Experiences of “Antara”: The Injectable Contraceptive in Rural Indian Women Presenting to a Tertiary Care Hospital of Eastern India

Abstract

Introduction

Depot medroxy progesterone acetate (DMPA) is an injectable contraceptive with well-proven effectiveness and excellent safety profile. It is marketed as Antara in India as a part of the government’s family planning programme.

Purpose

This study aimed to assess the experiences of women using Antara (DMPA) at a tertiary care hospital of Eastern India.

Materials and methods

An institution-based retrospective cross-sectional study was carried out in the family planning unit of the study institution from April 2021 to October 2022 among 200 women of reproductive age. Each of the mothers was administered a researcher-administered questionnaire containing questions pertaining to their sociodemographic characteristics and Antara use experience.

Results

The mean age of the study participants was 26.4 ± 5.9 years. Most of the participants were Hindus (55.0%), homemakers by their occupation (86.0%), and from lower socio-economic status. A significant proportion of the women had no formal education (14.0%) or had below primary education (14.5%). The most common reason provided by the participants for the discontinuation of Antara was the incidence of various side effects such as irregular menstruation, amenorrhea and apprehension. Lower educational status (p value < 0.001), poorer socio-economic status (p value < 0.001), and interval period starting of Antara (p value < 0.001) were statistically significantly associated with the discontinuation of the contraceptive.

Conclusions

Most women who started taking DMPA (Antara) discontinued due to the fear of side effects. Therefore, the focus should be to educate women regarding the benefits and side effects of DMPA through proper counselling.

Introduction

The first country in the world to launch a family planning programme is India with its chief aim of controlling population [1]. Apart from controlling population, India’s national family planning programme has concentrated now on more important issues of improving health and saving lives of mothers and children. It can be achieved through use of reversible spacing methods by preventing unwanted pregnancies. According to NFHS-5, the unmet need for contraception is 9.4%, and only 56.4% of currently married women reported that they use modern methods of contraception [2].

Socio-economic and educational status of the women and her family play an important role in acceptance of a contraceptive method. In India, most of the women have no role in making of reproductive decisions. To address all these issues, government has increased its efforts in the provision of safe, effective, long-acting, and reversible methods of contraception, which do not require continuous monitoring nor daily administration. Depot medroxyprogesterone acetate (DMPA), an injectable contraceptive, fulfils all of these criteria.

DMPA is a depo injection of 17 alpha-hydroxy progesterone-derivative progestine medroxy progesterone acetate [3]. It acts by inhibiting ovulation, thickening of cervical mucosa and causes endometrial atrophy. It makes the endometrium unsuitable for implantation. DMPA protects against endometrial cancer, does not increase risk of breast, ovarian, and cervical cancer, and does not cause any significant changes on blood pressure or on the coagulation system [4]. Its non-contraceptive benefits are decrease in the risk of endometrial cancer, iron deficiency anaemia, pelvic inflammatory disease, ectopic pregnancies, and uterine leiomyoma. It also relieves symptoms of endometriosis [5–7].

Approved by DCGI in 1993, DMPA has been in use in the country since 1994. However, the uptake of the agent has historically been poor, primarily due to high cost and lack of availability in public sector [8]. To overcome this, injection MPA was added to the contraceptive basket of Government of India under “Antara Program” in 2017 [9]. Under this programme, injection Antara is available freely to all women acceptors at all government facilities. Since the launch of the programme, DMPA, marketed as “Antara”, is being offered at all levels of healthcare as a safe and effective contraception choice. However, due to its recent nature, studies analysing the impact of “Antara” among Indian women of reproductive age with respect to family planning are scarce. In this context, the present study was planned to assess the experiences of women presenting to a tertiary care hospital of Eastern India with respect to using “Antara” and their attitudes towards it.

Materials and Methods

An institution-based retrospective cross-sectional study was carried out in the family planning unit of the Department of Obstetrics and Gynaecology of the Midnapore Medical College, a tertiary care teaching hospital of Paschim Medinipur district of West Bengal. The study was carried out during a period of 18 months, from April 2021 to October 2022.

The study population consisted of women of reproductive age, from rural background, who had taken a dose of injection “Antara” for the first time at the department of Obstetrics and Gynaecology of the study institute during the study period. Considering the prevalence of Antara usage as 9.8%, as reported by Gahlot et al., the minimum sample size for the present study was calculated using the Cochran’s formula for sample size calculation, at 95% confidence level and 5% absolute precision. Considering a 15% non-response rate and to even further consolidate data, the sample size was further increased to 200. Women who did not provide informed consent, those using DMPA as a part of the treatment of endometriosis or unexplained vaginal bleeding, urban women, and those diagnosed with hypertension or diabetes mellitus, were excluded from the present study.

The study was carried out using a pre-designed case-recording pro forma, patient records, and family planning unit cards that are recorded as a part of the Antara programme. Consecutive sampling was used to select the mothers from the Antara unit records and were contacted for the purpose of the study. Those mothers who provided informed consent were recruited till the required sample size of 200 was reached. Each of the mothers was administered a researcher-administered questionnaire containing questions pertaining to their sociodemographic characteristics and Antara use experience.

The present study was conducted after receiving appropriate approval from the Institutional Ethics Committee of the study institution. The data were analysed following the principles of descriptive and analytical statistics using the Statistical Package for the Social Sciences (SPSS) software version 20. Wherever applicable, a p value of < 0.05 was considered to be statistically significant.

Results

It was observed that the age of the women interviewed for the present study ranged from 16 to 43 years, while the mean age of the study participants was 26.4 ± 5.9 years. Most of the participants (60%) belonged to the age group of 21–30 years. Most of the mothers were Hindus (54.5%), homemakers by their occupation (80.5%), and from lower socio-economic status (class IV and V) as per the modified BG Prasad scale [10]. It was also observed that a significant proportion of the women had no formal education (14%) or had only pre-primary education (14.5%) (Table 1).

Table 1.

Sociodemographic characteristics of the study participants (n = 200)

Parameters	Frequency	Percentage (%)
Age groups (years)
≤ 20	34	17
21–30	120	60
> 30	46	23
Religion
Hinduism	109	54.5
Islam	86	43
Christianity	5	2.5
Occupation
Homemaker	161	80.5
Agricultural worker	12	6
Self-employed	22	11
Labourer	4	2
Maid	1	0.5
Socio-economic status (modified BG Prasad scale)
Class II	8	4
Class III	17	8.5
Class IV	98	49
Class V	77	38.5
Education
Illiterate	28	14
Non-formal schooling	29	14.5
Primary school completed	55	27.5
Middle school completed	15	7.5
Secondary school completed	42	21
Higher secondary school completed	16	8
Graduate or above	15	7.5
Parity
Nulliparous	4	2
1	83	41.5
2	68	34
> 2	45	22.5

Most of the mothers assessed as a part of the present study were found to be primipara (41.5%). When the DMPA (Antara) use pattern of the participants was assessed, it was seen that more than 60% of the women had a positive history of previous contraceptive use. Most women reported that they started taking Antara in the interval period between pregnancies (58.5%), with the need for birth spacing being the most common reason to start the injectable contraceptive (59.5%). Community health workers like accredited social health activists (ASHAs) and auxiliary nurse midwives (ANMs) were the most common source of information and motivation regarding the Antara use (80.5%) (Table 2).

Table 2.

Antara use characteristics of the study participants (n = 200)

Parameters	Frequency	Percentage (%)
Past use of contraception
Yes	121	60.5
No	79	39.5
Time of starting of Antara injection
Interval period	117	58.5
Post-abortal	20	10
Post-ectopic	1	0.5
Postpartum	62	31
Reason for starting Antara
Birth spacing	119	59.5
Birth limiting	81	40.5
Source of information about Antara
Community health worker	161	80.5
Doctor	16	8
Friends and neighbours	14	7
Relatives	9	4.5
Reason to use Antara
Easy to use	70	35
High efficacy	16	8
Low side effects	11	5.5
Prescribed by healthcare workers	103	51.5
Discontinued Antara
No	71	35.5
Yes	129	64.5
Reason for discontinuation of Antara (n = 129)
Side effects	66	51.2
Family did not want	6	4.6
Missed doses and did not continue	25	19.4
Planned pregnancy	12	9.3
Changed contraceptive	20	15.5

It was seen that the majority of the women, however, had discontinued DMPA at the time of their assessment (64.5%). The most common reason provided by the participants for the discontinuation of the contraceptive was the incidence of various side effects (Table 2). Of the side effects, inter-menstrual bleeding was the most commonly reported one (51.2%), followed by missed period (21.5%), and heavy bleeding after missed period (5%), respectively (Table 3).

Table 3.

Experiences of Antara use among participants (n = 200)

Experiences	Frequency	Percentage (%)
No side effects	26	13
Amenorrhoea	43	21.5
Irregular bleeding	103	51.5
Heavy bleeding after missed period	10	5
Weight gain	6	3
Headache	7	3.5
Abdominal pain	5	2.5

Owing to the high drop-out rate observed among the women, Chi-square analyses were carried out to ascertain any associations present between different sociodemographic and contraceptive-related characteristics reported by the participants and the discontinuation of Antara by them. It was seen that lower educational status among the women (p value < 0.001), poorer socio-economic status (p value < 0.001), and interval period starting of Antara (p value < 0.001) were statistically significantly associated with the discontinuation of the contraceptive. Regarding the side effects, it was observed that a statistically significant higher proportion of women who experienced amenorrhoea (p value 0.008) and heavier bleeding after missed period (p value 0.016) after taking the contraceptive had discontinued Antara. Other factors such as age, religion, occupation, parity, past use of contraceptive, and other side effects were not found to have statistically significant association with discontinuation of Antara among the women (Table 4).

Table 4.

Sociodemographic parameters statistically significantly associated with continuation of Antara among participants (n = 200)

Predictors	Continued Antara (n = 71)	Discontinued Antara (n = 129)	Chi-square value	p value
	N (%)	N (%)
Education
Illiterate	6 (8.5)	22 (17.1)	28.331	< 0.001
Non-formal schooling	15 (21.1)	40 (32)
Primary school completed	4 (5.6)	25 (19.4)
Middle school completed	2 (2.8)	13 (10.1)
Secondary school completed	22 (31)	20 (15.5)
Higher secondary school completed	13 (18.3)	3 (2.3)
Graduate or above	9 (12.7)	6 (4.7)
Socio-economic status
Class II	8 (11.3)	0 (0.0)	27.863	< 0.001
Class III	16 (22.5)	1 (0.8)
Class IV	37 (52.1)	61 (47.3)
Class V	10 (14.1)	67 (51.9)
Time of starting injection
Interval between pregnancies	22 (31)	95 (73.6)	12.568	< 0.001
Post-abortal	4 (5.6)	16 (12.4)
Post-ectopic	0 (0)	1 (0.8)
Postpartum	45 (63.4)	17 (13.2)
Amenorrhoea	6.829	0.008
Yes	8 (11.3)	35 (27.1)
No	63 (88.7)	94 (72.9)
Heavy bleeding after missed period
Yes	0 (0)	10 (7.8)	5.793	0.016
No	71 (100)	119 (92.2)

Discussion

India, being one of the few countries in the world to have comprehensive family planning national health programme in place, has explored a number of different modalities, presented to eligible couples via a “cafeteria choice” method [11]. Of them, injectable contraception like DMPA form an integral part, marketed as Antara and distributed freely from governmental healthcare institutions [12]. However, till date, the utilisation of DMPA has been quite low in the country, with only 0.6% of the eligible couples reported to be using them [2]. Exploring the experience of women in their use of DMPA is therefore essential in understanding this low uptake, on which the findings of the present study shed some light.

In the present study, the mean age of the women was 26.4 ± 5.9 years, similar to that reported by Rai et al. [13] and Nautiyal et al. [14], where the average age of acceptors of injection MPA was 26.6 and 26.5 years, respectively. As the study institution served a predominantly Hindu population, most of the participants (54.5%) were Hindus. Similarly, the socio-economic status and occupation of the participants also reflect the characteristics of the study population, where most families belong to the lower socio-economic classes and the majority of women are homemakers. In the present study, it was seen that a significant number of participants were illiterate or with non-formal education (28.5%). This is similar to the findings reported by other studies conducted on reproductive age rural Indian women, such as by Agrawal et al. [12]

The choice of contraceptive methods often depends on the parity of a woman. In the presents study, it was seen that out of the 200 women who had started Antara, most had one or more children, with only 2% being nulliparous at the time of interview. These findings are similar to those reported by Agrawal et al. [12] in their study conducted among rural women in Uttar Pradesh, 41.13% women had one child, 1.33% women had no child, and the rest were multiparous women. Another study in Karnataka also reported similar parity distribution among the assessed women [15].

When the experience of using DMPA (Antara) among the participants was assessed, it was observed that the primary source of information regarding the contraceptives for the overwhelming majority of women were community health workers such as ASHAs and ANMs. This is similar to the study by Agrawal et al. [12], in which the source of information about injection for most women was also reported to be health workers. This might be due to the fact that as the Antara programme is one of the most focused on reproductive and child care programmes by the Indian government, community health workers are motivated to educate reproductive age group mothers regarding the utilisation of the contraceptive [16]. This is why the findings of the present study differ from those done on the same topic elsewhere, such as by Ezegwui et al. [17] in Nigeria who found that the primary source of information regarding DMPA was friends and relatives.

In the present study, 58.5% (117/200) women had started Antara in the interval period, followed by those starting it in the postpartum period, post-abortal period, and post-ectopic period, respectively. Studies in Delhi and Uttar Pradesh also reflect similar patterns [12, 18]. DMPA, being a progestin-only contraceptive, does not impair lactation, and it represents a good contraceptive option for postpartum and lactating women [19]. However, not many women in India use DMPA in their postpartum period, because of lack of adequate counselling since antenatal period regarding best contraceptive for postpartum. The most common reasons for starting DMPA as reported by the women were prescription by local healthcare workers, ease of use, and high efficacy.

However, even though all of the women started using Antara in the present study, by the time of interview, a majority of them (64.5%) had discontinued the contraceptive. While such a high drop-out rate was similar to that reported by Agrawal et al. in Delhi, it was substantially higher than those reported in studies conducted in other countries [12, 20, 21]. This high rate of discontinuation of injection Antara is due to its menstrual side effects. It inhibits ovulation and causes menstrual problems such as withdrawal bleeding. Secondary amenorrhoea occurs due to anovulation and endometrial atrophy. These menstrual problems usually settle after 3–6 months [22]. However, lack of effective pre-administration counselling may cause apprehension due to inadequate knowledge about the method causing discontinuation of the method before the menstrual problems settle. This was found to be the case in the present study too, as among the women who discontinued Antara, more than half responded that they did so because of the side effects, most commonly amenorrhoea. This shows the need for ongoing counselling and management of the side effects. A statistically significant association between the side effects of amenorrhoea and heavy menstrual bleeding with discontinuation of the contraceptive further confirms this assessment.

Another objective of the present study was to ascertain the sociodemographic factors that are associated with the discontinuation of Antara among the women. It was observed that poorer educational status and lower socio-economic status of the women had statistical significant association with higher discontinuation of the contraception. This provides further evidence to the aforementioned issue of proper counselling regarding DMPA, and the lack of access to it. Better educated women and those belonging to the higher socio-economic classes are at a better position to avail better counselling from the professionals regarding the contraceptives, and therefore are at a lesser risk for discontinuation [12, 13]. Timing of injection may also influence the continuation rates as can be seen in the present study. Women who took injection in the postpartum period has significantly low rate of discontinuation of injection Antara when compared to women who took injection in the interval and post-abortal period. These findings are similar to other studies conducted on Antara use in the country. This finding represents a higher rate of acceptance and continuation of DMPA among postnatal women, probably due to the masking of the menstrual irregularity in postpartum period due to lactational amenorrhea. Thus, increased efforts for promoting this method in postnatal women for effective spacing between pregnancies may prove fruitful in significantly reducing the unmet need for contraception in postpartum period.

Limitations

The primary limitation of the present study was that it was single-centre study, assessing a dynamic population which was non-representative of the general Indian population. Furthermore, a community-based study involving multiple healthcare setups would have therefore provided more generalizable information regarding the DMPA use among reproductive women in the country.

Conclusions

Thus, it can be observed from the findings of the present study that in the study population, most women who started taking Antara discontinued it due to fear of side effects, myths, and misconceptions. Therefore, the focus should be to educate women regarding the benefits and side effects of DMPA through proper counselling. This should especially include those from the poorer and more uneducated sections of the society, as they are more vulnerable to discontinue the contraception due to inadequate knowledge about the method. Improving the literacy rate of women improves the compliance ultimately reducing maternal morbidity and mortality. Integration of injection Antara counselling right from antenatal period, appropriate selection of candidates for the method especially focusing on postpartum group of women as highlighted in our study can increase compliance.

Author contribution

SR involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content, and final approval of the version to be published. KS involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content, and final approval of the version to be published. TB involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content, and final approval of the version to be published. MST involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content, and final approval of the version to be published. AC involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content, and final approval of the version to be published.

Declarations

Conflict of interest

There was nothing to disclose regarding financial, personal, political, intellectual, or religious interests. There is no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained before enrolment.