|Year : 2015 | Volume
| Issue : 2 | Page : 68-73
Intrauterine contraceptive device acceptors in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Southeastern Nigeria - A 5-year review
VO Dinwoke, CI Okafor, A Eke
Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra, Nigeria
|Date of Web Publication||9-Jun-2015|
C I Okafor
PO Box 2866, Nnewi, Anambra
Background: Unsafe abortions of unintended pregnancies contribute significantly to maternal deaths in Nigeria. The intrauterine device (IUD) is a widely used method of contraception. Objectives: This study aimed to determine the contraceptive prevalence at this center, the proportion of the acceptors adopting the IUD method, and the sociodemographic characteristics and other parameters among the IUD clients. Findings from this study and the analysis of similar studies elsewhere will help improve contraceptive services, especially counseling and acceptance. Materials and Methods: This was a retrospective study of the period January 2004-Dec. 2008. The family planning register was used to trace the case records of the clients who had accepted IUDs over the 5-year period. Labor ward registers were used to calculate the number of deliveries over the same period. EPI Info Version 6 (2002) for Windows was used to analyze the data. Chi-squared tests were used and differences were considered significant if P < 0.05. Results: The total number of deliveries at our center in the studied period was 2,791, while the total number of contraceptive clients (for all methods) was 607, giving a contraceptive prevalence rate of 21.75%. IUD was the most accepted method, used by 344 (56.67%) women, followed by injectable progestogens, used by 172 (28.34%). Among IUD acceptors, most were multiparous women (para 2-5), numbering 168 (50.91%); most were in the age group of 26-30 years 100 (30.30%); male sterilization was not done at all (0%). Conclusion: IUD is a preferred contraceptive option among our women; however, the prevalence rate of modern contraceptive use at our center is still unacceptably low. More aggressive health education using the mass media, nongovernmental organizations (NGOs), religious and community leaders, and easy access to the commodities are required to reverse the trend.
Keywords: Contraceptive, IUD, prevalence
|How to cite this article:|
Dinwoke V O, Okafor C I, Eke A. Intrauterine contraceptive device acceptors in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Southeastern Nigeria - A 5-year review. Trop J Med Res 2015;18:68-73
|How to cite this URL:|
Dinwoke V O, Okafor C I, Eke A. Intrauterine contraceptive device acceptors in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Southeastern Nigeria - A 5-year review. Trop J Med Res [serial online] 2015 [cited 2019 Jan 18];18:68-73. Available from: http://www.tjmrjournal.org/text.asp?2015/18/2/68/158397
| Introduction|| |
The use of intrauterine devices (IUDs) for contraception has been growing in popularity throughout the world. 
Their safety and efficacy have made them the most commonly used reversible method of long-term contraception, with a worldwide figure of about 127 millions of clients as of the year 2000.  The majority (84.6%) of users of IUDs in the world are in China, while less than 5% of contraceptive users in the UK and the USA adopt them, most likely because of overestimated health risks associated with IUDs. 
One of the eight cardinal goals in the Millennium Declaration (Millennium Summit, New York, September 2000) is to improve maternal health. 
Maternal mortality figures in developing countries including Nigeria are still quite alarming. In Sub-Saharan Africa and South Asia, 1 in 13 and 1 in 35 women, respectively, die of causes related to pregnancy and childbirth, compared to 1 in 3,200 in Europe, 1 in 3,300 in USA, and 1 in 7,300 in Canada. 
In Nigeria, the average maternal mortality ratio is about 800 deaths per 100,000 live births, with a wide zonal variation, ranging from 165 in the Southwest to 1,549 in the Northeast. 
Some hospital-based studies in Kano, Lagos, and Cross River states revealed alarming figures ranging 2,500-7,500 maternal deaths per 100,000 live births.  Unsafe abortions of unintended pregnancies account for 40% of these maternal deaths in Nigeria. 
A nongovernmental organization (NGO), Campaign Against Unwanted Pregnancy (CAUP), reported that of an estimated 6.8 million pregnancies per year in Nigeria, 63% are unintended and most of them end in induced and often unsafe abortion. 
A high number of abortions often reflects an unmet need for family planning services.  IUD insertion immediately after abortion (induced or spontaneous) has been found to be safe, provided that current genital tract infection, risk of infection or hemorrhage, and genital tract trauma have been ruled out. 
The level of utilization of modern contraceptives in Nigeria is still quite low, with figures of 3.5% and 8.6% reported in 1990  and 1999,  respectively.
In a survey of 7,356 women in the USA in 2006-2008, nearly 99% of women aged 15-44 years who have ever had sexual intercourse with a male have used at least one contraceptive method. The leading method found in that study was oral contraceptive pills, followed by female sterilization.  Factors affecting the level of utilization of modern contraceptives in Nigeria include ignorance, myths, misconceptions, the poor attitude of service providers, nonavailability of the commodities, and low educational and economic status of women. ,
From the introduction of the first IUD in 1909, this method of contraception has undergone tremendous development toward the elusive "ideal." IUDs act by causing a foreign-body reaction in the endometrium, with increased prostaglandin production and leukocyte infiltration, thus inhibiting sperm transport and viability, thereby preventing fertilization. 
The earlier assumption that they act by preventing implantation is now known to be erroneous. 
The IUD currently used at our center is the copper T 380A; it has a failure rate of 0.8% per year. 
The objective of this retrospective study was to determine the contraceptive prevalence at our center, the proportion of the acceptors adopting IUD, and the sociodemographic parameters of the IUD clients. Our findings in comparison with findings from other centers will help to develop recommendations that will improve contraceptive services and acceptance.
| Materials and Methods|| |
The clients register of the family planning clinic in Nnamdi Azikiwe University Teaching Hospital (NAUTH) was used to trace the case records of all clients who had accepted the IUD over the 5-year period under review (January 1, 2004-December 31, 2008). Variables extracted included age, parity, source of contraceptive awareness, interval between last delivery or abortion and IUD insertion, whether the client was currently breast feeding or not, whether there was a desire for more children in future, history of prior contraception, complications reported, discontinuation, and method failures.
The daily activity register of the clinic was used to extract information about clients adopting other contraceptive methods.
The labor ward delivery register was used to extract information on the total number of deliveries over the same period.
EPI Info Version 6 (2002) for Windows, Centers for Disease control and prevention, Atlanta, GA was used for the analysis. Chi-squared tests were used where appropriate and differences were considered significant if P < 0.05.
| Results|| |
The total number of deliveries during the study period was 2,791, while the total number of contraceptive acceptors (for all available methods) was 607, giving a contraceptive prevalence rate of 21.75%. [Table 1] shows the distribution of contraceptive acceptors according to the methods. IUD was the most popular method at 344 (56.67%). The progestogen implant, which was not regularly available at that time, was the least utilized method, used by four clients (0.66%); of 344 IUD clients only 330 were traced for analysis. The age and parity distributions of the IUD clients are shown in [Table 2]. The peak age group was 26-30 years, with 100 clients (30.30%); regarding parity, the highest IUD use was in the para 2-5 group, with 168 (50.91%) clients, while only 3 (0.91%) nulliparas accepted IUDs.
|Table 1: Summary of new contraceptive acceptors (all available methods) at NAUTH January 2004-December 2008 |
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The intervals between last delivery or abortion and IUD insertion and any complications reported are shown in [Table 3]. There was no immediate postpartum or postabortion insertion. AA majority (43.94%) had their IUDs inserted before 6 months postpartum, by the end of 1 year; a total of 65.80% had inserted their IUDs. Abnormal vaginal bleeding (menorrhagia and irregular vaginal bleeding) was the commonest complication, occurring in 6.97%, and missing IUDs the least common, in 0.61%.
|Table 3: Last delivery/abortion to IUD insertion interval and complications |
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The sources of contraceptive awareness are shown in [Table 4]. The commonest source was family planning personnel (for 62.73%), followed by friends/relatives (16.67%), while the the least common source comprised churches, women's organizations, etc., at 10.00%.
| Discussion|| |
It has been estimated that about 50% of all couples in the world currently use a modern method of contraception.  This increased use of contraception has mainly occurred in developed societies. Nigeria, with one of the highest fertility rates in the world, has a very low contraceptive prevalence of 6% on the average. 
Comparing the 607 contraceptive clients in this study with the 2,791 deliveries in the center over the same period, a contraceptive prevalence of 21.75% was found for all the methods offered. This figure is much higher than the 12.8% prevalence reported from this center in an earlier study.  It is yet to be determined whether this increased prevalence is confirmatory of a rising awareness/utilization of modern contraceptive methods in this environment.
Far lower national contraceptive prevalence figures of 3.5%, 8.6%, and 8% were reported in 1990, 1999, and 2003, respectively ,,
The reasons adduced for the low contraceptive prevalence in Nigeria and other developing countries include ignorance, illiteracy, myths, misconceptions, and poverty.
Furthermore, the inadequate funding and poor organization of health-care systems contribute to this problem.
In a study of community leaders' perception of reproductive health issues carried out in Northeastern Nigeria,  most of the community leaders opined that married women should have no business with contraception, just as unmarried women should have no business with sex. They only accepted traditional methods, such as abstinence, coitus interruptus, and the calendar method-all with prior spousal consent. They objected strongly to the concept of limitation of births for economic reasons, as "God who sends the [offsprings] will provide for their upkeep."
Though modern contraceptive methods are clearly more effective, some women prefer the traditional methods, as the successful use of these methods requires commitment from their partners, which enhances marital cooperation and communications.  Some women also believe that using modern methods would endanger their health and future fertility.  Of all the contraceptive methods offered at our center, the IUD was the most popular, being accepted by 56.7% of all clients. This is consistent with an earlier study at this center, when IUD clients constituted 64% of clients,  and with another study in Lagos, Nigeria, where IUD clients constituted 68.3%. 
However, this finding is at variance with the findings in a rural population in this country, where IUDs were among the least-known forms of contraception (5.3%).  The fact that our study was hospital-based in a semiurban area may partly account for this difference.
The very low acceptance of sterilization (in only 1.15% of clients) may be a product of myths and misconception. Male sterilization (vasectomy) fared even worse victim in our environment, a finding buttressed by a study in Jos, North Central Nigeria. 
A majority (30.30%) of IUD acceptors in our study were in the 26-30-year age bracket. When added to the 31-35-year old acceptors (22.73%), the figure came up to 53.03% of IUD clients aged 26-35 years. This suggested that relatively younger women use IUDs more than older women. The finding of only 10 clients (3.03%) among the IUD acceptors aged 16-20 years is worrisome and appears to support similar findings of low contraceptive usage among sexually active adolescents in Ilorin  and Calabar,  Nigeria.
Regarding parity of IUD acceptors, the para 2-5 group constituted a majority (50.91%), while para 6-10 constituted 30.61%; the least frequent groups were nulliparous (0.91%) and above para 10 (0.91%). Birthspacing rather than child-limiting contraception appears to be the intent of a majority of the clients, as suggested by the finding that 58.79% still desired more children in the future. The preponderance of para 2-5 further supports this hypothesis. This is consistent with the observation of Komalafe et al.  that there appears to be an increasing use of birthspacing contraception in Osun State, Nigeria.
About two-thirds (65.76%) had IUDs inserted within 1 year of last delivery or abortion, and more than half (54.24%) were still breastfeeding at the time of IUD insertion. These findings suggested high motivation and preference for the IUD as a more reliable method (over lactational amenorrhea) of contraception among the clients. These are similar to findings in earlier studies. ,
The finding that the main source of information on contraception is the few existing family planning clinics/outreach personnel (for 62.73%), with with only 10.61% of clients getting information from the mass media (both print and electronic), is very discouraging, and this fact may have contributed to the relatively low awareness in our environment. The qualities of the ideal contraceptive have been variously stated to include 100% effectiveness, no health risks or side effects, being independent of intercourse, being easily and completely reversible, being easily administered, and usability independent of the service provider, , but such a method does not and may never exist.  Vaginal bleeding and abdominal pain are the commonest side effects of IUDs post insertion. This was confirmed in this study, where about 7% of IUD clients reported some form of bleeding and/or pain. Over the review period, only 2 clients (0.61%) reported the occasional complication of missing IUD, while 3 (0.91%) discontinued the method on account of menorrhagia and abdominal pains, but no case of failure (pregnancy with IUD in situ) was reported. These confirm the relatively high effectiveness and popularity of the method despite misgivings regarding it in the past. ,
The copper T 380A has been shown from controlled randomized trials to be the most effective IUD when considering bleeding, pain, or any other reasons for early discontinuation. 
Earlier concerns that IUDs predisposed users to upper genital tract infections have been allayed by a World Health Organization (WHO) systematic review that showed that prophylactic use of antibiotics to reduce this risk yielded no benefit with respect to pelvic inflammatory disease or IUD discontinuation rates, especially in populations with low prevalence of sexually transmitted infections.  Recent research toward advances in contraceptive technology have focused on the development of new types of IUDs, vaccines, hormonal contraceptive methods for men, and improved methods of emergency contraception. , Health care professionals must be knowledgeable about all forms of currently available contraceptives so as to offer informed counseling and help guide clients toward options to suit their particular needs.
The IUD has been cited by some workers as the best form of emergency contraception. ,, However, lack of awareness even among health professionals has been blamed for the pervasive low provision of postcoital IUDs and other forms of emergency contraception in many areas. , Workers in Calabar, Nigeria even advocated routine postpartum intrauterine device (PPIUD) insertion as a safe option to women desiring postpartum contraception. 
A very important limiting factor to contraception in this part of the world is the poor disposition of medical professionals themselves to contraceptive use, as was concluded by a study in Enugu, Nigeria. 
| Conclusion|| |
In conclusion, this study revealed that IUDs are still a popular and preferred contraceptive option among our women. However, the user prevalence of IUDs and other modern contraceptive methods is still quite low in our environment.
The government, mass media, community and religious leaders, NGOs, multinationals, and charitable organizations must integrate their efforts toward the dissemination of information and provision of dependable, accessible, and easily affordable family planning services.
All associated barriers among health professionals against the proper promotion of contraceptive use must be eliminated in order to improve uptake by women and sexually active adolescents.
IUDs may remain the most popular form of long-term contraceptive method in our environment until education and public enlightenment reduce the aversion to sterilization procedures.
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[Table 1], [Table 2], [Table 3], [Table 4]