The DMPA Street Theater Project

By, Diepiriye S. Kuku-Siemons

The Banglanatak troupe marched through the neighborhood searching for an ideal space to attract an audience. Their loud rhythmic drumming drove people out of their shops and homes onto the streets to witness the 'disturbance'. Many joined the excitement and procession, prodding the troupe for hints as to what was about to happen.

On the whole, audiences ranged from twenty to eighty, averaging fifty onlookers per show. In some places, people were clambering to see the street theater show, educating the population about the contraceptive Depot Medroxyprogesterone Acetate (DMPA). The DIMPA network project is implemented by PSP-One across nine towns and cities is shortly expanding to cover an additional ten towns in UP and Uttaranchal. The program objective is to promote the use of DMPA by enhancing consumer awareness of this method as a part of the basket of contraceptive choices and to ensure high quality of service provision by private clinics.

The role that women often fulfill in the management of the household, children and elders restricts her mobility and her ability to partake in the animated street theater spectacles. Discussions with the troupe leader revealed that their experience has been that more women attend if the group situates itself deep inside the residential sections of each colony. Earlier performances took place in markets- areas primarily populated by males. Market areas see a great deal of people in transit who are unlikely to assemble for more than two minutes, making it difficult to maintain a captive audience. Crowds in less commercial/more residential areas tend to stick around for the entire duration of the plays, which are brief- at most 15 minutes long. This is especially important in conveying social messages, beyond merely spreading the word that some strangers have appeared in the local area to make a vague public exhibition.

Use of local language or dialect is usually a better way to engage the community. However, in the case of Aligarh, while the troupe spoke in a different accent, this difference did not prove problematic to the objective of the activity. An overwhelmingly positive response after each performance implies that this is not a barrier. The troupe reports similar encouraging and inquisitive responses from males and females of ALL ages, notably including adolescents, youth and the elderly. There were a plethora of questions following the performance, and many were interested in the DMPA information leaflets distributed by the performers. Further, there were several inquiries directed towards the group regarding details of DMPA as well as the location of providers.

Surprisingly, youth and adolescents were equally engaged in not only the animated performance and drumming but also the plot of the skits. Elderly women notably paid close attention to the contraceptive method messages. One lady approached the troupe with numerous questions, asserting that her daughter-in-law was not present yet would benefit from knowledge of DMPA. She was so excited about the production that she disappeared, quickly returning with her son's wife at her side. Mothers-in-law have a great deal of influence within the household regarding her daughter-in-law, hence their involvement is key.

At the end of the short production, a moderator from the troupe pleases the crowd with a lively "Question/Answer" recap of the topics carefully covered in the skit. "Three months," one lady hesitantly blurted out, before quickly readjusting her head cover, lifting one length of her shawl to cover her smile. The ladies hovering in the doorways and corners nearby were happily vociferous after of her correct response to DMPA's duration of efficacy.

The real benefit of street theater lies in one fact: It is a spectacle. Spectacles are out-of-the-ordinary events which present an abstraction of life. A plethora of evidence based studies suggest significant unmet needs for a variety of methods of contraception, yet contraception is absent in everyday conversation. The variety reflects the diversity of health, lifestyle and social circumstances in which women find themselves, with varying degrees of personal agency regarding their own fertility. Introducing an external 'spectacle' of sorts, to raise the issue of birth spacing, contraception and women's ability to determine her fertility are subjects that many simply lack facilities to address. Street theater is an effective means by which to introduce topics into public discourse and eventually, raise public awareness.

There were a few service providers from the DIMPA Network
present at one staging of the performance. Abt Program Manager Sashwati Banerjee gave the feedback that their presence lent a greater sense of legitimacy to the message of the street theater play. Additionally, this easily serves to advertise the services of the providers and is an excellent way to link the traveling group of performers directly to the local context. Providers like Dr. Rakhi Mehotra recognized the potential synergy in the collaboration between providers and street theater, particularly among low income groups who may have limited exposure to mass media. One provider even suggested street theater productions near the provider's clinic in efforts to build local awareness.

The presence of local service providers at the performances may well alleviate any concerns about social differences/distances in language and class between the performers and the target community. Service providers should be encouraged to attend the street theater performances and field questions from audience members at the end of the performance. This synergetic relationship would allow both service providers and the local population to engage each other in a non-clinical setting, breaking barriers and diminishing reticence to discuss taboo subject matter in order to build a positive community dialogue about health.

Reproductive Justice: Informed Life-choice

By Diepiriye S. Kuku-Siemons

Depo Medroxyprogesterone Acetate (DMPA) is one of the most widely researched and documented safe and reliable means of contraception. DMPA is 99.7% effective and lasts up to three months, making it a viable alternative to oral contraception and IUDs . Long-acting injectable contraceptives such as DMPA remove the daily tensions surrounding reproductive and sexual health, especially for those who find other methods impractical. Although proven safe and effective, the oral contraceptive pill is impractical for many and does not address the myriad of circumstances and concerns of many couples. Due to a variety of health concerns and individual needs, IUDs are clinically unsafe for many women. Expanding the basket of choices of contraceptives promotes the praxis of reproductive rights.

There are a plentitude of circumstances in which couples in the prime of their fertility may wish to delay pregnancy. For example, young, urban career-oriented couples may choose DMPA as a highly effective means of long-term fertility control. Young couples struggling to meet the needs of existing children may find DMPA a convenient and easy-to-use contraceptive method of choice. Other young couples may be eager to have their first child, yet wish to postpone further offspring. In these cases contraceptives serve as a 'spacing' method, permitting women and their spouses to concentrate on pursuing studies/training or rigorous career paths. 'Spacing' also represents a responsible and mature attitude towards fertility, cultivating better and more informed parenting.

Clinical, demographic and social science professionals alike conclude that an unmet need for contraceptives monopolizes a great deal of women's time. Time spent dealing with fertility reduces precious time for responsible and effective parenting, care-taking of elders, income generation and self-development. DMPA specifically addresses a constraint of parenthood- namely time and stress management. Poverty exacerbates these constraints where reduced access to health care services as well as education and training all work to limit life-choices.

Risky choices

A recent study in the Indian Journal of Pediatrics of pregnant women from six urban slums revealed an 80.6% prevalence of anemia. The researchers concluded that in most instances, anemia resulted from inadequate dietary intake of iron, of which 90.9% of study participants fell far short of the daily recommended allowance. DMPA may reduce menstrual bleeding and promote a slight weight gain, making it a wholly beneficial and life-enhancing alternative. Other non-contraceptive benefits of DMPA include a reduction of pain associated with endometriosis as well as the palliative treatment of certain cancer.

Lactating mothers too often struggle with post-partum health, while at the same time seeking a reliable means of contraception that does not place her child at risk. The combined oral contraceptive pill is not a viable alternative for lactating mothers who harbor concerns over the effects of the quantity or quality of their breast milk. Lactating mothers may shoulder responsibilities towards her newborn child, existing children, spouse and other kin, rendering the daily attention and inflexibility of oral contraceptives an unnecessary hassle. DMPA has no adverse effects on breast milk while providing security and reassurance unparalleled.

Rights to Resources

Reproductive rights theorizes access to treatment and care, while reproductive justice works towards ensuring quality, safety, and practical access for women in a myriad of socio-economic circumstances. Purporting contraceptive choices as a reproductive right overlooks the varying circumstances which mediate a woman's personal agency and ability to decide. To transition from reproductive rights to reproductive justice it is necessary to expand the basket of choices to address the unmet needs for contraception and birth spacing as well as their practicality.

The utility of DMPA gives credence not only to reproductive health as a right, but also to reproductive justice by broadening the element of choice to a wider array of women, particularly those living in poverty or otherwise disenfranchised. Far too little research interrogates the intersection of poverty and unmet needs for pragmatic, safe and effective contraceptives. In real terms, poverty reduces access to education/training as well as quality health care. The unmet needs for contraception across all social-economic strata indicates an urgent necessity to re-examine these linkages in the form of expanding knowledge resources and availability of choices. Enhancing the basket of contraceptive choices can drastically enhance the lives of women in particular, and families in general, especially those traditionally disenfranchised.




References
Shali T, Singh C, Goindi G. Prevalence of anemia amongst pregnant mothers and children in Delhi. Indian J Pediatr [serial online] 2004 [cited 2006 Apr 17];71:946-946.

Review of “The Impact of Menstrual Side Effects on Contraceptive Discontinuation"

By Diepiriye S. Kuku-Siemons
May 2006

Review of “The Impact of Menstrual Side Effects on Contraceptive Discontinuation: Findings from a Longitudinal Study In Cairo, Egypt.” Published in: International Family Planning Perspectives, Vol. 31, No. 1, March 2005

Elizabeth Tolley, Sarah Loza, Laila Kafafi and Stirling Cummings published their findings from the study of 259 first time users of the IUD, the hormonal implant or the tri-monthly injectable (DMPA). The aim was to gauge women's bleeding patterns and perception of changes in their cycles subsequent to adopting their chosen method. Relatively few studies have interrogated women's perception and tolerance of menstrual changes as a result of adopting a new method of contraception , some of which appear to contradict one another. The findings of this study provide important insights for the improvement of counseling to address women's perception of bleeding changes.

The study collated both quantitative and qualitative data from surveys over a period of 18 months and from 48 women who participated in six focus group discussions (FGD). The study sought to shed light on the high discontinuation rate (70%) of DMPA users after one year, compared to 34% and 10% of IUD and implant users respectively. At the baseline study, participants reported an average of five bleeding days per cycle. After starting usage of IUD and DMPA, users reported eleven to twelve bleeding days per cycle. The researchers also noted that those women who chose to use the implant differed from IUD and injectable users: They were more experienced mothers who wished for no more children and had prior experience with another method of contraception. On average, implant users were also slightly less educated than those who chose other methods and averaged two to seven years elder to women who used injectables and IUDs. Though not fully explored in this present study, the authors noted that these differences in personal characteristics at the baseline could have influenced women's choice of IUD, implant or injectables.

In another population based survey of 252 women in New Zealand, bleeding irregularity or heavy bleeding were frequently cited as the primary reason for discontinuation of DMPA within 21 months of first adopting the method. Yet, the same study revealed amenorrhea as the primary reason for discontinuation between two and five years after adopting the method. Another randomized trial of two tri-monthly injectable contraceptives showed amenorrhea to be the cause given for discontinuation within twelve months of adopting DMPA. Another study in Bolivia showed a correlation between discontinuation and fewer (less than or equal to four) children or the belief that menstruation is important for the maintenance of good health.

A 1996 study in Egypt looked at counseling on injectables that women received from physicians, nurses and midwives. More than 50% of those providers and counselors believed that long-term amenorrhea could lead to sterility among other health complications. Many of those providers reported their belief that only couples seeking to effectively limit their family size should adopt DMPA. Such misconceptions may introduce biases when counseling and educating women and couples about the variety of available methods of contraception, including DMPA.

One fallout of provider bias in counseling comes in the conveyance of advantages and disadvantages of the various methods of contraception. IUD and implant users were given counseling that weighed heavily upon the advantages of those methods. In some cases, inaccurate or false information was given. By contrast, the same FGD revealed that many providers were more likely to explain disadvantages of DMPA rather than advantages. One provider explained in detail to those women who chose the implant or DMPA that they should expect their menstrual cycles to stop. When actual experiences deviated from the counseling, women were admittedly surprised, at best; many were alarmed.

Study Findings

Though implants caused many women to bleed heavily or led to amenorrhea altogether, injectables users reported nearly thrice the spotting as IUD users and over 60% more than the implant insofar as number of bleeding days. The unpredictability of bleeding days and patterns of bleeding (heavy, light, etc.) means that what was once a 'cycle' is rendered a variegated appearance of "traces" or "signs." By the second month just over one third had felt changes in their cycles and expressed concern over these changes.

In this study, women who chose DMPA reported "dramatic increases in the length of bleeding episodes" during the first months. Subsequent reports revealed "sharp declines" in bleeding among women who continued the method. These same women reported further declines in average number of bleeding days between the twelve and eighteen month period. One woman explained her understanding of the injectable after having used this method for two years:

"Two or three drops, then it stopped for four months. And it came again for a while, and then stopped. I mean that when the injectable is due, it gives me a sign. It comes down as a drop or two....The first two cycles I had spotting. Then it stopped altogether."

Among the women who discontinued use of DMPA, nearly one third cited amenorrhea as their primary cause for concern while only 7% did so due to other non-contraceptive effects. Notably, none mentioned a desire to return to normal fertility as a reason for discontinuation.

The menstrual diaries recorded by study participants revealed no significant statistical difference among women who continued versus discontinued use of DMPA insofar as "the proportion of total days recorded for each level of bleeding." This reinforces the idea that the unpredictability of the menstrual cycle is the most disconcerting aspect of DMPA use- not cessation of the menstrual cycle. The study found that while correcting for "personal characteristics, spousal attitudes or knowledge," bleeding inconsistency/length predicted likelihood of discontinuation of DMPA users at a rate of 4% per additional day above the average of five bleeding days per cycle reported at the baseline study.

The authors conclude that: "Our findings raise the possibility that counseling about bleeding and other side effects should be tailored to the personal and contraceptive experiences of women, and that partners may play an important role in how well some women tolerate contraceptive-related bleeding." To mitigate these concerns, DMPA providers should discuss the immediate, short-term and long-term changes in adopting this unique method of contraception. Pre DMPA Counseling* should address the specific experience of women with their menstrual cycles in order to better prepare them for the potential changes to her cycle. Spotting and various other forms of irregular bleeding are the greatest indicators of continued use. Addressing these concerns will normalize the experience and reassure women so that they know exactly what to expect from adopting DMPA.

*Pre DMPA Counseling:
- Adheres to pelvic screening guidelines
- Plans injections relative to menstrual cycle and childbirth
- Evaluates medical history including diabetes risk
- Assesses intensity and typical number of bleeding days per cycle
- Addresses perception and misconceptions of menstrual changes
- Incorporates Behavior Change Communication strategies to gain familial support of adoption of family planning






References:
Hubacher D et al., Factors affecting continuation rates of DMPA, Contraception, 1999, 60(6):345-351.
Rivera R, Chen-Mok M and McMullen S, Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD, Contraception, 1999, 60(3):155-160.
Tolley E and Nare C, Access to Norplant removal: an issue of informed consent, African Journal of Reproductive Health, 2001, 5(1):90-99.