Study of cu T utilization status and some of the factors associated with discontinuation of cu T in rural part of yavatmal district.

Introduction

The intrauterine device (IUD) is the most frequently used reversible family planning method in the world.(1) However, its usage is low in many developing countries with a majority of women choosing female sterilization for birth control.(2) Unlike female sterilization where long-term injuries and fatalities are known to occur,(3) IUCDs are relatively safer. Newer IUDs like the Cu T-380 A being offered as a part of the family welfare program in Maharashtra, provide a longer period of protection and has a failure rate of 0.8% in the first year of its insertion.(4) It is also one of the safest contraceptive devices.(4)

The estimation of the utilization status of IUDs needs reliable service statistics. Deficiencies in service statistics can produce biased estimates of utilization status.(5) The utilization rates are also influenced by early discontinuation.(67) It was observed that the quality of family planning services is an important determinant that affects the continuation rate of contraception methods.(8) The extent to which users continue/discontinue a contraception method is an important indicator of its quality because the risk of unwanted pregnancies is higher with high discontinuation rates.(9) Research suggests that contraceptive failures and discontinuation are responsible for more than half of the unwanted pregnancies in the Asian countries.(10)

A large-scale training program has been initiated for medical and paramedical personnel by the government to provide trained workforce for IUD insertion. We believe that the emphasis on IUD training would impact the utilization of the IUDs. The present study was carried out in rural parts of Yavatmal district, Maharashtra with the objective of assessing the Cu T utilization status and exploring the factors associated with their discontinuation.

Materials and Methods

A cross-sectional survey was conducted in April 2009 in Yavatmal district of Maharashtra. Thirty one primary health centers from eight blocks from tribal and non-tribal blocks were included for the survey. A large village from every primary health centre was selected for study. All reported Cu T beneficiaries in two calendar years 2007–2008 and 2008–2009 were surveyed. From the 859 reported beneficiaries, using a 5% margin of error and a 95% confidence level in the uncertainty, we calculated a sample-size of 120 assuming a response distribution of 90% in the community for random sampling.(11) A random sample of 137 beneficiaries was interviewed for exploring the factors related to Cu T continuation/discontinuation. Data were analyzed using appropriate statistical tests of significance.

The number of beneficiaries reported by ANMs in service statistics for contraception is considered representative of service utilization. The study staff assessed the current status of Cu T continuity in reported beneficiaries using a structured interview schedule. The over-reporting through routine service statistics was calculated as the difference between the numbers of beneficiaries by the two methods [Table 1].

Table 1

Distribution of some of the factors in relation to discontinuation of Cu T

Results

Among the 31 surveyed villages, 12 tribal villages had 348 reported Cu T beneficiaries in 2008 and 2009 while there were 511 reported beneficiaries in 19 nontribal villages in the service statistics. Our random sample of 137 beneficiaries included 44 beneficiaries and 93 beneficiaries for interview from tribal and nontribal villages respectively. The average age of Cu T beneficiaries was 23.8 years at the time of Cu T insertion. Majority of Cu T insertions (89.7%) were among women between 20 and 29 years of age. The age-pattern was similar among tribal and nontribal women. A vast majority of the couples (97.8%) were educated above the primary level. There were no significant difference in the literacy status of tribal and nontribal Cu T user women and their spouses. No nulli-parous women had Cu T inserted, while 76 (55.5%) had Cu T inserted with one living child. This trend was similar in tribal and nontribal area.

Sixty six out of 137 (48.2%) Cu Ts were already removed at the time of survey. Proportion of removal was higher in non-tribal area 54 (50.9%) than in tribal area 12 (38.7%). Out of 66 removals, maximum removals 23 (43.9%) were within 3 months of insertion. Main reasons cited for discontinuation have been listed in Table 2 and they include medical problems 20 (30.3%), planning a pregnancy 19 (28.8%) and automatic removal 19 (28.8%). Removal of Cu T was significantly associated with higher number of living children at the time of insertion and health complaints at the time of insertion.

Table 2

Reasons cited for Cu T removal

Discussion

Present survey showed 48.2% over reporting through service statistics for Cu T beneficiaries which is disturbing but on similar lines in some other states.(5) This may be due to increased attention on sterilization achievements and less rigorous monitoring of spacing methods. Continuous monitoring and emphasis on the quality of services rather than the volume may reduce the inflationary trend in IUD reporting. Follow up studies in this regards are important to device the interventions. Over reporting was higher in tribal area thus added attention required towards health services in tribal area.

Average age at the time of Cu T insertion was 23.8 years. Age wasn′t significantly associated with Cu T discontinuation. Most of the couples have education above primary level 134 (97.8%) which was higher than the overall 2001 census figure. According to 2001 census female literacy in Yavatmal rural area was 58.48%. Though there was no significant association with Cu T removal, Cu T acceptors were more literate than non acceptors.

No nulli-parous women had Cu T inserted. Cu T use was highest on 1st child and declined thereafter. Similar findings were also noted by Duolao Wang et al,(12) This may be explained in part by the fact that women with two or more children are more likely to be opting for permanent family planning methods like sterilization. But contrary to this women inserting Cu Ts on one child were more likely to discontinue early. This may be because families were accorded more priority for completing family size than spacing after one issue. Further research is needed in this area.

Expulsion was cited as most likely cause of IUD failure by Khader et al,(3) In the present study, 21% Cu Ts were reported to be expelled at the end of 3 months which was much higher than quoted in literature.(21213) Common causes of discontinuation of Cu T were medical problems (30.3%), planning a child (28.8%) which was also similar to observations in some other studies.(15–17) But most importantly automatic expulsion (28.8%) was also a significant cause of discontinuation. This group could be in need of contraceptive methods and can be identified by regular follow up. Though the major cause of discontinuation was medical problems they were not significantly related with discontinuation of Cu T, rather health complaints at the time of insertion were directly related to discontinuation of Cu T. Counseling prior to Cu T insertion and treatment of any medical ailment may reduce the discontinuation of Cu Ts.

Conclusions

Study suggests large scale over-reporting of Cu T beneficiaries, which can be reduced through rigorous monitoring. Common reasons for Cu T discontinuation are health complaints, women's desire to conceive, and automatic expulsion. In the present study discontinuation is found to be directly related to number of children and health complaints prior to IUD insertion. The problem of discontinuation of Cu T can be tackled through effective educational strategies on contraception, client selection and proper follow-up. Further large scale studies are definitely required in Indian setup to analyze the field situation of Cu T so as to formulate precise strategies to reduce discontinuation and to improve acceptance of Cu Ts.