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| Repositioning Family Planning is a multilateral initiative aimed at mobilizing commitment to strengthen family planning services in sub-Saharan Africa. This e-bulletin provides a forum for the exchange of information to improve sustainable access to family planning. |
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Resources
Toolkits
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Approaches for Expanding Choice and Access to Long-Acting Reversible Contraceptives and Permanent Methods of Family Planning
Introduction
Expanding access to long-acting reversible contraceptives (LARCs) and permanent methods (PMs) has multiple benefits. They give women greater choice in selecting a contraceptive that meets their needs for delaying, spacing, or limiting pregnancy. LARCs and PMs have the highest continuation rates of all family planning methods (and conversely, the lowest discontinuation rates), and as such, are more effective in actual use than short-acting methods for preventing unintended or closely spaced pregnancy. In the least developed countries, use of LARCs/PMs accounts for less than one-fifth (19 percent) of the contraceptive method mix. It is estimated that if 5,000 oral contraceptive users were to switch to an intrauterine device (IUD) or implant, approximately 1,250 unintended pregnancies could be averted over a 5-year period.i LARCs are also highly cost-effective for programs, ranging from about $0.05 per year of use for the CuT 380A IUD, to $1.80 per year of use for Jadelle, and around $5.40 per year of use for Implanon, when used for their full number of years of effectiveness.
What are the LARCs?
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ParaGard
Effective for up to 12 years of use ($0.56 per piece)
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Mirena
Effective for up to 5 years of use (variable costs)
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Jadelle Implant
Effective for up to 5 years of use ($8.50 per set)
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Sino-Implant II
Effective for up to 4 years of use ($8.50 per set)
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Implanon Implant
Effective for up to 3 years of use ($16.50 per piece)
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What are Permanent Methods (PMs)?
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Tubal Ligation (TL) for Female Sterilization
Permanent contraceptive effect (client price varies by country)
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Non-Scalpel Vasectomy (NSV) for Male Sterilization
Permanent contraceptive effect (client price varies by country)
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Who can use LARCs and PMs?
LARCs – IUDs and implants – are a good method choice for woman at any stage of life. There is a growing demand among older adolescents for an effective method to delay their first pregnancy. Married couples of all ages are choosing LARCs to enable them to achieve healthy pregnancy spacing intervals. Couples who have reached their desired number of children are using LARCs to prevent future pregnancies. Once the LARC is removed, the woman’s fertility returns. With the increasing popularity and affordability of implants, programs should ensure the availability of implant removal services.
PMs – tubal ligation (female sterilization) and vasectomy (male sterilization) – are a good method choice for women, men, and couples who have reached their desired number of children and wish to prevent future pregnancies. Both of these methods have a permanent contraceptive effect, and clients should understand that the procedure is not reversible.
What are some key factors that can expand access to LARCs and PMs?
Holistic programming, with its attention to supply side, demand side, and enabling environmental factors, is highly effective for addressing barriers and expanding access and choice to quality LARC/PM services.
Supply: The provision of LARCs and PMs requires skilled personnel trained to offer the methods, access to medical instruments and consumable supplies specific to each method, and attention to Infection prevention procedures when providing services, processing instruments, and disposing of medical waste. Many countries have introduced task shifting/sharing with supportive supervision and referral systems as a means of expanding access to these methods, ensuring quality of care and managing side effects.
Enabling Environment: Policies should ensure wide access to these methods for all women, without barriers related to age and parity. Likewise, policies should ensure that LARCs and PMs are affordable to clients and that cost does not present a barrier to use. The supply chain and information systems should ensure that contraceptives, equipment, and consumable supply needs are included in procurement plans and that data are used to avoid stockouts. Infection prevention procedures must be implemented, including hand washing, processing of equipment and supplies, and medical waste disposal.
Demand: Underutilized methods, such as LARCs and PMs, benefit from behavior change communication efforts to increase awareness about the methods and their attributes and to inform clients where they can find easy access to affordable, quality services. Counseling and interpersonal communication informs clients about the range of contraceptives available to them and enables them to make an informed and voluntary choice of the method they wish to use. To learn more about U.S. Agency for International Development’s (USAID’s) statutory and policy requirements for family planning click here.
What approaches are effective for expanding access to quality LARC and PM services?
Mobile Outreach: Mobile outreach for family planning is defined as family planning services provided by a mobile team of trained providers from a higher-level health facility or nongovernmental organization (NGO) to a lower-level facility or area with limited or no family planning or health services. Mobile outreach services are a way to provide a full range of family planning methods to underserved communities or to bring complementary family planning services for LARCs and PMs to facilities and communities where only short-acting methods (pills, injections, condoms) are available. Critical components for mobile outreach family planning services include providing information about and mobilizing the community for the visit, counseling clients to ensure informed and voluntary choice, a setting where quality family planning services can be safely provided, and ensuring a process for follow-up or referral for management of side effects. Learn more about mobile outreach here.
Dedicated Provider: Dedicated providers receive special training in LARCs and PMs and provide these services through mobile outreach or within their own facilities. Outreach visits by individual or pairs of dedicated providers may adhere to a routine schedule or be conducted on “event days” to reach large numbers of women. The dedicated providers expand access and choice to LARCs and PMs at clinics whose staff may not be trained to provide these methods where only short-acting methods are available or when integrating family planning into other health services, such as birthing or immunization sessions. Dedicated providers conduct group education and provide individual counseling and same-day LARC or PM services upon request. The outreach approach has been successful in urban and peri-urban areas where public transportation is readily available, such as taxis or buses. .
Task Shifting / Sharing: Many countries are experiencing human resource shortages or inequitable distribution of highly skilled health staff, particularly physicians and midwives. As a result, there have been concerted efforts to address these shortages and inequities by training other cadres of health workers to provide LARCs and PMs. For example, clinic officers are being trained in tubal ligation and no-scalpel vasectomy (NSV), and midwifery assistants are being trained in implants and IUDs, and district health officers are being trained as supervisors.
Social Franchise Private Providers: Social franchises for family planning are a branded network of private providers who agree to offer a package of family planning and reproductive health services and adhere to quality standards into their practices. They can be trained to offer LARCs and PMs within their package of family planning services, and many integrate these services with maternal and child health services that they provide. Social marketing approaches are often used to advertise these services and their prices to consumers. Some offer vouchers to poor women to cover the costs of LARC and PM services. To expand further access to family planning, some providers offer vouchers to low-income women and men to offset the costs of these family planning services, including LARCs and PMs.
Integrated Services: Increasingly more women are accessing integrated maternal, newborn and child health services – attending antenatal clinics, giving birth in facilities, and bringing their children for immunization, nutrition, and other child health services. Reaching women who are already at facilities is an effective way to educate, counsel, and offer family planning services, including LARCs and PMs.
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Antenatal Care (ANC): ANC is a good time to talk with women about their reproductive intentions for spacing or limiting future pregnancies and postpartum family planning options. Women who choose to have an IUD or TL at the time of birth should have their method choice noted on their health card. A signed consent form for TL can also be obtained at this time. NSV should also be offered as an option for couples who wish to prevent future pregnancies.
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Birthing: Only two methods, the IUD or TL, can be provided immediately following a birth (post-placental or intra-caesarean). Ideally the woman has decided on one of these methods during ANC counseling or in early labor; active labor is not considered an appropriate time to discuss these methods with women. All equipment and commodities must be available in the delivery unit. Before going home from the facility, women in the postpartum ward can be counseled about birth spacing, reproductive intentions for spacing or limiting, and postpartum family planning options. Women who choose to have an IUD or TL post-birth can receive the method prior to discharge. NSV should also be offered as an option for couples who wish to prevent future pregnancies.
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Postabortion: In general, all modern methods of FP, including LARCs and PMs can be used immediately after uterine evacuation, provided there are no severe complications requiring further treatment, the client receives adequate counseling, and the client makes an informed and voluntary choice of method. The time of treatment for incomplete abortion is not the best time for clients to make decisions about methods that are permanent.
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Immunization: Routine immunization sessions offer an opportunity to reach many women at one time with information about postpartum family planning and contraceptive options. Immunization providers can use the Systematic Screeningii tool to identify and refer women who want family planning to the appropriate service delivery point – often a service within the same facility. Dedicated providers who have been trained in LARCs and PMs can also participate in immunization sessions – either through mobile visits or as dedicated providers based at the facility – enabling women who choose a LARC or PM to receive this service before returning home.
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Nutrition and other Child Health Services: The content and timing of postpartum family planning and nutrition messages are mutually reinforcing. Following birth, women are encouraged to breastfeed exclusively for six months, which coincides with the period for practicing the lactation amenorrhea method (LAM). At six months, complementary feeding is introduced for the baby, and the mothers who are practicing LAM should transition to another modern contraceptive method. Nutritional feedings should be continued for the infant through 2 years of age, and mothers are advised to continue using a family planning method and wait until the child is at least 2 years old before attempting to become pregnant. Other child health visits – to the household by community health workers or at the facility – are opportunities for health workers to discuss women’s contraceptive needs and offer or refer them for family planning services.
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HIV and PMTCT services: Demand for and use of contraceptives among HIV-positive women mirrors that of the general population of women. HIV-positive women may first be identified during antenatal or birthing services, enter into the prevention of mother-to-child transmission of HIV (PMTCT) program, and transition to HIV care and treatment programs – all of these present opportunities for integrating family planning services, including LARCs and PMs. With effective HIV treatment, HIV-positive women can enjoy a long and full life and should have access to the same counseling and voluntary choice of family planning methods as all women of reproductive age.
i Calculation based on methodology described in Hubacher, D., et al. 2007. Contraceptive implants in Kenya: Current status and future prospects. Contraception 75(6):468–473.
ii Systematic Screening Tool; developed by Population Council and adapted for postpartum use by JHPIEGO under the ACCESS-FP project.
We Want to Tell Your Repositioning Story
Please contact Carmen Tull at ctull@usaid.gov and Alexandra Todd-Lippock at atoddlippock@usaid.gov with your successes in family planning programming.
Please contact Patricia MacDonald, USAID LARC/PM Technical Champion, for additional information at pmacdonald@usaid.gov.
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