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ORIGINAL ARTICLE
Open Access

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 and Aurélie Brunie
Global Health: Science and Practice June 2020, 8(2):220-238; https://doi.org/10.9745/GHSP-D-20-00013
Rebecca Callahan
aFHI 360, Durham, NC, USA.
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Elena Lebetkin
aFHI 360, Durham, NC, USA.
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  • For correspondence: elebetkin@fhi360.org
Claire Brennan
bRTI International, Research Triangle Park, NC, USA.
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Emmanuel Kuffour
cPopulation Council, Ghana.
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Angela Boateng
dGhana Health Service, Family Health Division, Accra, Ghana.
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Samuel Tagoe
eMarie Stopes International Ghana, Accra, Ghana.
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Anne Coolen
eMarie Stopes International Ghana, Accra, Ghana.
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Mario Chen
aFHI 360, Durham, NC, USA.
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Patrick Aboagye
dGhana Health Service, Family Health Division, Accra, Ghana.
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Aurélie Brunie
fFHI 360, Washington, DC, USA.
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Figures & Tables

Figures

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  • FIGURE 1.
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    FIGURE 1.

    Study Sample of Women, Aged 18–49 Years Old, Who Had a Contraceptive Implant Inserted in Public and Outreach Regions, Ghana

    Abbreviations: CLIC, Client Information Center; IDI, in-depth interview; RA, research assistant; rsLog, Reproductive Services Log.

  • FIGURE 2.
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    FIGURE 2.

    Outcomes Among Women Who Attempted to Have Contraceptive Implants Removed in Public and Outreach Regions, Ghana

    aPercentages are adjusted for sampling weights.

Tables

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    TABLE 1.

    Contraceptive Implant Acceptor Phone Survey Participants’ Demographic Characteristics by Context, Ghana

    Publica(N=1,159)Outreach(N=1,073)
    Age, years, mean (SD)29.6 (6.6)28.4 (6.2)
        18–29, %53.863.1
        30–39, %36.830.7
        40–49, %9.46.2
    Marital status
        Never married, %21.419.5
        Married/cohabitating, %73.076.4
        Divorced/widowed, %5.64.2
    Parity(n=1152)(n=1062)
        Mean (SD)2.3 (1.6)2.6 (1.6)
        0, %10.23.9
        1–2, %49.050.1
        3–4, %31.533.3
        5+, %9.412.7
    Highest education(n=1072)
        None, %6.75.5
        Primary, %11.015.5
        Middle, %51.858.4
        High school, %21.715.9
        >High school, %8.94.7
    Religion
        Christian, %92.393.6
        Muslim, %7.44.9
        Other/none, %0.31.5
    Have health insurance, %64.742.6
    Wealth quantiles(n=1155)(n=1073)
        Lowest, %16.323.9
        Second, %18.222.1
        Middle, %21.120.3
        Fourth, %22.418.0
        Highest, %22.015.8
    Months since implant inserted
        Mean (SD)19.5 (10.8)14.5 (7.4)
        0–6, %4.912.6
        7–12, %34.046.3
        13–18, %19.413.4
        19–24, %18.722.4
        25–36, %18.94.9
        >36 months, %4.10.5
    Implant typeb
        Jadelle, %61.986.3
        Implanon, %29.86.3
        Unknown, %8.37.4
    • Abbreviations: SD, standard deviation.

    • ↵a Frequencies are unadjusted; percentages and means are adjusted for sampling weights.

    • ↵b Implant type determined by comparing participant responses to number of rods in their implant and the duration of protection. Response combinations that do not describe any available implant are categorized as unknown.

    • View popup
    TABLE 2.

    Phone Survey Participants’ Reported Knowledge of Contraceptive Implant Removal Services by Context, Ghana

    Publica(N=1,159)Outreach(N=1,073)
    %95% CI%
    Aware implant can be removed before labeled duration88.285.8, 90.384.3
    Told by provider at insertion that implant can be removed before labeled duration(n=1020) 88.986.0, 91.3(n=905) 88.4
    Reasons provider mentioned that implant can be removed before labeled durationb(n=923)(n=800)
        Want children69.3N/A62.6
        Side effects60.5N/A62.0
        Any reason26.0N/A24.9
        Partner disapproves9.9N/A9.5
    Told at insertion where removal can be obtained
        Insertion place only46.5N/A33.3
        Place other than insertion place3.2N/A15.2
        Insertion place and another place40.5N/A38.1
        Not told about any place/don’t know9.8N/A13.4
    • ↵a Frequencies are unadjusted; percentages and means are adjusted for sampling weights.

    • ↵b Multiple responses possible, spontaneous mention.

    • View popup
    TABLE 3.

    Phone Survey Participant’s Reported Desire to Remove Contraceptive Implant, by Context, Ghana

    Publica(N=1,159)Outreach(N=1,073)
    %%
    Report wanting removal31.821.5
    Main reason for wanting removal/obtaining removal(n=373)(n=231)
        Other side effects/ health concerns37.749.4
        Bleeding side effects24.422.9
        Wanted children18.710.4
        Partner disapproved4.95.2
        Lost partner/partner away/infrequent sex3.52.6
        Other2.74.8
        Implant expired2.50.0
        Afraid of becoming infertile2.21.3
        Sexual side effects1.41.3
        Became pregnant1.11.3
        Too old/ menopause/ infecund0.70.4
        Don’t know0.20.4
    • ↵a Frequencies are unadjusted; percentages and means are adjusted for sampling weights.

    • View popup
    TABLE 4.

    Phone Survey Participants’ Reported Contraceptive Implant Side Effects and Social Influence by Context and Desire to Remove Implant, Ghana

    Publica(N=1,159)Outreach(N=1,073)
    Ever Wanted Removal(n=373)%Never Wanted Removal(n=786)%Ever Wanted Removal(n=231)%Never Wanted Removal(n=842)%
    Reported experiencing bleeding side effects85.275.6(n=230) 90.0(n=840) 77.3
        Most commonly mentioned bleeding side effectsb(n=315)(n=597)(n=208)(n=651)
            Stopped having period39.337.246.648.9
            Bleed more during period37.625.719.714.8
            Bleed less during period23.825.522.124.3
            Period lasts longer26.023.026.424.3
            Period is shorter13.815.418.318.0
    Reported experiencing side effects (other than bleeding)(n=372) 59.6(n=784) 40.3(n=230) 70.0(n=840) 38.0
        Most commonly mentioned other side effectsb(n=227)(n=315)(n=161)(n=320)
            Dizziness47.126.550.338.4
            Weight change43.240.140.433.4
            Headaches23.826.415.513.1
            Abdominal pain11.121.914.915.9
    Reported someone influenced to stop using implant40.531.851.529.8
        Person(s) influenced byb(n=154)(n=237)(n=118)(n=215)
            Neighbor or friend54.983.554.276.9
            Husband or partner42.114.431.412.0
            Mother9.77.214.46.8
            Other person/unspecified3.89.910.210.8
    • ↵a Frequencies are unadjusted, percentages and means are adjusted for sampling weights.

    • ↵b Multiple responses possible, spontaneous mention.

    • View popup
    TABLE 5.

    Phone Survey Participants’ Responses on Barriers to Contraceptive Implant Removal and Satisfaction With Services Among Women Who Attempted a Removal by Context, Ghana

    Publica(n=339)Outreach(n=132)
    %%
    Reason women reported they could not get a removal when they wanted tob
        Provider counseled to continue using20.616.7
        Provider not available8.616.7
        Provider would not remove11.510.6
        Provider unable to remove despite trying0.74.6
        Implant not palpable4.413.5
    Problems at removal site on armc(n=314)(n=101)
        Temporary pain at time of removal43.646.0
        Pain that lasted a few days43.654.1
        Scarring35.235.1
        Infection/swelling5.15.4
        Continue pain5.221.6
        Other unspecified0.05.4
    Ease of removal experience (among women who had a removal)(n=314)(n=101)
        Very easy53.055.5
        Somewhat easy20.812.9
        Somewhat difficult17.416.8
        Very difficult8.814.9
    • ↵a Frequencies are unadjusted; percentages and means are adjusted for sampling weights.

    • ↵b Each of these options were asked as a separate yes/no question.

    • ↵c Multiple responses possible, spontaneous mention.

    • View popup
    TABLE 6.

    Phone Survey Participants’ Reported Costs Associated With Contraceptive Implant Removal Services Reported by Respondents Who Removed Implant by Context, Ghana

    Publica(n=307)Outreach(n=101)
    Reported incurring cost for removal services not associated with transportationb, %75.084.2
        Mean cost incurred, US$c (SD)3.2 (1.8)5.0 (1.9)d
    Reported incurring cost for transportation, %70.655.5
        Mean cost incurred, US$c (SD)1.1 (0.7)1.1 (1.0)
    • Abbreviation: SD, standard deviation.

    • ↵a Frequencies are unadjusted; percentages and means are adjusted for sampling weights.

    • ↵b Costs includes fees for supplies, provider, and other facility-associated costs.

    • ↵c Respondents reported costs in Ghana cedis. Costs were converted to US$ using the exchange rate at the time of analysis (21 US cents=1.00 Ghana cedi). Means calculated from women who reported incurring costs only.

    • ↵d One respondent reported a cost of US$52.50, which was an extreme outlier. This response was removed from the analysis.

    • View popup
    TABLE 7.

    Phone Survey Participants’ Reported Contraceptive Method Uptake and Unmet Need After Implant Removal by Context, Ghana

    Publica(n=314)Outreach(n=101)
    %%
    Adopted contraceptive method after removal35.628.7
        Method used(n=116)(n=29)
            Injectable60.272.4
            Pill24.824.1
            Emergency Contraception11.13.5
            Intrauterine device2.40.0
            Implant0.70.0
            Other0.80.0
        Reasons for not adopting method(n=193b)(n=72)
            Want to get pregnant37.418.1
            Side effects/health concerns34.836.1
            Lost partner/partner away11.26.9
            Partner disapproves3.911.1
            Inconvenient1.34.2
            Other/unspecified11.423.8
    Unmet need for family planning after removalc33.353.5
    • ↵a Frequencies are unadjusted, percentages and means are adjusted for sampling weights.

    • ↵b Five respondents did not provide a response to this question, thus the reduced sample size.

    • ↵c Unmet need is defined as not adopting a method of family planning after removal for all reasons other than desiring pregnancy, reporting no sexual activity, and reporting infecundity.

    • View popup
    TABLE 8.

    Characteristics of Contraceptive Implant Acceptor Exit Interview Participants, Ghana

    Interviewees(n=50)
    Age, years, mean (SD)31.0 (7.0)
    Marital status, %
        Never married30.0
        Married/cohabitating58.0
        Divorced/widowed12.0
    Parity, mean (SD)3.3 (1.8) (n=47)
    Highest education, %
        None22.0
        Primary36.0
        Middle42.0
    Religion, %
        Christian92.0
        Muslim6.0
        Other/none2.0
    Have health insurance, %16.0
    Wealth quantiles, %(n=49)
        Lowest55.1
        Second28.6
        Middle12.2
        Fourth4.1
        Highest0.0
    Months since implant inserted, %(n=48)
    Mean (SD)51.4 (16.8)
        ≤ 2412.5
        25–3612.5
        488.3
        60+66.6
    Implant typea, %
        Jadelle84.0
        Implanon4.0
        Unknown12.0
    Adopted contraceptive method after removal, %66.0
    Contraceptive method used, %(n=33)
        Intrauterine device3.0
        Implant93.9
        Female sterilization3.0
    Reasons for not adopting method, %(n=16b)
        Want to get pregnant25.0
        Side effects/health concerns12.6
        Partner disapproves31.3
        Inconvenient18.8
        Other/unspecified12.6
    Unmet need for family planning after removalc24.0
    • ↵a Implant type determined by comparing participant responses to number of rods in their implant and the duration of protection. Response combinations that do not describe any available implant are categorized as unknown.

    • ↵b One respondent did not provide a response to this question, thus the reduced sample size.

    • ↵c Unmet need is defined as not adopting a contraceptive method after removal for all reasons other than desiring pregnancy, reporting no sexual activity, and reporting infecundity.

    • View popup
    TABLE 9.

    Outcome of Either Removal Attempt or Desire to Remove for Contraceptive Implant Acceptor In-depth Interview Participants by Context, Ghana

    Public(n=10)Outreach(n=10)
    No.No.
    Successful removal at first attempt32
    Removal at second or subsequent attempt64
    Removal not yet obtained11
    Wanted removal but have not attempted03
    • View popup
    TABLE 10.

    Characteristics of Contraceptive Implant Providers by Context, Ghana

    Public(n=8)Outreach(n=7)
    No.No.
    Provider cadre
        Nurse11
        Midwife22
        Community health nurse34
        Other20
    Experience with implant insertion
        1–2 years51
        3–5 years05
        6+ years31
    Experience with implant removals
        No experience10
        1–2 years43
        3–5 years04
        6+ years30
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Global Health: Science and Practice: 8 (2)
Global Health: Science and Practice
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June 30, 2020
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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
Global Health: Science and Practice Jun 2020, 8 (2) 220-238; DOI: 10.9745/GHSP-D-20-00013

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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
Global Health: Science and Practice Jun 2020, 8 (2) 220-238; DOI: 10.9745/GHSP-D-20-00013
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