Mera, March 2008: Long-acting and permanent methods of contraception benefit many

By Rosalyn Carson-DeWitt, Science Writer, Family Health International, Research Triangle Park, NC, USA and Marsden Solomon, Regional Medical Advisor, Family Health International, Nairobi, Kenya

Many women and men are certain that they are finished with childbearing, never wish to have children, or would like to ensure a reasonable space between infants. Yet long-acting and permanent methods (LAPMs) of contraception -- contraceptive implants, intrauterine devices (IUDs), and female and male sterilisation -- are far less popular than short-acting methods, such as oral contraceptives, injectables, and barrier methods. In many African countries, fewer than 5% of the women who use contraception use an LAPM.¹

General benefits of LAPMs

Reliability: LAPMs are the most effective contraceptive methods available. During a year of typical use, the pregnancy rate for couples using an LAPM ranges from 0.05% to 0.15%, depending on the method. LAPMs also appear to be 3 to 60 times more effective than short-acting methods.¹ The effectiveness of LAPMs may be enhanced because they do not require the user to act at the time of intercourse, or even on a daily or a monthly basis.

Safe use by postpartum and lactating women: An IUD can be inserted within 48 hours of giving birth, or insertion can be delayed until at least 4 weeks postpartum. Female sterilisation can be performed within the first postpartum week. By the sixth postpartum week, breastfeeding women can safely receive implants.¹

Cost-effectiveness: Because of the one-time higher cost of initiating the use of an LAPM, oral contraceptives and injectables may appear to cost less. But LAPMs generally prove to be more cost-effective over time.

Noncontraceptive health benefits: Female sterilisation may offer protection against ovarian cancer. IUDs decrease the risk of endometrial cancer. Implants may protect users from iron-deficiency anemia.

Improvements in family health: Reliably preventing a pregnancy reduces maternal and neonatal morbidity and mortality. In addition, with improved spacing between pregnancies, infants can breastfeed for a full 2 years.¹

Safe use in people living with HIV/AIDS: All LAPMs are now considered safe for use in HIV-positive men and women, and they are generally compatible with the simultaneous use of antiretroviral medications. Although some studies suggest that the effectiveness of contraceptive implants is somewhat lowered when they are used in conjunction with certain antiretroviral drugs,² more research may be needed to prove this.

Specific benefits to women with HIV/AIDS: The reliability of LAPMs prevents unintended pregnancies, and so reduces the rate of mother-to-child transmission of HIV.³

Contraceptive implants

Once inserted -- by a trained provider using an aseptic technique -- implants release progestin slowly over 3 to 5 years (depending on the type of implant).

Specific benefits of implants include their immediate reversibility upon removal, resulting in full restoration of fertility, and the safety of their use by women with cardiovascular risk factors such as high blood pressure, diabetes, or smoking. Implants that are inserted after the sixth postpartum week are also safe for breastfeeding women.

A woman who chooses to use an implant should be informed of potential side-effects including changes in bleeding patterns and, less commonly, headaches, abdominal pain, breast tenderness, mood changes, and nausea. However, she should also be told that most of these side-effects abate with time -- which may reduce the possibility that she will needlessly discontinue the method.

Intrauterine devices

The most common and effective IUD is the copper 380A, which lasts for at least 12 years. Complete reversibility upon removal and cost-effectiveness are other attractive characteristics of the IUD. Potential side-effects of IUDs include prolonged or heavy monthly bleeding, and increased cramping during menstruation. These side-effects usually subside after 3 to 6 months of IUD use.

Although it was once thought that a woman who has not had children should avoid using an IUD until she has completed childbearing, recent research shows that a woman of any age and any parity can use an IUD without any risk to her future fertility.⁴

Female sterilisation (tubal ligation)

Female sterilisation is a permanent form of contraception, achieved through the safe, simple surgical procedure performed under local anesthesia or light sedation in an outpatient facility. The procedure can be performed immediately or within the first 7 days postpartum, after 6 weeks postpartum, immediately postabortion, or at a time unrelated to past pregnancy. It is immediately effective.

Good counselling before the sterilisation procedure is always crucial; otherwise the woman may regret her decision.

Male sterilisation (vasectomy)

Vasectomy is a permanent form of contraception, achieved through a safe, simple, 15-minute surgical procedure performed with local anesthesia. Vasectomy can be performed at any medical facility with appropriate equipment and the ability to prevent infections. In general, men recover quickly from the procedure, and usually experience only low levels of discomfort and minor bruising.

Prevasectomy counselling is important to make sure that a man understands that vasectomy is a permanent method of contraception. Counselling can also reassure him that vasectomy in no way interferes with sex drive, the ability to obtain or maintain an erection, or the ability to achieve an orgasm. Because vasectomy is not immediately effective, men should be counselled to use another form of contraception for 3 months following the procedure.

Appropriate promotion

To best serve women and men who seek family planning services, health professionals should carefully familiarise themselves with the latest information and evidence regarding each LAPM. Providers should make sure that they are not following outdated guidelines that exclude clients (such as those infected with HIV) from using certain forms of contraception, particularly LAPMs. Similarly, providers should make sure that their clients do not have misconceptions about the suitability of LAPMs for people with HIV/AIDS.

Contraceptive implants, IUDs, tubal ligation, and vasectomy are safe, reliable, cost-effective forms of contraception for women and men who wish to limit their fertility on either a long-term or permanent basis. However, because LAPMs do not prevent sexually transmitted infections, men and women who choose these methods should be counselled to continue using condoms -- and so practice dual-method use -- to decrease the risk of contracting or transmitting HIV and other sexually transmitted infections.

References

1. Family Health International (FHI). Long-Acting and Permanent Methods: Addressing Unmet Need for Family Planning in Africa. Research Triangle Park, NC: FHI, 2008.
2. World Health Organization (WHO). Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva, Switzerland: Reproductive Health and Research, WHO, 2004.
3. World Health Organization (WHO). Prevention of Mother-to-Child Transmission of HIV. HIV Technical Briefs. Geneva, Switzerland: WHO, 2007.
4. World Health Organization (WHO) Department of Reproductive Health and Research and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva, Switzerland: CCP and WHO, 2007.

This article was reproduced with permission of the Mera journal, the leading publication of continuing medical education for health professionals in the English-speaking countries of Africa (info@fsg.co.uk, www.fsg.co.uk).