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
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 *
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