceptive that needs to be taken on a daily basis, e.g. the pill, and also for those women who may have a particularly erratic lifestyle. However, the guidelines do highlight that – particularly for young women and those who are considered to be at greater risk of infection – health professionals need to stress that LARC does not provide protection against sexually transmitted infections and that barrier methods, e.g. the condom should still be used in addition to LARC.
NICE has also recently produced draft guidance on public health interventions in relation to sexual health and these were out for consultation at the time of writing (NICE 2006). The draft guid- ance is entitled One-to-one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under-18 conceptions, especially among vulnerable and at-risk groups.
Recommendation 6 explicitly refers to midwifery. It states that those who provide antenatal, postnatal and child development services should regularly visit vulnerable women, aged 18 and under, who are pregnant or already mothers and discuss and pro- vide information about preventing sexually transmitted infections and LARC in line with the NICE clinical guideline.
Pregnancy does not protect against sexually transmitted infec- tions and yet some women will continue to practice high-risk sexual behaviours in pregnancy. Condoms are often seen as con- traceptive rather than preventive, but the protective elements of condoms should be discussed sensitively with pregnant women.
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Research by Dwyer (2001) found that pregnant women were largely unaware about the dangers associated with sexually trans- mitted infections during pregnancy. She found that 91% of couples rarely or never used condoms, either before or during pregnancy, despite the fact that 95% of women were unaware of their partner’s infection status. More than half of the women sampled were ignor- ant about the effect of sexually transmitted infections on their preg- nancy. More than one-quarter of the women (27%) had multiple partners during their pregnancy.
We have already discussed the National Chlamydia Screening Programme and how the programme offers opportunistic screen- ing to under-25s in community settings and aims to pick up those asymptomatic young people and their partners who otherwise would not have come forward for testing. There has been some discussion nationally around whether or not chlamydia screening for the under-25s should become a standard screen offered to pregnant women as chlamydia infection can be transmitted from mother to child. Screening may be an effective mechanism for reducing this transmission as some treatments for chlamydia can be prescribed during pregnancy.
However, Sir Muir Gray, Programme Director of the UK National Screening Committee issued a letter to the National Chlamydia Screening Programme highlighting the Committee’s current policy on chlamydia screening. Where chlamydia screen- ing is already being carried out in antenatal clinics it can continue;
but where screening is not being offered in pregnancy it should not be added to the range of tests offered to a woman until that pro- gramme has met its screening target for Down’s syndrome, cystic fibrosis, sickle cell anaemia and thalassaemia and has all midwives trained in the physical examination of the newborn (UK National Screening Committee 2006). So while chlamydia screening for all pregnant women is not being offered at the moment, it may be an option for consideration in the future.
There may be many reasons why midwives do not discuss safer sex during pregnancy. It may be that midwives are unsure of their own knowledge base around sexual health or are anxious about upsetting women or their partners. Or they may be embarrassed about discussing sexual health issues. However, the fact that women are pregnant means that they have had unprotected sex and although this does mean they have had unsafe sex, there are ideal opportunities to deliver sexual health promotion messages during pregnancy. Key times for discussion include booking, screening visits, if the midwife is aware of a change of partner and during the postnatal period.
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