The age of the 27 participants ranged from 20 to 33 years and had 2 to 4 children each. 55% had attended primary school only and none were formally employed, and all were housewives. Most of the women interviewed had used other types of modern contraceptive methods prior to using an LARC, with 63% using condoms. Currently 23 (85%) were using IUCD (both copper and hormonal devices) as LARC.
Qualitative study findings
Women’s experiences with initiating and continuing use of an LARC are explained under four themes, (i) Use of trusted networks for information on LARCs; (ii) Personal motivation and family support in decision to use LARC; (iii) Choice of LARC methods and access to providers; and (iv) Social and professional support instrumental in long term use of LARC, supported by sub-themes.
The figure below (figure 1) shows a conceptual model of LARC use decision making, which emerged inductively from the data. It illustrates women’s staged decision-making process about LARC uptake and use, providing a framework for understanding important influences at each stage. The model identifies the social influences operating at each stage, provided social relationships and personal interactions. As shown in the model, women are interested in initiating use of a contraceptive due to personal motives. They then proceed to gathering information about methods and providers from trusted sources, including female relatives and local LHWs. Experiences of satisfied users lessened women’s reservations about LARC methods; any lingering doubts were also addressed by skilled providers, helping them overcome this barrier to adopting use of a LARC. Women then proceeded to deciding the type of method to use, with support from their spouse, who also accompanied them to the provider. After initiating use of a LARC method, ongoing support of spouse, and skilled providers gave women the confidence to continue use of this contraceptive method.
Use of trusted networks for information on LARCs
Women sought to obtain information about different types of contraceptives, particularly about LARCs from different sources when they were contemplating using an LARC.
Most stated that their source of information about contraceptives in general and LARCs, were predominantly from female relatives (mothers, sisters, aunts, cousins). In all cases, these female relatives had also used contraceptive methods, including LARCs, mostly IUCDs. It seems a common practice, even normative, for married women to share their experiences of contraceptives with other women in their relatives network.
My older sisters are married, and they would talk about family planning methods; so, I knew from them that there were things you can use for having [a] gap in children. One of my sisters has been using the ring (IUCD), for 5, 6 years now. When we have a health problem, we first ask our mother or sister, sometimes mother-in-law also … [Respondent 3, 30-year-old]
In cases where, had medical interventions (e.g. cesarean section) they received information about LARC methods by their obstetricians and nurses. However, they consulted with family members about such advice:
Doctor said that I should have a gap of at least 3 years between children, because of operation (C-Section). She told me that the hospital has Family Planning clinic and I can get the challah (IUCD) and capsule (implant) from there, after my post-partum period (chillah) ends. I asked my mother about this; she and my sister had also used challah (IUCD) and they also told me to start using something … [Respondent 6, 26-year-old]
Verifying information from experienced users and professionals
Various misconceptions about both LARC methods were common. Many mentioned knowing someone who had experienced adverse side effects of IUCD (such as perforation through uterine wall and migrated to the abdomen or kidney) or they knew women who had become pregnant while using these contraceptive methods:
… My younger sister also had it, but she conceived with the tube (IUCD) inside and had her daughter same time as my son [Respondent 12, 24-year-old]
Information fueling these misconceptions was reportedly shared through social networks, where sometimes the use of a particular LARC was discouraged, even by the LHW:
…. I have heard that the rods (implant) can stop menstrual cycles and cause infertility, if used for a long time; so, I decided to use the ring (IUCD) [Respondent 18, 33-year-old]
It was also found that in addition to seeking information from female relatives, women sought advice of local LHWs, which was sometimes biased.
… My sister-in-law was using the capsules (Implant) so I asked her about her experience with using it; she said it was easy to use and she had no problems. Then I asked Baji (LHW) about it but she said the capsules (implant) can cause problem in the woman’s system, like I can stop having my periods or I can have too much bleeding or spotting. She also told me that some women had to take treatment before they could become pregnant again. She said better to get the tube (IUCD), so I decided to get that [Respondent 16, 27-year-old]
Some of the women who had experienced regular interactions with a doctor or a nurse at ante natal clinics and hospital following cesarean section were more likely to take advice from their doctor or a nurse about starting the use of an LARC.
… both my children were born by operation (C-Section); after my second operation, doctor told me to use a family planning method. She said they have capsules, which they put in the arm … [Respondent 14, 27-year-old]
Personal motivation and family support in decision to use LARC
Personal circumstance motivates decision to use LARC
Women’s concerns for their own or their child(ren)’s health was found to be a primary determinant in their decision to start using an LARC method, especially when traditional methods failed.
… the LHW told me that I will not get pregnant if I breastfeed the baby, but I became pregnant again when my daughter was 7 months old. Both my children were born by c-section operation. It’s very difficult to care for two young children, especially after operation so I thought I will have a gap of four, five years before having another baby [Respondent 11, 25-year-old]
A common factor among all the women who opted for LARC was the prior use of other modern contraceptive methods; condoms had been used by all, while some women had also used the contraceptive pill and injections. Women reported the desire to start using a long-term method, citing their husband’s reluctance to use condoms as well as their own difficulties with adherence to the regular taking of pills and receiving injections:
… we used Saathi (condoms) a few times; but my husband did not want to use the condoms and we did not want another child for some time, so I decided to get the tube (IUCD) [Respondent 24, 26-year-old]
Capsules (Implant) are good; better than injection or the tube (IUCD). With the tablets, you have to remember to take it every day and sometimes you can forget to take it on time. Injection also same problem [Respondent 7, 30-year-old]
Support of spouse in decision making
All the women shared that they had discussed child spacing with their husbands and had together considered the long-term contraceptive methods available, the duration of each, and the number of children they wanted. Since there is a cultural norm in Pakistan of seeking the approval of one’s husband in such matters of having an LARC.
My husband is also in favor of having gap in children. I told him about the tube (IUCD) and I can have it for five years or ten years; he said to get the 5 year one [Respondent 6, 26-years-old]
I talked to my husband about it (IUCD); he told me to get the IUCD when we had our first daughter (after two sons), but I wanted to have another girl before getting this (IUCD) [Respondent 30, 28-years-old]
Importance of support from female family members in decision making process
The supportive role of an older female relative, most typically mother, mother-in-law or elder sister was significant for respondents in choosing an LARC method and even influencing the spouse.
Both my children were born with gap of just six month and I wanted to have some gap before another child. So, I talked to my husband about this challah (IUCD) method and told him that there is option for 5 years and 10 years; but he did not allow me. Then I asked my mother-in-law and she told him to give permission to get the challah (IUCD) [Respondent 34, 24-years-old]
This supportive role of older female relatives was also observed in situations where a female relative (mostly a mother or sister-in-law) of the respondent expressed support for the decision of the respondent, citing reasons of low income, and high costs of living:
…. I got the IUCD after I had two children … (Respondent 9, 26-years-old); (MiL joined in discussion) …. after her second daughter, I told her to get the tube (IUCD); I also told my daughter the same thing; for me, both (daughter and daughter-in-law) are equal and having a boy or girl is Allah’s decision. Nowadays, everything is so expensive and raising children properly in limited income is difficult
Choice of LARC method and access to providers
After having decided on starting use of an LARC, women selected the appropriate LARC method and provider. Both these decisions were driven by the experiences of trusted members in their social networks.
Testimonies of LARC users
Respondents sought trusted female family members to enquire about appropriate LARC methods and providers. Their experience with either of the two LARC methods influenced respondents in deciding the choice of method and provider.
I got the capsules (implant) because two, three of my relative got the challah (IUCD) and they suffered from a lot of health problems. They said not to get it (IUCD) [Respondent 27, 29-year-old]
Women also preferred getting advice about LARC methods from providers recommended by a trusted relative:
… I asked my cousin also about the tube (IUCD), I knew she had it; she said she got it from NIH. So, I went there after the post-partum period ended [Respondent 17, 27-year-old]
Endorsement by professionals
LHWs are generally trusted for advice about women’s health, especially reproductive health, as well as their knowledge of contraceptive methods and their recommendations about suitable LARC providers. Some women also relied on their local LHW to accompany them to the selected LARC provider. Respondents invariably approached the LARC provider who was recommended by either a relative or the local LHW or their obstetrician:
I asked Baji (LHW) about the capsules, she also said it is good and very easy to use. She went with me also, to Poly Clinic to get the capsules …. [Respondent 18, 28-year-old]
Ease of access to providers
None of the respondents indicated access issues about LARC use, including distance to provider or affordability. If the chosen provider was at some distance from their residence, respondents generally travelled via public transport, often accompanied by a female relative, local LHW or spouse/husband:
I went to Poly Clinic on the local transport from here, with my sister-in-law (bhabi). She had also got hers from there, so I asked her to go with me (user) [Respondent 5, 29-years-old]
…. she (mother-in-law) took me to N Baji’s (LHW) house and asked her to go with us to the doctor in Falahi Markaz. My mother-in-law said to get the tube (IUCD) which is for 10 years and I had that placed from there. [Respondent 13, 20-years-old]
The respondents mentioned the availability of LARC methods at the local public sector health facilities, including local primary health care and Population Welfare Department clinics. The respondents had easy access to these facilities.
…. I had the tube (IUCD) placed from Falahi Markaz here in our village; other women in the village also got it from there. It’s also near my house and was easy for me to go to … [Respondent 7, 28-year-old]
Social and professional support is instrumental in continuing use of LARC
Women who were using an LARC were generally satisfied with the method and planned on continuing use for spacing or having reached their desired number of children, intended to continue it.
Spousal and family support for continued use of LARC
In continuing to use an LARC, the level of support from one’s spouse and social networks was found to be important. Women countered any negative social criticism when they had the support of their husband. They considered women who did not have support of their husband to be helpless and vulnerable to multiple pregnancies interspaced with very short time intervals:
I told my neighbor about this method as well, but she said her husband did not agree and now the poor thing (bechari) is pregnant again, with her third child. It’s all about the husband’s support in using the contraceptive methods! People say all kinds of things to me, but I say if my husband is with me on this, then I don’t care what you say. [Respondent 2, 24-years-old]
Women reported seeking advice from female family members about side effects and any discomfort experienced. They were generally advised by female family members not to worry about side effects as they were told these effects would settle over time. Women were reportedly reassured by such supportive advice, especially those who were using an LARC for the first time:
Few days after I had my ring (IUCD) placed, I felt some irritation and burning. I told my sister about it and she said it happens for some time, but it will go away in some days, so don’t worry about it. She said she also had it after she got hers (IUCD) but then it was fine. (I: When did she get her IUCD?) She has had it for four, five years now; actually, she had told me to get it after my daughter was born [Respondent 19, 27-years-old]
Seeking counselling and timely treatment from health care providers
Normality in monthly cycles was considered important by all participants; a deviation from routine was worrisome, leading to fears of this being an imminent sign of developing side effects. Respondents shared that their initial experience of some side effects like pain or some spotting or of heavier menstrual bleeding than normal, was alarming for them, and they were anxious about developing more serious health problems. Women reported dreading the thought of having the LARC removed, as they did not want another child at that time.
Initially I did not have any problem; but after about three months, I had some spotting two or three times. That really scared me, because I had heard of other women who had similar problems. But then it settled with the medicine doctor had given me; and now I’m afraid to share with anyone that all is ok for fear that I might develop some side effect again! [Respondent 35, 32-year-old]
Both current and past LARC users appeared to have been counselled well by their provider about the method and any expected side effects. As a result, when women initially noticed side effects, they reported not seeking immediate care in anticipation of the side effects resolving or subsiding with time. LARC providers were generally approached when side effects continued or increased in intensity:
After the IUCD, I had prolonged monthly bleeding, like it was 8 or 9 days and I was still having bleeding. So, I went back to the Falahi Markaz and doctor there gave me a medicine to take for one week, told me not to worry about this …. I took the medicine and now it’s been almost a year and thank God I have not had any problem again! [Respondent 16, 28-year-old]