The Knowledge and Use of Intra-Uterine Device by Women Attending Ante-Natal Clinic at Enugu State Teaching Hospital, Parklane

Abstract

Intrauterine contraception has been recognized globally as one of the modern long-term reversible contraceptive methods suitable for women of all reproductive ages. It represents the most cost-effective method for preventing unwanted pregnancies, scientifically proven for its safety, efficacy and cost-effectiveness and is known to last longer in preventing pregnancy than other methods. This study assessed the knowledge of mothers attending ESUT teaching hospital, Parklane on intrauterine contraceptive device, the use as well as the common side effects experienced by the users. A descriptive survey research design was used to sample 175 mothers. A structured researcher developed questionnaire was used for data collection. The findings revealed that more than half of the respondents have good knowledge of intrauterine device but only 23 (14%) respondents make use of it. The commonly experienced side effects identified were irregular bleeding (75%) and vaginal discharge (62.5%). Although, the respondents had good knowledge of intrauterine device, their uptake of the method was poor. Therefore, there is a need to improve contraceptive counseling to ensure that women understand the relative effectiveness of IUDS. The study also recommended the need for better education for both clients and providers to improve the accessibility and acceptability of intrauterine device.

1. Introduction

Approximately, two-thirds of the women worldwide use some form of contraception. The use of contraception is more prevalent in developed countries (72.4% of women) than in less developed countries (61.2% of women). Globally, 14.3% of women aged 15–49 years who are married or in a relationship use intrauterine contraception as the primary form of birth control [1].

It has been reported that globally, the intrauterine contraceptive device (IUD) has been recognized as one of the modern long-term reversible contraceptive methods suitable for women of all reproductive ages. It represents the most cost-effective method for preventing unwanted pregnancies. Scientifically proven for its safety, efficacy and cost-effectiveness, the copper T380A and Levonorgestrel releasing IUD is known to be more effective and longer lasting in preventing pregnancy than pills, patches and contraceptive rings. It is the most widely used method of contraception with approximately 160 million users worldwide [2, 3]. Advantages of the IUCD include reversibility, long-term efficacy and confidentiality. It is also considered safe and effective for use in selected HIV-infected patients [4].

In areas of Northern Africa and Eastern and Central Asia, IUDs are inexpensive to manufacture and are widely used. In Australia and the US, the uptake is significantly lower. In these countries misunderstandings about the risks of IUC linger because an earlier device, the Dalkon Shield, was found to promote infection, and has tainted the perceptions of healthcare providers and the public about the safety of this method in general [5].

The underuse of the IUD largely results from the lack of knowledge and misconceptions of both health care providers and the public regarding the IUD. Several reasons why health care providers are reluctant to use the IUD have been cited, such as the fear of complications, namely pelvic inflammatory disease, ectopic pregnancy, infertility, sepsis, and death, all of which may lead to legal ramification [6].

Intrauterine contraception is convenient, safe and highly efficacious, and is recommended as a first-line option for all women, including adolescent and nulliparous women. Despite this recommendation, uptake is relatively low; only 5.6% of all contraceptive users and 3% of adolescents were using an intrauterine device (IUD) in a 2010 survey. Two reasons for this discrepancy have been proposed. First, many young women are unaware of the availability of IUDs; two studies found that fewer than 50% of adolescents and young women had knowledge of them. Second, despite evidence-based guidelines promoting their use and studies demonstrating their safety in nulliparous and adolescent women, many providers are still reluctant to recommend IUDs [7].

Several studies have shown that several factors account for the poor IUD use among women. These factors relate to healthcare provider characteristics, health system and individual or user factors. While these may be enough, sociocultural norms, beliefs and practices may serve to regulate IUD use even among high risk women or sub-groups particularly in Africa where there are entrenched sociocultural norms, beliefs and practices on childbirth [2].

Mbuthia et al. [8] noted that increasing IUD use is particularly important in sub-Saharan Africa, where family planning uptake is often motivated by women’s desire to limit the number of births. Evidence from this region suggests that there is a large discrepancy between the proportion of women who want to limit the number of births and the proportion using long-acting and permanent methods such as the IUD, implying a large unmet need. Furthermore, the contraceptive provision in many sub-Saharan African countries has so far relied predominantly on short-term methods, such as oral pills, condoms and injectables.

IUDs are a highly effective form of contraception due to several mechanisms. The non-contraceptive benefits of hormonal IUDs include their use in heavy menstrual bleeding, dysmenorrheal, adenomyosis, endometriosis, endometrial hyperplasia and end stages of endometrial cancer in young patients.

Most of the side effects associated with IUDs are minor, which include abnormal uterine bleeding and pain. Complications with the placement of intrauterine devices include uterine perforation, expulsion, malposition in the uterus and migration of IUD into the abdominal cavity and viscera.

Although intrauterine devices pose some side effects and risks, IUDs are fairly easy to place making the intrauterine device an excellent form of long-acting reversible contraception [1].

1.1 Statement of problem

IUCD has established itself as an effective, reliable, and safe method of contraception with minimal complications. However, its acceptance remains low [9].

Gbagbo and Kayi [2] observed that IUCD is used by less than 2% of Ghanaian women in their reproductive age. Ghana’s Demographic and Health Surveys (GDHS) have all shown very low IUD usage among both married and unmarried women.

Mbuthia et al. [8] also pointed out that the IUD represents only 0.7% of modern method contraceptive use in sub-Saharan Africa, revealing the under-use of this method of contraception in the region, despite it being such an important choice for women elsewhere.

Following the findings made by different researchers, it can be said that the utilization of IUD is very low in other African countries. However, there is insufficient information regarding its knowledge and use among women in Nigeria, therefore, the researchers wish to find out the knowledge and use of intrauterine device among women attending antenatal clinics in ESUT Teaching Hospital Parklane, Enugu.

2. Research methodology

This chapter deals with the methods and techniques used for this research work.

2.1 Research design

A descriptive survey research design was selected for this study.

2.2 Area of the study

The area of the study is the Enugu State University Teaching Hospital, Parklane, Enugu. It is located in the Government Reserved Area (G.R.A). The hospital was established in 1952, became a specialist hospital in 2005 and a teaching hospital in May 2006. It is the only tertiary hospital owned by the state government. Geographically, on the North, it is bounded by the polo park shopping mall (shoprite), bounded by Christ the King Catholic Church on the South, bounded by solid FM radio station on the West and on the East by New Market.

2.3 Population of the study

The target populations for this study are women attending the antenatal clinic of Enugu state university of science and technology Parklane.

2.4 Sample size

The sample size was statistically determined using the Taro Yamane formula. On monthly basis, an average of 1194 women visit the clinic, 312 women visit weekly and an average of 49 women visit daily. A sample size of 175 was derived using this formula. (Source: Antenatal Unit Daily Attendance Records from March to April; 2020)

$$\mathrm{n}=\frac{\mathrm{n}}{1+\mathrm{N}\left(\mathrm{d}\right)}$$E1

where n = sample size, N = the population size, d = the level of precision (assumed to be 0.05 at 95% confidence level).

where N is 312

$$\mathrm{n}=\frac{312}{1+312{\left(0.05\right)}^2}$$E2

$$\mathrm{n}=\frac{312}{1+312\left(0.0025\right)}$$E3

$$=\frac{312}{1+0.78}$$E4

$$=\frac{312}{1.78}$$E5

$$\mathrm{n}=175.3$$E6

$$\mathrm{n}=175\text{women}$$

2.5 Sampling technique

Convenience sampling technique was used for this study.

2.6 Instrument of data collection

The instrument for data collection was a well-structured researcher developed questionnaire. The questionnaire was developed based on the research objectives and was divided into four sections. Section A contained questions on demographic data, Section B contained questions on knowledge of intrauterine device. Section C contained questions on the use of intrauterine device and Section D contained a question on the common side effects of the use of intrauterine device.

2.7 Validity and reliability of instrument: Face and content validity

A pilot test was conducted using 10% was carried out at Polyclinic and Uwani cottage hospital. The reliability of the study was determined using Pearson’s formula and a reliability of 0.8 was gotten.

2.8 Ethical considerations

The following ethical issues were considered while carrying out the research work. A letter of introduction was obtained by the researcher from the Head, department of nursing sciences UNEC; a letter of ethical clearance was obtained from the Chief Medical Director of ESUTTH Parklane permitting the researcher to share the questionnaire among the women attending the antenatal clinic. The nursing service department was notified about the ongoing research. The researcher explained the research process to the respondents and obtained verbal consent before giving out the questionnaires to them. Respondent’s personal information was kept confidential and anonymous. The principle of voluntary participation was applied to recruit participants for the research. All the authors whose works were used for this study were cited and referenced properly.

2.9 Method of data analysis

Questionnaires were collected and counted to ensure they are complete. Data collected were analyzed using descriptive statistical methods like tables, frequencies and percentages.

3. Presentation of data

This chapter deals with the presentation of results derived from the responses to the questionnaire administered. Data analysis was done based on the objectives of the study. A total of 175 copies of questionnaire were administered and 164 of the total questionnaire were properly filled and returned making a return rate of 93.7%.

3.1 Demographic data

Table 1 shows that the age distribution of the respondents was slightly varied with a mean age of 37.06 ± 7.34 and respondents aged between 35 and 44 years were comparatively higher (53.0%). Findings under educational qualification revealed that majority 91 (55.5%) had attained tertiary level of education, 48 (29.3%) had secondary education and 25 (15.2%) had primary education. 66 (40.2%) of the respondents were public workers, 52 (31.7%) were self-employed, 28 (17.1%) were unemployed, and 18 (11.0%) were private formal workers. Majority of the respondents, 161 (98.2%) were Christians while minority 3(1.8%) were Islams. Based on ethnicity, 143 (87.2) belonged to Igbo tribe, 14 (8.5%) were from other tribes, 5 (3.1%) were Yorubas while 2 (1.2%) were Hausas. Lastly, 90 (54.9%) have 3 and above living children, 48 (29.3%) had 2 living children, 17 (10.3%) had one living child while 9 (5.5%) had no child.

Category	Options	Frequency	Percentage (%)	Mean ± SD
Age	15–24	7	4.3	37.06 ± 7.34
	25–34	48	29.3
	35–44	87	53.0
	45 and above	22	13.4
Educational qualification	Primary	25	15.2
	Secondary	48	29.3
	Tertiary	91	55.5
Occupation	Unemployed	28	17.1
	Self-employed	52	31.7
	Public worker	66	40.2
	Private formal worker	18	11.0
Religion	Christian	161	98.2
	Islam	3	1.8
	Pagan	-	-
Tribe	Igbo	143	87.2
	Hausa	2	1.2
	Yoruba	5	3.1
	Others	14	8.5
Number of live births	0	9	5.5
	1	17	10.3
	2	48	29.3
	3 and above	90	54.9

Table 1.

Socio-demographic characteristics of the participants, n = 164.

3.2 The knowledge of intrauterine device (IUD) among women attending antenatal clinic in ESUT teaching hospital, Parklane

Table 2 shows that 121 (73.8%) of the respondents have heard about intrauterine contraceptive device. They identified their sources of information to include Friends 45 (37.2%), Doctor 34 (28.1%), Nurse 29 (24.0%) and Media/book 13 (10.7%). In addition, 84 (69.4%) of the study participants are aware that the facility offers intrauterine device services.

Variable	Options	Frequency	Percentage (%)
Have you ever heard about intrauterine contraceptive device?	Yes	121	73.8
	No	43	26.2
What is the source of your knowledge?	Doctor	34	28.1
	Nurse	29	24.0
	Friends/relatives	45	37.2
	Media/book	13	10.7
Are you aware that the facility offers intrauterine device services?	Yes	84	69.4
	No	37	30.6

Table 2.

The knowledge of intrauterine device (IUD) among women attending antenatal clinic in ESUT Teaching Hospital, Parklane, n = 164.

Variable	Options	Frequency	Percentage (%)
What family planning method do you use currently?	None	18	11.0
	Intrauterine device	23	14.0
	Implant	7	4.3
	Oral pills	16	9.8
	Injectable	11	6.7
	Male condoms	66	40.2
	Female condoms	3	1.8
	Natural method	20	12.2
	Tubal ligation	–	–
	Vasectomy	–	–
How long have you used this family planning method?	Less than 6 months	14	8.5
	6 months to 1 year	91	55.5
	2 years to 5 years	47	28.7
	Above 6 years	12	7.3
What are your reasons for using intrauterine device? (multiple responses)	Does not contain hormone	3	13.0
	I consider it to be very effective	9	39.1
	It is relatively inexpensive	5	21.7
	Quickly reversible on removal	12	52.2
	Does not interfere with breastfeeding	4	17.4
	The clinician recommended it	5	21.7
	My spouse supported it	3	13.0
	I want a method that cannot be detected by	1	4.3
	My spouse
	Lasts for a very long time	14	60.9
	Does not interfere with intercourse	6	26.1
Would you recommend Intrauterine device for other women?	Yes	13	56.5
	No	10	43.5

Table 3.

The use of intrauterine device (IUD) among women attending antenatal clinic in ESUT Teaching Hospital, Parklane, n = 164.

3.3 The use of intrauterine device (IUD) among women attending antenatal clinic in ESUT teaching hospital, Parklane

The most common family planning method used by 40.2% of the respondents was male condom. Less commonly, other methods identified include: intra uterine device (14.0%), natural method (12.2%). Oral pills (9.8%), injectable (6.7%), implant (4.3%) and female condoms (1.8%). However, 11% of the respondents used no method of family planning. The majority (55.5%) of the respondents have used their identified method for 6 months to 1 year. The reasons for using identified by the majority of the respondents include: quick reversal on removal (52.2%) and long lasting (60.9%). Other reasons were effectiveness (39.1%), does not interfere with intercourse (26.1%), recommendation by a clinician (21.7%), does not interfere with breastfeeding (17.4%), does not contain hormone (13.0%), spousal support (13.0%) and non-detectible by spouse (4.3%). Furthermore, over an average number (56.5%) of the respondents would recommend intrauterine device to other women.

3.4 The common side effects faced by women who use IUD

The opinions of the respondents on the side effects of IUD they face showed that 65.2% did not experience any side effects associated with the use of IUD while 34.8% found side effects associated with its use. The commonly experienced side effects identified were irregular bleeding (75.0%) and vaginal discharge (62.5%). Others include heavy menstrual bleeding (25.0%), abdominal cramps (25.0%) and pelvic pain (12.5%).

4. Discussion of findings

The study examined the knowledge and use of intra uterine device by women attending antenatal clinic of Enugu State Teaching Hospital, Parklane, Enugu.

73.8% of the respondents have heard about IUD. The highest number of the study participants identified friends/relatives (37.2%) as their source of information and 69.4% are aware that the facility offers intrauterine device services. This can conclusively be interpreted as a good level of knowledge on the part of the respondents. The tertiary level of education attained by the majority of the respondents may have been contributory to their level of knowledge. This goes in line with the results of the work by Eastman [10] which showed that only 12% of participants did not know what an IUD is. Contrary to the present study, 50% of the respondents learned about IUDs from professionals (including physicians, nurses and teachers) according to Eastman [10]. However, this finding disagrees with the work Sharma and Pal [11], whose results showed that regarding knowledge on different aspects of IUD, less than half of the study population (44.8%) had good knowledge regarding IUD. Also in disagreement is the findings by Westhuizen and Hanekom [4] which revealed that only 49.2% reported having heard about IUD.

Their good level of knowledge did not translate into a good usage as their level of usage was poor. Among all family planning methods enlisted, IUD was used by only 14.0% of the respondents. Of this proportion, 56.5% would recommend IUD to other women. These findings can be comparable with that of Mbuthia et al. [8] which noted that knowledge of IUD did not affect its uptake by participants as only 30 women were using IUD as a contraceptive method. These results were also found to be in concordance with that of Igwe [12] where the uptake rate of IUD was 13.2%. The major reasons for use identified were long lasting (60.9%) and quick reversal on removal (52.2%). These findings conform to the submissions of Bryant et al. [13], where almost all women mentioned multiple benefits of the IUD which included being long lasting, reversible and convenient. Similarities in the result were noted by Gbagbo and Kayi [2] where the respondents said their reason for IUD was their desire for long-acting family planning method (24%). Gomez and Freihart [14], in their study also identified that the study participants who chose IUD gave their reasons to be: ease of use, lack of requisite maintenance, effectiveness, long lasting, reduces cramps and makes period lighter and easily reversible.

Only 34.8% found some side effects associated with its use. The commonly experienced side effects identified were irregular bleeding (75.0%) and vaginal discharge (62.5%). The findings of this present study support that of Olamijulo et al. [15] whose results revealed that 32.6% of the IUCD users experienced some form of undesirable effects in association with its use. The most common undesirable effects reported by the clients were abnormal vaginal discharge (40.8%) while the least was dyspareunia (0.7%). Also slightly comparable is the findings of Igwe [12] which also showed that 7.8% of the clients had side effects that include abdominal pain (44.4%), menorrhagia (22.2%).

5. Implication for nursing

Practicing nurses/midwives are ideally placed to take a prominent role in advising clients and providing them with their chosen method of contraception. They cannot be expected to deliver a service if they are not adequately skilled and familiar with the most up-to-date clinical guidelines and national standards on IUD use and sexual health. To this end, education and training must be viewed as a fundamental aspect of effective and sustainable health service planning and delivery, ensuring that patients continue to receive the highest standards of care.

6. Limitations

Limitations to the study included the following: the high cost of printing questionnaires, reluctance of some respondents to fill the questionnaire as well as the physical stress associated with going to the hospital for data collection. In addition, the study focused on the urban population who are more affluent and better-educated women have the means and, based upon this study, are more likely to be knowledgeable about IUDs than the general population and cannot be generalized for the rural women.

7. Summary

This study was carried out to assess the knowledge and use of intra uterine device among women attending antenatal clinic in ESUT Teaching Hospital Parklane, Enugu. The objectives of this study were set and research questions formulated from them and both were according to the purpose of the study. Literature were reviewed ranging from conceptual and theoretical framework to empirical studies based on the research questions that were drawn. A descriptive survey method was adopted for the study and data was collected using a structured questionnaire. The data generated were statistically analyzed based on the research objectives and presented in Tables 1–4. Several findings were subsequently made. The knowledge of the respondents on IUD was good as more than an average number of the respondents have ever heard about intrauterine contraceptive device with friends and doctors being their main source of information. The results further showed that of all family planning methods, only 14% of the respondents used IUD and the major reasons identified were long lasting and quick reversal on removal. More than half of the respondents agreed that they would recommend IUDs to other women. The opinions of the respondents on the side effects of IUD showed that only 34.8% had side effects with its use. The commonly experienced side effects identified were irregular bleeding and vaginal discharge.

Variable	Options	Frequency	Percentage (%)
*Did you notice any side effects from using intrauterine device?	Yes	8	34.8
	No	15	65.2
If yes to*, What are the common side effects from using intrauterine device? (multiple responses)	Heavy menstrual bleeding	2	25.0
	Pelvic pain	1	12.5
	Dysmenorrhea	–	–
	Dyspareunia	–	–
	Vaginal discharge	5	62.5
	Abdominal cramps	2	25.0
	Irregular bleeding	6	75.0

Table 4.

The common side effects faced by women who use IUD, n = 23.

Based on the findings, a conclusion was drawn, recommendations, suggestion for further studies were proffered as well as the implication of the study to Nursing.

8. Conclusions

IUD is a safe, effective form of contraception whose widespread use could decrease the high rate of unintended pregnancies across the globe. However, it remains one of the least utilized family planning services. Even though, the majority of the respondents had good knowledge of IUDs, their uptake of IUDs was poor. This study has exposed a need to improve on contraceptive counseling to ensure that women understand the relative effectiveness of IUDs. Hence, when discussing contraception with women, health care practitioners should discuss the risks and benefits of IUD with women of reproductive age and recommend them as a first-line method.

9. Recommendations

Though their knowledge of IUD was good, there still lies a need for improvement in its use among women by healthcare professionals and policy makers. The researcher, therefore, recommends that:

1. Better education of both clients and providers is essential to improve accessibility and acceptability of the IUD. The IUD needs to be promoted and clients must be made aware of the availability of this option, while providers need to explore the opportunities to update their knowledge and skills to deliver an effective service.

2. The dispersion of accurate information addressing women’s beliefs & concerns is crucial to the continued use and growing acceptance of this beneficial method.

3. Increased training and on-the-job support for providers would increase women’s willingness to recommend the method, thus stimulating demand.

4. All levels of government and concerned organizations should carry out aggressive campaigns using print and electronic media, outreach programs, and rallies to achieve better awareness and use of IUD.

10. Suggestion for further studies

The researcher hereby suggests that a similar study should be carried out in other health care institutions in the state and within the south-eastern zone to compare results. Also, studies should be conducted to assess the barriers to/factors influencing the use of IUD among women of child bearing ages presenting in health care facilities.

A.

Instruction: please tick √ in the appropriate box

Section A: Demographic data

1. Age:

   1. 15–24 [ ]

   2. 25–34 [ ]

   3. 35–44 [ ]

   4. 45 – above [ ]

2. Highest educational level:

   1. Primary [ ]

   2. Secondary [ ]

   3. Tertiary [ ]

   4. Others specify________________

3. Occupation:

   1. Unemployed [ ]

   2. Self-employed [ ]

   3. Public worker [ ]

   4. Private formal worker [ ]

4. Religion:

   1. Christianity [ ]

   2. Islam [ ]

   3. Pagan [ ]

   4. Others Specify____________________

5. Tribe:

   1. Igbo [ ]

   2. Hausa [ ]

   3. Yoruba [ ]

   4. Others Specify_________________

6. Number of live births:

   1. 0 [ ]

   2. 1 [ ]

   3. 2 [ ]

   4. ≥ 3 [ ]

   Section B: Knowledge of intrauterine device

7. Have you ever heard about intrauterine contraceptive device?

   1. Yes [ ]

   2. No [ ]

8. What is the source of your knowledge?

   1. Doctor [ ]

   2. Nurse [ ]

   3. Friend/relatives [ ]

   4. Media/book [ ]

   5. Others Specify________________

9. Are you aware that the facility offers intrauterine device services?

   1. Yes [ ]

   2. No [ ]

   Section C: Use of intrauterine device

10. What family planning method do you use currently?

    1. None [ ]

    2. Intra uterine device [ ]

    3. Implant [ ]

    4. Oral pills [ ]

    5. Injectables [ ]

    6. Male condoms [ ]

    7. Female condoms [ ]

    8. Natural method [ ]

    9. Tubal ligation [ ]

    10. Valsectomy [ ]

11. How long have you used current family planning method?

    1. Less than 6 months [ ]

    2. 6 months to 1 year [ ]

    3. 2 years to 5 years [ ]

    4. Above 6 years [ ]

    If your answer to number 10 is intrauterine device continue question 12

12. What are your reasons for using intrauterine device? NB: Tick as many that apply.

    1. Does not contain hormone [ ]

    2. I consider it to be very effective [ ]

    3. It is relatively inexpensive [ ]

    4. Quickly reversible on removal [ ]

    5. Does not interfere with breastfeeding [ ]

    6. The clinician recommended it [ ]

    7. My spouse supported it [ ]

    8. I want a method that cannot be detected by my spouse [ ]

    9. Lasts for a very long time [ ]

    10. Does not interfere with intercourse [ ]

13. Would you recommend intrauterine device for other women?

    1. Yes [ ]

    2. No [ ]

    Section D: Common side effects of intrauterine device

14. Did you notice any side effects from using intrauterine device

    1. Yes [ ]

    2. No [ ]

15. What are the common side effects from using intrauterine device? NB: Tick as many that apply

    1. Heavy menstrual bleeding [ ]

    2. Pelvic pain [ ]

    3. Dysmenorrhea [ ]

    4. Dyspareunia [ ]

    5. Vaginal discharge [ ]

    6. Abdominal cramps [ ]

    7. Irregular bleeding [ ]

    8. Infection [ ]