What Goes In Must Come Out: A Mixed-Method Study of Access to Contraceptive Implant Removal Services in Ghana

Rebecca Callahan; Elena Lebetkin; Claire Brennan; Emmanuel Kuffour; Angela Boateng; Samuel Tagoe; Anne Coolen; Mario Chen; Patrick Aboagye; Aurélie Brunie

doi:10.9745/GHSP-D-20-00013

Key Findings

Although most contraceptive implant users in Ghana are able to access removal services, barriers, including cost, provider reluctance to remove, and difficult removals, exist.
Providers express confidence in removing implants, but many are less confident in their ability to perform difficult removals.

Key Implications

Family planning programs should review and strengthen potential gaps in removal service provision including access to removals for outreach clients, financial disincentives for removal, and provider training and referral systems for difficult removals.
More research is needed to assess the prevalence and consequences of difficult implant removals in different settings.

ABSTRACT

Background:

Access to quality removal services is a key component of informed choice in contraceptive implant use; however, limited data exist on users’ access to removal services. In Ghana, implants are available across the country and are the most commonly used contraceptive method among married women.

Methods:

From October 2017 and January 2018, we conducted a phone survey with a stratified random sample of 1,159 women who had obtained an implant from a public-sector Ghana Health Service clinic in 2 regions and 1,073 women who had an implant inserted through Marie Stopes International Ghana (MSIG) mobile outreach in 2 other regions. We also interviewed 50 women just after receiving an implant removal from MSIG. We conducted follow-up in-depth interviews with 20 implant acceptors and 15 implant providers across the 4 study regions.

Results:

More than four-fifths of women in both service delivery contexts knew that their implant could be removed before its labeled duration. Nearly half of public sector clients and one-third of outreach clients reported that their provider only told them of removal access at the place of insertion. Among women obtaining their implant in the public and outreach sectors, respectively, 32% and 21% reported ever wanting it removed and 61% and 55% who attempted removal obtained a removal on the first attempt. An additional 17% in each context were successful in having their implant removed within 1 week of the first attempt. Most women obtained removal from the same place they received their insertion (81% public, 70% outreach). Most women reported their overall removal experience was very or somewhat easy (74% public, 68% outreach). Challenges included cost, provider availability, interactions with providers, and difficult removals.

Conclusions:

Access to implant removal is not universal in Ghana. Strengthening removal services in both the public and outreach sectors is needed to ensure comprehensive access.

Received: December 19, 2019.
Accepted: March 31, 2020.
Published: June 30, 2020.

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