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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
Marie Stopes International
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Executive summary
Marie Stopes International 05
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
Marie Stopes International 13
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.
Marie Stopes International / Peter Barker
49%
14%
10%
4%
6%
17%
22%
43%
18%
14%
3%
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Findings
Marie Stopes International 15
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.
Marie Stopes International / Peter Barker
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.
Marie Stopes International
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.
Marie Stopes International / Peter Barker
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18 Discussion and recommendationsMarie Stopes International
Marie 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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