Influences on women’s decision making about intrauterine device use in Madagascar

Abstract

Objective

We explored influences on decision making about intrauterine device (IUD) use among women in the Women’s Health Project (WHP), managed by Population Services International in Madagascar.

Study design

We conducted six small group photonarrative discussions (n= 18 individuals) and 12 individual in-depth interviews with women who were IUD users and nonusers. All participants had had contact with WHP counselors in three sites in Madagascar. Data analysis involved creating summaries of each transcript, coding in Atlas.ti and then synthesizing findings in a conceptual model.

Results

We identified three stages of women’s decision making about IUD use, and specific forms of social support that seemed helpful at each stage. During the first stage, receiving correct information from a trusted source such as a counselor conveys IUD benefits and corrects misinformation, but lingering fears about the method often appeared to delay method adoption among interested women. During the second stage, hearing testimony from satisfied users and receiving ongoing emotional support appeared to help alleviate these fears. During the third stage, accompaniment by a counselor or peer seemed to help some women gain confidence to go to the clinic to receive the IUD.

Conclusion

Identifying and supplying the types of social support women find helpful at different stages of the decision-making process could help program managers better respond to women’s staged decision-making process about IUD use.

Implications

This qualitative study suggests that women in Madagascar perceive multiple IUD benefits but also fear the method even after misinformation is corrected, leading to a staged decision-making process about IUD use. Programs should identify and supply the types of social support that women find helpful at each stage of decision making.

Introduction

The intrauterine device (IUD) is a highly effective and safe contraceptive method that many women prefer because of its long-term yet quickly reversible protection against pregnancy [1], [2]. Increasing IUD use could also substantially reduce the impact of unintended pregnancy on maternal mortality in many regions of the world [3]. Despite these benefits, the IUD’s share in the contraceptive method mix has remained negligible in sub-Saharan Africa at around 2% [4], [5]. Supply-side barriers to IUD uptake have included a lack of trained providers, need for specific equipment and provider misconceptions about the IUD [4], [6]. Demand-side barriers have included low consumer knowledge, misconceptions about the IUD, fears about a foreign object inside the body and high up-front cost [6], [7].

Findings from program evaluations in a number of countries suggest that, along with improving access to IUD services, creating informed demand for the method is essential for increasing uptake and client satisfaction with the method postinsertion, particularly in settings where IUD use is rare [8], [9], [10]. Interpersonal communication is a common strategy used to improve informed demand for and client satisfaction with the IUD [11], [12]. Interpersonal communication involves a one-on-one exchange of information and support with close others within a social network, and is shaped by personal attitudes and beliefs as well as broader community norms [13]. Little information is available, however, about the specific strategies used in programs or the mechanisms of influence.

Population Services International (PSI) is implementing the Women’s Health Project (WHP) to increase supply and generate demand for long-acting reversible contraceptives (LARC) in 13 countries with significant unmet need for contraception and low use of LARC [9]. In Madagascar, where IUD use was formerly at around 2% [14], PSI began implementing the WHP in 2008 in eight sites across the country. Providers were trained in two methods, the copper-bearing IUD (TCu-380A®) and contraceptive implant, both of which were provided to clients at a subsidized price. The project also engages about 240 counselors across the eight sites, who received specialized training in promoting LARC methods. These counselors conduct home visits to present clients with the range of contraceptive choices available to them, using visual aids and product samples. They describe the benefits of the IUD and correct common misconceptions. Counselors also conduct follow-up visits with women who express interest in the IUD, sometimes bringing these women together in groups to hear testimony from satisfied users and accompanying women to the clinic upon request. Counselors do not receive additional financial incentive if a woman they counsel or accompany to the clinic receives an IUD.

For the 6-year period from July 2008 to June 2014, the WHP provided approximately 106,500 IUDs to women across the eight sites in Madagascar [15]. During that period, 767 (0.7%) women subsequently had the IUD removed by a WHP provider, although others may have had the IUD removed by a non-WHP provider unbeknownst to PSI [15]. Sixty-one percent of women who were provided with IUDs in the first year (July 2008–June 2009) reported no previous use of other methods.

The goal of this qualitative study was to better understand influences on women’s decision making about IUD use in Madagascar. This study focused on IUD use rather than LARC in general because, like other WHP countries, the project was more focused on IUDs than implants [9]. At the start of the WHP, little was known about influences on IUD use in Madagascar, and the extremely low numbers of women using the IUD in the country precluded conducting a quantitative survey to identify these influences. Therefore PSI-Madagascar sought to understand influences using qualitative methods. Because all participants had recent contact with WHP counselors, these interviews and discussions also provided an opportunity to explore how the strategies counselors used influenced decision making about the IUD.