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Long-Acting Contraception (David Hubacher)

Long-Acting Contraception (David Hubacher)

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Published by: National Press Foundation on Jun 29, 2011
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06/09/2014

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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)

H o w i w o rks: t 1. Pre ve n ts fe rti i ti n b y l za o cre a ti g i tra u te ri e n n n e n vi n m e n t h o sti e to ro l sp e rm 2. C o p p e r i n s e n h a n ce o a n ti sp e rm a cti n o

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

o w i w o rks: t o stl b y p re ve n ti g o vu l ti n y n a o

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

Countries with High IUD Use
20-29% 30-39% Tunisia, Mongolia, Egypt, Tajikistan, Israel, Kyrgyzstan, Jordan, Syria, Kazakhstan, Turkey, Belarus, Turkmenistan, Moldovia, Russia, Estonia, Cuba Finland, Latvia, Norway, Slovenia, France 40+ % China, Dem PR Korea, Uzbekistan, Vietnam

IUD Use in Other Countries
B ra zi l 1% I di n a 2% S o u th A fri ca 1 % M exi co 12% N i e ri g a 1% U SA 5%

IUD Use in the US: 45 Years of Change

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 effecti

Less than 1 pr women in one

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
• • • • • 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

m o n th s

Some obstacles to perfect use
• 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?

Risk of Unintended Pregnancy

Estimating Impact *
• 18M users of injectable/orals in subSaharan Africa • If 20% switched to implant • If apply regular discontinuation patterns
• •

• Prevent 1.8M unintended * Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancies in magnitude of the problem pregnancy in sub-Saharan Africa:5 yr
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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