Simultaneous prevention of unintended pregnancy and STIs: a challenging compromise.

BACKGROUND

Unintended pregnancy and sexually transmitted infections (STIs) are the major negative consequences of unsafe sex. Both are common and have long-term social and health consequences. Barrier methods of contraception can prevent both, but unfortunately they are much less effective than the more modern methods at pregnancy prevention. Modern effective contraceptives, however, do not protect against STIs and some may increase the risk of acquisition of infection. This comprehensive review discusses the magnitude of burden of reproductive ill-health, focussing on data from the European region, and explores the relationship between contraceptive use and STIs.

METHODS

Searches were performed by using Medline, Popline, EMBASE, Cochrane Library and the Social Sciences Citation Index databases for relevant English language publications from 1995 to 2012. Summaries were discussed by the European Society of Human Reproduction and Embryology (ESHRE) Workshop Group.

RESULTS

An understanding of patterns of sexual behaviour helps to understand the epidemiology of unintended pregnancy and STIs and gives pointers towards their prevention, but survey methodologies differ and results are hard to compare. Contraceptive prevalence and method mix vary widely between countries, and the use of the dual method of protection is very infrequent. Abortion rates have fallen in many European countries, particularly Eastern Europe, and contraceptive prevalence increased but unsafe abortion still accounts for 11% of maternal mortality in Eastern Europe. STIs are common but reporting systems are often rudimentary or non-existent and robust data are scarce. Providers still worry about the effect of intrauterine contraception on reproductive tract infections despite reassuring evidence to the contrary. New data on HIV acquisition and hormonal contraception are causing concern in settings where HIV infection is common. New developments in multipurpose technologies aimed at producing a single device/drug, which prevents infection and pregnancy simultaneously, are in early stages. While the benefits of national screening programmes for STIs remain uncertain, human papilloma virus (HPV) vaccination is clearly reducing HPV infection rates and gives hope for the public health benefits of other STI vaccines.

CONCLUSIONS

The consequences of unsafe sex-unintended pregnancy and STI-continue to present major public health problems worldwide even in countries where the prevalence of use of modern contraception is high. Robust systems for routine data collection are sorely needed in most countries and systematic attempts to compare patterns of sexual behaviour across men and women of all ages would be welcome.