4: LONG ACTING REVERSIBLE CONTRACEPTION (LARC) AMONG

RURAL REJANG WOMEN IN THE SONG DISTRICT, SARAWAK

Background review: Long acting reversible contraception or LARC includes

intrauterine devices (IUD), theintrauterine system (IUS), injectable
contraceptives and implants. LARC is not only highly effective in preventing
unwantedpregnancies but is also more cost effective than the combined oral
contraceptive pill. However, the cumulativeprevalence of LARC use in Sarawak
was only 8.9% in 2004 with 2.6% of that being IUDs, 6.0% injectable
contraceptivesand 0.3% implants.
Objectives: The aims of this study was to identify LARC choices among women
seeking contraception in KlinikKesihatan Song, Sarawak and the sociodemographic profile, parity and prior contraceptive choices of women on
theMillennium Development Goals (MDG) 4,5 and 6: Are We There Yet? 5717th
MALAYSIAN FAMILY MEDICINE SCIENTIFIC CONFERENCEIUD. A simple cost
analysis of available contraceptives was also done.
Methods: This retrospective case review was carried out between September
2012 till March 2013. All women onLARC as registered in theBuku Daftar
Pengamal Perancang Keluarga PKW 101 pind 2/2007were included. Women
onthe IUD were then identified and their individual Kad Perancang Keluarga PKW
1(a)/ 06 reviewed. Cost comparisonbetween the available contraceptive
methods was done based on the bulk prices quoted to the clinic by the
respectivepharmaceuticals. SPSS version 21.0 was used for data entry and
analysis.
Results: A total of 355 women were on LARC with 314 (88.5%) on the 3-monthly
progesterone only injection and the remaining41 (11.5%) on the copper IUD.
Women on the IUD aged between 22 to 47 years with an average age of 37.2 (SD
6.9) years.More than two thirds (70.7%) of the women were 35 years and above.
The majority (97.6%) were ethnic Pribumi of Ibandescent. Although parity ranged
from 1 to 7, half of them had a parity of 4 or more. Prior to IUD usage,52.4% of
these women were on oral contraceptives, 33.3% on injectables while only 2
(4.8%) had an IUD previously. Theremaining 4 (9.5%) women were on other
methods except condoms. Oral contraceptives cost RM0.88 RM3.77 per
monthusage, depending on type. Progesteron only injections were RM2.00 per
month. Although the cost per unit for the copperIUD was the highest, long term
(3 years) it worked out to be the cheapest at RM0.65 per month.
Conclusion: Injectable contraception was the main choice of LARC among rural
Rejang women in the Song district. Majorityof women on the IUD were older with
4 or more children, suggesting that it was more favourable among those
intending tolimit family size instead of spacing their pregnancies. The IUD was
the cheapest long term reversible contraceptiveoption. LARC especially the IUD
was cost effective and all women seeking contraception should be given this

option. Bypreventing unwanted and unplanned pregnancies, LARC improves

maternal health thus, bringing us closer to achievingMillenium Development Goal
5

Contraceptive services are provided by Ministry of Health, Family Planning and

Development Board as well as The Federation of Reproductive Health Association
Malaysia. In addition, contraception methods are available in private hospitals,
pharmacies as well as private clinics.
Most of the contraceptive methods are available in all four major service provider
although provision ranges from free to subsidised and full payments. In practice,
there were difficulties noted in many areas of contraceptive provision that posed
a challenge to the Malaysian women when accessing contraception.
Long Acting reversible contraception in particular hormonal Implants are only
available in Ministry of Health Hospitals for selected high risks patients.This
method currently is unavailable for women in Government Primary care clinics
such as Klinik Kesihatan.
Not all methods are available in all the service providers most of the time due to
disruption in supply of the methods, availability of trained Health care providers
in fitting the devices, differing costs of different methods.Choice and continuous
availability of methods are integral components in making sure women can
continue to use contraception to avoid pregnancy.
Contraceptive knowledge and training for healthcare providers are not uniform
and thus differing advices and management of contraceptive cases may be
offered by differing healthcare providers and thus may at times be Not the most
appropriate or even correct advice and management. This creates mis use of the
methods and thus resulting in decrease efficacy of the methods and increasing
rate of unintended Pregnancies.
The Fear Factor are very much prevalent in the Malaysian women in
terms of Myths and Misconceptions about the side effects of
Contraceptive methods.
Socio economic and religious constraints are also important factors that posed
difficulties for women in accessing contraception. Commonly, the rural women
may not have the economic ability to access highly effective methods such as
Long Acting reversible methods due to costs constraints as well as non
availability of trained personnel in a nearby clinic. Religious groups may impose
upon their own views and beliefs about contraceptive practice which may not be
in the best interest of the women concerned.
Malaysias Law is also not clearly defined as to provision of contraception to
adolescents thus limited access to this vulnerable group and exposed them to a
high incidence of teen pregnancies.

Among the women:

We need to correct the myth and misconception and the opposition towards
contraception.
We need to raise the socio economic status of women as it have been shown that
much higher incidence of Unintended Pregnancies occur in the lower and middle
income group.
We need to raise the education level of all girls and women as education is the
key to understanding and better family planning.

Among the Healthcare Professionals:

We need to continuously train all healthcare professionals and equipt them with
the most accurate and up to date contraceptive informations and management
skills.
We need to increase and ensure that all choices of contraceptive methods are
available, in particular the long acting reversible contraceptives and to ensure
that the supply of these methods are continuous and uninterrupted.

More than 150 million women become pregnant in developing countries annually
and an estimated 287,000 die from pregnancy-related causes. Contraception is
vital to prevent unnecessary maternal deaths, as well as sexually transmitted
infections. The objective of this study was to investigate preferred contraceptive
methods and the factors that influence contraceptive choice among women in
Kelantan, Malaysia. A cross-sectional study using interview-based questionnaires
was conducted, during July and August 2009, in local family planning clinics in
Kelantan. The questionnaire was administered to adult women (age 2050).
Prevalence of unplanned pregnancies was high (48%). Contraceptive preference
was Depo contraceptive injection (32%), oral contraceptive pills (27%),
intrauterine devices (15%) and contraceptive implants (12%); 9% used condoms.
Only 2% used contraception to protect against sexually transmitted infections or
HIV/AIDS. Younger women (OR 0.90; 95% CI 0.8070.993) were more likely to
use contraception. In conclusion, non-interrupted contraceptive methods were
preferred. More than 60% would stop using contraception if it interrupted
intercourse. From both a public health and infectious disease perspective, this is
extremely worrying.

Copper T intrauterine device (IUD) This IUD is a small device that is shaped in
the form of a T. Your doctor places it inside the uterus to prevent pregnancy. It
can stay in your uterus for up to 10 years. Typical use failure rate: 0.8%.

Levonorgestrel intrauterine system (LNG IUD)The LNG IUD is a small T-shaped

device like the Copper T IUD. It is placed inside the uterus by a doctor. It releases
a small amount of progestin each day to keep you from getting pregnant. The
LNG IUD stays in your uterus for up to 5 years. Typical use failure rate: 0.2%.
Hormonal Methods
ImplantThe implant is a single, thin rod that is inserted under the skin of a
womens upper arm. The rod contains a progestin that is released into the body
over 3 years. Typical use failure rate: 0.05%.
Injection or "shot"Women get shots of the hormone progestin in the buttocks or
arm every three months from their doctor. Typical use failure rate: 6%.
birth control pillsCombined oral contraceptivesAlso called the pill, combined
oral contraceptives contain the hormones estrogen and progestin. It is prescribed
by a doctor. A pill is taken at the same time each day. If you are older than 35
years and smoke, have a history of blood clots or breast cancer, your doctor may
advise you not to take the pill. Typical use failure rate: 9%.
Progestin only pillUnlike the combined pill, the progestin-only pill (sometimes
called the mini-pill) only has one hormone, progestin, instead of both estrogen
and progestin. It is prescribed by a doctor. It is taken at the same time each day.
It may be a good option for women who cant take estrogen. Typical use failure
rate: 9%.
the patchPatchThis skin patch is worn on the lower abdomen, buttocks, or
upper body (but not on the breasts). This method is prescribed by a doctor. It
releases hormones progestin and estrogen into the bloodstream. You put on a
new patch once a week for three weeks. During the fourth week, you do not wear
a patch, so you can have a menstrual period. Typical use failure rate: 9%, but
may be higher in women who weigh more than 198 pounds.

PRODUCT

NO
.

PRICE
(RM)

1. CONTRACEPTIVE PILLS
ETHINYLESTRADIOL 30MCG /LEVONORGESTREL 150MCG

5.00

ETHINYLESTRADIOL 30MCG/DESOGESTREL 150MCG

7.00

ETHINYLESTRADIOL 20MCG/ LEVONORGESTREL 100MCG

16.00

ETHINYLESTRADIOL 20MCG/DESOGESTREL 150MCG

16.00

PROGESTIN-ONLY PILL

10.00

DESOGESTREL 75MCG

40.00

DROSPIRENONE 3MG / ETHINYLESTRADIOL 30MCG

52.00

CYPROTERONE ACETATE 2MG / ETHINYESTRADIOL 35MCG

2. PROGESTIN INJECTION
MEDROXYPROGESTERONE ACETATE
NORETHISTERONE
3. MALE CONDOM
THREE PIECES
TWELVE PIECES
4. INTRAUTERINE CONTRACEPTIVE DEVICE (IUCD) INCLUDING
INSERTION

40.00
36.00
18.00
1.00
4.00
80.00

(3 YEARS DURATION)
5. IMPLANT INCLUDING INSERTION (3 YEARS DURATION)

500.00

6. VASECTOMY
LOCAL ANESTHESIA

300.00

GENERAL ANESTHESIA

550.00

Shiely F, Saifuddin M.S. Contraceptive choice and acceptability: The future for STI
risk in Kelantan, Malaysia. International Journal of STD and AIDS. 2013 June 19;