The introduction of Cyclofem into national family planning programmes: experience from studies in Indonesia, Jamaica, Mexico, Thailand and Tunisia. Task Force on Research on Introduction and Transfer of Technologies for Fertility Regulation, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland

Family Planning Practices, Programmes and Policies in India Including Implants and Injectables with a Special Focus on Jharkhand, India: A Brief Review

The National Family Health Survey (NFHS)-3 clearly delineates that the usage of contraceptive practices has increased considerably but is more inclined toward terminal methods of contraception especially the female sterilization. The fact is also evident from various studies carried out from time to time in different Indian states. Given the context we carried out a short review to understand the family planning practices, programs and policies in India including implants and injectable contraceptives with a special focus on the state of Jharkhand. We found that among the reversible methods IUCD (intra uterine contraceptive devices), OC (oral contraceptive) pills and condoms are the most commonly used methods. In this review, in addition to national picture, we specially focused on the state of Jharkhand owing to its very gloomy picture of family planning practices as per NFHS -3 reports. The current usage of any methods of contraception in Jharkhand is only 35.7% out of which terminal methods especially female sterilization accounts to 23.4% and male sterilization being only 0.4%. Similar picture is also reflected in the conventional methods such as; IUCD-0.6%, oral pill -3.8% and condom-2.7%. Compared to the national figure the unmet need for family planning in Jharkhand is also relatively high for the conventional reversible methods than that of terminal methods which is 11.9 and 11.3 respectively. Injectable contraceptives are available only through private or social marketing channels, because of which their use is limited. The studies carried out in different Indian states show improvement in contraceptive prevalence but the same needs further improvement.

The special programme of research in human reproduction: forty years of activities to achieve reproductive health for all

The Special Programme of Research in Human Reproduction (HRP), co-sponsored by the UNDP, UNFPA, WHO, and the World Bank, is celebrating 40 years of activities with an expansion of its mandate and new co-sponsors. When it began, in 1972, the main focus was on evaluating the acceptability, effectiveness, and safety of existing fertility-regulating methods, as well as developing new, improved modalities for family planning. In 1994, HRP not only made major contributions to the Plan of Action of the International Conference on Population and Development (ICPD); it also broadened its scope of work to include other aspects of health dealing with sexuality and reproduction, adding a specific perspective on gender issues and human rights. In 2002, HRP's mandate was once again broadened to include sexually transmitted infections and HIV/AIDS and in 2003 it was further expanded to research activities on preventing violence against women and its many dire health consequences. Today, the work of the Programme includes research on: the sexual and reproductive health of adolescents, women, and men; maternal and perinatal health; reproductive tract and sexually transmitted infections (including HIV/AIDS); family planning; infertility; unsafe abortion; sexual health; screening for cancer of the cervix in developing countries, and gender and reproductive rights. Additional activities by the Programme have included: fostering international cooperation in the field of human reproduction; the elaboration of WHO's first Global Reproductive Health Strategy; work leading to the inclusion of ICPD's goal 'reproductive health for all by 2015' into the Millennium Development Goal framework; the promotion of critical interagency statements on the public health, legal, and human rights implications of female genital mutilation and gender-biased sex selection. Finally, HRP has been involved in the creation of guidelines and tools, such as the 'Medical eligibility criteria for contraceptive use', the 'Global handbook for family planning providers', the 'Definition of core competencies in primary health care', and designing tools for operationalizing a human rights approach to sexual and reproductive health programmes.

Predicting impact of price increases on demand for reproductive health services: can it be done well?

OBJECTIVE

To assess criterion validity of a survey that uses contingent valuation to elicit estimates of client willingness-to-pay (WTP) higher prices for family planning and reproductive health services in three developing countries.

METHODS

Criterion validity was assessed at the individual client level and at the aggregate service level. Individual-level validity was assessed using a longitudinal approach in which we compared what women said they would do with their actual utilization behavior following a price increase. Aggregate-level validity was assessed using predictions derived from cross-sectional surveys and comparing these with actual utilization data. Phi coefficients and correlation statistics were calculated for individual and aggregate-level analyses, respectively.

RESULTS

None of the three individual-level cohorts exhibited statistically significant relationships between predicted and actual WTP. Approximately 70% of clients returned for follow-up care after the price increase, regardless of their responses on the WTP survey. For the aggregate analysis the correlation coefficient between predicted and actual percentage change in demand was not significant. Many clinics experienced higher demand after prices increased, suggestive of shifting demand curves.

CONCLUSIONS

A validated technique for predicting utilization subsequent to a price increase would be highly useful for program managers. Our individual and aggregate-level results cast doubt on the usefulness of WTP surveys for this purpose.

Costs and net health effects of contraceptive methods

BACKGROUND

Pregnancy and contraceptive methods both have important health effects that include risks and benefits. The net impact of contraception on women's health has not been reported previously.

STUDY DESIGN

This is a cost-utility analysis using a Markov model evaluated by Monte Carlo simulation using the societal perspective for costs. The analysis compared 13 methods of contraception to nonuse of contraception with respect to healthcare costs and quality-adjusted life years (QALYs). Discounting was applied for future costs and health effects. The base-case analysis applies to women of average health and fertility, ranging from 15 to 50 years of age, who are sexually active in a mutually monogamous relationship; smoking rates observed in women of reproductive age were used. Sensitivity analysis extended the analysis to nonmonogamous status and smoking status.

RESULTS

Compared with use of no contraception, contraceptive methods of all types result in substantial cost savings over 2 years, ranging from US$5907 per woman for tubal sterilization to US$9936 for vasectomy and health gains ranging from 0.088 QALYs for diaphragm to 0.147 QALYs for depot medroxyprogesterone acetate. Compared with nonuse, even with a time horizon as short as 1 year, use of any method other than sterilization results in financial savings and health gains. Most of the financial savings and health gains were due to contraceptive effects. In a population of patients, even modest increases in the use of the most effective methods result in financial savings and health gains.

CONCLUSIONS

Every method of contraception dominates nonuse in most clinical settings. Increasing the use of more effective methods even modestly at the expense of less effective methods will improve health and reduce costs. Methods that require action by the user less frequently than daily are both less costly and more effective than methods requiring action on a daily basis.

Delayed first injection of the once-a-month injectable contraceptive containing 25 mg medroxyprogesterone acetate and 5 mg estradiol-cypionate: effects on cervical mucus

The objectives of this study were to assess whether women who were administered the first injection of the once-a-month contraceptive containing estradiol cypionate and 25 mg depot-medroxyprogesterone acetate (MPA+E(2)C) on Day 7 of their menstrual cycle (delayed injection) exhibit the same degree of cervical mucus changes as women who receive it on Day 5 of their menstrual cycle. This was a multicenter, randomized, controlled clinical trial. A total of 158 women, aged between 18 and 38 years (inclusive), who, were willing to use MPA+E(2)C as their contraceptive method participated in the trial. Participants received a MPA+E(2)C injection on Day 5 (control group, n = 41) or Day 7 (delayed-injection group, n = 117) of their menstrual cycle. Participants who received MPA+E(2)C on Day 5 of their menstrual cycle (control group) exhibited fair or poor mucus quality and poor sperm penetration. Of those women who received MPA+E(2)C on Day 7 of their menstrual cycle (delayed-injection group), 3 (3%) showed good mucus or good sperm penetration at some time point during follow-up. It is possible to conclude that the first injection of MPA+E(2)C given on Day 7 of a menstrual cycle does not provide the same degree of inhibition of mucus quality and sperm penetration as that observed if it is administered on Day 5. However, the theoretical risk of pregnancy after receiving MPA+E(2)C on Day 7 would be expected to be low.

Delayed first injection of the once-a-month injectable contraceptive containing 25 mg of medroxyprogesterone acetate and 5 mg of E(2)-cypionate: effects on ovarian function

OBJECTIVE

To assess whether women who were administered the first injection of DMPA+E(2)C on day 7 of their menstrual cycle (delayed injection) exhibit the same degree of ovarian suppression as women who receive it on day 5 of their menstrual cycle.

DESIGN

Multicenter, randomized controlled trial.

SETTING

Reproductive health clinics.

PATIENT(S)

Women aged between 18 and 38 years (inclusive) willing to use DMPA+E(2)C as their method of contraception.

INTERVENTION(S)

Participants received a DMPA+E(2)C injection on day 5 (control group, n = 41) or day 7 (delayed-injection group, n = 117) of their menstrual cycle.

MAIN OUTCOME MEASURE(S)

Ovarian activity and follicular development determined by serial serum progesterone levels and vaginal ultrasound.

RESULT(S)

Participants who received DMPA+E(2)C on day 5 of their menstrual cycle (control group) exhibited no more than limited follicular growth (no follicle >16 mm). Of those women who received DMPA+E(2)C on day 7 of their menstrual cycle (delayed-injection group), 21 (18%) showed some follicular growth, of whom 4 (3%) ovulated.

CONCLUSION(S)

The first injection of DMPA+E(2)C given on day 7 of a menstrual cycle does not provide the same inhibition of ovarian activity as that observed when it is administered on day 5 of the menstrual cycle.

Injectable contraception. New and existing options

DMPA and MPA/E2C contraception offer women safe, effective, convenient, and reversible birth control choices. The use of DMPA, a 3-month injectable, is characteristically associated with amenorrhea. Lactating women and women in whom contraceptive doses of estrogen are contraindicated can use this progestin-only birth control method. Return of fertility can be delayed in women discontinuing DMPA to become pregnant. In some cases, the use of DMPA also confers important noncontraceptive and therapeutic benefits. A monthly estrogen/progestin injectable contraceptive, MPA/E2C should appeal to women who are concerned about daily pill taking, who prefer regular cycles to amenorrhea, and who find monthly injections acceptable and accessible. As is true for oral contraceptives, MPA/E2C represents an appropriate choice for women who prefer a rapidly reversible contraceptive. Currently, the proposed contraindications for MPA/E2C parallel those for combined oral contraceptives. As MPA/E2C contraception becomes available for American women, clinicians will learn how to best include this new method among the array of contraceptive choices. By individualizing contraceptive selection, counseling, and management approaches based on the relevant behavioral and medical considerations reviewed herein, clinicians can maximize their patients' success with injectable contraceptives. The more innovative that clinicians, family planning agencies, and insurers are in facilitating access to care (including reinjections), the more women will be able to avail themselves of safe, effective, and reversible methods of contraception. In addition to the physician's office or health clinic, other sites at which women might receive contraceptive injections include employee health clinics, college health clinics, or perhaps the pharmacy where the prescription is filled. Self-administration may become an appropriate option for some users of injectable contraception.

Comparison of ovarian follicular activity during treatment with a monthly injectable contraceptive and a low-dose oral contraceptive

Ovarian follicular development occurs during treatment with combined and progestin-only oral contraceptive (OC) pills and progestin-containing subdermal implants, and can be associated with the development of persistent functional cysts that may require surgical removal. Lunelle is a once-a-month injectable contraceptive containing estradiol cypionate 5 mg and medroxyprogesterone acetate 25 mg. A randomized, comparative study was undertaken to compare the effect on ovarian follicular activity associated with use of Lunelle and a low-dose OC. A total of 30 ovulatory subjects were randomly assigned to receive two cycles of treatment with either an OC containing ethinyl estradiol 20 microg and 0.1 mg levonorgestrel or Lunelle. During the second cycle of treatment, pelvic sonography was performed every 4 days, at which time the maximum follicle diameter was measured. Study end points were the presence of follicles >/=10, 20, and 30 mm. In all, 13 of 15 subjects in the OC group and 14 of 15 in the Lunelle group completed the study. Follicles measuring >/=10 mm were present in 11 of 13 (84.6%) in the OC users and in four of 14 (28.6%) in the Lunelle users (p <0.05). In the OC group, six of 13 subjects (46.1%) developed follicles >/=20 mm, and one of 13 (7.7%) developed follicles >/=30 mm. No subjects in the Lunelle group developed a follicle >/=20 mm in diameter. This study indicates that Lunelle is associated with a significantly lower incidence of ovarian follicular development compared to that of an OC containing 20 microg ethinyl estradiol and 0.1 mg levonorgestrel.

Reproductive health: an international perspective

The twentieth century began with approximately 1.6 billion human beings in the world and, with an increase of 96 million people per year, will end with over 6 billion people. Unless this trend is directly confronted by the world governments and their citizens, there will be nearly 8 billion by 2025 and over 11 billion by 2050. Thus, reproductive health is and will remain an issue of critical importance for all countries to realize and study. Part of this trend is because of the many pregnancies which occur in adolescents around the world. A number of issues have developed this century contributing to the many pregnant teenagers. For example, India has one of the world's largest populations of teenagers--over 23 million, representing over 26% of the total in the world. Effective methods for contraception and sexually transmitted diseases prevention are available, but not to all sexually active humans. However, many barriers to effective contraception exist around the globe. This article discusses some of them and also reviews use of contraceptive methods in various countries. These include oral contraceptives, emergency contraceptives, injectable and implantable contraceptives, intrauterine devices, barrier contraceptives and others. Reproductive health remains a critical, universal issue for all humans in the world. We all must examine the many pitfalls to controlling the world's populations, including lack of sex education, limited access to effective contraceptives, and others. We cannot afford to let the population continue unchecked. Effective strategies are needed at this time; otherwise, the population will continue to run out of control, negatively damaging the world for the coming generations. There is need to leave a positive, and not negative legacy for the next generation.

Contraceptive introduction reconsidered: a new methodology for policy and program development

Although new contraceptive technology has the potential for providing women with expanded options for fertility control, the historical record of international family planning shows that, in practice, introduction of new methods has not always broadened reproductive choice. Using the example of introduction of intrauterine devices into the Indian family planning program in the 1960s, we show that an exclusive focus on the technology itself is problematic and argue that methodologies are needed that relate introduction of new methods to user needs and program capacities. We summarize key findings from the Indonesian experience with Norplant introduction. Although an effort was made to address problems with previous approaches, major deficiencies in both the technical and interpersonal dimensions of care arose when the implants were made broadly available within the program. We subsequently present a methodology for contraceptive introduction developed by the World Health Organization. This methodology emphasizes the social and institutional context in which technology is used and suggests a participatory and research-based approach to program and policy development. We illustrate results from this new approach in its implementation in Vietnam and suggest areas for further evaluation.

Cyclofem/Cyclo-Provera: emerging countries' perspective

Cyclo-Provera, the original name of the combination of 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate, later known as Cyclofem and hereafter referred to MPA/E2C, has proven its use-effectiveness (pregnancy rate less than 1%) in routine service delivery conditions. Overall, the life-table discontinuation rates at 1 year ranged from 33.5% to 71.8%. Only a third of total discontinuations were attributable to the injectable contraceptive method, thus raising the importance of service delivery issues related to its continued use. The results of introductory trials in Mexico, Indonesia, Thailand, Tunisia, Jamaica and, more recently, Brazil, Colombia, Chile and Peru have demonstrated that MPA/E2C is a highly effective contraceptive that could be offered as an alternative to current fertility regulation methods for many women around the world. In addition, the results of studies were the basis for the approval of MPA/E2C by local health authorities and its inclusion in the Ministries of Health Family Planning Programs.

New once-a-month injectable contraceptives, with particular reference to Cyclofem/Cyclo-Provera

Once-a-month injectable contraceptives containing a progestogen and an estrogen have been developed that disrupt vaginal bleeding patterns less than the widely used progestogen-only preparations. Pharmacokinetic studies were undertaken of dosages and ratios of the progestogens and the respective estrogens. In Phase III clinical trials, annual pregnancy rates were below 0.4% for Mesigyna (norethisterone enanthate/estradiol valerate, Schering AG, Berlin, Germany) and below 0.2% for Cyclofem (MPA/E2C) (medroxyprogesterone acetate/estradiol cypionate, Aplicaciones Farmaceuticas, SA, Mexico and PT Tunggal, Indonesia). More than two-thirds of women had predictable, regular cycles, and discontinuation due to bleeding-related problems occurred less than half as often as with progestogen-only injectables. With MPA/E2C, return to fertility is similar to that observed with other hormonal or intrauterine methods, and both products have little effect on lipids or hemostasis. Introductory trials of MPA/E2C in 12000 women with 100000 woman-months of experience confirmed the high efficacy of the product in routine use. The use of MPA/E2C in a non-reusable injection device, Uniject (Becton Dickinson, Franklin Lakes, NJ) is discussed. Once-a-month hormonal contraceptives have been shown to provide a safe contraceptive option for all women and an alternative for women who wish to use injectable formulations that cause less disruption in vaginal bleeding and minimal side effects.

Vaginal bleeding patterns in users of Perlutal, a once-a-month injectable contraceptive consisting of 10 mg estradiol enanthate combined with 150 mg dihydroxyprogesterone acetophenide. A trial of 5462 woman-months

Perlutal (other names: Topasel, Perlutan) is a once-a-month injectable contraceptive that contains 10 mg estradiol enanthate and 150 mg dihydroxyprogesterone acetophenide. A prospective trial was conducted in 216 women in Medellín, Colombia, over five years (5,462 woman-months) to establish the rates of the different vaginal bleeding patterns during the use of Perlutal, and to assess their relation with discontinuation of the Perlutal regimen. It was found that with the use of Perlutal, the duration of menstrual bleeding decreased from 3.9 to 2.7 days (p < 0.01), and that the incidence of dysmenorrhea decreased from 31% to 1.6% (p < 0.01). At one year of follow-up, the incidence of altered bleeding patterns was 5.1%. The discontinuation rate due to an altered bleeding pattern was 3.9%. It is concluded that the low incidence of altered bleeding patterns observed with the use of Perlutal leads to a low discontinuation rate among users.

Return of fertility after discontinuation of the once-a-month injectable contraceptive Cyclofem

The objective of this study was to evaluate the return of fertility in women who used Cyclofem as a contraceptive method during the introductory studies conducted in Brazil, Chile, Colombia, and Peru. From these four cohorts, 101 women were eligible for the study. Thirty-one were not included in the study either because they refused to be interviewed, had initiated another contraceptive method the month after discontinuation, or were unable to be contacted. A total of 70 women were included in the study. Our results showed that the return to fertility rate after the discontinuation of Cyclofem was 1.4 per 100 women at the end of the first month and reached 82.9 at one year. More than 50% were pregnant at 6 months. Fifty-one (94.4%) pregnancies ended in a live birth, two were spontaneous first trimester abortions, and one was a hydatidiform mole. Return of fertility was not related to the woman's age at the time of discontinuation, her weight, or the number of Cyclofem injections. In conclusion, fertility is restored by 1 month following Cyclofem discontinuation. Users and potential users should be counseled regarding the rapid return of fertility after discontinuing this method of contraception.

Comparative phase III clinical trial of two injectable contraceptive preparations, depot-medroxyprogesterone acetate and Cyclofem, in Vietnamese women

A multicenter clinical trial was conducted in Viet Nam, comparing two injectable contraceptive preparations: the three-monthly injectable depot-medroxyprogesterone acetate (DMPA) and the once-a-month injectable Cyclofem. A total of 600 volunteers were randomized to the two treatment groups and followed for one year. No pregnancy occurred during the trial. Approximately one quarter of the women in each group discontinued early from the trial. In the DMPA group, this was mostly because of amenorrhea and vaginal bleeding irregularities. In the Cyclofem group, an equal number discontinued because of menstrual problems and personal reasons. These personal reasons are probably related to the inconvenience of having to return to the clinic for injection on a monthly basis. Thus, Vietnamese women experience less side effects with Cyclofem than with DMPA, and once Cyclofem is made more widely available and is more accessible, it may better meet their needs than does DMPA.

Contraceptive introduction and the management of choice: the role of Cyclofem in Indonesia

This paper presents a programmatic perspective on the relationship between the introduction of new contraceptive technology and expanding contraceptive options, using the example of Cyclofem in Indonesia. Past approaches to contraceptive introduction have considered only the characteristics of the new method in the decision-making process. In assessing whether the introduction of a new method actually expands contraceptive choice for women and whether the program has the managerial capabilities to assure quality of care in this process, the authors argue that consideration must be given to all methods within a delivery system and how new technology relates to the management of contraceptive choice. Using this perspective, the authors suggest that choice would not necessarily be expanded with scaled-up service delivery of a new once-a month injectable in the Indonesian public sector context.