Uptake of the levonorgestrel intrauterine system among recent postpartum women in Kenya: factors associated with decision-making

Abstract

Background

The levonorgestrel intrauterine system (LNG IUS) may become more available in the public sector of resource-poor countries, but it is unclear what product features might be attractive to users and what factors will influence uptake.

Study design

We recruited 671 women in Kenya who were seeking contraception at 6–12 weeks postpartum and gave them an opportunity to try the LNG IUS. We asked why they did or did not choose it, relative to the alternative options. χ² tests of association were done to examine participant characteristics and decision-making associated with choice.

Results

Participants chose the following methods: LNG IUS (16%), injectable (36%), subdermal implant (30%), progestin-only pills (15%) and copper intrauterine device (IUD) (3%). Reasons for not choosing the LNG IUS included fear of pain/injury/discomfort (34%), modesty issues regarding insertion (33%) and fear of hormonal/health side effects (31%). Nearly a third of LNG IUS acceptors said they would have chosen a short-acting method if the LNG IUS were not available, and only 21% would have chosen the copper IUD.

Conclusions

The LNG IUS could be an ideal method for increasing uptake of long-acting methods among recent postpartum women. Product attributes and comparisons to other contraceptive options are important factors in decision-making. Even among women comfortable with intrauterine contraception, great distinctions and preferences are apparent. Addressing specific misconceptions and fears with better information can help women make the best personal choices.

Introduction

Short birth intervals increase the risk of maternal mortality [1] and adverse outcomes for the newborn [2]; the United Nations Millennium Development Goals cite improved access to contraception as a key action for realizing improved health in resource-poor settings [3]. New technologies may offer important advantages and increase uptake.

Long-acting reversible contraception (LARC) consists of intrauterine devices/systems and subdermal implants; collectively, these are the most effective temporary (spacing) family planning methods [4] and are safe to use in the postpartum period [5]. Unlike injectables and oral contraceptives, LARC methods are easier to use because they do not require frequent periodic dosing and visits to health centers. In addition, the methods can provide between 3 and 10 + years of contraceptive protection, depending on the product chosen. Thus, LARC can be a very attractive option for women who want to avoid early repeat pregnancies.

Historically, the copper intrauterine device (IUD) has been the primary LARC method for public sector programs in sub-Saharan Africa. However, in the past two decades, prevalence of use has dropped or remained stagnant in many countries. Currently, in the region, prevalence of IUD use is quite low (0.5%) compared to injectables (6.8%) and oral contraceptives (4.3%) [6]. Just in the last decade, the subdermal implant has become increasingly popular (0.4%) and even outpaces the copper IUD in many countries (particularly those in Eastern Africa).

The levonorgestrel intrauterine system (LNG IUS) was first approved in Finland in 1990. Worldwide product registration has enabled millions of women to use it. However, the commercial product (known as Mirena®) that reaches sub-Saharan Africa (and developing countries in other regions of the world) is too expensive for the public sector. The International Contraceptive Access (ICA) Foundation (a partnership between Bayer Healthcare Pharmaceuticals and the Population Council) was formed in 2003 to donate and distribute free product known as “LNG IUS” to resource-poor settings. Since inception, the ICA Foundation has donated approximately 46,000 LNG IUSs to 17 different countries [7]; this generosity has helped pave the way for new opportunities.

The LNG IUS is a proven technology that is arguably overdue for expansion into resource-poor settings. The method increases hemoglobin and serum ferritin levels [8]; this could help alleviate chronic or acute anemia among postpartum (and other) women. In addition, because of near-universal postpartum/lactational amenorrhea, the postpartum period may be an ideal time for LNG IUS insertion; common progestin side effects may be either masked or alleviated during this time.

Though a new low-cost hormonal IUS is being developed [9], [10], [11], it will be years before it becomes widely available in the public sector of developing countries. Thus, one interim option is to offer the product to subgroups of the general population who are at highest need. We undertook this project (a) to provide postpartum women with another important method for preventing short birth intervals, (b) to assess how the LNG IUS might complement existing LARC options and (3) to characterize how the product is viewed. Together, the results can help prepare future efforts at introducing the product on a wider scale.