Long Abstract Determinants of Intra Uterine Device usage among Women in Reproductive Age in three states of North India Abstract: Background:

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1 Long Abstract Determinants of Intra Uterine Device usage among Women in Reproductive Age in three states of North India Authors: Nayanjeet Chaudhury, Mohd.Tariq, Ajay Singh Abstract: This paper examines the impact of Population Services International (PSI) led intervention on IUD use among married women. The study was conducted on randomly selected 6560 women from three northern states of India after two years of a baseline study. The analyses suggest that around 43% of currently married women in the age group of years were currently using at least one method for family planning. The IUD use among women was 5.4% in the selected states, which is significantly higher than 3.3% in baseline. A careful exploration of data suggests that IUD use was more among women with more than 30 years of age. It was also seen that 73% of the women who had two or more children of either sex, reported more use of IUD. Women who belonged to high Standard of Living (SLI) reported more use of IUD than others. Women who were exposed to intervention also reported more use of IUD. For example, 10.3 % of the women who were exposed to Inter Personal Communicators (IPC) activities reported using IUD compared to only 5.2% of those not exposed to IPC activities. The multiple logistic regression analysis also suggests that the perceived availability of IUD and exposure to any IPC activity had significantly higher odds of using IUD among women. Background: The current Contraceptive Prevalence Rate (CPR) in India stands 54.8 per cent, with an unmet need of 20.5 per cent for family planning 1. The unmet needs for family planning in a developing country 2 can be associated with closely spaced pregnancies, child births and abortions and consequently high maternal and infant mortality 3. Intra uterine device (IUD) is one of the most effective reversible long term contraceptive choices for women who wish to limit or space childbirths. In spite of these advantages, it has limited acceptability among Indian women due to lack of access to quality IUD services and accurate information, predominance of myths and misconceptions prevalent in the community 4, and provider bias against their use 5,6. The overall IUD prevalence rate in India has remained stagnant at less than 2% since a decade. The Population Services International (PSI) is currently implementing an integrated behavior change program for better health of the married women, named as PEHEL in 19 districts of three states of north India, namely, Uttar Pradesh, Rajasthan and Delhi. The program is intended to support the Government of India s (GoI) efforts to improve the health and quality of life of vulnerable and poor women in India by increasing the modern contraceptive prevalence rate (CPR) from 50% to 52% by 2012, increasing use of intrauterine devices (IUDs) by women of reproductive age (WRA) from 3% to 4.1% by The program employed a mass media campaign to generate awareness among women about the use of IUDs and at the same time focused on inter-personal 1

2 communication to improve acceptability of IUDs targeted at groups of women in reproductive age who intended to space their next pregnancies, in select geographies in the program areas. Objective of the Study: The objective of the study was to determine the prevalence of current IUD use among eligible women and to identify and prioritize key determinants of IUD use in the project geography. Data and Methods: In the selected states, a baseline study was conducted in 2010 among currently married women between the ages of 15 and 49 years, living in urban and peri-urban areas, and who belonged to B, C and D Socio-economic class as defined by Registrar General of India. The data for this study comes from the Mid line follow up assessment of the baseline study after two years of completion of the PEHEL project of PSI. The study was approved by PSI s International Research Ethics Board and the data collection was done from January to March 2012 by an external research organization. A multi-stage, systematic random sampling design was used, which provided project level representation of sample size of 6560 respondents. At the first stage, list of all the urban wards were prepared and using PPS sampling 164 wards were selected. Within the selected ward, we randomly selected two Census Enumeration Blocks (CEB). A complete house listing was carried out in each CEB to identify the eligible women. Once the list of all the eligible women in a CEB was prepared, a systematic random sampling was applied to select 20 women for the interviews. We ensured that only one woman from a household is interviewed, in case when we found more than one eligible women in a household, we used KISH grid to select the woman. Face to face interviews were conducted among women using a structured interview schedule. Analysis of data was done using SPSS. In order to look at the prevalence of IUD and its key determinants, bi-variate and multi-variate logistic regression analyses was carried out. Key Study Findings Profile Over all, the mean age of the women was 30.7 years (SD 7.4). More than a half of the women had education above tenth standard and belonged to SC, OBC or ST ethnic groups. More than a third of women had three or more children. Also, more than a half of the women had high Standard of Living (SLI). Around two fifth (43%) of currently married women in the age group years were currently using at least one method (excluding sterilization) for family planning (table 3). The mean number of living children was 2.3 (SD 1.3). More than a third (37%) of the women had more than 2 children. 2

3 IUD Use and determinants The overall current use of IUD among women was 5.4% at project level (Delhi-1.8%, Rajasthan- 5.4%, Uttar Pradesh-6.6%). The bi-variate analyses suggests that the reported IUD use was more than 6% among the women in higher age group (30 years and above) with highest reporting of 7.8 percent was among 40 to 49 years of women. It was also seen that women who have two or more children, around three fourth (72.6%) of them reported using IUD. Women who had higher standard of living1 also reported more use of IUD compared to women who had lower standard of living. Exposure to intervention was also positively related to IUD use. Of women who were exposed to any Inter Personal Communication (IPC) activities, 10.3 % reported using IUD compared to 5.2% of those not exposed to IPC activities. The multiple logistic regression analysis suggests that the perceived availability of IUD and exposure to any IPC activity had significantly higher odds of using IUD after controlling for age, education, religion and caste, women s knowledge about IUD, number of children, high standard of living index, social norms,. The data also shows that among the significant predictors, high standard of living and Exposure to IPC have fairly high Odds Ratios (3.2 and 1.7 respectively). Baseline Vs Midline The overall prevalence of current IUD use increased from 3.3 in baseline to 5.4% in midline. The intervention had two distinct arms; a) Focused Area (area exposed to IPC activities + Campaigns) b) Non- Focused Area (Areas exposed to only campaign). A Bi-variate analysis was carried out to compare the findings from baseline. The finding suggests that during baseline the IUD prevalence in focused area was Fig 1: Prevalence of IUD in Old districts during baseline and Midline 2.7 percent which increased to 6.4% during midline (fig. 1). This increase can be attributed to intensive IPC activities in the community. Having said that, the IUD use in non focused areas during midline remained more or less unchanged compared to baseline (2.5% Vs 2.2%) Baseline Midline 3.2 Focused Area Non focussed Area Over all 1 Standard of living Index is a composite score of different commodities that are used or owned by the respondent in her HH..The items which were taken into considerations are; Type of house, What kind of toilet facility does your household have?, What is the main source of lighting for your household?, What type of fuel does your household mainly use for cooking?, What is the main source of drinking water for members of your HH?, do you have a separate room, which is used, as a kitchen?, Does your household own this house or any other house?, Does your household own any agricultural land?, How much agriculture land does this household own?, Do you own a Pressure cooker, Chair,Cot/Bed, Table, Clock/watch, Electric fan, Bicycle, Radio/Transisto, Sewing, machine, Telephone (land line), Refrigerator, TV (B&W), TV (color), Moped/Scooter/Motorcycle), Car, Water pump, Bullock cart, Thresher, Tractor. 3

4 Discussion The current study was undertaken to explore different factors that contribute to IUD use among women as a long term contraceptive method. Women s knowledge about IUD and their exposure to intervention were the most important factors which seemed to be associated with women s IUD use behavior. This indicates that targeted women need longer and focused intervention to adopt the IUD. Demand generation activities and provision of good-quality IUD services, together with a supportive programmatic environment - when carried out simultaneously have shown increased acceptance of the IUD 7. Studies have also shown that, in general, women with higher number of children are associated with higher IUD use rate 1, 6 which holds true in this study as well. In the light of the current study it would be interesting to explore corroborating evidence before recommending promotion of IUD to older, high-parity women for limiting purposes. Yet, such a strategy might encourage contraceptive use among women who do not want more children but are concerned about child mortality and thus reluctant to undergo sterilization. In a study in China conducted from 1980 to 2010, the authors commented that an individual's contraceptive choice depends not only on the individual characteristics such as ethnicity, age, education, number of living children and sex of the last living child, but also on the strength of family planning policies 8. The study found that in China, a stronger family planning policy of an individual is associated with higher long term use of contraception such as IUDs. Although we cannot comment on individual policies for contraception in Indian women for want of such information from our study, it is possible to draw from our findings that women s awareness and more positive perceived availability may determine IUD use among our study participants. It is difficult to comment why IUD use is not popular in our younger study participants compared to older ones and the ones with two or more children. As suggested by other studies fear of unknown pain and side effect may be a deterrent to IUD use or any other longer term reversible contraceptive among young women. However, in our study, lack of awareness too seems to be a major predictor for poor IUD insertion rate as depicted in other studies 9. Where programs have access to foreign aid, method choice may reflect donor preferences; equally, absence of foreign aid may limit method mix and favour provision of the cheapest 4

5 methods of family planning regardless of effectiveness. The history of the country itself, with its international alliances, relationship with industry, demographic policies and cultural and religious influences, will create an environment more or less favorable to IUD use 10. Individuals considering use of the IUD are influenced by their own familiarity with contraception in general, by the acceptability of family planning in their socio-cultural and religious community, and by their wish to space or limit childbearing. A woman s attitudes to IUD is also influenced by her awareness about the method, and by her own evaluation of the relative risks and benefits associated with IUD use. In some cases, misinformation may dominate, fuelled by reports of severe complications with older IUD types that are no longer available 11. The option for prolonged duration of use add to its acceptability as an alternative to sterilization. The IUD is a proven alternative to for long term contraception. Given the high levels of unwanted pregnancies and un-met need for family planning in India, there is a need to devise easy-to-implement and effective programs that increase contraceptive knowledge and use. Programmatic Recommendations: The results clearly indicate that, focused areas have fared relatively better compared to nonfocused areas in terms of IUD use. However, the point of concern remains in the non-focused areas, where the prevalence of IUD use has not shown any improvement and has shown signs of stagnancy. It would be good to consider scaling up IPC activities in all the intervention areas. 5

6 Annexure Table 1: Selected demographic indicators of three states INDICATORS DELHI UP RAJASTHAN Total Population * 16,753, % of Total Population of 1% 16% 6% India * Population Density per sq km 11, * Currently Married Women 2351 (70.2) 9134 (75.0) 3065 (78.8) years ** Median age at Marriage ** ** ** TFR ** Contraceptive Prevalence 67% 44% 47% Rate (currently married women age 15-49) ** TFR (15-49) ** CBR** IMR*** CBR *** *Census of India RGI 2011 ** National Family Health survey ***SRS December 2011 Table 2: Socio-economic and demographic characteristics of the women at the project level Background characteristics Percent Number Age of female respondent Education level of the women Illiterate Literate without formal education Less than 10 class th passed Passed 12th class Above 12 class Occupation of the women Working for money Not working Religion Hindu Muslim Others (Christian, Sikh, Jain and Buddhist) Caste of the women 2 OBC SC ST General Exposure to media 2 OBC=Other backward class, ST=Scheduled caste, SC=Scheduled tribe 6

7 No Yes Standard of living index Low SLI Moderate SLI High SLI Have knowledge about IUD No Yes Current use of any family planning method No Yes Number of living children No children One child Two children Three children >=4children

8 Table 3: Current use of IUD by socio-economic and demographic characteristics of women Background characteristics Current use of IUD (%) Number Age of female respondent (Yrs) Education level of the women Illiterate Litterate without formal educaiton Less than 10 th class th passed Passed 12th class Above 12 class Occupation of the women Working for money Not working Religion Hindu Muslim Others (christian, sikh, jain and buddhist) Ethnicity Obc Sc St General Exposure to media No Yes Standard of living index Low SLI ModerateSLI High SLI Have knowledge about IUD 3 No Yes Number of living children No children One child Two children Three children >=4children Exposure to any IPC activity (mela, group meeting or one to one meeting) No Yes Exposure to any intervention No Yes Given correct response to any of these statements; A woman can use IUD multiple times in her lifetime, IUD can be used while breast feeding, IUD can be inserted after 1 ½ month of delivery, IUD has various period options like 3, 5 or more years, IUD is almost effective as sterilization, and the side effects of using IUD subside within 3-4 months. 8

9 Table 4: Predictors of current IUD Use among married women using Binary Logistic regression (IUD use=1, IUD-Non Use=0) Background characteristics Odds Ratio* 95.0% C.I.for EXP(B) Lower Upper Age group Education Illiterate Literate without formal education Less than 10 class th passed Passed 12th class Above 12 class Religion Hindu Muslim Others (christian, sikh, jain and buddhist) Caste Obc Sc St General Standard of Living Index Low sli Moderate sli High sli Number of Children IUD knowledge Perceived Availability of IUD Social norms Exposure to any IPC activity No Yes *Values that are statistically significant are highlighted. 4 IUD knowledge: A woman can use IUD multiple times in her lifetime, IUD can be used while breast feeding, IUD can be inserted after 1 ½ month of delivery, IUD has various period options like 3, 5 or more years, IUD is almost effective as sterilization, and the side effects of using IUD subside within 3-4 months. 5 Perceived Availability: Copper-T is offered at all private hospitals, My nearby doctor also provides Copper-T services. Copper-T is offered at clinic/ hospital within 2 km from my house, Copper-T is provided in my locality. 6 Social Norms: Many women in my community use Copper-T, Most of my friends do not use Copper-T, My relatives use Copper-T, Doctors in my locality recommend Copper-T for contraceptive solution. 9

10 1 International Institute for Population Sciences (IIPS), District level Household and Facility Survey (DLHS-3), : India. Mumbai: IIPS 2 Pallikadavath, S., Stones. R. W. (2006). Maternal and Social Factors Associated with Abortion in India: A Population-Based Study. International Family Planning Perspectives, 32(3), Sedgh, G., Bankole, A., Oye-Adeniran, B., Adewole, I. F., Singh, S., & Hussain, R. (2006). Unwanted Pregnancy and Associated Factors Among Nigerian Women. International Family Planning Perspectives, 32(4), Gandotra, M. M., and N. P. Das Contraceptive choice, shift and use continuation: A prospective study in Gujarat. Journal of Family Welfare 36(3): Khan, M.E., Bella C. Patel and R.B. Gupta "The quality of family planning services in Uttar Pradesh from the perspective of service providers". In Improving Quality of Care in India's Family Welfare Programme edited by Michael A. Koenig and M.E. Khan. Population Council. New Delhi. pp International Institute for Population Sciences (IIPS) and Macro International National Family Health Survey (NFHS-3), : India: Volume I. Mumbai: IIPS. 7 Khan, M.E., Sitanshu Sekhar Kar, Vikas Kishor Desai, Pratibha Patel and B P Itare 'The model works! Interim findings from an OR project on repositioning of IUD in Gujarat. Research Update No. 12, December New Delhi: Population Council/FRONTIERS. 8 Wang C. Trends in contraceptive use and determinants of choice in China: Contraception Jun;85(6): Bharadwaj P, Akintomide H, Brima N, Copas A, D'Souza R. Determinants of long-acting reversible contraceptive (LARC) use by adolescent girls and young women..eur J Contracept Reprod Health Care Aug;17(4): Sullivan TM, Bertrand JT, Rice J, Shelton JD,. Skewed contraceptive method mix: why it happens, why it matters. J Biosoc Sci 2006;38: Hutchings JE, Benson PJ, Perkin GW, Soderstrom RM. The IUD after 20 years: a review of worldwide experience. Int Fam Plann Persp 1985;11: