Contraceptive Discontinuation: Reasons, Challenges, and Solutions
On Tuesday, December 8th, Family Planning 2020 and Population Council released a new report, Contraceptive Discontinuation: Reasons, Challenges, and Solutions, that looks at why women stop using contraceptives.
Analyses of Demographic and Health Survey (DHS) data indicate that 38% of women with an unmet need for modern contraception have used a modern method of contraception in the past but have chosen to discontinue use. This phenomenon, called contraceptive discontinuation, is defined as starting contraceptive use and then stopping for any reason while still at risk of an unintended pregnancy. Discontinuation for reasons other than wanting to become pregnant contribute to unwanted fertility and can lead to pregnancies that may be terminated through unsafe abortion. Not all discontinuation is necessarily problematic. Some women discontinue a particular method because it is difficult to use or its use is unacceptable to the woman or her partner (for example, due to side effects) and subsequently switch to another method—one that is more suitable to them and oftentimes more effective. This evidence review focuses on the incidence of and reasons for discontinuation, on interventions to reduce discontinuation and/or enhance switching, and on the measurement and monitoring of discontinuation.
On average, over one-third of women who start using a modern contraceptive method stop using within the first year, and over one-half stop before two years. More than half of discontinuations are among women experiencing contraceptive failure or have method-related problems with its use, and so are still in need of effective contraception to prevent an unintended pregnancy. The likelihood of discontinuation is fairly similar across all methods except IUDs and implants, for which lower rates of discontinuation (other than for pregnancy or no further need, and for failure) are likely due to their greater contraceptive effcacy and the need for removal by a health care professional. A lack of robust longitudinal studies and limited qualitative research, however, limits our understanding of individual and couple decision-making that contributes to discontinuation, especially in developing countries.
The majority of women who discontinue for reasons other than wanting a child or no longer needing protection report that they do so due to “method-related concerns.” These primarily comprise side effects such as prolonged bleeding or amenorrhea, which can concern or frighten women (and their partners), especially if they are unexpected and experience problems with using the method, expressed by the woman or her partner. Side effects may also have adverse sociocultural consequences. In some cases discontinuation occurs when abnormal bleeding or spotting limits a woman’s ability to pray, prepare food, or have intercourse when bleeding or spotting, especially among clandestine users. Myths and rumors (e.g., causing infertility or cancer) also contribute to discontinuation.
Concerns around side effects or myths can be reduced through interventions such as:
- Enabling women to discuss potential side effects: When women are given the opportunity to discuss side effects with their providers and with members of their social networks, continuation can increase and switching can be facilitated through better understanding of the nature of side effects.
- Engaging male partners: Enhancing couple communication about method characteristics can be efective in supporting continued use, particularly in the postpartum period.
- Ensuring client confidentiality: In some settings, male opposition to family planning may cause discontinuation of any method, thus ensuring client confidentiality is a priority intervention.
- Dispelling misconceptions: Service providers need to dispel misconceptions about the timing of initiating a method, especially when switching, through the pregnancy checklist or testing, and also for the perceived need for occasional “rest periods” from using hormonal methods.
- Counseling women who experience prolonged amenorrhea: Knowing that their menses will return and the average time for this to happen can reassure women who want to plan to become pregnant in the future.
DHS data indicate that between seven and 27% of women stop using a contraceptive method for reasons related to the service environment, including service quality, availability of a sufcient choice of methods, commodity stock-outs, and inefective referral mechanisms. Interventions to address these include:
- Increasing the number of methods available: Broadening the method mix available to women during consultations or through referrals is crucial. Adding one method or its equivalent to a program is associated with an eight-percentage-point decrease in contraceptive discontinuation.
- Enabling women to switch immediately: Women must be able to continue protection against unintended pregnancy by starting use of a more acceptable and efective method immediately if they experience problems.
- Ensuring efective partnerships between alternative sources of supply and/or providers: For example, through task sharing, to facilitate wider options for selecting an acceptable method and/or switching to another.
- Improve follow-up mechanisms: Reminding women of appointments for resupply methods, for example through mobile technology, can reduce unintentional discontinuation due to missing the clinically allowable grace period for resupply.
- Bringing the methods to women: Women can incur significant time and transport costs for resupply leading to discontinuation or late resupply; community-based, workplace-based, or outreach services that take the method to the woman can enhance continuation.
Individuals’ and couples’ motivation, intentionality, and ambivalence for desiring or avoiding a pregnancy and its influence on discontinuation remains poorly understood. Incorrect understanding about physiology and the perceived meaning and significance of regular menstruation may govern women’s use of contraception over and above providers’ medical advice about a method. Better understanding of how women perceive whether they have discontinued is crucial, therefore, to inform appropriate counseling and information so that women do not completely stop using contraception when they do not want to conceive. Lessons can potentially be learned from approaches for enhancing adherence with other preventive commodities, for example to antiretroviral medication, to support women who are ambivalent about continued use of a method.
Despite discontinuation being what Jain and colleagues have termed the “leaking bucket” that reduces the impact of family planning programs, FP2020 does not track a dedicated indicator that measures all-method or method-specific continuation rates (Jain 2014a). Several program indicators, including those used by Family Planning 2020 (FP2020) and Performance Monitoring and Accountability 2020 (PMA2020), do measure the various factors associated with discontinuation (usually through DHS-type surveys), but capturing client-specific information about method use over time is challenging because data need to be collected prospectively. Most current measures of discontinuation and switching are retrospective through questionnaire surveys and contraceptive calendars, and health and demographic surveillance systems (HDSS) have rarely measured contraceptive use dynamics. Health management information systems that follow clients longitudinally do exist (e.g., DHIS2, CLIC) and could be adapted to measure, detect, and potentially reduce discontinuation and/or facilitate switching, but mainstreaming such systems, especially in public sector programs, would require a major investment and reorientation of existing client registration systems. Given the significant influence of discontinuation on achieving FP2020’s goal, however, such investment would seem to be not only warranted but an urgent priority.
We propose a theory of change that identifies several pathways through which interventions addressing heath systems, service quality, and the sociocultural environment could reduce unnecessary discontinuation. Although many of these are based on evidence demonstrating their feasibility and efectiveness in certain contexts, implementation research is needed urgently to determine their utility in specific national settings and among various subpopulations. Social science research is also needed to better understand fertility intentions and contraceptive use within specific contexts.