Although the annual number of global maternal mortality has decreased between 2000 and 2017, the maternal mortality ratio (MMR, number of maternal deaths per 100,000 live births) dropped by about 38% worldwide. However it is still remains very high in Nigeria (917 death per 100.000 live birth), as the region accounts for 14% of the whole maternal deaths (World Health Organization, 2019). Family planning has been reported to be the key in the increased female productivity by reducing their fertility and ensuring child survival and improved maternal health (Usman et al., 2019).

A variety of contraception options are available, these can be grouped into two categories. These are long-acting reversible and permanent contraceptive methods (like intrauterine devices, implants, and sterilization) and short-acting (like pills, condoms, spermicides, injectable, and other modern methods, and all traditional methods) (Mukamuyango et al., 2014).

Newer long-acting reversible contraceptive (LARC) methods such as intrauterine devices and sub dermal implants are preferred because they do not depend on patient conformity (Mukamuyango et al., 2014). They are highly effective and appropriate for most women and have the additional advantages of being long-lasting, convenient, well-liked by users and cost effective. LARC methods are 'forgettable'; they are not dependent on compliance with a pill-taking regimen, or coming back to the clinician for an injection (Bhandari et al.,  2019)  LARC method failure rates rival that of tubal sterilization at <1% for IUDs and the sub dermal implant  (Mukamuyango  et  al.,  2014; Bhandari et al.,  2019). 

Despite the improvement in availability and utilization of long acting reversible contraception, early discontinuation is becoming a major problem. Significant proportion of women discontinues the methods within one year even without any side effect (Staveteig et al., 2015). According to a report based in Nigeria, 13% of IUD users and 2% of Implanon users discontinue the methods during the first 12 months (Aruna et al., 2015).

Higher  discontinuation  rate  of  long  acting  reversible contraception is a public health concern; long acting reversible contraceptives which are designed to be used for 3 to 12 years are coast effective only when they serve for the intended period of time.

Against this background, this study aimed to document the trends and uptake of LARC methods among women in our setting, assess the characteristics of the acceptors, and identify the reason for discontinuation so that strategies can be put in place to maximize their benefits.

The study setting was a tertiary hospital located in Maiduguri, northeast Nigeria and catering for the metropolis and its environs. The family planning clinic of University of Maiduguri Teaching Hospital (UMTH), Maiduguri provides family planning services from Monday to Friday between 8.0 am to 4.0 pm. A consultant obstetrician and gynecologist, and four trained nurses direct activities in the clinic. Medical and nursing students and resident doctors in Obstetrics and Gynecology are posted to the clinic for clinical experiences. The services provided in the clinic include family planning counseling, same day provision of chosen methods to clients, teaching, research, training of students, and medical record documentations. Group family planning counseling is undertaken at regular intervals in the antenatal clinics. Approval for this study was obtained from the Ethics and Research Committee of the University of Maiduguri Teaching Hospital.

A retrospective study design to evaluate uptake of LARC (intrauterine contraceptive devises and implant) was conducted. All available client records from the family planning clinic from January 1st, 2015 to December 31st, 2019 were retrieved. Information was collected on socio-demographic characteristics, previous contraceptive use, method of contraception chosen at the first visit and reason for discontinuation within one year of insertion.

Data analysis

Data was analyzed using the statistical package for social sciences (SPSS) version 15. Missing responses were stated as such and excluded from analysis. Descriptive analysis was done using frequencies and percentages. Chi square was used as a test of association between methods of contraception used and demographic characteristics (other relevant factors such as reason for discontinuation). Significance level was established at P value of 0.05.

Four thousand and sixty four (4064) new clients accepted the available family planning methods in University of Maiduguri Teaching Hospital, Maiduguri, Borno State Nigeria during the study period. A total of 1752(43.1%) accepted sub dermal implant, 363(9.0%) accepted IUCD and 1947(47.9%) accepted others form of contraception. This is shown in Figure 1. There has been a general upward trend showing that LARC uptake has overtime continued to gain some increase among users in this study (as shown in Figure 2). Sub dermal implant uptake increased from 9.08% in 2015 to 22.79% in 2019 and IUCD  uptake  steadily  increased  from  1.47% in 2015 to 4.30% in 2019.

In this study, the trends and uptake of long-acting reversible contraception has increased, this is primarily attributable to an increase in Implant use, and IUCD uptake is low. The reason for discontinuation was desire for another pregnancy, irregular menses, husband refusal, weight gain and pelvic infection among LARC users. Socio demographic characteristics such as age of women, parity, occupation, education were the contributing factors of LARC use and early discontinuation.

The uptake rate of 52.1% for LARC in the study is high. This is in contrast to the finding from previous study (38.7, 2.0.4 and 14.8%) (Mohammed et al., 2017; Bolarinwa and Olagunju, 2019). This may be probably as a result of increase awareness and skill of health care provider on the insertion and removal skill. Among those who used LARC methods, substantial proportion of them used implants (43.1%) and only 9.0% used IUCD. This finding agreed with other findings which reported that majority of their respondents used implants (Aregay et al., 2018; Bolarinwa and Olagunju, 2019; Igwebueze, 2017). Lower rate of IUCD utilization among acceptors may be partially explained by misconceptions about LARC methods and their related side effect.

Annual trends in LARC uptake in the study demonstrate a steady upward slanting in contraceptive implants and decline in IUD uptake. This is in accordance from previous finding (Moreau et al., 2013; Adedini et al., 2019; Darroch et al., 2013).  Women might choose implants probably because they like the convenience and duration of contraceptive  protection,  and  implants  can  be inserted without undergoing a pelvic exam. This could suggest a provider preference for implants with a prepackaged applicator over IUCD that require a trocar for insertion (Bikorimana, 2015; Bolarinwa and Olagunju, 2019).

Clients using LARC were mostly aged 21 to 39 years, educated up to secondary level, multiparous and had at least one living child. This is similar to the study done in Kaduna and Enugu (Mohammed et al., 2017; Igwebueze, 2017). Findings showed that older women were more likely to use LARC methods, compared to their younger counterparts. Possible explanation for this is that older women tend to have more children, have completed their family size and perhaps desire no more children; hence their preference for LARC method compared to short acting contraceptives (Coombe et al., 2017; Bratlie et al.,   2014). Adolescent are less likely to use LARC, this is in line with some previous study (Nicole et al., 2017; Lisa et al, 2015; Francis et al., 2017); these group of clients are very fertile and vulnerable to unintended pregnancy and its complications. Unfortunately, it appears that our family planning clinic is not adolescent-friendly, or they are afraid of stigmatization. This may explain the poor uptake rate by adolescents in this study.

The results also showed that likelihood of using LARC methods was significantly much higher among multiparous women, particularly those who had 5 or more children, compared to their childless counterparts. In addition, women who had no desire for more children were more likely to adopt LARC methods than those who desired more children. This is expected, as long-acting contraceptives are generally viewed as permanent contraceptive methods and are mostly used to limit childbearing.

Furthermore, the use of LARC methods was higher among educated women compared to those with no education. This is in agreement with previous study (Luchowski et al., 2014; Ochako et al., 2016). Correct knowledge about LARC methods is a key factor to ensure increased and appropriate use, and also avoid misinformation that can hinder women to adopt methods not suitable for them.

The study shows that the acceptors of LARC were more likely from those who had never use any form of contraception before and those who have had sub-dermal implant want .to continue with the method. This is probably because they had good counseling on the effectiveness and safety on LARC in the clinics.

The finding that most of the clients uses LARC till the duration elapses and contraception failure is about 5% makes sense. With adequate counseling and provision, it is presumed that women who choose an IUD or implant intend to use it for a sustained period of time (Ochako et al., 2015; Thompson et al., 2018). IUDs and implants are also provider-discontinued methods, whereas injectable and some modern methods can be discontinued passively, require continuous renewal, or are coitus-dependent.

The study showed that younger women were more likely to discontinue the methods compared to older one (P<.05). The commonest reason for discontinuation was desire for another pregnancy among users and irregular menses. Clients aged less 20 years were less likely to continue the method till the duration elapse. This is in accordance with previous study. (ACOG, 2012; Ezegwui et al., 2011; The American College of Obstetricians and Gynecologists, 2014). The increased risk of early discontinuation among adolescents, as compared with older women, may reflect lower adherence to the method. Most pregnancies among teenagers are unintended and many can be attributed to contraception misuse or nonuse (Sharma et al., 2014) (Kalayu et al., 2015). Furthermore, women of low parity are more likely to discontinue due to desire for more pregnancy, while those with high parity were more like to continue till the time elapse.

Number of living children at the time of contraceptive use was significantly associated with the reason for discontinuation, suggesting that women wanted to space or limit childbirth as the number of surviving children increases. The higher the number of living children the higher the possibility of adopting LARC. The desire to limit the number of children will come to play when women believe they have sufficient numbers of children so rather adopting short-lasting, long-lasting methods will be better for them (Melese et al., 2017).

In addition, level of education was found to be associated with the reason for discontinuation of LARC. The possibility of women with at least secondary school education to control her reproductive need is very high. The higher the education of women the higher the propensity that they will continue the contraception till the duration elapses, and less likely to discontinue due to desire for more pregnancy. This is in line with previous study (Tadele, 2017; Azmoude et al., 2017; Biza et al., 2016; Zenebe et al. 2017; Adolescents and Long-Acting Reversible Contraception, 2012). Educated women tend to adhere more to contraception.

Furthermore, civil servants were less likely to discontinue due to desire of pregnancy and more likely to continue till the duration elapsed. This is possible because empowered women can able to control their reproductive need.

This review also found that pelvic infection, and husband refusal was other reason for discontinuation and, expulsion, weigh gain also contributed. This finding is in line with previous studies (Olson et al., 2018; Black et al., 2013; Thanel et al., 2018). Husband refusal is another barrier for contraception use. This probably may be their ignorant of the benefit of contraception in women reproductive life.

The  finding  in  this  study revealed that uptake of Jadelle and Implanon increased over the period of 2015 to 2019, but IUCD use remains low. Adolescent are less likely to use LARC. The identified reason for early discontinuation among LARC users was desire for another pregnancy, irregular menses, husband refusal, pelvic infection and weight gain. Adolescents should have access to client-friendly family planning services without bias, and stigmatization. Effective, confidential communication with sensitive language to inform adolescents of the different types of LARC is necessary to normalize offering LARC as a contraceptive option and improve its uptake among adolescents. Appropriate follow up case, management of side effects and involving men in family planning will improve the uptake and minimized the rate dis-continuation of LARC.

The study had some limitations. This study was a retrospective facility-based review of the uptake of LARC and the reason for early discontinuation. There were missing information on marital status, religion, sources of family planning information and husband education and occupation in the new client register. Such data can affect uptake rates of the methods by the clients. The study being a facility-based one cannot be generalized to all women of reproductive age for the entire study population.  Postpartum LARC was not included because of limited data. Despite these limitations, this study has filled an important gap in the literature on family planning by providing evidence on the trends, uptake, and reason for discontinuation of LARC use in centers, and highlights the characteristics of uses, in an area where fertility and maternal mortality is high and the utilization of these methods has remained consistently low.

The authors have not declared any conflict of interests.