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Reducing the number of unwanted pregnancies

Little used, long-term contraceptives can reduce the risk of abortion and maternal mortality

LUANA GEIGERJust 6% of Brazilian women use a long-term contraceptive method. These devices, which are placed in the uterus or implanted under the skin, continuously release compounds capable of inhibiting the development of female reproductive cells (eggs) or preventing male (sperm) from reaching the female genital tract. Doctors at the University of Campinas (Unicamp), however, believe that this percentage ought to be much higher—perhaps near the percentage in European countries where almost a quarter of women use a long-acting contraceptive method. Unicamp researchers conducted a survey showing that these contraceptive methods are more reliable than methods used on a daily or weekly basis—pills, patches and vaginal rings—and can reduce maternal mortality and unsafe abortions.

This conclusion is based on the monitoring of more than 20,000 women, between 1980 and 2012, who were attended by Unicamp gynecologists, received advice on contraceptive methods and used long-term contraceptives. Unlike the trend observed in other parts of Brazil, the university’s doctors always made long-acting reversible contraceptives (LARC) available. The result of this was that in the last 10 years, the doctors calculate they avoided 547 unsafe abortions, 60 maternal deaths and the deaths of 400 infants who might have had problems at birth or become ill after birth.

The data were published in the October 2014 issue of Human Reproduction. It is not difficult for the study’s coordinator, Dr. Luis Bahamondes, to explain the high degree of reliability of the LARC methods, such as intrauterine devices (IUD), the intrauterine system that releases levonorgestrel (a synthetic hormone) and implants. Previous studies have shown that LARC has a failure rate of less than 1%; the failure rate is 10% with pills.

One of the reasons why oral contraceptives have a higher rate of failure is that women often forget to take them. According to Dr. Bahamondes, if it were possible to monitor women on a daily basis so they never missed a pill, the failure rate would be 0.1%. “That would be a perfect world,” he says, “but to do that I would have to move into my patient’s home.” Consider another example, even patients with high blood pressure whose very lives depend on the continued use of medications to keep their pressure under control are not as conscientious as they should be: only 25% of them take the medication as prescribed by their doctors. “People eventually tire of medication and stop taking it,” says Dr. Bahamondes. “With LARC methods, this is not a problem.”

In fact, Dr. Bahamondes says the first question the women he sees at Unicamp usually ask is: “How often does it fail, doctor?” He says that when he tells them that women using an IUD, a system that releases levonorgestrel, or an implant, can expect a failure rate almost identical to women who have tubal ligation, they see there is little reason for surgery resulting in irreversible sterilization, which is still common in Brazil. Almost 30% of women of reproductive age opt for sterilization in Brazil, while 25% use oral contraceptives.

Copper and hormones
In the three decades of monitoring, the researchers compared the effectiveness of three long-term contraceptive methods—traditional IUDs containing copper; hormone-releasing IUDs; and subcutaneous implants that release hormones—in addition to quarterly injectable contraceptives, which, although not included in the long-term category, are also more effective than pills. Both hormone-releasing IUDs as well as injections and pills prevent pregnancy by inhibiting the release of the ova and altering the cervical mucus, which acts as a barrier to sperm. But the copper IUD prevents pregnancy because copper is toxic to male reproductive cells. None of these methods, however, protects against sexually transmitted diseases.

The Unicamp group used a mathematical model developed by the World Health Organization (WHO) and the Marie Stopes International organization to calculate the number of deaths and health problems that could be avoided by using different contraceptive methods. This calculation was done ​​only for the last 10 years because the mathematical model that uses Brazilian data is only available for more recent years, he says.

With such positive results, why are these long-acting methods so rare in Brazil? Dr. Bahamondes believes the reason is unrelated to their side effects, which in the case of implants and hormone-releasing IUDs are similar to those experienced by pill users. Still, 90% of women who opt for implants or hormonal IUDs continue to use them after a year, while only about half of those who take the pill continue to do so after this period.

Dr. Bahamondes believes there is less use of long-acting contraceptives in Brazil because Brazil follows a women’s health care policy similar to that of the United States. Tubal ligations and the use of pills also predominate in the United States—LARCs are more common in Western Europe—although U.S. public health experts are beginning to favor long-term contraceptives, particularly for more vulnerable populations such as teenagers.

In an article published in October 2014 in the New England Journal of Medicine, researchers at Saint Louis University followed a group of approximately 1,500 sexually active teenagers from the Saint Louis area, located in the U.S. Midwest for three years. The girls received information about various contraceptive methods and had free access to LARCs. Of this group, 72% opted for the long-acting methods. Among this group, there were 34 unplanned pregnancies and 9.7 abortions per group of 1,000 teenagers. These numbers are much lower than the average for the U.S. population: 159 unwanted pregnancies and 42 abortions per 1,000 teenagers.

“In Brazil, the public network offers the traditional IUD, while hormone-releasing IUDs are almost nonexistent in the private network,” says Dr. Bahamondes. He also faults the lack of training for doctors on advising the use of these methods to their patients. “The administrators of the Brazil’s Unified Health System have not yet realized that from a cost point-of-view, long-acting methods are equal to the pill in the long run, and they come with the added advantage of being more effective in preventing unwanted pregnancies,” he says. “There is no clear family planning policy in Brazil, thus the way forward is to empower women so that they have the opportunity to choose the best method,” he argues.

Effectiveness and duration of use of long-term contraceptives (No. 2012/12810-4); Grant mechanism: Regular Research Grant; Principal investigator: Dr. Luis Guillermo Bahamondes (Unicamp); Investment: R$72,148.75 (FAPESP).

Scientific article
BAHAMONDES, L. et al. Estimated disability-adjusted life years averted by long-term provision of long-acting contraceptive methods in a Brazilian clinic. Human Reproduction. October 2014.