Dissatisfaction with contraceptive methods.

BACKGROUND: Almost two thirds of Iranians eligible for using contraceptive methods use these methods. Their dissatisfaction with the methods would directly and indirectly affect the quality of family planning services and would bring about detrimental results for the service recipients and consequently for other family members. Therefore, identification and evaluation of the factors leading to dissatisfaction with contraceptive methods can help the authorities responsible for family planning services to provide some solutions to increase satisfaction with these methods.
METHODS: This research was a qualitative phenomenological study. The study population consisted of the women using intrauterine device (IUD) or contraceptive pills only as contraception, referred to 14-Masoum, Amir Hamzeh, Ebn-e Sina, Shahid Motamed, and Navab Safavi clinical centers. Sampling was goal-based, and 14 individuals participated in the study. Data collection was carried out in four months using deep interview. Data analysis was performed using seven-step Colaizzi's method.
RESULTS: The findings of the interviews were assigned 104 codes categorized into three groups; 1- physical and psychological harms experienced by the method, 2- the shortcomings of the methods, and 3- continuation in spite of dissatisfaction with the method.
CONCLUSIONS: According to the results, the users of contraceptive methods would have some experiences, which lead to their dissatisfaction with the methods. Since dissatisfaction with the methods will result in a decrease in continuation of use of the methods or discontinuation of the method, providing some policies to increase the satisfaction with contraceptive methods can cause more effective use of the methods and continuation of their use.

Uncontrolled population growth is a great problem of the current century,1 which has many undesirable consequences. It is considered an obstacle to economic and social development in most developing countries.2 It also affects different groups of the society, including mothers and infants, since these two groups are more susceptible to different diseases and their consequent mortality.3 Therefore, the best approach to decreasing population growth is implementing and expanding family planning programs.4

According to the latest statistics issued in 2001, in urban and rural areas of Isfahan, the coverage of family planning programs has been 78.2%, and the most frequently used methods have been contraceptive pills (18.9%) and IUD (11.9%). However, the effectiveness of these two methods has been 18.5% and 3.7% and their continuation of use was 21.38 months and 31.57 months for pills and IUD, respectively, and the rate of unwanted pregnancy has been about 36%.15 Although two thirds of the population eligible for using contraceptive methods is covered by family planning services and numerous studies have been carried out on different aspects of family planning,6 no study so far has been performed to evaluate the experiences of the users of these methods in aspects such as satisfaction or dissatisfaction with contraceptive methods. This is important because satisfaction with the methods improves the effectiveness of the methods and continued use of them, and negligence in this regard can directly or indirectly affect quality of the services.7

Since experiences, mentality, and interpretation of people greatly affect all aspects of life8 and is the basis of their behavior,910 the study of these experiences can lead to better understanding of needs, feelings, and perceptions of the users.

The aim of this research is to describe experiences that lead to a feeling of dissatisfaction with the contraceptive methods used.

Methods

This study considered the experience of dissatisfaction with contraceptive methods and was of a phenomenological type.

The population under evaluation consisted of all the women using LD pills or copper IUD, who referred to the medical centers of Isfahan during the course of this study.

The study started on 20 June, 2004, and continued until 30 October, 2004. Sampling was goal-based, and 14 individuals participated in the study (eight used IUD and six used LD pills). The age range of the participants was 20-35.

Deep interview was used for data collection and informed consent was obtained from them before beginning the interviews, on condition of confidentiality. The duration of each session was 25-60 minutes. Then, the interviews were transcribed and then compared with the original recordings.

In order to validate the data, after each interview the researcher transcribed the information, coded it, and analyzed the data. Then the description was presented to the participant to verify the accuracy of the content. After that the next interview was carried out.

To make sure of the reliability of the data, the researcher tried to gather the data carefully and the participants were asked to try to recall their memories as clearly as possible and provide exact information.

Colaizzi's method was used for data analysis. First, all the important points obtained from the interview material were extracted, the meaning of each important statement was coded, and the codes were categorized into groups, which were later presented to the respective participants for validation. At the next step, the results were combined to provide a comprehensive description of the phenomenon under study and reviewed for clarity. In the end, the data were presented again to the participants for validation.

Results

Dissatisfaction with contraceptive methods as experienced by contraceptive users was the subject of this study. In this research, dissatisfaction consisted of three main elements; 1- physical and psychological harms experienced by the users, 2- shortcomings of the methods, and 3-continuation in spite of dissatisfaction.

1- Physical and psychological harms experienced by the users

One of the participants stated:

“Ever since I use IUD, I lose a lot of blood during menstruation, sometimes even up to ten days, and even after the shower I have sometimes spotting.”

With regard to the descriptions provided by the participants, massive hemorrhage, prolonged hemorrhage, and spotting were extracted as the physical complications of using IUD.

Another participant said:

“Ever since I use the pills, I have gained weight; they must have increased my appetite.”

Still another one stated:

“When I took pills, I felt very depressed and wanted to keep off others and cry. I did not feel like talking to children and would beat them.”

Out of the above statement, items such as depression and impatience were extracted as psychological disadvantages experienced by the users as a result of these methods.

2- Shortcomings of the methods

Another main point of dissatisfaction with contraceptive methods was the shortcomings of the methods. Problems with following the religious rituals are among these shortcomings. In this regard, one of the participants stated:

“The first 2-3 days of the cycle, I experience spotting, I regularly take shower and say my prayers, then the hemorrhage gets worse and after that for 4-5 days I experience spotting. In this period, I cannot easily say my prayers.”

Forgetting to take the pills on time is another problem which leads to dissatisfaction with this method. One participant said:

“A disadvantage of these pills is that you forget to take them on time. Sometimes I remember the pills after I go to bed, and sometimes my husband reminds me.”

“It is so irritating that you should take the pill every night.”

3- Continuation in spite of dissatisfaction

Some statements provided by participants indicated continuation with the methods in spite of dissatisfaction. One participant said:

“Although the pills had undesirable effects on me, for instance I gained weight and became inpatient, I prefer to continue taking them because they prevent pregnancy.”

This statement indicates preference of the contraceptive effect of the pills over their side effects. Another participant said:

“I am not satisfied with the IUD, however, I do not know much about other methods and how they prevent pregnancy. Perhaps they have more undesirable effects.”

This indicates unfamiliarity with other contraceptive methods.

Discussion

As can be observed from the findings, the experience of physical and psychological disadvantages is one of the causes of dissatisfaction with these methods on the part of the users. Frohlich reported the commonest side effects of IUD to be changes in the menstrual cycle such as increased hemorrhage, spotting between menstruations or constant hemorrhage, infection and pain in the form of uterine cramps or pain and discomfort in the back.11 Moreover, the commonest side effects of LD pills are weight gain, nausea and vomiting, breast tenderness, mild headache, fatigue, and mood change.1 Rosenberg et al stated that experiencing the side effects of a method leads to dissatisfaction with the method, so that women who experience side effects such as bleeding problems, nausea, and headache would discontinue the method with a higher probability compared to those who did not experience such problems.12 The disadvantages of contraceptive methods are another cause of discontinuation of these methods. For instance, difficulties in following religious rituals after implementation of IUD can be mentioned. In this regard, Cebeci et al states that religion plays a role in the selection and use of the contraceptive method.13

Based on his findings, Rivera et al reported that removal of IUD owing to pain and bleeding is significantly affected by religion, so that removal of IUD in the first 12 months after its implementation was 9.2% in Muslim women, which was considerably higher than the 1.4% in Protestant women. He further states that Muslim have the highest rate of IUD removal owing to pain and bleeding as compared to women of other religions.14

Another disadvantage of pills considered by the participants was forgetting to use the pills on time and the need for a daily reminder. Ramstrom et al stated in this regard: forgetting to take the pills is one of the obstacles to continuing with this method.15

Also, based on his findings, Shulman et al stated that the need for a daily reminder is one of the factors leading to a decrease in the continuation of the method and its discontinuation.16

Another main point of this study was continuation with the method in spite of dissatisfaction.

Preference of the contraceptive effect of the pills over its side effects and unfamiliarity with other methods were among the factors that caused the participants to continue with methods although they were not satisfied with them.

Trlin and Perry states in this regard that the rate of dissatisfaction with sexual intercourse and the number of unwanted pregnancies in women who are not satisfied with their contraceptive method but still use the method is considerably higher than that in women who are satisfied with the contraceptive methods.17

McKinney et al believes if a woman is aware of the undesirable consequences of contraceptive methods, she tends to tolerate the side effects more, especially when she knows that the side effects constitute no risk to her health.18

In such cases, the role of family planning consultation is important. If contraceptive methods are selected with awareness and detailed explanation is provided to the users regarding the different aspects of the methods including the side effects and disadvantages, satisfaction with the methods will increase and these methods will be used for a longer time.

It seems that carrying out qualitative research on other aspects of family planning is essentially required. Thus, it is advisable to perform such studies with the purpose of increasing awareness of different methods of family planning. After this step, larger scale studies can be carried out based on the information obtained from smaller studies. Better understanding of these aspects can help to adopt measures for better and more effective contraceptive methods, which will in turn result in increased satisfaction with the methods.

The authors declare no conflict of interest in this study.