Transcript Contraceptive Security: Incomplete

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, 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)
“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)
Medical instruments needed to provide clinical methods
of family planning
Intrauterine Device
(IUD)
Hormonal Implant
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"
Insertion (Implanon®)
(1) Implanon® set (implant in preloaded, (1) Scissors, Operating,
Mayo, Curved, 6.75"
specially-designed applicator)
(1) Speculum, Vaginal,
(1) Cup, Iodine
(1) Forceps, Artery, Kelly, Straight, 5.5“ Graves, Medium
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"
Female Sterilization
(via Minilaparotomy)
(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), Doubleended (for postpartum procedures)
(1) Scissors, Tonsil, Metzenbaum, Curved,
Removal
7"
(1) Forceps, Sponge,
(1) Scissors, Operating, Mayo, Curved, 6.75"
Foerster, Straight, 9.5"
(1) Scalpel Handle, Su #3, graduated in cm
(1) Speculum, Vaginal,
(1) Jackson Vaginal Retractor (Deep Blade)
Graves, Medium
1.5"x3," or (1) Speculum Vaginal, Graves,
(1) IUD Removal forceps, Medium
Alligator Jaw, 8"
(1) Elevator, Uterine, Ramathibodi
(1) IUD String Retriever
(1) Hook, Tubal, Ramathibodi
No-scalpel
Vasectomy (NSV)
(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
http://www.engenderhealth.org/files/pubs/family-planning/LAPM-Equipment-List.pdf
Necessary, but not sufficient …
Medical Instruments + Equipment + FP Commodity =
Medical Instruments + Expendable Medical Supplies
Supplies
+ FP Commodity = “Supplies”
≠ “Contraceptive Security”
Services Are Needed to Provide Clinical Methods of Family Planning
So, why is this important?
Photo by P. Perchal/EngenderHealth
1. LA/PMs are highly
effective
Photo by Staff/EngenderHealth
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
LA/PMs are highly effective
Pregnancy Rates by Method
Withdrawal
Male Condom
Standard Days Method
Oral contraceptives
Depo-Provera
LAM
IUD (TCu-380A)
Typical use
Female sterilization
“Perfect” use
(but humans are imperfect)
Vasectomy
Implants
0
5
10
15
Percentage of women pregnant in first year of use
20
The cost of failure: unintended pregnancies
per 1000 users, by method
# of unintended pregnancies among 1,000
women in 1st year of (typical) use
Method
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
Spacing and Delaying Births, MWRA
Unmet need to space/delay
Using other FP method to space/delay
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0
Using IUD/implant to space/delay
Source: DHS
Variable demand, unmet need, & LAPM use
Limiting Births, MWRA
60
50
40
30
20
10
Unmet need to limit
Using other FP method to limit
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Using LA/PM to limit
Source: DHS
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
40
Injectables
39%
30
30.2
Pills
18%
20
14.3
10
Long-Acting
Reversible Methods
Condoms
10%
IUD
4%
0
Demand to
space/delay
Using to
space/delay
Source: MEASURE/DHS, Kenya DHS Survey, 2003; World
Population Prospects: The 2008 Revision.
Implants
4%
Traditional
25%
Only 8% of spacers/delayers
use an IUD or implant
Reproductive intent and contraceptive choice: LA/PMs
are underutilized among limiters in Kenya
MWRA (15-49 yr) 5.0 million (2003)
Kenya
40
35.7
30
Injectables
35%
Long-Acting and
Permanent Methods
25
20
Sterilization
17%
10
Pills
17%
IUD
6%
0
Demand to limit
Using to limit
Implants
5%
Traditional
17%
Condoms
3%
LAM
0%
Source: MEASURE/DHS, Kenya 2003 DHS Survey.
World Population Prospects: The 2008 Revision.
Only 28% of limiters use any
of the LA/PMs
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 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.
www.respond-project.org