Contraceptive Security: Incompletewithout Long-Acting and Permanent Contraception (LA/PMs)

Jane Wickstrom, MA and Roy Jacobstein, MD, MPH, EngenderHealthInternational Conference on Family Planning: Research and Best PracticesKampala, Uganda, 15-18 November, 2009

Methodology

Review of key documents– 13 national & regional contraceptive security strategies – Contraceptive security (CS) literature– Materials of key organizations working in CS

> E.g. RH Supplies Coalition, USAID|DELIVER, World Bank, UNFPA, IPPF

Secondary analysis of DHS data– Demand, met & unmet need for spacing & limiting births– FP method mix among spacers & limiters

The four LA/PMs

Long-Acting Reversible Methods– IUDs:

> CuT380A, ML-375> LNG-IUS

– Implants: > Jadelle> Sino-implant II> Implanon

Permanent Methods– Female Sterilization – Male Sterilization (Vasectomy)

Language conditions thought

International Definitions of Contraceptive Security:

“Ensuring that all people … can access and use affordable, high-quality supplies to ensure their better reproductive

health.” (RH Supplies Coalition website)

“Ensuring that all people … can access and use affordable, high-quality supplies to ensure their better reproductive

health.”(RH Supplies Coalition website)

“Reproductive health contraceptive security exists when people are able to choose, obtain and use the RH supplies they

want…..” (JSI/DELIVER SPARHCS)

“Reproductive health contraceptive security exists when people are able to choose, obtain and use the RH supplies they

want…..”(JSI/DELIVER SPARHCS)

Language conditions thought (cont.)

Contraceptive Security in National Strategies

“Definition of Contraceptive Security”

“For family planning programs, the vital importance of

contraceptives is often summed up by the slogan: No Product, No

Program. Without contraceptive security, families will be unable to

space their births, limit their family size, and time pregnancies.”

(Albania, National Contraceptive Security Strategy, June 2003)

“Definition of Contraceptive Security”

“For family planning programs, the vital importance of

contraceptives is often summed up by the slogan: No Product, No

Program. Without contraceptive security, families will be unable to

space their births, limit their family size, and time pregnancies.”

(Albania, National Contraceptive Security Strategy, June 2003)

Medical instruments needed to provide clinical methods of family planning

Hormonal ImplantIntrauterine Device

(IUD)Female Sterilization (via Minilaparotomy)

No-scalpel Vasectomy (NSV)

Insertion (Jadelle®, Sino-Implant II] 1) Implant (1) Forceps, Artery, Kelly, Straight, 5.5" (1) Cup, Iodine(1) Forceps, Mosquito, Delicate, Curved, 5“(1) Scalpel Handle, #3, graduated (cm)(1) Trocar (#10)

Insertion(1) IUD (Cu-T 380A or Multiload)(1) Cup, Iodine(1) Forceps, Schroeder (1) Cervical Tenaculum, 10"(1) Forceps, Sponge, Foerster, Straight, 9.5"(1) Sound, Uterine, Sims, 12.5"(1) Scissors, Operating, Mayo, Curved, 6.75"(1) Speculum, Vaginal, Graves, Medium

(1) Cup, Iodine(1) Forceps, Dressing, Standard Pattern, 5"(1) Forceps, Tissue, Delicate Pattern, 5.5"(2) Forceps, Artery, Kelly, Straight, 5.5"(2) Forceps, Intestinal, Allis, Delicate, 6" (5x6 teeth)(2) Forceps, Baby Babcock, 7.5"(1) Forceps, Schroeder Cervical Tenaculum, 10"(1) Forceps, Sponge, Foerster, Straight, 9.5"(1) Forceps, Sponge, Foerster, Curved, 9.5" (1) Needle Holder, Mayo Hegar, 7"(2) Richardson-Eastman Retractor, Small (for interval procedures)(1) Army-Navy Retractor (2-pc.set), Double- ended (for postpartum procedures)(1) Scissors, Tonsil, Metzenbaum, Curved, 7" (1) Scissors, Operating, Mayo, Curved, 6.75"(1) Scalpel Handle, Su #3, graduated in cm(1) Jackson Vaginal Retractor (Deep Blade) 1.5"x3," or (1) Speculum Vaginal, Graves, Medium(1) Elevator, Uterine, Ramathibodi(1) Hook, Tubal, Ramathibodi

(1) Cup, Iodine(2) Forceps, Artery, Kelly, Straight, 5.5"(1) Needle Holder, Mayo Hegar, 7"(1) Scissors, Operating, Mayo, Curved, 6.75"(1) NSV Ringed Forceps, 4 mm.(1) NSV Dissecting ForcepsInsertion (Implanon®)

(1) Implanon® set (implant in preloaded, specially-designed applicator)(1) Cup, Iodine(1) Forceps, Artery, Kelly, Straight, 5.5“

Removal (Implanon®, Jadelle®, Sino-Implant II)(1) Cup, Iodine(1) Forceps, Artery, Kelly, Straight, 5.5“(1) Scalpel Handle, #3, graduated (cm)(1) Forceps, Mosquito, Straight, 5"

Removal (1) Forceps, Sponge, Foerster, Straight, 9.5"(1) Speculum, Vaginal, Graves, Medium(1) IUD Removal forceps, Alligator Jaw, 8"(1) IUD String Retriever

http://www.engenderhealth.org/files/pubs/family-planning/LAPM-Equipment-List.pdf

Necessary, but not sufficient …

Medical Instruments + Equipment + FP Commodity = Supplies

Services Are Needed to Provide Clinical Methods of Family Planning

Medical Instruments + Expendable Medical Supplies

+ FP Commodity = “Supplies”

≠

“Contraceptive Security”

So, why is this important?

1. LA/PMs are highly effective

2. High unmet need for delaying, spacing and limiting births

3. Sub-optimal fit between reproductive intent and method use

4. People want and use LA/PMs when they are made available

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LA/PMs are highly effective

0 5 10 15 20

Implants

Vasectomy

Female sterilization

IUD (TCu-380A)

LAM

Depo-Provera

Oral contraceptives

Standard Days Method

Male Condom

Withdrawal

Percentage of women pregnant in first year of use

Pregnancy Rates by Method

Typical use

“Perfect” use (but humans are imperfect)

The cost of failure: unintended pregnancies per 1000 users, by method

Method# of unintended pregnancies among 1,000

women in 1st year of (typical) use

No method 850

Withdrawal 270

Male condom 150

Pill 80

Injectable 30

Implant 0.5

IUD (LNG-IUS, Copper T) 2 - 8

Sterilization (M/F) 1.5 - 5

Source:Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York NY: Ardent Media, 2007.

High demand, high unmet need, low IUD & implant use

05

1015202530354045

Burkin

a Fas

oDRC

EthiopiaGuine

aKen

yaMad

agas

car

Malawi

MaliNigeri

aRwan

daSen

egal

Tanza

niaTogo

Uganda

Zambia

Egypt

India (U

P)Pak

istan Hait

i

Using IUD/implant to space/delayUsing other FP method to space/delayUnmet need to space/delay

Spacing and Delaying Births, MWRA

Source: DHS

Variable demand, unmet need, & LAPM use

0

10

20

30

40

50

60

Burkin

a Fas

oDRC

EthiopiaGuine

aKen

yaMad

agas

car

Malawi

MaliNigeri

aRwan

daSen

egal

Tanza

niaTogo

Uganda

Zambia

Egypt

India (U

P)Pak

istan Hait

i

Using LA/PM to limitUsing other FP method to limitUnmet need to limit

Source: DHS

Limiting Births, MWRA

14.3

30.2

0

10

20

30

40

Demand tospace/delay

Using tospace/delay

Pills18%

Condoms10%

Traditional25%

Injectables39%

IUD4%

Implants4%

Source: MEASURE/DHS, Kenya DHS Survey, 2003; World Population Prospects: The 2008 Revision.

Long-Acting Reversible Methods

Long-Acting Reversible Methods

Only 8% of spacers/delayers use an IUD or implant

Only 8% of spacers/delayers use an IUD or implant

Reproductive intent and contraceptive choice: implants and IUDs have great potential to meet needs of delayers and spacers

MWRA (15-49 yr) 5.0 million (2003) Kenya

Injectables35%

Pills17%

Condoms3%

LAM0%

Traditional17%

Implants5%

IUD6%

Sterilization 17%

Source: MEASURE/DHS, Kenya 2003 DHS Survey. World Population Prospects: The 2008 Revision.

Only 28% of limiters use any of the LA/PMs

Only 28% of limiters use any of the LA/PMs

Long-Acting and Permanent Methods

Long-Acting and Permanent Methods

35.7

25

0

10

20

30

40

Demand to limit Using to limit

Reproductive intent and contraceptive choice: LA/PMs are underutilized among limiters in Kenya

MWRA (15-49 yr) 5.0 million (2003) Kenya

When available, people choose and like LA/PMs

Ghana’s midwives are trained and allowed to insert implants

CPR for implants rose more than 10-fold from 0.1% to 1.0% [1998-2003]

Turkey’s nurses and midwives begin inserting IUDs

CPR for IUDs rose from 8% to 19% [1983-1993]

Egypt’s FP program emphasizes IUD services (in context of choice)

CPR for IUDs rose from 4% to 36.5% [1980-2005]

Malawi’s clinical officers begin to perform female sterilization

CPR for female sterilization more than tripled to almost 6% [1992-2004]

Source: DHS

Contraceptive security is incomplete without LA/PMs

LA/PMs need to be included explicitly and fully in CS definitions, strategies, plans, and programmingFor true CS that includes LA/PMs, we need:– Medical instruments and supplies– Skilled, motivated, enabled providers– Suitable service setting

There is high demand and unmet need for LA/PMs to better meet individuals’ and couples’ RH intentionsCountries and donors increasingly interested in FP (MDG 5 and other MDGs)

Photo credits (from left to right): N. Rajani/EngenderHealth, C. Svingen/EngenderHealth, M. Reyners/EngenderHealth, C. Svingen/EngenderHealth, D. Peacock/EngenderHealth.

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