Long-Acting Contraception (David Hubacher)

8/6/2019 Long-Acting Contraception (David Hubacher)

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Long-acting ReversibleContraception (LARC)

David Hubacher, PhD

Senior Epidemiologist

FHI


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Outline of Talk

Description of long-acting reversiblecontraception (LARC)

Worldwide use of long-acting

Advantages and Disadvantages Service delivery factors

Comparison to short-acting reversible


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Characteristics of Long-actingReversible Contraception (LARC)

Device is inserted

Products lasts from 3 to 10+ years

Removal is required at some point

Simple clinic environment forservices

Nurse practitioners caninsert/remove


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Two body locations, threeproducts

Intrauterine contraception1.Copper IUD: ParaGard - 10+ years

T-shaped plastic frame withcopper attached

Non-hormonal


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ParaGard Copper intrauterinedevice (IUD)

:H o w it w o rks.1 Pre v e n ts fe rtiliza tio n b y

cre a tin g in tra u te rin ee n v iro n m e n t h o stile to

sperm.2 C op p er ion s en h an ce

-a n ti sp e rm a ctio n


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Intrauterine contraception

1.Copper IUD: ParaGard - 10+ years

T-shaped plastic frame withcopper attached

Non-hormonal

2.Intrauterine system (IUS): Mirena -5 years

T-shaped plastic frame withreservoir to release progestin(levonorgestrel)

Levonorgestrel absorbed in

genital tract


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Mirena


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Intrauterine Contraception

Since 1930sThe first long-acting reversible In US, nine major products used

over 50 yrs

Wide variety of shapes/sizes inother countries

T b d l i h


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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 thatreleases progestin


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Implanon

:o w it w o rkso stly b y p re v e n tin g o v u la tio n


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Implants

Developed in 1960s First came Norplant (6 rods),

then Jadelle (2), Implanon (1),Sino-implant (2)

Countries with highest use:Indonesia


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Varies tremendously Information from national

surveys

Limitation: most data sheets do

not list implants separatelybecause use is low

IUD is only LARC method

Worldwide LARC Use

t t H


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ountr es w t H gIUD 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 U t


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IUD Use n t erCountries

B ra zil %1In d ia %2

S o u th A frica %1M e x ico %1 2N ig e ria %1U S A %5

IUD U i th US 45 Y


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IUD Use in the US: 45 Yearsof Change


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Disadvantages of LARC

Invasive insertion procedure Requires removal procedure

Thus more difficult to stop using

itLess control over fertility

Side effects like all methods

but different


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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


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WHO Classification ofMethods

More effect

Less than 1 pm n in n Program A antages o


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Fewer commodities needed

More cost effective

More effective at preventingunintended pregnancy

One visit

One LARC insertion = 39 to 65 to 130 packs of pillsor 9 to 20 to 30 injections

More LARC fewer stock-outs ofmethods

Program A vantages oLARC

erv ce Prov s on


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Trained personnel

Equipment and supplies

Autoclave for sterilizing equipment

Clinic needs electricity supply Contraceptive commodities

erv ce Prov s onRequirements


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Cost varies tremendously

ParaGard copper IUD:

$1 for international donors but $800in US

Mirena:

$850 in US, $200 in Kenya, limiteddonations

Jadelle and Implanon implants $25 to international donors

Sino-implant (II)

$8 to international donors

Cost of LARC

LAR vs ort act ng


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Injectables and OralContraceptives

Great methods if usedconsistently and correctly

40-60% of users stop within 12months

For variety of reasons, notalways by choice

This can lead to unintendedpregnancy

LAR vs. ort-act ngMethods

Cumulative Probability of


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Cumulative Probability ofDiscontinuation

m on th s

Some obstacles to


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Some obstacles toperfect 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?

R s o Un nten e


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R s o Un nten ePregnancy


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18M users of injectable/orals in sub-Saharan Africa

If 20% switched to implant

If apply regular discontinuationpatterns

Prevent 1.8M unintendedpregnancies in 5 yr

Estimating Impact *

* , , .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


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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

Conclusions

Long-Acting Contraception (David Hubacher)

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