Introduction
Long-acting reversible contraception (LARC) is defined as birth control a method that provides effective contraception for extended periods. The ‘long’ implies that the contraceptives require administration of less than once per cycle or month. In comparison to other methods of contraception, LARCs do not require frequent repeat administration; and are not intended to result in permanent sterilization. Examples of available LARC methods include intrauterine system (IUS) or intrauterine contraceptive, Intrauterine device (IUD), and contraceptive implants commonly traded as Implanon and Norplant. Specifically, the categories can be differentiated as progesterone-only intrauterine systems, progesterone-only subdermal implants, progesterone-only injectable contraceptives, copper intrauterine devices, and combined vaginal rings. However, some shorter-acting methods are at times considered longer-acting reversible contraception, examples of which include combined injectable contraceptive and Depo Prova injection (NICE, 2005).
The paper analyses the elements of clinical care for the administration of LARC methods in sexual health clinics, hospital services, community contraceptive clinics, and general practice. The implementation of clinical guidelines on the effective use of LARCs by the Department of Health is considered a development standard especially if it is monitored by the Healthcare Commission. For each local health community in England and Wales, the implementation of the guideline will form part of the service development plans. In an attempt to establish the reasons why professionals should advocate for LARC usage among women of all ages, the paper enumerates statistical evidence that compares the performance and failures rate between LARC methods and combined oral contraceptives. After enumerating the benefits associated with LARC methods, the implementation process for both the providers and the user is outlined. Although LARC is numerously detailed, the possible challenges that may deter its effective implementation are also elaborated (NICE, 2005).
Whether professionals should advocate LARC
The occurrence of unintended pregnancies has been on the increase. In some developed countries, up to 20 percent of pregnancies are terminated through induced abortion while close to 30 percent of children are born out of mistimed or unplanned pregnancies. Annually roughly 20 million pregnancies end in induced abortion; out of which 200,000 are found in the UK while over 1 million are in the United States. Research has established that despite these increased terminations; almost all pregnancies cases can be prevented. As a matter of fact, with most individuals having access to at least some modern methods of contraception, consistent and proper use of the appropriate methods is said to prevent over 95% of pregnancies. Failure of contraception has been reported in very few cases to result in unintended pregnancies. According to Stevens, Kelly, and Kulick, pregnancies resulting from failure to use any method of contraception are common in developing countries, while the failure of the couples in industrialized countries to use their preferred method correctly and consistently (2001, 60-65).
The majority of women, who have undergone an abortion, did not intend to get pregnant and most were positive about correctly using contraception. Sadly, the results point to the fact that most users of contraceptives are not good at using them. For instance, of the 10.683 women surveyed in the US who had an abortion in 200-2001, five in every 10 women were found to have been using contraceptives during the month of conception; 80 percent of the 300 women having induced abortion in Scotland had also used contraception during the month of conception. From the two studies, 28% and 55% used condoms while 14% and 20% used oral contraceptives during conception in US and Scotland, respectively. Correct and consistent use determines the effectiveness of the contraceptive pill and condoms as indicated by the two studies. Oral contraception commonly suffers from poor compliance as indicated in one of the US studies where 47 percent of women claimed missing one or more pills a month and 22 percent missed two or more.
Due to discontinuation and poor compliance with oral contraceptives, an estimated 700,000 unintended pregnancies annually are reported in the USA. Higher rates of inconsistency and poor use have been reported with methods of contraception that are used during every instance of intercourse, such as condoms. Higher rates of discontinuation are common with all methods of contraception, but for methods that are easy to discontinue close to half of the women who began using a method reported to have stopped within one year. As evident in the statistics, individuals stop using the pill or condoms by inertia more than a well-made decision. Others despite having a condom will forget to use it, while users of the pill fail to go for more supplies when out of stock. In contrast, long-acting reversible contraceptives such as IUDs and IUS are incomparably effective as they are associated with little rates of discontinuation and almost nil rates of compliance (Taylor, Keyse, and Bryant, 2006).
The studies from the US study indicated a failure rate of 15 percent and 8 percent for contraceptive pills and condoms respectively, while 0.1 percent and 0.05 percent for IUS and contraceptive implants. Additionally, 47 percent and 32 percent of first-time users had stopped using the condoms and the pill respectively, compared to 16 percent and 19 percent who had their Implant and IUS removed in one year. Cases of unintended pregnancies were rarely reported by women using LARC, and less than 1 percent of the women having an abortion in the US and Scottish studies were using LARC (Trussel, 2007, 759).
Advantages of LARC
According to Frost, Darroch, and Remez (2008, 1-5), the potential of the LARC has been widely recognized. England’s NICE (National Institute for Health and Clinical Excellence) national evidence-based guidelines were convinced that “increased use of LARC will lower the rates of unintended pregnancies”. In recent years, a drop in teenage pregnancies in the USA has been associated with the increased use of Depo Provera. Similarly, a Californian study to investigate condom use pointed to the reduced rates of pregnancies among young mothers who reported to have been avoiding unintended pregnancies using LARC. During the 2 years of study, while 33 percent of condom users and 30 percent of oral contraceptives became pregnant, and no teenager using Norplant conceived.
Therefore, with evidence from the studies indicating that individuals suffer the consequences of unintended pregnancies due to inconsistent and incorrect use; while long-acting methods provide the effectiveness desired of contraceptive use; considering that most people who don’t want to have babies would rather prevent pregnancies than a resort for an abortion, health professionals should advocate for use of LARC.
Whether or not health professionals need to advocate LARC depends on the geographic areas of study. Schunmann and Glasier (2006) believe that most countries have reported reduced use of long-acting contraceptives, with only 16 percent of women between the ages of 15 to 59 in consensual union using the contraceptive pill, 13 percent depending on condoms, and 15 percent relying on partner sterilization, compared to a paltry 9 percent on LARC. The developing countries boast of an 18 percent use of LARC, but few countries record single use of the methods such as implants in Indonesia, IUD in China, and Injectibles in South Africa. Consequently, countries that recorded high rates of unintended pregnancies for young women and maternal mortality for mothers suffer the consequences of reduced LARC use.
While only 2 percent of UK women use implants and 2 percent use IUS, less than 1 percent usage is reported in the United States. Although advocating LARC would likely increase the usage and eventual reduction on the rampant cases of unintended pregnancies, potential providers should also be encouraged on LARC due to their reservations. In the UK, this is true of family doctors and practice nurses, which reflects health professionals of other countries as well. In the UK for instance, the health professionals concentrate on the effects of Depo Provera on born marrow density and due to lack of experience in the dissemination of intrauterine methods, conclude that women withdraw from using Implanon, a few months upon commencing use. Their view on discontinuation is misguided despite the increased cases of doctors reporting the removal of implants than continuance incidences. Clinic-based studies conducted in UK and Scotland established decreased rates of Implanon continuation over 3 years in comparison to the contraceptive pill. In appreciation of the recommendations from the studies, the government of England and Scotland are promoting campaigns for both users and providers on the use of LARC (Peterson and Curtis, 2005).
Elements of implementation
The prescription and effective use of LARC cannot be successful if several aspects are not keenly taken into consideration. Firstly, a woman upon expressing a desire to use contraception deserves to be freely provided with information detailing the available options. The information should also allow for the woman to choose among all the contraceptive methods including long-acting methods. Secondly, contraceptive administrators should have adequate information concerning all contraceptive options available, such as
- Currently available LARC methods (injectable contraceptives, Intrauterine devices, implants, and intrauterine systems) compared to the oral contraceptive pill are relatively cost-effective, even if discontinued after 1 year of use.
- Implants, IUS, and IUDs are utterly cost-effective compared to Injectable contraceptives
- To reduce the number of unintended pregnancies, women should increase the uptake of LARC methods.
Thirdly, counseling before the administration of the contraceptive should equip potential users with pertinent information. This advice delivered both verbally and in writing, taking into consideration their individual needs will enable informed decision making of the appropriate and effective method should inform about contraceptive efficiency, risks, and likely side effects, duration of use, initiation and discontinuation process, non-contraceptive advantages, and situations that need professional help while using the method (Glasier, et al., 2008, 213-214).
Fourthly, healthcare professionals must receive adequate training for the implementation process to be effective. Therefore
- Healthcare providers and professionals ought to be capable to assist women to consider and choose based on benefits and risks, the preferable contraceptive method that serves their own needs. Additionally, as a follow-up measure, the professionals should willingly manage the unprecedented problems and side effects associated from thwithoption of a given method.
- Contraceptive professionals providing other contraceptive methods apart from LARC methods in their practice should have an arrangement in place for referring potential LARC users to the right places.
- Providers and administrators specializing in intrauterine and subdermal contraceptives should frequently be trained to develop and improve the relevant skills and experience in the administration of the methods.
However, provision of contraceptive options often takes care of the majority groups; without considering special groups of women. In that case, the above process should ensure the information caters to the woman’s specific needs. Where necessary, the providers should offer support during the decision-making stage by either availing an interpreter for women that are non-English speakers or ensuring adequate help for women with learning disabilities or sensory impairments. Concerning the young, utmost attention should be paid to the legal standards concerning the provision of contraceptives to the young and disabled women; adopting Fraser guidelines when administering contraceptive methods for women aged 16 and below. The providers should keenly attach the individual needs and relevant contraceptive options, instead of following the advice of carers or relatives. An exception however exists in a situation where the woman cannot understand or take responsibility for choices of contraceptives available. In this case, the carers and members around the woman should discuss and agree on the appropriate care plan for the woman.
A study conducted by Hairon (2008, 23) on the attitude of women toward contraception aimed at understanding their concerns, and finding ways of encouraging increased uptake of the long-acting methods. Primary in the concern was the fear of possible side effects of contraceptives on their fertility. Fundamentally, the research began by requiring practitioners to desist referring to the methods as ‘long-acting’ but instead to stress the lasting protection of the methods. From the study, potential side effects that deterred women included weight gain, which seemed much of a threat than fear of unintended pregnancies. Although it was evident that some barriers to the uptake could not be overcome, suggestions to improve acceptability included reversibility capabilities, further information on ease of use, and possible effects on weight according to other women’s experiences. Factors such as reliability and efficacy on unintended pregnancies and diseases, ease of use, safety, reversibility, side-effects, and accessibility determine the decision to use a specific method of contraceptive. Similarly, familiarity was cited as an important aspect determining the acceptability of relatively new contraceptive methods. In the study, the introduction of LARC methods seemed ‘unusual’ due to increased uptake of oral contraceptives by the majority of the women, which was seen as a norm. This point brought out the position of a health professional in making sure all the available options are made known to contraceptive users before advising on a specific method (Hairon, 2008, 23-24).
However, during the study, the women despite being aware of the possible side-effects emphasized the importance of contraceptives and were therefore willing to take the risks. On the contrary, concern over healthcare professionals brought out by the inability of some women to see a doctor was associated with confidentiality issues, embarrassment, and inconvenient access. At this point, many respondents preferred being attended to by female professionals, posing a challenge on the role of nurses in the administration of contraceptive methods. Others were specific to indicate that they were shy to openly have discussions concerning contraception with providers. As such, it was imperative for health professionals to readily offer contraceptive information to women as they are considered knowledgeable than the potential users. In turn, the professionals ought to be proactive, present adequate information for decision making, ask the right questions openly and avoid making assumptions.
Challenges of implementing LARC
Despite the benefits accruing from the adoption of long-acting contraceptives, Taylor et al believe that certain issues likely to counter its implementation are equally important. Primarily, costs of advocating the methods; coercion and sexually transmitted infections, stand out as issues to be considered (2006). The cost of long-acting methods is considered expensive by some program managers and providers. The National Hospital Service spends as low as US$15 for an IUD and as high as US$125 for an IUS annually excluding costs for insertion procedure and consultation (Darney et al., 1998, 929-932). These costs are considered relatively higher in other countries, especially if the knowledge and use of the methods are yet to be embraced. However, considering the effectiveness of LARC and the unexpectedly high cost of pregnancy, NICE believes that in comparison to the pill and condoms, LARC is cost-effective; even if discontinuation is to occur at the end of the first year of usage.
The second issue is coercion, whereby too much enthusiasm toward a specific method of contraception may force individuals into using a method without considering the potential risks associated. For instance, LARC’s inability to be discontinued without the help of a doctor and their ‘invasive procedure’ would easily result in coercion should one desire to use the contraceptive (Trussel 2007). However, the free healthcare that is available for such women ensures that they do not suffer the consequences of coercion. Such women have so much loyalty to their reservations that it feels almost impossible to try and persuade them on otherwise ‘uncommon’ contraceptive options. Unlike another oral contraceptive, this unique trait by UK women is important in that women who had previously been persuaded to use methods they did not approve will easily discontinue if an available option is presented.
Thirdly, the belief that increased use of LARC will decrease the likelihood of using condoms, hence heightening the chances of contracting Sexually transmitted Infections discredits the otherwise effective methods of preventing unintended pregnancies. This is a common situation for young people especially the unmarried as they wouldn’t be worried about pregnancies, but instead, expose themselves to the risks of STIs and even AIDS. As indicated by the study conducted in California, teenagers on contraceptive implants compared to those on condoms and oral contraceptives reported less use of condoms. The number of users that reported new STIs during their second year was fewer compared to those using contraceptive pills and condoms. Although higher numbers of teenagers claimed to be on contraceptives and condoms were reported to inconsistently use the contraceptives in preventing unintended pregnancies, the trends were also reflective in the adult users. Despite, the intended plan of encouraging users of oral contraceptives and condoms to adopt LARCs remains, a threatening factor is the exposure of increased rates of STIs hampers the future of LARC use.
Therefore, while LARC is associated with most benefits to women intending to avoid unwanted pregnancies and desiring to stop a contraceptive method whenever without effects, it is also important to take into consideration the likely consequences of a given method. On the other hand, health professionals should propagate their goal of trying to persuade women to undo most of their reservations regarding LARC; because considering the accruing benefits that the users are to acquire upon adoption, the effort is worth putting in.
Conclusion
The debate on whether or not the adoption of LARC should be advocated remains a hotly contended issue. However, studies conducted in England and Scotland have established the numerous benefits that recur to users compared to other contraceptives. Although the users would be the likely beneficiaries of information concerning the use of long-acting methods, the providers should equally be educated on the administration, always ensuring their misconceptions and reservations are correct.
Based on failure rates, LARC outcompetes contraceptive pills and male condoms; trends indicated by the rates of continuance and correct use. The use of LARC takes the responsibility of correctly and consistently using contraceptives from the hands of the users and instead provides for the effectiveness and reliability, otherwise not guaranteed by oral contraceptives and condoms. As a result, LARC, though considered expensive by some providers and program managers is a better option for women willing to avoid unintended pregnancies rather than resort to abortion in case of failure. Although many factors that were of concern by women using other contraceptives presented a greater challenge on the acceptability of LARC methods, availability of adequate information to aid their decision making, coupled with the numerous benefits associated with LARC uses ensured increased uptake.
References
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