This study enrolled 359 participant’s majority (53.8%) of whom were aged 40–44 years. This age group is lower than the mean age of 51 (4.1) years reported in a Turkish study29. Nearly two thirds (65.2%) of the study participants lived in the rural settings, a finding similar to that of a Kenyan30 study at 62.6% and two Nigerian31,32 studies where more than two-thirds (68.6%) and 63.2% respectively lived in the rural settings. This finding contrasts with that reported in Malawi33 and Ghana34. In Malawi33 than two-thirds (80.2%) of the women enrolled lived in the rural settings while in the Ghanaian study34 more than two-thirds live in the urban settings. Furthermore, most (72.1%) of the participants enrolled were married just like that reported in a previous study conducted in Nigeria32 where 71.8% were married. This is contrast with Kenya30 at 51.6% and Botswana35 (32.9%) was lower than that in the current study. Most (63%) of the women enrolled got their first child when aged between 20–34 years. This finding matches that from Nigeria31 at 53.8%. Furthermore, 45.4% of this study’s participants were multiparous, a finding higher than Malawi33 at 34.1%. Parity is a major predictor for contraception use. The higher the number of children, the greater the likelihood for contraception. Parity assessment also goes in line with the fact that more than half (54.7%) of this study participants did not have fertility desire. A finding that contrasts what was reported in Malawi33 and the United States of America36 where 58.8% of the participants still had a fertility desire.
Secondly, this study reports that less than half 160 (44.6%) of all the perimenopausal women enrolled were using contraceptives. Although this figure was higher than the contraceptive rate reported by KDHS at 37.1% in women aged 40–49 years, it is still unacceptably low.11 This low uptake rate could be attributed to the fact that many participants had a chronic or comorbid disease which could cause adverse pregnancy outcomes. Studies in countries with developed economies showed a high prevalence of rate contraception use despite a chronic disease with a prevalence of 89.3% in Iran37 and 73.7% in USA38 This is because these countries with developed economies have better health policies, economic status and behavioural factors that promote contraceptive use. The overall proportion of contraception reported in this study matches that reported in Canada where the overall proportion of contraception use among women aged 40 years or more was 40.3%.39 The rate of contraception uptake was stratified by age brackets, with the highest proportion (62.5%; n = 100) being among those aged 40–44 years. This proportion of contraception among those aged 40 to 44 years of age is higher than that reported in a previous Kenya Demographic Health Survey (KDHS) of 201411 at 48.4%. This difference could be attributed to temporal changes in trends. As the population rises, economic circumstances change and more women get sensitized, so does the proportion of contraception use. However, the KDHS study was national, and this could influence the overall proportions compared to the current study which was conducted in a single centre in a public national hospital. Additionally, the proportion of contraception among women aged 40–44 years reported in this study is higher than that in Malawi33 where 37.5% of women in this age group were on contraceptives. Higher proportions of contraception among women aged 40-44years were reported in the United States of America at 75%38 and in a systematic review sanctioned by the European Society of Human Reproduction and Embryology (ESHRE) between 66–90%.40 (Baird et al., 2009). This difference could be attributed to socioeconomic differences, affordability and accessibility to contraceptives in the countries under review.
Third, among all participants on contraceptives, 92.5% of them were using modern contraceptives; a finding that compares to a Turkish demographic health survey of 2013 at 90.9%.41 A previous study42 proposed that women who have contraindications for using combined hormonal contraceptives can use progestin-only contraceptives such as pills, implants and injectables. This study reports that DMPA was the most commonly (23.1%) used contraceptive by women older than 40 years. The high DMPA use reported in this study could be attributed to its rising popularity Sub-Saharan Africa in comparison to global rates43. Furthermore, its high effectiveness, convenience, relatively long duration of action and secrecy especially in women whose spouses oppose the use of contraceptives could contribute to the high usage43. The low adoption of DMPA in countries with developed economies could be because progestin injectables, pills and implants have unwanted side effects such as heavy, irregular, prolonged uterine bleeding44. For late reproductive age women with a desire for conception, DMPA causes fertility delay which is ruinous when it co-exists with advanced maternal age.45 (FSRH, 2017). The risks of DMPA use could also outweigh its benefits in patients with uncontrolled blood pressure (≥ 160/95mmHg), stroke, ischemic heart disease, vascular disease, diabetes with vascular disease and in those with multiple risk factors for cardiovascular disease.45 Therefore, premenopausal women with chronic diseases and other comorbidities could use progestin implants as they are safer compared to DMPA until menopause.44
This study reports a low (1.25%) utilization rate of combined oral contraception (COCs) among women aged 40–44 and more than 50 years while none of those aged 45–49 years used COCs. These findings are consistent with findings from other demographic health surveys conducted in Ethiopia46 and Nigeria47 where low rates of COC use of 2.1% and 1.4% respectively. The clinical decision to recommend the use COC in women over > 40 years is based on health risks and non-contraceptive benefits of this form of contraception.48 These COCs are contraindicated for women with risk for cardiovascular disease attributed to smoking, obesity, uncontrolled hypertension, or diabetes.48 Male or female sterilization is a popular method in the Western countries with 68.9% of women older than 40 years in the United States of America reporting their sterilization or that of their partners.49 Particularly, male sterilization (vasectomy) is very common in developed countries with approximately 28% of women aged 40–44 and 30% of those aged 45–49 years reporting that their male partners had undergone vasectomy in the United Kingdom.50 However, in demographic health surveys conducted in Kenya,11 Nigeria47 and Ethiopia46, none of the perimenopausal women interviewed reported that their male spouses had undergone vasectomy. This is because many African women have a negative perception on vasectomy as it causes impotence to their partners, it is not culturally acceptable and increases the likelihood of marital infidelity.51 On the other hand, this study reports that Bilateral tubal ligation (BTL) was the second most popular contraceptive method used by 12.5% of women aged 40–44 years with a declining probability of use as the age groups advanced. This could be attributed to the fact that majority of the women older than 40 years had achieved their desired family size and had chronic illnesses making BTL an optimal contraceptive option. This explains the reason why the hospital data obtained from this study was almost double that previously reported average of 7.1% in Kenya’s demographic health survey11. Despite this increasing popularity of BTL, sterilization does not confer non-contraceptive benefits of treating vasomotor symptoms and regulating menstrual cycles that have been reported48 with other forms of oral contraceptives.
Lastly, the study reviewed participants characteristics that promoted or impeded contraception uptake. Women aged between 40–44 years were significantly more likely to use contraception compared to those aged 45–49 years (p = 0.047) and older than 50 years (p = 0.003). This finding is similar to previous studies in Malawi33, Canada39, Congo52 and Ghana.34 Older women have reduced likelihood of pregnancy and coital frequency limiting their desire for contraception.36 This contrasts findings from countries with developed economies such as the United Kingdom where there was a higher uptake of contraceptives among perimenopausal women.50 In a study conducted in Rochester in New York, women in their forties had a low perception of being pregnant despite presenting with unplanned pregnancy.36 This matches with the current study’s finding where 14.5% of the women enrolled reported having had unplanned pregnancy in their forties. It is recommended that women in their forties use contraception to prevent unintended pregnancies due to the increased likelihood of fetal-maternal morbidity and mortality and advanced risk of chronic comorbidities further worsening pregnancy outcomes.53
Married women were more likely (p = 0.005) to be on contraceptives than the non-married similar to a study in Ethiopia54 (p = 0.002). In Malawi33, it was reported that the use of contraceptives among married women increases with the advancement in age (peaking between 40–44 years). Couples who are married might opt to postpone conception using contraceptives, or they might be content with the number of children already born, increasing their desire for contraception.33,55 Married women have a higher coital frequency compared to single women further increasing their need for contraception to either space or postpone childbirth.56 Furthermore, multiparous women had a significantly greater likelihood (p = 0.003) of using contraceptives compared to women with low parity. This is similar to findings in Nigeria31 Vanga-Congo52 where multiparous women were significantly (p < 0.001) more likely to use contraceptives compared to women with a low parity. Women with many children have a lower desire for children, further increasing contraception uptake compared to low parity women who might still desire to conceive.57
Those professing the catholic faith were significantly (p = 0.013) more not to use contraception compared to those professing other faith in this study. This study found 70% of Catholics did not use contraceptives which was even higher than another study conducted in Kenya58 where Catholics were less likely to use a contraceptive method than those with a different religious background. The Roman Catholic Church discourages its faithful’s from using modern contraceptives as birth control measures as it promotes marriage promiscuity.58 (Agata, 2020). In countries which are predominantly catholic, the church influences the government policies, limiting contraceptive use. Despite these measures, Catholics are still using modern contraceptives such as women of reproductive in Zambia59 at 47.6 percent (Lasong, 2019),
Women diagnosed with hypertension were significantly (p = 0.013) more likely to use modern non-hormonal contraceptives compared to hormonal contraceptives. The most common contraceptive methods used by the hypertensive women were bilateral tubal ligation and copper intra uterine device at 30.8% each. This is similar to a study in Iran37 where 37.8% of women over 40 years used sterilization, while the second popular method used was withdrawal (35.4%) as most of these women reverted to natural methods after the diagnosis of hypertension. Previous studies have reported that the incidence of hypertension in non-pregnant women increases with the advancement of age, making perimenopausal women at an increased risk.60 For women on hormonal contraceptives, such as combined oral contraceptives, there is need for a complete evaluation for obesity, hypertension, diabetes or migraine and smoking history to evaluate for suitability of use.61 This is because women using progestin-only pills and have pre-existing hypertension have been noted to have an increased risk of stroke compared to hypertensive women not on this form of hormonal contraception.61
Cardiac conditions such as rheumatic heart disease, ischemic heart disease, cardiomyopathy, pulmonary hypertension, arrhythmias and congenital heart disease are also at risk.62 This study observed that 42 (11.7%) of the women enrolled had a history of heart disease with less than half of them 17 (40.5%) were on contraceptives. A mixed study in Uganda found a low prevalence of 14% in women aged 15–55 years with rheumatic heart disease.63 Cardiac diseases could lead to life threatening events and maternal-fetal complications thus contraceptive use is extremely vital to protect against unintended pregnancies64 Pregnancy is contraindicated in some cardiac diseases such as severe mitral stenosis, severe ventricular systemic dysfunction and severe coarctation.64 The likelihood of thrombotic stroke occurrence was demonstrated to vary based on the estrogen-ethinylestradiol dose and progesterone.20,65,66 However, the transdermal patch may confer greater likelihood for stroke compared to combined oral contraceptives65,66. The use of combined oral contraceptives among women with heart disease increases the risk of arterial, venous and cardiac thrombosis.65 non-hormonal contraceptives such as barrier methods are considered to be safer for cardiac patients although they carry a higher likelihood (five-fold) of contraception failure.67
This was a hospital-based study and its findings cannot be generalized to the entire community as most of the women enrolled had comorbidities that made them visit the hospital. There is need for future studies conducted in communities and adopting mixed methods to assess the influence of probable contraception use confounders such as cultural and geographic factors.