title: Estimated disability-adjusted life years averted by long-term provision of long acting contraceptive methods in a Brazilian clinic.
abstract: OBJECTIVE
  What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago.
  
  
  CONCLUSIONS
  Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted.
  
  
  BACKGROUND
  LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce.
  
  
  METHODS
  We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012.
  
  
  METHODS
  Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted.
  
  
  RESULTS
  We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted.
  
  
  CONCLUSIONS
  The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world.
  
  
  CONCLUSIONS
  LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population.
  
  
  BACKGROUND
  This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil bahamond@caism.unicamp.br.
authors.forename: Luis
authors.initials: L
authors.lastname: Bahamondes
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: Bruna F
authors.initials: BF
authors.lastname: Bottura
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: M Valeria
authors.initials: MV
authors.lastname: Bahamondes
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: Mayara P
authors.initials: MP
authors.lastname: Gonçalves
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: Vinicius M
authors.initials: VM
authors.lastname: Correia
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: Ximena
authors.initials: X
authors.lastname: Espejo-Arce
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: Maria H
authors.initials: MH
authors.lastname: Sousa
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: Ilza
authors.initials: I
authors.lastname: Monteiro
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil.
authors.forename: Arlete
authors.initials: A
authors.lastname: Fernandes
mesh_terms: D001938:Brazil; D003267:Contraception / Q000379:methods*; D003271:Contraceptive Agents, Female / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007435:Intrauterine Devices, Copper; D007436:Intrauterine Devices, Medicated; D016912:Levonorgestrel / Q000627:therapeutic use; D008525:Medroxyprogesterone / Q000627:therapeutic use; D011247:Pregnancy; D049168:Pregnancy, Unplanned; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D003271:Contraceptive Agents, Female; D016912:Levonorgestrel; D008525:Medroxyprogesterone
keywords: Brazil; contraceptive methods; disability-adjusted life years; effectiveness; long-acting reversible contraceptives (LARCs)