Factors associated with early discontinuation of contraceptive implants among women of reproductive age in wakiso district, a facility based crossesctional study

FACTORS ASSOCIATED WITH EARLY DISCONTINUATION OF CONTRACEPTIVE
IMPLANTS AMONG WOMEN OF REPRODUCTIVE AGE IN WAKISO DISTRICT, A
FACILITY BASED CROSS-SECTIONAL STUDY
BY
DDUNGU UMARU
MB.Ch.B (Mak)
A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF MASTERS OF PUBLIC HEALTH OF
MAKERERE UNIVERSITY
NOVEMBER 2019

iii
ACKNOWLEDGEMENT
I extend my gratitude and sincere appreciation to all those that supported me in ensuring that this
study is a success. My sincere thanks go to my supervisors Dr. Simon Peter Kibira and Mr.
Ssenyonga for availing adequate time for engagements and support during the period of the
study. I also thank the district health team especially health facility in-charges of Wakiso district
for support and coordination during data collection in their respective facilities. Special
recognition goes to Dr. Sseviri Mathias, Betty Nabuuma and Namulondo Edith sharing
information about the district during literature review.
Special thanks go to my research assistants who were committed and provided valuable time in
data collection. They included Nabagesera Prever, Nakiyimba Viola, Tindimweebwa Ruth,
Nakalembe Margaret Bateera Ann and all assistants from private health facilities who
participated in data collection. On a similar note, I also thank all respondents who participated in
the study for their time and efforts to respond to questions as honestly as possible.
Lastly, appreciate the support from my work manager Dr. Kirima Andrew who provided a
favorable studying environment for me during the period of this project

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TABLE OF CONTENTS
APPROVAL................................................................................................................................. i
DECLARATION........................................................................................................................ii
ACKNOWLEDGEMENT........................................................................................................iii
LIST OF TABLES AND FIGURES.......................................................................................vii
ACRONYMS AND ABBREVIATIONS............................................................................ viii
DEFINITIONS ............................................................................................................................9
ABSTRACT..................................................................................................................................x
1.0 INTRODUCTION AND BACKGROUND .....................................................................1
1.1 Introduction.......................................................................................................................................1
1.2 Background........................................................................................................................................2
2.0 LITERATURE REVIEW ......................................................................................................5
2.1 Early Discontinuation of Contraceptive Implants .............................................................................5
2.2 Proportion of Early Discontinuation of implants...............................................................................5
2.3 Determinants of Early Discontinuation of Implants..........................................................................6
2.4 Factors that influence the overall duration of use of implants.........................................................8
3.0 STATEMENT OF THE PROBLEM, JUSTIFICATION, CONCEPTUAL
FRAMEWORK AND RESEARCH QUESTIONS ................................................................9
3.1 Statement of the Problem.................................................................................................................9
3.2 Justification of the Study.................................................................................................................10
3.3 Conceptual Framework...................................................................................................................11
3.4 Research Questions.........................................................................................................................12
4.0 STUDY OBJECTIVES........................................................................................................13
4.1 Aim ..................................................................................................................................................13
4.2 General Objective............................................................................................................................13
4.3 Specific Objectives...........................................................................................................................13
5.0 METHODOLOGY..............................................................................................................14
5.1 Study Area .......................................................................................................................................14
5.2 Study Population .............................................................................................................................14
5.3 Study Design....................................................................................................................................15
5.4 Sample Size......................................................................................................................................15

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5.5 Sampling Procedure ........................................................................................................................15
5.6 Study Variables................................................................................................................................15
5.6.1 Dependent variables. ................................................................................................................15
5.6.2 Independent variables...............................................................................................................16
5.7 Data Collection ................................................................................................................................17
5.7.1 Training of Research Assistants...............................................................................................17
5.7.2 Tools.........................................................................................................................................17
5.7.3 Pre-testing.................................................................................................................................17
5.7.4 Field editing of data..................................................................................................................17
5.7.5 Missing data .............................................................................................................................17
5.8 Data Management and Analysis......................................................................................................18
5.8.1 Data Management.....................................................................................................................18
5.8.2 Data Analysis ...........................................................................................................................18
5.9 Ethical Considerations.....................................................................................................................18
6.0 RESULTS..............................................................................................................................20
6.1 Characteristics of the study population ..........................................................................................20
6.2 Proportion of Early discontinuation................................................................................................22
6.3 Determinants of early discontinuation ...........................................................................................23
6.4 Factors that influence overall duration of use of implants.............................................................27
7.0 DISCUSSION......................................................................................................................32
8.0 CONCLUSIONS.................................................................................................................38
9.0 RECOMMENDATIONS...................................................................................................39
9.1 Recommendations for family planning programs...........................................................................39
9.2 Recommendations for further research..........................................................................................39
REFERENCES............................................................................................................................40
APPENDICES............................................................................................................................44
1. Number of Respondents per Health Facility .................................................................................44
2. Consent Forms for Respondents.......................................................................................................46
2.1 Consent form in English..............................................................................................................46
2.2 Consent form in Luganda......................................................................................................48
3. Questionnaire....................................................................................................................................50

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4. List of codes and description of categorical variables.......................................................................54

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LIST OF TABLES AND FIGURES
Table 1: Dependent Variables for Factors Associated with Early Discontinuation of Implants among
Women of Reproductive Age 15 – 49 years in Wakiso District.................................................................16
Table 2a: Other Client-based Characteristics for Women of Reproductive Age 15 – 49 Years who
Discontinued Implants in Wakiso District during the Study .....................................................................22
Table 2b: Other Provider-related Characteristics for Women of Reproductive Age 15 – 49 Years who
Discontinued Implants in Wakiso District during the Study .....................................................................23
Table 3: Proportion of Women of Reproductive Age 15 – 49 years who Discontinued Implants Early in
Wakiso District..........................................................................................................................................24
Table 4a: Bivariate Analysis for Client-based Determinants of Early Discontinuation of Implants among
Women of Reproductive Age in Wakiso District .......................................................................................25
Table 4b: Bivariate Analysis for Provider-related Determinants of Early Discontinuation of Implants
among Women of Reproductive Age in Wakiso District ...........................................................................26
Table 5: Multivariate Analysis for Determinants of Early Discontinuation of Implants among Women of
Reproductive Age 15 – 49 years in Wakiso District..................................................................................28
Table 6a: Bivariate Analysis for Client-based Factors That Influence Overall Duration of Use of
Implants among Women of Reproductive Age in Wakiso District.............................................................30
Table 6b: Bivariate Analysis for Provider-related Factors That Influence Overall Duration of Use of
Implants among Women of Reproductive Age in Wakiso District.............................................................32
Table 7a: Multivariate Analysis for Client-based Factors That Influence Duration of Use of Implants
Table 7b: Multivariate Analysis for Provider-based Factors That Influence Duration of Use of Implants
Figure 1: A conceptual Framework for Factors Associated with Implant Discontinuation among Women
of Reproductive Age 15-45 years in Wakiso District ................................................................................11

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ACRONYMS AND ABBREVIATIONS
AOR Adjusted Odds Ratio
CCP Center for Communication Programs
CHS College of Health Sciences
CI Confidence Interval
CYP Couple years of protection
DESA United Nations Department of Economic and Social Affairs
FP Family Planning
FY Financial Year
HC Health Center
IUD Intrauterine Device
Mak Makerere University
MakSPH Makerere University School of Public Health
MOH Ministry of Health
NGO Non-government Organization
PR Prevalence Ratio
PFP Private for Profit
PMA Performance Monitoring and Accountability
PNFP Private Not for Profit
RHR Department of Reproductive Health and Research
UBOS Uganda Bureau of Statistics
UNFPA United Nations Program for Family Planning
WHO World Health Organization

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DEFINITIONS OF TERMS
Contraceptive implant discontinuation: This is the surgical removal of an implant meant for
contraception from a woman who has been using the method irrespective of whether or not she
is switching to another method.
Early discontinuation of contraceptive implants: This is the surgical removal of viable
implant from a woman before 18 months since insertion of the same implant.
Expiry of an implant: This is complete usage of the implant up to the end of its designed
duration of 3 years for Implanon or 5 years for Jadelle.
Duration of use: This is the time interval for which a woman has retained the contraceptive
implant from the date of insertion as recorded on the client’s card or any other means of
verification to the date it is discontinued.
Reproductive age: Age of a woman ranging from 15 to 49 years.
Switching: Re-using another method or replacing a similar method of contraception within a
month after discontinuation of the implant.

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ABSTRACT
Introduction: Over the recent years, there has been a gradual increment in the number of
women using contraceptive implants in Uganda. In Wakiso district, the number of implant
insertions increased from 6,344 in the FY 2015/16 to 14,389 in FY 2017/2018. However, there
was also an increasing trend in the number of implants discontinued by women in the district.
Studies on contraceptive discontinuation did not focus on implants and the critical interval of 18
months from the time of insertion. This study intended to contribute to the body of knowledge
needed to improve retention of contraceptive implants among users. Therefore, the study
estimated the proportion of women who discontinue implants early, established factors
associated with early discontinuation of implants and determined factors that influence the
duration of use of implants among women 15 – 49 years in Wakiso district.
Methods: This is a facility-based cross-sectional study involving 397 women of reproductive
age 15 – 49 years, who had discontinued contraceptive implants from 42 health facilities in
Wakiso district. Sampling was by stratified technique and I analyzed data with STATA 14. I
used modified Poisson and quantile regression analysis techniques using a significance level (α)
of 0.05 for test statistics.
Results: The proportion of early implant discontinuation was 31%. Early discontinuation was
determined by; side effects [adjusted PR = 1.20; 95% CI = 1.05 – 1.37] and incurring costs on
retention of implants [adjusted PR = 1.15; CI = 1.04 – 1.28]. Overall duration of use of implants
was influenced by discontinuation due to side effects [β = -9.63; CI = -16.6 - -2.63], insertions
during breastfeeding [β = -5.00; CI = -8.95 - -1.05], incurring costs on retention of an implant [β
= -7.38; CI = -13.3 - -1.47] and not counseling a woman [β = -6.47; CI = -12.1 - -0.86].
Conclusion: The proportion of early discontinuation was considerably high at 31 percent.
Addressing side effects and costs on retention would help prevent early discontinuation. In
addition, ensuring counselling before implant insertions would improve retention of implants.
Recommendations: A proportion of 19 percent should be set as a target for early
discontinuation. FP programs should focus on managing side effects, mitigating costs on
retention and counselling to improve retention of implants.

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CHAPTER ONE
1.0 INTRODUCTION AND BACKGROUND
1.1 Introduction
Contraceptive implants are small rods of the size of a matchstick that release a synthetic
hormone similar to the natural hormone progesterone when inserted into a woman’s body to
prevent pregnancy (WHO/RHR and Johns Hopkins Bloomberg School of Public Health/CCP,
Knowledge for Health Project, 2018). Over the recent years, there had been a global
improvement in the uptake of contraceptive implants from 0.2% in 1994 to 0.7% in 2015
(United Nations DESA, Population Division, 2015), partly due to a reduction in prices of
contraceptive implants and an increment in donor investment through the Implant Access
Program. In Uganda, the uptake of contraceptive implants improved from nearly zero in 1994
up to 3.5% by 2015 (United Nations DESA, Population Division, 2015) moving up to 6.3% in
2016. This had contributed to an improvement in the modern contraceptive prevalence rate
(mCPR) from 11.3% in 1994 to 35% (Uganda Bureau of Statistics and ICF, 2017).
To benefit from the full advantages of contraceptive implants, women need to avoid early
discontinuation of the implants. Whereas WHO recommended birth-to-pregnancy interval of at
least 24 months, a decision that was reached with compromise, all researchers unanimously
agreed that birth–to–pregnancy intervals of less than 18 months should be avoided in order to
avoid very high risks of poor maternal, perinatal, infant and neonatal outcomes (WHO, 2007).
For uniformity therefore, early discontinuation of implants can be considered when a woman
stops using an implant before 18 months since insertion of the same implant irrespective of the
period since last delivery or termination of pregnancy or whether or not she has ever had a
pregnancy.
Early discontinuation of contraceptives may result in short birth-to-pregnancy intervals, which
in turn is associated with maternal mortality and morbidities such as premature rupturing of
membranes, anemia, puerperal endometritis, increased risk of uterine rupture and pre-eclampsia
(WHO, 2007). Short birth intervals are also associated with a number of undesirable perinatal

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outcomes such as prematurity, fetal death, low birth weight, small for gestation age babies and
neonatal death.
In Wakiso district, there was an increasing trend in the number of implants discontinued by
women each year with unknown reasons for this trend (Wakiso District Health Office, 2016,
2017 & 2018). This study assessed factors associated with early discontinuation of implants
among women of reproductive age in Wakiso district in order to inform strategies to improve
retention of implants among users.
1.2 Background
Over the recent years, there had been a gradual increment in the number of women who use
contraceptive implants. Globally, the contraceptive prevalence for implants tripled from 0.2% in
1994 to 0.7% in 2015. In sub-Saharan Africa, it increased from nearly zero in 1994 to 2.6% in
2015 (United Nations DESA, Population Division, 2015). Similar trends have been noted in
Uganda. In financial year (FY) 2015/2016, 210,272 women used implants (MOH- Uganda,
2016) and this number increased to 269,783 in FY 2016/2017 (MOH, Uganda, 2017). This had
led to an increment in the share of implants on the contraceptive method-mix among married
and unmarried women from 13.2% in 2016 to 17.5% in 2018 (MakSPH; Bill & Melinda Gates
Institute for Population and Reproductive Health, 2018).
In Wakiso district, a similar trend had been noted where 6,341 women used implants in the FY
2015/2016, 8519 women in 2016/17 and 14,380 women in FY 2017/18. However, there was
also an increasing trend in the number of implants discontinued within the district. In the FY
2015/16, there were 1,395 implant discontinuations reported (Wakiso District Health Office,
2016). The number of implant discontinuations increased to 2,215 in FY 2016/17 (Wakiso
District Health Office, 2017) and 3,595 in FY 2017/18 (Wakiso District Health Office, 2018).
Wakiso district also had a low performance in family planning indicators as deduced from the
regional performance with a modern contraceptive prevalence rate of 40.4% (UBOS, 2017),
which was below the national target of 50% by 2040 and an unmet need for family planning
methods of 20.5% against a national target of 10%.
A high level of contraceptive discontinuation can negatively affect the impact of family
planning programs. Between 4 to 28% of the total fertility is accounted for by births resulting
from contraceptive discontinuation (Blanc, et al., 2002). Blanc and others determined that the

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total fertility rate could be reduced by 20% to 48% in absence of births occurring following
contraceptive discontinuation for any reason other than the intention to become pregnant. Such
a reduction in the total fertility rate could be very useful in controlling the population growth in
Wakiso, which was the most populated district in Uganda with an estimated population of
nearly 2 million people (UBOS, 2017). Contraceptive discontinuation is also associated with
higher rates of unwanted and mistimed pregnancies and their consequences such as stillbirths
and abortions (Anrudh & Winfrey, 2017 and Ali, et al., 2012). Ali et al determined that 5 – 20%
the unwanted pregnancies that resulted from contraceptive discontinuation due to method
failure alone resulted in miscarriages, stillbirths or abortions in most countries.
Furthermore, the contribution estimated by programs that use Couple Years of Protection (CYP)
as a performance measure is inflated when implants are discontinued before their estimated
durations of use. Stover and others ( 2000) described this concept as wastage and misreporting,
two recognized variables affecting use of CYP as a performance measure in programs providing
family planning services.
Studies on contraceptive use or discontinuation had not focused on implants but the general
short-term methods including pills, condoms and injectable (Ali, et. al; Mumah, et al., 2015).
Others included only intrauterine devices as contraceptives (Grunloh et. al, 2013; Micaela, et
al., 2013). Tadesse, et al. (2017) focused on implants, but they defined discontinuation at 3
years after insertion, which limits the duration of use under study to that time interval.
Grunloh, et al. (2013) and Asaye, et al. (2018) had considered early discontinuation at different
cut-off durations. At a cut-off duration of 6 months for early discontinuation, Grunloh et. al
determined a low implant discontinuation rate of 7% and not being marrried was the only factor
associated with early discontinuation at that cut off duration. Asaye et.al determined a
discontinuation rate of 65% at cut-off of 2.5 years for early discontinuation of implants where
having no children, not being counseled for possible side effects, having no appointment for
follow-up and having developing side effects were associated with early discontinuation.
With the increasing use of contraceptive implants in Wakiso district and Uganda, an
improvement in the method mix in favor of implants and a critical interval of 18 months for
birth-to-pregnancy, it was imperative to understand factors associated with implant
discontinuation if the district was to benefit from the trends on implant use. This study therefore

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estimated the magnitude of early discontinuation of implants, established determinants of early
discontinuation and determined factors that influenced the overall duration of use of implants,
among women of reproductive age in Wakiso district.

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CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 Early Discontinuation of Contraceptive Implants
There was no standard definition for early discontinuation of contraceptive methods. A few
studies that had studied the concepts of early discontinuation had had varying cut-off points in
form of months for which contraception was being used before discontinuation. In the study to
measure discontinuation within 6 months among users of the levo-norgestrel, intrauterine
system, copper intrauterine device (IUD), and etonogestrel implant, Grunloh et al (2013) used 6
months as the cutt-off point for early discontinuation. In a different study meant to assess early
Implanon discontinuation and associated factors among Implanon user women in Debre Tabor
town, Asaye, et al. (2018) used a cut-off period of 2.5 years to define early discontinuation.
In her report on the technical consultation of birth spacing, WHO recommended a period of at
least 24 months as the birth-to-pregnancy interval after a compromise on the different opinions
of consultants who analyzed the consequences and risks in terms of maternal, perinatal and
neonatal outcomes at shorter and longer intervals. Despite several view on the appropriate birth-
to-pregnancy intervals, all consultants unanimously agreed that births below 18 months should
be avoided. Therefore, 18 months became a critical birth-to-pregnancy interval and it formed
the basis for 18 months as a cut-off for our operational defination of early implant
discontinuation.
2.2 Proportion of Early Discontinuation of implants
On review of recent and old literature, no studies had been done to define the magnitude of
early discontinuation of implants before the critical interval of 18 months after insertion.
However, at a cut-off of 2.5 years for early discontinuation, Mengstu, et al. (2018) estimated the
proportion of early discontinuation at 65%. At a cut-off interval of 6 month for early
discontinuation, Kalmuss, et al., (1996) estimated 7.6% and Grunloh et al. (2013) estimated 7%
of women who discontinue implant early. The two proportions were calculated out of all
women who were using implants rather than only those who discontinued implant.

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2.3 Determinants of Early Discontinuation of Implants
In the context of this study, early discontinuation is when a woman stops using a contraceptive
implant before 18 months since insertion of the same implant. There was no scientific literature
on determinants of implant discontinuation before 18 months after insertion. The closest
literature included studies where early discontinuation was considered at a very low cut-off
interval of 6 months (Grunloh et al., 2013) and at a very high cut-off interval of 2.5 years
(Birhane, et al., 2015). Other studies did not address the concept of early discontinuation at all,
but established significant determinants in general (Melese Siyoum, 2017; Tadesse, et al., 2017;
Zemenu, et al., 2017). Furthermore, other studies did not only miss out the concept of early
discontinuation but they were more general in terms of contraceptives studied in that they
studied discontinuation of all contraceptions combined (Atnafe, et al., 2016; Blanc, et al., 2002)
and some excluded implants (Ali, et al., 2012).
Birhane et al. (2015) studied on type of implant called Implanon and they considered a high cut-
off period of 2.5 years for a definition of early discontinuation of Implanon. Limitations of their
study include a bias towards one type of implant and high cut-off period for the operational
definition. Nevertheless, their study determined health concerns, wanting more children, side
effects, husband opposition, inconvenience to use, religious opposition and contraceptive failure
were the reasons for early discontinuation of Implanon defined as Implanon removal before 2.5
years. In the same study, lack of an appointment for follow up, lack of satisfaction with weight
gain and presence of side effects were associated with early discontinuation of Implanon.
In a study by Atnafe, et al. (2016), age group 25 years and above, marital status, number of
children, future marital status and source of family planning information were independently
associated with switching of long acting method among revisit clients in public health facilities
of Dire Dawa city. On adjusting the model, multiple logistic regression analysis revealed that
married women were 2.4 times less likely to switch compared to unmarried women (AOR =
2.41, CI: 1.01 – 5.74)). Women who had 2-4 children were 3 times less likely to switch
compared to those had one child (AOR = 3.00, CI: 1.59 – 5.67) as well as women who had
more than 5 children (AOR = 2.07). Women who did not want any more children were 5.1
times less likely to switch compared to women who wanted to have more children (AOR = 5.11,
CI: 1.25 – 24.8). In this study however, findings were not discriminative of the type of

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contraceptive method studied. Both implants and IUD were studied and there was no study of
the concept of early discontinuation.
Melese Siyoum (2017), established determinants for discontinuation of Implanon. Tertiary
education/college and above (p = .016) as compared to no formal education, no history of
pregnancy (p = .001), not having got counselling services (p = .044), not being satisfied with the
method given (p = .001) and prior experience of side effects were associated with
discontinuation of the implant. Independently, husband and others as main deciders of the
method as opposed to the woman herself were associated with discontinuation of the method.
On the other hand, age groups between 25 and 35 years (OR = 0.17 and 0.35) compared to the
age group below 21 years, Primary (OR = .082) and Secondary school (OR = .095),
effectiveness and no side effects as reasons for choosing the method were associated with
continued use of the method. This study however, looked at Implanon only and without a
concept of early discontinuation and therefore, it had a different focus compared to our planned
study that encompassed all implants and a concept of early discontinuation.
Relatedly, Tadesse, et al. (2017) identified determinants for discontinuation of contraceptive
implants among women in Diguna Fango district in southern Ethiopia. Residence in rural area,
age less than 20 years, having no formal education, having not more than 4 children, history of
abortion and presence of side effects were individually associated with discontinuation of
implants before 3 years. On the other hand, follow up appointment given, not being satisfied
with the services, another person (husband or health provider) being the decision maker to use
implant and providing counselling were individually associated with retention of the implant to
3 years. On adjusting for confounding, multiple logistical regression revealed that the same
factors contributed to the outcome of Implanon discontinuation other than decision maker to use
Implanon, side effects and service satisfaction. However, like Birhane et al (2015), this study
assessed implant discontinuation at a very high cut-off interval of 3 years.
In summary, available studies on determinants of early discontinuation use very low or very
high cut-off time intervals rather than the critical interval of 18 months to define early
discontinuation or they do not have a focus on the type of contraceptive. This study will focus
on all implants with a cut-off interval of 18 months for early discontinuation.

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2.4 Factors that influence the overall duration of use of implants.
Analyses of several studies on use of contraceptive implants revealed marked variation in the
duration of use of implants depending on the area of study (Ali, et al., 2012; Atnafe, et al., 2016;
Melese Siyoum, 2017; Power, et al., 2007). A number of factors in turn influenced the duration
of use. Most studies assessed factors that influence contraceptives use in general mixing short-
term methods such as contraceptive pills and injectable (Ali, et al., 2012; Mumah, et al.,
2015)(as well as intrauterine devices (Grunloh, et al., 2013; Micaela, et al., 2013). Short-term
methods intrinsically protect a woman against unwanted pregnancy for a short duration and they
are associated with higher risks of method failure (WHO/RHR and Johns Hopkins Bloomberg
School of Public Health/CCP, Knowledge for Health Project, 2018) while intrauterine devices
have a different side effect profile compared to implants.
Furthermore, Tadesse and otehrs (2017) established the determinants of discontinuation of
Implanon, one of the contraceptive implants used by women, from which factors that influence
duration of use can be deduced. Age less than 20 years, no formal education, more than 4
children and history abortion, side effects and residence in rural area were determinants. Other
determinants were being satisfied with the service, giving follow up appointment and decision
being made by another person. However, this study addressed discontinuation as a categorical
event that occurs or not after a specified time interval. Factors that influence the duration of use
before 3 years in the study may be considered as significant or non-significant based on odds
ratios when the reverse is true. Therefore, the identified factors in the studies were limited to the
time interval used to define discontinuation in the study and they could not be inferred to any
period after that.
In summary, previous studies lacked focus on the type of contraceptive under study as well as
being biased and restrictive on duration of use of contraceptives for only a specified period as
defined in the respective studies. This study therefore, focused on implants (Implanon and
Jadelle) and it modelled factors that influenced use of implants with the overall duration of use
as a continuous variable to eliminate the above pitfalls.

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CHAPTER THREE
3.0 STATEMENT OF THE PROBLEM, JUSTIFICATION, CONCEPTUAL
FRAMEWORK AND RESEARCH QUESTIONS
3.1 Statement of the Problem
There is an increasing trend of discontinuation of contraceptive implants by women in Wakiso
district. In the financial year (FY) 2015/16, there were 1,395 implant removals reported
(Wakiso District Health Office, 2016). The number of implant removals increased to 2,215 in
FY 2016/17 (Wakiso District Health Office, 2017) and 3,595 in FY 2017/18 (Wakiso District
Health Office, 2018) leading to implant removal- to-insertion ratios of 0.22, 0.26 and 0.25 in the
respective financial years.
Contraceptive discontinuation is associated with a high un-met need for contraception that
reduces the impact of family planning programs (Jain, et al., 2013). It is also associated with a
high number of unintended pregnancies and their consequences such as stillbirths, miscarriages
and abortions (Jain & Winfrey, 2017; Ali, et al., 2012). Short birth-to-pregnancy intervals of
less than 18 months (early discontinuation) are associated with maternal mortality and
morbidities such as premature rupturing of membranes, anemia, puerperal endometritis,
increased risk of uterine rupture and pre-eclampsia (WHO 2007).
Literature on factors associated with early discontinuation of contraceptives is scanty and not
specific to implants. Previous studies lacked focus on the type of contraceptive under study and
they focused on duration of use of contraceptives for only a specified period (Ali, et al., 2012;
Castle & Askew, 2015; Mumah, et al., 2015; Grunloh, et al., 2013; Micaela, et al., 2013). In
these studies, early discontinuation was considered at low (Grunloh et al., 2013) or high (Asaye,
et al., 2018; Birhane, et al., 2015) cut-off intervals compared to the critical interval of 18
months.
This study sought to determine the proportion of women who discontinue implants early and
establish factors associated with early discontinuation. It also determined factors that influenced
the overall duration of use of implants among women of reproductive age 15 – 49 years who
had discontinued in Wakiso district.

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3.2 Justification of the Study
This study estimated the burden of early discontinuation of contraceptive implants and proposed
a target proportion, which can be used for monitoring and evaluation of early discontinuation of
implants in family planning programs.
This study established determinants of early discontinuation as key areas of focus in ensuring
retention of implants and preventing short birth-to-pregnancy intervals. Prevention of early
discontinuation of implant would improve maternal, perinatal and neonatal outcomes of
pregnancies carried by women who use contraceptives, with an aim achieving sustainable
development goal 3.
The study also established additional factors, which can be a focus to improve retention of
implants by women. Improving retention of implants prevents unwanted pregnancies with a
resultant reduction in total fertility, as well as reducing unmet need for contraception.

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3.3 Conceptual Framework
Unknown proportion
Early discontinuation
(before 18 months)
Implant insertion Duration of use (0 – 60 months) Implant discontinuation
Provider-basedfactors
Type of
implant
Cost on
retention
Cost of
insertion
Client-basedfactors
Knowledge of
side effects
Prior use
of implant
Education
Level
Marital
status
Parity
Age
Religion
Cost of
transport
Place of
insertion
Figure 1: A conceptual Framework for Factors Associated with Implant Discontinuation among Women of Reproductive Age 15-45
years in Wakiso District

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Description of the conceptual framework
After an implant insertion, a woman uses the contraceptive method for varying duration ranging
from zero upto 60 months. However, an unknown proportion of women discontinue implants
before 18 month, defined as early discontinuation, due to possible client-based and provider-
related factors. The rest of women discontinue implants at 18 or more months with several
factors influencing the overall duration of use of the implant. Client-based factors include age,
parity, education level, religion, parity and prior use of implants. Provider-related factors
include place of insertion, cost of implant, cost of transport, cost on retention, place of insertion
and knowledge on side effects.
Age is apossible determinant of early discontinuation as well as a factor that influences overall
duration of use of implants. However, it can also be a determinant of parity, education level,
marital status and prior use of implants.
Education level can be a determinat of early discontinuation as well as a factor that influences
overalll duration of use. howvwer, it can also be a determinant of parity, cost of insertion and
place of insertion.
Place of insertion is a possible determinant of early discontinuation and a possible factor that
influences overall duration of use of implants. On the otherhand, it also infuences cost of
transport, type of implant, cost on retention and prior use of implants.
3.4 Research Questions
1. What is the proportion of early implant discontinuation among women of reproductive
age 15 – 19 years who discontinue implants in Wakiso district?
2. What are the determinants of early discontinuation of implants among women of
reproductive age 15 – 49 years who discontinue implants in Wakiso district?
3. What factors influence the overall duration of use of implants among women of
reproductive age 15 – 49 years who discontinue implants in Wakiso district?

13
CHAPTER FOUR
4.0 STUDY OBJECTIVES
4.1 Aim
The study aimed at contributing to the body of knowledge needed to improve retention of
contraceptive implants among users, which would eventually result in an improvement in the
contraceptive prevalence rate, reduction in unmet need for family planning and attainment of
FP2020 and Uganda national vision of 2040.
4.2 General Objective
To assess factors associated with discontinuation of implants among women of reproductive age
(15 – 49 years) in Wakiso district in order to inform strategies for improving retention of
implants with an ultimate goal of increasing contraceptive prevalence; reducing total fertility
rate; and reducing maternal and neonatal morbidity and mortality.
4.3 Specific Objectives
1. To estimate the proportion of women of reproductive age 15 – 49 years in Wakiso
district who discontinued implants early among those who discontinued implants.
2. To establish the determinants of early discontinuation of contraceptive implants among
women of reproductive age 15 – 49 years who discontinued implants in Wakiso district.
3. To determine factors that influenced overall duration of use of implants among women
of reproductive age 15 – 49 years who discontinued implants in Wakiso district.

14
CHAPTER FIVE
5.0 METHODOLOGY
5.1 Study Area
The study was conducted in Wakiso district, which lies in the south central region of Uganda
and located 00 29N, 32 29E and it had an estimated population of 2,319,500 people. The district
has seven health sub-districts, a total of 104 government-supported health facilities of which 67
are purely government-aided and the remaining 37 are private not for profit (PNFP). It also has
a number of private for profit health facilities that support the health system. About half of the
district’s population is within a kilometer reach of a health facility. Most of the health facilities
are able to provide family planning services with direct support from the central government as
well as support from implementing partners in health such as Marie Stopes Uganda,
Reproductive Health Uganda and Population Services International. The district has an
estimated population of 468,534 women in reproductive age group of 15 – 49 years. It lies in a
region with contraceptive prevalence rate of 40.4%. Wakiso shares on the national contraceptive
prevalence for implants of 17.5 percent (MakSPH; Bill & Melinda Gates Institute for
Population and Reproductive Health, 2018). It has an unmet need for family planning of 20.5%
and 60.2% of the demand for family planning is satisfied. In the district, 33126 women were
expected to be using contraceptive implants. There were 52 government aided facilities, 18
private not for profit (PNFP) or faith-based facilities and 103 purely private facilities, which
were reporting data at the district. Only 42 out of 173 health facilities removed an average of at
least two implant per month in the FY 2017/2018 of which 21 were in government aided, four
were in are PNFP and 17 were in PFP health facilities.
5.2 Study Population
The study was composed of women of reproductive age of 15 – 49 years who had discontinued
implants from government-aided, PNFP and PFP health facilities in Wakiso district.
Eligibility criteria
For inclusion in the study,

15
- A facility from which a woman was selected must have had an average of at least two women
discontinue an implant per month in the FY 2017/18 in order to increase the chances of finding
a respondent in the shortest period of three months meant for the study.
- For a respondent to be included in the study there must have been a visible record of the date
of insertion of the contraceptive implant, either as a client card or captured and retrievable from
the facility/supporting partner’s records.
5.3 Study Design
A facility-based cross-sectional study was conducted among women of reproductive age 15 - 49
years who had discontinued implants in health facilities of Wakiso district. Data were collected
over two and half months from 23rd
–March to 10th
- June 2019. Every woman was interviewed
on the same day she discontinued the implant and the date on which she inserted the implant
was recorded from her client card that had been given to her after insertion. Being a facility-
based study allowed accurate capturing of dates of removal of the implants and minimized
recall bias. The study estimated duration of use of contraceptive implants as well as the
proportion and determinants of early discontinuation of implants in Wakiso district.
5.4 Sample Size
The sample size was determined by using a desired precision d = 0.05, an arbitrary estimated
prevalence P of 0.5 for the prevalence of early discontinuation in Wakiso district, a confidence
level of 95% and z- statistic for the level of confidence Z = 1.96. Using Leslie Kish (1965)
formula for calculating the sample size in surveys and a response rate of 97% in women
(Uganda Bureau of Statistics and ICF, 2017), a sample size of 397 respondents was used in the
study (initial size n = 385 and non-responders = 12)
5.5 Sampling Procedure
I used stratified sampling technique for the study. I stratified health facilities by ownership into
government-aid facilities (21 health facilities), PFP (17 health facilities) and PNFP facilities (4
health facilities) and I allocated respondents to each strata proportionately basing on the
proportion implant removal from each ownership in FY 2017/18. There were 233 respondents
allocated to government-aided health facilities, 148 respondents in PFP facilities and 16
respondents in PNFP facilities. I again stratified each ownership into strata equivalent to the

16
number of health facilities in each ownership. Therefore, there were 21 strata in government-
aided ownership, 17 strata in PFP ownership and 4 strata in PNFP ownership. Respondents were
allocated proportionately in each strata based on the proportion of implant removal reported by
each health facilities in FY 2017/18. The number of respondents allocated to each strata/health
facility is indicated in appendix 1. In each strata (health facility), a woman who had
discontinued an implant at a health facility was recruited into the study and interviewed until the
number required for that strata (health facility) was reached.
5.6 Study Variables
5.6.1 Dependent variables.
The dependent variables of the study are summarized in table 1.
Table 1: Dependent Variables for Factors Associated with Early Discontinuation of Implants
among Women of Reproductive Age 15 – 49 years in Wakiso District
Variable Description Measurement
Duration of use
Time interval from the date of
insertion of the implant to the
date of discontinuation
Measured in months by dividing the
difference between the date of
discontinuation and date of insertion by
30. Each month was considered to have
30 days.
Early
discontinuation
Discontinuation of an implant
before 18 months from the
date of insertion.
A binary variable coded as “Yes” if an
implant was discontinued before 18
months from the time of insertion, and
“No” if 18 or more months
Proportion of early
discontinuation
Percentage of women who
discontinue implants before 18
months from the time of
insertion among those who
discontinued.
Measured as “Yes” to early
discontinuation divided by sample size.

17
5.6.2 Independent variables
The independent variables used in the study are summarized in appendix 4. I categorized “age
of eldest child” based on growth and development stages in human beings into infant (Less
than 1 years), early child ( 1 – 4 years), middle child (5 – 9 years), Adolescent (10-19 years)
and others (20 – 30 years). “Cost of implant” was categorized in relation to the cut-off for figure
for categorization of low-income countries, into free (0 shillings), Low cost (1 – 5000/=) and
high cost (5001 - 90000/=). Age was categorized in relation to reproductive health
characteristics into 15 - 24 years and 25 - 49 years. “Cost of transport” was categorized into
none (zero cost), low cost (1 – 5000/=) and high cost (5001 – 20,000/=). “Knowledge on side
effects” was categorized basing on number of side effects a respondent would remember as
Poor (No side effect), Fair (1-2 side effects), Good (3 – 5 side effects) and Excellent (6 – 7 side
effects). “Marital status” was categorized into not married (single, divorced and widowed) and
currently married (cohabiting and married).
5.7 Data Collection
5.7.1 Training of Research Assistants
There were five main research assistants who collected data from 21 government health
facilities. In each PFP and PNFP facility, a health worker other than a mid-wife or one who
worked in maternal and child health department was selected as a research assistant for data
collection. Therefore, there were 17 research assistant from PFP facilities and 4 from PNFP
facilities. The five main research assistants in government health facilities were trained for one
day on contents of the study, contents of the questionnaire and interview skills. The practicum
was done on random clients at Entebbe hospital who agreed to be interviewed for this sake.
Each research assistants in PFP and PNFP health facilities was trained on the same day of
recruitment where s/he was taken through the contents of the study, contents of the
questionnaire and trained on interview skills.
5.7.2 Tools
An interviewer-administered questionnaire was used in the study. Early discontinuation of
implants was the key construct during questionnaire development. Its development was focused
on the three research question and three specific objectives of the study. The format of the

18
questionnaire was decided to be interviewer-administered with closed-ended items. Each
question item was kept short and the whole questionnaire was kept at three pages with 32
questions rather than initial 36 questions before review and revision. The questionnaire was
later pilot-tested at Entebbe hospital on five respondents.
5.7.3 Pre-testing
The questionnaire was pretested from Entebbe general hospital on five women between 15 -49
years who had discontinued implants. Key findings from the pretest were; need to emphasize
viewing the client’s record for date of insertion, emphasizing respondent’s age in complete
years only and including an option of none for under respondent’s religion. On the question
“Does your partner have another wife you know of?” an option was included to cater for the
widows and those who divorced. The word “main” was added in the question “what was your
main reason for removing the implant?” to prevent multiple answers from the respondent. On
the question “what are some of the side effects an implant can cause?” a comment was added
emphasizing that an interviewer should keep on probing for more answers.
5.7.4 Field editing of data
The principal investigator conducted random and where necessary, targeted supportive
supervision visits to research assistants to ensure accurate, consistent and complete data. Each
research assistant was supervised physically at least once to ensure consistent, complete and
accurate entry of data.
5.7.5 Missing data
On site, each research assistant crosschecked to ensure that each question on the interviewer-
administered questionnaire was addressed before a respondent left. Missing data on site
ownership were inferred from the client’s code, where every code was related to the health
facility. Missing data on age were completed by inferring to the calculated age as a difference
between the date of birth of the respondent and the date of removal. Only 11 out of 397
observations were missing data with no relationship between missing data values and observed
values (missing completely at random). There were four observations, which were missing in
cost of implant, three in type of counselling, four in co-wife and one in priority to discontinue.
The eleven data missing completely at random (2.8% of data) were handled by list-wise

19
deletion, where the entire observation (respondent) was deleted from the dataset to allow
complete case analysis.
5.8 Data Management and Analysis
5.8.1 Data Management
I used EPI INFO 7 to capture information from questionnaires; then extracted an excel dataset
that was imported into STATA SE/14.0 for analysis. Data were entered by the principal
investigator into EPI INFO 7 and cleaning was conducted using STATA SE/14.0 to remove
duplicate entries and to crosscheck for any data entry errors. Categorical variables were coded
as listed in appendix 4. The analyses in this study did not require assumption of normality of
data. There were no transformations done on any variable.
5.8.2 Data Analysis
The response rate in the study was 100%; however, 2.8% (11) observations were deleted by list-
wise deletion for complete case analysis. Therefore, 386 observation were analyzed. Descriptive
statistics are presented in text and tables. Results of Bivariate and multivariate analysis are
presented in tables.
I used descriptive statistics to determine the proportion of women who discontinued implants
early. Since the prevalence of early discontinuation was more than 10%, I used modified
Poisson to establish determinants of early discontinuation of implants. Because duration of use
was non-normally distributed, I used quantile regression analysis to determine factors that
influenced overall duration of use of implants. For inclusion into a multivariate model, only
variables with a p-value of 0.20 or less after bivariate analysis were considered while
establishing determinants of early discontinuation of implants and determining factors that
influenced overall duration of use of implants. Variables in the multivariate model were
included by forward stepwise selection using adjusted R-squared (r2
adj) as the adjusted
information criterion. The significance level (alpha) was set at 5% for all tests of significance.
5.9 Ethical Considerations
The study sought approval and abided by the rules and regulations of the institutional review
board of Makerere university school of public health. Permission to conduct the study was also
sought from the district health officer’s office of Wakiso district. At every health facility, the in-

20
charge was informed of the study before the actual interaction with respondents. A consent form
was administered to every participant for approval to participate in the study. Each consent form
was translated in Luganda language to be easily understood by any client. Clients were assigned
identification codes rather than including their names on the questionnaire to assure anonymity
and confidentiality. Consent forms and questionnaires were kept safely under lock and key
limited to access by the investigator and faculty at MakSPH.

21
CHAPTER SIX
6.0 RESULTS
This study was conducted to estimate the proportion of women who discontinue implants early,
establish factors associated with early discontinuation of implants and to determine factors that
influence the duration of use of implants among women of reproductive age 15 – 49 years in
Wakiso district.
6.1 Characteristics of the study population
The average age of the respondents was 28.3 years (SD = 6.12) and most respondents 261
(67.6) were adults in age group 25 – 49 years. The median duration of use of implants was 25
months. Parity ranged from zero to 10 pregnancies (IQR = 1 - 4) with the highest proportion of
respondents (55.3 %) having a parity of two to four pregnancy. The number of living children
per respondent ranged from zero to nine children (IQR= 1 - 4) and most respondents had either
one (28%) or two (24%) living children. Most respondents (44%) had planned to have four
children with a range of one to 10 children (IQR = 4 - 5). Two-thirds, 256 (66.3%) of the
respondents had discontinued Implanon and the rest discontinued Jadelle. Most respondents,
249 (64.5%) had attained secondary level of education or above it and the rest had stopped
education in primary or did not have education at all. Most women, 314 (81.4) were married
and the rest were not. Only 51 (13.2%) respondents had wanted a different method other than
the implant they had received. Most respondents, 351 (90.9%) had been informed of a follow up
plan. On the other hand, 159 (41.2%) had an actual follow up visit related to the implant which
was discontinued. Less than half 165 (42.8%) respondents wanted to switch to a different
method within one month. Most respondents, 351 (90.9%) had been counselled on side effects
of implants and less than one-third, 105 (27.2%) incurred a cost to retain the implant. Tables 2a
and 2b show other characteristics of the study population.

22
Table 2a: Other Client-based Characteristics for Women of Reproductive Age 15 – 49 Years
who Discontinued Implants in Wakiso District during the Study
Variable Number (%), 386 (100)
Parity
No pregnancy 14 (3.63)
One pregnancy 99 (25.7)
2 – 4 pregnancies 213 (55.3)
5 or more pregnancies 60 (15.5)
Reasons for discontinuation
Conceive 91 (23.6)
Side effects 173 (44.8)
Expiry 76 (19.7)
Others 46 (46 (11.9)
Religion
Christian 271 (70.2)
Moslem 105 (27.2)
Other 10 (2.6)
Has a co-wife
No 231 (59.8)
Yes 112 (29.0)
Not applicable 43 (11.2)

23
Table 2b: Other Provider-related Characteristics for Women of Reproductive Age 15 – 49 Years who
Discontinued Implants in Wakiso District during the Study
Variable Number (%), 386 (100)
Place of insertion
Government facility 243 (63%)
Non-government facility 138 (35.7)
Don’t know 5 (1.3)
Cost of implant insertion
Free 304 (78.8)
1 – 5000 51 (13.2)
5001 - 90000 31 (8.0)
Cost of transport
None 98 (25.4)
1 – 5000 shillings 273 (70.7)
5001 – 20000 shillings 15 (3.9)
Cost on retention
No 281 (72.8)
Yes 105 (27.2)
Side effect knowledge
Poor 20 (5.2)
Fair 163 (42.2)
Good 154 (39.9)
Excellent 49 (12.7)
Type of counselling
Individual 98 (25.4)
Group 226 (58.6)
Both 34 (8.8)
Not counselled 28 (7.3)

24
6.2 Proportion of Early discontinuation
The proportion of women who discontinue implants before 18 months was 30.7% (95% CI =
25.2 – 36.9). A Mann-Whitney test indicated that the median duration of use for those who
discontinue early (Mdn = 10.1 months) was significantly lower than that of women who
discontinue implants at 18 months or more (Mdn = 35.4 months), z = 15.936, p < .001, r = 0.81.
Table 3 below shows other descriptive statistics related the proportion of early discontinuation
Table 3: Proportion of Women of Reproductive Age 15 – 49 years who Discontinued Implants Early in
Wakiso District
Early
Discontinuation
Number Min. duration
of use
(months)
Max. duration
of use
(months)
Median
duration of
use
Proportion (%) ( (95%
CI)
No 260 18 73.5 35.4 69.3 (63.1 – 74.8)
Yes 126 0.03 17.9 10.1 30.7 (25.2 – 36.9)
Total 386 100
Among those who discontinued early, 53 (42%) planned to switch to another method within a
month, only 24 women (19%) wanted to conceived and 92 women (73%) discontinued due to
side effects. Among those who discontinued early, 46 women (36.5%) had incurred a cost to
retain implants.
6.3 Determinants of early discontinuation
Determinants of early discontinuation were grouped into client-based and provider-related
factors during analysis. For client-based factors during bivariate analysis, side effects was the
significant determinant of early discontinuation. The prevalence ratio was 20% higher among
women who discontinued due to side effects compared to women who discontinued due to a
need to conceive. Table 4a shows findings from the bivariate analysis of client-based factors.

25
Table 4a: Bivariate Analysis for Client-based Determinants of Early Discontinuation of Implants among
Women of Reproductive Age in Wakiso District
Variable
Early discontinuation n (%)
Unadjusted Prevalence ratio p-value
No Yes
Age group
25 – 49 years 183 (70.1) 78 (29.9) 1.00 (ref)
15 – 24 years 77 (61.6) 48 (38.4) 1.01 (0.92 – 1.11) 0.879
Parity
Nulliparous 9 (64.3) 5 (35.7) 1.00 (ref)
One pregnancy 64 (64.6) 35 (35.4) 0.943 (0.77 – 1.16) 0.567
2 – 4 pregnancies 143 (67.1) 70 (32.9) 0.956 (0.79 – 1.16) 0.638
5 or more pregnancies 44 (73.3) 16 (26.7) 0.936 (0.77 – 1.14) 0.501
Highest education level
None 10 (66.7) 5 (33.3) 1.00 (ref)
Primary 82 (67.2) 40 (32.8) 0.86 (0.66 – 1.13) 0.267
Secondary or higher 168 (67.5) 81 (32.5) 0.882 (0.67 – 1.17) 0.363
Conceive 67 (73.6) 24 (26.4) 1.00 (ref)
Side effects 81 (46.8) 92 (53.2) 1.20 (1.07 – 1.36) 0.003
Others 36 (78.3) 10 (21.7) 0.99 (0.83 – 1.18) 0.885
Marital status
Married 211 (67.2) 103 (32.8) 1.00 (ref)
Not Married 49 (68.1) 23 (31.9) 0.99 (0.88 – 1.12) 0.854
Religion
Christian 186 (68.6) 85 (31.4) 1.00 (ref)
Moslem 67 (63.8) 38 (36.2) 1.04 (0.94 – 1.15) 0.455
Follow up visit
No 156 (68.7) 71 (31.3) 1.00 (ref)
Yes 104 (65.4) 55 (34.6) 1.06 (0.95 – 1.10) 0.191
Primary method of choice
Implant 229 (68.4) 106 (31.6) 1.00 (Ref)
Different method 31 (60.8) 20 (39.2) 1.05 (0.91 – 1.22) 0.515
Side effect knowledge
Poor 13 (65) 7 (35) 1.00 (ref)
Fair 111 (68.1) 52 (31.9) 0.89 (0.70 – 1.13) 0.322
Good 102 (66.2) 52 (33.8) 0.95 (0.76 – 1.19) 0.637
Excellent 34 (69.4) 15 (30.6) 0.87 (0.69 – 1.15) 0.365
Switcher
No 148 (67.0) 73 (33.0) 1.00 (ref)
Yes 112 (67.9) 53 (32.1) 0.97 (0.88 – 1.06) 0.464

26
For provider-related factors, cost on retention of implants was the significant determinant of
early discontinuation. The prevalence of early discontinuation was 15% higher among women
who incurred costs on retention of implants compared to women who did not incur costs. Table
4b shows findings of bivariate analysis for provider-related factors.
Table 4b: Bivariate Analysis for Provider-related Determinants of Early Discontinuation of Implants among
Women of Reproductive Age in Wakiso District
Variable Early discontinuation n (%)
Unadjusted Prevalence
ratio
p-value
No Yes
Type of Implant
Implanon 171 (66.8) 85 (33.2) 1.00 (ref)
Jadelle 89 (68.5) 41 (31.5) 1.04 (0.96 – 1.13) 0.325
Place of insertion
Government facility 167 (68.7) 76 (31.3) 1.00 (ref)
Non-government facility 92 (66.7) 46 (33.3) 1.03 (0.95 – 1.12) 0.420
Free 207 (68.1) 97 (31.9) 1.00 (ref)
1 – 5000 shillings 34 (66.7) 17 (33.3) 1.10 (0.94 – 1.27) 0.225
5001 – 90000 shillings 19 (61.3) 12 (38.7) 1.10 (0.95 – 1.28) 0.201
Cost of transport
None 71 (72.5) 27(27.5) 1.00 (ref)
1 – 5000 shillings 179 (65.6) 94 (34.4) 1.07 (0.97 – 1.18) 0.174
5001 – 20000 shillings 10 (66.7) 5 (33.3) 1.05 (0.85 – 1.29) 0.657
Cost on retention
No 201 (71.5) 20 (28.5) 1.00 (ref)
Yes 59 (56.2) 46 (43.8) 1.15 (1.04 – 1.27) 0.010
Counselling on side effects
No 19 (54.3) 16 (45.7) 1.00 (ref)
Yes 241 (68.7) 110 (31.3) 0.96 (0.82 – 1.12) 0.601
Type of counselling
Individual 67 (68.4) 31 (31.6) 1.00 (ref)
Group 149 (65.9) 77 (34.1) 1.05 (0.96 – 1.16) 0.287
Both 27 (79.4) 7 (20.6) 0.92 (0.78 – 1.09) 0.337
Not counselled 17 (60.7) 11 (39.3) 1.07 (0.86 – 1.31) 0.542

27
During multivariate analysis, reason for discontinuation and follow up visits were client-based
factors considered for analysis. Parity, marital status and switching improved the final model
and they were included in analysis. However, follow up visit did not improve the final model
and it was dropped from the analysis. For provider-related determinants, cost of implant
insertion, cost of transport and cost on retention were considered for the final model. However,
cost of transport and cost of implant insertion did not improve the model and were eliminated.
Counselling on side effect improved the model and it was included despite p = 0.601. Side
effects and cost on retention were significant determinants of early discontinuation after
controlling for respective factors. The prevalence of early discontinuation was 20% higher
among women who discontinued implants due to side effects compared to women who
discontinued due to the need to conceive holding other factors constant. The prevalence of early
discontinuation of implants was 15% higher among women who incurred cost on retention
compared to women who did not incur costs on retention holding all other factors constant.
Table 5 summarizes findings after multivariate analysis.

28
Table 5: Multivariate Analysis for Determinants of Early Discontinuation of Implants among Women
of Reproductive Age 15 – 49 years in Wakiso District
Variable Unadjusted PR p-value Adjusted PR p-value
Client-based factors
Conceive 1.00 (ref) 1.00 (ref)
Side effects 1.20 (1.07 – 1.36) 0.003 1.20 (1.05 (1.37) 0.009
Others 0.99 (0.83 – 1.18) 0.885 0.99 (0.83 – 1.17) 0.895
Switcher
No 1.00 (ref) 1.00 (ref)
Yes 0.97 (0.88 – 1.06) 0.464 1.01 (0.90 – 1.13) 0.917
Marital status
Currently Married 1.00 (ref) 1.00 (ref)
Not Married 0.99 (0.88 – 1.12) 0.854 0.99 (0.90 – 1.10) 0.908
Parity
High 1.00 (ref) 1.00 (ref)
Moderate 1.02 (0.89 – 1.17) 0.76 0.99 (0.87 – 1.13) 0.885
Low 1.01 (0.86 – 1.19) 0.861 1.01 (0.87 – 1.16) 0.922
Facility-related factors
Cost on retention
No 1.00 (ref) 1.00 (ref)
Yes 1.15 (1.04 – 1.27) 0.010 1.15 (1.04 – 1.28) 0.010
No 1.00 (ref) 1.00 (ref)
Yes 0.96 (0.82 – 1.12) 0.601 0.94 (0.81 – 1.09) 0.411

29
6.4 Factors that influence overall duration of use of implants.
Factors that influence overall duration of use of contraceptive implants were also grouped into
client-based and provider-related factors. In bivariate analysis, for client-based factors, age
group 15 – 24 years, side effects and switching influenced overall duration of use of implants.
Age group 15 – 24 years reduced median duration of use by 9.33 months compared to age group
25 – 49 years. Side effects reduced the median duration of use by 10.2 months compared
discontinuation due to a need to conceive. Women who wanted to switch after discontinuation
had more median duration of use of 9.47 months compared to those who never wanted to
switch. Table 6a shows finding of bivariate analysis for client-based factors that influence
overall duration of use.

30
Table 6a: Bivariate Analysis for Client-based Factors That Influence Overall Duration of Use
of Implants among Women of Reproductive Age in Wakiso District
Variable Count (median duration of
use)
Unstandardized beta coefficient
(B)
p-value
Age group
25 – 49 years 261 (29.8) 1.00 (ref)
15 – 24 years 125 (21.9) -9.33 (-14.6 - -4.03) 0.001
Parity
Nulliparous 14 (24.4) 1.00 (ref)
One pregnancy 99 (23.3) 4.43 (-15.2 – 24.1) 0.658
2 – 4 pregnancies 213 (25.0) 1.6 (-17.0 – 20.2) 0.866
5 or more pregnancies 60 (34.7) 9.66 (-9.8 – 29.1) 0.329
Highest education level
None 15 (25.3) 1.00 (ref)
Primary 122 (24.5) 2.17 (-13.2 – 17.6) 0.782
Secondary and above 249 (25.7) 7.3 (-7.9 – 22.5) 0.344
Marital status
Married 314 (25.0) 1.00 (ref)
Not Married 72 (25.2) 0.733 (-7.21 – 8.68) 0.856
Religion
Christian 271 (26.6) 1.00 (ref)
Moslem 105 (24.3) -2.27 (-8.62 – 4.07) 0.482
Other 10 (23.0) -4.70 (-15.8 – 6.36) 0.404
Conceive 91 (24.6) 1.00 (ref)
Side effects 173 (16.6) -10.2 (-16.9 - -3.57) 0.003
Others 46 (25.2) -3.00 (-9.94 – 3.94) 0.396
Follow up visit
No 277 (27.0) 1.00 (ref)
Yes 159 (24.2) -4.5 (-11.0 – 2.03) 0.176
Primary method of choice
Implant 335 (25.1) 1.00 (ref)
Different method 51 (25.0) 0.54 (-6.65 – 7.73) 0.883
Switcher
No 221 (24.2) 1.00 (ref)
Yes 165 (32.7) 9.47 (3.49 – 15.45) 0.002

31
For provider-related factors, insertion during breast feeding, learning about implants from
relatives first, low cost of transport of 1 – 5000 shillings and not being counselled before
insertion significantly influenced duration of use. For women whose implants were inserted
while she was breastfeeding, their median duration of use was lower by 6.96 months compared
to women who whose implants were inserted when they were not breastfeeding. The median
duration of use of implants was 8.27 months higher among women who first learned about
implants from relatives compared to women who first learnt about implants from a health
worker. The median duration of use of implants was 7.93 months lower for women who spent
1-5000 shilling on transport compared to women who never spent any money on transport. The
median duration of use was 7.77 months lower for women who had not been counseled on
implants compared to women who had been counselled individually. Table 6b shows finding of
bivariate analysis for provider-related factors that influence overall duration of use.

32
Table 6b: Bivariate Analysis for Provider-related Factors That Influence Overall Duration of Use of
Implants among Women of Reproductive Age in Wakiso District
Variable Count (median duration of
use)
Unstandardized beta coefficient
(B)
p-value
Inserted during breast
feeding
No 155 (28.7) 1.00 (Ref)
Yes 231 (23.9) -6.96 (-13.3 - -0.59) 0.032
Type of Implant
Implanon 256 (24.3) 1.00 (ref)
Jadelle 130 (29.6) -3.04 (-10.4 – 4.32) 0.419
Place of insertion
Government facility 243 (25.3) 1.00 (ref)
Non-government facility 138 (25.1) 0.54 (-6.53 – 7.61) 0.882
First learnt about implant
Health worker 196 (24.9) 1.00 (ref)
Friend 132 (28.1) 0.24 (-7.86 – 8.34) 0.954
Relative 52 (24.5) 8.27 (0.41 – 16.13) 0.039
Free 304 (26.9) 1.00 (ref)
1 – 5000 shillings 51 (22.8) -7.73 (-15.8 – 0.39) 0.062
5001 – 90000 shillings 31 (24.0) -5.5 (-21.0 – 10.0 0.486
Cost of transport
None 98 (30.9) 1.00 (ref)
1 – 5000 shillings 273 (24.6) -7.93 (-15.2 - -0.69) 0.032
5001 – 20000 shillings 15 (28.5) -4.23 (-17.8 – 9.33) 0.540
Cost on retention
No 281 (27.2) 1.00 (ref)
Yes 105 (21.5) -7.64 (-16.5 – 1.20) 0.090
No 35 (21.5) 1.00 (ref)
Yes 351 (25.3) 0.34 (-10.4 – 11.1) 0.950
Type of counselling
Individual 98 (25.1) 1.00 (ref)
Group 226 (25.4) -3.70 (-10.9 – 3.52) 0.314
Both 34 (30.5) 7.03 (-4.83 – 18.9) 0.214
Not counselled 28 (21.7) -7.77 (-14.0 - -1.55) 0.015
Follow up plan
No 35 (22.1) 1.00 (ref)
Yes 351 (25.4) 6.74 (-1.21 – 14.7) 0.096

33
In multivariate analysis, for client-based factors, age group, parity, highest education level,
follow up visit, reasons for discontinuation and switching were considered for the multivariate
analysis. However, highest education level and follow up visit did not improve the final and
they were eliminated from the model. Side effect influenced overall duration of use. The median
duration of use was reduced by 9.9 months if a woman discontinued implants due to side effects
compared to women who discontinued due to a need to conceive, holding other factors constant.
Table 7a summarizes finding of multivariate analysis for client-based factors.

34
Table 7a: Multivariate Analysis for Client-based Factors That Influence Duration of Use of Implants
among Women of Reproductive Age in Wakiso District
Variable
Unstandardized
coefficient (B)
p-value
Standardized
coefficient (β)
p-value
Reasons for
discontinuation
Conceive 1.00 (ref) 1.00 (ref)
Side effects -10.2 (-16.9 - -3.57) 0.003 -9.91 (-16.6 - -3.034) 0.005
Others -3.00 (-9.94 – 3.94) 0.396 -3.14 (-9.19 – 2.91) 0.308
Age group
25 – 49 years 1.00 (ref) 1.00 (ref)
15 – 24 years -9.33 (-14.6 - -4.03) 0.001 -1.57 (-5.65– 2.51) 0.450
Parity
Nulliparous 1.00 (ref) 1.00 (ref)
One pregnancy 4.43 (-15.2 – 24.1) 0.658 -6.14 (-14.2 – 1.93) 0.135
2 – 4 pregnancies 1.6 (-17.0 – 20.2) 0.866 -7.17 (-15.3 – 0.98) 0.085
5 or more pregnancies 9.66 (-9.8 – 29.1) 0.329 -6.37 (-15.1 – 2.38 0.153
Switcher
No 1.00 (ref) 1.00 (ref)
Yes 9.47 (3.49 – 15.45) 0.002 -1.20 (-5.17 – 2.77) 0.552
For provider-related factors, insertion during breast feeding, first heard about implant, cost of
insertion, cost of transport, cost of retention, type of counselling and follow up plan were
considered for multivariate analysis. However, first heard about implant and follow up plan did
not improve the final model and they were dropped from the analysis. Type of implant and
place of insertion improved the final model and they were included in the analysis. Cost on
retention, insertions during breastfeeding and not being counseled influenced overall duration of
use of implants. The median duration of use was reduced by 7.38 months if a woman incurred a

35
cost to retain an implant compared to when she did not, holding other factors constant. The
median duration of use of implants reduced by 5 months if a woman inserted an implant while
breastfeeding compared to when she was not breastfeeding, holding other factors constant. The
median duration of use reduced by 6.47 months if a woman was inserted an implant without
counselling compared to who was inserted after counselling, holding other factors constant.
Table 7b: Multivariate Analysis for Provider-based Factors That Influence Duration of Use of Implants
among Women of Reproductive Age in Wakiso District
Variable
Unstandardized
coefficient (B)
p-value
Standardized
coefficient (β)
p-value
Type of implant
Implanon 1.00 (ref) 1.00 (ref)
Jadelle -3.04 (-10.4 – 4.32) 0.419 0.633 (-3.66 – 4.92) 0.772
Cost on retention
No 1.00 (ref) 1.00 (ref)
Yes -7.64 (-16.5 – 1.20) 0.090 -7.38 (-13.3 - -1.47) 0.015
Cost of transport
None 1.00 (ref) 1.00 (ref)
1 - 5000 -7.93 (-15.2 - -0.69) 0.032 -3.82 (-8.59 – 0.96) 0.117
5001 - 20000 -4.23 (-17.8 – 9.33) 0.540 -1.33 (-14.1 – 11.4) 0.837
Insertion during
breastfeeding
No 1.00 (Ref) 1.00 (ref)
Yes -6.96 (-13.3 - -0.59) 0.032 -5.00 (-8.95 - -1.05) 0.013
Type of counselling
Individual 1.00 (ref) 1.00 (ref)
Group -3.70 (-10.9 – 3.52) 0.314 -2.55 (-8.11 – 3.01) 0.368
Both 7.03 (-4.83 – 18.9) 0.214 0.78 (-4.87 – 6.43) 0.785
Not counselled -7.77 (-14.0 - -1.55) 0.015 -6.47 (-12.07 - -0.86) 0.024
Place of insertion
Government facility 1.00 (ref) 1.00 (ref)
Non-government facility 0.54 (-6.53 – 7.61) 0.882 -0.52 (-3.52 – 2.48) 0.735

36
CHAPTER SEVEN
7.0 DISCUSSION
This facility-based cross-sectional study was conducted to determine the magnitude of early
discontinuation of contraceptive implants and establish determinants of early discontinuation of
implants. It also determined factors that influenced overall duration of use of implants among
women of reproductive age 15 – 49 years who discontinued implants in Wakiso district.
Determinants of early discontinuation of implants and factors that influence overall duration of
use were categorized into client-based and Facility-related factors.
Proportion of early discontinuation of implants
Among those who discontinued implants in Wakiso district, nearly one-third (31%) of them
discontinued early. In Uganda, there was limited information on assessment of early
discontinuation of implants with a cut-off of 18 months and therefore, the negative impact of
such a proportion on retention and use of contraceptives cannot be estimated yet. Kalmuss, et
al., (1996) and Grunloh et al. (2013) used 6 months to describe early discontinuation, and they
used total number of women who inserted implants in computing the proportion of early
discontinuation to derive proportions of 7.6% and 7% respectively. Mengstu, et al. (2018)
assessed for early discontinuation of Implanon and not both implant types with early
discontinuation defined at a cut-off of 2.5 years. In this study, 32% of women who discontinued
implants early used Jadelle and therefore, findings from the study by Mengstu, et al cannot be
related to this study. Only 19% of women who discontinued early did so in order to conceive,
majority (73%) discontinued due to side effects and more than half of them (53%) were not
planning to use any family planning method for at least a month. As revealed by Anrudh &
Winfrey (2017) and Ali, et al (2012), discontinuation of contraceptive is associated with higher
rates of mistimed and unwanted pregnancies together with their negative consequences
including stillbirths and abortions unless the client is switching to a different method of
contraception. For compesation in early discontinuation, one would prefer women to
discontinue and switch or to discontinue in order to conceive. In this study, among those who
discontinued early, 53 (42%) planned to switch to another method within a month and only 24
women (19%) wanted to conceive. Therefore, for inadventurous early discontinuation, a target

37
proportion can be determined by {sum of (women who discontinue early and switch = 53 plus
women who discontinue early to conceive = 24) / by total of women who discontinue early} of
0.307 equivalent to 19%.
Determinants of early discontinuation of implants
In this study, the significant determinants to early discontinuation of implants were side effects
and costs on retention of the implants. In an efficient family planning program, women would
be expected to discontinue implants when there is a need to conceive, when they have reached
menopause or when the implants expired. In this study, I compared all reasons for
discontinuation to the need to conceive.
The prevalence of early discontinuation of implants was 20% higher among women who
discontinued due to side effects compared to those who discontinued due to the need to
conceive and this association was significant before and after controlling for all other factors.
This finding was in line with other studies in Ethiopia (Birhane et al., 2015; Melese Siyoum,
2017; and Tadesse et al 2017), which revealed that side effects were significant reasons for
discontinuation of contraceptives. Worse still, among those who discontinued early, only 54%
women planned to switch to another method, leaving a large proportion (46%) of women at risk
of unintended pregnancies and their negative consequences. For efficiency of family planning
program, this would call for interventions that address comprehensive management of side
effects among other interventions to minimize early discontinuation.
Cost on retention of the implant was the only facility-related determinant of early
discontinuation of implants. The prevalence of early discontinuation among women who
incurred a cost to retain the implants was 15% more than the prevalence of women who did not
incur a cost, both before and after controlling for other factors. In this study, for every five
women, four (79%) got the implant inserted at no cost. They had not opted for insertions that
involved a cost at whichever ownership of a health facility, be it government, PFP nor PNFP
facilities. This was more likely so because of financial constraints or a need to minimize
expenditure. Introducing a cost such as buying medicines to manage side effects, spending
money on transport to health facilities to address concerns on the implant in order to retain the
implants defeats women’s goals of cost free contraception. Therefore, they were more likely to
discontinue implants for alternative methods of contraception or even none. In fact, only 43% of

38
the women who discontinued early and incurred a cost on retention of the implant had planned
to switch to a new method. For efficiency of family planning programs, there is need to relieve
women of costs incurred to retain implants that are already inserted.
Factors that influence overall duration of use of implants
From the above results, duration of use was significantly influenced by discontinuation due to
expiry and side effects, insertion of implants during breastfeeding, incurring costs on retention
of implants and not being counselled on the implant before insertion.
Client-based factors
The median duration of use reduced by 9 months and 18 days if a woman discontinued an
implant due to side effects compared to those who discontinued in order to conceive. This
relationship was strongly significant before and after controlling for age, parity and switching.
Despite being general on pills, Jadelle, IUD and injectable contraceptives, findings from the
study by Tadesse, et al., (2017) also agree with this study that side effect lower the duration of
use contraceptives. Tadesse, et al., (2017) had determined that the odds of discontinuing
contraceptives before 3 years among those who discontinued due to side effects were 1.7 times
the odds among those who discontinued because of other reasons. In this study, it can be
deduced that nearly half (47%) of women who discontinued implants due to side effects did not
plan to switch to a new method, which is detrimental to the success of family planning
programs. Focusing on management of side effects among women who use implants can
improve the duration of use of the method.
However, without controlling for other factors, overall duration of use was influenced by young
age group 15 – 24 years, moderate parity and whether a woman had planned to switch. The
median duration of use was significantly reduced by 9 minutes and 8 days if a woman was of a
young age group 15 – 24 years compared to when she was of an adult age group 25 – 49 years.
However, on controlling for other factors, age group did not significantly influence the overall
duration of use of implants. Age is strongly correlated with the number of living children a
woman had. It would bel expected that the more children a woman has, the least likely that she
would discontinue a contraceptive to risk becoming pregnant. Previous studies that were
reviewed did not assess the effect of age on overall duration of use of implants. The study by
Tadesse, et al., (2017), which revealed that the odds of discontinuing an implanon before 3

39
years among age group of less than 20 years were 3.3 times less compared to who were 35 years
and more, can not be used for comparison. This is because my study combine both Implanon
and Jajdelle and it determines median duration of use rather than odds of discontinuing before 3
years. Nevertheless, both studies agree that as the age increases, women use implants for a
longer duration. In addition, the finding is in line with the Uganda Demographic and Health
survey-2016 findings that reveal that contraceptive use increases with with increasing age until
the age group 40 – 44 years. However, this relationship of age group and duration of use can be
modified by parity reasons for discontinuation and switching.
The median duration of use was reduced by 8 months and 3 days if a woman had a moderate
parity of 2 – 4 pregnancies compared to women who had a high parity of 5 – 10 pregnancies.
However, this association was marginally significant. Just like age, parity is also correlated with
the number of children a woman has; and therefore, parity would follow the same trend in
duration of use as age of a woman. However, this relationship can also be modified by reasons
for discontinuation, age group and switching.
This study also revealed that without controlling for age, parity and reasons for discontinuation,
the median duration of use of implants significantly increased by 9 months and 15 days if a
woman planned to switch to a new method compared to women who had not planned to switch.
However, on controlling for the above factors, switching did not influence the duration of use.
Provider-based factors
The median duration of use significantly by nearly 7 months and 21 days if a woman was
inserted an implant when she was breastfeeding compared to when it was inserted when she was
not breastfeeding. On controlling for type of implant, type of counselling, place of insertion,
cost of transport and cost of retention, the effect of inserting implants when a woman was
breastfeeding was reduced to 5 months.
Individually, cost on retention of the implant did not significantly influence the duration of use
of implants. However, on controlling cost of transportation, type of implant, type of counselling,
place of insertion and whether the implant was inserted when a woman was breastfeeding, it
was a significant determinant to the overall duration of use of implants. The median duration of
use of implants reduced by 7.4 months if a woman incurred a cost on retaining the implant
compared to women who never incurred any cost.

40
The median duration of use reduced by 7 months and 27 days if a woman incurred a cost on
transportation to and from the health facility where she access family planning services
compared to women who did not incur any cost at all. This finding is contrary to the plausible
ideology. One would think that as women struggle to access contraceptives services including
removal services due to transportation costs and limited access to removal services, those who
get the implants would take longer while using them compared to ones who can access services
at no costs involved in transportation. Further exploration of this phenomenon will be important
if more retention of implants is to be achieved among women. In general, cost of transportation
was not a significant factor after controlling for type of implant, type of counselling, place of
insertion, cost of retention and whether the implant was inserted when a woman was
breastfeeding.
The median duration of use increased by 8 months and 9 days if a woman first learnt about the
implant from a relative compared to when she first learnt about the implant from a health
worker. However, on controlling for other factors, this variable did not improve the model and it
was dropped in the adjusted analysis.
The median duration of used reduced significantly by 7 months and 24 months if a woman did
get any form of counselling compared to those who were counselled individually. On
controlling for cost of transportation was not a significant factor after controlling for type of
implant, place of insertion, cost of transport, cost of retention and whether the implant was
inserted when a woman was breastfeeding, the effect not counselling a woman on the median
duration of use reduced to 6 months and 15 days. This is in line with plausible ideology that any
form of counselling would increase awareness on the contraceptive method and therefore more
chances of retaining it except when a client is in a need to conceive, expiry or she has reached
menopause. Therefore, family planning programs should also focus on ensuring that women are
counseled if they are to use contraceptives for a longer duration.
Limitations of the study
This study was conducted in Wakiso district, a cosmopolitan district with health facilities
located in both rural and urban areas. Therefore, findings of this study may not be applicable in
an area with a significantly different demographic distribution. During the period of the study,
Wakiso had at least five stakeholders who were implementing family planning programs with

41
great variability in their operations within the region. Therefore, great variability in the findings
would also be expected depending on the program a woman had attended or was exposed. There
was potential recall bias, since nearly 30% of the questions in the questionnaire required the
respondent to recall the answer. Even though research assistants were trained before data
collection, interviewer bias could not be excluded from the study. Five main research assistants
were used in the study. From each PFP and PNFP, one individual was responsible for data
collection to limit bias.

42
CHAPTER EIGHT
8.0 CONCLUSIONS
Thirty one percent of women discontinued implants early among all women of reproductive age
15 – 49 years who had discontinued implants. This proportion is high considering the fact that
less than half of women who discontinued implants early planned to switch to a new method
and only one fifth discontinued in order to conceive. A proportion of 19% for early
discontinuation would be an acceptable target for monitoring and evaluating early
discontinuation in family planning programs.
Determinants of early discontinuation are side effects and incurring costs to retain implants.
Nearly half of women who discontinue early due to side effects do not plan to switch to a new
method within a month and more than half of women who incur costs to retain implants and
eventually discontinue early do not plan to switch as well.
Factors influencing overall duration of use of implants are; lack of counselling to women before
inserting implants, side effects, incurring costs to retain implants and insertion of implants while
a woman is breastfeeding.
Further inquiry into the paradoxical reduction in the duration of use of implants when they are
inserted in women who are breastfeeding compared to those who are not breast feeding may be
warranted.

43
CHAPTER NINE
9.0 RECOMMENDATIONS
9.1 Recommendations for family planning programs
1. A proportion of not more than 19 percent among women who discontinue implants
should be used to evaluate for early discontinuation of implants, just enough to
accommodate for early discontinuation due to a need to conceive.
2. Family planning programs should focus on management and counseling on side effects
in order to prevent early discontinuation as well as improving on the retention of
implants.
3. Family planning programs should also focus on mitigating costs incurred by women to
retain implants in order to prevent early discontinuation of implants. Measures to
mitigate such costs may include franchising with private health facilities to provide free
side effect management care to any woman using an implant.
4. Family planning programs should ensure that comprehensive counseling of
women/couples before providing contraceptive implants is mandatory and implemented
by all providers of contraceptive services in order to improve retention of the implants.
9.2 Recommendations for further research
1. By plausibility, insertion of implants during breastfeeding would be associated with a
high duration of use compared to insertion when a woman is not breastfeeding. In our
study, the reverse was true. Therefore, qualitative studies are recommended to
understand possible reasons for this phenomenon.
2. This study was conducted in a cosmopolitan district. Therefore, I recommend for a
different study to be done in a setting that is predominantly rural or urban for
comparison of the findings.

44
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48
APPENDICES
1. Number of Respondents per Health Facility
Health Facility Site Ownership Number of respondents
Buwambo HC Government 11
Bweyogerere HC Government 15
Entebbe Hosp Government 34
Kajansi HC Government 13
Kakiri HC Government 5
Kasangati HC Government 32
Kasanje HC Government 3
Kawanda HC Government 2
Kira HC Government 9
Kitala HC Government 7
Kyengera HC Government 10
Mende HC Government 5
Mutungo HC Government 7
Nabweru HC Government 10
Nakawuka HC Government 5
Namayumba HC Government 15
Namulonge HC Government 8
Nansana HC Government 9
Ndejje HC Government 5
Nsangi HC Government 4
Wakiso HC Government 24
Anna Grace MC PFP 7
Diva MC PFP 6
Doctor Clinic Sseguku PFP 2
Good Life Clinic PFP 8
Gwatiro Nursing Home PFP 7
Kikajo Maternity center PFP 5
Kyebando Nursing Home PFP 5
LLM Medical clinic PFP 17
Mariestopes Clinic PFP 3

49
Masajja Nursing PFP 10
MildMay Uganda Hosp PFP 15
Mukwano HC PFP 16
Naluvule MC PFP 2
Nurture Africa PFP 17
Nyange general clinic PFP 13
Our Lady of Fatima PFP 11
St. Mary MS PFP 4
Kiziba HC PNFP 7
Kireka SDA PNFP 2
Nampunge HC PNFP 3
TASO Clinic PNFP 4
Total 42 397

50
2. Consent Forms for Respondents
2.1 Consent form in English
Consent form for the study
Factors Associated with Early Discontinuation of Contraceptive Implants among Women of
Reproductive Age in Wakiso District, a Facility-Based Cross-Sectional Study.
What are some general things you should know about research studies?
You are being asked to take part in a research study. To join the study is voluntary. You may
refuse to join, or you may withdraw your consent to be in the study, for any reason. Research
studies are designed to obtain new knowledge that may help other people in the future. You will
not receive any direct benefit from being in the research study. Details about this study are
discussed below. It is important that you understand this information so that you can make an
informed choice about being in this research study. You will be given a copy of this consent
form.
What is the purpose of this study?
The study will contribute to the body of knowledge needed to improve retention of
contraceptive implants among users, which will eventually result in an improvement in the
contraceptive prevalence rate, reduction in unmet need of family planning and attainment of
FP2020 and Uganda national vision of 2040.
How many participants will take place in this study?
The study will involve 397 respondents.
How will the interview be conducted?
You will be asked questions from an already structured questionnaire.
How long will the interview last?
Each interview will last approximately 15 minutes.
What are the possible benefits from being in this study?

Factors associated with early discontinuation of contraceptive implants among women of reproductive age in wakiso district, a facility based crossesctional study

Factors associated with early discontinuation of contraceptive implants among women of reproductive age in wakiso district, a facility based crossesctional study

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Factors associated with early discontinuation of contraceptive implants among women of reproductive age in wakiso district, a facility based crossesctional study