WHO probes birth control pill, HIV infection link

*41% of southern Nigerian women accept reversible contraceptive device after delivery
*Age, educational attainment, marital status, parity, number of living children, previous use affected choice

The World Health Organization (WHO) has said it would convene an expert review group later in 2016 to examine the links between the use of various hormonal contraceptive methods and women’s risk of Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) acquisition.

Also, Nigerian researchers have reported that a high percentage, 41 per cent, of women delivering in private health care facilities in southern Nigeria accept immediate postpartum intrauterine device (IUD) insertion.

An IUD or coil is a small contraceptive device, often ‘T’-shaped, often containing either copper or levonorgestrel, which is inserted into the uterus. They are one form of long-acting reversible contraception, which are the most effective types of reversible birth control.

Meanwhile, the expert review group will assess whether current WHO guidance needs to change in the light of a new review of data, published in AIDS on August 9, 2016, which was commissioned by WHO.

For the past 25 years, there has been mixed evidence as to whether use of hormonal contraceptive methods (particularly depot medroxyprogesterone acetate [DMPA]) is associated with a woman’s risk of acquiring HIV.

WHO, in a statement, said it is committed to engaging with stakeholders and has been continuously monitoring and reviewing new evidence and providing guidance accordingly. WHO commissioned this systematic review to analyse findings from all studies published in the past two years and to synthesize them with the previous evidence published in 2014.

In addition to the previously available evidence, the systematic review analysed ten new studies. Reassuringly, it found that most of the data for oral contraceptive pills, injectable norethisterone enanthate (NET-EN), and levonorgestrel implants continue to indicate no association with risk of HIV acquisition. These new data, however, do strengthen existing concerns about a possible increase in risk of HIV acquisition in women using injectable DMPA, although the statistical significance of these studies varies and they are observational in nature.

According to the WHO, a research consortium is currently undertaking a randomised trial to compare the risks of HIV acquisition among women using different contraceptive methods. The trial will provide evidence as to whether using any of these methods causes an increased risk of women acquiring HIV. The results from this research will not be available for several years.

Evaluating emerging evidence is extremely important to determine what guidance should be given to women, particularly in sub-Saharan Africa where high rates of HIV coincide with high use of DMPA injectable contraception.

WHO is concerned that access to preferred contraceptive methods for women, their partners, and for couples, is maximised, while protecting women’s health and that of their communities. Women have the right to the latest and best information and to access their preferred options when choosing a contraceptive method that is safe, effective and acceptable.

According to the new study published in Global Health: Science and Practice 2016, scale-up of postpartum IUD services is a promising approach to increasing uptake of long-acting reversible contraceptives among women in Nigeria.

The researchers from Marie Stopes International Organisation, Abuja, Nigeria, and United Nations Population Fund, Accra, Ghana, led by George I.E. Eluwa; Ronke Atamewalen; Kingsley Odogwu; and Babatunde Ahonsib, found that 41 per cent of women delivering in the social franchise private facilities chose the postpartum IUD and that the factors associated with acceptance included, lower education, higher parity, and being single.

They said that scale-up of postpartum IUD services in both public and private facilities have the potential to significantly increase use of long-acting reversible contraception in Nigeria.

The study is titled “Success Providing Postpartum Intrauterine Devices in Private-Sector Health Care Facilities in Nigeria: Factors Associated With Uptake.”

Earlier studies have shown that the use of modern contraceptive methods in Nigeria remained at 10 per cent between 2008 and 2013 despite substantive investments in family planning services. Many women in their first postpartum year, in particular, have an unmet need for family planning.

The researchers evaluated use of postpartum IUD insertion and determined factors associated with its uptake in Nigeria.

The study was conducted in South East and South South Nigeria among 11 private health care providers between May 2014 and February 2015. The states included Anambra, Abia, Delta, Ebonyi, Edo, and Enugu. All women who attended antenatal care at the 11 facilities were counseled on all available methods of contraception including the postpartum IUD. Women who presented at labour also received counseling about family planning methods including the postpartum IUD. Women who met medical eligibility criteria for IUD insertion and had no contraindications to IUD use were offered the postpartum IUD.
Postpartum IUD insertion is ideal for some women for many reasons including convenient timing.

Data were abstracted from participating facility records and evaluated using a cross-sectional analysis. Categorical variables were calculated as proportions while continuous variables were calculated as medians with the associated interquartile range (IQR).

Multivariate logistic regression analysis was used to identify factors associated with uptake of the postpartum IUD while controlling for potential confounding factors, including age, educational attainment, marital status, parity, number of living children, and previous use of contraception.

The results showed: “During the study period, 728 women delivered in the 11 facilities. The median age was 28 years, and most women were educated (73 per cent had completed at least the secondary level). The majority (96 per cent) of the women reported they were married, and the median number of living children was three (IQR, two to four). Uptake of the postpartum IUD was 41 per cent (n=300), with eight per cent (n=25) of the acceptors experiencing expulsion of the IUD within six weeks post-insertion.

“After controlling for potential confounding factors, several characteristics were associated with greater likelihood of choosing the postpartum IUD, including lower education, having a higher number of living children, and being single. Women who had used contraceptives previously were less likely to choose the postpartum IUD than women who had not previously used contraception (adjusted odds ratio, 0.68; 95 per cent confidence interval, 0.55 to 0.84).”

The postpartum period is a particularly vulnerable time for women for unintended pregnancy, with studies reporting pregnancy rates of six per cent to 40 per cent within the first postpartum year, depending on the population, and unmet need for modern contraceptives at 61 per cent.

IUDs, including the TCu380A copper-bearing IUD and the levonorgestrel intrauterine system, confer similar contraceptive protection as that obtained with tubal ligation but are reversible and low-cost, thus making them an appealing contraceptive choice.

Postpartum IUD insertion, in particular, is ideal for some women because the IUD does not interfere with breast- feeding; the timing is convenient for both women and the health care provider; and postpartum insertion is associated with less discomfort and fewer side effects than interval insertion (that is, insertion of the IUD six weeks or more after delivery).

In addition, postpartum IUD insertion affords a unique opportunity to address the contraceptive needs of women with limited access to medical care since the delivery and postpartum period may be one of the few times such women are in contact with medical services.

Safety of early postpartum IUD insertion has been studied since the 1960s and the procedure is practiced worldwide; however, less is known about postpartum IUD uptake.

Concerns over the possible risk of infection, bleeding, higher expulsion rates, and even provider reimbursements have limited use of the procedure. Barriers to uptake include cost, lack of provider knowledge or availability, visit protocols for insertion, and misconceptions about IUDs.

Nigeria is the seventh most populous country in the world; in 2015, the population was over 178 million people and the total fertility rate (TFR) was 5.5 children per woman. There has been minimal change in the TFR over the last 10 years, with TFR in 2003 reported at 5.7 children per woman. TFR is higher in rural areas (6.2) than in urban regions (4.7).

The contraceptive prevalence rate (CPR) increased marginally between 2003 and 2013, from 13 per cent to 15 per cent. Only 10 per cent of married women use a modern method of contraception, and use of long-acting reversible contraceptives (LARCs) is reported to be around one per cent (0.2 per cent for implants and 0.8 per cent for IUDs).

The aim of the study was to determine key factors associated with uptake of postpartum IUD insertion in Nigeria. Such information is useful for informing, planning, and providing targeted programming for scale-up of LARCs in Nigeria.

Marie Stopes International Organization, Nigeria supports a social franchise network for private health care providers in the country to deliver quality family planning services at affordable cost. Health care providers within the network are trained on how to provide LARCs to clients in addition to a wide range of other methods.