Fertility transition in Sub-Saharan Africa has been slow: The total fertility rate for the region was 6.8 in the late 1970s and is now a little below 5.0.1 In addition, modern contraceptive use is low: Only 25% of married women in Sub-Saharan Africa were using a modern method in 2015, compared with 58% globally. Contraceptive use is increasing, however, largely because of rising uptake of the injectable. In 2015, the method accounted for 45% of all modern method use in Sub-Saharan Africa, and the pill accounted for an additional 22%.2 The injectable is highly effective and can be delivered by lower-level paramedical staff, but these advantages are offset by low adherence, high discontinuation and low switching to alternative methods after discontinuation.3–5
Improving women’s access to a wider range of methods—including long-acting reversible methods (LARCs), defined here as the IUD and the implant—will give women more choice and should reduce unmet need, which is increasingly the result of discontinuation of short-acting methods.6 LARCs are typically used for longer durations than the injectable or the pill,3 and thus are particularly appropriate for the growing number of women who want to cease childbearing altogether.7 Women may use LARCs longer because those who choose them are more committed to long-term avoidance of pregnancy; another reason may be that LARC discontinuation requires a firm decision and a visit to a health facility, where health staff may encourage clients to persist with the method. According to a randomized, controlled trial in the United States, characteristics of the method rather than of the user account for the difference in discontinuation between LARCs and other reversible methods.8
Major initiatives to increase access to LARCs in Africa—funded by bilateral donors and foundations, and implemented with input from such international nongovernmental organizations as Marie Stopes International (MSI) and Population Services International (PSI)—have been launched in the past decade. Some of these projects were designed for the general population, whereas others were focused on women who had recently given birth or had an abortion, those living with HIV, those affected by conflict and the young. Many placed equal emphasis on the IUD and the implant, but some were dedicated to one or the other.9
The objective of this article is to review key components of LARC uptake in Sub-Saharan Africa with the aim of guiding policies and programs. We assess trends in access to the IUD and implant, including method knowledge and availability at facilities; examine trends in use, source of supply, discontinuation and characteristics of users; and discuss the prospects for expanding method choice by increasing the availability of LARCs in national programs and the policy implications of our results.
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