Providers' Views on Hormonal Family Planning Methods for Young Women: A Qualitative Study from Dosso, Niger

"As programs continue to expand method choice and new contraceptive technologies undergo research and development, highly desirable features such as discretion need to be considered."

Family planning (FP) use is not common in Niger, and modern contraceptive use there is primarily characterised by implants, injectables, and pills. FP providers play an integral role in supporting women's access to an expanded method choice and are often considered trusted sources of knowledge for FP. This qualitative study explores providers' views on the three hormonal FP methods and why they think young women may choose these methods in Niger.

                                       

The data for this study were collected as part of a larger assessment of a FP segmentation counseling tool used by FP providers with clients in government-run integrated health centres (IHCs) in Niger. More details on the segmentation strategy can be found at Related Summaries, below. The overall assessment of the segmentation approach was designed with 3 study arms: Arm 1 was comprised of IHCs with a demand generation programme and the segmentation strategy, Arm 2 included IHCs with the segmentation strategy, and Arm 3 served as a control arm, where the IHCs did not have any specific demand generation or segmentation activities. For the qualitative data collection, 8 IHCs in each arm were randomly selected for inclusion.

The in-depth interviews were conducted with 24 FP providers in 24 IHCs in Dosso region, Niger, between February-March 2020. Providers were asked about the suitability of different FP methods for women, including unmarried adolescents and young married women with children.

The study found that providers typically felt that young, unmarried women should not be having sex; however, if they were having sex, providers felt it was better for them to use FP than to risk an unintended pregnancy. Notably, at least one provider expressed that she never sees young, unmarried women at the clinic; thus, providers' views about contraceptive use among unmarried women may not be based on any actual experience.

The majority of providers (92%) stated that a provider's role is not to recommend a contraceptive method and that it is up to the client (and, in some cases her husband) to decide which method to use. Providers clearly stated that their role is to provide full information; with that information, clients can ask questions and choose a method. That said, providers acknowledged that at times, clients do ask for the providers' recommendations, but they avoid recommending specific methods.

In content analysis of interview data about the characteristics and attributes of the FP methods available and chosen by clients, several key themes emerged and are discussed in turn in the article: (a) the discretion of the method; (b) compliance with method use; (c) comfort and familiarity with the method; (d) myths and misconceptions about implants; (e) husband opposition to the implant; and (f) concerns about return to fertility post method use.

To focus on (a), for example, many providers believed discretion to be the most important method attribute for women. In a predominately Muslim society like Niger, where early marriage is common, and FP is not normative, FP use is something women like to keep private. Providers disagreed on whether implants or injectables are more discrete for clients. That said, providers felt that clients appreciate the implant's discretion, effectiveness, long-acting nature, and ease of use.  Providers perceived that the majority of women choose injectables due to familiarity with the method, the fact that it is "invisible" to an outsider, and a lack of awareness of implants. Providers stated that while women may not initially choose the implant, when given more information about it, they were more open to adopting it or switching from another method, and they were less likely to believe local myths. Providers believed that women find pills to be indiscreet.

In this study, while providers reported that they counsel on a full range of methods and the client chooses a method, prior research on provider bias has demonstrated that in some cases, providers limit method availability based on a client's age, marital status, and parity. The segmentation strategy implemented in 2 of the 3 arms (i.e., with 2/3 of the providers interviewed) was meant to address these biases by asking 12 questions and identifying the client's segment and counseling on method options based on the segment and not on preconceived perspectives of the provider. This study did not find any differences by study arm or provider characteristics in providers' recommended method or in the providers' perceived preferences of clients; this fact might reflect the small sample size or that all providers had similar perspectives on appropriate methods for married and unmarried young women.

The findings of this study suggest that increasing awareness of men and women within the community of implants as a potential method, providing unbiased counseling on a full range of FP methods, and encouraging couple communication about contraception can be strategies to help ensure that women in Niger have access to an expanded method choice.

In conclusion: "It is important to consider the characteristics of FP methods that matter the most to clients as funding goes into programs to promote FP use and to develop new contraceptive technologies. Furthermore, FP visits and counseling sessions are important opportunities for providers to not only provide FP methods but also to help women identify the method that best meets their needs. These visits provide an opportunity for providers to address concerns about method side effects and ensure that all women are able to choose from a full range of methods when or if they want to use contraception."