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Long-acting Reversible Contraception (LARC)

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Presentation on theme: "Long-acting Reversible Contraception (LARC)"— Presentation transcript:

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® 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® 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® years Intrauterine system (IUS): Mirena® - 5 years Subdermal implant – upper arm Implanon ® - 3 years Match-stick sized rod that releases progestin

10 Mostly by preventing ovulation
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
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

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: Mirena:
$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

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 * 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.

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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