By :DR NOR HUDA BT MAT ALI CLINICAL O&G SPECIALIST HOSPITAL TENGKU AMPUAN AFZAN KUANTAN

What is LARC Concept of unmet needs in contraception Role of LARC Issues / misconception

LONG ACTING REVERSIBLE CONTRACEPTION

Methods of birth control that provides effective contraception for an extended period of time without requiring user action

NICE guidelines 2013

Methods

that require admission less than once per cycle or month includes intrauterine system, intauterine devices, subdermal implants and injectable contraception

LARC

A concept that has influenced the development of family planning programme for more than 20 years

Women with unmet need are those:1. Who are fecund and sexually active but are not taking any method of contraception 2. Not wanting any more children or 3. Wanting to delay the birth of their next child

Unmet needs is especially high among groups such as :1.ADOLESCENCE 2.MIGRANTS 3.URBAN SLUM DWELLERS 4.REFUGEES 5. WOMEN IN POST PARTUM PERIOD

Over the past decades rising rate of contraception have reduced unmet need in most countries BUT in some countries persistently high indicaying that greater efforts are needed to understand/adress the cause of unmet need

CONCEPT OF UNMET NEED

Added as indicator in MDG of improving maternal health

To reduce the mortality rate of pregnant women, the United Nations has launched a Millennium Development Goal to make promoting the well-being of pregnant women its fifth goal and have also subcategorized it as 5A and 5B. The former is to reduce the death rate of pregnant women by 75%, while the latter is to make available fertility health service.

Lead to unintended pregnancy, poses risk to women, families & societies

? POLICY MAKERS CONCERN ABOUT UNMET NEED

Friday January 4, 2013

Infant nearly thrown into trash compactor

A newborn infant was packed into a rubbish bag and was almost thrown into a trash compactor by rubbish collectors. Luckily for the child, her cries saved her.

As October 2011, world population has reached 7 billion.

40% were born unplanned & 25% unwanted pregnancy

36% Women died of giving birth. 20 million undergo unsafe abortion. 500,000 died during pregnancy & giving birth
186 women died during abortion every day

In the United States, 42% of adolescents aged 15-19 yrs have had sexual intercourse. Using contraceptive methods with relatively high typical use failure rates (Abma JC et al, Vital Health Stat
23 2010)

82% of adolescent pregnancies in United States are unplanned, accounting for >1/5th of all unintended pregnancies

NEWS RELEASE 125 Maiden Lane, 7th Floor, New York, NY 10038 Ph 212 248 1111 Fax 212 248 1951 Rebecca Wind
mediaworks@guttmacher.org Tuesday, July 17, 2012

USE OF HIGHLY EFFECTIVE CONTRACEPTIVE METHODS INCREASES SUBSTANTIALLY, BUT REMAINS LOW AMONG WOMEN AT HIGHEST RISK OF UNPLANNED PREGNANCY Greater Use Could Significantly Reduce Rates of Unintended Pregnancy Use of the most effective contraceptive methods increases

USE OF HIGHLY EFFECTIVE CONTRACEPTIVE METHODS INCREASES SUBSTANTIALLY, BUT REMAINS LOW AMONG WOMEN AT HIGHEST RISK OF UNPLANNED PREGNANCY

The proportion of women using highly effective longacting reversible contraceptive methodsnamely, the implant and intrauterine device (IUD)increased significantly between 2002 and 2009, growing from 2.4% to 8.5%. This finding comes from a newly released study, "Changes In Use of Long-Acting Contraceptive Methods in the United States, 20072009," by Lawrence B. Finer et al. of the Guttmacher Institute, which also found that use of these methods increased among almost every demographic group. This increase occurred simultaneously with a decline in both sterilization and the use of less effective short-term methods such as condoms and the birth control pill. Despite this overall increase, use of long-acting methods in the United States remains substantially lower than in other developed countries such as the United Kingdom (11%), France (23%) and Norway (27%).

When used for their full term, which runs from three to 10 years depending on the method and brand, long-acting reversible contraceptive methods are highly cost-effective. More important, they are among the most effective methods currently available and have failure rates of less than 1%. Contrary to the views held by some, current medical guidelines show that use of these methods is safe for young women and women with no children. The authors suggest that increasing awareness and use of the implant and IUD could give women more options that better meet their needs at different stages of their lives. More widespread use of highly effective long-acting methods could therefore play an important role in lowering the high rates of unintended pregnancy in the United States. This article is currently available online, and will appear in a forthcoming issue of Fertility and Sterility.

LARCs are the best tools we have to fight against unintended pregnancies. IUDs & implants are the most effective

reversible contraception.

POSTPARTUM LARC BENEFIT

-Ensure reliable contraception (immediate insertion)

-Expulsion - perforation -With immediate insertion

RISK
High risk for rapid repeat pregnancy (20% within 2 years (Schelar et all 2007: Chilld Trends Research brief)

Of adolescents in postpartum period the implants was more likely to be placed before resumption of sexual activity than IUD, thus reducing repeated pregnancy

Almost of all abortions performed in US are repeat abortions Inserting implants or IUD immediately significantly reduced the risk of repeat abortion (Goodman S et al: Contraception 2008) Benefits of providing LARC to adolescents after abortion outweight the risk

Condition

Implant

Copper IUD

LNGIUD

Clarification/evidence/ comments

AGE: Menarche < 18Y Menarche < 20Y 1 1 2 2 Concern exists about risk for expulsion from nulliparity & STDs from sexual behaviour in youger age group

POST PARTUM - <10 min after placenta delivery -10 min 4W -<4W (NO BF) -<4W (BF) -> 4W -Peuperal sepsis POST ABORTION 1st trimester 2nd trimester 3rd trimester Immediate septic

1 2 1 2 1 2 2 2 1 4 1 2 4 4

2 2 2 2 1 4 1 2 4 4

Insertion of IUD might substantially worsen the condition

-Risk of complication from immediate & delayed insertion did not differ -- Expulsion after 2nd trimester abortion was greater -- safety between copper & LNG IUD did not differ

1 1 1 1

U.S. Medical Eligibility Criteria for Contraceptive Use 2010. Centers for CDC. MMWR Recomm Rep 2010;59(RR-4):1-86

1.
2.

INTRAUTERINE DEVICES CONTRACEPTIVE IMPLANTS

? safety

RR of PID increase in 1st 20 days Risk : 0-2% (no cervical infection) & 0-5% if presence Mirena may lower the risk

? infertility ? Technical

Determinant of tubal infertility : chlamydial antibodies Rapid return of baseline fecundability

difficulty

Little evidence suggest more difficult compared with older women >1/2 of young nulliparous report discomfort

? Routine STD screen

15-19y : 2nd highest for chlamydial & highest for gonorrhea All adolescent should be screened Routine antibiotic not reccomended

? Expulsion rate

Expulsion rate for all IUD users : 3-5%, 5-22% adolescent Young age, previousexpulsion & nulliparity may slightly increase risk

? Changes in bleeding pattern

Expect changes in their menstrual bleeding Counselling for better understanding

Causes changes in bleeding patterns

Most common reason for discontinuation Anticipatory guidance may improve satisfaction/ continuation

Higher Hb level

Secondary health benefits

Reduction in dysmenorrhea/pelvic pain

Adolescent should be encouraged to consider LARC methods Counselling about LARC methods should occur at all health care provider visits with sexually active adolescents Health care providers should consider LARC methods for adolescents & help to make those methods acccesible to them

THANK YOU