Dr Surya Protocol 13-08-24.pptx111111111111111111111111111

DMPA 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111166666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666Introduction

Background

Mexico was the site of several advanced Amerindian civilizations -- including the Olmec, Toltec, Teotihuacan, Zapotec, Maya, and Aztec -- until Spain conquered and colonized the area in the early 16th century. Administered as the Viceroyalty of New Spain for three centuries, it achieved independence in the early 19th century.

Geography

Area

total : 1,964,375 sq km
land: 1,943,945 sq km
water: 20,430 sq km

Climate

varies from tropical to desert

Natural resources

petroleum, silver, antimony, copper, gold, lead, zinc, natural gas, timber

People and Society

Population

total: 130,739,927

Ethnic groups

Mestizo (Indigenous-Spanish) 62%, predominantly Indigenous 21%, Indigenous 7%, other 10% (mostly European) (2012 est.)

Languages

Spanish only 93.8%, Spanish and indigenous languages (including Mayan, Nahuatl, and others) 5.4%, indigenous only 0.6%, unspecified 0.2% (2020 est.)

Religions

Roman Catholic 78%, Protestant/evangelical Christian 11.2%, other 0.002%, unaffiliated (includes atheism) 10.6% (2020 est.)

Population growth rate

0.72% (2024 est.)

Government

Government type

federal presidential republic

Capital

name: Mexico City (Ciudad de Mexico)

Executive branch

chief of state: President Andrés Manuel LÓPEZ OBRADOR (since 1 December 2018)
head of government: President Andrés Manuel LÓPEZ OBRADOR (since 1 December 2018)

Legislative branch

summary: bicameral National Congress consists of the Senate (128 seats) and the Chamber of Deputies (500 seats)

Diplomatic representation in the US

chief of mission: Ambassador Esteban MOCTEZUMA Barragán (since 20 April 2021)

Diplomatic representation from the US

chief of mission: Ambassador Ken SALAZAR (since 14 September 2021)

Economy

Economic overview

upper-middle income economy; highly integrated with US via trade and nearshore manufacturing; low unemployment; inflation gradually decreasing amid tight monetary policy; state intervention in energy sector and public infrastructure projects; challenges from income inequality, corruption, and cartel-based violence



Real GDP (purchasing power parity)

$2.873 trillion (2023 est.)
$2.783 trillion (2022 est.)
$2.678 trillion (2021 est.)

Real GDP per capita

$22,400 (2023 est.)
$21,800 (2022 est.)
$21,100 (2021 est.)

Exports

$649.312 billion (2023 est.)
$630.384 billion

1. Dr. Suresh Bangla Junior Resident Centre for Community Medicine AIIMS, New Delhi PRESENTER Thesis Protocol Presentation 1

2. Chief-Guide Dr. Sanjay Kumar Rai Professor Centre for Community Medicine AIIMS, New Delhi Co-guide Dr. Kapil Yadav Professor Centre for Community Medicine AIIMS, New Delhi Co-guide Dr. Baridalyne Nongkynrih Professor Centre for Community Medicine AIIMS, New Delhi 2

3. TITLE Prevalence of contraceptive usage and determinants of DMPA usage among women of reproductive age group in a resettlement colony of Delhi: A Mixed method study 3

4. OUTLINE Introduction Rationale Objectives Review of literature Methodology Analysis Ethical considerations

5. INTRODUCTION Current prevalence of contraceptive usage in India is 67% and in Delhi it is 75.1% Modern contraceptive use by currently married women is increased from 48% to 56% from 2015-16 to 2019-21 5 Family, N., & Survey, H. (n.d.). Government of India Ministry of Health and Family Welfare COMPENDIUM OF FACT SHEETS INDIA AND 14 STATES/UTs (2019-21) Distribution of contraceptive usage in Delhi

6. Introduction (2/5) Current unmet need of family planning in INDIA is 9% 1 Unmet need of contraception leads to unintended pregnancies and illegal abortions leading to significant mortality 2 Due to unintended pregnancy and complications, it results in 67% unsafe abortions resulting in death of 1.8 million women in India in the period of 2007-11 which accounts to death of 8 women in each day 2 6 1 Family, N., & Survey, H. (n.d.). Government of India Ministry of Health and Family Welfare COMPENDIUM OF FACT SHEETS INDIA AND 14 STATES/UTs (2019-21) 2 1 Family, N., & Survey, H. (n.d.). Government of India Ministry of Health and Family Welfare COMPENDIUM OF FACT SHEETS INDIA AND 14 STATES/UTs (2019-21) 2 Elizabeth L, Susheela S, Chowdhury, Sadia A. Fertility Regulation Behaviors and Their Costs: Contraception and Unintended Pregnancies in Africa and Eastern Europe & Central Asia HNP discussion paper series. 2007 Washington, DC World Bank © World Bank

7. Introduction (3/5) According to NFHS-5 Data there is huge variation in the distribution of prevalence of contraceptive usage in India ranging from 27% (Meghalaya) to 77% (Chandigarh) 1 One standard deviation increase in the proportion of men who believe that contraception is women’s business was associated with a 12% reduced likelihood of contraceptive use (OR = 0.88, 95% CI 0.82–0.95) 7 1 Family, N., & Survey, H. (n.d.). Government of India Ministry of Health and Family Welfare COMPENDIUM OF FACT SHEETS INDIA AND 14 STATES/UTs (2019-21) 2 1 Family, N., & Survey, H. (n.d.). Government of India Ministry of Health and Family Welfare COMPENDIUM OF FACT SHEETS INDIA AND 14 STATES/UTs (2019-21) 2 Men’s Attitude Towards Contraception and Sexuality, Women’s Empowerment, and Demand Satisfied for Family Planning in India 2020

8. Introduction (4/5) Depot Medroxy Progesterone Acetate (DMPA) is an injectable contraceptive agent DMPA can be given by oral, intramuscular, and subcutaneous routes. I.M. Dosage is 150 mg , and half-life is 50 days 8 Family Planning Division Ministry of Health and Family Welfare Government of India REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (DMPA) 2019 C24H34O4-Medroxy Progesterone Acetate

9. Introduction (5/5) Prevalence of DMPA usage in India is 3% and in Delhi it is 1.8% 1 When we compare the world’s statistics we lag. Current prevalence of DMPA usage in Indonesia is 31.9% and Bhutan 28.9% , Sri Lanka 14.8% and in Nepal 9.2% respectively 2 MOHFW included DMPA in ANTARA programme in 2017 under which it is available free of cost in government run health centers and hospitals 1 9 1 Family Planning Division MOHFW, Government of India Annual Report-Family 2021 2 Bansode OM, Sarao MS, Cooper DB. Contraception. [Updated 2023 Jul 24]. In: Stat Pearls [Internet]. Treasure Island (FL) 2024

10. Benefits of DMPA over others It is a highly effective contraceptive method with a standard regimen, the first-year effectiveness is 99.7% The perfect use failure rate of 0.3% is lower in comparison to 0.5% of female sterilization, 0.8% of IUCD and 3% of COC s It is a once in three months drug, no need of repeated visits to the facility Can be safely used in breastfeeding women and women with renal diseases 10 Family Planning Division Ministry of Health and Family Welfare Government of India REFERENCE MANUAL FOR DMPA 2019

11. Benefits of DMPA over others(2/2) Can reduce the cramp pain by reducing the synthesis of prostaglandins Protects against endometrial cancer and ovarian cancer, reduces sickle-cell crisis in women with sickle cell anemia, protects against ectopic pregnancy (since ovulation will not occur) Improves anemia by reducing the menstrual blood loss 11 Family Planning Division Ministry of Health and Family Welfare Government of India REFERENCE MANUAL FOR DMPA 2019

12. Drawbacks of DMPA It does not protect against STI It causes changes in the menstrual cycle and bleeding due to its inevitable effect on women’s body hormones Return of fertility takes 7-10 months from the date of last injection Cannot be given in patients with deranged LFT It decreases the bone mineral density 12 Family Planning Division Ministry of Health and Family Welfare Government of India REFERENCE MANUAL FOR DMPA 2019

13. RATIONALE U nmet need for family planning down to 9% from 13% as reported in NFHS-4. But a negative trend is also observed for contraceptive discontinuation that is reported as 50% for NFHS-5 as compared to 33% in NFHS-4 1 Prevalence of contraceptive usage was less than half in urban slums of India and Unmet need of family planning in Delhi slums was 17% which is significantly higher than the national average 2 13 1 Gupta, R. Key findings from NFHS-5 India report: Observing trends of health indicators between NFHS-4 and NFHS-5 Saparya Tripati 2020 2 Unmet need for family planning services among young married women (15–24 years) living in urban slums of India kriti yadav 2020

14. RATIONALE Fully meeting women's contraceptive needs in LMIC'S would reduce the unintended pregnancies by 68% , unsafe abortions by 72% and reduce the maternal deaths by 62% 1 Without contr aceptive use the maternal death would have been 1.8 times higher than the present, thus the contraceptive usage has averted 44.3% maternal deaths worldwide 2 14 1 Gupta, R., Singh, P., Gupta, R., Akhtar, N., Gupta, C., & Sharma, P. (2017). Contraceptive use: Its prevalence, awareness, practices and determinants in a rural population of Northern India. International Journal of Medical Science and Public Health 2 Family Planning Division, MoHFW, Government of India Annual Report-Family Planning 2019-21

15. Highest discontinuation rate of 63% was observed in the usage of injectable contraceptives 1 Even though DMPA is freely available its usage is very low 1 Limited awareness and myths regarding DMPA 2 Previous studies did not consider the influence of spouse on choosing contraceptive method 15 1 Family, N Ministry of Health and Family Welfare, GoI. National Family health Survey (NFHS-5), 2019-21, India Report. 2 Fonseca, M., Deshmukh, P. Y., & Kharat , D. (2017). DMPA: acceptance and compliance in a tertiary care hospital in Mumbai, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 6(9), 3879. https://doi.org/10.18203/2320-1770.ijrcog20174026 RATIONALE

16. OBJECTIVES Objective 1 To estimate the prevalence of different types of contraceptive usage among women of reproductive age group in Urban field practice area of UHC Dakshinpuri Delhi Objective 2 To assess the factors associated with the utilization of DMPA among women of reproductive age group in Urban field practice area of UHC Dakshinpuri Delhi 16

17. Operational Definitions Contraceptive prevalence rate 17 World Health Organization. Reproductive Health and Research. (2006). Reproductive health indicators : guidelines for their generation, interpretation and analysis for global monitoring. World Health Organization. All   The percentage of women aged 15-49 years, married or in-union, who are currently using, or whose sexual partner is using, at least one method of contraception, regardless of the method used

18. Operational definitions continued Unmet need of family planning Women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child Reproductive age group Women of age 18-49 years 18 World Health Organization. Reproductive Health and Research. (2006). Reproductive health indicators : guidelines for their generation, interpretation and analysis for global monitoring. World Health Organization.

19. Review of literature Literature was reviewed by electronic search through Medline via PubMed and google scholar. Key words used included Contraception, Family Planning DMPA, contraceptives determinants of DMPA, injection depot Medroxy progesterone acetate. Recent 20 years studies have been considered 19

20. Global studies on Prevalence of contraception SI Author Title Study Methodology Results 1 Islam 2023 1 Exploring the Influencing Factors for Contraceptive Use among Women: A Meta-Analysis of Demographic and Health Survey Data from 18 Developing Countries SRMA of 18 developing countries Pooled prevalence is 63% OR for respondent education: 1.39 (95% CI: 1.17 to 1.65) OR for husband education: 1.60 (95% CI: 1.32 to 1.93) OR for place of residence: 0.88 (95% CI: 0.78 to 0.98) OR for current working status: 1.47 (95% CI: 1.30 to 1.66) 2 Amoah 2023 2 Determinants and prevalence of modern contraceptive use among sexually active female youth in the Berekum East Municipality, Ghana Cross sectional study Berekham East Municipal, Ghana The modern contraceptive prevalence rate among the study participants was 76% Contraceptives ever used were emergency contraceptive pills 88 (41.7%) condoms 84 (39.8%), injectables 80 (37.9%) and the rest used the Calendar method 16 (7.58%), with-drawl 15 (7.11%), and implants 11 (5.21%) 3 Rominski 2020 3 Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970–2019: a systematic analysis for the Global Burden of Disease Study 2019 SRMA of 1162 Global Population Surveys Pooled prevalence is 65.4% 162·9 million (155·6–170·2) women had unmet need for contraception, of whom 29·3% (27·9–30·6) resided in sub-Saharan Africa and 27·2% (24·4–30·3) resided in south Asia Women aged 15–19 years (64·8% [62·9–66·7]) and 20–24 years (71·9% [68·9–74·2]) had the lowest rates of demand satisfied 20 2 Amoah, E. J., Hinneh , T., & Aklie , R. (2023). Determinants and prevalence of modern contraceptive use among sexually active female youth in the Berekum East Municipality, Ghana. PloS One, 18(6), e0286585. https://doi.org/10.1371/journal.pone.0286585 1 Islam, M. A., Khan, M. N. A., Raihan, H., & Barna , S. D. (2022). Exploring the Influencing Factors for Contraceptive Use among Women: A Meta-Analysis of Demographic and Health Survey Data from 18 Developing Countries. International 3 Haakenstad, A& Lozano, R. (2022a). Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970–2019: a systematic analysis for the Global Burden of Disease Study 2019.

21. Global studies on Prevalence of contraception SI Author Title Study Methodology Results 4 Boa 2020 1 Prevalence and factors associated with the utilization of modern contraceptive methods among married women of childbearing age in Yemen: a secondary analysis of national survey data Secondary data analysis of the National survey data Yemen 4692 reported using any form of contraception, giving us prevalence rate of 38.0% (95% CI: 36.4 to 39.5) the reproductive age. The authors estimated that 32.8% (95% CI: 31.4 to 34.2) of the 12363 women n=4054were using a modern contraceptive method 5 E. Case 2019 2 Contraceptive use among adolescent and young women in North and South Kivu Democratic Republic of the Congo: A cross- sectional population-based survey Cross-sectional population-based surveys in program area of north and South Kivu Modern contraceptive prevalence among young women was 16.5% Modern contraceptive prevalence among women aged 15-49 was higher Adolescent childbearing prevalence was 18.0% in North Kivu Adolescent-friendly SRH services were limited nationwide 6 Mahfouz 2019 3 Contraceptive Use and the Associated Factors among Women of Reproductive Age in Jazan City, Saudi Arabia: A Cross-Sectional Survey cross-sectional study conducted among 450 women in Jazan Prevalence was 64.9% . Almost 95.6% of participants had heard about a contraceptive method. Around 75% of them were familiar with pills About 70.7% of the women thought the best place to find contraceptives was at a pharmacy 21 1 Boah, M (2023). Prevalence and factors associated with the utilisation of modern contraceptive methods among married women of childbearing age in Yemen: a secondary analysis of national survey data 2 Casey N. (2020). Contraceptive use among adolescent and young women in North and South Kivu, Democratic Republic of the Congo: A cross-sectional population-based survey. PLoS Medicine, 17(3), e1003086 3 Mahfouz, M. S., Elmahdy (2023). Contraceptive Use and the Associated Factors among Women of Reproductive Age in Jazan City, Saudi Arabia: A Cross-Sectional Survey

22. Indian studies on Prevalence of contraception SI Author Title Study Methodology Results 1 Osborn 2022 1 A study on contraceptive prevalence rate and factors influencing it in a rural area of Coimbatore, South India Observational cross-sectional study Coimbatore Contraceptive Prevalence Rate among eligible couples was found to be 75% (95% CI: 73.6–76.4). Most commonly used method among the study participants was tubectomy (81.6%), followed by condoms (11.4%), intrauterine devices (6.3%), and oral contraceptive pills (0.7%) 2 Panda 2021 2 Spatial distribution and factors influencing modern contraceptive practice among tribal married women in India: evidence from National Family Health Survey 5 (2019–2021) Secondar analysis of 91,976 tribal married women participants aged 15 to 49 years from National Family Health Survey 5 conducted during the years 2019 to 2021 The overall prevalence of modern contraceptive practices was found to be 53% among tribal married women, which was below the national average Sterilization was the most preferred method of modern methods injectables were the least preferred method. More than 80% of the married women get the information from the public health facility and health workers 3 Avinash 2021 3 Prevalence of Contraceptive Methods among Eligible Couples in an Urban Area of Chennai - A Cross Sectional Study Cross sectional study conducted among married eligible couples living in the urban area named Semencheri in Chennai Prevalence was 64.9% Almost 95.6% of participants had heard about a contraceptive method. Around 75% of them were familiar with pills. About 70.7% of the women thought the best place to find contraceptives was at a pharmacy 22 1 Osborn, J. A., Sriram, R., Karthikeyan, S., & Ravishankar, S. L. (2021). A study on contraceptive prevalence rate and factors influencing it in a rural area of Coimbatore, South India. Journal of Family Medicine and Primary Care, 10(6), 2246. https://doi.org/10.410 2 Panda, S. N., Barik, M., Acharya, A. S., Kanungo, S., & Pati, S. (2023). Spatial distribution and factors influencing modern contraceptive practice among tribal married women in India: evidence from National Family Health Survey 5 (2019–2021). BMC Women’s Health 3 Avinash, K. R. D., Suganthi , S., & Venmathi , E. (2021). Prevalence of Contraceptive Methods among Eligible Couples in an Urban Area of Chennai - A Cross Sectional Study. Journal of Pharmaceutical Research International, 262–267.

23. Indian studies on Prevalence of contraception SI Author Title Study Methodology Results 4 B. Sawas 2018 1 A cross-sectional study of contraceptive prevalence and factors responsible for usage of different contraceptive methods in an urban slum area Observational cross-sectional study Urban slum areas of Aurangabad Contraceptive prevalence was found to be 53.84% Use of tubal ligation was found maximum (12.05%) followed by condom, O.C.P Contraceptive use was found to be significantly associated with age, number of living son, and number of living children of women 5 Dowerah 2018 2 Prevalence and pattern of contraceptive use and unmet need among women of reproductive age in urban Mysuru A community based Cross-Sectional study was carried out among 457 married women in the reproductive age group In Mysuru The prevalence of contraceptive use was found to be 55.1% The most common contraceptive used was the terminal method of tubectomy. Male Condom was the most common temporary method of contraception used 6 Hasan 2014 3 A study on prevalence of contraceptive use and its determinants among eligible couples in urban slums of Gorakhpur district A cross-sectional study was conducted from September 2013-August 2014 in urban slums of District Gorakhpur 67.4% of all eligible couple had ever used a contraceptive method. About one third of females (28.9%) had undergone Permanent sterilization followed by Condom (21.3%) use. About (15.0%) DMPA and IUCD were used in about equal in proportion. OCPs were used only by (12.4%) females 23 1 Sawase, G. B.,, M. K. (2018). A cross-sectional study of contraceptive prevalence and factors responsible for usage of different contraceptive methods in an urban slum area. International Journal of Community Medicine 2 Dowerah, J., Murthy, N., & Kulkarni, P. (2020). Prevalence and pattern of contraceptive use and unmet need among women of reproductive age in urban Mysuru. Clinical Epidemiology and Global Health, 8(4), 1221–1224 3 Hasan, A., Nandeshwar , A. A., Srivastava, D. K., & Khan, A. A. (2018). A study on prevalence of contraceptive use and its determinants among eligible couples in urban slums of Gorakhpur district. International Journal of Community Medicine and Public Health/International Journall of Community Medicine and Public Health, 5(10)

24. Global studies on Determinants of DMPA SI Author Title Study Methodology Results 1 Ali 2022 1 Perspectives on DMPA-SC Self-Injection Among Adolescents in Malawi Cross sectional study and Six focus group discussions were conducted involving 36 adolescents Concerns about self-injection included fear of pain, injury, and doubt in ability to self-inject. Never-married adolescents had additional concerns about privacy at home and potential long-term effects on fertility. Health surveillance assistants were considered the most private, convenient, and affordable sources for potential DMPA-SC SI 2 Osinowo 2020 2 Knowledge, Perception, and Practice of DMPA-SC/Self-Injectable Contraceptive among Women: Findings from Mixed-Method Study in South-West and North-Central, Nigeria A cross-sectional health facility study across 4 Nigerian States 95.7% reported current use of family planning; 94.3% reported ever use DMPA-SC, and 46.5% reported ever use DMPA-SC/SI The reason for the use of DMPA-SC/SI was because it was easy to use, effective and self-administered The factors that discourage women from using DMPA-SC/SI were mainly fears associated with side effects , for and fear of SI-self-injury 3 Y. Ermias 2017 3 Factors associated with provision of depot medroxyprogesterone acetate to adolescents by US health care providers Secondary data analysis of National Health Surveys A total of 247 respondents participated in the study. One hundred and seventy-three (70.0 %) were using Depot Medroxyprogesterone Acetate and 74 (30.0 %) were using Norethisterone Enanthate/Estradiol Valerate Abdominal pain, headache, irregular bleeding are the main reasons to discontinue 24 1 Ali, G& Gunda, A. (2023). Perspectives on DMPA-SC for self-injection among adolescents with unmet need for contraception in Malawi. Frontiers in Global Women’s Health 2 Osinowo, K. (2021). Knowledge, Perception, and Practice of DMPA-SC/Self-Injectable Contraceptive among Women: Findings from Mixed-Method Study in South-West and North-Central, Nigeria. Texila International Journal of Public Health, 9(3), 65–80. https://doi.org/10.21522/tijph.2013.09.03.art007 3 Ermias, Y., Morgan, I., Curtis, K., Whiteman, M., Horton, L., & Zapata, L. (2019). Factors associated with provision of depot medroxyprogesterone acetate to adolescents by US health care providers. Contraception, 99(5), 300–305. https://doi.org/10.1016/j.contraception.2019.01.005

25. Global studies on Determinants of DMPA SI Author Title Study Methodology Results 4 Priyanti 2016 1 Side Effects and Determinant of the Use of 3-Month Contraceptive Injection Analytical cross-sectional study at Mojokerto Indonesia The results showed that the duration of use of 3-month contraceptive injection was significant with side effect of menstrual disorders (PR=0.142,95%CI: 0.040-0.502) and decreased libido (PR=0.275; 95%CI: 0.100-0.756) 5 Laryea 2011 2 Characteristics and contributory factors for injectable contraceptive usage among women in Kumasi, Ghana Descriptive cross-sectional survey at Kumasi, Ghana The mean age for women on Depot Medroxyprogesterone Acetate was higher than those on Norethisterone Enanthate/Estradiol Valerate (p < 0.001) The effectiveness of method, recommendation from other users, low incidence of forgetfulness and the relatively longer intervals for administration were the commonest reasons for the use of injectables among respondents. Most users, 225 (91.1 %), were satisfied with the method and will recommend to other potential users. Only 10.8 % of the 68 respondents reporting undesirable effects of the injectables 25 1 Priyanti, S., & Syalfina , A. D. (2018). Side Effects and Determinant of the Use of 3-Month Contraceptive Injection. Jurnal Kesehatan Masyarakat, 20–27. https://doi.org/10.15294/kemas.v14i1.9209 2 Laryea, D. O., Ankobeah , F., Morhe , E. S. K., Amoako, Y. A., & Spangenberg, K. (2016). Characteristics and contributory factors for injectable contraceptive usage among women in Kumasi, Ghana. Contraception and Reproductive Medicine, 1(1). https://doi.org/10.1186/s40834-016-0019-0

26. Indian studies on Determinants of DMPA SI Author Title Study Methodology Results 1 Bairagya 2021 1 Prevalence and reasons behind use of injectable contraceptive among the women of reproductive age group: A cross‑sectional survey in rural areas of Nadia District West Bengal A sub‑center‑based observational, cross-sectional survey was conducted among 212 reproductive age group women living in the rural areas of a district West Bengal High proportion of teenage marriages; over half of mothers unwilling to have more children One-third used injectable contraceptives, with ASHA as primary suggestion provider. Discomfort with previous methods and service provider recommendations were main reasons for use 2 Gupta 2019 2 Determinants of injectable depot medroxyprogesterone acetate contraception among women of reproductive age: A study from Southern Haryana India This community-based study with cross-sectional design was conducted during April 2019–October 2019 Among previous contraceptive users, oral pills were the most common method. Clients who switched to DMPA cited privacy and confidentiality as reasons. Side effects, including irregular vaginal spotting, amenorrhea, and weight gain, were reported by over 80% of subjects 3 S hilpa M 2019 3 Profile and compliance of recipients of injection depot Medroxy progesterone acetate as a contraceptive method in the government tertiary care hospital in Mandya, South Karnataka, India A record-based study of 18 months (January 2018 to June 2019). The records of 266 women who utilized inj. DMPA as contraception at MIMS Mandya Out of 266 women, 48.5% were aged 21-25 years, and 64.3% were primipara (first-time mothers). Most women who initiated injectable DMPA (Antara) were in the lactational period (56.0%). Irregular bleeding (54.8%) was the most common side effect . Discontinuation rates were 55.6% after the first injection and 16.9% after the second injection 26 1 Bairagya, A., Basu, G., Mondal, R., & Roy, S. K. (2021). Prevalence and reasons behind use of injectable contraceptive among the women of reproductive age group: A cross-sectional survey in rural areas of Nadia District, West Bengal. Journal of Family Medicine and Primary Care, 10(7), 2566. https://doi.org/10.4103/jfmpc.jfmpc_2465_20 2 Chawla, S., Gupta, V., Gour, N., & Goel, P. (2020). Determinants of injectable depot medroxyprogesterone acetate contraception among women of reproductive age: A study from Southern Haryana, India. Indian Journal of Community and Family Medicine 3 N, S. M., & M, S. (2020). Profile and compliance of recipients of injection depot medroxy progesterone acetate as a contraceptive method in the government tertiary care hospital in Mandya, South Karnataka, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology

27. Indian studies on Determinants of DMPA SI Author Title Study Methodology Results 4 Aman 2019 1 Depot medroxy progesterone acetate (DMPA): Its acceptance, compliance and factors influencing continuation rates among women attending Lal Ded Hospital in Kashmir longitudinal hospital-based study which was conducted at Lal Ded Hospital, an associated hospital of Government Medical College Srinagar Side effects: Irregular bleeding, amenorrhea, weight gain, headache. Dropout rate: Highest after 1st and 2nd injections . Parity distribution: Most women had 2 or more children The study concluded that DMPA is highly effective contraceptive with low failure rate, when women are effectively counselled 5 Fonseca 2017 2 DMPA: acceptance and compliance in a tertiary care hospital in Mumbai, India Cross sectional study at Mumbai India Most women were aged 26-30, receptive to contraceptive counseling. DMPA had low failure rate, effective with proper counseling Common side effect: irregular bleeding spotting in 63% of women . Side effects: Irregular bleeding, amenorrhea, weight gain, headache, no problems. Dropout rate: Highest after 1st and 2nd injections 27 1 Aman, F. (2019). Depot medroxy progesterone acetate (DMPA): Its acceptance, compliance and factors influencing continuation rates among women attending Lal Ded Hospital in Kashmir. Journal of Medical Science and Clinical Research, 7(12) 2 Fonseca, M., Deshmukh, P. Y., & Kharat , D. (2017b). DMPA: acceptance and compliance in a tertiary care hospital in Mumbai, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology , 6(9), 3879. https://doi.org/10.18203/2320-1770.ijrcog20174026

28. Summary of ROL Global Studies On Prevalence of Contraception Indian Studies On Prevalence of Contraception Global Studies On Determinants of DMPA Indian Studies On Determinants of DMPA Prevalence of contraceptive usage varied between 16.5% in Kivu to 76% In East Municipal Ghana Educational status, economic conditions, Deprivation from Health facilities are the factors associated with contraceptive usage According to NFHS-5 it varied from 27% Meghalaya to 77% Chandigarh with overall prevalence of 67% and unmet need of 9% Prevalence of contraceptive usage varied 53.84% In Urban Slums of Aurangabad to 75% In Coimbatore Overall reasons for the use of DMPA-SC/SI was because it was easy to use, effective and self administered The factors that discourage women were mainly fears associated with side effects of injection like menstrual disorders and decreased libido Weight gain etc. DMPA had low failure rate and effective with proper counseling Common side effects Dysmenorrhea Weight gain GI disturbances Pain at site Headache etc. 28

29. METHODOLOGY Study design : Cross sectional M ixed method study Sampling Technique: Simple random sampling (Quantitative) Purposive and Snow-ball sampling ( Qualitative) Study setting : UFPA of urban health center Dakshinpuri New Delhi Study population : Married women aged between 18-49 years 29

30. Urban Field Practice Area 30 UFPA Delhi INDIA

31. ELIGIBILITY Criteria Inclusion criteria Women residing in the area as defined by the study for at least six months Married women of age 18-49 years Participants must be able to provide information about their contraceptive usage and experiences Exclusion criteria Women who are pregnant Women who were unavailable to contact after three attempts Women who are critically ill 31

32. Sample size calculation Prevalence(p) of contraceptive usage in Delhi according to NFHS 5 data is 76.4% 1 Absolute precision(d) is 5% Z = 1.96 P = 0.764 = 0.05 n = 1.962 * 0.764 * (1 - 0.764) / 0.052 n = 0.6927 / 0.0025 = 277.062 n ≈ 278 After adding 10% non-response rate and rounding off sample size would be 310 32 Family, N., & Survey, H. (n.d.). Government of India Ministry of Health and Family Welfare COMPENDIUM OF FACT SHEETS INDIA AND 14 STATES/UTs (2019-21)

33. STUDY TOOLS Pre- tested Semi- structured questionnaire Questionnaire adopted from NFHS 5 will be used It is available freely in public domain, and permission for general usage is given 33 Woman Questionnaire.xls [Internet]. [cited 2024 May 12]. Available from: https://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Frchiips.org%2Fnfhs%2FNFHS-3%2520Data%2FQuestionnaires%2520Excel%2FWoman%2520Questionnaire.xls&wdOrigin=BROWSELINK

34. Personal In-depth Interview Personal in-depth interviews will be done by purposive and Snow-ball sampling containing present/past DMPA users and Doctors,ANMs,ASHAs,Husband/MIL Interview will be containing open ended questions to explore the qualitative outcome better Personal details Healthcare system - related Community-related Facilitators/barriers Others 34

35. Focus Group Discussions FGD will be conducted by purposive sampling including, DMPA users /Non-DMPA users Mother-in-law’s USHA workers Husbands Recording will be done electronically or manually and it will be transcript and translated 35

36. Data Analysis Procedure Data will be collected digitally by Epi collect , extracted and coded in MS excel statistical analysis will be done in R analyzer 2.0.4 Key steps Descriptive Statistics Subgroup Analysis Relevant statistical tests will be decided based on the Q-Q (quantile-Quantile) plot P rinciple component analysis will be done to reduce the dimensionality and to know the key factors 36

37. Data Analysis Procedure 2/2 Cluster Analysis will be based on similar characteristics to identify patterns in contraceptive usage Cox Proportional-Hazards Model will be used to assess the impact of various factors on the time to discontinuation of DMPA Correlation matrix will be formed to know the correlation between various factors and usage of DMPA 37

38. Analysis of qualitative data 38

39. Activity AUG 2024 SEP 2024 OCT 2024 NOV 2024 DEC 2024 JAN 2025 FEB 2025 MAR 2025 APR 2025 MAY 2025 JUN 2025 JUL 2025 Protocol submission Ethical Clearance Finalizing and piloting tools Data collection Data entry Data analysis Preliminary presentation of results TIMELINE OF EVENTS 39

40. Ethical considerations (1/2) After obtaining approval from E thics committee at AIIMS New Delhi, the study will be started Informed, written consent will be obtained from all the participants who agree to take part in the study Their identities will be kept confidential, and they will be explained the same 40

41. Ethical considerations (2/2) Participants will also be provided information regarding the expected duration of participation, the benefits from the research that they can expect, risks, if any, associated with the study, maintaining confidentiality of the records The participant will also be explained that he/she has all freedom to participate/withdraw from the study at any time they wish without any penalty or loss of benefits to which the subject would otherwise be entitled. The data will not be shared outside the study team 41

42. THANK YOU 42