title: Comparing Effectiveness of Active and Passive Client Follow-Up Approaches in Sustaining the Continued Use of Long Acting Reversible Contraceptives (LARC) in Rural Punjab: A Multicentre, Non-Inferiority Trial.
abstract: BACKGROUND
  The use of long-acting reversible contraceptive (LARC) methods is very low in Pakistan with high discontinuation rates mainly attributed to method-related side effects. Mixed evidence is available on the effectiveness of different client follow-up approaches used to ensure method continuation. We compared the effectiveness of active and passive follow-up approaches in sustaining the use of LARC-and within 'active' follow-up, we further compared a telephone versus home-based approach in rural Punjab, Pakistan.
  
  
  METHODS
  This was a 12-month multicentre non-inferiority trial conducted in twenty-two (16 rural- and 6 urban-based) franchised reproductive healthcare facilities in district Chakwal of Punjab province, between November 2013 and December 2014. The study comprised of three groups of LARC clients: a) home-based follow-up, b) telephone-based follow-up, and c) passive or needs-based follow-up. Participants in the first two study groups received counselling on scheduled follow-up from the field workers at 1, 3, 6, 9, and 12 month post-insertion whereas participants in the third group were asked to contact the health facility if in need of medical assistance relating to LARC method use. Study participants were recruited with equal allocation to each study group, but participants were not randomized. The analyses are based on 1,246 LARC (intra-uterine contraceptive device and implant) users that completed approximately 12-months of follow-up. The non-inferiority margin was kept at five percentage points for the comparison of active and passive follow-up and six percentage points for telephone and home-based approach. The primary outcome was cumulative probability of method continuation at 12-month among LARC users.
  
  
  RESULTS
  Women recruited in home-based, telephone-based, and passive groups were 400, 419 and 427, respectively. The cumulative probability of LARC continuation at 12 month was 87.6% (95% CI 83.8 to 90.6) among women who received home-based follow-up; 89.1% (95% CI 85.7, 91.8) who received telephone-based follow-up; and 83.8% (95% CI 79.8 to 87.1) who were in the passive or needs-based follow-up group. The probability of continuation among women who were actively followed-up by field health educators-either through home-based visit or telephone-based follow-up was, 88.3% (95% CI 85.9 to 90.0). An adjusted risk difference of -4.1 (95% CI -7.8 to -0.28; p-value = 0.035) was estimated between active and passive follow-up. Whereas, within the active client follow-up, the telephone-based follow-up was found to be as effective as the home-based follow-up with an adjusted risk difference of 1.8 (95% CI -2.7 to 6.4; p-value = 0.431).
  
  
  CONCLUSIONS
  A passive follow-up approach was 5% inferior to an active follow-up approach; whereas telephone-based follow-up was as effective as the home-based visits in sustaining the use of LARC, and was far more resource efficient. Therefore, active follow-up could improve method continuation especially in the critical post-insertion period.
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Waqas
authors: W
authors: Hameed
authors: Department of Uro-Gynecology, University of Ghent, 9000 East Flanders, Belgium.|Department of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors: Syed Khurram
authors: SK
authors: Azmat
authors: Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors: Moazzam
authors: M
authors: Ali
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Muhammad
authors: M
authors: Ishaque
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Ghazunfer
authors: G
authors: Abbas
authors: Marie Stopes International, Research, Monitoring and Evaluation Department, London, United Kingdom.
authors: Erik
authors: E
authors: Munroe
authors: Marie Stopes International, Research, Monitoring and Evaluation Department, London, United Kingdom.
authors: Rebecca
authors: R
authors: Harrison
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Wajahat Hussain
authors: WH
authors: Shamsi
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Ghulam
authors: G
authors: Mustafa
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Omar Farooq
authors: OF
authors: Khan
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Safdar
authors: S
authors: Ali
authors: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors: Aftab
authors: A
authors: Ahmed
mesh_terms: D003271:Contraceptive Agents, Female / Q000008:administration & dosage* / Q000592:standards; D005500:Follow-Up Studies; D006801:Humans; D010154:Pakistan; D010342:Patient Acceptance of Health Care; D017060:Patient Satisfaction; D012424:Rural Population
chemical_list: D003271:Contraceptive Agents, Female