Development and Uptake of Long-Acting Reversible Contraception Services in Rwanda, 2009-2016.

Background: Long-acting reversible contraception (LARC) is highly effective at preventing pregnancy. However, in sub-Saharan Africa, LARC education for clients is relatively limited and providers are often not skilled in their insertion. Before 2009, only 1% of family planning clients in Rwanda received an LARC. Materials and Methods: We trained Rwandan government clinic nurses to promote, insert, and remove copper intrauterine devices (IUDs) and hormonal implants. Training started in two large urban clinics, and those nurses trained three successive waves of clinic nurses. Initial LARC promotions were clinic based, but in 2015 included community-based promotions in eight clinics. We compare IUD and implant insertions by year and clinic and discuss implementation successes/obstacles. Results: From 2009 to 2016, 222 nurses from 21 government clinics were LARC trained. The nurses performed 36,588 LARC insertions (19% IUD, 81% implant). LARC insertions increased over time, peaking at 8,897 in 2013. However, in 2014, the number dropped to 4,018 after closure of one large clinic, funding discontinuation, and supply stock-outs. With new funding in 2015, insertions increased reaching 8,218 in 2016. Catholic and non-Catholic and rural and urban clinics performed similarly, whereas clinics affiliated with community-based promotions performed better (p > 0.05). Between 2012 and 2014, 13% of family planning initiators chose the implant and 4% the IUD. Conclusions: LARC supply-demand services increased the proportion of family planning initiators choosing LARC to 17%. Challenges included inconsistent funding, irregular supplies, and staff turnover. Rural and Catholic clinics performed as well as urban and non-Catholic clinics. Concerted efforts to improve IUD uptake are needed.

Are Procured Quantities of Implants Adequate and Appropriate? Modeling Procurement, Inventory, and Consumption of Contraceptive Implants During Rapid Uptake.

Donors and others are concerned that implants procured under the Family Planning 2020 Initiative exceed the number sought by clients, resulting in accumulating stocks. To explore this issue, we examined 3 questions across 9 countries: (1) How accurate were procurement quantities given requirements for filling supply chains for the rapidly growing implant programs? (2) Is there a standard factor that can be applied to consumption data to predict procurement volumes required? (3) How accurately do demographic estimates mirror dispensed-to-client data? We created a model incorporating public-sector supply chain system parameters to calculate system "imputed" inventory and the system "filled-to-max" inventory. Comparing results determined the adequacy of the procurement quantities. The proportion of consumption that the filled-to-max inventory represented through time suggests whether a standard factor can be applied to consumption to predict necessary procurement volumes. We compared demographic estimates to consumption data to determine the usability of the former in predicting demand. According to model results, 3 of the 9 countries came close to procuring accurate quantities over the study period between 2010 and 2017, 4 had procurement volumes lower than what was required to fill the supply chain to maximum inventory requirement levels, and 2 had volumes that exceeded the need. We found no standard factor for relating inventory quantities to consumption rates across countries, given that inventory needs can vary based on system design parameters and the rates of growth or decline in consumption. Finally, we observed that our demographic estimates were on average lower than the dispensed-to-client data in the 6 countries for which these data were available. Study results show that the significant investments in procurement quantities for the rapidly growing implant programs were justified based on consumption and system design. This research should assure observers that rapid increases in implant procurement quantities (where data are available) have generally not resulted in overstocks of the system to date. It suggests that the relationship between procurement quantities and consumption levels cannot be accurately assessed without understanding the country supply chain, inventory control parameters, and current and future demand.

Uma via periférica para os hormônios sexuais: empresariamento, biologias, classe e corpos femininos / A peripheral route for sex hormones: entrepreneurialism, biologies, class and female bodies

Esta tese apresenta a vida social de implantes hormonais subdérmicos produzidos e comercializados unicamente no Brasil desde a década de 1990 por uma empresa de manipulação de medicamentos denominada Elmeco. Esses objetos farmacológicos são compostos por dois elementos fundamentais: um tubo de silicone e uma substância química derivada dos chamados hormônios sexuais. Desde essa composição tecnológica podem ser manejados em distintas combinações através da realização de procedimento de inserção sob a pele. A ascendência destes objetos biomédicos está relacionada às políticas demográficas internacionais nas décadas de 1960 e 1970, quando um consórcio político-científico, coordenado pelo Population Council, buscava sistemas de administração de contraceptivos hormonais eficazes para controlar a fertilidade de mulheres de países periféricos na geopolítica global. Desde os primórdios da preparação deste sistema de administração de hormônios, pesquisadores brasileiros estiveram envolvidos nas pesquisas clínicas, com destacada contribuição do médico e pesquisador Elsimar Coutinho na cidade de Salvador, Bahia. Mesmo diante de vigorosas reações de pesquisadores brasileiros, durante a década de 1980, os ensaios clínicos com a primeira marca registrada de implante hormonal subdérmico no mundo, o Norplant®, foram proibidas no país e a vida desta forma farmacêutica foi provisoriamente encerrada localmente. Este episódio, entretanto, não significou o fim da vida dos implantes subdérmicos no Brasil. Desde a década de 1990, com o engajamento de Elsimar Coutinho, foi edificada uma empresa-laboratório de manipulação de medicamentos com o nome Elmeco. Assumindo a chave metodológica proposta por Geest e Whyte (1996) esta tese delineia três fases na vida social dos implantes hormonais subdérmicos produzidos pela Elmeco: a) fase de fabricação, produção e comercialização: destaca-se o processamento da cadeia produtiva operada na Elmeco, b) a fase intermediária: apresenta-se o processo de distribuição dos produtos aos seus consumidores que, no caso dos implantes, processa-se centralmente na clínica, que é, ao mesmo tempo, o espaço físico e um tipo de prática sobre o corpo hormonal; c)a fase final: analisa-se as eficácias farmacológicas destes pequenos fármacos, tomando os diferentes atores envolvidos em seu transcurso existencial: as mulheres, as farmacêuticas e os médicos. Cada estágio do ciclo de vida dos implantes possui atores, espacialidades, temporalidades e um regime de valores e normas, que são apresentadas na tese. Ainda que se procure delinear as singularidades de cada fase, um interesse comum permaneceu ao longo de toda a tese: as modificações nas relações entre corpo e objeto que se estabelecem a partir das práticas através das quais os implantes nucleiam associações e relações farmacopolíticas e, ao fazê-lo, customiza corpos sexualizados e formas de vida com distinções de classe nos cenários da biomedicina contemporânea que se enseja dentro da racionalidade neoliberal do século XXI. A eficácia farmacêutica é o último e decisivo estágio de vida, pois ela enseja o próprio sentido da existência de objetos farmacológicos. Nos contextos estudados, as relações corpo-objeto se orientam em direção à finalidade de existência deste objeto farmacológico, que são as modificações corporais possibilitadas pelos imaginários farmacêuticos dos hormônios sexuais androgênicos. Hibridizados, corpo-objeto, fazem-se um tipo de ciborgue farmacoquimico empresa cujos atributos valorizados são as atitudes enérgicas.

This thesis presents the social life of subdermal hormonal implants produced and marketed only in Brazil since the 1990s by a drug-handling company called Elmeco.They are composed of two fundamental elements: a silicone tube and a chemical substance derived from the so-called sex hormones. The ascendancy of these biomedical objects is related to international demographic policies in the 1960s and 1970s when a political-scientific consortium, coordinated by the Population Council, sought effective hormonal contraceptive delivery systems to control the fertility of women from peripheral countries in global geopolitics . Since the beginning of the preparation of this system of hormone administration, Brazilian researchers have been involved in clinical research, with a distinguished contribution by the physician and researcher Elsimar Coutinho in the city of Salvador, Bahia. Even in the face of vigorous reactions from Brazilian researchers during the 1980s, clinical trials with the world's first brand of subdermal hormone implant Norplant® were banned in the country and life in this pharmaceutical form was provisionally closed locally. This episode, however, did not mean the end of life of the subdermal implants in Brazil. Since the 1990s, Elsimar Coutinho has been involved in the development of a drug-handling laboratory with the name Elmeco. Assuming the methodological key proposed by Geest and Whyte (1996), this thesis delineates three phases in the social life of the subdermal hormonal implants produced by Elmeco: a) manufacturing phase, production and commercialization: we highlight the processing of the production chain operated at Elmeco, b) the intermediate phase: the process of distribution of the products to its consumers is presented, which in the case of implants, is processed centrally in the clinic, which is both physical space and a type of practice on the body hormonal; c) the final phase: the pharmacological efficacies of these small drugs are analyzed, taking the different actors involved in their existential course: women, pharmacists and doctors. Each stage of the implant life cycle has actors, spatiality, temporalities, and a regime of values and norms, which are presented in the thesis. Although one tries to delineate the singularities of each phase, a common interest remained throughout the thesis: the modifications in the relations between body and object that are established from the practices through which the implants nucleate associations and pharmacopolitical relations and, at the same time, to do so, customizes sexualized bodies and life forms with class distinctions in the scenarios of contemporary biomedicine that comes within the neoliberal rationality of the 21st century. Pharmaceutical efficacy is the ultimate and decisive stage of life, since it gives rise to the very meaning of pharmacological objects. In the contexts studied, body-object relations are oriented toward the purpose of existence of this pharmacological object, which are the bodily modifications made possible by the pharmaceutical imaginaries of the androgenic sex hormones. Hybridized, body-object, they become a type of cyborg pharmacoquimico company whose valued attributes are energetic, productive, vibrant, sexualized, strong and beautiful attitudes that are possible through a unique ordering of practicality, effectiveness, continuous functioning and excitement and continuous stimuli.

Inpatient Postpartum Long-Acting Reversible Contraception and Sterilization in the United States, 2008-2013.

OBJECTIVE: To measure rates of long-acting reversible contraception (LARC), including intrauterine devices and contraceptive implants, and tubal sterilization during delivery hospitalizations and correlates of their use. METHODS: This retrospective cohort study used the 2008-2013 National Inpatient Sample, a publicly available all-payer database. We identified delivery hospitalizations with the International Classification of Diseases, 9th Revision, Clinical Modification codes for intrauterine device insertion, contraceptive implant insertion, and tubal sterilization. We used weighted multivariable logistic regression to examine associations between predictors (age, delivery mode, medical comorbidity, payer, hospital type, geographic region, and year) and likelihood of LARC and sterilization and to compare characteristics of LARC and sterilization users. RESULTS: Our sample included 4,691,683 discharges, representing 22,667,204 delivery hospitalizations. Long-acting reversible contraception insertion increased from 1.86 per 10,000 deliveries (2008-2009) to 13.5 per 10,000 deliveries (2012-2013; P<.001); tubal sterilization remained stable (711-683 per 10,000 deliveries; P=.24). In multivariable analysis adjusting for all predictors, compared with neither LARC nor sterilization, LARC use was highest among women with medical comorbidities (count per 10,000 deliveries: 15.04, standard error 2.11, adjusted odds ratio [OR] 1.92, 95% confidence interval [CI] 1.72-2.13), nonprivate payer (13.50, standard error 2.14, adjusted OR 5.23, 95% CI 3.82-7.16), and at urban teaching hospitals (14.92, standard error 2.25, adjusted OR 20.85, 95% CI 12.73-34.15). Sterilization was least likely among women aged 24 years or younger (251.04, standard error 4.88, adjusted OR 0.12 95% CI 0.12-0.13, compared with 35 years or older) and most likely with cesarean delivery (1,568.74, standard error 20.81, adjusted OR 6.25, 95% CI 5.88-6.63). Comparing only LARC and sterilization users, LARC users tended to have nonprivate insurance (84.95% compared with 57.17%, adjusted OR 1.90, 95% CI 1.38-2.63) and deliver at urban teaching hospitals (94.65% compared with 45.47%, adjusted OR 38.39, 23.52-62.64) in later study years (2012-2013; 55.72% compared with 32.18%, adjusted OR 8.26, 95% CI 4.42-15.44, compared with 2008-2009). CONCLUSION: Long-acting reversible contraception insertion increased from 1.86 to 13.5 per 10,000 deliveries but remained less than 2% of the sterilization rate. Inpatient postpartum LARC insertion is more likely among sicker, poorer women delivering at urban teaching hospitals.

Long-Acting Reversible Contraceptive Placement Among Active-Duty U.S. Army Servicewomen.

OBJECTIVE: To quantify uptake of long-acting reversible contraceptives (LARC)-intrauterine devices (IUDs) and hormonal implants-among U.S. Army active-duty female soldiers and identify characteristics associated with uptake. METHODS: This retrospective cohort study used the Stanford Military Data Repository, which includes all digitally recorded health encounters for active-duty U.S. Army soldiers from 2011 to 2014. We analyzed data from women aged 18-44 years to assess rates of LARC initiation using medical billing codes. We then evaluated predictors of LARC initiation using multivariable regression. RESULTS: Among 114,661 servicewomen, 14.5% received a LARC method; among those, 60% received an IUD. Intrauterine device insertions decreased over the study period (38.7-35.9 insertions per 1,000 women per year, ß=0.14, 95% confidence interval [CI] -0.23 to -0.05, P<.05), whereas LARC uptake increased, driven by an increase in implant insertions (20.3-35.4/1,000 women per year, ß=0.41, CI 0.33-0.48, P<.001). Younger age was a positive predictor of LARC uptake: 32.4% of IUD users and 62.6% of implant users were in the youngest age category (18-22 years) compared with 9.6% and 2.0% in the oldest (36-44 years). The likelihood of uptake among the youngest women (compared with oldest) was most marked for implants (adjusted relative risk 7.12, CI 5.92-8.55; P<.001). A total of 26.2% of IUD users had one child compared with 13.2% among non-LARC users (adjusted relative risk 1.94, CI 1.85-2.04, P<.001). The majority (52.2%) of those initiating IUDs were married, which was predictive of uptake over never-married women (adjusted relative risk 1.52, CI 1.44-1.59, P<.001). CONCLUSION: Among servicewomen, we observed low but rising rates of LARC insertion, driven by increasing implant use. Unmarried and childless soldiers were less likely to initiate LARC. These findings are consistent with potential underutilization and a need for education about LARC safety and reversibility in a population facing unique consequences for unintended pregnancies.

Demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos Town, North West Ethiopia.

BACKGROUND: Ethiopia is the second most populous country in sub Saharan Africa with high total fertility rate, and high maternal and child mortality rates. In sub Saharan African countries, including Ethiopia, even though studies show that demand for contraception is high, the practice is low. Particularly, in Ethiopia, despite the fact that practices on long acting and permanent methods are believed to be low, there are limited evidences on the real magnitude of demand for the methods. METHODS: To assess demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos town, Amhara Regional State, North West Ethiopia, A community based cross sectional study was conducted, from April 08-19, 2012. Systematic sampling technique was used to select 523 study participants. Pre tested structured Amharic version questionnaire was used to collect the data through interview. Both bivariate and multiple logistic regressions were used to identify associated factors. RESULTS: Among 519 respondents, 323 (62.2%) were using modern family planning (FP) methods in which 101 (19.5%) were using long acting and permanent contraceptive methods (LAPMs). Among all respondents, 171 (32.9%) had unmet need for LAPMs. The total demand for LAPMs was 272 (52.4%) of which 37.1% were satisfied and 62.9% unsatisfied demand. Being in the older age group (40-44 years) [AOR = 2.8; 95% CI:1.12, 9.55], having no desire for more child [AOR = 20.37; 95% CI:9.28, 44.72], desire to have a child after 2 years [AOR = 6.4; 95%CI:3.04,13.47], not ever heard of modern FP [AOR = 5.73; 95% CI:1.26, 25.91], not ever using of modern FP [AOR = 1.89; 95% CI:1.01, 3.55] and having no spousal discussion in the last six month [AOR = 1.642, 95% CI: 1.049, 2.57) were some of the factors significantly associated with demand for LAPMs. CONCLUSIONS: Demand and unmet need for LAPMs were high in the study area. Therefore raising awareness of the community, counseling/discussion about the methods with all clients, encouraging spousal involvement are fundamental areas of intervention. Moreover, increasing the availability and accessibility of LAPMs is required to meet the unmet needs.

Suspect online sellers and contraceptive access.

BACKGROUND: Issues surrounding contraception access have been a national focus. During this debate, adolescent and adult women may seek these products online. Due to safety concerns, including potential counterfeit forms, we wished to assess whether online "no prescription" contraceptives were available. STUDY DESIGN: We assessed online availability of reversible, prescription contraceptive methods resulting in <10 undesired pregnancies/year, i.e., Depo-Provera shot; oral contraceptives; NuvaRing; Ortho Evra patch; Paragard and Mirena IUDs; and Implanon/Nexplanon implants. Using Google search "buy ITEM no prescription," we reviewed the first five result pages for "no prescription" vendors. Searches were conducted 1/3/2012-2/20/2012. RESULTS: All contraceptives were available as "no prescription" products. Furthermore, IUDs were advertised as "over-the-counter" and YouTube videos provided "how to" videos, including a cartoon version. We also found that illicit online pharmacy marketing is shifting from direct search engine access to social media (Facebook, Twitter, Slidehare, flickr). CONCLUSION: Online contraceptive sales represent patient safety risks and a parallel system of high-risk product access absent professional guidance. Providers should educate patients, while policy makers employ legal strategies to address these systemic risks.

The availability and accessibility of the contraceptive implant from family planning agencies in the United States, 1991-1992.

During the first year and a half after the hormonal contraceptive implant became available in February 1991, an estimated 81,100 women obtained this method from family planning agencies in the United States. Nevertheless, according to a recent survey of family planning providers, implant availability through the family planning clinic system is still far from universal. By September 30, 1992, only 40% of all family planning agencies were offering implant services to their clients: That proportion ranged from 30% of health department family planning providers to 80% of Planned Parenthood affiliates. Some of the key reasons cited by agencies that do not yet provide implants include the special clinician training required to learn insertion and removal procedures, and the cost of the method. Furthermore, full accessibility of this method to low-income women attending family planning clinics has been limited primarily to those who receive Medicaid, which has paid for more than 60% of all hormonal implants inserted by family planning agencies.