Long-Acting and Permanent Contraception: An International Development, Service Delivery Perspective Roy Jacobstein, MPH, MD Recent scientific findings about long-acting and permanent methods of contraception underscore their safety, effectiveness, and wide eligibility for individuals who desire them. This has led to new guidance from the World Health Organization to inform national policies, guidelines, and standards for service delivery. Although developing countries have made much progress in expanding the availability and use of family planning services, the need for effective contraception in general (and long-acting and permanent methods in particular) is large and growing because the largest cohorts in human history are entering their reproductive years. More than half a billion people will use contraception in developing countries (excluding China) by 2015, an increase of 200 million over levels of use in 2000. The health, development, and equity rationales that historically have underpinned and energized the international family planning effort remain valid and relevant today. Despite the other compelling challenges faced by the international health community, the need to make family planning services more widely available is pressing and should remain a priority. J Midwifery Womens Health 2007;52:361–367 © 2007 by the American College of Nurse- Midwives. keywords: contraception, female sterilization, implants, international family planning, IUDs, reproductive health, vasectomy, WHO Medical Eligibility Criteria INTRODUCTION of maternal mortality and an even greater risk of maternal morbidity. By contrast, women in developed countries Over the past four decades, the organized international face a lifetime risk of maternal death of one in 2800 family planning effort has made great progress in ex- 2 panding the availability and use of voluntary reproduc- (.035%). tive health and family planning services. Access to Recent scientific findings and new understanding modern contraception has become recognized by the about long-acting and permanent methods of contracep- international community as a basic human right; how- tion underscore their safety and effectiveness. This has ever, obstacles and challenges remain. led to new guidance from the World Health Organization 3 Meeting the current needs for family planning is (WHO), as well as continuing strong support by the US difficult. An even greater challenge will be to meet the Agency for International Development (USAID) for contraceptive needs of the largest cohorts in human family planning in general and for long-acting and history to enter their reproductive years. There will be permanent methods of contraception in particular. The more than half a billion contraceptive users in developing methods considered “long-acting” in this context are countries (excluding China) by 2015, an increase of 200 intrauterine devices (IUDs) and implants; vasectomy and million people over the number of people using contra- female sterilization are considered “permanent.” In- ception in 2000. Whereas the rates of modern contracep- jectables, such as Depo-Provera (Pfizer U. S. Pharma- tive use in North America and Western Europe are over ceuticals, New York, NY), are considered “short-acting” 70%, such use is still very low in East Africa (17%), because their lengths of action are only from 1 to Middle Africa (5%), and West Africa (6%). 3 months. Related to these levels of contraceptive use, maternal WHO’s guidance documents are available to inform mortality is a great rarity in the developed world (e.g., national policies, guidelines, and standards for delivery two deaths per 100,000 live births in Sweden), whereas of family planning services, which in turn should help in the developing world, maternal morbidity and mortal- foster wider access to family planning services. Wider ity is much more common. For example, there are one or access to and use of family planning, especially of more maternal deaths for every 100 births in 17 of the 36 long-acting and permanent methods of contraception, countries in West, Middle, and East Africa.1 Women in which are the most effective contraceptives available, sub-Saharan Africa face a one in 16 (6.25%) lifetime risk can substantially reduce the high levels of maternal mortality and morbidity in developing countries, as well as unwanted pregnancies and abortion. Address correspondence to Roy Jacobstein, MPH, MD, Clinical Director, In recognition of the pressing need to make quality, the ACQUIRE Project, EngenderHealth, 440 Ninth Avenue, New York, voluntary family planning services more widely avail- NY 10001. E-mail: [email protected] able, the Office of Population at USAID designed the The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the Access, Quality, and Use in Reproductive Health (AC- United States Government. QUIRE) Project, a 5-year, $150 million project that Journal of Midwifery & Women’s Health • www.jmwh.org 361 © 2007 by the American College of Nurse-Midwives 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.01.001 Issued by Elsevier Inc. focuses on facility-based services and clinical contracep- Table 1. WHO Medical Eligibility Criteria, Classification Categories tion, especially long-acting and permanent contraception. Provider With Classification Provider With Clinical Limited Clinical WHO GUIDANCE FOR FAMILY PLANNING USE Category Judgment Judgment WHO has developed evidence-based tools that help 1 Use method in any Yes, use the method circumstances providers and clients choose an appropriate contraceptive 2 Generally use the method Yes, use the method method. These tools include a family planning handbook 3 Use of method not usually No, do not use the for frontline providers, a counseling tool, and two guid- recommended unless other method ance documents: Medical Eligibility Criteria for Contra- more appropriate methods ceptive Use3 and Selected Practice Recommendations for are not available or not 4 acceptable Contraceptive Use. The eligibility criteria and practice 4 Method not to be used No, do not use the recommendations are based on systematic reviews of the method latest clinical and epidemiological research. They are 3 meant to inform and rationalize national service delivery From the World Health Organization. guidelines, policies, standards, and practices, leading to improved access, quality, and use of the range of modern family planning methods. Updated guidelines and poli- THE COPPER INTRAUTERINE DEVICE cies also can help reduce or eliminate unjustified medical The copper IUD (CuT 380A) has an effectiveness profile 5 policy and practice barriers. comparable to that of female sterilization, vasectomy, The Medical Eligibility Criteria gives guidance on the and implants. Three to eight women per 1,000 using the safety and appropriate use of modern methods of contra- CuT 380A IUD become pregnant in the first year of use.6 ception. The question addressed is, “In the presence of a A long-term international study sponsored by WHO given medical condition or client characteristic, can a found an average annual failure rate of 0.4% or less, and particular family planning method be used, and with a cumulative failure rate after 12 years of use of 2.2%,7 what degree of caution or restriction, as reflected in four which is comparable to that of female sterilization. classification categories?” These classification categories Copper-bearing IUDs have been shown to be very safe represent gradations based on likely benefits and risks. The Medical Eligibility Criteria’s schema also distin- for most women (Category 1 or Category 2). This guishes among providers “with clinical judgment” and includes women who are: postpartum, postabortion, and “with limited clinical judgment” (Table 1). For providers farther from pregnancy or birth (i.e., “interval” IUD with limited clinical judgment, Categories 1 and 2 insertion); breastfeeding; HIV-infected; young and/or become “Yes, use the method,” while Categories 3 and 4 nulliparous; and unable to use hormonal methods. IUDs become “No, do not use the method.” These distinctions are highly protective against ectopic pregnancy via their and simplifications are helpful, particularly in the coun- high efficacy in preventing any pregnancy. Women who tries of sub-Saharan Africa and South Asia, where human use copper-bearing IUDs have a 91% lower absolute risk resources for health care are scarce, and thus much of of ectopic pregnancy than do women using no contra- family planning service delivery must be provided by ception.8 However, among women who do become providers with relatively limited training. pregnant while using an IUD, the relative risk of ectopic The Selected Practice Recommendations functions as pregnancy is higher than in non-users, with an estimated a set of frequently asked questions. Practice recommen- 6% to 8% being ectopic.9 Still, this means that 92% to dations address common clinical issues that arise in the 94% of the rare pregnancies in IUD users will not be provision of modern contraceptive methods. Based on ectopic. While some women report increases in men- systematic review of available scientific evidence but- strual bleeding with copper IUD use, no significant tressed by expert consensus, the Selected Practice Rec- changes in hemoglobin levels have been found.10 WHO ommendations addresses 33 common questions providers thus advises that the CuT 380A can generally be used by are likely to have