Factors affecting continuation rates of DMPA

doi:10.1016/S0010-7824(99)00104-3

Contraception

Volume 60, Issue 6, December 1999, Pages 345-351

https://doi.org/10.1016/S0010-7824(99)00104-3 Get rights and content

Abstract

A prospective study was conducted with 430 new depot medroxyprogesterone acetate (DMPA) acceptors to estimate continuation rates and investigate factors associated with length of use. Data were collected on services received and sociodemographic characteristics of participants. Women were enrolled over the course of 1 year and were followed for up to 13 months. Failure to return to the same clinic within 104 days of the last injection was the outcome of interest. The 3-, 6-, 9-, and 12-month continuation rates were 68%, 67%, 55%, and 51%, respectively. In the bivariate analysis, women who were told to return to the clinic for side effects were more likely to continue using DMPA than those who were not given such advice (p <0.05). Likewise, women who received information on DMPA efficacy, side effects, and amenorrhea were more likely to continue using DMPA compared to those who did not receive such information (p <0.05). A proportional hazards regression model was constructed to estimate the simultaneous effect of various factors on length of use. In results consistent with the bivariate analysis, women who were told to return to the clinic were 2.7 times more likely to continue using DMPA compared to women who did not receive that advice. Likewise, women who were told about the possibility of amenorrhea were 2.5 times more likely to continue using DMPA compared to those who did not receive that information. The regression model also identified new factors such as number of children, attitude toward menstruation, lactating at admission, and spousal input on method choice. The findings suggest that providers play an important role in ensuring the highest possible continuation rates for DMPA.

Introduction

The most recent publications reporting 12-month continuation rates for depot medroxyprogesterone acetate (DMPA) users in the United States are disappointing: 34%,1 35%,2 and 42%.3 Continuation rates from earlier publications range from a low of 23%4 to 61% in an African population.5 The rates vary among populations, but the reasons for discontinuing do not; menstrual disturbances are the single major medical reason given for terminating use.6, 7 Although we know why women stop using DMPA, only limited information is available on the role that services play on the length of use. For example, a DMPA acceptor who has a good experience with her provider may be more likely to return for subsequent injections than a woman who had negative experiences. As side effects are the most common reasons for discontinuing, women who are not warned of possible menstrual changes, for example, might be more inclined to stop using DMPA compared to women who are fully informed. Thus, information received at the time of the first injection may dictate, to some extent, the continued use of the method.

Although it may seem obvious that good information leads to better continuation rates, the hypothesis has been examined only minimally. One study designed to measure the impact of counseling on DMPA continuation showed that women receiving intensive structured counseling used the method longer compared to women receiving regular counseling.8 In an attempt to improve dismal rates of continuation, researchers in Pittsburgh, PA, tested a strategy to provide intensive reminders for reinjection dates9; they found that only 43% of women receiving them were still using DMPA after 12 months, compared to 45% of women in the no-reminder group. Although it has been suggested in numerous publications that good counseling is the key in maintaining high DMPA continuation rates,10, 11, 12 this has never been explored vigorously with attention to specific provider practices and information shared at the time of the first injection.

Section snippets

Materials and methods

We conducted a prospective study in 30 government health centers in Bolivia that were introducing DMPA. The purpose of the research was to document use patterns, to measure continuation rates, and to study factors associated with continued method use. Women were invited to participate in the study if they wanted to use DMPA, did not have any contraindications to its use, did not receive a DMPA injection in the previous 3 months, and if they were residents of the facility’s catchment. A total of

Results

Of the participants, two-thirds desired no more additional children; >40% had four or more children; 57% were lactating at the time of admission; and only one-third had used a modern method previously (Table 1).

Most participants received services from a female nurse and >50% received services from a physician (Table 2). Before receiving an injection, providers informed many women about alternative methods of contraception. For example, more than three-quarters of the DMPA acceptors were told

Discussion

Although there will always be users who discontinue early, the results from this study suggest that providers can increase the length of use of DMPA. First, DMPA acceptors need complete and accurate information on possible side effects. Continuous long-term pregnancy protection is preferred to sporadic and unsatisfactory use of a variety of contraceptives; the more known at the time of adopting a method, the greater likelihood of sticking with it. Providers who emphasize only the positive

Acknowledgements

CARE funded this study and Family Health International (FHI) provided technical assistance. The source funding on this project for both institutions was the United States Agency for International Development (USAID); The work of FHI was conducted under contract CCP-A-00-95-00022-02. We are grateful to the DMPA users who participated in this study and the CARE-hired interviewers, Elia Farfán and Susana Acuña. We thank David Grimes, John Stanback, and Paul Feldblum of FHI for their helpful

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Cited by (63)

Predictors of DMPA-SC continuation among urban Nigerian women: the influence of counseling quality and side effects
2018, Contraception
Citation Excerpt :
Compared to IUDs and other long-term methods, continuation of injectable contraceptives is more difficult to maintain. Even as injectable contraceptives are gaining popularity in low-resource settings [22–24], especially for young women [25], continuation on injectable contraception is low in many settings [26,27]; discontinuation typically occurs within one year with estimated rates of up to 77%, and particularly high rates of drop-off observed after the first and second injections [3,26,28,29]. In one study in Nigeria, more than 50% of sampled women using DMPA-IM did not continue within one year [30].
In 2015, private healthcare providers in Nigeria introduced DMPA-SC (depot medroxyprogesterone acetate administered subcutaneously) into the method mix. We aimed to [1] examine the sociodemographic predictors of continued DMPA-SC use after 3 months, and [2] characterize the additional influences of contraceptive counseling quality and experiences of side effects on continuation.
From March to August, 2016, we conducted phone interviews with a convenience sample of women obtaining DMPA-SC from selected providers to survey them about their experience obtaining an initial dose of DMPA-SC. Study coordinators contacted women again about 3 months later after when they were due for reinjection. We used logistic regressions to examine the likelihood of having obtained a subsequent dose of DMPA-SC at follow-up as predicted by sociodemographic characteristics, a quality of counseling indicator based on responses to a 14-item scale, and reports of side effects experienced.
Of the 541 DMPA-SC users who completed the first survey, 311 were reached again via phone after 3 months to conduct a second survey. Multivariate results for sociodemographic predictors of continued DMPA-SC use show that those with some college education or more (OR=2.79; 95% CI: 1.09–7.14), and those with four or more children (OR=2.89; 95% CI: 1.09 0 7.67) were more likely to obtain another dose. Our summary quality measure showed that women overall rated the quality of their initial counseling session high. Logistic regressions indicated that higher quality during the initial counseling session is related to the likelihood of getting another dose of DMPA-SC (OR=2.04; 95% CI: 1.12–3.47) whereas experiencing more bleeding reduced the likelihood of continuation after 3 months (OR=0.15; 95% CI: 0.07–0.34).
Among urban Nigerian women, both counseling quality and experiencing side effects were important factors in predicting continued use of DMPA-SC after 3 months. These findings are consistent with previous studies of DMPA and injectable contraception continuation.
New contraceptive methods that are designed for increased access and ease of use, combined with high quality provision, have potential to increase contraceptive use in settings with low levels of contraceptive prevalence. Higher quality counseling can help encourage women's continuation of a new injectable contraceptive method at 3 months.
Intrauterine Contraception Continuation in Adolescents and Young Women: A Systematic Review
2016, Journal of Pediatric and Adolescent Gynecology
Adolescents are at high risk for unintended pregnancies. Although intrauterine devices (IUDs), long-acting reversible contraceptives (LARCs), are known to be highly effective in preventing pregnancy, little is known about IUD adherence in adolescents. In this systematic review (SR) we examined IUD continuation rates compared with other forms of contraception in young women aged 25 years and younger.
A systematic search of Ovid Medline, Cochrane Library, and Embase was conducted for the years 1946-2015. Included studies examined IUD use in women 25 years of age and younger, compared IUD use with another form of contraception, and measured continuation rates at 12 months. The quality of each study was appraised using the Downs and Black criteria, and 12-month continuation rates among studies were pooled and analyzed according to contraceptive type.
Of 3597 articles retrieved, 9 studies met criteria for SR. Synthesized across studies, 12-month continuation was significantly higher for IUD users (86.5%, 12,761/14,747) compared with oral contraceptives (39.6%, 1931/4873), Depo-Provera (Pfizer Inc, New York, NY) hormonal injection (39.8%, 510/1282), vaginal ring (48.9%, 196/401), and transdermal patch (39.8%, 37/93; all P values < .001). There was no statistically significant difference in 12-month continuation between the IUD and another LARC method, the subdermal etonogestrel implant (85.3%, 4671/5474).
Findings of this SR suggest that continuation rates for IUDs are generally higher compared with other contraceptive methods for women aged 25 years and younger. In a population with high rates of unintended pregnancies, generally low adherence, and imperfect use with other non-LARCs, IUD use should be encouraged.
Interest in self-administration of subcutaneous depot medroxyprogesterone acetate in the United States
2016, Contraception
Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is a low-dose formulation of depot medroxyprogesterone acetate (DMPA) that nonmedical personnel can administer safely and effectively. We sought to determine United States women's interest in self-administration of DMPA-SC to understand whether such use can overcome barriers to contraceptive access.
We analyzed survey data on contraceptive attitudes collected in March–July 2011 from 1592 women at 13 family planning and six abortion clinics throughout the US. A mixed-effects logistic regression model with random site effects examined the determinants of interest in self-administering DMPA-SC.
Overall, 21% [95% confidence interval (CI): 19%–23%] of women reported interest in self-administration. A multivariable model found that women currently using DMPA (Adjusted Odds Ratio [AOR] = 3.93, 95% CI: 2.37–6.53, p < .001) and women who previously used DMPA (AOR = 1.71, 95% CI: 1.26–2.32, p < .001) were more likely to have an interest in DMPA-SC than those who never used it. Women reporting difficulty obtaining or refilling a prescription were almost twice as likely to have interest in DMPA-SC as women who reported no difficulty (AOR = 1.99, 95% CI: 1.43–2.77, p < .001). Women surveyed at abortion sites were more likely to report interest in self-administration than women surveyed at family planning sites (AOR = 1.55, 95% CI: 1.05–2.30, p < .05). Interest in DMPA-SC was primarily driven by a desire to eliminate unnecessary return visits to a facility for repeat injections.
Offering women the option to self-administer DMPA-SC at home can expand access and tailor contraceptive provision to the needs of clients, thus supporting client-centered care. To the extent that self-administration may improve contraceptive continuation, DMPA-SC can prevent unintended pregnancies among women who discontinue DMPA use because of difficulty returning for repeat injections.
There is substantial interest in self-administration of DMPA-SC among current DMPA users, women who have recently had an abortion and women reporting difficulty returning to a family planning provider. Offering self-administration of DMPA-SC could potentially increase contraceptive continuation, reduce unintended pregnancies and enhance reproductive autonomy among DMPA users.
Hormonal Contraception
2015, Williams Textbook of Endocrinology
Women's preferences for contraceptive counseling and decision making
2013, Contraception
Little is known about what women value in their interactions with family planning providers and in decision making about contraception.
We conducted semistructured interviews with 42 black, white and Latina patients. Transcripts were coded using modified grounded theory.
While women wanted control over the ultimate selection of a method, most also wanted their provider to participate in the decision-making process in a way that emphasized the women's values and preferences. Women desired an intimate, friend-like relationship with their providers and also wanted to receive comprehensive information about options, particularly about side effects. More black and Spanish-speaking Latinas, as compared to whites and English-speaking Latinas, felt that providers should only share their opinion if it is elicited by a patient or if they make their rationale clear to the patient.
While, in the absence of medical contraindications, decision making about contraception has often been conceptualized as a woman's autonomous decision, our data indicate that providers of contraceptive counseling can participate in the decision-making process within limits. Differences in preferences seen by race/ethnicity illustrate one example of the importance of individualizing counseling to match women's preferences.
Menstrual Suppression in the Adolescent
2013, Journal of Pediatric and Adolescent Gynecology
Menstrual suppression, the use of contraceptive methods to eliminate or decrease the frequency of menses, is often prescribed for adolescents to treat menstrual disorders or to accommodate patient preference. For young women using hormonal contraceptives, there is no medical indication for menstruation to occur monthly, and various hormonal contraceptives can be used to decrease the frequency of menstruation with different side effect profiles and rates of amenorrhea. This article reviews the different modalities for menstrual suppression, common conditions in adolescents which may improve with menstrual suppression, and strategies for managing common side effects.

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Original Research ArticlesFactors affecting continuation rates of DMPA

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Obstet Gynecol

Contraception

Contraception

Contraception

Am J Obstet Gynecol

Contraception

Contraception

Obstet Gynecol

Original Research Articles
Factors affecting continuation rates of DMPA