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.
Highlights
Long-acting reversible contraceptives, such as the intrauterine device (IUD), remain underutilised in Pakistan with high discontinuation rates
We focused on IUDs because Pakistan’s national health policies do not allow the insertion of implants by a mid-level practitioner as it is considered a surgical procedure
The Suraj model was implemented across three provinces of Punjab, Sindh, and Khyber Pakhtunkhwa (KP) while the Community Midwife (CMW) model was implemented in Punjab province only because: (1) CMWs were not operational in Sindh province and (2) there were practical constraints of time, budgeting, and logistics in KP province
Summary
Long-acting reversible contraceptives, such as the intrauterine device (IUD), remain underutilised in Pakistan with high discontinuation rates. 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. The caveat with an increase in the contraceptive prevalence rate would be that, 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 essential for achieving family planning (FP) goals in Pakistan
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