WHO South-East Asia Journal of Public Health
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ORIGINAL RESEARCH
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 309-319

Early discontinuation of intrauterine device in Nepal – a retrospective study


Department of Public Health, Institute of Health Sciences, Kathmandu, Nepal

Date of Web Publication25-May-2017

Correspondence Address:
Subash Thapa
Department of Public Health, Nepal Institute of Health Sciences, Kathmandu
Nepal
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DOI: 10.4103/2224-3151.207027

PMID: 28615557

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  Abstract 


Background: The Intrauterine Device (IUD) is the least popular method of contraception for family planning in Nepal. In addition, discontinuation in the early days after insertion is very high and information related to factors affecting early discontinuation is very limited.
Methods: A retrospective study was carried out over a 5-year period to determine the associated factors for early discontinuation of the IUD. Insertion, consultation and removal records of IUD users of Kshetrapati Family Welfare Centre, Kathmandu, were reviewed. Removal within 12 months of insertion is defined as early discontinuation. The study participants were selected randomly. Uni-variate and logistic regression analysis were used to analyse predictors of early discontinuation of IUD.
Results: The results showed that one fifth of the 230 women using IUD discontinued within the first year of insertion. Side-effects were the main reason for early discontinuation followed by expulsion. Woman's occupational status, husband's occupational status, husband's educational status, experience of side-effects and follow-up practice were associated with early discontinuation of IUD. Menstrual disorder and abnormal vaginal discharge were also associated with early discontinuation.
Conclusion and recommendation: Risks of IUD discontinuation were found to be very high during the early days of insertion and side-effects were identified as the major cause. So, proper management of side-effects would be very important to reduce early discontinuation of IUD.

Keywords: Intrauterine device, discontinuation, follow-up, side-effect, reproductive intention.


How to cite this article:
Thapa S. Early discontinuation of intrauterine device in Nepal – a retrospective study. WHO South-East Asia J Public Health 2012;1:309-19

How to cite this URL:
Thapa S. Early discontinuation of intrauterine device in Nepal – a retrospective study. WHO South-East Asia J Public Health [serial online] 2012 [cited 2019 Nov 13];1:309-19. Available from: http://www.who-seajph.org/text.asp?2012/1/3/309/207027




  Introduction Top


The intrauterine device (IUD) is the least popular method of contraception for family planning in Nepal. Only 0.4% of women use the IUD and among them, about 13% remove it within the first year and 20% remove it within the second year.[1] This behaviour is mainly governed by women's reproductive intentions, reproductive status, the combined impact of age, duration of marriage and number of surviving children.[2],[3]

Likelihood of discontinuation of contraception is higher among women of low parity and those who had not achieved their desired family size at the start of the segment of use.[4],[5],[6] The family size preference is apparently more important than preference about sex of children in determining contraception use.[7],[8] However, women who want to space births are twice as likely to discontinue using the IUD within the first year as compared with those who want to limit childbirth.[9] Studies had noted that women of lower age, along with low education and those who have tried other contraceptive methods are more likely to discontinue IUD, although education does not always emerge as a key determinant.[3],[10],[11]

A study in Southern Jordan reported that planned pregnancy was the main reason for discontinuation of all contraceptive devices.[8] Especially for IUDs, side-effects and health concerns also play an important role in discontinuation.[7],[12] Irregular bleeding, lower abdominal pain, and vaginal discharge appear to be other key reasons for discontinuation.[10] In the context of Nepal, side-effects are the most frequently cited reason for stopping use. Only a few discontinue use because they want more children.[1],[13] Another important point is that 40% of IUD users do not practice follow-up visits even when they were told by the health workers. The main reason is that many women experience no pain or problems with the method. Similarly, the women do not feel any need for the follow-up and it takes a long time to reach to the health facility.[1]

Low use and high discontinuation is a public health concern. The study of discontinuation and its causes clearly remains important for programme planning and guidance. In Nepal, very few studies on IUD have been documented; and studies that have been conducted lack appropriate design and power of analysis. In the current study, an attempt has been made to determine the factors associated with the early discontinuation of IUD. The study, at first, examined the socio-demographic characteristics of IUD users. Then, the study identified the reasons for early discontinuation of IUD and examined the association between those factors.


  Material and methods Top


The study was a retrospective one in which women inserting IUD from January to December, 2004 were followed over a period of five years (2004–2009), based on the data of the IUD users of the Kshetrapati Family Welfare Centre (KFWC) in Kathmandu. During the period, some women were found to discontinue using IUD whereas some were continuing the use. Within a period of one year, 540 women opted for IUD (TCu 380A) at the family welfare centre and simple random sampling was done to cover the required sample size of 230 women. The sample size was estimated by means of power calculation based on the discontinuation rate of 13%[1] in the first year with a level of significance of 0.05 and power of 95%.[14],[15]

In KFWC, women going in for IUD were at first registered in an insertion record, then their follow-up visits and complaints were recorded in a consultation record and finally, the women discontinuing use were recorded in a removal record. These three different records were reviewed for the study purpose. Consent for data review was taken from the board of directors of KFWC, Kathmandu. The institutional ethical review board of B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal approved the study protocol and consent process.

Variables studied were age during insertion, place of residence, educational status, occupational status, husband's educational status, husband's occupational status, total number of children, sex of last child, reproductive intention, duration of use of IUD, side-effects and follow-up practice. During routine clinic hours, information from the IUD users regarding side-effects such as pain in abdomen, and excessive menstrual bleeding were all taken through interview by the IUD trained nurses in the family planning centre and recorded in the appropriate record. Similarly, early discontinuation of IUD has been defined as removing IUD within the first 12 months after insertion and the women in this category were known as “early discontinues”.[1],[2],[10] Meanwhile, women removing the IUD after 12 months as well as women who were still continuing use during the study period were known as “women who did not discontinue early”.

All analyses were carried out using PASW statistic version 18.0. Univariate statistics were used to test association and to calculate the crude odds ratio and confidence intervals. A logistic regression analysis was then carried out to identify the selected variables that were the best independent predictors of early discontinuation of IUD, after adjusting for the husband's education status, husband's occupation status and women's occupation status. Husband's education status, husband's occupation status and women's occupation status were entered in the model at the first step and then, selected variables were entered into the model. Similarly, Kaplan–Meier analysis was used to identify the relationship between side-effects and continuation of IUD.


  Results Top


Characteristics of the IUD users and reasons for early discontinuation

In order to determine the associated factors for early discontinuation of IUD, insertion, consultation and removal records of 230 IUD users were reviewed for a five-year period. During the period of study, all the women were using TCu 380A IUD. No significant difference was found between users whose records were reviewed and those whose records were not reviewed in terms of sociodemographic characteristics. [Table 1] shows a comparison of different characteristics between the women who discontinued early with those who did not.
Table 1: Characteristics of IUD users, and comparison between women who discontinued early and who did not discontinue earlyi

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Overall (N =230), Brahmin and Kshetri women (35.7%) were found to be proportionately higher than other ethnicity. Similarly, a great majority of the women were Hindus (74.8%) followed by Buddhist (16.5%) and Christian (4.8%). IUD was used by women of almost all reproductive age groups with the highest number in the age group of 24–34 years. IUD was mostly used by suburban women (79.5%) and early discontinuation was also very high among them.

By education, IUD was mostly used by women who can only read and write (37.8%). A majority of the women were housewives by occupation and early discontinuation was also found to be high among them. Similarly, the husbands of the women were more involved in business, followed by agriculture. The women whose husbands were farmers had higher rates of early discontinuation, whereas most of the women whose husbands were businessmen did not discontinue early. Similarly, early discontinuation was high among women whose husbands had secondary or higher education.

Women having no child were not found using IUD and a majority of women having two children were found to be using IUD. Early discontinuation was more among women who have two children. A great majority of women had an IUD inserted while the age of their last child was less than four and early discontinuation was higher among these women. However, equal proportions of women were found having a male or female child at last pregnancy, but early discontinuation was higher among women having a female child at last pregnancy. Health workers and friends were found to be the major sources of information about IUD. Similarly, early discontinuation was higher among women who intended to space birth than women who intended to limit birth by using IUD.

[Table 2] shows the reasons for early discontinuation of IUD and association of different side-effects with early discontinuation. Side-effect was the main reason mentioned by the women for early discontinuation of IUD, followed by expulsion. Of the total users (N=230), 47.4% complained of having side-effects after insertion of IUD and early discontinuation was also found higher among them. The major complaints were bleeding, menstrual disorder, abnormal vaginal discharge, itching and other complains. Menstrual disorder and abnormal vaginal discharge were associated with early discontinuation of IUD. Of the total users (N=230), 65.7% visited for follow-up which includes both, follow-up for complaining side-effects (40.9%) and follow-up for routine checkup without side-effects (24.8%). Of the women visiting for follow-up, 39.1% made follow-up visits twice and 33.1% made a follow-up visit only once. Early discontinuation was higher among women who do not practice follow-up.
Table 2: Reasons for early discontinuation of IUD and its association with side-effects

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One fifth of the total users (21.3%) discontinued IUD within the first year of insertion. The discontinuation rate reached 31.3% in the second year, 40.4% in the third year, 46.5% in the fourth year and 50% in the fifth year of insertion. A great majority of the women (N=163) had also used family planning methods in the past. Most of them used depo-provera (49.1%). The proportion of women who repeated IUD for the second time was 9.6%. The other devices used in the past were Norplant (5.7%), pills (5.7%) and condom (0.9%). Among the women removing IUD (N=115), 22.6% used nothing and 14% wanted childbirth after discontinuation of IUD. However, 23.4% of them used depo-provera and 13 % went for permanent sterilization.

Association of selected factors with early discontinuation of IUD

Univariate analysis identified association of woman's occupational status, husband's occupational status, husband's educational status, side-effects and follow-up with early discontinuation of IUD. Results based on logistic regression analyses are shown in [Table 3]. In these models, place of residence, reproductive intention, side-effects, and follow-up exposure variables were used. Significant association was detected only between side-effect and early discontinuation of IUD after adjusting with woman's occupational status, husband's occupational status, and husband's educational status. Similarly, [Figure 1] illustrates the relationship between side-effects and continuation of IUD. It has been shown from the diagram that women experiencing side-effects have low probability of continuing use of IUD as compared with those not experiencing any side-effects.
Table 3: Logistic regression analysis of selected variables and risk of early discontinuation of IUD+

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Figure 1: Kaplan-Meier analysis showing relationship between side-effect and continuation of IUD

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  Discussion Top


This study was carried out to examine the factors associated with early discontinuation of IUD in Nepal. The results are consistent with previous studies suggesting that experiencing side-effects is associated with early discontinuation of IUD. This study found that side-effect is the main reason for IUD discontinuation which was well supported by the evidence shown by some previous studies.[1],[13],[16]

Sociodemographic variables are not the major constraints for discontinuation of the IUD.[17] This study also supported the same finding that women's literacy and age were not associated with early discontinuation, while some studies had found women with low education; lower parity and age are more likely to discontinue use of the IUD.[10],[11] Studies in Nepal suggest that the IUD is popular among urban and suburban women, which was also well documented in this study.[1] Residing in a rural area is associated with increased risk of discontinuation.[18] However, in this study, place of residence was not associated with early discontinuation of IUD, but women's occupational status was associated with early discontinuation.

Studies documented that spousal approval has a direct impact on women's reproductive behaviour.[19] Similarly, experience of side-effects and their impact on continuation were significantly affected by spousal factors.[19] This study also identified early discontinuation of IUD associated with husband's educational and occupational status. Muslim women appear to be more likely to discontinue use of IUD than women of other religions, although in some Muslim countries, such as Turkey and Iran, discontinuation rates are fairly low.[9],[10],[20] A great majority of the women in this study were Hindu, and no association was found between religion and early discontinuation.

The family size preference is apparently more important than sex of the last child in determining reproductive intention and contraception behaviour.[4],[7] Women's reproductive intentions govern their choice of method and guide them for making a conscious decision for discontinuation.[2],[9] However, no association was found between total number of children and sex of last child with early discontinuation behaviour. Similarly, no association was found between reproductive intention and early discontinuation of IUD.

The rate of discontinuation of IUD in the first year in the study was higher as compared with a cohort study done among Jordanian women.[21] Some studies concluded planned pregnancy as the most common reason for discontinuation of all methods of contraception.[7],[8] This study found that side-effect was the major reason for IUD discontinuation. The risk of early discontinuation was nearly three times higher among women experiencing side-effects, even after adjusting with women's occupational status, husband's occupational status, and husband's educational status. This finding was consistent with previous studies elsewhere.[1],[13],[20] This study identified abdominal pain as the most common side-effect while a study done among Jordanian women found bleeding as the most common side-effect experienced.[21] The study identified menstrual disorder and abnormal vaginal discharge as the most significant side-effects for early discontinuation of IUD.

In Nepal, although the majority of users report that they were told when to return to the facility for a follow-up visit, only about 60% of IUD users practice follow-up.[1] An association between early discontinuation of IUD and follow-up visit was found in this study.

Different methods of contraception used by women after discontinuation of IUD had been identified by the study. Only one fourth of the women discontinuing IUD switched to a permanent method and a great majority switched to less effective methods. On the other hand, 22.7% of women did not use any devices after removing IUD, which signifies the high risk of unwanted pregnancy.

This study has several programmatic implications.[5] First, the high rate of early discontinuation due to side-effects and expulsion suggests the need of special pre-insertion screening and counselling services. Second, issues related to side-effects need to be more openly discussed and properly addressed. Third, there might be some possibilities that encouraging for follow-up service within a few months after insertion will minimize and prevent early discontinuation.

The current study has several methodological strengths. Women using IUD were recruited from a large set of 540 IUD users. A detailed analysis of the variables was carried out over a long period of time. However, the findings of the current study need to be interpreted in the context of its methodological shortcomings.

Due to the retrospective method, it could be argued that the observed associations are due to information and selection bias. Small sample size is an important limitation of this study. In addition, the study was carried out among the users of a family planning centre; the findings may have limited generalizability. Health service factors, familial factors as well as sociocultural factors were also shown to be associated with the discontinuation of contraception in previous studies.[9],[10],[11] Unfortunately, it was beyond the scope of this study to collect information on these factors.


  Conclusion and recommendation Top


This study identified that the early discontinuation of IUD was very high in Nepal and side-effects were found to be the only major reason for early discontinuation. So, it was understood that proper management of side-effect in early days would reduce early discontinuation. This IUD discontinuation study, along with future research in this area, can help policy-makers and programme managers track family planning progress and help them to meet the goal of reproductive health for all. Thus, further research in this area is required.



 
  References Top

1.
USAID, Engender Health. Contraceptive use and discontinuation patterns in Nepal. 2003. http:// www.engenderhealth.org/files/pubs/family-planning/ nepal_report_on_contraceptive_use.pdf - accessed 18 July 2012.  Back to cited text no. 1
    
2.
Ali Mohamed, John Cleland. Contraceptive discontinuation in six developing countries: a cause-specific analysis. International Family Planning Perspectives. 1995; 21(3):92-97.  Back to cited text no. 2
    
3.
Zlidar VM. New survey findings: the reproductive revolution continues. Baltimore: Johns Hopkins Bloomberg School of Public Health, 2003.  Back to cited text no. 3
    
4.
Chowdhury AI, Fauveau V, Aziz KM. Effect of child survival on contraception use in Bangladesh. Journal of Biosocial Science. 1992; 24(4):427–432.  Back to cited text no. 4
    
5.
Mahdy NH, El-Zeiny NA. Probability of contraceptive continuation and its determinants. Eastern Mediterranean Health Journal. 1999; 5(3):526–539.  Back to cited text no. 5
    
6.
Rehan N, Inayatullah A., Chaudhary I. Efficacy and continuation rates of Norplant in Pakistan. Contraception. 1999; 60(1):39–43.  Back to cited text no. 6
    
7.
Asari VG. Determinants of contraceptive use in Kerala: the case of son/daughter preference. Journal of Family Welfare. 1994; 40(3):19–25.  Back to cited text no. 7
    
8.
Youssef RM. Contraception use and probability of continuation: community-based survey of women in southern Jordan. Eastern Mediterranean Health Journal. 2005; 11(4):545-558.  Back to cited text no. 8
    
9.
Bhat PN, Halli SS. Factors influencing continuation of IUD use in South India: evidence from a multivariate analysis. Journal of Biosocial Science. 1998; 30(3):297–319.  Back to cited text no. 9
    
10.
Rivera R, Chen-Mok M, McMullen S. Analysis of user characteristics that may affect early discontinuation of the TCu-380A IUD. Contraception. 1999; 60(3):155-160.  Back to cited text no. 10
    
11.
Petta CA, Amatya R, Farr G, Chi I. An analysis of the personal reasons for discontinuing IUD use. Contraception. 1994; 50(4):339-347.  Back to cited text no. 11
    
12.
Salhan S, Tripathi V. Factors influencing discontinuation of intrauterine contraceptive devices: an assessment in the Indian context. European Journal of Contraception and Reproductive Health Care. 2004; 9(4):245–259.  Back to cited text no. 12
    
13.
Ministry of Health, University Research Corporation. Developing strategies to increase IUD use in urban areas. Kathmandu, 1993.  Back to cited text no. 13
    
14.
Lemeshow S, Hosmer DW, Klar J, Lwanga SK. Adequacy of sample size in health studies. Statistics in Medicine. 1990; 9(11):1382.  Back to cited text no. 14
    
15.
Machin D, Campbell MJ, Fayers MP, Pinal APY. Sample size tables for clinical studies. 2nd edn. London, Blackwell Science, 1997.  Back to cited text no. 15
    
16.
Mahdy NH, El-Zeiny NA. Probability of contraceptive continuation and its determinants. Eastern Mediterranean Health Journal. 1999; 5(3):526- 539.  Back to cited text no. 16
    
17.
Marie Stopes International Nepal. Intra uterine contraception in Nepal - a cohort study. 2006.  Back to cited text no. 17
    
18.
Petta CA, Amatya R, Farr G, Ching I-cheng. An analysis of the personal reasons for discontinuing IUD use. Contraception. 1994; 50(4):339-347.  Back to cited text no. 18
    
19.
Mahboob El-Alam, Searing H, Bradley J, Shabnam F. IUD use and discontinuation in Bangladesh. New York; The Acquire Project, 2007.  Back to cited text no. 19
    
20.
Jenabi E., Alizade SM., Baga RI. Continuation rates and reasons for discontinuing TCu380A IUD use in Tabriz, Iran. Contraception. 2006; 74(6):483–486.  Back to cited text no. 20
    
21.
Khader YS, El-Qaderi S, Khader AM. Intrauterine contraceptive device discontinuation among Jordanian women: rate, causes and determinants. Journal of Family Planning and Reproductive Health Care. 2006; 32:161-164.  Back to cited text no. 21
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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