Magnitude and factors for method discontinuation and switching among long acting reversible contraceptive users in health facilities of Southern Ethiopia

Family planning is one of the most cost effective health promotion programs reducing maternal and child mortality by roughly 30% and 10%, respectively [1]. Despite significant reduction of maternal and child mortality due to fertility related causes from 1990, the burden of both maternal and child mortality high in low resource setting countries Approximately 295,000 maternal deaths occurred globally in 2017 and 94% of which was from low resource countries. Sub-Saharan Africa and South Asia accounted for 86% (254,000) of global maternal deaths in 2017 [2]. Similarly, 5.4 million children died in 2017 globally and 89% of them are from low and middle income countries. Fortunately, the vast majority of maternal and child deaths can be prevented with proven interventions including effective birth control using modern contraceptions mainly LARCs [3].

Worldwide contraceptive utilization has increased during the last 10 years [4]. Unfortunately, many other regions of the developing world including Africa still have a high unmet need for family planning. In sub-Saharan Africa, an estimated 25% of women and couples who want to space or limit their births are not using any form of contraception. Because more than half of Africa’s population is under the age of 25, unmet need for family planning is likely to rise as these individuals enter their reproductive years [5].

Long-acting reversible contraceptives (LARCs) are contraceptive methods that prevent unplanned pregnancy for a long period of time without the need to any further responsibility by the user. They include the Intrauterine Contraceptive Devices (IUCD), Implants and Jadelle [6, 7]. Such modern contraceptives are more effective and cost-effective methods that play a role in reaching the national and international birth control goals.

The government of Ethiopia, national fertility rate of 4.6 children per women with a 2.7% per year population growth rate [8] has targeted 55% contraceptive prevalence rate by the year 2020. Of which, 35% is targeted for LARCs [9] implying that much needs to be done to catalyze the uptake of these methods. Despite this target, the utilization coverage of LARCs remains small sometimes missed component of many national reproductive health and family planning programs [5]. In light of this, the country has implemented different strategies such as task shifting to enhance the utilization coverage of LARCs at the primary healthcare level in all regions, including the southern region.

Method discontinuation and switch off are challenges for underutilization of most effective modern contraceptives, LARCs in limited resource settings for several reasons [10, 11]. Method discontinuation in this study refers to stopping use of specific LARCs within the recommended duration and discontinuing the previous method and switching to another LARCs [12]. Desire to conceive, unexpected conception, and side effect or health concern were the most prevalent reasons reported for discontinuing contraceptive methods, regardless of the method currently in use [11]. Method shift (switch off) from LARCs [13] to any other short-acting methods mainly due to poor competency of providers in counseling, providers’ gender, providers’ position and sector, provider myths is one of the reasons for inconsistent use of LARCs [13].

In low income countries including Ethiopia, the proportion of family planning users who switch off from reversible long acting family planning methods to less effective methods reaches up to 40.4% [13]. According to the 2016 Ethiopian Demographic Health Survey (EDHS), percentage of long acting reversible contraceptive method episodes discontinued within 12 months were IUCD (13%) followed by implants (11%) among women age 15–49 [14].

Southern nation's nationalities and people’s regional health bureau of Ethiopia set a strategic plan to achieve the coverage of long acting reversible family planning users from 24 to 60% according to the Health Sector Transformation Plan (HSTP) in 2020 [9]. However, the utilization coverage of the long acting reversible family planning is significantly lower than the expected coverage due to various reasons. Discontinuation from using and switching from long acting reversible family planning methods to short acting methods might contribute to low utilization of long acting reversible family planning methods. The reasons for discontinuation and switching might be highly contextual depending on cultural variations and time elapse. Method discontinuation and switching from long acting family planning to short acting modern or traditional methods leads to the risk of unplanned pregnancy [15] that may expose for unsafe abortion [16] and Sexually transmitted infections (STIs)/ Human immunodeficiency virus (HIV) infection [17]. However, information regarding methods discontinuation from using long acting reversible family planning methods and shift from highly effective method to less effective methods is largely unknown in the study area. Therefore, the aim of this study was to determine the magnitude of discontinuation and switching, and reasons for method discontinuation and switching off long acting reversible contraceptives.

Despite years had been counted since we had started implementing birth control through family planning methods, there is lower rate of utilization and early discontinuation and switching of long acting family planning methods that may expose women for unintended pregnancy. The present study determined the magnitude of early discontinuation and switching of common long acting modern family planning methods, reasons for discontinuation and factors associated with early discontinuation.

This study found that about seven in ten women discontinued any long acting reversible family planning method. This is by far higher than the findings from Honduras, where 41% of women discontinued using their first choice of LARC within 1-year follow up [19] and a Kenyan study, which found that the 12-month contraceptive discontinuation rate for all the methods was 30.5% and IUCD (6.4%) followed by Implants (8%), in 2014 [20]. In addition, it was higher than from the finding of the Ethiopian national health survey which indicated overall discontinuation rate of 35% for all the methods and method specific 1 year discontinuation of IUCD (13%) followed by Implants (11%) [14]. In fact, the findings of the EDHS may not be incomparable with this study due to the fact that the design of EDHS is population based whereas this study is facility based and among high risk group for discontinuation [14]

] Furthermore, the finding of the study was higher than the study from South East Ethiopia specifically for implanon [7] where 18.7% of women removed implanon within first year of use and (38.5%) of women removed implanon after the second year of use. However, higher discontinuation rate is not necessarily at risk of unintended pregnancy due to the fact that desire to become pregnant is one of the most important reproductive rights of women..

The overall mean duration of LARCs use was four folds less than the recommended duration of use for the three LARCs analysed in this study. This finding could imply the risk of unintended pregnancy due to improper use of LARC methods. This finding has lower duration of use when compared to findings from other parts of Ethiopia [21, 22] and in UK [23] which ranged from 19.5 months to 27 months for implanon. In addition, the mean duration of LARC methods is lower than the findings from demographic health survey (DHS) of 14 developing countries where the mean duration of uninterrupted IUCD use was 37 months [24]. However, as to our knowledge there were no studies for Jadelle to compare mean duration of use. In any case of the above findings, our findings suggest that there might be the risk of improper use of LARC methods which in turn leads to unintended pregnancy. Therefore, the findings of study imply many efforts should be made to improve average duration of use of LARC methods to reduce the risk of unintended pregnancy.

Three in ten women in this study switched from the methods they were using to any other modern contraceptive methods. This is slightly higher than a study done in other parts of the country, Dilla (27.6%) [25]. Here, as long as all methods are effective in preventing unintended pregnancy, the women may prefer to another method following discontinuation. But, switching from LARC methods to modern short-acting family planning methods may widen risk of unintended pregnancy and switching from one type of LARC to another type may also lead to risk of pregnancy. In our study, a significant number of women switched from previously used specific LARC methods to short acting family planning that may also expose them for unintended pregnancy. Our finding is higher than the findings from Bangladeshi (15.4%) [13] and Senegal (17%) [26]. Whereas, the findings of this study is lower than the finding reported in Ethiopia [5‐7, 13]. Switching from LARC methods to other short-acting methods (less effective methods) might be due to failure to counselling, providers’ gender factor, position and sector, provider myths that this finding call for implementing strategies to increase continuation rate of utilization of long acting family planning methods [6]. Moreover, higher proportion of Switching from one type of LARC methods to the other LARC methods might be another odd finding of this study, implying that the methods may have been improperly inserted. Hence, additional studies should be conducted regarding to competency of family planning providers so that their skill gap regarding insertion of LARC methods may be filled with additional training.

The two most cited reasons mentioned by the women for discontinuation of LARC methods in our study were desire to get pregnant and method specific side effect. Despite there is a difference in the design of the study, the findings of our study is consistent with findings extracted from the Ethiopian demographic health survey [22]. Similarly, reasons for implanon removal were similar with the study done in South Africa, which showed implanon was removed by the side effect and a desire for more pregnancies [27]. Moreover, side effect was also the main reason citedin the study done in Zambia (11%) [28] and consistent with the findings from the African population and health research centre for East African [29].

In our logistic regression analysis, only number of living children of women was significantly associated with discontinuation of long acting reversible family planning methods. Although the design of the study varies, our finding is consistent with study done in Ethiopia [22]. However, in our finding primiparous women were more likely to discontinue when compared to the grand multipara women whereas a demographic health analysis indicated that higher number of living children is associated with discontinuation [22]. While other variables like age of women, duration of use of LARCs, and educational status were not associated with discontinuation in our findings. Similarly, there was no single variable associated with switching of LARC methods.

Our finding showed that discontinuation of long acting reversible family planning method was high. Method switching from long acting reversible family planning methods to short acting family planning methods was also high in our finding that may expose the women to unintended pregnancy. Desire to get pregnant and method specific side effect were most common reasons for both method discontinuation and method switching. In our study, primiparous women (those women having one living children) were more likely to discontinue use of long acting reversible family planning methods. Hence, re-evaluating family planning services focusing on how can effectively counsel side effects of corresponding long acting reversible family planning methods and training should also be provided for community health workers. Further, context based implementation research should be required to design more effective methods of family planning information for women as well as their sexual mates.