Making Removals Part of Informed Choice: A Mixed-Method Study of Client Experiences With Removal of Long-Acting Reversible Contraceptives in Senegal

Aurélie Brunie; Fatou Ndiaté Rachel Sarr Aw; Salif Ndiaye; Etienne Dioh; Elena Lebetkin; Megan M. Lydon; Elizabeth Knippler; Sarah Brittingham; Marème Dabo; Marème Mady Dia Ndiaye

doi:10.9745/GHSP-D-22-00123

Key Findings

Most study participants were satisfied after first interacting with a provider about a removal; however, while the majority of participants who had their method removed were satisfied, most participants who kept their method were dissatisfied.
Areas of potential improvement to further strengthen access to removal services in Senegal include improving client flow, strengthening counseling messages at insertion and when advising clients to keep their method and on uptake of a new method after removal, as well as lowering pricing.

Key Implications

Similar strategies can be deployed to strengthen removal services for both implants and intrauterine devices.
Program managers should reinforce counseling on side effects and on post-removal method switching and reinsertion.
Policy makers should develop guidance to harmonize service fees across facilities and review procurement and funding mechanisms for supplies to support continued service availability and ensure costs are not passed on to clients.

ABSTRACT

Background:

Ensuring access to removal services for implants and intrauterine devices (IUDs) is essential to realize informed choice and voluntary family planning. We document removal desires and experiences among women who received an implant or IUD from the public sector in 3 districts of Senegal.

Methods:

We conducted a phone survey of 1,868 implant and IUD users, 598 follow-up surveys with those who had ever asked a provider for a removal, and 24 in-depth interviews (IDIs) with women who had ever wanted an implant removal. We analyzed survey data descriptively and IDI data thematically.

Results:

Fifty-eight percent of implant users and 54% of IUD users reported having wanted a removal. Desired pregnancy and contraceptive-induced menstrual changes (CIMCs) were the main reasons for removal desires. Fifty-four percent of implant users and 55% of IUD users who asked a provider for a removal reported challenges accessing services, with over two-thirds noting long lines or wait times. Sixty-three percent of implant users and 73% of IUD users who saw a provider were satisfied with the outcome of their first interaction. Over 90% of participants had not been told about the removal cost at insertion. Almost all participants who had their method removed obtained a complete removal during their first clinical procedure. Around two-thirds of participants who obtained a removal did not take up another method at that time. IDIs confirmed the influence of CIMCs on removal desires and show some partner influence is common in removal decision making. Barriers include lack of available qualified providers and supplies. Provider interactions play an important role in satisfaction with removal services.

Conclusion:

Participants’ experiences accessing removal services were generally positive. Areas of potential improvement include client flow, counseling messages at insertion, and when advising clients to keep their method, pricing, and post-removal reinsertion or method switching.

Received: March 17, 2022.
Accepted: August 9, 2022.
Published: October 31, 2022.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-22-00123

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