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.

Access to the copper IUD as post-coital contraception: results from a mystery caller study.

OBJECTIVE: To assess access to the copper IUD as post-coital contraception (PCC) and identify barriers to obtaining this contraceptive method. STUDY DESIGN: We used a "mystery caller" approach to survey primary care, family planning, and Ob/Gyn clinics in nine U.S. cities, identified via online search. A single researcher called 199 clinics, assuming the role of a patient seeking the copper IUD for PCC. Using a standard script, the researcher collected information regarding access to the copper IUD and respondent's knowledge of the copper IUD's indication for PCC. The primary outcome was availability of the copper IUD as PCC. Secondary outcomes included any provision of the copper IUD, awareness of the copper IUD's indication for use as PCC, and offering accurate information regarding the copper IUD as PCC. Fisher's exact test was used to compare outcomes by clinic type. RESULTS: Two thirds (68%) of primary care clinics, 87% of family planning clinics, and all Ob/Gyn clinics offered the copper IUD (p<.001). Only 11% of primary care clinics, however, were aware of the copper IUD's use as PCC, as compared with 63% of family planning clinics and 24% of Ob/Gyn clinics (p<.001). Few primary care or Ob/Gyn clinics offered the copper IUD as PCC, while 49% of family planning clinics did so (p<.001). CONCLUSION: Access to the copper IUD as PCC is limited and varies by clinic type. Knowledge gaps exist regarding the use of the copper IUD as PCC, as well as regarding the general medical guidelines for copper IUD placement. IMPLICATIONS: A majority of primary care and Ob/Gyn clinics do not offer the copper IUD as PCC, and only about half of family planning clinics do so. Barriers included lack of knowledge, unavailability of device, unavailability of an appointment with a trained provider, and outdated IUD provision protocols.

Emergency Contraception.

Emergency contraception (EC) may help prevent pregnancy in various circumstances, such as contraceptive method failure, unprotected sexual intercourse, or sexual assault, yet it remains underused. There are 4 approved EC options in the United States. Although ulipristal acetate requires a provider's prescription, oral levonorgestrel (LNG) is available over the counter for women of all ages. The most effective method of EC is the copper intrauterine device, which can be left in place for up to 10 years for efficacious, cost-effective, hormone-free, and convenient long-term primary contraception. Ulipristal acetate tends to be more efficacious in pregnancy prevention than is LNG, especially when taken later than 72 hours postcoitus. The mechanism of action of oral EC is delay of ovulation, and current evidence reveals that it is ineffective postovulation. Women who weigh more than 75 kg or have a body mass index greater than 25 kg/m(2) may have a higher risk of unintended pregnancy when using oral LNG EC; therefore, ulipristal acetate or copper intrauterine devices are preferable in this setting. Providers are often unaware of the range of EC options or are unsure of how to counsel patients regarding the access and use of EC. This article critically reviews current EC literature, summarizes recommendations, and provides guidance for counseling women about EC. Useful tips for health care providers are provided, with a focus on special populations, including breast-feeding women and those transitioning to long-term contraception after EC use. When treating women of reproductive age, clinicians should be prepared to counsel them about EC options, provide EC appropriately, and, if needed, refer for EC in a timely manner.

Emergency contraception: separating fact from fiction.

Rates of unintended pregnancy and abortion are high, yet many doctors do not feel comfortable discussing emergency contraception with patients, even in cases of sexual assault. Since the approval of ulipristal acetate (ella) for emergency contraception, there has been even more confusion and controversy. This article reviews various emergency contraceptive options, their efficacy, and special considerations for use, and will attempt to clarify myths surrounding this topic.

Non-availability of the IUD and contraceptive choice.

The Copper 7 and Lippes Loop IUD are no longer distributed in the United States, and the cost of the Progestasert precludes usage in many family planning clinics. The impact of the loss of this widely used contraceptive method was assessed in a pilot study at the UCLA Family Planning Clinic. The clients who would have selected an IUD at the time of their clinic visit between March and December of 1986 instead chose oral contraceptive pills (55%) or barrier methods (45%) but their level of dissatisfaction with the methods they received was significantly greater than that of all other contraceptors, and this led to their subsequent selection of another method which, in the majority (66%), was of lower efficacy than the IUD. There were two unplanned conceptions amongst twenty women who would have chosen an IUD, both due to non-compliance with oral contraceptive pills; and at the time of survey in March 1987, no clients had opted for sterilization. Women who no longer have their choice of the IUD represent a high risk for contraceptive dissatisfaction and failure, but have not made precipitous decisions to undergo permanent sterilization.

PIP: The Copper 7 and Lippes Loop IUD are no longer distributed in the US, and the cost of the Progestasert precludes usage in many family planning clinics. The impact of the loss of this widely used contraceptive method was assessed in a pilot study at the UCLA Family Planning Clinic. The clients who would have selected an IUD at the time of their clinic visit between March and December of 1986 instead chose oral contraceptive pills (55%) or barrier methods (45%) but their level of dissatisfaction with the methods they received was significantly greater than that of all other contraceptors, and this led to their subsequent selection of another method which, in the majority (66%), was of lower efficacy than the IUD. There were 2 unplanned conceptions amongst 20 women who would have chosen an IUD, both due to non-compliance with oral contraceptive pills; and at the time of survey in March 1987, no clients had opted for sterilization. Women who no longer have their choice of the IUD represent a high risk for contraceptive dissatisfaction and failure, but have not made precipitous decisions to undergo permanent sterilization.

The return of the IUD.

PIP: Over the course of 5 months in late 1985 and early 1986, Ortho Pharmaceutical Corporation ceased manufacturing their nonmedicated IUD, the Lippes Loop, and G.D. Searle and Company stopped US sales of their copper-bearing IUDs, the TCu 200 and the Copper-7. Both companies cited reasons that were business-related, not safet-related: In recent years, the Lippes Loop had lost ground in sales to Copper-bearing IUDs; in addition, since the late 1970s, the number of lawsuits filed against Searle by women alleging that they had been injured by IUD use had mushroomed. Thus, Ortho and Searle elected to remove their IUDs from the US market, even though the FDA still considered them safe and effective methods of birth control. After this, attention was turned to other IUDs as yet unlicensed in the US. 1 such IUD, the TCu 380A, was developed by the The Population Council in 1972, and has been used by many women around the world since 1982. But it was not until October 1987 that The Population Council was able to license the IUD. The TCu 380A represents an improvement over the TCu 200, in part because it carries 380 mm squared of copper instead of 200 mm squared. The copper on the TCu 380A comes both around the stem and fitted to the IUD's crossbar; as a result, the device delivers more copper ions to the uterine fundus, enhancing the contraceptive effect. A number of studies have shown the 4 year pregnancy rate associated with the TCu 380A to be less than 2 per 100 users.^ieng