Reasons for Brazilian women to switch from different contraceptives to long-acting reversible contraceptives

Uptake, discontinuation, and continuation rate of long-acting contraceptive methods when offered at no cost in Campinas, Brazil

OBJECTIVES

This study aimed to compare the uptake, reasons for discontinuation, continuation, and satisfaction of long-acting contraceptive methods (LARC) when offered at no cost in Campinas, Brazil.

STUDY DESIGN

This was a prospective cohort study conducted at University of Campinas, Campinas, São Paulo, Brazil, including women aged 18 to 48 years, who adopted one of three methods. Participants underwent telephone follow-up every 3 months for up to 24 months after insertion. Satisfaction was assessed at the end of 2 years of use through the Likert scale.

RESULTS

We invited 1222 women, and among the 971 women who volunteered to participate in follow-up, 414 (42.6%) chose the levonorgestrel 52-mg intrauterine device (IUD), 358 (36.9%) chose the etonogestrel (ENG) implant, and 199 (20.5%) chose the TCu380A IUD. Discontinuation due to bothersome bleeding was higher among users of the ENG implant (10/358; 2.4%) and the TCu380A IUD (32/199; 8.9%), and expulsion was higher for the TCu380A IUD (30/199; 15.1%). Women continued at 24 months were 340/414 (82.1%), 270/358 (75.4%), and 119/199 (59.8%) among users of the levonorgestrel 52-mg IUD, ENG implant, and TCu380A IUD, respectively. The users of the levonorgestrel 52-mg IUD (301/339, 88.8%), the ENG-implant (222/270, 82.2%), and the TCu380A IUD (105/119, 88.2%) were satisfied or very satisfied by 24 months of follow-up.

CONCLUSIONS

The three LARC methods had great uptake, high continuation, and discontinuation due to bothersome bleeding was higher among users of the ENG implant and the TCu380A IUD, and expulsion was higher for the TCu380A IUD compared to the 52-mg levonorgestrel IUD. Most of the participants reported being very satisfied.

IMPLICATIONS

When the LARC methods were offered at no cost in a Brazilian public clinic the uptake, satisfaction and continuation were high by 24 months after device placement, and high level of satisfaction was reported by most of the participants.

Etonogestrel-releasing subdermal contraceptive implant: Budget impact analysis based on the Brazilian private healthcare system

High rates of unplanned pregnancies persist despite pharmacological developments and advancements in contraceptive methods. Here, we demonstrate that the etonogestrel-releasing subdermal contraceptive implant (IMP-ETN) may be an appropriate and cost-effective alternative to levonorgestrel-releasing intrauterine systems (LNG-IUSs) for women in Brazil. For our pharmacoeconomic analysis, we reviewed the literature on IMP-ETN regarding its acceptance, eligibility criteria, choice, relations with age, adverse events and, finally, the unmet need in the fee-for-service private healthcare sector. We considered qualitative observations in combination with quantitative analysis and performed a deterministic sensitivity analysis to investigate whether this technology can be self-sustainable over a period of five years. The target population for this analysis comprised 158,696 women. Compared with the continued use of LNG-IUSs, adopting the IMP-ETN can result in a cost avoidance of $ 7.640.804,02 in the first year and $ 82,455,254.43 in five years. Disseminating information among physicians will promote this change and strengthen the potential cost avoided by private health system payers. These savings can be used to improve other healthcare programs and strategies. Moreover, the principles of care can be promoted by improving and adapting healthcare systems and expanding treatment and follow-up strategies. This would also provide support to women's reproductive rights and improve their quality of life. Our results suggest that the IMP-ETN has a favorable cost-effectiveness profile. Given all its advantages and negative incremental cost impact over a period of five years, the IMP-ETN may be a more favorable alternative to LNG-IUSs. Therefore, it should be offered to beneficiaries with a private healthcare plan. This analysis overcomes previous barriers to the use of cost-benefit models, and our results may help balance decision-making by policymakers, technical consultants, and researchers.

Long-Acting Contraceptive Switching and Its Associated Factors among Married Women in Southwest Ethiopia

Introduction

Contraceptive switching from a more effective to a less effective method is a concern, especially in developing countries with high unmet needs for family planning. Indeed, the lack of understanding regarding the reasons behind contraceptive switching behavior in the study area poses a significant challenge in effectively addressing this issue.

Objective

This study aimed to assess the magnitude and factors associated with long-acting contraceptive switching in Mizan-Aman town, southwest Ethiopia.

Methods

A community-based cross-sectional study was conducted, involving 345 women randomly selected from the population of married women in their reproductive age group. Data collection was conducted through interviewer-administered questionnaires. Bivariate and multivariable logistic regression analyses were employed to ascertain factors linked with contraceptive method switching status. Statistical significance was determined at a P-value of less than .05.

Results

Out of the 345 participants interviewed, the prevalence of switching from long-acting to short-acting contraceptives was 28.4%, 95% CI (13.6%, 33.2%). Upon adjusting for confounding variables, factors significantly associated with contraceptive switching included women aged 31-35 [adjusted odds ratio (AOR) = 0.58; 95% CI (0.36, 0.74)] and aged 41-49 [AOR = 0.54; 95% CI (0.48, 0.82)], those with formal education [AOR = 0.79; 95% CI (0.52, 0.87)], those desiring future pregnancy [AOR = 2.12; 95% CI (1.98, 3.38)], experiencing complications from previous method use [AOR = 3.67; 95% CI (2.57, 7.40)], and encountering stockouts of their preferred contraceptive choice [AOR = 2.01; 95% CI (1.39, 3.24)].

Conclusion and recommendation

The study area exhibited a notable prevalence of switching from long-acting contraceptives. Complications arising from prior method use and the unavailability of preferred contraceptive options emerged as significant factors influencing this switching behavior. Thus, it underscores the importance of providing counseling and ongoing support to women, ensuring access to safer and more effective modern contraceptive methods.

Reproductive Planning and the Choice of Long-acting Reversible Contraceptive Primary to Health: A Cross-Sectional Study

OBJECTIVE

 Evaluate the different perspectives that involve the choice of long-acting reversible contraceptives (LARCs), the issues related to this process and the consequences of deciding one method in the women's in the primary health care (PHC) center in Sousas, a district in Campinas, SP (Brazil).

METHODS

 This is an analytical cross-sectional study, it was performed at the PHC in Sousas. Data were collected through the analysis of medical records and interviews with women who live in Sousas and had the insertion of the copper intrauterine device (IUD) (D) from April 2021 to April 2022 or the etonogestrel implant (I) from May to December 2022. The study was approved by the Research Ethics Committee of the Medical Science School at the State University of Campinas (UNICAMP).

RESULTS

 Reason for choosing this LARC: medical (D: 52%; I: 100%), easy adhesion (D: 71%; I: 67%), effectiveness (D: 55%; I: 100%). Indication by health professionals (D: 65%; I: 100%). And improvement of clinical characteristics: mood (D: 77%; I: 67%), body mass index (BMI; D: 52%; I: 33%), and libido (D: 84%; I: 67%).

CONCLUSION

 It is suggested that women tend to decide between LARCs when guided by their doctor or PHC health professionals, and they select LARCs because of the ease of use and low failure rates. Therefore, this study highlights how LARCs can positively interfere in the aspects that pervade contraception, such as BMI, libido, and mood.

Reasons reported by women for choosing the levonorgestrel intrauterine system as a contraceptive method

OBJECTIVE

To assess the reasons provided by women for choosing the use of the 52 mg levonorgestrel intrauterine system (LNG-IUS) as a contraceptive method.

METHODS

We conducted a cross sectional study from January 2021 to August 2021 at the University of Campinas, Campinas, SP, Brazil. Women who had never used the 52 mg LNG-IUS and were requesting it for contraception answered a questionnaire asking for their sociodemographic characteristics, the last contraceptive method in use, how they received information about the device, and their main reasons for choosing the method.

RESULTS

We enrolled 516 women, 365 (70.7%) of whom were under the age of 35 and 352 (68.2%) of whom were parous. The last contraceptive method in use was a short-acting reversible method among 387 (80.8%) women, 454 (88%) reported that they wanted to use the IUS only for contraception, and the main source of information was their health care providers. The main reported reasons for choosing the method were because it is safe, has high contraceptive efficacy, and reduces menstrual bleeding.

CONCLUSION

Health care providers should continue their efforts to provide guidance about the LNG-IUS, including the non-contraceptive benefits, which may contribute to a reduction in the number of unplanned pregnancies.

[Contraception in other countries: The example of Brazil]

In Brazil, women have free access to contraception through the public health system, the Unified Health System (SUS) which offers the following contraceptive methods: Male and female condoms, diaphragm, spermicide, copper intrauterine device (IUD), combined oral and injectable contraceptive hormones, progestin-only contraceptives and injections of medroxyprogesterone acetate (DMPA), emergency pill, female sterilization and vasectomy. However, difficulties in scheduling appointments, women's lack of information about contraceptive methods, and the limited availability of different methods all contribute to high rates of unintended pregnancies. The rate of contraceptive use by Brazilian women aged 18 to 49 is approximately 62%; poorer parts of the country and low levels of education are among the main factors associated with lower rates of contraceptive method use. There are therefore challenges to be taken up to minimize the rates of unwanted pregnancies, which are still too high, such as better distribution, better offer of different contraceptive methods for all regions of the country and better training of professionals involved in women's health care.

Etonogestrel-releasing contraceptive implant in a patient using thalidomide for the treatment of erythema nodosum leprosum: a case report

INTRODUCTION

Thalidomide is an immunomodulatory drug and first choice in the treatment of erythema nodosum leprosum. Given its teratogenic potential, it is essential that an effective contraceptive method is used, especially a long-acting reversible contraceptive (LARC) method. The subdermal etonogestrel (ENG)-releasing implant is an adequate method due to the high effectiveness and long-term use. However, interaction between thalidomide and ENG has not been well documented. Concern arises because thalidomide interacts with cytochrome P450 (CYP450) enzymes that metabolize sexual steroids. AIM: We aimed to study the effectiveness and safety of the ENG-implant in a thalidomide user.

METHODS

Case report of a sexually active 21-year-old patient with both Hansen's disease and leprosy reaction type 2 treated with thalidomide requiring effective contraception. Follow-up was up to 36 months after implant placement.

RESULTS

Contraception with ENG-implant was effective and safe, based on clinical parameters (reduction of menstrual flow and cervical mucus thickening) and laboratory parameters (gonadotropins and sexual steroids).

CONCLUSION

To the best of our knowledge, this is the first case reported which presents a patient in simultaneous use of thalidomide and ENG-implant. Although this case report preliminary supports effectiveness and safety of ENG-implant as a contraceptive option in women using thalidomide, rigorous drug-drug interaction research is needed to better characterize the interaction between thalidomide and the ENG-implant.

Female Body Mass Index and the election of a Long-Acting Reversible Contraception for the first time

OBJECTIVE

We evaluated Brazilian women with different body mass index (BMI, kg/m² ) values who were switching from a short-acting reversible contraceptive (SARC) to a long-acting reversible contraceptive (LARC) method in relationship to the reasons reported for switching and the LARC method chosen.

METHOD

We analyzed retrospective data from 1,508 women aged 18-49 years who chose a LARC for the first time. The variables were sociodemographic, BMI, SARC in use, the reason given for switching, the chosen LARC [copper intrauterine device (Cu-IUD), levonorgestrel (52mg) intrauterine system or etonorgestrel implant], and expectations of the LARC. We used the Chi-square, Mann-Whitney and Kruskal-Wallis tests to compare BMI groups. The significance level adopted was 5%.

RESULTS

The obesity group, 320 women (21.2%), reported weight gain (P <0.000) and fear of pregnancy (P = 0.004) as the most frequent reasons for switching, while the normal weight group, 637 women (42.2%), reported more loss of libido (P <0.000) and other personal complaints (P = 0.002). The IUD was chosen by 851 women (56.6%) and significantly by the largest number of obese women.

CONCLUSION

Women in different BMI categories report different reasons for switching from SARC methods and elect different LARC methods for contraception.

[Contraceptive discontinuities in the use of oral and injectable hormonal contraceptives, and male condoms]

The study aimed to estimate the total contraceptive discontinuity rates in the use of oral and injectable hormonal contraceptives, and male condoms and dropout rates due to switches to more effective and less effective methods. Data on 2,051 women, users of primary healthcare services in three Brazilian state capitals, were collected using the contraceptive calendar. The results showed that 24.5% of users of oral hormonal contraceptives, 33.5% of users of injectables, and 39% of users of male condoms had discontinued the respective method after 12 months of use, independently of the reason, and that the rates varied little between the capitals but did depend on the method. The main reason for discontinuing use of the contraceptive method was the desire to become pregnant (20.8%). Conception while using the method was reported by 20% of the women, a proportion that reached 25.7% in users of male condoms. After 12 months with the method, the dropout rate for reasons related to the contraceptive method was 11.4% in users of injectables; 15.9% of users of male condoms switched to a more effective method; and 16.3% of users of injectables switched to a less effective method. Contraceptive discontinuity rates were high and varied according to the contraceptive method.

Insertion experience of women and health care professionals in the Kyleena® Satisfaction Study

Purpose: The Kyleena^® Satisfaction Study (KYSS) is a prospective, observational study conducted to assess satisfaction with LNG-IUS 12 (Kyleena^®) in clinical practice and aims to provide adequate information for counselling women on what to expect regarding insertion and satisfaction.Materials and methods: Women deciding to use LNG-IUS 12 during routine counselling were informed of the study and provided informed consent. A baseline analysis was conducted to evaluate demographics, ease of insertion assessed by investigators, pain at insertion rated by women, additional interventions for insertion, and adverse events.Results: 1,110 women (536 parous, 574 nulliparous) had an insertion attempt and were included. Insertion was rated as easy in 494 (92.2%) parous and 516 (89.9%) nulliparous women. Pain was assessed as none or mild by 475 (88.6%) parous and 387 (67.4%) nulliparous women. Additional interventions were not required for most insertions (705; 63.6%). Overall 111 (10.0%) women reported adverse events at the time of baseline analysis.Conclusions: This analysis demonstrates that LNG-IUS 12 insertion is easy and associated with no or mild pain in most women. Additional interventions for insertion are not required in most cases. After 3 months, the number of adverse events is low.Implications: The present baseline analysis of the Kyleena^® Satisfaction Study (KYSS) demonstrates that most women rate insertion pain of LNG-IUS 12 as none or mild and clinicians consider insertion easy in the majority of cases.

Perceptions of Contraception and Patterns of Switching Contraceptive Methods Among Family-planning Acceptors in West Nusa Tenggara, Indonesia

OBJECTIVES

The perceptions of family-planning (FP) acceptors regarding contraception influence the reasons for which they choose to switch their method of contraception. The objective of this study was to analyze the perceptions of contraception and rationales for switching contraceptive methods among female FP acceptors in West Nusa Tenggara, Indonesia.

METHODS

This study involved the analysis of secondary data from the Improve Contraceptive Method Mix study, which was conducted in 2013 by the Center for Health Research, University of Indonesia. The design of the study was cross-sectional. We performed 3 stages of sampling using the cluster technique and selected 4819 women who were FP acceptors in West Nusa Tenggara Province, Indonesia as the subjects of this study. The data were analyzed using multiple logistic regression.

RESULTS

The predominant pattern of switching contraceptive methods was switching from one non-long-term method of contraception to another. Only 31.0% of the acceptors reported a rational pattern of switching contraceptive methods given their age, number of children, and FP motivations. Perceptions of the side effects of contraceptive methods, the ease of contraceptive use, and the cost of the contraceptives were significantly associated (at the level of α=0.05) with rational patterns of switching contraceptive methods.

CONCLUSIONS

Perceptions among FP-accepting women were found to play an important role in their patterns of switching contraceptive methods. Hence, fostering a better understanding of contraception through high-quality counseling is needed to improve perceptions and thereby to encourage rational, effective, and efficient contraceptive use.

Estimated disability-adjusted life years averted by free-of-charge provision of the levonorgestrel-releasing intrauterine system over a 9-year period in Brazil

BACKGROUND

The objective was to analyse the contribution of the provision at no cost to users of the 20 µg/day levonorgestrel-releasing intrauterine system (LNG-IUS) towards disability-adjusted life years (DALY) averted over a 9-year period.

METHODS

We analysed data from 15 030 new users of the LNG-IUS who had the device inserted at 26 Brazilian teaching hospitals between January 2007 and December 2015. The devices came from the International Contraceptive Access Foundation (ICA), a not-for-profit foundation that donates the devices to developing countries for use by low-income women who desire long-term contraception and who freely choose to use this device. Estimation of the DALY averted included live births averted, maternal morbidity and mortality, child mortality and unsafe abortions averted.

RESULTS

A total of 15 030 women chose the LNG-IUS as a contraceptive method during the study period. Over the 9 years of evaluation, the estimated cumulative contribution of the Brazilian program in terms of DALY averted consisted of 486 live births, 14 cases of combined maternal mortality and morbidity, 143 cases of child mortality and 410 unsafe abortions.

CONCLUSIONS

Provision of the LNG-IUS at no cost to low-income Brazilian women reduced unwanted pregnancies and probably averted maternal mortality and morbidity, child mortality and unsafe abortions. Family planning programs, policymakers and stakeholders based in low-resource settings could take advantage of the information that the provision of this contraceptive at no cost, or at affordable cost to a publicly-insured population, is an effective policy to help promote women's health.

Barriers and myths that limit the use of intrauterine contraception in nulliparous women: a survey of Brazilian gynaecologists

OBJECTIVE

To understand the extent to which barriers and misperceptions about intrauterine contraception (IUC) remain among Brazilian gynaecologists, particularly for nulliparous women.

METHODS

An online survey was developed to assess Brazilian gynaecologists' knowledge and attitudes towards IUC. Data collected included demographic and professional data, main barriers when considering IUC for women in general and/or nulliparous women, attitudes towards inclusion of IUC in contraceptive counselling, and opinions on what could increase IUC prescription for nulliparous women. A question regarding knowledge about WHO medical eligibility criteria (WHO MEC) was also included in the survey.

RESULTS

101 gynaecologists completed the survey. The insertion rate in nulliparous women was 79.2%. Brazilian gynaecologists were more likely to consider IUC in counselling or provide it on request for parous than for nulliparous women (p<0.05) and perceived more complications in nulliparous women. 74.2% of gynaecologists recognised a higher risk of pelvic inflammatory disease (PID)/infertility associated with IUC use in nulliparous women than in parous women. Difficult and painful insertion were also relevant for 83.2% and 77.3% of the gynaecologists, respectively. Respondents showed a high level of awareness of the WHO MEC classification.

CONCLUSIONS

The three most commonly reported barriers to considering IUC as a contraceptive option for nulliparous woman were concerns about PID and difficult or painful insertion. The challenge is to ensure that gynaecologists understand the evidence and do not disregard IUC as a potential option for nulliparous women.

Non-hormonal and hormonal intrauterine contraception: survey of patients' perceptions in four Latin American countries

OBJECTIVES

This study sought to understand women's perceived barriers to the use of hormonal and non-hormonal intrauterine contraception in Latin America.

METHODS

We developed an online survey for women in Argentina, Brazil, Colombia and Mexico who were seeking contraception. The questions aimed at evaluating patient awareness of negative stories and statements, as well as perceived barriers to the copper intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS).

RESULTS

The survey was mailed to 2300 women. A total of 1953 responses were received from Argentina (n = 465), Brazil (n = 380), Colombia (n = 613) and Mexico (n = 495). More women reported having heard negative stories about the copper IUD than about the LNG-IUS. More women believed that the copper IUD, rather than the LNG-IUS, was suitable only for those who had already had children. More women believed that weight gain (14.3% vs. 38.2%; p < 0.001), mood swings (14.1% vs. 38.7%; p < 0.001) and infertility (16.3% vs. 19.9%; p = 0.016) were possible side effects of the LNG-IUS. By contrast, more women believed that abortion (36% vs. 22.7%; p < 0.001), pelvic infections (42.1% vs. 15.7%; p < 0.001) and ectopic pregnancy (43.5% vs 23.5%; p < 0.001) were side effects more associated with the copper IUD. More believed the copper IUD was associated with less pain during placement and removal compared with the LNG-IUS (42.8% vs. 31.2%; p < 0.001). The perception of increased risk of contracting a sexual transmitted disease did not differ between the methods (IUD vs. LNG-IUS, 21.7% vs. 20.3%; p = 0.388).

CONCLUSIONS

Respondents to a web-based survey in four Latin American countries have misperceptions regarding the adverse effects and risks of intrauterine contraception, which may hamper the use of these safe and efficient contraceptive methods. Education about the true risks and benefits involved is fundamental to improving patient acceptance and compliance as well as reducing unplanned pregnancies and unsafe abortions.

Comparison of two cohorts of women who expulsed either a copper-intrauterine device or a levonorgestrel-releasing intrauterine system

AIM

To assess if there is a difference in the characteristics of the women who expelled a copper-intrauterine device (TCu-IUD) or the levonorgestrel-releasing intrauterine system (LNG-IUS) and the frequency of expulsions over different periods of observation.

METHODS

We retrospectively analyzed 19 697 medical charts of women consulting between January 1980 and December 2013 who requested a TCu-IUD or a LNG-IUS.

RESULTS

The medical records of 17 644 Cu-IUD and 2053 LNG-IUS users returning to the clinic for a follow-up visit after insertion of an IUC were reviewed. Of these, 1532 Cu-IUD and 254 LNG-IUS parous users were found to have expelled the IUC for a first time. The mean age at insertion (± standard deviation) was 26.3 ± 6.6 years (range 16-49) for Cu-IUD users and 31.7 ± 7.6 years (range 18-48) for LNG-IUS users (P < 0.001). A total of 263 (13.4%) and 12 (4.3%) of the Cu-IUD and the LNG-IUS users were ≤19 years old, and 49.1% and 54.1% of the expulsions among the Cu-IUD and LNG-IUS users, respectively, were reported in the first six months after placement. A regression model showed that the variables significantly associated with an expulsion of either a Cu-IUD or LNG-IUS were age < 25 years, less than two deliveries and using a Cu-IUD.

CONCLUSION

Our findings showed that the characteristics associated with IUC expulsion were age under 25 years, having had less than two deliveries and being users of Cu-IUD.

A retrospective evaluation of the intrauterine device in a patient population in Buenos Aires, Argentina

BACKGROUND

The intrauterine device (IUD) is a long-acting reversible contraceptive method that is safe for a wide range of women, including adolescents and nulliparous women. Globally, it is often underutilised due to misperceptions among patients. Examination of characteristics associated with IUD discontinuation including adverse effects and IUD expulsion can inform provider practices to improve contraception success and patient satisfaction with this method. We studied IUD performance at a public family planning clinic in Buenos Aires, Argentina, serving a predominantly immigrant, low-income population.

METHODS

We conducted a retrospective evaluation of 1047 IUD insertions between 2002 and 2007 with 5 years of follow-up data. We performed bivariate and survival analysis to examine characteristics associated with IUD discontinuation: adverse outcomes including pain, bleeding, and IUD expulsion, and time to removal.

FINDINGS

Of 1047 patients, only 188 (18%) had their IUD removed within 5 years. The main causes of IUD discontinuation were involuntary (38%) reasons such as an IUD expulsion and personal choice (34%) such as desiring pregnancy.

CONCLUSIONS

Findings suggest overall good long-term performance with IUD insertion, with minimal complaints or adverse outcomes. These findings may help to support providers serving similar populations in promoting this method.

Knowledge and attitudes of Latin American obstetricians and gynecologists regarding intrauterine contraceptives

BACKGROUND

Intrauterine contraceptives (IUCs), including the copper intrauterine device and the levonorgestrel-releasing intrauterine system (LNG-IUS), are among the reversible contraceptive methods with high effectiveness. However, use is low in many settings, including some Latin American countries, mainly due to the influences of myths, fears, and negative attitudes, not only of users and potential users, but also of different cadres of health care professionals. The purpose of this study was to assess the knowledge and attitudes of a group of Latin American obstetricians and gynecologists regarding IUCs.

METHODS

A survey was conducted during a scientific meeting organized in Chile in 2014 to present and discuss updated information about contraception. Obstetricians and gynecologists from 12 Latin American countries, who reported that they provide daily contraception services in both the public and private sectors, participated in the meeting. Participants who agreed to take part in the survey responded to a multiple-choice questionnaire on issues regarding knowledge, use, and attitudes about IUCs.

RESULTS

Of the 210 obstetricians and gynecologists participating in the meeting, the respondents to each question varied from 168 (80.0%) to 205 (97.6%). Almost 50% recognized that the failure rate of combined oral contraceptives, patches, and vaginal rings is 8%-10%. Furthermore, 10% of the participants did not recognize the high contraceptive effectiveness of long-acting reversible contraceptive methods. Additionally, almost 80% of the respondents answered that they did not offer IUCs to nulligravidas and almost 10% did not offer IUCs to adolescents, albeit almost 90% of the respondents reported that nulligravidas are candidates for an LNG-IUS.

CONCLUSION

Some deficiencies and contradictions in terms of knowledge and attitudes were identified from the answers of the Latin American obstetricians and gynecologists who participated in the survey. The knowledge and attitudes of health care professionals about IUCs are important in order to provide adequate counseling and to expand the use of IUCs.

Effect of vaginal administration of misoprostol before intrauterine contraceptive insertion following previous insertion failure: a double blind RCT

STUDY QUESTION

Is pretreatment with misoprostol useful in insertion of intrauterine contraceptives (IUCs) after insertion failure at the first attempt?

SUMMARY ANSWER

Pretreatment with intravaginal administration of 200 mcg of misoprostol after IUC insertion failure 10 and 4 h before the second attempt of IUC placement was significantly better than placebo at facilitating the insertion of an IUC.

WHAT IS KNOWN ALREADY

One of the reasons for low use of IUCs is the concept that insertion is difficult. Misoprostol was used in several randomized clinical trials (RCT) before IUC insertion to facilitate the insertion. In general, the results showed no significant differences when compared with placebo. However, most previous studies have been carried out among unselected women whereas the present study is among women with previous insertion failure.

STUDY DESIGN, SIZE, DURATION

This was a double blind RCT conducted between February 2013 and October 2014. Participants were 104 women who requested an insertion of an IUC and the insertion failed at the first attempt. After insertion failure, the women received a sealed envelope with misoprostol or placebo. The randomization system (1: 1) in one block size was computer-generated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at a tertiary care centre. The women were instructed to insert vaginally one tablet of misoprostol 200 µg (Prostokos, Hebron, Cariacica, PE, Brazil) or placebo 10 and 4 h before the woman returned to the clinic for a new insertion attempt. The outcomes were successful IUC insertion and the use of a cervical dilator immediately prior to the insertion procedure.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 2639 women requested the insertion of an IUC during the study period. The IUC was inserted at the first attempt in 2535 women (96%) and 104 women in whom we were unable to insert the device were eligible to participate in the RCT. Four women declined and 100 women were randomized (55 for the misoprostol group and 45 for the placebo group). From the 100 participating women, the levonorgestrel-releasing intrauterine system (LNG-IUS) was chosen by 55 and 37 women and the TCu380A intrauterine device (Cu-IUD) was chosen by none and 8 women in the misoprostol and placebo group, respectively. Seven and three women allocated to misoprostol and placebo, respectively, never returned to the clinic after randomization. We placed the IUC in 42 (87.5%) out of the 48 women and in 26 (61.9%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.0066). Regarding the Evaluable Population the relative risk (RR) of successful insertions was 1.41 (95% confidence interval (CI) for absolute difference (8.2, 43.0), P = 0.0066); in the Intent-to-Treat Population the RR (95% CI) was 1.32 (0.3, 36.9). Multiple regression analysis showed that the significant variables associated with the insertion failure were the number of Caesarean section ≥1 (P = 0.020) and the use of placebo (P = 0.026). Dilators were used in 21 (43.7%) out of the 48 and 21 (50%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.804).

LIMITATIONS, REASONS FOR CAUTION

The limitations were that the majority of the women chose the LNG-IUS, and consequently the data for the Cu-IUD were limited, and there was a small number of nulligravidas.

WIDER IMPLICATIONS OF THE FINDINGS

The results show that IUC insertion difficulties and failures are not common. Pretreatment with intravaginal misoprostol facilitated IUC insertion after failure of insertion at the first attempt, and insertion failure was associated with number of Caesarean sections.

STUDY FUNDING/COMPETING INTERESTS

This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/10085-0, and from the National Research Council (CNPq), grant #573747/2008-3. All the TCu380A IUDs were donated by Injeflex, São Paulo, Brazil, and all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations were provided in the form of unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov NCT01754649.

Permeation measurement of gestodene for some biodegradable materials using Franz diffusion cells

Biodegradable poly(d,l-lactide) (PDLLA), Poly(trimethylene carbonate) (PTMC), polycaprolactone (PCL), poly(caprolactone-co-d,l-lactide) (PCDLLA) and poly(trimethylene carbonate-co-caprolactone) (PTCL) are recently used for clinical drug delivery system such as subcutaneous contraceptive implant capsule due to their biodegradable properties that they could possess long-term stable performance in vivo without removal, however their permeation rate is unknown. In the work, biodegradable material membranes were prepared by solvent evaporation using chloroform, and commercial silicone rubber membrane served as a control. Gestodene was used as a model drug. Gestodene has high biologic progestational activity which allows for high contraceptive reliability at very low-dose levels. The permeation rate of gestodene for several biodegradable materials was evaluated. In vitro diffusion studies were done using Franz diffusion cells with a diffusion area of 1.33 cm². Phosphate buffer solution (PBS, pH 7.4), 10% methanol solution and distilled water were taken in donor and receiver chambers at temperature of 37 °C respectively. The in vitro experiments were conducted over a period of 24 h during which samples were collected at regular intervals. The withdrawn samples were appropriately diluted and measured on UV–vis spectrophotometer at 247 nm. Conclusion data from our study showed that permeation rate of PCDLLA with CL ratio more than 70% could be more excellent than commercial silicone rubber membrane. They may be suitable as a candidate carrier for gestodene subcutaneous contraceptive implants in contraceptive fields.

Estimated disability-adjusted life years averted by long-term provision of long acting contraceptive methods in a Brazilian clinic

STUDY QUESTION

What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago.

SUMMARY ANSWER

Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted.

WHAT IS KNOWN ALREADY

LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce.

STUDY DESIGN, SIZE AND DURATION

We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted.

MAIN RESULTS AND THE ROLE OF CHANCE

We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted.

LIMITATIONS, REASONS FOR CAUTION

The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world.

WIDER IMPLICATIONS OF THE FINDINGS

LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population.

STUDY FUNDING/COMPETING INTERESTS

This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.