Introduction of the injectable contraceptive NET-EN into family planning clinics in Bangladesh.

Bulletin ofthe WorldHealth Organization, 63(4): 785-791 (1985) © World Health Organization 1985 Introduction of the injectable contraceptive NET-EN into family planning clinics in Bangladesh S. S. RAHMAN,' S. JABEEN, M. MALAKAR,3 S. RAHMAN,4 J. KHATOON,5 N. AHMED,6 S. M. CHOWDHURY, S. E. HOLCK,8 B. BUSCA,9 & H. AKHTER10 In preparation for introducing the injectable contraceptive norethisterone enantate (NET-EN) into the nationalfamily planning programme, afield study was conducted in six family planning clinics in Bangladesh. A total of913 women elected to receive injections of NET-ENevery 8 weeksfor 6 months and every 12 weeks thereafter. At 12 months offollow- up, the overall discontinuation rate was 37.3 per 100 women, the most common reasonfor discontinuation being bleeding disturbances. Marked differences in continuation rates in different centres pointed out the need for further research into clinic characteristics that may affect acceptance and continuation rates. Problems encountered during the study helped to pinpoint service delivery issues that need to be considered when introducing NET- EN into afamilyplanningprogramme, including the needfor thorough training ofall clinic staff, adequate supplies ofNET-EN, andprovision ofalternative methods ofcontraception for women who may not be able to return for the next scheduled visit. The provision of family planning services nationwide is a major priority of the Government of Bangladesh, and most family planning clinics in Bangladesh currently provide oral contraceptives, intrauterine devices (IUDs) and barrier methods, especially condoms; many also provide sterilization services, or referral for such services. The injectable contraceptive depot-medroxyprogesterone acetate (DMPA) has been available to a limited extent in Bangladesh, but the fact that it has not been approved for use as a contraceptive in the United States of America has contributed to its not being made widely available in Bangladesh. Another injectable con- traceptive, norethisterone enantate (NET-EN), has been demonstrated in phase III clinical trials to be as ' Director, Bangladesh Fertility Research Programme, Dhaka, Bangladesh. 2 Professor of Obstetrics and Gynaecology, Sir Salimullah Medical College, Dhaka, Bangladesh. 3Director, Christian Health Care Project, Dhaka, Bangladesh. 4Director, Fertility Services and Training Centre, Dhaka, Bangladesh. s Director, Tillottoma Mobila Sangstha, Rajshahi, Bangladesh. 6 Project Coordinator, Bangladesh Association for Voluntary Sterilization, Tongi, Dhaka, Bangladesh. ' Superintendent, Christian Health Care Project, Chandra- ghona, Chittagong Hill Tracts, Bangladesh. 8 Medical Officer, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1211 Geneva 27, Switzerland. Requests for reprints should be addressed to this author. 9 Programmer Analyst, Human Reproduction Programme Team, World Health Organization, Geneva, Switzerland. '0 Formerly Temporary Adviser, World Health Organization, Geneva, Switzerland. effective as DMPA in preventing conception, and there are indications that it produces fewer menstrual disturbances than does DMPA. NET-EN was considered for use in family planning clinics in Bangladesh for several reasons. First, injections are generally accepted in Bangladesh as an effective mode of administration of medications. Second, since NET-EN is generally given only every two months, it is especially convenient for women who live some distance from health service delivery points and thus find it difficult to make frequent visits to the clinic. This regimen offers an alternative for women who prefer not to take a daily pill. Third, the effectiveness of NET-EN is an important factor since induced abortion is not legal in Bangladesh and pregnancy is associated with relatively high morbidity and mortality rates. In general, for women who want effective temporary contraception, or for women who want permanent contraception but do not want to undergo a surgical procedure, injectable contraceptives provide an alternative to oral contraceptives and intrauterine devices. However, there has been limited experience with the use of injectable contraceptives in Bangladesha b a CHOWDHURY, T. A. Preliminary report on the use of Noristerat as a contraceptive in 100 consecutive self-motivated users in a private clinic. Presented at a Workshop on the Injectable Con- traceptive: Noristerat, April 1980. Bangladesh Fertility Research Programme (unpublished report). b JAHAN, F. A. Experience with norethisterone enantate as injec(able contraceptive. Presented at a Workshop on the Injectable Contraceptive: Noristerat, April 1980, Bangladesh Fertility Research Programme. 4583 -785- S. S. RAHMAN ET AL. and, before NET-EN could be provided to family planning clinics on a nationwide basis, the following information was needed: -the overall acceptability of NET-EN to Bangladeshi women, -the side-effects that would present problems to the women and the best ways of managing them, -the type of staff training that would be needed, and -the best way of ensuring adequate supplies. In order to obtain more information on these various points, a phase IV study of NET-EN was con- ducted in six family planning clinics in Bangladesh, over a period of 3 years. This report discusses the findings from this study, focusing on factors affect- ing the acceptability of NET-EN and service delivery issues. METHODS Six family planning clinics participated in the study, which was coordinated by the Bangladesh Fertility Research Programme in Dhaka. Three of the clinics were located in Dhaka, the capital city (Mohammedpur Fertility Services and Training Centre, Sir Salimullah Medical College Hospital, and the Christian Health Care Project), one was located in a town approximately 15 km from Dhaka (Bangladesh Association for Voluntary Sterilization), and the other two were located several hundred kilometres from Dhaka (Tillottoma Mobila Sangstha in Rajshahi and the Christian Health Care Project in Chittagong). Each clinic recruited approximately 150 apparently healthy parous women between the ages of 18 and 39 years, who came to the clinic for con- traception and who were not lactating. The women were informed about NET-EN and its possible side- effects and asked if they were willing to participate in the study. The initial intramuscular injection of 200 mg was given during the first 5 days of the menstrual cycle, with subsequent injections every 8 weeks for the first 6 months and every 12 weeks thereafter, giving a total of 8 injections over approximately 18 months. At each scheduled visit, information was recorded on any complaints since the previous visit. In addition, the women were asked if they had had acceptable bleeding, unacceptable bleeding, or no bleeding since the last visit. Similar information was obtained if a woman came for an unscheduled visit, when an injection was not given. Any treatment other than NET-EN was recorded on the follow-up forms. Women who discontinued the regimen were questioned in detail on their reasons for doing so. Women who returned for an injection more than 5 days after the date of their scheduled visit were considered "late for follow-up" and excluded from the study. Women who did not return for a scheduled visit were followed up to obtain information on why they had not returned, many being visited in their homes. To assess the quality of the data collected, a 10%o sample of the study subjects was selected for reinterview, approximately 3 months before the end of the study. These subjects were asked their age, the number of live births they had had, the number of NET-EN injections they had received, whether or not they were still using NET-EN, and if not, why they had stopped. In addition, they were asked if they felt they had benefited from the use of NET-EN, and, if they had stopped using NET-EN, whether or not they were using another method of contraception. Characteristics on admission The authors recruited 913 subjects to the study- 150 in each of five of the centres, and 163 at the Sir Salimullah Medical College Hospital. Selected characteristics of the subjects on admission are shown in Table 1. The mean age of the subjects was 26.8 years, and the mean number of live births was 3.4. Almost a quarter of the women reported 5 or more live births. About half the subjects lived in a town, the rest in a rural area. During the previous 2 years, 632 of the women (69.20%o) had not used any method of con- traception. Among the 281 who had used contracep- tion during this time, the most frequently used Table 1. Characteristics of subjects on admission to the study Characteristic No. % Age (years) 18-24 269 29.5 25-29 375 41.0 30-39 269 29.5 Number of live births 1 or 2 378 41.4 3or4 316 34.6 5+ 219 24.0 Previous contraceptive method (within past two years) None 632 69.2 Oral contraceptive 192 21.0 IUD 10 1.1 Injectable contraceptive 51 5.6 Other 28 3.1 786 INTRODUCTION OF NET-EN IN BANGLADESH Table 2. Cumulative life-table non-competitive discontinuation rates at 6, 12 and 18 months, by reason for dis- continuation Discontinuation rate (per 100 women)0 Reason for discontinuation 0-6 months 0-12 months 0-18 months Heavy and/or prolonged bleeding 4.3 (0.7) 6.3 (0.9) 6.7 (0.9) Irregular bleeding or spotting 2.8 (0.6) 3.9 (0.7) 5.2 (0.9) Amenorrhoea 2.8 (0.6) 5.1 (0.8) 6.4 (1.0) Pregnancy 0.2 (0.2) 0.2 (0.2) 0.4 (0.3) Other medical reasons 2.6 (0.6) 5.4 (0.9) 7.1 (1.0) Desire for pregnancy 1.3 (0.4) 2.6 (0.6) 3.1 (0.7) No further need for contraception 1.0 (0.4) 1.7 (0.5) 1.9 (0.5) Other personal reasons 6.1 (0.8) 8.8(1.0) 9.7(1.1) Late for follow-up 2.0 (0.5) 2.3 (0.5) 2.5 (0.6) Lost to follow-up 6.6 (0.9) 8.7 (1.0) 11.0 (1.2) Total 26.3 (1.5) 37.3 (1.6) 42.9 (1.7) ° Figures in parentheses give standard error. method was oral contraceptives (reported by 192 subjects as the most recent method), followed by injectable contraceptives (51 subjects). Discontinuation rates and reasons for discontinuing The overall cumulative discontinuation rates were 26.3 per 100 women at 6 months, 37.3 per 100 at 12 months, and 42.9 per 100 at 18 months (Table 2). The most common reason for discontinuing was a disturbance in bleeding. Heavy and/or prolonged bleeding was the single most frequent reason (6.3 per 100 women at 12 months), but amenorrhoea was not uncommon (5.1 per 100 women at 12 months), while irregular bleeding or spotting was given as a reason somewhat less frequently (3.9 per 100 women). Three women became pregnant during the study, giving a cumulative pregnancy rate of 0.4 per 100 women at 18 months. A variety of complaints fell within the category of "other medical reasons", the most common being fatigue, headache, and dizziness. Women who did not return for a scheduled injection and who could not be contacted. to determine the reason were considered "lost to follow- up". Some of these women lived in places that were relatively inaccessible or at a great distance from the clinic, and in these cases home visits were not made; others had given imprecise or inaccurate addresses or had moved away or were temporarily living elsewhere when contact was attempted. Subjects were lost to follow-up at a rate of 8.7 per 100 women at 12 months and 11.0 per 100 women at 18 months. The overall discontinuation rates varied markedly by centre, as did the reasons for discontinuation (Table 3). The lowest discontinuation rate of 14.7 per 100 women at 12 months was seen in the Moham- medpur Fertility Services and Training Centre. This rate was considerably lower than that in any other centre, the next lowest being 37.3 per 100 women in the Sir Salimullah Medical College Hospital. The highest discontinuation rate was found by the Bangladesh Association for Voluntary Steriliz- ation-52.0 per 100 women at 12 months. The variation in rate of discontinuation because of bleed- ing disturbances was most dramatic, with relatively high rates at the Bangladesh Association for Voluntary Sterilization, markedly low rates in the Mohammedpur Fertility Services and Training Centre, and intermediate rates elsewhere. The rate of loss of subjects to follow-up also varied considerably among the centres, from 1.4 per 100 women at Mohammedpur Fertility Services and Training Centre to 17.6 at Tillottoma Mobila Sangstha in Rajshahi. In contrast, neither the overall discontinuation rate, nor the individual reasons for discontinuation varied much by age group. Women aged 30 years and over had a somewhat lower discontinuation rate at 12 months (33.1 per 100 women) than women aged 25-29 years (39.4 per 100) or 19-24 years (39.0 per 100). Not surprisingly, women in this last age group gave "desire for pregnancy" as a reason for dis- continuation more frequently than did the older women. Similarly, women of parity 1 or 2 had a 787 S. S. RAHMAN ET AL. Table 3. Cumulative life-table non-competing rates of discontinuation at 12 months, by reason for discontinuation and by centre0 Discontinuation rate (per 1 00 women) CHCP CHCP Reason for discontinuation BAVS (Dhaka) TMS MFSTC SSMCH (Chittagong) Heavy and/or prolonged bleeding 23.5 (3.9) 0.8 (0.7) 3.3 (1.6) 1.5 (1.0) 6.3 (2.3) 4.0 (1.8) Irregularbleedingorspotting 8.1 (2.8) 5.3(1.9) 5.4(2.0) 0 1.6(1.2) 4.9(2.2) Amenorrhoea 10.7 (2.8) 1.9 1.4) 6.1 (2.2) 1.5 1.1) 4.4 (1.9) 7.2 (2.5) Pregnancy 1.6 (1.1) 0 0 0 0 0 Othermedicalreasons 1.3(1.3) 8.1 (2.6) 1.4(1.0) 2.7(1.4) 13.6 (3.1) 4.5(2.0) Desire for pregnancy 1.8 1.3) 1.5 (1.0) 6.8 (2.3) 0.7 (0.7) 3.9 (1.7) 0 No further need for contraception 3.9 (1.9) 0 1.7 (1.2) 1.5 (1.0) 0.9 (1.0) 2.6 (1.5) Otherpersonalreasons 6.1 (2.3) 17.0 (3.4) 4.0(1.8) 5.6(1.9) 4.9(2.0) 15.6 (3.2) Late for follow-up 9.5 (2.9) 3.0 (1.5) 0 0.7 (0.7) 0 2.4 (1.4) Lostto follow-up 1.8 (1.3) 10.8 (2.7) 17.6 (3.4) 1.4 (1.0) 9.1 (2.4) 9.8 (2.6) Total 52.0 (4.1) 40.0 (4.0) 38.7 (4.0) 14.7 (2.9) 37.3 (4.0) 41.4 (4.0) a BAVS: Bangladesh Association for Voluntary Sterilization; CHCP: Christian Health Care Project; TMS: ,Tillottoma Mobila Sangstha; MFSTC: Mohammedpur Fertility Services and Training Centre; SSMCH; Sir Salimullah Medical College Hospital. " Figures in parentheses give standard error. somewhat higher discontinuation rate at 12 months (43.2 per 100 women) than women of parity 3 or 4 (33.8 per 100) or 5 or greater (33.7 per 100). There was no significant difference in discontinuation rates for women living in rural or urban areas (39.6 versus 35.5 per 100 women, respectively, at 12 months). Similarly, a history of contraceptive use in the previous 2 years did not markedly affect continuation rates. Follow-up visits At each follow-up visit, subjects were asked about bleeding patterns and about any problems occurring since the previous visit. The proportion of women who reported "acceptable bleeding" since the previous visit was 647o at the first follow-up visit, decreased to 52% by the third follow-up visit, and then increased to 68%o by the seventh follow-up visit. At the first and second visits, 9% of women reported "unacceptable bleeding", with the proportion decreasing to 3% by the last visit. The proportion reporting "no bleeding" since the previous visit varied from 26%o at the first follow-up to 43% by the fourth visit, and had decreased to 28%o by the last visit. The six centres varied markedly in the responses on bleeding. The proportion reporting "acceptable bleeding" ranged from 12%o at the Sir Salimullah Medical College Hospital to 8707 at Mohammedpur Fertility Services and Training Centre (all follow-up visits combined). The most common complaint at follow-up was fatigue, 36%o of women complaining of fatigue or tiredness on at least one visit. Spotting was the next most frequent complaint, reported by 2707o of the women. Irregular bleeding (1507o), dizziness (1507o), and abdominal pain (1 I Wo) were other frequent complaints. Altogether, 43%70 of the subjects were given medi- cations other than NET-EN at follow-up visits. Ferrous sulfate, multivitamins and oral con- traceptives for disturbances of bleeding accounted for the vast majority of medications given. Reinterview results Of a sample of 90 study subjects selected for reinterview, 57 were located and interviewed. Of the remaining 33, one was not at home when the inter- viewer called, 10 had moved house, and for 18 women, the address provided could not be located; the remaining four were not able to be interviewed for other reasons. Before reinterview was attempted, 10 of the 33 were considered "lost to follow-up" and nine had completed the study. The remaining 14 had discontinued for various reasons. Of the 57 reinter- viewed, 30 were successfully contacted in advance and were interviewed in the clinic; 27 were interviewed in 788 INTRODUCTION OF NET-EN IN BANGLADESH their homes. These 57 women were somewhat older and of greater parity than the women who were not located. Information provided at reinterview was compared with that recorded at the beginning of the study. Age given at reinterview was the same or less than two years greater than the age given on admission for 46 subjects (81 %). The same number of live births was reported on admission and at reinterview by 37 subjects (65%o). At the time of reinterview, 45 of the 57 subjects had discontinued the contraceptive regimen; 35 of the 45 gave, at reinterview, the same reason for discontinu- ation as the one they had given at the time they discontinued. Four subjects were recorded as dis- continuing because they had reached the end of the study but gave another reason on reinterview. Of the remaining six subjects who gave different reasons for discontinuation, four had discontinued at least one year before reinterview. When asked at reinterview whether or not they felt they had benefited from injectable contraception, 38 (67%) responded affirmatively. In general, the more injections the women had received, the more likely they were to give a positive response to the question. Of the 45 women who had discontinued the regimen, only ten reported using contraceptives at the time of reinterview- four had been sterilized, three were taking oral contraceptives, and three were using injectable contraceptives. DISCUSSION This study had two main objectives -to determine the side-effects and continuation rates of NET-EN, and to identify service delivery aspects that would be important in providing NET-EN in family planning clinics in Bangladesh. The continuation rates in this study are fairly encouraging with respect to the potential acceptability of NET-EN in Bangladesh. An overall continuation rate of 62.7 per 100 women at one year is considerably higher than those observed in similar studies of NET-EN in Mexico and Pakistan (1,2) and compare favourably with continuation rates for oral contraceptives in Bangladesh, which range from 44.6% to 69.2% at.one year (3-5). The main method-related problem contributing to dis- continuation of NET-EN was disturbance of bleed- ing. Heavy, prolonged, and irregular bleeding appeared to be greater problems than amenorrhoea. A variety of other medical and personal reasons were frequently given on discontinuation of NET-EN, but did not appear to be related specifically to the use of NET-EN. The most notable finding regarding discontinu- ation of NET-EN was the marked difference between centres. This is particularly striking given the lack of any major differences with respect to age, parity, residence, and history of contraception of the subjects. These findings imply that the specific approach adopted in each clinic had a considerable impact on continuation rates and acceptance of NET- EN. The most likely source of the variability observed is the approach of the clinic staff to counselling, both on first administration of NET-EN, and at follow-up visits. Since different staff attitudes and methods of counselling were not specifically examined in this study, it is not possible to explore their effects in more detail. However, given the apparent influence of clinic characteristics on continuation rates, additional research in this area seems warranted. Much was learned about service delivery issues through problems encountered during the conduct of the study. Thorough training of staff in the administration of injectable contraceptives is essential and should cover their mechanism of action, efficacy, common side-effects, mode and frequency of administration, and contraindications to their use. Since the various clinics entered the study at different times, not all clinic staff participated in training sessions. As a result, there was some confusion about the interval between injections and about the appropriate treatment of bleeding disturbances. This resulted in some women receiving injections at 70-day intervals and might also partly account for the differences between clinics in rates of dis- continuation. Staff changes in the participating clinics also created problems. New staff members were not always thoroughly informed about the study protocol or completion of forms, with the result that errors were made. The effect of a possible lack of knowledge about the injectable contraceptives themselves was more difficult to document, but the experience pointed out the importance of ensuring that new clinic staff are taught about injectable contraceptives, since this method of contraception might not be included in the general training programme of family planning clinic workers. The necessity of ensuring that adequate supplies of the drug are available was highlighted when one clinic participating in the study ran out of NET-EN, and a few women had to discontinue from the study. After the 150 women had been recruited to the study in this clinic, other women attending the clinic asked for NET-EN, and were given injections, resulting in inadequate supplies for study subjects. Clearly, the potential demand for injectable contraceptives needs to be accurately estimated when supplies are ordered. Follow-up of all study subjects proved to be 789 S. S. RAHMAN ET AL. impracticable. A number of women discontinued because they moved during the study (31 subjects known to have moved, as well as an unknown number included in "lost to follow-up"), and others temporarily changed their residence. Such move- ments can interrupt the regular schedule of injections, and provision should be made for providing alternative methods of contraception to women who may not be able to return at the scheduled time. There was concern about the quality of the data being collected, because of the non-uniform training of clinic staff, changes in staff in some of the clinics, and a change in the principal investigator midway through the study. However, the reinterview data were reassuring. Given the fact that many women in Bangladesh do not know their exact age, the correlation between information provided on age on admission and at reinterview is acceptable. The same is true for the number of live births reported, since there can be confusion about the number of live births as opposed to numbers of pregnancies and living children. In general, at reinterview the study subjects gave the same reasons for discontinuing as they had given when taking the decision. The majority of subjects who gave different responses were reinter- viewed a year or more after having discontinued. Four women who discontinued after eight injections ("end of study") gave other reasons at reinterview for discontinuing, which suggests that even at the end of a study reasons for discontinuing should be specifically asked for. In conclusion, the continuation rates observed in this study suggest that NET-EN is likely to be well accepted in family planning clinics in Bangladesh. However, the differences in continuation rates between the various centres point out the need for additional research on the role of clinic staff in affecting acceptability and continuation. When planning to introduce NET-EN into family planning programmes, consideration needs to be given to training clinic staff, providing for subsequent training of new staff, maintaining adequate supplies of NET-EN, and providing alternative methods of contraception for women who may not be able to return for the next scheduled injection. RESUMI2 INTRODUCTION D'UN CONTRACEPTIF INJECTABLE, L'ENANTATE DE NORtTHISTtRONE, DANS LES CENTRES DE PLANIFICATION FAMILIALE DU BANGLADESH L'utilisation de l'enantate de norethisterone (EN-NET) a et envisagee au Bangladesh dans les centres de planification familiale pour plusieurs raisons: l'injection est un mode d'administration des medicaments generalement bien accepte, la longue duree d'action du contraceptif ne n6cessite qu'une visite tous les deux mois aux services de sante et l'EN-NET est tres efficace. Une etude de terrain de phase IV a e realisee dans six centres de planification familiale afin de voir si cette methode est dans l'ensemblejug&e acceptable par les femmes bangladeshi et de recueillir des donnees sur les effets secondaires associes, sur la meilleure conduite a tenir en leur presence et sur la formation a donner au personnel. Un total de 913 femmes ont e recrutees parmi les femmes non allaitantes de 18 a 39 ans venues se renseigner sur la contraception dans un centit de planification familiale et disposees a employer un contraceptif injectable. La premiere injection d'enantate de norethisterone a &6 administree par voie i.m. au cours des cinq premiers jours du cycle menstruel et les injections suivantes, toutes les 8 semaines pendant les six premiers mois puis toutes les 12 semaines. Le suivi a dure jusqu'a ce que les interess6es quittent spontanement l'etude ou 18 mois au maximum; elles ont e interrogees sur les effets secondaires, notamment les saignements, et les motifs de l'abandon de la m6thode. Leur age moyen etait de 26,8 ans et la parite moyenne de 3,4. Au total, 69% des femmes n'avaient pas employe de methode anticonceptionnelle pendant les deux annees precedentes. Le taux d'abandon global (etabli par la meme methode que les tables de survie) est de 26,3 pour 100 femmes a 6 mois, de 37,3 pour 100 a 12 mois et de 42,9 pour 100 a 18 mois. La cause la plus frequente d'interruption reside dans des saignements importants et/ou prolonges (6,3 pour 100 femmes a 12 mois). L'amenorrh& est egalement une cause frequente d'abandon (5,1 pour 100 femmes), 1'irregularite de la menstruation ou le 'spotting' etant invoques moins souvent (3,9 pour 100 femmes). Trois femmes ont eu une grossesse pendant l'etude, avec un taux cumulatif de grossesses a 18 mois egal a 0,4 pour 100 femmes. Le taux de sujets perdus de vue est de 8,7 pour 100 femmes a 12 mois. Le taux global d'abandon est extremement variable d'un centre a l'autre (de 14,7 a 37,3 pour 100 femmes a 12 mois), mais il ne varie guere en fonction de l'age ou de la parite et ne depend pas de la pratique anterieure eventuelle de la contraception. Outre les dysmenorrhees, il convient de citer parmi les sympt6mes courants signales aux visites de contr8le la fatigue, les vertiges et les douleurs abdominales. Le sulfate ferreux, les complexes polyvitaminiques et les contraceptifs oraux ordonnes pour les troubles de la mens- truation representent l'essentiel des medicaments prescrits. Globalement, les taux de poursuite observes sont encourageants et donnent a penser que l'EN-NET est accep- table dans le cadre des centres de planification familiale du 790 INTRODUCTION OF NET-EN IN BANGLADESH 791 Bangladesh. Cependant, il semble, au vu des ecarts entre les taux observes dans les divers centres, que des recherches supplementaires sont necessaires sur le r6le de l'equipe du centre de consultation dans l'acceptation et la poursuite de cette methode de contraception. L'etude met de plus en evidence qu'il est indispensable de former des personnels nouveaux, de prevoir un approvisionnement suffisant en enantate de norethisterone et d'envisager, a l'intention des formes qui risquent de ne pas pouvoir revenir pour l'injection suivante, d'autres methodes anticonception- nelles. REFERENCES 1. WALTHER MEADE, C. ET AL. A clinical study of norethis- terone enanthate in rural Mexico. Studies in family planning, 15: 143-148 (1984). 2. WHO SPECIAL PROGRAMME OF RESEARCH, DEVELOP- MENT, AND RESEARCH TRAINING IN HUMAN REPRO- DUCTION. 12th Annual Report. Geneva, World Health Organization, 1983. 3. CHOWDHURY, F. I. Use pattern of oral contraceptives in rural Bangladesh: a case study of Sulla. Journal of Bangladesh development studies, 6 (3): 280-283 (1978). 4. MESHAM, A. A comparative study of regular and low- dose oral contraceptives in Dhaka. In: Proceedings of the 4th Annual Contributors' Conference, Dhaka, Bangladesh Fertility Research Programme, 1979. 5. RAHMAN, S. Use effectiveness of oral pill between two delivery systems: clinic vs field worker. In: Proceedings of the 4th Annual Contributors' Conference, Dhaka, Bangladesh Fertility Research Programme, 1979.