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Indian Journal of Community Medicine

Profile of IUD Acceptors Attending Post Partum Unit of a Teaching Hospital

Author(s): Romy Biswas, Saswati Nandy, Kaninika Mitra, Pankaj Kumar Mandal, Sarbjit Ray, Akhil Bandhu Biswas

Vol. 27, No. 3 (2002-07 - 2002-09)

Deptt. of Community Medicine, R.G. Kar Medical College & Hospital, Kolkata

Abstract:

Research question: What are the socio-demographic characteristics of Intrauterine device (IUD) acceptors and what is the continuation rate of IUD among them?

Objectives: 1. To assess the socio-demographic characteristics of women using the copper-T intrauterine device. 2. To find out the incidence of expulsion, removal, pregnancy and continuation rate.

Study design: Record based retrospective study.

Setting: Post Partum Unit (P.P. Unit), R.G. Kar Medical and Hospital, Kolkata.

Participants: 387 IUD acceptors attending PP unit from Jan-Dec 1999.

Statistical analysis: Life table technique adopted to calculate expulsion, removal and continuation rates.

Results: Study revealed that IUD was most popular among spacing methods adopted at this centre (93.25%). Most of the acceptors were housewives in the age group of 20-24 years and 89.1% of them were literate. Husbands of the acceptors were mostly in the age group 30-34 years, engaged as labourers, in business or in service and 91.2% of them were also literate. About 58.9% acceptors had one living child and 48.6% of women had become mother before 20 years of age. In 73.9% of cases, IUD was inserted within 10 days of menstruation. The continuation rates of 97.6 and 93.7 were observed at the end of 6 and 12 months of use respectively. A higher proportion of women had the device removed for personal than medical reasons.

Keywords: IUD acceptors, P.P. Unit, Socio-demographic profile, Continuation rate

Introduction:

The family welfare programme is a priority health programme for our country, Inspite of integrated and concerted efforts, the programme has not been able to make an appreciable reducation of Crude Birth Rate. This was mainly because it had almost become synonymous with sterilisation and majority of the couples had undergone sterilisation only after achieving their desired family size of more than three children1,2. Of late, therefore, the programme has shifted its focus on spacing methods with the purpose of bringing about a decline in country's birth rate.

A prospective client usually analyses the pros and cons of a method in terms of its effectiveness, safety and incidence of side effects. Studies on Intrauterine device (IUD) acceptors, its retention and/discontinuation rates are limited. However, such studies may be of great importance in the light of more stress given to spacing methods. Therefore, the present study was conducted.

Material and Methods:

The study was a record based retrospective study conducted at the Post Partum Unit (P.P. Unit) of R.G. Kar Medical College & Hospital, Kolkata.

All the 387 women accepting the Cu-T-200 intrauterine device (IUD) from the Post Partum Unit (P.P. Unit) of R.G. Kar Medical College & Hospital, Kolkata, during the period from 1st January to 31st December 1999 formed the study subjects.

The date of acceptance was recorded on prescribed from as well as in the follow-up register maintained in the clinic. Information on certain variables such as residential address, age, educational status of wife and husband, occupation, number of living children (both male and female) were noted from the records maintained in the clinic. Follow-up records regarding retention or discontinuation of IUD of each study subject for one year were analysed from the follow-up register for IUD acceptors maintained in the clinic. The net termination rates by type and the continuation rates were calculated by life table technique.

The information for all items stated above were collected from existing records maintained by P.P. Unit.

Results:

Table I: Socio-demographic profile of IUD acceptors and their spouses (n=387).

Characteristics Acceptors Husbands
No. (%) No. (%)
Education
Illiterate 42 (10.9) 34 (8.8)
Primary school 105 (27.1) 85 (21.9)
Middle school 106 (27.4) 66 (17.0)
High school 117 (30.2) 157 (40.6)
Graduate and above 17 (4.4) 45 (11.6)
Occupation
Labourer 4   144 (37.2)
Business 1 (0.3) 88 (22.7)
Service 4 (1) 118 (30.5)
Others -   32 (8.3)
Unemployed -   5 (1.3)
Housewife 378 (97.7) -  
Age of acceptors
15-19 years 30(7.8)
158(40.8)
126(32.6)
73(18.8)
24.8
  0(0)
28(7.2)
125(32.3)
234(60.5)
30.4
 
20-24 years        
25-29 years        
30+ years        
Mean (years)        
Number of living children
1 228 (58.9)
2 143 (37.0)
3 14 (3.6)
4 2 (0.5)
Mean 1.5
Mean (sons) 0.9
Mean (daughters) 0.6
Age at first child birth
<15 years 8 (2.1)
15-19 years 180 (46.5)
20-24 years 159 (41.1)
25-29 years 30 (7.8)
30+ years 10 (2.5)
Mean (years) 19.7

Out of 415 women attending the P.P. Unit, 387 mothers had accepted IUD as a method of family planning from the P.P. Unit of R.G. Kar Medical College & Hospital, Kolkata during the period from 1st January to 31st December 1999. IUD was found to be the most acceptable spacing method and was adopted by 93.25% of all those adopting spacing methods from the facility. Month-wise analysis of acceptance of IUD showed that number of acceptors ranged from 58 in the month of June 1999 to 20 in the month of October 1999 but no definite trend was observed. More than half (57.3%) of the acceptors were residing within 5 km. distance from the facility while more than one third (36.3%) were residing within 5 to 9 km. distance. Only 6.41% of acceptors were coming from a distance of 10 km. or more.

The socio-demographic profile of IUD acceptors and their spouses has been shown in Table I.

Education:

Most of the acceptors (89.1%) and their spouses (91.2%) were literate. About one fourth of acceptors (27.1%) and their husbands (21.9%) had education upto primary school level. 30.2% of the acceptors and 40.6% of husbands had education upto high school level while 4.4% and 11.6% of the acceptors and their spouses respectively were graduates and above.

Occupation:

About 97.7% of the acceptors were found to be housewives while 1% were service holder and labourers respectively. The spouses of the acceptors were found to be labourers in 37% while 30.5% and 22.7% were employed in services and private business respectively. A very few (1.3%) of the spouses were unemployed.

Age:

Most of the acceptors (73.4%) were in the age group 20-29 years. The modal age group was 20-24 years and comprised 40.8% of the sample. The mean age of acceptors was 24.8 years. The husbands were more or less equally distributed between 25-29 years (32.3%) and 30-34 years (28.9%) and 11.6% of the husbands were above 40 years of age. The mean age of husbands at the time of their wives' acceptance of IUD was 30.4 years.

Number of living children:

More than half (58.9%) of the acceptors with just one child had adopted the method as compared to about one third (37%) of the acceptors with two living children. The mean number of living children at the time of IUD acceptance was 1.5. The average number of sons and daughters of the acceptors were 0.9 and 0.6 respectively.

Age at first child birth:

Age at marriage and date of delivery of the acceptors could not be analysed because of gross incompleteness of the records. 48.9% of the acceptors gave birth to their first child between 20 to 29 years of age. However, 48.6% and 2.5% were below 20 years and above 30 years of age respectively when the first child was born. The mean age of the acceptors at first child was found to be 19.7 years.

Table II: Interval between last menstrual period and IUD insertion (n=387).

Interval Acceptors
No.
(%)
<10 days 286 (73.9)
10-14 days 37 (9.6)
15 days and above 64 (16.5)

Table II reveals that IUD was inserted within 10 days of their last menstrual period (LMP) in 73.9% of acceptors. The rest of the acceptors had their IUD insertions done 10 days after LMP or even later.

Table III: Net cumulative termination and continuation rates per 100 women by months of use.

Months of
use
Pregnancy
rate
Net cumulative
expulsion rate
Net cumulative removal
rate for
Total termination
rate
Continuation
rate
Medical reasons Personal reasons Total
6 0.0 0.8 0.8 0.8 1.6 2.4 97.6
12 0.0 0.9 1.9 3.5 5.4 6.3 93.7

Net cumulative termination and continuation rates per 100 women by months of use are shown in Table III. No pregnancy was reported among the study sample during the reference period.

Of the 387 women, two women reported expulsion giving a net cumulative expulsion rate of 0.8 and 0.9 per 100 users at the end of 6 and 12 months respectively.

Removals had taken place for both personal and medical reasons. Personal reasons included "wants another child", "husband objects", whereas, medical reasons included bleeding, pain, pelvic infection etc. A higher proportion of acceptors had the device removed for personal reasons than for medical reasons. Of the 387 acceptors studied, 11 had the device removed for either medical (4) or personal (7) reasons giving a net cumulative removal rate of 1.9 for medical reasons and 3.5 for personal reasons per 100 user at the end of 12 months. The total termination rate being 2.4 and 6.3 at the end of 6 and 12 months respectively. The continuation rate showed a decline upto the end of 12 months, though the decline was of small magnitude.

Table IV shows the net cumulative rates for Cu-T-200 for present study in comparison with other studies. The net cumulative termination rate observed in the present study was lower than those in other studies.

Table IV: Net cumulative rates for Cu-T-200: Other studies Vs present study.

Studies Month of use Pregnancy
rate
Net cumulative
expulsion rate
Net cumulative removal
rate for
Continuation
rate
Medical reasons Personal reasons
Zipper 1971 12 0.0 1.2 0.8 - 98.0
Tatum 1972 12 2.2 7.2 5.6 - 87.0
Sivin 1973 9 0.7 4.9 2.9 - 88.0
Sivin 1973 9 1.8 3.5 6.8 - 82.0
CTU, 12 1.2 7.0 9.0 12.9 69.9
ICMR 1973 24 1.5 9.4 15.0 21.5 52.6
Jalagar 1977 6
0.0
0.0
1.8
2.8
93.0
  12 0.0 2.2 2.9 3.6 91.0
  18 0.0 4.8 6.4 8.8 80.0
Present study 6 0.0 0.8 0.8 0.8 97.6
  12 0.0 0.9 1.9 3.5 93.7

(Quoted in Jalagar et al3)

Discussion:

A total of 387 mothers had accepted IUD as a spacing method of family planning from the P.P. Unit of R.G. Kar Medical College & Hospital, Kolkata during the period from 1st January to 31st December 1999. IUD was the most acceptable method (93.25%) among the women attending the clinic for adopting spacing method during the same period. Most of the acceptors (93.6%) were residing within 10 km distance from the clinic and they had easy communication facilities to reach the clinic. No definite seasonal trend was observed regarding acceptance of IUD.

The findings of the socio-demographic profile of the acceptors are more or less comparable with those of other studies2-5. Literacy rate among the acceptors as well as their spouses was found to be 89.1% and 91.2% respectively. More than one third (34.6%) of the acceptors and more than half (52.2%) of their spouses had an educational status of high school and above. More or less similar observations were made by Jalagar et al3 (10.9% of acceptors illiterate) and Rajeswari et al2 (8.7% of acceptors and 6.3% of the spouses illiterate) in different urban areas of India. Philip et al5 observed that the education of both husband and wife acts as a favourable factor in adoption of the device. Major occupation of spouses was found to be labourer (37%) followed by service (30.5%) and business (22.7%). More or less similar pattern was observed by Mariam et al4 and Jalagar et al3.

Since IUD is a spacing method, a higher proportion of users were in the age group 20-29 years (73.4%) and the modal age group was 20-24 years. The findings were more or less similar to those observed in other studies2-4 in different parts of India. The mean age of acceptors was 24.8 years. However, the mean age of acceptors was found to be lower as compared to other studies2,3 (Rajeswari et al 28.4 years and Jalagar et al 27.4 years).

A greater proportion of acceptors (58.9%) had one child only and 37% had accepted the method after two living children. The mean number of living children in the present study was 1.5. This is in contrast to the finding of other studies2-5 where a greater number of acceptors had two living children. They also observed that some of the acceptors had no living children. The mean number of living children was also reported to be higher than that observed in present study.

The average number of living sons (0.9) was found to be higher than the average number of living daughters (0.6) at the time of acceptance of the device. Other studies2-5 also showed a similar picture. Studies reporting the acceptance of permanent measures like tubectomy and vasectomy have shown that the client had more sons than daughters. It is interesting that this happens to be true in this case also where a reversible method is involved. This brings to sharp focus, the value placed by Indian couples on male children and the implication of these values in accepting even reversible method is worth pursuing.

Age at marriage of the acceptors could not be analysed because of gross incompleteness of the records. It was revealed that about half (48.6%) of acceptors gave birth to their first child before 20 years of age. This may be due to a comparatively lower age at marriage of the studied acceptors.

On the advice of ICMR the insertion should as far as possible be performed within ten days of the menstrual period to rule out the possibility of pregnancy at the time of insertion6,7. 73.9% of the sample had accepted the device within ten days of LMP. Surprisingly in about 16.5% of the women, the insertion was done 15 days after the LMP or even later. Similar observation was also made by Jalagar et al3.

The net cumulative termination rate observed in the present study was lower than those of other studies (as quoted in Jalagar et al3) with Cu-T-200 device.

In the present study, continuation rates of 97.6 and 93.7 were observed at the end of 6 and 12 months of use respectively. Also, a higher proportion of women had the device removed for personal reasons than for medical reasons. This indicates the high tolerance of women using the device. The continuation rates showed steady decline up to the end of 12 months, though the decline was of small magnitude.

Since younger women had opted for the device so many women requested removal, as they wanted another pregnancy. This shows that better follow-up services in the later months of use may improve continuation rates. The data collected are, however, secondary in nature and suffer from the inadequacies inherent in such informations. This study had limitations such as the study population was drawn from P.P. Unit of a teaching hospital and, therefore, may be subjected to selectivity and rates were based on only reported events of pregnancies, removals and expulsions. Hence conclusions may be accepted cautiously.

Conclusions and recommendation:

This study, basically a record based, retrospective study has its inherent limitations characteristic of such studies. Inspite of the weakness and loopholes of routine record keeping, such analysis from time to time has relevance to the service providers in providing feed back, and to the policy makers in focussing on the changes (if any) in the socio-demographic variables that determine the choice of the eligible couples to opt for Copper T as spacing method.

This study shares some features common with the previous studies2-5. The modal age 20-24 years of the acceptors, their literacy status (89.1% literate) and occupation of the husband (about 1/3rd salaried people) all tally with the findings of the previous studies2-4. The study shows certain positive changes in acceptors' practices. The mean number of living children is 1.5 which is lesser than that in the previous studies2-5 and higher proportion (60%) of the couples had accepted IUD after 1 living child only. These are definitely changes signifying better awareness and acceptance among the clients. The higher continuation rate and lower termination rate in comparison to the previous studies3 are also indicating towards better operative efficacy. The excellent acceptance rate of IUD in our study may be explained as follows:-

Highly motivated beneficiaries: Many of the women who attended the PP Unit are motivated before hand for IUD insertion as IUD insertion facilities are not available in most of the F.P. clinics surrounding the PP Unit and these clinics refer women to attend the PP Unit with the specific purpose only.

Co-ordination with peripheral clinics and other agencies: There exists a functional feedback and co-ordination between the PP unit and these peripheral clinics. Anganwadi workers and supervisors also motivate some of the cases and refer them to the PP Unit.

High skilled staff: Health personnel attached to this PP unit are highly skilled and experienced for IUD insertion. They screen the women properly to select the suitable one for IUD insertion. The follow-up procedure is also very efficient and the waiting time for these clients is minimum.

Two findings are however, causing concern. Firstly, 48.6% of these couples had their first child before the age of 20 yeas thus calling for more motivation for delaying the first pregnancy. Of course, the basic fact behind this may be a comparatively lower age at marriage of those couples which could not be ascertained due to incompleteness in record keeping. This itself calls for certain steps to be taken to make the record keeping process complete, updated and more relevant. Secondly, the insertion of 16.5% of IUDs beyond 15 days of LMP is also a point of worry which is not in accordance with the norm prescribed by ICMR, though this observation was also shared by previous authors3 as well. Periodic reorientation and training of personnel entrusted with the responsibilities may take care of this lapse.

Acknowledgements:

I am thankful to the Principal, all faculty members and other staff of Deptt. of Community Medicine and the Post Partum Unit, R.G. Kar Medical College & Hospital, Kolkata for their whole hearted support in completing this project. Receipt of Dr. M.M. Ganguly Memorial Award of IAPSM (W.B. Chapter) for the year 2001 is also gratefully acknowledged.

References:

  1. Biswas AB, Roy A, Biswas R. Adoption of small family norms in a rural community of West Bengal. Indian Journal of Community Medicine 1994; XIX(24): 68-71.
  2. Rajeswari NV, Hasalkar JB. IUD retention in Shimoga District of Karnataka. The Journal of Family Welfare 1996; 42(1): 44-50.
  3. Jalagar VB, Murty KS. A study of the characteristics of acceptors of Copper T device. The Journal of Family Welfare 1982; XXVIII(4): 54-61.
  4. Mariam SPA, Sampoornam N. A case study of IUCD acceptors at Chintadripet, Madras. The Journal of Family Welfare, March 1972; XVIII(3): 50-4.
  5. Philip L, Rama Rao D. The IUD - An innovation for Family Planning. The Journal of Family Welfare, March 1974; XX(3): 37-46.
  6. Gray R et al (1980). Manual for the provision of IUDs, WHO, Geneva.
  7. Hawkins DF, Elder MG (1979). Human Fertility Control: Theory and Practice, Butterworth London.
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