In this study, the overall proportion of implants discontinuation among women was 55.3% (95% CI:51.21%-59.34%) of which Implanon was 34.3% and Jaddles 21%. The proportion of Implanon discontinuation is in line with a study conducted in Mekelle city, North Ethiopia 38%(24). This might be due to the similarity of study design and religion composition between Mekelle and Bahir Dar cities. However, for Implanon, this is lower than a study done in Debretabore, Northwest Ethiopia, 65% (95%, CI: 60.4–69.5%) with a mean duration of 21.5 ± 8.4 months (22). The most suggested reason for this might be time elapsed, education as it was not associated factor for discontinuation in Debretabore.
Implant discontinuation in this study was low compared with secondary data analyzed from EDHS 2016, where 61% of implant users discontinued (11). This might be due to the discrepancy of population structure of the national pattern and variation in duration of utilization before discontinuation. This study also lower than a study done in Colorado, Western United States that is 81.7% (25). The possible explanation might be the discontinuation in Colorado was within 30 months of utilization. The other explanation might be most of the health professionals in our setup might didn’t easily accept complaints of removal since the proportion of utilization of implants is low (18.4%) in our setup (26).
However, the implant discontinuation in this study was higher than that of studies conducted in the Sidama region, southern Ethiopia of 10.3% (27). This difference might be due to duration of utilization in Sidama region was within one year and presence of the religious varieties in Sidama region, as most of the study participants in Bahir Dar were Orthodox. Recently even if the proportion of implants utilization is increasing in Ethiopia, customers visit health facilities for removal is also increasing since in earlier times a significant number of users think impossible to discontinue the implants before the due date after once inserted due to awareness gap(10). And also, due to the pandemic of COVID-19 health care providers might not expense much time for detailed counseling.
The current finding is also higher than the study conducted in Uganda, 6.8%(28), Nigeria, 58.1%(29), a systematic review and meta-analysis in low-income countries, 20%(8), and Maryland, 33.2%(30). This difference might be due to culture and religion may contribute to this gap as more than 90% of this study participants were orthodox Christian. This might be due to the proportion of discontinuation in Uganda, low-income countries and Maryland showed for only within one year and in Nigeria within three years of utilization. In addition, the study design is community-based in Uganda and retrospective in Nigeria. This difference may also be due to inadequate pre-injection counseling, as evidenced by 62.7% of participants in this study were not counseled about adverse effects and were not counseled about the benefits of implants. Furthermore, this difference may be due to differences in socioeconomic status, knowledge, and attitudes toward implants compared with the above countries.
In this study, the odds of discontinuation of implants were reduced by 51% and 61% among women who have no formal education and attended primary school respectively compared with women who attended college and above. This is in line with related studies conducted in Bahir Dar, northwest Ethiopia (19) and Debre Markose town, northeast Ethiopia (31). This finding is incoherent to my expectation and the possible explanation might be women who had higher education levels might seek healthcare sooner than their counterparts when they have complaints and any disturbance from normal physiology and this might increase to discontinue (19). And also, women who have lower educational levels might accept counseling and reassurances provided by health professionals about their complaints of implants so that they might reduce discontinuation.
On the other hand, this finding is not supported by a study done in Sidama region, Southern Ethiopia (32), and Hawassa City, Southern Ethiopia (1). This finding is incoherent to my expectation and the possible reasons could be different as follows. This is might be due to the variety in the composition of study participants concerning educational level in which more than half of the participants in this study attended secondary school and above. It might be also due to the differences in study design (community based) and duration of implants (for one year) compared to a study conducted in Sidama region. The differences in sociocultural of the population might also brought this variation.
This study revealed that the odds of discontinuation of implants among women who desire to be pregnant in the near future was 2.6 times higher than their counter parts. This is in agreement with studies done in Ambo town, Central Ethiopia (33), Hawassa city [1], analyzed of EDHS 2016 data (11), Kenya (34), Nigeria (35), and Zambia (36). The suggested reason could be the improper choice of methods as the nature of the implant is long-acting. Evidence shown that implants must be removed when the clients have desire to conceive (37). The other possible reason might be women with less or have no children might intend to have children as evidenced by 19% and 55% of the study participants in this research had no alive children and have one-two Childrens respectively. And also, this might be due to more than 60% of participants in this study had a desire to be pregnant in the near future.
Women who had not used modern contraceptives before their current implants were about 2.0 times more likely to discontinue their implants than other women. This is in line with a study done in Kucha District, southern Ethiopia where didn’t use ever modern contraception was a determinant factor for discontinuation(38). On the other hand, this finding is not supported by studies conducted in Sidama region (32), Hawassa city (1), and worldwide (6). This could be experienced mothers acquired the necessary knowledge and attitude towards the implants, while others could be influenced by false beliefs, myths, and misconceptions. This might also be due to women who have used contraceptives before current implant and experienced different side effects especially from short-acting could appreciate the safety and other advantages of implants and can tolerate minor side effects (7). On the other hand, this difference also might be as a result of familiarity and high prevalence of implants utilization in developed nations compared to our setup(6).
The odds of discontinuation of implants among women who had not received pre-insertion counseling services about the benefits of the implants was 1.7 times higher than from their counter parts. This is parallel with studies conducted in Sidama region (32) and Hawassa City (1). The possible reason for this similarity might be attributed to didn’t receive counseling about the advantages of the method might have a negative impact on users to tolerate minor discomforts or side effects (39). Pre-insertion counseling about the possible side effects and support by health professionals might help women to continue the utilization of contraception. On the other hand, this similarity might be due to the quality-of-service delivery is almost similar across parts of our country regarding addressing comprehensive counseling services.
However, this finding is inconsistent with a study conducted in Myanmar (12). Proposed explanations for this may be due to lower socioeconomic status, lower quality of services, and lower participant attitudes towards implants in our system than in Myanmar (38). This is evidenced by only 30% of all women using modern contraceptives were informed at the time they started the current method about the method’s side effects, what to do if they experience side effects, and other possible solutions(39).
The odds of discontinuing implants among women who experienced side effects were about 2.0 times higher than those who did not experience side effects. This is consistent with the studies conducted in analysis of EDHS 2016 data (11&40), Nigeria(41), South Africa(420, and North America(430.The most likely reason for this is that once a woman develops side effects, she does not tolerate the counseling and treatment services offered by health care professionals for fear of developing other health complications in the future(15). On the other view, it may be due to discomfort, not well addressed pre-insertion counseling about possible side effects or development of side effects may lead to other physiological or psychological effects. Unexpected changes in menstrual bleeding due to the nature of the method by itself might enforce women to seek removal (44).
Also, when there is the development of side effects women might influenced by their relatives and partners(45). Probably some of the side effects may not be improved after management given for some users and this leads to the removal of the method. However, the finding of this study contradict with a study done in Dale district, Southern Ethiopia where developing side effect was not associated with discontinuation of Implanon(23).
Limitation
Since this study was conducted on implants discontinuation as a whole unlike most of other studies which were done on a single contraceptive, it was somewhat challenging to obtain literature in line with the title (especially in our nation). Since it is a cross-sectional study, it is not possible to establish a temporal relationship between discontinuation of implants and explanatory variables.