Expanding Contraceptive Method Choice With a Hormonal Intrauterine System: Results From Mixed Methods Studies in Kenya and Zambia

Although the hormonal intrauterine system has limited availability in low- and middle-income countries, this highly effective long-acting reversible contraceptive method has the potential to be an important addition to the method mix. Introduction of the method in the public sector under “real-world” conditions in Kenya and Zambia shows promise to increase contraception use and continuation. Key Messages Making the hormonal intrauterine system (IUS) available in public facilities in low-income countries could increase uptake of long-acting contraception because it appeals to some women who would not otherwise choose a long-acting method; 30% of hormonal IUS adopters would have chosen a short-acting method if the hormonal IUS had not been available. Satisfaction and continuation rates were high among interviewed hormonal IUS adopters. Providers also reported that most hormonal IUS adopters were satisfied and rarely returned with complaints that could not be addressed with additional counseling. Providers reported that many women were not willing to try a method they were hearing about for the first time. Key Implications When taking steps to increase the availability of the hormonal IUS, donors and policy makers must fund demand-creation efforts to increase awareness of a new long-acting contraceptive option that has characteristics that are distinctly different from other long-acting and short-acting methods. Program managers should develop introduction and scale-up plans that allow for ongoing support and mentorship of providers in offering a new long-acting contraceptive method. ABSTRACT Introduction: Few women in low- and middle-income countries have access to the hormonal intrauterine system (IUS). Past research from a small number of facilities and the private sector suggest the IUS could be an important addition to the contraceptive method mix because it is the only long-acting method some women will adopt and users report high satisfaction and continuation. We aimed to determine whether these promising results were applicable in public facilities in Kenya and Zambia. Methods: We used a mixed-methods approach with program monitoring data, interviews with women who received an IUS, and qualitative focus group discussions with providers. Data were collected in 2017–2019. Results: Facilities in Kenya and Zambia reported 1,985 and 428 IUS insertions, respectively. If the IUS had not been available, 30% of adopters would have chosen a short-acting method. Women and providers gave diverse reasons for adopting the IUS, with the desire for fewer side effects being frequently mentioned in focus group discussions. Many IUS adopters first heard of the method on the day it was inserted (70% in Kenya, 47% in Zambia), yet providers reported that many women were unwilling to try a method they were just hearing about for the first time. Satisfaction and continuation were high: 86% of adopters in Kenya were still using the method 3–6 months after insertion and 78% were in Zambia (average 10 months post insertion). Providers also reported that most IUS adopters were satisfied; they rarely returned with complaints that could not be addressed with additional counseling. Conclusion: Expanding IUS access through the public sector shows promise to increase contraception use and continuation in low- and middle-income countries. Efforts to strengthen availability should consider demand and engage directly with various communities, including youth, around availability of a new long-acting option.