Back to the Future: A Call to Action for FP and LAPMs Scott Radloff Director Office of Population and Reproductive Health USAID ACQUIRE End-of-Project Meeting September 17, 2008

Family Planning: responds to a panoply of problems… Enables couples to decide number/spacing of births Reduces child mortality Reduces maternal mortality/morbidity Reduces abortion Improves women’s opportunities Key intervention in HIV settings Essential component of health programs Mitigates adverse effects of population dynamics on: –natural resources –economic growth –state stability

Unmet need of 201 million in developing countries translates to: 23 million unplanned births 22 million abortions 2 million miscarriages 1.4 million infant deaths 142,000 pregnancy-related deaths [1/2 in Africa] –53,000 from unsafe abortion –89,000 from other causes Source: Guttmacher Policy Review, Summer 2008, Vol 11, Number 3

Pop Quiz Question

As CPR rises, demand for limiting rises

As CPR rises, demand for limiting occurs at earlier ages Age at which demand for limiting equals demand for spacing by modern CPR, all available DHS since 2000 (n=44)

Answer Pop Quiz

Substantial demand for limiting and spacing in African countries

Still, Africa is characterized by high unmet need and low use of LAPMs…

2 children, 30 years of contraceptive use - options: 10,950 pills (1 every day) 360 packets of pills (1 every month) 120 injections (1 every 3 months) 6 implants (1 every 5 years) 3 IUDs (1 every 10 years) 1 sterilization (1 in a lifetime)

LAPMs have lower discontinuation rates and longer duration of effectiveness… Method Discontinuation Rate by 1 yr Duration of effectiveness Pill50%Daily use Condom50%Event use Injectable40%1-3 mos Implanon48%3 yrs Jadelle/Norplant25%5-7 yrs IUD (hormonal, copper)25%5-12 yrs Sterilization (M/F)10%lifetime AQUIRE 2007

Source:MEASURE/DHS, Kenya 2003 DHS Survey. Ross, Stover, and Adelaja, MWRA (15-49 yr) 5.1 million (2005) % LAPM use to limit: 27% Long-Acting and Permanent Methods LAPMs are underutilized among limiters in Kenya

Source:MEASURE/DHS, Kenya DHS Survey, % Long-Acting and Permanent Methods LA use to space: 8% Long-Acting methods have potential for use among spacers in Kenya

And, LAPMs are suitable for various reproductive intentions… D Long Acting: Implants and IUDs Delaying first births -Youth -Nulliparous S H+ L Permanent: Vasectomy, Female Sterilization Spacing pregnancies -Postpartum -Postabortion HIV+ women can use any LAPM Limiting births after desired fertility goals are reached - High Parity - Low Parity - Any age

Time Socio-cultural norms Cost Process Physical Inappropriate eligibility criteria Poor CPI Provider bias Knowledge Location  ↑ ↑ Access  ↑↑ Choice  ↑↑ Quality Barriers to LAPM services Outcomes when barriers are overcome: But, there are still barriers to LAPMs…

BREAK DOWN THAT WALL ! ! !

What can be done to increase the use of LAPMs?

“Unpack” LAPMs LAPMs ‘Packed’ = specific clinical requirements for service provision LAPMs ‘Unpacked’ = suitable for multiple reproductive intentions –Spacing – Long-acting methods –Delaying – Long-acting methods –Limiting – Long-acting methods, permanent methods “Long-Acting” effectiveness is not the same as “Long-Term” use (it’s not all or none)

Integrate LAPMs into all other PRH technical priorities… Contraceptive security including clinical equipment and supplies Community-based FP Frees up clinical capacity for LAPMs, increases referrals Healthy timing and spacing of pregnancies IUDs and implants help achieve longer spacing intervals FP/MCH integration Postpartum and PAC, immediate use of IUD, M/F sterilization FP/HIV integration All LAPMs are safe methods and good options for HIV/AIDS

Future opportunities for LAPMs… –The Sino-implant revolution –Meeting the latent, and growing demand for limiting, at younger ages –Increasing L-A use for spacing, delaying –Reaching postpartum and post-abortion clients –Engaging private sector services –Expanding approaches to reach rural areas –Expanding urban and peri-urban services –Offering comprehensive men’s health care

BACK (AND FORWARD) TO THE FUTURE Sometimes, going forward requires going back to “Big, Boring Programs” or “Proven, Time-Tested Approaches Adapted to New Settings”

In closing……