Why intrauterine device (IUD) utilization is low in southwestern Ethiopia. A mixed‐method study

Abstract

Introduction

An intrauterine device (IUD) is a highly effective long‐acting and reversible contraceptive method widely available around the world. However, only a small proportion of women in developing countries, including Ethiopia, are currently using the method. Therefore, this study aimed to identify why IUD utilization is low in southwestern Ethiopia.

Material and methods

A mixed‐method study involving health facilities and communities was conducted. The focus group discussions and key informant interviewees for the qualitative study were selected purposively, whereas 844 women family planning users were selected using systematic random sampling from November 1–30, 2020. Quantitative data was collected using Open Data Kit and analyzed using Stata version 16.0. Multivariable logistic regression analyses were done to identify significant factors influencing IUD use. The qualitative data were tape‐recorded, transcribed, and finally, thematic analyses were done.

Results

A total of 784 participants were involved in the study yielding a response rate of 92.9%. Among all respondents, only 1.3%, 2.4%, and 30.0% had been using an IUD, preferred an IUD, and had the intention to use an IUD, respectively. The main reported barriers to use an IUD among qualitative participants were fear of side‐effects, religious prohibitions of contraception use, husband disapproval, lack of training by health workers, misconceptions, and longer duration of use. IUD information (AOR = 2.19 [CI: 1.56–3.08]), and rich wealth status (AOR = 1.70 [CI: 1.13–2.56]) were associated with the intention to continue or start to use an IUD.

Conclusions

IUD use and information on IUDs in the study area was very low. Information about IUDs, wealth status, and partner disapproval were determinant factors for intention to use an IUD. Thus, a regular awareness creation program using accessible media platforms by the government and stakeholders on IUD use is necessary to provide reliable information to the community and resolve misconceptions. In addition, women's empowerment to balance partner dominance on decision‐making of contraception use and health care worker training on long‐acting reversible contraceptives (LARCs) to increase access to LARC services are necessary to increase uptake of LARCs in general and of IUDs, in particular in the study regions.

IUD use and information on IUDs was very low. Fear of side‐effects, religious prohibitions of contraception use, husband disapproval, lack of training by health workers, misconceptions, and longer duration of use were the main reported barriers among participants.

Abbreviations

AOR

adjusted odds ratio

IUD

intrauterine device

LARC

long‐acting reversible contraceptive

Key message.

Intrauterine device information and use was very low. Fear of side‐effects, religious prohibitions of contraception use, husband disapproval, lack of training by health workers, misconceptions, and longer duration of use were the main reported barriers among participants.

1. INTRODUCTION

Long‐acting reversible contraceptives (LARCs) comprise intrauterine devices (IUDs) and contraceptive implants and are the most effective reversible contraceptive methods. ¹ Worldwide, an IUD is the second most popular contraceptive method (14.3%). ² , ³ However, in sub‐Saharan Africa, the contraceptive method mix is skewed toward short‐acting contraceptive methods which constitute 82% of modern contraceptive use, while permanent and LARC methods remain underutilized. ⁴ As a result, the rate of unintended pregnancy is among the highest in the world with 91 pregnancies per 1000 women aged 15–49 years. ² , ³ , ⁵

The use of an IUD contraceptive method varies widely. For instance, 18% in Eastern and southeastern Asia, ³ and in Northern Africa, while it is 27.8% in Tunisia, and 36.1% in Egypt. ⁶ Even though the use of modern contraceptive methods have nearly tripled; increasing from 14% to 41% between 2005 and 2019 among married women in Ethiopia, the contribution of an IUD to the method mix is negligible. ⁷ The utilization of an IUD varies from 5.2% in Addis Ababa to 0.4% in the Gambella region to null in the Somali region of Ethiopia. ⁷

The Ethiopia Federal Ministry of Health has considered the important role of long‐acting and permanent contraceptives and aims to increase the availability of these methods to 20% of all family planning users. Recent data shows that 2%, 8%, and 23% of reproductive‐age women utilized implants, and injectable contraceptives, respectively. ⁸

Therefore, this study aimed to examine why IUD utilization is very low in the nation's southwestern regions of Ethiopia.

2. MATERIAL AND METHODS

2.1. Study setting and period

A study was conducted in Gambela Region, Ilubabor, and Bench Sheko zones southwest of southwest Ethiopia. The Gambela region is divided into three administrative zones (Anuak, Nuer, and Majang), 12 districts, and one special woreda (Itang). Illubabor has 14 districts and one city administration, a total population of 968 303 according to the Zonal health report 2012 EFY. Benji Sheko has six districts and two city administration administrations with a total population of 639 629. Overall, the study area has a total population of 1 608 239. The study was conducted from October 1 to November 30, 2020.

2.2. Study design and population

A mixed‐method cross‐sectional study design was employed among all women in the reproductive age group who came to the health facilities in the selected district of the study region and zones for family planning services. Key informants interview included health care providers, community, and religious leaders.

2.3. Sample size calculation

To estimate the sample size, a single population proportion formula, n = (Z_α/2)²P*(1 − P)/d², with the assumptions of desired precision (d) = 4%, design effect 2, confidence level of 95%, and the proportion of long‐acting and permanent contraceptive methods 19.5% ⁹ were used. Finally, considering a 15% non‐response rate, the calculated minimum sample size was 851.

2.4. Sampling techniques

First, all the public hospitals and 30% of the health centers (selected using the lottery method) found in a region and zones of southwest Ethiopia were selected. Second, the sampling frame was estimated from the preceding quarter's reports of each health facility to allocate proportion to size allocation and apply a systematic random sampling technique to recruit study participants at each selected health facility.

In addition, for the qualitative data collection: 30 key informant interviews were conducted among purposively selected healthcare providers, religious and leaders, community leaders, whereas 24 focus group discussions were conducted among women and male health development army, in urban and rural settings of each region and zone. The interview guides are available as Supporting Information Appendix S1.

2.5. Data collection tools and procedure

A structured interviewer‐administered questionnaire was used for the quantitative data collection. The interviews were conducted in a private environment in the health facility compound. It involved sociodemographic characteristics, reproductive history, knowledge about an IUD, practice, intention to use an IUD, and misconceptions of an IUD which was developed based on similar studies conducted previously. ¹⁰ , ¹¹ , ¹² , ¹³ In addition, the wealth index, and reproductive autonomy scale questionnaire were adapted from Ethiopian Public Health Institute 2016, and the development and validation of a reproductive autonomy scale. ¹⁴ , ¹⁵ Quantitative data collectors and supervisors were diploma and BSc health professionals, respectively. For qualitative data collection, unstructured guides and facility audit tools were used to collect information on sociocultural factors, myths and misconceptions, health system barriers and facilitators. All the focus group discussions and key informant interviews were conducted in the nearest available primary schools in the villages after getting permission from local administrators and school directors. All the interviews were tape‐recorded for transcription and translation and 2 days training was given to the data collectors on the objectives of the study, the contents of the questionnaire, issues related to the confidentiality of the responses, the rights of respondents, and a day practical session on Open Data Kit. A pretest on 5% of the sample size was conducted on women out of the study, and the questionnaire was corrected and modified based on the pretest results.

2.6. Variable measurement

IUD information: We asked for every exposure to information about IUD choice, barriers to using an IUD, and misconceptions about an IUD. Those who had exposure to IUD information were asked additional IUD knowledge questions. The intention to use IUD participants were asked if they had a plan in the future to use an IUD as yes/no questions.

2.7. Data analysis

All data were electronically collected on‐site, uploaded daily to the kobo server database using Open Data Kit version 1.25.1 (https://getodk.org/), and the data was exported to STATA software version 16.0 (https://www.stata.com/) for further analysis. Descriptive statistics were used to describe variables based on their nature. We conducted a principal component analysis to create a ranking for the wealth status of the study participants. Bivariate logistics regression was used to identify variables with p < 0.25 as a candidate variable for multivariable logistic regression analysis. Variables having p < 0.05 after multivariable logistic regression analysis were considered independent predictors for the intention to use IUD. For qualitative data, verbatim transcription of audio recorded information was done and the coding of the transcript and thematic analysis was assisted by ATLAS.ti version 7.1 software (https://atlasti.com/). Finally, the results were organized in conditions that summarized subthemes and key quotes.

2.8. Ethics statement

Ethical clearance was obtained from the Institutional Review Board of Jimma University, Institute of Health school of Post‐Graduate Studies (reference no. JIRB‐755/20) on October 15, 2020. An official letter of cooperation from the University, Gambela regional health bureau, Bench Sheko Zonal health department and Illubabaor Zonal health department was used to communicate with respective administrative bodies in the study area. After obtaining a letter of permission to carry out the study from each administrative body, informed verbal consent was taken from each participant prior to interview after explaining the purpose of the study.

3. RESULTS

Among the total expected sample of 844 women in the reproductive age group, 784 participated in the study with a response rate of 93%. The mean (+/‐SD) age of the study participants was 28 ± 6 years. Most of the study participants were in the age range between 25 and 29 years (32%), were married (94%), and were protestant by religion (57%) (Table 1).

TABLE 1.

Sociodemographic characteristics of study participants in southwest Ethiopia 2020.

		Total
Variables		N = 784
		(93.6%)
Age Mean = 28 ± 6 years	15–19	51 (6.5%)
	20–24	208 (26.5%)
	25–29	249 (31.8%)
	30–34	174 (22.2%)
	35–49	102 (13.0%)
Ethnicity	Oromo	351 (44.8%)
	Amhara	112 (14.3%)
	Agnuak	92 (11.7%)
	Bench	84 (10.7%)
	Nuer	33 (4.2%)
	Kaffa	30 (3.8%)
	Kanbata	29 (3.7%)
	Others	53 (6.8%)
Marital status	Married	734 (93.6%)
	Single	25 (3.2%)
	Separated	16 (2.0%)
	Widowed	9 (1.2%)
Religion	Protestant	447 (57.0%)
	Orthodox	187 (23.9%)
	Muslim	146 (18.6%)
	Others	4 (0.5%)
Educational status	Unable to read and write	148 (18.8%)
	Able to read and write	36 (4.6%)
	Primary school (1–8 grade)	231 (29.5%)
	Secondary school (9–12 grade)	200 (25.5%)
	Diploma	138 (17.6%)
	Degree and above	31 (3.9%)
Respondent occupational status	Housewife	542 (69.1%)
	Government employee	141 (17.9%)
	Merchant	62 (7.9%)
	Student	34 (4.3%)
	Daily labor	5 (0.6%)
Educational status of the husband	Unable to read and write	67 (8.8%)
	Able to read and write	200 (26.4%)
	Primary school (1–8 grade)	146 (19.2%)
	Secondary school (9–12 grade)	192 (25.3%)
	Diploma	14 (1.8%)
	Degree and above	140 (18.5%)
Occupational status of the husband	Farmer	337 (44.5%)
	Merchant	322 (42.5%)
	Government employee	50 (6.61%)
	Daily labor	28 (3.7%)
	Driver	20 (2.6%)

3.1. Obstetric characteristics of study participants

The mean and standard deviation of age at first sexual intercourse, first marriage, and first birth was 17.5 (±2.4), 18.9 (±3.1), and 20.4 (±3.4), respectively. Out of 91% of women who had ever been pregnant, 15.7% had experienced unintended pregnancy and 9.2% had a history of abortion. Only 1.2% of the participants used an IUD during the study period (Table 2).

TABLE 2.

Obstetrics characteristics of study participants in southwest Ethiopia 2020.

Variables		N = 784
Ever been pregnant	Yes	712 (90.8%)
	No	72 (9.2%)
Number of pregnancies (N = 712)	One	230 (32.4%)
	Two	172 (24.1%)
	Three and more	310 (43.5%)
Ever encountered unintended pregnancy	Yes	112 (15.7%)
	No	600 (84.3%)
Ever encountered abortion	Yes	68 (9.2%)
	No	647 (87.3%)
Ever given birth	Yes	643 (90.0%)
	No	69 (10.0%)
Ever encountered child/infant death	Yes	87 (13.6%)
	No	556 (86.4%)
Total number of children ever born to you (N = 698)	one	237 (36.8%)
	Two	175 (27.2%)
	Three and more	231 (35.9%)
Fertility status in the last 5 years	Not pregnant in the last 5 years	109 (15.3%)
	Pregnant, not wanted at all	15 (2.1%)
	Pregnant, wanted later	97 (13.7%)
	Pregnant, wanted then	488 (68.9%)
Current use of contraceptive	IUD	9 (1.2%)
	implants	126 (16.1%)
	Injectables	532 (67.8%)
	Pills	81 (10.3%)
	Others	36 (4.6%)

3.2. Proportion of women using IUD

According to this study, very few women had been using an IUD. The reasons for not using an IUD were they did not know about IUD among 57%, fear of side‐effects among 27.1%, not informed by health care providers among 6%, and unavailability of the method among 6% (Figure 1).

FIGURE 1.

Main reasons for not using an intrauterine device (IUD) so far among contraceptive users in southwest Ethiopia 2020.

3.3. Barriers for non‐use of IUD

Information about modern contraceptives was universal among study participants. However, 48% did not have information about an IUD. The qualitative findings also supported the lack of information related to an IUD among the communities.

“…low coverage of IUD is due to lack of awareness and lack of health education program. Also, women in our community preferred implant and Depo‐Provera since they want to have a baby in a short time interval” (age 44 years married male, Bir kebele Bench sheko).

3.4. Fear of side‐effects

Fear of side‐effects as a reason for not using IUD was also identified by a woman who participated in the focus group discussion which was conducted in Ilubabor zone, Alle district, Kundi kebele.

“… I am not confident to decide to use IUD because I fear its side‐effects, this is why I am still using an oral pill” (female developmental army, age 40 years, para 3).

3.5. Religion

Religion was identified as a barrier for not using an IUD. One of the key informants from the Muslim religion in Gambela stated that:

“Personally I do not have any information or knowledge about the IUD contraceptive method, and it is not commonly used by many women in my community. I do not have the interest to use IUD to avoid pregnancy because my religion does not allow us to use any kind of contraceptive method” (26‐year‐old, married, 10 + 3 education).

3.6. Husband disapproval

Husband disapproval was also indicated as a reason for not using an IUD. A 27‐year‐old woman who was para 1 from Onga kebele of Ilubabor zone expressed her view as.

“… according to the information we get from the health workers, IUD has many advantages. Nevertheless, some husbands said that IUD may migrate in the body of his wife and became hidden to remove. Therefore, most husbands do not agree with their partner's use of IUD in our kebele”.

3.7. Removal related barriers

Furthermore, complaints associated with the place of removal of an IUD also become a reason for not using it for birth control.

“… I was trained about loops (IUD). I know very well about its advantages. It has only minimal side‐effects. But did not use it because during insertion and removal there is a problem. For removal services, most of the time women were referred to Mettu Hospital. Why? if they cannot remove why they inserted it? Also, the uterus may be lacerated during insertion. Also, other women did not know anything about the loops and their side‐effects. So, the coverage of loop is low due to the above‐mentioned issues” (Bure kebele of Ilubabor, 26‐year‐old, married woman, para 0).

3.8. Duration of IUD

A 27‐year‐old lady from Mizan, Bench sheko zone indicated that an IUD being used for a long duration made women not select an IUD for birth control.

“… a reason why most of the community cannot use IUD is because of its long duration of use. Due to this most women prefer to use IUD after they meet their fertility desire. Because there may be a challenge to be pregnant after a long duration of using this contraception method” (40‐year‐old married woman, Mizan).

3.9. Lack of training

An interview was done with health care workers working in the family planning unit to identify if there are supply barriers to an IUD use. Lack of training about IUDs was identified.

“… I took training especially on Implanon next contraceptive method. I am providing available types of contraception except for IUD. The reason why I am not providing IUD service was because I was not trained on IUD” (28‐year‐old, female health care provider, Ilubabor zone).

3.9.1. Misconception

The study showed that 5% of participants had misconceptions and beliefs that “IUD cause infertility (%?),” followed by “it interferes with sexual intercourse” (4%), “causes infection” (4%), “spontaneously expel from the uterus” (3%), and “restrict daily/routine activities” (2%). A 26‐year‐old male, a member of the health developmental army from the Onga Kebele, Ilubabor zone, indicated that

“…. loop has been given for preventing pregnancy. However, there are some rumors in the community, if it will be taken for a prolonged period, the behavior of drugs or its side‐effect causes infertility”.

3.10. Women's intention to use an IUD in southwest Ethiopia

In this study, the prevalence of intention to continue or start to use an IUD in the future was 30%. The motives behind their intention to use were limiting childbirth among 40.3%, spacing childbirth among 30.5%, convenient compared to other methods among 14.4%, and health care providers recommendation among 14.8%.

3.11. Factors associated with women's intention to use an IUD

A binary logistic regression analysis showed that distance from the nearest health facility, educational status, husband's occupation, number of children, occupational status, having information about an IUD, reproductive health autonomy, and wealth status were found to be statistically significant factors associated with an intention to use an IUD.

After controlling for potential confounders, a multivariable logistic regression analysis showed that having information about an IUD and wealth status were significantly influencing modern contraceptive users in southwest Ethiopia (Table 3).

TABLE 3.

Multivariable logistic regression analysis on factors affecting the intention to continue or start using intrauterine device (IUD) in the future in southwest Ethiopia 2020.

Variables	Intention to use IUD			COR	p‐value	AOR	p‐value
	Category	No	Yes
IUD Information	No	298	78	1		1.000
	Yes	250	158	2.41 (1.75–3.32)	0.000	2.15 (1.56–3.00)	0.000
Wealth index	Poor	205	57	1		1
	Average	183	80	1.57 (1.06–2.33)	0.10	1.39 (0.9–2.01)	0.10
	Rich	160	99	2.22 (1.51–3.27)	0.000	1.76 (1.2–2.56)	0.00

Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratio.

Women having IUD information were 2.2 (adjusted odds ratio = 2.19 [CI: 1.56–3.00]) times more likely to have the intention to continue or start using an IUD in the future than those who had no exposure to IUD information.

Wealth status has also been found to be a significant predictor of an intention to use an IUD in southwestern Ethiopia. Women in the rich wealth status were 1.7 (adjusted odds ratio = 1.70 [CI: 1.13–2.56]) times more likely to have the intention to continue or start using an IUD in the future than women in the poor wealth status.

4. DISCUSSION

In this study we determined that IUD use in southwestern Ethiopia was very low, and only a third of family planning users had an intention to use the method. This could be attributed to different health system challenges, lack of information about the method, and sociocultural and socioeconomic factors.

In this study, 52% of women had received IUD information from either health care providers, friends or media which was slightly higher than the Ethiopian Public Health Institute 2016 report (45.6%). The differences might be due to the study period, and the study participants having access to information from different media than before. The finding was similar to the study conducted in Nepal, and Addis Ababa where 48.7% and 42.6% of the respondents heard about IUD and were knowledgeable about IUD, respectively. ¹² , ¹⁶

We found that only 1.3% of interviewed women had ever used an IUD and 1.1% were currently using an IUD. This finding was in line with a study done on promotion of IUD in low‐ and middle‐income countries, where IUD use has not shown much progress except the postpartum IUD in which a modest increase in use has been reported. ¹⁷ The possible reason for the extremely low progress was found to be the negative perception by both the providers and clients about IUD use which is also true in our context. However, IUD use in our study was lower than the one reported from Metu rural community, Ethiopia, where IUD use was 4.1% ¹⁸ and Australia where it was 2.3%. ¹⁹

The main reasons for not using an IUD in our study included lack of knowledge, fear of side‐effects, not informed by health care providers, religion, husband disapproval, removal related issue, and misconception which is in line with a study conducted in Nepal. ²⁰ Furthermore, our study revealed that supply‐side barrier for not using an IUD was lack of IUD training among health care providers. This finding was similar to a study conducted in Ghana. ²¹ The possible explanation for this was that even if the long‐acting reversible contraceptive training was given by different stakeholders for health professionals, there is high staff turnover and IUD insertion and removal is usually challenging due to low preference of IUD by users and hence trainees will not reach competency to provide the service.

The prevalence of intention to use IUD in our study was 30%. This finding was higher than the study conducted in Debre Markos Town, northwest Ethiopia (11.6%), ⁹ and lower than the study from Nekemte town, southwestern Ethiopia (47.9%). ¹⁰ The possible explanation for low intention to use IUD might be fear of side‐effects, rumors, and the difference in study setting.

In this study, 52.2% of contraceptive users cited fear of side‐effects as the main reasons for not using IUD in the future. This was higher than a study done in Nepal, which was 42.8%. ²² This might be due to the difference in the study population.

The other reasons for not using IUD in the future were husband disapproval in 14.2% of the participants, and lack of knowledge in 13.9%. These are lower than the study conducted in Nepal which shows 31.6% and 23.5% of the participants cited lack of sufficient knowledge, and husband's disapproval, respectively. ²² This might be due to the existence of health extension workers in the community which might have improved the knowledge of women and their partners in Ethiopia.

The odds of intention to use an IUD were less likely in women with the poorest wealth index compared to women in the average and richest wealth index. The possible reasons might be the poorest women might not have access to IUD service and information through media.

Likewise, women exposed to IUD information were 2.1 times more likely to have an intention to continue or start using an IUD in the future compared to those who have no exposure to IUD information. This study is in line with a study conducted in Uganda. ²³ The possible reason might be those exposed to IUD information are more likely to have better knowledge and low misconception and hence may have more intention to use IUD.

In this study, 0.8%–5.2% of respondents agreed with some of the statements described as beliefs and misconceptions about the IUD. Of these respondents, 5.2% agreed to the negative statements that “IUD cause infertility”, and 4.3% agreed to “it interferes with sexual intercourse”. A cross‐sectional study conducted in Addis Ababa indicated similar findings where 5.2% agreed that “IUD causes infertility”, and 6.8% agreed that “it interferes with sexual intercourse”. ²⁴ Another case–control study in Addis Ababa also found that 8.6% of IUD users and 10.1% of non‐users perceived that IUD causes infertility. ¹² Similarly, the study from Accra, Ghana showed that “the male partner can feel the device during sexual intercourse” was the second top‐cited misconception. ²⁵ Furthermore, the interference of IUD with sexual pleasure and the belief that IUD use can cause infertility was among the stated misconceptions in Uganda. ²³

Moreover, about 4% and more than 3% of participants of this study agreed with the negative statement that “IUD causes infection” and “spontaneously expel from the uterus”. Similarly, there is a perception that “using IUD is a breeding ground for infection” in the study from Scotland, UK. ²⁶ This finding was similar to a study from Ghana. ²⁵ Furthermore, 40.1% and 11.7% of the cases, and 31.4% of the controls in studies from Addis Ababa perceive that IUD causes infection. ¹² , ²⁴ The difference in the proportion of misconceptions and beliefs might be a time factor as misconceptions and beliefs related to IUD are decreasing over time among family planning users because of improved access to accurate information about the method.

The misconceptions that “IUD causes cancer” and “IUD migrates to another organ” in our study, were also identified in the study from Accra, Ghana and Scotland, UK where there is a perception that “IUD is capable of moving inside the body”. ²⁵ , ²⁶ Similarly, a study in Malawi showed that there is a perception that IUD can leave the uterus, migrate to the heart and cause death, and interfere with sexual intercourse. ²⁷ Furthermore, a woman participated in the qualitative study conducted in Greater Accra Region, indicated that using IUD could cause cancer. ²⁸

These findings imply that the misconceptions and beliefs related to IUD are common across the different parts of the globe. Unless it is timely corrected, these beliefs and misconceptions may contribute to the low demand and uptake of IUD service everywhere. ²⁵ , ²⁶

This study is strong in using a mixed method design to explore supply and demand side factors in areas where IUD use was very low. Although the findings are not free from social desirability bias, we tried to minimize it by explaining the purpose of the study in detail for each qualitative and quantitative study participant.

5. CONCLUSION

Nearly half of the study participants had no information about IUDs and only one in 100 women used an IUD. Lack of knowledge and fear of side‐effects were the most cited reasons for not using an IUD. Most contraceptive users were not sure of the negative statements on misconceptions and beliefs toward IUD use. Moreover, the main reasons for not using an IUD in the future were fear of side‐effects, husband disapproval, and lack of knowledge. Nearly one‐third of women had an intention to use an IUD and information about IUDs, and wealth status was positively associated with intention to use an IUD.

A regular awareness creation program using accessible media platforms by the government and stakeholders on IUD use is necessary to provide reliable information to the community and resolve misconceptions. In addition, women empowerment to balance partner dominance on decision‐making of contraception use and health care worker training on LARCs to increase access to LARCs services are necessary to increase uptake of LARCs in general, and IUDs, in particular in the study regions.

AUTHOR CONTRIBUTIONS

DA: Conception of the research, study design, literature review, data analysis, interpretation and drafting of the manuscript; TW, AK, AT, and ZA: data analysis, interpretation, and quality assessment and reviewed the manuscript. All authors have read and approved the manuscript.

FUNDING INFORMATION

This research data collection was funded by Marie Stopes International Ethiopia.

CONFLICT OF INTEREST STATEMENT

The authors confirm that there are no conflicts of interest.

Supporting information

Appendix S1.

Amenu D, Wakjira T, Tadele A, Kebede A, Asefa Z. Why intrauterine device (IUD) utilization is low in southwestern Ethiopia. A mixed‐method study. Acta Obstet Gynecol Scand. 2023;102:905‐913. doi: 10.1111/aogs.14587

DATA AVAILABILITY STATEMENT

The data will be available based upon request.