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

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

Two body locations, three products

Intrauterine contraception
1.Copper IUD: ParaGard - 10+ years T-shaped plastic frame with copper attached Non-hormonal

ParaGard Copper intrauterine device (IUD)

H o w i w o rks: t 1. Pre ve n ts fe rti i ti n b y l za o cre a ti g i tra u te ri e n n n e n vi n m e n t h o sti e to ro l sp e rm 2. C o p p e r i n s e n h a n ce o a n ti sp e rm a cti n o

Two body locations, three products

Intrauterine contraception
1.Copper IUD: ParaGard - 10+ years T-shaped plastic frame with copper attached Non-hormonal 2.Intrauterine system (IUS): Mirena 5 years T-shaped plastic frame with reservoir to release progestin (levonorgestrel) Levonorgestrel absorbed in genital tract

Mirena

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

Two body locations, three products

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 that releases progestin

Implanon

o w i w o rks: t o stl b y p re ve n ti g o vu l ti n y n a o

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

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

Countries with High IUD Use

20-29% 30-39% Tunisia, Mongolia, Egypt, Tajikistan, Israel, Kyrgyzstan, Jordan, Syria, Kazakhstan, Turkey, Belarus, Turkmenistan, Moldovia, Russia, Estonia, Cuba Finland, Latvia, Norway, Slovenia, France 40+ % China, Dem PR Korea, Uzbekistan, Vietnam

IUD Use in Other Countries

B ra zi l 1% I di n a 2% S o u th A fri ca 1 % M exi co 12% N i e ri g a 1% U SA 5%

IUD Use in the US: 45 Years of Change

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

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 Methods

More effecti

Less than 1 pr women in one

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 pillsor 9 to 20 to 30 injections

More LARC fewer stock-outs of methods

Service Provision Requirements

Trained personnel Equipment and supplies Autoclave for sterilizing equipment Clinic needs electricity supply Contraceptive commodities

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

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

Cumulative Probability of Discontinuation

m o n th s

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?

Risk of Unintended Pregnancy

Estimating Impact *
18M users of injectable/orals in subSaharan Africa If 20% switched to implant If apply regular discontinuation patterns

Prevent 1.8M unintended * Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancies in magnitude of the problem pregnancy in sub-Saharan Africa:5 yr
and potential role of contraceptive implants to alleviate it. Contraception 2008;78(1):73-78.

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