Estimated disability-adjusted life years averted by long
Human Reproduction, Vol.29, No.10 pp. 2163– 2170, 2014
Advanced Access publication on August 1, 2014 doi:10.1093/humrep/deu191
ORIGINAL ARTICLE Fertility control
Estimated disability-adjusted life
years averted by long-term provision
of long acting contraceptive methods
in a Brazilian clinic
Luis Bahamondes*, Bruna F. Bottura, M. Valeria Bahamondes,
Mayara P. Gonçalves, Vinicius M. Correia, Ximena Espejo-Arce,
Maria H. Sousa, Ilza Monteiro, and Arlete Fernandes
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
*Correspondence address. Caixa Postal 6181, 13084-971, Campinas, SP, Brazil. Tel: +55-19-3289-2856; Fax: +55-19-3289-2440;
E-mail: [email protected]
Submitted on April 28, 2014; resubmitted on June 25, 2014; accepted on July 3, 2014
study question: 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.
summary answer: 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.
what is known already: 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.
study design, size and duration: 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.
participants/materials, setting, 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 ¼ 13 826), the LNG-IUS (n ¼
1525), implants (n ¼ 277) and DMPA (n ¼ 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality
and unsafe abortions averted.
main results and the role of chance: 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.
& The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
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Bahamondes et al.
limitations, reasons for caution: 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.
wider implications of the findings: 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.
study funding/competing interest(s): 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.
Key words: contraceptive methods / long-acting reversible contraceptives (LARCs) / effectiveness / disability-adjusted life years / Brazil
Unplanned pregnancy is a major problem of public health in developing
and in many developed countries. In the USA almost 50% of all pregnancies are unplanned (Blumenthal et al., 2011; Finer et al., 2012; Jones et al.,
2012, 2014; Wilson et al., 2013), and in the UK it was reported that the
abortion rate was 17.5 per 1000 women (Opinion Survey 2008/09,
2009), while a Scottish study conducted in 2006 (Abortion statistics,
2013) showed that 30% of pregnancies were unintended. A large proportion of the unintended pregnancies occurred in adolescent girls and the
UK has one of the highest pregnancy rates among adolescents (Abortion
In the USA, combined oral contraceptives (COCs) and tubal ligation
are the most commonly used contraceptives, accounting for 28 and
27%, respectively, whereas intrauterine devices (IUDs) were used only
by 5.6% of women in 2006 (Jones et al., 2012), although this rate has
increased in recent years (Xu et al., 2012). The scenario is different
among European women and IUD use is more common, with the
highest rates observed in the Scandinavian countries, including rates of
23.3% in Norway and 16.6% in Sweden, and 10% in the UK (United
Nations, 2012). The Brazilian proﬁle is similar to the USA, and for the
year 2006 it was observed that female sterilization (29.1%) and COCs
(24.7%) were the most prevalent form of contraception; IUD, implants
and injectables accounted only for 6.0% among users of modern
contraceptive methods (United Nations, 2012; Information Please
Despite the availability of contraceptive methods, the rates of unintended pregnancy remain high. This apparent contradiction can be
explained by the lack of contraceptive use, the perceived low risk of pregnancy, the cost of the methods, the opposition to use by the partner or by
women because they are concerned about health-related consequences, and religious opposition. Furthermore, unplanned pregnancy
may be attributed to incorrect or inconsistent use of contraception. Additionally, women’s satisfaction with the current method is an important
variable for a high continuation rate and it is important that healthcare
professionals (HCPs) provide appropriate counselling about the different contraceptives available in any particular setting.
In recent years there has been an increase in interest worldwide about
the use of long-acting reversible contraceptives (LARCs) (the copper
IUD, the levonorgestrel-releasing intrauterine system [LNG-IUS], the
levonorgestrel [LNG]- and etonogestrel [ENG]-releasing subdermal
implants) and depot-medroxyprogesterone acetate [DMPA], which, although it is not a LARC method, presents an extremely low contraceptive failure rate (Espey and Ogburn, 2011; Winner et al., 2012). LARC
methods are independent of women or couple compliance, with
failure rates ,1/100 women-years (similar to the observed rates of
female sterilization) (Winner et al., 2012), and are cost-effective, including from the British National Health Service perspective (Mavranezouli
and LARC Guideline Development Group, 2008).
However, there is scarce information about the long-term use of
LARC and also among women not involved in clinical trials (Dı́az et al.,
1992a,b; Bahamondes et al., 2005; Aoun et al., 2014). Additionally, information about the women and child beneﬁts of LARC use is also scarce
(Tsui et al., 2010; Cleland et al., 2012; Stover and Ross, 2013). Consequently, the objective of this study was to evaluate pregnancy and continuation rates and, for the ﬁrst time, to estimate the disability-adjusted
life year (DALY) (www.mariestpoes.org/impact2, 2012) averted
among LARC and DMPA users at a Brazilian university-based clinic established .30 years ago.
Materials and Methods
This was a retrospective study carried out at the Human Reproduction Unit,
Department of Obstetrics and Gynaecology, School of Medical Sciences,
University of Campinas (UNICAMP), Campinas, SP, Brazil. The protocol
was approved by the Ethical Committee; however, informed consent was
not obtained because we reviewed medical records and the data were
retrieved without identifying the women. The common practice at the
clinic is that, upon admission, the HCPs on duty ﬁll out a medical record
with the women’s and medical history and the contraceptive method provided. After appropriate counselling about effectiveness, safety, side-effects
and beneﬁts of all the contraceptive methods available at the clinic, the
women choose a method and, according to Brazilian law for the public
sector, all the methods were provided at no cost to the women. However,
LNG- and ENG-releasing implants were only available sporadically due
Disability-adjusted life years averted by contraception
to the high market cost. At any follow-up visit, we recorded pregnancy,
removals or a switch to another method.
Women of 12 – 50 years of age who came to the clinic were offered all
contraceptive methods including DMPA, the LNG-IUS (Mirenaw, Bayer
Oy, Turku, Finland), the LNG-releasing implant (Norplantw, Bayer Oy,
Turku, Finland, up to August 2001) and then the ENG-releasing implant
(Implanonw, Merck, Oss, Holland), and the copper IUD (TCu200B up to
April, 1988) and then the TCu380A (ParaGardw, Ortho Pharmaceutical,
Don Mills, Ontario, Canada, and since the year 2001, Optimaw, Injeﬂex,
São Paulo, Brazil). The women have the right to choose any method according to the eligibility criteria established by the World Health Organization
(WHO) (WHO, 2010), and have the right to discontinue or switch to
another method at any time, and the reason (s) and date were recorded.
We reviewed 50 004 medical charts available at the clinic from women
who consulted for the ﬁrst time from 2 January 1980 through 31 December
2012. Three persons performed the data collection and before the data collection started we deﬁned all the clinical outcomes which were to be used.
Every week a senior researcher checked the collection of the data and performed at random a second survey of at least 20% of the records. For the
purpose of this report we only take into account users of the copper IUD,
the LNG-IUS, implants and users of DMPA. We excluded women who participated in Phase II or III of clinical trials for the development of new contraceptives, or those who discontinued or were lost to follow-up before
completing 1 year of use. Women who received an LNG-IUS only for therapeutic purposes were also excluded.
We considered both the copper IUDs (the TCu200B and the TCu380A) as
the same device and the two implants (Norplant and Implanon) as the
same implant. For the data analysis regarding contraceptive use, we considered all the years as continuous use if a woman who received an IUD, an
LNG-IUS, or an implant changed to a new IUD, a LNG-IUS, or an
implant on the same day as removal at the end of the contraceptive lifespan. Expulsion of an IUD or an LNG-IUS and insertion of a new one on
the same day was also considered as continuous use. For IUD, LNG-IUS
or implants, the cut-off of the data was the day of removal without any
new insertion or pregnancy. For DMPA users, we considered that the
woman was in use for the 3-month interval after a record of the last injection. For women who stopped the use of any contraceptive and switched
to another method, we considered the entire length of use of each different
contraceptive. For women who reached menopause, the cut-off of the data
was the last menstrual day or the day on which the second test FSH value
(measured 90 days apart) was .40 mIU/ml. Contraceptive failure was
considered when a pregnancy occurred during use of the method. For
women who expelled, totally or partially, an IUD/LNG-IUS and became
pregnant we considered this an unplanned pregnancy attributed to IUD/
LNG-IUS failure. All the pregnancies recorded were diagnosed or conﬁrmed at the clinic by a urinary pregnancy test and/or ultrasonography,
and all were considered as unplanned pregnancies. For women who did
not follow-up, we made an effort to obtain data via telephone interviews
and the cut-off of the data was the last visit to the clinic.
Life-table analysis (annual interval) was used to evaluate clinical performance, and the signiﬁcance of the differences between the users of each
method was evaluated through the Wilcoxon-Gehan test. The data were
presented as cumulative rate of continuation and cumulative discontinuation rates of pregnancy. The cumulative data were presented up to 20
years of use divided by each 5 years; however, the total period of evaluation
was 31 years. For each contraceptive method, the rates were presented as
a percentage with the corresponding SEM. The sociodemographic data
were presented as mean + SEM or percentage distribution for categorical
For the estimation of DALY averted we used the programme developed by
Marie Stopes International (www.mariestopes.org/impact2, 2012). The
programme is pre-loaded with national data for developing countries from
different sources including Demographic and Health Surveys, UN Population
Prospects, UN maternal and child mortality data, WHO Global Burden of
Disease, and the Guttmacher Institute. Maternal deaths averted were estimated by multiplying the estimated number of pregnancies averted in a
given year by the number of maternal deaths per pregnancy in that same
year. Maternal DALYS are separated into: (i) Years of lost life (YLL)—
mortality related DALYS and (ii) Years lost to disability (YLD)—morbidity
related DALYs. These two sub-sets of the maternal DALY are estimated
and reported separately in the model. The YLL and YLD calculations use
the maternal mortality ratio, which changes over time (WHO, 2003, 2008,
2012). Child deaths averted were calculated by multiplying live births
averted by previous birth interval coefﬁcient. Unsafe abortions averted
were estimated by multiplying the number of live births averted by the
number of abortions per 100 live births, as given by the unsafe abortion
ratio. For DALY analysis, the estimated DALY averted was only for the last
10 years of the review, because the software was only available over that
period. The software used was SPSS v. 20 and Impact 2. Signiﬁcance was
established at P , 0.05.
After the revision of the medical records, we obtained 29 416 contraceptive segments of use; however, only 25 015 segments corresponding to 20 821 new users or switchers to any LARC methods or DMPA
with at least 1 year of follow-up. Overall 14% of the women among the
four methods under evaluation never returned to the clinic. Table I
shows the main sociodemographic characteristics of the women
according to the decade in which they were admitted to the clinic.
The mean (+SD) age of the women at admission ranged from
26.1 + 5.5 (range 12 –47) years in the 1980s to 31.9 + 7.4 (range
16 –50) years in the decade to 2010. The percentage of women with
one or two pregnancies ranged from 60.8% in the 1980s to 65.4% in
the decade to 2010. Regarding the years of schooling, the most
common range was 1–4 years (52.6%) in the 1980s and 9–12 years
(55.5%) in the decade to 2010.
The most common contraceptive method in use at admission to the
clinic was COC, albeit declining from 57.0% in the 1980s to 31.5% in
the decade to 2010 (Table II). The most common contraceptive
chosen at admission was copper IUD, chosen by 48.3, 74.5 and 60.9%
during the 1980s, 1990s and 2000s, respectively (Table III). Table IV
and Fig. 1 show that after 20 years of evaluation, 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, the copper IUD and DMPA, respectively.
Although there is a trend of high contraceptive efﬁcacy among the
LNG-IUS and DMPA users, the differences were not signiﬁcant
between the four groups (P , 0.059). The cumulative continuation
rates (SEM), also after 20 years of evaluation, were 15.1 (3.7), 3.9
(1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, the implants, the
copper IUD and DMPA, respectively (P , 0.001).
Figure 2 shows the DALY (maternal morbidity and mortality, child
mortality, and unsafe abortions) averted. Over the last 10 years of evaluation, the estimation of the contribution of the clinic to DALY averted
was 30 –59 maternal deaths; 289– 375 child mortalities averted; 319–
434 combined maternal morbidity and mortality and child mortality,
and 423– 547 unsafe abortions.
Bahamondes et al.
Table I Selected characteristics of the women seeking contraception according to decade of admission to the clinic.
Years at admission
Age at admission, yearsa (range)
26.1 + 5.5 (12– 47)
27.2 + 6.3 (14– 47)
29.1 + 6.9 (13– 49)
31.9 + 7.4 (16– 50)
Number of pregnancies, n (%)
Years of schooling, n (%)
Mean + SEM.
Table II Contraceptive method in use prior to the ﬁrst consultation at the clinic.
Previous contraceptive method, n (%)
Years at admission
Fertility awareness methods
DMPA or CIC
COC, combined oral contraceptives; DMPA, depot-medroxyprogesterone acetate; CIC, combined injectable contraceptive; IUD, intrauterine device; LNG-IUS, levonorgestrel-releasing
The data reﬂect the overall progress made in Brazilian society. The mean
age of the women consulting at the clinic increased with each decade,
possibly mirroring the fact that the primary health network is working
better than 30 years ago, enabling these women to obtain contraceptive
methods at other locations. Consequently, they may be consulting at this
teaching centre only because they want to use a LARC method. In addition, the proportion of women with three or more pregnancies declined
over time, as did the number of illiterate women; women with at least
9 years of schooling increased during the 30 years of observation.
These results indicate that, at least in the studied population living in an
urban area in the most developed Brazilian state, women increased
their socio-economic status (Mendes Ada et al., 2012). Additionally,
contraceptive use at the ﬁrst consultation at the clinic and awareness
of unplanned pregnancy also improved; the proportion of women who
consulted and reported no use of any method declined from 12.6% in
the 1980s to 4% at time of writing.
COC was the most prevalent contraceptive method in use at
admission, with the exception of the years 2010–2011 in which the
male condom was the most prevalent method, which may reﬂect
women being conscious of protecting themselves against human
Disability-adjusted life years averted by contraception
Table III Contraceptive method chosen at the ﬁrst admission to the clinic.
Contraceptive method chosen, n (%)
Years at admission
DMPA or CIC
Table IV Cumulative rates of discontinuation due to pregnancy and continuation rates every 5 years, according to
contraceptive method (n 5 25 015).
Length of use (years) and variable
Data are presented as rate (SEM).
*Wilcoxon (Gehan) test.
immunodeﬁcient virus acquisition after massive governmental campaigns
(Okie, 2006). Another possibility is that the women were not satisﬁed
with the contraceptive method in use and decided to use condoms
before choosing a new contraceptive method at the clinic. The most
prevalent contraceptive method chosen at admission was copper IUD
followed by COC; however, in the last years of evaluation the
LNG-IUS increased in acceptance among the women who consulted
at our clinic.
Brazilian women were less likely to accept the LNG-IUS in the early
years of the clinic activities even though LNG-IUS has been offered
since 1980, albeit at limited availability. One of the explanations was
that Brazilian women were reluctant to accept pharmacological
induced amenorrhoea during the early years of this survey (Nascimento
et al., 2002; Estanislau do Amaral et al., 2005) and the women who liked
monthly menstrual bleeding were those who attended ,8 years of
school, were of low socio-economic class, and reported that monthly
bleeding made them feeling healthy and provides a conﬁrmation of not
being pregnant (Estanislau do Amaral et al., 2005; Makuch et al.,
2011). However, the associated variables with liking menstruation
were less common during the latter years of evaluation, and the
opinion of the Brazilian women about menstruation changed. In a nationwide study (Makuch et al., 2012), it was reported that among the women
interviewed, 64.3% disliked menstruation and the desired frequency of
menstrual bleeding was ‘never’ for 65.3% and ‘less than once-a-month’
for 18.2%. Furthermore, we cannot ignore that from the year 2006
our clinic was the only public sector centre in the city with availability
of the LNG-IUS on demand and at no cost for the women, and the
cost of contraceptive methods is one of the main barriers against their
use (Mavranezouli and LARC Guideline Development Group, 2008;
Winner et al., 2012; Eisenberg et al., 2013).
The contraceptive failure rates presented for the four methods were
similar to previous reports (Sivin et al., 1991, 1993, 2000; Sivin and Stern,
1994; Meirik et al., 2001; Sivin, 2007; Winner et al., 2012). The data
showed that the LNG-IUS and DMPA had lower rates of unplanned pregnancy; however, the rate of contraceptive failure with implants
(Norplant/Implanon combined) and copper IUD (TCu200B and
TCu380A combined), albeit a little higher, was not signiﬁcantly different
than the other two methods. This may only reﬂect the fact that Norplant
and TCu200B IUD showed a higher pregnancy rate than Implanon and
TCu380A IUD, respectively, and the low number of users of implants
in our survey (Sivin et al., 2000; Winner et al., 2012).
It is possible to argue that many pregnancies occurred among women
who never returned to the clinic. This speculation may or may not be true
(Ferreira et al., 2014). Most of the women who became pregnant
Bahamondes et al.
Figure 1 Cumulative discontinuation (Life-table analysis) rate by method, due to unplanned pregnancy. DMPA, depot-medroxyprogesterone acetate;
IUD, intrauterine device; LNG-IUS, levonorgestrel-releasing intrauterine system.
Figure 2 Estimated disability-adjusted life year (DALY)—maternal
morbidity and mortality, child mortality, total mortality and unsafe abortions averted.
returned to the clinic to remove the IUD/LNG-IUS or the implant and to
obtain information about the risks to the baby of becoming pregnant with
the contraceptive in place. Additionally, these women have the right to
obtain prenatal care at our high-risk pregnancy university clinic, a fact
that encourages women to return. It could be speculated that due to
the fact that abortion is restricted in Brazil, many women who became
pregnant instead of coming back for follow-up would seek unsafe abortions in other settings, making an artiﬁcially low failure rate in this study.
However, the cumulative pregnancy rates observed for the four methods
up to 20 years were similar to those reported elsewhere, which reinforces our data (Sivin et al., 1991, 1993, 2000; Sivin and Stern, 1994;
Meirik et al., 2001; Sivin, 2007; Winner et al., 2012). This low contraceptive failure was correlated to .50% and almost 15% of continuation rates
of use among IUD/LNG-IUS acceptors at 5 and 20 years of follow-up,
respectively, which is also similar to previous reports (Sivin et al., 1991,
1993, 2000; Sivin, 2007; Winner et al., 2012).
Regarding the DALY averted, it is obvious that these ﬁgures are only
estimates derived from a mathematical model. Nevertheless, we may
conclude that the quality of the services provided by this clinic in over
30 years has contributed towards fulﬁlling the healthcare requirements
of the most vulnerable segment of the population, particularly regarding
maternal morbidity and mortality, child mortality and unsafe abortions,
which contribute in part to maternal mortality. Brazil has a restrictive
law about abortion and for this reason we considered that the abortions
averted were unsafe; however, we cannot be sure that 100% of abortions
were unsafe. Despite the fact that we have made progress in addressing
the reproductive needs of our population, more work is necessary to try
to close the health inequity gap in Brazil because the gains were not equal
across the population and inequity is still a great challenge for health
There are some strengths and limitations in this study. The main
strengths were the large number of women as well as the many years of
evaluation, the fact that the data came from a real-life situation from a
clinic with .30 years of operation, and the possibility to evaluate the
DALY score with the potential women’s morbidity and mortality, the
child mortality and abortions averted. However, the main limitations
are the number of medical records from women who never returned to
the clinic and consequently the pregnancy rate could be different, the
fact that we analysed 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 due to the sporadic availability of this method.
Disability-adjusted life years averted by contraception
In conclusion, our data showed that the LARC methods and DMPA
are highly effective and women who were well counselled used these
methods for a long time. The health beneﬁts regarding 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 methods
(Wellings et al., 2007; Blumenthal et al., 2013; Trussell et al., 2013), at
no cost, or at least at affordable cost, to the underprivileged population.
The authors acknowledge the ﬁnancial support received 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 2001 all the
TCu380A IUD were donated by Injeﬂex, São Paulo, Brazil, and from
2006 all the LNG-IUS were donated by the International Contraceptive
Access Foundation (ICA), Turku, Finland. Both donations were as an
L.B., M.V.B., I.M. and A.F. conceived the study and were responsible for
the development of the protocol, analysing and interpreting the data, and
for writing and revising the ﬁnal version of the manuscript. B.F.B., M.P.G.
and V.M.C. were responsible for the revision of the medical records. L.B.
and X.E.-A. were responsible for the second revision of the medical
records. M.H.S. performed the statistical analysis including the DALY
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
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