Long-Acting Reversible Contraceptives

Overview

Successful family planning programs include a broad mix of contraceptive methods. Offering short-acting methods such as injectables, oral contraceptive pills, and barrier methods; long-acting reversible contraceptives (LARCs) like the intrauterine device (IUD) and implants; and permanent methods like vasectomy and tubal ligation allows programs to meet the varied and changing needs of their diverse clients. LARCs are an essential part of the method mix because they include both hormonal and nonhormonal options, are highly effective for years at a time, and are removable at any time.

Continue reading to learn more about long-acting reversible contraceptives (LARCs).

The intrauterine device (IUD) and the contraceptive implant are long-acting reversible contraceptives (LARCs). Both IUDs and implants can be removed at any time, and fertility is rapidly restored. LARCs are the most effective forms of reversible contraception—during the first year of typical IUD or implant use, fewer than 1% of women will become pregnant. Unlike most short-acting methods, IUDs and implants are not “user dependent.” Once a provider inserts them, they require no daily action or coital adherence on the part of the user, lowering the risk of unplanned pregnancy due to user error or unintentional discontinuation.

Many women in low- and middle-income countries who want no more children are using less effective, short-acting methods of contraception. Looking only at a country’s contraceptive prevalence rate can mask an unmet need for long-acting methods that offer women a more reliable way to limit their number of pregnancies. Addressing unmet need for “limiting methods” by increasing access to LARCs is an important strategy for reducing unintended pregnancies. LARCs are also an appropriate option for women who want to space their births—that is, they want more children but want to delay their next pregnancy.

Young people are at high risk for early and/or unintended pregnancy and can benefit from increased access to LARCs. Emerging evidence demonstrates the safety and effectiveness of LARCs for young people. The World Health Organization, USAID, global health and development organizations, and medical professional associations have issued statements affirming the safety and appropriateness of LARCs for young people. The American Academy of Pediatrics issued a policy statement recommending LARCs as the first-line contraceptive choice for adolescents.

Click through the menu below to explore messages, research, and educational resources related to this topic.

Family planning programs throughout the world need to prepare to meet the growing demand for LARCs by acknowledging and addressing barriers on the supply side by reducing stockouts of commodities and consumable supplies; introducing task sharing so that nurses, midwives, and even health extension workers can help meet demand for services; and implementing ongoing quality assurance measures. On the demand side, programs must address provider biases and client concerns by ensuring providers are well trained, competent, supportive of LARC usage, and able to offer quality counseling and timely insertion and removal services to clients. Another key to making LARCs accessible to greater numbers of clients is ensuring that they are affordable. Although the initial cost of commodities and service provision for some LARCs can be higher than for shorter-acting methods and can be seen as a barrier, LARCs are far more cost-effective in the long term, as fewer resupply and clinic visits are needed.

  • Long-acting reversible contraceptives (LARCs) are the most effective forms of reversible contraception—once inserted, they require no regular resupply or action on the part of the user.
  • LARCs can help women and couples achieve their reproductive intentions to delay, space, or limit childbearing.
  • Including LARCs in the method mix has great potential to decrease contraceptive discontinuation and reduce unintended pregnancies.
  • Successful voluntary LARC programs require adequate supplies and provider training to ensure that all clients who choose LARCs are able to have them inserted and removed in a timely, safe manner.
  • Long-acting reversible contraceptives (LARCs): Contraceptive methods, including the IUD and the implant, that provide protection from pregnancy for years at a time
  • Intrauterine device (IUD): A small, flexible plastic frame that a trained provider inserts into a woman’s uterus to provide very effective, safe, and long-term protection from pregnancy; both copper and hormonal IUDs are available 
  • Implants: Small, flexible plastic rods or capsules that are placed just under the skin of the upper arm and release a progestin hormone into the body
  • Unmet Need: Percentage of women who do not want to become pregnant but are not currently using contraception

The Global Health eLearning Center offers a course Community-Based Family Planning. The course, which has recently been updated and revised, orients the learner to the essential elements for designing and implementing successful, sustainable CBFP programs. It describes three popular approaches to CBFP—provision by community health workers (CHWs), mobile outreach services, and drug shops—and provides an opportunity for users to practice what they learned using a case study.

Population, Health, and Environment explores the intersections of these three facets of development. Learners will understand the fundamentals of the PHE approach including PHE relationships, the benefits of integration, program considerations, the PHE policy and advocacy landscape, and how the PHE approach can contribute to global development priorities, such as the Sustainable Development Goals and Family Planning 2020 in an efficient and effective way.

USAID’s Training Resource Package for Family Planning (TRP) offers curricula and tools for trainers to design, implement, and evaluate family planning and reproductive health (FP/RH) training. All TRP modules are available for free download and adaptation for local contexts. Modules include comprehensive lessons on a variety of family planning options as well as general sessions on the benefits of family planningfamily planning counseling, and WHO guidance for family planning providers. The TRP also offers users general resources on instructional design and training of trainers to support users’ professional development goals.

Below is a selection of peer-reviewed articles on community-based family planning and related topics. 

Agarwal S, Lasway C, L’Engle K, Homan R, Layer E, Ollis S, et al. Family Planning Counseling in Your Pocket: A Mobile Job Aid for Community Health Workers in Tanzania. Glob Health Sci Pract. 2016;4(2):315-325. Using mobile job aids can help CHWs deliver integrated counseling on family planning and HIV/STI screening by following a step-by-step service delivery algorithm. Lessons learned during the pilot led to the development of additional features during scale-up to exploit the other major advantages that mHealth offers, including better supervision of health workers and accountability for their performance, improved communication between supervisors and workers, and access to real-time data and reports to support quality improvement.

Weidert K, Gessessew A, Bell S, Godefay H, Prata N. Community Health Workers as Social Marketers of Injectable Contraceptives: A Case Study from Ethiopia. Glob Health Sci Pract. 2017;5(1):44-56. Volunteer community health workers (CHWs) administered injectable contraceptives to women in the community for a small fee while providing counseling and referrals for other methods. Over nearly 3 years, more than 600 CHWs provided an estimated 15,410 injections. The model has the potential to improve sustainability of community-based distribution programs by incorporating social marketing principles to partially recover commodity costs and compensate CHWs.

Gueye B, Wesson J, Koumtingue D, Stratton S, Viadro C, Talla H, et al. Mentoring, Task Sharing, and Community Outreach Through the TutoratPlus Approach: Increasing Use of Long‐Acting Reversible Contraceptives in Senegal. Glob Health Sci Pract. 2016;4 Suppl 2:S33-S43. Mentoring, task sharing, and community outreach at 100 rural facilities in Senegal led to an 86% increase over 6 months in the number of women choosing long-acting reversible contraceptives (from 1,552 to 2,879). Concurrent improvement of facilities and provider skills, coupled with the application of Senegal’s task-sharing policy, are increasing the range of contraceptive methods available to women throughout the country.

Charyeva Z, Oguntunde O, Orobaton N, Otolorin E, Inuwa F, Alalade O, Abegunde D, Danladi S. Task Shifting Provision of Contraceptive Implants to Community Health Extension Workers: Results of Operations Research in Northern Nigeria. Glob Health Sci Pract. 2015;3(3):382-394. With training and supportive supervision, male and female Community Health Extension Workers (CHEWs) in Nigeria safely and effectively provided contraceptive implants, and virtually all clients said they were satisfied. Most CHEWs achieved competency after five client insertions. However, the CHEWs provided only an average of four insertions per health facility per month. Realizing the true potential of providing implants calls for a context with dedicated providers and robust outreach.

Schaefer L. Task Sharing Implant Insertion by Community Health Workers: Not Just Can It Work, but How Might It Work Practically and With Impact in the Real World. Glob Health Sci Pract. 2015;3(3):327-329. Demonstrating that a health service, such as providing contraceptive implants, can be safely task shared to less highly trained workers is crucial but is only one step toward effective implementation at scale. Providers need dedicated time, enough clients, supplies, supervision, and other system support, allowing them to maintain their competency, confidence, and productivity.

The High Impact Practices in Family Planning (HIPs) team at USAID has developed briefs that synthesize the evidence and provide recommendations on how to implement selected HIPs.

Community Group Engagement: Changing Norms to Improve Sexual and Reproductive Health (2016; PDF, 690KB) describes the evidence on and experience with community group engagement (CGE) interventions that aim to foster healthy sexual and reproductive health (SRH) behaviors. The distinguishing characteristic of CGE interventions from other social and behavior change (SBC) interventions is that they work with and through community groups to influence individual behaviors and/or social norms rather than shifting behavior by targeting individuals alone. Specifically, community support can shift individual behaviors, including contraceptive behaviors, either by changing norms or individual knowledge and attitudes.

When appropriately designed and implemented, community health worker (CHW) programs can increase use of contraception, particularly where unmet need is high, access is low, and geographic or social barriers to use of services exist. CHWs are particularly important to reducing inequities in access to services by bringing information, services, and supplies to women and men in the communities where they live and work rather than requiring them to visit health facilities, which may be distant or otherwise inaccessible. Community Health Workers: Bringing family planning services to where people live and work (2015; PDF, 829KB) discusses the evidence for CHW programs, as well as the support and training CHWs need to be successful.

Mobile outreach services address inequities in access to family planning services and commodities in order to help women and men meet their reproductive health needs. Evidence demonstrates that mobile services can successfully increase contraceptive use, particularly in areas of low contraceptive prevalence, high unmet need for family planning, and limited access to contraceptives, and where geographic, economic, or social barriers limit service uptake. When well-designed, they help programs broaden the contraceptive method mix available to clients, including increasing access to long-acting reversible contraceptives (LARCs) and permanent methods (PMs). Mobile outreach services: expanding access to a full range of modern contraceptives (2014; PDF, 429KB) describes the role of mobile outreach programs as a means of reducing inequities in access to family planning services (particularly LARCs and PMs), discusses the potential contribution of these programs, and outlines key issues for planning and implementation.

Small commercial drug shops and pharmacies are often the first line of health care in poor countries, especially in rural areas that have very few private or public clinics. Evidence shows that with appropriate training and support, staff can facilitate the use of modern contraception, especially in urban slums and rural areas where the unmet need is high, access is poor, and health-worker shortages and other barriers prevent men, women, and youth from accessing family planning services. Drug Shops and Pharmacies: Sources for family planning commodities and information (2013; PDF, 797KB) describes the importance of these outlets for distributing commodities and information and outlines key issues for planning and implementing programs to support pharmacy and drug-shop staff. In 2017, technical experts hosted a complementary webinar.

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