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ORIGINAL ARTICLE
Open Access

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 and Girmay Adane
Global Health: Science and Practice March 2016, 4(1):16-28; https://doi.org/10.9745/GHSP-D-15-00365
Yewondwossen Tilahun
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Sarah Mehta
bPathfinder International, Watertown, MA, USA
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Habtamu Zerihun
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Candace Lew
cPathfinder International, Washington, DC, USA
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Mohamad I Brooks
bPathfinder International, Watertown, MA, USA
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Tariku Nigatu
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Kidest Lulu Hagos
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Mengistu Asnake
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Adeba Tasissa
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Seid Ali
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Ketsela Desalegn
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Girmay Adane
aPathfinder Ethiopia, Addis Ababa, Ethiopia
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Figures & Tables

Figures

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  • Figure1
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    An instructor in Ethiopia demonstrates how to insert an IUD using a pelvic model.

  • FIGURE
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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.

Tables

  • Figures
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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 MethodBefore No. (%)After No. (%)Percentage Point DifferenceP Value
    Long-acting reversible methods3,436 (6.9)10,529 (20.5)13.6<.001
     Implants3,260 (6.6)7,586 (14.8)8.2<.001
     IUDs176 (0.4)2,943 (5.7)5.3<.001
    Short-acting methods46,242 (93.1)40,713 (79.5)-13.6<.001
     Injectables37,647 (75.8)32,934 (64.3)-11.5<.001
     Pills6,551 (13.2)3,733 (7.3)-5.9<.001
     Condoms2,044 (4.1)4,046 (7.9)3.8<.001
    Total49,678 (100.0)51,242 (100.0)
    • View popup
    TABLE 2 Background Characteristics of IUD Users (N = 2,943)
    No. (%)No. (%)
    RegionNo. of previous pregnancies
     Oromia926 (31.5) 0221 (7.5)
     Tigray729 (24.8) 1484 (16.4)
     Amhara657 (22.3) 2–41,426 (48.5)
     SNNPR631 (21.4) >4812 (27.6)
    Residence Mean (SD)3.3 (2.3)
     Rural1,838 (62.5)No. of birthsa
     Urban1,104 (37.5) 038 (1.4)
     Missing1 (0.0) 1477 (17.5)
    Marital Status 2–41,436 (52.8)
     Married/living together2,709 (92.0) >4759 (27.9)
     Never married190 (6.5) Missing12 (0.4)
     Divorced/separated/widowed42 (1.4) Mean (SD)3.5 (2.1)
     Missing2 (0.1)No. of living childrenb
    Religion 012 (0.4)
     Orthodox1,929 (65.5) 1500 (18.6)
     Protestant540 (18.3) 2–41,444 (53.8)
     Muslim393 (13.4) >4715 (26.6)
     Catholic74 (2.5) Missing13 (0.5)
     Traditional3 (0.1) Mean (SD) 3.4 (2.0)
     Missing4 (0.1)Sources of information about IUD service
    Educational level Health professionalc2,377 (80.8)
     No education1,316 (44.7) Health extension worker502 (17.1)
     Primary1,114 (37.9) Media35 (1.2)
     Secondary356 (12.1) Health development army11 (0.4)
     More than secondary152 (5.2) Relatives5 (0.2)
     Missing5 (0.2) Mobile van3 (0.1)
    Age Othersd10 (0.3)
     <20182 (6.2)
     20–24633 (21.5)
     25–29930 (31.6)
     30–34614 (20.9)
     >34580 (19.7)
     Missing4 (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.

    • View popup
    TABLE 3 Previous Use of Contraception Among New IUD Acceptors
    No. (%)
    Ever used family planning2,943 (100.0)
    Yes (Method shift)2,394 (81.3)
    No (New acceptors)531 (18.0)
    Missing18 (0.6)
    Method used at index visit among those who had ever used family planning2,394 (100.0)
    Nonea258 (10.8)
    Long-acting reversible methods355 (14.8)
     Implanon292 (12.2)
     Jadelle51 (2.1)
     Norplant12 (0.5)
    Short-acting methods1,780 (74.3)
     Injectables1,609 (67.2)
     Combined oral contraceptives116 (4.8)
     Condoms7 (0.3)
     Breastfeeding11 (0.5)
     Natural methods (withdrawal, SDM, etc.)37 (1.5)
    Missing1 (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.

    • View popup
    TABLE 4 Characteristics of Women Seeking IUD Removal Services (N=165)
    No. (%)No. (%)
    RegionNo. of previous pregnancies
     Oromia63 (38.2) 023 (13.9)
     Tigray30 (27.9) 136 (21.8)
     Amhara46 (18.2) 2–471 (43.0)
     SNNPR26 (15.8) >427 (16.4)
    Residence Missing8 (4.8)
     Rural87 (52.7) Mean (SD)2.6 (2.3)
     Urban78 (47.3)Ever given birtha
    Marital status Yes130 (91.5)
     Married/living together140 (84.8) No5 (3.5)
     Never married10 (6.1) Missing7 (4.9)
     Divorced/separated/widowed5 (3.0)No. of living childrenb
     Missing10 (6.1) 136 (27.7)
    Religion 2–472 (55.4)
     Orthodox106 (64.2) >422 (16.9)
     Protestant27 (16.4) Mean (SD)2.9 (1.9)
     Muslim22 (13.3)Duration of IUD use, months
     Catholic2 (1.2) <632 (19.4)
     Missing8 (4.8) 6–1218 (10.9)
    Educational level 13–2429 (17.6)
     No education61 (37.0) 25–3623 (13.9)
     Primary47 (28.5) 37–6022 (13.3)
     Secondary34 (20.6) 61–8412 (7.3)
     More than secondary16 (9.7) >8410 (6.1)
     Missing7 (4.2) Missing19 (11.5)
    Age Mean (SD)30.5 (31.3)
     <209 (5.5)
     20–2434 (20.6)
     25–2949 (29.7)
     30–3432 (19.4)
     >3434 (20.6)
     Missing7 (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.

    • View popup
    TABLE 5 Reasons for Seeking IUD Removala (N = 158)
    No. (%)
    Want to become pregnant68 (43.0)
    Side effects/health concerns41 (25.9)
    Husband/partner disapproves32 (20.3)
    Other family member disapproves11 (7.0)
    Infrequent sex/husband away9 (5.7)
    Became pregnant while using4 (2.5)
    Don’t want to give a reason4 (2.5)
    Wants more effective method3 (1.9)
    Marital dissolution/separation3 (1.9)
    Completion of effective duration of use2 (1.3)
    I don’t think I can be pregnant/menopausal1 (0.6)
    Lack of access/too far for facility1 (0.6)
    Otherb7 (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.

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Global Health: Science and Practice: 4 (1)
Global Health: Science and Practice
Vol. 4, No. 1
March 21, 2016
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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
Global Health: Science and Practice Mar 2016, 4 (1) 16-28; DOI: 10.9745/GHSP-D-15-00365

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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
Global Health: Science and Practice Mar 2016, 4 (1) 16-28; DOI: 10.9745/GHSP-D-15-00365
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