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

doi:10.9745/GHSP-D-21-00252

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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%
Mozambique 25.5 0.8 1.7
Nampula 21.8 0.3 1.0
Sofala 14.4 0.5 1.3
Abbreviations: CPR, contraceptive prevalence rate, IUD, intrauterine device.

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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)
≤19	46 (13.7)	52 (11.4)	98 (12.4)
20–24	93 (27.8)	147 (32.2)	240 (30.2)
25–29	94 (28.1)	121 (26.5)	215 (27.2)
30–34	51 (15.2)	71 (15.6)	122 (15.4)
≥35	51 (15.2)	65 (14.3)	116 (14.7)
Marital status (N=792)
Married	88 (26.3)	260 (56.9)	348 (43.9)
Living in union	40 (11.9)	36 (7.9)	76 (9.6)
Divorced/separated/widowed	9 (2.7)	12 (2.6)	21 (2.6)
Never married nor lived in union	198 (59.1)	149 (32.6)	347 (43.8)
Parity (N=794)
Nulliparous	58 (17.8)	31 (6.8)	89 (11.2)
1–2	143 (42.6)	264 (57.6)	407 (51.3)
3+	135 (40.2)	163 (35.6)	298 (37.5)
Method
Two-rod levonorgestrel implant	251 (74.7)	342 (74.5)	593 (74.6)
One-rod etonogestrel implant	10 (3.0)	11 (2.4)	21 (2.6)
Intrauterine device (copper)	38 (11.3)	30 (6.5)	68 (8.6)
Method unknown^b	37 (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 hospital	32 (9.5)	29 (6.3)	61 (7.7)
District hospital	35 (10.4)	114 (24.8)	149 (18.7)
Urban health center	227 (67.6)	247 (53.8)	474 (59.6)
Rural health center	42 (12.5)	69 (15.0)	111 (14.2)
Reason for removal^a^,b
On schedule/expired	92 (28.2)	136 (30.5)	228 (29.5)
Side effects^c	96 (29.4)	103 (23.1)	199 (25.8)
Desire to be pregnant	58 (17.8)	119 (26.7)	177 (22.9)
Switch method	29 (8.9)	32 (7.2)	61 (7.9)
Other adverse events^d	32 (9.8)	11 (2.5)	43 (5.6)
Family opposition^e	6 (1.8)	19 (4.3)	25 (3.2)
Method failure	5 (1.5)	8 (1.8)	13 (1.7)
Others	8 (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 Use	Nampula, No. (%)	Sofala, No. (%)	Total, No. (%)
One-rod etonogestrel (n=19)
Within first 3 months	6 (66.7)	2 (20.0)	8 (42.1)
Before expiration	3 (33.3)	7 (70.0)	10 (52.6)
On schedule/expired (33–36 months)	0 (0)	0 (0)	0 (0)
After expiration	0 (0)	1 (10.0)	1 (5.3)
Two-rod levonorgestrel implant (n=576)
Within first 3 months	29 (11.7)	28 (8.5)	57 (9.9)
Before expiration	179 (72.5)	259 (78.7)	438 (76.0)
On schedule/expired (57–60 months)	17 (6.9)	20 (6.1)	37 (6.4)
After expiration	22 (8.9)	22 (6.7)	44 (7.6)
Intrauterine device (copper) (n=66)
Within first 3 months	14 (37.8)	2 (6.9)	16 (24.2)
Before expiration	21 (56.8)	27 (93.1)	48 (72.7)
On schedule/expired (117–120 months)	0 (0)	0 (0)	0 (0)
After expiration	2 (5.4)	0 (0)	2 (3.0)
All methods (n=661)
Within first 3 months	49 (16.7)	32 (8.7)	81 (12.3)
Before expiration	203 (69.3)	293 (79.6)	496 (75.0)
On schedule/expired	17 (5.8)	20 (5.4)	37 (5.6)
After expiration	24 (8.2)	23 (6.3)	47 (7.1)

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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 Method^a(n=114) No. (%)	Total (N=795) No. (%)
Not removed following counseling	--	--	--	112 (98.2)	112 (14.1)
Removed: no difficulty	579 (97.6)	21 (100)	64 (95.5)	--	664 (83.5)
Removed: with difficulty	9 (1.5)	0 (0)	1 (1.5)	--	10 (1.3)
Removed: significant difficulty	0 (0)	0 (0)	0 (0)	--	0 (0)
Attempted but not removed: referred	4 (0.7)	0 (0)	1 (1.5)	--	5^b (0.6)
Not removed: referred	1 (0.2)	0 (0)	1 (1.5)	2^c (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.

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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 counseled	46 (15.2)	142 (38.3)	188 (27.9)
Counseled only	16 (5.3)	36 (9.7)	52 (7.7)
Counseled and chose a method	141 (46.7)	92 (24.8)	233 (34.6)
Counseled and referred for a method	2 (0.7)	1 (0.3)	3 (0.4)
Counseled and refused a method	97 (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)

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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 implant	21 (63.6)	0 (0)	4 (66.7)	25 (64.1)
Selected etonogestrel implant	2 (6.1)	0 (0)	2 (33.3)	4 (10.3)
Selected copper IUD	10 (30.3)	0 (0)	0 (0)	10 (25.6)

Abbreviations: IUD, intrauterine device, LARC, long-acting reversible contraceptive.

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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-user	31 (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.

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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 problems	27 (81.8)	31 (100)	58 (90.6)
Difficulty	3 (9.1)	0 (0)	3 (4.7)
Did not respond	3 (9.1)	0 (0)	3 (4.7)
Time taken, minutes/visit
≤2	9 (27.3)	20 (64.5)	29 (45.3)
3–5	17 (51.5)	8 (25.8)	25 (39.1)
6–9	5 (15.2)	0 (0)	5 (7.8)
Did not respond	2 (6.1)	3 (9.7)	5 (7.8)