Long-acting Reversible Contraception

Report
Long-acting Reversible
Contraception (LARC)
David Hubacher, PhD
Senior Epidemiologist
FHI
Outline of Talk
• Description of long-acting reversible
contraception (LARC)
• Worldwide use of long-acting
• Advantages and Disadvantages
• Service delivery factors
• Comparison to short-acting reversible
Characteristics of Long-acting Reversible
Contraception (LARC)
•
•
•
•
•
Device is inserted
Products lasts from 3 to 10+ years
Removal is required at some point
Simple clinic environment for services
Nurse practitioners can insert/remove
Two body locations, three products
• Intrauterine contraception
1. Copper IUD: ParaGard® - 10+ years
• T-shaped plastic frame with copper attached
• Non-hormonal
ParaGard – Copper intrauterine device (IUD)
How it works:
1. Prevents fertilization by
creating intrauterine
environment hostile to sperm
2. Copper ions enhance antisperm action
Two body locations, three products
• Intrauterine contraception
1. Copper IUD: ParaGard® - 10+ years
• T-shaped plastic frame with copper attached
• Non-hormonal
2. Intrauterine system (IUS): Mirena® - 5 years
• T-shaped plastic frame with reservoir to
release progestin (levonorgestrel)
• Levonorgestrel absorbed in genital tract
Mirena
Intrauterine Contraception
•
•
•
•
Since 1930s
The first long-acting reversible
In US, nine major products used over 50 yrs
Wide variety of shapes/sizes in other
countries
Two body locations, three products
• Intrauterine contraception
1. Copper IUD: ParaGard® - 10+ years
2. Intrauterine system (IUS): Mirena® - 5 years
• Subdermal implant – upper arm
3. Implanon ® - 3 years
• Match-stick sized rod that releases progestin
Implanon
How it works:
Mostly by preventing ovulation
Implants
• Developed in 1960s
• First came Norplant (6 rods), then Jadelle
(2), Implanon (1), Sino-implant (2)
• Countries with highest use: Indonesia
Worldwide LARC Use
• Varies tremendously
• Information from national surveys
• Limitation: most data sheets do not list
implants separately because use is low
• IUD is only LARC method reported
Countries with High IUD Use
20-29%
Tunisia,
Mongolia,
Tajikistan, Israel,
Jordan, Syria,
Turkey, Belarus,
Moldovia, Russia,
Finland, Latvia,
Norway, Slovenia,
France
30-39%
Egypt,
Kyrgyzstan,
Kazakhstan,
Turkmenistan,
Estonia, Cuba
40+ %
China,
Dem PR Korea,
Uzbekistan,
Vietnam
IUD Use in Other Countries
Brazil
India
South Africa
Mexico
Nigeria
USA
1%
2%
1%
12%
1%
5%
IUD Use in the US: 45 Years of Change
12
10
8
6
4
2
0
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
Disadvantages of LARC
• Invasive insertion procedure
• Requires removal procedure
– Thus more difficult to stop using it
– Less control over fertility
• Side effects like all methods
– but different
Advantages of LARC
•
•
•
•
•
•
One procedure/clinic visit
Easy to use
Nothing to remember
Discrete use
Return to fertility is very rapid
Most effective reversible strategy
WHO Classification of Methods
More effective
Less than 1 pregnancy per 100
women in one year
Less effective
About 30 pregnancies per 100
women in one year
Program Advantages of LARC
• Fewer commodities needed
• More cost effective
• More effective at preventing unintended
pregnancy
• One visit
• One LARC insertion =
39 to 65 to 130 packs of pills…or
9 to 20 to 30 injections
• More LARC  fewer stock-outs of methods
Service Provision Requirements
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•
•
•
•
Trained personnel
Equipment and supplies
Autoclave for sterilizing equipment
Clinic needs electricity supply
Contraceptive commodities
Cost of LARC
• Cost varies tremendously
• ParaGard copper IUD:
– $1 for international donors but $800 in US
• Mirena:
– $850 in US, $200 in Kenya, limited donations
• Jadelle and Implanon implants
– $25 to international donors
• Sino-implant (II)
– $8 to international donors
LARC vs. Short-acting Methods
• Injectables and Oral Contraceptives
– Great methods if used consistently and
correctly
– 40-60% of users stop within 12 months
– For variety of reasons, not always by choice
– This can lead to unintended pregnancy
Cumulative Probability of Discontinuation
70
60
50
Short-acting
Implant
DMPA/OC
40
30
20
10
0
0
3
6
9
12
15
18
months
Some obstacles to perfect use
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•
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•
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Commodity stock-outs at public sector clinics
Cost at pharmacies/private facilities
Ambivalence toward contraception/pregnancy
Motivation can wane over time
Great effort required
Abstinence episodes
Partner opposition
Side effects: who wants another dose?
The FP queue: who wants to be seen there?
Risk of Unintended Pregnancy
Estimating Impact *
• 18M users of injectable/orals in sub-Saharan
Africa
• If 20% switched to implant
• If apply regular discontinuation patterns
• Prevent 1.8M unintended pregnancies in 5 yr
* Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in
sub-Saharan Africa: magnitude of the problem and potential role of
contraceptive implants to alleviate it. Contraception 2008;78(1):73-78.
Conclusions
• Long-acting reversible contraception
–
–
–
–
Underused in many countries
Women need more choices
Expanded use could have tremendous benefit
Essential components: Voluntary uptake and removal
on demand

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