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

Abstract

BackgroundLong-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.MethodsA 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.ResultsThe 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.ConclusionCMWs 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.

Family Planning Vouchers in Low and Middle Income Countries: A Systematic Review

“…However, a related test of six‐month probability distributions from 0–24 months found a significantly greater probability of IUD continuation in each six‐month period among voucher clients compared to clients who paid out of pocket (Hameed et al. ).…”

“…However, one of the studies noted that the probability of continuation was consistently higher for the voucher cohort compared to the non‐voucher cohort at each six‐month internal (Hameed et al. ).…”

“…As an exception, one study compared 24‐month IUD continuation among clients seen by community midwives and voucher clients seen by private franchised providers (Hameed et al. ).…”

“…; Hameed et al. ; Bajracharya et al. ; Anon ; IFPS Technical Assistance Project [ITAP] 2012; Meuwissen et al.…”

“…and Pierce 1977; Stycos and Mundigo 1974;Carranza 2010;Echeverry 1975;Fendall 1971;Treadway et al 1976;Population Council 1993;Anon 1975;Isaacs 1975;Lim 1974;Chow et al 1969;Cernada and Chow 1969;Obare et al 2013;Chin-Quee et al 2010;Agha 2011;Khurram Azmat et al 2013;Hameed et al 2015;Bajracharya et al 2016;Anon 2010; IFPS Technical Assistance Project [ITAP] 2012; Meuwissen et al 2006a;Kemplay et al 2013;Boddam-Whetham et al 2016;Brody et al 2013). Although the specifics vary between programs, the voucher strategy identifies beneficiaries from disadvantaged groups and gives individuals a voucher that they can take to a contracted public or private provider for service (Sandiford et al 2005).…”