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Long-acting Reversible Contraception (LARC)

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.

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Long-acting Reversible Contraception (LARC)

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  1. Long-acting Reversible Contraception (LARC) David Hubacher, PhD Senior Epidemiologist FHI

  2. 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

  3. 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

  4. Two body locations, three products • Intrauterine contraception • Copper IUD: ParaGard® - 10+ years • T-shaped plastic frame with copper attached • Non-hormonal

  5. ParaGard – Copper intrauterine device (IUD) How it works: Prevents fertilization by creating intrauterine environment hostile to sperm Copper ions enhance anti-sperm action

  6. Two body locations, three products • Intrauterine contraception • Copper IUD: ParaGard® - 10+ years • T-shaped plastic frame with copper attached • Non-hormonal • Intrauterine system (IUS): Mirena® - 5 years • T-shaped plastic frame with reservoir to release progestin (levonorgestrel) • Levonorgestrel absorbed in genital tract

  7. Mirena

  8. 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

  9. Two body locations, three products • Intrauterine contraception • Copper IUD: ParaGard® - 10+ years • Intrauterine system (IUS): Mirena® - 5 years • Subdermal implant – upper arm • Implanon ® - 3 years • Match-stick sized rod that releases progestin

  10. Implanon How it works: Mostly by preventing ovulation

  11. Implants • Developed in 1960s • First came Norplant (6 rods), then Jadelle (2), Implanon (1), Sino-implant (2) • Countries with highest use: Indonesia

  12. 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

  13. Countries with High IUD Use

  14. IUD Use in Other Countries Brazil 1% India 2% South Africa 1% Mexico 12% Nigeria 1% USA 5%

  15. IUD Use in the US: 45 Years of Change

  16. 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

  17. 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

  18. WHO Classification of Methods

  19. 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

  20. Service Provision Requirements Trained personnel Equipment and supplies Autoclave for sterilizing equipment Clinic needs electricity supply Contraceptive commodities

  21. 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

  22. 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

  23. Cumulative Probability of Discontinuation months

  24. 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? The FP queue: who wants to be seen there?

  25. Risk of Unintended Pregnancy

  26. 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. 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

  27. 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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