Evaluation of the Use of Jadelle Contraceptive Implant by Women in the City of Parakou in 2016

Introduction: Maternal mortality is still very high in Benin. Being one of the methods of reducing this mortality, contraception is still very rarely used in Benin, particularly in Borgou district. The objective of this work was to evaluate the experience of using Jadelle contraceptive implants by women in the city of Parakou in the Borgou department. Methodology: This was a descriptive cross-sectional study, with retrospective and prospective data collection over the period from March 1 to July 31, 2016. Results: A total of 320 women were involved in the study. The mean age was 28.29 years, with extremes of 16 and 44 years. Socio-professionally, housewives predominated (56.88%). Sixty-eight point forty-four percent of women were educated and only 111 (34.69%) women had reached secondary school; married women were mostly represented. Obstetrically, multi-gestures were the most affected (43.75%). Birth spacing was the main reason for choosing Jadelle (48.13%). Majority of patients had their husbands consent to use Jadelle contraceptive method (85.31%). Sixty-eight point fifty-two percent of women had used this contraceptive method for 2 to 4 years. Jadelle had been chosen by the majority (78.75%) of the women, for its long duration of action and its easy use. The dropout rate for Jadelle was 35/320 (10.94%) after 3 years of use. The failure rate for this method was 0.31% (1/320). The satisfaction rate was 87.5%. Conclusion: Jadelle contraceptive implants are an important part of contraceptive methods in Parakou.


Introduction
By spacing births and reducing the frequency of miscarriages, the use of this contraception makes it possible both to reduce the high rate of maternal mortality in emerging countries (10 to 70/10,000 versus 3/10,000 in developed countries) and also infant mortality (113/1000 in Africa versus 12/1000 in Europe) [1]. The Benin Demographic and Health Survey (EDSB-IV) indicate high fertility rate (4.9 children per woman), a high rate of children and many early pregnancies (37%) [2]. In recent years, less restrictive modern contraceptive methods have been developed, including progestin implants. Contraceptive prevalence rate is low in Benin (12.5%), with 8% for modern methods [2]. The contraceptive implant, using a progestogen derivative as the active ingredient, has raised hope for interesting effective contraception to women who have a contraindication or intolerance to estrogen-progestogen pill or Intrauterine Device (IUD).
Among these implants, the so-called new generation Jadelle implants have been marketed from the United States since 1996. These are 2-stick implants, each containing 75 mg of Levonorgestrel, manufactured using new chemical proceeds.
These implants are effective for 5 years [3]. However, its prescription can only be considered in the light of its tolerance. A study reported 27% removal of contraceptive implants before the end of the expiry date of contraceptive effectiveness.
The bad experiences with progestin implants recorded in the literature concern mainly women in developed countries. There are few studies in Africa on this issue.
The situation in Borgou district seems very worrying. Indeed, the Demographic and Health Survey in Benin reveals that this district has the highest fertility rate in Benin (4.9 children per woman with an index of 5.4 in rural areas) [2]. Modern contraceptive methods, particularly progestin-only implants, are rarely used (1.1%) by women in this department [2]. Through this work, we therefore suggest to evaluate the use of Jadelle contraceptive implants by women in Parakou, a town in the department of Borgou in Benin.

Method
This is a descriptive cross-sectional study over a period of 5 months from March 1 to July 31, 2016.

Study Population
The study population consists exclusively of women who have used Jadelle contraceptive implants at least once in their lifetime. These are patients who have

Sampling
The minimum sample size was calculated by the SCHWARTZ formula ( )

Data Collection
The information was collected by a documentary review using a tabulation form that concerned the medical files; supplemented by an individual "investigator-investigated" interview.

Variables
The variables studied were: age, sex, level of education, ethnicity, religion, marital status, background, type of contraception previously used, gestational age, parity, desire for pregnancy, duration of using Jadelle implants, Jadelle implant side effects, patients satisfaction. Satisfaction was assessed by the law of all or nothing: it was coded yes/no.
Any woman who had used subcutaneous Jadelle implants at least once was considered a user of Jadelle.
The potential patient is a woman who attends a health center at the request of a family planning service: information, contraceptive prescription, insertion or withdrawal, follow-up or other services. Abandonment: Abandoning a contraceptive method is synonymous with stopping its use for any other reason than the desire for maternity or the expiry of the time limit for using the method.
The failure rate of a contraceptive method is the number of pregnancies contracted out of the total number of users of that method during a given period.
The duration of effectiveness of Jadelle implants is five years.

Data Processing and Analysis
The data entry was made using the EPI DATA 3.1 French version. The data were then analyzed using EPI INFO version 7 software. Text processing, tables and graphs were made possible thanks to Microsoft Word and Excel version 2010.
Quantitative variables are expressed as means with their standard deviation and qualitative variables as proportions with their confidence interval.

Ethical Considerations
We obtained the agreement of the Departmental Director of Health of Borgou  (Table 1) In total, 320 women were involved in our study with a mean age of 28.29 years

Reasons for Contraception
The need for contraception was motivated by spacing birth for 85.64% of patients. Table 2 shows the distribution of patients by reasons for choosing Jadelle contraception. Fourteen point sixty nine percent of patients had not obtained their husband consent. Figure 1 shows the distribution of patients by their main source of information on Jadelle implants. Midwives were the primary source of information for patients.

Previous Contraceptive Methods
Before Jadelle implants, 81.25% of patients did not have a contraceptive method;

Wear Duration of Jadelle
Average duration of Jadelle use was 42.39 months with extremes of 11 and 72 months. Figure 3 shows the distribution of patients by duration of Jadelle implants.

Reasons for Jadelle Withdrawal
One hundred and thirty-seven patients had their jadelle implants removed.
There were 51 (15.94%) cases of abandonment: side effects (40); husband opposition (4); religious reasons (5); discomfort (1); change of contraceptive method (1). The proportion of abandonment was 11/320 (3.45%) at 1 year and 35/320 (10.94%) at 3 years; Table 4 shows the distribution of patients according to the reasons for implant removal. We recorded one case of pregnancy despite the placement of Jadelle implants, which represents a failure rate of 0.31%.

Patients Satisfaction
Two hundred and eighty (87.5%) patients were generally satisfied and had agreed to counsel their family and friends.

Discussion
Participants mean age in our study was 28.29 years. This result is similar to those of Sergeant [3], Kouakou [5], and Adetoro [6] who reported an average age of 28 years. However, other authors have found a mean age of 32 years higher than that of our series. The 20 -29 age group was the most represented in our series (47.50%). Martin [7] in France, had noted a predominance of the 20 to 25 age group. These results show that younger women are particularly interested in contraceptive implants.
The Muslim religion predominated in our series (59.38%). But this religious configuration is similar to that of the city of Parakou where she resides. Argina [8] had obtained a predominance of the Christian religion in her series. Despite the reluctance of some religions, it could be said that religion has little influence on the use of contraceptive implants.
Married women were in majority represented (86.56%) in our series. This result is close to that of Ralisata [9]. Married women have more or less regular M. V. Vodouhe et al. Open Journal of Obstetrics and Gynecology sexual relations and seem to be aware of their high risk of pregnancy... Housewives were the most represented in our series (56.88%). This result is similar to that reported by some authors [9] [10].
Multiparity was also predominant in some studies [9] [10]. These observations could be justified by the fact that women with children would be more inclined to birth spacing due to their difficulties, but 5.63% of Jadelle users in our series were nulligest: This shows that this contraceptive method is not limited to women with children.
More than 10% of our Jadelle users had a history of wanted pregnancy interruption (abortion). This proportion is lower than that obtained by Ralisata [9] (45.40%). This history of abortion may justify the choice of a long-term contraceptive method such as Jadelle so as not to have to make a radical and risky choice such as abortion.
Most of the spouses (85.31%) of our patients were consenting to the use of Jadelle implants by their wives. The lack of access to good information on different contraceptive methods could justify the hostility of some men, hence the usefulness of strengthening the different means of raising awareness among the population.
A high proportion of patients (70; 21.87%) reported side effects, with amenorrhea predominating (5.94%), Igwe [11] in Nigeria and Bitzer [12] in Switzerland also reported higher proportions of amenorrhea under contraceptive implants, 58.8% and 33% respectively. Some studies report the prevalence of other bleeding disorders under contraceptive implants: spotting (54.70%) in Senegal [13], irregular bleeding (27%) in Belgium [14]. In our study, we observed a small proportion of side effects unrelated to the menstrual cycle under Jadelle. Similar results have been reported by Lankoande [15] and Croxatto [16].
Complications at the insertion site of Jadelle implants were rare. In contrast, in the United States in 1995, Wysowski [17] reported 24 women hospitalized for infectious complications. The occurrence of complications from the implant insertion site would in most cases be related to the competence of the providers and the asepsis conditions. Jadelle implants average duration was 42.39 months in our study. This duration is higher than those reported by Argina [8] in Ethiopia and Dugoff [18] in the United States respectively 25.3 months and 13.2 months. Maternity was the main reason for removing Jadelle implants for our patients (48.18%). This result is similar to those of Champootaweep [19], and Igwe [11]. Like Musham [20] in the United States, in our serie, side effects were the first reason for abandoning Jadelle (29.20%). Sihvo [21] in Finland had reported cases of Jadelle abandonment for depression and nervousness. The drop-out rate was 10.94% at 3 years in our series. This rate is lower than that reported by Sergent [3] in France: 30% before 2 years. Contraceptive implants seem to be better tolerated by women in Benin. Other prospective follow-up studies, after the insertion of Jadelles, will Open Journal of Obstetrics and Gynecology certainly be able to better inform us on the issue.
We noted a failure rate of 0.31% in our study. Koné [10] had objectified 2 cases of pregnancy in patients who were on anti-tuberculosis drugs. In view of all this, we could say that Jadelle remains an effective and acceptable contraceptive method. Most of our patient under Jadelle were satisfied (87.5%) and had agreed to recommand it to their family and friends. Sergeant [3] reported a dissatisfaction rate of 81%, lower than that in our study, and according to our results Jadelle users were predominantly educated (68.44%). Hodonou [22] had reported the positive attitude of married teachers towards contraception. Sépou [23] had also shown that there was a significant relationship between educational level and contraceptive use. Most health information and awareness is provided in French and therefore requires a certain level of education to be understood.
One of the limitations of our study was that it was partly retrospective, leading to information bias. Moreover, not all users of Jadelle implants were interviewed.

Conclusion
Jadelle's users are young. Most of them had never used a contraceptive method previously. Side effects were rare and dominated by menstrual disorders typed amenorrhea. Most of them were satisfied.