Abstract:
OBJECTIVE: The objective was to address bias in contraception efficacy studies through a randomized study trial of
intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUDs) and a levonorgestrel (LNG) implant.
STUDY DESIGN: We analyzed data from the Evidence for Contraceptive Options and HIV Outcomes Trial, which
assessed HIV incidence among 7829 women from 12 sites in eSwatini, Kenya, South Africa and Zambia seeking
effective contraception and who consented to be randomized to DMPA-IM, copper IUD or LNG implant. We
used Cox proportional hazards regression adjusted for condom use to compare pregnancy incidence during
both perfect and typical (i.e., allowing temporary interruptions) use.
RESULTS: A total of 7710 women contributed to this analysis. Seventy pregnancies occurred during perfect and 85
during typical use. There was no statistically significant difference in perfect use pregnancy incidence among the
methods: 0.61 per 100 woman-years for DMPA-IM [95% confidence interval (CI) 0.36–0.96], 1.06 for copper IUD
(95% CI 0.72–1.50) and 0.63 for LNG implants (95% CI 0.39–0.96). Typical use pregnancy rates were also largely
similar: 0.87 per 100 woman-years for DMPA-IM (95% CI 0.58–1.25), 1.11 for copper IUD (95% CI 0.77–1.54) and
0.63 for LNG implants (95% CI 0.39–0.96).
CONCLUSIONS: In this randomized trial of highly effective contraceptive methods among African women, both perfect and typical use resulted in low pregnancy rates. Our findings provide strong justification for improving access
to a broader range of longer-acting contraceptive options including LNG implants and copper IUD for African
women.
