Study setting and Design
An institution-based cross-sectional study design was conducted in Bahir Dar city health facilities which provide Family Planning services including LARCs from April 1 to May 30 /2021. Bahir Dar is the capital city of Amhara National Regional State in the Federal Democratic Republic of Ethiopia located in the Northwest direction at 565 km away from Addis Ababa, the capital city of Ethiopia (14). The population of Bahir Dar City was estimated to be 389,177 in the year 2020 based on the 2007 census (15).
The Bahir Dar city has one specialized referral, one comprehensive referral, and one primary public hospital (Tibebe Ghion, Felege Hiwot, and Addis Alem respectively), 6 health centers (Abay health center, Han health center, Shimbet health center, Menelik health center, Bahir Dar health center, and Shum-abo health center), 10 health posts, two specialized clinics (family guidance association and Maire stope), 4 private general hospitals and 35 medium private clinics (16). Family guidance association and Maire stop specialized clinics are non-governmental facilities that provide consistent family planning services including implants and Intrauterine contraceptive devices. Therefore, these were included in this study.
Source population
All reproductive-age women who were using long-acting reversible contraceptive methods in health facilities of Bahir Dar city.
Study population
All reproductive-age women who were using long-acting reversible contraceptive methods came to selected health facilities of Bahir Dar city with contraceptive-related issues during the study period.
Inclusion criteria and Exclusion criteria
Inclusion criteria
All reproductive age women who were using LARCs came to the selected health facilities for any issue concerning the method before completion of duration; like removal, side effects, and follow-up during the actual data collection period.
Exclusion criteria
All women who were using LARCs came to the selected health facilities for the removal of LARCs who got the service outside Bahir Dar city and who came to change Implanon to Jaddles, Jaddles to Implanon, and implants to IUCD or vice versa.
Sample size determination
Accordingly, for the first and second specific objectives, the sample size was calculated separately, and the larger sample size was taken to be used for this study. Sample size determination for objective one was calculated by using single population formula by considering the following assumptions: 95% CI, the prevalence (P) of LARC discontinuation taken from a study conducted in Hawassa city which was 57% with a non-response rate of 10% (1).
N =\(z({\frac{\alpha }{2})}^{2}\frac{p(1-P)}{{ d}^{2}}\), Where n is the minimum sample size required, p is expected proportion of discontinued LARCS, z=1.96 (95% CI) and d= 0.05 is the margin of error between the sample and the population. Applying the equation; n = \(({1.96)}^{2}\frac{0.57\ast 0.43}{{ \left(0.05\right)}^{2}}\) = 377, with 10% non-response rate the final sample was calculated as 377+ (377*10/100) =377+37.8= 377+38=415.
Sample size determination for objective two was calculated by using double population formula with Epi-info version 7.2.1 Stat Calc by considering the following assumptions: Two-sided significant level (1 - alpha): 95% CI, power (1 - beta, % chance of detecting):80%, the ratio of Exposed: Unexposed =1, and nonresponse rate of 10%. Exposed in this case means exposed to factors for removal (experiencing side effects, lack of counseling, and desire for pregnancy). These factors were taken from a study conducted in Hawassa city (1) (Table 1).
Table1 1: Sample size determination using associated factors of discontinuation of reversible long-acting contraceptive methods among women in Bahir Dar city Health facilities, Northwest Ethiopia, 2021.
S.no
|
1
|
2
|
3
|
Factors
|
Removal due to experience of side
|
Removal due to lack of counseling
|
Removal due to desire for pregnancy
|
Reference
|
1
|
1
|
1
|
AOR
|
2.09
|
2.48
|
2.34
|
Power
|
80
|
80
|
80
|
CI
|
95%
|
95%
|
95%
|
Ratio
|
1
|
1
|
1
|
% of un exposed outcome
|
47.2
|
25.8
|
44.8
|
% of the exposed outcome
|
35.3
|
44.8
|
36.4
|
Sample size with 10% non-response rate
|
286
|
207
|
240
|
Finally, the calculated sample size for the second objective with a 10% nonresponse rate is less than that of the first objective. Therefore, the sample size of the first objective was the sample size of this study which is 415.
Sampling technique
All public health facilities of Bahir Dar city which has LARC services were included in the study (3 hospitals and 6 health centers). Two Nongovernmental specialty clinics (Family Guidance Association and Maire stops) were also included since they provide LARCs service. The other private health facilities were not included since they have no full LARC services (insertion and removal). Hence a total of eleven (11) health facilities were included in this study.
The study subjects were identified based on the information obtained from the Family planning registration book. The information obtained from two Months report from the family planning registration book of one year preceding this study period in similar months observed that a total of 830 women were booked or used LARCs in health facilities of Bahir Dar City. The average two-month client flows for health facilities were taken.
The proportionally allocated sample size for each facility was calculated as ni=Ni*nf/N; where ni=sample size in each facility,
Ni=number of women who were using LARCS in each facility within two months,
nf =total sample size of this study (415), and
N=all women in Bahir Dar City health facilities who were using LARCs (830).
Finally, the total sample size was met by using the systematic sampling technique of daily caseload. K was calculated by dividing the total two-month caseload in Bahir Dar City for the total proportional allocated cases as 830/415=2. Therefore, every other woman was included in the sample until the total sample size for this study was obtained. Based on the client's card order information was collected from participants after completion of the service. The procedure was continued throughout the data collection period until the required sample size was achieved (Figure 2).
Variables
Dependent variable
Long-acting reversible contraceptives discontinuation (Yes/No)
Independent variables
Socio-demographic characteristics
Age, marital status, religion, ethnicity, occupation, maternal educational status, husband's educational status, and husband's occupation
Obstetric related factors
Parity, number of living children, history of abortion, and desire for pregnancy in near future.
Contraceptive method and Health facility-related factors
Past contraceptive utilization, type of LARC used, side effects, follow-up, type of health facility, counseling, who choose LARC, has no husband/go abroad, loss of implant in the arm, the expulsion of IUCD/missing of string, and becoming pregnant/method failure
Other factors including Myths and Misconceptions
Peer pressure/neighbor's influence, husband objection/order, decreasing of sexual activity/Libido, fear of migration of the LARC to other body parts, fear of infertility, and fear of cancer.
Operational Definition
Long-acting reversible contraceptive methods (LARCs): contraceptive methods which serve as 3–10 years but can be removed at any time (not permanent); only implants and IUCD (17).
Discontinuation of LARCs: starting using and cessation of long-acting reversible contraceptives before completion of duration due to any issue concerning with the method (1).
Misconception: without scientific evidence, the woman perceived LARCS can cause infertility, cancer, shifting to other body sites, and reduce sexual activity (18).
Follow-up: is schedule or appointment given for the mother to come to health facilities on regular basis or when she has concerns with the method not only appointed by the due date.
Side effect: when the women develop at least one of the following after LARC insertion: menstrual disruption, insertion site pain, difficultly to work, headache, acne, and weight change (14, 17).
Data Collection Instruments, Collectors, and Procedures
The data for this study were collected by using a pre-tested structured interview-based questionnaire which was adapted from previous literature (1) with some modifications. There are four main parts to this questionnaire. These are socio-demographic characteristics, obstetric-related factors, contraceptive method and health facility-related factors, and others factors including myths and misperceptions about LARCS. To check for its consistency, the questionnaire was first developed in English and translated into Amharic and then finally back to English.
Data collectors were five Nurses (3 diplomas and 2 degrees) and six Midwives (2 diplomas and 4 degrees) who were not working in health facilities. Data were collected from study subjects through a face-to-face interview-guided questionnaire. Data were collected and the questionnaire was filled by data collectors after obtaining written consent from the study participants.
Data collectors have gathered information from study subjects around the family planning room after completion of the service provided by health care providers. Three supervisors with a qualification of degree and skilled in data collection supervised the data collection. The principal investigators supervised and provided all necessary items for data collection, checked completeness and logical consistency, and solve problems during the time of data collection daily.
Data Quality Assurance
To assure the quality of data, properly designed data collection tools were used. Data collectors and supervisors were trained about research objectives, data collection tools, procedures, and interview techniques for one day. Before the actual data collection, the questionnaire was tested on 5% of the total sample size (21 women) who were used LARC methods at Zenzelima Health Center (11 women) and Meshenti Health Center (10 women) to check the contextually of data.
The questionnaires were revised and get amended as necessary after the pretest was done. The principal investigator, together with three supervisors supervised the technique of data collection and completeness of tools on the daily basis, and accordingly, appropriate feedback was forwarded. To resolve differences and assure their quality, data double entry was performed.
Data Processing, Analysis, and presentation
After data collection, the questionnaire was checked for completeness, data entered, coded, checked, and cleared by using EPI DATA V-3.1 and then exported to Statistical Package for Social Science [SPSS] V-25 computer software. Then analysis (Descriptive statistic to summarize data) and Bi-variate logistic regression were performed at 95% confidence level with LARCs discontinuation for each factor. From the bivariate regression analysis, variables at p < 0.25 were entered into multivariate logistic regression analysis with a 95% confidence level, multicollinearity test was done to check the correlation between each independent variable, and the model goodness of fit was tested using Hosmer and Lemeshow test.
Variables with a p-value less than 0.05 in the multivariate logistic regression analysis were considered as statistically significant factors for LARCs discontinuation. Finally, the descriptive statics results were presented using text, tables, and graphs based on the type of data.
Ethical Consideration
The study gets research ethics approval from Bahir Dar University, College of Medicine and Health Sciences Institutional Review Board (IRB). The permission and agreement consent was obtained from the Bahir Dar city Health Department and the selected health facilities before data collection.
Voluntary, informed, written, and signed consent were obtained from heads of selected health facilities in Bahir Dar city and participants before data collection started. The participants were also assured that their responses could not result in any harm and offered full rights not to participate, the name did not write on the tool, and confidentiality was maintained.