Providers’ views on hormonal family planning methods for young women: a qualitative study from Dosso, Niger

Study setting

The data for this study were collected as part of a larger assessment of a FP segmentation counseling tool used by FP providers with clients in government run integrated health centers (IHCs) in Niger. More details on the segmentation strategy can be found elsewhere (Speizer et al., 2021) but briefly, this approach has providers asking each client a series of 12 questions that are used to identify which of five segments each client belongs to. Following segmentation, providers counsel clients on family planning method options with targeted messages based on their assigned segment. While no one method is specifically identified as appropriate for all groups, the counseling cards encourage modern method use, particularly for the segments that seem more open to family planning use. As part of the parent study, quantitative and qualitative data were collected from 45 IHCs in Boboye, Dosso, Doutchi, Falmey, Loga, and Tibiri health districts in Dosso region. Because the implementation partner (Pathfinder International) had previously undertaken segmentation as part of a targeted demand creation program in Dosso region, this was a pre-determined region for the study. Three types of districts and IHCs were identified: the original demand creation/segmentation districts (implemented since 2017); segmentation only districts (where segmentation was launched in 2019, about six months before data collection); and comparison districts (no segmentation). Dosso is a region in the south western part of Niger, where the majority of the population live in a rural setting. Within each study district, all facilities were identified and classified as Type 1 (lower volume) and Type 2 (higher volume). Based on the facility breakdown of the initial 15 intervention site facilities (8 Type 1 and 7 Type 2), we identified a similar list of facilities by type from the study districts. Random selection of facilities by type and district was used to identify the 15 facilities in each of the two other study samples. In five of the six districts (exception Boboye), because of the small number of IHCs most facilities were included in the sample; in Boboye where there were more Type 1 facilities, only four of 16 facilities were included in the sample. From the quantitative data collected in the 45 facilities for this study (Speizer et al., 2021), we see that among clients surveyed, 58% used injectable methods, 28% used pills, and 13% used implants; use of implants was slightly higher in implementation than comparison site facilities (12.0% and 17.6% in facilities in the two intervention arms and 10.5% in the comparison arm facilities).

Study design

As discussed above, the overall assessment of the segmentation approach was designed with three study arms: Arm 1 was comprised of IHCs with a demand generation program and the segmentation strategy, Arm 2 included IHCs with the segmentation strategy, and Arm 3 served as a control arm where the IHCs did not have any specific demand generation or segmentation activities. For the qualitative data collection, eight IHCs in each arm were randomly selected for inclusion. At each selected IHC, one family planning provier was approached and asked to consent for an IDI; in many facilities, this was the only family planning provider available on the day of interview. Providers from all three arms (8 per arm) were interviewed about their experience providing FP services and in addition, providers in Arms 1 and 2 were asked about their experience with the segmentation counseling tool.

The semi-structured interview guide was designed with two parts. Part 1 included two vignettes of hypothetical FP clients: a 17 year old, unmarried, nulliparous adolescent who was seeking FP; and a 23 year old married woman with two children seeking a FP method. Vignettes are a useful tool in qualitative interviewing that provides an opportunity to ask respondents about hypothetical scenarios to understand their attitudes, beliefs and norms (Cislaghi & Heise, 2016; Learning Collaborative to Advance Normative Change, 2019). These two scenarios were developed to examine provider perspectives on FP provision to a stigmatized group (i.e., unmarried and nulliparous women) and to typical young users (married women with children). In the client exit interview data from these same sites, about 13% of clients are in the age group 15–19 and another 28% are aged 20–24. Notably, the overwhelming majority of clients are married or living with their partners (98%) and have two or more children (80%) (Speizer et al., 2021). Each vignette was followed by questions about how the provider would navigate a consultation, including how they would start a conversation with this client and what additional information they might want to know about the client. Providers were then asked what FP methods they would recommend for each client and what methods might be better or worse for them. Finally, they were asked what method they think each hypothetical client would choose after having been given information on all methods and why they think she would choose this method. Many providers responded to the questions by summarizing their thoughts in general about methods women may or may not like to use, and why, and did not just specifically focus on the hypothetical clients mentioned. (Note that although vignettes were used as part of the segmentation evaluation, this study used the in-depth interview data collected via vignettes to investigate only provider responses to questions about hormonal methods; thus, not all vignette data are reported here, only the data related to hormonal methods). Part 2 of the interview guide included questions about providers’ experiences with and opinions about the segmentation tool (Arms 1 and 2 only). The interview guide was pilot tested with four providers working in IHCs outside the study area before data collection began. The guides were tested for clarity, flow, and to ensure the questions were appropriate. Modifications to the questions and the guide were made based on feedback from the pilot testing. The final guides used can be found as Extended data (Speizer, 2021). The qualitative data used for the analyses described in this paper are comprised of Part 1 of the 24 in-depth interviews (IDIs) collected with providers across all three study arms. Information on provider perspectives on the segmentation tool (Arms 1 and 2) are provided elsewhere (MacLachlan et al., 2022).

Data collection

Data were collected in February and March of 2020. Two interviewers, one female and one male, conducted the 24 IDIs, with each interviewer responsible for 12 interviews. Interviewers, hired by GRADE Africa as part of the data collection team, were not age or gender matched with interviewees. All participants provided written informed consent prior to being interviewed. Interviews were conducted in a private room or space within or close to study IHC where each of the providers worked. The interviews were audio recorded with the written consent of participants. The interviews were conducted in French, Hausa, or Zarma, depending on the comfort level and preference of the interviewee. The duration of the interviews ranged from 33 minutes to 104 minutes.

Analysis

All audio recordings of the IDIs were translated from Hausa and Zarma and transcribed into French by trained translators and transcriptionists in Niamey, Niger. During data collection, four transcriptions were compared to audio recordings by the supervisor in Niger to ensure the fidelity of the transcriptions. Once all interviews had been transcribed into French, de-identified and anonymized, transcripts were uploaded for analysis to Dedoose version 9.0.46,¹ a qualitative analysis software that permits collaboration (Dedoose, 2021). A preliminary codebook was created by the master coder (EM) based on the interview guide questions and an initial review of three randomly selected interview transcripts and was entered into Dedoose for coding. The codebook included major thematic codes called “parent” codes and smaller sub-thematic codes referred to as “child” codes. These a priori codes were developed from the interview guide and for any content related to the three hormonal methods of interest (implants, injectables, birth control pills). No other conceptual framework or literature source was used to develop our a priori codes. This preliminary code book was used by the master coder to code six interviews. The six coded interviews were reviewed by all coders after which all coding and the code book were revised based on discussion among all coders. Four coders (AMJ, BA, KLC, SC) then applied all the parent codes to the remaining interviews and two coders (AMJ, BA) then applied child codes. All four coders involved in coding parent codes had an average Cohen’s kappa score of 0.79 and a range of 0.72 to 0.89, when each was compared to a master coder (Gwet, 2014; Landis & Koch, 1977). Thematic analysis was then completed and summarized for each family planning method discussed in the interviews. The team developed a matrix of the emerging themes in MS Excel and discussed the themes extensively during team meetings. At times the team decided to merge themes, add new themes, or take out themes based on the consensus view of the team. Distinctions in responses were examined by the characteristics of the providers (study arm, age, sex, and length of service); however, no differences were observed in perspectives of method preferences by these provider characteristics. Where distinctions were reported by the type of woman (unmarried or married), these are highlighted in the text. The quotes presented in this paper were translated from French into English by the first author and reviewed and approved by the Niger study team to ensure accurate interpretations.

Ethical approval

Ethical approval for all consent procedures, surveys, and IDI guides was obtained from the National Ethics Committee for Health Research (CNERS) in Niger (#049/2019; approved 14 Jan. 2020), and the University of North Carolina at Chapel Hill’s Institutional Review Board (#19-3042; approved 3 Jan. 2020).

Provider characteristics

Providers ranged in age from 25 years to 59 years, were predominantly female (83%), and had worked as FP providers for 1 to 28 years, with a mean of 7.5 years of experience (see Table 1). Providers interviewed included chief of IHC (12%), deputy chief of IHC (17%), midwife (25%), nurse (21%), FP provider (17%), and volunteer (8%). All included providers offered family planning services in their facilities and all facilities provided all three of the main methods discussed here: implant, injectables, and pills.

Summary of main findings

The overwhelming majority of providers (92%) stated that a provider’s role is not to recommend a contraceptive method and that it is up to the client and in some cases her husband, to decide which method to use. Providers clearly stated that their role is to provide full information and with that information clients can ask questions and choose a method. That said, providers acknowledged that at times, clients do ask for the providers’ recommendations, but providers avoid recommending specific methods. While many providers indicated that the unmarried hypothetical client should not be having sex, the feeling was that if she was having sex, it was better for her to use a method than risk an unintended pregnancy or a sexually transmitted infection. When asked which method they believed would be most suitable in each of the vignettes, most providers named the contraceptive implant to be the most suitable, for both married and unmarried clients because of a rapid return to fertility. Regarding women’s method preferences (according to providers) one of the most significant themes emerging from the interviews was that the injectable is the most popular FP method for women coming to the IHC. Relatedly, when asked what method they thought each hypothetical client would choose, the majority of providers said that women overwhelmingly would prefer injectables. However, providers stated that while some women may not initially choose the implant, once they were told more about it, they were more open to adopting it and less likely to believe negative local myths about implants. Overall, providers did not consider the contraceptive pill to be desirable by women due to its lack of discretion and challenges associated with effective compliance. As mentioned above, an examination of whether responses differed by provider age, gender, years of service and study arm indicated that providers had similar perspectives on young women’s preferred methods and similar rationale for these reported preferences by the different characteristics of providers. Thus, results are discussed across providers and not disaggregated by these characteristics.

In content analysis of interview data about the characteristics and attributes of the FP methods available and chosen by clients, several key themes emerged. The themes identified were: (a) the discretion of the method; (b) compliance with method use; (c) comfort and familiarity with the method; (d) myths and misconceptions about implants; (e) husband opposition to the implant; and (f) concerns about return to fertility post method use. Notably some of the reasons providers gave overlapped across the themes. For example, clients’ fear of pain with implant insertion and removal is highlighted under comfort and familiarity as it relates to clients’ concerns and understanding about implant upon arrival at a facility, especially their lack of familiarity with the implant. That said, this could also be identified in the myths and misconceptions category because of clients’ a priori concerns about pain with insertion and removal. The results are presented below by the main themes that emerged through the analysis and a summary of these results can be seen in in Table 2.

Discretion of method

The providers felt that many women want a FP method that is discreet— providers stated that the majority of women seen at a IHC want to keep FP use a secret from various people including their parents, their sexual partners, their husbands and the community at large. When asked about what method women prefer, providers would compare the methods in terms of discretion, such as this comparison of injectables and the implant versus oral contraceptive pills for adolescents:

Many providers expressed their opinion that pills are the least discreet method choice for women as they are taken daily and can be found in their belongings. One provider described the inevitability of pills being discovered in this comparison of the implant and pills:

However, in one regard, pills were considered discreet. According to providers, pills were the method that disrupted women’s menstrual cycles the least when compared to injectables and the implant. This benefit relates to young women who want to keep their FP use secret and whose parents or sexual partners may notice changes in their menstrual cycle caused by their FP use. In contrast, injectable and implant use may be discovered as they are reported to cause more disruptions in menstruation and irregular bleeding.

Providers had divided thoughts about whether the injectable is more discreet than the implant. For almost all providers, the discreet nature of the implant was an important factor in naming the implant as the most suitable method for women. Some called the implant “invisible” or “secret” and stated that no one, even a woman’s husband, will know that she has an implant. Furthermore, providers reported that women share these same beliefs about the implant.

For other providers the visibility of the implant itself in the arm and/or the bandage following insertion is a downside to the implant since both can be seen by others. These providers stated they would even advise against an implant for a woman since people will know she is using FP. For providers who think that injectables are more discreet, they often mentioned that the injection cannot be seen like the scars left over from implant insertion:

Providers also report that women voice the sentiment that injectables are less conspicuous than implants to them:

However, some providers felt that even though the injection is discreet, it is possible injectable users can be discovered because they have to go to the clinic every three months for reinjection and cannot explain these IHC visits to their husbands and others. Providers shared that both married and unmarried women prefer not to be seen at the health center for fear of what others may think of them. This is especially true for adolescents, who will even come to the clinic at night for their follow-up injections to avoid detection:

In contrast, the implant provides discretion for women by reducing IHC visits to a minimum.

While differing opinions of the providers are reported regarding whether or not the implant or injectable is more discreet, the discretion of the implant and injectables is an important factor for providers and their clients.

Compliance with method use

Overall, providers expressed widespread support for the use of implants by both married and unmarried sexually active women due to their effectiveness, long-acting nature, and the simplicity of their use. Notably, providers acknowledged that their clients (and their husbands) did not necessarily have the same enthusiasm for this method. A principal reason providers favor implants for their clients is that there is no risk of non-compliance with using this method of FP. Once inserted into a woman’s arm, she does not need to take a daily dose or return to the health center for refills or re-injections. Providers frequently contrasted this characteristic of the implant with the risk of clients forgetting to take the pill correctly or not returning for injections every three months, thus putting themselves at risk for pregnancy. Many providers strongly recommend the implant for adolescent users, who they believed would struggle with forgetfulness, for these reasons.

Other providers stated that married women with children may be more forgetful than younger women since they have more responsibilities to manage. Similarly, some providers put women’s preference for the 3 month injectable schedule in contrast to the daily use of oral contraceptive pills. These providers indicated that the relatively long time period of three months between injections was appreciated by the women, who could put off going to the IHC at least during those months:

Comfort and familiarity with the family planning method

Another theme that emerged from the interviews was the idea of women’s familiarity and overall comfort, both physical and psychological, with the various FP methods. Pills and injectables have a longer history in Niger. One provider eloquently explained the historic popularity of injectables as one of the only FP methods available to women outside of oral contraceptive pills:

Many providers felt that there is strong community support for injectables as the method that most women have experience with and have told their friends about. Thus, many women come to the facility with a pre-conceived desire for injectables as this is what others in their community use. Women can sometimes be reluctant to try any other method, even with counseling:

That said, some providers reported that some women who come into the clinic with injectables as their first choice may, following counseling by the provider, switch to implants. Providers shared that clients, both new and returning, when “counselled well” and presented with the full range of methods, will sometimes switch their choice to the implant. This occurrence happens at IHCs because when informed about the implant, women appreciate the implant’s attributes when compared to injectables:

Women are also hesitant to choose implants because of their fear of the pain of implant insertion and removal. Providers mentioned several times that women, after hearing stories in their communities about the process of insertion and removal, fear the implant.

Providers recounted that clients have heard negative stories of women’s experiences of pain due to implant insertion and/or removal, perhaps without receiving anesthesia. The providers gave examples of women who initially refuse the implant due to the fear of being cut and then accept it after hearing an explanation of the process and use of anesthesia.

Myths and misconceptions about implants

As discussed above for fear of pain with insertion and removal of implant, providers felt that there were the most rumors, concerns, and misconceptions surrounding implants. Several rumors in the community were mentioned by providers, including beliefs that a woman who dies with an implant in her arm will go to hell or not be able to “reach paradise”, and that if a woman gains too much weight with an implant, the implant can get lost in her body.

These myths and misconceptions are described as having a powerful influence over women’s contraceptive method choice and they counter providers’ appreciation for the implant as a method. Providers discussed having to address these perceptions among women through counseling or by encouraging satisfied implant users to help dispel implant myths in their communities. While providers state that these myths are common, some providers shared that women’s attitudes and openness towards implants are changing with more education and counseling about FP methods.

Husband opposition to the implant

While providers spoke of husbands being opposed to FP use generally, some providers also discussed husbands specifically being opposed to their wives using an implant as a method of FP. They mentioned that a woman’s use of an implant could be contentious enough as to cause serious marital problems between her and her husband. Four providers gave specific examples of instances when a client returned to the health center and demanded that the implant be removed at the request of her husband. In the excerpt below, one provider recounts a time when a client returned with her husband who demanded she remove her implant but accepted her use of injectables instead.

Concerns about return to fertility post method use

An important reason why providers preferred implants for both married and unmarried women is the rapid return to fertility after removal of the implant relative to injectables or pills. Providers stated that once a woman decides she wants to become pregnant, she can remove the implant and conceive a child without delay. The immediate return of fertility is particularly important for unmarried clients who could potentially get married at any point while using the implant and want to start childbearing soon after marriage.

Providers felt strongly about injectables as the wrong choice when compared to the implant when serving adolescents. Providers’ preference for the implant for adolescents is mainly due to injectables’ known side effect of delaying the return to fertility after stopping use (Barden-O’Fallon et al., 2021) and the implications this has for adolescents wanting to become pregnant when they marry later on:

At least one provider mentioned that the delay in return to fertility, that is a common side of effect of stopping injectables, can lead to permanent sterility:

As previously discussed, changes to bleeding and menstruation cycles were a side effect that providers stated some clients found to be troublesome and undesirable especially if they make the method more detectable; however, this did not emerge as a major theme beyond how they related to return to fecundability.