Lived experience of women who underwent early removal of long-acting Contraceptive Methods in Bedesa town, Wolaita Zone, Southern Ethiopia: A phenomenological study

doi:10.21203/rs.3.rs-29638/v1

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Lived experience of women who underwent early removal of long-acting Contraceptive Methods in Bedesa town, Wolaita Zone, Southern Ethiopia: A phenomenological study

https://doi.org/10.21203/rs.3.rs-29638/v1

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Background

Long-acting contraceptive methods can play a pivotal role in ining reducing maternal mortality. In The total fertility rate of Ethiopia is as high as 4.6 children per woman, which is manifested by short birth-interval. However, this rapid population growth is not in line with the weak economic growth of the country. Therefore, this study was done to explore the lived experiences of women who underwent early removal of long-acting contraceptive methods in Bedesa town, Southern Ethiopia.

Methods

A phenomenological study design was employed from April 16–22, 2020 to conduct this qualitative study among Bedessa town community. Individual In-depth interviews were used to collect data from a sampled study participants recruited through criterion sampling method. Based on the theoretical saturation of data, this study included a total of 10 in-depth interviews of sampled women.. Open code version 4.03 was used to code and facilitate analysis. The study used thematic analysis technique after the transcripts were read and re-read separately by the investigators to identify emerging themes.

Results

This study revealed that the majority of participants were able to mention at least three types of contraceptive methods. Participants frequently said that the side effect of the long-acting family planning methods as the main reason for early removal. Furthermore, heavy and irregular menses were mentioned as the most frequently occurring side effects. Delayed fertility after removal of long-acting contraceptive was one of frequently stated fear by the clients. Some of the participants indicated that counseling provided by health professionals was not adequate.

Conclusion

The majority of our study participants taught that the side effects of long-acting family planning methods outweigh than benefits. Besides, the counseling service provided by health care providers was not adequate. Therefore, proper counseling services should be given to mothers who are taking long-acting family planning methods.

Sexual & Reproductive Medicine

Family planning

long-acting family planning method

early removal

Bedesa

Family planning (FP) is a low cost yet effective method of preventing maternal health problems [1, 2]. There are two types of contraceptives methods, namely short acting and long-acting and permanent methods. Long-acting methods can be used for both limiting and spacing childbirth, while permanent methods used only for limiting childbirths. Short-acting methods are suitable for women who want to space childbirths [3]

Long-acting contraceptive methods can play a key role in reducing maternal mortality. It can substantively reduce the number of unintended births[4]. Moreover, avoiding barriers to the use of contraceptives and enhancing the demand for family planning could prevent 54 million unintended pregnancies. Besides, it could prevent more than 79,000 maternal and one million infant death per year [5].

In Ethiopia, it is common a large family size (number of children) with short birth-interval. The total fertility rate in Ethiopia is as high as 4.6 children per woman. However, this rapid population growth is not in line with the weak economic growth of the country. Such imbalance between populationsize and economic growth will certainly have a negative impact on the wellbeing of the nation.

Family planning is considered as the key strategy used to improve the imbalance mentioned above and tackle existing problems [6].

Contraceptive use helps women to space the births of their children, which benefits the health of the mother and child [7–9]. Studies suggest that the provision of quality family planning services can increase uptake, the prevalence of family planning use, and decreases early discontinuation of contraceptive methods. Though many women who use long-acting contraceptives are happy with their choices, a substantial number of users then request early removal [4, 10]

According to the EDHS-2016 report, the discontinuation rate of modern contraceptives was 35%. Implant and IUD are the highest rated contraceptives with 11% and 13% annual discontinuation rates, respectively. The most common reason for discontinuation of the family planning method is the desire to become pregnant, side effects, wanting a more effective method, infrequent sex or husband away, and inconvenience of use [9].

Another mixed method study conducted by FMOH showed that 17% of the women removed their Implanon before the recommended three-year post insertion removal date [8]. A similar study conducted in the Tigray region showed that the Implanon discontinuation rate in 1 year was 16% [7, 10].

Despite high effectiveness, the use of long-acting family planning methods (both reversible and irreversible) has lagged though they are3 -60 times more effective than the short acting contraceptives during a year of typical use [11]. A study conducted in Arba Minch town showed that heavy and irregular menses was recognized as the potential factors for early removal of Implanon [7, 10].

Wolaita Zone (one of the most densely populated zonareas in Ethiopia) is characterized by a crude population density of 385 people/square kilometer [6]. Since providing the most effective contraceptive methods is a vital strategy for the improvement of balancing population growth with the economic growth of the locality, this study aimed to explore the lived experience of mothers who underwent early removal of long acting contraceptive methods in the study area.

A phenomenological study design was used to explore the lived experience of sampled women in Bedesa town, southern Ethiopia. Those women aged 15–49 years who removed long-acting in the past 12 months were considered as women who recently had long-acting family planning removal were included into the study. A criterion sampling approach was employed to recruit 10 participants. The interview continued until information saturation was reached. Data were collected through in-depth interviews (IDIs) using an interview guide. The interview guide consists of on basic socio-demography, desire for family size, knowledge and experiences of family planning, advantages, perceived side effects of long-acting family planning, perceptions about FP, partner involvement and peer pressure concerning the use of family planning, professionals support and plan on family planning. This recruitment was facilitated through the health center head. Every study participant was encouraged to discuss their opinions openly. All interviews were conducted in a separate quiet room to avoid interruption from outside. Each IDI lasted for approximately 30 to 38 min. Each team checked the contents of the respective interviews. Interviews were conducted in the Amharic language. The free flow of information was encouraged through probing. To ensure the quality of the interviews, interviewers repeated the summary of interview to study participant. The team members double-checked the text of each interview. All interviews were tape-recorded with the consent of interviewees. A unique identification number was assigned to all the recorded files. Audio data were transcribed verbatim and translated to English. The data were first saved in plain text format and imported into open code software version 4.03 to facilitate coding and categorizing. The process of coding began with reading each transcript multiple times and their respective translations to ensure a degree of standardization. The coded data were compared and organized into groups. Finally, the thematic approach was used to classify and organize data according to key categories. The findings encompass direct quotes of women and narrated as without editing the grammar to avoid loss of its meaning. Quotes that best described the several categories and stated the frequently mentioned idea were chosen from several groups.

Ethical Consideration

Before conducting the study, ethical approval was obtained from the ethical review committee of the college of health science, Wolaita Sodo University. Informed written consent was obtained from study participants. The information obtained is kept confidential, and the collected data remained anonymous.

Socio-demographic Characteristics Of The Participants

We carried out ten in-depth interviews among mothers who underwent early removal of long-acting family planning methods. All study participants were married., The majority of participants, were protestant in religion. In terms of age, the participants were between 25–32 years old, and the mean age was 29.10± (3.01SD). The majority of the participants (8 out of 10) were government employees, 2 out of 10 were housewives. Half of all study participants were Diploma holder (5 out of 10).

Table 1

Socio-demographic characteristics of women who underwent early removal of long-acting family planning methods in Bedesa town, Wolaita Zone,2020.
Code	Age	Religion	Ethnicity	Educational status	Marital status	Occupation
IDI1	25	Protestant	Wolaita	Diploma	Married	Health informatics technician
IDI2	32	Protestant	Wolaita	Diploma	Married	government employee
IDI3	32	protestant	Wolaita	2 nd cycle	Married	Home manager
IDI4	25	protestant	Wolaita	BSC	Married	Teacher
IDI5	28	Protestant	Wolaita	Diploma	Married	Runner
IDI6	30	Protestant	Wolaita	2nd cycle	Married	Merchant
IDI7	25	Orthodox	Wolaita	High school	Married	Home manager
IDI8	30	Protestant	Wolaita	Digree	Married	Midwives
IDI9	32	Protestant	Wolaita	Diploma	Married	Government
IDI10	32	Protestant	Wolaita	Diploma	Married	Government

Family planning from user perspectives

This study showed that the majority of participants were able to mention at least three types of contraceptive methods available. These were injectable, pills, condoms, Implanon, and IUDs. Though the study participants tried to mention the names of contraceptives in their own words, some of them were unable to specify the exact names.

“… I know different types of contraceptives, such as the one given for 3 months, contraceptives inserted into the upper arms. The methods are available in the Bedesa health facility. I have the experience of using injectable contraceptives and contraceptive inserted into the upper arms…” (IDI0)

“Family planning helps to prevent unplanned pregnancy … In using contraceptives inserted under the skin; there is no need of reminding daily. When we are using oral contraceptive pills there is a need to remember frequently.” (IDI₄) \

Participants' Perception On Long-actingg Family Planning Method

Women perceive LAFP methods differently. Most of the participants had a fear of procedures during insertion and removal of long-acting family planning. Delayed fertility after removal of long-acting was another frequently stated fear by the clients. Some of them perceived that, these contraceptive methods need eating special food and drinks. Some concerns of women on long-acting family planning methods were fear of death, paralysis, which causes medical illness and discomfort during sex.

“I feared to use loop because of the information that was circulating in the community… mothers who used loop as birth control developed paralysis…. which refrained me from using it (IDI 1)”.

“Implant can move in your body from arm to leg, it can stab you, and you ’can’t work while the implant is in your arm. It is painful on insertion and removal; and challenging to do hard works like cooking food and washing clothes. Health workers are not interested to remove within six months after insertion”. (IDI 10)

“IUD is not good during sex. It can be lost in the body and may cause foul smelling vaginal discharge”. (IDI 6)

Reasons For Early Removal Of Long-acting Family Planning

Even though unreasonable early removal is not advisable, women who are using LAFP have the right to remove it when needed. The majority of participants mentioned that the side effect of the method was the main reason of early removal. There are different side effects mentioned for early removal, of which frequently mentioned were heavy and irregular menses, weight loss, and dizziness. The other side effects that the study participants mentioned were crampy abdominal pain, skin discoloration, itching, behavioral change, numbness, burning sensation on micturation, malaisma, headache, sleep disturbance, amenorrhea, delayed fertility, dysmenorrhea, frequent hunger, thirst, weakness, difficulty of walking, and activity intolerance.

“…I decided to discontinue early because of heavy and irregular menses and weight loss. The bleeding stayed for one to two month. I also had skin discoloration and itchy skin” (IDI₁₀)

“…Implanon was inserted for 3 years, but it was kept only for 7 months. Because, I was not comfortable, my facial skin color was changed and black patches like melasma appeared on my face. In addition to this, there was a movement in my abdomen like baby kicking during pregnancy, persistent neck pain, and absence of menses.” (IDI ₁ )

Almost all clients received counseling services (just before utilization) by the health care provider at the time of the health facility visit. However, some of them mentioned the inadequacy of the counseling service.

“Health workers gave me a counseling service before inserting Implanon. However, they didn’t inform me in detail about the benefits and risks of Implanon.” (IDI3)

“The health care providers informed me that an implant is more advantageous than Injectable. Injectable do have effect on bone damage, cause weight gain and contains additives. Pills are also full of additives, which may lead to gastritis.” (IDI₅).

Male’s involvement in contraceptive use and sharing responsibilities in reproductive life is important. However, there was no consensus about the role of husbands in contraceptive decision making and use. Some women mentioned good support from their husbands for contraceptive use:

“…I stopped the injectable to get pregnant due to the influence made by my husband and few neighbors. Following the cessation of the injectable, I was on normal menstrual period for one year and half. Finally, I got pregnant and faced no problem during the whole pregnancy period until I gave birth at the health center.” (IDI₇₎

Another woman point out that husband’s disapproval was one of the reasons for the early removal of Implanon “… My intention is to use Implanon for 3 years; however, my husband was against my intention. He even fought with me and bitten my hands.” (IDI₁₀)

Desired Family Size

Seeking more children was also found to be the other reason for the early removal of long-acting family planning methods. Majority of women desired two to three children. But some of them desired more than five children

“…. Even though I took Implanon according to my personal choice and voluntary base, I have removed it because of seeking more children.” (IDI₂).

User's Experience On Contraceptive Use

The majority of participants sufficiently explained their lived experience of contraceptive use. The most commonly mentioned experiences were types of contraceptive methods used, duration of using contraceptives and decisions for changing from one family planning method to the other. They also said that long term use resulted in some problems with their health status.

“…Before I gave my first birth, I had been using depo. I used Jadelle after the second child. But Jadelle was removed because of side effects, and then I switched Jadelle to depo.” (IDI2)

Experience After Long-acting Family Planning Methods Removal

This study identified that most women perceive that they regained their health immediately after removing the contraceptive method. Due to the side-effects of contraceptives, some of the study participants discouraged to use any type of contraceptive. Furthermore, most study participants diverted their attention to short-acting contraceptives, mainly Depo-Provera, after the removal of Implanon.

“…After removal of Implanon, I regained my health and peaceful life. I have changed to Depo Provera and I have been comfortable with depo. ” (IDI₁₀)

“… After removal of Implanon, the bleeding was not improved and I went to health center and they removed it. But the bleeding kept without showing any improvement. ” (IDI₇)

Participant Suggestion And Future Plan

Most mothers identified different sorts of opinion regarding long-acting family methods. The most frequently mentioned were the use of a safe method, absence of health professional’s influence, and delaying of contraceptive use till the first child-delivery.

“…information regarding family planning needs adequate counseling. However, Health professionals do not give adequate information. Most of the times mothers get information from the neighbours and get worried. ” (IDI ₁₀ )

“…I visited health facility three months after Implanon insertion to take Implanon off, but the health professional did not agree to remove it before six months.” (IDI ₈ )

This study found that most of the participants were able to mention at least three types of FP methods, which is consistent with a similar research conducted in Arba Minch town[6]. However, the findings of demographic and health surveys of Ethiopia showed that women in reproductive age know at least one method of FP[12, 13]. The possible reason for the difference could be due to frequent promotion or advertisement of the methods by various stakeholders. The findings of this study also showed that a low proportion of respondents had awareness of permanent methods. Our findings were also substantiated by another study from Adigrat town [14] and Nekemte town[15].

Some study participants of this study believe that the implant could move freely in the body and get lost, and they also thought that implant and IUCD cause illness. The result of this study is consistent with the study conducted on Wolaita Zone, Southern Ethiopia [11]. This might be due to the presence of rumors circulating in the community regarding long-acting family planning methods.

It was also found that most women had a fear of procedures during insertion and removal of Implanon. Most women also stated that health care providers do not remove long-acting family planning methods before six months despite women requests. Similarly, another study found that the Implanon removal procedure has created disconfort on the users, and enforced them to remove the contraceptive in another non-public health facility [16]. This may be due to the inaccessibility of removal services at the health facility and lack of adequate information before providing and after removal of long acting family planning methods.

In this study, desiring more children was recognized as one of the common reasons for early removal of implanon. This result is consistent with other studies conducted in Southern and Northern Ethiopia [17–20]. Similarly, another study conducted in southern Nigeria showed that looking for more children causes a high rate of early removal of Implanon [21].

In this study, husband involvement was revealed important for long-acting contraceptive use to get the planned family size. This finding is consistent with the study conducted in Indonesia that husbands support the utilization of long-acting contraceptive methods [22, 23]. This may be because decision making is made mostly by the husband. In contrary to this, another study showed that there is no relation with contraceptive use continuation and husband support[24].

Our study explored problems on the health care providers’ counseling process for mothers who took any of the implants (Norplant, jaddle, or IUD). Accordingly, mothers informed that the counseling was not clear enough on describing the merits and demerits of different types of implants. Also, the professionals assured clients with wrong information for the sake of implanting only. Furthermore, they did not describe the counseling sessions as cordial and open to allow clients to discuss their concerns on the implants freely [7]. This might also be a reason for the early removal of long-acting family planning methods.

This study identified side effects that are reported to be the main reason for the early removal of LAFP, which is consistent with other studies [7, 9, 16, 25–30]. The most frequently mentioned side effects were heavy and irregular menses, weight change, and dizziness. This finding is similar to studies conducted in Ethiopia and other low income countries [7, 25, 28]. The reason for discontinuation may be due to inadequate counseling and lack of support from health care providers.

The finding of this study revealed that weight loss one of the major side effects of early removal of long-acting family planning which is consistent with a qualitative study done in Arba Minch town[7]. On the otherhand, the finding of other studies showed that weight gain is another side of long-acting family planning methods [16, 26]. This may be explained by individual genetic variation and individual differences on the occurrence of side effects.

The findings of this study indicated that the main reasons mentioned for early removal of long-acting family planning methods were fear of side effects, wrong myths and misconceptions about long-acting family methods and desired to have family size. Besides, husband opposition and inadequate counseling were found to be other reasons for the early removal of Implanon. Most of the women regained their health after removal of Implanon. Therefore, health professionals should provide adequate counseling to change the myths and misconceptions of clients on long-acting family planning methods. Moreover, due attention should be given to access to services both for insertion and removal of long-acting contraceptives and to increase male participation in family planning methods to enhance joint decision making.

FMOH: Federal Ministry of Health, IDI: Indepth Interview, LAFP: Long acting Family Planning

Ethics approval and consent to participate

Before conducting the study, ethical approval was obtained from ethical review committee of college of health science, Wolaita Sodo University. Informed written consent was obtained from every study participants. The information’s obtained are kept completely confidential and the collected data remained anonymous.

Consent for publication:

Not applicable

Availability of data and materials

Data was uploaded as supporting files in manuscript tracking sytem

Competing interest:

The authors declared that they have no conflict of interest.

Funding:

Not applicable

Author’s contribution:

AA, MS, LK, MW, HC, and KS have involved in conceptualization, data curation formal analysis. Acquisition, investigation, methodology, software supervision validation visualization writing original draft writing review and editing.

Acknowledgment:

We would like to acknowledge Hepi Project University for providing materials used for the work.

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LAFPBedessa.opcx

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Lived experience of women who underwent early removal of long-acting Contraceptive Methods in Bedesa town, Wolaita Zone, Southern Ethiopia: A phenomenological study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Introduction

Methods And Materials

Ethical Consideration

Results

Socio-demographic Characteristics Of The Participants

Family planning from user perspectives

Participants' Perception On Long-actingg Family Planning Method

Reasons For Early Removal Of Long-acting Family Planning

Desired Family Size

User's Experience On Contraceptive Use

Experience After Long-acting Family Planning Methods Removal

Participant Suggestion And Future Plan

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Competing interest:

Funding:

Author’s contribution:

Acknowledgment:

References

Supplementary Files

Status:

Version 1