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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 144-149

Determinants of injectable depot medroxyprogesterone acetate contraception among women of reproductive age: A study from Southern Haryana, India


1 Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh, India
2 Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India

Date of Submission07-Jan-2020
Date of Decision24-Feb-2020
Date of Acceptance02-Apr-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Suraj Chawla
Department of Community Medicine, SHKM Government Medical College, Nalhar - 122 107, Nuh, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_2_20

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  Abstract 

Introduction: The safety and effectiveness of Depot Medroxyprogesterone Acetate (DMPA) (available by the name of “Antara” in Government of India supply) has resulted in inclusion of this injectable contraceptive in the basket of family planning choices and thus has opened the way for clients to avail of a safe, effective, and hassle-free method with full confidentiality, which is also free of cost in public health facilities all over India.
Material and Methods: This community-based study with cross-sectional design was conducted during April 2019–October 2019. During first 3 months of the study, all the females who adopted the DMPA contraception were included in the study and the factors for opting DMPA were assessed.
Results: Among those who had previously used contraceptives, oral pills were the most prevalent method. Most of the clients who opted to DMPA agreed that they switched because of privacy and confidentiality attached to DMPA. The side effects were reported by more than four-fifth of subjects, and the most common side effects were irregular spotting per vaginally, amenorrhea, and weight gain.
Conclusion: The present study has shown some light regarding the factors responsible for injectable DMPA uptake as a family planning method and the facilitators and barriers to consistent injectable DMPA use. The study findings are expected to be utilized for framing policies to improve compliance of DMPA and making it more acceptable, client-friendly initiative.

Keywords: Confidential, discontinuation, health-care worker, side effects


How to cite this article:
Gupta V, Chawla S, Gour N, Goel PK. Determinants of injectable depot medroxyprogesterone acetate contraception among women of reproductive age: A study from Southern Haryana, India. Indian J Community Fam Med 2020;6:144-9

How to cite this URL:
Gupta V, Chawla S, Gour N, Goel PK. Determinants of injectable depot medroxyprogesterone acetate contraception among women of reproductive age: A study from Southern Haryana, India. Indian J Community Fam Med [serial online] 2020 [cited 2021 Dec 6];6:144-9. Available from: https://www.ijcfm.org/text.asp?2020/6/2/144/304791


  Introduction Top


India was the first country in the world to launch a family planning program, as early as 1952, with the main aim of controlling its population. An expert committee of the WHO, in 1971, defined family planning as, “a way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote the health and welfare of family groups and thus contribute effectively to the social development of a country.”[1] In April 1976, the country framed its first “National Population Policy,” which was subsequently revised in 2000 and is now running under RMNCH+A (Reproductive, Maternal, Newborn, Child, and Adolescent Health, 2013) strategy, so that each and every couple of India get awareness of the need of the family planning methods. India's population has already reached 1.26 billion, and considering the high decadal growth rate of 17.64, the country's population is slated to surpass that of China by 2028.[2]

Over the years, the National Family Planning Programme too has evolved with a shift in focus from merely population control to more critical issues of saving the lives and improving the health of mothers and children through use of reversible spacing methods leading to reduction in unwanted, closely spaced, and mistimed pregnancies and thus avoiding pregnancies with higher risks and chances of unsafe abortions.[3] The widespread adoption of family planning, in a society, is an integral component of modern development and is essential for the integration of women into social and economic life.

The contraceptive prevalence rate provided in National Family Health Survey-4, 2015-2016 (NFHS) among the currently married women is 53.5%, which has decreased from 56.3% reported in NFHS-3.[4] In 2011, the couple protection rate was about 40% for India, which is still far behind to achieve the 60% couple protection rate goal.[5] At present, the spacing options are limited to condoms, intrauterine contraceptive device (IUCDs), and oral pills contributing to 5.9%, 1.9%, and 4.2% share of modern contraceptive prevalence rate, respectively. Development of a long-acting reversible contraceptive such as depot medroxyprogesterone acetate (DMPA) was a goal of family planning researchers for many years.[6]

It is estimated that currently, an estimated forty-two million women worldwide use injectable contraceptives as a method of choice. DMPA is the fourth most prevalent contraceptive and is widely used as an effective, safe, and acceptable method of contraception across the world. DMPA is a private and confidential method, convenient, and easy to use (does not require daily routine or additional supplies); acts for 3 months with a grace period of 4 weeks; completely reversible; does not interfere with sexual pleasure or intercourse; pelvic examination is not required before use; suitable for women who are not eligible to use an estrogen-containing contraceptive; suitable for breastfeeding women (after 6 weeks postpartum) as it does not affect quantity, quality, and composition of breast milk; provides immediate postpartum (in nonbreastfeeding women) and postabortion contraception; and may be used by women at any age or parity if they are at risk of pregnancy.[7]

With a standard regimen, the 1st-year effectiveness is 99.7% when the drug is used correctly. The perfect use failure rate of 0.3% is lower in comparison to 0.5% of female sterilization, 0.8% of IUCD, and 3% of combined oral contraceptives (COCs).[8] A WHO study in more than 3 million woman months of DMPA use has reassured that DMPA does not increase the risk of overall cancers, congenital deformities or infertility and keeps the fertility intact. However, it usually takes about four months longer for a woman to achieve pregnancy after discontinuing DMPA than after discontinuing other reversible contraceptive methods.

The safety and effectiveness of DMPA (available by the name of “Antara” in Government of India supply) has resulted in inclusion of this injectable contraceptive in the basket of family planning choices and thus has opened the way for clients to avail of a safe, effective, and hassle-free method with full confidentiality, which is also free of cost in public health facilities all over India. In Nuh (earlier Mewat) district, the contraceptive use among currently married women is lowest (15.5%) among all districts of Haryana and only 0.2% are using injectables as contraception method while unmet need is very high (31.0%).[4] Taking into consideration the above factors, this study is planned to be conducted in rural area with the objectives to assess the factors responsible for injectable DMPA uptake as a family planning method among eligible couples (married women 15–45 years of age) and to assess the facilitators and barriers to consistent injectable DMPA use.


  Material and Methods Top


Study duration

This community-based study with cross-sectional design was conducted during April 2019–October 2019. During the first 3 months of the study, all the females coming to Primary Health Center (PHC) for opting the DMPA as family planning option were included in the study and the factors for opting DMPA were assessed. Participants opting for injectable contraceptives were screened based on the checklist by the medical officer for the contraindications and then injection DMPA was administered 150 mg deep intramuscular in the gluteal region and next doses were given at an interval of 3 months. Over the next 1 month of the study, the facilitator factors were assessed for those who were coming for the second dose of DMPA, and in the last 2 months of the study, females who remained drop outs for DMPA (who do not turn up for the next dose of DMPA in grace period, i.e. within 4 weeks of due date) were enlisted and home visits were made to contact them to assess the reasons and barriers responsible for discontinuation of DMPA. Ethical approval was obtained from the Institutional Ethical Committee of SHKM Government Medical College, Nalhar, Nuh, Haryana.

Study setting

The study was conducted in the area catered by PHC, Nagina of district Nuh of Haryana state. PHC, Nagina, is the field practice area of Department of Community Medicine, SHKM Government Medical College, Nalhar.

Study size and sampling

The study included all the eligible couple visiting PHC Nagina to opt for DMPA as a family planning method during the first 3 months of study. At Nagina PHC, nearly 40–50 females/month were opting DMPA as family planning method, so the total study sample size estimated was 120–150 females. In the present study, 124 females those who were willing to participate in the study could be enrolled.

Study participants

The study participants were females those who are currently married and of 15–49 years of age, those who were visiting to PHC Nagina for opting DMPA as a family planning method. They were interviewed at different points of period to assess factors responsible for injectable DMPA uptake and subsequently to assess the facilitators and barriers related to DMPA use.

Exclusion criteria

Females not willing to give verbal informed consent and with contraindications to DMPA were excluded from the study. Among dropouts, the individuals who were not available even after paying three home visits were excluded from the study.

Data collection

Informed written consent was obtained from all the study participants. A pretested, predesigned questionnaire was used by the investigator to interview the selected study participants. The questionnaire included the information regarding age, education, family size, caste, per capita income, facilitators, and barriers related to DMPA.

Statistical analysis

The responses to the schedule by each participant was entered into excel sheet, the data were tabulated, and the data were analyzed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp. Armonk, NY, USA). All the tests were performed at significance level of 5%; thus, an association was significant if the “P” <0.05. Categorical variables were presented as percentage (%). The variables with quantitative data were presented as mean (standard deviation). The Pearson's Chi-square test was used for categorical variables and Student's t-test for quantitative data.


  Results Top


In the present study, nearly one-third of subjects were having age more than 30 years and one-third of subjects belonged to 26–30 years' age group. More than two-fifth of subjects (43.5%) were illiterate and around only one-tenth of subjects were graduate or diploma or above. More than 90% of subjects were homemakers and around 60% of subjects were staying in joint family. As the Nuh district is Muslim dominated, in the present study, most of the subjects were Muslims (82.3%) and around two-fifth of subjects (38.7%) belonged to lower-middle socioeconomic class [Table 1].
Table 1: Sociodemographic characteristics of study subjects (n=124)

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Obstetrics details showed that more than half of the study subjects (54.8%) got married at the age of <21 years, and due to lower age of marriage, majority of them were having family size of four or more. The present study revealed that around one-third of subjects had history of one or more miscarriage or abortion [Table 2].
Table 2: Previous obstetrics details of study subjects (n=124)

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Out of the total study subjects who came for DMPA, 77.4% were not having any previous contraceptive history. Among those who had previously used contraceptives, oral pills were the most prevalent method. Most of the clients who opted to DMPA (82.1%) agreed that they switched because of privacy and confidentiality attached to DMPA. The firsthand source of information or guidance for DMPA was most commonly through health-care workers and friends or social media [Table 3].
Table 3: Previously used contraceptives among study subjects

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During the follow–up, 54.8% of women continued the use of DMPA while more than two-fifth of subjects discontinued the DMPA, i.e., they did not turn up for the second dose of DMPA. The most common reasons for continuation of DMPA were husband unawareness and it does not interfere with sexual intercourse/pleasure. The spouse insistence and side effects were among the frequent reasons for the discontinuation of DMPA [Table 4].
Table 4: Follow-up details of study subjects for depot medroxyprogesterone acetate

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The side effects were reported by most of the study subjects (84.6%), and the most common side effects were irregular spotting per vaginally, amenorrhea, and weight gain. Around 50% of subjects were convinced with the DMPA use and they were in favor of recommending it to the family members and friends [Table 5].
Table 5: Side effects of depot medroxyprogesterone acetate among study subjects (n=124)

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  Discussion Top


DMPA as a family planning method is being made widely available at free of cost by the Government of India at public health institutions. The acceptance of DMPA as family planning method in Western countries is widespread due to its safety and effectiveness. As per NFHS-4 (2015–16) in Mewat region, the acceptance to any family planning methods is poor.[4] The prevalence of injectable contraceptive use is 3.5% worldwide. It is 15% for Sri Lanka, 10% for Nepal, 7% for Bangladesh, 5.9% for Bhutan, and 2.7% for Pakistan, whereas nationally the current use of DMPA is 0.1%.[8],[9]

In the present study, the firsthand source of information or guidance for DMPA was most commonly came through health-care workers and friends or social media. Furthermore, there is local radio station for Mewat, where the health talks are being delivered by faculties of medical college, that is why the radio was one of the source of information regarding DMPA contraception. Similarly, in a study conducted by Taklikar et al., doctors were the most common source of information regarding contraception among the users. In the present study, nearly two-third of subjects were having age more than 26 years who opted for DMPA as family planning method. Similarly, in most of the studies, maximum contraceptives were utilized by the eligible couples of 26–33 years' age group.[10],[11],[12],[13]

In this study, the most common reasons for continuation of DMPA were husband unawareness (privacy) and it does not interfere with sexual intercourse/pleasure. Furthermore, health education imparted through local radio station was among the reasons for acceptance of DMPA contraception. In a study by Burke et al., the reasons for acceptance were privacy, convenience, free of hassles of daily intake, and coitus independent.[14]

In the current study, more than two-fifth of subjects discontinued the DMPA, i.e., they did not turn up for the second dose of DMPA. Various studies have shown discontinuation rate of DMPA in the range of 42.5%–70%.[15] Most discontinuations were reported after 1st or 2nd injection when the menstrual irregularities are at their peak. Major reasons for discontinuation were irregular vaginal spotting, amenorrhea, and influence of spouse against the injectable.

In the present study, the side effects were reported by more than four-fifth of subjects, and the most common side effects were irregular spotting per vaginally, amenorrhea, and weight gain. Various other studies had shown similar side effects; those studies had also reported advantages of DMPA use such as no significant effect on blood pressure in postpartum women and lactation remained unaffected.[14],[16],[17],[18]

Acceptance and continuation can be increased by proper selection of clients thorough counseling, appropriate timing of injections, and good supportive care. Standardized protocols for counseling, periodic orientation for providers, diligent follow-up, and surveillance for side effects are some of the suggestions to sustain and continue DMPA contraceptive program.[19] In Mexico, the continuation rate was high in women who had received in-depth counseling compared to women who received only routine counseling and some general information about DMPA in the first visit. In-depth counseling consisted of detailed information of the drug along with emphasis on how to handle the side effects and this was given at each reinjection visit every 3 months. As a result, at the end of 1 year, only 6% discontinued in this group compared to 27% in the routine counseling group.[20]


  Conclusion Top


As single DMPA injection provides contraception for 3 months with minimal side effects, this family planning method might have had higher acceptance level compared to other existing contraceptive methods. The present study revealed that most of the client got the information regarding DMPA contraception through health-care workers and friends or social media. Privacy and no interference in sexual pleasure were responsible for its continuation, while spouse insistence and menstrual irregularities were the most of cause of its discontinuation.

Limitations

Limitation of the present study is that it included clients attending only single health center, so multicentric studies with larger sample size are recommended to develop a suitable program to improve acceptance and remove barriers for DMPA use. Furthermore, the studies on DMPA determinants are very confined in India, so the relevant comparisons of determinants were done using the studies from other developing countries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization. Family Planning in Health Services: Report of a WHO Expert Committee. Geneva: World Health Organization; 1971.  Back to cited text no. 1
    
2.
Ministry of Health & Family Welfare. Reference Manual for Injectable Contraceptive (DMPA). New Delhi, India: Government of India Nirman Bhawan; 2016.  Back to cited text no. 2
    
3.
Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: An analysis of 172 countries. Lancet 2012;380:111-25.  Back to cited text no. 3
    
4.
International Institute for Population Sciences. National Family Health Survey (NFHS-4), 2014-15: India (Internet). Vol. 1. Mumbai, India: IIPS; 2014-15. Available from: http://www.rchiips.org/nfhs/reports.html. [Last accessed 2019 May 24].  Back to cited text no. 4
    
5.
Park K. Park's Textbook of Preventive and Social Medicine. 23rd ed. New Delhi, India: Banarsidas Bhanot Publishers; 2015. p. 504-8.  Back to cited text no. 5
    
6.
Population Foundation India. Evidences on Contraceptive Method Mix in developing countries: South/South-East Asia (Internet). Available from: http://populationfoundation.in/wp-content/ uploads/2016/02/3-Contraceptive-Method-Mix-_Infographic_ Final-1.pdf. [Last accessed 2019 May 20].  Back to cited text no. 6
    
7.
Association of Reproductive Health Professionals (Internet). Available from: https://www.arhp.org/Publications-and-Resources/ Quick-Reference-Guide-for-Clinicians/choosing/Injectable. [Last accessed 2019 May 25].  Back to cited text no. 7
    
8.
Family Health International. Types, Availability, and use of Injectables. New Delhi, India: FHI Briefs; 2010.  Back to cited text no. 8
    
9.
Nautiyal R, Bijalwan R, Maithili B, Sinha LN. Feasibility of injectable Depot medroxyprogesterone acetate in a semi urban camp setting. Int J Reprod Contracept Obstet Gynecol 2016;5:1056-60.  Back to cited text no. 9
    
10.
Gahlot A, Nath S, Kumar P, Nath M. Study of prevalence of different contraceptive methods feasibility of DMPA among married women in urban area of Rama Medical College, Kanpur. Indian. J Forensic Community Med 2017;4:90-4.  Back to cited text no. 10
    
11.
Taklikar CS, More S, Kshirsagar V, Gode V. Prevalence of contraceptive practices in an urban slum of Pune city, India. Inter J Med Sci Public Health 2015;4:1772-7.  Back to cited text no. 11
    
12.
Ingle GK, Kumar A, Singh S, Gulati N. Reasons for nonacceptance of contraceptive methods among Jhuggi Jhompri deliveries of Delhi. Indian J Prev Soc Med 1999;30:32-7.  Back to cited text no. 12
    
13.
Jalang'o R, Thuita F, Barasa SO, Njoroge P. Determinants of contraceptive use among postpartum women in a county hospital in rural KENYA. BMC Public Health 2017;17:604.  Back to cited text no. 13
    
14.
Burke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, et al. Factors affecting continued use of subcutaneous depot medroxyprogesterone acetate (DMPA-SC): A secondary analysis of a 1-year randomized trial in Malawi. Glob Health Sci Pract 2019;7:54-65.  Back to cited text no. 14
    
15.
Manna N, Bhattacharjee A, Kundu A, Lahiri A. Non-acceptance of injectable contraceptives from Antara clinic: A qualitative study in West Bengal, India. IOSR J Dental Med Sci 2019;18:48-51.  Back to cited text no. 15
    
16.
Hatcher RA, Rinehart W, Blackburn R, Geller JS. DMPA-Injectable contraceptive in the essentials of contraceptive technology – A handbook for clinic staff. Population Information Program, Johns Hopkins University, School of Public Health Baltimore; 1997. p. 1-21.  Back to cited text no. 16
    
17.
World Health Organization. Injectable Contraceptives – Their Role in Family Planning Care. Geneva: World Health Organization; 1990. p. 65-82.  Back to cited text no. 17
    
18.
Phadke A. A Thorough critique of depo-provera – Book review. Indian J Med Ethics 2005;11:30.  Back to cited text no. 18
    
19.
Hirve S. Injectables as a choice – Evidence-based Lesson. Indian J Med Ethics 2005;11:12-3.  Back to cited text no. 19
    
20.
Canto De Cetina TE, Canto P, Ordoñez Luna M. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate. Contraception 2001;63:143-6.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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