Long-Acting and Permanent Methods

LAPMs contribute to family planning programs.

Family Health Research: 2008, Vol. 2, Issue 1

Long-acting and permanent methods (LAPMs) of contraception remain a relatively small — and sometimes missing — component of national family planning programs in sub-Saharan Africa. These methods can enhance family planning programs in meaningful ways if challenges to their availability, access, and acceptability can be overcome.

Responding to individual needs

The intrauterine device (IUD), implants, vasectomy, and female sterilization are appropriate choices for many people who want safe and effective protection against an unintended pregnancy. The long-term effectiveness and reversibility of the IUD and implants make these methods suitable for women and couples who want to space their pregnancies, for young people who want to delay marriage and parenthood, and for women who discontinue other methods of family planning but still want to avoid pregnancy. Vasectomy and female sterilization are best suited for individuals and couples who are certain they do not want more children.

Providing a range of methods, including LAPMs, gives family planning clients more contraceptive choices. A woman who has more choices is more likely to start using a method, be satisfied with her choice, and continue using the method until she no longer wishes to prevent pregnancy.

Continuation rates appear to be substantially higher among women who use reversible LAPMs than they are among women who use short-acting methods such as oral contraceptives and injectables. This may be because of the high rates of contraceptive effectiveness and ease of use associated with LAPMs. In Africa, research suggests that about 80 percent of the women who choose the IUD — and even more women who choose implants — continue using the method for at least one year.¹ In contrast, data from surveys in some developing countries suggest that only 60 percent to 70 percent of women who choose oral contraceptives or injectables are still using them after one year. Although individuals can be very satisfied with reversible LAPMs, it is essential that programs provide ongoing services to clients wishing to discontinue or switch methods.

Short- versus Long-acting and Permanent Contraceptive Methods in Kenya

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Sustaining programs

Over time, LAPMs are also cost-effective for programs. When compared with the use of other methods, the use of LAPMs results in fewer unintended pregnancies and fewer clinic visits. This eases the burden on overextended health systems and providers. If used for at least three years, the IUD and implants, along with vasectomy, are considered the three most cost-effective methods when all direct medical costs associated with the methods, their side effects, and unintended pregnancies are taken into account.

Reaching national health goals

LAPMs can contribute to healthy timing and spacing of pregnancies, which improve the outcomes of pregnancy and childbirth for mothers and their children. The risk that a woman will die during her lifetime as a result of pregnancy, childbirth, or unsafe abortion is about one in 16 in sub-Saharan Africa.² Harmful outcomes like these can be avoided if a woman waits at least two years after the birth of a child to become pregnant again.

The use of LAPMs is also part of an important but often overlooked strategy for preventing mother-to-child transmission of HIV. Meeting an unmet need for family planning among HIV-infected women who do not wish to become pregnant is at least as cost-effective as the traditional strategy of providing HIV counseling, testing, and treatment with antiretroviral drugs such as nevirapine.³ The use of family planning to avoid unintended pregnancy is already preventing the birth of an estimated 173,000 HIV-infected infants each year in sub-Saharan Africa.

Overcoming challenges

Providing women and couples access to a range of contraceptive choices, including LAPMs, protects their human rights and benefits public health. Yet several strong barriers to LAPM use persist in sub-Saharan Africa.

Policy-makers and program managers are sometimes reluctant to make LAPMs part of the mix of contraceptive methods because of perceived cost barriers. As a result, commodities, equipment and supplies, and opportunities to train providers are not always available. Even when programs provide LAPMs, stockouts of the necessary commodities or equipment can be problematic.

Limited access to LAPMs is a problem. Short-acting methods are becoming increasingly available through commercial outlets and community-based distribution, especially in rural areas, where most people live. However, the provision of LAPMs is often confined to urban facilities. Distance to clinics and fees for services can make it difficult to obtain services.

Even when trained providers are available, medical barriers inhibit access. Providers may not provide LAPMs to their clients because of unnecessary restrictions, such as age or the number of children a woman already has. They may not be familiar with the latest evidence, and so may unintentionally deny a client an LAPM for inappropriate medical reasons. Or they may not offer comprehensive information about all methods, thus limiting the ability of clients to make informed contraceptive choices.

Many potential clients lack information about LAPMs or have misconceptions about the methods. Even in countries where most people know about family planning, fewer people know of methods other than the IUD and vasectomy. Myths and misconceptions are also widespread for these methods.

Experience suggests that some of these obstacles to LAPM use can be overcome. To do so, policy-makers and program managers must promote an enabling environment through evidence-based policies and guidelines, improved provision of services, and the education of health providers, communities, and individuals.

LAPMs and HIV LAPMs are suitable options for most women and couples who want to prevent unintended pregnancies. Women living with HIV may rely on an IUD, implant, or female sterilization for contraception, with only two exceptions. If a woman has an AIDS-related illness, she should postpone surgical sterilization until after her condition improves. And IUD insertion is not usually recommended as a first choice for a woman who has developed AIDS if she is not on antiretroviral therapy, or is not responding to treatment. This is because her suppressed immune system could increase the risk of infection during insertion. However, HIV-infected IUD users who develop AIDS generally may continue using the device. Vasectomy can be used by any man, regardless of his HIV status.

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References

1. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the TCu-389A IUD. Contraception 1999;60(3):155-60.

3. Reynolds HW, Janowitz B, Homan R, et al. The value of contraception to prevent perinatal HIV transmission. Sex Transm Dis 2006;33(6):350-56.