Effects of the use of contraceptives: a case of women in the Greater Accra and Ashanti regions of Ghana

INTRODUCTION

Contraceptive methods may be used for reasons such as women wanting to space out their children to women wanting to enjoy sex without the burden or worry of unwanted pregnancy.¹ Contraception is the use of drugs, devices, or surgery to prevent pregnancy.² Contraceptives have been classified as very effective (0-0.9 pregnancies per 100 women), effective (1-9 pregnancies per 100 women), moderately effective (10-19 pregnancies per 100 women), and less effective (20 or more pregnancies per 100 women). Examples of the very effective methods commonly used are male and female sterilization, intrauterine devices, copper and levonorgestrel containing and implants.^2,3 Examples of effective methods are combined contraceptives oral and injectables, progestin-only orals and injectables, combined contraceptive vaginal ring and lactational amenorrhea (LAM). Examples of moderately effective methods are male condoms and the standard days' method (calendar method). One less effective method is the female condom. These methods have different mechanisms of action and effectiveness in preventing unintended pregnancy.^2,3

Using emergency contraception (EC) that only contains levonorgestrel prevents fertilization by inhibiting ovulation. Reviewing levonorgestrel EC mode of action and evaluating evidence for a postovulatory impact on viable pregnancy development in exposed and succeeding cycles have been a bone of contention, meanwhile, contraceptive usage during a woman's reproductive years can help prevent unintended pregnancies, maternal deaths, and other non-reproductive problems.^4-6 Side effects such as nausea, vomiting, dizziness, headache, and breast tenderness have been reported, however, they are not in comparison to each other, as to which side effects are reported most.⁷ Stroke and cancer have been reported as adverse events for levonorgestrel.⁸

In addition, the use of contraceptives has been related to pulmonary embolism and stroke, both of which have substantial mortality rates.⁹

Contraceptive methods excluding the LAM and calendar method are widely used and accepted because of the quest for effective birth control to help space children in career women.¹⁰ Thus, this study aimed to find out if women in the greater Accra and Ashanti regions of Ghana encounter health issues as has been identified in extant literature, during and after the use of such contraceptives. The study also sought to compare extent of side effects and adverse effects about different types of contraceptives available.

METHODS

Study design

This is a descriptive study which uses a questionnaire to assess the prevalence of health issues during and after use of different types of contraceptives in selected populace.

Study area

Research was conducted in greater Accra, capital city of Ghana, and Kumasi metropolis centrally located in the Ashanti region of Ghana. Greater Accra region has smallest area of 16 administrative regions in Ghana, occupying a total land surface of 3,245 km². However, it is the most populated, with about 5.45 million. Kumasi is second largest city in Ghana and the administrative capital of Ashanti region. It is fast-growing metropolis with an estimated population of about 5.44 million.

Inclusion and exclusion criteria

This study included all women between 15-50 years. This implies that women under fifteen years old were excluded from the study. Women who were not willing to take part in study were respected as such.

Ethical consideration

Ethical clearance was sought from the ethical clearance department of the Kumasi technical university (IRID). respondents were informed of their right to decline to participate in this research.

Sampling

The study used a convenient sampling method where questionnaires were answered by women from different social backgrounds. The questionnaire consisted of both close-ended and open-ended questions which were made available through Google forms. Others were administered by data collectors.

Data analysis

Statistical package for social sciences (SPSS), version 25 was used to analyse the data gathered.

RESULTS

Demographics

Contraceptives were more patronised in women of the age group 21-30 years, comprising 61.8%, with senior high school as their highest educational level (41.6%). Oral-progestin only and combined oral contraceptives are the preferred types, 42.9% and 31.4% respectively. The respondents have some knowledge about how contraceptives work and their long-term effects (Table 1).

Side effects experienced with the different types of contraceptives

Amongst the side effects that were reported are headache, nausea, decreased sex drive, weight gain, weight loss, breast tenderness, irregular menstrual cycle, spotting or bleeding within periods, abdominal cramping and increased vaginal discharge. The findings indicate that 27.3% of respondents in the oral-estrogen-only group reported the most headaches. Nausea was highly reported in the oral-progestin-only group (22.1%). Decreased sex drive was highly reported in the injectable short-term group (41.7%). Weight gain was highly reported in the COC group (Table 2). Additionally, spotting or bleeding within periods was the most reported side effect, 33.2% (Table 3).

A boxplot of the number of side effects against the type of contraceptive also revealed that a greater number of side effects per respondent were reported amongst the IUD, short-term injectables and the implant groups (Figure 1).

Adverse effects experienced with the different types of contraceptives used

Some adverse effects were considered in the questionnaire. The respondents were to indicate a “yes” or “no”. DVT was also highly reported in the COC group, closely followed by the oral-progestin only. Hypertension was also high in the COC group (Table 4). Also, the commonest adverse effects overall, were hypertension and DVT, 10.25% and 9.5% respectively amongst the respondents (Table 5).

To examine the relationship between the age of women and the choice of the type of contraceptive.

Cross-tabulation and chi-square analysis were done. The choice of type of using the age groups and type of contraceptive as variable. Findings indicate that the type of contraceptive differed statistically significantly by age group (28, n=401), p<0.01, Cramer’s v=0.573). This means that the age of a woman influences the type of contraceptive they select for use.

Note: OP-Oral-progestin only, OE-Oral-estrogen only, COC-Combined oral contraceptives, IUD-Intrauterine devices, IST-Injectable short-term, BC-Barrier-condom, DSD-Decreased sex drive, BT-Breast tenderness, WG-Weight gain, S/B-Spotting or bleeding within periods, IVD-Increased vaginal discharge, AC-abdominal cramping.

Note: OP-Oral-progestin only, OE-Oral-estrogen only, COC-Combined oral contraceptives, IUD-Intrauterine devices, IST-Injectable short-term, BC-Barrier-condom, DSD-Decreased sex drive, BT-Breast tenderness, WG-Weight gain, S/B-Spotting or bleeding within periods, IVD-Increased vaginal discharge, AC-abdominal cramping.

Note: OP-Oral-progestin only, OE-Oral-estrogen only, COC-Combined oral contraceptives, IUD-Intrauterine devices, IST-Injectable short-term, BC-Barrier-condom, DVT-Deep vein thrombosis.

Note: OP-Oral-progestin only, OE-Oral-estrogen only, COC-Combined oral contraceptives, IUD-Intrauterine devices, IST- Injectable short-term, BC-Barrier-condom, DVT-Deep vein thrombosis.

DISCUSSION

In the study, the preferred type of contraceptive was oral-progestin only, as out of the 401 respondents, 172 women chose this type of contraceptive, comprising 42.9% of the total as shown in Table 1. The findings indicate that 27.3% of respondents in the oral-estrogen-only group reported the most headaches. Nausea was highly reported in the oral-progestin-only group (22.1%). Decreased sex drive was highly reported in the Injectable short-term group (41.7%). Weight gain was highly reported in the COC group (Table 2). Additionally, spotting or bleeding within periods was the most reported side effect, 33.2% (Table 3). It was also revealed that a greater number of side effects per respondent were reported amongst the IUD, Short-term injectables and implant groups (Figure 1). DVT was also highly reported in the COC group, closely followed by the oral-progestin only. The hypertension was also high in the COC group (Table 4). Also, the commonest adverse effects overall, were hypertension and DVT, 10.25% and 9.5% respectively amongst the respondents (Table 5).

The emergency contraceptives which are patronised mostly among the youth, contain progestin-only steroids such as levonorgestrel.¹¹ There is ease of application and access. There is no invasion as with the injectables or IUDs. The combined oral contraceptives, although inconvenient due to the daily dosing, is the second preferred in the study although other studies cite it as the most preferred.¹² This may not be directly tied to the effectiveness of this type of contraceptive but rather its availability and cost-effectiveness.

The side effects such as nausea vomiting, dizziness, headache, and breast tenderness have been reported, however, not in comparison to each other, as to which side effects are reported most and within which contraceptive group.⁷ In this study, comparisons have been made. Headache, nausea, and decreased sex drive have been classified under central nervous system (CNS)-related side effects; a greater percentage of respondents are likely to experience headaches with estrogen-only than oral-progestin only (Table 2). Headaches are a very common condition that people experience many times during their lives. They are the most common form of pain and a major reason cited for days missed at work or school, as well as visits to healthcare providers.¹³ It has principally been relegated to the head as pain is experienced in the head and face areas of the body, hence, CNS-related. Many women report headaches as a common side effect of hormonal contraceptives.^12,14 This is confirmed in this study as 20.4% of respondents reported headaches. Nausea is also a reported side effect of emergency contraceptives.¹⁵ Changes in hormonal balance that are elicited by these contraceptives trigger the chemoreceptor trigger zone in the brainstem leading to such side effects as nausea and vomiting.¹⁶ As evidenced in pregnancies when progesterone is high, continuous use of these contraceptives does likewise, 22.1% of oral progestin users were the highest. Although it was reported in the other types of contraceptives totalling 16.5% amongst the whole sample of respondents. Respondents seem to experience nausea and decreased sex drive more with the oral-progestin only and the combined oral contraceptives. Breast tenderness, weight loss and weight gain were classified under metabolic-related side effects. Weight gain is a known side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists.^17,18 It was realized in the findings that weight gain is more predominant with the combined oral contraceptives in this study too (34.10%), closely followed by 31% of IUD users. Implants as well as the IUDs cause a greater degree of spotting within period, increased vaginal discharge and abdominal cramping than the oral contraceptives in the study.¹⁹ These are classified as menstrual-related side effects. Overall, spotting and bleeding between periods was the most common side effect amongst the 401 respondents and this is expected.^20,21

Hypertension and DVT were the highly reported adverse effects (10.2% and 9.5% respectively) of the adverse effects. These are also notable adverse effects, especially with combined oral contraceptives.^22,23 Additionally, for this study, the prevalence in COCs was closely rivalled by that in oral-progestin only (12.2%), that of the COCs being 13.5%. Uterine fibroid reports were also noteworthy (7.5%). Stroke and cancer have been reported as adverse events for levonorgestrel and COCs.^8,11 These effects are evident because steroidal products can antagonize the role of natural steroids like cortisol in the human body which has a role to play in hypertension and the regulation of sugars in the blood.²⁴

There is a lack of monitoring systems as also identified in the research by Pillay Diantha and few channels for reporting of these untoward effects.²⁵

Discrepancies

It must however be noted that the researchers did not take into consideration the concomitant use of other medicines by these respondents. The number of years of use may not be a continuous use of these contraceptives as quite a huge percentage preferred to use rarely or only when necessary. Failure rates of the different types of contraceptives were also not considered in this study.

CONCLUSION

Contraceptive use may be a cause of discomfort with the side effects reported in women of reproductive age. Additionally, it may be a contributing factor to other health conditions in susceptible women.

ACKNOWLEDGEMENTS

Authors would like to thank to Dean of Health Sciences, Prof. Osei-Djarbeng for his guidance and support.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of Kumasi Technical University to conduct this research. Ref. No. IRID/EC2024/HS0001

REFERENCES

1. 1. Higgins JA, Smith NK. The sexual acceptability of contraception: reviewing the literature and building a new concept. J Sex Res. 2016;53(4-5):417-56.
2. 2. Cameron ST. Contraception and sterilization. Dewhurst’s Textbook of Obstetrics and Gynecology 9^th Edition. John Wiley and Sons, Ltd, west Sussex UK. 2018:939-53.
3. 3. undesa_pd_2022_world-family-planning. Available at: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2023/Feb/. Accessed on 10 February, 2024.
4. 4. Kahlenborn C, Peck R, Severs WB. Mechanism of action of levonorgestrel emergency contraception. The Linacre Quarterly. 2015;82(1):18-33.
5. 5. Endler M, Li RH, Danielsson KG. Effect of levonorgestrel emergency contraception on implantation and fertility: A review. Contraception. 2022;109:8-18.
6. 6. Edietah EE, Njotang PN, Ajong AB, Essi MJ, Yakum MN, Mbu ER. Contraceptive use and determinants of unmet need for family planning; a cross sectional survey in the North West Region, Cameroon. BMC Women's Heal. 2018;18:1-8.
7. 7. Arowojolu AO, Okewole IA. Vaginal bleeding following the use of a single dose of 1.5 mg levonorgestrel. Parity. West Afr J Med. 2004;23(3):191-3.
8. 8. Leelakanok N, Methaneethorn J. A systematic review and meta-analysis of the adverse effects of levonorgestrel emergency oral contraceptive. Clin Drug Investigation. 2020;40:395-420.
9. 9. Tanis BC, Rosendaal FR. Venous and arterial thrombosis during oral contraceptive use: risks and risk factors. In Seminars in Vascular Medicine. 2003;069-84.
10. 10. Teye JK. Modern contraceptive use among women in the Asuogyaman district of Ghana: is reliability more important than health concerns? Afri J Reproduct Heal. 2013;17(2):58-71.
11. 11. Agyepong KO. Attitude, knowledge and usage of contraceptives among men in Ejura Sekyedumase (Doctoral dissertation, University of Cape Coast). Thesis. 2019.
12. 12. MacGregor EA. Contraception and headache. Headache: J Head Face Pain. 2013;53(2):247-76.
13. 13. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Europ J Pain. 2006;10(4):287-333.
14. 14. Sabatini R, Cagiano R, Rabe T. Adverse effects of hormonal contraception. J Reproduct Med Endocrinol. 2011;8(1):130-56.
15. 15. Rodriguez MI, Godfrey EM, Warden M, Curtis KM. Prevention and management of nausea and vomiting with emergency contraception: a systematic review. Contraception. 2013;87(5):583-9.
16. 16. Zhong W, Shahbaz O, Teskey G, Beever A, Kachour N, Venketaraman V, et al. Mechanisms of nausea and vomiting: current knowledge and recent advances in intracellular emetic signaling systems. Int J Molecular Sci. 2021;22(11):5797.
17. 17. Gallo MF, Lopez LM, Grimes DA, Carayon F, Schulz KF, Helmerhorst FM. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2014(1):CD003987.
18. 18. Edelman A, Jensen JT, Bulechowsky M, Cameron J. Combined oral contraceptives and body weight: do oral contraceptives cause weight gain? A primate models. Human Reproduct. 2011;26(2):330-6.
19. 19. Hubacher D, Chen PL, Park S. Side effects from the copper IUD: do they decrease over time? Contraception. 2009;79(5):356-62.
20. 20. Archer DF, A-Philput C, Weber ME. Management of irregular uterine bleeding and spotting associated with Norplant®. Human Reproduct. 1996;11:24-30.
21. 21. Zimmerman LA, Sarnak DO, Karp C, Wood SN, Yihdego M, Shiferaw S, Seme A. Measuring experiences and concerns surrounding contraceptive induced side-effects in a nationally representative sample of contraceptive users: evidence from PMA Ethiopia. Contraception: X. 2022;4:100074.
22. 22. Stegeman BH, De Bastos M, Rosendaal FR, Van Hylckama Vlieg A, Helmerhorst FM, Stijnen T, et al. Different combined oral contraceptives, and the risk of venous thrombosis: systematic review and network meta-analysis. BMJ. 2013;347:f5298.
23. 23. Sugiura K, Kobayashi T, Ojima T. Thromboembolism as the adverse event of combined oral contraceptives in Japan. Thrombosis Res. 2015;136(6):1110-5.
24. 24. Van Raalte DH, Diamant M. Steroid diabetes: from mechanism to treatment. Neth J Med. 2014;72(2):62-72.
25. 25. Pillay D, Morroni C, Pleaner M, Adeagbo OA, Chersich MF, Naidoo N, et al. Gaps in monitoring systems for Implanon NXT services in South Africa: An assessment of 12 facilities in two districts. S Afr Med J. 2017;107(10):827-3.