Long-Acting Reversible Contraceptives: An Important Approach to Reduce Unintended Pregnancies

Carolina Vieira
2016 Revista Brasileira de Ginecologia e Obstetrícia  
Unintended pregnancies are a major public health concern worldwide. In Brazil, as much as 55% of pregnancies are unplanned. 1 Unplanned pregnancy is associated with an increased risk of maternal, neonatal and infant morbidity and mortality. 2 It also reduces educational and career opportunities for mothers, and it may contribute to socioeconomic deprivation and widening income disparities. 3 The total cost attributed to unplanned pregnancy in Brazil is estimated to be R$ 4.1 billion (roughly
more » ... billion (roughly US$ 1.85 billion) annually. 4 Part of the high rate of unplanned pregnancies may be due to the relatively low use of long-acting reversible contraceptives (LARCs), specifically contraceptive implants and intrauterine devices (IUDs). 5 Less than 2% of Brazilian women who take contraceptives use LARCs. 6 By comparison, in the UK, LARCs are used by 31% of women using contraceptives, and the rate of unplanned pregnancies there is estimated to be 16.2%. 7 There are many reasons for the low prevalence rate of women using LARCs in Brazil, some of which are: only one type of LARC is available for free in the public health system (copper IUD); a lack of training in LARC methods in the majority of the obstetrics and gynecology residence programs; and biased information and inadequate counseling on LARCs being offered by some healthcare providers. The CHOICE project was responsible for bringing LARCs and unplanned pregnancies to the spotlight of the reproductive planning discussion. The CHOICE project was an observational cohort study developed to promote the use of LARC methods in the St. Louis region (USA). It was designed to investigate if high and stagnant rates of unintended pregnancy could be reduced by increasing the uptake of LARC methods. In order to achieve this objective, the project removed two major barriers in the use of LARC methods: the lack of access to free LARCs and the lack of adequate information on the safety and efficacy of these methods. 8 When the barriers of cost, access and knowledge were removed, 75% of the CHOICE cohort chose a LARC method at baseline enrollment. 9 The continuation rates of LARC methods were higher than those of non-LARC methods at 12 and 24 months (86 against 55% at 12 months; 77 against 41% at 24 months). 9,10 Overall, 84% of LARC users were satisfied with the method at 12 months, while only 53% of participants using short-acting methods were satisfied at the same period. 9 Although there is a concern that an increased uptake of LARC methods could increase risk-taking sexual behavior, the CHOICE project showed that the provision of no-cost contraception was not associated with increased risk-taking sexual behaviors. 11 Additionally, the superiority of LARC methods was confirmed over short-acting methods; implants and IUDs were 22 times more effective than oral contraceptive pills, patches, or rings. 12 In order to evaluate the population impact of this huge increase of LARCs use in the St. Louis region, the average annual rates of teen pregnancy, birth and induced abortion among the CHOICE participants were compared with the national rates of these outcomes. When compared with the national data, the CHOICE project showed over 75% reduction in all three outcomes. 13 In Brazil, studies using LARCs also showed low rates of premature discontinuations, and high continuation and satisfaction rates when adequate counseling was provided. 14,15 Therefore, counseling and evidence-based information are crucial to facilitate the decisions of women regarding a Editorial
doi:10.1055/s-0036-1583761 pmid:27213515 fatcat:rwiyrq7gmjhcdka7mmhmeinsbe