Expanding Contraceptive Method Choice With a Hormonal Intrauterine System: Results From Mixed Methods Studies in Kenya and Zambia

Sitrin, Deborah; Pfitzer, Anne; Ndirangu, Gathari; Kamanga, Ameck; Onguti, Brenda; Ontiri, Susan; Chilambwe, J.; Kabwe, Victor; Aladesanmi, Lola; Elliott, Leah; Bhatnagar, Neeta

doi:10.9745/ghsp-d-20-00556

Cited by 6 publications

(16 citation statements)

References 28 publications

(32 reference statements)

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“…Similar to findings from another hormonal IUD pilot program in the region [ 17 ], qualitative interviews indicate that some women may not be willing to try a method they are hearing about for the first time. Since the hormonal IUD was relatively new in Zambia, it is not surprising that many women learned about this method from providers.…”

Section: Discussionsupporting

confidence: 53%

“…Initial efforts to introduce the hormonal IUD in Zambia can provide valuable learnings that can inform broader method introduction in Zambia and other countries. A recent pilot study of hormonal IUD introduction with postpartum and postabortion care clients in four provinces in Zambia found high satisfaction and continuation rates among users, with providers also reporting generally high satisfaction among women trying the method [ 17 ]. However, existing evidence on uptake of the hormonal IUD among the general population in public sector settings remains limited.…”

Section: Introductionmentioning

confidence: 99%

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What are the prospects for the hormonal IUD in the public sector? A mixed-method study of the user population in Zambia

et al. 2022

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Background The levonorgestrel-releasing intrauterine device (IUD)—also known as the hormonal IUD—is a highly effective contraceptive method that has not been widely available in the public sector in Zambia. Early introduction efforts can provide critical insights into the characteristics of users, reasons for method choice, and experiences getting their method. Methods We conducted a survey with 710 public sector clients who received a hormonal IUD, copper IUD, implant or injectable in two provinces of Zambia, and additional in-depth interviews with 29 women. We performed descriptive analyses of survey data and fitted multivariable logistic regression models to assess factors associated with hormonal IUD use. Qualitative interviews were analyzed thematically. Results Factors associated with hormonal IUD use included full-time or self-employment (relative to both implant and copper IUD use), as well as being older, wealthier, and partner not being aware of method use (relative to implant use only). Common reasons for choosing long-acting methods were duration, perception that the method was “right for my body,” and convenience. In addition, a portion of hormonal IUD acceptors mentioned effectiveness, potential for discreet use, few or manageable side effects, and treatment for heavy or painful periods. Between 83 and 95% of women said that they were counseled about menstrual changes and/or non-bleeding side effects; however, more hormonal IUD acceptors recalled being counseled on the possibility of experiencing reduced bleeding (88%) than amenorrhea (43%). Qualitative interviews indicate that women seek methods with minimal or tolerable side effects. While most women reported their partner was aware of method use, men may be more consistently involved in the decision to use contraception rather than in the choice of a particular method. Qualitative results show an appreciation of the lifestyle benefits of reduced bleeding (especially lighter bleeding), although amenorrhea can be cause for concern. Conclusions Initial efforts to introduce the hormonal IUD can provide valuable learnings that can inform broader method introduction to expand choice and better suit women’s needs in Zambia and elsewhere. Scale-up plans should include emphasis on high quality counseling and demand generation. Plain English Summary The government of Zambia is committed to increasing access to high-quality contraception and making more choices available to users. To date, the hormonal IUD, a highly effective, long-lasting contraceptive has not been widely available in the country. A study in pilot introduction settings provided insights into why women chose the methods, their characteristics, and their experiences getting their methods. The 710 women in the study received family planning services in public sector settings in two provinces in Zambia. Women in the study who received a hormonal IUD, copper IUD, implant, or injectable completed a quantitative survey; in-depth interviews were also conducted with 29 women. Results showed common reasons for choosing the long-acting methods (hormonal IUD, copper IUD or implants) were their duration, perception that the method was “right for my body,” and convenience. In addition, some hormonal IUD acceptors indicated that they were attracted to the method’s effectiveness, potential for discreet use, few or manageable side effects, and treatment for heavy or painful periods. Qualitative interviews with women also showed that women want contraceptive methods that lead to minimal or tolerable side effects. Male partners were typically aware of contraceptive use; however, men were less involved with decisions about the particular method women selected. Use of the hormonal IUD can lead to reduced menstrual bleeding, and in the interviews, women indicated that they liked reduced bleeding (especially lighter bleeding), although amenorrhea (paused bleeding) can be cause for concern. The results can help inform broader method introduction.

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Section: Discussionsupporting

confidence: 53%

Section: Introductionmentioning

confidence: 99%

What are the prospects for the hormonal IUD in the public sector? A mixed-method study of the user population in Zambia

et al. 2022

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“… 15 An observational study, focusing on the post-partum period, reported that 86% of hormonal intrauterine device users interviewed 3–6 months after insertion in Kenya, and 79% of those interviewed in Zambia with an average time of 10 months after insertion were still using this method. 16 Qualitative data in Kenya, Nigeria, and Zambia suggest that key opinion leaders, providers, and users recognise the advantages of the hormonal intrauterine device, and support its inclusion in the contraceptive method mix. 17 , 18 , 19 In this study, we therefore aimed to expand the knowledge about the use of the hormonal intrauterine device, copper intrauterine device, and subdermal implant by measuring continuation rates at 6 months and 12 months and assessing women's experiences and satisfaction using these methods in sub-Saharan Africa in the private sector in Nigeria and the public sector in Zambia.…”

Section: Introductionmentioning

confidence: 99%

Expanding long-acting contraceptive options: a prospective cohort study of the hormonal intrauterine device, copper intrauterine device, and implants in Nigeria and Zambia

Brunie¹,

Stankevitz²,

Nwala³

et al. 2021

The Lancet Global Health

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Background 30 years after the introduction of the levonorgestrel-releasing intrauterine device in Europe, several sub-Saharan African countries are seeking to broaden access to this contraceptive method. In this study, we aimed to assess 12-month continuation of the hormonal intrauterine device, copper intrauterine device, and implants, as well as to assess women's experiences and satisfaction using these methods in the private sector in Nigeria and the public sector in Zambia. MethodsWe did a prospective cohort study of long-acting reversible contraceptive users across 40 private sector clinics in Nigeria and 21 public sector clinics in Zambia. Eligible women were aged 18-49 years in Nigeria and 16-49 years in Zambia, had chosen to receive the hormonal intrauterine device, copper intrauterine device, or implant (either a 5-year levonorgestrel-releasing subdermal implant or a 3-year etonogestrel-releasing subdermal implant), and, in Nigeria only, had access to a telephone. Women were interviewed within 100 days of receiving their contraceptive method either via telephone in Nigeria or in person in Zambia, with follow-up surveys at 6 months and 12 months. The primary outcomes were method-specific, 12-month continuation rates-ie, continuation rates of the hormonal intrauterine device, copper intrauterine device, and implant across Nigeria and Zambia. We used Kaplan-Meier methods to estimate the cumulative probabilities of method-specific continuation and a log-rank test to compare contraceptive methods. We analysed self-reported satisfaction and experiences as a secondary outcome. FindingsBetween June 25 and Nov 22, 2018, we enrolled a total of 1542 women (n=860 in Nigeria and n=682 in Zambia) receiving a long-acting reversible contraceptive. In total, 835 women (266 [32%] hormonal intrauterine device users, 274 [33%] copper intrauterine device users, and 295 [35%] implant users) in Nigeria and 367 (140 [38%] hormonal intrauterine device users, 149 [40%] copper intrauterine device users, and 78 [21%] implant users) in Zambia were included in the study analysis. The 12-month cumulative continuation rates were 86•8% (95% CI 82•1-90•4) for the hormonal intrauterine device, 86•9% (82•1-90•4) for the copper intrauterine device, and 85•0% (80•2-88•7) for implants in Nigeria. In Zambia, the 12-month cumulative continuation rates were 94•7% (89•2-97•4) for the hormonal intrauterine device, 89•1% (82•3-93•4) for the copper intrauterine device, and 83•1% (72•2-90•1) for implants. At least 71% of respondents across the timepoints were very satisfied with their method, and at least 55 (79%) of 70 reported having recommended their contraceptive method to someone else. Across the methods, the most commonly self-reported positive aspect of long-acting reversible contraceptive use at 12 months was effectiveness in Nigeria (range 93-94%) and long-lasting duration in Zambia (48-60%). Between 124 (50%) of 248 and 136 (59%) of 230 Nigerian participants and 26 (42%) of 62 and 66 (57%) of 117 Zambian participants reported nothing negati...

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“…Offering youth a full range of contraceptive options, including long-acting and reversible contraceptives (LARCs) through adolescent-friendly contraceptive services is one of several promising elements of High-Impact Practices (HIPs) in Family Planning [6]. LARCs, like IUDs and implants, have higher efficacy and continuation among adolescents who choose them compared to short-acting methods [7][8][9]. Previous studies demonstrate that youth, including adolescents ages 15 to 19, will use a variety of methods, including LARCs, when offered a full range of choices in an enabling environment [10][11][12][13].…”

Section: Introductionmentioning

confidence: 99%

A cross-country qualitative study on contraceptive method mix: contraceptive decisionmaking among youth

et al. 2021

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Background Youth ages 15 to 24, who comprise a large portion of sub-Saharan Africa, face a higher burden of unmet contraceptive need than adults. Despite increased international and national commitments to improving young people’s access to contraception, significant barriers impede their access to a full range of methods. To further explore these barriers among youth in Kenya, Nigeria, and Uganda, we conducted a qualitative study to capture the challenges that affect contraceptive method decisionmaking and complicate youth access to the full method mix. Methods To understand factors that impact young people’s contraceptive decisionmaking process across all three countries, we conducted a total of 35 focus group discussions with 171 youth ages 15 to 24 and 130 in-depth interviews with key stakeholders working in youth family planning. Questionnaires aligned with the High Impact Practices in Family Planning’s elements of adolescent-friendly contraceptive services. Data were coded with MAXQDA and analyzed using a framework for contraceptive decisionmaking to identify relevant patterns and themes. Results In all three countries, youth reported that condoms are the most commonly sought contraceptive method because they are easiest to access and because youth have limited knowledge of other methods. Youth from diverse settings shared uncertainty and concern about the safety and side effects of many methods other than condoms, complicating their ability to take full advantage of other available methods. While most youth in Kenya, Nigeria, and Uganda reported at least moderate confidence in obtaining the information needed to help choose a method, and only a few youth reported that they are completely unable to access contraceptives, other barriers still present a major deterrent for youth, including cost, inconvenient facility hours and long wait times, and stigma from family, community members, and providers. Conclusions Young people’s ability to fully exercise their method choice remains limited despite availability of services, leading them to take the path of least resistance. Program implementers and policymakers should consider the diverse and often interconnected barriers that youth face in attempting to enjoy the benefits of a full spectrum of contraceptive methods and design multi-level interventions to mitigate such barriers.

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Expanding Contraceptive Method Choice With a Hormonal Intrauterine System: Results From Mixed Methods Studies in Kenya and Zambia

Cited by 6 publications

References 28 publications

What are the prospects for the hormonal IUD in the public sector? A mixed-method study of the user population in Zambia

What are the prospects for the hormonal IUD in the public sector? A mixed-method study of the user population in Zambia

Expanding long-acting contraceptive options: a prospective cohort study of the hormonal intrauterine device, copper intrauterine device, and implants in Nigeria and Zambia

A cross-country qualitative study on contraceptive method mix: contraceptive decisionmaking among youth

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