Continuation rates and reasons for discontinuation of intra-uterine device in three provinces of Pakistan: results of a 24-month prospective client follow-up

Hameed et al. Health Research Policy and Systems 2015, 13(Suppl 1):53 DOI 10.1186/s12961-015-0040-9 RESEARCH Open Access Continuation rates and reasons for discontinuation of intra-uterine device in three provinces of Pakistan: results of a 24-month prospective client follow-up Waqas Hameed1*, Syed Khurram Azmat1,2, Muhammad Ishaque1, Wajahat Hussain1, Erik Munroe3, Ghulam Mustafa1, Omar Farooq Khan1, Ghazunfer Abbas1, Safdar Ali1, Qaiser Jamshaid Asghar1, Sajid Ali1, Aftab Ahmed1 and Hasan Bin Hamza4 Abstract Background: Long-acting reversible contraceptives, such as the intrauterine device (IUD), remain underutilised in Pakistan with high discontinuation rates. Based on a 24-month prospective client follow-up (nested within a larger quasi-experimental study), this paper presents the comparison of two intervention models, one using private mid-level providers branded as “Suraj” and the other using community midwives (CMWs) of Maternal Newborn and Child Health Programme, for method continuation among IUD users. Moreover, determinants of IUD continuation and the reasons for discontinuation, and switching behaviour were studied within each arm. Methods: A total of 1,163 IUD users, 824 from Suraj and 339 from the CMW model, were enrolled in this 24-month prospective client follow-up. Participants were followed-up by female community mobilisers physically every second month to ascertain continued IUD usage and to collect information on associated factors, switching behaviour, reasons for discontinuation, and pregnancy occurrence. The probabilities of IUD continuation and the risk factors for discontinuation were estimated by life table analysis and Cox proportional-hazard techniques, respectively. Results: The cumulative probabilities of IUD continuation at 24 months in Suraj and CMW models were 82% and 80%, respectively. The difference between the two intervention areas was not significant. The probability distributions of IUD continuation were also similar in both interventions (Log rank test: χ2 = 0.06, df = 1, P = 0.81; Breslow test: χ2 = 0.6, df = 1, P = 0.44). Health concerns (Suraj = 57.1%, CMW = 38.7%) and pregnancy desire (Suraj = 29.3%, CMW = 40.3%) were reported as the most prominent reasons for IUD discontinuation in both intervention arms. IUD discontinuation was significantly associated with place of residence in Suraj and with age (15–25 years) in the CMW model. Conclusion: CMWs and private providers are equally capable of providing quality IUD services and ensuring higher method continuation. Pakistan’s National Maternal Newborn and Child Health programme should consider training CMWs and providing IUDs through them. Moreover, private sector mid-level providers could be engaged in promoting the use of IUDs. Keywords: Discontinuation, Family planning, Intra-uterine device, Social franchise * Correspondence: 1 Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan Full list of author information is available at the end of the article © 2015 Hameed et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hameed et al. Health Research Policy and Systems 2015, 13(Suppl 1):53 Page 38 of 98 Background Long-acting reversible contraceptives (LARC), such as the intrauterine device (IUD), remain underutilised in Pakistan. LARC provide safe and effective protection against unintended pregnancies for an extended period of time with an added advantage of minimal user involvement. The dynamics of contraceptive usage in Pakistan point towards low usage of LARC, compared to shortterm methods [1,2]. One of the possible reasons for low usage could be the fear of side effects [1,3,4]. The 2012–2013 Pakistan Demographic and Health Survey [1] reports a contraceptive prevalence rate of 35.4%, comprising 26.1% modern and 9.3% traditional method users. The most commonly reported methods used by married women of reproductive age (MWRA) include condoms (8.8%), followed by female sterilisation (8.7%), injectables (2.8%), IUDs (2.3%), pills (1.6%), and lactational amenorrhea (1.5%) [1]. Despite the evidence that longterm contraceptive methods, such as IUDs and implants, are more effective in reducing the total fertility rate (TFR) than short-term methods like condoms and pills [5], their use is less than desirable in Pakistan. On the other hand, female sterilisation, which is commonly used, is undertaken by women with an average age of 39 and only after 6+ children and thus may have limited impact on the TFR [6]. The greater reliance on short-term contraceptives in Pakistan lead to only a marginal decrease in the TFR from 4.1 in 2003–2006 to 3.8 births per woman in 2010–2012 [1,2]. The caveat with an increase in the contraceptive prevalence rate would be that, although desirable, it in itself is not the sole determinant for population reduction, which is in turn impacted by effective and persistent use of contraceptives. Changing the dynamics of contraceptive method mix with an increased share of LARC methods is therefore essential for achieving family planning (FP) goals in Pakistan. High fertility and greater reliance on short-term contraceptive methods in Pakistan requires a rethinking of the FP strategy. Estimates suggest that only by switching 4% of current oral contraceptive users (about 100,000 MWRA) in Pakistan to IUDs or implants, more than 25,000 unintended pregnancies could be averted over a 5-year period [7]. If Pakistan is to achieve the FP 2020 commitments, it is imperative that the focus of FP interventions be reoriented towards enhancing IUD use (and other longer term methods such as implants) among young women in order to maximise the impact of IUD use on population stabilisation. The Marie Stopes Society (MSS) Pakistan launched a quasi-experimental research project aimed at promoting healthy timing and spacing of pregnancies through increased use of IUDs in rural and under-served communities in eight districts in Punjab, Sindh, and Khyber Pakhtunkhwa (KP) provinces of Pakistan. These activities were aimed at supplementing the Government of Pakistan’s efforts targeting FP promotion and provision by providing a reliable evidence base with respect to effective FP intervention strategies that are relevant in the local context. The 41-month (including 24 months of intervention) operations/operational research project tested two FP service delivery models: (1) the MSS social f (...truncated)