Factors Associated with Early Discontinuation of Contraceptive Implants Among Women of Reproductive Age in Wakiso District, a Facility Based Cross-Sectional Study

FACTORS ASSOCIATED WITH EARLY DISCONTINUATION OF CONTRACEPTIVE IMPLANTS AMONG WOMEN OF REPRODUCTIVE AGE IN WAKISO DISTRICT, A FACILITY BASED CROSS-SECTIONAL STUDY

DDUNGU UMARU

MB.Ch.B (Mak)

A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTERS OF PUBLIC HEALTH OF MAKERERE UNIVERSITY

NOVEMBER 2019 APPROVAL

DECLARATION

ACKNOWLEDGEMENT

I extend my gratitude and sincere appreciation to all those that supported me in ensuring that this study is a success. My sincere thanks go to my supervisors Dr. Simon Peter Kibira and Mr. Ssenyonga for availing adequate time for engagements and support during the period of the study. I also thank the district health team especially health facility in-charges of Wakiso district for support and coordination during data collection in their respective facilities. Special recognition goes to Dr. Sseviri Mathias, Betty Nabuuma and Namulondo Edith sharing information about the district during literature review.

Special thanks go to my research assistants who were committed and provided valuable time in data collection. They included Nabagesera Prever, Nakiyimba Viola, Tindimweebwa Ruth, Nakalembe Margaret Bateera Ann and all assistants from private health facilities who participated in data collection. On a similar note, I also thank all respondents who participated in the study for their time and efforts to respond to questions as honestly as possible.

Lastly, appreciate the support from my work manager Dr. Kirima Andrew who provided a favorable studying environment for me during the period of this project

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TABLE OF CONTENTS APPROVAL ...... i DECLARATION ...... ii ACKNOWLEDGEMENT ...... iii LIST OF TABLES AND FIGURES ...... vii ACRONYMS AND ABBREVIATIONS ...... viii DEFINITIONS ...... 9 ABSTRACT ...... x 1.0 INTRODUCTION AND BACKGROUND ...... 1 1.1 Introduction ...... 1 1.2 Background ...... 2 2.0 LITERATURE REVIEW ...... 5 2.1 Early Discontinuation of Contraceptive Implants ...... 5 2.2 Proportion of Early Discontinuation of implants...... 5 2.3 Determinants of Early Discontinuation of Implants ...... 6 2.4 Factors that influence the overall duration of use of implants...... 8 3.0 STATEMENT OF THE PROBLEM, JUSTIFICATION, CONCEPTUAL FRAMEWORK AND RESEARCH QUESTIONS ...... 9 3.1 Statement of the Problem ...... 9 3.2 Justification of the Study ...... 10 3.3 Conceptual Framework ...... 11 3.4 Research Questions ...... 12 4.0 STUDY OBJECTIVES ...... 13 4.1 Aim ...... 13 4.2 General Objective ...... 13 4.3 Specific Objectives ...... 13 5.0 METHODOLOGY ...... 14 5.1 Study Area ...... 14 5.2 Study Population ...... 14 5.3 Study Design ...... 15 5.4 Sample Size ...... 15

5.5 Sampling Procedure ...... 15 5.6 Study Variables ...... 15 5.6.1 Dependent variables...... 15 5.6.2 Independent variables ...... 16 5.7 Data Collection ...... 17 5.7.1 Training of Research Assistants ...... 17 5.7.2 Tools ...... 17 5.7.3 Pre-testing ...... 17 5.7.4 Field editing of data ...... 17 5.7.5 Missing data ...... 17 5.8 Data Management and Analysis ...... 18 5.8.1 Data Management...... 18 5.8.2 Data Analysis ...... 18 5.9 Ethical Considerations ...... 18 6.0 RESULTS ...... 20 6.1 Characteristics of the study population ...... 20 6.2 Proportion of Early discontinuation ...... 22 6.3 Determinants of early discontinuation ...... 23 6.4 Factors that influence overall duration of use of implants...... 27 7.0 DISCUSSION ...... 32 8.0 CONCLUSIONS ...... 38 9.0 RECOMMENDATIONS ...... 39 9.1 Recommendations for family planning programs ...... 39 9.2 Recommendations for further research ...... 39 REFERENCES ...... 40 APPENDICES ...... 44 1. Number of Respondents per Health Facility ...... 44 2. Consent Forms for Respondents ...... 46 2.1 Consent form in English ...... 46 2.2 Consent form in Luganda ...... 48 3. Questionnaire ...... 50

4. List of codes and description of categorical variables...... 54

LIST OF TABLES AND FIGURES

Table 1: Dependent Variables for Factors Associated with Early Discontinuation of Implants among Women of Reproductive Age 15 – 49 years in Wakiso District ...... 16

Table 2a: Other Client-based Characteristics for Women of Reproductive Age 15 – 49 Years who Discontinued Implants in Wakiso District during the Study ...... 22

Table 2b: Other Provider-related Characteristics for Women of Reproductive Age 15 – 49 Years who Discontinued Implants in Wakiso District during the Study ...... 23

Table 3: Proportion of Women of Reproductive Age 15 – 49 years who Discontinued Implants Early in Wakiso District ...... 24

Table 4a: Bivariate Analysis for Client-based Determinants of Early Discontinuation of Implants among Women of Reproductive Age in Wakiso District ...... 25

Table 4b: Bivariate Analysis for Provider-related Determinants of Early Discontinuation of Implants among Women of Reproductive Age in Wakiso District ...... 26

Table 5: Multivariate Analysis for Determinants of Early Discontinuation of Implants among Women of Reproductive Age 15 – 49 years in Wakiso District ...... 28

Table 6a: Bivariate Analysis for Client-based Factors That Influence Overall Duration of Use of Implants among Women of Reproductive Age in Wakiso District...... 30

Table 6b: Bivariate Analysis for Provider-related Factors That Influence Overall Duration of Use of Implants among Women of Reproductive Age in Wakiso District...... 32

Table 7a: Multivariate Analysis for Client-based Factors That Influence Duration of Use of Implants among Women of Reproductive Age in Wakiso District ...... 34

Table 7b: Multivariate Analysis for Provider-based Factors That Influence Duration of Use of Implants among Women of Reproductive Age in Wakiso District ...... 35

Figure 1: A conceptual Framework for Factors Associated with Implant Discontinuation among Women of Reproductive Age 15-45 years in Wakiso District ...... 11

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ACRONYMS AND ABBREVIATIONS

AOR Adjusted Odds Ratio

CCP Center for Communication Programs

CHS College of Health Sciences

CI Confidence Interval

CYP Couple years of protection

DESA United Nations Department of Economic and Social Affairs

FP Family Planning

FY Financial Year

HC Health Center

IUD Intrauterine Device

Mak Makerere University

MakSPH Makerere University School of Public Health

MOH Ministry of Health

NGO Non-government Organization

PR Prevalence Ratio

PFP Private for Profit

PMA Performance Monitoring and Accountability

PNFP Private Not for Profit

RHR Department of Reproductive Health and Research

UBOS Uganda Bureau of Statistics

UNFPA United Nations Program for Family Planning

WHO World Health Organization

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DEFINITIONS OF TERMS

Contraceptive implant discontinuation: This is the surgical removal of an implant meant for contraception from a woman who has been using the method irrespective of whether or not she is switching to another method.

Early discontinuation of contraceptive implants: This is the surgical removal of viable implant from a woman before 18 months since insertion of the same implant.

Expiry of an implant: This is complete usage of the implant up to the end of its designed duration of 3 years for Implanon or 5 years for Jadelle.

Duration of use: This is the time interval for which a woman has retained the contraceptive implant from the date of insertion as recorded on the client’s card or any other means of verification to the date it is discontinued.

Reproductive age: Age of a woman ranging from 15 to 49 years.

Switching: Re-using another method or replacing a similar method of contraception within a month after discontinuation of the implant.

ABSTRACT

Introduction: Over the recent years, there has been a gradual increment in the number of women using contraceptive implants in Uganda. In Wakiso district, the number of implant insertions increased from 6,344 in the FY 2015/16 to 14,389 in FY 2017/2018. However, there was also an increasing trend in the number of implants discontinued by women in the district. Studies on contraceptive discontinuation did not focus on implants and the critical interval of 18 months from the time of insertion. This study intended to contribute to the body of knowledge needed to improve retention of contraceptive implants among users. Therefore, the study estimated the proportion of women who discontinue implants early, established factors associated with early discontinuation of implants and determined factors that influence the duration of use of implants among women 15 – 49 years in Wakiso district.

Methods: This is a facility-based cross-sectional study involving 397 women of reproductive age 15 – 49 years, who had discontinued contraceptive implants from 42 health facilities in Wakiso district. Sampling was by stratified technique and I analyzed data with STATA 14. I used modified Poisson and quantile regression analysis techniques using a significance level (α) of 0.05 for test statistics.

Results: The proportion of early implant discontinuation was 31%. Early discontinuation was determined by; side effects [adjusted PR = 1.20; 95% CI = 1.05 – 1.37] and incurring costs on retention of implants [adjusted PR = 1.15; CI = 1.04 – 1.28]. Overall duration of use of implants was influenced by discontinuation due to side effects [β = -9.63; CI = -16.6 - -2.63], insertions during breastfeeding [β = -5.00; CI = -8.95 - -1.05], incurring costs on retention of an implant [β = -7.38; CI = -13.3 - -1.47] and not counseling a woman [β = -6.47; CI = -12.1 - -0.86].

Conclusion: The proportion of early discontinuation was considerably high at 31 percent. Addressing side effects and costs on retention would help prevent early discontinuation. In addition, ensuring counselling before implant insertions would improve retention of implants.

Recommendations: A proportion of 19 percent should be set as a target for early discontinuation. FP programs should focus on managing side effects, mitigating costs on retention and counselling to improve retention of implants.

CHAPTER ONE

1.0 INTRODUCTION AND BACKGROUND

1.1 Introduction

Contraceptive implants are small rods of the size of a matchstick that release a synthetic hormone similar to the natural hormone progesterone when inserted into a woman’s body to prevent pregnancy (WHO/RHR and Johns Hopkins Bloomberg School of Public Health/CCP, Knowledge for Health Project, 2018). Over the recent years, there had been a global improvement in the uptake of contraceptive implants from 0.2% in 1994 to 0.7% in 2015 (United Nations DESA, Population Division, 2015), partly due to a reduction in prices of contraceptive implants and an increment in donor investment through the Implant Access Program. In Uganda, the uptake of contraceptive implants improved from nearly zero in 1994 up to 3.5% by 2015 (United Nations DESA, Population Division, 2015) moving up to 6.3% in 2016. This had contributed to an improvement in the modern contraceptive prevalence rate (mCPR) from 11.3% in 1994 to 35% (Uganda Bureau of Statistics and ICF, 2017).

To benefit from the full advantages of contraceptive implants, women need to avoid early discontinuation of the implants. Whereas WHO recommended birth-to-pregnancy interval of at least 24 months, a decision that was reached with compromise, all researchers unanimously agreed that birth–to–pregnancy intervals of less than 18 months should be avoided in order to avoid very high risks of poor maternal, perinatal, infant and neonatal outcomes (WHO, 2007). For uniformity therefore, early discontinuation of implants can be considered when a woman stops using an implant before 18 months since insertion of the same implant irrespective of the period since last delivery or termination of pregnancy or whether or not she has ever had a pregnancy.

Early discontinuation of contraceptives may result in short birth-to-pregnancy intervals, which in turn is associated with maternal mortality and morbidities such as premature rupturing of membranes, anemia, puerperal endometritis, increased risk of uterine rupture and pre-eclampsia (WHO, 2007). Short birth intervals are also associated with a number of undesirable perinatal

outcomes such as prematurity, fetal death, low birth weight, small for gestation age babies and neonatal death.

In Wakiso district, there was an increasing trend in the number of implants discontinued by women each year with unknown reasons for this trend (Wakiso District Health Office, 2016, 2017 & 2018). This study assessed factors associated with early discontinuation of implants among women of reproductive age in Wakiso district in order to inform strategies to improve retention of implants among users.

1.2 Background

Over the recent years, there had been a gradual increment in the number of women who use contraceptive implants. Globally, the contraceptive prevalence for implants tripled from 0.2% in 1994 to 0.7% in 2015. In sub-Saharan Africa, it increased from nearly zero in 1994 to 2.6% in 2015 (United Nations DESA, Population Division, 2015). Similar trends have been noted in Uganda. In financial year (FY) 2015/2016, 210,272 women used implants (MOH- Uganda, 2016) and this number increased to 269,783 in FY 2016/2017 (MOH, Uganda, 2017). This had led to an increment in the share of implants on the contraceptive method-mix among married and unmarried women from 13.2% in 2016 to 17.5% in 2018 (MakSPH; Bill & Melinda Gates Institute for Population and Reproductive Health, 2018).

In Wakiso district, a similar trend had been noted where 6,341 women used implants in the FY 2015/2016, 8519 women in 2016/17 and 14,380 women in FY 2017/18. However, there was also an increasing trend in the number of implants discontinued within the district. In the FY 2015/16, there were 1,395 implant discontinuations reported (Wakiso District Health Office, 2016). The number of implant discontinuations increased to 2,215 in FY 2016/17 (Wakiso District Health Office, 2017) and 3,595 in FY 2017/18 (Wakiso District Health Office, 2018). Wakiso district also had a low performance in family planning indicators as deduced from the regional performance with a modern contraceptive prevalence rate of 40.4% (UBOS, 2017), which was below the national target of 50% by 2040 and an unmet need for family planning methods of 20.5% against a national target of 10%.

A high level of contraceptive discontinuation can negatively affect the impact of family planning programs. Between 4 to 28% of the total fertility is accounted for by births resulting from contraceptive discontinuation (Blanc, et al., 2002). Blanc and others determined that the

total fertility rate could be reduced by 20% to 48% in absence of births occurring following contraceptive discontinuation for any reason other than the intention to become pregnant. Such a reduction in the total fertility rate could be very useful in controlling the population growth in Wakiso, which was the most populated district in Uganda with an estimated population of nearly 2 million people (UBOS, 2017). Contraceptive discontinuation is also associated with higher rates of unwanted and mistimed pregnancies and their consequences such as stillbirths and abortions (Anrudh & Winfrey, 2017 and Ali, et al., 2012). Ali et al determined that 5 – 20% the unwanted pregnancies that resulted from contraceptive discontinuation due to method failure alone resulted in miscarriages, stillbirths or abortions in most countries.

Furthermore, the contribution estimated by programs that use Couple Years of Protection (CYP) as a performance measure is inflated when implants are discontinued before their estimated durations of use. Stover and others ( 2000) described this concept as wastage and misreporting, two recognized variables affecting use of CYP as a performance measure in programs providing family planning services.

Studies on contraceptive use or discontinuation had not focused on implants but the general short-term methods including pills, condoms and injectable (Ali, et. al; Mumah, et al., 2015). Others included only intrauterine devices as contraceptives (Grunloh et. al, 2013; Micaela, et al., 2013). Tadesse, et al. (2017) focused on implants, but they defined discontinuation at 3 years after insertion, which limits the duration of use under study to that time interval.

Grunloh, et al. (2013) and Asaye, et al. (2018) had considered early discontinuation at different cut-off durations. At a cut-off duration of 6 months for early discontinuation, Grunloh et. al determined a low implant discontinuation rate of 7% and not being marrried was the only factor associated with early discontinuation at that cut off duration. Asaye et.al determined a discontinuation rate of 65% at cut-off of 2.5 years for early discontinuation of implants where having no children, not being counseled for possible side effects, having no appointment for follow-up and having developing side effects were associated with early discontinuation.

With the increasing use of contraceptive implants in Wakiso district and Uganda, an improvement in the method mix in favor of implants and a critical interval of 18 months for birth-to-pregnancy, it was imperative to understand factors associated with implant discontinuation if the district was to benefit from the trends on implant use. This study therefore

estimated the magnitude of early discontinuation of implants, established determinants of early discontinuation and determined factors that influenced the overall duration of use of implants, among women of reproductive age in Wakiso district.

CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Early Discontinuation of Contraceptive Implants

There was no standard definition for early discontinuation of contraceptive methods. A few studies that had studied the concepts of early discontinuation had had varying cut-off points in form of months for which contraception was being used before discontinuation. In the study to measure discontinuation within 6 months among users of the levo-norgestrel, intrauterine system, copper intrauterine device (IUD), and etonogestrel implant, Grunloh et al (2013) used 6 months as the cutt-off point for early discontinuation. In a different study meant to assess early Implanon discontinuation and associated factors among Implanon user women in Debre Tabor town, Asaye, et al. (2018) used a cut-off period of 2.5 years to define early discontinuation.

In her report on the technical consultation of birth spacing, WHO recommended a period of at least 24 months as the birth-to-pregnancy interval after a compromise on the different opinions of consultants who analyzed the consequences and risks in terms of maternal, perinatal and neonatal outcomes at shorter and longer intervals. Despite several view on the appropriate birth- to-pregnancy intervals, all consultants unanimously agreed that births below 18 months should be avoided. Therefore, 18 months became a critical birth-to-pregnancy interval and it formed the basis for 18 months as a cut-off for our operational defination of early implant discontinuation.

2.2 Proportion of Early Discontinuation of implants

On review of recent and old literature, no studies had been done to define the magnitude of early discontinuation of implants before the critical interval of 18 months after insertion. However, at a cut-off of 2.5 years for early discontinuation, Mengstu, et al. (2018) estimated the proportion of early discontinuation at 65%. At a cut-off interval of 6 month for early discontinuation, Kalmuss, et al., (1996) estimated 7.6% and Grunloh et al. (2013) estimated 7% of women who discontinue implant early. The two proportions were calculated out of all women who were using implants rather than only those who discontinued implant.

2.3 Determinants of Early Discontinuation of Implants

In the context of this study, early discontinuation is when a woman stops using a contraceptive implant before 18 months since insertion of the same implant. There was no scientific literature on determinants of implant discontinuation before 18 months after insertion. The closest literature included studies where early discontinuation was considered at a very low cut-off interval of 6 months (Grunloh et al., 2013) and at a very high cut-off interval of 2.5 years (Birhane, et al., 2015). Other studies did not address the concept of early discontinuation at all, but established significant determinants in general (Melese Siyoum, 2017; Tadesse, et al., 2017; Zemenu, et al., 2017). Furthermore, other studies did not only miss out the concept of early discontinuation but they were more general in terms of contraceptives studied in that they studied discontinuation of all contraceptions combined (Atnafe, et al., 2016; Blanc, et al., 2002) and some excluded implants (Ali, et al., 2012).

Birhane et al. (2015) studied on type of implant called Implanon and they considered a high cut- off period of 2.5 years for a definition of early discontinuation of Implanon. Limitations of their study include a bias towards one type of implant and high cut-off period for the operational definition. Nevertheless, their study determined health concerns, wanting more children, side effects, husband opposition, inconvenience to use, religious opposition and contraceptive failure were the reasons for early discontinuation of Implanon defined as Implanon removal before 2.5 years. In the same study, lack of an appointment for follow up, lack of satisfaction with weight gain and presence of side effects were associated with early discontinuation of Implanon.

In a study by Atnafe, et al. (2016), age group 25 years and above, marital status, number of children, future marital status and source of family planning information were independently associated with switching of long acting method among revisit clients in public health facilities of Dire Dawa city. On adjusting the model, multiple logistic regression analysis revealed that married women were 2.4 times less likely to switch compared to unmarried women (AOR = 2.41, CI: 1.01 – 5.74)). Women who had 2-4 children were 3 times less likely to switch compared to those had one child (AOR = 3.00, CI: 1.59 – 5.67) as well as women who had more than 5 children (AOR = 2.07). Women who did not want any more children were 5.1 times less likely to switch compared to women who wanted to have more children (AOR = 5.11, CI: 1.25 – 24.8). In this study however, findings were not discriminative of the type of

contraceptive method studied. Both implants and IUD were studied and there was no study of the concept of early discontinuation.

Melese Siyoum (2017), established determinants for discontinuation of Implanon. Tertiary education/college and above (p = .016) as compared to no formal education, no history of pregnancy (p = .001), not having got counselling services (p = .044), not being satisfied with the method given (p = .001) and prior experience of side effects were associated with discontinuation of the implant. Independently, husband and others as main deciders of the method as opposed to the woman herself were associated with discontinuation of the method. On the other hand, age groups between 25 and 35 years (OR = 0.17 and 0.35) compared to the age group below 21 years, Primary (OR = .082) and Secondary school (OR = .095), effectiveness and no side effects as reasons for choosing the method were associated with continued use of the method. This study however, looked at Implanon only and without a concept of early discontinuation and therefore, it had a different focus compared to our planned study that encompassed all implants and a concept of early discontinuation.

Relatedly, Tadesse, et al. (2017) identified determinants for discontinuation of contraceptive implants among women in Diguna Fango district in southern Ethiopia. Residence in rural area, age less than 20 years, having no formal education, having not more than 4 children, history of abortion and presence of side effects were individually associated with discontinuation of implants before 3 years. On the other hand, follow up appointment given, not being satisfied with the services, another person (husband or health provider) being the decision maker to use implant and providing counselling were individually associated with retention of the implant to 3 years. On adjusting for confounding, multiple logistical regression revealed that the same factors contributed to the outcome of Implanon discontinuation other than decision maker to use Implanon, side effects and service satisfaction. However, like Birhane et al (2015), this study assessed implant discontinuation at a very high cut-off interval of 3 years.

In summary, available studies on determinants of early discontinuation use very low or very high cut-off time intervals rather than the critical interval of 18 months to define early discontinuation or they do not have a focus on the type of contraceptive. This study will focus on all implants with a cut-off interval of 18 months for early discontinuation.

2.4 Factors that influence the overall duration of use of implants.

Analyses of several studies on use of contraceptive implants revealed marked variation in the duration of use of implants depending on the area of study (Ali, et al., 2012; Atnafe, et al., 2016; Melese Siyoum, 2017; Power, et al., 2007). A number of factors in turn influenced the duration of use. Most studies assessed factors that influence contraceptives use in general mixing short- term methods such as contraceptive pills and injectable (Ali, et al., 2012; Mumah, et al., 2015)(as well as intrauterine devices (Grunloh, et al., 2013; Micaela, et al., 2013). Short-term methods intrinsically protect a woman against unwanted pregnancy for a short duration and they are associated with higher risks of method failure (WHO/RHR and Johns Hopkins Bloomberg School of Public Health/CCP, Knowledge for Health Project, 2018) while intrauterine devices have a different side effect profile compared to implants.

Furthermore, Tadesse and otehrs (2017) established the determinants of discontinuation of Implanon, one of the contraceptive implants used by women, from which factors that influence duration of use can be deduced. Age less than 20 years, no formal education, more than 4 children and history abortion, side effects and residence in rural area were determinants. Other determinants were being satisfied with the service, giving follow up appointment and decision being made by another person. However, this study addressed discontinuation as a categorical event that occurs or not after a specified time interval. Factors that influence the duration of use before 3 years in the study may be considered as significant or non-significant based on odds ratios when the reverse is true. Therefore, the identified factors in the studies were limited to the time interval used to define discontinuation in the study and they could not be inferred to any period after that.

In summary, previous studies lacked focus on the type of contraceptive under study as well as being biased and restrictive on duration of use of contraceptives for only a specified period as defined in the respective studies. This study therefore, focused on implants (Implanon and Jadelle) and it modelled factors that influenced use of implants with the overall duration of use as a continuous variable to eliminate the above pitfalls.

CHAPTER THREE

3.0 STATEMENT OF THE PROBLEM, JUSTIFICATION, CONCEPTUAL FRAMEWORK AND RESEARCH QUESTIONS

3.1 Statement of the Problem

There is an increasing trend of discontinuation of contraceptive implants by women in Wakiso district. In the financial year (FY) 2015/16, there were 1,395 implant removals reported (Wakiso District Health Office, 2016). The number of implant removals increased to 2,215 in FY 2016/17 (Wakiso District Health Office, 2017) and 3,595 in FY 2017/18 (Wakiso District Health Office, 2018) leading to implant removal- to-insertion ratios of 0.22, 0.26 and 0.25 in the respective financial years.

Contraceptive discontinuation is associated with a high un-met need for contraception that reduces the impact of family planning programs (Jain, et al., 2013). It is also associated with a high number of unintended pregnancies and their consequences such as stillbirths, miscarriages and abortions (Jain & Winfrey, 2017; Ali, et al., 2012). Short birth-to-pregnancy intervals of less than 18 months (early discontinuation) are associated with maternal mortality and morbidities such as premature rupturing of membranes, anemia, puerperal endometritis, increased risk of uterine rupture and pre-eclampsia (WHO 2007).

Literature on factors associated with early discontinuation of contraceptives is scanty and not specific to implants. Previous studies lacked focus on the type of contraceptive under study and they focused on duration of use of contraceptives for only a specified period (Ali, et al., 2012; Castle & Askew, 2015; Mumah, et al., 2015; Grunloh, et al., 2013; Micaela, et al., 2013). In these studies, early discontinuation was considered at low (Grunloh et al., 2013) or high (Asaye, et al., 2018; Birhane, et al., 2015) cut-off intervals compared to the critical interval of 18 months.

This study sought to determine the proportion of women who discontinue implants early and establish factors associated with early discontinuation. It also determined factors that influenced the overall duration of use of implants among women of reproductive age 15 – 49 years who had discontinued in Wakiso district.

3.2 Justification of the Study

This study estimated the burden of early discontinuation of contraceptive implants and proposed a target proportion, which can be used for monitoring and evaluation of early discontinuation of implants in family planning programs.

This study established determinants of early discontinuation as key areas of focus in ensuring retention of implants and preventing short birth-to-pregnancy intervals. Prevention of early discontinuation of implant would improve maternal, perinatal and neonatal outcomes of pregnancies carried by women who use contraceptives, with an aim achieving sustainable development goal 3.

The study also established additional factors, which can be a focus to improve retention of implants by women. Improving retention of implants prevents unwanted pregnancies with a resultant reduction in total fertility, as well as reducing unmet need for contraception.

3.3 Conceptual Framework

Implant insertion Duration of use (0 – 60 months) Implant discontinuation Unknown proportion

Early discontinuation (before 18 months)

Religion Place of Age insertion Cost of transport

Parity

Type of Marital implant

basedfactors status

basedfactors

- Client Education Cost of

Level insertion Provider

Prior use Knowledge of Cost on of implant side effects retention

Figure 1: A conceptual Framework for Factors Associated with Implant Discontinuation among Women of Reproductive Age 15-45 years in Wakiso District

Description of the conceptual framework

After an implant insertion, a woman uses the contraceptive method for varying duration ranging from zero upto 60 months. However, an unknown proportion of women discontinue implants before 18 month, defined as early discontinuation, due to possible client-based and provider- related factors. The rest of women discontinue implants at 18 or more months with several factors influencing the overall duration of use of the implant. Client-based factors include age, parity, education level, religion, parity and prior use of implants. Provider-related factors include place of insertion, cost of implant, cost of transport, cost on retention, place of insertion and knowledge on side effects.

Age is apossible determinant of early discontinuation as well as a factor that influences overall duration of use of implants. However, it can also be a determinant of parity, education level, marital status and prior use of implants.

Education level can be a determinat of early discontinuation as well as a factor that influences overalll duration of use. howvwer, it can also be a determinant of parity, cost of insertion and place of insertion.

Place of insertion is a possible determinant of early discontinuation and a possible factor that influences overall duration of use of implants. On the otherhand, it also infuences cost of transport, type of implant, cost on retention and prior use of implants.

3.4 Research Questions

1. What is the proportion of early implant discontinuation among women of reproductive age 15 – 19 years who discontinue implants in Wakiso district? 2. What are the determinants of early discontinuation of implants among women of reproductive age 15 – 49 years who discontinue implants in Wakiso district? 3. What factors influence the overall duration of use of implants among women of reproductive age 15 – 49 years who discontinue implants in Wakiso district?

CHAPTER FOUR

4.0 STUDY OBJECTIVES

4.1 Aim

The study aimed at contributing to the body of knowledge needed to improve retention of contraceptive implants among users, which would eventually result in an improvement in the contraceptive prevalence rate, reduction in unmet need for family planning and attainment of FP2020 and Uganda national vision of 2040.

4.2 General Objective

To assess factors associated with discontinuation of implants among women of reproductive age (15 – 49 years) in Wakiso district in order to inform strategies for improving retention of implants with an ultimate goal of increasing contraceptive prevalence; reducing total fertility rate; and reducing maternal and neonatal morbidity and mortality.

4.3 Specific Objectives

1. To estimate the proportion of women of reproductive age 15 – 49 years in Wakiso district who discontinued implants early among those who discontinued implants. 2. To establish the determinants of early discontinuation of contraceptive implants among women of reproductive age 15 – 49 years who discontinued implants in Wakiso district. 3. To determine factors that influenced overall duration of use of implants among women of reproductive age 15 – 49 years who discontinued implants in Wakiso district.

CHAPTER FIVE

5.0 METHODOLOGY

5.1 Study Area

The study was conducted in Wakiso district, which lies in the south central region of Uganda and located 00 29N, 32 29E and it had an estimated population of 2,319,500 people. The district has seven health sub-districts, a total of 104 government-supported health facilities of which 67 are purely government-aided and the remaining 37 are private not for profit (PNFP). It also has a number of private for profit health facilities that support the health system. About half of the district’s population is within a kilometer reach of a health facility. Most of the health facilities are able to provide family planning services with direct support from the central government as well as support from implementing partners in health such as Marie Stopes Uganda, Reproductive Health Uganda and Population Services International. The district has an estimated population of 468,534 women in reproductive age group of 15 – 49 years. It lies in a region with contraceptive prevalence rate of 40.4%. Wakiso shares on the national contraceptive prevalence for implants of 17.5 percent (MakSPH; Bill & Melinda Gates Institute for Population and Reproductive Health, 2018). It has an unmet need for family planning of 20.5% and 60.2% of the demand for family planning is satisfied. In the district, 33126 women were expected to be using contraceptive implants. There were 52 government aided facilities, 18 private not for profit (PNFP) or faith-based facilities and 103 purely private facilities, which were reporting data at the district. Only 42 out of 173 health facilities removed an average of at least two implant per month in the FY 2017/2018 of which 21 were in government aided, four were in are PNFP and 17 were in PFP health facilities.

5.2 Study Population

The study was composed of women of reproductive age of 15 – 49 years who had discontinued implants from government-aided, PNFP and PFP health facilities in Wakiso district.

Eligibility criteria

For inclusion in the study,

- A facility from which a woman was selected must have had an average of at least two women discontinue an implant per month in the FY 2017/18 in order to increase the chances of finding a respondent in the shortest period of three months meant for the study.

- For a respondent to be included in the study there must have been a visible record of the date of insertion of the contraceptive implant, either as a client card or captured and retrievable from the facility/supporting partner’s records.

5.3 Study Design

A facility-based cross-sectional study was conducted among women of reproductive age 15 - 49 years who had discontinued implants in health facilities of Wakiso district. Data were collected over two and half months from 23rd –March to 10th - June 2019. Every woman was interviewed on the same day she discontinued the implant and the date on which she inserted the implant was recorded from her client card that had been given to her after insertion. Being a facility- based study allowed accurate capturing of dates of removal of the implants and minimized recall bias. The study estimated duration of use of contraceptive implants as well as the proportion and determinants of early discontinuation of implants in Wakiso district.

5.4 Sample Size

The sample size was determined by using a desired precision d = 0.05, an arbitrary estimated prevalence P of 0.5 for the prevalence of early discontinuation in Wakiso district, a confidence level of 95% and z- statistic for the level of confidence Z = 1.96. Using Leslie Kish (1965) formula for calculating the sample size in surveys and a response rate of 97% in women (Uganda Bureau of Statistics and ICF, 2017), a sample size of 397 respondents was used in the study (initial size n = 385 and non-responders = 12)

5.5 Sampling Procedure

I used stratified sampling technique for the study. I stratified health facilities by ownership into government-aid facilities (21 health facilities), PFP (17 health facilities) and PNFP facilities (4 health facilities) and I allocated respondents to each strata proportionately basing on the proportion implant removal from each ownership in FY 2017/18. There were 233 respondents allocated to government-aided health facilities, 148 respondents in PFP facilities and 16 respondents in PNFP facilities. I again stratified each ownership into strata equivalent to the

number of health facilities in each ownership. Therefore, there were 21 strata in government- aided ownership, 17 strata in PFP ownership and 4 strata in PNFP ownership. Respondents were allocated proportionately in each strata based on the proportion of implant removal reported by each health facilities in FY 2017/18. The number of respondents allocated to each strata/health facility is indicated in appendix 1. In each strata (health facility), a woman who had discontinued an implant at a health facility was recruited into the study and interviewed until the number required for that strata (health facility) was reached.

5.6 Study Variables

5.6.1 Dependent variables.

The dependent variables of the study are summarized in table 1.

Table 1: Dependent Variables for Factors Associated with Early Discontinuation of Implants among Women of Reproductive Age 15 – 49 years in Wakiso District

Variable Description Measurement

Measured in months by dividing the Time interval from the date of difference between the date of Duration of use insertion of the implant to the discontinuation and date of insertion by date of discontinuation 30. Each month was considered to have 30 days.

A binary variable coded as “Yes” if an Discontinuation of an implant Early implant was discontinued before 18 before 18 months from the discontinuation months from the time of insertion, and date of insertion. “No” if 18 or more months

Percentage of women who discontinue implants before 18 Proportion of early Measured as “Yes” to early months from the time of discontinuation discontinuation divided by sample size. insertion among those who discontinued.

5.6.2 Independent variables

The independent variables used in the study are summarized in appendix 4. I categorized “age of eldest child” based on growth and development stages in human beings into infant (Less than 1 years), early child ( 1 – 4 years), middle child (5 – 9 years), Adolescent (10-19 years) and others (20 – 30 years). “Cost of implant” was categorized in relation to the cut-off for figure for categorization of low-income countries, into free (0 shillings), Low cost (1 – 5000/=) and high cost (5001 - 90000/=). Age was categorized in relation to reproductive health characteristics into 15 - 24 years and 25 - 49 years. “Cost of transport” was categorized into none (zero cost), low cost (1 – 5000/=) and high cost (5001 – 20,000/=). “Knowledge on side effects” was categorized basing on number of side effects a respondent would remember as Poor (No side effect), Fair (1-2 side effects), Good (3 – 5 side effects) and Excellent (6 – 7 side effects). “Marital status” was categorized into not married (single, divorced and widowed) and currently married (cohabiting and married).

5.7 Data Collection

5.7.1 Training of Research Assistants

There were five main research assistants who collected data from 21 government health facilities. In each PFP and PNFP facility, a health worker other than a mid-wife or one who worked in maternal and child health department was selected as a research assistant for data collection. Therefore, there were 17 research assistant from PFP facilities and 4 from PNFP facilities. The five main research assistants in government health facilities were trained for one day on contents of the study, contents of the questionnaire and interview skills. The practicum was done on random clients at Entebbe hospital who agreed to be interviewed for this sake. Each research assistants in PFP and PNFP health facilities was trained on the same day of recruitment where s/he was taken through the contents of the study, contents of the questionnaire and trained on interview skills.

5.7.2 Tools

An interviewer-administered questionnaire was used in the study. Early discontinuation of implants was the key construct during questionnaire development. Its development was focused on the three research question and three specific objectives of the study. The format of the

questionnaire was decided to be interviewer-administered with closed-ended items. Each question item was kept short and the whole questionnaire was kept at three pages with 32 questions rather than initial 36 questions before review and revision. The questionnaire was later pilot-tested at Entebbe hospital on five respondents.

5.7.3 Pre-testing

The questionnaire was pretested from Entebbe general hospital on five women between 15 -49 years who had discontinued implants. Key findings from the pretest were; need to emphasize viewing the client’s record for date of insertion, emphasizing respondent’s age in complete years only and including an option of none for under respondent’s religion. On the question “Does your partner have another wife you know of?” an option was included to cater for the widows and those who divorced. The word “main” was added in the question “what was your main reason for removing the implant?” to prevent multiple answers from the respondent. On the question “what are some of the side effects an implant can cause?” a comment was added emphasizing that an interviewer should keep on probing for more answers.

5.7.4 Field editing of data

The principal investigator conducted random and where necessary, targeted supportive supervision visits to research assistants to ensure accurate, consistent and complete data. Each research assistant was supervised physically at least once to ensure consistent, complete and accurate entry of data.

5.7.5 Missing data

On site, each research assistant crosschecked to ensure that each question on the interviewer- administered questionnaire was addressed before a respondent left. Missing data on site ownership were inferred from the client’s code, where every code was related to the health facility. Missing data on age were completed by inferring to the calculated age as a difference between the date of birth of the respondent and the date of removal. Only 11 out of 397 observations were missing data with no relationship between missing data values and observed values (missing completely at random). There were four observations, which were missing in cost of implant, three in type of counselling, four in co-wife and one in priority to discontinue. The eleven data missing completely at random (2.8% of data) were handled by list-wise

deletion, where the entire observation (respondent) was deleted from the dataset to allow complete case analysis.

5.8 Data Management and Analysis

5.8.1 Data Management

I used EPI INFO 7 to capture information from questionnaires; then extracted an excel dataset that was imported into STATA SE/14.0 for analysis. Data were entered by the principal investigator into EPI INFO 7 and cleaning was conducted using STATA SE/14.0 to remove duplicate entries and to crosscheck for any data entry errors. Categorical variables were coded as listed in appendix 4. The analyses in this study did not require assumption of normality of data. There were no transformations done on any variable.

5.8.2 Data Analysis

The response rate in the study was 100%; however, 2.8% (11) observations were deleted by list- wise deletion for complete case analysis. Therefore, 386 observation were analyzed. Descriptive statistics are presented in text and tables. Results of Bivariate and multivariate analysis are presented in tables.

I used descriptive statistics to determine the proportion of women who discontinued implants early. Since the prevalence of early discontinuation was more than 10%, I used modified Poisson to establish determinants of early discontinuation of implants. Because duration of use was non-normally distributed, I used quantile regression analysis to determine factors that influenced overall duration of use of implants. For inclusion into a multivariate model, only variables with a p-value of 0.20 or less after bivariate analysis were considered while establishing determinants of early discontinuation of implants and determining factors that influenced overall duration of use of implants. Variables in the multivariate model were included by forward stepwise selection using adjusted R-squared (r2adj) as the adjusted information criterion. The significance level (alpha) was set at 5% for all tests of significance.

5.9 Ethical Considerations

The study sought approval and abided by the rules and regulations of the institutional review board of Makerere university school of public health. Permission to conduct the study was also sought from the district health officer’s office of Wakiso district. At every health facility, the in-

charge was informed of the study before the actual interaction with respondents. A consent form was administered to every participant for approval to participate in the study. Each consent form was translated in Luganda language to be easily understood by any client. Clients were assigned identification codes rather than including their names on the questionnaire to assure anonymity and confidentiality. Consent forms and questionnaires were kept safely under lock and key limited to access by the investigator and faculty at MakSPH.

CHAPTER SIX

6.0 RESULTS

This study was conducted to estimate the proportion of women who discontinue implants early, establish factors associated with early discontinuation of implants and to determine factors that influence the duration of use of implants among women of reproductive age 15 – 49 years in Wakiso district.

6.1 Characteristics of the study population

The average age of the respondents was 28.3 years (SD = 6.12) and most respondents 261 (67.6) were adults in age group 25 – 49 years. The median duration of use of implants was 25 months. Parity ranged from zero to 10 pregnancies (IQR = 1 - 4) with the highest proportion of respondents (55.3 %) having a parity of two to four pregnancy. The number of living children per respondent ranged from zero to nine children (IQR= 1 - 4) and most respondents had either one (28%) or two (24%) living children. Most respondents (44%) had planned to have four children with a range of one to 10 children (IQR = 4 - 5). Two-thirds, 256 (66.3%) of the respondents had discontinued Implanon and the rest discontinued Jadelle. Most respondents, 249 (64.5%) had attained secondary level of education or above it and the rest had stopped education in primary or did not have education at all. Most women, 314 (81.4) were married and the rest were not. Only 51 (13.2%) respondents had wanted a different method other than the implant they had received. Most respondents, 351 (90.9%) had been informed of a follow up plan. On the other hand, 159 (41.2%) had an actual follow up visit related to the implant which was discontinued. Less than half 165 (42.8%) respondents wanted to switch to a different method within one month. Most respondents, 351 (90.9%) had been counselled on side effects of implants and less than one-third, 105 (27.2%) incurred a cost to retain the implant. Tables 2a and 2b show other characteristics of the study population.

Table 2a: Other Client-based Characteristics for Women of Reproductive Age 15 – 49 Years who Discontinued Implants in Wakiso District during the Study Variable Number (%), 386 (100) Parity No pregnancy 14 (3.63) One pregnancy 99 (25.7) 2 – 4 pregnancies 213 (55.3) 5 or more pregnancies 60 (15.5) Reasons for discontinuation Conceive 91 (23.6) Side effects 173 (44.8) Expiry 76 (19.7) Others 46 (46 (11.9) Religion Christian 271 (70.2) Moslem 105 (27.2) Other 10 (2.6) Has a co-wife No 231 (59.8) Yes 112 (29.0) Not applicable 43 (11.2)

Table 2b: Other Provider-related Characteristics for Women of Reproductive Age 15 – 49 Years who Discontinued Implants in Wakiso District during the Study Variable Number (%), 386 (100) Place of insertion Government facility 243 (63%) Non-government facility 138 (35.7) Don’t know 5 (1.3) Cost of implant insertion Free 304 (78.8) 1 – 5000 51 (13.2) 5001 - 90000 31 (8.0) Cost of transport None 98 (25.4) 1 – 5000 shillings 273 (70.7) 5001 – 20000 shillings 15 (3.9) Cost on retention No 281 (72.8) Yes 105 (27.2) Side effect knowledge Poor 20 (5.2) Fair 163 (42.2) Good 154 (39.9) Excellent 49 (12.7) Type of counselling Individual 98 (25.4) Group 226 (58.6) Both 34 (8.8) Not counselled 28 (7.3)

6.2 Proportion of Early discontinuation

The proportion of women who discontinue implants before 18 months was 30.7% (95% CI = 25.2 – 36.9). A Mann-Whitney test indicated that the median duration of use for those who discontinue early (Mdn = 10.1 months) was significantly lower than that of women who discontinue implants at 18 months or more (Mdn = 35.4 months), z = 15.936, p < .001, r = 0.81. Table 3 below shows other descriptive statistics related the proportion of early discontinuation

Table 3: Proportion of Women of Reproductive Age 15 – 49 years who Discontinued Implants Early in Wakiso District

Early Number Min. duration Max. duration Median Proportion (%) ( (95% Discontinuation of use of use duration of CI) (months) (months) use

No 260 18 73.5 35.4 69.3 (63.1 – 74.8)

Yes 126 0.03 17.9 10.1 30.7 (25.2 – 36.9)

Total 386 100

Among those who discontinued early, 53 (42%) planned to switch to another method within a month, only 24 women (19%) wanted to conceived and 92 women (73%) discontinued due to side effects. Among those who discontinued early, 46 women (36.5%) had incurred a cost to retain implants.

6.3 Determinants of early discontinuation

Determinants of early discontinuation were grouped into client-based and provider-related factors during analysis. For client-based factors during bivariate analysis, side effects was the significant determinant of early discontinuation. The prevalence ratio was 20% higher among women who discontinued due to side effects compared to women who discontinued due to a need to conceive. Table 4a shows findings from the bivariate analysis of client-based factors.

Table 4a: Bivariate Analysis for Client-based Determinants of Early Discontinuation of Implants among Women of Reproductive Age in Wakiso District Early discontinuation n (%) Variable Unadjusted Prevalence ratio p-value No Yes Age group 25 – 49 years 183 (70.1) 78 (29.9) 1.00 (ref) 15 – 24 years 77 (61.6) 48 (38.4) 1.01 (0.92 – 1.11) 0.879 Parity Nulliparous 9 (64.3) 5 (35.7) 1.00 (ref) One pregnancy 64 (64.6) 35 (35.4) 0.943 (0.77 – 1.16) 0.567 2 – 4 pregnancies 143 (67.1) 70 (32.9) 0.956 (0.79 – 1.16) 0.638 5 or more pregnancies 44 (73.3) 16 (26.7) 0.936 (0.77 – 1.14) 0.501 Highest education level None 10 (66.7) 5 (33.3) 1.00 (ref) Primary 82 (67.2) 40 (32.8) 0.86 (0.66 – 1.13) 0.267 Secondary or higher 168 (67.5) 81 (32.5) 0.882 (0.67 – 1.17) 0.363 Reasons for discontinuation Conceive 67 (73.6) 24 (26.4) 1.00 (ref) Side effects 81 (46.8) 92 (53.2) 1.20 (1.07 – 1.36) 0.003 Others 36 (78.3) 10 (21.7) 0.99 (0.83 – 1.18) 0.885 Marital status Married 211 (67.2) 103 (32.8) 1.00 (ref) Not Married 49 (68.1) 23 (31.9) 0.99 (0.88 – 1.12) 0.854 Religion Christian 186 (68.6) 85 (31.4) 1.00 (ref) Moslem 67 (63.8) 38 (36.2) 1.04 (0.94 – 1.15) 0.455 Follow up visit No 156 (68.7) 71 (31.3) 1.00 (ref) Yes 104 (65.4) 55 (34.6) 1.06 (0.95 – 1.10) 0.191 Primary method of choice Implant 229 (68.4) 106 (31.6) 1.00 (Ref) Different method 31 (60.8) 20 (39.2) 1.05 (0.91 – 1.22) 0.515 Side effect knowledge Poor 13 (65) 7 (35) 1.00 (ref) Fair 111 (68.1) 52 (31.9) 0.89 (0.70 – 1.13) 0.322 Good 102 (66.2) 52 (33.8) 0.95 (0.76 – 1.19) 0.637 Excellent 34 (69.4) 15 (30.6) 0.87 (0.69 – 1.15) 0.365 Switcher No 148 (67.0) 73 (33.0) 1.00 (ref) Yes 112 (67.9) 53 (32.1) 0.97 (0.88 – 1.06) 0.464

For provider-related factors, cost on retention of implants was the significant determinant of early discontinuation. The prevalence of early discontinuation was 15% higher among women who incurred costs on retention of implants compared to women who did not incur costs. Table 4b shows findings of bivariate analysis for provider-related factors.

Table 4b: Bivariate Analysis for Provider-related Determinants of Early Discontinuation of Implants among Women of Reproductive Age in Wakiso District Unadjusted Prevalence Variable Early discontinuation n (%) p-value ratio No Yes Type of Implant Implanon 171 (66.8) 85 (33.2) 1.00 (ref) Jadelle 89 (68.5) 41 (31.5) 1.04 (0.96 – 1.13) 0.325 Place of insertion Government facility 167 (68.7) 76 (31.3) 1.00 (ref) Non-government facility 92 (66.7) 46 (33.3) 1.03 (0.95 – 1.12) 0.420 Cost of implant insertion Free 207 (68.1) 97 (31.9) 1.00 (ref) 1 – 5000 shillings 34 (66.7) 17 (33.3) 1.10 (0.94 – 1.27) 0.225 5001 – 90000 shillings 19 (61.3) 12 (38.7) 1.10 (0.95 – 1.28) 0.201 Cost of transport None 71 (72.5) 27(27.5) 1.00 (ref) 1 – 5000 shillings 179 (65.6) 94 (34.4) 1.07 (0.97 – 1.18) 0.174 5001 – 20000 shillings 10 (66.7) 5 (33.3) 1.05 (0.85 – 1.29) 0.657 Cost on retention No 201 (71.5) 20 (28.5) 1.00 (ref) Yes 59 (56.2) 46 (43.8) 1.15 (1.04 – 1.27) 0.010 Counselling on side effects No 19 (54.3) 16 (45.7) 1.00 (ref) Yes 241 (68.7) 110 (31.3) 0.96 (0.82 – 1.12) 0.601 Type of counselling Individual 67 (68.4) 31 (31.6) 1.00 (ref) Group 149 (65.9) 77 (34.1) 1.05 (0.96 – 1.16) 0.287 Both 27 (79.4) 7 (20.6) 0.92 (0.78 – 1.09) 0.337 Not counselled 17 (60.7) 11 (39.3) 1.07 (0.86 – 1.31) 0.542

During multivariate analysis, reason for discontinuation and follow up visits were client-based factors considered for analysis. Parity, marital status and switching improved the final model and they were included in analysis. However, follow up visit did not improve the final model and it was dropped from the analysis. For provider-related determinants, cost of implant insertion, cost of transport and cost on retention were considered for the final model. However, cost of transport and cost of implant insertion did not improve the model and were eliminated. Counselling on side effect improved the model and it was included despite p = 0.601. Side effects and cost on retention were significant determinants of early discontinuation after controlling for respective factors. The prevalence of early discontinuation was 20% higher among women who discontinued implants due to side effects compared to women who discontinued due to the need to conceive holding other factors constant. The prevalence of early discontinuation of implants was 15% higher among women who incurred cost on retention compared to women who did not incur costs on retention holding all other factors constant. Table 5 summarizes findings after multivariate analysis.

Table 5: Multivariate Analysis for Determinants of Early Discontinuation of Implants among Women of Reproductive Age 15 – 49 years in Wakiso District Variable Unadjusted PR p-value Adjusted PR p-value

Client-based factors Reasons for discontinuation Conceive 1.00 (ref) 1.00 (ref) Side effects 1.20 (1.07 – 1.36) 0.003 1.20 (1.05 (1.37) 0.009 Others 0.99 (0.83 – 1.18) 0.885 0.99 (0.83 – 1.17) 0.895 Switcher No 1.00 (ref) 1.00 (ref) Yes 0.97 (0.88 – 1.06) 0.464 1.01 (0.90 – 1.13) 0.917 Marital status Currently Married 1.00 (ref) 1.00 (ref) Not Married 0.99 (0.88 – 1.12) 0.854 0.99 (0.90 – 1.10) 0.908 Parity High 1.00 (ref) 1.00 (ref) Moderate 1.02 (0.89 – 1.17) 0.76 0.99 (0.87 – 1.13) 0.885 Low 1.01 (0.86 – 1.19) 0.861 1.01 (0.87 – 1.16) 0.922

Facility-related factors Cost on retention No 1.00 (ref) 1.00 (ref) Yes 1.15 (1.04 – 1.27) 0.010 1.15 (1.04 – 1.28) 0.010 Counselling on side effects No 1.00 (ref) 1.00 (ref) Yes 0.96 (0.82 – 1.12) 0.601 0.94 (0.81 – 1.09) 0.411

6.4 Factors that influence overall duration of use of implants.

Factors that influence overall duration of use of contraceptive implants were also grouped into client-based and provider-related factors. In bivariate analysis, for client-based factors, age group 15 – 24 years, side effects and switching influenced overall duration of use of implants. Age group 15 – 24 years reduced median duration of use by 9.33 months compared to age group 25 – 49 years. Side effects reduced the median duration of use by 10.2 months compared discontinuation due to a need to conceive. Women who wanted to switch after discontinuation had more median duration of use of 9.47 months compared to those who never wanted to switch. Table 6a shows finding of bivariate analysis for client-based factors that influence overall duration of use.

Table 6a: Bivariate Analysis for Client-based Factors That Influence Overall Duration of Use of Implants among Women of Reproductive Age in Wakiso District Variable Count (median duration of Unstandardized beta coefficient p-value use) (B) Age group 25 – 49 years 261 (29.8) 1.00 (ref) 15 – 24 years 125 (21.9) -9.33 (-14.6 - -4.03) 0.001 Parity Nulliparous 14 (24.4) 1.00 (ref) One pregnancy 99 (23.3) 4.43 (-15.2 – 24.1) 0.658 2 – 4 pregnancies 213 (25.0) 1.6 (-17.0 – 20.2) 0.866 5 or more pregnancies 60 (34.7) 9.66 (-9.8 – 29.1) 0.329 Highest education level None 15 (25.3) 1.00 (ref) Primary 122 (24.5) 2.17 (-13.2 – 17.6) 0.782 Secondary and above 249 (25.7) 7.3 (-7.9 – 22.5) 0.344 Marital status Married 314 (25.0) 1.00 (ref) Not Married 72 (25.2) 0.733 (-7.21 – 8.68) 0.856 Religion Christian 271 (26.6) 1.00 (ref) Moslem 105 (24.3) -2.27 (-8.62 – 4.07) 0.482 Other 10 (23.0) -4.70 (-15.8 – 6.36) 0.404 Reasons for discontinuation Conceive 91 (24.6) 1.00 (ref) Side effects 173 (16.6) -10.2 (-16.9 - -3.57) 0.003 Others 46 (25.2) -3.00 (-9.94 – 3.94) 0.396 Follow up visit No 277 (27.0) 1.00 (ref) Yes 159 (24.2) -4.5 (-11.0 – 2.03) 0.176 Primary method of choice Implant 335 (25.1) 1.00 (ref) Different method 51 (25.0) 0.54 (-6.65 – 7.73) 0.883 Switcher No 221 (24.2) 1.00 (ref) Yes 165 (32.7) 9.47 (3.49 – 15.45) 0.002

For provider-related factors, insertion during breast feeding, learning about implants from relatives first, low cost of transport of 1 – 5000 shillings and not being counselled before insertion significantly influenced duration of use. For women whose implants were inserted while she was breastfeeding, their median duration of use was lower by 6.96 months compared to women who whose implants were inserted when they were not breastfeeding. The median duration of use of implants was 8.27 months higher among women who first learned about implants from relatives compared to women who first learnt about implants from a health worker. The median duration of use of implants was 7.93 months lower for women who spent 1-5000 shilling on transport compared to women who never spent any money on transport. The median duration of use was 7.77 months lower for women who had not been counseled on implants compared to women who had been counselled individually. Table 6b shows finding of bivariate analysis for provider-related factors that influence overall duration of use.

Table 6b: Bivariate Analysis for Provider-related Factors That Influence Overall Duration of Use of

Implants among Women of Reproductive Age in Wakiso District Variable Count (median duration of Unstandardized beta coefficient p-value use) (B) Inserted during breast feeding No 155 (28.7) 1.00 (Ref) Yes 231 (23.9) -6.96 (-13.3 - -0.59) 0.032 Type of Implant Implanon 256 (24.3) 1.00 (ref) Jadelle 130 (29.6) -3.04 (-10.4 – 4.32) 0.419 Place of insertion Government facility 243 (25.3) 1.00 (ref) Non-government facility 138 (25.1) 0.54 (-6.53 – 7.61) 0.882 First learnt about implant Health worker 196 (24.9) 1.00 (ref) Friend 132 (28.1) 0.24 (-7.86 – 8.34) 0.954 Relative 52 (24.5) 8.27 (0.41 – 16.13) 0.039 Cost of implant insertion Free 304 (26.9) 1.00 (ref) 1 – 5000 shillings 51 (22.8) -7.73 (-15.8 – 0.39) 0.062 5001 – 90000 shillings 31 (24.0) -5.5 (-21.0 – 10.0 0.486 Cost of transport None 98 (30.9) 1.00 (ref) 1 – 5000 shillings 273 (24.6) -7.93 (-15.2 - -0.69) 0.032 5001 – 20000 shillings 15 (28.5) -4.23 (-17.8 – 9.33) 0.540 Cost on retention No 281 (27.2) 1.00 (ref) Yes 105 (21.5) -7.64 (-16.5 – 1.20) 0.090 Counselling on side effects No 35 (21.5) 1.00 (ref) Yes 351 (25.3) 0.34 (-10.4 – 11.1) 0.950 Type of counselling Individual 98 (25.1) 1.00 (ref) Group 226 (25.4) -3.70 (-10.9 – 3.52) 0.314 Both 34 (30.5) 7.03 (-4.83 – 18.9) 0.214 Not counselled 28 (21.7) -7.77 (-14.0 - -1.55) 0.015 Follow up plan No 35 (22.1) 1.00 (ref) Yes 351 (25.4) 6.74 (-1.21 – 14.7) 0.096

In multivariate analysis, for client-based factors, age group, parity, highest education level, follow up visit, reasons for discontinuation and switching were considered for the multivariate analysis. However, highest education level and follow up visit did not improve the final and they were eliminated from the model. Side effect influenced overall duration of use. The median duration of use was reduced by 9.9 months if a woman discontinued implants due to side effects compared to women who discontinued due to a need to conceive, holding other factors constant. Table 7a summarizes finding of multivariate analysis for client-based factors.

Table 7a: Multivariate Analysis for Client-based Factors That Influence Duration of Use of Implants among Women of Reproductive Age in Wakiso District Unstandardized Standardized Variable p-value p-value coefficient (B) coefficient (β) Reasons for

discontinuation Conceive 1.00 (ref) 1.00 (ref) Side effects -10.2 (-16.9 - -3.57) 0.003 -9.91 (-16.6 - -3.034) 0.005 Others -3.00 (-9.94 – 3.94) 0.396 -3.14 (-9.19 – 2.91) 0.308 Age group 25 – 49 years 1.00 (ref) 1.00 (ref) 15 – 24 years -9.33 (-14.6 - -4.03) 0.001 -1.57 (-5.65– 2.51) 0.450 Parity Nulliparous 1.00 (ref) 1.00 (ref) One pregnancy 4.43 (-15.2 – 24.1) 0.658 -6.14 (-14.2 – 1.93) 0.135 2 – 4 pregnancies 1.6 (-17.0 – 20.2) 0.866 -7.17 (-15.3 – 0.98) 0.085 5 or more pregnancies 9.66 (-9.8 – 29.1) 0.329 -6.37 (-15.1 – 2.38 0.153 Switcher No 1.00 (ref) 1.00 (ref) Yes 9.47 (3.49 – 15.45) 0.002 -1.20 (-5.17 – 2.77) 0.552

For provider-related factors, insertion during breast feeding, first heard about implant, cost of insertion, cost of transport, cost of retention, type of counselling and follow up plan were considered for multivariate analysis. However, first heard about implant and follow up plan did not improve the final model and they were dropped from the analysis. Type of implant and place of insertion improved the final model and they were included in the analysis. Cost on retention, insertions during breastfeeding and not being counseled influenced overall duration of use of implants. The median duration of use was reduced by 7.38 months if a woman incurred a

cost to retain an implant compared to when she did not, holding other factors constant. The median duration of use of implants reduced by 5 months if a woman inserted an implant while breastfeeding compared to when she was not breastfeeding, holding other factors constant. The median duration of use reduced by 6.47 months if a woman was inserted an implant without counselling compared to who was inserted after counselling, holding other factors constant.

Table 7b: Multivariate Analysis for Provider-based Factors That Influence Duration of Use of Implants among Women of Reproductive Age in Wakiso District Unstandardized Standardized Variable p-value p-value coefficient (B) coefficient (β) Type of implant Implanon 1.00 (ref) 1.00 (ref) Jadelle -3.04 (-10.4 – 4.32) 0.419 0.633 (-3.66 – 4.92) 0.772 Cost on retention No 1.00 (ref) 1.00 (ref) Yes -7.64 (-16.5 – 1.20) 0.090 -7.38 (-13.3 - -1.47) 0.015 Cost of transport None 1.00 (ref) 1.00 (ref) 1 - 5000 -7.93 (-15.2 - -0.69) 0.032 -3.82 (-8.59 – 0.96) 0.117 5001 - 20000 -4.23 (-17.8 – 9.33) 0.540 -1.33 (-14.1 – 11.4) 0.837 Insertion during

breastfeeding No 1.00 (Ref) 1.00 (ref) Yes -6.96 (-13.3 - -0.59) 0.032 -5.00 (-8.95 - -1.05) 0.013 Type of counselling Individual 1.00 (ref) 1.00 (ref) Group -3.70 (-10.9 – 3.52) 0.314 -2.55 (-8.11 – 3.01) 0.368 Both 7.03 (-4.83 – 18.9) 0.214 0.78 (-4.87 – 6.43) 0.785 Not counselled -7.77 (-14.0 - -1.55) 0.015 -6.47 (-12.07 - -0.86) 0.024 Place of insertion Government facility 1.00 (ref) 1.00 (ref) Non-government facility 0.54 (-6.53 – 7.61) 0.882 -0.52 (-3.52 – 2.48) 0.735

CHAPTER SEVEN

7.0 DISCUSSION

This facility-based cross-sectional study was conducted to determine the magnitude of early discontinuation of contraceptive implants and establish determinants of early discontinuation of implants. It also determined factors that influenced overall duration of use of implants among women of reproductive age 15 – 49 years who discontinued implants in Wakiso district. Determinants of early discontinuation of implants and factors that influence overall duration of use were categorized into client-based and Facility-related factors.

Proportion of early discontinuation of implants

Among those who discontinued implants in Wakiso district, nearly one-third (31%) of them discontinued early. In Uganda, there was limited information on assessment of early discontinuation of implants with a cut-off of 18 months and therefore, the negative impact of such a proportion on retention and use of contraceptives cannot be estimated yet. Kalmuss, et al., (1996) and Grunloh et al. (2013) used 6 months to describe early discontinuation, and they used total number of women who inserted implants in computing the proportion of early discontinuation to derive proportions of 7.6% and 7% respectively. Mengstu, et al. (2018) assessed for early discontinuation of Implanon and not both implant types with early discontinuation defined at a cut-off of 2.5 years. In this study, 32% of women who discontinued implants early used Jadelle and therefore, findings from the study by Mengstu, et al cannot be related to this study. Only 19% of women who discontinued early did so in order to conceive, majority (73%) discontinued due to side effects and more than half of them (53%) were not planning to use any family planning method for at least a month. As revealed by Anrudh & Winfrey (2017) and Ali, et al (2012), discontinuation of contraceptive is associated with higher rates of mistimed and unwanted pregnancies together with their negative consequences including stillbirths and abortions unless the client is switching to a different method of contraception. For compesation in early discontinuation, one would prefer women to discontinue and switch or to discontinue in order to conceive. In this study, among those who discontinued early, 53 (42%) planned to switch to another method within a month and only 24 women (19%) wanted to conceive. Therefore, for inadventurous early discontinuation, a target

proportion can be determined by {sum of (women who discontinue early and switch = 53 plus women who discontinue early to conceive = 24) / by total of women who discontinue early} of 0.307 equivalent to 19%.

Determinants of early discontinuation of implants

In this study, the significant determinants to early discontinuation of implants were side effects and costs on retention of the implants. In an efficient family planning program, women would be expected to discontinue implants when there is a need to conceive, when they have reached menopause or when the implants expired. In this study, I compared all reasons for discontinuation to the need to conceive.

The prevalence of early discontinuation of implants was 20% higher among women who discontinued due to side effects compared to those who discontinued due to the need to conceive and this association was significant before and after controlling for all other factors. This finding was in line with other studies in Ethiopia (Birhane et al., 2015; Melese Siyoum, 2017; and Tadesse et al 2017), which revealed that side effects were significant reasons for discontinuation of contraceptives. Worse still, among those who discontinued early, only 54% women planned to switch to another method, leaving a large proportion (46%) of women at risk of unintended pregnancies and their negative consequences. For efficiency of family planning program, this would call for interventions that address comprehensive management of side effects among other interventions to minimize early discontinuation.

Cost on retention of the implant was the only facility-related determinant of early discontinuation of implants. The prevalence of early discontinuation among women who incurred a cost to retain the implants was 15% more than the prevalence of women who did not incur a cost, both before and after controlling for other factors. In this study, for every five women, four (79%) got the implant inserted at no cost. They had not opted for insertions that involved a cost at whichever ownership of a health facility, be it government, PFP nor PNFP facilities. This was more likely so because of financial constraints or a need to minimize expenditure. Introducing a cost such as buying medicines to manage side effects, spending money on transport to health facilities to address concerns on the implant in order to retain the implants defeats women’s goals of cost free contraception. Therefore, they were more likely to discontinue implants for alternative methods of contraception or even none. In fact, only 43% of

the women who discontinued early and incurred a cost on retention of the implant had planned to switch to a new method. For efficiency of family planning programs, there is need to relieve women of costs incurred to retain implants that are already inserted.

Factors that influence overall duration of use of implants

From the above results, duration of use was significantly influenced by discontinuation due to expiry and side effects, insertion of implants during breastfeeding, incurring costs on retention of implants and not being counselled on the implant before insertion.

Client-based factors

The median duration of use reduced by 9 months and 18 days if a woman discontinued an implant due to side effects compared to those who discontinued in order to conceive. This relationship was strongly significant before and after controlling for age, parity and switching. Despite being general on pills, Jadelle, IUD and injectable contraceptives, findings from the study by Tadesse, et al., (2017) also agree with this study that side effect lower the duration of use contraceptives. Tadesse, et al., (2017) had determined that the odds of discontinuing contraceptives before 3 years among those who discontinued due to side effects were 1.7 times the odds among those who discontinued because of other reasons. In this study, it can be deduced that nearly half (47%) of women who discontinued implants due to side effects did not plan to switch to a new method, which is detrimental to the success of family planning programs. Focusing on management of side effects among women who use implants can improve the duration of use of the method.

However, without controlling for other factors, overall duration of use was influenced by young age group 15 – 24 years, moderate parity and whether a woman had planned to switch. The median duration of use was significantly reduced by 9 minutes and 8 days if a woman was of a young age group 15 – 24 years compared to when she was of an adult age group 25 – 49 years. However, on controlling for other factors, age group did not significantly influence the overall duration of use of implants. Age is strongly correlated with the number of living children a woman had. It would bel expected that the more children a woman has, the least likely that she would discontinue a contraceptive to risk becoming pregnant. Previous studies that were reviewed did not assess the effect of age on overall duration of use of implants. The study by Tadesse, et al., (2017), which revealed that the odds of discontinuing an implanon before 3

years among age group of less than 20 years were 3.3 times less compared to who were 35 years and more, can not be used for comparison. This is because my study combine both Implanon and Jajdelle and it determines median duration of use rather than odds of discontinuing before 3 years. Nevertheless, both studies agree that as the age increases, women use implants for a longer duration. In addition, the finding is in line with the Uganda Demographic and Health survey-2016 findings that reveal that contraceptive use increases with with increasing age until the age group 40 – 44 years. However, this relationship of age group and duration of use can be modified by parity reasons for discontinuation and switching.

The median duration of use was reduced by 8 months and 3 days if a woman had a moderate parity of 2 – 4 pregnancies compared to women who had a high parity of 5 – 10 pregnancies. However, this association was marginally significant. Just like age, parity is also correlated with the number of children a woman has; and therefore, parity would follow the same trend in duration of use as age of a woman. However, this relationship can also be modified by reasons for discontinuation, age group and switching.

This study also revealed that without controlling for age, parity and reasons for discontinuation, the median duration of use of implants significantly increased by 9 months and 15 days if a woman planned to switch to a new method compared to women who had not planned to switch. However, on controlling for the above factors, switching did not influence the duration of use.

Provider-based factors

The median duration of use significantly by nearly 7 months and 21 days if a woman was inserted an implant when she was breastfeeding compared to when it was inserted when she was not breastfeeding. On controlling for type of implant, type of counselling, place of insertion, cost of transport and cost of retention, the effect of inserting implants when a woman was breastfeeding was reduced to 5 months.

Individually, cost on retention of the implant did not significantly influence the duration of use of implants. However, on controlling cost of transportation, type of implant, type of counselling, place of insertion and whether the implant was inserted when a woman was breastfeeding, it was a significant determinant to the overall duration of use of implants. The median duration of use of implants reduced by 7.4 months if a woman incurred a cost on retaining the implant compared to women who never incurred any cost.

The median duration of use reduced by 7 months and 27 days if a woman incurred a cost on transportation to and from the health facility where she access family planning services compared to women who did not incur any cost at all. This finding is contrary to the plausible ideology. One would think that as women struggle to access contraceptives services including removal services due to transportation costs and limited access to removal services, those who get the implants would take longer while using them compared to ones who can access services at no costs involved in transportation. Further exploration of this phenomenon will be important if more retention of implants is to be achieved among women. In general, cost of transportation was not a significant factor after controlling for type of implant, type of counselling, place of insertion, cost of retention and whether the implant was inserted when a woman was breastfeeding.

The median duration of use increased by 8 months and 9 days if a woman first learnt about the implant from a relative compared to when she first learnt about the implant from a health worker. However, on controlling for other factors, this variable did not improve the model and it was dropped in the adjusted analysis.

The median duration of used reduced significantly by 7 months and 24 months if a woman did get any form of counselling compared to those who were counselled individually. On controlling for cost of transportation was not a significant factor after controlling for type of implant, place of insertion, cost of transport, cost of retention and whether the implant was inserted when a woman was breastfeeding, the effect not counselling a woman on the median duration of use reduced to 6 months and 15 days. This is in line with plausible ideology that any form of counselling would increase awareness on the contraceptive method and therefore more chances of retaining it except when a client is in a need to conceive, expiry or she has reached menopause. Therefore, family planning programs should also focus on ensuring that women are counseled if they are to use contraceptives for a longer duration.

Limitations of the study

This study was conducted in Wakiso district, a cosmopolitan district with health facilities located in both rural and urban areas. Therefore, findings of this study may not be applicable in an area with a significantly different demographic distribution. During the period of the study, Wakiso had at least five stakeholders who were implementing family planning programs with

great variability in their operations within the region. Therefore, great variability in the findings would also be expected depending on the program a woman had attended or was exposed. There was potential recall bias, since nearly 30% of the questions in the questionnaire required the respondent to recall the answer. Even though research assistants were trained before data collection, interviewer bias could not be excluded from the study. Five main research assistants were used in the study. From each PFP and PNFP, one individual was responsible for data collection to limit bias.

CHAPTER EIGHT

8.0 CONCLUSIONS

Thirty one percent of women discontinued implants early among all women of reproductive age 15 – 49 years who had discontinued implants. This proportion is high considering the fact that less than half of women who discontinued implants early planned to switch to a new method and only one fifth discontinued in order to conceive. A proportion of 19% for early discontinuation would be an acceptable target for monitoring and evaluating early discontinuation in family planning programs.

Determinants of early discontinuation are side effects and incurring costs to retain implants. Nearly half of women who discontinue early due to side effects do not plan to switch to a new method within a month and more than half of women who incur costs to retain implants and eventually discontinue early do not plan to switch as well.

Factors influencing overall duration of use of implants are; lack of counselling to women before inserting implants, side effects, incurring costs to retain implants and insertion of implants while a woman is breastfeeding.

Further inquiry into the paradoxical reduction in the duration of use of implants when they are inserted in women who are breastfeeding compared to those who are not breast feeding may be warranted.

CHAPTER NINE

9.0 RECOMMENDATIONS

9.1 Recommendations for family planning programs

1. A proportion of not more than 19 percent among women who discontinue implants should be used to evaluate for early discontinuation of implants, just enough to accommodate for early discontinuation due to a need to conceive. 2. Family planning programs should focus on management and counseling on side effects in order to prevent early discontinuation as well as improving on the retention of implants. 3. Family planning programs should also focus on mitigating costs incurred by women to retain implants in order to prevent early discontinuation of implants. Measures to mitigate such costs may include franchising with private health facilities to provide free side effect management care to any woman using an implant. 4. Family planning programs should ensure that comprehensive counseling of women/couples before providing contraceptive implants is mandatory and implemented by all providers of contraceptive services in order to improve retention of the implants.

9.2 Recommendations for further research

1. By plausibility, insertion of implants during breastfeeding would be associated with a high duration of use compared to insertion when a woman is not breastfeeding. In our study, the reverse was true. Therefore, qualitative studies are recommended to understand possible reasons for this phenomenon. 2. This study was conducted in a cosmopolitan district. Therefore, I recommend for a different study to be done in a setting that is predominantly rural or urban for comparison of the findings.

REFERENCES

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Anrudh, K. J. & Winfrey, W., 2017. Contribution of Contraceptive Discontinuation to Unintended Births in 36 Developing Countries. Studies in Family Planning, 48(3), pp. 269 - 278.

Asaye, M. M., Nigussie, S. T. & Ambaw, M. W., 2018. Early Implanon Discontinuation and Associated Factors among Implanon User Women in Debre Tabor Town, Public Health Facilities, Northwest Ethiopia, 2016. International Journal of Reproductive Medicine, Volume 2018.

Atnafe, M., Assefa, N. & Alemayehu, T., 2016. Long-acting Family Planning Method Switching among Revisit Clients of Public Health Facilities in Dire Dawa, Ethiopia. Contraception and Reproductive Medicine, 1(18).

Aziz, M. M., El-Gazza, F. A. & Elgibaly, O., 2018. Factors associated with first-year discontinuation of Implanon in Upper Egypt: clients' and providers' perspectives. BMJ Sexual and Reproductive Health, 28 Jun.

Bilen, M.A et al., 2018. The role of Counselling on Modern Contraceptive Utilization among HIV positive Women: The Case of Northwest Ethiopia. BMC Women Health, 18 (121).

Birhane, K., Hagos, S. & Fantahun, M., 2015. Early discontinuation of implanon and its associated factors among women who ever used implanon in Ofla District, Tigray, Northern Ethiopia. International Journal of Pharma Sciences and Research, 6(2), pp. ISSN : 0975-9492.

Blanc, K. A., Curtis, L. S. & Croft, N. T., 2002. Monitoring Contraceptive Continuation: Links to Fertility Outcomes and Quality of Care. Studies in Family Planning, 33(2), pp. 127 – 140.

Bradley, E. K. S., Schwandt, M. H. & Khan, S., 2009. Levels, Trends, and Reasons for Contraceptive Discontinuation. DHS Analytical Studies No. 20.

Castle, S. & Askew, I., 2015. Contraceptive Discontinuation: Reasons, Challenges and Solutions, New York: Population Council.

Grunloh, S. D, et al., 2013. Characteristics Associated with Discontinuation of Long-Acting Reversible Contraception within the First 6 Months of Use. Obstetrics and Gynecology, 122(6), pp. 1214 - 21

Jain, K. A., Obare, F., RamaRao, S. & Ian, A., 2013. Reducing Unmet Need by Supporting Women with Met Need. International Perspectives on Sexual and Reproductive Health, 39(3), pp. 133 - 41.

Jain, K. A. & Winfrey, W., 2017. Contribution of Contraceptive Discontinuation to Unintended Births in 36 Developing Countries. Studies in Family Planning, 48(3), pp. 269 - 278.

Kish, L., 1965. Survey Sampling. s.l.:John Wiley & Sons Inc.

Makerere University, School of Public Health at the College of Health Sciences; The Bill & Melinda Gates Institute for Population and Reproductive Health at The Johns Hopkins Bloomberg School of Public Health, 2018. Performance Monitoring and Accountability 2020 (PMA2020) Survey round 6, PMA2018/Uganda-R6, Uganda and Baltimore, Maryland, USA: s.n.

Melese Siyoum, Z. M. M. A. H. K., 2017. Implanon Discontinuation Rate and Associated Factors among Women who ever Used Implanon in the Last Three Years in Debre Markos Town, Northwest Ethiopia, 2016, Cross Sectional Study. ARC Journal of Public Health and Community Medicine, 2(1), pp. 8 - 16.

Mengstu, M. A., Tewodros, S. N. & Ambaw, W. M., 2018. Early Implanon Discontinuation and Associated Factors among Implanon User Women in Debre Tabor Town, Public Health Facilities, Northwest Ethiopia, 2016. International Journal of Reproductive Medicine, Volume 2018, p. 10.

Micaela, E. O., Jeffrey, F. P., Qiuhong, Z. & Tessa, M., 2013. Twenty Four–Month Continuation of Reversible Contraception. Obstetrics and Gynecology, 122(5), pp. 1083 - 1091.

Ministry of Health, Uganda, 2014. Uganda Family Planning Costed Implementation Plan, 2015–2020.. Kampala: Ministry of Health, Uganda.

MOH, Uganda, 2017. Annual Health Sector Performance Report, Financial Year 2016/2017, Kampala: s.n.

Power, J., French, R. & Cowan, M. F., 2007. Subdermal Implantable Contraceptives Versus Other Forms of Reversible Contraceptives or Other Implants as Effective Methods for Preventing Pregnancy. Cochrane Database of Systematic Reviews, 3(3).

Rademacher, H. K. et al., 2016. Expanding Access to a New, More Affordable Levonorgestrel Intrauterine System in Kenya: Service Delivery Costs Compared With Other Contraceptive Methods and Perspectives of Key Opinion Leaders. Global Health: Science and Practice, 4(2), pp. S83 - S93.

Stover, J., Bertrand, T. J. & Shelton, D. J., 2000. Empirically based conversion factors for calculating couple-years of protection.. Evaluation Review, 24(1), pp. 3 - 46.

Tadesse, A. et al., 2017. Determinant of Implanon Discontinuation among Women who ever Used Implanon in Diguna Fango District, Wolayita Zone, Southern Ethiopia: A Community Based Case Control Study. International Journal of Reproductive Medicine, 2017(Article ID 2861207), p. 8.

The RESPOND project, 2011. New Developments in the Calculation and Use of Couple-Years of Protection (CYP) and Their Implications for the Evaluation of Family Planning Programs— Meeting Highlights. NEW YORK : The RESPOND project/EngenderHealth.

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UBOS, 2017. The National Population and Housing Census 2014 - Area Specific Profiles, Kampala, Uganda: s.n.

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Wakiso District Health Office, 2016. HMIS FORM 128: District/HSD Annual Report, s.l.: s.n.

Wakiso District Health Office, 2017. HMIS FORM 128: District/HSD Annual Report, s.l.: s.n.

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WHO, Department of Reproductive Health and Research, 2015. WHO Statement on Progestogen-only implants, Geneva: WHO Press.

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Zemenu, S. Y., Liyew, M., Wubareg, S. & Sisay, S., 2017. Contraceptive Discontinuation, Method Switching and Associated Factors among Contraceptive Discontinuation, Method Switching and Associated Factors among. Family Medicine & Medical Science, 6(213).

APPENDICES

1. Number of Respondents per Health Facility Health Facility Site Ownership Number of respondents Buwambo HC Government 11 Bweyogerere HC Government 15 Entebbe Hosp Government 34 Kajansi HC Government 13 Kakiri HC Government 5 Kasangati HC Government 32 Kasanje HC Government 3 Kawanda HC Government 2 Kira HC Government 9 Kitala HC Government 7 Kyengera HC Government 10 Mende HC Government 5 Mutungo HC Government 7 Nabweru HC Government 10 Nakawuka HC Government 5 Namayumba HC Government 15 Namulonge HC Government 8 Nansana HC Government 9 Ndejje HC Government 5 Nsangi HC Government 4 Wakiso HC Government 24 Anna Grace MC PFP 7 Diva MC PFP 6 Doctor Clinic Sseguku PFP 2 Good Life Clinic PFP 8 Gwatiro Nursing Home PFP 7 Kikajo Maternity center PFP 5 Kyebando Nursing Home PFP 5 LLM Medical clinic PFP 17 Mariestopes Clinic PFP 3

Masajja Nursing PFP 10 MildMay Uganda Hosp PFP 15 Mukwano HC PFP 16 Naluvule MC PFP 2 Nurture Africa PFP 17 Nyange general clinic PFP 13 Our Lady of Fatima PFP 11 St. Mary MS PFP 4 Kiziba HC PNFP 7 Kireka SDA PNFP 2 Nampunge HC PNFP 3 TASO Clinic PNFP 4 Total 42 397

2. Consent Forms for Respondents

2.1 Consent form in English

Consent form for the study

Factors Associated with Early Discontinuation of Contraceptive Implants among Women of Reproductive Age in Wakiso District, a Facility-Based Cross-Sectional Study.

What are some general things you should know about research studies?

You are being asked to take part in a research study. To join the study is voluntary. You may refuse to join, or you may withdraw your consent to be in the study, for any reason. Research studies are designed to obtain new knowledge that may help other people in the future. You will not receive any direct benefit from being in the research study. Details about this study are discussed below. It is important that you understand this information so that you can make an informed choice about being in this research study. You will be given a copy of this consent form.

What is the purpose of this study?

The study will contribute to the body of knowledge needed to improve retention of contraceptive implants among users, which will eventually result in an improvement in the contraceptive prevalence rate, reduction in unmet need of family planning and attainment of FP2020 and Uganda national vision of 2040.

How many participants will take place in this study?

The study will involve 397 respondents.

How will the interview be conducted?

You will be asked questions from an already structured questionnaire.

How long will the interview last?

Each interview will last approximately 15 minutes.

What are the possible benefits from being in this study?

There will be no anticipated direct benefit to participation in this study. However, this study will help the research learn more about implant discontinuation and contribute to the strategies to improve implant retention among users.

What are the possible risks involved with being in this study?

Apart from discomfort that may result from your individual opinions related to the questions asked, there is no risk associated with participating in this study.

How will your privacy be protected?

No participant will be identified in any report or publication about this study.

What if you want to stop before your part in the study is complete?

You can withdraw from this interview at any time, without any penalty.

Will you receive anything for being in this study?

You will not receive any payment or contribution towards anything while you are in this study.

Who is sponsoring this study?

This research is not funded by any organization or body but the principal investigator.

What if you have questions relating to this study or your rights as a research participant?

If you have any questions or concerns, you may contact, anonymously if you wish, the Chair IRB on 0772886377

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Participant Signature Date

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Staff Conducting Consent Study Staff Signature Date

2.2 Consent form in Luganda

OKUKIRIZA OKWETABA MU KUNONYEREZA

Ensonga ezekusiza kukujamu bukapuso bwa famire pulaningi mubakyala abali mu myaka ejizala mu disiyulikiti ya Wakiso.

Nsonga ki zolina okumanya ku kunonyereza?

Osabiddwa okwetaba mu kunonyereza kuno. Okwetabamu kwa kyeyagalire. Osobola okugana oba okulekera aw’okukiriza ikwetaba mu kunonyereza kuno olwensonga yonna. Okunonyereza kukolebwa okusobola okufuna amagezi amapya mu kugonjola ekizibu. Osobola obutafuna migaso jamangu oba egirabwako essawa eyo okuva mu kunonyera kuno. Ensonga ezikwa ku kunonyereza kuno mubujuvu zirambuliddwa wamanga. Kyamugaso nnyo okumanya obubaka obwo wamanga osobole okusalawo no bumanyirivu. Ojakuwebwa kopi y’okukirizako.

Lwaki okunonyereza kuno kukulebwa? Ebirowoozo ebinaava mu kunonyereza kuno bijja kwongera ku kumaya engeri gyetuyinza okuyamba abakyala okusigala ng’abakyakozesa kapuso za famire pulaningi okumala akasera akawerako.

Bantu bameka abagenda okwetaba mu kunonyereza kuno? Abantu 397 bebajja okwetaba mu kunonyereza kuno.

Eriyo emigaso gyenfuna ng’anzikiriza okwetaba mu kunonyereza kuno? Teri migaso gyirabwako mangu gyojja kufuna okuva mu kunonyereza kuno. Ebirowoozo ebinaava mu kunonyereza kuno bijjakwongera ku kumaya engeri gyetuyinza okuyamba abakyala okusigala ng’abakyakozesa kapuso za famire pulaningi okumala akasera akawerako.

Okunonyereza kugenda kolebwa kutya? Ogenda kubuzibwa ebibuzo ebiwandikidwa ku lupapula nga bwoyanukula.

Ngenda kumala kabanga ki mu kunonyereza kuno? Ogenda kutwala e dakika nga 15.

Buzibuki bwenyinja okufuna obwekusiza ku kunonyereza kuno? Tewali buzibu bwetusibira kukutuukako nga buva mukunonyereza kuno.

Singa oyagala okuva mu kunonyereza nga ebibuuzo tebinagwayo?

Olina edembe okusalawo obuteetaba mu kunonyereza kuno oba okukuvamu nga tobonerezedwa muntu yena.

Okwetaba kwange n’ebinkwatako binakumibwa bitya? Abanonyereza bajja okufuba okulaba nti teri muntu yena gwekitakwatako aja kumanya bikwatako era teri ajjakusobola kumanya nga twanja ebivude mu kunonyereza.

Naasasulwa olw’okweta mu kunonyereza kuno? Neda. Tetusubira kusasula sente yonna kebeere ya ntabula.

Ani gwenyinza okutukirira singa nina ebibuzo ku kunonyereza?

Bwoba olina ekibuzo kyonna oba okwemulugunya, kubira akulira a kakiko akaola kubyokunonyereza Dr. Sizane ku simimu – 0772886372.

Bwoba okuriza okwetaba mu kunonyereza kuo, teeka e kinkumu ne nakuzomwezi mu bibangirizi wa manga.

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Ekinkumu kyo Enaku z’omwezi

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Akakasa okukiriza kwo Ekinkumu kyo akakasa okukiriza kwo Enaku z’omwezi

3. Questionnaire Title: Factors Associated with Early Discontinuation of Contraceptive Implants among Women of Reproductive Age in Wakiso District, a Facility-Based Cross-Sectional Study. Interviewer’s name: Respondent’s code (Facility code – respondent order) Date interview is (Date/Mon/Year) conducted: Time interview started: (Hour: Min) Respo No. QUESTIONS RESPONSES/CODING nse code Section A: Background and socio-demographic When was the implant 1 inserted? (View client’s (Date/Mon/Year) record) In what month and year Month____ 2 were you born? Year ______How old are you? (age in 3 ______years) Never attended school -----0 Primary 1 – 7 ------1 What is the highest level of 5 Senior 1 – 4 (Lower secondary)------2 school you completed? Senior 5 – 6 (Upper secondary) ------3 Tertiary ------4 Not married and not living with a man(single) ---- 0 Not married but living with a man (cohabiting) ---1 Married and living with a husband most of the times Regarding marriage, which (married)—2 6 of the following best Married but not living with husband all the time describes you? (separated/distance) ----3 Divorced ------4 Husband died (widow) ------5 Moslem ------0 7 Which religion are you? Christian ------1 None ------2 Does your partner have No ------0 8 another wife or partner that Yes ------1 you know of? Not Applicable ---2

Section B: Reproductive history and preference How many pregnancies have you ever had 9 ______including miscarriages, abortions and births? How many living children 10 ______do you have? How many children did/do you wish to have 11 altogether? ______(skip to 10 if not sure) How old is your eldest 12 child? (in complete years) (Skip to 11 if no child) ______Are you still interested in I do not want any more child at all (Limiter)------0 13 having more children in I still want to have at least one child (Spacer)-----1 future? No sure/whatever happens -----2 Section C: Contraceptive factors When you left home to the health facility, was your Yes -----1 14 first priority to remove the No -----0 implant? What type of implant did One-rod/for 3 years ------1 15 you remove? two-rod implant/for 5 years ------2 To become pregnant ------0 I have reached menopause ------1 Infrequent sex/no longer have a sexual partner/husband is away-2 What was your main Abnormal bleeding ------3 reason for removing the 16 Not having menstrual blood ------4 implant? (Do not read the Headache ------5 options to her) Dizziness ------6 Numbness/pain or itching of the insertion arm ----7 Husband forced me to remove it ----8 Others ------9 A friend ------1 From whom did you first A relative ------2 17 learn about the implant A health worker ---3 before you used it? I do not remember ----4

Had you ever used an No ------0 18 implant before the one you Yes ------1 removed? At the time you inserted the implant, were you yes -----1 19 breasting and not on any No -----0 other family planning method Did you have the implant Government health facility ------1 inserted from a 20 Non government health facility ------2 government or non- I don’t know------3 government health facility? My self ------1 Who decided for you an Husband ------2 21 implant as the method of A relative ------3 family planning to use? Health worker ------4 Others (specify) ------5 On the day you inserted the implant, was there another Yes, I wanted a different method ----1 22 method that you wanted to No, I wanted the implant ------0 take other than the implant but instead you didn’t Condoms ------1 Pills ------2 If yes, what method did Injectable ------3 23 you want to use? IUD ------4 Permanent method -----5 Other method ------6 How much money did you None ------0 pay at the health facility to 24 I don’t remember ------1 get the implant inserted? ______(or fill in the amount) (in shillings) How much money do you spend on transport to 25 access family planning ______services (Transport to and from the health facility) Have you ever spent yes -----1 26 money (such as to buy No -----0 medicine to manage side

effect) because of the implant you have removed

Information to client On the day you inserted the I was not educated/counselled -----0 implant, were you As a group ------1 27 educated/counselled about Individually ------2 family planning methods Both ------3 as a group or individually? None of the above (specify) ------4 Before you inserted the Yes -----1 28 implant, were you told that No -----0 it had possible side effects? Tick whatever she mentions (do not read the answers) 1. Irregular menstrual bleeding 2. Not having menstrual periods What are some of the side 3. Headache effects an implant can 29 4. Dizziness cause? (Keep on probing 5. Palpitations for more answers) 6. Weight gain or loss 7. Nausea Others (specify ) ______Were you told what to do in case you had any yes -----1 30 challenge with the implant No -----0 including side effects Did you ever contact a health worker whether on phone or visited a health yes -----1 31 facility for any issue No -----0 related to the implant other than today’s visit Now that you have removed the implant, would you want to have No ------0 32 another family planning Yes ------1 method in a period of not more than 1 month? Thank the respondent for availing time to respond to the questions Time interview is ended:

4. List of codes and description of categorical variables. Variable Value Label Description 1 Government Ownership of a health facility from Site ownership 2 PFP where a respondent discontinued the 3 PNFP implant. 1 Christian Religion 2 Moslem Respondent's religion 3 None 1 Implanon Type of implant discontinued by a Type of implant 2 Jadelle respondent 1 No Implant was inserted while the Inserted during breastfeeding 2 Yes respondent was breast feeding 1 Gov't facility Kind of health facility from where a Place of insertion 2 Non-gov't facility respondent inserted the implant 1 No ..whether a respondent has ever spent Cost on retention 2 Yes money to manage any side effect. 1 No …whether a respondent was Counselling on side effects 2 Yes counselled on side effect 1 No …whether a respondent was Follow up plan informed of a follow up plan after 2 Yes insertion 1 No ….whether a respondent visited or Follow up visit called to address concerns on the 2 Yes implant 1 No ….whether a respondent wanted a different contraceptive method other Wanted Different Method than an implant on the day of 2 Yes insertion 1 No ….whether a respondent wanted to Switcher continue with a contraceptive within 2 Yes 30 days after discontinuation 1 No ….whether a respondent's first Priority to discontinue 2 Yes intention was to remove the implant ….whether a respondent has ever Prior use implant used an implant before the one 1 No discontinued 2 Yes 1 No ….whether a partner has a second or Has a Co-wife 2 Yes more sexual partner

3 Not Applicable 1 Health worker From whom the respondent first learn First learnt about implant 2 Friend about an implant 3 Relative 1 Implant Method wanted by the respondent on the day of insertion. Different method Method of primary choice = IUD, Condoms, Injectable, Pills, 2 Different method Permanent method, any other modern method. 1 Currently Married Respondent's marital status. Currently Marital Status married = Cohabiting, married. Not 2 Not married married = Single, Widow, Divorced Primary or no Respondent highest level of formal 1 education education. Secondary and above = Level of Education Secondary and Lower secondary, Upper secondary, 2 above tertiary. 1 Myself 2 Husband Person who decide for the respondent Decider 3 Health worker to use the implant 4 Relative 5 Others 1 Spacer Contraceptive goal 2 Limiter Contraceptive goal of the respondent 3 Not sure 1 Individual 2 Group Type counselling given to the Type of counselling 3 Both respondent before insertion 4 Not counselled 1 No Implant discontinued before 18 Early discontinuation 2 Yes months 1 15 - 24 years Age category in which a respondent Age group 2 25 - 49 years belongs 1 Conceive Respondent’s main reason for 2 Expiry discontinuing the implants. Side 3 Others effect includes Amenorrhea, Reason for discontinuation Dizziness, Headache, Abnormal bleeding, Numbness. Others include 4 Side effects Infrequent sex, Menopause and partner disapproval. Eldest child 1 Infant

2 Early child Age category in which the oldest 3 Middle child living child belongs; infant (Less than 4 Adolescent 1 years), early child ( 1 – 4 years), middle child (5 – 9 years), Adolescent (10-19 years) an adults 5 Other (20 - 30 years) 1 Free Amount of money spent by the 2 Low cost respondent during insertion of the Cost of Implant implant. Free (zero cost), Low cost (1 – 5000/=) and High cost (5001 - 3 High cost 90000/=). 1 None Cost of movement to and from the 2 Low cost health facility a client usually 3 High cost receives family planning services. Cost of transport None (zero cost), low cost (1 – 5000/=) and high cost (5001- 20000/=). 1 Poor Respondent’s awareness of side 2 Fair effects of implants based on number 3 Good of side effects mentioned. Poor (No Side effect knowledge side effect), Fair (1-2 side effects), Good (3 – 5 side effects) and 4 Excellent Excellent (6 – 7 side effects). 1 Nulliparous Number of pregnancies ever carried by a respondent. Nulliparous (0 2 Primipara pregnancies), Primipara (1 Parity 3 Multiparous pregnancy), multiparous (2 - 4 pregnancies) and Grand multiparous 4 Grand multiparous (more than 4 pregnancies)