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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 16  |  Page : 81-85

A 10-year review of progestogen-only injectable contraceptive use at a private facility in Lagos, Southwest Nigeria


1 Department of Obstetrics and Gynaecology, Ave Maria Hospital, Lagos, Nigeria
2 Department of Radiology, Ave Maria Hospital, Lagos, Nigeria

Date of Submission01-Nov-2019
Date of Decision27-Jan-2020
Date of Acceptance21-May-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Dr. Olaolopin Ijasan
Department of Obstetrics and Gynaecology, Ave Maria Hospital, Victoria Island, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_50_19

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  Abstract 


Background: Progestogen-only injectable contraceptives are affordable, long acting, and reversible. It can be administered by a trained nonmedical staff and does not require storage, making it specifically suitable for use in developing countries where contraceptive prevalence rates are low. Aim: This study aims to determine the sociodemographic characteristics of clients at the family planning clinic who accepted progestogen-only injectable contraceptives, their side effects, and discontinuation rates. Materials and Methods: In the retrospective study, clients who accepted and used progestogen-only injectable contraceptives at the Family Planning Clinic for over 10 years between August 1, 2008, and July 31, 2018, had their data collected using a structured pro forma. Results: Of the 197 clients who used progestogen-only injectable contraceptives during the study period, medical records of 181 (91.8%) of them were available and retrieved, while medical records of 16 were missing. The total number of contraceptive users during the same period was 1690, giving an acceptance rate of 11.7% for progestogen-only injectable contraceptives. The mean age of clients was 32.8 ± 6.2 years. Most (34.8%) of the participants were in the age group of 30–34 years. Most (95.6%) of the participants were married and 92.2% had at least a secondary school education. The majority (55.8%) of the participants used it for child spacing, while 44.2% used it to limit their families. The discontinuation rate at 1 year was 72.4%. Of the 181 participants, 65 (35.9%) reported side effects. The most common side effect was menstrual disorders (30.9%). No pregnancy was reported during use. Conclusion: Progestogen-only injectable contraceptives are effective and safe. Sociodemographic characteristics of users, side effects, and efficacy are similar to other local studies. However, the acceptance rate is low and the discontinuation rate at 1 year is higher than in other centers.

Keywords: Progestogen only injectable contraceptives, depot medroxyprogesterone acetate, norethisterone enanthate, acceptance rates, discontinuation rates


How to cite this article:
Ijasan O, Upeh ER. A 10-year review of progestogen-only injectable contraceptive use at a private facility in Lagos, Southwest Nigeria. N Niger J Clin Res 2020;9:81-5

How to cite this URL:
Ijasan O, Upeh ER. A 10-year review of progestogen-only injectable contraceptive use at a private facility in Lagos, Southwest Nigeria. N Niger J Clin Res [serial online] 2020 [cited 2021 Jan 24];9:81-5. Available from: https://www.mdcan-uath.org/text.asp?2020/9/16/81/301647




  Introduction Top


Contraception is the deliberate prevention of conception through the use of various devices, sexual practices, surgical procedures, and hormonal contraceptives, including progestogen-only contraceptives injectables for family planning.[1],[2],[3]

The contraceptive injectable has been available since 1960 and has traditionally been produced as depot medroxyprogesterone acetate (DMPA), a crystalline suspension delivered intramuscularly at a dose of 150 mg/1.0 mL.[4] DPMA derived from progesterone is administered at the dose of 150 mg every 90 days.[5] Norethisterone enanthate (NET-EN) is less widely used, and it is administered at the dose of 200 mg every 60 days.[5],[6],[7],[8] Sayana Press® is DMPA 104 mg in 0.65 ml prepared methodically for subcutaneous injection in the UK in 2011, with fewer side effects when compared with DPMA and NET-EN.[9]

Over the years, DPMA and NET-EN are used globally for fertility management because it is safe and efficacious.[10] Return to fertility is said to be faster with NET-EN than DPMA. NET-EN and DPMA do not harm the ability of women to conceive following the termination of use and do not delay fertility as with other forms of contraception.[11]

The use of contraceptives is lower in developing countries and significantly lower in Africa.[12] In Nigeria, the prevalence of injectable progestin contraceptives is 2.0% among current users of these modern methods of contraception.[8] Progestogen-only injectable contraceptives have been found suitable for developing countries like ours because it is private, independent of intercourse and partner cooperation. It is affordable, long acting, and reversible.[8] It can be administered by a trained nonmedical staff and does not require storage.[13] Other benefits include the convenience of a 3- or 2-month dosing schedule, contraceptive effectiveness, and minimal or no lactation impairment.[5] Protection against frequency of crisis in sickle cell patients, seizures in epileptics, endometrial and ovarian cancer, endometriosis, uterine leiomyomas, pelvic inflammatory disease, and ectopic pregnancy are some of its noncontraceptive benefits.[7],[14]

Its primary mechanism of action is ovulation inhibition, while other supporting mechanisms include thickened cervical mucus (thereby inhibiting sperm transport)[10] and creation of an endometrium unfavorable to implantation of the blastocyst.[15]

Progestogen-only injectable contraceptives can be administered 6 weeks postpartum in a breastfeeding client and immediately in a nonbreastfeeding client.[16] The majority of studies show no adverse effects of progestogen-only injectables on breast milk, the volume of breast milk, infant growth, or development.[17] However, recent studies suggest a slight increase in the proportion of milk.[18] Most of the concerns about the use of a progestogen-only injectable in the first 6 weeks postpartum relate to the theoretical risks of sex steroids being transferred via breast milk to an infant with immature organs, central nervous system, or liver.[5]

Menstrual irregularities persist as the major setback in the use of this contraceptive product adjudged for the increased rate of discontinuation among users.[1],[10] Other complications include delay in return to fertility, fluid retention, worsening acne, headaches, weight gain, bone density loss, accidental pregnancy, mood swings, hot flushes, and breast discomfort. However, there is little evidence to suggest that the injection causes these symptoms.[1],[19] In recent times, Sayana Press®, a bio-equivalent to Depo-Provera®, is usually preferable to Depo-Provera® in women on anticoagulants, bleeding disorder, and obesity.[20] There is a new observational suggestion that the DPMA may increase the risk of HIV acquisition;[10],[21] however, there are few statistical bases for this and the magnitude of risk remains in oblivion.[6] It is pertinent to note that the benefits of using a progestogen-only injectable by breastfeeding women under 6 weeks postpartum and those above 40 years outweigh any risks.[5],[20],[22]


  Materials and Methods Top


A total of 197 progestogen-only injectable contraceptive users were detected through the family planning clinic of Ave Maria Hospital (AMH), Lagos, between August 1, 2008, and July 31, 2018, as identified from the clinic register. The institutional review board of AMH approved the study and provided a waiver of the patient consent. Of the 197 progestogen-only injectable contraceptive users, 16 medical records were missing and excluded from the analysis (n=16), leaving a total of 181 progestogen-only injectable contraceptive users for final analysis. Their medical records were retrieved and appropriate data were collected utilizing a standardized pro forma.

The data retrieved included the age of clients, parity, type of injectable contraceptive (DMPA or NET-ET), the number of doses taken, side effects, previously used contraceptives, occupation, and educational status. A client who did not return for another dose of progestogen-only injectable for a minimum of 1 year from her last dose was assumed lost to follow-up. The data were managed using SPSS software (version 17.0; SPSS Inc.; Chicago, Illinois, USA). Categorical variables were summarized using percentages and frequencies. The continuous variables were expressed in mean and standard deviation.


  Results Top


The total number of contraceptive users during the study period was 1690, while the total number of clients who accepted and used progestogen-only injectable contraceptives during the study period was 197, giving an acceptance rate of 11.7%.

Of the 181 progestogen-only injectable contraceptive users, 102 (56.4%) clients used DPMA, while 79 (43.6%) used NET-EN. Eighty clients (44.2%) used it to limit their families, while 101 clients (55.8%) used it for child spacing.

[Table 1] shows sociodemographic variables. Most users (34.8%) of progestogen-only injectable contraceptives were in the age group of 30–34 years. The mean age was 32.8 ± 6.2 years with a range of 17–48 years. Most users (36.5%) were multiparas who had at least four children or more (36.5%). The median parity was 3 with a range of 0–10. Out of the 181 clients, most (50.8%) had postsecondary education. Majority (95.6%) were married.
Table 1: Sociodemographic variables of clients

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[Figure 1] shows the source of referral. The most common source of referral was from health personnel (64.1%), followed by friends/relatives (29.9%) and husbands (3.9%).
Figure 1: The source of referral. The most common source of referral was from health personnel (64.1%), followed by friends/relatives (29.9%) and husbands (3.9%)

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[Figure 2] shows side effects of progestogen-only injectable contraceptives. Side effects were reported by 35.9% of users. The most common side effect was menstrual disorders (30.9%), followed by weight gain (1.7%) and delayed return to fertility (1.7%). Headache, acne, and bloatedness were least with 0.6%.
Figure 2: Side effects of progestogen-only injectable contraceptives. MD=menstrual disorder. DRF=delayed return to fertility

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[Figure 3] shows reasons for discontinuation. The most common reasons for discontinuation were inconvenience (15.3%), followed by side effects (7.9%). Planning pregnancy and husband disapproval were 1.1%.
Figure 3: Reasons for discontinuation. The most common reasons for discontinuation were inconvenience (15.3%)

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[Figure 4] shows the duration of use in months. The majority (72.4%) used injectables for <12 months (discontinuation rate at 1 year), while 18.8% used it for between 12 and 24 months.
Figure 4: Duration of use (months). The majority (72.4%) used injectables for <12 months (discontinuation rate at 1 year)

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  Discussion Top


Our findings show that the percentage of women who accepted and used progestogen-only injectable contraceptives out of clients attending the family planning clinic was 11.7%. This is <31.49% reported in Ile-Ife, 23.3% in Calabar, and 26.8% in Ilorin. The difference in acceptor rates may be a reflection of varying effectiveness of methods and skills of family planning counselors.

In this study, more clients used DPMA (56.4%) than NET-EN (43.6%). This is similar to several local studies where DPMA is more popular than NET-EN primarily because it requires less frequency of administration.[1],[5],[8],[10] There is perceived economic loss from transportation and man-hours with more frequency of administration of NET-EN.

The 30–34 years age range had the highest frequency of users (34.8%) with parity of four or more (36%), which is similar to the study by Akadri and Odelola in Sagamu.[1] The mean age of 32.8 years in this study is similar to the mean ages of several local studies.[1],[8] In this study, the age groups with the lowest frequency of users were below 20 years [Table 1]. The poor attitude among health-care providers toward teenagers, societal disapproval of sexual activity among young people, ignorance, and fear of being labeled promiscuous are some of the reasons that are responsible for the low prevalence of contraceptive use in this age group.

Most users of progestogen-only injectable contraceptives in this study have postsecondary school education [Table 1]. This is consistent with the findings of several studies.[5],[22] It has been shown that educated women tend to appreciate the importance of family planning and generally tend to accept modern contraceptives.[5] Users of progestogen-only injectable contraceptives as reflected in this study and several other local studies[1],[5],[8] are likely to be in their early thirties, educated, and multiparous [Table 1]. This sociodemographic trend has been noticed in the use of all modern contraception generally.[8],[23] It is believed that the nulliparous women preferred and will benefit from other contraceptive methods which would prevent pregnancy and possibly sexually transmitted diseases.[5]

It can be deduced from this study that 55.8% preferred progestogen-only injectable contraceptives for child spacing [Figure 3]. This is consistent with findings at Sagamu[1] and Calabar,[5] where more women used it for spacing than limiting children. The majority of users were referred to the family planning clinic by health-care personnel [Figure 1]. This is consistent with a study by Sensoy et al.[12] In general, most contraceptive users are referred by health workers.[1] Besides, the advantages of modern family planning are emphasized during health talks at the antenatal clinics.

The majority of clients used injectables for <12 months, giving discontinuation in a year of 72.4% [Figure 4]. This is much higher than in Calabar (43%),[5] with the reason being lost to follow-up. This might be associated with difficult transportation means in a cosmopolitan setting like Lagos and perceived need for frequent hospital visits for the administration of injections. Several studies point to the side effects, especially menstrual irregularities as the main reason for discontinuation of progestogen-only injectable contraceptives.[1] However, in this study, inconvenience was the most common reason, followed by side effects [Figure 2] and [Figure 3]. For Cover et al.,[23] the most common reasons for discontinuity were those of husbands' disapproval and forgetting or being late for injection visit. Other reasons were weight gain[5],[19] and secondary amenorrhea.[1],[5] No pregnancy was reported in the period of this study. This is similar to other local studies.[1],[8]

Limitation of the study

The limitations of this study included the fact that some case notes were missing and could not be retrieved. A lot of clients were also lost to follow-up (74.6%). These proportions of clients were assumed to have stopped using progestogen-only injectables, thereby contributing to the high discontinuation rate at 1 year of 72.4%. However, they might have continued to use progestogen-only injectables at other peripheral centers.


  Conclusion Top


The sociodemographic characteristics of progestogen-only injectable contraceptive users in the facility studied are similar to those established in other studies and centers. At our center, high discontinuation rate at 1 year (72.4%), low acceptance rate (11.6%), and poor follow-up are noticed with progestogen-only injectable contraceptive use. Other centers have lower discontinuation rates and higher acceptance rates. The well-established most common side effect, menstrual disorders, as reported at other centers is confirmed by this study. Like other local studies, no pregnancy was reported in this study during the use of progestogen-only injectable contraceptives.

Recommendations

Effective education programs with the involvement of the print and electronic media will help to reverse this trend. Well-informed and adequate pre-commencement counseling and re-enforcement during follow-up visits can do much to promote satisfaction and the continuous use of these agents. Family planning service providers should be trained to acquire more effective counseling skills. Women choosing this contraceptive method should be counseled that despite the major side effect of menstrual irregularities and inconvenience of multiple hospital visits, progestogen-only injectables are very effective.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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