Expanding Access to the Intrauterine Device in Public Health Facilities in Ethiopia: A Mixed-Methods Study

Yewondwossen Tilahun; Sarah Mehta; Habtamu Zerihun; Candace Lew; Mohamad I Brooks; Tariku Nigatu; Kidest Lulu Hagos; Mengistu Asnake; Adeba Tasissa; Seid Ali; Ketsela Desalegn; Girmay Adane

doi:10.9745/GHSP-D-15-00365

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An instructor in Ethiopia demonstrates how to insert an IUD using a pelvic model.
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FIGURE
Timeline of Ethiopia's IUD Initiative, IFHP+’s Programmatic Support, and Pathfinder International’s Study
Abbreviations: FGD, focus group discussion; IUD, intrauterine device; IFHP+, Integrated Family Health Program; KII, key informant interview.

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TABLE 1 Contraceptive Method Mix among Family Planning Clients in 40 Selected Ethiopian Health Centers Before (Jul–Dec 2011) and After (Mar–Aug 2014) the IUD Scale-Up Initiative

Contraceptive Method	Before No. (%)	After No. (%)	Percentage Point Difference	P Value
Long-acting reversible methods	3,436 (6.9)	10,529 (20.5)	13.6	<.001
Implants	3,260 (6.6)	7,586 (14.8)	8.2	<.001
IUDs	176 (0.4)	2,943 (5.7)	5.3	<.001
Short-acting methods	46,242 (93.1)	40,713 (79.5)	-13.6	<.001
Injectables	37,647 (75.8)	32,934 (64.3)	-11.5	<.001
Pills	6,551 (13.2)	3,733 (7.3)	-5.9	<.001
Condoms	2,044 (4.1)	4,046 (7.9)	3.8	<.001
Total	49,678 (100.0)	51,242 (100.0)

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TABLE 2 Background Characteristics of IUD Users (N = 2,943)

	No. (%)		No. (%)
Region		No. of previous pregnancies
Oromia	926 (31.5)	0	221 (7.5)
Tigray	729 (24.8)	1	484 (16.4)
Amhara	657 (22.3)	2–4	1,426 (48.5)
SNNPR	631 (21.4)	>4	812 (27.6)
Residence		Mean (SD)	3.3 (2.3)
Rural	1,838 (62.5)	No. of births^a
Urban	1,104 (37.5)	0	38 (1.4)
Missing	1 (0.0)	1	477 (17.5)
Marital Status		2–4	1,436 (52.8)
Married/living together	2,709 (92.0)	>4	759 (27.9)
Never married	190 (6.5)	Missing	12 (0.4)
Divorced/separated/widowed	42 (1.4)	Mean (SD)	3.5 (2.1)
Missing	2 (0.1)	No. of living children^b
Religion		0	12 (0.4)
Orthodox	1,929 (65.5)	1	500 (18.6)
Protestant	540 (18.3)	2–4	1,444 (53.8)
Muslim	393 (13.4)	>4	715 (26.6)
Catholic	74 (2.5)	Missing	13 (0.5)
Traditional	3 (0.1)	Mean (SD)	3.4 (2.0)
Missing	4 (0.1)	Sources of information about IUD service
Educational level		Health professional^c	2,377 (80.8)
No education	1,316 (44.7)	Health extension worker	502 (17.1)
Primary	1,114 (37.9)	Media	35 (1.2)
Secondary	356 (12.1)	Health development army	11 (0.4)
More than secondary	152 (5.2)	Relatives	5 (0.2)
Missing	5 (0.2)	Mobile van	3 (0.1)
Age		Others^d	10 (0.3)
<20	182 (6.2)
20–24	633 (21.5)
25–29	930 (31.6)
30–34	614 (20.9)
>34	580 (19.7)
Missing	4 (0.1)
Mean (SD)	28.0 (6.0)

↵ Abbreviations: IUD, intrauterine device; SD, standard deviation; SNNPR, Southern Nations, Nationalities, and People’s Region.
↵a Denominator is 2,722 women who had previously been pregnant.
↵b Denominator is 2,684 women who had ever given birth.
c Includes nurses, midwives, and health officers working in health centers.
↵d Includes neighbors and school.

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TABLE 3 Previous Use of Contraception Among New IUD Acceptors

	No. (%)
Ever used family planning	2,943 (100.0)
Yes (Method shift)	2,394 (81.3)
No (New acceptors)	531 (18.0)
Missing	18 (0.6)
Method used at index visit among those who had ever used family planning	2,394 (100.0)
None^a	258 (10.8)
Long-acting reversible methods	355 (14.8)
Implanon	292 (12.2)
Jadelle	51 (2.1)
Norplant	12 (0.5)
Short-acting methods	1,780 (74.3)
Injectables	1,609 (67.2)
Combined oral contraceptives	116 (4.8)
Condoms	7 (0.3)
Breastfeeding	11 (0.5)
Natural methods (withdrawal, SDM, etc.)	37 (1.5)
Missing	1 (0.0)

Abbreviations: IUD, intrauterine device; SDM, Standard Days Method.
↵a Had used family planning in the past but were not using any method at the time of their index visit.

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TABLE 4 Characteristics of Women Seeking IUD Removal Services (N=165)

	No. (%)		No. (%)
Region		No. of previous pregnancies
Oromia	63 (38.2)	0	23 (13.9)
Tigray	30 (27.9)	1	36 (21.8)
Amhara	46 (18.2)	2–4	71 (43.0)
SNNPR	26 (15.8)	>4	27 (16.4)
Residence		Missing	8 (4.8)
Rural	87 (52.7)	Mean (SD)	2.6 (2.3)
Urban	78 (47.3)	Ever given birth^a
Marital status		Yes	130 (91.5)
Married/living together	140 (84.8)	No	5 (3.5)
Never married	10 (6.1)	Missing	7 (4.9)
Divorced/separated/widowed	5 (3.0)	No. of living children^b
Missing	10 (6.1)	1	36 (27.7)
Religion		2–4	72 (55.4)
Orthodox	106 (64.2)	>4	22 (16.9)
Protestant	27 (16.4)	Mean (SD)	2.9 (1.9)
Muslim	22 (13.3)	Duration of IUD use, months
Catholic	2 (1.2)	<6	32 (19.4)
Missing	8 (4.8)	6–12	18 (10.9)
Educational level		13–24	29 (17.6)
No education	61 (37.0)	25–36	23 (13.9)
Primary	47 (28.5)	37–60	22 (13.3)
Secondary	34 (20.6)	61–84	12 (7.3)
More than secondary	16 (9.7)	>84	10 (6.1)
Missing	7 (4.2)	Missing	19 (11.5)
Age		Mean (SD)	30.5 (31.3)
<20	9 (5.5)
20–24	34 (20.6)
25–29	49 (29.7)
30–34	32 (19.4)
>34	34 (20.6)
Missing	7 (4.2)
Mean (SD)	28.5 (6.7)

Abbreviations: IUD, intrauterine device; SD, standard deviation; SNNPR, Southern Nations, Nationalities, and People’s Region.
↵a Denominator is 142 women who had previously been pregnant.
↵b Denominator is 130 women who had ever given birth.

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TABLE 5 Reasons for Seeking IUD Removal^a (N = 158)

	No. (%)
Want to become pregnant	68 (43.0)
Side effects/health concerns	41 (25.9)
Husband/partner disapproves	32 (20.3)
Other family member disapproves	11 (7.0)
Infrequent sex/husband away	9 (5.7)
Became pregnant while using	4 (2.5)
Don’t want to give a reason	4 (2.5)
Wants more effective method	3 (1.9)
Marital dissolution/separation	3 (1.9)
Completion of effective duration of use	2 (1.3)
I don’t think I can be pregnant/menopausal	1 (0.6)
Lack of access/too far for facility	1 (0.6)
Other^b	7 (4.4)

↵a Women selected as many reasons as applied to their situation (categories are not mutually exclusive).
↵b Includes age, switched methods, and acquired a sexually transmitted infection.