Contraceptive Security: Incomplete without Long-Acting and Permanent Contraception (LA/PMs) Jane Wickstrom, MA and Roy Jacobstein, MD, MPH, EngenderHealth International Conference on Family Planning: Research and Best Practices Kampala, Uganda, 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 Implant Intrauterine 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 Forceps Insertion (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

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 Photo by Staff/EngenderHealth Photo by P. Perchal/EngenderHealth

LA/PMs are highly effective 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 1 st year of (typical) use No method 850 Withdrawal 270 Male condom 150 Pill 80 Injectable 30 Implant 0.5 IUD (LNG-IUS, Copper T) Sterilization (M/F) 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 Using IUD/implant to space/delayUsing other FP method to space/delay Unmet need to space/delay Spacing and Delaying Births, MWRA Source: DHS

Variable demand, unmet need, & LAPM use Using LA/PM to limitUsing other FP method to limitUnmet need to limit Source: DHS Limiting Births, MWRA

Source:MEASURE/DHS, Kenya DHS Survey, 2003; World Population Prospects: The 2008 Revision. Long-Acting Reversible Methods 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

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 Long-Acting and Permanent Methods 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% [ ] Turkey’s nurses and midwives begin inserting IUDs CPR for IUDs rose from 8% to 19% [ ] Egypt’s FP program emphasizes IUD services (in context of choice) CPR for IUDs rose from 4% to 36.5% [ ] Malawi’s clinical officers begin to perform female sterilization CPR for female sterilization more than tripled to almost 6% [ ] Source: DHS

Contraceptive security is incomplete without LA/PMs LA/PMs need to be included explicitly and fully in CS definitions, strategies, plans, and programming For 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 intentions Countries 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.