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ORIGINAL ARTICLE
Open Access

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 and Marème Mady Dia Ndiaye
Global Health: Science and Practice October 2022, 10(5):e2200123; https://doi.org/10.9745/GHSP-D-22-00123
Aurélie Brunie
aFHI 360, Washington, DC, USA.
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Fatou Ndiaté Rachel Sarr Aw
bIntraHealth International, Dakar, Senegal.
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Salif Ndiaye
cCentre de Recherche pour le Développement Humain, Dakar, Senegal.
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Etienne Dioh
bIntraHealth International, Dakar, Senegal.
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Elena Lebetkin
dFHI 360, Durham, NC, USA.
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  • For correspondence: elebetkin@fhi360.org
Megan M. Lydon
dFHI 360, Durham, NC, USA.
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Elizabeth Knippler
eDepartment of Surgery, Duke University School of Medicine, Durham, NC, USA; formerly of FHI 360, Durham, NC, USA.
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Sarah Brittingham
dFHI 360, Durham, NC, USA.
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Marème Dabo
fSénégal Ministère de la Santé et de l'Action Sociale, Direction de la Sante de la Mère et de l'Enfant, Division Planification Familiale, Dakar, Senegal.
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Marème Mady Dia Ndiaye
fSénégal Ministère de la Santé et de l'Action Sociale, Direction de la Sante de la Mère et de l'Enfant, Division Planification Familiale, Dakar, Senegal.
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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.

Tables

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    TABLE 1.

    Participant Characteristics and Counseling Received at Implant and IUD Insertion in 3 Districts of Senegala

    ImplantIUD
    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, %
     Single3.72.01.62.01.51.3
     Married/cohabitating88.691.192.792.790.890.6
     Divorced/widowed7.86.95.75.37.88.1
    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, %
     None21.719.419.912.512.210.6
     Primary30.329.031.332.133.738.8
     Middle16.918.715.917.414.716.2
     Secondary school16.718.018.115.317.616.9
     Higher than secondary school14.515.014.822.722.017.5
    Religion, %    
     Muslim95.195.696.493.794.293.1
     Christian4.94.43.76.35.96.9
    Wealth quintilesb, %  
     Lowest4.53.53.62.11.71.4
     Second3.64.34.41.20.60.7
     Middle4.44.34.12.11.10.7
     Fourth15.213.812.78.58.610.8
     Highest72.374.275.186.288.086.3
    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, %    
     Jadelle61.256.757.6N/AN/AN/A
     Implanon17.619.218.7N/AN/AN/A
     Unknown21.324.123.7N/AN/AN/A
    Contraceptive use history, %    
     Previous use of current method22.518.919.419.618.520.0
     Previous use of any modern method75.976.477.690.193.294.4
    Partner knowledge of current method at time of insertion86.386.987.082.483.484.4
    Told at insertion that removal can be obtained any time92.994.193.696.297.197.5
    Told at insertion where removal can be obtained
     Insertion place only, %55.555.156.255.657.160.0
     Place other than insertion place0.70.81.10.41.01.3
     Insertion place and another place27.028.325.324.825.921.9
     Not told about any place15.414.716.717.814.615.0
     Not sure1.41.20.71.41.51.9
    • 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.

    • View popup
    TABLE 2.

    Participant Experiences Using Implants and IUDs in 3 Districts of Senegala

    Implant, %
    (n=1,202)b
    IUD, %
    (n=450)b
    Participants reporting CIMCs77.453.6
    Type of CIMCs reportedc,d
     Bleed more during period27.155.2
     Bleed less during period12.09.1
     Period lasts longer35.644.8
     Bleeding disturbancese60.846.9
     Stopped having period33.111.2
    Concern with CIMCsd
     Very concerned29.427.5
     Somewhat concerned32.530.4
     Not at all concerned38.242.1
    Impact of CIMCs on daily lifed
     Positive1.50.8
     Negative35.533.9
     No impact63.065.3
    Participants reporting weight gain37.820.1
    Participants reporting side effects other than weight gain and CIMCs37.544.2
    Type of side effect reporteda,f
     Headaches31.111.1
     Weight loss25.36.6
     Abdominal pain29.342.9
     Dizziness22.99.1
     Vaginal infectionsN/A24.8
     Pelvic discomfort/painN/A14.7
    Impact of side effects on daily lifef
     Greatly impacted19.618.2
     Impacted a little33.430.2
     No impact47.051.6
    • 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.

    • View popup
    TABLE 3.

    Participant’s Reported Desire to Remove Implant or IUD in 3 Districts of Senegala

    Implant, %
    (n=1,362)
    IUD, %
    (n=506)
    Reported desire to remove
     Never wanted a removal42.146.0
     Wanted a removal but have not asked a provider14.213.4
     Asked provider for removal43.640.5
    Reasons for wanting to stop using methodb,c
     Desired pregnancy25.836.8
     Bleeding disturbancesd20.610.3
     Bleed more during period or period longer11.37.4
    Reasons for not asking providere,c
     Busy/no time44.033.8
     Changed mind/decided to keep14.116.2
     Method came out on own0.013.3
    Reasons for wanting to stop using methodb,f
     Desired pregnancy29.927.6
     Bleeding disturbancesc23.412.8
     Bleed more during period or period longer15.416.7
     Partner disapproved12.77.7
     Weight loss12.33.2
     Weight gain11.61.3
    Timing of removal decisionf
     Decided before coming to facility95.689.0
     Decided at facility visit4.411.0
    Social influence reported for removal desiref
     Self66.675.4
     Husband/partner27.118.8
     Otherg6.35.8
    • 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 Senegala

    AOR (95% CI)
    (n=820b)
    Age group, years
     18–24Reference
     25–340.72 (0.45, 1.14)
     35–49+0.65 (0.36, 1.17)
    Education level
     NoneReference
     Primary/middle1.04 (0.67, 1.61)
     Secondary or higher0.74 (0.44, 1.24)
    Religion
     ChristianReference
     Muslim1.51 (0.69, 3.30)
    Parity
     0Reference
     1–20.56 (0.19, 1.66)
     3–40.41 (0.13, 1.28)
     5+0.34 (0.10, 1.19)
    Fertility intentions
     Do not want more children/do not want to have children/unsureReference
     Want more children/want to have children1.24 (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 method0.74 (0.50, 1.11)
    Partner knowledge of current method at time of insertion1.18 (0.74, 1.89)
    Informed choice1.42 (1.03, 1.96)c
    Received method wanted0.81 (0.45, 1.44)
    Insertion was free0.76 (0.54, 1.07)
    Informed method could be removed at any time1.00 (0.55, 1.81)
    Experienced amenorrhea1.61 (1.12, 2.32)c
    Experienced bleeding disturbances1.13 (0.81, 1.56)
    Experienced shorter or reduced bleeding0.55 (0.33, 0.91)c
    Experienced longer or heavier bleeding1.23 (0.87, 1.75)
    Experienced weight gain0.94 (0.68, 1.30)
    Experienced other side effectsd2.61 (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.

    • View popup
    TABLE 5.

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

    Implant
    (n=438)
    IUD
    (n=160)
    Location of first removal attempt, %
     Same place as insertion81.580.7
     Different place18.519.4
    Reported facing challenges accessing facility or at facility53.555.1
    Challenges faced,b,c %
     Long line/long wait67.175.6
     Difficulty getting away from house29.431.4
     Difficulty finding money to pay for transport and services23.819.8
     Provider was not available17.810.5
     Difficulty finding transport10.84.7
    Outcome of first removal attempt, %
     Method removed, reported satisfied to remove53.363.6
     Method removed, reported would have preferred to keep4.03.9
     Still has method, reported satisfied to keep9.99.7
     Still has method, reported would have preferred to remove32.222.7
     Partial/failed removal0.70.0
    Reasons provider did not remove at first interaction,b,d %
     Provider counseled to keep method33.950.0
     Qualified provider not available30.622.0
     Equipment/supplies not available for removal12.02.0
     Consultation period over/client arrived late to clinic11.52.0
     Provider refused to remove6.614.0
    Outcome of most recent removal attempt, %
     Method removed, reported satisfied to remove81.082.1
     Method removed, reported would have preferred to keep6.96.4
     Still has method, reported satisfied to keep5.96.4
     Still has method, reported would have preferred to remove5.75.1
     Partial/failed removal0.50.0
    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.

    • View popup
    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 Senegala

    Implant
    (n=379)
    IUD
    (n=136)
    Had method removed during first clinical procedure, %99.7100.0
    Reported complication at removal, %58.136.0
    Complications reported,b,c %
     Temporary pain at time of removal63.685.7
     Pain/discomfort that lasted throughout the day33.622.5
     Pain/discomfort that lasted a few days21.88.2
    Told by provider there were difficulties during removal, %17.74.4
    Reported duration of removal procedure, mean (range), minutes14.5 (0–120)11.3 (0–75)
    Reported time spent at facility for removal, mean (range), minutes81.0 (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 expensive1.10.0
     Same price3.32.3
     Less expensive1.40.0
     Was not told price at insertion93.396.2
    Reported ease of overall removal experience, %
     Very easy36.958.8
     Somewhat easy38.028.7
     Somewhat difficult17.910.3
     Very difficult7.12.2
    Did not obtain another contraceptive method after removal, %66.264.7
    Reasons reported,b,d %
     Afraid of side effects19.118.2
     Partner disapproved10.48.0
     Any reason other than desired pregnancy, sexual inactivity, or infecundity21.917.7
    • 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.

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Global Health: Science and Practice: 10 (5)
Global Health: Science and Practice
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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
Global Health: Science and Practice Oct 2022, 10 (5) e2200123; DOI: 10.9745/GHSP-D-22-00123

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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
Global Health: Science and Practice Oct 2022, 10 (5) e2200123; DOI: 10.9745/GHSP-D-22-00123
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