Progestin-only injectables and implants are highly effective, long-acting contraceptive methods used by most women [
The main mechanism of action of Implanon is stopping the release of an egg from the ovary, thickening mucus in the cervix, which may prevent the sperm from reaching the egg, and changing the lining of the uterus [
Over 4.5 million women have used Implanon worldwide [
An institution-based unmatched case-control study was employed at Bahir Dar town health institutions from March 1, 2019, to June 1, 2019. Bahir Dar town is the capital city of Amhara Region in Northwest Ethiopia, and it is 560 km away from Addis Ababa, the capital city of Ethiopia. According to the Bahir Dar town health department office report, the total population of Bahir Dar town is 364,339 and, in the town, there are 34 health institutions; among these, there are 2 government hospitals, 3 private hospitals, 10 government health centers, 1 private health center, and 10 medium private clinics, which provide family planning services including Implanon insertion and removal.
This includes all women of the reproductive age group (15–49) who requested Implanon removal in the Bahir Dar town health institutions before completion of three years in the study period.
This includes all women of the reproductive age group (15–49) who requested Implanon removal in the Bahir Dar town health institutions at completion of three years in the study period.
The study population included all women of the reproductive age group who requested Implanon removal in selected health institutions in the study period.
All women in the selected health institutions who requested removal of Implanon before completion of three years during the study period were included as cases.
All women in the selected health institutions who requested removal of Implanon at the intended time (appointment date for removal) during the study period were included as controls. Women who requested removal of Implanon for conceiving/child birth in the study period were excluded.
No formal education, age <20 years, and had side effects were determinant factors of Implanon discontinuation in the previous study conducted in southern Ethiopia and Debre Markos [
In each selected health facility, the cases were selected consecutively until the required sample size was reached, and we selected three controls per case using the systematic sampling method. The control interval for each health facility was 2, and we used the lottery method to select the first client in each health facility..
It includes Implanon discontinuation and coded as follows: 1 = Implanon discontinuation and 0 = recommended date.
Independent variables include sociodemographic variables (age in years, marital status, women’s educational status, partner’s educational status, religion and occupation, and husband’s involvement), obstetric factors (number of children, abortion, and future plan of child birth), and method-related factors (weight gain, side effects, follow-up, counseling, discussion with their partners, and place of insertion).
It is discontinuation of the use of Implanon before completion of three years.
Counseling includes making the women aware of its long protection, effectiveness, and side effects due to insertion and removal.
It is the development of at least one of the following conditions: menstrual disruption, headache, and insertion arm pain.
We recruited 13 midwives who were working in the selected health institutions as data collectors after providing one-day training, and the principal investigator as supervisor was there to follow the data collection activity. The pretest was conducted in Addisalem Primary Hospital and Gamby General Hospital, which were out of the selected study facility before the actual data collection process.
We used a structured, pretested questionnaire, adopted from EDHS 2016 and other published literature studies conducted in Wolaita Zone, Southern Ethiopia, and Bale Zone, Southeast Ethiopia [
We translated the questionnaire into Amharic language, which is the mother tongue in the study area, for easy communication and understanding. We gave one-day training for data collectors regarding the purpose of the study, data collection technique, and ethical concerns during data collection. The principal investigator strictly followed the overall activity of the data collection process. We conducted a pretest on 28 individuals. All returned questionnaires were examined for completeness and consistency throughout the data collection period.
After coding, the data were entered into Epi Info version 7.2.2 and exported into Statistical Package for Social Science (SPSS) version 23 for analysis. Frequency was used to describe the characteristics of the study. Bivariable logistic regression analysis was performed to select candidate variables for multivariable binary logistic regression analysis. Those variables with a
A total of 559 (141 cases and 418 controls) participants took part in the study with a response rate of 100%. The mean age of the case and control mothers was 26.87 (SD = ±4.98) and 28.51 (SD = ±4.8) years, respectively. One hundred and sixty-one (38.5%) control mothers and 44 (31.2%) cases were found to be in the age category of 25–29 years. Among the total, 102 (72.3%) cases and 286 (68.4%) controls attained a certificate and above. From the partner’s educational status, 69 (48.9%) cases and 206 (68.4%) controls attained a certificate and above. Regarding the occupational status of women, forty-nine (8.8%) cases and 193 (34.5%) controls were employed (Table
Sociodemographic characteristics of study participants among women who use Implanon in Bahir Dar town health institutions, Northwest Ethiopia, December 2019.
Variables | Categories | Cases ( | Controls ( |
---|---|---|---|
Age of respondents in years | <20 | 12 (8.5%) | 9 (2.2%) |
20–24 | 35 (24.8%) | 89 (21.3%) | |
25–29 | 44 (31.2%) | 161 (38.5%) | |
30–34 | 38 (27%) | 109 (26.1%) | |
≥35 | 12 (8.5%) | 50 (12%) | |
Marital status | Single | 50 (35.5%) | 138 (33%) |
Married | 75 (53.2%) | 253 (60.5%) | |
Widowed | 8 (5.7%) | 10 (2.4%) | |
Divorced | 8 (5.7%) | 16 (3.8) | |
Religion | Orthodox | 97 (68.8%) | 260 (62.2%) |
Muslim | 21 (14.9%) | 96 (23%) | |
Protestant | 23 (16.3%) | 61 (14.6%) | |
Women’s education status | No education | 20 (14.2%) | 40 (9.6%) |
Primary education | 2 (1.4%) | 30 (7.2%) | |
Secondary education | 17 (12.1%) | 62 (14.8%) | |
Certificate and above | 102 (72.3%) | 286 (68.4%) | |
Partner’s educational status | No education | 34 (24.2%) | 88 (21.1%) |
Primary education | 7 (5%) | 19 (4.5%) | |
Secondary education | 31 (22%) | 105 (25.1%) | |
Certificate and above | 69 (48.9% | 206 (68.4%) | |
Maternal’s occupational status | Housewife | 23 (16.3%) | 71 (17%) |
Farmer | 9 (6.4%) | 8 (1.9%) | |
Merchant | 35 (24.8%) | 99 (23.7%) | |
Employed | 49 (34.8%) | 193 (46.2%) | |
Others (students) | 25 (17.7%) | 46 (11%) |
This study showed that 357 (85.4%) controls and 95 (67.4%) cases had children during insertion of Implanon. The future plan of the study participants among cases 133 (94.3%) and controls 363 (86.8%) was needed to space child birth, and others were needed to limit child birth. Among the total study participants, 116 (82.3%) cases and 373 (89.2%) controls have no history of abortion (Table
Obstetric and gynecological characteristics of study participants among women who use Implanon in Bahir Dar town health institutions, Northwest Ethiopia, December 2019.
Variables | Cases ( | Controls ( | |
---|---|---|---|
Having children | No | 46 (32.6%) | 61 (14.6%) |
Yes | 95 (67.4%) | 357 (85.4%) | |
No. of children | Less than four children | 104 (95.4%) | 331 (92.7%) |
Four and above | 5 (4.6%) | 26 (7.3%) | |
Future plan | Space child birth | 133 (94.3%) | 363 (86.8%) |
Stop child birth | 8 (5.7%) | 55 (13.2%) | |
History of abortion | No | 116 (82.3%) | 373 (89.2%) |
Yes | 25 (17.7%) | 45 (10.8%) | |
Partner want to be pregnant in the next two years | No | 81 (57.4%) | 230 (55%) |
Yes | 60 (42.6%) | 188 (45%) |
About 70 (49.6%) cases and 261 (62.4%) controls had an individual counseling service before inserting Implanon, and 30 (21.3%) cases and 22 (5.3%) controls did not get any type of counseling before inserting Implanon. Among those who have used Implanon, 75 (53.2%) cases and 320 (76.6%) controls had a discussion with their partners. Those who used Implanon by themselves were 85 (60.3%) cases and 259 (61.96%) controls. Among the study participants, 84 (59.6%) cases and 217 (51.9%) controls got Implanon insertion at the health center.
Forty-six (32.6%) cases and 115 (27.5%) controls had follow-up appointment during the Implanon utilization period. Among the cases, 84 (59.6%) experienced side effects, and 139 (33.3%) controls also developed a side effect. Among women who developed side effects, menstrual disruption was the most common side effect for both cases (39.7%) and controls (12.2%), and other side effects were headache 32 (22.7%) and 36 (8.6%), irritability/restlessness 30 (21.3%) and 25 (6%), weight gain 17 (12.1%) and 36 (8.6%), and amenorrhea 16 (8.6%) and 47 (11.2%) for cases and controls, respectively (Table
Characteristics of study participants regarding counseling and other variables, Bahir Dar, Northwest Ethiopia, December 2019.
Variables | Categories | Cases ( | Controls ( | |
---|---|---|---|---|
Types of counseling provided | Individual counseling | 70 (49.6%) | 261 (62.4%) | |
Mass counseling | 20 (14.2%) | 26 (6.2%) | ||
With partner | 21 (14.9%) | 109 (26.1%) | ||
No counseling | 30 (21.3%) | 22 (5.3%) | ||
Counseling about | Advantage | Yes | 85 (60.3%) | 276 (66%) |
No | 56 (39.7%) | 142 (34%) | ||
Side effect | Yes | 41 (29.1%) | 205 (49%) | |
No | 100 (70.9%) | 213 (51%) | ||
Effectiveness | Yes | 48 (34%) | 197 (47.1%) | |
No | 93 (66%) | 221 (52.9%) | ||
When to insert and remove | Yes | 73 (51.8%) | 215 (51.4%) | |
No | 68 (48.2% | 203 (48.6%) | ||
Discussion with partner | Yes | 75 (53.2%) | 320 (76.6%) | |
No | 66 (46.8%) | 98 (23.4%) | ||
Who accompanied with you? | Husband | 38 (27%) | 137 (32.8%) | |
Mother | 4 (2.8% | 14 (3.3%) | ||
Nobody | 93 (66%) | 258 (61.7%) | ||
Others | 6 (4.3%) | 9 (2.2%) | ||
Who was a decision maker to use Implanon? | Wife | 85 (60.3%) | 259 (61.96%) | |
Husband/partner | 25 (17.7%) | 64 (15.31%) | ||
Healthcare provider | 31 (22%) | 95 (22.73%) | ||
Place of insertion | Health center | 84 (59.6%) | 217 (51.9%) | |
Health post | 7 (5%) | 23 (5.5%) | ||
Hospital | 30 (21.3%) | 93 (22.2%) | ||
NGO and private clinic | 20 (14.2%) | 85 (20.3%) | ||
Why did you use Implanon? | Low failure rate | No | 82 (58.2%) | 198 (47.4%) |
Yes | 59 (41.8%) | 220 (52.6%) | ||
Low follow-up | No | 61 (41.3%) | 144 (34.4%) | |
Yes | 80 (56.7%) | 274 (65.6%) | ||
Less side effects | No | 119 (84.4%) | 279 (66.7%) | |
Yes | 22 (15.6%) | 139 (33.3%) | ||
Lack of other methods | No | 122 (86.5% | 387 (92.6%) | |
Yes | 19 (13.5%) | 31 (7.4%) | ||
Useful for a long period | No | 64 (45.4%) | 191 (45.7%) | |
Yes | 77 (54.6%) | 227 (54.3%) | ||
Experiencing a side effect | Yes | 84 (59.6%) | 139 (33.3%) | |
No | 57 (40.4%) | 279 (66.7%) | ||
What type of side effect? | Menstrual bleeding | Yes | 56 (39.7%) | 51 (12.2%) |
No | 85 (60.3%) | 367 (87.8%) | ||
Weight gain | Yes | 17 (12.1%) | 36 (8.6%) | |
No | 124 (87.9%) | 382 (91.4%) | ||
Headache | Yes | 32 (22.7%) | 36 (8.6%) | |
No | 109 (77.3%) | 382 (91.4%) | ||
Irritability/restlessness | Yes | 30 (21.3%) | 25 (6%) | |
No | 111 (78.7%) | 393 (94%) | ||
Menstrual cycle stops | Yes | 16 (11.3%) | 47 (11.2% | |
No | 125 (88.7%) | 371 (88.8%) | ||
Follow-up after insertion | Yes | 46 (32.6%) | 115 (27.5%) | |
No | 95 (67.4%) | 303 (72.5%) | ||
Satisfied by healthcare provider | No | 70 (49.6%) | 170 (40.7%) | |
Yes | 72 (50.4%) | 248 (59.3%) |
After adjusting other variables in a multivariable logistic regression analysis, women’s educational status, absence of children, no counseling, purpose/future plan of Implanon use, did not get counseling about side effects, experiencing side effects, and no discussion with their partners were determinants of Implanon discontinuation.
Women who had attended primary and secondary education level were 89.6% less likely to discontinue Implanon as compared to those who had a certificate and above educational level (AOR = 0.104, 95% CI (0.02–0.48)) and (AOR = 0.48, 95% CI (0.24–0.952)), respectively. The study also revealed that the odds of Implanon discontinuation was 2.04-fold higher among women who had not had children compared to their counterparts (AOR = 2.04, 95% CI (1.2–3.4)). There was 2.24-fold higher odds of Implanon discontinuation among women who had not discussed with their partners than those discussed with their partner (AOR = 2.2, 95% CI (1.39–3.57)). The odds of Implanon discontinuation was 3.5 times higher among women who had got mass counseling during the insertion of Implanon than those who had got individual counseling service (AOR = 3.5, 95% CI (1.75–7.01)). Women who did not get counseling on side effects of Implanon insertion were 1.7 times more likely to discontinue than those who got counseling about side effects during insertion of Implanon (AOR = 1.7, 95% CI (1.07–2.7)). The odds of discontinuing Implanon were 2.2-folds higher among women who experienced side effects as compared to those who were not experiencing side effects (AOR = 2.2, 95% CI (1.4–3.4)). The odds of discontinuing Implanon were 2.5 times higher among women who want to space children than those women who want to limit child birth (Table
Determinant of Implanon discontinuation of study participants among women who use Implanon in Bahir Dar town health institutions, Northwest Ethiopia, December 2019.
Variables | Implanon discontinuation | COR (95% CI) | AOR (95% CI) | ||
---|---|---|---|---|---|
Cases ( | Controls ( | ||||
Women’s educational level | |||||
No education | 20 (14.2%) | 40 (9.6%) | 1.402 (0.78, 2.5) | 0.76 (0.39, 1.5) | |
Primary education | 2 (1.4%) | 30 (7.2%) | 0.187 (0.04, 0.79) | 0.1 (0.02, 0.48) | |
Secondary education | 17 (12.1%) | 62 (14.8%) | 0.77 (0.43, 1.37) | 0.48 (0.24, 0.95) | |
Certificate and above | 102 (72.3%) | 286 (68.4%) | 1 | 1 | |
Purpose of using Implanon | |||||
Space child birth | 133 (94.3%) | 363 (86.8%) | 2.5 (1.17, 5.4) | 2.5 (1.14, 5.78) | |
Stop child birth | 8 (5.7%) | 55 (13.2%) | 1 | 1 | |
Having children | No | 46 (32.6%) | 61 (14.6%) | 2.8 (1.8, 4.4) | 2.04 (1.2, 3.4) |
Yes | 95 (67.4%) | 357 (85.4%) | 1 | 1 | |
Types of counseling | |||||
Mass counseling | 20 (14.2%) | 26 (6.2%) | 2.86 (1.51, 5.43) | 3.5 (1.75, 7.01) | |
With partner | 21 (14.9%) | 109 (26.1%) | .71 (0.42, 1.22) | 0.84 (0.47 ,1.5) | |
No counseling | 30 (21.3%) | 22 (5.3%) | 5.08 (2.76, 9.35) | 2.34 (1.14, 4.8) | |
Individual counseling | 70 (49.6%) | 261 (62.4%) | 1 | 1 | |
Discussion with partner | No | 66 (46.8%) | 98 (23.4%) | 2.87 (1.92, 4.29) | 2.2 (1.39, 3.57) |
Yes | 75 (53.2%) | 320 (76.6%) | 1 | 1 | |
Counseling side effects | No | 100 (70.9%) | 213 (51%) | 2.34 (1.55, 3.54) | 1.7 (1.07, 2.7) |
Yes | 41 (29.1%) | 205 (49%) | 1 | 1 | |
Experienced side effects | Yes | 84 (59.6%) | 139 (33.3%) | 2.95 (1.99, 4.38) | 2.2 (1.4, 3.4) |
No | 57 (40.4%) | 279 (66.7%) | 1 | 1 |
The odds of Implanon discontinuation in this study were reduced by 90% and 52% among women who had attended primary and secondary education as compared with those who had a certificate and above, respectively. This finding is in line with studies conducted in Debre Markos town, Ethiopia [
The odds of Implanon discontinuation among women who had not had children during insertion were 2.04 times than those who had children during insertion. This finding is consistent with other studies, as observed in Bangladesh, Burkina Faso, and Debre Tabor [
Not discussing with a partner was also a determinant for Implanon discontinuation. The odds of Implanon discontinuation among women who had not discussed with their partner during insertion of Implanon were 2.2 times more likely than those who had discussed with their partner. This might be due to differences in a conflict of interest of partners to have additional children that leads to discontinuation. This is in line with studies conducted in Bale zone, Ethiopia [
Presence of side effects was associated with Implanon discontinuation. The odds of Implanon discontinuation among women who had experienced a side effect were 2.2 times more likely when compared to those women who had not experienced a side effect. This finding was in agreement with previously published works [
Because of the nature of the design, there might be recall bias and information bias. The side effects were not labeled in severity. Another limitation is that the study was institution based, so it might not be generalized.
The determinants of Implanon discontinuation in the current study were women’s educational status, absence of children, no counseling, not informed about the side effects, absence of discussion with their partners, and had side effects. The aforementioned findings demand the involvement of health sector stakeholders to provide preinsertion counseling according to the national guideline for family planning services by giving emphasis on possible expected side effects and consider about counseling on their partners.
Adjusted odds ratio
Confidence interval
Crude odds ratio
Ethiopian Demographic and Health Survey
Epidemiological information.
The dataset is accessible from the corresponding author upon rational request.
The authors obtained ethical approval from Bahir Dar University, College of Health Sciences, School of Public Health Institutional Review Board.
Written informed consent was obtained from all study participants who were 18 years and above. Also, written informed consent was obtained from parents of those who were 17 years and below. Confidentiality of the information collected was maintained by avoiding personal identifiers from the data collection tool, and collected data were used for study purpose only.
This study was presented in the 31st Ethiopian Public Health Association (EPHA) Annual Conference.
The authors declare that they have no conflicts of interest.
TY was involved in conceptualization, data curation, formal analysis, investigation, methodology, software, and writing original draft. EM was involved in conceptualization, data curation, formal analysis, investigation, methodology, and review. KAB was involved in conceptualization, data curation, formal analysis, investigation, methodology, software, and writing original draft, reviewing, and editing. BD was involved in conceptualization, data curation, methodology, software, and writing original draft, reviewing, and editing. All authors read and approved the final manuscript.
The authors would like to thank the study participants, Bahir Dar University, Bahir Dar City Administration Health Office, and data collectors.