“When it comes to time of removal, nothing is straightforward”: A qualitative study of experiences with barriers to removal of long-acting reversible contraception in Western Kenya

Abstract

Objective Barriers to removal of long-acting reversible contraception (LARC) threaten reproductive self-determination, but their influence on contraceptive behaviors is not well understood. We describe perspectives of women in Western Kenya concerning LARC removal barriers. Study design We used a qualitative descriptive approach with conventional content analysis to analyze transcripts for content and themes from eight focus group discussions ( n = 55 participants) and one client journey mapping workshop ( n = 9 participants) with women ages 18–49 in Western Kenya who were currently using or had formerly used contraceptives. Findings Our primary themes concerned women's experience of LARC removal barriers and the impact on their behaviors and attitudes towards contraception. Women described providers being unwilling to remove LARC, regardless of rationale (including expiration, seeking pregnancy, or experiencing intolerable side effects) or demanding unaffordable fees. Women were reluctant to try LARC for fear of having to use the method for its entire lifespan even if they did not like it. Women saw LARC removal barriers as increasing their risk of unintended pregnancy through non-replacement of expired devices and fostering distrust in the health system. Conclusion Barriers to LARC removal may discourage utilization of LARC and contraceptive services generally, which can undermine women's efforts to achieve reproductive self-determination. Implications Our findings affirm the importance of timely LARC removal to ensure that family planning programs uphold women's reproductive autonomy.

Contributions of side effects to contraceptive discontinuation and method switch among Kenyan women: a prospective cohort study

“…All of these may be important explanatory factors in switch and discontinuation 44,48 . Even where contraceptive services are available and generally free, recent evidence from Kenya has shown that provider barriers to LARC removal may restrict women’s ability freely to decide to switch or stop LARC use 18 …”

“…Most contraceptive methods are readily available, with public service delivery outlets offering an average of seven different FP method types 17 ; however, nearly half of public facilities experienced a stockout of at least one method on the date of the survey 17 . Informal payments and provider bias have also been documented as barriers to women who wish to initiate, switch or discontinue contraceptive use 18–20 . Furthermore, few studies have assessed Kenyan women’s preferences for, and responses to, specific contraceptive‐induced side effects 6 .…”

“…17 Informal payments and provider bias have also been documented as barriers to women who wish to initiate, switch or discontinue contraceptive use. [18][19][20] Furthermore, few studies have assessed Kenyan women's preferences for, and responses to, specific contraceptive-induced side effects. 6 Understanding the contribution of side effects to contraceptive use behaviours in priority geographical regions such as Kenya is critical for honing global priorities for contraceptive method development and services.…”

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

“…This may begin to change as hormonal IUDs become more widely available, particularly in the public sector 15 , 16 . However, while service delivery patterns of IUD uptake have been documented in the literature, there are few studies describing women’s experiences seeking IUD removal 8 , 17 or provider experiences providing care.…”

“…Clinical challenges are closely related to programmatic challenges associated with scaling-up the availability of both implant insertion and removal services: providing sufficient training to health care providers, including in difficult removal techniques such that providers are confident in their removal skills; ensuring that appropriate equipment and supplies are available for both routine and difficult removals; and establishing necessary referral mechanisms as needed, including for difficult removals or where providers may insert but not remove implants 5,7 . A few recent studies which document the client perspective in relation to implant removals in sub-Saharan Africa reiterate these challenges [8][9][10][11][12][13] .…”