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Long-acting ReversibleContraception (LARC)
David Hubacher, PhD
Senior Epidemiologist
FHI
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Outline of Talk
Description of long-acting reversiblecontraception (LARC)
Worldwide use of long-acting
Advantages and Disadvantages Service delivery factors
Comparison to short-acting reversible
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Characteristics of Long-actingReversible Contraception (LARC)
Device is inserted
Products lasts from 3 to 10+ years
Removal is required at some point
Simple clinic environment forservices
Nurse practitioners caninsert/remove
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Two body locations, threeproducts
Intrauterine contraception1.Copper IUD: ParaGard - 10+ years
T-shaped plastic frame withcopper attached
Non-hormonal
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ParaGard Copper intrauterinedevice (IUD)
:H o w it w o rks.1 Pre v e n ts fe rtiliza tio n b y
cre a tin g in tra u te rin ee n v iro n m e n t h o stile to
sperm.2 C op p er ion s en h an ce
-a n ti sp e rm a ctio n
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Two body locations, threeproducts
Intrauterine contraception
1.Copper IUD: ParaGard - 10+ years
T-shaped plastic frame withcopper attached
Non-hormonal
2.Intrauterine system (IUS): Mirena -5 years
T-shaped plastic frame withreservoir to release progestin(levonorgestrel)
Levonorgestrel absorbed in
genital tract
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Mirena
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Intrauterine Contraception
Since 1930sThe first long-acting reversible In US, nine major products used
over 50 yrs
Wide variety of shapes/sizes inother countries
T b d l i h
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Two body locations, threeproducts
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 thatreleases progestin
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Implanon
:o w it w o rkso stly b y p re v e n tin g o v u la tio n
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Implants
Developed in 1960s First came Norplant (6 rods),
then Jadelle (2), Implanon (1),Sino-implant (2)
Countries with highest use:Indonesia
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Varies tremendously Information from national
surveys
Limitation: most data sheets do
not list implants separatelybecause use is low
IUD is only LARC method
Worldwide LARC Use
t t H
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ountr es w t H gIUD 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
IUD U t
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IUD Use n t erCountries
B ra zil %1In d ia %2
S o u th A frica %1M e x ico %1 2N ig e ria %1U S A %5
IUD U i th US 45 Y
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IUD Use in the US: 45 Yearsof Change
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Disadvantages of LARC
Invasive insertion procedure Requires removal procedure
Thus more difficult to stop using
itLess control over fertility
Side effects like all methods
but different
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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
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WHO Classification ofMethods
More effect
Less than 1 pm n in n Program A antages o
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Fewer commodities needed
More cost effective
More effective at preventingunintended 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 ofmethods
Program A vantages oLARC
erv ce Prov s on
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Trained personnel
Equipment and supplies
Autoclave for sterilizing equipment
Clinic needs electricity supply Contraceptive commodities
erv ce Prov s onRequirements
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Cost varies tremendously
ParaGard copper IUD:
$1 for international donors but $800in US
Mirena:
$850 in US, $200 in Kenya, limiteddonations
Jadelle and Implanon implants $25 to international donors
Sino-implant (II)
$8 to international donors
Cost of LARC
LAR vs ort act ng
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Injectables and OralContraceptives
Great methods if usedconsistently and correctly
40-60% of users stop within 12months
For variety of reasons, notalways by choice
This can lead to unintendedpregnancy
LAR vs. ort-act ngMethods
Cumulative Probability of
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Cumulative Probability ofDiscontinuation
m on th s
Some obstacles to
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Some obstacles toperfect 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?
R s o Un nten e
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R s o Un nten ePregnancy
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18M users of injectable/orals in sub-Saharan Africa
If 20% switched to implant
If apply regular discontinuationpatterns
Prevent 1.8M unintendedpregnancies in 5 yr
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
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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
Conclusions