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

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FIGURE
Flow Chart for Implant and IUD Users’ Removal Experiences in 3 Districts in Senegal
Abbreviations: IDI, in-depth interview; IUD, intrauterine device.
^a Ever asked a provider for a removal.
^b Ever wanted a removal but never asked a provider for one.

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TABLE 1.

Participant Characteristics and Counseling Received at Implant and IUD Insertion in 3 Districts of Senegal^a

	Implant			IUD
	Completed Phone Survey (n=1,362)	Eligible for In-person Survey (n=594)	Completed In-person Survey (n=438)	Completed Phone Survey (n=506)	Eligible for In-person Survey (n=205)	Completed In-person Survey (n=160)
Age, years, mean (SD)	31.2 (6.8)	29.8 (6.2)	30.0 (6.4)	36.2 (7.3)	35.6 (8.0)	36.2 (7.7)
Marital status, %
Single	3.7	2.0	1.6	2.0	1.5	1.3
Married/cohabitating	88.6	91.1	92.7	92.7	90.8	90.6
Divorced/widowed	7.8	6.9	5.7	5.3	7.8	8.1
Parity, mean (SD)	2.6 (1.7)	2.3 (1.5)	2.4 (1.6)	3.3 (1.7)	3.2 (1.7)	3.3 (1.7)
Highest education, %
None	21.7	19.4	19.9	12.5	12.2	10.6
Primary	30.3	29.0	31.3	32.1	33.7	38.8
Middle	16.9	18.7	15.9	17.4	14.7	16.2
Secondary school	16.7	18.0	18.1	15.3	17.6	16.9
Higher than secondary school	14.5	15.0	14.8	22.7	22.0	17.5
Religion, %
Muslim	95.1	95.6	96.4	93.7	94.2	93.1
Christian	4.9	4.4	3.7	6.3	5.9	6.9
Wealth quintiles^b, %
Lowest	4.5	3.5	3.6	2.1	1.7	1.4
Second	3.6	4.3	4.4	1.2	0.6	0.7
Middle	4.4	4.3	4.1	2.1	1.1	0.7
Fourth	15.2	13.8	12.7	8.5	8.6	10.8
Highest	72.3	74.2	75.1	86.2	88.0	86.3
Months since method inserted, mean (SD)	29.4 (6.4)	30.5 (6.4)	30.7 (6.4)	29.5 (6.2)	29.8 (5.6)	29.5 (5.6)
Implant type, %
Jadelle	61.2	56.7	57.6	N/A	N/A	N/A
Implanon	17.6	19.2	18.7	N/A	N/A	N/A
Unknown	21.3	24.1	23.7	N/A	N/A	N/A
Contraceptive use history, %
Previous use of current method	22.5	18.9	19.4	19.6	18.5	20.0
Previous use of any modern method	75.9	76.4	77.6	90.1	93.2	94.4
Partner knowledge of current method at time of insertion	86.3	86.9	87.0	82.4	83.4	84.4
Told at insertion that removal can be obtained any time	92.9	94.1	93.6	96.2	97.1	97.5
Told at insertion where removal can be obtained
Insertion place only, %	55.5	55.1	56.2	55.6	57.1	60.0
Place other than insertion place	0.7	0.8	1.1	0.4	1.0	1.3
Insertion place and another place	27.0	28.3	25.3	24.8	25.9	21.9
Not told about any place	15.4	14.7	16.7	17.8	14.6	15.0
Not sure	1.4	1.2	0.7	1.4	1.5	1.9

Abbreviations: IUD, intrauterine device; N/A, not applicable; SD, standard deviation.
↵^a Data are from phone survey participants. Nonresponses varied across items; small amounts of data are missing.
↵^b Relative wealth was measured using the EquityTool (https://www.equitytool.org/). The national version of the EquityTool compares participants to the national population.

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TABLE 2.

Participant Experiences Using Implants and IUDs in 3 Districts of Senegal^a

	Implant, % (n=1,202)^b	IUD, % (n=450)^b
Participants reporting CIMCs	77.4	53.6
Type of CIMCs reported^c^,d
Bleed more during period	27.1	55.2
Bleed less during period	12.0	9.1
Period lasts longer	35.6	44.8
Bleeding disturbances^e	60.8	46.9
Stopped having period	33.1	11.2
Concern with CIMCs^d
Very concerned	29.4	27.5
Somewhat concerned	32.5	30.4
Not at all concerned	38.2	42.1
Impact of CIMCs on daily life^d
Positive	1.5	0.8
Negative	35.5	33.9
No impact	63.0	65.3
Participants reporting weight gain	37.8	20.1
Participants reporting side effects other than weight gain and CIMCs	37.5	44.2
Type of side effect reported^a^,f
Headaches	31.1	11.1
Weight loss	25.3	6.6
Abdominal pain	29.3	42.9
Dizziness	22.9	9.1
Vaginal infections	N/A	24.8
Pelvic discomfort/pain	N/A	14.7
Impact of side effects on daily life^f
Greatly impacted	19.6	18.2
Impacted a little	33.4	30.2
No impact	47.0	51.6

Abbreviations: CIMCs, contraceptive-induced menstrual changes; IUD, intrauterine device; N/A, not applicable.
↵^a Data are from phone and in-person survey participants. Nonresponses varied across items; small amounts of data are missing.
^b Due to the design of the questionnaires, this information is not available for participants who said in the phone survey that they asked a provider for a removal but who did not complete the in-person interview.
↵^c Multiple responses possible, spontaneous mention; responses with values of ≥10% reported.
↵^d Among participants who reported CIMCs.
↵^e Bleeding disturbances include irregular bleeding, spotting, and having a period more often.
↵^f Among participants reporting side effects other than weight gain and CIMCs.

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TABLE 3.

Participant’s Reported Desire to Remove Implant or IUD in 3 Districts of Senegal^a

	Implant, % (n=1,362)	IUD, % (n=506)
Reported desire to remove
Never wanted a removal	42.1	46.0
Wanted a removal but have not asked a provider	14.2	13.4
Asked provider for removal	43.6	40.5
Reasons for wanting to stop using method^b^,^c
Desired pregnancy	25.8	36.8
Bleeding disturbances^d	20.6	10.3
Bleed more during period or period longer	11.3	7.4
Reasons for not asking provider^e^,^c
Busy/no time	44.0	33.8
Changed mind/decided to keep	14.1	16.2
Method came out on own	0.0	13.3
Reasons for wanting to stop using method^b^,^f
Desired pregnancy	29.9	27.6
Bleeding disturbances^c	23.4	12.8
Bleed more during period or period longer	15.4	16.7
Partner disapproved	12.7	7.7
Weight loss	12.3	3.2
Weight gain	11.6	1.3
Timing of removal decision^f
Decided before coming to facility	95.6	89.0
Decided at facility visit	4.4	11.0
Social influence reported for removal desire^f
Self	66.6	75.4
Husband/partner	27.1	18.8
Other^g	6.3	5.8

Abbreviation: IUD, intrauterine device.
↵^a Data are from phone and in-person survey participants. Nonresponses varied across items; small amounts of data are missing.
↵^b Multiple responses possible, spontaneous mention; responses with values of ≥10% reported.
↵^c Among participants who wanted a removal but have not asked a provider.
↵^d Bleeding disturbances include irregular bleeding, spotting, and having period more often.
↵^e Responses do not total 100% as only responses with at least 10% of participants responding are listed.
↵^f Among participants who have asked a provider for a removal.
↵^g Includes other relative, friend, colleague, community health worker, and other unspecified.

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TABLE 4.

Association of Factors With Participants Asking a Provider to Remove Implant in 3 Districts of Senegal^a

	AOR (95% CI) (n=820^b)
Age group, years
18–24	Reference
25–34	0.72 (0.45, 1.14)
35–49+	0.65 (0.36, 1.17)
Education level
None	Reference
Primary/middle	1.04 (0.67, 1.61)
Secondary or higher	0.74 (0.44, 1.24)
Religion
Christian	Reference
Muslim	1.51 (0.69, 3.30)
Parity
0	Reference
1–2	0.56 (0.19, 1.66)
3–4	0.41 (0.13, 1.28)
5+	0.34 (0.10, 1.19)
Fertility intentions
Do not want more children/do not want to have children/unsure	Reference
Want more children/want to have children	1.24 (0.76, 2.04)
Wealth (urban score)
Low (quintile 1–3)	Reference
Middle (quintile 4)	0.89 (0.57, 1.40)
High (quintile 5)	1.03 (0.68, 1.56)
Previous use of current method	0.74 (0.50, 1.11)
Partner knowledge of current method at time of insertion	1.18 (0.74, 1.89)
Informed choice	1.42 (1.03, 1.96)^c
Received method wanted	0.81 (0.45, 1.44)
Insertion was free	0.76 (0.54, 1.07)
Informed method could be removed at any time	1.00 (0.55, 1.81)
Experienced amenorrhea	1.61 (1.12, 2.32)^c
Experienced bleeding disturbances	1.13 (0.81, 1.56)
Experienced shorter or reduced bleeding	0.55 (0.33, 0.91)^c
Experienced longer or heavier bleeding	1.23 (0.87, 1.75)
Experienced weight gain	0.94 (0.68, 1.30)
Experienced other side effects^d	2.61 (1.89, 3.60)^c

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
↵^a Data are from phone and in-person survey participants. Nonresponses varied across items; small amounts of data are missing.
↵^b Sample size of implant users (n=1,362) is reduced to n=820 in the multivariable regression model due to missing data.
↵^c Statistically significant (P≤.05).
↵^d Other side effects include any mentioned non-bleeding side effects other than weight gain.

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TABLE 5.

Experience Seeking Removals Among Participants Who Asked a Provider for an Implant or IUD Removal in 3 Districts of Senegal^a

	Implant (n=438)	IUD (n=160)
Location of first removal attempt, %
Same place as insertion	81.5	80.7
Different place	18.5	19.4
Reported facing challenges accessing facility or at facility	53.5	55.1
Challenges faced,^b^,^c %
Long line/long wait	67.1	75.6
Difficulty getting away from house	29.4	31.4
Difficulty finding money to pay for transport and services	23.8	19.8
Provider was not available	17.8	10.5
Difficulty finding transport	10.8	4.7
Outcome of first removal attempt, %
Method removed, reported satisfied to remove	53.3	63.6
Method removed, reported would have preferred to keep	4.0	3.9
Still has method, reported satisfied to keep	9.9	9.7
Still has method, reported would have preferred to remove	32.2	22.7
Partial/failed removal	0.7	0.0
Reasons provider did not remove at first interaction,^b^,^d %
Provider counseled to keep method	33.9	50.0
Qualified provider not available	30.6	22.0
Equipment/supplies not available for removal	12.0	2.0
Consultation period over/client arrived late to clinic	11.5	2.0
Provider refused to remove	6.6	14.0
Outcome of most recent removal attempt, %
Method removed, reported satisfied to remove	81.0	82.1
Method removed, reported would have preferred to keep	6.9	6.4
Still has method, reported satisfied to keep	5.9	6.4
Still has method, reported would have preferred to remove	5.7	5.1
Partial/failed removal	0.5	0.0
Number of attempts until complete removal, mean (SD)	1.4 (0.7)	1.3 (0.5)

Abbreviations: IUD, intrauterine device; SD, standard deviation.
↵^a Data are from in-person survey participants. Nonresponses varied across items; small amounts of data are missing.
↵^b Multiple responses possible, spontaneous mention; responses with values of ≥10% reported.
↵^c Among participants who reported facing a challenge accessing facility or at facility.
↵^d Among participants who reported still having method after first removal attempt.

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TABLE 6.

Implant and IUD Removal Procedures and Post-Removal Contraceptive Use Among Participants Who Had Their Method Removed at the Time of the Survey in 3 Districts of Senegal^a

	Implant (n=379)	IUD (n=136)
Had method removed during first clinical procedure, %	99.7	100.0
Reported complication at removal, %	58.1	36.0
Complications reported,^b^,c %
Temporary pain at time of removal	63.6	85.7
Pain/discomfort that lasted throughout the day	33.6	22.5
Pain/discomfort that lasted a few days	21.8	8.2
Told by provider there were difficulties during removal, %	17.7	4.4
Reported duration of removal procedure, mean (range), minutes	14.5 (0–120)	11.3 (0–75)
Reported time spent at facility for removal, mean (range), minutes	81.0 (1–420)	77.7 (0–360)
Reported cost of removal, mean (range), CFA [US$]	1891 (0–20000) [3.21 (0–33.96)]	1327 (0–17000) [2.25 (0–28.86)]
Reported cost of insertion, mean (range), CFA [US$]	1491 (0–9000) [2.53 (0–15.28)]	1118 (0–12000) [1.90 (0–20.37)]
Actual cost for removal compared to removal cost told at time of insertion, %
More expensive	1.1	0.0
Same price	3.3	2.3
Less expensive	1.4	0.0
Was not told price at insertion	93.3	96.2
Reported ease of overall removal experience, %
Very easy	36.9	58.8
Somewhat easy	38.0	28.7
Somewhat difficult	17.9	10.3
Very difficult	7.1	2.2
Did not obtain another contraceptive method after removal, %	66.2	64.7
Reasons reported,^b^,^d %
Afraid of side effects	19.1	18.2
Partner disapproved	10.4	8.0
Any reason other than desired pregnancy, sexual inactivity, or infecundity	21.9	17.7

Abbreviations: CFA, West African CFA franc; IUD, intrauterine device.
↵^aData are from in-person survey participants except for cost of insertion which is from the phone survey. Nonresponses varied across items; small amounts of data are missing.
↵^bMultiple responses possible, spontaneous mention; responses with values of ≥10% reported.
^cAmong participants who reported complications at removal.
↵^dAmong participants who did not obtain another contraceptive method after removal.