THERE are many reasons to recommend the long acting reversible contraception (LARC) methods — levonorgestrel(LNG)-releasing or copper intrauterine devices (IUDs) and contraceptive implants.
These extremely effective methods have few contraindications and can be used by most women, including adolescents. They have a low risk of complications and side effects, and high satisfaction and continuation rates.
Once inserted, they require no further action, with the result that enhanced uptake significantly decreases teenage pregnancy and abortion rates. In addition, the LNG-IUD is a first-line option for the management of heavy menstrual bleeding and reduces hysterectomy rates, and the copper-IUD provides highly effective post-coital emergency contraception.
While LARC use in Australia is increasing, the contraceptive pill continues its dominance, with approximately 33% of contraceptive users. LARC use remains low at around 11% overall and 6% in women aged 16–29 years compared, for instance, with 24% in Sweden and 25% in France.
The recent Australasian Sexual Health Conference run by the Australasian Sexual Health Alliance laid the groundwork for an effective interdisciplinary reproductive health strategy to enhance the provision of LARC.
Low LARC uptake is related to a range of factors, including misperceptions of women, their partners, the media, and, unfortunately, some health professionals, about issues such as the suitability of IUDs for young or nulliparous women. As highlighted at the recent conference, the small increased risk of pelvic inflammatory disease with IUD insertion is limited to the first 20 days post-insertion, and doubling up an effective LARC method with condoms is a useful preventive strategy if required. The misperceptions detailed above and outdated information can be overcome by evidence-based school education, effective health promotion and health professional education. Training doctors and nurses to provide information about the benefits of LARC, expected side effects including a change in vaginal bleeding pattern, and the ease of the majority of IUD insertions, can increase uptake and continuation rates.
More awareness increases demand, and timely insertion can be a challenge where LARC services are limited, including in rural and remote areas. The low Medicare remuneration for LARC insertion, and costs for training, maintenance of skills and capital equipment can make LARC provision expensive and limits the availability of outpatient and bulk-billing services. Many public hospitals have long IUD waiting lists and the number of trained primary care providers remains low.
Inserting a contraceptive implant should be within every GP’s scope of practice, and training and remuneration pathways for nurses and midwives would further enhance provision. Same day “Quick Start” implant insertion compared to delayed initiation decreases the risk of unintended pregnancy by 60%. While inserting an IUD requires greater procedural skill and investment in equipment, this skill is within the scope of many GPs and appropriately trained nurses and midwives.
However, training opportunities are limited. Public hospitals are ideally placed to provide primary care clinical training, but are frequently frustrated in their efforts by problems including insurance and cumbersome requirements for external trainees to become honorary staff members. Visible and rapid referral pathways to qualified inserters are therefore needed, for instance in the form of “one-stop LARC insertion hubs”. Innovations such as the app provided by New York City Council directing women to their nearest IUD inserter should also not be beyond the reach of Australia.
Immediate postpartum and post-abortion LARC insertion reduces the rates of rapid repeat pregnancy and abortions. While good models of inpatient postpartum LARC insertion exist, hospitals are limited by staff training and availability, high device cost, local policies and hospital religious affiliations. While immediate post-surgical abortion provision of LARC is well established, post-medical abortion provision could be improved by protocols supporting same-day provision of the contraceptive implant and rapid referral pathways for IUD insertion.
In conclusion, contraception choices are determined by a myriad of factors. LARC insertion is associated with a higher up-front cost than seeking a pill prescription; however, LARC is highly cost effective over its 3–10-year duration and does not require scheduled repeat visits to a health professional during this time. While not every woman will want a LARC method, we need to ensure that those who do can access insertion in a timely and cost-effective manner.
Further translational research is needed and will be informed by results from Monash University’s Australian Contraceptive Choice Project. This study, presented at the Australasian Sexual Health Conference, aims to increase LARC uptake by training GPs to provide structured contraceptive counselling and implementing rapid referral pathways to insertion.
The benefits of LARC are well established – now for action to enhance uptake!
Dr Deborah Bateson is the medical director of Family Planning NSW, is a clinical associate professor in the discipline of obstetrics, gynaecology and neonatology at the University of Sydney and adjunct associate professor at La Trobe University’s Australian Research Centre in Sex, Health and Society.
Dr Kathleen McNamee is the medical director of Family Planning Victoria and an adjunct senior lecturer at the department of Obstetrics and Gynaecology at Monash University. She has a general practice background and has worked in the area of Family Planning for over 20 years both as a clinician and educator.
Dr Bateson and Dr McNamee are co-authors of Contraception: an Australian clinical practice handbook.
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