[The loop, after 20 years: evaluation of its utilization in the world]. / Le sterilet, 20 ans apres: bilan de son utilisation dans le monde

PIP: The IUD has evolved from ring designs through plastic radio-opaque spirals to devices containing hormones or bio-active copper. 70% of IUDs are now used in China, where the preferred from is the stainless steel ring; the Lippes loop is preferred in other developing countries. The contraceptive mechanism of the IUD may consist of a combination of effects such as irritation of the uterine environment, and the indirect effect of the copper on sperm motility. Effectiveness rates of different IUDs vary, but generally fall between 1 and 3 pregnancies/100 women/year. Important IUD side effects include menstruation disorders and heavy bleeding, pain, expulsion of the IUD, perforation of the uterine wall, increased risk of pelvic inflammatory disease, and increased risk of ectopic pregnancy. The IUD is generally not belived to have extreme effects on the post-removal return to fertility. Given these complications, it seems clear that IUD users should be carefully screened and counselled, and followed closely post-insertion in case of side effects. Generally, risks are higher for younger women. Different risk factors have been identified as IUD contraindications, e.g nulliparity, multiple sexual partners. Protocols for insertion and extraction include recommendations that IUDs be placed at the rear of the uterus, or that the type be selected based on uterine measurements. Discussion of the safety of the method has been affected by serious side effects attributed to the Dalkon shield, an IUD introduced in the 1970s.^ieng

The effects of three different regimens of oral contraceptives and three different intrauterine devices on the levels of hemoglobin, serum iron and iron binding capacity in anemic women.

The effects on hemoglobin, iron and iron binding capacity (IBC) in 150 moderately anemic women of 1) a 21-day low-dose combined pill, 2) the same low-dose combined pill for 21 days, followed by 7 days of an iron-containing pill, 3) the same low-dose combined pill administered for 63 consecutive days, followed by 7 days of no pill intake, 4) Lippes IUD, 5) TCu 220C and 6) Progestasert were studied. The three pill regimens were associated with an increase in hemoglobin and serum iron after 12 months. However, the iron pill and 63-day schedule groups produced an increase in hemoglobin and iron at the 6th month ans a diminution of IBC at 12 months. The Lippes and TCu 220C groups did not show any change in hemoglobin, iron or iron binding capacity after 12 months. The Progestasert group showed an increase in hemoglobin and iron levels at 6 and 12 months, and a diminution of IBC at 12 months. The pill and Progestasert have advantages as contraceptives in anemic women.

PIP: The effects on hemoglobin, iron, and iron binding capacity (IBC) in 150 moderately anemic women of 1) a 21-day low-dose combined pill; 2) the same low-dose combined pill for 21 days, followed by 7 days for an iron-containing pill; 3) the same low-dose combined pill administered for 63 consecutive days, followed by 7 days of no pill intake; 4) Lippes loop IUD; 5) TCu 220C; and 6) Progestasert were studied. The 3 pill regimens were associated with an increase in hemoglobin and serum iron after 12 months. However, the iron pill and 63-day schedule groups produced an increase in hemoglobin and iron at the 6th month and a diminution of IBC (suggesting a replenishment of iron stores) at 12 months. The Lippes Loop and TCu 220C groups did not show any change in hemoglobin, iron, or IBC after 12 months. The Progestasert group showed an increase in hemoglobin and iron levels at 6 and 12 months, and a diminution of IBC at 12 months. The pill and Progestasert have advantages as contraceptives in anemic women.

Contraceptive use in China.

PIP: An estimate is made of the relative use of the various contraceptive methods--IUDs, sterilization, oral contraceptives (OCs), condoms, injectable contraceptives, abortion, and other contraceptive products approved for general use but only available in limited supply--in China at this time. All of the major contraceptive methods are available without cost. The user is permitted to be absent from work with pay when he/she chooses either IUD insertion/removal, vasectomy, tubal ligation, and induced abortion. IUDs, OCs, sterilization, and condoms account for most of the contraceptive practice in China. Abortion is also available, particularly as a backup to failed contraception. A look at the family planning program in the major municipal area of Tianjin provides an indication of the impact of the national planned birth program. In Tianjin, contraceptives are distributed without cost through the union representative or in the commune. Many men and women obtain their contraceptive supplies at work. The Tianjin program of social and economic incentives and disincentives is typical of such programs throughout China, but the specific details vary from province to province. There are many advantages to having the "only-child certificates" issued by the Tianjin Municipal Revolutionary Council. Economic sanctions are recommended for couples who have a 2nd child. The IUD is the most widely used method in China and is the method most often recommended for women living in rural areas. The IUD may account for as much as 50% of national contraceptive practice. The most widely used IUD consists of a single ring of tightly coiled stainless steel wire. Male and female sterilization is available in most parts of China and accounts for about 30% of contraceptive practice. OC use may be estimated to account for about 8-10% of national contraceptive practice. The condom accounts for about 6% of national contraceptive practice and the injectable for about 1% of total contraceptive use.^ieng

A candle means night.

PIP: The Program for the Introduction and Adaptation of Contraceptive Technology de Mexico (PIACT de Mexico) developed a series of pamphlets for use by rural, illiterate, Mexican women. The graphic design and pictorial sequence were the most important features of the pamphlets which answered questions such as where to obtain oral contraceptives and how to use them. The director of the material development must have rapport with the target audience, who should be involved in the content, sequence, and identification of symbols. Content must be limited to important messages. 10 messages can be portrayed in a pamphlet. Nonverbal materials require more time and effort than verbal materials. Several groups of women were asked to arrange the individual messages into the sequence that was most logical to them. In a test of the pamphlet's effectiveness, 700 interviews of illiterate women found that 70% understood 13 pages and 60-70% could interpret the remaining 3. The pamphlet was 16 pages long and printed in black and white. Backgrounds were kept simple, and a combination of photographs of professional models and line drawings told the stories.^ieng

Use and acceptance of the "paper pill". A novel approach to oral contraception.

A randomized, crossover study comparing the acceptance of and attitudes towards two dosage forms of the same oral contraceptive product - a paper presentation and the conventional tablet, was carried out in a network of rural and suburban research centers in the State of Durango, México. The results failed to show any significant advantage (in terms of acceptability or continuation) of the paper formulation. Although two-thirds of the participants indicated a preference for the conventional tablet, there was a high degree of acceptance of the paper formulation among new oral contraceptive acceptors.

PIP: A randomized, crossover study comparing the acceptance of and attitude towards 2 dosage forms of the same oral contraceptive product -- a paper presentation and the conventional tablet -- was carried out in a network of rural and suburban research centers in the State of Durango, Mexico. 68 women used the paper pill for 3 months and then switched to the tablet for another 3, while 70 women took the tablet 1st and switched to the paper pill. The results failed to show any significant advantage in terms of acceptability or continuation for the paper formulation. Both formulations were perceived as effective and easy to use. 2/3 of the participants indicated a preference for the tablets at the end of the study, but there was a high degree of acceptance of the paper formulation among new oral contraceptive acceptors. The authors believe that an improved paper formulation could be successfully introduced into a national program, if there were substantial savings in cost associated with the "paper pill."

The Who Expanded Research Programme in Human Reproduction.

PIP: The WHO Expanded Programme of Research, Development and Research Training in Human Reproduction which is in the initial stages of implementations, implementation, out of a feasibility study of the agencies concerned with promoting research in human reproduction. The objective of the Programme is to increase understanding of human reproductive processes leading to the development of a variety of safe, acceptable, and effective methods for the regulation of human reproduction. Priority research areas are listed. Task forces will be set up to systematize research efforts in the priority areas establishing collaborative oriented research areas. Leading scientists working in priority areas must be brought together as the initial phase of the Programme. Research and training centers will be set up and provide a multidisciplinary research effort within a single large institution. The Programme includes a plan to establish a worldwide network of research centers concerned with clinical trials. Other components of the Programme include: increasing the provision of supplies to collaborating laboratories and scientists; an improved documentation service; and other WHO research activities in the field of human reproduction.^ieng

Family planning within and beyond MCH. (maternal and child health).

PIP: Advocates of family planning through maternal and child health (MCH) facilities often argue that reduction of infant mortality must precede and motivat family planning while national family planning program proponents argue that reduction of infant mortality is not possible before reduction of fertility. The National Family Planning Program of Ghana, an approach within and beyond MCH, explicitly aims to reduce the rate of population growth. The Secretariat for the Program is part of the Ministry of Finance and Economic Planning, responsible for budget approval, development planning, and coordination of the activities of other ministries. The program is thus assured of status, visibility, and finance. Other ministries also have responsilities in the program. The private sector, e.g., communication networks and commercial distributors will be utilized in order to reach the estimated 75% of the population for whom MCH services are not generally available. Hospitals and health centers operated by the Ministry of Health will continue to provide family planning services.^ieng

Health and demographic priorities for contraception.

PIP: Family planning programs focused on high risk women (older, higher parity) can have a significant impact on fertility and can reduce maternal and infant mortality and morbidity which are positively associated with maternal age and parity. This group of women, which is responsible for a substantial proportion of population growth in developing countries, tends to accept family planning most readily and to adopt contraception on a more permanent basis than younger women. Such contraceptive programs, because they can be justified on the basis of health grounds alone, are likely to be better received by officials and religious and political groups who might normally oppose population control. Administrative suggestions for such programs include defining high risk women, designing special motivational techniques and information materials for these women, and using indigenous midwives as patient recruiters and contraceptive supply agents. These programs can be most effective in countries where contraception is little practiced, and where older women with several children contribute significantly to the total number of births.^ieng

Intrauterine contraception.

Intrauterine devices have been used for over 2000 years. The modern devices (loop, coil and bow) were developed in 1959. The data on 11,222 first insertions from 43 contributing institutions were analyzed by the National Committee on Maternal Health. With the intrauterine loop, expulsions occurred in less than 10% of patients, removals for medical and personal reasons in a further 15%, and pelvic infections in 1.7% during the first year following insertion. Pregnancies occurred during the first year in 2.4% of patients fitted with a loop. Typical of the modern intrauterine devices, the loop is highly effective, readily accepted, and well tolerated by approximately 75% of patients.