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ORIGINAL ARTICLE
Open Access

Introducing Long-Acting Contraceptive Removal Indicators in a Pilot Study in Mozambique: Dynamics of Discontinuation and Implications for Quality of Care

Ana Jacinto, Adalgisa Viola Ronda, Connie Lee, Fariyal F. Fikree and Eric Ramirez-Ferrero
Global Health: Science and Practice February 2022, 10(1):e2100252; https://doi.org/10.9745/GHSP-D-21-00252
Ana Jacinto
aPathfinder International, Maputo, Mozambique.
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Adalgisa Viola Ronda
aPathfinder International, Maputo, Mozambique.
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Connie Lee
bPathfinder International, Washington, DC, USA.
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  • For correspondence: clee@pathfinder.org
Fariyal F. Fikree
cConsultant, Washington, DC, USA.
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Eric Ramirez-Ferrero
dMOMENTUM Integrated Health Resilience Project, Corus International, Washington, DC, USA; formerly of Pathfinder International, Washington, DC, USA.
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    TABLE 1

    Modern CPR and Long-Acting Reversible Contraceptive CPR, Nampula and Sofala Provinces, Mozambique, 2015

    Modern CPR%IUD CPR%Implant CPR% 
    Mozambique25.50.81.7
    Nampula21.80.31.0
    Sofala14.40.51.3
    • Abbreviations: CPR, contraceptive prevalence rate, IUD, intrauterine device.

    • View popup
    TABLE 2.

    Demographic Characteristics of LARC Removal Clients,a Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Nampula (n=336) No. (%)Sofala (n=459) No. (%)Total (N=795) No. (%)
    Age, years (N=791)
     ≤1946 (13.7)52 (11.4)98 (12.4)
     20–2493 (27.8)147 (32.2)240 (30.2)
     25–2994 (28.1)121 (26.5)215 (27.2)
     30–3451 (15.2)71 (15.6)122 (15.4)
     ≥3551 (15.2)65 (14.3)116 (14.7)
    Marital status (N=792)
     Married88 (26.3)260 (56.9)348 (43.9)
     Living in union40 (11.9)36 (7.9)76 (9.6)
     Divorced/separated/widowed9 (2.7)12 (2.6)21 (2.6)
     Never married nor lived in union198 (59.1)149 (32.6)347 (43.8)
    Parity (N=794)
     Nulliparous58 (17.8)31 (6.8)89 (11.2)
     1–2143 (42.6)264 (57.6)407 (51.3)
     3+135 (40.2)163 (35.6)298 (37.5)
    Method
     Two-rod levonorgestrel implant251 (74.7)342 (74.5)593 (74.6)
     One-rod etonogestrel implant10 (3.0)11 (2.4)21 (2.6)
     Intrauterine device (copper)38 (11.3)30 (6.5)68 (8.6)
     Method unknownb37 (11.0)76 (16.6)113 (14.2)
    • ↵a Missing information: Nampula: age=1, marital status=1; Sofala: age=3, marital status=2, parity=1.

    • ↵b Method of use at the time of the visit was not captured in the standard removal addendum for clients whose method was not removed.

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    TABLE 3.

    Type of Facilities Visited by Clients Seeking Long-Acting Reversible Contraceptive Method Removal and Reported Reason for Removal, Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Nampula (n=336)
    No. (%)
    Sofala (n=459) No. (%)Total (N=795) No. (%)
    Facility category
     Provincial hospital32 (9.5)29 (6.3)61 (7.7)
     District hospital35 (10.4)114 (24.8)149 (18.7)
     Urban health center227 (67.6)247 (53.8)474 (59.6)
     Rural health center42 (12.5)69 (15.0)111 (14.2)
    Reason for removala,b
     On schedule/expired92 (28.2)136 (30.5)228 (29.5)
     Side effectsc96 (29.4)103 (23.1)199 (25.8)
     Desire to be pregnant58 (17.8)119 (26.7)177 (22.9)
     Switch method29 (8.9)32 (7.2)61 (7.9)
     Other adverse eventsd32 (9.8)11 (2.5)43 (5.6)
     Family oppositione6 (1.8)19 (4.3)25 (3.2)
     Method failure5 (1.5)8 (1.8)13 (1.7)
     Others8 (2.5)18 (4.0)26 (3.4)
    • ↵a N=772. When multiple responses were given, only the first reason was recorded.

    • b Missing information: Nampula: Reason for Removal=10; Sofala: Reason for Removal=13.

    • ↵c Vaginal bleeding, vaginal discharge, headache, or weight gain or loss.

    • ↵d Arm discomfort/pain or back pain.

    • ↵e Husband/in-law opposition or mother opposition.

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    TABLE 4.

    Duration of Use by Long-Acting Reversible Contraceptive Method, Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Duration of UseNampula, No. (%)Sofala, No. (%)Total, No. (%)
    One-rod etonogestrel (n=19)
     Within first 3 months6 (66.7)2 (20.0)8 (42.1)
     Before expiration3 (33.3)7 (70.0)10 (52.6)
     On schedule/expired (33–36 months)0 (0)0 (0)0 (0)
     After expiration0 (0)1 (10.0)1 (5.3)
    Two-rod levonorgestrel implant (n=576)
     Within first 3 months29 (11.7)28 (8.5)57 (9.9)
     Before expiration179 (72.5)259 (78.7)438 (76.0)
     On schedule/expired (57–60 months)17 (6.9)20 (6.1)37 (6.4)
     After expiration22 (8.9)22 (6.7)44 (7.6)
    Intrauterine device (copper) (n=66)
     Within first 3 months14 (37.8)2 (6.9)16 (24.2)
     Before expiration21 (56.8)27 (93.1)48 (72.7)
     On schedule/expired (117–120 months)0 (0)0 (0)0 (0)
     After expiration2 (5.4)0 (0)2 (3.0)
    All methods (n=661)
     Within first 3 months49 (16.7)32 (8.7)81 (12.3)
     Before expiration203 (69.3)293 (79.6)496 (75.0)
     On schedule/expired17 (5.8)20 (5.4)37 (5.6)
     After expiration24 (8.2)23 (6.3)47 (7.1)
    • View popup
    TABLE 5.

    Removal Outcome by Long-Acting Reversible Contraceptive Method, Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Levonorgestrel Implant (n=593)
    No. (%)
    Etonogestrel Implant (n=21)
    No. (%)
    Copper Intrauterine Device (n=67)
    No. (%)
    Unknown Methoda(n=114)
    No. (%)
    Total
    (N=795)
    No. (%)
    Not removed following counseling------112 (98.2)112 (14.1)
    Removed: no difficulty579 (97.6)21 (100)64 (95.5)--664 (83.5)
    Removed: with difficulty9 (1.5)0 (0)1 (1.5)--10 (1.3)
    Removed: significant difficulty0 (0)0 (0)0 (0)--0 (0)
    Attempted but not removed: referred4 (0.7)0 (0)1 (1.5)--5b (0.6)
    Not removed: referred1 (0.2)0 (0)1 (1.5)2c (1.8)4 (0.5)
    • ↵a Method of use at the time of the visit was not captured in the standard removal addendum for clients whose method was not removed.

    • ↵b Two clients were referred for removal; data missing for three clients about referral or rescheduled appointment.

    • ↵c Missing data for two clients who were referred for difficult removals.

    • View popup
    TABLE 6.

    Family Planning Outcomes of Clients Who Had Long-Acting Reversible Contraceptive Method Successfully Removed, Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Nampula (n=302)Sofala (n=371)Total (N=673)
    No. (%)No. (%)No. (%)
    Family planning counseling provision
     Not counseled46 (15.2)142 (38.3)188 (27.9)
     Counseled only16 (5.3)36 (9.7)52 (7.7)
     Counseled and chose a method141 (46.7)92 (24.8)233 (34.6)
     Counseled and referred for a method2 (0.7)1 (0.3)3 (0.4)
     Counseled and refused a method97 (32.1)100 (27.0)197 (29.3)
    Method uptake by client
     Long-acting reversible contraceptive (continuers)18 (12.8)21 (22.8)39 (16.7)
     Short-acting reversible contraceptive (switchers)116 (82.3)71 (77.2)187 (80.3)
     Tubal ligation (switchers)7 (5.0)0 (0)7 (3.0)
    • View popup
    TABLE 7.

    Clients Who Had LARC Method Removed and Selected a LARC, Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Method Removed
    Levonorgestrel Implant (n=33) No. (%)Etonogestrel Implant (n=0) No. (%)Copper IUD (n=6) No. (%)Total (N=39) No. (%)
    Selected levonorgestrel implant21 (63.6)0 (0)4 (66.7)25 (64.1)
    Selected etonogestrel implant2 (6.1)0 (0)2 (33.3)4 (10.3)
    Selected copper IUD10 (30.3)0 (0)0 (0)10 (25.6)
    • Abbreviations: IUD, intrauterine device, LARC, long-acting reversible contraceptive.

    • View popup
    TABLE 8.

    FP Status of Clients Who Sought LARC Method Removal for Vaginal Bleeding, Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Nampula (n=80)
    No. (%)
    Sofala (n=86)
    No. (%)
    Total (N=166)
    No. (%)
    Non-user31 (38.7)27 (31.4)58 (34.9)
    LARCs (not removed)14 (17.5)30 (34.9)44 (26.5)
    LARCs (continuers and switchers)2 (2.5)1 (1.2)3 (1.8)
    Short-acting reversible contraceptive (switchers)33 (41.3)28 (32.5)61 (36.8)
    Tubal ligation (switchers)0 (0)0 (0)0 (0)
    • Abbreviation: LARC, long-acting reversible contraceptive.

    • View popup
    TABLE 9.

    Health Care Provider Reported Ease and Time Taken in Recording in the Removal Addendum at Each LARC Removal Visit, Nampula and Sofala Provinces, Mozambique, December 2018–May 2019

    Nampula (n=33)
    No. (%)
    Sofala (n=31)
    No. (%)
    Total (N=64)
    No. (%)
    Ease in recording
     No problems27 (81.8)31 (100)58 (90.6)
     Difficulty3 (9.1)0 (0)3 (4.7)
     Did not respond3 (9.1)0 (0)3 (4.7)
    Time taken, minutes/visit
     ≤29 (27.3)20 (64.5)29 (45.3)
     3–517 (51.5)8 (25.8)25 (39.1)
     6–95 (15.2)0 (0)5 (7.8)
     Did not respond2 (6.1)3 (9.7)5 (7.8)
    • Abbreviation: LARC, long-acting reversible contraceptive.

Additional Files

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Introducing Long-Acting Contraceptive Removal Indicators in a Pilot Study in Mozambique: Dynamics of Discontinuation and Implications for Quality of Care
Ana Jacinto, Adalgisa Viola Ronda, Connie Lee, Fariyal F. Fikree, Eric Ramirez-Ferrero
Global Health: Science and Practice Feb 2022, 10 (1) e2100252; DOI: 10.9745/GHSP-D-21-00252

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Introducing Long-Acting Contraceptive Removal Indicators in a Pilot Study in Mozambique: Dynamics of Discontinuation and Implications for Quality of Care
Ana Jacinto, Adalgisa Viola Ronda, Connie Lee, Fariyal F. Fikree, Eric Ramirez-Ferrero
Global Health: Science and Practice Feb 2022, 10 (1) e2100252; DOI: 10.9745/GHSP-D-21-00252
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