Long-acting family planning method switching among revisit clients of public health facilities in Dire Dawa, Ethiopia
© The Author(s). 2016
Received: 1 March 2016
Accepted: 16 June 2016
Published: 14 September 2016
“Contraceptive switching” from one method to another is a common phenomenon. Switching from a more effective long-acting method to a less effective method exposes women for unplanned pregnancy. The aim of this study was to assess the level and factors associated with long-acting family planning method switching to other methods.
A facility-based cross-sectional study was conducted from January to March 2013 on 634 women attending public health facilities in Dire Dawa City Administration, Ethiopia. Participants of the study were revisit clients of family planning service and were interviewed as they appear in the clinics. Data were analyzed using crude and adjusted logistic regression, and results were reported using OR and corresponding 95 % CI.
Long-acting family planning method switching among revisit clients was 40.4 %; switching from implant was 29.8 % and from IUCD, it was 10.6 %. The main reasons for methods switching were side effects of the methods such as bleeding, weight loss, and feeling of arm numbness. The tendency of switching was less among married women (AOR = 2.41, 95 % CI: 1.01, 5.74), women who had 2–4 and 5 and more children (AOR 3.00, 95 % CI: 1.59, 5.67) and (AOR 2.07, 95 % CI: 1.17, 3.66), respectively. It was also less among women who want to stop birth (AOR 5.11, 95 % CI: 1.15, 24.8), among those who mentioned health care providers as source of information for family planning (AOR 1.88, 95 % CI: 1.18, 3.01), and among women whose husbands were aware of their use of the methods (AOR 3.05, 95 % CI: 1.88, 4.94).
Method switching from long-acting contraceptives to less effective methods is high. Method switching was significant among unmarried women, who had one child, plan to postpone fertility, and whose husbands were not aware of their wive’s use of the method. In the provision of family planning service, the health care providers should give adequate information about each method and risks of method switching. Appropriate family planning Information Education and Communication (IEC) and Behavioral Change Communication (BCC) strategies should be emphasized.
The term “contraceptive switching” refers to the case where a person changes method of birth control . Many family planning users switch from long-acting contraceptive to other methods. Long-acting contraceptives, such as implant and intrauterine contraceptive device are convenient for users and have high effectiveness in preventing pregnancy . Despite the advantages, long-acting contraceptive methods remain not the primary choice among clients and the uptake of the method is minimal [3–6]. In many developing countries, majority of current contraceptive users had used at least one other method; such as oral contraceptives, injectable and other methods in the past. An exception is Cambodia, where only a quarter of current users have switched from other methods. Countries with the highest rates of contraceptive switching are Gabon and Colombia, where more than 80 % of current users have used another method before .
Switching from a more effective method to a less effective method (long-acting to short-acting contraceptives) creates a period for unplanned pregnancy. During the early period of use, as clients are still learning how to use the new method accurately and consistently, the risk of unplanned pregnancy is high . Unplanned pregnancy increases the risk of unsafe abortion and STIs/HIV infection [8, 9]. Currently, more than 200 million women in developing countries want to avoid pregnancy but they cannot do it for many reasons. Some of the major obstacles are lack of access to proper information and proper health care services, contraceptive failure, contraceptive discontinuation, opposition from husbands, misperceptions about side effect and cost [10–14].
Though family planning enables couples to control their fertility, during method switching, the risk of adverse effects and failure to adapt the new method results in unplanned pregnancy . So far method switching has received little attention from researchers and health executive bodies, hence, the size of the problem is not clearly known.
The aim of the study was to assess the level and factors contributing to method switching from long-acting contraceptives to other methods in Dire Dawa city, Ethiopia. Identification of the levels of method switching and factors related to switching will help researchers and health executive bodies at national and regional level to guide programs, lead proper implementation and evaluate the outcomes of interventions.
The study was conducted in Dire Dawa City Administration, Eastern Ethiopia from January to March 2013. Dire Dawa is a city located about 525 km from Addis Ababa, the capital of Ethiopia. The total population of the city is 342,827 of which 233,224 (67.93 %) lives in urban and 108,610 (32.07 %) in the rural areas . The city has five hospitals (1 public, 3 private and 1 company), 16 health centers (9 in urban and 7 in rural), 31 health post, 9 kebeles, 38 peasant associations, and two non-governmental clinics (Marie Stopes and FGAE). Family planning is given in all public and private health facilities integrated with the routine health system in maternal and child health (MCH) clinics .
A facility based cross-sectional study using quantitative and qualitative techniques was conducted. The sample size for the quantitative study was 634. In this study, data was generated from four health centers and one public hospital. Facility client registration was used as a sampling frame and systematic random sampling was used to identify specific women for interview. Only revisit women were invited for interview. To support and supplement the quantitative findings, four Focus Group Discussions (FGDs) consisting of 8–12 participants were conducted. Participants of the FGDs were selected on the basis of prior use of long-acting methods and their willingness to share their experiences.
The quantitative data was collected using pre-tested structured questionnaire adapted from Family Health International (FHI) 2009 questions. Open-ended discussion guide was used to lead the discussion of the focus groups. Female high school graduates collected the data and two nurses supervised the data collection process. A one-day training on the objective of the study, data collection tools and interview methods was given for the research team by the principal investigator.
Quality of data was maintained through adequate training of study tool, continuous follow-up during data collection, on-site supervision, and pre-test on one of the nearby health centers. In addition, data was carefully checked for completeness and consistency on daily basis. Each questionnaire was assigned a unique code to maintain its anonymity and facilitate data entry. Any confusion on the data collection procedure and/or responses was handled in a timely fashion.
Frequencies and odds ratios with 95 % confidence intervals (CI) were used to describe the results and show the presence of association between independent and dependent variable. Multiple logistic regression was used to control the effect of confounders. Qualitative data were tape recorded, transcribed verbatim and hand summarized using summary sheet. Notes taken during interviews also helped to complete the template.
The study was approved by the Institutional Research Ethical Review Committee (IRERC) of College of Health and Medical Sciences, Haramaya University. Official letter of cooperation was obtained from Dire Dawa Town Health Bureau. Participants were briefed about the purpose, procedures, potential risk, benefits, and right of participants to withdraw from the study at any time. Before the start of data collection, written informed consent was obtained from study participants. Confidentiality and privacy of information were maintained throughout the research process.
Socio-demographic characteristics of re-visit clients at family planning clinics in public health facilities, Dire Dawa City Administration, 2013 (n = 634)
Age of the women
Educational status of the women
Canot read and write
Primary (1–8 grade)
Secondary (9–12 grade)
Diploma and above
Educational status of husband
Canot read and write
Primary (1–8 grade)
Secondary (9–12 grade)
Diploma and above
Religion of the women
Occupation of the women
Marital Status of the women
Fertility characteristics of re-visit clients to family planning clinics in public health facilities, Dire Dawa City Administration, 2013
Ever given birth (n = 634)
Number of children (n = 555)
Intention to have more children (n = 555)
Depends on husband
Depends on God
I am not sure
Family planning related characteristics of re-visit client at public health facilities in Dire Dawa City Administration, 2013(n = 634)
Family planning related characteristics
Where do you get information about family planning?
Health care providers
Health Extension Workers
Is your husband aware about your use of family planning?
Who chooses family planning method for you?
Health care provider
Do religious leader in your area consider family planning?
I donot know
Which family planning methods religious leaders considered? (n = 120)
Short methods only
Predictors of long acting family planning method switching among re-visit clients in public health facilities, Dire Dawa City Administration, 2013(n = 634)
Crude OR (95 % CI)
Adjusted OR(95 % CI)
4.2 (2.06, 8.69)*
Number of children
3.00 (1.59, 5.67)*
Future fertility control
To space birth
To stop birth
Depends on husband
Depends on God
I am not sure
Source of family planning information
Health Extension Workers
Health care providers
Husband is aware about use of Family planning
Results of multiple logistic regression showed that, married women were 2.4 times less likely to switch method compared to unmarried women (AOR = 2.41, 95 % CI: 1.01, 5.74). Women who had 2–4 children were 3.0 times less likely to switch long-acting method than those who have one child (AOR = 3.00, 95 % CI: 1.59, 5.67). Similarly, women who had more than 5 children were 2.07 times less likely to switch long-acting method than those who have one child (AOR = 2.07, 95 % CI: 1.17, 3.66). Women who want no more pregnancies were 5.1 times less likely to switch method compared to those who wish to have more children (AOR = 5.11, 95 % CI: 1.15, 24.8). Women who got initial information about family planning from health care providers were 2 times less likely to switch compared to those women who received information from their husband (AOR = 1.88, 95 % CI = 1,18,3.01). On other hand, women whose husbands were aware about their use of long-acting family planning method were 3.05 times less likely to switch compared to those whose husbands were aware of their use of the method (AOR = 3.05, 95 % CI = 1.88–4.94) (Table 4).
Long-acting Family Planning method switching among revisit clients was 40.4 %. The major determining factors for method switching were age of the respondent, educational status of husband/partner, marital status, number of children, and desire for having more children. The main reasons for method switching from long-acting method to other methods were bleeding, weight loss, and numbness in the arm.
Participants in this study were selected only from public health facilities, as majority of family planning users in the city are visiting public health facilities. Yet, there are some women who receive service from private and NGO clinics, the views of these women are not reflected in this report. Similarly, the perspectives of husband/partner and health care provider were not included. Hence readers are advised to read the paper taking these into account.
Method switching was 40.4 %, and switching from implant was 29.8 % and the rest, 10.6 %, switched from IUCD. This is relatively low compared to reports from other studies. For example, in Egypt method switching from IUCD and Norplant to another method was 45.9 % . Similar study from 14 developing countries showed that there were high rates of switching in Peru (70.5 %) and Morocco (69.8 %). In Vietnam, two-thirds of women who had an IUCD reported to switch to other methods (n = 306/434) . In contrast to our findings, method switching is low in Bolivia (16.7 %) and Kazakhstan (25.2 %). Reports of USAID in 2007, indicated that high method switching can be indicative of low satisfaction with the method used or poor service delivery. On the other hand, lower levels of method switching could mean user choices are limited .
The result from logistic regression analysis showed that women whose age ranged from 25–29 years were three to four fold less likely to switch method. Women who were 30–34 years of age were four times less likely to switch compared to those who were 15–19 years, and women who were 35 and above were six times less likely to switch compared to those women who were 15–19 years old. Similar study in Indonesia showed that as age increases, the probability of method switching decreases; those in the age group of 30–39 years had a low probability of switching method compared to their counterparts .
Married women were two times less likely to switch method compared to unmarried ones. In contrast to this study, studies in the Northern Africa indicated that method switching was common among married women than unmarried . Women who had 2–4 children were three times less likely to switch long-acting method than those who had one child. In addition, women who had more than five children were two times less likely to switch long-acting method than those who had one child. Similar study from Indonesia in 2010 showed that women who want to stop birth were five times less likely to switch method compared to those who need additional children. This showed that women at higher parity were less likely to switch methods compared to women with no children [11, 12].
Majority of FGD participants reported that side effects were the primarily reasons for shifting methods. “I have four children and I decided to take family planning then the health care provider convinced me to take long term contraceptives and their advantages. But I couldn’t tolerate excessive bleeding and and becoming weak and tired, that pushed me to change the method”-----28 year old woman [Sabian Health Center]
“After insertion of IUD, my menstruation became twice in a month and problem of stomachache became a common phenomenon, hence, it appeared very difficult to continue with it”. —35year old [Melka health center].
“Since the time I put implant in my arm, I had seen no menstruation at all. I am afraid if blood accumulates in my abdomen, it can cause presser. So, I decided to take the implant out and shift to pills.” --------22 year old woman - [Legeharie health center].
One FGD participant said, “I have been using implant in my arm without my husband knowing about it, I was comfortable with the method. After a year he came to know that I am using this method and he went to the health facility and quarreled with the nurses. I was afraid thought that he may leave me and I might be left alone, so I terminated the method”….…30 year old woman [Legeharie Health Center].
A qualitative study in Nigeria showed that, lack of support from the husband does not only hinder a woman’s decision to use a long-acting contraceptive methods, but it also may lead to premature termination of its use . Husbands/partners, who do not support women on the use of family planning, tend to have more children, and prevent their wives from using any family planning.
Some religious leaders discourage the use of family planning. This is true both in Christian and Muslim religions and fertility control discussions are not generally favored. In this study, few women reported that religious leaders advised them on the use of family planning. A study done in 2011 in Indonesia, where Islam is the dominant religion, method switching is not significantly associated with religion .
In this study, bleeding associated with the use of family planning and husband/partner not being aware of wife’s use of long-acting fertility control methods were the main reasons for method switching. Similar studies from developing countries reported the same kind of result whereby two-fifths of the women switched due to side effects and the remaining switched because their husbands disliked the methods [24, 25].
Conclusion and Recommendation
Method switching from long-acting family planning to other method is high. Method switching is common among unmarried women, women who had one child, women who want to space children and women who were not sure of their future fertility, women who reported other than health care provider as a source of family planning information, and those who reported their husbands were not aware of their use of long-acting family planning methods. The main reason for method switching was adverse effects such as bleeding and numbness in the arm.
Authors would like to recommend, women should be advised properly at the start of family planning. The advice should focus on the method and its side effects, and intervention for problems related to the use. Health executive bodies should strengthen their effort in addressing the problems of women switching long-acting methods through effective IEC and BCC strategies.
AOR, adjusted odds ration; BCC, behavioral change communication; CI, confidence interval; COR, crude odds ratio; FGAE, Family Guidance Association of Ethiopia; FGD, focus group discussion; FHI, Family Health International; HEW, Health Extension Worker; HIV, human immuno virus; IEC, information education and communication; IRERC, Institutional Research Ethical Review Committee; IUCD, intrauterine contraceptive devices; MCH, Maternal and Chile Health; NGO, Non-Governmental Organization; OR, odds ratio; SD, standard deviation; STIs, sexually transmitted illnesses; USAID, United States AID.
Authors would like to thank Dire Dawa City Administration Health Office, health facilities and family planning service providers for facilitating data collection.
The cost of research is covered by the first author.
Availability of data and materials
The dataset(s) supporting the conclusions of this article is (are) available in the figshare repository at DDI 10.6084/m9.figshare.3406867.
MA initiated the research, wrote the research proposal, conducted the field work, supervised data entry, analyzed the data and wrote the manuscript. NA and TA participated in refining the the proposal, supervised the field activity, analyzed the data, and wrote the report. All authors read and approved the final manuscript.
The authors declare that they have no competing interest.
Ethics approval and consent to participate
The study was approved by the Institutional Research Ethical Review Committee (IRERC) of College of Health and Medical Sciences, Haramaya University, Ethiopia. Written informed consent was obtained from study participants after they were briefed on the study.
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