title: Continuation rates and reasons for discontinuation of intra-uterine device in three provinces of Pakistan: results of a 24-month prospective client follow-up.
abstract: BACKGROUND
  Long-acting reversible contraceptives, such as the intrauterine device (IUD), remain underutilised in Pakistan with high discontinuation rates. Based on a 24-month prospective client follow-up (nested within a larger quasi-experimental study), this paper presents the comparison of two intervention models, one using private mid-level providers branded as "Suraj" and the other using community midwives (CMWs) of Maternal Newborn and Child Health Programme, for method continuation among IUD users. Moreover, determinants of IUD continuation and the reasons for discontinuation, and switching behaviour were studied within each arm.
  
  
  METHODS
  A total of 1,163 IUD users, 824 from Suraj and 339 from the CMW model, were enrolled in this 24-month prospective client follow-up. Participants were followed-up by female community mobilisers physically every second month to ascertain continued IUD usage and to collect information on associated factors, switching behaviour, reasons for discontinuation, and pregnancy occurrence. The probabilities of IUD continuation and the risk factors for discontinuation were estimated by life table analysis and Cox proportional-hazard techniques, respectively.
  
  
  RESULTS
  The cumulative probabilities of IUD continuation at 24 months in Suraj and CMW models were 82% and 80%, respectively. The difference between the two intervention areas was not significant. The probability distributions of IUD continuation were also similar in both interventions (Log rank test: χ(2) = 0.06, df = 1, P = 0.81; Breslow test: χ(2) = 0.6, df = 1, P = 0.44). Health concerns (Suraj = 57.1%, CMW = 38.7%) and pregnancy desire (Suraj = 29.3%, CMW = 40.3%) were reported as the most prominent reasons for IUD discontinuation in both intervention arms. IUD discontinuation was significantly associated with place of residence in Suraj and with age (15-25 years) in the CMW model.
  
  
  CONCLUSIONS
  CMWs and private providers are equally capable of providing quality IUD services and ensuring higher method continuation. Pakistan's National Maternal Newborn and Child Health programme should consider training CMWs and providing IUDs through them. Moreover, private sector mid-level providers could be engaged in promoting the use of IUDs.
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. waqas.hameed1@gmail.com.
authors.forename: Waqas
authors.initials: W
authors.lastname: Hameed
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. syedkhurram.azmat@ugent.be.|Department of Urogynecology, University of Ghent, Ghent, Belgium. syedkhurram.azmat@ugent.be.
authors.forename: Syed Khurram
authors.initials: SK
authors.lastname: Azmat
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. ishaque.sheikh@mariestopespk.org.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Ishaque
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. wajahat.hussain@mariestopespk.org.
authors.forename: Wajahat
authors.initials: W
authors.lastname: Hussain
authors.affiliation: Research, Monitoring and Evaluation Department, Marie Stopes International, London, UK. erik.munroe@mariestopes.org.
authors.forename: Erik
authors.initials: E
authors.lastname: Munroe
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. ghulam.mustafa@mariestopespk.org.
authors.forename: Ghulam
authors.initials: G
authors.lastname: Mustafa
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. dr.omar@mariestopespk.org.
authors.forename: Omar Farooq
authors.initials: OF
authors.lastname: Khan
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. ghazanferabbas@gmail.com.
authors.forename: Ghazunfer
authors.initials: G
authors.lastname: Abbas
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. safdar.ali@mariestopespk.org.
authors.forename: Safdar
authors.initials: S
authors.lastname: Ali
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. jamshaid.asghar@mariestopespk.org.
authors.forename: Qaiser Jamshaid
authors.initials: QJ
authors.lastname: Asghar
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. khaskaelianthro@gmail.com.
authors.forename: Sajid
authors.initials: S
authors.lastname: Ali
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. aftab.ahmed@mariestopespk.org.
authors.forename: Aftab
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Freelance Public Health Consultant, Adelaide, Australia. drhasanhamza@gmail.com.
authors.forename: Hasan Bin
authors.initials: HB
authors.lastname: Hamza
mesh_terms: D000293:Adolescent; D000328:Adult; D003150:Community Health Workers; D003268:Contraception Behavior; D005193:Family Planning Services; D005260:Female; D005500:Follow-Up Studies; D006078:Government Programs; D006282:Health Personnel; D006801:Humans; D007434:Intrauterine Devices / Q000706:statistics & numerical data*; D015993:Life Tables; D009042:Motivation; D010154:Pakistan; D011247:Pregnancy; D016016:Proportional Hazards Models; D011446:Prospective Studies; D055815:Young Adult