Use and discontinuation of intrauterine contraceptive device in the Greater Accra Region of Ghana

Use and discontinuation of intrauterine contraceptive device in the Greater Accra Region of Ghana Background: The intrauterine contraceptive device is one of the modern long-acting and reversible contraception that is very safe and effective. Yet, less than 2 % of women are using intrauterine devices in Ghana. This study therefore explored the experiences and barriers to intrauterine contraceptive device use and discontinuation in Greater Accra Region, Ghana. Methods: Intrauterine contraceptive device users and providers were purposively selected from eight private family planning clinics in the Greater Accra Region. Semi-structured interview guides were used for in-depth interviews during data collection. The interviews were audio-taped to ascertain accurate accounts of the interviews and recordings replayed for analytical responses. Field assistants transcribed the interviews conducted themselves and read through the transcripts produced twice to increase familiarity with the dataset. A list of code labels was created and a series of categories for the main themes that emerged from the transcripts were developed. The transcribed data was organized, coded and manually thematically analysed in word. Study results were presented in tables and quotes from respondents. Results: Results showed that key motivations for intrauterine contraceptive device use include effectiveness, benefits, and efficacy of the device, fertility regulation, peace of mind, contraceptive method switching, health provider effects, desire for long-acting contraceptive method, and partner characteristics. Intrauterine contraceptive device discontinuation was due to bleeding irregularities, vaginal infections, desire to increase fertility, physical features of the intrauterine device, and partner disapproval of use. Other reasons in both cases pertained to non- hormonal aspects of the intrauterine device, partner characteristics, and provider encouragement and influence. Conclusions: Several factors influence the use and discontinuation of intrauterine device in Ghana. Comprehensive contraceptive counselling on the intrauterine device is essential in promoting uptake and knowledge of the intrauterine device at the health facility level. Various targeted messages are also needed to dispel misconceptions at the community level. Keywords: Use, Discontinuation, Intrauterine contraceptive device, Greater Accra Region, Ghana * Correspondence: gbagbofredyao2002@yahoo.co.uk; fygbagbo@uew.edu.gh University of Education Winneba, Box 25, Winneba, Ghana Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 2 of 17 Background Methods Globally, the intrauterine contraceptive device (IUD) has Study design been recognised as one of the modern long-term revers- The study employed a retrospective and cross-sectional ible contraceptive methods suitable for women of all re- qualitative design with an in-depth interview to obtain, productive ages [1]. It represents the most cost effective analyze, interpret and report data. This was adapted reversible method for preventing unwanted pregnancies from a previous study that used a cross-sectional de- [2]. Scientifically proven for its safety, efficacy and cost- signed [20]. The purpose of using this qualitative design effectiveness [3], the copper T380A and Levonorgestrel in this study was to explore a range of opinions and its releasing IUD is known to be more effective and longer different interpretations with the aim of maximizing the lasting in preventing pregnancy than tubal sterilization, opportunity to understand the different positions taken pills, patches and contraceptive rings [4, 5]. by different members of the social milieu. This design A number of studies show that several factors account therefore enabled an in-depth exploration of women’s for the poor IUD use among women [6–8]. These fac- experiences with the IUDs as represented differently tors relate to healthcare provider characteristics, health from their own perspective. system and individual or user factors [9, 10]. While these may be enough, sociocultural norms, beliefs and prac- Study population tices may serve to regulate IUD use even among high Women in their reproductive ages (15–49 years) who risk women or sub-groups particularly in Africa where had ever received family planning (FP) services, and par- there are entrenched sociocultural norms, beliefs and ticularly, IUD from the study facilities were selected to practices on childbirth [10]. participate in the study. Women who were eligible to Health provider characteristics that contribute to low partake in the study were: Non-IUD users, current IUD IUD utilisation include misperception that IUD is associ- users and women who had ever used IUD. The justifica- ated with an ongoing risk of pelvic inflammatory disease tion for choosing these women was because their experi- (PID) and resultant infertility which particularly hinder ences for not using, using or discontinuing the IUD use IUD use among nulliparous women, especially if they helped to answer the research questions. They were also are single or have several sexual partners [11]. In most appropriate individuals to provide rich detailed in- addition, few health care providers are shown to be hesi- formation on IUD use. Trained and practicing IUD ser- tant to insert an IUD into nulliparous women because of vice providers (midwives and medical doctors) from the perceived technical challenges [12]. family planning units of public, private and NGO health Individual factors which prevent IUD uptake are often facilities were also purposively interviewed to obtain di- accentuated by misconceptions, beliefs and myths. vergent opinions on their experiences with FP choices Whilst women report conceptual concerns and fears including IUDs. about having a foreign body placed inside their womb, a lack of counselling and adequate information about Study setting IUDs from healthcare providers to enable them make in- The study was conducted in six renowned health facil- formed decisions [13], fear of painful insertion [14, 15] ities (2 public, 2 private and 2 NGO) that provide family and the perception of IUDs as abortifacients, risks of planning services within the Greater Accra Region. The PID and ectopic pregnancy [16] deterred IUD use. selection of these facilities was purposive. This was Although IUDs are considered as one of the most popular based on complete family planning data availability from long acting and reversible contraceptive methods worldwide the regional health directorate and the facilities client in- [17], they are used by less than 2% of Ghanaian women in formation management systems from 2008 to 2015. their reproductive age [18]. Ghana’sDemographic and These facilities so far have not examined factors affect- Health Surveys (GDHS) have all shown very low IUD usage ing uptake, satisfaction and acceptability of reversible among both married and unmarried women [19]. Whilst family planning methods, hence creating a gap between reasons for low IUD use are poorly understood, the DHS client demand and provider supply which justifies the does not provide an in-depth understanding of the factors need to conduct the study in this setting to inform FP or reasons associated with low use because the methodology decisions. is purely quantitative. This study therefore aimed to explore women’s knowledge and perception about IUD, reasons for Ethical considerations IUD use, barriers facing IUD uptake and provider character- Written informed consent was obtained from all inter- istics influencing IUD using a qualitative method to provide viewees for their participation and for the audio- in-depth information that will complement the GDHS data recording of the interviews. Interviews were conducted on IUD to inform policy and programme interventions in private places such as consulting rooms, respondents’ aimed at increasing IUD uptake in Ghana. homes and offices as recommended by respondents to Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 3 of 17 protect the confidentiality of responses and enhance the asked to answer the research objectives. Family planning comfort of respondents. This study received ethical providers were interviewed on the nature of their rela- approval from the Ghana Health Service (GHS) Ethical tionship with clients, clients’ knowledge on the IUD and Review Committee (ERC). Permission was also sought clients reasons for discontinuation of the IUD. from the various health facilities and respondents used Three female research assistants were trained by the in this study. lead investigator to administer the interview guides. Al- though they were encouraged to be flexible during data Data collection procedure collection, strict adherence to the study guide was dis- Data collection began using a sample frame. A list of couraged if new topics in relation to originally stated women who had visited the identified health facilities for questions emerged during the discussions. This flexibil- IUD insertion or removal during the past six months ity was to encourage capturing of emerging issues which were obtained from the client information system after are different from the order given in the interview guides several unsuccessful attempts to directly recruit the re- [21]. The field research assistants were also oriented on quired number of participants at the study sites. Consid- key ethical issues regarding research ethics involving ering the general low patronage of IUDs at the study site humans as research subjects and were encouraged to be during the period of data collection, it was very challen- nonjudgmental in their responses to the experiences of ging obtaining the required number of respondents for a the study participants. Face to face in-depth interviews meaningful analysis hence the need to fall on client re- were conducted in the local language ‘Twi’ or in English. cords for retrospective interview of current and previous Nine (9) study participants were interviewed in ‘Twi’ IUD users from the indicated facilities. Clients using and the rest were in English. The In-depth Interviews other modern contraceptive methods were also inter- lasted for an average of 40 min. viewed to explore why they are not using IUDs but other The interviews were audio-taped with permission from methods. Family planning providers offering modern participants to ascertain accurate accounts of the inter- family planning methods, including IUD insertions and views. The recordings were then replayed for analytical removal in the selected facilities were also interviewed to responses. Interviews were transcribed immediately examine their experiences about clients concerns with thereafter while ‘Twi’ interviews were translated to Eng- providing IUD services. lish and later transcribed. Field assistants transcribed the Participants were recruited either by face-face or interviews they conducted themselves. As the transcripts through phone calls after they were informed about the were produced, they were read through to increase fa- nature, benefits, risks, and purpose of the study and con- miliarity with the data. Data was manually analysed by sented to participate. Information on voluntary partici- the researchers using the thematic analysis approach. To pation, rights to withdraw and consent was made known do this, a list of code labels was created and a series of to study respondents. Half of the in-depth interviews categories for the main themes that emerged from the (IDIs) were conducted at health facilities, whilst the transcripts were developed. The transcribed data was remaining were held at respondent’s home, and at places then organized, coded and manually thematically ana- deemed convenient and comfortable for respondents. lysed in word. Results of the study were then presented Data were collected using modified research instru- using descriptive statistics and quotes from respondents. ments to build upon previous literature. In line with the study objectives and issues identified in the literature Results reviewed, four (4) different semi-structured interview Table 1 presents the socio-demographic characteristics guides were developed to address the research questions. of respondents excluding FP providers. For IUD users, The interview guides contained questions on partici- six (6) were aged between 40 and 49 years, and the pants’ socio-demographic data (such as age, educational remaining were between 25 and 29 years. Two (2) out of level, current FP use, previous FP method use, and the ten participants had no formal education. Only one parity); FP knowledge, and knowledge about IUD, and woman was unmarried but she had two (2) children. factors/reasons for IUD use. Questions for IUD users’ Majority (8) had been using the IUD for more than six differed slightly from questions asked of women who (6) months; only two (2) women had used it for two had ever used the IUD. For instance, whilst IUD users months and five months respectively. Twelve (12) were questioned on their perception about the IUD women had ever used the IUD for duration of two weeks when they initially began using it, women who had re- to thirteen (13) years. Their current FP methods com- moved the IUD were asked to report on reasons for prised of both modern and traditional FP methods such their removal of the IUD, side-effects, and future inten- as, implants, injectable, condom, withdrawal and the cal- tions to use the IUD. Thus, although questions differed endar method. Two (2) were not using a method; one slightly on some respects, a few similar questions were was pregnant, and three were trying to get pregnant. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 4 of 17 Table 1 Socio-demographic characteristics of study Table 1 Socio-demographic characteristics of study respondents respondents (Continued) Characteristic IUD Ever IUD Non-IUD Total Characteristic IUD Ever IUD Non-IUD Total users users users users users users n =10 n =12 n =7 N =29 n =10 n =12 n =7 N =29 Age Less than 6 months 5 3 3 11 20–25 2 2 4 6 months −1 year 3 3 6 26–30 2 3 3 8 2 years- 5 years 2 2 31–35 3 2 5 6 years–10 years 36–40 1 3 4 More than 10 years 41–45 3 1 4 Previous FP method 46–50 2 2 4 None 3 1 4 Educational status IUD 2 11 13 No education 2 2 IUS 1 1 Primary 1 1 3 5 Implant 1 2 3 Secondary 3 2 4 9 Injectables 1 1 2 Tertiary 4 9 13 Pills 2 1 3 Marital status Male Condom Unmarried 1 2 1 4 Female condom Married 9 9 6 24 Male condom Divorced/separated Calendar method 1 1 Widowed 1 1 Tubal ligation Occupation Number of years used previous FP method Unemployed 1 1 Less than 6 months 1 3 4 Self-employed 7 4 4 15 6 months −1 year 2 5 1 8 Public worker 1 3 4 2 years- 5 years 3 3 Private formal worker 2 5 2 9 6 years–10 years 2 2 Parity More than 10 years 1 1 11 1 Total 28 22 3 1 6 Amongst these women, one didn’t complete primary 33 4 3 10 education, two had completed senior high school, and 42 3 5 the rest had tertiary education. Two (2) participants 52 2 worked in the public service, six (6) worked in private 6+ organizations, and four (4) were self-employed. Current FP method From the total IDIs conducted, seven (7) respondents None 2 2 4 had never used IUD as an FP method. Their ages ranged between 25 years to 32 years. Only one (1) was not mar- Trying to get pregnant/ 42 6 pregnant ried. Two (2) were currently using the implants; one (1) IUD 10 10 was using injectables; two (2) were trying to get preg- nant, and the remaining two (2) were not using any FP Implant 1 2 3 method. The highest educational status attained by re- Injectables 1 1 2 spondents in this group was secondary, (four respon- Male Condom 1 1 dents) and three (3) had completed junior high school. Female condom Almost all women had at least two (2) children, except Withdrawal 1 1 two women who were trying to get pregnant. Calendar method 2 2 Seven (7) IUD providers participated in the IDIs. Three out of the seven from NGO facilities whilst the Tubal ligation remaining four (4) were from private (2) and public (2) Number of years using current FP facilities. The professional qualifications of FP providers Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 5 of 17 ranged from Health assistant, Midwife, Nursing officer, encouraged or motivated by family, friends or staff, Obstetrician and gynaecologist. There was a sole male whilst the other two admitted being motivated by their FP provider in the study who worked as an Obstetrician. friends, and health providers. A respondent categorically All providers have been providing FP services for more reported that her desire to use the IUD was out of a than 5 years except the health assistant who was not strong personal volition irrespective of her partner’s con- professionally trained and specialized to offer IUD inser- sent. A respondent said: tions for women. Her responses are therefore not in- cluded in the analysis. “Nobody encouraged me to use the IUD. My husband, A total of thirty-six (36) IDIs were conducted. Out of mum and siblings even did not want me to do the FP this number, ten (10) women were currently using IUD, since they were all afraid of the side effects. So it was twelve (12) had ever used the IUD, and seven (7) had my own decision. I just got up one day and decided to never used the IUD. The remaining seven (7) were fam- go and do it because my children have very short ily planning (FP) providers. Majority (12) of interviewees intervals in relation to age. So even my husband doesn’t were selected from NGO facilities. Of the FP providers know I’ve done FP unless I tell them” (29 year old interviewed, only one was not providing IUD services. married woman currently on copper-T IUD for 1 year). Her responses are therefore not included in the analysis. The number of IDIs conducted at each study setting is Although the walked-in clients reported to have volun- presented in Table 2. tarily consented for IUD based on the counselling they received, clients who had the IUD following post- Knowledge of family planning abortion care reported to have been coerced/forced/en- Findings showed that all women had good knowledge couraged/influenced to have an IUD as post abortion about FP methods. Each study participant knew of at contraception to avoid repeat unwanted pregnancy and least, three FP methods and how it works. The com- abortion. Two respondents mentioned that they were re- monly mentioned FP methods were injectables, im- spectively encouraged and influenced to use the IUD by plants, and pills. However, half of the women could not the provider after having undergone an induced abor- provide the name of the implants by themselves, but tion. A respondent stated that: were able to describe where and how it was inserted. Very few (three) respondents mentioned sterilization “I refused an immediate family planning uptake (vasectomy and tubal ligation), diaphragm. One woman despite the in-depth counselling given me after the mentioned IUS. Furthermore, the interviews showed previous abortion. So when I went and got pregnant that IUD users and ever IUD users had adequate know- and came again for another abortion, she said by force ledge of the IUD compared to women who were not she will do one for me so I agreed for her to do it for using IUD. Study respondents’ level of knowledge about me although it was against my wish” (40 year old the mechanism of action (i.e. how the IUD works) of the married woman on Copper-T, IUD for1 year). IUD, description of its physical features, and who can use it was comparatively the same among current and Half of the participants reported no side effects previous IUD users. after switching from injectables to having the IUD inserted. Again, another half felt slight abdominal Findings from current IUD users pains soon after insertion of the IUD which was re- From the IDIs, only ten (10) women were currently lieved after ingesting pain killers given by the pro- using the IUD. Out of the ten women, five (5) voluntar- vider. One respondent stated: ily decided to use the IUD whilst the remaining were given the IUD as a post-abortion contraception method. “I went back to the IUD because for me it was very Three women who voluntarily preferred to use the IUD successful. I never had any problems with the IUD stated it was their personal decision; they were not compared to when I was using the injectables. I didn’t Table 2 Number of IDIs conducted at each study setting Study group Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Total IUD users 3 2 211110 Ever IUD users 4 1 121312 Non-IUD users 2 – 11217 FP providers 3 1 1 1 – 17 Total 12 4 554636 Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 6 of 17 have any problems with my period, I didn’t have any stopped. Since then I have not experienced any major weight issues and headaches compared to the problem just that my menses is not flowing like it injectables that I previously used” (43 year old should be.” (46 year old married woman on Copper-T unmarried woman using Copper –T 380A for 2years) 30A for 1year). Another respondent indicated that: Two respondents reported that this was their second time of using the IUD. Both of them reported no side ef- “my experience so far is that my menstrual flow has fects on both occasions. According to one participant, she reduced from 5 days to 4 days since using the IUD for removed the IUD to test her fertility and continued usage six months now after I delivered my last baby. I decided after childbirth as encouraged by her doctor’sexplanation to ask a doctor friend and he said nothing is wrong with and counselling. She narrated her story as follows: me. I also realized, comparing this with the injectables that I used to be on, the severe heart beat and headache “….So he said that IUD will be the best solution so I I used to have disappeared. Initially, I was a bit tensed, went into that. I used that for about 6 years, I met this that maybe my husband will find out. So one day, I guy we talked about marriage and he was like the asked him about it whether he can feel anything. And thing that people are telling him is that if you take it he said no. So he asked is it like the other ones? I said off you won’t get pregnant again. He insisted that no, your menstrual cycle is it normal? I said normal, before we get married I should get pregnant for him regular 28days cycle. I said I’mok. Idon’t know; I’mnot first. So I took it off and became pregnant the following worried. I feel normal. I feel ok. So I’ve been encouraging month and got married but aborted the pregnancy on some of my colleagues to do the IUD” (29year old health grounds after which I had another replaced for married woman on Copper T 380 A for 2years) 3years. I took it out again and I got pregnant again (laugh) after I gave birth, I read about LNG-IUS and I In another instance, one participant indicated having went to the hospital requesting for it because of its prolonged menstrual flow and offensive vaginal dis- advantages. But I was told it is not available in Ghana charges. According to her, the duration of menstruation is yet. I was like okay am not going to have any babies any slightly longer and heavier compared to when she had not time soon so let me go back to my Copper IUD. So I had inserted the IUD. She narrated her experiences as follows: it again for almost 10years now.” (43year old unmarried woman on Copper-T 380A for 10years). “You are just there and then you get a discharge. It’s not too comfortable, but then, I initially tried to cope until the discharge became offensive which compelled Factors that influence IUD uptake me to seek medical help that advised me to remove it Table 3 presents an illustrative summary of factors influ- after two months of unsuccessful treatment. encing IUD uptake in order of most frequently mentioned I realize that, even though it is just about two months Table 3 Illustrative summary of factors influencing IUD use since removing the IUD, It’s a little better. Now the among current IUD users discharges come at the time of ovulating. Although I No. Factors influencing IUD uptake Frequency Percentage (%) realize that there are more discharges it’s no longer 1 Prevention of unwanted pregnancy 20 21 offensive. I learnt it’s going to go back to normal after 2 Reduce births 17 18 a while” (42 year old married woman wo used 3 Space births 15 16 Copper-T 380A for 2months but currently on com- 4 Prevent abortion 11 11 bined oral contraceptive pills). 5 Contraceptive failure 10 10 Another respondent asserted that her menstrual flow 6 Avoid forgetfulness in taking pill 6 9 is now irregular compared to when she hadn’t inserted 7 Substitute to other FP methods 55 the IUD. Also, she initially experienced some brief due to unpleasant experiences periods of vaginal discharge, which did not smell but 8 Desire for a long lasting 44 permanent method currently doesn’t have any discharge. She indicated that: 9 Concentrate on work, or business 3 3 “……I later realized that some ‘water* (referring to 10 Non-hormonal method 2 2 discharge) comes from my vagina. But they told me 11 Concentrate on academics 1 1 that when we see some water and we don’t like it we Total 94 100 should come back. But I didn’t go back and the water Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 7 of 17 factors. Respondents gave varied reasons for current use one that you inject or has something to do with your of IUD compared to other methods. The main reasons re- blood. Those ones I hear people have complications, ported to have determined IUD uptake pertained to pro- hormonal disturbances, I think IUD is best because it tection against unwanted pregnancy, to reduce births or just blocks your womb and no sperm enters to have an space childbearing. egg fertilized” (23year old married woman, on Copper- Other factors that influenced IUD uptake were centred 380A for 2years. on the characteristics and benefits of the IUD over im- plants, pills and injectables. Half of respondents’ decision Partner characteristics also determined preference for for using the IUD was premised on past contraceptive fail- IUD use in a few cases. For one woman, the decision to ure and a desire for a long lasting family planning method. use the IUD was fear of partner’s reaction to successive In a narrative account, a study participant’s decision to pregnancy, and to avoid problems with partner. Narrat- adopt the IUD was due to ineffectiveness of traditional ing her story she said: natural FP method; to avoid unpleasant previous experi- ences with other FP methods; fear of partner’sreactionto “I became pregnant for the fourth time and I fear my successive pregnancy, and desire for a different FP method husband will complain and refuse my education. My other than implants, injectables or pills in order to avoid husband suggested an abortion and IUD. He another repeated abortion. She admits being encouraged encouraged me this is the best after the abortion which by the provider to use IUD during post-abortion counsel- I did” (29year old married woman, on Copper-T 380A ling. The need to avoid unpleasant side effects with the for 3 year). pills, injectables as well as forgetting to take the pills and ease of use influenced IUD uptake. Two women reported: Another respondents indicated that: “I had issues with the tablet because I kept forgetting “I already have four kids and my husband is giving me yes and your menstrual cycle change with it and all problems to have more. if I tell him about family that. That is why I went for the IUD” (39year old planning he would not allow me to do so I came to do unmarried woman on Copper-T IUD for, 2years) this on my own secretly” (44year old married woman on Copper-T 380A for 2years). Another respondent indicated that: The insistence and encouragement of some health “I had wanted to do the 5years type of IUD but it providers led to IUD uptake for some women. A re- wasn’t available. I was told the 5years type of IUD, the spondent categorically admitted being encouraged by implants and 3 months injectables are almost the providers to use IUD after post-abortion counselling. same. Since I had done the 3 months and felt dizzy, I They claimed providers did not directly influence their decided to do the 10 years IUD because that one isn’t choice, but rather advised on the need for adopting an medicine but just something to close the vagina” effective method to prevent repeated abortions. A re- (29year old married woman, using copper-T 380A spondent asserted in the following: for 2years) “——So when I went and got pregnant and came again Two respondents were convinced about the efficacy of and she said by force she will do one for me so I the IUD influenced their choice of the IUD as a method agreed for her to do it for me”….(40year old married to prevent pregnancy. One said: “It was effective for me woman, 3 children on Copper T 380A for 3years). previously and it’s still the best for me” (23 year old mar- ried woman on Copper-T 380A for 1 year). Another respondent indicated that: Another also said: “I was more convinced about the ef- ficacy of it the choice” (43 year old unmarried woman, “—midwife insisted on me taking an IUD after doing on Copper-T 380A for 2 years). the abortion else she will not help me again. Because In furtherance to the reasons for IUD use, two women of the respect I had for her, I had the IUD soon after also decided to use IUD because of its non-hormonal the abortion for free” (28year old widow, 2 children on nature which does not affect their hormonal system. In Copper T 380A for 1year). their view, the IUD was the best method. One noted in the following: Perceptions about IUD “IUD is the best method because, I think it does not Study participants’ indicated to have had mixed reac- have any hormonal thing when you do it unlike the tions when first introduced to the IUD. Majority (8) of Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 8 of 17 the respondents said they were scared when they first without him knowing” (29year old married woman on heard about the IUD. The insertion procedure created copper-T 380A for 5 years). fear amongst them hence did not opt for an IUD as FP method. Two respondents explained: Some respondents were just curious and desirous to try a longer lasting FP method when initially informed “I have heard about FP before. They say some FP is about the IUD by a health provider. Other respondents put in the arms, some too were injections and some were further motivated to use the IUD with positive as- too were inserted in the womb. But I didn’t know how surances and encouragement from friends. Further, an- it looks like. So when I came and it was explained to other woman also expressed indifference when initially me I was scared so I didn’t do it but opted for the informed about it. She said: ‘I just wanted to protect my- injection” (40 year old married woman on injectables). self, I didn’t have any attitude towards it’ (29 year old married woman, on Copper-T 380A for 2 months). The other respondent indicated: Perception of health risks associated with using the IUD “Yes, I was very afraid; because I had not done some In Ghana, knowledge about Family Planning methods is before. I’m a person full of fear. I taught of something generally acquired though formal and informal public different. But the provider took time to counsel me and education. Whereas the educated population read about even used models for demonstrations on how it is done. family planning methods when the need arises, the less Despite my fears, I tried it. I taught it will be painful for educated obtain family planning information in health months but nothing of that sort happened” (25 year old facilities, friends and significant others including televi- married woman, on Copper-T 380A for 3years). sion, radio and social media adverts. When respondents were asked whether using the IUD was associated with Women’s perception of the IUD was also associated health risks, seven (7) reported no health risks associated with myths and negative reactions from friends. They with using the IUD, while one (1) respondent couldn’t raised concerns about some myths that they had heard tell whether or not the IUD posed a health risk. She about the IUD getting stuck in the womb, and potential indicated: health risks in later years. For respondents who associ- ated myths and misconceptions about the IUD, they af- “I was not scared of any risk, because I didn’t think firmed that their perceptions had now changed. A there will be any. But there was one thing that was at respondent reported that her lack of knowledge about the back of my mind, that if I am not comfortable with how the IUD works, and how it looked like made her it, I will take it out. Do you know, if I am not afraid. The fact that “something” was going to be comfortable I didn’t think that they could do something, inserted in the womb created fear, because her under- you know negative, but all I was thinking is that, if I am standing of the procedure is similar to undergoing a D not comfortable, I will take it out” (42year old married & C. However, her perception changed after explana- woman, on Copper–T 380A for 5 years) tions from the provider. She explained: A respondent admitted that no health risks were pos- “Oh in the beginning when they were about to fix it sible except risk of getting infected through usage of and it scared me a bit because I didn’t know how it unsterilized equipment. However, one woman feared be- will work or how it is. Ehee, but they made us ing sterilized after using the IUD. Another participant understand that it wasn’t anything scary. Something had no knowledge about whether IUD usage could harm that they said they will put in your womb, you will be her in future. She explained: a bit scared” (46year old married woman on Copper – T 380A for 5months) ‘If there is a development that it affects something Other respondents who did not discuss their FP because the copper something scared me, because I choices with their partners, feared that their partners didn’t understand why you should have metal in you might find out about having the IUD since the strings but I googled and read about it and I think its ok, it were likely to be visible. One respondents indicated that: doesn’t have any health risks’ (23year old unmarried woman on Copper-T 380A for 3 months). “Initially, I was a bit tensed, that maybe my husband will find out. So one day, I asked him about it whether Although majority (7) of the women interviewed felt he can feel anything in me during sex. And he said no. safe with using the IUD, a few (five) disliked the uncom- I then became comfortable keeping it all these years fortable feeling of the strings hanging in vagina during Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 9 of 17 menses, bathing and somehow wished the string will be reported side-effects and reasons for IUD removal is ‘cut off ’. Three of them had this to say: outlined in Table 4. The results indicate that reasons for removal of the IUD “Yeah the little thing that I don’t like about it is that, do not differ substantially from the side-effects experi- when you are having your menses the bleeding brings enced by respondents. Other reasons that led respondents the strings out. They put the “T” thing in the womb, to remove the IUD involve partner disapproval with the and then they leave this (referring to the string) to use of a FP method. One of the respondents explained hang out into the vagina. So as you, you know, if, that her partner disapproves of FP and so she was scared mensuration stops it sort of goes in to…“Aha”, When that although she has the IUD, the partner might notice you are taking shower and your hand just goes there, the IUD and there might be a problem with that. She you can feel it. I would have wished they will even cut states: my string out” (42year old married woman, on Copper –T 380A for 5 years). “My fear is maybe what if you are making love with your husband one day and the IUD gets remove by Another respondent explained: itself. Sometimes it bothers my mind and I’m scared when having sex” (31year old married woman on “oh the first time I fixed it, the thread was lying Copper-T 380A for 8 months). around my vagina so I was afraid so I was pushing it in, then I later went there to complain about it. They The physical features of the IUD also deterred some removed it for me and then fixed another IUD for me participant from continued use of the method. A respon- but still there’s some thread lying around my vagina. dents indicated that: Anytime I wash that area, I feel it but now I don’t care” (23 year old married woman, on LNG-IUS for 1 year). “I think the uneasiness of that thread thing makes me dislike it. You know, once you’re cleaning it wants to Another respondent was of the view that: come out and you have to push it there, you know… it has to be in there, it doesn’t need to stick out so that “the previous IUD I inserted, I don’t know what brings uneasiness” (47year old married woman on happened maybe I had a heavy flow in a particular Copper-T 380A for 2 years). month and it came out and you know it has a string attached to it, so I think it was choking me around my Another respondent said: cervix and when I was sitting, it was so down, I was feeling a little pain that’s why I went to change it; ‘Why should I allow that nasty thing to be put in my but apart from that, I’m ok with the current one body? The shape of it alone puts me off so I will as its very comfortable” (29year old married woman, always go for another decent method and certainly not on Copper –T 380A for 2 years). the IUD’ (25 year old unmarried woman using the injectable for 3years) Findings from women who have ever used the IUD as post abortion contraception Table 4 Summary of side-effects of IUD and reasons for Four respondents previously used the IUD as a post- removal abortion contraception after repeated abortions. A re- Reported Side-effects with Reported reasons for IUD experienced removal of IUD spondent exclaimed: “They rather gave it to me because of the abortion and they didn’t sell it to me. It was free � Heavy bleeding � Heavy prolonged bleeding after I did the abortion to protect me” (39 year old � Foul vaginal discharge � Vaginal discharge (sometimes coloured) widow, on Copper-T 380A for 4 years). The other re- spondents however paid for the IUD separately. � Infections � To give birth � Abdominal cramps � Abdominal cramps � Spotting bleeding � Spotting or irregular bleeding Problems or side-effects experienced with using IUD Generally, findings showed that at least, each woman � Prolonged bleeding � Infections (study participant) suffered from one of several side ef- � Irregular bleeding � Feeling of device removing fects of the IUD after a few weeks of insertion. For some, � Discomfort with strings the side-effects was severe and sufficient to warrant a re- � Partner disapproval of FP method moval of the IUD. An illustrative summary of the Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 10 of 17 Three respondents removed the IUD to give birth, but “I first went to a public hospital in Kumasi which had two of them categorically expressed their intentions of only short term FP methods. I wasn’t really convinced inserting the IUD again after birth. They both indicated so I heard about the IUD from a NGO facility which I their intentions as follows: visited just for something more permanent. So I just walked in she took me through all the methods and “I removed the IUD to have another baby, but right after my last baby I was advised on that as the best after the pregnancy, I will wear the IUD again to option based on being hypertensive” (47 year old protect myself from unplanned pregnancy because it is married woman on Copper-T 380A for 8 years). good for me” (39year old widow, who previously used Copper –T 380A for 4years). Another respondent said: The other respondents said: ‘I actually brought the LNG-IUS from the USA to be inserted for me here in Ghana because I really love it “—even this when I was coming to remove it, the nurse but very expensive to be inserted in the USA’ (23year asked me [laughing] ‘why do you want to remove it’ old unmarried woman on LNG-IUS for 2 years) and I said I want to give birth again to two children. I think my partner is okay with the IUD and I will have Other respondents also mentioned avoidance of side it again after delivery” (38year old married woman, effects with other FP methods and reduced forgetfulness who previously used copper –T 380A for 2 years). in taking the pill. One respondent reported: “Oh yeah I love the IUD because there was nothing like I have forgotten to take my pills, I have forgotten Reasons for IUD use among ever IUD users to do this or that. It was just convenient I didn’t have Many reasons were noted for the use of IUD among the to worry about anything. I didn’t have to worry. Once respondents who have ever used an IUD. Key among the it was there and I was assured that it was 99% safe. reasons for women’s use of the IUD however pertained So I didn’t worry” (….38 year old married woman, on to a desire for a long acting FP method compared to copper-T 380A for 2 years). short term FP methods. Summary of reasons given are arranged in order of most frequently mentioned in Two accounts from two women which capture their (Table 5). decision to use the IUD is presented in the following: To satisfy a desire for long acting family planning method, some respondents went out at all lengths to en- “The fact that it’s inside makes me satisfied. I don’t sure that they had their desired FP method of choice. A have to see it, apart from the little pain I will respondent explained that: experience over the months, I’m done. I can’tbe faithful to that, taking the pill” (….26year old single Table 5 Illustrative summary of reasons for IUD use among ever woman ever used Copper-T 380A) IUD users No. Reasons for IUD use Frequency Percentages (%) The other respondent indicated that: among ever IUD users 1 Desire for long acting family 18 24 “Because I was told it has nothing to do with the planning method hormones and cells in me I think it is normal” (32year 2 Avoid unpleasant side effects with 15 20 old married woman, ever used Copper-T 380A). other FP types 3 Avoid forgetfulness to take pill 12 16 4 No hormonal influence 9 12 Perception of health risks associated with using the IUD 5 Perception of no side effects 7 9 Mixed responses were obtained when the question on 6 Protect against pregnancy 5 7 perception of health risk was asked. One woman feared that the IUD could cause cancer. According to her: 7 Provider influence 4 5 8 Preference for an ‘obscure’ FP 34 “When I was going I didn’t know what to do and you (‘obscure = hidden’) know I was asking a lot of questions so I was going on 9 Health reasons 2 2 the internet and my elder sister who passed away last 10 Prevent worry 1 1 year was telling me “Don’t do it!. Don’t do these things, Total 76 100 they give cancer. “She died out of cancer but she said Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 11 of 17 “don’t do it again”. They give cancers, the one…that with the LNG-IUS because of the hormone they can thing insert here two things affect your blood and you cause issues of the hormone imbalance things like that. get bloated up. You know, there were lot of fears” I didn’t experience it anyway” (40year old married (.47year old woman on LNG IUS for 3 years). woman, on LNG-IUS for 3 years) Another woman believed that though the IUD was ef- In contrast to some respondents’ stated fears about the fective in preventing pregnancy but the risk of contract- IUD, two other women could not certainly tell whether ing infections through the IUD makes it not to be totally using the IUD was risky to their health. One said: safe. She explained that: “health risk? Not as I know” (….38 year old woman on “When it comes to health risks, I don’t know how you Copper-T380A). want me to; .oh you will still get STIs, you will still have seamen coming into you. You will still get the Similarly, two other women believed since they didn’t STIs” (….30 year old woman on Copper-T 380A). experience any side effects or problems with the IUD, and upon the recommendation of health providers, then Another risk as mentioned by a 26 year old woman per- there was no health risks associated with it. One of them tained more to a misconception about the IUD moving indicated that: around the body into other organs by itself after insertion. She also mentioned the probability of experiencing perfor- “I don’t know much but so far, no. I’ve been to two ation in the uterus when IUD is inserted. Although a rear midwives and they themselves said they used that one. occurrence with trained and competent providers the That’s what makes me go in for that one” (….31year probability of perforation has been reported in clinical in- old woman, o Copper-T 380A for 2 years). cidents relating to IUD insertion due to provider errors and use of rigid instruments among others. In the respon- dents own words she indicated that: Future intention to use IUD Women were asked about their future intention to use “With the health risk you know when you put it on, the IUD, and from their responses, only five (5) declared when you insert they have this nylon thread, that they their intention to use it again because it was good, useful wrap it, sometimes it comes off as it helps the IUD to and effective for them. One respondent said: move around. You may not know, sometimes there may be some perforation or something. It may hurt u. “I will come for the same thing when God willing I give I think that is, that makes it the only problem but birth”…38year old married woman, 2 children aside that, it’s not a problem”. Another woman also reported However, this same woman maintains that “I don’t think there are any health risks, if u have an IUD inserted u “Yes, but right after the pregnancy, I will wear the IUD don’t let everybody play around that part because if their again to protect myself because it is good for me”… fingers are…., I think the health risk is more about us 39year old widow, 4 children and how you take care of yourself”. One respondent experiencing vaginal discharges was It was clear from the IDIs that some women wished concerned that the discharges were due to the Copper theIUD wouldhaveworkedfor them becausethey IUD she had used for the past 2 years and might be risky preferred a longer acting method, and also since it to her health. She said: was recommended by a provider. Unfortunately some respondents experienced heavy/painful menses and “Yeah, as I was saying about the discharges, I fear it frequent expulsion when given the IUD hence had to could lead to something else” (…32year old single have it removed two months after insertion. Two woman on Copper-T 380A) women reported: According to another woman, she was of the view that “It’s not all that safe since I had heavy and painful women risk having an ectopic pregnancy after using the menses when I was on IUD. I mean I wish it had IUD as a FP method. She explained saying: worked for me, honestly. I really wished it had worked for me, I mean I was really counting on it. The fact “Obviously yeah. You risk ectopic. You risk ectopic that I mean it will be there for the next 5 years, for the pregnancy I know that. I may say it has been argued next 10 years, you are protected and all that, u don’t Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 12 of 17 have a problem. I really hoped it worked”….(30year observation made however is, clients who don’t have old unmarried woman ever used Copper-T 380A) such facilities regardless of their educational levels tend to rely on service providers and/or significant others for The other said: information on family planning services. On this same issue, three providers also mentioned that only few cli- “I was quite unfortunate to have had the IUD falling ents have heard of IUD, and out of this number, very off by its self on three occasions so I had to discontinue few have ever seen or touched it before. A provider nar- its use. But if it was working for me, I would have rated her experience as follows: loved it. Why? Because it doesn’t let me grow fat or anything. You know, you stay your normal and you “Yes, have you heard about IUD? You ask. You came know that after five years which is quite a long time, in here we do family planning, which one do you like? you can change it. Five or ten years I think for you to The person if she’s … She will tell you that, I don’t change it. If you feel some uneasiness, you just walk have any idea about family planning” (IUD provider). into the facility and you just take it off” (47year old woman, on Copper-T IUD for 4 years). On the other hand, a male provider strongly professed that because clients have little knowledge of modern FP methods particularly, IUD, he mostly provided it for Women’s knowledge about the IUD them based on their past medical history, parity and the All family planning providers reported that women (also number of previous deliveries. Thus, he directly influ- clients) have very little knowledge of the IUD pertaining enced clients’ use of the IUD. He indicated that: to its mechanism of action, its physical features, how it feels, and the essence of the copper around it. They at- “Well over there, if they come, most of them don’t tributed women’s knowledge of the IUD from shared ex- know about the IUD. Theirs is that they are here to periences of friends, and which is represented negatively. protect themselves against pregnancy or are here for Thus, when they asked clients knowledge of the IUD, FP. So I take them through all the methods and then I clients primarily stated their misconceptions, side-effects ask how many children they have. And most of them and myths neglecting the usefulness and efficacy. On too they gave birth at my place so I already know their provider said: history. After the counselling they will ask me, out of the whole lot which one am I choosing for them? You “Sometimes, they can be influenced by their friends. If see, they are such that they have that trust and belief I’m giving it percentage wise, it’s about 30percent of in me, so anything I say they comply” ( IUD provider). them who know depo, IUD, secure and all those stuffs from their friends” (IUD provider) Women’s reasons for not using the IUD Another provider reported that: From the interviews, providers stated that women’s rea- sons for not using the IUD is mainly because of the fear “When you ask them, they tell you yes, I’ve heard it, but of inserting the IUD in the uterus, and fears about the I’ve not seen it so you let them touch it and feel how it is IUD. Fears about the IUD pertain to myths and miscon- before you do it for them. They will ask you so what is it, ceptions, as well as fears that the IUD will affect their the wire that we are seeing there, it is just plastic. So health in the long term.. A respondent narrated some they hold it to see how flexible it is. This is just a copper misconceptions and fears as follows: that is wound around it and is nothing that is going to hurt them, or touch anything” (IUD provider). “I learnt the IUD can walk to the heart. I also learnt a woman had a baby and the baby was carrying IUD in Two providers asserted that among women who had her hand. If you get IUD, you won’t have children visited them for contraceptive counselling and uptake, again. They have been saying all these things. So I tell less educated women tended to have no knowledge them, it is not true.” about the IUD compared to educated clients who some- times search the internet to read and obtain knowledge Other reasons such as male partners’ disapproval of IUD of the IUD prior to their visit to the FP clinic. The avail- use, (and any other FP method); fear of male partners’ ability of internet services on smart phones provides knowledge about the IUD, and the uncomfortable feeling quick information to users in areas that have good re- of the strings during sexual intercourse. Poor knowledge ception. This enable clients seeking information on base of the IUD, a strong mind-set and resistance to the contraception to browse quickly for knowledge. The IUD also deterred uptake. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 13 of 17 Concerning fears about the procedure for inserting the Why do you want to take it off, and she tells you, I IUD, a female provider explained that unlike the short want to change it. It has been there for long so I want term FP methods like injectables or pills which are un- to change it. Just take it off and do something else for obtrusive, IUD is noticeable and can be felt by the part- me” (IUD Provider). ner through the strings which lie in the vagina during intercourse. There is therefore a greater chance of it It was also noted that other women also wanted to test been detected or felt by the partner even when the their fertility or reproducibility after prolonged IUD use. partner has no knowledge about it. According to an IUD provider’s account: Providers’ reasons for clients IUD removals “They think once is been there for long without them The main reasons for clients’ removal of the IUD from getting pregnant, they should remove it and see if providers view is the side effects evident through bleed- they are still fertile. And so they will remove, they ing, cramps, vaginal infection, and abnormal menstrual will get pregnant and then they will come for help” cycle. The second key reason is for reproduction. Other (IUD Provider). reasons providers cited are to prevent feuds with their partners in circumstances where the IUD was inserted without partners’ knowledge and approval; fear of IUD Client- provider- relationship in health facilities during FP from moving to other parts of the body; fear of IUD counselling causing fibroid and cancer after prolonged use and for All FP providers unanimously agreed having a good other health reasons. positive relationship with clients during contraceptive counselling. They described the counselling sessions as “The reason for them taking it out, some of them they cordial and open to allow clients to freely discuss their bleed even after. Some can bleed for the whole 28days. concerns, and ask questions about the IUD, as well as They become very anaemic, fatigued and weak. For other FP methods. Counselling is done in an open man- some, it’s not all, but as soon as you take it off and put ner in a language which clients understand to facilitate them on medication for a week, that thing ceases and communication. you monitor that client for about three cycles, you see that the client will be happy; and have the normal Ways to encourage IUD uptake among women menstrual flow. The second thing too is that, she will Currently, education on family planning services is inte- come with that problem, you will take it off and this grated into general sexual and reproductive health pro- will go and interfere with her normal menstrual cycle, motion and education programmes at the local, regional then she will be having abnormal menstrual cycle; and national levels. The scope of the sexual education at instead of 28 days, at times they can go 26, 40.” the public level is basic information on human (IUD Provider) reproduction and mechanism of how contraceptives work. Although there is a national family planning stan- Another provider said: dards and protocols guiding family planning educational activities, the implementation of this protocol is deter- “Some of them they come in for it without the consent mined by who is doing the education, the target popula- from their partners. So along the way, their partners tion, mode of education and the level of theoretical and find out. And it tends to bring a quarrel among practical experience of the educator. In this regard, com- them so they quickly come for it to be removed” prehensive education on long acting and reversible con- ( IUD provider). traceptives as well as permanent methods looking at medical eligibility, side effects and complications are A female provider categorically maintained that some usually reserved for clinical trainings of providers and women who came to remove the IUD did so for no obvi- not the general public. Consequently, the limited scope ous reason; neither were they experiencing complica- of IUD education compels potential clients’ new users or tions except to change to a different FP method. She adopters of IUD to rely on self-education by reading or indicated that: information from significant others some of whom have limited knowledge shrouded with some of the identified “There are instances they don’t come with any myths and misconceptions that prevents IUD use and complaint, they feel it has been there for quite a long encourages discontinuation when side effects occur time, so they feel they should take it off and change to among users. another method to see the best. Somebody who has To encourage IUD use among women, all the FP providers been on the IUD for 7 years will come and take it off. suggested a holistic education and public sensitization. The Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 14 of 17 holistic education as reported encompasses information on “some IUD providers don’t tell the clients everything eligibility, side effects and complications for women on the about the method they only tell them the benefits IUD, as well as other long term FP methods for informed de- without informing them about the side effects and cisions on choice. Comprehensive education in this regard, complications. So when the clients leave and have any should be carried out through the media (print and elec- bad effect they lose trust in the method and provider tronic) and mobile information vans particularly in rural and rush back to have it remove. They won’t remove it communities. Additionally, messages should be targeted at if well informed” ( IUD provider) dispelling the myths and misconceptions about the IUD. Sexually active young individuals should also be educated at the junior high school level on IUDs for future decision mak- Discussion ing. FP providers also recommended the use of text messages This study aimed to explore determinants of IUD use to promote IUDs on social media as a medium for reaching among women currently using the IUD, and women out to young people most of whom appears to frequent so- who had ever used the IUD; explore women’s experi- cial media in recent times. ences with the IUD pertaining to perceptions, side ef- The sole male provider interviewed in the study fects; reasons for removal; health risks, and future stressed that public education aimed at promoting IUD intention to use the IUD. Also, another objective was to adoption should consider the social context within explore level of knowledge of IUD among all women which services are provided to encourage positive com- using a modern family planning (FP) method. munity attitudes, especially in areas where there is Findings show that women’s reactions and perceptions strong resistance or opposition to contraceptive prac- of the IUD was shaped by and associated with prior tices. This will involve working with key opinion leaders knowledge on the device, myths, fears and misinforma- on values clarification and satisfied clients in these com- tion that they had heard about the IUD from their munities to share experiences with IUDs. A female pro- friends despite their full awareness of the importance of vider working at one of Marie Stopes centre however contraceptive use. Two-thirds of IUD users and few past lamented that measures put in place by the organization IUD users were scared to consider the IUD as a FP to increase awareness and knowledge of long acting FP method upon initially hearing of it. To a large extent, in- methods was inadequate. This she further explained that adequate knowledge of the IUD, reinforced by general the activities being implanted to increase awareness and myths surrounding use of modern FP methods accounts knowledge of long acting FP methods are ‘above the line for low uptake of the IUD. Some studies also show that marketing strategies’ which do not necessarily translate misinformation, and lack of correct knowledge results in into uptake of services since there are issues of behav- low uptake of LARC [22]. Women’s perceptions and ioural change and modification that must equally be ad- knowledge are therefore shaped by these myths which dressed to compliment the efforts being made in the further discourage contraceptive use and lead to open area of education and awareness creation at the commu- and incessant negative expressions of contraception. nity level to ensure high uptake. Women’s negative perceptions about the IUD corrob- The need for effective counselling that focuses on the orate with providers responses. Providers stated that the positive aspects of the IUD was recommended to en- fear of how IUD was inserted, misconceptions and fears courage interest and uptake among women. According about the IUD based on myths deterred women from to an IUD provider she indicated that: accepting the IUD as a FP method. Yet, women who wanted to space, limit or stop childbearing had positive “ for counselling to be effective, we need to tell them perceptions of the IUD. Similarly, women who preferred the benefits of IUD, it saves time, it saves your money, the IUD as FP method after being encouraged by pro- it makes you do your house chores. There’s always viders held positive attitudes about it, in contrast to peace at home, family are happy. Economic situation, those who expressed side effects with it. Proper and ef- because now the economy, when you insert IUD, is for fective counselling focusing on the benefits/ advantages long term. It doesn’t prevent you from doing your of the IUD should be provided to women desiring to use normal duties. The time that you waste here to come a long acting reversible, and possibly, non-hormonal and do the 3 months, sometimes you tend to forget. contraception to prevent pregnancies. When you insert IUD, you are at peace. You get time Lack of adequate knowledge may prevent IUD use; to do your real job” (IUD provider). however, when women believe that FP providers are knowledgeable and can be trusted to maintain confiden- On the contrary a provider indicated the relevance of tiality, advice on method use, side effects and potential informing clients about side effects and possible compli- health risks. Women will be more receptive and con- cations of IUDs as well. The provider stated that: vinced to take up the IUD as a first choice FP method. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 15 of 17 FP providers therefore have a major role to play in en- ‘obscure’ FP method; non-hormonal benefits; provider couraging positive attitudes towards using the IUD influence and encouragement; health reasons; protection through counselling. from contraceptive failure; freedom from emotional wor- On the contrary, some findings from the study show ries; ease of use in order to focus on work and school. that because some clients are ignorant about family The side effects of using IUD were reported as heavy planning methods, there are elements of provider biases prolonged bleeding, vaginal discharges, infections, spot- during counselling which leads to some providers either ting or irregular bleeding, and abdominal cramps. These advising clients to use IUD based on their personal ex- are consistent with empirical evidence that IUDS are as- periences or preference for IUD. In some reported in- sociated with irregular bleeding in some women [25]. stances the providers ‘forced’ clients to have an IUD as a Participants reported that continuous experience of post abortion contraception. This observation defeats these side effects for more than four months led to re- the purpose of family planning counselling as it does not moval of the IUD. Findings are supported by providers encourage choice and medical eligibility for IUD. Un- who also attributed women’s removal of the IUD to announced continuous supportive supervision of family mainly side effects. Women’s continuous experiences of planning service providers in their facilities will provide side effects served as a barrier to future intention to a valuable opportunity to identify gaps and provider IUD use. Among these women, some wished that the biases during family planning counselling for further IUD worked for them, but felt that the side effects were provider refresher education and updates on family plan- indications of negative reactions, and the bodily system’s ning counselling and decision making. rejection of the IUD, as well as potential health risks Women’s reasons for using the IUD varied slightly with continued use. among current and ever users. Among current IUD Although none of the women suffering infections from users, preventing unwanted pregnancy emerged as the using the IUD associated it with lack of personal hy- most important motivating factor, whilst the desire for a giene, cross infection from partner infidelity, or poor in- long acting FP was mentioned most often among ever sanitary lavatory conditions as common potential IUD users. Although the ever IUD users would have triggers of infections, there are other known causes of loved to continue using the IUD, unbearable side effects vaginal infections following IUD insertion among of heavy menses and cramps lead to discontinuation. A women which is important for providers to hint clients further probe on this assertion shows that the type of so that post IUD infections are not unnecessarily associ- IUD being referred to is the Cupper T 380 . There were ated with these or the method. Similarly, understanding few reported instance were clients opted for LNG-IUS pre-exposure history of women regarding infections but was not available in the facility. Perhaps, the avail- could enhance pre and post-method counselling. ability of LNG-IUS (hormonal IUD) in facilities would Partners’ disapproval of FP use also contributed to re- have been preferred over Copper-T 380A which might moval of the IUD. Although this revelation is not new in have increased IUD usage in the study area. This sug- our context through anecdotal evidence, it should be gests that among ever IUD users, there is an unmet need useful and practical to informing providers to find ways for LNG-IUS (hormonal IUD) which calls for program- to encourage and educate male partners’ in contracep- ming and contraceptive security. The observation that tion uptake. Few women who had ever used the IUD IUDs have shown no or minimal reported side effects is pointed out that, due to fear of negatively impacting their an opportunity to use such satisfied clients for public marriages decided to remove the IUD clandestinely. Some education on IUDs to ensure continuity and increasing however noted that their partners were not informed patronage since clients will really choose an IUD due to about it, hence their decision to have it removed. In their their understanding on the duration and perceived bene- view, the ‘strings’ heightened their dislike for the IUD, and fits over other methods. to which their partners might notice. Two-thirds of women expressed desire for a long act- Mixed views on perceptions of health risks associated ing method of protection for convenience purposes, ease with using the IUD were reported. Study participants of use, and avoid contraception failure. Post abortion thought having the IUD inserted might cause cancer, ec- women currently using the IUD, including women who topic pregnancy, STIs, and uterine perforation. Although removed it to give birth expressed immense usefulness two-thirds of women thought otherwise, it is important and satisfaction since using it. They considered it to be that women are given appropriate and accurate informa- very effective in serving the purpose they desired with- tion on all health complications that accompany each out side effects. There is evidence demonstrating the ef- modern FP use. They should also be made to understand ficacy, safety, and cost-effectiveness of the IUD in that individual differences, hormonal balance, and spe- pregnancy prevention [23, 24]. Other determinants of cific criteria pertain to the uptake of one modern FP IUD use include: to prevent abortions; preference for an method over the other. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 16 of 17 The women in the study (a sample predisposed to sensitive about the mode of communication. It knowing about FP by having visited a FP clinic before) should be in a language that people can understand knew of at least one modern method. This finding is and relate to, whiles considering the social context consistent with previous findings in Ghana’s Demo- and social exchange systems. graphic and Health Surveys (2008, 2014) which report  Design interventions (for instance, community universal contraceptive knowledge among all women. At interventions) to promote uptake of LARC methods least, all women mentioned three contraception types and enhance existing service provision channels to with the injectables and implants most frequently men- provide accurate information and services on IUD in tioned, followed by pills, condoms, and IUD. Less than order to make it accessible, and available to young one-third of the women interviewed mentioned male women desirous of LARC. Community interventions and female sterilization, and diaphragm. One study re- should be sensitive to the social context and spondent mentioned the IUS as her current contracep- appropriate medium of communication. tive method. Nine (9) out of the total selected women  Sensitize all persons visiting MSI centres on FP were currently not using any contraception. Social and methods and post-abortion contraception through cultural norms governing fertility, in addition to fear of distribution of brochures and FP documentaries on contraceptive side effects, myths, and health risks may video tapes. Documentaries should be comprehen- hinder contraceptive use. Demand creation through sive, and focus on advantages of IUD use, safety, effi- mass education with FP providers needs to be intensified cacy and side effects to increase and sustain positive and promoted among women in reproductive ages. In- attitudes. terventions should also focus on couples counselling to  Ensure the provision of comprehensive sexuality increase positive attitudes towards contraception for education for young girls and boys at senior high both partners. schools to equip them with appropriate information It is also important to mention that from non-IUD on family planning, contraception, and birth control users’ socio-demographic data, there is a high propensity methods as means of regulating fertility, spacing and for these women to increase their fertility since they are reducing births. The resent positive outcome of the within active reproductive ages (20–35) but are not advocacy drive on sexuality education in schools using any contraceptives due to unpleasant past experi- resulting in the inclusion of sexuality education in ences with IUD use. Although they all reported fears schools curriculum in Ghana is timely as this with using IUD again or any contraceptive, it is import- provides a good entry point for this policy ant that FP providers provide effective counselling for implementation in schools for the desired results this group of women on other available and accessible alternatives of contraceptives to meet their FP needs. A key policy implication is task sharing IUD insertion Past IUD users who have switched from IUD to other and removal with mid-level providers in Ghana to en- FP methods are also highly susceptible to becoming sure greater provider availability in all health facilities to pregnant should their contraceptive use become incon- improve uptake. This is a fall out from table1 indicating sistent/ irregular, or in the case of method failure. Only few numbers of FP providers in the study facilities. The one woman out of the previous IUD users is currently researchers believed there would have been higher pro- using a LARC. Amongst the remaining, one-third is try- vider numbers if an IUD task sharing policy is in place ing to become pregnant, while the rest are using a mix and being implemented. of short term and traditional methods due to the un- availability of preferred FP choice of implants (implanon Conclusion NXT). In sum, the contraceptive history patterns of past IUD users are risky and raise concerns over unmet need A number of factors influence the use or discontinu- for implants (implanon NXT) in the FP facilities. ation of IUD in Ghana. Provider capacity building for in-depth client counselling is required to make in- Implications formed decisions at the facility level. Various targeted Results from this study has several programmatic and messages and use of satisfied clients are also needed policy implications for improving uptake of LARC, espe- to dispel IUD related myths and misconceptions at cially IUD for women in all reproductive ages. Programs the community level. A future large scale study is should: also required to investigate if there are any seasonal, socio-economic and demographic variations in FP up- Focus on using social media to debunk myths and take within health facilities in Ghana. This when done misconceptions that people have about LARC, will provide further information to informed national particularly, IUD. Use of social media should be FP programme and policy decisions. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 17 of 17 Abbreviations 6. Sanfield A. Popularity disparity: attitudes about the IUD in Europe and the ERC: Ethical review committee; FP: Family planning; GDHS: Ghana United States. Guttmacher Policy Rev. 2007;10:19–24. demographic and health survey; GHS: Ghana health service; IDI: In-depth 7. Black K, Lotke P, Kai J, Buhling N, Zite B. A review of barriers and myths interview; IUD: Intra uterine device; IUS: Intra uterine system; LARC: Long preventing the more widespread use of intrauterine contraception in acting and reversible contraceptive; LNG: Levongesterol nulliparous women. Eur J Contracept Reprod Health Care. 2012;17:340–50. 8. Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol. 2002; Acknowledgments 99:275–80. The authors are grateful to all the facilities and respondents that participated 9. Postlethwaite D, Trussell J, Zoolakis A, Shabear R, Petitti D. A comparison of in the study. Many thanks also to Marie Stopes International Ghana for the contraceptive procurement pre- and post- benefit change. Contraception. logistical support during data collection. 2007;76:360–5. 10. Goodman S, Hendlish SK, Benedict C, Reeves MF, Pera-Floyd M, Foster- Funding Rosales A. Increasing intrauterine contraception use by reducing barriers to This study was fully funded by the authors with some support from Marie post-abortal and interval insertion. Contraception. 2008;78:136–42. Stopes Ghana. 11. Middleton AJ, Naish J, Singer N. General practitioners’ views on the use of the levonorgestrel-releasing intrauterine system in young, nulligravid Availability of data and materials women, in London, UK. Eur J Contracept Reprod Health Care. The raw data collected is available upon reasonable request. 2011;16:311–8. 12. Allen RH, Goldberg AB, Grimes DA. Expanding access to intrauterine Authors’ contributions contraception. Am J Obstet Gynecol. 2009;4(56):1–5. GFY conceptualized the study, provided guidance to the field work and the 13. Lyus R, Lohr P, Prager S. Board of the Society of family planning. Use of the report. EAK supervised the field work, analyzed the data and drafted the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous initial report. Both authors have all approved the final submission. women. Contraception. 2010;81:367–71. 14. Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating Ethics approval and consent to participate evidence to practice: the provision of intrauterine contraception. Obstet This study received ethical approval from the Ghana Health Service (GHS) Gynecol. 2008;111:1359–69. Ethical Review Committee (ERC). Permission was also sought from the 15. Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine various facilities and respondents used in this study. To protect the devices and the risk of tubal infertility among nulligravid women. N Engl J confidentiality of responses and enhance the comfort of respondents, the Med. 2001;345:561–7. interviews were conducted in private places chosen by the respondents. The 16. Allen RH, Bartz D, Grimes DA, et al. Interventions for pain with intrauterine In-depth Interview sessions averagely lasted for 40 min. device insertion. Cochrane Database Syst Rev. 2009;3:CD007373. Written informed consent was obtained from all interviewees for their 17. Mishell D, Sulak P. The IUD: dispelling the myths and assessing the participation and for the audio-recording of the interviews. To obtain this, potential. Dialogues Contraception. 1997;5(2):1–4. participants were informed of the objectives of the study and its intended 18. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. purpose in the language they understood. Those who could read and write Ghana demographic and health survey 2014. Accra: GSS, GHS, and ICF signed the consent form whilst those who could not read or write gave Macro; 2014. verbal consent after the explanations. 19. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. Ghana demographic and health survey (1993, 1998, 2003, 2008, 2014). Consent for publication Accra: GSS, GHS, and ICF Macro. Although there was no individual ‘Consent for publication’ since the study 20. Schwandt HM, Creanga AA, Adanu RM, Danso KA, Agbenyega T, Hindin MJ. did not contain any personally identifiable data, all respondents and facilities Pathways to unsafe abortion in Ghana: the role of male partners, women contacted during the study agreed and provided verbal consent for the and health care providers. Contraception. 2013;88(4):509–17. study to publish anonymously. 21. Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception. 2008;78: Competing interests 197–200. The authors declare that they have no competing interests. 22. Wickstrom J, Jacobstein R. Contraceptive security: incomplete without long- acting and permanent methods of family planning. Stud Fam Plan. 2011;42: 291–8. Publisher’sNote 23. Weston MR, Martins SL, Neustadt AB, Gilliam ML. Factors influencing uptake Springer Nature remains neutral with regard to jurisdictional claims in of intrauterine devices among postpartum adolescents: a qualitative study. published maps and institutional affiliations. Am J Obstet Gynecol. 2012;206:40.e1–7. 24. Mohamed AM, Rachael SK, Cleland JN, Thoai D, Shah IH. Long-term Author details contraceptive protection, discontinuation and switching behaviour: 1 2 University of Education Winneba, Box 25, Winneba, Ghana. Regional intrauterine device (IUD) use dynamics in 14 developing countries. London: Institute for Population Studies, University of Ghana, Box LG 96, Accra, Ghana. World Health Organization and Marie Stopes International; 2011. 25. Hatcher R, Trussell J, Nelson A, Cates W, Stewart F. Contraception Received: 31 January 2018 Accepted: 6 April 2018 technology. 19th ed. New York: Ardent Media; 2008. References 1. World Health Organization. Medical eligibility criteria for contraceptive use. 4th ed. Geneva: World Health Organization; 2009. 2. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79(1):5–14. 3. Chiou CF, Trussell J, Reyes E, et al. Economic analysis of contraceptives for women. Contraception. 2003;68:3–10. 4. Grimes D, Jones KP, Knutson CC, Wysocki S. Use of intrauterine contraception in the United States: Association of Reproductive Health Professionals. Washington, DC: Elsevier Inc.; 2004. 5. Yoost J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Patient Preference Adherence. 2014;8:947–57. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Contraception and Reproductive Medicine Springer Journals

Use and discontinuation of intrauterine contraceptive device in the Greater Accra Region of Ghana

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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Reproductive Medicine
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Abstract

Background: The intrauterine contraceptive device is one of the modern long-acting and reversible contraception that is very safe and effective. Yet, less than 2 % of women are using intrauterine devices in Ghana. This study therefore explored the experiences and barriers to intrauterine contraceptive device use and discontinuation in Greater Accra Region, Ghana. Methods: Intrauterine contraceptive device users and providers were purposively selected from eight private family planning clinics in the Greater Accra Region. Semi-structured interview guides were used for in-depth interviews during data collection. The interviews were audio-taped to ascertain accurate accounts of the interviews and recordings replayed for analytical responses. Field assistants transcribed the interviews conducted themselves and read through the transcripts produced twice to increase familiarity with the dataset. A list of code labels was created and a series of categories for the main themes that emerged from the transcripts were developed. The transcribed data was organized, coded and manually thematically analysed in word. Study results were presented in tables and quotes from respondents. Results: Results showed that key motivations for intrauterine contraceptive device use include effectiveness, benefits, and efficacy of the device, fertility regulation, peace of mind, contraceptive method switching, health provider effects, desire for long-acting contraceptive method, and partner characteristics. Intrauterine contraceptive device discontinuation was due to bleeding irregularities, vaginal infections, desire to increase fertility, physical features of the intrauterine device, and partner disapproval of use. Other reasons in both cases pertained to non- hormonal aspects of the intrauterine device, partner characteristics, and provider encouragement and influence. Conclusions: Several factors influence the use and discontinuation of intrauterine device in Ghana. Comprehensive contraceptive counselling on the intrauterine device is essential in promoting uptake and knowledge of the intrauterine device at the health facility level. Various targeted messages are also needed to dispel misconceptions at the community level. Keywords: Use, Discontinuation, Intrauterine contraceptive device, Greater Accra Region, Ghana * Correspondence: gbagbofredyao2002@yahoo.co.uk; fygbagbo@uew.edu.gh University of Education Winneba, Box 25, Winneba, Ghana Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 2 of 17 Background Methods Globally, the intrauterine contraceptive device (IUD) has Study design been recognised as one of the modern long-term revers- The study employed a retrospective and cross-sectional ible contraceptive methods suitable for women of all re- qualitative design with an in-depth interview to obtain, productive ages [1]. It represents the most cost effective analyze, interpret and report data. This was adapted reversible method for preventing unwanted pregnancies from a previous study that used a cross-sectional de- [2]. Scientifically proven for its safety, efficacy and cost- signed [20]. The purpose of using this qualitative design effectiveness [3], the copper T380A and Levonorgestrel in this study was to explore a range of opinions and its releasing IUD is known to be more effective and longer different interpretations with the aim of maximizing the lasting in preventing pregnancy than tubal sterilization, opportunity to understand the different positions taken pills, patches and contraceptive rings [4, 5]. by different members of the social milieu. This design A number of studies show that several factors account therefore enabled an in-depth exploration of women’s for the poor IUD use among women [6–8]. These fac- experiences with the IUDs as represented differently tors relate to healthcare provider characteristics, health from their own perspective. system and individual or user factors [9, 10]. While these may be enough, sociocultural norms, beliefs and prac- Study population tices may serve to regulate IUD use even among high Women in their reproductive ages (15–49 years) who risk women or sub-groups particularly in Africa where had ever received family planning (FP) services, and par- there are entrenched sociocultural norms, beliefs and ticularly, IUD from the study facilities were selected to practices on childbirth [10]. participate in the study. Women who were eligible to Health provider characteristics that contribute to low partake in the study were: Non-IUD users, current IUD IUD utilisation include misperception that IUD is associ- users and women who had ever used IUD. The justifica- ated with an ongoing risk of pelvic inflammatory disease tion for choosing these women was because their experi- (PID) and resultant infertility which particularly hinder ences for not using, using or discontinuing the IUD use IUD use among nulliparous women, especially if they helped to answer the research questions. They were also are single or have several sexual partners [11]. In most appropriate individuals to provide rich detailed in- addition, few health care providers are shown to be hesi- formation on IUD use. Trained and practicing IUD ser- tant to insert an IUD into nulliparous women because of vice providers (midwives and medical doctors) from the perceived technical challenges [12]. family planning units of public, private and NGO health Individual factors which prevent IUD uptake are often facilities were also purposively interviewed to obtain di- accentuated by misconceptions, beliefs and myths. vergent opinions on their experiences with FP choices Whilst women report conceptual concerns and fears including IUDs. about having a foreign body placed inside their womb, a lack of counselling and adequate information about Study setting IUDs from healthcare providers to enable them make in- The study was conducted in six renowned health facil- formed decisions [13], fear of painful insertion [14, 15] ities (2 public, 2 private and 2 NGO) that provide family and the perception of IUDs as abortifacients, risks of planning services within the Greater Accra Region. The PID and ectopic pregnancy [16] deterred IUD use. selection of these facilities was purposive. This was Although IUDs are considered as one of the most popular based on complete family planning data availability from long acting and reversible contraceptive methods worldwide the regional health directorate and the facilities client in- [17], they are used by less than 2% of Ghanaian women in formation management systems from 2008 to 2015. their reproductive age [18]. Ghana’sDemographic and These facilities so far have not examined factors affect- Health Surveys (GDHS) have all shown very low IUD usage ing uptake, satisfaction and acceptability of reversible among both married and unmarried women [19]. Whilst family planning methods, hence creating a gap between reasons for low IUD use are poorly understood, the DHS client demand and provider supply which justifies the does not provide an in-depth understanding of the factors need to conduct the study in this setting to inform FP or reasons associated with low use because the methodology decisions. is purely quantitative. This study therefore aimed to explore women’s knowledge and perception about IUD, reasons for Ethical considerations IUD use, barriers facing IUD uptake and provider character- Written informed consent was obtained from all inter- istics influencing IUD using a qualitative method to provide viewees for their participation and for the audio- in-depth information that will complement the GDHS data recording of the interviews. Interviews were conducted on IUD to inform policy and programme interventions in private places such as consulting rooms, respondents’ aimed at increasing IUD uptake in Ghana. homes and offices as recommended by respondents to Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 3 of 17 protect the confidentiality of responses and enhance the asked to answer the research objectives. Family planning comfort of respondents. This study received ethical providers were interviewed on the nature of their rela- approval from the Ghana Health Service (GHS) Ethical tionship with clients, clients’ knowledge on the IUD and Review Committee (ERC). Permission was also sought clients reasons for discontinuation of the IUD. from the various health facilities and respondents used Three female research assistants were trained by the in this study. lead investigator to administer the interview guides. Al- though they were encouraged to be flexible during data Data collection procedure collection, strict adherence to the study guide was dis- Data collection began using a sample frame. A list of couraged if new topics in relation to originally stated women who had visited the identified health facilities for questions emerged during the discussions. This flexibil- IUD insertion or removal during the past six months ity was to encourage capturing of emerging issues which were obtained from the client information system after are different from the order given in the interview guides several unsuccessful attempts to directly recruit the re- [21]. The field research assistants were also oriented on quired number of participants at the study sites. Consid- key ethical issues regarding research ethics involving ering the general low patronage of IUDs at the study site humans as research subjects and were encouraged to be during the period of data collection, it was very challen- nonjudgmental in their responses to the experiences of ging obtaining the required number of respondents for a the study participants. Face to face in-depth interviews meaningful analysis hence the need to fall on client re- were conducted in the local language ‘Twi’ or in English. cords for retrospective interview of current and previous Nine (9) study participants were interviewed in ‘Twi’ IUD users from the indicated facilities. Clients using and the rest were in English. The In-depth Interviews other modern contraceptive methods were also inter- lasted for an average of 40 min. viewed to explore why they are not using IUDs but other The interviews were audio-taped with permission from methods. Family planning providers offering modern participants to ascertain accurate accounts of the inter- family planning methods, including IUD insertions and views. The recordings were then replayed for analytical removal in the selected facilities were also interviewed to responses. Interviews were transcribed immediately examine their experiences about clients concerns with thereafter while ‘Twi’ interviews were translated to Eng- providing IUD services. lish and later transcribed. Field assistants transcribed the Participants were recruited either by face-face or interviews they conducted themselves. As the transcripts through phone calls after they were informed about the were produced, they were read through to increase fa- nature, benefits, risks, and purpose of the study and con- miliarity with the data. Data was manually analysed by sented to participate. Information on voluntary partici- the researchers using the thematic analysis approach. To pation, rights to withdraw and consent was made known do this, a list of code labels was created and a series of to study respondents. Half of the in-depth interviews categories for the main themes that emerged from the (IDIs) were conducted at health facilities, whilst the transcripts were developed. The transcribed data was remaining were held at respondent’s home, and at places then organized, coded and manually thematically ana- deemed convenient and comfortable for respondents. lysed in word. Results of the study were then presented Data were collected using modified research instru- using descriptive statistics and quotes from respondents. ments to build upon previous literature. In line with the study objectives and issues identified in the literature Results reviewed, four (4) different semi-structured interview Table 1 presents the socio-demographic characteristics guides were developed to address the research questions. of respondents excluding FP providers. For IUD users, The interview guides contained questions on partici- six (6) were aged between 40 and 49 years, and the pants’ socio-demographic data (such as age, educational remaining were between 25 and 29 years. Two (2) out of level, current FP use, previous FP method use, and the ten participants had no formal education. Only one parity); FP knowledge, and knowledge about IUD, and woman was unmarried but she had two (2) children. factors/reasons for IUD use. Questions for IUD users’ Majority (8) had been using the IUD for more than six differed slightly from questions asked of women who (6) months; only two (2) women had used it for two had ever used the IUD. For instance, whilst IUD users months and five months respectively. Twelve (12) were questioned on their perception about the IUD women had ever used the IUD for duration of two weeks when they initially began using it, women who had re- to thirteen (13) years. Their current FP methods com- moved the IUD were asked to report on reasons for prised of both modern and traditional FP methods such their removal of the IUD, side-effects, and future inten- as, implants, injectable, condom, withdrawal and the cal- tions to use the IUD. Thus, although questions differed endar method. Two (2) were not using a method; one slightly on some respects, a few similar questions were was pregnant, and three were trying to get pregnant. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 4 of 17 Table 1 Socio-demographic characteristics of study Table 1 Socio-demographic characteristics of study respondents respondents (Continued) Characteristic IUD Ever IUD Non-IUD Total Characteristic IUD Ever IUD Non-IUD Total users users users users users users n =10 n =12 n =7 N =29 n =10 n =12 n =7 N =29 Age Less than 6 months 5 3 3 11 20–25 2 2 4 6 months −1 year 3 3 6 26–30 2 3 3 8 2 years- 5 years 2 2 31–35 3 2 5 6 years–10 years 36–40 1 3 4 More than 10 years 41–45 3 1 4 Previous FP method 46–50 2 2 4 None 3 1 4 Educational status IUD 2 11 13 No education 2 2 IUS 1 1 Primary 1 1 3 5 Implant 1 2 3 Secondary 3 2 4 9 Injectables 1 1 2 Tertiary 4 9 13 Pills 2 1 3 Marital status Male Condom Unmarried 1 2 1 4 Female condom Married 9 9 6 24 Male condom Divorced/separated Calendar method 1 1 Widowed 1 1 Tubal ligation Occupation Number of years used previous FP method Unemployed 1 1 Less than 6 months 1 3 4 Self-employed 7 4 4 15 6 months −1 year 2 5 1 8 Public worker 1 3 4 2 years- 5 years 3 3 Private formal worker 2 5 2 9 6 years–10 years 2 2 Parity More than 10 years 1 1 11 1 Total 28 22 3 1 6 Amongst these women, one didn’t complete primary 33 4 3 10 education, two had completed senior high school, and 42 3 5 the rest had tertiary education. Two (2) participants 52 2 worked in the public service, six (6) worked in private 6+ organizations, and four (4) were self-employed. Current FP method From the total IDIs conducted, seven (7) respondents None 2 2 4 had never used IUD as an FP method. Their ages ranged between 25 years to 32 years. Only one (1) was not mar- Trying to get pregnant/ 42 6 pregnant ried. Two (2) were currently using the implants; one (1) IUD 10 10 was using injectables; two (2) were trying to get preg- nant, and the remaining two (2) were not using any FP Implant 1 2 3 method. The highest educational status attained by re- Injectables 1 1 2 spondents in this group was secondary, (four respon- Male Condom 1 1 dents) and three (3) had completed junior high school. Female condom Almost all women had at least two (2) children, except Withdrawal 1 1 two women who were trying to get pregnant. Calendar method 2 2 Seven (7) IUD providers participated in the IDIs. Three out of the seven from NGO facilities whilst the Tubal ligation remaining four (4) were from private (2) and public (2) Number of years using current FP facilities. The professional qualifications of FP providers Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 5 of 17 ranged from Health assistant, Midwife, Nursing officer, encouraged or motivated by family, friends or staff, Obstetrician and gynaecologist. There was a sole male whilst the other two admitted being motivated by their FP provider in the study who worked as an Obstetrician. friends, and health providers. A respondent categorically All providers have been providing FP services for more reported that her desire to use the IUD was out of a than 5 years except the health assistant who was not strong personal volition irrespective of her partner’s con- professionally trained and specialized to offer IUD inser- sent. A respondent said: tions for women. Her responses are therefore not in- cluded in the analysis. “Nobody encouraged me to use the IUD. My husband, A total of thirty-six (36) IDIs were conducted. Out of mum and siblings even did not want me to do the FP this number, ten (10) women were currently using IUD, since they were all afraid of the side effects. So it was twelve (12) had ever used the IUD, and seven (7) had my own decision. I just got up one day and decided to never used the IUD. The remaining seven (7) were fam- go and do it because my children have very short ily planning (FP) providers. Majority (12) of interviewees intervals in relation to age. So even my husband doesn’t were selected from NGO facilities. Of the FP providers know I’ve done FP unless I tell them” (29 year old interviewed, only one was not providing IUD services. married woman currently on copper-T IUD for 1 year). Her responses are therefore not included in the analysis. The number of IDIs conducted at each study setting is Although the walked-in clients reported to have volun- presented in Table 2. tarily consented for IUD based on the counselling they received, clients who had the IUD following post- Knowledge of family planning abortion care reported to have been coerced/forced/en- Findings showed that all women had good knowledge couraged/influenced to have an IUD as post abortion about FP methods. Each study participant knew of at contraception to avoid repeat unwanted pregnancy and least, three FP methods and how it works. The com- abortion. Two respondents mentioned that they were re- monly mentioned FP methods were injectables, im- spectively encouraged and influenced to use the IUD by plants, and pills. However, half of the women could not the provider after having undergone an induced abor- provide the name of the implants by themselves, but tion. A respondent stated that: were able to describe where and how it was inserted. Very few (three) respondents mentioned sterilization “I refused an immediate family planning uptake (vasectomy and tubal ligation), diaphragm. One woman despite the in-depth counselling given me after the mentioned IUS. Furthermore, the interviews showed previous abortion. So when I went and got pregnant that IUD users and ever IUD users had adequate know- and came again for another abortion, she said by force ledge of the IUD compared to women who were not she will do one for me so I agreed for her to do it for using IUD. Study respondents’ level of knowledge about me although it was against my wish” (40 year old the mechanism of action (i.e. how the IUD works) of the married woman on Copper-T, IUD for1 year). IUD, description of its physical features, and who can use it was comparatively the same among current and Half of the participants reported no side effects previous IUD users. after switching from injectables to having the IUD inserted. Again, another half felt slight abdominal Findings from current IUD users pains soon after insertion of the IUD which was re- From the IDIs, only ten (10) women were currently lieved after ingesting pain killers given by the pro- using the IUD. Out of the ten women, five (5) voluntar- vider. One respondent stated: ily decided to use the IUD whilst the remaining were given the IUD as a post-abortion contraception method. “I went back to the IUD because for me it was very Three women who voluntarily preferred to use the IUD successful. I never had any problems with the IUD stated it was their personal decision; they were not compared to when I was using the injectables. I didn’t Table 2 Number of IDIs conducted at each study setting Study group Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Total IUD users 3 2 211110 Ever IUD users 4 1 121312 Non-IUD users 2 – 11217 FP providers 3 1 1 1 – 17 Total 12 4 554636 Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 6 of 17 have any problems with my period, I didn’t have any stopped. Since then I have not experienced any major weight issues and headaches compared to the problem just that my menses is not flowing like it injectables that I previously used” (43 year old should be.” (46 year old married woman on Copper-T unmarried woman using Copper –T 380A for 2years) 30A for 1year). Another respondent indicated that: Two respondents reported that this was their second time of using the IUD. Both of them reported no side ef- “my experience so far is that my menstrual flow has fects on both occasions. According to one participant, she reduced from 5 days to 4 days since using the IUD for removed the IUD to test her fertility and continued usage six months now after I delivered my last baby. I decided after childbirth as encouraged by her doctor’sexplanation to ask a doctor friend and he said nothing is wrong with and counselling. She narrated her story as follows: me. I also realized, comparing this with the injectables that I used to be on, the severe heart beat and headache “….So he said that IUD will be the best solution so I I used to have disappeared. Initially, I was a bit tensed, went into that. I used that for about 6 years, I met this that maybe my husband will find out. So one day, I guy we talked about marriage and he was like the asked him about it whether he can feel anything. And thing that people are telling him is that if you take it he said no. So he asked is it like the other ones? I said off you won’t get pregnant again. He insisted that no, your menstrual cycle is it normal? I said normal, before we get married I should get pregnant for him regular 28days cycle. I said I’mok. Idon’t know; I’mnot first. So I took it off and became pregnant the following worried. I feel normal. I feel ok. So I’ve been encouraging month and got married but aborted the pregnancy on some of my colleagues to do the IUD” (29year old health grounds after which I had another replaced for married woman on Copper T 380 A for 2years) 3years. I took it out again and I got pregnant again (laugh) after I gave birth, I read about LNG-IUS and I In another instance, one participant indicated having went to the hospital requesting for it because of its prolonged menstrual flow and offensive vaginal dis- advantages. But I was told it is not available in Ghana charges. According to her, the duration of menstruation is yet. I was like okay am not going to have any babies any slightly longer and heavier compared to when she had not time soon so let me go back to my Copper IUD. So I had inserted the IUD. She narrated her experiences as follows: it again for almost 10years now.” (43year old unmarried woman on Copper-T 380A for 10years). “You are just there and then you get a discharge. It’s not too comfortable, but then, I initially tried to cope until the discharge became offensive which compelled Factors that influence IUD uptake me to seek medical help that advised me to remove it Table 3 presents an illustrative summary of factors influ- after two months of unsuccessful treatment. encing IUD uptake in order of most frequently mentioned I realize that, even though it is just about two months Table 3 Illustrative summary of factors influencing IUD use since removing the IUD, It’s a little better. Now the among current IUD users discharges come at the time of ovulating. Although I No. Factors influencing IUD uptake Frequency Percentage (%) realize that there are more discharges it’s no longer 1 Prevention of unwanted pregnancy 20 21 offensive. I learnt it’s going to go back to normal after 2 Reduce births 17 18 a while” (42 year old married woman wo used 3 Space births 15 16 Copper-T 380A for 2months but currently on com- 4 Prevent abortion 11 11 bined oral contraceptive pills). 5 Contraceptive failure 10 10 Another respondent asserted that her menstrual flow 6 Avoid forgetfulness in taking pill 6 9 is now irregular compared to when she hadn’t inserted 7 Substitute to other FP methods 55 the IUD. Also, she initially experienced some brief due to unpleasant experiences periods of vaginal discharge, which did not smell but 8 Desire for a long lasting 44 permanent method currently doesn’t have any discharge. She indicated that: 9 Concentrate on work, or business 3 3 “……I later realized that some ‘water* (referring to 10 Non-hormonal method 2 2 discharge) comes from my vagina. But they told me 11 Concentrate on academics 1 1 that when we see some water and we don’t like it we Total 94 100 should come back. But I didn’t go back and the water Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 7 of 17 factors. Respondents gave varied reasons for current use one that you inject or has something to do with your of IUD compared to other methods. The main reasons re- blood. Those ones I hear people have complications, ported to have determined IUD uptake pertained to pro- hormonal disturbances, I think IUD is best because it tection against unwanted pregnancy, to reduce births or just blocks your womb and no sperm enters to have an space childbearing. egg fertilized” (23year old married woman, on Copper- Other factors that influenced IUD uptake were centred 380A for 2years. on the characteristics and benefits of the IUD over im- plants, pills and injectables. Half of respondents’ decision Partner characteristics also determined preference for for using the IUD was premised on past contraceptive fail- IUD use in a few cases. For one woman, the decision to ure and a desire for a long lasting family planning method. use the IUD was fear of partner’s reaction to successive In a narrative account, a study participant’s decision to pregnancy, and to avoid problems with partner. Narrat- adopt the IUD was due to ineffectiveness of traditional ing her story she said: natural FP method; to avoid unpleasant previous experi- ences with other FP methods; fear of partner’sreactionto “I became pregnant for the fourth time and I fear my successive pregnancy, and desire for a different FP method husband will complain and refuse my education. My other than implants, injectables or pills in order to avoid husband suggested an abortion and IUD. He another repeated abortion. She admits being encouraged encouraged me this is the best after the abortion which by the provider to use IUD during post-abortion counsel- I did” (29year old married woman, on Copper-T 380A ling. The need to avoid unpleasant side effects with the for 3 year). pills, injectables as well as forgetting to take the pills and ease of use influenced IUD uptake. Two women reported: Another respondents indicated that: “I had issues with the tablet because I kept forgetting “I already have four kids and my husband is giving me yes and your menstrual cycle change with it and all problems to have more. if I tell him about family that. That is why I went for the IUD” (39year old planning he would not allow me to do so I came to do unmarried woman on Copper-T IUD for, 2years) this on my own secretly” (44year old married woman on Copper-T 380A for 2years). Another respondent indicated that: The insistence and encouragement of some health “I had wanted to do the 5years type of IUD but it providers led to IUD uptake for some women. A re- wasn’t available. I was told the 5years type of IUD, the spondent categorically admitted being encouraged by implants and 3 months injectables are almost the providers to use IUD after post-abortion counselling. same. Since I had done the 3 months and felt dizzy, I They claimed providers did not directly influence their decided to do the 10 years IUD because that one isn’t choice, but rather advised on the need for adopting an medicine but just something to close the vagina” effective method to prevent repeated abortions. A re- (29year old married woman, using copper-T 380A spondent asserted in the following: for 2years) “——So when I went and got pregnant and came again Two respondents were convinced about the efficacy of and she said by force she will do one for me so I the IUD influenced their choice of the IUD as a method agreed for her to do it for me”….(40year old married to prevent pregnancy. One said: “It was effective for me woman, 3 children on Copper T 380A for 3years). previously and it’s still the best for me” (23 year old mar- ried woman on Copper-T 380A for 1 year). Another respondent indicated that: Another also said: “I was more convinced about the ef- ficacy of it the choice” (43 year old unmarried woman, “—midwife insisted on me taking an IUD after doing on Copper-T 380A for 2 years). the abortion else she will not help me again. Because In furtherance to the reasons for IUD use, two women of the respect I had for her, I had the IUD soon after also decided to use IUD because of its non-hormonal the abortion for free” (28year old widow, 2 children on nature which does not affect their hormonal system. In Copper T 380A for 1year). their view, the IUD was the best method. One noted in the following: Perceptions about IUD “IUD is the best method because, I think it does not Study participants’ indicated to have had mixed reac- have any hormonal thing when you do it unlike the tions when first introduced to the IUD. Majority (8) of Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 8 of 17 the respondents said they were scared when they first without him knowing” (29year old married woman on heard about the IUD. The insertion procedure created copper-T 380A for 5 years). fear amongst them hence did not opt for an IUD as FP method. Two respondents explained: Some respondents were just curious and desirous to try a longer lasting FP method when initially informed “I have heard about FP before. They say some FP is about the IUD by a health provider. Other respondents put in the arms, some too were injections and some were further motivated to use the IUD with positive as- too were inserted in the womb. But I didn’t know how surances and encouragement from friends. Further, an- it looks like. So when I came and it was explained to other woman also expressed indifference when initially me I was scared so I didn’t do it but opted for the informed about it. She said: ‘I just wanted to protect my- injection” (40 year old married woman on injectables). self, I didn’t have any attitude towards it’ (29 year old married woman, on Copper-T 380A for 2 months). The other respondent indicated: Perception of health risks associated with using the IUD “Yes, I was very afraid; because I had not done some In Ghana, knowledge about Family Planning methods is before. I’m a person full of fear. I taught of something generally acquired though formal and informal public different. But the provider took time to counsel me and education. Whereas the educated population read about even used models for demonstrations on how it is done. family planning methods when the need arises, the less Despite my fears, I tried it. I taught it will be painful for educated obtain family planning information in health months but nothing of that sort happened” (25 year old facilities, friends and significant others including televi- married woman, on Copper-T 380A for 3years). sion, radio and social media adverts. When respondents were asked whether using the IUD was associated with Women’s perception of the IUD was also associated health risks, seven (7) reported no health risks associated with myths and negative reactions from friends. They with using the IUD, while one (1) respondent couldn’t raised concerns about some myths that they had heard tell whether or not the IUD posed a health risk. She about the IUD getting stuck in the womb, and potential indicated: health risks in later years. For respondents who associ- ated myths and misconceptions about the IUD, they af- “I was not scared of any risk, because I didn’t think firmed that their perceptions had now changed. A there will be any. But there was one thing that was at respondent reported that her lack of knowledge about the back of my mind, that if I am not comfortable with how the IUD works, and how it looked like made her it, I will take it out. Do you know, if I am not afraid. The fact that “something” was going to be comfortable I didn’t think that they could do something, inserted in the womb created fear, because her under- you know negative, but all I was thinking is that, if I am standing of the procedure is similar to undergoing a D not comfortable, I will take it out” (42year old married & C. However, her perception changed after explana- woman, on Copper–T 380A for 5 years) tions from the provider. She explained: A respondent admitted that no health risks were pos- “Oh in the beginning when they were about to fix it sible except risk of getting infected through usage of and it scared me a bit because I didn’t know how it unsterilized equipment. However, one woman feared be- will work or how it is. Ehee, but they made us ing sterilized after using the IUD. Another participant understand that it wasn’t anything scary. Something had no knowledge about whether IUD usage could harm that they said they will put in your womb, you will be her in future. She explained: a bit scared” (46year old married woman on Copper – T 380A for 5months) ‘If there is a development that it affects something Other respondents who did not discuss their FP because the copper something scared me, because I choices with their partners, feared that their partners didn’t understand why you should have metal in you might find out about having the IUD since the strings but I googled and read about it and I think its ok, it were likely to be visible. One respondents indicated that: doesn’t have any health risks’ (23year old unmarried woman on Copper-T 380A for 3 months). “Initially, I was a bit tensed, that maybe my husband will find out. So one day, I asked him about it whether Although majority (7) of the women interviewed felt he can feel anything in me during sex. And he said no. safe with using the IUD, a few (five) disliked the uncom- I then became comfortable keeping it all these years fortable feeling of the strings hanging in vagina during Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 9 of 17 menses, bathing and somehow wished the string will be reported side-effects and reasons for IUD removal is ‘cut off ’. Three of them had this to say: outlined in Table 4. The results indicate that reasons for removal of the IUD “Yeah the little thing that I don’t like about it is that, do not differ substantially from the side-effects experi- when you are having your menses the bleeding brings enced by respondents. Other reasons that led respondents the strings out. They put the “T” thing in the womb, to remove the IUD involve partner disapproval with the and then they leave this (referring to the string) to use of a FP method. One of the respondents explained hang out into the vagina. So as you, you know, if, that her partner disapproves of FP and so she was scared mensuration stops it sort of goes in to…“Aha”, When that although she has the IUD, the partner might notice you are taking shower and your hand just goes there, the IUD and there might be a problem with that. She you can feel it. I would have wished they will even cut states: my string out” (42year old married woman, on Copper –T 380A for 5 years). “My fear is maybe what if you are making love with your husband one day and the IUD gets remove by Another respondent explained: itself. Sometimes it bothers my mind and I’m scared when having sex” (31year old married woman on “oh the first time I fixed it, the thread was lying Copper-T 380A for 8 months). around my vagina so I was afraid so I was pushing it in, then I later went there to complain about it. They The physical features of the IUD also deterred some removed it for me and then fixed another IUD for me participant from continued use of the method. A respon- but still there’s some thread lying around my vagina. dents indicated that: Anytime I wash that area, I feel it but now I don’t care” (23 year old married woman, on LNG-IUS for 1 year). “I think the uneasiness of that thread thing makes me dislike it. You know, once you’re cleaning it wants to Another respondent was of the view that: come out and you have to push it there, you know… it has to be in there, it doesn’t need to stick out so that “the previous IUD I inserted, I don’t know what brings uneasiness” (47year old married woman on happened maybe I had a heavy flow in a particular Copper-T 380A for 2 years). month and it came out and you know it has a string attached to it, so I think it was choking me around my Another respondent said: cervix and when I was sitting, it was so down, I was feeling a little pain that’s why I went to change it; ‘Why should I allow that nasty thing to be put in my but apart from that, I’m ok with the current one body? The shape of it alone puts me off so I will as its very comfortable” (29year old married woman, always go for another decent method and certainly not on Copper –T 380A for 2 years). the IUD’ (25 year old unmarried woman using the injectable for 3years) Findings from women who have ever used the IUD as post abortion contraception Table 4 Summary of side-effects of IUD and reasons for Four respondents previously used the IUD as a post- removal abortion contraception after repeated abortions. A re- Reported Side-effects with Reported reasons for IUD experienced removal of IUD spondent exclaimed: “They rather gave it to me because of the abortion and they didn’t sell it to me. It was free � Heavy bleeding � Heavy prolonged bleeding after I did the abortion to protect me” (39 year old � Foul vaginal discharge � Vaginal discharge (sometimes coloured) widow, on Copper-T 380A for 4 years). The other re- spondents however paid for the IUD separately. � Infections � To give birth � Abdominal cramps � Abdominal cramps � Spotting bleeding � Spotting or irregular bleeding Problems or side-effects experienced with using IUD Generally, findings showed that at least, each woman � Prolonged bleeding � Infections (study participant) suffered from one of several side ef- � Irregular bleeding � Feeling of device removing fects of the IUD after a few weeks of insertion. For some, � Discomfort with strings the side-effects was severe and sufficient to warrant a re- � Partner disapproval of FP method moval of the IUD. An illustrative summary of the Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 10 of 17 Three respondents removed the IUD to give birth, but “I first went to a public hospital in Kumasi which had two of them categorically expressed their intentions of only short term FP methods. I wasn’t really convinced inserting the IUD again after birth. They both indicated so I heard about the IUD from a NGO facility which I their intentions as follows: visited just for something more permanent. So I just walked in she took me through all the methods and “I removed the IUD to have another baby, but right after my last baby I was advised on that as the best after the pregnancy, I will wear the IUD again to option based on being hypertensive” (47 year old protect myself from unplanned pregnancy because it is married woman on Copper-T 380A for 8 years). good for me” (39year old widow, who previously used Copper –T 380A for 4years). Another respondent said: The other respondents said: ‘I actually brought the LNG-IUS from the USA to be inserted for me here in Ghana because I really love it “—even this when I was coming to remove it, the nurse but very expensive to be inserted in the USA’ (23year asked me [laughing] ‘why do you want to remove it’ old unmarried woman on LNG-IUS for 2 years) and I said I want to give birth again to two children. I think my partner is okay with the IUD and I will have Other respondents also mentioned avoidance of side it again after delivery” (38year old married woman, effects with other FP methods and reduced forgetfulness who previously used copper –T 380A for 2 years). in taking the pill. One respondent reported: “Oh yeah I love the IUD because there was nothing like I have forgotten to take my pills, I have forgotten Reasons for IUD use among ever IUD users to do this or that. It was just convenient I didn’t have Many reasons were noted for the use of IUD among the to worry about anything. I didn’t have to worry. Once respondents who have ever used an IUD. Key among the it was there and I was assured that it was 99% safe. reasons for women’s use of the IUD however pertained So I didn’t worry” (….38 year old married woman, on to a desire for a long acting FP method compared to copper-T 380A for 2 years). short term FP methods. Summary of reasons given are arranged in order of most frequently mentioned in Two accounts from two women which capture their (Table 5). decision to use the IUD is presented in the following: To satisfy a desire for long acting family planning method, some respondents went out at all lengths to en- “The fact that it’s inside makes me satisfied. I don’t sure that they had their desired FP method of choice. A have to see it, apart from the little pain I will respondent explained that: experience over the months, I’m done. I can’tbe faithful to that, taking the pill” (….26year old single Table 5 Illustrative summary of reasons for IUD use among ever woman ever used Copper-T 380A) IUD users No. Reasons for IUD use Frequency Percentages (%) The other respondent indicated that: among ever IUD users 1 Desire for long acting family 18 24 “Because I was told it has nothing to do with the planning method hormones and cells in me I think it is normal” (32year 2 Avoid unpleasant side effects with 15 20 old married woman, ever used Copper-T 380A). other FP types 3 Avoid forgetfulness to take pill 12 16 4 No hormonal influence 9 12 Perception of health risks associated with using the IUD 5 Perception of no side effects 7 9 Mixed responses were obtained when the question on 6 Protect against pregnancy 5 7 perception of health risk was asked. One woman feared that the IUD could cause cancer. According to her: 7 Provider influence 4 5 8 Preference for an ‘obscure’ FP 34 “When I was going I didn’t know what to do and you (‘obscure = hidden’) know I was asking a lot of questions so I was going on 9 Health reasons 2 2 the internet and my elder sister who passed away last 10 Prevent worry 1 1 year was telling me “Don’t do it!. Don’t do these things, Total 76 100 they give cancer. “She died out of cancer but she said Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 11 of 17 “don’t do it again”. They give cancers, the one…that with the LNG-IUS because of the hormone they can thing insert here two things affect your blood and you cause issues of the hormone imbalance things like that. get bloated up. You know, there were lot of fears” I didn’t experience it anyway” (40year old married (.47year old woman on LNG IUS for 3 years). woman, on LNG-IUS for 3 years) Another woman believed that though the IUD was ef- In contrast to some respondents’ stated fears about the fective in preventing pregnancy but the risk of contract- IUD, two other women could not certainly tell whether ing infections through the IUD makes it not to be totally using the IUD was risky to their health. One said: safe. She explained that: “health risk? Not as I know” (….38 year old woman on “When it comes to health risks, I don’t know how you Copper-T380A). want me to; .oh you will still get STIs, you will still have seamen coming into you. You will still get the Similarly, two other women believed since they didn’t STIs” (….30 year old woman on Copper-T 380A). experience any side effects or problems with the IUD, and upon the recommendation of health providers, then Another risk as mentioned by a 26 year old woman per- there was no health risks associated with it. One of them tained more to a misconception about the IUD moving indicated that: around the body into other organs by itself after insertion. She also mentioned the probability of experiencing perfor- “I don’t know much but so far, no. I’ve been to two ation in the uterus when IUD is inserted. Although a rear midwives and they themselves said they used that one. occurrence with trained and competent providers the That’s what makes me go in for that one” (….31year probability of perforation has been reported in clinical in- old woman, o Copper-T 380A for 2 years). cidents relating to IUD insertion due to provider errors and use of rigid instruments among others. In the respon- dents own words she indicated that: Future intention to use IUD Women were asked about their future intention to use “With the health risk you know when you put it on, the IUD, and from their responses, only five (5) declared when you insert they have this nylon thread, that they their intention to use it again because it was good, useful wrap it, sometimes it comes off as it helps the IUD to and effective for them. One respondent said: move around. You may not know, sometimes there may be some perforation or something. It may hurt u. “I will come for the same thing when God willing I give I think that is, that makes it the only problem but birth”…38year old married woman, 2 children aside that, it’s not a problem”. Another woman also reported However, this same woman maintains that “I don’t think there are any health risks, if u have an IUD inserted u “Yes, but right after the pregnancy, I will wear the IUD don’t let everybody play around that part because if their again to protect myself because it is good for me”… fingers are…., I think the health risk is more about us 39year old widow, 4 children and how you take care of yourself”. One respondent experiencing vaginal discharges was It was clear from the IDIs that some women wished concerned that the discharges were due to the Copper theIUD wouldhaveworkedfor them becausethey IUD she had used for the past 2 years and might be risky preferred a longer acting method, and also since it to her health. She said: was recommended by a provider. Unfortunately some respondents experienced heavy/painful menses and “Yeah, as I was saying about the discharges, I fear it frequent expulsion when given the IUD hence had to could lead to something else” (…32year old single have it removed two months after insertion. Two woman on Copper-T 380A) women reported: According to another woman, she was of the view that “It’s not all that safe since I had heavy and painful women risk having an ectopic pregnancy after using the menses when I was on IUD. I mean I wish it had IUD as a FP method. She explained saying: worked for me, honestly. I really wished it had worked for me, I mean I was really counting on it. The fact “Obviously yeah. You risk ectopic. You risk ectopic that I mean it will be there for the next 5 years, for the pregnancy I know that. I may say it has been argued next 10 years, you are protected and all that, u don’t Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 12 of 17 have a problem. I really hoped it worked”….(30year observation made however is, clients who don’t have old unmarried woman ever used Copper-T 380A) such facilities regardless of their educational levels tend to rely on service providers and/or significant others for The other said: information on family planning services. On this same issue, three providers also mentioned that only few cli- “I was quite unfortunate to have had the IUD falling ents have heard of IUD, and out of this number, very off by its self on three occasions so I had to discontinue few have ever seen or touched it before. A provider nar- its use. But if it was working for me, I would have rated her experience as follows: loved it. Why? Because it doesn’t let me grow fat or anything. You know, you stay your normal and you “Yes, have you heard about IUD? You ask. You came know that after five years which is quite a long time, in here we do family planning, which one do you like? you can change it. Five or ten years I think for you to The person if she’s … She will tell you that, I don’t change it. If you feel some uneasiness, you just walk have any idea about family planning” (IUD provider). into the facility and you just take it off” (47year old woman, on Copper-T IUD for 4 years). On the other hand, a male provider strongly professed that because clients have little knowledge of modern FP methods particularly, IUD, he mostly provided it for Women’s knowledge about the IUD them based on their past medical history, parity and the All family planning providers reported that women (also number of previous deliveries. Thus, he directly influ- clients) have very little knowledge of the IUD pertaining enced clients’ use of the IUD. He indicated that: to its mechanism of action, its physical features, how it feels, and the essence of the copper around it. They at- “Well over there, if they come, most of them don’t tributed women’s knowledge of the IUD from shared ex- know about the IUD. Theirs is that they are here to periences of friends, and which is represented negatively. protect themselves against pregnancy or are here for Thus, when they asked clients knowledge of the IUD, FP. So I take them through all the methods and then I clients primarily stated their misconceptions, side-effects ask how many children they have. And most of them and myths neglecting the usefulness and efficacy. On too they gave birth at my place so I already know their provider said: history. After the counselling they will ask me, out of the whole lot which one am I choosing for them? You “Sometimes, they can be influenced by their friends. If see, they are such that they have that trust and belief I’m giving it percentage wise, it’s about 30percent of in me, so anything I say they comply” ( IUD provider). them who know depo, IUD, secure and all those stuffs from their friends” (IUD provider) Women’s reasons for not using the IUD Another provider reported that: From the interviews, providers stated that women’s rea- sons for not using the IUD is mainly because of the fear “When you ask them, they tell you yes, I’ve heard it, but of inserting the IUD in the uterus, and fears about the I’ve not seen it so you let them touch it and feel how it is IUD. Fears about the IUD pertain to myths and miscon- before you do it for them. They will ask you so what is it, ceptions, as well as fears that the IUD will affect their the wire that we are seeing there, it is just plastic. So health in the long term.. A respondent narrated some they hold it to see how flexible it is. This is just a copper misconceptions and fears as follows: that is wound around it and is nothing that is going to hurt them, or touch anything” (IUD provider). “I learnt the IUD can walk to the heart. I also learnt a woman had a baby and the baby was carrying IUD in Two providers asserted that among women who had her hand. If you get IUD, you won’t have children visited them for contraceptive counselling and uptake, again. They have been saying all these things. So I tell less educated women tended to have no knowledge them, it is not true.” about the IUD compared to educated clients who some- times search the internet to read and obtain knowledge Other reasons such as male partners’ disapproval of IUD of the IUD prior to their visit to the FP clinic. The avail- use, (and any other FP method); fear of male partners’ ability of internet services on smart phones provides knowledge about the IUD, and the uncomfortable feeling quick information to users in areas that have good re- of the strings during sexual intercourse. Poor knowledge ception. This enable clients seeking information on base of the IUD, a strong mind-set and resistance to the contraception to browse quickly for knowledge. The IUD also deterred uptake. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 13 of 17 Concerning fears about the procedure for inserting the Why do you want to take it off, and she tells you, I IUD, a female provider explained that unlike the short want to change it. It has been there for long so I want term FP methods like injectables or pills which are un- to change it. Just take it off and do something else for obtrusive, IUD is noticeable and can be felt by the part- me” (IUD Provider). ner through the strings which lie in the vagina during intercourse. There is therefore a greater chance of it It was also noted that other women also wanted to test been detected or felt by the partner even when the their fertility or reproducibility after prolonged IUD use. partner has no knowledge about it. According to an IUD provider’s account: Providers’ reasons for clients IUD removals “They think once is been there for long without them The main reasons for clients’ removal of the IUD from getting pregnant, they should remove it and see if providers view is the side effects evident through bleed- they are still fertile. And so they will remove, they ing, cramps, vaginal infection, and abnormal menstrual will get pregnant and then they will come for help” cycle. The second key reason is for reproduction. Other (IUD Provider). reasons providers cited are to prevent feuds with their partners in circumstances where the IUD was inserted without partners’ knowledge and approval; fear of IUD Client- provider- relationship in health facilities during FP from moving to other parts of the body; fear of IUD counselling causing fibroid and cancer after prolonged use and for All FP providers unanimously agreed having a good other health reasons. positive relationship with clients during contraceptive counselling. They described the counselling sessions as “The reason for them taking it out, some of them they cordial and open to allow clients to freely discuss their bleed even after. Some can bleed for the whole 28days. concerns, and ask questions about the IUD, as well as They become very anaemic, fatigued and weak. For other FP methods. Counselling is done in an open man- some, it’s not all, but as soon as you take it off and put ner in a language which clients understand to facilitate them on medication for a week, that thing ceases and communication. you monitor that client for about three cycles, you see that the client will be happy; and have the normal Ways to encourage IUD uptake among women menstrual flow. The second thing too is that, she will Currently, education on family planning services is inte- come with that problem, you will take it off and this grated into general sexual and reproductive health pro- will go and interfere with her normal menstrual cycle, motion and education programmes at the local, regional then she will be having abnormal menstrual cycle; and national levels. The scope of the sexual education at instead of 28 days, at times they can go 26, 40.” the public level is basic information on human (IUD Provider) reproduction and mechanism of how contraceptives work. Although there is a national family planning stan- Another provider said: dards and protocols guiding family planning educational activities, the implementation of this protocol is deter- “Some of them they come in for it without the consent mined by who is doing the education, the target popula- from their partners. So along the way, their partners tion, mode of education and the level of theoretical and find out. And it tends to bring a quarrel among practical experience of the educator. In this regard, com- them so they quickly come for it to be removed” prehensive education on long acting and reversible con- ( IUD provider). traceptives as well as permanent methods looking at medical eligibility, side effects and complications are A female provider categorically maintained that some usually reserved for clinical trainings of providers and women who came to remove the IUD did so for no obvi- not the general public. Consequently, the limited scope ous reason; neither were they experiencing complica- of IUD education compels potential clients’ new users or tions except to change to a different FP method. She adopters of IUD to rely on self-education by reading or indicated that: information from significant others some of whom have limited knowledge shrouded with some of the identified “There are instances they don’t come with any myths and misconceptions that prevents IUD use and complaint, they feel it has been there for quite a long encourages discontinuation when side effects occur time, so they feel they should take it off and change to among users. another method to see the best. Somebody who has To encourage IUD use among women, all the FP providers been on the IUD for 7 years will come and take it off. suggested a holistic education and public sensitization. The Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 14 of 17 holistic education as reported encompasses information on “some IUD providers don’t tell the clients everything eligibility, side effects and complications for women on the about the method they only tell them the benefits IUD, as well as other long term FP methods for informed de- without informing them about the side effects and cisions on choice. Comprehensive education in this regard, complications. So when the clients leave and have any should be carried out through the media (print and elec- bad effect they lose trust in the method and provider tronic) and mobile information vans particularly in rural and rush back to have it remove. They won’t remove it communities. Additionally, messages should be targeted at if well informed” ( IUD provider) dispelling the myths and misconceptions about the IUD. Sexually active young individuals should also be educated at the junior high school level on IUDs for future decision mak- Discussion ing. FP providers also recommended the use of text messages This study aimed to explore determinants of IUD use to promote IUDs on social media as a medium for reaching among women currently using the IUD, and women out to young people most of whom appears to frequent so- who had ever used the IUD; explore women’s experi- cial media in recent times. ences with the IUD pertaining to perceptions, side ef- The sole male provider interviewed in the study fects; reasons for removal; health risks, and future stressed that public education aimed at promoting IUD intention to use the IUD. Also, another objective was to adoption should consider the social context within explore level of knowledge of IUD among all women which services are provided to encourage positive com- using a modern family planning (FP) method. munity attitudes, especially in areas where there is Findings show that women’s reactions and perceptions strong resistance or opposition to contraceptive prac- of the IUD was shaped by and associated with prior tices. This will involve working with key opinion leaders knowledge on the device, myths, fears and misinforma- on values clarification and satisfied clients in these com- tion that they had heard about the IUD from their munities to share experiences with IUDs. A female pro- friends despite their full awareness of the importance of vider working at one of Marie Stopes centre however contraceptive use. Two-thirds of IUD users and few past lamented that measures put in place by the organization IUD users were scared to consider the IUD as a FP to increase awareness and knowledge of long acting FP method upon initially hearing of it. To a large extent, in- methods was inadequate. This she further explained that adequate knowledge of the IUD, reinforced by general the activities being implanted to increase awareness and myths surrounding use of modern FP methods accounts knowledge of long acting FP methods are ‘above the line for low uptake of the IUD. Some studies also show that marketing strategies’ which do not necessarily translate misinformation, and lack of correct knowledge results in into uptake of services since there are issues of behav- low uptake of LARC [22]. Women’s perceptions and ioural change and modification that must equally be ad- knowledge are therefore shaped by these myths which dressed to compliment the efforts being made in the further discourage contraceptive use and lead to open area of education and awareness creation at the commu- and incessant negative expressions of contraception. nity level to ensure high uptake. Women’s negative perceptions about the IUD corrob- The need for effective counselling that focuses on the orate with providers responses. Providers stated that the positive aspects of the IUD was recommended to en- fear of how IUD was inserted, misconceptions and fears courage interest and uptake among women. According about the IUD based on myths deterred women from to an IUD provider she indicated that: accepting the IUD as a FP method. Yet, women who wanted to space, limit or stop childbearing had positive “ for counselling to be effective, we need to tell them perceptions of the IUD. Similarly, women who preferred the benefits of IUD, it saves time, it saves your money, the IUD as FP method after being encouraged by pro- it makes you do your house chores. There’s always viders held positive attitudes about it, in contrast to peace at home, family are happy. Economic situation, those who expressed side effects with it. Proper and ef- because now the economy, when you insert IUD, is for fective counselling focusing on the benefits/ advantages long term. It doesn’t prevent you from doing your of the IUD should be provided to women desiring to use normal duties. The time that you waste here to come a long acting reversible, and possibly, non-hormonal and do the 3 months, sometimes you tend to forget. contraception to prevent pregnancies. When you insert IUD, you are at peace. You get time Lack of adequate knowledge may prevent IUD use; to do your real job” (IUD provider). however, when women believe that FP providers are knowledgeable and can be trusted to maintain confiden- On the contrary a provider indicated the relevance of tiality, advice on method use, side effects and potential informing clients about side effects and possible compli- health risks. Women will be more receptive and con- cations of IUDs as well. The provider stated that: vinced to take up the IUD as a first choice FP method. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 15 of 17 FP providers therefore have a major role to play in en- ‘obscure’ FP method; non-hormonal benefits; provider couraging positive attitudes towards using the IUD influence and encouragement; health reasons; protection through counselling. from contraceptive failure; freedom from emotional wor- On the contrary, some findings from the study show ries; ease of use in order to focus on work and school. that because some clients are ignorant about family The side effects of using IUD were reported as heavy planning methods, there are elements of provider biases prolonged bleeding, vaginal discharges, infections, spot- during counselling which leads to some providers either ting or irregular bleeding, and abdominal cramps. These advising clients to use IUD based on their personal ex- are consistent with empirical evidence that IUDS are as- periences or preference for IUD. In some reported in- sociated with irregular bleeding in some women [25]. stances the providers ‘forced’ clients to have an IUD as a Participants reported that continuous experience of post abortion contraception. This observation defeats these side effects for more than four months led to re- the purpose of family planning counselling as it does not moval of the IUD. Findings are supported by providers encourage choice and medical eligibility for IUD. Un- who also attributed women’s removal of the IUD to announced continuous supportive supervision of family mainly side effects. Women’s continuous experiences of planning service providers in their facilities will provide side effects served as a barrier to future intention to a valuable opportunity to identify gaps and provider IUD use. Among these women, some wished that the biases during family planning counselling for further IUD worked for them, but felt that the side effects were provider refresher education and updates on family plan- indications of negative reactions, and the bodily system’s ning counselling and decision making. rejection of the IUD, as well as potential health risks Women’s reasons for using the IUD varied slightly with continued use. among current and ever users. Among current IUD Although none of the women suffering infections from users, preventing unwanted pregnancy emerged as the using the IUD associated it with lack of personal hy- most important motivating factor, whilst the desire for a giene, cross infection from partner infidelity, or poor in- long acting FP was mentioned most often among ever sanitary lavatory conditions as common potential IUD users. Although the ever IUD users would have triggers of infections, there are other known causes of loved to continue using the IUD, unbearable side effects vaginal infections following IUD insertion among of heavy menses and cramps lead to discontinuation. A women which is important for providers to hint clients further probe on this assertion shows that the type of so that post IUD infections are not unnecessarily associ- IUD being referred to is the Cupper T 380 . There were ated with these or the method. Similarly, understanding few reported instance were clients opted for LNG-IUS pre-exposure history of women regarding infections but was not available in the facility. Perhaps, the avail- could enhance pre and post-method counselling. ability of LNG-IUS (hormonal IUD) in facilities would Partners’ disapproval of FP use also contributed to re- have been preferred over Copper-T 380A which might moval of the IUD. Although this revelation is not new in have increased IUD usage in the study area. This sug- our context through anecdotal evidence, it should be gests that among ever IUD users, there is an unmet need useful and practical to informing providers to find ways for LNG-IUS (hormonal IUD) which calls for program- to encourage and educate male partners’ in contracep- ming and contraceptive security. The observation that tion uptake. Few women who had ever used the IUD IUDs have shown no or minimal reported side effects is pointed out that, due to fear of negatively impacting their an opportunity to use such satisfied clients for public marriages decided to remove the IUD clandestinely. Some education on IUDs to ensure continuity and increasing however noted that their partners were not informed patronage since clients will really choose an IUD due to about it, hence their decision to have it removed. In their their understanding on the duration and perceived bene- view, the ‘strings’ heightened their dislike for the IUD, and fits over other methods. to which their partners might notice. Two-thirds of women expressed desire for a long act- Mixed views on perceptions of health risks associated ing method of protection for convenience purposes, ease with using the IUD were reported. Study participants of use, and avoid contraception failure. Post abortion thought having the IUD inserted might cause cancer, ec- women currently using the IUD, including women who topic pregnancy, STIs, and uterine perforation. Although removed it to give birth expressed immense usefulness two-thirds of women thought otherwise, it is important and satisfaction since using it. They considered it to be that women are given appropriate and accurate informa- very effective in serving the purpose they desired with- tion on all health complications that accompany each out side effects. There is evidence demonstrating the ef- modern FP use. They should also be made to understand ficacy, safety, and cost-effectiveness of the IUD in that individual differences, hormonal balance, and spe- pregnancy prevention [23, 24]. Other determinants of cific criteria pertain to the uptake of one modern FP IUD use include: to prevent abortions; preference for an method over the other. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 16 of 17 The women in the study (a sample predisposed to sensitive about the mode of communication. It knowing about FP by having visited a FP clinic before) should be in a language that people can understand knew of at least one modern method. This finding is and relate to, whiles considering the social context consistent with previous findings in Ghana’s Demo- and social exchange systems. graphic and Health Surveys (2008, 2014) which report  Design interventions (for instance, community universal contraceptive knowledge among all women. At interventions) to promote uptake of LARC methods least, all women mentioned three contraception types and enhance existing service provision channels to with the injectables and implants most frequently men- provide accurate information and services on IUD in tioned, followed by pills, condoms, and IUD. Less than order to make it accessible, and available to young one-third of the women interviewed mentioned male women desirous of LARC. Community interventions and female sterilization, and diaphragm. One study re- should be sensitive to the social context and spondent mentioned the IUS as her current contracep- appropriate medium of communication. tive method. Nine (9) out of the total selected women  Sensitize all persons visiting MSI centres on FP were currently not using any contraception. Social and methods and post-abortion contraception through cultural norms governing fertility, in addition to fear of distribution of brochures and FP documentaries on contraceptive side effects, myths, and health risks may video tapes. Documentaries should be comprehen- hinder contraceptive use. Demand creation through sive, and focus on advantages of IUD use, safety, effi- mass education with FP providers needs to be intensified cacy and side effects to increase and sustain positive and promoted among women in reproductive ages. In- attitudes. terventions should also focus on couples counselling to  Ensure the provision of comprehensive sexuality increase positive attitudes towards contraception for education for young girls and boys at senior high both partners. schools to equip them with appropriate information It is also important to mention that from non-IUD on family planning, contraception, and birth control users’ socio-demographic data, there is a high propensity methods as means of regulating fertility, spacing and for these women to increase their fertility since they are reducing births. The resent positive outcome of the within active reproductive ages (20–35) but are not advocacy drive on sexuality education in schools using any contraceptives due to unpleasant past experi- resulting in the inclusion of sexuality education in ences with IUD use. Although they all reported fears schools curriculum in Ghana is timely as this with using IUD again or any contraceptive, it is import- provides a good entry point for this policy ant that FP providers provide effective counselling for implementation in schools for the desired results this group of women on other available and accessible alternatives of contraceptives to meet their FP needs. A key policy implication is task sharing IUD insertion Past IUD users who have switched from IUD to other and removal with mid-level providers in Ghana to en- FP methods are also highly susceptible to becoming sure greater provider availability in all health facilities to pregnant should their contraceptive use become incon- improve uptake. This is a fall out from table1 indicating sistent/ irregular, or in the case of method failure. Only few numbers of FP providers in the study facilities. The one woman out of the previous IUD users is currently researchers believed there would have been higher pro- using a LARC. Amongst the remaining, one-third is try- vider numbers if an IUD task sharing policy is in place ing to become pregnant, while the rest are using a mix and being implemented. of short term and traditional methods due to the un- availability of preferred FP choice of implants (implanon Conclusion NXT). In sum, the contraceptive history patterns of past IUD users are risky and raise concerns over unmet need A number of factors influence the use or discontinu- for implants (implanon NXT) in the FP facilities. ation of IUD in Ghana. Provider capacity building for in-depth client counselling is required to make in- Implications formed decisions at the facility level. Various targeted Results from this study has several programmatic and messages and use of satisfied clients are also needed policy implications for improving uptake of LARC, espe- to dispel IUD related myths and misconceptions at cially IUD for women in all reproductive ages. Programs the community level. A future large scale study is should: also required to investigate if there are any seasonal, socio-economic and demographic variations in FP up- Focus on using social media to debunk myths and take within health facilities in Ghana. This when done misconceptions that people have about LARC, will provide further information to informed national particularly, IUD. Use of social media should be FP programme and policy decisions. Gbagbo and Kayi Contraception and Reproductive Medicine (2018) 3:8 Page 17 of 17 Abbreviations 6. Sanfield A. Popularity disparity: attitudes about the IUD in Europe and the ERC: Ethical review committee; FP: Family planning; GDHS: Ghana United States. Guttmacher Policy Rev. 2007;10:19–24. demographic and health survey; GHS: Ghana health service; IDI: In-depth 7. Black K, Lotke P, Kai J, Buhling N, Zite B. A review of barriers and myths interview; IUD: Intra uterine device; IUS: Intra uterine system; LARC: Long preventing the more widespread use of intrauterine contraception in acting and reversible contraceptive; LNG: Levongesterol nulliparous women. Eur J Contracept Reprod Health Care. 2012;17:340–50. 8. Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol. 2002; Acknowledgments 99:275–80. The authors are grateful to all the facilities and respondents that participated 9. Postlethwaite D, Trussell J, Zoolakis A, Shabear R, Petitti D. A comparison of in the study. Many thanks also to Marie Stopes International Ghana for the contraceptive procurement pre- and post- benefit change. Contraception. logistical support during data collection. 2007;76:360–5. 10. Goodman S, Hendlish SK, Benedict C, Reeves MF, Pera-Floyd M, Foster- Funding Rosales A. Increasing intrauterine contraception use by reducing barriers to This study was fully funded by the authors with some support from Marie post-abortal and interval insertion. Contraception. 2008;78:136–42. Stopes Ghana. 11. Middleton AJ, Naish J, Singer N. General practitioners’ views on the use of the levonorgestrel-releasing intrauterine system in young, nulligravid Availability of data and materials women, in London, UK. Eur J Contracept Reprod Health Care. The raw data collected is available upon reasonable request. 2011;16:311–8. 12. Allen RH, Goldberg AB, Grimes DA. Expanding access to intrauterine Authors’ contributions contraception. Am J Obstet Gynecol. 2009;4(56):1–5. GFY conceptualized the study, provided guidance to the field work and the 13. Lyus R, Lohr P, Prager S. Board of the Society of family planning. Use of the report. EAK supervised the field work, analyzed the data and drafted the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous initial report. Both authors have all approved the final submission. women. Contraception. 2010;81:367–71. 14. Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating Ethics approval and consent to participate evidence to practice: the provision of intrauterine contraception. Obstet This study received ethical approval from the Ghana Health Service (GHS) Gynecol. 2008;111:1359–69. Ethical Review Committee (ERC). Permission was also sought from the 15. Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine various facilities and respondents used in this study. To protect the devices and the risk of tubal infertility among nulligravid women. N Engl J confidentiality of responses and enhance the comfort of respondents, the Med. 2001;345:561–7. interviews were conducted in private places chosen by the respondents. The 16. Allen RH, Bartz D, Grimes DA, et al. Interventions for pain with intrauterine In-depth Interview sessions averagely lasted for 40 min. device insertion. Cochrane Database Syst Rev. 2009;3:CD007373. Written informed consent was obtained from all interviewees for their 17. Mishell D, Sulak P. The IUD: dispelling the myths and assessing the participation and for the audio-recording of the interviews. To obtain this, potential. Dialogues Contraception. 1997;5(2):1–4. participants were informed of the objectives of the study and its intended 18. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. purpose in the language they understood. Those who could read and write Ghana demographic and health survey 2014. Accra: GSS, GHS, and ICF signed the consent form whilst those who could not read or write gave Macro; 2014. verbal consent after the explanations. 19. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. Ghana demographic and health survey (1993, 1998, 2003, 2008, 2014). Consent for publication Accra: GSS, GHS, and ICF Macro. Although there was no individual ‘Consent for publication’ since the study 20. Schwandt HM, Creanga AA, Adanu RM, Danso KA, Agbenyega T, Hindin MJ. did not contain any personally identifiable data, all respondents and facilities Pathways to unsafe abortion in Ghana: the role of male partners, women contacted during the study agreed and provided verbal consent for the and health care providers. Contraception. 2013;88(4):509–17. study to publish anonymously. 21. Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception. 2008;78: Competing interests 197–200. The authors declare that they have no competing interests. 22. Wickstrom J, Jacobstein R. Contraceptive security: incomplete without long- acting and permanent methods of family planning. Stud Fam Plan. 2011;42: 291–8. Publisher’sNote 23. Weston MR, Martins SL, Neustadt AB, Gilliam ML. Factors influencing uptake Springer Nature remains neutral with regard to jurisdictional claims in of intrauterine devices among postpartum adolescents: a qualitative study. published maps and institutional affiliations. Am J Obstet Gynecol. 2012;206:40.e1–7. 24. Mohamed AM, Rachael SK, Cleland JN, Thoai D, Shah IH. Long-term Author details contraceptive protection, discontinuation and switching behaviour: 1 2 University of Education Winneba, Box 25, Winneba, Ghana. Regional intrauterine device (IUD) use dynamics in 14 developing countries. London: Institute for Population Studies, University of Ghana, Box LG 96, Accra, Ghana. World Health Organization and Marie Stopes International; 2011. 25. Hatcher R, Trussell J, Nelson A, Cates W, Stewart F. Contraception Received: 31 January 2018 Accepted: 6 April 2018 technology. 19th ed. New York: Ardent Media; 2008. References 1. World Health Organization. Medical eligibility criteria for contraceptive use. 4th ed. Geneva: World Health Organization; 2009. 2. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79(1):5–14. 3. Chiou CF, Trussell J, Reyes E, et al. Economic analysis of contraceptives for women. Contraception. 2003;68:3–10. 4. Grimes D, Jones KP, Knutson CC, Wysocki S. Use of intrauterine contraception in the United States: Association of Reproductive Health Professionals. Washington, DC: Elsevier Inc.; 2004. 5. Yoost J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Patient Preference Adherence. 2014;8:947–57.

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Contraception and Reproductive MedicineSpringer Journals

Published: Jun 6, 2018

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