2011 CYP Update: Newly Calculated Factors Process, Calculation, Justification, Implications

Outline Process/Methodology used for the update Items included in factor calculations Look at methods through 3 categories –Those with recommended changes –New methods –Those with no recommended changes from the 2000 CYP factors

Process/Methodology Used for the Update Peer reviewed literature review Gray literature review –Online search engine (Rollyo) –Organizational and individual contacts Secondary analysis of DHS data Utilization of data from articles and analysis to determine justification of method updates Selection of specific data/articles to be included in new estimates –Real world usage –Length of follow-up in studies –Impact of inclusion/exclusion of articles on estimates (continuation rates) Method specific calculations Consultative meetings throughout

Factors Included in CYP Calculations Use Effectiveness - all methods Duration of use - long acting and permanent methods and Fertility Awareness Methods (continuation rates and age) Coital Frequency - condoms, spermicides (coitus-dependent methods) Consistency of Use - condoms, spermicides (coitus-dependent methods) Wastage - pills, condoms, spermicides Overlapping Coverage*- all methods in 2000 * Use of a method during postpartum amenorrhea

Overlapping Coverage (Postpartum Amenorrhea) 2000 estimates used secondary analysis of DHS data to estimate number of postpartum amenorrheic women using any method. MethodNumber of Countries Percentage Amenorrheic* 2000 CYP with Overlapping Coverage 2000 CYP without Overlapping Coverage Pill181.7%14 IUD142.6% Injection125.4%4.24 Condom195.9%10598 * Percentage of women less than 6 months postpartum that are currently amenorrheic and using any method.

Overlapping Coverage MethodNumber of Countries 2011 Percentage Amenorrheic 2011 Percentage Amenorrheic 2000 Pill12.6%1.7% IUD11.2%2.6% Injection22.6%5.4% Condom23.4%5.9% Updated analysis using DHS after Going to disregard overlapping coverage during postpartum amenorrhea

Methods with CYP Factor Changes IUD Implants Sterilization Natural Family Planning (Fertility Awareness Methods)

IUD 2000 USAID CYP Factor (with rounding): 3.5 CYP per IUD inserted Equation: Average duration * effectiveness * proportion not overlapping 3.9 years * 96.4% * 97.4%= 3.6 Justifications for recommending a change: –Change in average duration of use (continuation/discontinuation) –Eliminating effectiveness from the equation because it is included in average duration of use

IUD Average Duration of Use Calculated by fitting an exponential decay curve to the continuation data (R=ae -rt ) From 4 articles: Ali et al (secondary analysis of DHS data) 2 WHO studies providing 12 years of follow up (clinical trials) Jenabi et al providing 1 month continuation rates Uses Ali data for the first 3 years and then applies the curve from the WHO data to the Ali data for years Truncated at 5 and10 years Average duration of use is 4.6 years Compared to 3.9 years in 2000 Changes CYP from 3.5 to 4.6 CYP for 5 year IUD is 3.3

Implants 2000 USAID CYP Factor: 3.5 CYP per implant (Norplant) 2.0 CYP per implant (Implanon, added later) 3.5 CYP per implant (Jadelle, added later) Equation: Average duration * effectiveness 3.6 years * 100% = 3.6 Justifications for recommending a change: –Change in average duration of use (continuation/discontinuation) –Addition of Sino-Implant (II) –Eliminating effectiveness from the equation because it is included in average duration of use

Implant Duration of Use Calculated by fitting an exponential decay curve to the continuation data (R=ae -rt ) Uses Norplant data to estimate the curve Based on 4 studies: 3 doing secondary analysis of DHS data and one study of real world use in Senegal* Factors are for 3, 4, and 5 year implants. Due to differences in country registration duration * Tuladhar et al. 1998, Fathonah et al. 2000, African Population and Health Research Center 2001, Ba et al. 1999

Implant Duration of Use 3 Year Implant: 2.4 years use 2.4 CYP per insertion 4 Year Implant: 3.0 years use 3.0 CYP per insertion 5 Year Implant: 3.6 years use 3.6 CYP per insertion

Sterilization 2000 USAID CYP Factor: –Asia10 CYP –Latin America10 CYP –Africa8 CYP –Near East/North Africa8 CYP Equation: Mean age at time of sterilization, discounted for reduced fertility due to age, adjusted for higher parity among women opting for sterilization Justifications for recommending a change: –Change in mean age at time of sterilization

Sterilization RegionNumber of Countries 2011 CYP Factor 2011 CYP Factor 2000 Africa Asia LAC CYP Global Factor: 10

Sterilization Discussion Points: –Different methodological approaches >Fertility and parity adjustments (USAID) >Mortality adjustments (Marie Stopes) >Weighted averages used for regional estimates (Marie Stopes)

Natural Family Planning 2000 USAID CYP Factor: 2 CYP per trained adopter Terminology change: Fertility Awareness Based Methods (FAM) Standard Days Method (SDM) Based on average duration of use- 1.5 years 2011 CYP Factor: 1.5 CYP per trained adopter

New Methods Vaginal Ring Contraceptive Patch CYP of 15 for each, based on CYP for oral contraceptives

Methods Without CYP Factor Changes Oral Contraceptives Condoms –Male –Female Spermicides Injectables –Depo –Noristerat –Cyclofem Emergency Contraception

Oral Contraceptives 2000 USAID CYP Factor (with wastage adjustment): 15 cycles per CYP Equation: Number required / effectiveness / proportion not overlapping 13 / 92.4% / 98.3%= 14 Justification for No Recommended Change: New effectiveness data does not support a change No change in result with the elimination of overlapping coverage No new data on wastage

Condoms and Spermicides 2000 USAID CYP Factor (with wastage adjustment): 120 units per CYP Equation: Number required (coital frequency, consistency of use) / proportion not overlapping 98 / 94.1% = 105

Condoms and Spermicides Based on Rutenberg’s 1993 analysis: The Fertility Impact of Inconsistent Condom Use of Contraception. Coital frequency of 5.6 based on secondary analysis of DHS data. Assumes condoms are used for 50% of coital acts among those reporting themselves to be condom users. Consistency of Use Average Monthly Coital Frequency Always (100%) Most of the time (75%) Sometimes (50%) Infrequently (25%) Low (1-4) Low to Moderate (5-6) Moderate to High (7-8) High (9-10)

Condoms and Spermicides Justification for No Recommended Change: –Coital frequency data is no longer collected in DHS so there is a lack of comparable data. –Minimal change from elimination of overlapping coverage. –No new data on wastage.

Injectables 2000 USAID CYP Factor: 4 doses per CYP (Depo Provera) 6 doses per CYP (Noristerat) 13 doses per CYP (Cyclofem) Equation (Depo Provera): Average duration ( biologically ) / effectiveness / proportion not overlapping 4 / 100% / 94.6% = 4 Justification for No Recommended Change: –New effectiveness data does not support a change. –No change from elimination of overlapping coverage.

Emergency Contraception 2000 USAID CYP Factor (added later): 20 doses per CYP Equation: CYP for Pills / effectiveness 15 / 75% = 20 Justification for No Recommended Change: –Methodology developed after 2000 with input from various experts, no need to modify –New effectiveness data does not support a change.

Methods Not Changing Method2000 CYP Conversion Factor Oral Contraceptives15 cycles per CYP Condoms120 units per CYP Female Condoms120 units per CYP Vaginal Foaming Tablets120 units per CYP Depo Provera Injectable4 doses per CYP Noristerat Injectable6 doses per CYP Cyclofem Monthly Injectable13 doses per CYP

Methods with Changing Factors Copper T 380-A IUD3.5 CYP per IUD inserted Norplant Implant3.5 CYP per implant Implanon Implant2.0 CYP per implant Jadelle Implant3.5 CYP per implant Emergency Contraceptive Pills20 doses per CYP Natural Family Planning (SDM)2 CYP per trained, confirmed adopter LAM4 active users per CYP (or 0.25 CYP per user) Sterilization Asia Latin America Africa Near East/North Africa 10 CYP 8 CYP

Issues for Discussion Sterilization methodology Free vs. sold condoms Continuation differences by provider Limitations of using DHS data