Side effects are the most common reason cited by Bangladeshi women who stop using oral contraceptives, according to a survey of rural women with recent experience with the pill.1Fifty-three percent of women who had discontinued oral contraceptive use attributed their decision to side effects, while 21% cited the desire for a child. In a multivariate analysis that confirmed the importance of side effects, pill discontinuation was also significantly more common among women who were Muslims, those who had used some other method before the pill, those who had not been visited by a family planning fieldworker and those who were not supported by their husband in their decision to use the pill.

Oral contraceptives contribute a substantial share of overall contraceptive prevalence in Bangladesh, representing about half of all modern method use in 1997. Past research has suggested that patterns of pill use among Bangladeshi women are somewhat irregular, and side effects have been mentioned as a possible contributor to these patterns of use.

A survey of contraceptive knowledge, attitudes and practices was undertaken in Bangladesh in 1995 and 1996 to analyze women's use of the pill. The survey was restricted to women who were either current users of oral contraceptives or who were former users (i.e., had ceased use during the six months immediately before the survey). Participation was limited to women living in rural areas of Bangladesh covered by the government's family planning fieldworkers. Although the classification of women as former or current pill users was based on their own reports, the researchers were able to confirm the information by checking the fieldworkers' contraceptive use registers.

A total of 1,403 currently married women aged 15-49 were surveyed. The survey respondents were 30 years old, on average, and had a mean of 3.2 children. Eighty-five percent were Muslim, and most had no formal schooling. (The women's average educational level was 2.3 years.)

Forty-three percent of the women were former users of the pill. Discontinuation was significantly more common among Muslim women (44%) than among non-Muslim women (36%), but was significantly less common among women whose husband had a supportive attitude toward their pill use, who had used the pill for four years or more, who were using the pill as their first method, who had been visited by a fieldworker and who had never experienced side effects.

The survey respondents were asked to describe side effects that they had felt during their first three months of pill use. Fifty-seven percent of the sample mentioned dizziness, while 29% cited weakness, 23% nausea, 10% a burning sensation and smaller percentages such side effects as excessive or irregular bleeding or abdominal pain, among others. Oral contraceptive discontinuation was not related to the number of side effects the women reported having experienced.

When asked to give the main reason why they stopped taking the pill, 53% attributed their decision to side effects, 21% cited wanting another child, and small percentages (about 3% each) cited their husband's dislike of the pill, a pregnancy, a belief that the pill is hazardous or a lack of supplies.

To determine how side effects and pill discontinuation might be related, the investigators conducted a multivariate regression analysis. Overall, women who had experienced side effects were significantly more likely than those who had not to have discontinued oral contraceptive use (odds ratio, 1.4). In contrast, women were less likely to have discontinued use if they had used the pill for longer durations: 12-23 months of use (odds ratio, 0.5), 24-47 months of use (0.4), and 48 months or more (0.2).

When the effects of the experience of side effects and duration of pill use were controlled, several other attributes significantly affected whether women discontinued oral contraceptive use. The risk of having stopped using the pill was significantly elevated among Muslims (odds ratio, 1.5), among women who had used a method before the pill (1.8), among those who had not been visited by a fieldworker (3.4) and among those whose husbands were not supportive of their use of the pill (1.9).

Among women who had discontinued pill use but wanted no more children, 72% were using no method of contraception at the time of the survey, 10% were using the injectable, 8% traditional methods, 7% the condom and 4% other methods.

The researchers note that the study had several limitations. First, its reliance on the respondents' recollections of their pill use and their experiences while using the method leaves the analysis subject to recall bias. In addition, the cross-sectional research design prevents the authors from establishing causal relationships.

The researchers offer three conclusions drawn from their analyses. First, service providers should be sure to counsel pill clients about potential side effects, about how problems can be managed and about what methods can be used if the pill proves unacceptable. In addition, husbands and male partners should be counseled about correct pill use and how use can be continued, as well as about condom use as an alternative method. Finally, service providers need in-service training to enable them to adequately inform clients about pill-related side effects.--M. Klitsch

=subhead =subhead REFERENCE

1. Khan MA, Side effects and oral contraceptive discontinuation in rural Bangladesh, Contraception, 2001, 64(3):161-167.