Both new adopters and continuing users of reversible family planning methods are at high risk for method discontinuation, according to a cohort study conducted in Honduras.1 During the 12-month study—one of the few to simultaneously examine a comprehensive range of factors thought to be associated with method discontinuation—41% of women stopped using their method. Discontinuation was associated with parity and other demographic characteristics (odds ratios, 1.3–2.0), as well as with the experience of various side effects (1.6–2.1), but was not related to clinic service quality.
To examine method discontinuation patterns, the researchers interviewed women who were obtaining contraceptives from one of 13 public or private clinics in four urban areas in Honduras in 2006. Women were eligible for the study if they were aged 15–44 and were new or continuing users of the pill, injectable or IUD. They were interviewed after receiving their method and again 12–15 months later. At baseline, the women were asked about their demographic characteristics, previous use of contraceptives, birth history and motivation to avoid pregnancy; they also answered questions about their partner's involvement in family planning (e.g., the number of times the respondent had discussed family planning with her partner in the past year) and the quality of clinic services (e.g., whether all of the respondent's questions had been answered). At follow-up, the women updated their demographic information and reported their contraceptive use since baseline and their experiences of method side effects. If a woman stopped using her original method, she was classified as having discontinued use of the method; if she stopped using the method and did not switch to a new one, she was considered to have had an episode of contraceptive nonuse. Eight hundred women were interviewed at baseline, of whom 671 (84%) completed a follow-up interview. The researchers used life-table analysis to provide information on the pace of method discontinuation among new users; Cox proportional hazards models were used to assess whether there were associations between method discontinuation and individual characteristics, fertility motivation, experience of side effects, service quality and method characteristics for the full sample of women.
At baseline, most women were younger than 35 and were married or in a union (94% for each); 77% lived in an urban area. Only 3% of the women had no children. Thirty-four percent did not want any children in the future; the remainder wanted a child within two years (12%), wanted children in two or more years or at some undetermined point in the future (47%), or were undecided about whether to have children (6%). Seventy-two percent were using the injectable, while 21% were using the IUD and 7% the pill. Nearly half (48%) were new users, and 20% had been using their contraceptive method for a year or less.
Only 36% of the women reported that they had been told about the benefits and disadvantages of their method during their clinic visit. Forty-three percent said they had been told how to use their method effectively, and 58% felt that their provider had answered all of their questions. About one-third said that their provider had discussed at least two methods with them during the visit.
At follow-up, two-thirds of respondents reported having had at least one side effect from their method during the past 12 months; headaches and amenorrhea were most common, experienced by 27% and 22% of respondents, respectively. More than one-third of respondents, and half of those with contraceptive side effects, felt that side effects ?interfered with their daily lives or personal ?relationships, and 45% of all women had ?recently discussed their side effects or health concerns with friends or family. Seventy-nine percent had discussed family planning with their partner in the previous year.
During the follow-up period, 41% of the women discontinued their method. This rate was significantly higher among users of the pill (49%) and the injectable (44%) than among IUD users (28%). Forty-three percent of those who discontinued their method switched to a different method during the study period; method switching occurred among 18% of the total sample, and was almost equally common across methods (17–19%).
During the first six months, 12% of women who were using a method for the first time experienced a period of nonuse and 23% discontinued their method altogether. By 12 months, 30% had experienced a period of nonuse and 45% had discontinued use. Injectable users had the highest rates of nonuse and discontinuation; after 12 months, for example, 50% had discontinued the method, compared with 31% of IUD users and 44% of pill users.
In multivariate analyses, women 25 or older were more likely than those aged 15–24 to stop using their method (odds ratio, 1.3). In addition, the odds of discontinuation were higher among women with 0–1 children than among those with two or more (1.4), and higher among those who were not in a union than among those who were married or in a union (2.0). Women who had experienced heavy bleeding, weight gain and dizziness while using contraceptives were more likely than those without any side effects to have discontinued their method (1.6–2.1). Those who felt these side effects interfered with their daily lives or personal relationships had elevated odds of method discontinuation (1.8), while women who had discussed their side effects or health concerns with friends or family had reduced odds of discontinuation (0.8). The only predictors of nonuse were not being in a union (2.3), wanting a child within two years (2.0) and having heavy bleeding (1.9). Measures of clinic service quality and length of method use at baseline were not related to discontinuation or nonuse.
The researchers acknowledge several limitations: Measures of quality of care may have been affected by courtesy bias; the respondents' ability to remember the timing of events may have influenced their reports of discontinuation; and contraceptive use patterns in the sample may have differed from those of women attending other types of clinics.
The investigators note that the high rate of discontinuation seen in the study "is to be ?expected" in countries such as Honduras, where reversible methods are most often used for child spacing, and "is not necessarily a negative outcome, so long as women who want to delay or limit childbearing are able to adopt an alternate method." Providers should "be prepared for discontinuation" and encourage women "to return to the provider if they have problems with a method." But although some discontinuation is likely, the ?researchers suggest that "programs that provide comprehensive services, including counseling concerning methods' side effects and approaches to switching methods, could improve continuation and lead to a reduction of unintended pregnancies and improved maternal and child health outcomes."
1. Barden-O'Fallon J et al., Contraceptive discontinuation among Honduran women who use reversible methods, Studies in Family Planning, 2011, 42(1): 11–20.