Long-acting Reversible Contraception (LARC)

David Hubacher, PhDSenior EpidemiologistFHI

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 contraception1. Copper IUD: ParaGard® - 10+ years• T-shaped plastic frame with copper attached• Non-hormonal

ParaGard – Copper intrauterine device (IUD)

How it works:1. Prevents fertilization by

creating intrauterine environment hostile to sperm

2. Copper ions enhance anti-sperm action

Two body locations, three products

• Intrauterine contraception1. 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 contraception1. Copper IUD: ParaGard® - 10+ years2. Intrauterine system (IUS): Mirena® - 5 years

• Subdermal implant – upper arm3. Implanon ® - 3 years• Match-stick sized rod that releases progestin

Implanon

How it works:Mostly by preventing ovulation

Implants

• Developed in 1960s• First came Norplant (6 rods), then Jadelle

(2), Implanon (1), Sino-implant (2)• Countries with highest use: Indonesia

• 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

Worldwide LARC Use

Countries with High IUD Use20-29%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 Use in Other Countries

Brazil 1%India 2%South Africa 1%Mexico 12%Nigeria 1%USA 5%

IUD Use in the US: 45 Years of Change

1965 1970 1975 1980 1985 1990 1995 2000 2005 20100

2

4

6

8

10

12

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 effective Less than 1 pregnancy per 100 women in one year

Less effective About 30 pregnancies per 100 women in one year

• 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

Program Advantages of LARC

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

Service Provision Requirements

• 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

Cost of LARC

• 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

LARC vs. Short-acting Methods

Cumulative Probability of Discontinuation

0 3 6 9 12 15 180

10

20

30

40

50

60

70

Short-actingImplantDMPA/OC

months

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?

Risk of Unintended Pregnancy

• 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

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.

• 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