Provider and lay perspectives on intra-uterine contraception: a global review

Common misperceptions and public knowledge about intrauterine devices among US-based online respondents

OBJECTIVES

Misperceptions about intrauterine devices (IUDs) may dissuade potential users and public beliefs are not well understood. We sought to describe public knowledge of mechanism of action, failure rate, and IUD health risks. Secondary objectives included identifying inaccurate information and information sources about IUDs.

STUDY DESIGN

We conducted a convenience-based survey of participants living in the United States 18 years and older using Amazon Mechanical Turk and ResearchMatch. We collected information on demographics, reproductive history, and IUD knowledge. We asked about IUD mechanism of action, failure rate, potential health risks, and information sources. We used multivariable logistic regression to test the association between gender and perceived lower (vs. higher) risks of IUDs.

RESULTS

We included 1597 individuals with 726 (45.5%) self-reported men and 871 (54.5%) self-reported women. For both hormonal and non-hormonal IUDs, participants most often selected implantation prevention as the primary mechanism of action. In our sample, 55.5% of individuals believed the failure rate was greater than five percent. Weight gain, uterine perforation, and expulsion were cited as health risks likely to occur ≥5% of the time by 42.1%, 34.3%, and 38.4% of participants, respectively. Participants identified healthcare providers as their primary source of contraceptive information. Our multivariable logistic regression analysis revealed women had higher odds of perceiving IUDs as higher risk (aOR=1.35, 95% CI 1.09-1.68) compared to men.

CONCLUSIONS

Individuals underestimated IUD effectiveness while overestimating perceived health risks. Our results highlight areas to target education about IUDs to support informed contraceptive decision-making.

IMPLICATIONS

Participants misunderstood IUD mechanism of action, underestimated efficacy, and overestimated failure rates and health risks. Providers should begin clinical counseling by assessing baseline knowledge, since mechanism of action, side effect profiles, and concepts like female anatomy should not be assumed to be known.

Provider bias and family planning in Upper Egypt: a simulated client approach

BACKGROUND

Provider bias is a main barrier that extensively violates the right of free family planning method choice. Egypt is one of the countries that shows skewness in its method mix. Provider bias and insufficiency of alternative methods are identified as potential factors underlying this phenomenon which contributes to high unmet needs and discontinuation rates. Provider bias may be influenced by cultural beliefs and societal trends and is usually overlooked as a possible cause of this skewed method mix. This study aims to explore the presence of provider bias in rural Upper Egypt and its potential causes, a community with conservative cultural beliefs and least contraceptive prevalence rates.

METHODS

This is a qualitative study using the "simulated client's approach." The study was conducted in 16 villages in Assiut and Sohag governorates in Egypt. The simulated clients visited 30 clinics, 15 in each governorate, including primary healthcare units and private clinics. Three scenarios were used to explore the physicians-imposed restrictions for contraceptive use with different clients' eligibility criteria. Data was analyzed using the grounded theory methodology.

RESULTS

Recommending a contraceptive method for the mystery clients was not based on informed choice. Most providers had method or client bias. Copper IUD was the most favorable contraceptive method recommended by providers, with negative attitude towards using hormonal contraception. Nulliparous and young clients were discouraged to use contraception before proving fertility or offered temporary methods as emergency contraception or condoms. Providers have shown misconceptions related to infertility-associated complications of contraceptive use, especially for the young and nulliparous women.

CONCLUSION

In this study, providers had a clear bias towards recommending IUD rather than all other contraceptive methods, which was hindered in some cases by the lack of insertion skills. Interventions to reduce provider bias should go beyond technical training. Moreover, training on reproductive rights should be a main component of routine training. Providers should regularly receive research results and be oriented toward recent medical eligibility criteria of contraceptive methods use. Moreover, the sociocultural beliefs of providers that may affect their practice should be explored and addressed.

Claims in the clinic: A qualitative group interview study on healthcare communication about unestablished side effects of the copper IUD

BACKGROUND

Lay online communication about health-related issues has in recent years largely been associated with the spread of misinformation and decreased trust in healthcare. Such communication has included claims about systemic side effects of the copper IUD. In Sweden, a social media group centered on this issue now gathers around 8,700 members. This study aimed to use the case of reported yet unestablished side effects of the copper IUD to investigate experiences of and reasoning about healthcare encounters between caregivers and patients contesting established medical knowledge.

METHODS

We conducted qualitative, semi-structured, digital group interviews with members of the social media group (seven groups, n = 23) and with midwives and gynecologists (six groups, n = 15). We also gathered essays written by social media group members (n = 23). The material was analyzed thematically.

RESULTS

The participant accounts pointed towards tensions related to principles of evidence-based medicine, i.e., perceived insufficiency of research on the safety of the copper IUD and lack of clarity in routines for reporting and following up suspected side effects, and of patient-centered care, i.e., listening respectfully to patients. Tension between caregivers' obligation to adhere to evidence-based medicine while also providing patient-centered care was noted.

CONCLUSION

Healthcare providers' efforts to assess and address patient claims contesting established medical knowledge should include ensuring and communicating sufficient research, clarifying procedures for reporting suspected side effects, and improving person-centered care. This can increase the quality of care while contributing to the mitigation of distrust in healthcare and the spreading of health-related misinformation.

Mapping Long-acting Reversible Contraceptive Interventions to the Social Ecological Model: A Scoping Review

INTRODUCTION

Long-acting reversible contraception (LARC) is one option for preventing unintended pregnancies and short interpregnancy intervals. Efforts to increase access to contraception may benefit from applying the social ecological model (SEM), a framework that considers individual, interpersonal, organizational, community, and policy influences on behavior. We aimed to summarize findings from interventions on LARC use and map interventions to SEM levels.

METHODS

We conducted a scoping review of the 2010-2020 literature in PubMed/MEDLINE and Embase databases to summarize interventions that did and did not increase LARC use. Although increasing LARC use is not an appropriate goal from a reproductive autonomy standpoint, it is the stated goal of much of the research conducted to date and typically indicates an improvement in access. We mapped these interventions to SEM levels and categorized their strategies: cost support, patient counseling, administrative support, provider training, and other.

RESULTS

Of 27 interventions reviewed, 17 (63%) increased LARC use. We observed a greater proportion of interventions that increased LARC uptake among those with strategies implemented at policy (8/10 [80%]) or organizational (14/19 [74%]) SEM levels compared with interventions implemented at other SEM levels. When both individual and organizational SEM-level components were implemented, five of six interventions (83%) increased uptake. All five interventions with both organizational- and policy-level components increased LARC use. Among the 27 interventions, patient counseling (n = 12) and cost support (n = 12) were common strategies. Five of 12 interventions (42%) involving patient counseling and 11 of 12 (92%) involving cost support increased LARC use.

CONCLUSIONS

Organizational and policy SEM components and cost support strategies were most prevalent in interventions that increased LARC use. Future interventions to improve access to contraception, while respecting patient autonomy, could incorporate more than one SEM level.

"If I use family planning, I may have trouble getting pregnant next time I want to": A multicountry survey-based exploration of perceived contraceptive-induced fertility impairment and its relationship to contraceptive behaviors

Objectives

We aim to assess women's perceptions regarding contraceptive effects on fertility across a diversity of settings in sub-Saharan Africa and how they vary by women's characteristics. We also aim to examine how such beliefs relate to women's contraceptive practices and intentions.

Study design

This study uses cross-sectional survey data among women aged 15 to 49 in nine sub-Saharan African geographies from the Performance Monitoring for Action project. Our main measure of interest assessed women's perceptions of contraceptive-induced fertility impairment. We examined factors related to this belief and explored the association between perceptions of contraceptive-induced fertility impairment and use of medicalized contraception (intrauterine device, implant, injectable, pills, emergency contraception) and intention to use contraception (among nonusers).

Results

Between 20% and 40% of women across study sites agreed or strongly agreed that contraception would lead to later difficulties becoming pregnant. Women at risk of an unintended pregnancy who believed contraception could cause fertility impairment had reduced odds of using medicalized contraception in five sites; aORs ranged from 0.07 to 0.62. Likewise, contraceptive nonusers who wanted a/another child and perceived contraception could cause fertility impairment were less likely to intend to use contraception in seven sites, with aORs between 0.34 and 0.66.

Conclusions

Our multicountry study findings indicate women's perception of contraceptive-induced fertility impairment is common across diverse sub-Saharan African settings, likely acting as a deterrent to using medicalized contraceptive methods.

Implications

Findings from this study can help improve reproductive health programs by addressing concerns about contraception to help women achieve their reproductive goals.

Marshallese Mothers' and Marshallese Maternal Healthcare Providers' Perspectives on Contraceptive Use and Reproductive Life Planning Practices and Influences

Pacific Islander communities experience significant maternal and infant health disparities including high maternal and infant mortality. Contraception and reproductive life planning prevent approximately one-third of pregnancy-related deaths and neonatal deaths. We report the results of formative research devoted to understanding Marshallese mothers' as well as their maternal healthcare providers' practices and influences related to contraceptive use and reproductive life planning. This study used an exploratory, descriptive qualitative design to explore Marshallese mothers' and maternal healthcare providers' practices and influences of contraception use and reproductive life planning. Twenty participants were enrolled in the study, 15 Marshallese mothers and five Marshallese maternal healthcare providers. For the Marshallese mothers, two themes emerged: (1) Reproductive Life Planning Practices and Information; and (2) Reproductive Life Planning Influences. For the Marshallese maternal healthcare providers, two themes emerged: (1) Reproductive Life Planning Practices; and (2) Reproductive Life Planning Influences. This is the first study to document Marshallese mothers' and maternal healthcare providers' practices and influences with contraceptive use and reproductive life planning. Study results will inform the development of a culturally-adapted contraception and reproductive life planning tool with an educational program for Marshallese family units and maternal healthcare providers serving Marshallese women.

Mapping Evidence Regarding Decision-Making on Contraceptive Use among Adolescents in Sub-Saharan Africa: A Scoping Review

This scoping review mapped and synthesised existing evidence on the influence of individual, parental, peer, and societal-related factors on adolescents' decisions to use contraception in sub-Saharan Africa (SSA). Peer-reviewed and review articles published before May 2022, targeting adolescents aged 10-19 years were searched in PubMed, MEDLINE with Full Text via EBSCOhost, PsychINFO via EBSCOhost, CINAHL with Full Text via EBSCOhost, Google Scholar, Science Direct, and Scopus databases. Seven studies were included and analysed using thematic analysis based on the social-ecological model (SEM) and reported using the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Individual (fear of side effects, fear of infertility), parental (parental disappointment and disapproval), peer (social stigma), partner (association with promiscuity and multiple sexual partners), societal and community (contraceptive use disapproval and stigma), and institutional and environmental factors (lack of privacy and confidentiality) influence contraceptive decisions among adolescents. These also include a lack of accurate information, social exclusion, negative health provider attitudes, and a lack of infrastructure that provides privacy and safe spaces. Identifying and addressing core issues within the context of local cultural practices that restrict contraceptive use is important. Holistic, inclusive approaches that promote the well-being of adolescents must be utilised to provide a conducive environment that ensures privacy, confidentiality, safety, and easy access to contraceptive services.

On the verge between the scientific and the alternative: Swedish women's claims about systemic side effects of the copper intrauterine device

The article intervenes in discussions on lay knowledge production about health in the Internet era, through the case of a group of women claiming that their use of copper intrauterine devices has led to systemic side effects. Based on online group interviews and written essays, we examine how women embracing these knowledge claims navigate various sources of information, focusing on the role of scientificity in these epistemic negotiations. The women were found to be involved in an active, scientifically oriented process of knowledge formation, which we refer to as a collective labour of scientific patchworking. Meanwhile, due to a perceived lack of scientifically based expertise on their condition, the women reported having little choice but turn to resources with weaker scientific foothold. We argue that the tendency to portray these women's claims as unscientific simplifies the nature of lay knowledge production, potentially deepening divides between medical authorities and the public.

Analgesics for intrauterine device placement

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To examine the effectiveness of analgesics for routine intrauterine device (IUD) placement on patient (e.g. pain, side effects, satisfaction) and provider outcomes (e.g. ease of placement, need for adjunctive placement measures, placement success) compared with placebo or no treatment.

Factors associated with use of long-acting reversible and permanent contraceptives among married women in rural Kenya: A community-based cross-sectional study in Kisii and Kilifi counties

Long-acting and permanent contraceptive methods (LAPM) are effective and economical methods for delaying or limiting pregnancies, however they are not widely used. The Kenya government is promoting the use of modern methods of family planning through various mechanisms. This study aimed to determine the prevalence and factors associated with the use of LAPM among married women of reproductive age in targeted rural sub-counties of Kilifi and Kisii counties, Kenya. Baseline and end line Data from a program implemented on improving Access to Quality Care and Extending and Strengthening Health Systems (AQCESS) in Kilifi and Kisii counties of Kenya were used. Multi-stage sampling was used to sample 1117 and 1873 women for the end line and baseline surveys, respectively. Descriptive analysis was used to explore the respondents' characteristics and use of LAPM on a self-weighted samples. Univariable and multivariable binary logistic regression models using svy command were used to assess factors associated with the use of LAPM. A total of 762 and 531 women for the baseline and end line survey, respectively were included in this study. The prevalence of use of LAPM for baseline and end line survey were 21.5% (95% CI: 18.7-24.6%) and 23.2% (95% CI: 19.6%-27.0%), p-value = 0.485. The use of LAPM in Kisii and Kilifi counties was higher than the national average in both surveys. The multivariable analysis for the end line survey showed having 3-5 number of children ever born (aOR = 2.04; 95% CI: 1.24-3.36) and future fertility preference to have another child (aOR = 0.50; 95% CI: 0.26-0.96) were significantly associated with odds of LAPM use. The baseline showed that having at least secondary education (aOR = 1.93; 95%CI: 1.04-3.60), joint decision making about woman's own health (aOR = 2.08; 95%CI: 1.36-3.17), and intention to have another child in future (aOR = 0.59; 95%CI: 0.40-0.89) were significantly associated with the use of LAPM. Future fertility preference to have another child was significantly associated with the use of LAPM in the two surveys. Continued health promotion and targeted media campaigns on the use of LAPM in rural areas with low socioeconomic status is needed in order to improve utilization of these methods. Programs involving men in decision making on partner's health including family planning in the rural areas should be encouraged.

Providers' approaches to contraceptive provision in Cape Town

Background

Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counseling. This study explores primary care providers' perspectives and approaches to contraceptive service provision for women attending public sector clinics in South Africa, with the intention of ascertaining established practices and training needs.

Methods

Ten in-depth interviews were conducted at five primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included nurses providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analyzed using a thematic analysis approach.

Results

Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Contraceptive prescribing practices were influenced by women's medical history and preferred bleeding patterns. Providers' concerns about adherence to methods for younger women and suspected adverse events for older women impacted on prescribing. Challenges experienced when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and their work pressure due to providing other health services.

Discussion

Health care providers play a critical role in facilitating women's right to access high quality contraceptive services. Providers saw themselves as negotiators during contraceptive counseling. They considered both women's preferences and their own recommendations for contraception, to provide information that would enable women to make informed contraceptive decisions. By reinforcing this approach to contraceptive counseling and focusing on shared decision-making, should encourage autonomy in method selection and limit the influence of provider's contraceptive method selection.

Attitudes Toward the Copper IUD in Sweden: A Survey Study

Background

While the efficacy and safety of the contraceptive copper intrauterine device (IUD) have been affirmed, alongside its importance for the prevention of unintended pregnancies, some studies have pointed to negative attitudes toward the device. In recent years, social media communication about it has included claims about systemic side effects, unsubstantiated by medical authorities. Research from the Swedish context is sparse. This study investigates attitudes toward the copper IUD and any correlations between negative attitudes toward or experiences of the device, and (1) sociodemographic characteristics, (2) the evaluation of the reliability of different sources of information, and (3) trust in healthcare and other societal institutions.

Methods

A survey was distributed online to adult women in Sweden (n = 2,000). Aside from descriptive statistics, associations between negative attitudes toward or experiences of the copper IUD and sociodemographic and other variables were calculated using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). Open survey responses (n = 650) were analyzed thematically.

Results

While many reported positive attitudes toward and experiences of the IUD, 34.7% of all respondents reported negative attitudes and 45.4% of users reported negative experiences. Negative attitudes were strongly correlated with negative experiences. Negative attitudes and experiences were associated with low income, but no conclusive associations were identified with other socioeconomic variables. Negative attitudes and experiences were associated with lower levels of confidence in and satisfaction with healthcare, as well as lower self-assessed access and ability to assess the origin and reliability of information about the IUD. In open responses, negative comments were prevalent and included references to both common and unestablished perceived side-effects. Respondents pointed to problematic aspects of information and knowledge about the copper IUD and called for improved healthcare communication and updated research.

Conclusion

Healthcare provider communication about the copper IUD should promote reproductive autonomy and trust by providing clear information about potential side effects and being open to discuss women's experiences and concerns. Further research on copper IUD dissatisfaction and ways in which health professionals do and may best respond to it is needed.

Educational Multimedia Tool Compared With Routine Care for the Uptake of Postpartum Long-Acting Reversible Contraception in Individuals With High-Risk Pregnancies: A Randomized Controlled Trial

OBJECTIVE

To assess whether an intervention with a multimedia educational tool, compared with routine care, would increase the use of long-acting reversible contraceptives (LARC) at 12 weeks postpartum in individuals with high-risk pregnancies.

METHODS

In this single-center randomized trial, we assigned individuals aged 13-50 years with high-risk pregnancies to either a multimedia educational tool or routine care. Participants were included during pregnancy through postpartum day 1. Those randomized to the multimedia educational tool (MET) group were provided a tablet with the preloaded 3-5-minute multimedia presentation (https://prezi.com/view/jpFrXaPnnxuqRkcI3A4a/), which was viewed without the presence of research staff and resent by secure email every 4 weeks if undelivered. The primary outcome was uptake of LARC (implant or intrauterine device) within 12 weeks of delivery. The secondary outcomes included overall use of any method of contraception and composite maternal and neonatal adverse outcomes. A priori estimates indicated that 380 participants were needed to detect a 40% difference in use of LARC (baseline 40%; alpha=0.05, power=0.8, assumed loss to follow-up 20%). Relative risk (RR) and number needed to treat (NNT), along with 95% CIs, were calculated.

RESULTS

From July 2020 through December 2020, 536 persons were screened and 380 randomized as follows: 190 for the multimedia educational tool and 190 for routine care. Demographic characteristics were similar between groups. The primary outcome-available for more than 90% of participants-was higher in the MET group (32.4%) than in the routine care (RC) group (20.9%) (RR 1.55; 95% CI 1.09-2.21; NNT nine, with 95% CI 5-42). Overall use of contraception was also higher in the MET group than in the RC group (RR 1.16; 95% CI 1.03-1.32).

CONCLUSION

Among individuals with high-risk pregnancies, compared with routine care, use of a multimedia-based educational tool increased the uptake of postpartum LARC by 55%.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04291040.

FUNDING SOURCE

Funded in part by Investigator-Initiated studies of Organon.

Perspectives of health care providers regarding the levonorgestrel-releasing intrauterine system

OBJECTIVES

The aims of the study were to assess the number of insertions per month of the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) and gauge the knowledge and opinions of health care providers with regard to some of its characteristics and the reasons why women liked using the method.

METHODS

An online questionnaire survey was conducted between January and July 2021 at the University of Campinas, Brazil. The survey comprised physicians and nurses from centres that had requested and received donated devices.

RESULTS

A total of 65 health care providers answered the questionnaire (41 physicians and 24 nurses). The main misconceptions were related to insertion after an ectopic pregnancy: 60/65 (92.3%) answered that users with previous ectopic pregnancy must have frequent follow-up. Wrong answers were also given on the occurrence of acne (37/65, 56.9%) and depression (32/65, 49.2%). Participants reported that the LNG-IUS was highly effective (100%), long-acting (93.9%) and an appropriate method for controlling uterine bleeding (90.8%) and that it had few side effects (86.2%).

CONCLUSION

Our study suggests that health care providers from centres that requested and received LNG-IUS donations, even though they reported adequate knowledge about the device, still had misconceptions with regard to its clinical management.

Migration and Contraception among Mexican Women: Assessing Selection, Disruption, and Adaptation

Despite the sizeable impact of migration on childbearing, less is known about how it shapes contraceptive use undergirding fertility. We utilize binational survey data collected in 2006/7 by the Migration, Gender, and Health among Immigrant Latinos in Durham, NC study to assess how selection, disruption, and adaptation shape contraceptive use among Mexican migrant women. We address selectivity with respect to both socio-demographic and formative sexual initiation characteristics, comparing migrants to non-migrants in Mexico. We examine the disruptive effect of migration on contraception among migrant women sexually initiated in Mexico. Finally, we compare current methods between Mexican migrants and non-migrants to assess adaptation to U.S. contraceptive practices. We find migrant selectivity is less important than context in shaping immigrant women's contraceptive practices, though migrant women sexually initiated in the United States exhibit earlier and higher levels of contraceptive use than their migrant peers initiated in Mexico. Migration also disrupts contraceptive trajectories. Many migrants discontinue contraceptive use pre-migration in response to their husbands' solo migration. Partner separation also reduces contraceptive use immediately after migration. Finally, migrants show numerous signs of adaptation to the U.S. context, mainly via the adoption of oral contraception. The main obstacle for contraceptive use in Durham is lack of information about where to obtain it. Efforts to improve immigrants' reproductive health should recognize the deleterious effect of policies encouraging family separation. Healthcare must reach immigrant women soon after arrival, be attuned to pre-migration contraceptive practices, and recognize the unique vulnerabilities of women migrating at older ages.

Choosing intrauterine device of mothers in rural area, Indonesia: Based on Health Belief Model Theory

This study aimed to identify the correlation between perceived susceptibility, perceived seriousness, perceived benefit, self-efficacy, perceived barrier, cues to action, and the choice of using the intrauterine device. A cross-sectional study was carried out to 109 mothers in Ngudikan Village. Data were collected using questionnaires. The data was analyzed using the Spearman Rank correlation with a level of significance α=0.05. The result show that there is a correlation between perceived susceptibility (p=0.000; r=0.436), perceived seriousness (p=0.000; r=0.402), perceived benefits (p=0.033; r=0.204), perceived barriers (p=0.00, r=-0.614), perceived self-efficacy (p=0.008; r=0.253) and cues to action (p=0.006; r=0.261) had a correlation with the choice of intrauterine device in Nganjuk, Indonesia. Perceived susceptibility, perceived seriousness, perceived benefits, self -efficacy, and cues to action will affect the decision of mothers in choosing an intrauterine device. This study recommended further research on a transcultural nursing approach to follow up on the result of this study.

Role of social network in decision making for increasing uptake and continuing use of long acting reversible (LARC) methods in Pakistan

INTRODUCTION

Despite evidence from recent Demographic Health Surveys that show 98% of the adult Pakistani population have an awareness of at least one modern contraceptive method, only 25% of married couples in Pakistan used a modern method of contraception. Of the modern contraceptive methods, LARC usage has increased only from 2.1 to 3%. This low uptake is puzzling in the context of high awareness of LARC methods and its availability through public sector facilities at subsidized costs. This study aimed to understand the social influences in initiating and continuing use of an LARC methods for contraception in a rural setting in Pakistan.

METHODS

In-depth interviews were conducted with 27 women who were using a LARC method for contraception. Data was managed using NVivo 12 and themes were identified using a content analysis approach to analyze the transcripts.

RESULTS

Four key themes, supported by sub-themes relating to a temporal model, were identified to explain women's experiences with initiating and continuing use of a LARC. The themes were (i) Use of trusted networks for information on LARCs; (ii) Personal motivation and family support in decision to use LARC; (iii) Choice of LARC methods and access to providers; and (iv) Social and professional support instrumental in long term use of LARC. Results highlight the significant role of immediate social network of female family members in supporting the women in initiating LARCs and maintaining the method's use.

CONCLUSION

This study contributes to an in depth understanding of the decision-making process of women who adopted LARC and maintained its use. Women who proceeded to use an LARC and who persisted with its use despite the experience of side effects and social pressures, were able to do so with support from other female family members and spouse.

Barriers to post-placental intrauterine device receipt among expectant minority women

PURPOSE

We aimed to identify barriers to breastfeeding-compatible post-placental intrauterine devices (IUDs) for expectant predominantly non-Hispanic African-American women.

MATERIALS AND METHODS

This cross-sectional survey study, conducted at 3 Cleveland community partner locations, enrolled 119 expectant predominantly unmarried but partnered non-Hispanic African-American women. The survey assessed contraceptive, IUD-specific and breastfeeding attitudes and intentions. Survey responses were described with percentages and frequencies, and compared by feeding intention using 2-sided Chi-Square tests. Factor analysis with Varimax rotation identified 2 potential measures of reluctance to post-placental IUD acceptance. The relationship of factors scores to maternal characteristics was assessed.

RESULTS

Feeding intention (breastfeeding versus not) was not related to perceived barriers to post-placental IUD receipt among expectant minority women. A "Personal Risks Reluctance" factor included low risk IUD events (migration and expulsion), misconceptions (delayed fertility return), menstrual changes and partner preference: a higher score was significantly associated with younger age group but no other maternal characteristics. A "Not Me Reasons" factor included provider and insurance barriers, and was not related to any maternal characteristics.

CONCLUSIONS

Expectant minority women's perceived barriers to post-placental IUDs are not related to prenatal feeding intentions. We identified two clinically relevant factors that appear to measure barriers to post-placental IUD acceptance.

Attitudes and Practices of Healthcare Professionals and Clinical Medical Students on Contraception: A Cross-Sectional Study in Cape Coast, Ghana

Background

Healthcare providers play a major role in the implementation of family planning policies. In Ghana, there has been a conscious effort to improve the knowledge of preservice and practicing health professionals on family planning. However, there have been concerns about the appropriateness of the attitudes and practices of these health cadres and, hence, their propensity to become barriers to the uptake of contraception in the general population. This study is aimed at assessing the attitudes and practices of healthcare workers and clinical-year medical students in contraceptives use, advocacy, and service provision.

Methods

A cross-sectional survey was conducted among health workers and clinical-year medical students from January 1 to June 30, 2018. Variables assessed included sexual activity status, previous and current contraceptive use, and satisfaction with contraceptive use among others. Data from 400 self-administered, structured questionnaires comprising close- and open-ended questions was entered in SPSS version 22 and analysed using same. The variables assessed were presented as means, frequencies, and percentages.

Results

About 58% of the respondents were sexually active. Half of the participants (50.2%) had used a form of contraception before, with condoms and other barrier methods being the most preferred (67.7%). However, only 18% of respondents were on a form of contraceptive at the time of the survey. Four out of five (82.6%) of the users of these contraceptives were satisfied with their past use. A little over half of the participants had discussed contraception with their partners. Over four-fifths of participants thought family planning was beneficial and were willing to encourage others to use a method of family planning. Majority (63.7%) of the participants had had formal training in family planning, but only 72 (18%) were actively involved in the provision of family planning services.

Conclusions

Although the attitudes of the health workers and trainees toward family planning were excellent generally, only a few were using a method of contraception at the time of the survey despite the fact that most of them were sexually active. There is a need to intensify communication on behaviour change towards contraception among health professionals and clinical-year medical students in order to strengthen their role as change agents in an effort to improve community uptake.

Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up

Background

Health service providers play a key role in addressing women’s need for postpartum pregnancy prevention. Yet, in Nepal, little is known about providers’ knowledge, attitudes, and practice (KAP) on providing postpartum family planning (PPFP), particularly the immediate postpartum intrauterine device (PPIUD). This paper assesses providers KAP towards the provision of PPIUDs in Nepal prior to a PPIUD intervention to gain a baseline insight and analyzes whether their KAP changes both 6 and 24 months after the start of the intervention.

Methods

Data come from a randomized trial assessing the impact of a PPIUD intervention in Nepal between 2015 and 2017. We interviewed 96 providers working in six study hospitals who completed a baseline interview and follow-up interviews at 6 and 24 months. We used descriptive analysis, McNemar’s test and the Wilcoxon signed-rank test to assess KAP of providers over 2 years.

Results

The PPIUD KAP scores improved significantly between the baseline and 6-month follow-up. Knowledge scores increased from 2.9 out of 4 to 3.5, attitude scores increased from 4 out of 7 to 5.3, and practice scores increased from 0.9 out of 3 to 2.8. There was a significant increase in positive attitude and practice between 6 and 24 months. Knowledge on a women’s chance of getting pregnant while using an IUD was poor. Attitudes on recommending a PPIUD to different women significantly improved, however, attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Practice of PPIUD counseling and insertion improved significantly from baseline to 24 months, from 10.4 and 9.4% to 99% respectively.

Conclusions

Although KAP improved significantly among providers during the PPIUD intervention, providers’ knowledge on a women’s chance of getting pregnant while using an IUD and attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Provider KAP could be improved further through ongoing and more in-depth training to maintain providers’ knowledge, reduce provider bias and misconceptions about PPIUD eligibility, and to ensure providers understand the importance of birth spacing.

Contraceptive knowledge among women at risk of unintended pregnancy in Kingston, Jamaica

Low contraceptive knowledge may limit contraception initiation or continuation and, consequently, could represent an important, modifiable cause of unintended pregnancy. The objective of this analysis was to identify correlates of knowledge among women at risk of unintended pregnancy. We analyzed data from a study of 222 young women attending a public clinic in Kingston in November 2018 to March 2019. We measured contraceptive knowledge with seven questions on method reversibility, ability to use covertly, contraindications, and side effects. We used multivariable linear regression to evaluate the correlates of summary knowledge scores and report beta coefficients, which represent differences in mean summary knowledge scores. The mean knowledge score was low (2.7; range = 0-7). Only 30.2% of the participants correctly identified intrauterine devices as more effective than oral contraception, male condoms, and withdrawal. Women who reported that their provider discussed contraception scored higher (adjusted ß = 0.37, p = 0.05) than those not reporting this. Women who perceived implants as very/mostly safe scored higher (adjusted ß = 0.45, p = 0.01) than those perceiving the device as mostly/very unsafe. Finally, compared to contraception non-users, women using less-effective contraception had a lower score (adjusted ß = -0.40, p = 0.04) while those using effective contraception did not differ in scores (ß = -0.30, p = 0.18). Overall, we found poor contraceptive knowledge among young women in Kingston. Providers appeared to hold an important role in women's understanding of contraception.

A rapid scoping review of fear of infertility in Africa

Background

Fear of infertility (FOI) is often reported in studies about reproductive health but this literature not yet mapped. The aim of this rapid scoping review of qualitative studies was to describe the nature of FOI in Africa.

Methods

Eligibility criteria were qualitative data from Africa reporting views of women and men of any age. MEDLINE and CINAHL databases were searched for English language citations to February 2019 using keywords related to fear, infertility and Africa. Two independent reviewers screened texts for inclusion.

Results

Of 248 citations identified, 38 qualitative and six review papers were included. FOI was reported in diverse groups (e.g., men, women, fertile, infertile, married, unmarried, teachers, religious leaders). Two types of fears were identified: (1) fear of triggering infertility due to specific reproductive choices and (2) fear of the dire future consequences of infertility. Choices were perceived to affect fertility via internal accumulation and blockage (e.g., of menstrual blood), structural damage (e.g., burnt eggs), internal movement of contraceptive material, deliberate toxicity preventing population growth and behavioral effects impeding sexual activity. Diverse feared consequences of infertility were reported (e.g., polygamy, economic hardships). Fears were reported to affect reproductive behaviour (e.g., stopping contraception), help-seeking and social behaviour.

Conclusion

FOI is a phenomenon that should be studied in its own right. Fears could originate from genuine threats, incorrect knowledge, distortions of truths, or dissemination of false information. Rigorous studies are needed to better understand FOI and integrate it in health education, client counselling and family planning service provision.

Assessment of knowledge and skills training needs among employed midwives in health and medical centers, compared to expected duties as a part of Health System Reform Program, 2019

INTRODUCTION

As a part of healthcare providers of the Health System Reform Program, midwives are required to master the necessary knowledge and skills to meet the related demands of society. This study was aimed to assess the knowledge and skills training needs of practicing midwives of health and medical centers of Isfahan.

METHODS

This study is a descriptive cross-sectional study. The statistical target population was midwifery experts working in Isfahan health centers and the samples were selected through simple random sampling (sample size 250). Data were collected by two questionnaires to assess knowledge and skill needs. The validity of the questionnaires was confirmed by experts of the province and city health centers and medical education experts and its reliability was calculated by Cronbach's alpha (98%). Data were analyzed using SPSS 23 software and descriptive and analytical statistical methods (frequency, mean, variance).

RESULTS

The first five knowledge training priorities of employed midwives in health and medical centers, which comprise most of the means values, are pregnancy complications and abnormalities (3.64 ± 1.21); mammography and its interpretation (64.3 ± 1.30); skills and principles of parenting (3.59 ± 1.24); shortness of breath and palpitations during pregnancy (3.58 ± 1.16); and common mental disorders (3.57 ± 1.16). The most important skills training needs were Excel (1.21 ± 3.59), PowerPoint (27.1 ± 54.3), internet (3.52 ± 1.25), and parameters registration and reporting in the SIB system (3.49 ± 1.28). Employed midwives of the health and medical centers displayed a significant difference in feeling the need for training in some subjects.

CONCLUSION

Needs assessment is the foundation of purposeful training, and better training leads to improved performance of personnel and organizations. Therefore, it is imperative that reliable and documented data be utilized for promotion and improvement of in-service training programs of employed midwives of the health and medical centers of Isfahan province and also for revising university curriculums. Taking these measures would lead to the empowerment of personnel and general development of society.

Improving sexual and reproductive health knowledge and practice in Mozambican families with media campaign and volunteer family health champions

Objective

To increase knowledge, attitudes and practice of sexual and reproductive health and family planning and to reduce maternal and neonatal mortality rates in Mozambique.

Design

An implementation research project’s intermediate evaluation, applying two cross-sectional surveys. The surveys were planned for 316 subjects before and after interventions.

Setting

Research performed in Natikiri district of Nampula province in northern Mozambique, targeting a suburban and rural populations in their homes.

Participants

452 people were surveyed (91 before, 361 after), all belonging to the Macua ethnic group.

Interventions

A media campaign (2 weekly radio spots, bimonthly theatre performances) was performed for 8 months (2017 to 2018) and family health champions’ teachings (monthly home visits) performed for 3 months, on sexual and reproductive health and family planning. Outcome measures planned and measured were adolescent’s and adult’s knowledge, attitudes and practice about those. Data were analysed by gender, age group and frequencies, using a CI of 95% (p<0.5 statistically significant).

Results

Radio spots, community theatre and volunteer champions increased population’s knowledge about sexual and reproductive health and led to a more positive attitude toward family planning. Concerning attitude, results show differences between adults’ proportions before and after: (1) did you hear about sexual and reproductive health (p=0.0425); (2) knows project key messages (p<0.001); (3) knows prenatal visits importance (p=0.0301); (4) access to contraceptives was easy (p<0.001). Adolescents showed statistically significant differences before and after: (1) knows project key messages (p<0.001); (2) access to contraceptives was easy (p=0.0361). Family planning practice did not increase in both groups.

Conclusion

A health education intervention, using a media campaign and local volunteers, is useful to promote mother and child health. There is an unmet need for family planning and the use of modern contraception is below desired practice, needing further research about cultural barriers. Communication for behaviour change activities will pursue and impact will be assessed to document family planning practice improvement.

Investigating the quality of family planning counselling as part of routine antenatal care and its effect on intended postpartum contraceptive method choice among women in Nepal

Background

Though modern contraceptive use among married women in Nepal has increased from 26% in 1996 to 43% in 2016, it remains low among postpartum women. Integration of counselling on family planning (FP) at the time of antenatal care (ANC) and delivery has the potential to increase post-partum contraceptive use. This study investigates the quality of FP counselling services provided during ANC visits and women’s perceptions of its effectiveness in assisting them to make a post-partum family planning (PPFP) decision.

Methods

In-depth interviews (IDIs) were conducted with 24 pregnant women who had attended at least two ANC visits in one of the six public hospitals that had received an intervention that sought to integrate FP counselling in maternity care services and introduce postpartum intrauterine device insertion in the immediate postpartum period. IDIs data were collected as part of a process evaluation of this intervention. Women were selected using maximum variation sampling to represent different socio-demographic characteristics. IDIs were audio recorded, transcribed verbatim in Nepali, and translated into English. Data were organized using Bruce-Jain quality of care framework and analyzed thematically.

Results

Overall, the quality of FP counselling during ANC was unsatisfactory based on patient expectations and experience of interactions with providers, as well as FP methods offered. Despite their interest, most women reported that they did not receive thorough information about FP, and about a third of them said that they did not receive any counselling services on PPFP. Reasons for dissatisfaction with counselling services included very crowded environment, short time with the provider, non-availability of provider, long waiting times, limited number of days for ANC services, and lack of comprehensive FP-related information, education and counselling (IEC) materials. Women visiting hospitals with a dedicated FP counselor reported higher quality of FP counselling.

Conclusions

There is an urgent need to re-visit the format of counselling on PPFP during ANC visits, corresponding IEC materials, counselling setting, and to strengthen availability and interaction with providers in order to improve quality, experience and satisfaction with FP counselling during ANC visits. Improvements in infrastructure and human resources are also needed to adequately meet women’s needs.

Knowledge about the intrauterine device and interest in using it among women users of primary care services

OBJECTIVE

to analyze the level of knowledge about the intrauterine device, the interest in using it and the relationship between these events among women in reproductive age.

METHOD

cross-sectional study conducted with 1858 women between 18 and 49 years old, attending Primary Health Care Facilities. Data were obtained in face-to-face interviews. The level of knowledge was evaluated by items with answers options "agree", "disagree" and "I don't know". Knowledge was categorized as below/equal and above the median. Chi-square and multiple logistic regression were used in Stata 14.2 (95% confidence level).

RESULTS

intrauterine device current use was not frequent (1.7%; n=32) and the level of knowledge was higher among women between 25 and 34 years old, white, living in Aracaju (Sergipe), who were more educated, and who were currently using or had already used the intrauterine device. Interest in using the intrauterine device (38.0%; n=634) was higher among younger women, single, more educated, had health insurance, no children and with higher level of knowledge about the intrauterine device.

CONCLUSION

the level of knowledge about the intrauterine device was associated with the interest in using it.

Expanding choice and access in contraception: an assessment of intrauterine contraception policies in low and middle-income countries

BACKGROUND

Globally 214 million women of reproductive age in developing regions have unmet needs in modern contraceptives. Intrauterine contraception (IUC) is highly effective, has few medical contraindications, low discontinuation, and is a low cost modern contraceptive method. However, there is relatively low use of IUDs in LMICs. One reason for this may be policies that restrict IUD availability and use. This study assess national policies pertaining to IUD from a diverse set of countries.

METHODS

Between December 2015 and February 2016, a 12-question survey pertaining to IUD policy was sent to WHO regional and country representatives.

RESULTS

Sixty-nine surveys were used from countries through WHO regional offices. Among those surveyed, 87% (n = 60) had policies pertaining to IUD use. Among them, 84% (n = 58) reported that hormonal IUDs were available, but only 42% (n = 29) had them in the public sector. Free IUDs in the public sector were available in 75% (n = 52) of countries. For IUD promotion, 75% (n = 52) of countries reported cooperation with NGOs, and 48% (n = 33) received free devices from donors. Policy restrictions beyond the WHO guidelines existed in 15 countries and included restrictions to use for women who were nulliparous, adolescent, unmarried, or had multiple partners.

CONCLUSIONS

National policy is important in facilitating modern contraceptive uptake. While many countries who responded in the survey, have policies about IUD use in place, 16% still had none on IUD. Another gap identified was low availability of hormonal IUDs, especially in the public sector. Private sector remains untapped potential in expanding method choice by making IUDs available and accessible in developing countries. Most countries do have policy in place to facilitate IUD use, though there are still gaps in the accessibility of IUDs in many countries. Lastly there is a need to revisit restrictive policies that prevent IUD use for specific populations of women for whom IUDs can be beneficial in realizing their reproductive needs.

Choices and services related to contraception in the Gaza strip, Palestine: perceptions of service users and providers

BACKGROUND

Reliable contraception enables women and men to plan their family sizes and avoid unintended pregnancies, which can cause distress and anxiety, but also increase maternal mortality. This study explored potential barriers to contraceptive use for women in the Gaza Strip, Palestine from user and provider perspectives.

METHODS

A convenient sample was used to recruit women, who were current contraception users, from three healthcare clinics that provide family planning care, two governmental and one non-governmental. A 16-item questionnaire was completed by 204 women, including socio-demographic data, contraceptive use and eight questions exploring user experience. Additionally, 51 women attended focus groups for a deeper insight into their contraceptive use experience and potential barriers. Furthermore, 14 healthcare providers were interviewed about their experience with service provision. Quantitative data are presented as means and frequencies and qualitative data were analysed item by item and are presented in themes jointly with the quantitative data.

RESULTS

Women reported usage of only three main modern methods of contraception with 35.2% using intrauterine devices, 25.8% combined oral contraception and 16.4% condoms, while only 3.1% used the hormonal implant. Expectations from family planning services were low with most women attending the clinic having already decided their contraceptive method with decisions being made by husbands (41.2%) or women jointly with their partner (33.3%), only 13.7% took advice from service providers. Healthcare providers experienced high prevalence of beliefs that modern contraceptives cause infertility and cancer. Main barriers to effective family planning services were misconceptions of potential harm, poor availability and limited choice of contraceptive methods.

CONCLUSION

Women's contraceptive choices in Gaza are limited by prevalent misconceptions and fears as well as recurring shortages, negatively impacting fertility control. Men are a major factor in choosing a contraceptive method, however, they have limited access to information and therefore, potentially more misconceptions. Therefore, male community members need to be included in the delivery of information on contraceptives to increase women's choice. Furthermore, greater access to long-acting reversible contraceptives, such as the hormonal implant, and improved availability might be key factors in improving contraceptive uptake in Gaza and, thus, reducing unintended pregnancies.

An Exploratory Analysis of Factors Associated With Interest in Postpartum Intrauterine Device Uptake Among Pregnant Women and Couples in Kigali, Rwanda

Background:

The desire to space or prevent future pregnancies is high among postpartum women in Rwanda. However, the use of long-acting reversible contraception (LARC), especially the highly effective and cost-effective copper intrauterine device (IUD), is very low, whereas the rates of unintended pregnancy are high. This study aims to identify factors associated with pregnant women’s and couple’s interest in receiving a postpartum intrauterine device (PPIUD) within 6 weeks after delivery.

Methods:

A total of 150 pregnant women or couples attending antenatal care (ANC) in Kigali, Rwanda participated in this cross-sectional study. After participating in a postpartum LARC counseling session, surveys assessed participants’ demographics, pregnancy experiences and desires, and PPIUD knowledge, attitudes, practices, and interest. Multivariable logistic regression was used to model factors associated PPIUD interest within 6 weeks postpartum.

Results:

Although only 3% of women had ever used an IUD previously, 124 (83%) women were interested in receiving a PPIUD after counseling. Self-reporting physical side effects (adjusted odds ratio [aOR], 0.21; 95% confidence interval [CI], 0.06-0.75) and infection (aOR, 0.19; 95% CI, 0.04-0.85) as disadvantages to the IUD were significantly associated with no interest in receiving a PPIUD. Interest did not differ by male involvement.

Conclusion:

Recommendations to increase PPIUD uptake include educating pregnant women and couples about the method during ANC and addressing client myths and misconceptions about the IUD. This strategy allows pregnant women and couples to make informed decisions about their future contraception use, reduce unmet need for family planning, and reduce unintended pregnancy.

Delivering postpartum family planning services in Nepal: are providers supportive?

Background

Health service providers play a key role in addressing women’s need for pregnancy prevention, especially during the postpartum period. Yet, in Nepal, little is known about their views on providing postpartum family planning (PPFP) services and postpartum contraceptive methods such as immediate postpartum intra-uterine devices (PPIUD). This paper explores the perspectives of different types of providers on PPFP including PPIUD, their confidence in providing PPFP services, and their willingness to share their knowledge and skills with colleagues after receiving PPFP and PPIUD training.

Methods

In-depth interviews were conducted with 14 obstetricians/gynecologists and nurses from six tertiary level public hospitals in Nepal after they received PPFP and PPIUD training as part of an intervention aimed at integrating PPFP counseling and insertion into routine maternity care services. The interviews were audio recorded, transcribed, and analyzed using a thematic approach.

Results

Providers identified several advantages of PPFP, supported the provision of such services, and were willing to transfer their newly acquired skills to colleagues in other facilities who had not received PPFP and PPIUD training. However, many providers identified several supply-side and training-related barriers to providing high quality PPFP services, such as, (i) lack of adequate human resources, particularly a FP counselor; (ii) work overload; (iii) lack of private space for counseling; (iv) lack of IUDs and information, education and counseling materials; and (v) lack of support from hospital management.

Conclusions

Providers appeared to be motivated to deliver quality PPFP services and transfer their knowledge to colleagues but identified several barriers which prevented them from doing so. Future efforts to improve provision of quality PPFP services should address the barriers identified by providers.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3777-3) contains supplementary material, which is available to authorized users.

Method-Specific Attributes that Influence Choice of Future Contraception Among Married Women in Nairobi's Informal Settlements

Despite an extensive evidence base on contraceptive method choice, it remains uncertain which factors are most influential in predisposing women toward certain methods and against others. This paper addresses this gap in knowledge by making use of rarely‐measured perceptions about specific methods, perceived social network experience of methods, and women's own past experiences using specific methods. We draw on baseline data from the project, “Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning.” Using conditional logit analysis, we ascertain which perceived method‐specific attributes, including past experience of methods by women themselves and by their friends, predict preferred future contraceptive method among 317 women living in Nairobi slums who are using no method but intend to start in the next 12 months. Results show that satisfaction with past use, positive experience of use by a woman's social network, husband/partner's approval, lack of interference with menses, and perception of safety for long term use were all associated with choice of a future method.

Women's attitudes and beliefs towards specific contraceptive methods in Bangladesh and Kenya

BACKGROUND

Missing from the huge literature on women's attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants).

METHODS

In each site, 2424 to 2812 married women aged 15-39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study.

RESULTS

While current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower.

CONCLUSIONS

High levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.