In this study, approximately half (53%) of the surveyed women attending public family planning clinics in Mbarara City, Southwestern Uganda opted for early removal of their contraceptive implants. The identified factors associated with early contraceptive implant removal were; experiencing side effects, selecting an implant for career-related reasons, and intended duration of implant use less than two years.
The prevalence of early implant removal in our study was high at 53%. Comparable findings were observed in a study in Kembata, Ethiopia, where early implant removal stood at 56.4%. Both studies, conducted in low to middle-income countries, were multicenter and featured a majority of participants aged 21–35 years—a demographic linked to high fertility rates (19). In Uganda, this age group is known to have a peak in the general fertility rate (260 births per 1,000 women) (1)
The prevalence in our study is higher than have been found in related studies within Uganda Kawempe National Referral Hospital reported a 42% early implant discontinuation, possibly influenced by the definition of early removal at 18 months; additionally, a health facility-based study in Wakiso district, Uganda, revealed a 31% prevalence, potentially attributed to associated removal costs (6, 20). Our study's prevalence also exceeded that of a tertiary center in Ilorin, Nigeria (26.1%)(21), with the difference potentially explained by the higher education levels in the Ilorin study (65.9% tertiary education) compared to our study (22.4% tertiary education). Higher education equips women to comprehend contraceptive implications, fostering continued usage despite potential challenges, as educated women have access to diverse information sources beyond healthcare workers (21, 22).
The prevalence in our study is lower than the one found in a study at four public health facilities in Debre Tabor, Ethiopia where the prevalence of early implant discontinuation was 65%; this could be because the cut-off for early implant removal was set at 2.5 years (9). The study in Ethiopia also included participants 15–49 years some of whom we missed in our study when we include those aged 18–49 years. The difference can as well be due to the socio-cultural differences among the participants in the different study settings. Women in the bracket of 15–19 years in sub-Saharan Africa have been associated with a high likelihood of contraceptive discontinuation due to desire for pregnancy (23).
In our study, women who at the time of implant insertion had intended to have them for < 2 years were more likely to remove them early compared to those whose intended duration was ≥ 2 years. This finding is consistent with the finding in the study conducted in public health facilities in Ethiopia where women were more likely to have early implant removal if they desired to conceive in the near future (< 2 years) as compared to one who desired to conceive later. (24) This might be due to women who, at the time of implant insertion, may have experienced a pregnancy loss, or were anticipating completing their career obligations soon but still desired to have children in the near future (24, 25). While no studies directly link career obligations to early implant removal, women may choose implants either to limit family size after reaching their desired number of children or to space pregnancies. Some women opt for implants due to career responsibilities, wanting to fulfill work or study commitments before committing to conceiving children. We hypothesize that women choosing implants for career-related reasons may be more prone to early removal. Initially focused on avoiding pregnancy to fulfill work or study commitments, their priorities may shift once these obligations are met. This shift, coupled with concerns about childlessness or aging, may contribute to the observed pattern of early implant removal. Further scientific inquiry into the interplay between career aspirations, contraceptive choices, and family planning outcomes could provide valuable insights into these complex dynamics.
Participants who experienced side effects had a higher likelihood of opting for early implant removal, aligning with similar observations in a study conducted at a national referral hospital in Central Uganda and a multicenter investigation spanning four public facilities in Ethiopia (6, 9). This may be because some of the side effects may interfere with the socio-cultural values of women which may be unacceptable in some settings. Also, women may fail to tolerate some of the side effects or fear anticipated (even when unjustified) complications related to these side effects or myths (26).
Our study findings have implications for public health and point towards opportunities for optimizing contraceptive counseling strategies. Enhancing pre- and post-insertion counseling could alleviate concerns, particularly among women susceptible to side effects. Additionally, a tailored approach is warranted, encouraging women with plans for implant use less than two years or those motivated by career obligations to explore short-acting contraceptive methods as more suitable alternatives. These measures collectively contribute to minimizing the public health consequences of a high contraceptive discontinuation which include career drop-outs, unsafe abortions, undesired large family sizes and increased family expenditure.
Limitations
Our study was subject to several limitations that are worth mentioning. First, considering the fact that we relied on self-report for some of the exposure factors, there is a potential for social desirability bias, wherein participants may have provided responses they deemed socially desirable, leading to the underreporting of sensitive issues or the overreporting of socially-accepted behaviors, such as career ambitions. This bias is likely to exaggerate the reported factor associated with early implant removal. Secondly, the study's scope was confined to women attending public family planning clinics in Mbarara City. As a result, the generalizability of our findings may be limited to those settings and may not accurately represent the picture that applies to women attending private facilities.
To further enrich the understanding of the factors influencing early implant removal, we recommend the implementation of qualitative studies specifically designed to explore patient and healthcare providers' experiences and perspectives. Additionally, conducting more extensive scientific inquiry into the cultural factors influencing women's attitudes towards implant discontinuation would contribute to a more comprehensive understanding, thus better informing family planning programs in the region.