§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Robert Ainsworth.]
9.55 pm§ Dr. Jenny Tonge (Richmond Park)I should like to think of this Adjournment debate as my contribution to the 50th anniversary of the national health service.
Before I became a Member of Parliament, I was a family planning doctor and general practitioner for many years, and I saw hundreds of examples of young women who needed emergency contraception and could not obtain it. In many cases, that led to unwanted babies or abortions. The problem lies in the fact that appointments have to be made with GPs and it often takes two or three days before one can see them. Casualty departments are overcrowded and, in any case, are not appropriate places to discuss such matters. Moreover, there are fewer family planning clinics than there used to be, and women often have to wait until after the weekend before they can go to one. Thus, women often cannot get emergency contraception within the prescribed 72 hours unless they are very brave and persistent. Young teenagers, in particular, are terribly afraid of making a fuss.
I must state at the outset that I regret the fact that there is so much sexual activity among young teenagers. Many factors are to blame, as I am sure the Minister realises. The fact that unwanted pregnancies and abortion rates are highest in areas of social deprivation will not have escaped her notice, and I know that she is already addressing the problem of sex education by trying to improve matters in schools and to increase personal responsibility among young people. I commend her for those much-needed efforts.
Emergency contraception is not meant to be a substitute for either sex education or regular contraception. They must go hand in hand. However, it is a practical way in which to deal with the world as it is, and its wider use would prevent the high rate of abortion among young women, which must be our main priority. This country has the highest teenage pregnancy rate in Europe. Out of every 1,000 women under the age of 16, 8.5 get pregnant, and in the 16 to 19 age group, between 58 and 59 out of every 1,000 get pregnant. It simply will not do. Half to a third of those pregnancies end in abortion.
The problem is not limited to teenagers. Many older women who are otherwise quite responsible about their sexual lives and their relationships have contraceptive accidents and need better access to emergency contraception.
There are two forms of emergency contraception. The fitting of an intra-uterine contraceptive device, commonly known as a coil, must be done within five days. I do not intend to go into that this evening because the device must be fitted by a properly trained doctor in a clinic.
I want to concentrate on the emergency contraceptive pill. It is a dose of oestrogen and progesterone female sex hormones, which have been used since the 1950s. Indeed, in the 1960s, when I was on the pill, I took the equivalent dose of the emergency contraceptive pill every day—21 days out of 28—and so did many women of my generation.
Emergency contraception is a dose repeated once, after 12 hours, and it prevents pregnancy in about 90 per cent. of episodes. In most cases, its effect is to prevent the 623 release of the egg from the ovary. It is important for people to know that. If it is taken later in the menstrual cycle, it will prevent implantation in the wall of the uterus of the fertilised egg. It has the same effect as a coil or an intra-uterine device. It is not an abortion in any shape or form. I repeat that point: emergency contraception cannot be used to cause an abortion.
§ It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Motion made, and Question proposed, That this House do now adjourn.—[Janet Anderson.]
§ Dr. TongeEmergency contraception cannot be used to cause an abortion. If a woman is already pregnant, emergency contraception does not work. Abortion occurs after implantation, and the emergency contraceptive pill intervenes before that stage.
Recently, the Daily Mail ran an article claiming that I and my supporters were promoting abortion over the counter. The journalist who wrote that article should be thoroughly ashamed. We are trying to prevent unwanted pregnancies and abortions. Such misleading, inaccurate and unbalanced reporting will harm the very people who need most help. The press are ready to condemn single parents and unmarried mothers, and when people try to do something about the problem, they condemn them, too. Over the years, the press has been responsible for pill scares, which have caused many unwanted pregnancies and abortions. They have put women off taking the birth control pill, and now they are trying to put them off emergency contraception.
I shall deal with some of the issues. The fear of thrombosis is often mentioned. Sixty in 100,000 women who become pregnant will get a deep-vein thrombosis. It is a little-known fact that pregnancy is quite a dangerous condition. In my pill-taking days, when women were taking the higher dose of pill, the rate of thrombosis was 30 in 100,000. With the new pills used today, the risk is even lower: 15 to 30 in 100,000. In the past 10 years, with the use of the emergency contraceptive pill, there have been very few cases of thrombosis. The levels are similar to those of the general population who are neither pregnant nor taking the pill: about 5 in 100,000. It is not a risk.
A one-off high dose of oestrogen and progesterone carries no contra-indications, except if there is an active attack of migraine—anyone knows when that is happening. That is caused by dilation of the cerebral arteries and may be affected by oestrogen.
Suspected pregnancy is a contra-indication simply because the method does not work after implantation of the fertilised egg. As I said, it will not cause an abortion. Experience in the past 40 years has shown that the use of the ordinary contraceptive pill does not have any adverse effects on a baby, even if the mother continues to take the pill while she is pregnant.
A large dose of the same hormone—such as a young woman taking it two or three times in one month—would disrupt the menstrual cycle, but would not have any other effect. Indeed, if a baby swallows a whole packet of contraceptive pills—four or five times the dose of the emergency contraception—the mother is told that it may make her baby very sick, but that, apart from dealing with that, she need take no action.
624 The emergency contraceptive pill is safer than aspirin, paracetamol, many of the caffeine products that are available as pep pills and many drugs that are currently on sale in supermarkets and petrol stations. Indeed, one can buy contraception in the form of condoms at petrol stations, but, if a condom breaks or the method goes wrong, one cannot get a remedy anywhere in the time scale about which I am talking. I know that this is controversial, but I believe that emergency contraception available over the counter from properly trained pharmacists could prevent an abuse of the method.
§ Dr. Evan Harris (Oxford, West and Abingdon)In this country, we spend much time and money in training pharmacists, only to lock them away in the back of chemists' shops. Does my hon. Friend agree that advice on emergency contraception is an example of how we could use the professionalism and expertise of pharmacists—properly remunerated, I should add—to take the load off national health service clinics and casualty departments, as she suggests?
§ Dr. TongeI thank my hon. Friend for that intervention, with which I whole-heartedly agree. Pharmacists often know much more than many general practitioners about drugs and their interactions. Indeed, I have often seen pharmacists save a difficult situation by correcting a prescription. So, yes, I would welcome greater use of pharmacists.
If the emergency contraceptive pill were made available over the counter, women would have to pay for it, which I believe would, in some cases, be a positive factor. Teenagers, particularly young teenagers, would be reluctant to pay for the pills again when they found out that they could get them free from a clinic, nurse or GP. That would have the added advantage of ensuring that very young people would, on the subsequent times that they needed this method, receive adequate counselling about their sexual behaviour, contraceptive needs and sexual health, which is what we all want. However, I appreciate that that may not be possible immediately.
A pilot scheme operating in Washington state allows for emergency contraception to be available on prescription. Under a protocol agreed by local doctors, local nurses and pharmacists may dispense the emergency contraceptive pill—they are, of course, trained to ask the right questions. The scheme has recently received the blessing of the only company in the United Kingdom that currently makes a packaged form of emergency contraception—Schering Pharmaceuticals—so there would be no difficulty in making emergency contraception available, especially in the light of the Crown review of the prescription, supply and administration of medicines.
The proposals that I have outlined would not make young women more vulnerable. Young women are most vulnerable when they have no one to turn to. They become scared and then they do nothing—they become yet another unwanted pregnancy or abortion statistic. If emergency contraception were made more widely available from nurses and pharmacists under a protocol, young women would have people to turn to at very short notice.
The Minister is committed to reducing the number of teenage pregnancies. I believe that my proposals, combined with her commendable efforts on sex education 625 for young people, would go a long way towards that commitment. I apologise for this list, but my colleagues in the House and in the medical profession, and I are backed by the British Medical Association, the Royal College of Obstetricians and Gynaecologists, the Royal College of Nursing, the Royal Pharmaceutical Society, the Family Planning Association—to which I owe a great debt, as it trained me in this field and it was one of the original organisations to promote family planning—and especially the Birth Control Trust, which I thank very much for its work on this matter. We all want to know how the Government intend to proceed.
§ 10.8 pm
§ The Minister for Public Health (Ms Tessa Jowell)I thank the hon. Member for Richmond Park (Dr. Tonge) for raising this important issue. I pay tribute to her, and to other hon. Members who have worked so hard—particularly in recent weeks—to focus public attention on it. The question of ease of access to emergency contraception is an essential part of broader family planning provision.
The hon. Lady made very clear the case for accessible emergency contraception. Emergency contraception is precisely that: contraception to be used in an emergency, possibly when the regular form of contraception fails. As the hon. Lady rightly said, without it many women may live in fear of an unwanted pregnancy, and may be forced into seeking an abortion. Abortion is, of course, a last resort, but too many women in Britain today resort to it because contraception has failed. In 1997, 170,000 abortions were carried out, the majority for women in their 20s.
Let us look briefly at the facts about emergency contraception. It is provided free as part of national health service comprehensive family planning services. Although we are talking about a pill on this occasion, it is important to remember—as the hon. Lady pointed out—that emergency contraception is available in two forms, the copper intra-uterine device and hormonal emergency contraception.
Hormonal emergency contraception, on which I want to concentrate, was first licensed in the United Kingdom in 1984. It is effective for up to 72 hours after unprotected sex—a fact which I still do not think is lodged sufficiently in the minds of many women, especially young women. It prevents a fertilised egg from being implanted in the uterus, or, alternatively, suppresses ovulation. As the hon. Lady said, it is very effective: more than 95 per cent. of women who take emergency contraceptive pills do not become pregnant. However, it is intended to be used only occasionally, and is not a form of long-term birth control. As the hon. Lady said—I want to underline this—neither is it a form of abortion.
From the data that we have on prescription items, we know that more emergency contraception is being used. As I said in a parliamentary written answer to the hon. Lady, the number of prescription items increased from just under 400,000 in 1992–93 to well over 700,000 in 1996–97.
Emergency contraception is safe and effective, with few contra-indications. Safety and correct use will remain paramount, whatever changes are made in the future to 626 ease accessibility. A study published today suggests that making emergency contraception more easily obtainable does no harm, that women are not more likely to use emergency contraception repeatedly and that the rate of unwanted pregnancies may be reduced.
The hon. Lady is interested in exploring further whether hormonal emergency contraception might be made more widely available through different routes. I think that we can do much more both to increase information for women and to improve access through existing services.
The current position is that emergency contraception is classified as a prescription-only medicine under both European Community and United Kingdom law. Medicines are so classified if they are likely to present a danger, either directly or indirectly, even when used correctly, if taken without medical supervision; or if they are frequently used incorrectly and, as a result, are likely to present a direct or indirect danger to human health.
§ Dr. TongeDoes not the Minister accept, having listened to the experts and to what I said tonight, that the emergency contraceptive pill does not fit into either of those categories?
§ Ms JowellThose are the terms on which the emergency contraceptive pill is currently licensed. That judgment is made by the licensing authority. There is a well-established process for changing the legal classification from prescription-only to pharmacy availability.
The first stage is that the holder of the marketing authorisation, being satisfied of safety in use, proposes the change. My understanding is that only one company is licensed to produce the emergency contraceptive to which the hon. Lady referred. The proposal can come from other sources, and has on occasion come from professional bodies.
It is important to stress that third parties, whoever they may be, must still have detailed information on safety in use, and the manufacturer must be involved in producing patient information for medicine use in the absence of medical supervision.
The second hurdle is the assessment of the safety of a change in classification, which involves the assessment of available scientific and epidemiological evidence by the Medicines Control Agency; careful consideration of the medicine's risks and benefits; rigorous evaluation of the evidence on safety in use; and an evaluation of the direct danger of the medicine based on an assessment of the seriousness, severity or frequency of adverse reactions.
There is also an evaluation of any indirect danger to health; for example, wider public health issues, such as a possible increase in sexually transmitted diseases if increased use of the emergency pill leads to decreased reliance on barrier methods, must be considered.
The third stage is for the Committee on Safety of Medicines to consider every application for deregulation from prescription-only status to pharmacy availability. The committee examines again the evidence of safety in use in relation to criteria for prescription-only status and advises on the product's risks and benefits in the context of its proposed over-the-counter availability.
The penultimate stage is public consultation. If the committee is satisfied that the risks and benefits are acceptable, on the basis of the available evidence, a period 627 of public consultation follows. Consultation makes possible a wider debate on the social, ethical and moral aspects, as well as the scientific and broader public health issues. The responses are then considered by the Medicines Commission. Only after those four stages have been completed does the Medicines Commission advise Ministers on the proposal to amend the prescription-only medicines order. Ministers then make a decision. Emergency contraception is no exception to that process.
Another route, to which the hon. Lady alluded, is the supply and administration of medicines under group protocols. As she knows, the Crown review into the prescribing, supply and administration of medicines has been considering related issues. The full review is drawing towards a conclusion, and Ministers expect its second report in the summer. The first report, setting out recommendations for the supply and administration of medicines under group protocols, was published towards the end of April, and recommended that the majority of patients should continue to receive medicines on an individual basis, but that group protocols should be used in certain limited situations.
The provision of contraception as part of a comprehensive family planning service could be one such area. Highly qualified nurses are working in family planning, and some of them are currently working effectively under group protocols. I believe that the first report of the Crown review forms a solid basis for setting standards to develop good practice in that area of care. We wish to consider the implications carefully before consulting further on detailed proposals, and we hope to undertake consultation in the next few weeks.
The hon. Lady referred to the scheme being conducted in Washington state in the north-west of the United States of America. Pharmacists are participating in a pilot study in which a collaborative agreement between pharmacists and a prescribing clinician enables the pharmacists to provide the emergency contraceptive pill directly to women according to an agreed protocol. That is a new project in its early days of piloting, and I understand that it will be subject to proper evaluation. We certainly want to consider carefully the implications for the United Kingdom of that type of experiment.
I want to deal with some of the broader aspects. What I have said will make it clear to the hon. Lady that the immediate change is not in prospect. It is essential, however, to consider how we can make emergency contraception more accessible to women who need it. As the hon. Lady said, for the emergency contraceptive pill to be effective, it must be readily accessible within the 72-hour window of opportunity. It can be prescribed by any general practitioner who provides contraceptive services, and it is available at any family planning clinic, most genito-urinary medicine or sexual health clinics and some accident and emergency departments. Young people can also go to young person's clinics or Brook advisory centres. It is not acceptable for women to have difficulty making appointments with their GPs, to find family planning clinics closed or to be turned away from accident and emergency departments. Health authorities should ensure that that does not happen.
No matter how accessible the contraception is, the other side of the coin is information. People must be aware of what emergency contraception offers. Women need timely information about the accessibility of emergency contraception, and about how it works and when it should 628 be taken. Raising awareness has been a key Government priority. The Department of Health recently funded an awareness-raising campaign by the Health Education Authority, which stressed that the emergency contraceptive pill can be taken up to 72 hours after unprotected sex, and that the other form of emergency contraception—the copper intra-uterine device—can be inserted after up to five days. I am heartened by much of the media coverage that has sought to dispel the myth of the morning-after pill. The hon. Lady referred to what she considered to be irresponsible reporting, but we need to recognise that the media can be important allies for us, particularly in getting the message across to vulnerable young women.
Just lately, some responsible reports referred to the 72-hour time interval, which remains insufficiently understood. More broadly, it is important to get across to as many women as possible further information about exactly how emergency contraception works.
The contraceptive education service run by the Family Planning Association, with Department of Health funding, has published a detailed leaflet for women and their partners on both forms of emergency contraception. As part of contraceptive awareness week, it has launched an information pack on emergency contraception for health promotion units. The service provides answers to questions from women and their partners across a wide range of contraceptive issues, including emergency contraception, and the CES helpline provides information on the location of family planning clinics.
In summary, therefore, whether or not we move in time to a greater accessibility by increasing the places from which women can obtain the emergency contraceptive pill, certain principles will continue to apply. First, safety and correct use will remain paramount. Secondly, women and their partners have the right to a confidentially provided service, and ways will need to be found to ensure that that is honoured, if the pattern of access changes. They also have the right to detailed advice and support in making decisions on their long-term contraception plans, so appropriate mechanisms for referral to a family planning doctor or nurse will need to be firmly in place. Information and accessibility are two key elements which we need to apply to making contraceptive advice more widely available.
The hon. Lady rightly referred to the Government's work on reducing teenage pregnancies. She will know better than most hon. Members that that is a highly complex issue, which cannot rely on one single remedy. It is important that the provision of contraception for young women who she, I and other hon. Members would agree have become sexually active before their time must be in the context of advice, support and counselling.
§ Dr. TongeDoes the Minister agree that that young, vulnerable group of women are reluctant to seek help because they have to go to a GP in whom they may not have confidence, because he is known in the area, or to a local casualty department or a local family planning clinic, where they may be known and told off or castigated for what they have done?
§ Ms JowellIn many cases, that is so, particularly where young women live in small communities. They are concerned that if they go to the doctor, they may be 629 spotted by their auntie or another member of their family in the waiting room. That is a deterrent. Although we recognise that many GPs handle the issue with great sensitivity and care, we need to reflect carefully on the particular needs of young women, in providing not just
630 advice on contraception and sex but the opportunity to talk about sex and contraception in the context of relationships. Later this year, we shall introduce specific proposals for reducing teenage pregnancy, of which these proposals will form part.
§ Question put and agreed to.
§ Adjourned accordingly at half-past Ten o'clock.