Feasibility of free-of-charge long-acting reversible contraception

Long-acting reversible contraceptives (LARCs, intrauterine devices and implants) are easy to use and highly effective contraceptive methods. Increasing LARC use provides an opportunity to reduce the incidence of unplanned pregnancy and the need for abortion services. Since 2013 the city of Vantaa, Finland, has offered all women with no history of previous LARC use the opportunity to initiate LARC methods free of charge at the city’s family planning clinics. This programme combined with Finnish national registers, enabled us to evaluate several key factors in providing family planning services and the overall effects of free-of-charge LARC provision. We aimed to evaluate the profile of family planning service users; study the real-life discontinuation rates of LARC methods; compare the need for induced abortion between free-of charge LARC initiators, women choosing other contraceptive options and age-matched controls in the population; and compare the overall use of reproductive health services between free-of-charge LARC initiators and women initiating, switching between, or continuing with short-acting reversible contraceptives (SARCs, pills patches, and rings). All the studies included in this thesis were retrospective cohort studies. The study participants included all 15–44-year-old women living in the city of Vantaa on 1 January 2013 (n = 54,721). Of these women 11,790, used the family planning services of the city, 2,035 initiated free-of-charge LARCs, 1,525 initiated or switched between SARC methods and 2,626 continued with their current SARC method at the family planning clinics of Vantaa in 2013–2014. Levonorgestrel-releasing intrauterine systems (LNG-IUSs) were the most popular choice of LARC methods with 59% of women initiating free-of-charge LARC choosing it, while 32% chose implants, and 9% chose copper intrauterine devices (Cu-IUDs). We found that young women were more likely to use family planning services and to discontinue free-of-charge LARC methods than women over 30 years of age, as were women with a history of delivery or a history of a sexually transmitted infection. Women speaking a native language other than Finnish or Swedish were less likely to use the services, but more likely to discontinue free-of-charge LARC methods. Free-of-charge LARCs had a reasonably low discontinuation rate, with 28% of women discontinuing within two years of use. Most women discontinued due to problems with the method, and only 16% due to a wish to conceive. The most common problems with all LARC methods were bleeding disturbances. The discontinuation rate of LNG-IUSs was the lowest, with 24 % discontinuing within two years followed by implants (33%) and Cu-IUDs (38%). Choosing free-of-charge LARCs reduced the need for abortion care by 80% compared to all other contraceptive options, and by 90–95% compared to initiating or switching between SARC methods. Compared to continuing with the familiar SARC method, free-of-charge LARCs halved the need for abortion care. Women initiating free-of-charge LARCs had a similar need for overall reproductive health services in primary and specialized care concerning gynaecological problems and method related issues as women initiating or switching between SARC methods. Women continuing with their familiar SARC method had less need for reproductive health services than women initiating or switching between methods. Young, sexually active and fertile women were reached well with the family planning services in Vantaa, but young women with a foreign native language were underrepresented among service users. All free-of-charge LARCs had a relatively high continuation rate, but LNG-IUS use was most often continued. Increasing LARC use can be a way to reduce the need for abortion care, but the overall need for reproductive health services is similar among women initiating LARC or SARC methods. Women continuing with their familiar SARC method had the lowest overall need for reproductive health services. These service need should be acknowledged when designing free-of-charge LARC programmes and estimating resources needed for these programmes.