Background

30 years after the introduction of the levonorgestrel-releasing intrauterine device in Europe, several sub-Saharan African countries are seeking to broaden access to this contraceptive method. In this study, we aimed to assess 12-month continuation of the hormonal intrauterine device, copper intrauterine device, and implants, as well as to assess women's experiences and satisfaction using these methods in the private sector in Nigeria and the public sector in Zambia.

Methods

We did a prospective cohort study of long-acting reversible contraceptive users across 40 private sector clinics in Nigeria and 21 public sector clinics in Zambia. Eligible women were aged 18–49 years in Nigeria and 16–49 years in Zambia, had chosen to receive the hormonal intrauterine device, copper intrauterine device, or implant (either a 5-year levonorgestrel-releasing subdermal implant or a 3-year etonogestrel-releasing subdermal implant), and, in Nigeria only, had access to a telephone. Women were interviewed within 100 days of receiving their contraceptive method either via telephone in Nigeria or in person in Zambia, with follow-up surveys at 6 months and 12 months. The primary outcomes were method-specific, 12-month continuation rates—ie, continuation rates of the hormonal intrauterine device, copper intrauterine device, and implant across Nigeria and Zambia. We used Kaplan-Meier methods to estimate the cumulative probabilities of method-specific continuation and a log-rank test to compare contraceptive methods. We analysed self-reported satisfaction and experiences as a secondary outcome.

Findings

Between June 25 and Nov 22, 2018, we enrolled a total of 1542 women (n=860 in Nigeria and n=682 in Zambia) receiving a long-acting reversible contraceptive. In total, 835 women (266 [32%] hormonal intrauterine device users, 274 [33%] copper intrauterine device users, and 295 [35%] implant users) in Nigeria and 367 (140 [38%] hormonal intrauterine device users, 149 [40%] copper intrauterine device users, and 78 [21%] implant users) in Zambia were included in the study analysis. The 12-month cumulative continuation rates were 86·8% (95% CI 82·1–90·4) for the hormonal intrauterine device, 86·9% (82·1–90·4) for the copper intrauterine device, and 85·0% (80·2–88·7) for implants in Nigeria. In Zambia, the 12-month cumulative continuation rates were 94·7% (89·2–97·4) for the hormonal intrauterine device, 89·1% (82·3–93·4) for the copper intrauterine device, and 83·1% (72·2–90·1) for implants. At least 71% of respondents across the timepoints were very satisfied with their method, and at least 55 (79%) of 70 reported having recommended their contraceptive method to someone else. Across the methods, the most commonly self-reported positive aspect of long-acting reversible contraceptive use at 12 months was effectiveness in Nigeria (range 93–94%) and long-lasting duration in Zambia (48–60%). Between 124 (50%) of 248 and 136 (59%) of 230 Nigerian participants and 26 (42%) of 62 and 66 (57%) of 117 Zambian participants reported nothing negative about their contraceptive method.

Interpretation

Our study showed high continuation rates and satisfaction across long-acting reversible contraceptives, including the hormonal intrauterine device, a method that has been largely underused in sub-Saharan Africa. This finding supports the inclusion of the hormonal intrauterine device as a valuable addition to the mix of contraceptive methods in Nigeria and Zambia.

Funding

Bill & Melinda Gates Foundation.

中文翻译：

---

扩大长效避孕选择：尼日利亚和赞比亚激素宫内节育器、含铜宫内节育器和埋植剂的前瞻性队列研究

 背景

在欧洲推出左炔诺孕酮宫内节育器 30 年后，一些撒哈拉以南非洲国家正在寻求扩大这种避孕方法的使用范围。在这项研究中，我们旨在评估激素宫内节育器、含铜宫内节育器和埋植剂的 12 个月持续使用情况，并评估妇女在尼日利亚私营部门和赞比亚公共部门使用这些方法的体验和满意度。

 方法

我们对尼日利亚 40 家私营诊所和赞比亚 21 家公立诊所的长效可逆避孕药使用者进行了一项前瞻性队列研究。符合条件的女性年龄在尼日利亚为 18-49 岁，在赞比亚为 16-49 岁，选择接受激素宫内节育器、铜宫内节育器或植入物（5 年左炔诺孕酮释放皮下植入物或 3 年依托孕烯） -释放皮下植入物），并且仅在尼日利亚可以使用电话。妇女在接受避孕方法后 100 天内接受采访，在尼日利亚通过电话或在赞比亚亲自进行采访，并在 6 个月和 12 个月进行后续调查。主要结果是特定方法的 12 个月持续率，即尼日利亚和赞比亚的激素宫内节育器、含铜宫内节育器和植入物的持续率。我们使用 Kaplan-Meier 方法来估计特定方法延续的累积概率，并使用对数秩检验来比较避孕方法。我们分析了自我报告的满意度和体验作为次要结果。

 发现

2018年6月25日至11月22日期间，我们总共招募了1542名接受长效可逆避孕药的女性（尼日利亚n=860，赞比亚n=682）。尼日利亚共有 835 名女性（266 名 [32%] 激素宫内节育器使用者、274 名 [33%] 铜质宫内节育器使用者和 295 名 [35%] 埋植剂使用者），以及 367 名女性（140 名 [38%] 激素宫内节育器使用者），研究分析包括赞比亚 149 名（40%）铜宫内节育器使用者和 78 名（21%）植入物使用者。激素宫内节育器的 12 个月累积继续使用率为 86·8% (95% CI 82·1–90·4)，铜宫内节育器为 86·9% (82·1–90·4)，尼日利亚的植入率为 85·0% (80·2–88·7)。在赞比亚，激素宫内节育器的 12 个月累积继续使用率为 94·7%（89·2–97·4），铜宫内节育器为 89·1%（82·3–93·4），种植体为 83·1% (72·2–90·1)。在各个时间点，至少 71% 的受访者对他们的方法非常满意，70 人中至少有 55 人 (79%) 报告曾向其他人推荐过他们的避孕方法。在所有方法中，长效可逆避孕药使用 12 个月时最常见的自我报告积极方面是尼日利亚的有效性（范围 93-94%）和赞比亚的持续时间长（48-60%）。 248 名尼日利亚参与者中的 124 名（50%）至 230 名尼日利亚参与者中的 136 名（59%）以及 62 名赞比亚参与者中的 26 名（42%）至 117 名赞比亚参与者中的 66 名（57%）表示，他们的避孕方法没有任何负面影响。

 解释

我们的研究表明，长效可逆避孕药的继续使用率和满意度很高，包括激素宫内节育器，这种方法在撒哈拉以南非洲地区基本上没有得到充分利用。这一发现支持将激素宫内节育器作为尼日利亚和赞比亚避孕方法组合的一个有价值的补充。

 资金

比尔及梅琳达·盖茨基金会。