Respondent characteristics
IDIs were conducted with 100 respondents across five respondent groups (see Table
1): postpartum women [
35], their partners [
23], community leaders [
12], community health workers [
19] and facility-based providers [
12]. Several follow-up interviews were conducted, but unfortunately this information was not consistently recorded. Two respondents (both women) declined to participate stating that they needed to tend their fields.
Postpartum women participating in this study were aged between 18 and 43 with a median age of 28. Their partners were slightly older, with a median age of 37 (range 23–60). A majority of women (85 %) and their partners (91 %) were married or cohabiting. Half of the women and about two thirds (65 %) of their partners had completed primary school. Reported parity from postpartum women ranged between 1 and 6 children compared to 1 and 11 reported by partners. The median age of the youngest infant, as reported by men and women was 6 and 6.5 months, respectively.
All community leaders were male, most were married (92 %) and had a median age of 42 years (range 29–65). More than half of community leaders (58 %) had completed primary school education and nearly all (92 %) reported the ability to read and write.
CHWs reported high education (68 % completing primary school education) and literacy levels (100 %). CHWs had a median age of 43 (range 25–52) and a majority were married (68 %). Facility- based workers were younger (median age 35) than CHWs, a majority (75 %) were male and were non-clinical nurses (75 %).
Contraceptive side effects as a pivotal concern
In general, postpartum women participating in this study were conversant with hormonal contraceptive methods and had used them in the past. Women largely held positive views of modern methods of contraception due to their reported health benefits (“It gives my body time to breathe”) and economic benefits (“We can focus more on each child and earn more money”). As one woman explained, “I think [FP] is very good because it reduces the number of people. It is even better because you can increase their level of education [and have a] better life” (32-year-old mother of 2, current condom user). This finding was consistent across age, district and regardless of distance between a woman’s home and the nearest health facility.
When probed regarding attitudes toward contraceptives, a majority of women (25 of 34) reported concerns regarding side effects of hormonal methods, which they consistently described as a major deterrent to use. One woman explained, “Every [modern] method seems to have its problems…I have not seen a safe method yet” (20-year-old mother of 1, currently using the calendar method). Another woman who was disillusioned by modern contraceptive methods said, “The calendar [method] is the best because it doesn’t have chemicals or injection” (24-year-old mother of 2, currently using the calendar method).
Whether experienced firsthand by postpartum women or described by other community members, respondents reported that negative side effects frequently led women to avoid future use of hormonal contraceptive methods, discontinue use, switch methods, or use methods incorrectly, which sometimes resulted in unintended pregnancies. As one woman recounted: “I used to get the injection but it was disturbing me- I used to bleed a lot. Therefore, I stopped and started using the pill. After the pill I went back to the injection, stopped again then got pregnant” (39-year-old mother of 5, currently using the injection). Another woman who became pregnant after switching to a less effective FP method said, “My stomach was giving me problems, so I decided to use the calendar [method], but my husband interrupted the calendar” (42-year-old mother of 6, current FP use unknown).
The idea that women sought a series of contraceptive methods “to see which one will match with me” (29-year-old mother of 3, currently not using any method) was expressed by numerous women such as a 20-year-old woman who explained, “If [the implant] affects you, you leave it and use pills” (20-year-old mother of 1, currently abstaining).
The results presented in the following sections outline the types of FP side effects reported by women and their partners, including contaminated breast milk, infertility and sterility, and excessive and prolonged bleeding. We then present the sources of influence that affect women’s decisions to use hormonal FP methods divided by partners, the community, religious leaders and facility-based providers.
Side effects attributed to hormonal contraceptives
There was some variation in perceived side effects by method (see Table
2), but all hormonal methods were perceived to be associated with contaminated breast milk (
Uchafu- dirt), infertility/sterility (“… it burns eggs” (24-year-old mother of 2, current FP use unknown)), and excessive bleeding. Women also described stomach pains (“my stomach was on fire” (39-year-old mother of 5, current injection user)), dizziness, fatigue, missed menses and vomiting as side effects of hormonal contraceptives. Among women who have never used hormonal contraceptives, their awareness of negative side effects experienced by others discouraged uptake. For a breakdown of responses to perceived or experienced side effects by respondent type see Table
3.
Table 2
Side effects associated with hormonal contraception by respondent group
Injections/ “Depo” | Bloating | X | | |
Missing menses | X | | |
Stomach pain | X | X | |
Weight gain | X | X | X |
Headache | X | | |
Pills | Sterility | X | X | |
Nausea | X | | |
Weight loss | X | | X |
Implants/ “sticks” | Cancer | | | X |
Across hormonal contraceptives | Excessive and/or prolonged bleeding | X | X | X |
Sterility | X | X | X |
Contamination of breastmilk | X | X | X |
Table 3
Views on hormonal contraceptives and side effects by respondent group
Postpartum women | Women are concerned/confused about how hormonal contraceptives function | ● Visit health center to speak with provider |
Women link side effects to other illnesses/conditions (e.g., impaired child development, sterility) | ● Abstain from, switch or discontinue hormonal contraceptive use |
Partners of postpartum women | Husbands/partners primarily concerned about wife/partner experiencing side effects (e.g., losing excessive blood, feeling ill and/or becoming infertile) or passing illness to breastfeeding children. | ● Encourage woman to discontinue or change contraceptive method |
● Use condoms to avoid side effects |
● Abstain while partner is breastfeeding |
Community members including CHWs, religious and political leaders | Religious authorities pressure families to avoid FP as it “kills God’s eggs” and could extend the duration of menses thereby inhibiting religious participation | ● Encourage families to avoid all FP methods—especially hormonal contraceptives |
Community impressions that FP side effects foster laziness and may induce infertility | ● Encourage women to discontinue use to avoid fatigue/laziness and infertility |
Health care providers | Providers describe challenges to counseling on FP and side effects especially time constraints. Providers have an impression that women are disinterested in counseling and “only want to get the method and go” | ● Encourage women to continue with method if side effects are not severe |
Providers perceive the distribution of contraception to be more important than discussion of side effects | ● Encourage alternative methods in instance of severe side effects (and provide these methods) |
Providers weigh the benefit of secrecy (associated with injectables) over the drawback of side effects among patients whose husbands oppose contraceptive use | ● Allow women to choose their preferred contraceptive method, notwithstanding potential side effects |
Contaminated breast milk (“My child is too young”)
A common concern expressed by both postpartum women and their partners was a negative impact of hormonal methods on breast milk and, consequently, on their infant’s health. Specifically, respondents said pills spoil breast milk and induce diarrhea, malaise, fever and other life-threatening illnesses among infants. However, women were unable to describe the mechanism by which contraceptives harm their children: “They say if you use [FP] while the child is small, it is affected…now there I don’t understand [how it is affected], I just hear” (29-year-old mother of 3, currently not using any method). Origins of infant health conditions that appeared inexplicable (e.g. an infant who cannot walk) or for which a provider’s explanation was deemed inadequate, were often attributed to hormonal contraception.
In an effort to minimize infant exposure to this perceived contamination (“I do not want to harm my child” (28-year-old mother of 5, currently abstaining)), women often opted to reinitiate the use of hormonal contraceptives once a child passed a developmental milestone: “I would like to use family planning after I see my child is older and can walk, about two years old. Because at this stage, I do not see the use of the injection or pills when my child is still young” (27-year-old mother of 2, currently not using any method).
Infertility and sterility
All respondent groups, and health providers in particular, noted the slow uptake of hormonal contraceptive methods in some communities as a result of widespread concerns regarding temporary infertility associated with contraceptive use or, more severely, the onset of sterility. For example, a husband explained: “They say these pills, once they spread in the body; they cause sterility…that’s what community members told us” (38-year-old partner). Sterility was of particular concern among young women, who feared they would have difficulty getting pregnant after prolonged use of pills. Some women attributed sterility to a blocked uterus: “Those pills, when I swallow them, they will go and stay in my womb, one on-top of the other, and then I will not be able to get another child” (28-year-old mother of 5, current FP use unknown). Missed menses and amenorrhea were seen as proof of sterility, and therefore were a concern for women: “You can stay up to three months like a man [without menstruation]” (30-year-old mother of 3, current condom user). A slightly older woman added, “And those injections, how long will I use them? At the end you will have to stop using [them]. There are women who are advised that you can use these injections continuously and later, you are unable to give birth” (39-year-old mother of 5, current injectable user).
Excessive and prolonged bleeding
Women described how long-term bleeding associated with all hormonal contraceptives, and injections in particular, interrupted their day-to-day lives. Women noted that bleeding impeded their ability to perform domestic duties, tend to their families and earn a living. Some women also pointed out that prolonged bleeding interrupted their religious practice, since women can be prohibited from handling religious books while menstruating: “When you use the injection, you get heavy and experience long [menstrual] bleeding. Therefore, you are not able to pray…you cannot hold the book of God until the bleeding stops” (35-year-old mother of 4, currently not using any method).
Sources of influence regarding family planning use
Partner
A few women interviewed disclosed that their partners, or other men they know, discourage and/or oppose the decisions of their wives to use family planning. As one woman explained, “They [male partners] refuse. They really don’t like us using family planning” (18-year-old mother of 1, not currently using any FP method). Men who agreed with this statement most frequently cited adverse side effects experienced by their wives as their primary reason for opposition.
Partners of postpartum women were generally responsive to physical distress their partners experienced from using hormonal contraceptives: “[My husband] is afraid of the problems that I might get” (18-year-old mother of 1, not currently using any FP method). To avoid negative side effects, women and husbands reported using condoms or switching to traditional methods (rhythm or calendar methods). While switching to condoms was undesirable for some men (using condoms is like “licking sugar with the wrapper still on…you cannot taste the sweetness” (A male CHW)), some husbands were willing to use condoms to avert the side effects of hormonal methods: “When I saw that the injection caused her to have stomach problems, she stopped and started using the pill. When I saw that the pill was also giving her problems, I made her stop and I started using condoms” (34-year-old partner).
Women and men also reported abstaining from sex after childbirth, a time period that ranged from 40 days to 5 years, but typically lasted 2 years. Partners of postpartum women were forceful in agreeing that women should not take hormonal methods while breastfeeding: “My wife is still breastfeeding, how can you use [contraceptives] while she is breastfeeding?” (42-year-old partner).
The community itself was shown to play an important role in disseminating views on FP side effects. Women reported being influenced by the views of community members. One woman described how older community members scorn families using contraceptives: “At home, I used to hear now and again, even older women used to say, 'You use contraceptives? Contraceptives are bad! They will just hurt you'” (30-year-old mother of 5, current injection user). However, negative views of hormonal methods were not universal, as one woman explained: “The community cannot discriminate against her, when she gets side effects, she stops. The community does not discriminate because it is a personal decision” (24-year-old mother of 2, currently using the calendar method).
A commonly held perception across community members was that hormonal methods induce side effects such as excessive bleeding, which leads to laziness. This perception caused community members to gossip about suspected FP users, thereby discouraging uptake. A husband explained: “Some will say she is using family planning because she does not like kids, some will say she is lazy and she does not like to farm, everyone will say his or her own things. This harassment will lead others not to use family planning methods” (38-year-old partner).
Religious leaders
According to all respondent groups, religious leaders’ views also affect contraceptive uptake. Interviewed religious leaders objected to FP as it “wasted” or “killed” sperm or eggs. One Muslim religious leader lamented that “year after year” husbands and wives using contraceptives are preventing birth: “Contraceptives kill God’s eggs.” Only one of seven interviewed religious leaders, a Christian pastor, expressed positive sentiments towards the use of contraceptives, saying, “I give advice about family planning, because God gave us [sexual] urge.” Although there was opposition to the use of contraception from both Christian and Islamic groups, leaders from both religions showed leniency toward married couples using contraceptives. However, many families have internalized disapproval of religious leaders: “My religion does not allow me [to use contraceptives]” (35-year-old mother of 4, currently not using any method). Another woman continued to say, “They [religious leaders] disagree about FP. They want us to have children. They don’t agree. We kill eggs when we use FP” (24-year-old mother of 4, currently using pills).
Facility-based providers
Most women reported that health care providers did not counsel them about side effects that can be expected for particular contraceptive methods: “[A provider] comes in and tells you that you should use FP if you want good health…they tell you to use this injection, but they do not tell you the side effects” (42-year-old mother of 6, current FP use unknown). Another woman expressed frustration, saying, “No one educates us! You are just told [to use FP] until the nurse gets angry [and says], ‘You come and tie your tubes, you have given birth to enough children, it’s enough now!’”(39-year-old mother of 5, current injectable user). One woman described how an absence of facility-based counselling fosters distrust and leads women to bypass providers for informal pharmacies where they self-prescribe inappropriate methods: “They use medication that does not suit them. For example, if you have high blood pressure, you have to go and get examined; they look at your uterus. If you have high blood pressure, pills are not for you. What suits you is the injection or an implant. Now, they take a method themselves without undergoing tests” (28-year-old mother of 5, currently not using any method).
However, some women expressed a more cordial relationship with their service providers. One woman said, “They [facility-based health providers] told us, if you see differences—that one [method] affects you, go there [to the facility]. If you go there they test you, then they change [the method] for you” (39-year-old mother of 6, current injection user).
Providers emphasized that their aim is to encourage FP uptake and meet demand for FP within time and supply constraints. While providers could detail side effects in interviews, they noted that women often come to facilities with a particular method already in mind and are determined to use that method, which makes discussions about side effects challenging: “They choose what they want. If they want Depo [likely referring to the injectable progestogen-only brand of hormonal contraceptive Depo-Provera], we give them Depo. If they want pills, we give them pills. If they want implants, we give them implants. What they want is what we give them” (Provider, Enrolled Nurse).
Providers encouraged method switching in response to severe side effects, but urged women to “be patient” and wait for less severe side effects to pass: “You advise them that this is how these medications are. If you are not very ill and you are just losing weight that is not a problem. But if you have headaches or are bleeding a lot, we have to change [contraceptive] methods” (Provider, Nurse Midwife).
Providers also described how the benefit of secrecy outweighs the drawback of side effects among many patients. Several providers described how women appreciate injections because this method is long-lasting yet discreet, despite protracted bleeding: “Their husbands do not like it [FP] at all. We tell them to bring their husbands so that we can counsel both of them and they refuse. They tell you, ‘Nurse, it is not easy for me to take pills. Give me the injection.’” (Provider, Nurse Midwife).