1.2.12 In it for the Long Haul: Long Acting Methods




Wednesday, November 13, 2013


Ronald Anguzu, Makerere University School of Public Health
Raymond Tweheyo, Makerere University School of Public Health
Juliet Sekandi
David Serwadda

Title of Abstract / Titre:

Health Facility Provision of Long Acting Reversible Contraceptives (LARC) in Lubaga, Uganda: Provider Perspectives and Facility Related Factors

Abstract Type / Type de résumé:

Research Abstract

Topic / Sujet:

Family planning practice

Significance/background / Importance/contexte :

Uganda’s low contraceptive prevalence of 30% and high total fertility rate (TFR) of 6.2 contributes to unsafe induced abortions, unwanted pregnancy and high maternal mortality.

These  undesirable consequences of public health concern may be attributed to low contraceptive use (Nalwadda et al., 2010). Long acting reversible contraceptives (LARC) use i.e. implants, injectables and intra-uterine devices (IUD) is still low at 18.8% (UBOS, 2011) despite increased LARC use being proposed as a strategy to reverse high maternal mortality rates (Blumenthal et al., 2011).

The most cost-effective contraceptives are LARC methods (Morse et al., 2012, Mavranezouli, 2008) though rarely used in sub-Saharan Africa (SSA) partly due to limited access (Dhont et al., 2009). In SSA, LARC is still underused and attempts to increase its uptake haven’t been successful (Neukom et al., 2011). Renewed focus has been put on increasing access to long-acting contraceptives and to effectively increase its uptake (Townsend et al., 2011).

This study aimed to establish the proportions of health facilities providing LARC and to establish health system barriers associated with provision of LARC in Lubaga division, Kampala district, Uganda

Main question/hypothesis / Question principale/hypothèse:

There is a low uptake of long - acting reversible contraceptive methods among females of reproductive age 15 – 49 years in Kampala district.

The current LARC uptake in Kampala district is 20.5%. The uptake of IUD is still low at 1.4%, implant uptake is much less at 0.3% however injectable contraceptive uptake is higher at 18.8% (UBOS, 2007). Uganda’s Millennium Development Goal 5 target for contraceptive prevalence rate to be achieved by 2015 at 35% (MoFPED, 2010) is yet to be attained.

This low contraceptive uptake is associated with unwanted pregnancies, unsafe induced abortions and maternal deaths (Nalwadda et al., 2010) despite increased use of LARC methods being proposed as a strategy to reverse this trend (Blumenthal et al., 2011)

The reasons for low LARC uptake in Lubaga division are not known hence this study intends to identify the reasons for low LARC uptake in Lubaga division so as to improve implementation and performance of family planning services in Lubaga division.

Methodology / Méthodologie:

A health facility-based, cross-sectional study design was employed using both qualitative and quantitative data collection methods from 5th March to 30th April, 2012 in Lubaga division, Kampala district.

Probability proportionate–to–size sampling using average daily family planning (FP) clinic attendance was used to select 20 facilities among 125 registered health facilities in Lubaga division. Sixteen private clinics were randomly selected, 2 private–not–for profit and 2 private–for–profit facilities were purposively selected and 5 key informants were purposively selected.

Health facility barriers to LARC provision were assessed using pre-tested facility observation checklists and key informant interviews with unit heads on duty. The outcome variable was health facility type i.e. private or public.

Chi square tests using SPSS® 17.0 computed crude odds ratios (COR) with the corresponding 95% confidence intervals to measure the association between the outcome variable and independent variables. Fudged odd ratios were obtained by addition of an arbitrary constant of 5 observations to all cross-tabulation cells. Thematic content analysis was used for qualitative data and quotes presented verbatim.

Ethical approval was obtained from Makerere University School of Public Health Institutional Review Board and informed consent sought from key informants.

Results/key findings / Résultats/conclusions principales:

Potential health facility related barriers to LARC provision were no availability of IUD methods in public health facilities, this was consistent with a key informant from a public facility who stated that; ‘I think IUD is not available because the ‘pull system’ is used to procure contraceptives, drugs and other supplies’.

Injectable contraceptives were provided by all health facilities, significant by facility type (COR=2.68, 95%CI 1.21-5.99). Other potential barriers to LARC provision in public health facilities were no supervision of family planning services (COR=4.84, 95%CI 2.24-10.48) and no availability of medical officers (COR=3.16, 95%CI 1.43-6.97). Lower ‘cadre’ health workers i.e. clinical officers and nurses/midwives provided FP services which was statistically significant by facility type at COR=4.04, 95%CI 1.86-8.81 and COR=2.68, 95%CI 1.21-5.99 respectively.

Significant by facility type; 75% of all health facilities had family planning guidelines COR=2.84, 95%CI 1.27-6.31 and none (0%) of public health facilities had screening checklists for FP users COR=3.5, 95% CI 1.59-7.67.

Knowledge contribution / Contribution aux connaissances sur le sujet:

Though administration of contraceptives is predominantly provided by lower ‘cadre’ health workers i.e. clinical officers, nurses and midwives in peri-urban Kampala, intra-uterine device (IUD) methods are not administered in public health facilities.

The health system barriers to long acting reversible contraceptive provision at both private and public health facilities in Lubaga division are established however differences in LARC provision within Kampala district and rural-urban gaps in LARC provision in Uganda may need to be assessed.

Training of health workers in FP service provision may increase administration and therefore demand for LARC methods within urban and potentially rural areas in Uganda.


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