Ensuring sufficient service capacity for removals of long-acting reversible contraceptives: a mixed-method study of provider experiences in Senegal

Abstract

Background: As the number of implants and intrauterine devices (IUD) used in sub-Saharan Africa continues to grow, ensuring sufficient service capacity for removals is critical. This study describes public sector providers’ experiences with implant and IUD removals in two districts of Senegal. Methods: We conducted a cross-sectional study with providers trained to insert implants and IUDs from all public facilities offering long-acting reversible contraceptives. Data collection elements included a survey with 55 providers and in-depth interviews (IDIs) with eight other providers. We performed descriptive analysis of survey responses and analyzed qualitative data thematically. Results: Nearly all providers surveyed were trained in both implant and IUD insertion and removal; 42% had received training in the last two years. Over 90% of providers felt confident inserting and removing implants and removing IUDs; 15% were not confident removing non-palpable implants and 27% IUDs with non-visible strings. Challenges causing providers to refer clients or postpone removals include lack of consumables (38%) for implants, and short duration of use for implants (35%) and IUDs (20%). Many providers reported counseling clients presenting for removals to keep their method (58% implant, 31% IUD), primarily to attempt managing side effects. Among providers with removal experience, 78% had ever received a removal client with a deeply-placed implant and 33% with an IUD with non-visible strings. Qualitative findings noted that providers were willing to remove implants and IUDs before their expiration date but first attempted treatment or counseling to manage side effects. Providers reported lack of equipment and supplies as challenges, and mixed success with difficult removals. Conclusions: Findings on provider capacity to perform insertions and regular removals are positive overall. Potential areas for improvement include availability of equipment and supplies, strengthening of counseling on side effects, and support for managing difficult removals.

Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal

“…All facilities had staff trained on both insertion and removal. We observed some minor gaps related to the availability of equipment and consumables for regular removals which aligns with findings from the provider interviews from this study reported elsewhere ( 16 ). Importantly, this study was performed in public facilities benefiting from NGO support, therefore as found in other studies, the availability of equipment and consumables may be high compared to other facilities ( 7 , 21 – 23 ).…”

“…We conducted a cross-sectional survey of all public health facilities offering insertion of long-acting reversible contraceptives (LARCs) in two districts of Senegal - urban Dakar Centre and primarily rural Kolda). This study was part of a larger project that also examined client and provider experiences with removal services; these results are presented elsewhere ( 16 , 17 ). Trained research assistants administered the health facility questionnaire to the in-charge of the facility or designee (maternal and child health department in-charge or midwife); after they provided written consent for the health facility, these respondents could solicit input from other staff based on expertise relevant to specific questions.…”

What is needed to improve quality of implant removal services in Nigeria? results of a landscape assessment

“…Training opportunities that foster clinical competency are needed for training in removals: Christofield et al reported that a substantial percentage of providers in Uganda and Kenya never practiced implant removal on a client during training (18). In Senegal, Lebetkin et al reported substantially higher percentages of providers who felt confident in performing uncomplicated removals (96 percent) than in our Nigeria assessment, but 15 percent did not feel confident removing non-palpable implants and an additional 15 percent did not provide this service (36).…”

Removal of long-acting reversible contraceptive methods and quality of care in Dar es Salaam, Tanzania: Client and provider perspectives from a secondary analysis of cross-sectional survey data from a randomized controlled trial

“…Despite this increase, there has been little attention to LARC removal in LMICs, prompting researchers and advocates to identify LARC removals as an overlooked aspect of contraceptive care, with training and availability of services for removals lagging behind insertions [6]. The limited existing literature on LARC removals from LMICs points to barriers including long wait times, associated costs, provider refusal and unavailability, and provider training [2,[7][8][9][10][11][12]. Providers can act as gatekeepers to LARC removal, encouraging clients to continue use of the method or refusing to provide the service altogether, reflecting what has also been documented in the U.S. [12][13][14].…”