the dynamics of iud use among vietnamese women final

8/12/2019 The Dynamics of IUD Use Among Vietnamese Women FINAL

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The dynamics of intrauterine device(IUD) use among Vietnamese women

A retrospective study

Thang Huu Nguyen, Min Hae Park, Minh Hai Le and Thoai D. Ngo


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Acknowledgements

This report was written by Thang Huu Nguyen, Min Hae Park, Minh Hai Le and Thoai D. Ngo. Thoai D. Ngo

is the Principal Investigator (PI) who conceptualised, designed and oversaw this study. Thang Huu Nguyen

oversaw the implementation and completion of the study at the local level in Viet Nam. Minh Hai Le provided

fieldwork support and data analysis. Min Hae Park assisted with the data analysis and writing of the report.

The authors would like to thank the following individuals for their critical review of the report: Adrienne Testa,

Louise Lee-Jones, Chris Golden, Rachael Sadler, Hang Bich Nguyen and Nhuan Thi Dinh. Thanks are also

due to Vicky Anning, who edited the report. This study could not have been completed without support from

the Departments of Health (DOH) in the provinces of Thai Nguyen, Khanh Hoa and Vinh Long. Particularly,

we would like to thank Drs. Hoan Van Bui, Phung Tan Le and Nghia Huu Huynh. We are grateful to all field

officers and the staff at the commune health stations who dedicated their time and effort to the study. Finally, the

study would not have been possible without the participation of the women who choose intrauterine devices

(IUDs) as their preferred contraceptive option.

For citation purposesNguyen TH, Park MH, Le MH and Ngo, TD. The dynamics of intrauterine device (IUD)use among Vietnamese

women: a retrospective study.London: Marie Stopes International, 2011.

Cover photograph credit

Marie Stopes International

02 A retrospective studyMarie Stopes International

Marie Stopes International delivers quality family

planning and reproductive healthcare to millionsof the worlds poorest and most vulnerable women.

Vision:A world in which every birth is wanted

Mission: Children by choice, not chance

Acronyms

CHS Commune health station

DHS Demographic and Health Survey

FP Family planningIUD Intrauterine device

LTFP Long-term family planning

MSI Marie Stopes International

MSI Viet Nam Marie Stopes International Viet Nam

PI Principal Investigator

RHFPReproductive health and family planning

SRH Sexual reproductive health

TFR Total fertility rate


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Contents

Marie Stopes International 03

Contents

1. Executive summary 04

2. Introduction 06

3. Study methodology 08

3.1 Study design, setting and participants 08

3.2 Sampling method 08

3.3 Survey instrument and data collection 09

3.4 Data monitoring and management 09

3.5 Analysis 09

4. Findings 10

4.1 Socio-demographic profile of IUD users 10

4.2 Reasons for choosing the IUD 10

4.3 Continuation and discontinuation of IUD at 12, 24 and 36 months 11

4.4 Reasons for discontinuation 13

4.5 Switching behaviours 14

4.6 Satisfaction with the IUD service at CHSs 15

5. Discussion and recommendations 16

References 19

Table 1: Socio-demographic characteristics of 1,316 women who had IUDs inserted between 2006-2009 11

Table 2:IUD discontinuation rates at 12, 24 and 36 months, by socio-demographic characteristics 12

Table 3: IUD discontinuation rates at 12, 24 and 36 months, by measures of satisfaction 14

Figure 1: Multi-stage sampling strategy: selection of provinces, communes and study participants 08

Figure 2: IUD discontinuation rates at 12, 24 and 36 months in all three provinces 10

Figure 3:Reasons for IUD discontinuation among 434 women who had ever had an IUD removed 13

Figure 4: Health effects among women who reported health concerns as the main reason for IUD discontinuation 13

Box 1: What is an IUD? 06

Box 2: Viet Nam country profile 06

Box 3: Description of study locations: Thai Nguyen, Khanh Hoa and Vinh Long provinces 08

Support for this research was provided by Marie Stopes International (MSI).

Tables and figures


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Executive summary

Marie Stopes International04

The intrauterine device (IUD)is the most commonly

used reversible method of contraception worldwide

and the only long-term reversible method available in

Viet Nam. Despite the reliance on IUDs in Viet Nam,

12.5% of Vietnamese women discontinue IUD use

within 12 months of insertion,1and contraceptive

options are limited.

Contraceptive discontinuation contributes to an estimated

28-52% of unintended pregnancies in developingcountries,2and may serve as one of the driving forces

behind the fact that Viet Nam has one of the highest

abortion rates in the world (26 abortions per 1,000 women

of reproductive age3). Despite the availability of legal and

safe induced abortion, unsafe abortions account for an

estimated 11% of the direct causes of maternal mortality.4

In order to improve womens health and facilitate the

achievement of desired family sizes, Viet Nam must

strengthen its family planning programme to improve

contraceptive continuation and reduce the burden

of unwanted fertility.

Marie Stopes International Viet Nam (MSI Viet Nam)

is one of the leading providers of sexual reproductive

health (SRH)and family planning (FP)services in

Viet Nam, offering a comprehensive range of high-quality

services to women and men of reproductive age.

In 2009 alone, MSI Viet Nam provided SRH/FP

services to more than 400,000 clients. MSI Viet Nam

has developed innovative, client-focused approaches

to healthcare delivery, and works with local healthproviders to improve SRH/FP service quality.

To inform FP programmes and improve service delivery,

MSI Viet Nam collaborated with three provincial health

departments to explore the dynamics of IUD use. We

conducted a retrospective study among women who

had received IUD services between 2006 and 2009

at commune health stations (CHSs)located in Thai

Nguyen, Khanh Hoa and Vinh Long provinces. We

examined the socio-demographic profile of IUD

users in these provinces and sought to describe

discontinuation and method-switching behaviours.

1. Executive summary



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Executive summary


The study took place in two CHSs in each province

involving: 505 women in Thai Nguyen; 376 women

in Khanh Hoa; and 445 women in Vinh Long. A total

of 1,326 women were interviewed, and data on 1,316

women who met the study inclusion cr iteria were

analysed. The womens mean age was 33.8 years

(age range: 19-49 years at time of IUD insertion).

Most IUD users had completed primary education,

and the majority of women were farmers (38%)

or housewives (29%). Most women had one (23%)or two children (50%). The majority (99%)of IUD

users were married women.

After 12 months, 12.2% of women had discontinued

IUD use, while 20.5% had discontinued use after

24 months and 26.6% had discontinued after 36

months. The highest rates of discontinuation were

observed among the oldest women (age >40 years),

and among those who worked as farmers or manual

workers. Of those women who removed their IUD,

50% (n=211/434)cited health concerns as the main

reason for discontinuation. This was mainly attributed

to excessive menstrual bleeding, weight loss and

infection. Other commonly cited reasons for removal

included: IUD replacement (17%); switching methods

or misplanning (14%); and IUD expulsion (10%).

Following IUD removal, the majority of women

switched to another contraceptive method. Of these,

most (86%; n=387)switched to alternative modern

methods, notably oral contraception (28%)and

condoms (17%), but 15% switched to traditional

methods such as withdrawal. Half of women whoswitched methods did so within one week of IUD

removal, but 12% of women waited more than two

months before adopting a new method. Satisfaction

with government IUD services was high. However,

dissatisfaction was associated with high rates

of discontinuation.

This study shows that early discontinuation of IUDs

is common practice in Viet Nam. Given the reliance on

the IUD as the only long-term reversible contraceptive

method available, the following issues need to be

addressed: high discontinuation rates; delays in adopting

new methods; and switching to traditional methods.

To improve continuation and strengthen IUD service

provision in Viet Nam, FP programmes should focus on:

improving IUD follow-up services to ensure thatwomens concerns, especially those relating to

health, are addressed when they arise

ensuring that family planning and contraceptive

options are discussed prior to IUD removal; women

who wish to prevent pregnancy should be advised

about the most reliable alternative methods, and the

delay to adopting new methods should be minimised

targeting IUD counselling and advice at women who

are at greatest risk of early discontinuation and

women who are most likely to switch to unreliable

methods, notably older women and individuals

working in manual occupations

tailoring FP campaign messages and counselling

services so that they are appropriate to their

target groups

involving husbands in FP counselling where

appropriate, as many decisions on contraceptive

choice are made jointly by couples

working with women to identify reasons for

dissatisfaction with IUD services, and ways in which

service quality and continuation can be improved

including unmarried women in FP campaigns;

these women currently represent a tiny proportionof IUD users.

Contraceptive discontinuationcontributes to an estimated 28-52% ofunintended pregnancies in developingcountries,2and may serve as one ofthe driving forces behind the fact thatViet Nam has one of the highestabortion rates in the world (26 abortionsper 1,000 women of reproductive age3).


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Introduction

Marie Stopes International06

2. Introduction

The intrauterine device (IUD)is the most commonly

used reversible method of contraception worldwide.

In 2007, it was used by an estimated 162 million

women, corresponding to 23% of users of any

contraceptive method.5 The prevalence of IUD

use is highest in Asia, where 18% of all women

of reproductive age and one in four users of any

contraceptive method relies on the IUD.5

The IUD is a safe and effective long-term family planningmethod. Compared to other reversible methods such

as the oral contraceptive pill, the IUD is associated with

lower rates of failure(1.8% at 12 months, compared to

6.9% for the pill and 2.9% for injectables)and lower rates

of discontinuation (12.2% at 12 months, compared to

34% for the pill and 46% for injectables).5The IUD can

remain in place for up to 12 years; therefore, it is well

suited to women of all reproductive ages.8Additionally,

the IUD is also the most cost-effective reversible method

currently available.9

Despite these attractive features, IUDs are underutilised

in many parts of the world, such as sub-Saharan Africa

and North America.10Discontinuation rates at 12-24

months after insertion are high in many countries.11

This is pertinent for FP programmes, since discontinuation

of reversible methods of contraception makes a

substantial contribution to the number of unwanted

pregnancies. One study of 15 developing countries

estimated that contraceptive discontinuation accounted

for 28-52% of unwanted fertility in the three yearspreceding the survey.2

The situation in Viet Nam

Viet Nam has a strong national FP programme, enforced

through its two-child policy.12It is estimated that 79%

of women who are married or in union currently use a

contraceptive method.5However, Viet Nam faces one

of the highest abortion rates in the world, at 26 abortions

per 1,000 women of reproductive age.3Despite the

availability of legal and safe induced abortion, unsafe

abortions account for an estimated 11% of the direct

causes of maternal mortality.4

Intrauterine devices (IUDs)are small T- or

horseshoe-shaped devices made of plastic,

which are inserted into a womans uterus

to prevent pregnancy

IUDs have been used since the beginning of

the twentieth century, but became a popular

contraceptive method from the 1960s onwards6

IUDs may be copper-bearing or Levonorgestrel

(hormone)-releasing; copper-bearing IUDs

can remain in place for up to 12 years.7

BOX 1:What is an IUD?

Viet Nam is a largely rural country with more

than 85 million inhabitants from 54 different

ethnic groups

women of reproductive age make up more than

half of the female population

total fertility rate (TFR)is 1.9 children per woman

contraceptive prevalence is 79%.

BOX 2:Viet Nam country profile14

The IUD dominates the contraceptivemethod mix in Viet Nam. IUDs areused by 44% of women, accountingfor more than half of all contraceptiveuse in the country.5


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07IntroductionMarie Stopes International

The IUD dominates the contraceptive method

mix in Viet Nam. IUDs are used by 44% of women,

accounting for more than half of all contraceptive

use in the country.5However, the 12-month reported

IUD failure rate is relatively high at 3%, and

discontinuation rates are estimated at 12.5%.1IUD

expulsion is also more frequently reported than in

other countries.13High discontinuation rates can

contribute to considerable numbers of unintended

pregnancies;2in Viet Nam, a lack of contraceptiveoptions after IUD discontinuation, combined with

the pressures of a prescriptive two-child policy,

may be factors in Viet Nams high abortion rate.1

Despite the prominence of IUDs in the methods mix

in Viet Nam, knowledge about the dynamics of IUD

use is limited. Few published studies have explored

IUD discontinuation in the Vietnamese context in the

last 15 years.15The most recent Demographic and

Health Survey (DHS)was conducted almost ten

years ago.1Marie Stopes International Viet Nam

(MSI Viet Nam)collaborated with three provincial

departments of health to conduct a community-based

study of the dynamics of IUD use in Viet Nam, providing

up-to-date knowledge to inform FP programmes and

service delivery.

MSI Viet Nam is one of the leading providers of sexual

reproductive health (SRH)and family planning (FP)

services in Viet Nam, offering a comprehensive range

of high-quality services to women and men of reproductive

age. In 2009 alone, MSI Viet Nam provided SRH/FP

services to more than 400,000 clients. MSI Viet Nam

has developed innovative, client-focused approaches

to healthcare delivery, and works with local health

providers to improve SRH/FP service quality.

A more detailed examination of IUD use and

discontinuation in Viet Nam could identify ways

to improve continuation of this effective method,

and consequently to reduce unintended fertility

and advance reproductive health. This information

will also provide insight into how national FP services

may be strengthened to improve IUD continuation.

The aim of this study is to provide detailed

information on the dynamics of IUD use in Viet Nam.

More specifically, this study set out to examine:

the socio-demographic profile of IUD users

continuation rates and reasons for IUD

discontinuation at 12, 24 and 36 months

method-switching behaviours of women

who discontinued IUD use.

Marie Stopes International / Duc Minh Nguyen


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08 Study methodologyMarie Stopes International

3.1 Study design, setting and participants

We conducted a retrospective study among women

who had received IUD services from 2006-2009

at commune health stations (CHSs)located in three

provinces: Thai Nguyen, Khanh Hoa and Vinh Long.

These provinces were chosen to represent different

regions of the country (north, central and south).

The study was approved by the Department of

Health Ethics Committees in all three provinces.

Women who met the following criteria were

eligible for inclusion in the study:

aged 15-49 years

received an IUD insertion from a government

family planning outreach camp in one of the

three selected provinces in 2006-2009

willing to give informed verbal consent and

able to return for follow-up visits; and

still resident in the province.

3. Study methodology

Face-to-face interviewer-administered surveys

were conducted to ask women about their IUD use,

discontinuation and method-switching behaviours.

3.2 Sampling method

We used a multi-stage sampling strategy (see Figure 1).

The three provinces were selected to ensure that

cultural and regional differences were represented

in the study. Furthermore, MSI Viet Nam is working

with the departments of health in these provinces tostrengthen family planning services. Two commune

health stations were randomly selected from each

province. To be eligible for selection, CHSs had to

have participated in annual government-supported

family planning campaigns in 2006-2009. From the

six selected CHSs, a list of all women who received

IUD services in the family planning campaigns from

2006-2009 was obtained. All women who met the

inclusion criteria were invited to participate in the study.

BOX 3:Description of study locations: Thai Nguyen, Khanh Hoa and Vinh Long provinces

Thai Nguyen is a peri-urban province in a mountainous region of northern Viet Nam, with a population

of 1.1 million people representing around eight different ethnic groups

Khanh Hoa is a predominantly rural province in central Viet Nam. It has a population of more than 1.1 million

Vinh Long is a province located in southern Viet Nam, with a population of around 1 million.16

FIGURE 1.Multi-stage sampling strategy: selection of provinces, communes and study participants

Vinh Long Thai NguyenKhanh Hoa

Sampling of 3 provinces

Van Gia

commune

Ninh Da

commune

Tan Hoa

commune

Phuong 8

commune

Quang Son

commune

Ban Dat

commune


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09Study methodologyMarie Stopes International

Marie Stopes International / Peter Barker

3.3 Survey instrument and data collection

A face-to-face, interviewer-administered questionnaire

was conducted in the respondents home. It posed

questions about socio-demographic information,

IUD use, discontinuation and switching behaviours.

This questionnaire had been developed and previously

used in a similar study in the Philippines17and was

translated and revised to be culturally appropriate

in the Vietnamese context.

Questions included the date of most recent IUD

insertion, year of most recent removal, level of

education, occupation, marital status, number of

children(sons and daughters), reasons for choice

of contraceptive method, switching behaviours and

satisfaction with IUD services. The questionnaire

was piloted among 20 women in advance to assess

feasibility and validity. Data collection took place

between April and June 2010.

3.4 Data monitoring and management

Data monitoring was carried out by a research

coordinator and a CHS staff member at each study

site. Every two weeks, the following measures

were assessed:

any deviations from the study protocol

completeness and accuracy of respondents records

security of respondents details

completeness of study service inventory logs, and

conduct of study staff.

The intra- and inter-variability of interviewers was

also assessed. All data were checked for consistencyand logical errors in the field and the support office.

All data were double-entered in Epi Info Version 3.5.1

(Centers for Disease Control and Prevention, GA, USA)

by two people.

3.5 Analysis

The socio-demographic characteristics of IUD

users were reported and differences in discontinuation

rates were assessed using Pearsons chi-square test.

Survival (time-to-failure)methods were used to analyse

IUD use and rates of discontinuation. Rather than

analysing multiple IUD insertions and removals, data

were treated as single-record, single-failure data.

Survival analyses were restricted to womens most

recent IUD insertion. All statistical analyses were

performed using Stata 11.1 (StatCorp LP, College

Station, TX, USA).


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11FindingsMarie Stopes International

4.3 Continuation and discontinuation

of IUD at 12, 24 and 36 months

Among the respondents, 78% of women (n=1,021)

were using an IUD at the time of the survey. The mean

duration of IUD use among the 369 women who had

removed an IUD in the previous four years was 1.0 year

(SD 1.08). Figure 2 shows IUD discontinuation ratesat 12, 24 and 36 months. Discontinuation of IUD use

was 12.2% at 12 months, 20.5 % at 24 months and

26.6% at 36 months.

Table 2 shows IUD discontinuation rates at 12, 24 and 36

months by womens socio-demographic characteristics.

Discontinuation at 36 months was associated with

province (p=0.002). The highest rates of discontinuation

were in peri-urban Thai Nguyen (29.7% compared

to 22.3% in Khanh Hoa and 20.2% in Vinh Long.

Discontinuation was strongly associated with age

group at 12 months (p=0.001), 24 months (p40 years).

IUD discontinuation at 24 and 36 months was also

associated with womens occupation: the highest

rates of discontinuation were observed among

farmers (23.7% at 24 months; 30.2% at 36 months)

and workers/freelance/ handcraft (23.5% at 24 months;

29.0% at 36 months), while the lowest rates were

among housewives (15.4% at 24 months; 18.6%at 36 months).

Discontinuation of IUD use at 12 months was also

associated with the number of sons; women with two

or more sons were more likely to have discontinued

IUD use at 12 months than women with one or no sons.

There was no association between IUD discontinuation

and education level, marital status or number of children.

Almost all women (96%)had their most recent IUD

removal at the CHS where they had the IUD inserted.

Only two women had the IUD removed at a private

clinic, and six women reported that the IUD had either

been expelled or that they had removed it themselves.

Characteristics N (%)

Province

Thai Nguyen 499 (37.9)

Khanh Hoa 376 (28.6)

Vinh Long 441 (33.5)

Age group

25 years 164 (12.5)

26-30 years 310 (23.5)

31-35 years 335 (25.5)

36-40 years 263 (29.0)

>40 years 244 (18.5)

Education

No education 26 (2.0)

Primary education 568(43.3)

Secondary education 534 (40.7)

High school or university education 184 (14.0)

TABLE 1.Socio-demographic characteristics of 1,316* women who had IUDs inserted between 2006-2009

Characteristics N (%)

Occupation

Farmer 494 (37.7)

Housewife 377 (28.8)

Worker/freelance/handcraft 183 (14.0)

Government/business/other 257 (19.6)

Marital status

Married 1,298 (98.7)

Not married

(divorced/separated/single)

17 (1.3)

Number of children

No children 101 (7.7)

1 305 (23.2)

2 656 (49.9)

3-9 254 (19.3)

*Not all 1,316 women had data for every variable.


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12 FindingsMarie Stopes International

TABLE 2.IUD discontinuation rates at 12, 24 and 36 months, by socio-demographic characteristics

IUD Discontinuation N (%)

N% At 12months

P-value At 24months

P-value At 36months

P-value

Province

Thai Nguyen 499 71 (14.2) 0.151 113 (22.7) 0.073 148 (29.7) 0.002**

Khanh Hoa 376 38 (10.1) 66 (17.6) 84 (22.3)

Vinh Long 441 50 (11.3) 77 (17.5) 89 (20.2)

Age group

25 years 164 16 (9.8) 0.001** 30 (18.3) 40 years 244 47 (19.3) 72 (29.5) 80 (32.8)

Education level

No education/primary 594 70 (11.8) 0.730 113 (19.0) 0.738 144 (24.2) 0.600

Secondary 534 63 (11.8) 109 (20.4) 136 (25.5)

High school or university 188 26 (13.8) 34 (18.1) 41 (21.8)

Occupation

Farmer 494 74 (15.0) 0.084 117 (23.7) 0.002** 149 (30.2)


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Findings


4.4 Reasons for discontinuation

Among the 434 women who had ever had an IUD

removed, the majority (49%)cited health concerns as

the main reason for removal (Figure 3). Other commonly

reported reasons included switching FP methods or

misplanning (14%), expulsion (10%)and replacement

of the IUD (17%). Only 6% of women had their IUDs

removed because of the desire to have children.

Among those women who cited health concerns as the

main reason for IUD removal, 43% reported excessive

menstrual bleeding as a problem, 18% reported weight

loss, 14% reported infection and 3% reported discomfort

during sexual intercourse (Figure 4).

FIGURE 3.Reasons for IUD discontinuation among 434 women who had ever had an IUD removed

Health

Switched FP method or misplanning

Expulsion of IUD

Menopause or widowed

Desire for children

IUD of date or replacement

Total number of women, N=434

Excessive menstrual bleeding

Weight loss

Infection

Discomfort during sex

Other

N=208

FIGURE 4.Health effects among women who reported health concerns as the main reason for IUD discontinuation

Among the 434 women who hadever had an IUD removed, the majority(49%) cited health concerns as themain reason for removal.


49%

14%

10%

4%

6%

17%

22%

43%

18%

14%

3%


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Findings


Approximately 79% of women who would not

recommend the IUD to friends or relatives had

discontinued use by 36 months, compared toonly 21% of those who would readily recommend

the method.

Women who were satisfied or very satisfied

with the IUD services were more likely to switch

to a modern method of contraception than those

women who were not satisfied (87% compared

to 73%; p=0.003).

4.6 Satisfaction with the IUD service at CHSs

When asked about their satisfaction with the IUD

service at the CHS, 91% of women (n=1,192)reported

that they were satisfied or very satisfied, 8% (n=105)

felt neutral and only 1% (n=11)were not satisfied.

The levels of satisfaction with IUD service were not

significantly different by province (p=0.183). About 96%

of the respondents (n=1,252)reported that they would

use IUD services at their CHSs if they needed a family

planning method in the future, and 98% (n=1,283)

would recommend the IUD to friends or relatives.

IUD discontinuation was strongly associated with

all measures of satisfaction (Table 3). Among women

who were not satisfied with the IUD services at theCHS, more than 90% had discontinued the method

at 36 months, compared to 23% of women who were

satisfied or very satisfied. Similarly, among women

who said that they would not readily use IUD services

at the CHS if they needed contraceptives in the future,

three-quarters had discontinued use at 36 months,

compared to 19% of those who said they would

readily use the services again.


Women who were satisfied or very

satisfied with the IUD services weremore likely to switch to a modernmethod of contraception than thosewomen who were not satisfied(87% compared to 73%; p=0.003).


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16 Discussion and recommendationsMarie Stopes International

5. Discussion andrecommendations

This report has highlighted that early discontinuation

of IUDs is common practice in Viet Nam, with more than

a quarter of women discontinuing use within three years.

The discontinuation rates reported in this study are

consistent with the rates reported in the 2002 DHS.1

Given the heavy reliance on the IUD in the contraceptive

method mix in Viet Nam, high discontinuation rates arelikely to contribute to substantial unintended pregnancy

and high abortion rates. Early discontinuation is

especially likely among older women and those

who work as farmers or in other manual occupations,

identifying potential sub-populations that may

be targeted for FP services or campaigns.

The majority of Vietnamese women discontinue

IUD use due to health concerns, including excessive

menstrual bleeding, weight loss and infection. Similar

findings were reported in an IUD mobile outreach

programme study by MSI Philippines.17Health effects

are also the main reason for switching to an alternative

method of contraception, highlighting the primacy

of health concerns in womens decisions regarding

contraceptive choices.

Despite the fact that only 6% of women reportedly

remove their IUD due to the desire to have children,

half of all women wait for more than a week before

switching to an alternative method after discontinuation,

and 12% wait for more than two months. Furthermore,

15% of women who switch to another method beginusing traditional methods (notably withdrawal), which

are unreliable and place women at risk of pregnancy.

Older women are most likely to switch to a different

method after IUD discontinuation, but they are also

more likely to switch to unreliable methods such

as withdrawal.

Discontinuation of long-term reversible methods

of contraception makes a considerable contribution

to unwanted pregnancy. Examination of the dynamics

of discontinuation can identify ways in which FP

services may be strengthened to improve continuation,

switching behaviours and level of satisfaction with

services. This is one of the few studies that haveexplored IUD discontinuation in the Vietnamese

context, and provides up-to-date knowledge that

can inform FP programmes and service delivery.

The IUD is an effective contraceptive method that

is well suited to women of all reproductive ages.

However, this study has shown that the profile of IUD

users in Viet Nam is dominated by married women

with children, indicating a missed opportunity in family

planning service provision among younger unmarried

women. This is particularly salient in the Vietnamese

context because the IUD is the only long-term reversible

method of contraception that is widely available. In

this study, 98% of women had completed primary

education; in Viet Nam as a whole, the literacy rate

among females aged 15 years and over was 92% in

2009.14Husbands play an important role in choosing

family planning methods, with 90% of women making

decisions regarding contraceptive methods jointly

with their husbands.


Husbands play an important role inchoosing family planning methods,with 90% of women making decisionsregarding contraceptive methodsjointly with their husbands.


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17Discussion and recommendationMarie Stopes International

Satisfaction with IUD services is an important factor

in discontinuation. Women who are satisfied with the

services are more likely continue IUD use, and are more

likely to switch to a modern method of contraception

following IUD removal. This result confirms the findings

of a previous study of the Viet Nam 1997 DHS data,

which showed that women living in communities with

high-quality health centres were less likely to discontinue

use of modern contraceptive methods.15This highlights

the fact that MSI Viet Nams work with CHSs to improve

service provision may be key in improving the continued

use of modern methods in these provinces. Examinationof the reasons for womens dissatisfaction with IUD

services would identify areas for further strengthening

of FP services and ways in which IUD continuation

can be improved.

The majority of IUD insertions and removals take

place in the same government clinic, presenting a

good opportunity for ensuring continuity of services,

including FP counselling and follow up. Experiences of

IUD campaigns in countries such as India and Turkey

have highlighted that provision of sufficient high-quality

follow-up care is essential for instilling womens

confidence in this method.10

This is one of the first community-based studies

focusing on the dynamics of IUD use in Viet Nam.

It presents findings about the profile of IUD users

and women at risk of IUD discontinuation, which

can inform FP programmes and improve service

delivery. It has the advantage of providing information

on a geographically wide cross-section of IUD users

across three provinces in contemporary Viet Nam.

However, there are limitations to this study. Notably,

the methods of data collection (self-reported, recall

data)meant that women reported only the year ofIUD removal. Information on the month or date of

removal was not available from clinic records. Thus

estimates of IUD use duration could only be reported

to the nearest year, and more detailed information on

discontinuation (e.g. at three months or six months)

is unavailable. In addition, women reported on only

their most recent IUD removal, therefore not all

episodes of IUD use during 2006-2009 could

be considered.



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18 Discussion and recommendationsMarie Stopes International


This study is unable to discern some of the more

complex patterns of IUD use. For example, we cannot

distinguish whether women are using IUDs to space

or stop births. The use of contraceptive calendars rather

than a standard questionnaire could have generated

more complete and accurate data, and could have

provided further insight into the relationship between

patterns of childbearing (e.g. stopping and spacing

behaviours)and IUD use. However, our estimated

discontinuation rates are consistent with those

reported in the most recent DHS, which does calculate

discontinuation rates using the calendar method,

indicating that the impact of these issues may have

been negligible.

Recommendations for FP services:

improve IUD follow-up services to ensure that

womens concerns, especially those relating to

health, are addressed when they arise

ensure that family planning and contraceptive

options are discussed prior to IUD removal; women

who wish to prevent pregnancy should be advised

on the most reliable alternative methods, and the

delay to adopting new methods should be minimised

target IUD counselling and advice at women who are

at greatest risk of early discontinuation and women

who are most likely to switch to unreliable methods,

notably older women and individuals working in

manual occupations

tailor FP campaign messages and counsellingservices so they are appropriate to their target groups

involve husbands in FP counselling where

appropriate, as many decisions on contraceptive

choice are made jointly by couples

work with women to identify reasons for dissatisfaction

with IUD services, and ways in which service quality

and continuation can be improved

include unmarried women in FP campaigns;

these women currently represent a tiny proportion

of IUD users.

Involve husbands in FP counsellingwhere appropriate, as many decisionson contraceptive choice are madejointly by couples.


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References

1. Committee for Population Family and Children [Vietnam] and ORC Macro. Vietnam Demographic

and Health Survey 2002: Calverton, Maryland, USA: Committee for Population, Family and Children

and ORC Macro, 2003.

2. Blane A, Curtis S, Croft T. Does contraceptive discontinuation matter? Quality of care and fertility

consequences. MEASURE Evaluation Technical Report No. 3.: University of North Carolina

at Chapel Hill: Carolina Population Center, 1999.

3. Sedgh G, Henshaw SK, Singh S, Bankole A, Drescher J. Legal Abortion Worldwide: Incidence

and Recent Trends. Perspectives on Sexual and Reproductive Health2007;39(4):216-25.

4. Vietnam Ministry of Health, and Maternal and Child Health and Family Planning Department.

Vietnam Ministry of Health, Maternal and Child Health and Family Planning Department,

Research on maternal mortality in Vietnam, 2000-2001. Hanoi: Vietnam Ministry of Health, 2003.

5. United Nations. World Contraceptive Use 2009: United Nations, 2009.

6. World Health Organization. Mechanism of action, safety and efficacy of intrauterine devices:

report of a WHO scientific group. Geneva: World Health Organization, 1987.

7. OBrien PA, Kulier R, Helmerhorst FM, Usher-Patel M, dArcangues C. Copper-containing,

framed intrauterine devices for contraception: a systematic review of randomized controlled trials.

Contraception2008;77(5):318-27.

8. Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review.

Contraception2009;79(6):418-23.

9. Chiou C-F, Trussell J, Reyes E, Knight K, Wallace J, Udani J, et al. Economic analysis

of contraceptives for women. Contraception2003;68(1):3-10.

10. dArcangues C. Worldwide use of intrauterine devices for contraception.

Contraception2007;75(6, Supplement 1):S2-S7.

11.Ali M, Cleland J. Contraceptive discontinuation in six developing countries: a cause-specif ic analysis.

International Family Planning Perspectives1995;21:92-97.

12. UNFPA Viet Nam. Population Growth in Viet Nam: What the Data from 2006 Tell us With a Focus on the Sex Ratio at Birth. Hanoi: UNFPA VIet Nam, 2007.

13. Hieu DT, Van HT, Donaldson PJ, Nga QL. The pattern of IUD use in Vietnam.

International Family Planning Perspectives1995;21:6-10.

14. General Statistics Office of Vietnam. Report on Completed Census Results:

The 1/4/2009 Population and Housing Census. 2010.

15. Do MP, Koenig MA. Effect of family planning services on modern contraceptive method

continuation in Vietnam. J Biosoc Sci2007;39(2):201-20.

16. General Statistics Office of Vietnam. Population and population density in 2008 by province.

17. Ngo TD, Pernito VL. Discontinuation of IUDs among women receiving mobile outreach services

in the Philippines, 2006-2008. London: Marie Stopes International, 2009.

References



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