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J. biosoc. Sci. (2005) 37, 319332  2004 Cambridge University Press doi:10.

1017/S0021932004006856

DETERMINANTS OF EARLY DISCONTINUATION OF IUCD USE IN RURAL NORTHERN DISTRICT OF INDIA: A MULTIVARIATE ANALYSIS AND ITS VALIDATION
VRIJESH TRIPATHI*, DEOKI NANDAN SUDHA SALHAN* *Department of Obstetrics and Gynaecology, V.M. Medical College and Safdarjung Hospital, New Delhi, India and Department of Social & Preventive Medicine, S.N. Medical College, Agra, India

Summary. The purpose of this study was to examine the determinants for early discontinuation among IUCD users in a rural district of northern India. Multivariate analysis indicated several signicant predictors of early discontinuation of IUCD use. The risk of discontinuation increased more than two times in the presence of factors such as more than usual amount of menstrual ow before insertion and intermenstrual bleeding after insertion. Similarly, residence or alternatively those coming from villages without health centres were nearly two times more likely to discontinue. Menstrual disturbance increased the risk nearly three-fold. If only those women who report normal menstrual cycles had IUCDs inserted, it is very likely that the high discontinuation rate due to menstrual disturbance could be reduced. Knowledge about the IUCD and its eectiveness decreased the risk of early discontinuation but was not a statistically signicant factor in multivariate analysis. Validation of the developed model was done by using the bootstrapping method and the model was found to be 18% noisy. These ndings may help family planning providers in counselling and practice.

Introduction In India, Lippes loop IUCDs have been distributed free of cost to users through family welfare clinics since 1965. The Copper-T 200 has been distributed in the same manner since 1975 (Ramachandran, 1994). However, the Indian family planning programme has depended heavily on permanent methods of contraception (Zavier & Padmadas, 2000): about 80% of couples eectively protected are sterilized, and the rest are using spacing methods (Pathak, 1996). According to the NFHS-1 (199293) 319

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survey (National Family Health Survey, 1995), for India as a whole the acceptance rate for the IUCD before 1980 was less than 1%, but this increased to about 4% during 199091. For some states, such as Gujarat, Haryana, Tamil Nadu and Uttar Pradesh, it was more than 4%. However, there seem to be few studies with methodological vigour that provide information on the extent of early discontinuation of spacing methods, particularly in the rst 6 months of acceptance. It may be surprising to know that the IUCD, being one of the primary methods of family planning currently available in the Indian National Family Planning Programme, has indicated early discontinuation rates since its introduction in the country. However, there is no information on area-specic data in the country to show early discontinuation rates during short-term use of this device and reasons thereof. It is generally believed that the discontinuation rate for the IUCD is in the range of 2040% at the end of one year (Bhatnagar et al., 1988a, b; Prabhavathi & Sheshadri, 1988; Bhat & Hasalkar, 1993; Schaap, 1993; Rajeshwari & Hasalkar, 1996; Saxena, 1996). Not much attention has been given either to discontinuation rates or the factors responsible for the continuation or discontinuation of IUCD use. There are hardly any studies that can explain how social, psychological, personal and other factors contribute to the continuation or discontinuation of IUCD use; or how the quality of follow-up services by clinics, counselling and other factors encourage or discourage continuation. There is also no information on the processes through which these decisions are taken, one possible exception being an urban-based ICMR (1986) study. However, by widening the scope and scale of the study to include all available contraceptive devices, this study lacks perspective and a goal-oriented approach. Moreover, it can be hypothesized that factors associated with early discontinuation, i.e. within six months, will be quite dierent from those factors associated with discontinuation beyond one year. For example, desire for a child will play a more signicant role as a factor inuencing IUCD discontinuation beyond six months. The present study is an attempt to ll some of these knowledge gaps by focusing on the IUCD and its acceptability within six months specically in a rural area of northern India. Data The sample was selected using a multistaged stratied sampling design utilizing data collected from 235 women acceptors in a rural district of Bulandshahar in western Uttar Pradesh in northern India. The total population of the district was 285 million as per the 1991 census, comprising around 2% of the total population of Uttar Pradesh. The average crude birth rate since January 1st 1995 was discerned to be 338 per 1000 population: 343 in rural and 315 in urban areas respectively. Of the births since January 1st 1995, 602% turned out to be of order 3 and above. Two block level Primary Health Centres (PHC), Gulaothi and Malagarh, in which there are a total of fty subcentres (SC) and 120 villages, were chosen to conduct the study. According to the 1991 census their population was 111,000 and 156,000 respectively (Rapid Household Survey, 1998). These pre-determined block level PHCs were selected with probability proportion to size, i.e. number of IUCDs inserted in each PHC during one year.

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Some safeguards were taken to ensure that the sampling did not suer from any time- or place-related bias. It was decided to take sampling at six-monthly intervals, since, despite the fact that the target approach has been abandoned by policymakers (Sen, 2000), the mind-set of health workers has not shown any change. Even though there is no pressure to complete the annual targets, family planning programme activities in India peak during the last quarter of the year (JanuaryMarch). Keeping in mind this trend at the PHCs in the last couple of years, it was decided to sample at six-monthly intervals, so that the respondents did not disproportionably come from this period. This also ensured that the IUCDs did not belong to the same manufacturing batch so that discontinuation could not be related to manufacturing inconsistencies. Also, it naturally follows that during the months of JanuaryMarch, the auxiliary nurse midwives (ANMs)/lady health visitors (LHVs) are overworked due to this target-oriented mind-set and hence are unable to provide a good service. By dividing the sample into two groups of 120 acceptors each, it ensured that this possibility of slackness on the part of health workers did not inordinately aect the results, even though the number of discontinuers was slightly higher in the rst round of sampling than in the second. It was attempted to get an equal number of respondents from villages with and without a health facility to assess whether the presence of a health centre aects continuation of IUCD use. The eldwork was conducted from September 2000 to September 2001. The reference period for obtaining information was from March 2000 to February 2001. The interview schedule was also translated into the local language (Hindi) and the interviews were held with the acceptors on the structured questionnaire at their residence. Those couples who had accepted an IUCD during the six months prior to the date of survey were selected and followed up at the lapse of six months. The main reasons for non-coverage of sampled cases were no such person lived in the area, temporarily gone out, permanently gone out, daughter of the village and visitor to the village. The present study seeks to examine the early discontinuation experiences of women currently using contraception who had accepted the IUCD six months prior to the initiation of the data collection and six months after the rst interview of the woman accepting the IUCD in a rural area of Bulandshahar district. Duration of use by status of termination at the cut-o point was taken as a dependent variable to study the risk of discontinuation of IUCD use. Before starting any preliminary analysis, the data were thoroughly scrutinized for validity and internal consistencies. Of the 235 respondents, one was excluded because of accidental pregnancy and six for expulsion of the IUCD. Methods Data were analysed in terms of discontinuation of IUCD use at six months. The discontinuation rate was estimated by using the KaplanMeier method (Kaplan & Meier, 1958). Univariate and multivariate survival analysis was done using the Cox proportional hazards model for determining the factors associated with continuation and early discontinuation of IUCD acceptors (Christensen, 1987; Kleinbaum, 1996;

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Katz, 1999). Selected covariates were considered in the Cox proportional hazards model analysis to identify the determinants related to early discontinuation of IUCD use. All the covariates that showed at least a moderate association ( < 025) were put into a multivariate Cox proportional hazards model to identify the independent covariates that are associated with early discontinuation of IUCD use. For this, a forward selection was used with probability levels for entry and removal at 005 and 010 respectively. The developed model was checked for linearity and proportionality assumption. To check the proportionality assumption, graphical as well as goodness-of-t methods were used. To overcome the problem of strong violation in the linearity assumption in relation to acceptors age, in addition to the consideration of womans age, its square was also added to the analysis. Under validation, an examination of the predictive accuracy of the multivariate model is necessary mainly to quantify the utility of a model to be used for prediction and to check a model for overtting or lack of t. Validation was done using the bootstrapping method (Efron & Tibshirani, 1993; Harrell et al., 1996). Measurements of predictive accuracy can be made through an easily interpretable index of predictive discrimination and through methods for assessing calibration of predicted survival probabilities. One way to assess calibration of probability predictions is to form sub-groups of IUCD users and check for bias by comparing predicted and observed responses. Shrinkage is the attening of the plot of predicted (x-axis) and observed (y-axis) probabilities away from the 45 degree line, caused by overtting. The estimate of slope was based on the mean slope from 200 bootstrap samples of the data. An adjusted slope close to one indicates little shrinkage and good calibration. The collected data were arranged and variables included in the study were extracted through SPSS. The Cox proportional hazards model analysis was carried out using SPSS 101. Validation of the model was performed through S-plus-40. Results The overall continuation rate for the IUCD was 796% (including expulsion and accidental pregnancy) at the end of six months, estimated by the KaplanMeier method. Thus, the discontinuation rate was 204% at six months (Fig. 1). The distribution of IUCD acceptors and cumulative probabilities of discontinuation at six months are considered in relation to various covariates in Table 1. IUCD acceptors were typically Hindu housewives in the age group 2530 years. More than 90% of respondents had at least one son; 75% were rst-time IUCD users. The mean age at rst pregnancy and youngest childs mean age were 195 and 194 years respectively. Sixty-eight per cent reported using the IUCD as a stopping rather than spacing device. By and large two types of acceptors were encountered. Thirty-two per cent of women came to the centre without any said preference or clarity about the available choices. Sixty-eight per cent came with a denite idea of what method they preferred, based upon discussions with their husbands, relatives and others. Only 27% of the respondents reported an irregular menstrual cycle before insertion.

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Fig. 1. Cumulative probability of IUCD use.

Cumulative probabilities of discontinuation for IUCD use tend to be higher among women from villages without a health centre, those with a more than usual amount of menstrual ow, those who experienced dysmenorrhoea before insertion or pain during insertion and for all medical reasons. However, parity, fear of side-eects and desire for another child did not appear to exert an inuence on discontinuation. Table 2 shows the ndings of the univariate analysis presented as relative risks (RR) and 95% condence intervals estimated by the Cox proportional hazards model. Women who had adopted the IUCD postpartum or concurrent with an MTP (medical termination of pregnancy) tended to continue to use it at the end of six months more than those who had adopted during interval, that is, within 7 days of their last menstrual period (LMP). Those women who intended to continue use for more than two years had a lesser chance of discontinuing than otherwise. Women who had experienced pain during insertion had twice the chance of discontinuing at six months. The husband was a better motivator than relatives, friends and health sta for the continuation of IUCD use. If a doctor had inserted the IUCD, acceptors showed a better chance of continuing (RR=05, CI=020126) than where an ANM/LHV had done so. Social taboos about menstruation aecting routine household activities like cooking and performing religious ceremonies had little impact on discontinuation of IUCD use. When the eect of wifes education on the relative risk was examined, it was observed that women who had received up to middle education were more likely to discontinue than were illiterate women, the value of RR being 12 against the variable of wifes education which had three categories: illiterate, up to middle and high school and above. The relative risk of this variable further illustrates that high school and above women were more likely to discontinue than were illiterate women (RR=13, CI=050330), indicating that education can alter the risk of method abandonment. The husbands educational level has a protective yet not signicant eect upon discontinuation of IUCD use. The higher the educational status of the husband, the lower is the discontinuation rate for IUCD use.

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Table 1. Descriptive characteristics and discontinuation probability for each covariate of IUCD users
Covariates Socioeconomic Age (mean 28 years) Category % Discontinuation probability at six months

Residence Type of family Womans education

Husbands education

Family income per month (Rs) Reproductive history Age at rst pregnancy (mean 195 years) Parity (average 3) Total living children (average 26) Age of youngest child (average 194 years) Menstrual pattern Amount of ow before insertion Dysmenorrhoea before insertion

< 25 2530 > 30 years With health centre Without health centre Nuclear Joint Illiterate Up to middle High school & above Illiterate Up to middle High school & above < 10,000 R10,000

202 548 250 516 484 636 364 390 498 112 158 482 360 890 110

239 187 210 136 277 174 266 182 210 230 222 213 183 195 280

1520 R21 12 R3 12 R3 <2 R2 Irregular Regular Usual More than usual None Mild Severe

548 452 368 632 513 487 421 579 272 728 842 158 364 576 66 123 351 526 320 680 158 842

180 233 202 205 214 194 230 186 194 198 170 390 133 226 400 72 219 236 247 184 361 175

Counselling & quality of care Who told you about IUCD? Husband Friends/relatives Health sta/others Is this the same method that No you had in mind when Yes coming to the clinic? Knowledge about IUCD and No its eectiveness Yes

Early discontinuation of IUCD use in India Table 1. Continued


Covariates Category %

325

Discontinuation probability at six months

Counselling & quality of care continued Condition for acceptance First time 746 Switched over 254 Reason for acceptance Stopping 680 Spacing 320 Type of insertion Interval 798 Postpartum 171 Concurrent with MTP 31 Intention to continue (years) %2 436 >2 561 Who inserted? ANM/LHV 811 Doctor 189 Pain during insertion No 825 Yes 175 Attitude of health sta Indierent 351 Cooperative 649 Medical, psychological & personal Abdominal/ pelvic pain No Yes Intermenstrual bleeding No Yes Menstrual disturbances No Yes Excessive white discharge No Yes Fear of side-eects No Yes Body ache/weakness No Yes Menstruation aecting No routine activities Yes Desire for another child No Yes 513 487 636 364 811 189 851 149 794 206 759 241 851 149 697 303

197 224 184 247 217 154 143 260 160 224 116 175 341 187 214 132 280 141 289 165 372 178 353 202 213 179 273 211 158 198 217

The univariate analysis showed that residence, amount of menstrual ow before insertion, severe pain before insertion, pain during insertion, abdominal pain, intermenstrual bleeding, menstrual disturbances and excessive white discharge were signicant at the p < 005 level. An irregular menstrual cycle acted as a protective factor but did not show a statistically signicant relationship with discontinuation at six months. This may be because menstrual disturbance was considered as a separate variable in this analysis under medical reasons for discontinuation. Acceptors

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Table 2. Univariate and multivariate analysis by Cox proportional hazards model


Covariates Socioeconomic Age Age2 Residence Type of family Womans education Husbands education Family income Reproductive history Parity Age at rst pregnancy Total living children Age of youngest child Menstrual pattern Amount of ow before insertion Dysmenorrhoea/pain before insertion Counselling & quality of care Who told you about IUCD? Is this same method that you had in mind when coming to the clinic? Knowledge about IUCD and its eectiveness Condition for acceptance Reason for acceptance Type of insertion Intention to continue (years) Who inserted? Pain during insertion Attitude of health sta Medical, psychological & personal Abdominal/ pelvic pain Intermenstrual bleeding Menstrual disturbances Excessive white discharge Fear of side-eects Body ache/weakness Menstruation aecting routine activities Desire for another child Category Univariate RR (95% CI) Multivariate RR (95% CI)

Continuous variable Continuous variable Without health centre Joint Up to middle High school & above Up to middle High school & above RRs10,000 >3 R21 years >3 R2 years Regular More than usual Mild Severe Friends/relatives Health sta/others Yes

10 10 21 13 12 13 09 08 16 09 13 07 13 09 26 17 38

(093107) 11 (054220) (099101) 09 (099101) (117393) 19 (103351) (087218) (063224) (050330) (041205) (034191) (070348) (055180) (075240) (049157) (073232) (051189) (138486) 24 (126453) (087349) (139102)

31 (072133) 34 (080141) 07 (040130)

Yes 04 (023082) 04 (019076) Switched over 12 (063228) Spacing 14 (079257) Postpartum 07 (029162) Concurrent with MTP 06 (089469) >2 06 (032103) Doctor 05 (020126) Yes 20 (103372) Cooperative 12 (062213) Yes Yes Yes Yes Yes Yes Yes Yes 24 21 27 21 11 17 07 11 (128440) (118375) 23 (127420) (149501) 30 (157540) (107398) (053216) (093311) (027170) (061209)

Early discontinuation of IUCD use in India Table 3. Validity indices of Cox hazards model
Index original Training Shrinkage coecient Dxy 100 052 100 055 Test 082 048

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Optimism Index corrected Re-sample 018 007 082 045 200 200

Dxy: Somers D-rank correlation.

coming from distant villages without a sub-centre showed twice the probability of discontinuation. When the acceptor had a previous obstetric history of more than the usual amount of menstrual ow before insertion, the discontinuation rate of the acceptor was almost twice that of an acceptor who had no such previous history (RR=26, CI=138486). Similarly, when there was a history of pain (dysmenorrhoea) prior to IUCD insertion, it was found that acceptors with mild pain were at twice the risk of discontinuing (RR=17, CI=087349) and those with severe pain at four times the risk of discontinuation (RR=38, CI=1391020) than acceptors with no pain. Women reporting intermenstrual bleeding since their last menstrual period were nearly two times (RR=21, CI=118375) more likely to have removals for bleeding than women without this complaint. Women complaining of menstrual disturbance were nearly three times (RR=27, CI=149501) as likely to have removals during the rst six months. All the variables that showed a moderate association ( < 025) were put into the multivariate model. Findings from the multivariate analysis, using the Cox proportional hazard model, identied ve variables, as reported in Table 3: namely, amount of ow before insertion, knowledge of IUCD and its eectiveness, residence, intermenstrual bleeding and menstrual disturbances. Interestingly, this multivariate analysis undid the overriding nature of medical reasons for early discontinuation of IUCD use. The multivariate model was examined for predictive accuracy to quantify the utility of the model to be used for prediction and to check for overtting. The calibration curve for Cox proportional hazard models relating to six month IUCD continuation is presented in Fig. 2. The presented calibration curve deals with the bootstrap estimate of calibration accuracy for six-month estimates from the nal Cox proportional hazard models of IUCD continuation. Also, validity indices, namely the shrinkage coecient and Somers Dxy rank correlation, are presented in Table 3. The bias corrected calibration seemed to be satisfactory in this case. The shrinkage coecient related to IUCD continuation was 082. The shrinkage coecient indicated that with regard to calibration accuracy, 18% of the model tting was noisy. The calculated Somer Dxy rank correlation related to the model for IUCD continuation was 045. The Somer Dxy measure, being the honest estimate of the discrimination aspect of predictive accuracy, also indicated satisfactory validity of the developed model. In summary, the measure of validity of the developed model demonstrated that this was good enough to describe the factors associated with early discontinuation of IUCD in rural area in North India.

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Fig. 2. Bootstrap estimates of calibration accuracy for 6 months from the nal Cox PH model for IUCD continuation. The dots correspond to the apparent predictive accuracy. X marks the bootstrap-corrected estimates.

Discussion The present study focuses upon early discontinuation of IUCD use and the factors associated with it. Notably, the sample had more stoppers than spacers. Spacers were more likely (15 times) to discontinue than were stoppers, but these gures were not statistically signicant. This is counter to the ndings of Bhat & Halli (1998), whose sample had more spacers than stoppers. Secondly, Gandotra & Das (1990) found that educational level was a highly signicant factor in IUCD continuation. This corroborates the ndings of Bhat & Halli (1998), who found that wifes educational level was important in the interval 46 months of use and husbands education in the interval 712 months. However, our studys analysis showed that women who had studied up to high school level and above were more likely to discontinue than were illiterate women. This is counterintuitive because illiterate women would not be expected to be inclined to use the IUCD longer than educated women. This was indicative of the notion that literate women show less tolerance than illiterate women. However, neither of the above two factors emerged as signicant predictors in the multivariate analysis. The multivariate analysis indicated ve predictors. There was a greater risk of discontinuation associated with residence, amount of menstrual ow before insertion, intermenstrual bleeding and menstrual disturbances. However, knowledge about the IUCD and its eectiveness was not a statistically signicant predictor. Residence or alternatively distance from the nearest health centre nearly doubled the risk of discontinuation of IUCD use. Bhat & Halli (1998) had a similar nding which, however, does not corroborate with that of Phillips et al. (1990). One hypothesis is that acceptors from remote villages have stronger motivation as they have come a greater distance to accept the method (Phillips, 1978). However, this may not necessarily be the case if the method is accepted through an outreach facility. Alternatively, an acceptors area of residence may reect the degree of social sanction

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and misconceptions about the methods side-eects in the neighbourhood. A person living away from an SC/PHC village would be less likely to revisit the centre on account of side-eects, especially if her rst visit had not given her the condence and respect she desired from the service providers. Hence, though the programme has made signicant advances in this area, additional improvements could be made in side-eect counselling and management. It should be ensured that female health workers visit their clients at their homes, at least twice: once within 15 days and the second visit at 3 months to tackle any side-eects or apprehensions with proper counselling. This is to ensure that immediate side-eects and persistent side-eects are duly taken care of. Amount of menstrual ow before IUCD insertion was a pointer to the fact that women who experience greater than usual ow before insertion were more than twice as likely to discontinue than others. This is an important predictor inuencing discontinuation of IUCD use. However, a review of the literature, specically of Indian studies, showed that none of the surveys included information on menstrual history of the acceptors. This is especially important since women with a previous history of excessive menstrual ow should not be recommended IUCD use. If women seeking IUCD insertion are asked about their menstrual cycle, and only those women who report a normal cycle have an IUCD inserted, it is very likely that the high discontinuation rate due to menstrual disturbances could be reduced. Many women who discontinue using the IUCD due to menstrual disturbances could associate their changes in the menstrual cycle with IUCD insertion, while in fact it could be that it was not the IUCD insertion that caused the disturbances. A problem that was not addressed earlier could then be attributed to enhancing the discontinuation rate. This kind of problem could be avoided by proper screening and history taking before IUCD insertion. Counselling, which has a major role in containing discontinuation, could help to lessen this eect: women who report an abnormal menstrual pattern should not then accept the IUCD, or the doctor/ANM/LHV should not insert the device. Intermenstrual bleeding and menstrual disturbances were the two overriding medical factors that increased the probability of discontinuation of IUCD use, more than doubling the chance of discontinuation. It is often better for such acceptors to be advised to shift to an alternative method rather than compelling them to continue for a longer period of time. Intermenstrual bleeding is a signicant and major problem that needs to be addressed. Proper medication and treatment should immediately be dispensed. Further counselling should provide better understanding and tolerance of short-term side-eects that are easily treatable. The programme should consider, however, that women who experience persistent side-eects may be best advised to switch to another method before they discontinue contraceptive use altogether. Knowledge of the IUCD and its eectiveness was entered at step 2 in the multivariate analysis, primarily because it was a protective factor. Full, adequate and respondent-associated counselling, explaining not only its advantages but also information regarding its ecacy, convenience, reversibility and side-eects, emerged as an important predictor of early discontinuation of IUCD use. It is important to provide balanced counselling in this eld because it oers an opportunity to provide

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women, and possibly their husbands also, with health information about their bodies that they may not otherwise be able to obtain. Although the informal communication channels of friends and family play a major role in motivation, they can also help spread inaccurate information. It is for this purpose that health personnel should encourage potential acceptors to talk about their needs, to explore with them their options and to impart accurate and balanced information. Armed with such knowledge, a woman would be less sceptical and more tolerant. However, this kind of counselling should also include knowledge regarding indicators, in which case she should immediately report to an SC/PHC for proper medication and redress. Counselling should include information about side-eects that are commonly experienced by women (pelvic pain, intermenstrual bleeding, excessive white discharge, menstrual disturbances and physical weakness) and how these problems could be managed. The importance of the role of balanced counselling has been dealt with by other researchers as well, namely Gandotra & Das (1990) and Bhat & Halli (1998). This analysis indicated that women who accepted the IUCD under pressure were less likely to continue using the method than were other women, and may be less willing to seek help for problems when they occurred. Pre-insertion and follow-up counselling and strengthening of Information, Education and Communication systems may help to decrease the early discontinuation rate. Other factors that were reported to have association with early discontinuation, including severe dysmenorrhoea, pain during insertion, pelvic pain and excessive white discharge, were found to be signicant in the univariate analysis only and did not emerge as independent covariates in the multivariate analysis. A review of the literature revealed pelvic pain as a determinant though never an isolated independent reason for discontinuation (Chaudhuri, 2000). This is because it is often a symptom of a more serious problem. Women who experience heavy bleeding are more likely than others to experience pain as a side-eect. Intermenstrual bleeding may also cause cramping, weakness and dizziness. Physical weakness and desire for another child are causes of discontinuation but they did not show any signicant impact upon discontinuation in the analysis. Counselling and quality of care variables were analysed to view the eects of interpersonal relations, choice of methods, provider and client information exchange and technical competence on IUCD discontinuation (Bruce, 1990; Jain et al., 1992). Although a number of strategies were pursued in the analysis to detect and quantify the signicance of quality of care variables, only moderate inuences of these variables on continuity of contraceptive use were found. For example, if the doctor had inserted the IUCD, acceptors had a better chance of continuing than in cases where an ANM/LHV had done so, perhaps because of the better technical skill involved or psychological conditioning that they had been given the best facility and product. However, the observed eects were trivial in comparison with the overwhelming inuence of side-eects. Nevertheless, the results appear to be in conformity with several other studies suggesting that the eect of quality of care upon contraceptive continuation may not be as strong as is commonly believed (Phillips et al., 1989). But these negative results may indicate that there are quality dimensions that these quality of care variables are ignoring. It is not sucient to provide counselling at the time of acceptance; what transpires in these sessions is probably

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more important for ensuring continuity of contraception. With respect to follow-up, frequency of visits (whose eect could not be investigated due to reciprocal causation) and quality of services rendered at that time could be important for duration of use. Hard data on these aspects were missing since this study did not take into account the viewpoints of ANMs, nor were they interviewed to ascertain their degree of knowledge, attitude, work conditions and problems. Such data would be needed before branding quality of care as a relatively minor determinant of contraceptive continuation/discontinuation. Acknowledgments Dr Ajit Singh, Chief Medical Ocer, Dr V. K. Dwivedi, District Health Education and Information Ocer and Mr Tyagi, District Coordinator, Nehru Yuva Kendra, Bulandshahar (Uttar Pradesh), are remembered by the authors with gratitude and thanks for their liberal help in the collection of research data. References
Bhat, P. N. M. & Halli, S. S. (1998) Factors influencing continuation of IUCD use in South India: evidence from a multivariate analysis. Journal of Biosocial Science 30, 297319. Bhat, P. N. M. & Hasalkar, J. B. (1993) Factors Influencing IUCD Retention in Northern Karnataka. PRC Working Paper No. 30. JSS Institute of Economic Research, Dharwad. Bhatnagar, S., Murali, I. et al. (1988a) A Field Study of IUCD Acceptors in the State of UP. National Institute of Health and Family Welfare, New Delhi. Bhatnagar, S., Murali, I. et al. (1988b) A Field Study of IUCD Acceptors in the State of Maharashtra. National Institute of Health and Family Welfare, New Delhi. Bruce, J. (1990) Fundamental elements of the quality of care: a simple framework. Studies in Family Planning 21(2), 6191. Chaudhuri, S. K. (2000) Practice of Fertility Control. A Comprehensive Textbook. B. I. Churchill Livingstone, New Delhi. Christensen, E. (1987) Multivariate survival analysis using Coxs regression model. Hepatology 7(6), 13461358. Efron, B. & Tibshirani, R. (1993) An Introduction to Bootstrap. Chapman and Hall, New York. Gandotra, M. M. & Das, N. P. (1990) Contraceptive choice shift and use continuation: a prospective study. Journal of Family Welfare 35, 5469. Harrell, F. E. Jr, Lee, K. L. & Mark, D. B. (1996) Tutorial in biostatistics: multivariable prognostic models: issues in developing models, evaluating assumption and adequacy, and measuring and reducing errors. Statistics in Medicine 15, 361387. ICMR (1986) Indian Council of Medical Research, Task Force Study on Psycho-Social Factors Affecting Continuation and Discontinuation of the Intrauterine Device and Oral Pill in Urban India. Indian Council of Medical Research, New Delhi. Jain, A. K., Bruce, J. & Barbara, M. (1992) Setting standards of quality in family planning programs. Studies in Family Planning 23(6), 392395. Kaplan, E. L. & Meier, P. (1958) Nonparametric estimation from incomplete observation. Journal of American Statistical Association 53, 457481. Katz, M. H. (1999) Mutivariable Analysis: A Practical Guide for Clinicians. Cambridge University Press, Cambridge. Kleinbaum, D. G. (1996) Survival Analysis: A Self Learning Text. Springer, New York.

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