Contraceptive discontinuation—ceasing to use one's current method of contraception—is common, though rates vary widely by country. According to Demographic and Health Survey (DHS) data from 18 countries, 20–50% of users of reversible modern methods of contraception discontinued their method during the first 12 months of use.1 In a 2009 study of DHS data from eight countries, the 12-month discontinuation rate ranged from 18% to 49%.2 Contraceptive discontinuation can be active, as it is when a woman must visit a clinic to have her IUD removed, or passive, requiring no extra effort, as it is whewoman misses an appointment for a reinjection or forgets to refill her prescription for birth control pills. Data from a wide range of countries show that contraceptive methods that can be passively discontinued, such as oral contraceptives, condoms, injectables and traditional methods, have higher rates of discontinuation than methods requiring active discontinuation, such as the IUD and implants.2–6
Not all women who discontinue a contraceptive method become nonusers; some switch to another, more (or less) effective method. However, women who want to avoid pregnancy but discontinue contraceptive use without switching to a new method are at risk for unplanned pregnancies and unwanted or mistimed births, which can lead to maternal, neonatal and infant morbidity and mortality.7–9 High rates of stopping may indicate missed opportunities to promote and sustain contraceptive use,10,11 and, therefore, can be a measure of family planning service quality. High-quality services that provide a range of contraceptive methods and offer counseling can increase the likelihood that women will switch rather than discontinue use altogether.12,13 A 2010 study of oral contraceptive discontinuation and switching behavior in 19 countries found that, on average, 35% of women who discontinued contraceptive use because of method dissatisfaction switched to another method within three months, leading the authors to suggest that more attention should be paid to the issue of method switching as opposed to simply method discontinuation.3
Whether a woman discontinues use of one method and switches to another or stops practicing contraception altogether depends on several factors. For example, women who stop using one method are not likely to switch or reinitiate use if they are not with a partner (because of divorce, separation or death of a spouse), can no longer become pregnant (are infecund) or want to become pregnant. Research has estimated that reduced need accounts for 7–20% of discontinuation of all reversible methods.13
Other factors include age, parity and union status, each of which is associated with discontinuation more consistently than are education, area of residence or household income.5,14However, urban women and women with higher levels of education and socioeconomic status are more likely to switch than stop after discontinuing a method, whereas older age is related to a decreased likelihood of switching.5,6 Side effects and health concerns are among the most common reasons women give for discontinuing a method.1,14 Though experiencing side effects increases the likelihood of method discontinuation,15,16 it is not known if it is associated with a woman's decision to switch to another method.
Research on service quality and contraceptive discontinuation has produced mixed results.11,17–21 Few studies have looked specifically at service quality and method switching; but, according to a 2005 study of switching behaviors in Bangladesh, women who had more contacts with family planning outreach workers were less likely to discontinue a method or stop use altogether than women who had fewer such contacts.22 Furthermore, although method characteristics influence discontinuation, they would not be expected to inhibit switching behavior, as long as other types of contraceptive methods are accessible. In research from Morocco, for example, women who lived near facilities that offered three or more methods were more likely to switch than were women who lived near facilities that offered fewer method choices.19
The goal of this analysis is to examine the differences between women who resumed contraceptive use shortly after discontinuing a method and women who stopped practicing contraception for at least one month before beginning another method or stopped altogether. We assess factors identified by previous studies as related to contraceptive use and discontinuation; these include demographic characteristics, fertility desires, perceived service quality, and experience with the discontinued method and its side effects. We also collected information on women's contraceptive decision making and include variables related to the degree of engagement with their partner, family and friends in discussing family planning methods and decisions to discontinue. We aim to compare method switchers with stoppers and to use the results to identify programmatic implications.
The study uses data from Honduras, a small Central American country with a population of approximately 7.3 million people. The prevalence of modern contraceptive use is relatively high in Honduras: 56% among married women aged 15–49.23 Female sterilization is the most commonly used modern method (21%), followed by the reversible methods of interest in this study: injectables (14%), birth control pills (11%) and the IUD (7%).23 The public sector—the Secretary of Health system of hospitals, health centers with doctors and dentists (CESAMOs), and rural health clinics staffed by nurses (CESARs)—supplies contraceptive services to 44% of the country's family planning users. The Honduran Family Planning Association (commonly known as ASHONPLAFA), the local International Planned Parenthood Federation affiliate, is the country's main private provider of family planning services, serving 25% of all users. Pharmacies, which provide contraceptives to 13% of users overall, are the most common provider of birth control pills, supplying 35% of pill users nationwide. Additional providers of contraceptive services include other private clinics and hospitals (9%) and hospitals of the Honduran Institute of Social Services (5%).
The data for this analysis come from a panel study on the determinants of contraceptive discontinuation conducted in four urban areas of Honduras: Tegucigalpa, San Pedro Sula, Santa Rosa de Copán/La Entrada and Gracias. The data were collected in two rounds: First, we administered a baseline survey questionnaire between October and November 2006; we conducted a follow-up survey one year later. The baseline data were collected from exit interviews with women who received the injectable, birth control pills or an IUD during a family planning appointment at one of 13 selected health facilities, which included seven CESAMOs, one Secretary of Health hospital and five ASHONPLAFA clinics. Eligible women were aged 15–44. They were either new or continuing users of one of the three reversible methods. No enrollment quotas by method type were required. All eligible, consenting women were interviewed until a total of 200 interviews were obtained from each of the four urban areas. Overall, 800 interviews were completed.
Follow-up data were collected between October and December 2007 from 84% (671) of the women who had participated at baseline. Interviewers used contact information provided by the respondents at baseline to locate the women and arrange for the follow-up interviews.
The baseline survey questionnaire collected information on demographic characteristics, birth histories, previous contraceptive use, perception of service quality at clinic appointment, motivation to avoid pregnancy and the family planning decision-making environment. The follow-up questionnaire collected information on contraceptive use for each month since the baseline interview (using a contraceptive calendar); experience of and reaction to side effects during the 12-month follow-up; and updates on demographics, fertility motivations and the decision-making environment.
Authorization for the study was obtained from the Institutional Review Board (IRB) of the University of North Carolina at Chapel Hill, the Honduran Secretary of Health and ASHONPLAFA. Written consent was obtained from each participant at baseline and follow-up.
The data on discontinuation behavior were extracted from the modified DHS monthly contraceptive calendars of the 273 women who discontinued their baseline method during the study period. Women were considered switchers if they began a method within a month of discontinuing the baseline method. They were considered stoppers if they did not use any other method during the follow-up period or resumed use of the same or another method after at least one month of nonuse. The dependent variable is coded "1" for switching and "0" for stopping with an episode of nonuse.
Independent variables included demographic characteristics, fertility desires, service quality, method characteristics, the experience of and reaction to side effects, communication with others about side effects and main reason for discontinuation.
At the baseline interview, women were asked to respond yes or no to the following questions about the quality of counseling and service provision during their appointment: Had all their questions been answered by a provider? Had they received information on how to use their contraceptive method effectively? Had they received information on the advantages and disadvantages of their method? Had they ever been informed of side effects of their method? Several questions about women's clinic appointment experiences (their level of satisfaction with a clinic's cleanliness, degree of privacy, quality of provider treatment and care) were omitted from the study because responses produced little variation (fewer than 10% were negative).
At follow-up, women were asked to respond yes, no or no side effect to the following questions about their experience of side effects during the study period: Had they had any side effects? Had they had two or more side effects? Had their side effects included abdominal pain, amenorrhea, dizziness, facial spotting, heavy bleeding, infections, irregular bleeding, nausea or vomiting, weight gain or weight loss? Although the women mentioned some or all of these side effects, at least 50 women each mentioned headaches, amenorrhea and heavy bleeding, the side effects selected for inclusion in the analysis. Women who experienced no side effects were included in the reference category of women who responded no when asked about specific side effects.
A cross-tabulation was constructed to compare the characteristics of women who switched methods to those of women who stopped use for at least one month. Pearson's chi-square test was used to identify associations between the dependent variable and each independent variable. Independent variables associated with the dependent variable with at least a 90% degree of significance were considered for the multivariate analysis.
A further descriptive analysis was conducted among women who discontinued their baseline method because of headaches, amenorrhea or heavy bleeding. The analysis compared the attitudes and behaviors of women who switched to another method with those of women who stopped practicing contraception for at least one month, by side effect. The analysis included only the most commonly experienced side effects (headaches, amenorrhea and heavy bleeding). Pearson's chi-square test was used to identify significant differences between groups in their reactions to specific side effects.
A multivariate logistic regression was conducted to identify differences between women who switched methods and women who stopped and did not resume use of any method for a least one month. Before building the multivariate model, we used Spearman's p to identify associations between predictor variables. Correlations between predictor variables were assessed before running the regression. In any pair of variables with a correlation greater than +/-0.6, we eliminated one from the model. Union status was captured in the null categories for partner variables. Women not experiencing side effects were part of null categories. All analyses were run using STATA version 10.1.
A total of 273 women (41%) from the full panel sample discontinued their baseline method during the 12 months of the study. Table 1 presents characteristics of the full sample by whether they continued their baseline method throughout the 12-month study period or discontinued contraceptive use for at least one month. The two groups of women differed significantly in the proportions who were not currently in a union (7% of continuers vs. 16% of discontinuers) or who used the injectable at baseline (69% vs. 78%).
Of the 273 discontinuers, 117 switched to another method and 156 stopped contraceptive use for one month or more (Table 2). Compared with stoppers, women who switched tended to be younger and more highly educated; they also were more likely to be in union (90% vs. 80%), urban (84% vs. 68%) and of lower parity (55% vs. 42%). Switchers were also more likely than stoppers to be using the IUD and less likely to be using the injectable at baseline, to be new method users (62% vs. 47%), to have discussed discontinuing with their partner prior to doing so (86% vs. 60%) and to have discontinued because of problems with the method (88% vs. 49%). A greater percentage of switchers than stoppers experienced side effects (90% vs. 70%), including side effects that interfered with daily activities (55% vs. 35%) or the relationship with their partner (41% vs. 24%). Also, a significantly greater percentage of switchers than stoppers discussed these side effects with two or more people (57% vs. 32%), their partner (63% vs. 37%) or a health worker (49% vs. 27%). Among women who switched, 37% chose the pill, 21% an injectable and 14% the IUD; 14% chose traditional methods and 13%, condoms (not shown).
An additional descriptive analysis of the attitudes and behaviors of discontinuers, by type of side effect, revealed significant differences in health-seeking behaviors, discussion of side effects and decisions to stop contraceptive use between those who switched to a new method and those who stopped (Table 3). However, results should be interpreted with caution because of the small subgroups. Among women who had headaches (82), the only significant difference between those who switched and those who stopped was in the percentage who discussed ceasing use of the baseline method with their partner before deciding to stop (89% vs. 70%). Among women with amenorrhea (66), switchers were significantly more likely than stoppers to have sought help from a clinic or health worker (64% vs. 36%). For women with heavy bleeding (64), switchers were significantly more likely than stoppers to have discussed side effects with two or more people (100% vs. 86%), with their partner specifically (81% vs. 46%), and to have discussed with their partner beforehand the decision to stop using their baseline method (97% vs. 68%). The results indicated that there were no significant differences by perceived severity of the side effect (i.e., whether side effects interfered with daily activities or relationship with partner). Further significant differences might be detected with larger sample sizes.
In the multivariate analysis, fewer variables were associated with the dependent variable than in the bivariate analysis (Table 4).* Among demographic variables, only area of residence remained significant, indicating that among women in urban areas, the odds of switching instead of stopping were almost 2.6 times as high as the odds among women in rural areas. Compared with women who had used a method for more than a year, those who had used a method for a year or less were significantly more likely to have switched than to have stopped (odds ratio, 3.5). As in the bivariate analysis, experiencing amenorrhea was associated with a reduced risk of switching methods (0.3). However, heavy bleeding, which was associated with switching in the bivariate analysis, lost significance in the multivariate analysis. Women who sought help with side effects from a clinic or health worker and who discussed discontinuing a method with their partner before doing so were also significantly more likely to have switched to another method than to have stopped (2.0 and 3.2, respectively). And, women who discontinued their baseline method because of problems with it were more likely to switch than were women who discontinued because of reduced need or for other reasons (6.1).
Contraceptive discontinuation was common in the study population: More than four out of 10 women quit using their baseline method within the 12-month study period. However, 43% of these women switched to another method within a month. In a comparison of switchers and stoppers, we found significant differences in demographic characteristics, experience of side effects, discussion of discontinuation and main reason for discontinuation.
The study had some limitations. For example, right and left censoring of the data marked the periods before and after the study. Also, the analysis focused on the discontinuation and what happened in the next month; as a result, additional censoring of the data due to analytic constraints occurred. For instance, switchers may have used a new method for only a single month or in the index month immediately following discontinuation of the baseline method. Similarly, stoppers may have resumed use of the same or another method after a lapse of one month or more, in effect becoming switchers. A larger study population and a longer period of observation could address some of these issues.
In the literature, switching is assessed for the first three months after discontinuation, even though pregnancy could occur during this period.3 However, assessing switching for just one month may not produce fewer significant results. Research from the 2002 U.S. National Survey of Family Growth found that most switching occurs in the first month after discontinuation; the probability of resuming contraceptive use after discontinuation was 72% in the first month, and reached only 76% by three months.24
Another limitation of the analysis is its assessment of switching behavior rather than duration of contraceptive use. A woman who discontinued her baseline method early in the study period could have switched to—and subsequently discontinued—another method; therefore, she may have had fewer months of contraceptive use than a woman who discontinued at month 11 without adopting another method. Data from only 12 months does not allow for close examination of contraceptive use, though we do know that the mean time until discontinuation of the baseline method was comparable for the two groups of women: 6.0 months for switchers and 6.4 months for stoppers. Finally, the influence of side effects and related behaviors on discontinuation may be affected by the inclusion of women with no side effects in the reference group for these variables.
Despite these limitations, the study yielded interesting findings. Multivariate analysis showed that women living in urban areas were more likely to be switchers than stoppers, possibly because more urban than rural women used IUDs, which require an active decision and a clinic visit to discontinue. Urban women also have easier access to family planning services, including a more diverse supply of methods and providers. Conversely, limited access to services, as well as a lack of encouragement to seek help for side effects from a clinic or health worker, may reduce method switching.
Of all variables related to side effects, seeking help from a health clinic was most strongly related to method switching. Though side effects may lead to method discontinuation, their relationship with subsequent use is less clear. According to our findings, only amenorrhea was negatively associated with switching. This suggests that amenorrhea discourages the immediate uptake of new methods. Formative qualitative work in Honduras with current and previous users of contraceptives indicates that amenorrheic women discontinue for two main reasons: to determine their pregnancy status and to reestablish regular menstrual patterns. In our study, amenorrhea was most common among injectable users. These findings suggest an opportunity for providers to teach women about amenorrhea during initiation of the injectable and to discuss the adoption of nonhormonal barrier methods with women who otherwise may take a break from contraception to determine if they are pregnant.
Finally, the study found an association between switching and discussing discontinuation with a partner before deciding to discontinue. The study did not, however, determine what it is about discussions with a partner (or others) that supports switching behavior. Do discussions reinforce a woman's decision to use family planning and encourage her to try a different method (i.e., the quality of the discussion)? Or do discussions represent supportive relationships and being able to confide troubles and discuss family planning options with a partner or spouse or others (i.e., the quality of the relationship)?
Answers to these questions are beyond the scope of the present research, yet point to avenues for further investigation. In the meantime, our findings underscore the need for Honduran family planning programs to provide women with a full array of contraceptive methods and providers, ensuring that all women have access to services that support contraceptive continuation. Our findings also suggest that Honduran family planning programs, in their effort to support women's continuing contraceptive use, should encourage them to talk with their partners, family and others about stopping or switching methods before making—and acting on—a decision.