Profile of Women Seeking an Intra-uterine Contraceptive Device at a Community Health Centre in Pretoria, South Africa

1.1. Background

An intra-uterine contraceptive device (IUCD) is a T-shaped piece of equipment made of copper and plastic, which is meant to be inserted into the uterus in order to serve as a contraceptive. It is a commonly used form of reversible contraception that lasts for at least five to ten years. After being inserted into the uterus, the device's two threads pass through the cervix and remain in the vagina, making it simple to remove [1, 2]. The two primary types of IUCDs are non-hormonal metallic (copper) and hormonal levonorgestrel-releasing intra-uterine systems, such as the Mirena and Jaydess [3].

The mode of operation of the copper IUCD is that it releases copper ions into the uterine cavity, which are harmful to sperm entering the uterus and fallopian tubes [4, 5]. Levonorgestrel, a hormone secreted daily by the hormonal IUCD, thickens cervical mucous and lowers sperm motility and viability. Prior to the ovum entering the uterus, early in the reproductive cycle, the IUCDs largely impede fertilisation [4]. IUCDs cause a significant inflammatory response in the uterus. The presence of macrophages, leucocytes, prostaglandins, and other enzymes in both uterine and tubal fluid impairs the transfer of spermatozoa and ova [3, 6]. IUCDs are safe and appropriate for almost all women, including those who are married or otherwise, who do or do not have children, and who are young or older than 40. However, an IUCD is medically contraindicated in some circumstances, such as when active sexually transmitted diseases and pelvic inflammatory disease are present or cervical or uterine cancer [1, 5-7].

The South African primary healthcare facilities that provide the copper-T IUCD comply with the country's national clinical requirements. This contraceptive approach is inexpensive and has a low dropout rate. The use of IUCDs is comparatively low in low- and middle-income countries [8]. The use of IUCDs varies by country, with about 14.3% of women of reproductive age worldwide using IUCDs. However, the reasons for the variations are not well documented [9]. According to the United Nations (UN) and a study done in Nigeria, the number of women worldwide who rely on IUCDs increased from 133 million in 1994 to 159 million in 2019 [10, 11]. Some significant changes in methods occurred among women using some form of contraception during 2008–2014, with the largest change occurring among long-acting reversible contraceptive users [12]. While only 6% of women on contraception used an IUCD or subcutaneous implant as their primary method in 2008, this increased to 12% in 2012 and 14% in 2014 [12].

In India, more women who used IUCDs were unemployed; although the association between contraceptive use and employment was heterogenous considering the methods and sectors, there was no relationship between contraceptive use and a lower likelihood of employment [13]. Data from Demographic Health Surveys conducted between 1996 and 2000 in the 22 sub-Saharan African countries between 2010 and 2016 showed contraceptive use among married women to be increased in all of these countries. In the first period, the prevalence of IUCD use was less than 10% in 14 countries, and the mean for all countries was 11%. By the second period, IUCD use was lower than 10% in only four countries (Benin, Chad, Guinea and Mali), and the mean had risen to 24%, in part because of steep increases in most of the East African countries [14]. When assessing the profile of IUCD users in Nigeria, the participants’ ages ranged from 15 to 50 years, with most (56.4%) aged between 25 to 34 years and a mean age of 33.66 years. Most of the IUCD seekers were multiparous women (62.9%), 95.7% were Christian, and 95.7% were married [15]. Most (98.9%) of the respondents had formal education; 74.9% had a secondary level of education, 19.3% had tertiary education, and 4.7% had primary levels of education. With the majority having had secondary education, it was concluded that educated participants are more likely to accept the IUCD compared to those without secondary education [15]. A survey conducted in Ethiopia showed 3.1% of the IUCD users to be younger than 20 years, and most (93.8%) were married. More than three-quarters (79.6%) were Christian, while about 5.5% were found to be illiterate, and 40% had three or more births [16]. In South Africa, only about one-third of women aged 15–19 years used some form of contraception, with oral contraception accounting for 5.0% of use and IUCDs accounting for 0.4%, according to a national household survey conducted to evaluate contraceptive coverage among 6 296 women aged 15–49 years [17].

A study on the profile of IUCD users in Southern Nigeria showed that 77.9% of women obtained their information about contraception from clinical personnel, 9.7% from friends and relatives, 4.0% from community health workers, and 2.5% from print and media [3]. Radio/television and outreach contributed less as sources of information about contraception, at 1.8% and 1.5%, respectively [3]. In Ethiopia, the partner or husband’s approval (23.4%) as well as the service provider’s choice (33.6%) were the main factors supporting the use of IUCDs among many women [15]. Among Ethiopian women who had just delivered (they were in the early postpartum period), almost 42.6% showed good awareness of the IUCD [2]. In this group, 29.2% were informed by the media, 25.1% by healthcare professionals, 14.5% by family members/friends, and 4.3% by their husbands [2]. Another study carried out in Addis Ababa, Ethiopia, showed that 71.4% of the participants had information about the IUCD, and of those women, 32.1% reported having a husband, family and/or friend opposed to the utilisation of an IUCD. However, the source of information about IUCDs for the majority of the respondents was healthcare professionals (63.8%) [11]. In another Ethiopian study, conducted in Ambo, knowledge of IUCDs was assessed in women who had the intention to use a postpartum IUCD (PPIUCD), and 49% were found to have good knowledge of PPIUCD [2]. While 38.6% of the participants knew that a PPIUCD could prevent pregnancies for more than ten years, about 34.9% replied that they are not appropriate for women at high risk of contracting sexually transmitted infections (STIs) [2]. Only 24.1% had knowledge that the PPIUCD does not interfere with sexual intercourse or desire, and most (41.9%) knew that it could be removed at any time that they want it to be [2]. In addition, 61.2% believed that the PPIUCD does not move through the body after insertion, while 35.4% felt that the PPIUCD can interfere with sexual intercourse [2]. The majority (56.3%) of those polled disagreed that a PPIUCD could harm a woman's womb, while 27.5% believed that it does not cause cancer [2]. The knowledge and attitudes about IUCDs among reproductive-aged women in Saint Louis, Missouri, USA, were assessed, which showed that they had moderate knowledge on IUCDs. Most (98%) knew that STIs are not prevented by IUCDs. Conveniency (36%), pregnancy prevention (59%), and minimal side effects (28%) were the three most frequently cited reasons for using an IUCD [18].

In South Africa, in a study carried out to assess the quantity and quality of knowledge about the IUCD and to evaluate its acceptability for future use, even individuals who were aware of the existence of IUCDs had a lack of general information about them [19]. There was also a clear link between education and knowledge, with patients who had completed Grade 12 or higher being significantly more likely than those with lower levels of education to be aware of the IUCD. Several true or false questions demonstrated a lack of comprehension as well as myths about the IUCD in South Africa. The IUCD was thought to cause cancer by a third of participants (33.1%), and it was thought to move around in the body by 38.3%. About 41% of patients had no idea how long it would take to work [20].

When assessing the knowledge of contraceptives in Nepal, the majority of the participants (92.3%) had heard about contraception, whereas 7.70% had not [21]. The most well-known type of contraception was the injection (Depo-Provera – 92.7%), while pills and condoms were known by 91.7% and 89.6%, respectively. The IUCD was known by 69.4% of participants, while the implant, female sterilisation, and male sterilisation were known by 69.4%, 62.7%, and 57.5% of clients, respectively. Furthermore, abstinence was known as a contraceptive method by 39.4% of participants, withdrawal by 35.2%, the rhythm method by 11.4%, lactational amenorrhea by 8.8%, and EC by 23.3% [21]. IUCD users in Lagos University Teaching Hospital, Nigeria, showed that they had used other contraceptive methods before using the IUCD. Condom use accounted for 16.2% of users, the IUCD for 44.8%, oral contraceptives for 17%, injectable contraceptives for 19.5%, and sub-dermal implants for 2.5% [11]. Participants in a study, with respect to the knowledge of IUCDs and other contraception in South Africa, indicated that they had heard about tubal ligation (73.5%), male sterilisation (23.3%), the IUCD (49.2%), oral contraceptives (91.7%), and the progesterone-only pill (1.6%) [20]. Among others, 47.7% had heard about EC, 97.9% about the injection (Depo-Provera/Nur-Isterate), 99.5% about the male condom, 76.7% about the female condom, 1.6% about spermicides/jelly, 1.0% about the diaphragm/cap, 10.9% about hormone implants, and 6.2% about natural methods [20]. At Jubilee Hospital, Pretoria, it was found that the male condom was the most well-known contraceptive technique (98.4%), followed by the female condom (96.8%), the pill (96%), and the subdermal implant (82.9%) [22]. The least known method was the vaginal ring (6.40%), followed by the patch (11.10%), vasectomy (20.60%), calendar method (20.63%) and sterilisation (69.80). Among other methods that were known were the loop (73.00%) and withdrawal (79.37%) [22]. Regarding the IUCD, knowledge was assessed among women in more than 30 clinics of two South African provinces and found to be little, and emphasis was placed on educating women on this particular contraceptive method [17]. In Cape-town, South Africa, while assessing the awareness of and interest in the use of an IUCD in a population of HIV-infected women, it appeared that awareness in the chosen sample was around 37%. After an IUCD information meeting, more than 34% showed interest in the use of the device; this interest was inversely linked with the age of the participants and slightly related to existing menses complaints [23].

1.2. Aim and Objective

The aim of the study was to determine the profile of women seeking to use IUCD at a Pretoria community health centre (CHC). The study's objectives included identifying the socio-demographic characteristics of the participants, their motivations for choosing the IUCD, the sources of information they used to learn about the device, their prior use of contraceptive methods, and their knowledge of the IUCD.

2.1. Study Design

A descriptive quantitative study was carried out with a cross-sectional design using a piloted questionnaire.

2.2. Population Sample and Sampling Size

From June 2021 to December 2021, all women seeking an IUCD at Temba CHC were considered for the study. The sample was drawn from those who signed assent (under 18 years of age) and consent (above 18 years). The Temba CHC registration data show that every week, roughly five women request an IUCD. After six months, a sample size of 120 was estimated; however, a higher number of participants was received during data collection, with a 10.8% increase in sample size (n=129).

Inclusion criteria were women of childbearing age (15–49 years) requesting an IUCD at Temba CHC during the data collection period. Exclusion criteria were sick and mentally disturbed women who need urgent medical care and virgin women.

2.3. Data Collection

The researcher trained a retired female nurse who had previously worked in Temba CHC's mother and child section to be a research assistant (RA). The RA was based at the designated unit from the start of the data-collecting period until its conclusion, per the agreement. Her responsibility was to describe the study's aim and objectives to all women seeking an IUCD. She helped them to sign the consent forms (for those who consented) and got in touch with parents or guardians so that assent could be signed for minors who agreed to participate in the study. The two languages that are used in the Temba community, Setswana and English, allowed the RA to express herself. The researcher created the questionnaire in English, and the RA gave it to the study participants who consented. The questionnaire was divided into five sections: socio-demographics, motivation for choosing IUCD, source of information on IUCD, previous contraceptive methods used, and knowledge of IUCD. Before being used in the current survey, this questionnaire underwent testing in another CHC situated about 65 km from Temba CHC.

2.4. Reliability and Validity

To ensure reliability in the current research study, the questionnaire was tested for stability using a test-retest. The same questionnaire was given to the same participant more than once under similar circumstances. During the pilot study, a few candidates (n= 6) who came to the pilot center to book for IUCD insertion completed the questionnaire, and when they came back a week later for the IUCD insertion, they were given the same questionnaire to complete. Their answers were similar to the ones they had provided a week previously. This was taken as evidence of the consistency and that the questionnaire should provide the same outcomes if repeated in similar circumstances.

In addition, content validity, as well as face validity, was assessed. In terms of content validity, the questionnaire covers all aspects of IUCDs as presented in the objectives of the study. After the pilot study, the questionnaire was restructured by the two supervisors to match the different objectives of the study. Regarding face validity, the questionnaire was peer-reviewed by two family physicians who are not part of the current study project.

The pilot study was conducted in Phedisong 4 CHC, which is 65 km away from Temba CHC in Ga-Rankuwa. The researcher made an effort to reduce data contamination by keeping this distance. It is a CHC like Temba, and the majority of its users speak Setswana and English. They also share the same culture, food, and languages as the Temba locals.

2.5. Data Analysis

The information from the completed questionnaires was captured on an Excel spreadsheet. Coding of data was done in order to use only numerical data in the statistical analysis. Data were imported into the Statistical Package for the Social Sciences (SPSS) software version 27 for descriptive analysis. Results of this analysis are presented in tables and Figs. (1-3).

2.6. Ethical Considerations

Before starting data collection, the researcher secured a letter of approval from the Temba CHC Operational Manager and an ethical clearance certificate from the Sefako Makgatho Health Sciences University Research and Ethics Committee (SMUREC/M/32/2021: PG). The Tshwane District Research Committee also granted permission to conduct the study (project number 13/22). Anonymity and confidentiality were maintained throughout the entire research procedure. No proof of identification was required. Before enrolling a participant, their written assent or consent was required. The study's participants were informed about their right to leave the study at any point if they felt uncomfortable; however, no participants dropped out.