PLoS ONE
Public Library of Science
image
Incidence and determinants of Implanon discontinuation: Findings from a prospective cohort study in three health zones in Kinshasa, DRC
Volume: 15, Issue: 5
DOI 10.1371/journal.pone.0232582
  • PDF   
  • XML   
  •       
Abstract

BackgroundKinshasa is Africa's third largest city and one of the continent’s most rapidly growing urban areas. PMA2020 data showed that Kinshasa has a modern contraceptive prevalence of 26.5% among married women in 2018. In Kinshasa’s method mix, the contraceptive implant recently became the dominant method among contraceptive users married and in union. This study provides insight into patterns of implant use in a high-fertility setting by evaluating the 24-month continuation rate for Implanon NXT and identifying the characteristics associated with discontinuation.MethodologyThis community-based, prospective cohort study followed 531 Implanon users aged 18–49 years at 6, 12 and 24 months. The following information was collected: socio-demographic characteristics, Method Information Index (MII) and contraceptive history. The main outcome variable for this study was implant discontinuation. The incidence rate of discontinuation is presented as events per 1000 person/months (p-m), from the date of enrolment. The Cox proportional hazards modelling was used to measure predictors of discontinuation.ResultsA total of 9158.13 p-m were available for analysis, with an overall incidence rate of 9.06 (95% CI: 9.04–9.08) removals per 1000 p-m. Of nine possible co-variates tested, the likelihood of discontinuation was higher among women who lived in military camps, had less than three children, never used injectables or implants in the past, had experienced heavy/prolonged bleeding, and whose MII score was less than 3.ConclusionIn addition to four client characteristics that predicted discontinuation, we identified one programmatic factor: quality of counseling as measured by the Method Information Index. Community providers in similar contexts should pay more attention to clients having less than three children, new adopters, and to clients living military camps as underserved population, where clients have less access to health facilities. More targeted counselling and follow-up is needed, especially on bleeding patterns.

Akilimali, J., P., K. P., J., and Todd: Incidence and determinants of Implanon discontinuation: Findings from a prospective cohort study in three health zones in Kinshasa, DRC

Background

The Democratic Republic of the Congo (DRC) is Africa’s fourth most-populous and one of the region’s fastest growing countries [1]. DRC has one of the highest fertility rates in the world: the most recent Demographic and Health Survey (DHS) estimated a country-level total fertility rate of 6.6, a slight increase since the 6.3 TFR estimated with the 2007 DHS [2, 3]. Contraceptive use is low in DRC: the modern contraceptive prevalence rate (MCPR) among women aged 15–49 years married or living in union is estimated at 7.8% for the country as a whole [3].

Kinshasa, the capital of the DRC, is Africa's third largest city (after Lagos and Cairo) and one of the continent’s most rapidly growing urban areas [2,4]. PMA2020 data showed that Kinshasa had a modern contraceptive prevalence rate (MCPR) of 26.5% among women married or in union in 2018 [5], and 64.1% of last births were unintended [5]. Although the MCPR is similar to other major cities in francophone sub-Saharan Africa (SSA), it remains low in comparison to the capital cities of nearby Anglophone countries, such as Nairobi, 58.3% [6], Harare, 58.2%[7], Lusaka, 54.7%[8], and Kampala, 40.2%[9]. As of the most recent PMA2020 survey in Kinshasa, the implant surpassed condoms as the dominant method among FP (family planning) users married and living union [5].

In the DRC, only trained physicians and nurses are typically authorized to provide injections and insert implants. In late 2016 Tulane University began a pilot study in Kinshasa (in three health zones) of an innovative approach to test the acceptability and feasibility of having nursing students insert Implanon NXT at the community level. Women interested in a contraceptive method participated in a series of mini-campaigns at a community location (not in a fixed clinic); the nursing students provided a range of five methods, including Implanon NXT insertion to interested clients.

As part of their practical training, the students provided FP services at the community level: at outreach events (mini-campaigns) set up in a central location (e.g., near a referral health facility, beside a market), door-to-door, or from their own homes. Nursing students offered a range of five contraceptive methods: Implanon NXT, DMPA-SC, oral pills, condoms, and Cycle beads. Prospective clients often preferred these community services to fixed facilities in their neighbourhoods, because they were less expensive and required less waiting time.

Although Implanon NXT is generally well tolerated, previous studies have indicated that a proportion of women will discontinue its use because of unacceptable side effects [10, 11]. Another study showed that implant, injectable, and IUD users experienced more disturbances in bleeding patterns than pills users [12]. The acceptability of side effects of a given contraceptive method influences its compliance rates. It was observed that the women having frequent or prolonged bleeding had discontinued the contraceptive method more often as compared to those having delayed bleeding episodes or oligomenorrhoea [12].

Providing women with a choice of contraceptive methods and high-quality counselling are essential components of rights-based family planning (FP) [13]. Although Implanon is gaining in popularity among contraceptive users living in union in Kinshasa [5], virtually nothing is known about continuation rates, reasons for discontinuation, or the quality of services available for removal. Implant discontinuation, while being an important outcome of the quality of FP services [14, 15], has never been studied in the DRC context.

Additionally, studies reporting the use and continuation rates of Implanon are scarce, particularly those conducted at the community level (outside a fixed clinic). We did not find any studies that have quantitatively documented discontinuation rate among user in a community setting. This research provides insights into patterns of implant use in a high-fertility country by evaluating the 24-month continuation rate for Implanon and identifying the characteristics associated with continuation of this method at 24 months. This article also highlights some of the reasons that clients chose to have the method removed. The findings of this research are useful in documenting continuation rates for Implanon provided in a community setting in Africa, as well as identifying factors related to discontinuation.

Methodology

Population and design

Between November 2016 and January 2019, we conducted a cohort study of 531 women who chose to use Implanon NXT. The study took place in three selected health zones of Kinshasa: Masina I, Ndjili and Kokolo. The selection of zones took into account the proximity of the training institutes in which the students were trained. In addition, for logistical efficiency, we needed to limit that number of health zones to be covered and selected three with different characteristics to capture different types of clients. Kokolo health zone consists of compounds that house military personnel and their families. Military compounds differs from other health zones in that they are a closed encampment within the city with their own health system, though often underfunded and affording less access to family planning than in the non-military population.

Nursing students from local nursing schools received training in contraceptive counseling and provision, including insertion of Implanon NXT. They provided FP services at the community level as part of their practical training. Between October 2016 and January 2017, a total of 1,010 prospective clients came to “four campaign days” (community outreach events) at which they received counselling on a range of methods; Out of the 702 women who received Implanon NXT, 531 women aged 18 to 49 years old agreed to participate in the study and gave their informed consent to be interviewed at 6,12 and 24 months. The research team obtained participants’ addresses and phone numbers at baseline, then made phone calls to locate these acceptors and schedule in-person follow-up interviews. If needed, two community agents in each health zone were tasked with contacting acceptors at the addresses they had provided.

An experienced team of 2 supervisors and 12 data collectors were trained for three days before data collection at baseline and two days before the subsequent rounds of data collection. The interviewers used a structured questionnaire to collect data at baseline, 6, 12, and 24 months. The questionnaire was translated into Lingala, the most commonly spoken language in Kinshasa, during training sessions. The data collection tools were pre-tested and checked for consistency, then modified as deemed necessary. Interviewers collected the data on smartphones equipped with the SurveyCTO application. Supervisors monitored the data collection and checked the data for completeness before submission to a secure server. They also held regular meetings with the interviewers to ensure data quality.

For the follow-up interviews, respondents were asked to appear at a central community location. Those who did not were called or visited by the two community agents, based on information collected at baseline. Women were considered lost to follow-up if they could not be located at the address or at the phone number(s) given, after 3 attempts to contact them at 6, 12 or 24 months. Participants received U.S. $5.00 as reimbursement for transportation costs per follow-up visit.

Measurement of outcomes and other variables of interest

We collected socio-demographic characteristics (age, gender, marital status, education, socio economic status [SES], number of living children, and residence (military camps vs non-military camps), as well as the Method Information Index (MII) and contraceptive history. Data collectors recorded the date of Implanon insertion. At each follow-up visit acceptors were asked about side effects (especially if they experienced heavy bleeding), if the Implanon was still in place, and (if not), the reasons for removal of the implant and the date of removal.

Outcome definitions and measures

Participants were closely monitored at 6, 12, and 24 months post-insertion. The main outcome variable for this study was method discontinuation. Data collectors verified the presence of implant in the woman’s left arm at each interview visit. Time until removal was treated as a continuous variable, measured in months, with a maximum allowable time of 24 months. The event of interest was defined as discontinuation of Implanon use.

Covariates

The MII (Method Information Index) is a proxy measure for quality of counselling. It is calculated by summing the binary responses of clients to the following 3 questions: “During your visit today, were you told about other methods of family planning that you could use?”; “Were you told about side effects or problems that you might have with (your chosen) method?”; and “Were you told what to do if you experienced side effects or problems?” The index, ranging from 0 to 3, was used as an ordinal variable as well as a binary variable (3 or less than 3) in the analyses. The MMI is used when direct observation of the client provider interaction is not possible; it captures a woman’s recall and understanding of the information exchanged at the time of adoption, in addition to whether the exchange occurred [16].

The household wealth index was constructed based on principal component analysis [17] to create an index from a set of household assets (e.g. radio, tape recorder, television set, bicycle, flashlight), housing conditions (roof material, number of rooms, wall type, windows, availability and type of latrine), and ownership of livestock. The study participants were classified according to the wealth index score, into three groups (high, medium, low). The Cronbach’s alpha was 0.76.

We recoded respondent’s age as 18–24 and 25–49 years. In terms of education, women with less than a high school education were classified as “less than secondary school” and “completed secondary school.”. Residence fell into one of two categories: military area or non-military area. We recoded marital status as “married/living in union” or “not married.” And we classified number of children as less than 3 children versus 3 children and more.

The responses to the question on experience of heavy/prolonged bleeding was binary: yes or no. Women who needed to change their tampon or pad after less than 2 hours during more than 7 days were considered as having prolonged or heavy bleeding. Because no respondents had ever used the IUD, we classified contraceptive history into two categories: ever used injectable or implant and never used either of these methods.

Analytic methods

Interviewers collected data using a mobile phone (SurveyCTO)., then submitted it to a cloud server. Do-file checking and cleaning were updated daily, and errors discovered were corrected in the field. We completed a final data cleaning prior to data analysis.

All analyses were carried out using Stata version 15. For continuous variables, means and standard deviation (SD) were calculated; for categorical data, proportions and their respective 95% confidence intervals were calculated. We used the chi-square test and Fisher´s exact test when appropriate.

The incidence rate of discontinuation is presented as events per 1,000 person/months (p-m), from the date of enrolment. The Kaplan-Meier curve was used to determine the probability of discontinuation as a function of time of inclusion in the cohort. The log-rank test was employed to compare survival curves based on determinants. The Cox proportional hazards modeling allowed us to identify predictors of discontinuation from the date of insertion of the device (Implanon) to the end point, which was set at 24 months. The following variables were considered for inclusion to the Cox regression model: age, education, residence, marital status, wealth level, number of living children, contraceptive history, experience of heavy bleeding, and Method Information Index. This model provided the adjusted hazard ratios (AHR) and 95% confidence intervals (CI). The proportionality test based on Schoenfeld residuals allowed verification of compliance with the assumption of proportionality of risks. Variance-inflation factors (VIF) were estimated to assess multicollinearity. All tests were two-sided, and the level of significance was set at p <0.05.

Ethical review

This study received IRB approval from Tulane University (16 –#911338) and the Kinshasa School of Public Health (ESP/CEI/071/ 2016 and ESP/CEI/125/ 2018).

Results

Sample description

Of 531 women enrolled in the study, 116 (22%) were lost to follow-up (LTFU), resulting in 415 cases for inclusion in the analysis (see Fig 1). Those LTFU were similar to those retained in the analysis in terms of education, matrimonial status, residence, number of living children, contraceptive history, MMI, and the experience of heavy bleeding. However, the women who were LTFU were younger (25 vs 28 years; p < 0.001) and lower on the wealth index (44% vs 30%, p = 0.015) than those remaining in the analysis. (Table 1).

Flow diagram showing the way follow-up of participants was done from the insertion end point.
Fig 1
Flow diagram showing the way follow-up of participants was done from the insertion end point.
Table 1
Sociodemographic characteristics and past contraceptive use of women LTFU and women included in the analysis.
Lost to Follow-UpIncluded in the analysisp
n(116)%n(415)%
Age: mean (SD)25.37 (5.22)27.96 (6.39)< 0.001
Instruction level0.374
 • Less than secondary school2723.38120.0
 • Completed secondary school8976.733480.0
Matrimonial Status0.070
 • Not married10388.833982.0
 • Married/partnered1311.27618.0
Residence0.653
 • Military area2420.79423.0
 • Non military area9279.332177.0
SES0.015
 • Lowest third5144.012630.4
 • Middle third3631.014134.0
 • Highest third2925.014835.6
Number of living children0.303
 • ≤ 25244.816440.0
 • 3 or more6455.225160.0
Contraceptive history0.487
 • Ever used injectable or implant108.64511.0
 • Never used injectable or implant10691.437089.0
Experienced heavy/ prolonged bleeding *0.174
 • Yes9*21.413131.57
 • No33*78.628468.43
Method Information Index0.798
 • < 35144.018845.3
 • = 36556.022754.7
*Data collected before lost to follow up

Profile of respondents at baseline

Among the 415 women retained in the analysis, the mean age was 28 years; 82.0% were unmarried; 60% had at least 3 children. Most (80.0%) had graduated from secondary school, and 23.0% lived in a military camp. In terms of family planning, 59% had never used an injectable or implant in the past; 55% reported receiving information about all 3 items in the Method Information Index; and a third (32%) reported experiencing heavy bleeding (Table 1).

Evolution of discontinuation

From 415 women retained in the analysis, 83 (20%: 95% CI: 16.2–23.8) had removed the Implanon NXT during the 24-month study period. From the date of insertion, the removal rate was 5.5% (by 6 months), 8.4% (by 12 months), 10.1% (by 18 months) and 20.0% (by 24 months) (S1 Table).

Predictors of discontinuation in multivariate analysis

A total of 9158.13 p-m were available for analysis, with an overall incidence rate of 9.06 (95%CI: 9.04–9.08) removals per 1000 p-m (Figs 2 and 3).

Incidence of discontinuation based on residence and parity.
Fig 2
Incidence of discontinuation based on residence and parity.
Incidence of discontinuation based on bleeding pattern and quality of counseling.
Fig 3
Incidence of discontinuation based on bleeding pattern and quality of counseling.

We tested nine variables as possible co-variates of discontinuation. The likelihood of discontinuation was higher among women who lived in the military camps, who had less than three children, who never used injectables or implants in the past, who had experienced heavy/prolonged bleeding, and who score less than 3 on the MII (Table 2).

Table 2
Cox proportional hazard regression analysis of discontinuation rates.
Hazard ratio*
CharacteristicstotalDurationEventIncidence (1000 P-m)Crude (95%CI)pAdjusted (95%CI)p
Age
 • 18–241463187.753510.981.38 (0.89–2.14)0.1460.75 (0.45–1.24)0.257
 • 25–492695970.38488.0411
Instruction level
 • Less than secondary school811819.08179.351.04 (0.61–1.77)0.8970.98(0.55–1.76)0.955
 • Completed secondary school3347339.05668.9911
Matrimonial Status
 • Not married3397503.08648.530.74(0.44–1.24)0.2540.70 (0.41–1.22)0.214
 • Married/partnered761655.051911.4811
Residence
 • Military area941865.722915.542.08 (1.33–3.27)0.0012.28 (1.36–3.81)0.002
 • Non military area3217292.41547.4011
SES
 • Lowest third1262786.622810.051.09 (0.65–1.83)0.7321.48 (0.83–2.66)0.186
 • Middle third1413122.62258.010.86 (0.51–1.47)0.5860.83 (0.48–1.44)0.509
 • Highest third1483248.88309.2311
Number of living children
 • ≤ 21643350.765416.123.31 (2.11–5.20)< 0.0013.64(2.19–6.08)< 0.001
 • 3 or more2515807.38294.9911
Contraceptive history
 • Ever used injectable or implant451076.1521.8611
 • Never used injectable or implant3708081.988110.025.49 (1.35–22.32)0.0174.49 (1.09–18.55)0.038
Experienced heavy/ prolonged bleeding
 • Yes1312800.733913.922.05 (1.33–3.16)0.0011.96 (1.26–3.04)0.003
 • No2846357.41446.9211
Method Information Index
 • < 31884112.464911.921.81 (1.17–2.81)0.0082.08 (1.32–3.28)0.002
 • = 32275045.67346.7411
Overall4159158.13839.06
*p-m: person-months

Reasons for early discontinuation

The majority of discontinuers did so because of side effects (72.3%). The most commonly reported side effect was heavy bleeding (30.0%). Also, nearly one discontinuer out of five mentioned opposition of her partner/husband. Opposition of partner was cited more among discontinuers who experienced heavy bleeding than those who did not experience it (30.8 vs 9.1%). (S2 Table). Our data show that among the 83 clients who had had an implant removed, 64.7% went to the Health center, 27.1% to the hospital and 8.2% in the resident of Nurse for removing the device (S3 Table).

Discussion

This study found that 20% of Implanon acceptors had discontinued by 24 months post-insertion. This discontinuation rate is similar to the one found in a study conducted in Nigeria in which 19.3% had discontinued during the same period [18]. However, this discontinuation rate is lower to that found in the clinical trial on implant discontinuation, conducted in 21 centers in nine European countries, in which 31% had discontinued using the implant at 2 years [19]. The discontinuation rate in Kinshasa was also slightly lower than found in; Sudan (43.5%) [20]; Ethiopia (46.5%), [21] and Australia (50%) [22], and another study from Nigeria [23]

In this analysis, predictors for early discontinuation included lower parity, residence in a military camp, lack of previous implant or injectable use, experience of heavy/prolonged bleeding, and low MII. Our findings on parity diverge from those in a study conducted in Ethiopia, in which for every additional child, the likelihood of modern contraceptive discontinuation decreased by 12% [24]. These multiparous women may be highly motivated not to remove Implanon early, since they are more likely to have achieved their desired family size and may have a higher level of motivation to avoid another pregnancy. Conversely, women with less children might be more likely to discontinue if they interpret the side effects as a risk to their future fertility. Controlling unwanted fertility with highly effective reversible contraception allowed couples to have the number of children they want at the time they want to have. However, fertility delay or impairment as a result of prior contraception use may lead to dissatisfaction and lower contraception use irrespective of actual desire [25, 26].

Women in military camps have limited access to modern family planning methods and are less likely to be using contraception [27]. In the DRC, military camps are closed environments and difficult to access by the civilian population; as such, they are not often targeted by mass health activities, including FP campaigns. Women living in military camps may have less access to a health facility, whereas those living near a health facility tend to have better knowledge of contraceptives than those living far from one [28, 29].

Dissatisfaction with bleeding patterns was the most common reason for early discontinuation, which is consistent with previous other studies [30, 31]. Counselling women on expected bleeding patterns has been shown to improve continuation rates for injectables and implant [3036]. In this study, bleeding duration emerged as an important predictor of discontinuation. This finding has several implications. Providers should recognize that medical advice on contraceptive side effects does not always resonate with women using the method; even light bleeding, when prolonged, may lead women to worry and discontinue use. Reported increases in length of bleeding predicted discontinuation, even when women's perceptions of those changes did not [34]. During counseling, providers should carefully discuss possible bleeding and actively encourage women to return in case of concern. During follow up visits by Implanon users, providers should examine the intensity and duration of vaginal bleeding to assess the gravity of the situation and rule out other causes such as infection, interactions with other medications, and gynecological pathology.

The quality of family planning counseling is a key issue in continuous use [37]. In this study low-quality family planning counseling, as measured by the MII score during the exit interview, was associated with subsequently higher 24-month discontinuation rates. This finding is consistent with the literature, which shows that a client's reception / understanding of contraceptive information is a critical component in realizing full method choice and high-quality care [38]. This study confirms a consistent association of high MII scores and continuation rates on each round of follow up over the 24-month period [37].

Although other studies have found that quality of care is associated with subsequent continuation of contraceptive use [3941], to the best of our knowledge, this is the first study conducted in a community setting to find a persistent pattern of high MII scores and lower rates of discontinuation over a 24-month follow-up period.

This study has several limitations. First is the possibility of misclassification of heavy bleeding, which women may have incorrectly reported. The bleeding should be recorded using the categories suggested by the WHO [42]. Second, there is a possibility of the response bias inherent to MII. Indeed, in the absence of observation of the counseling session, this analysis relies on self-reported data. Prior work comparing exit interview data to observation in facility surveys demonstrated that clients tended to overreport when asked if they received counseling about side effects of their method [43]. The recurring issue with the question: “were you told about side-effects?” is that it does not ask the more critical question: “and were you told that these side effects are normal and do not present a risk for your health / future fertility?” Although recall bias is also a potential limitation, the MII questions were asked to clients as part of an exit survey shortly after interacting with the provider.

The authors acknowledge that the performance of the nursing students could have been influenced by their awareness of being evaluated. Yet this influence could operate in opposing directions. Whereas they could perform better under observation than otherwise, they might also performance less well from being nervous about the observation. Another potential limitation of this study is that the research team could not ascertain discontinuation rates of the women who were LTFU.

Finally, although we have used Cox regression, we cannot exclude a potential confounding effect of other variables such as the effect of women’s autonomy on method discontinuation.

To our knowledge, this study is the first to report continuation rate for implants offered at the community level (outside a fixed clinic). The study reinforces the importance of the quality of FP counselling in method continuation. Furthermore, it shows that dissatisfaction with bleeding patterns can push women to remove Implanon early. These findings provide useful programmatic guidance to policy makers, healthcare workers, and other stakeholders involved in FP programming in helping to understand factors associated with discontinuation of Implanon NXT at the community level.

Conclusions

In addition to four client characteristics that predicted discontinuation, we identified one programmatic factor: quality of counseling as measured by the Method Information Index. Community providers in similar contexts should pay more attention to clients having less than three children, new adopters, and to clients living military camps as underserved population, where clients have less access to health facilities. More targeted counselling and follow-up is needed, especially on bleeding patterns.

References

1 

United Nations. World Population prospects: the 2015 revision, volume II: demographic profiles. New York, NY: United Nations, 2015.

2 

Ministère du Plan et Macro International. Enquête Démographique et de Santé, République Démocratique du Congo 2007. Calverton, Maryland, U.S.A: Ministère du Plan et Macro International, 2008.

3 

Ministère du Plan et Suivi de la Mise en œuvre de la Révolution de la Modernité (MPSMRM), Ministère de la Santé Publique (MSP) et ICF International. Enquête Démographique et de Santé en République Démocratique du Congo 2013–2014. Rockville, Maryland, USA: MPSMRM, MSP et ICF International, 2014.

4 

UN-HABITAT. The challenge of slums: global report on human settlements 2003. London and Sterling. London, UK: Earthscan Publications Ltd; 2003.

5 

Performance Monitoring and Accountability 2020 (PMA2020). 2016a. PMA2016/DRC-Round 5: Family Planning Key Indicator Brief. Baltimore, MD: Kinshasa School of Public Health, Tulane School of Public Health and Tropical Medicine, and Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health. https://www.pma2020.org/sites/default/files/PMA2018-Kinshasa-R7-FP-Brief-20190201_EN.pdf [Accessed 27 April 2019].

6 

Kenya National Bureau of Statistics (KNBS) and ICF Macro (2015) Kenya Demographic and Health Survey Key Indicators 2014. Calverton, Maryland: KNBS and ICF Macro; https://dhsprogram.com/pubs/pdf/PR55/PR55.pdf

7 

Zimbabwe National Statistics Agency (ZIMSTAT) and ICF International (2012) Zimbabwe Demographic and Health Survey 2010–11. Calverton, Maryland: ZIMSTAT and ICF International Inc; http://dhsprogram.com/pubs/pdf/FR254/FR254.pdf

8 

Central Statistical Office (CSO) [Zambia], Ministry of Health (MOH) [Zambia], and ICF International (2014) Zambia Demographic and Health Survey 2013–14. Rockville, Maryland: Central Statistical Office, Ministry of Health, and ICF International. https://www.dhsprogram.com/pubs/pdf/FR304/FR304.pdf

9 

Uganda Bureau of Statistics, ICF International (2012) Uganda Demographic and Health Survey 2011. Calverton, Maryland, USA: UBOS and ICF International; https://dhsprogram.com/pubs/pdf/FR264/FR264.pdf

10 

B Affandi. . An integrated analysis of vaginal bleeding patterns in clinical trials of Implanon. Contraception, 58 (6 Suppl) (1998), pp. , pp.99S–107S Article Download PDF , doi: 10.1016/s0010-7824(98)00123-1

11 

H.B. Croxatto, J. Urbancsek, R. Massai, H. Coelingh Bennink, A van Beek. . A multicentre efficacy and safety study of the single contraceptive implant Implanon. Implanon Study Group Hum Reprod, 14 (1999), pp. , pp.976–981

12 

Datey S.,Gaur LN, Saxena B.N. Vaginal bleeding patterns of women using different contraceptive methods (implants, injectables, IUDs, oral pills)—An Indian experience: An ICMR task force study,Contraception, Volume 51, Issue 3, 1995, Pages 155–165

13 

K Hardee, J Kumar, K Newman, L Bakamjian, S Harris, M Rodriguez, et al. Voluntary, human rights- based family planning: a conceptual framework. Stud Fam Plann. 2014;45(1):, pp.1–18. , doi: 10.1111/j.1728-4465.2014.00373.x

14 

AK Jain, F Obare, S RamaRao, I Askew. . Reducing unmet need by supporting women with met need. Int Perspect Sex Reprod Health. 2013; 39(03):, pp.133–141.

15 

J Barden-O’Fallon, IS Speizer, LM Calhoun, M Corroon. . Women's contraceptive discontinuation and switching behavior in urban Senegal, 2010–2015. BMC Women’s Health. 2018; 18(1):, pp.35, doi: 10.1186/s12905-018-0529-9

16 

KT Chang, M Mukanu, B Bellows, W Hameed, AM Kalamar, et al. Evaluating Quality of Contraceptive Counseling: An Analysis of the Method Information Index. Stud Fam Plann. 20193;50(1):, pp.25–42. , doi: 10.1111/sifp.12081

17 

Deon Filmer, Lant Pritchett. . Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography. 2001;38(1):, pp.115–132. , doi: 10.1353/dem.2001.0003

18 

H Ezegwui, L Ikeako, C Ishiekwene, T Oguanua. . The discontinuation rate and reasons for discontinuation of Implanon at the family planning clinic of University of Nigeria Teaching Hospital (UNTH) Enugu, Nigeria. Niger J Med. 2010;20(4):, pp.448–450.

19 

HB Croxatto, J Urbancsek, R Massai, H Coelingh Bennink, A van Beek. . A multicentre efficacy and safety study of the single contraceptive implant Implanon. Implanon Study Group. Hum Reprod1999;14: , pp.976–81. , doi: 10.1093/humrep/14.4.976

20 

SW Maina, GO Sanjo, SN Ndwigah, and Sylvia A Opanga. . Determinants of discontinuation of contraceptive methods among women at Kenyatta National Hospital, Kenya. Afr J Pharmacol Ther. 2016;5:, pp.28–34.

21 

Melese S. Implanon discontinuation rate and associated factors among women who ever used Implanon in the last three years, in Debre Markos Town, Northwest Ethiopia; 2015.

22 

C. Harvey, C. Seib, J Lucke. . Continuation rates and reasons for removal among Implanon users accessing two family planning clinics in Queensland, Australia. Contraception, 80 (2009), p. , pp.527, doi: 10.1016/j.contraception.2009.05.132

23 

OR Balogun, N Olaomo, AS Adeniran, AA Fawole. . Implanon sub-dermal implant: an emerging method of contraception in Ilorin, Nigeria. J Med Biomed Sci. 2014;3(1):, pp.1–5.

24 

T Bekele., A. Gebremariam, P Tura. . Factors Associated with Contraceptive Discontinuation in Agarfa District Bale Zone, South East Ethiopia. Epidemiology. 2015;5(179)

25 

B Kaplan, R Nahum, Y Yairi, M Hirsch, J Pardo, Y Yogev, et al. Use of various contraceptive methods and time of conception in a communitybased population. Eur J Obstet Gynecol Reprod Biol. 2005;123:, pp.72–76. , doi: 10.1016/j.ejogrb.2005.06.033

26 

R Kulier, PA O’Brien, FM Helmerhorst, M Usher-Patel, C D’Arcangues. . Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev. 2007;4:, pp.CD005347

27 

P Akilimali, P Anglewicz, HN Engale, GK Kurhenga, J Hernandez, P Kayembe, et al. Differences in family planning outcomes between military and general populations in Kinshasa, Democratic Republic of the Congo: a cross-sectional analysis. BMJ Open. 20181222;8(12):, pp.e022295, doi: 10.1136/bmjopen-2018-022295

28 

SK Chaudhuri. Practice of Fertility ControlA Comprehensive Textbook. New Delhi: BI Churchill Livingstone, 2000

29 

World Health Organization. Contraceptive Methods Mix Guidelines for Policy and Service Delivery. Geneva: WHO,1993

30 

D Mansour, T Korver, M Marintcheva-Petrova, IS Fraser. . The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care2008;13(Suppl 1):, pp.13–28.

31 

A Smith, S Reuter. . An assessment of the use of Implanon in three community services. J Fam Plann Reprod Health Care2002;28:, pp.193–6. , doi: 10.1783/147118902101196540

32 

V Halpern, DA Grimes, L Lopez, MF Gallo. . Strategies to improve adherence and acceptability of hormonal methods for contraception. Cochrane Database Syst Rev2006:CD004317.

33 

D Hubacher, N Goco, B Gonzalez, D Taylor. . Factors affecting continuation rates of DMPA. Contraception1999;60:, pp.345–51. , doi: 10.1016/s0010-7824(99)00104-3

34 

EM Belsey, Task Force on Long-Acting Systemic Agents for Fertility Regulation. . The association between vaginal bleeding patterns and reasons for discontinuation of contraceptive use. Contraception1988; 38:, pp.207–25. , doi: 10.1016/0010-7824(88)90039-x

35 

E Tolley, S Loza, L Kafafi, S Cummings. . The impact of menstrual side effects on contraceptive discontinuation: findings from a longitudinal study in Cairo, Egypt. Int Fam Plan Perspect2005;31:, pp.15–23.

36 

Z.-W. Lei, S.C. Wu, R.J. Garceau, S. Jiang, Q.-Z. Yang, W.-L Wang. et al. Effect of pretreatment counseling on discontinuation rates in Chinese women given depo- medroxyprogesterone acetate for contraception. Contraception1996; 53:, pp.357–61. , doi: 10.1016/0010-7824(96)00085-6

37 

Nirali M. Chakraborty, Karen Chang, Benjamin Bellows, Karen A. Grépin, Waqas Hameed, Amanda Kalamar, et al. Association Between the Quality of Contraceptive Counseling and Method Continuation: Findings From a Prospective Cohort Study in Social Franchise Clinics in Pakistan and Uganda. Global Health: Science and Practice Mar2019, 7(1) , pp.87–102.

38 

S RamaRao, R Mohanam. . The quality of family planning programs: concepts, measurements, interventions, and effects. Stud Fam Plann. 2003;34(4):, pp.227–248. , doi: 10.1111/j.1728-4465.2003.00227.x

39 

AK Jain, S RamaRao, J Kim, M Costello. . Evaluation of an intervention to improve quality of care in family planning programme in the Philippines. J Biosoc Sci. 2011;44(1):, pp.27–41. , doi: 10.1017/S0021932011000460

40 

MA Koenig, MB Hossain, M Whittaker. . The influence of quality of care upon contraceptive use in rural Bangladesh. Stud Fam Plann. 1997;28(4):, pp.278–289.

41 

S Pariani, DM Heer, MDV Arsdol. . Does choice make a difference to contraceptive use? Evidence from East Java. Stud Fam Plann. 1991;22(6):, pp.384–390.

42 

World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction. . The analysis of vaginal bleeding patterns induced by fertility regulating methods. Contraception1986;34:, pp.253–60. , doi: 10.1016/0010-7824(86)90006-5

43 

Y Choi. . Estimates of side effects counseling in family planning using three data sources: implications for monitoring and survey design. Stud Fam Plann. 2018;49(1):, pp.23–39. , doi: 10.1111/sifp.12044


21 Feb 2020

PONE-D-19-25274

Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC

PLOS ONE

Dear Dr Akilimali,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Apr 06 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

    A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
    A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
    An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Also, pre-testing of the questionnaire was mentioned but not on whom this pre-testing took place and how many participants were involved. Please update with this information as appropriate.

Additional Editor Comments (if provided):

This is a well-written manuscript regarding efforts to broaden access to long-acting reversible contraception in a context with a very low contraceptive prevalence rate. I agree with the reviewer that further information regarding context, sample selection, and results will enhance the manuscript and will be pleased to see a revised submission.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Methodology: page 4 -perhaps use another word instead of "opted" rather use chose? to use Implanon.

Can you comment on the experience of nursing students to provide the service. Did they provide a better service as they knew research would evaluate their service provision.

What is meant by providing services at community level outreach event? was it a campaign to specifically target contraceptive uptake or the Implant? what other methods were available ? other helath services?Could they have got implanon at a local service nearby (for post insertion support)

You say it was not possible to interview all 702, so what was the convenience sample limited to? those who agreed to stay?

Why were the three districts chosen? noting one was very different? was there a programme that wanted to ensure IMplanaon wa smade available to the women in these areas?

Did you collect data on who removed the implant? was it the same nurses and where did they go?

The methodology says women were interviewed on the phone? on page 5 but a few sentance later it says women were asked to appear ? at a central community location. these two statements contradict each other. If many women lived in a military camp why did the study not ask for permission to interview them at the camp or did they also have to go to a community venue? again in analytic methods it says data was collected on a mobile phone?

Did women get reimbursed for participation

Results:

Could you have tracked the LTFP via clinics in case they had the implant removed?

Conclusions: The woman in military camps - were they working or just living with men employed by the military? if working perhaps the heavy bleeding impacted on their work or the camps had poor facilities? if they lack access to health facilities how did they get their implants removed? and if they all received equal conselling on a variety of methods why would they have less knowledge than other woman. Is it that the camps provide no Health facilities to their staff?

Later in the conclusion it says the study was conducted in a community setting? rather enrollment was conducted in a community setting but interviews were on the phone? not in the community ? see earlier comments.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.


15 Mar 2020

Comments from the reviewer are below in bold font, and our responses follow each comment in plain font

Reviewer #1:

Page 4 -perhaps use another word instead of "opted" rather use chose? to use Implanon.

We agree and have updated accordingly.

Can you comment on the experience of nursing students to provide the service. Did they provide a better service as they knew research would evaluate their service provision.

We appreciate this comment. To address this issue, we have added the following text to the discussion section: “The authors acknowledge that the performance of the nursing students could have been influenced by their awareness of being evaluated. Yet this influence could operate in opposing directions. Whereas they could perform better under observation than otherwise, they might also performance less well from being nervous about the observation.”

What is meant by providing services at community level outreach event? was it a campaign to specifically target contraceptive uptake or the Implant? what other methods were available ? other health services? Could they have got implanon at a local service nearby (for post insertion support)

As part of their practical training, the students provided FP services at the community level: at outreach events (mini-campaigns) set up in a central location (e.g., near a referral health facility, beside a market), door-to-door, or from their own homes. Nursing students offered a range of five contraceptive methods: Implanon NXT, DMPA-SC, oral pills, condoms, and Cycle beads. Prospective clients often preferred these community services to fixed facilities in their neighborhoods, because they were less expensive and required less waiting time.

You say it was not possible to interview all 702, so what was the convenience sample limited to? those who agreed to stay?

In addition to “willingness to stay,” the respondent needed to provide consent for the interview. So, out of the 702 women who received Implanon NXT, 531 women aged 18 to 49 years old agreed to participate in the study and gave their informed consent to be interviewed at 6,12 and 24 months.

Why were the three districts chosen? noting one was very different? was there a programme that wanted to ensure Implanon was made available to the women in these areas?

The selection of zones took into account the proximity of the training institutes in which the students were trained. In addition, for logistical efficiency, we needed to limit that number of health zones to be covered and selected three with different characteristics to capture different types of clients (to increase the generalizability of the results).

Did you collect data on who removed the implant? was it the same nurses and where did they go?

Nursing students received training in the removal of Implanon NXT in the 4th year of nursing school. At the large majority of outreach events, a more experienced nurse handled the removal of implants (not the nursing students), and often the client was referred to the health facility near the outreach site for the removal. Our data show that among the 83 clients who had had an implant removed, 65% went to the Health center, 27% to the hospital and 8% in the resident of Nurse to remove the device.

The methodology says women were interviewed on the phone? on page 5 but a few sentences later it says women were asked to appear ? at a central community location. these two statements contradict each other. If many women lived in a military camp why did the study not ask for permission to interview them at the camp or did they also have to go to a community venue? again in analytic methods it says data was collected on a mobile phone?

During this study, trained interviewers used smart phone technology to collect data during a face-to-face interview. The use of mobile technology for data collection allowed interviewers to automatically upload data to a secure electronic server instead of having to code and enter data manually. Data was collected using interview face to face using mobile phone as tools ( SurveyCTO). These were not phone interviews. However women were re-contacted by phone to schedule the follow-up interviews.

Did women get reimbursed for participation?

Participants received U.S. $5.00 as reimbursement for transportation costs.

Could you have tracked the LTFP via clinics in case they had the implant removed?

Unfortunately, this is not possible. The client record system at these clinics would not have this type of information, nor is it clear that women using the community service would ever have registered with the nearby clinic.

The woman in military camps - were they working or just living with men employed by the military? if working perhaps the heavy bleeding impacted on their work or the camps had poor facilities? if they lack access to health facilities how did they get their implants removed? and if they all received equal counselling on a variety of methods why would they have less knowledge than other woman. Is it that the camps provide no Health facilities to their staff?

Most of the participants from Military camps were the wives of military personnel. Military camps are closed settings in which the health structures are less likely to receive technical and financial support from development partners. Also, results from a previous survey show that women in military camps have lower levels of knowledge and use of contraception than do their civilian counterparts. Because one of these development partners has begun supporting the military camp health facilities in recent years, Implant users have access to trained personnel who can remove implants.

Later in the conclusion it says the study was conducted in a community setting? rather enrollment was conducted in a community setting but interviews were on the phone? not in the community? see earlier comments.

The study was conducted in a community setting and participants were interviewed face to face using a questionnaire programmed on a mobile phone. During this study, trained interviewers used smart phone technology to collect data. The use of mobile technology for data collection allowed interviewers to automatically upload data to a secure electronic server instead of having to code and enter data manually. Data was collected during face to face interviews using mobile phone as tools ( SurveyCTO). This was not a phone survey.

Submitted filename: Cover letter and response to reviewers.docx

10 Apr 2020

PONE-D-19-25274R1

Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC

PLOS ONE

Dear Dr Akilimali,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by May 25 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

    A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
    A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
    An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

This manuscript has largely responded to the queries raised by the prior reviewer. It will be suitable for publication once two minor changes are made:

- Please add the description of the participants' context as military wives to the manuscript, ideally in the Introduction section. You identify the program as novel but do not mention the circumstances of the context where family planning services are traditionally limited and women less aware of contraceptive options.

- Please add the reimbursement of travel expenses to the Methods section - this is a required feature to report.

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.


13 Apr 2020

April 14th, 2020

To: Catherine S. Todd

Academic Editor

PLOS ONE

Re: Revised version manuscript PONE-D-19-25274 R2

Dear Editor,

Thank you very much for the opportunity to revise and resubmit our manuscript. The comments we received helped to improve our research.

Our revised submission includes the following documents: (1) the manuscript with changes tracked, (2) a clean revised manuscript including tables and (3) the rebuttal letter with our responses to each point raised by the editor and reviewers.

Below is our reply to the comments and suggestions of the reviewers on a point-by-point basis.

We would like to thank the referees for the valuable and constructive comments and suggestions. We are hoping that we have adequately dealt with the comments and suggestions, and that the revised version is to your satisfaction.

Looking forward to hearing from you.

Sincerely,

Dr. Pierre Zalagile Akilimali

Kinshasa School of Public Health

University of Kinshasa

Democratic Republic of Congo

Reviewer’s Comments

Please add the description of the participants' context as military wives to the manuscript, ideally in the Introduction section.

Kokolo health zone consists of compounds that house military personnel and their families. Military compounds differs from other health zones in that they are a closed encampment within the city with their own health system, though often underfunded and affording less access to family planning than in the non-military population. We have added a statement about this on page 5 in Method section.

You identify the program as novel but do not mention the circumstances of the context where family planning services are traditionally limited and women less aware of contraceptive options.

Please add the reimbursement of travel expenses to the Methods section - this is a required feature to report.

We have added the following statement “Participants received U.S. $5.00 as reimbursement for transportation costs per visit.” to page 7 of the manuscript.

Submitted filename: Cover letter and response to reviewers.docx

20 Apr 2020

Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC

PONE-D-19-25274R2

Dear Dr. Akilimali,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:


28 Apr 2020

PONE-D-19-25274R2

Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC

Dear Dr. Akilimali:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Catherine S. Todd

Academic Editor

PLOS ONE

https://www.researchpad.co/tools/openurl?pubtype=article&doi=10.1371/journal.pone.0232582&title=Incidence and determinants of Implanon discontinuation: Findings from a prospective cohort study in three health zones in Kinshasa, DRC&author=P. Z. Akilimali,Hernandez J.,Anglewicz P.,Kayembe K. P.,Bertrand J.,Catherine S. Todd,Catherine S. Todd,Catherine S. Todd,Catherine S. Todd,Catherine S. Todd,&keyword=&subject=Research Article,Medicine and Health Sciences,Diagnostic Medicine,Signs and Symptoms,Hemorrhage,Medicine and Health Sciences,Pathology and Laboratory Medicine,Signs and Symptoms,Hemorrhage,Medicine and Health Sciences,Vascular Medicine,Hemorrhage,Medicine and Health Sciences,Women's Health,Obstetrics and Gynecology,Contraception,Female Contraception,Biology and Life Sciences,Bioengineering,Biotechnology,Medical Devices and Equipment,Medical Implants,Engineering and Technology,Bioengineering,Biotechnology,Medical Devices and Equipment,Medical Implants,Medicine and Health Sciences,Medical Devices and Equipment,Medical Implants,Medicine and Health Sciences,Pharmacology,Drugs,Contraceptives,Biology and Life Sciences,Bioengineering,Biotechnology,Medical Devices and Equipment,Contraceptives,Engineering and Technology,Bioengineering,Biotechnology,Medical Devices and Equipment,Contraceptives,Medicine and Health Sciences,Medical Devices and Equipment,Contraceptives,Social Sciences,Sociology,Education,Schools,Medicine and Health Sciences,Health Care,Nursing Science,People and Places,Population Groupings,Age Groups,Children,People and Places,Population Groupings,Families,Children,Research and Analysis Methods,Research Design,Cohort Studies,