Lived experience of women who underwent early removal of long-acting Contraceptive Methods: A phenomenological study

Background: Long-acting contraceptive methods can play a pivotal role in reducing maternal mortality. In Etiopia, the total fertility rate per woman is 4.6. However, this rapid population growth is not in line with the weak economic growth of the country. Therefore, this study was performed 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 to include a total of 10 in-depth interviews of sampled women. Participants were recruited through the criterion sampling method. Open code version 4.03 was used to code and facilitate analysis. Transcripts were read and re-read separately to identify emerging themes. A thematic analysis technique was used. Results: This study revealed that the side effects of long-acting family planning methods were 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 contraceptives was one of the most frequently stated fears by clients. It was also stated that counseling provided by health professionals was not adequate. Conclusion: The majority of study participants taught that the side effects of long-acting family planning methods outweigh the benets. In addition, the counseling services provided by health care providers were not adequate. Therefore, proper counseling services should be given to mothers who are taking long-acting family planning methods.


Background
Family planning (FP) is a low-cost yet effective method of preventing maternal health problems [1,2].
There are two types of contraceptive methods: short acting and long-acting and permanent methods. Long-acting methods can be used for both limiting and spacing childbirth, while permanent methods are 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 also signi cantly 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. In addition, it could prevent more than 79,000 maternal and one million infant deaths per year [5].
In Ethiopia, it is common to have a large family size with a shorter 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 an imbalance between population size and economic growth will certainly have a negative impact on the wellbeing of the nation. Family planning is considered the key strategy used to improve the imbalance mentioned above and tackle existing problems [6].
According to the EDHS 2016 report , the discontinuation rates of Implant and IUD were 35% and 11%, respectively. Another mixed method study conducted by FMOH showed that 17% of the women removed their Implanon before the recommended removal date [7]. A similar study conducted in the Tigray region showed that the Implanon discontinuation rate in 1 year was 16% [8,9]. The most common reasons for discontinuation are the desire to become pregnant, side effects, wanting a more effective method, infrequent sex or husband away, and inconvenience of use [10].
The Wolaita Zone is characterized by a crude population density of 385 people/square kilometer [6].
Providing the most effective contraceptive methods is a vital strategy for the improvement of balancing population growth with the economic growth of the locality. Thus, this study aimed to explore the lived experience of mothers who underwent early removal of long-acting contraceptive methods in the study area.

Methods
A phenomenological study design was used to explore the lived experience of sampled women in Bedesa town, southern Ethiopia. Women aged 15-49 years who removed long-acting therapy in the past 12 months were included. 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 consisted of basic sociodemography, 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, professional support and plans for family planning. This recruitment was facilitated through the head of the health center. Every study participant was encouraged to openly discuss their opinions. 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 ow of information was encouraged through probing. To ensure the quality of the interviews, interviewers repeated the summary of interviews to study participants. The team members checked the text of each interview twice.
All interviews were tape-recorded with the consent of interviewees. A unique identi cation number was assigned to all the recorded les. Audio data were transcribed verbatim and translated to English. The data were rst saved in plain text format and imported into open code software version 4.03 to facilitate coding and categorizing. The coding process 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 ndings 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 the study participants. The information obtained is kept con dential, and the collected data remained anonymous.

Sociodemographic 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+ (3.01 The majority of the participants (8 out of 10) were government employees, and 2 out of 10 were housewives. Half of all study participants were diploma holders (5 out of 10) ( Table 1). User experience on contraceptive use The majority of participants su ciently 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 rst 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) Most women perceived that they regained their health immediately after removal of the long-acting contraceptive method. Furthermore, most study participants diverted their attention to short-acting contraceptives, mainly Depo-Provera.
"…After removal of Implanon, I regained my health and peaceful life. I have changed to Depo Provera, and I have been comfortable with depo. " (IDI 10 ) "… After removal of Implanon, the bleeding was not improved, and I went to the health center, and they removed it. However, the bleeding remained without showing any improvement. " (IDI 7 ) Some participants had 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 require eating special food and drinks. Some concerns of women regarding long-acting family planning methods were fear of death and paralysis, which causes medical illness and discomfort during sex.
"I feared using 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 such as cooking food and washing clothes. Health workers are not interested in removal 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 methods The majority of participants mentioned that the side effects of the method were the main reason for early removal. There are different side effects mentioned for early removal, of which the frequently mentioned were heavy and irregular menses, weight loss, and dizziness. The other mentioned side effects 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, di culty 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 months. I also had skin discoloration and itchy skin" (IDI 10 ) "…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 such as melasma appeared on my face. In addition, 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 by the health care provider. However, some of them mentioned that the counseling service was not adequate.
"Health workers gave me a counseling service before inserting Implanon. However, they didn't inform me in detail about the bene ts and risks of Implanon." (IDI3) "The health care providers informed me that an implant is more advantageous than injectable.
Injectables do have an effect on bone damage, cause weight gain and contain additives. Pills are also full of additives, which may lead to gastritis." (IDI 5 ).
Male involvement in contraceptive use and sharing responsibilities in reproductive life is essential.
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 in uence 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." (IDI 7) Another woman pointed out that the 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." (IDI 10 ) Seeking more children was also found to be the other reason for the early removal of long-acting family planning methods. The majority of women desired two to three children. However, some of them desired more than ve children "…information regarding family planning needs adequate counseling. However, health professionals do not provide adequate information. Most of the time, mothers obtain information from neighbours and become 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 )

Discussion
This study identi ed side effects of long acting family planning methods as the main reason for the early removal which is consistent with other studies [8,[10][11][12][13][14][15][16][17]. The most frequently mentioned side effects were heavy and irregular menses, weight change, and dizziness. This nding is similar to studies conducted in Ethiopia and other low-income countries [8,12,15]. The reason for discontinuation may be due to inadequate counseling and lack of support from health care providers. This study also found that desiring more children was recognized as one of the common reasons for the early removal of longacting family planning methods, which agrees with other similar studies [18][19][20][21]. Similarly, another study conducted in southern Nigeria showed that looking for more children causes a high rate of early removal of Implanon [22].
In this study, husband involvement was very important to use long-acting contraceptive use and to obtain a planned family size. This nding is consistent with the study conducted in Indonesia that husbands support the utilization of long-acting contraceptive methods [23,24]. In contrast, another study showed that there is no relation with contraceptive use continuation and husband support [25].
Some participants believed 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 in the Wolaita Zone, Southern Ethiopia [26]. This might be due to the presence of rumors circulating in the community regarding long-acting family planning methods.
Our study explored problems with the health care providers' counseling process. Another study also showed that the counseling was not enough and health care providers did not to allow clients to discuss their concerns freely [7]. This might also be a reason for the early removal of long-acting family planning methods.
According to the ndings of current study most of the participants had information about family planning methods, which is consistent with similar research conducted in Arba Minch town [6]. However, the ndings of demographic and health surveys of Ethiopia showed that women of reproductive age know less information on family planning methods [27,28]. The possible reason for these differences could be the frequent promotion or advertisement of the methods by various stakeholders. The ndings of this study also showed that a low proportion of respondents had awareness of permanent methods. Our ndings were also substantiated by another study from Adigrat town [29] and Nekemte town [30].