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Emefa Judith Modey (10363910)

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Emefa Judith Modey (10363910) University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH, COLLEGE OF HEALTH SCIENCES, UNIVERSITY OF GHANA, LEGON CONTRACEPTIVE DISCONTINUATION AND SWITCHING AMONG WOMEN IN THE SHAI-OSUDOKU AND NINGO PRAMPRAM DISTRICTS, GHANA BY EMEFA JUDITH MODEY (10363910) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF DOCTOR OF PHILOSOPHY DEGREE IN PUBLIC HEALTH JULY 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that this thesis is the product of my original independent research conducted in Greater Accra Region under the supervision of Professor Richard Adanu, Dr. Richmond Aryeetey and Dr. Amos Laar. I affirm that this work has neither been published nor submitted in whole or in part to any institution for any academic award. All references made to other researchers’ works have been duly acknowledged. ……………………………………. …………………………. Emefa Judith Modey Date (PhD Candidate) ……………………………………. …………………………. Professor Richard Adanu Date Principal Supervisor ……………………………………. …………………………. Dr. Richmond Aryeetey Date Co-Supervisor ……………………………………. …………………………. Dr. Amos Laar Date Co-Supervisor i University of Ghana http://ugspace.ug.edu.gh ABSTRACT INTRODUCTION: The intended and continued use of contraceptives is critical for attaining individual reproductive health goals and the prevention of unintended births that may be subject to induced abortions. Women who eventually overcome barriers and adopt a contraceptive method, encounter challenges that result in discontinuation, switching, or method failure. The occurrence of discontinuation for reasons other than the desire to conceive or switching to less effective methods, places women at an increased risk of unintended pregnancies. Identifying the period within which any form of discontinuation or switching is likely to occur and the reasons influencing these, will facilitate the identification of opportunities for providing a more accurate guide to users and encourage the delivery of context–appropriate support to users of family planning services. OBJECTIVE: This study sought to identify the occurrence of contraceptive discontinuation and switching among women in the Shai-Osudoku and Ningo Prampram districts, Ghana. METHODS: Individual in-depth interviews with 20 women reporting for reproductive and child health care services at the district Hospital were undertaken. This was complimented by a retrospective survey of 1,114 women using a structured questionnaire that incorporated the contraceptive calendar to collect reproductive histories. Cox regression and life table analysis was used to estimate discontinuation or switching. RESULTS: All method discontinuation for any reason at 12, 24 and 36 months after starting use were 4%, 18% and 38% respectively. This study identifies increasing age, number of children, use of contraceptives between births, after childbearing and receiving counselling on methods were associated with the reduced risk of ii University of Ghana http://ugspace.ug.edu.gh contraceptive discontinuation at all times of follow up. A change in marital status and was associated with increased contraceptive discontinuation. At 12 months of use 10% of women discontinued because they are afraid of side effects of contraceptives, this increases to 37% at 24 months of use. Women who expressed fear of side effects of contraceptives had a 60% increase in the hazard of discontinuation at all times of follow up [HR=1.60 95% CI (1.17, 2.20)] whilst women who experienced side effects had a 50% increase in the hazard of discontinuation [HR=1.34; 95% CI (1.04, 1.75)] compared to women who discontinued for any other reason implying dissatisfaction with the method. A reduced need for contraceptives was associated with a 57% increase in the hazard of discontinuation at all times of follow up [HR=1.57; 95% CI (1.22, 2.01)]. Discontinuation of the pill was significantly increased compared to users of the male condom [HR=2.35, 95% CI (1.40, 3.97)] and compared to all other methods [HR=1.68; 95% CI (1.26, 2.25)]. Approximately 39% of switching occurred within the next month of use. Increasing number of children and counselling on methods were associated with a reduction in the hazard of discontinuation. The choice of switching to modern method was associated with an increased hazard at all times of follow up and the male condom was the preferred method for 20% of all switchers. Overall, 3.4% of pregnancies were identified as unintended, with the emergency contraceptive identified as the method with the most failures recorded. CONCLUSION: A reduced need for contraceptives, fear of side effects and the experience of side effects carry an increased risk of discontinuation compared to all other reasons. The strength of the influence that fears of side effects play in method selection, discontinuation and choice of method switched to where switching occurs, is a critical but amenable element if allocated the necessary attention. iii University of Ghana http://ugspace.ug.edu.gh DEDICATION To CJ and Kay iv University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS To the Dean of the School of Public Health (my primary supervisor) Prof. Richard Adanu, for his unshakeable support, unwavering encouragement, patience and motivation. I could not have imagined a more dedicated mentor. I would like to express my immense gratitude to my academic co-supervisors, Dr. Aryeetey and Dr. Laar who offered instrumental guidance, encouragement and support throughout this learning process. To my past and current Heads of department Prof. A. Ankomah and Prof. K. Torpey, thank you for your leadership, I am grateful for the concern, encouragement and continued support. To all faculty of the department of population family and reproductive health. Thank you for the diverse ways you have assisted and encouraged me. I would like to also thank all faculty members from the school of public health who in diverse ways have shared their knowledge and expertise with me during the course of this work. I am grateful to my fellow postgraduate students from the School of Public Health, especially those from the Population Family and Reproductive health department (PFRH) for their invaluable assistance. To all my friends old and new, my support team A, thank you for standing by me and offering help in multiple ways to keep the drive. I am grateful to Dr. Deda Ogum- Alangea and Dr. Abubakar Manu for the emotional and physical support, prayers at v University of Ghana http://ugspace.ug.edu.gh each stage, and reassurances whenever I was in doubt. I also wish to thank Mr. Tony Godi, Dr. Dwomoh, and the entire Biostatistics department for their technical assistance and advice. I wish to acknowledge the financial support received from the BSU-PHH through the college of health sciences postgraduate research grant. Most importantly I would like to express my sincere gratitude to my Husband and family for their understanding and support throughout the duration of this study. I thank you for the immense financial, emotional and prayer support and sacrifices through all the tough times particularly when I needed it most. I would not be here without you. And finally to God Almighty who knew that this was possible and has made it possible in His time. vi University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................ i ABSTRACT .................................................................................................................. ii DEDICATION .............................................................................................................. iv ACKNOWLEDGEMENTS ........................................................................................... v TABLE OF CONTENTS ............................................................................................ vii LIST OF TABLES ..................................................................................................... xiii LIST OF FIGURES ..................................................................................................... xv LIST OF ABBREVIATIONS ..................................................................................... xvi DEFINITION OF TERMS ...................................................................................... xviii CHAPTER ONE ............................................................................................................ 1 1.0 INTRODUCTION ................................................................................................... 1 1.1 Fertility, Contraceptive use, Discontinuation and Switching in Ghana ............... 3 1.2 Conceptual framework ......................................................................................... 5 1.3 Problem Statement ............................................................................................... 9 1.4 Justification ........................................................................................................ 11 1.5 Main Objective................................................................................................... 13 1.6 Specific objectives ............................................................................................. 13 1.7 Hypotheses ......................................................................................................... 13 CHAPTER TWO ........................................................................................................
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