By Byron Mutingwende
The Zimbabwe National Family Planning Council (ZNFPC) has provided a comprehensive overview of contraceptive use in the country.
The ZNFPC Service Delivery Coordinator for Manicaland Province, Mr Kennedy Majero, provided the update on Monday 15 October 2018 during a Sexual Reproductive Health and Rights (SRHR) Media Advocacy workshop in Mutare.
It has emerged that contraceptive options for women with HIV are similar to those of women without HIV and include barrier methods; hormonal methods; the IUD; female and male sterilisation; the lactational amenorrhoea method, also known as LAM; and fertility awareness-based methods.
Majero said for women who want to avoid childbearing, contraceptive method effectiveness (how well a method works) is one of the most important characteristics for choosing a method.
“Contraceptive failure can occur with any method. However, some methods are more effective than others. A contraceptive method may fail when it is used both correctly and consistently. Typical use rates vary depending on user characteristics, user behaviour, the adequacy of counselling, and access to resupply.
“Differences between correct and typical use rates are greater for some methods than for others. Client-controlled methods may have low pregnancy rates with correct and consistent use but higher pregnancy rates with typical use,” Majero said.
He gave an example whereby the combined oral contraceptives have a pregnancy rate of 0.3 percent when used correctly and consistently but a pregnancy rate of 8 percent with typical use. In contrast, the pregnancy rates for typical use of IUDs or injectable contraceptives are almost the same as those for their correct and consistent use because the effectiveness of these methods depends little on user behaviour.
“For example, the TCu-380A IUD has a pregnancy rate of 0.6 percent with correct and consistent use and a rate of 0.8 percent in typical use. When considering the pregnancy rates for various methods, keep in mind that women who use no method at all have a risk of pregnancy as high as 85% over a period of one year.”
One of the most effective contraceptive methods is the use of condoms. Condoms are the only method that has the ability to prevent transmission of STIs/HIV and prevent pregnancy. However, the effectiveness for both pregnancy and STI/HIV prevention depends greatly on the client’s ability to use condoms consistently and correctly.
In real-life situations, correct and consistent use may be difficult to achieve. Condoms may not be used with every act of intercourse or are sometimes used incorrectly.
According to Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. Nineteenth Revised Edition. New York: Ardent Media, Inc., 2007, when used correctly every time a couple has intercourse, the male condom has a pregnancy rate as low as 2 percent, and the female condom has a rate of 5 percent. In common use, their pregnancy rates are much higher – around 15 percent for the male condom and 21 percent for female condom.
The dual method use refers to a couple using a condom to protect against HIV/STI transmission while using another method for pregnancy prevention.
The dual method use helps to reduce the risk of unintended pregnancy; the transmission of HIV between partners, including the transmission of a different strain of HIV to a partner already infected with HIV; and the risk of acquiring or transmitting other STIs. The dual method use may not be easy for couples to achieve and requires on-going support and encouragement by providers.
Women have used combined oral contraceptives (COCs) for more than 30 years to prevent millions of unintended pregnancies throughout the world. More than 84 million women worldwide, half of who live in developing countries, currently use them.
COCs can differ in hormone content, dosage, and the number of pills per pack. All combined pills contain synthetic oestrogen, usually ethinyl estradiol, and one of the various types of progestin.
The most common combined pill is monophasic, where the hormone content is constant in all 21 active pills. COCs also exist as biphasic and triphasic pills, where the ratio of oestrogen to progestin varies among the active pills two or three times during the cycle. There are no clinically significant differences in effectiveness or safety between multiphasic and monophasic pills.
Both the type and the amount of hormone contained in each formulation of pill are related to its potential for side effects. High-dose pills containing 50 to 150 micrograms (µg) of estrogen were commonly used until the late 1970s. Today, those pills have been replaced by low-dose pills, which generally contain 30 to 35 µg of ethinyl estradiol. Some types of low-dose pills contain as little as 20 µg of oestrogen.
The COCs are packaged with either 21 or 28 pills per pack. The 21-pill pack contains only active pills and requires women to take a seven-day break between packs. The 28-pill pack contains 21 active pills and seven inactive or hormone-free pills. These inactive pills often contain iron and are included to minimise the risk of women forgetting to start a new pack of pills on time after a seven-day break. The seven-day period, when no active pills are taken, is called the “hormone-free interval.”
The primary mechanism of action of COCs is the suppression of ovulation. The release of an egg, which commonly occurs in the middle of the menstrual cycle, is prevented by COCs.
In the very rare cases where ovulation may occur, another contraceptive mechanism of COCs acts to prevent fertilization. COCs have an effect on the cervical mucus. The progestin contained in COCs causes the cervical mucus to become thick and prevents sperm penetration; the sperm cannot pass through the cervix and fertilization cannot take place.
The safety and effectiveness of contraceptive pills have been proven through extensive studies – in fact, COCs are the most widely studied drug ever prescribed. When used correctly and consistently, their pregnancy prevention rate is greater than 99 percent.
Unfortunately, in typical use, COCs are often not used correctly. This results in lower effectiveness of about 92 percent. The protection offered by contraceptive pills is reversible, and when pills are discontinued, fertility returns quickly, making them good options for planned childbearing.
However, because the effects of COCs wear off rapidly, oral contraceptives require daily pill taking.
Oral contraceptives provide some protection from symptomatic pelvic inflammatory disease (PID), but offer no protection from the acquisition of sexually transmitted infections (STIs) that affect the lower reproductive tract.
Contraceptive pills have many non-contraceptive health benefits. They also have some side effects that some women find difficult to tolerate. Oral contraceptives are associated with adverse health risks for a small number of women, but these are extremely rare.
Women who take COCs can experience certain side effects. Although these side effects may be unpleasant or unacceptable for some women, they are generally not medically harmful.
Common side effects include nausea, sudden weight changes among a few women when they start or stop COCs, dizziness, mild headaches, breast tenderness, and mood swings.
Combined pills may also cause bleeding changes. Most women experience a reduction in the amount of menstrual bleeding. The majority of women have regular menstrual bleeding while taking COCs; however, some women may experience amenorrhea while others have breakthrough bleeding – that is, bleeding between periods.
This bleeding ranges from spotting to light bleeding episodes. Because some cultures or religions restrict sexual and religious activities during menstruation, breakthrough bleeding may interfere with a woman’s daily life. Breakthrough bleeding is generally not harmful to a woman’s health.
COCs are safe for the overwhelming majority of women. The MEC identifies a number of medical conditions that do not prohibit COC use.
According to the MEC, women with category 1 conditions can use COCs without any restrictions. For example, COCs can be used freely by women who are: past menarche and younger than 40 years; have endometriosis; endometrial or ovarian cancer; uterine fibroids; family history of breast cancer; varicose veins; irregular, heavy, or prolonged bleeding; iron-deficiency anaemia; or an STI or PID. COCs are also safe for women who may have chronic hepatitis or be carriers of the hepatitis virus but do not have acute hepatitis disease.
For women with category 2 conditions, the advantages of using the method outweigh the theoretical or proven risks. Thus, women with category 2 conditions can generally use COCs, but careful follow-up may be required in some cases.
Examples of such conditions include being 40 years old or older, breastfeeding after six months postpartum, superficial thrombophlebitis, uncomplicated diabetes, cervical cancer, unexplained vaginal bleeding, and undiagnosed breast mass.
While COCs are safe for the majority of women, a small number of women with certain characteristics or medical conditions are not considered good candidates for COC use.
According to the MEC, COCs are not generally recommended for women with category 3 conditions, when theoretical or proven risks usually outweigh the advantages of using the method.
Some examples of these conditions include: breastfeeding between six weeks and six months after delivery, non-breastfeeding and less than 21 days postpartum, blood pressure of 140–159/90–99 mm Hg, migraine without aura in women younger than 35 years who wish to continue use, symptomatic gallbladder disease when medically-treated and/or current, and use of the antibiotics rifampicin or rifabutin.
Women with these conditions should not use COCs unless other, more appropriate methods are not available or acceptable. Careful follow-up will be required.
Women with category 4 conditions should not initiate and use COCs because of unacceptable health risks. Examples of these conditions include: breastfeeding during the first six weeks postpartum; blood pressure of 160/100 mm Hg or higher; migraines with aura; history of or acute deep venous thrombosis; ischemic heart disease or stroke; complicated diabetes; current breast cancer; acute/flare hepatitis (category 3 or 4 depending on severity); severe cirrhosis; malignant liver tumours; or benign liver tumours, with the exception of focal nodular hyperplasia (which is a tumour that consists of scar tissue and normal liver cells).
After a woman starts taking COCs, she should take one pill each day, preferably at the same time of day. Failing to take the pill daily increases the risk of pregnancy. Women using the 21-pill pack take a seven-day break from pill taking each month. The 28-pill pack users take seven inactive pills during the hormone-free interval and do not take a break between pill packs.
Women need advice about what to do if they forget to take a pill. If a woman misses one or two active pills in a row or starts a new pack one or two days late, she should take one missed pill as soon as she remembers. She should take the next pill in the pack at the regular time. Depending on when she remembers that she missed a pill(s), she may take 2 pills on the same day – one at the moment of remembering and the other at the regular time – or even at the same time.
Progestin-only pills, or POPs, contain no oestrogen and only 25 to 30 percent of the progestin in combined pills. All pills in a POP pack are active and have the same amount of progestin. POP packs can range from 28 to 35 pills per pack. The medical eligibility criteria for POP use are similar to those of implants.
Because POPs contain no oestrogen, they are especially suitable for women who breastfeed since this type of pill does not affect milk supply and quality. POPs are also well suited for women for whom the use of oestrogen is not recommended, such as women at risk of cardiovascular disease and women who smoke.
Unlike COCs, which generally suppress all ovarian activity, the effect of POPs on ovulation varies from woman to woman and from cycle to cycle. There are also some differences in the way POPs work in breastfeeding and non-breastfeeding women. In women who are breastfeeding, lactation works together with POPs to suppress ovulation more consistently. POPs also thicken cervical mucus, which acts as a barrier to sperm.
The side effects of POPs are similar to those of implants. However, if a woman is breastfeeding, she is much less likely to have irregular or prolonged bleeding episodes and more likely to have amenorrhea.
The effectiveness of POPs depends on a very strict pill-taking schedule. Progestin-only pills must be taken within three hours of the same time every day – or within 12 hours for POPs containing 75mcg of desogestrel – because their contraceptive effect declines dramatically after 24 hours. Progestin pills should be taken daily with no break between packs.
Injectable contraceptives are safe and highly effective. Providers find that injectables are easy to administer, and many women find that they are convenient to use. More than 24 million couples throughout the world now use injectable contraceptives, and their use is increasing rapidly.
An estimated 14 million women use DMPA, best known commercially as Depo-Provera, worldwide. Women using DMPA receive a deep intramuscular injection once every three months at a dose of 150 milligrams.
Injections may be given in the deltoid muscle of the upper arm or the gluteus muscle of the buttocks. The deltoid is generally more accepted by women and is more easily accessed by the provider. The choice should depend mainly on the woman’s preference.
The active ingredients in DMPA are suspended in water, so the vial must be lightly shaken to dissolve any sediment at the bottom. The injection site should not be massaged after the injection because that causes the hormone to be absorbed more rapidly than desired.
Following an injection, the hormone level remains high enough to prevent pregnancy for at least three months.
Implants and progestin-only pills are a safe and highly effective contraceptive option for most women including those with HIV.
Emergency contraceptive pills, although not intended to be used as a “regular” method of contraception, provide an important alternative for preventing unintended pregnancy after unprotected intercourse. This presentation provides a concise overview of these methods.
Implants and progestin-only pills are a safe and highly effective contraceptive option for most women including those with HIV. Emergency contraceptive pills, although not intended to be used as a “regular” method of contraception, provide an important alternative for preventing unintended pregnancy after unprotected intercourse. This presentation provides a concise overview of these methods.
The IUD, also known in some places as the intrauterine contraceptive device or IUCD, is one of the world’s most widely used family planning methods. It is the second most commonly used form of contraception, with the first being female sterilization. The IUD is the most common form of reversible contraception, used by about 100 million women worldwide. Currently, sixty-seven percent of IUD users live in China. However, IUD acceptance is growing in other parts of the world.