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Femiject, A Once-A-Month Combined Injectable Contraceptive: Experience From Pakistan
Femiject, A Once-A-Month Combined Injectable Contraceptive: Experience From Pakistan
Femiject, A Once-A-Month Combined Injectable Contraceptive: Experience From Pakistan
Health Care
Rubina Izhar , Samia Husain , Muhammad Ahmad Tahir & Sonia Husain
To cite this article: Rubina Izhar , Samia Husain , Muhammad Ahmad Tahir & Sonia
Husain (2020): Femiject, a once-a-month combined injectable contraceptive: experience
from Pakistan, The European Journal of Contraception & Reproductive Health Care, DOI:
10.1080/13625187.2020.1799348
Article views: 4
CLINICAL STUDY
Introduction want contraception are not happy with the methods avail-
able to them [10]. Non-compliant COC users may switch to
Pakistan is the sixth most populous country in the world
CICs after receiving adequate counselling. POIC users who
[1]. Contraceptive use is around 35% and only 26% use
have no contraindication to combined preparations may
modern methods. Injectable contraceptives are chosen by
also use CICs. This approach can help them choose a
almost 3% of contraceptive users. Around 45% of injectable contraceptive that suits them better.
contraceptive users, however, report side effects; major Greenstar Social Marketing is a private organisation in
side effects include irregular menstrual periods (55%) [2]. Pakistan. It launched its low-cost contraception service
Thus, an effective form of long-acting reversible contracep- Sabz Sitara in 1995, which led to an improvement in avail-
tion (LARC) is currently underused. ability of all contraceptive methods in the country. In 2010,
Combined oral contraceptives (COCs) provide good Femiject, a new CIC containing 50 mg norethisterone enan-
menstrual cycle control [3]; however, women sometimes thate and 5 mg oestradiol valerate, was introduced to the
forget to take their pill. According to a study in Saudi market; there is, however, a lack of data on its use. We
Arabia, only 18% of women knew what to do after missing conducted this study to compare the continuation rates
more than two pills [4]. The need to take pills daily is cum- with three contraceptive methods: the once monthly CIC
bersome, which leads to dissatisfaction in many users [5]. Femiject, the 3 monthly POIC DMPA, and COCs. We also
Injectables achieve better compliance compared with assessed levels of satisfaction and bleeding patterns with
COCs. The most often used are 3 monthly progestogen- all three methods.
only injectable contraceptives (POICs), of which depot
medroxyprogesterone acetate (DMPA) is the most widely
used formulation. However, women report abnormal bleed- Methods
ing patterns with its use [6]. Combined injectable contra- A prospective observational study was conducted at Aziz
ceptives (CICs) address the disruption in bleeding patterns. Medical Centre, Karachi. The study population comprised
Oestrogen improves the cycle irregularity seen with POICs. women aged 19–35 years who requested contraception. A
Compliance is also improved in comparison with COCs [7]. non-probability consecutive sampling technique was used
Once-a-month CICs produce bleeding patterns that are to recruit women to the study. Women were eligible if
acceptable and comparable to those of non-users [8]. A they were not pregnant or in the postpartum period and
Cochrane review reported that fewer women stopped only if they had regular, spontaneous menstrual cycles
using CICs compared with POICs [9]. Most women who (21–35 days). Women were excluded if they had any
CONTACT Samia Husain samiahusain_scorpio@hotmail.com Department of Gynaecology and Obstetrics, Aziz Medical Centre, B-151, Block W, Allama
Iqbal Town, North Nazimabad, Karachi 74600, Pakistan
ß 2020 The European Society of Contraception and Reproductive Health
2 R. IZHAR ET AL.
contraindications to hormonal contraceptive use; thus, Kaplan–Meier survival plots. The curves were compared
women older than 35 years or who smoked were excluded, using the Mantel–Haenszel log-rank test. A significance
as were women with chronic hypertension, diabetes or a level of 5% was chosen. Satisfaction scores were calculated
history of alcohol or drug abuse. Women who had received using the Kruskal–Wallis test. Bonferroni correction was
another injectable contraceptive 6 months prior to recruit- used to calculate difference between groups. Cronbach’s
ment were also excluded. alpha was calculated to assess the internal consistency of
In Pakistan, women either use COCs or POICs. Pakistani the scale. Bleeding patterns were compared for the COC
law forbids sex before marriage. As contraceptives are not and CIC methods. The v2 test and Fisher’s exact test were
used by unmarried women, our sample comprised married used to compare the groups.
women only. Legal abortion is not available in Pakistan. Data were coded to ensure confidentiality. The study
Women were offered all three studied methods of was carried out in accordance with the Declaration of
contraception. Helsinki and was supervised by Dr Tahir Ghani, head of
All women gave their written informed consent to par- Aziz Medical Centre. The study was approved by the
ticipate. Women who met the inclusion criteria were coun- centre’s institutional review board (IRB 006-2016).
selled by trained health professionals and told about the
benefits of contraception. The methods available were
Results
introduced in an unbiased manner. Emphasis was placed
on continuation of the method. Participants were thus The study comprised 171 women with a median age of 27
enabled to make an informed choice. Women who chose years (range 19–35 years) and a median parity of 2 (range
COCs or a POIC were asked to take part in the study. 1–5). The median duration of intended use of the contra-
Consenting women were offered information leaflets. ceptive method was 2 years (range 1–3 years). Of the par-
Participants were divided into three groups: (1) COCs ticipants, 109 (63.7%) were employed and 122 (71.3%) had
(30 lg ethinylestradiol and 150 lg levonorgestrel); (2) some formal education. Sixty women (35.1%) chose the
DMPA (a 3 monthly POIC containing 150 mg DMPA); and COC, 53 (31.0%) chose DMPA and 58 (33.9%) chose the
(3) CIC (a once monthly CIC containing 50 mg norethister- CIC. Table 1 shows the sociodemographic characteristics of
one enanthate and 5 mg oestradiol valerate). Women were the study population.
prescribed their chosen contraception; CIC and COC users DMPA was mostly chosen by older women (p ¼ .036)
were advised to attend the clinic every month (COCs were and women who intended to use contraception for a lon-
dispensed for 1 month at a time). Women were evaluated ger period (3 vs 2 years; p ¼ .001). More women with no
twice: at the beginning of the study and at 12 months. formal education chose DMPA (p˂ .001). Table 2 shows a
Those who stopped using contraception before 12 months comparison of participants’ characteristics with their choice
were evaluated at the time they stopped and were asked of contraception. Most of the educated women chose the
about their reasons for discontinuation. A woman was CIC (n ¼ 54, 93.1%) or COCs (n ¼ 56, 93.3%). CIC users had
termed compliant if she did not stop her contraception. a better continuation rate compared with COC or DMPA
For the purposes of the study, the participants were users (p ¼ .034) (Figure 1).
included in the analysis only if they complied with fol- Comparison of bleeding patterns on the final visit
low-up. showed that, compared with women using COCs, CIC users
A pro forma was used to collect data. The first section were less likely to self-report light flow (86.2% vs 96.6%;
of the form collected data on participants’ sociodemo- p ¼ .044) and more likely to report spotting (60.3% vs 3.3%;
graphic characteristics. The second section included ques- p ˂ .001) (Table 3).
tions on their menstrual cycle. A separate section was A higher proportion of women were satisfied or very
included to collect data on satisfaction with the chosen satisfied with the CIC (n ¼ 37, 63.8%). Women who chose
method. Women answered three separate questions, based the CIC said they were likely or very likely to use it again
on a Likert scale: (1) ‘Were you satisfied with your choice of (n ¼ 37, 63.8%), while only 17 (28.3%) COC users and 13
contraception?’ (1 ¼ very unsatisfied, 2 ¼ unsatisfied, (24.5%) DMPA users said they were likely or very likely to
3 ¼ neutral, 4 ¼ satisfied, 5 ¼ very satisfied); (2) ‘Would you use their method again. When asked about recommending
use it again?’ (1 ¼ very unlikely, 2 ¼ unlikely, 3 ¼ neutral, their chosen method, 15 (25.9%) CIC users said they would
4 ¼ likely, 5 ¼ very likely); (3) ‘Would you recommend it to a
Table 1. Sociodemographic characteristics of the study popula-
friend?’ (1 ¼ definitely no, 2 ¼ no, 3 ¼ neutral, 4 ¼ yes, tion (N ¼ 171).
5 ¼ definitely yes). It was anticipated that this tool would Characteristic Value
allow us to assess women’s thoughts on future use of the Age, years 27 (19–35)
method. It would also help us see whether they would rec- Duration of contraceptive use, months 6 (1–12)
ommend it to their friends. Duration of intended contraceptive use, years 2 (1–3)
Parity 2 (1–5)
Data were analysed using SPSS Statistics for Windows, Employment status
version 15.0 (SPSS, Chicago, IL, USA). The normality of data Unemployed 62 (36.3)
was assessed using the Shapiro–Wilk test. Quantitative vari- Employed 109 (63.7)
Educational status
ables that were not normally distributed were represented No formal education 49 (28.7)
by median and range. The Mann–Whitney U test was used Some formal education 122 (71.3)
to compare the groups. Frequencies and percentages were Chosen contraceptive method
CIC 58 (33.9)
calculated for quantitative variables. The v2 test and COCs 60 (35.1)
Fisher’s exact test were used and a significance level of 5% DMPA 53 (31.0)
was chosen. Continuation rates were analysed using Data are presented as median (range) or n (%).
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 3
1.0 CIC
COCs
0.8
DMPA
Cumulative continuation rate
0.6
0.4
0.2
0.0
0 2 4 6 8 10 12
Duration of contraceptive use (months)
Figure 1. Kaplan–Meier survival curves of women who continued method use during follow-up.
not recommend it to a friend, and 43 (71.7%) COC users discontinuation in the CIC group was spotting (32.8%).
and 32 (60.4%) DMPA users would not recommend their Forgetting to take the pill was the most common reason
chosen method to a friend (Table 4). The internal consist- for discontinuation in the COC group (56.7%). Desire for
ency of the scale was calculated using Cronbach’s another method was the main reason in the DMPA group
alpha (0.917). (45.3%). Side effects were also significantly different
At the end of the study period more women continued (p ¼ .001) in the three groups. CIC users had bleeding prob-
with the CIC (n ¼ 17, 29.3%). The commonest reason for lems (29.3%), COC users reported nausea (36.7%) and
4 R. IZHAR ET AL.
DMPA users reported bloating (34%). However, 50% of CIC the CIC, which is much lower than the rate (34.5%)
users (vs 6.7% and 9.4% of COC and DMPA users, respect- obtained in an Iranian study [14] but higher than that
ively) reported no side effects (Table 5). reported from Mexico (26%) [15]. A continuation rate of
81% was reported from China [16]. A discussion on con-
tinuation rate is incomplete without mentioning the rea-
Discussion
sons for discontinuation. The women in our study
Findings and interpretation discontinued the CIC method because of spotting (32.8%).
Pakistan is a Muslim country where women are particularly
Our results show that women were more likely to continue
concerned about bleeding patterns, because bleeding
the CIC method. Satisfaction with the CIC was higher than
affects their religious obligations. Irregular bleeding (65.6%)
with DMPA or COCs. Almost a third of women, however,
was also the most common reason for discontinuation in
experienced spotting while using the CIC which led them
to discontinue use. Iran [17], also a Muslim country. Forgetfulness (56.7%) was
Women require rapid access to their contraceptive of the main reason for discontinuation in the COC group. The
choice [11]. In our study, 31% of women chose DMPA and need for daily pill intake is a major hurdle in uptake of this
35% chose the COC, which is in agreement with studies method. Around half of users report problems with adher-
worldwide: women use COCs more than any other method ence [18]. Women are at a risk of unintended pregnancy
[12]. Contraceptive use depends on education and the with non-adherence. Side effects also contribute to discon-
intended duration of use of the method. In our study, older tinuation. Women faced different side effects with different
women and those who were not planning a pregnancy in preparations. CIC users reported bleeding problems
the near future chose DMPA. These results are in agree- (29.3%), COC users nausea (36.7%), and DMPA users bloat-
ment with those of previous studies [13]. In our analysis, ing (34.0%). These reported side effects are similar to those
educated women mostly chose the CIC or COCs. previously reported [19].
Few women were compliant to the end of the study, Every method has some side effects, but some are
but the continuation rate was superior in CIC users. acceptable to women while others are not. Acceptability
Nevertheless, only 29.3% of participants continued to use impacts satisfaction and continuation of a method. We
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 5
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adherence to oral contraceptives: the role of time- and place- women’s contraceptive decision making: do preferences for
based cues. Int J Behav Med 2018;25:431–437. contraceptive attributes align with method choice? Perspect
[19] Chebet JJ, McMahon SA, Greenspan JA, et al. ‘Every method Sex Reprod Health 2016;48:119–127.
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