Original research articleInfluences on women’s decision making about intrauterine device use in Madagascar☆
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.
Section snippets
Methods
From October to December 2008, we conducted 6 small group photonarrative discussions and 12 individual interviews in three urban/periurban sites across Madagascar: Antsirabe, Toamasina and Mahajanga. The six small group discussions each included three participants (total n= 18 individuals). WHP counselors at each site identified IUD users and nonusers who had received information about the IUD from a WHP counselor within the past 4 months. We collected demographic information from participants
Results
Women who participated in small group discussions and interviews ranged in age from 24 to 38 years (mean=31.1 years) (Table 1). Most (83.3%) were married and had between two and six living children. Half of participants had completed some primary school, 23.3% had completed primary school, and 16.7% had completed high school. Most earned money by selling goods or washing laundry (data not shown). These demographic characteristics were not substantially different for IUD users and nonusers (Table 1
Discussion
We sought to explore influences on women’s decision making about IUD use and to identify ways of supporting more women to achieve their contraceptive goals. We found that women in Madagascar readily perceived the IUD’s long-term protection from pregnancy as a benefit that aligned well with their concern for their family’s lack of financial capacity to support more children and their desire to maintain harmony in their household. Women’s investment and interest in learning more about this method
Acknowledgements
We would like to thank the study participants for sharing their time and perspectives with us. We would like to acknowledge the contribution of Ietje Reerink, who contributed to the development of this study and provided feedback on the manuscript. Reid Smith, Navendu Shekhar and Dan Rosen also contributed to the development and design of this study. Digital Development Communications and, in particular, Mamihasina Raminosoa assisted with planning for and supporting photonarrative discussion
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2021, Enfermeria ClinicaCitation Excerpt :The motivation of the family to use the IUD can also affect a person's confidence.18 The experience of people who used the IUD can increase a person's confidence.19 Respondents who have used non-IUD for years will have higher perceived self-efficacy toward non-IUD.
Expanding contraceptive method choice with a hormonal intrauterine system: Results from mixed methods studies in Kenya and Zambia
2021, Global Health Science and PracticeProvider and lay perspectives on intra-uterine contraception: A global review
2017, Reproductive Health
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The program described in this article was funded by an anonymous donor. The authors declare no financial or other conflicts of interest.