LARCs administered by HEWs in the current study were effective in preventing pregnancy with low removal and low expulsion, which is comparable with previous studies where the service was provided in health centers [18, 19]. Level of discontinuation varied depending on the duration of follow-up, which for IUCD was 19.9% in a 10-year retrospective study in a university hospital in Nigeria , while it was 4.5% in a five-year retrospective study in the same country . For implants, it reached as high as 24% in a retrospective study done in the United States  and even higher in Nigeria . The most common reason for discontinuation of use in the current study was the desire to become pregnant, followed by menopause or side effects. When the reason for discontinuation was side effects, the rate of discontinuation was higher in the first year, and when the reason was the desire to become pregnant, it slightly increased with the length of follow-up [20, 21, 23]. In our study, side effects accounted for most of the reasons for discontinuation. The maximum length of follow-up in the current study is eight months, and more discontinuation is likely for fertility reasons if the follow-up of the study participants was continued beyond this period.
Contraceptive prevalence has significantly improved in Ethiopia in the past decade [2, 24]. This change is partly attributed to the work of the health extension program through the delivery of health education, which is likely to have increased contraception awareness and the demand for LARCs [8, 25–27]. The finding of the current study is in line with these. The availability of health posts in short distances for the community staffed with HEWs improved access by reducing cost and time for the provision of LARCs and at times were the only outlets to access modern family planning. This is a significant finding of task-sharing because more qualified HEWs may further increase access through direct service delivery instead of just activities to raise awareness.
In the current study, new LARC acceptors were more likely to be empowered to decide on contraception use, and access to modern family planning is less dependent on health posts and L4HEWs. In such areas where there are alternative service providers, it may be cost-effective to engage empowered clients and relocate these resources to areas where alternative outlets are limited [28, 29].
Method mix in Ethiopia is improving slowly . Injectable contraception slightly declined from 80% in 2011 to 70% in 2016 [8, 24]. Such skewed distribution of method use may be a reflection of availability and readiness of the health sector to provide other options . In this study, from the facility performance report, mixed LARC methods increased by threefold over an eight-month period.
A study that assessed factors affecting LARC use in Nigeria, Ethiopia, and the Democratic Republic of Congo identified the lack of equipment, private room, and products as a cause for the limited provision of that option in the studied countries. In Ethiopia, 44% of sites assessed indicated that LARC was available along with other options . When availability was coupled with capacity building to nurse providers, method uptake among new users and method shift improved [31–33]. Method shift was well demonstrated in the present study where both capacity building and the availability of equipment and supplies were ensured.
L4HEWs played a role in method choice mostly by giving information during counseling and direct recommendations in a small proportion of cases [34, 35]. Significantly more clients are empowered to decide on what type of LARC to use on their own or at least to discuss it with their partners. This is the general trend where informed and empowered clients who know about LARCs and would like to space births tend to prefer them [25, 36]. Other studies in rural areas have indicated that established gender norms make it impossible for a married woman to make decisions in fertility and family planning methods . It is therefore important to keep addressing these issues whenever they are identified as challenges.
Most LARC users were satisfied with the method they were using although they experienced minor side effects. The low level of side effects in general and the extremely low level of severe side effects leading to discontinuation in the current study is in agreement with many previous studies [38–42]. Side effects are often an important reason to discontinue treatment [43, 44], and since patients who experienced them may develop negative attitudes toward these methods, it is important for providers to counsel clients on the major side effects and how they could be handled if they occur.
One of the strengths of this study is it assessed LARC delivery through L4HEWs in a setting where there are few studies or reports that document service delivery by L4HEWs. Its findings have a clear potential to serve as an evidence base to better implement task-sharing activities in Ethiopia. One of the limitations arises from its design. A retrospective cohort study design is open for recall bias in some of the data, which were collected by interviewing the respondents. Also, only a limited number of relevant variables could be examined compared to what could be done if the data were collected prospectively. However, the cohort nature of the design allows for a discussion of causal associations between exposure and outcome variables.