As a result of the significant improvements in maternal and infant health and in social and economic well-being generated by the modern family planning movement, which began in the early 1900s, family planning has been hailed as one of the 10 greatest achievements in U.S. public health history.1–4 Yet despite the emergence of a variety of highly effective contraceptive methods in recent years, persistently high rates of unintended pregnancy underscore the fact that one of the original goals of the family planning movement—promoting and supporting informed fertility decisions—remains as relevant today as it was 100 years ago. In light of this conundrum and our collective experience as providers and researchers at a Title X–supported grantee agency, we recommend that over the coming decade, the service delivery research agenda include a relatively unexplored phenomenon that has important implications for the prevention of unintended pregnancy: contraceptive cycling, or recurring episodes of method uptake, discontinuation and switching over the course of a woman’s reproductive life span.
Dynamics of Contraceptive Use
As the term “contraceptive cycling” implies, contraceptive use is a dynamic process shaped by the interplay of individual, interpersonal, economic, social and cultural factors affecting individuals at different points in time. In addition to attitudes, beliefs and experiences regarding method safety and effectiveness, as well as ease of access to contraceptive services, these factors include evolving pregnancy desires and life circumstances (e.g., relationships, births, pregnancy experience, and plans for schooling or employment).5–8
While our experiences suggest that contraceptive cycling is a common phenomenon, research in this area has been limited, in part because of the methodological challenges and costs of prospectively monitoring contraceptive behavior over extended periods. Nevertheless, existing research does provide valuable insight into the ubiquity of method discontinuation and switching, as exemplified in Frost and colleagues’ study of a nationally representative sample of women at risk of unintended pregnancy.9 They found that 38% of participants had used the same methods continuously in the previous year, 23% had used contraceptives continuously but had switched methods at least once and 15% had experienced gaps in method use despite being at continued risk of unintended pregnancy. (Another 15% reported gaps in use because of pregnancy or periods of sexual inactivity, and 8% were consistent nonusers.)
A number of retrospective and prospective studies have found that the likelihood of contraceptive discontinuation is especially high within the first few months of use, and that method-related factors (e.g., ease of use or side effects) represent a key determinant of discontinuation.10–15 An event history analysis of reversible contraceptive use, based on the 2002 National Survey of Family Growth, demonstrated this point, as nearly half of the episodes of new method initiation ended within a year for method-related reasons.15 While seven in 10 episodes of discontinuation were followed by the uptake of a different contraceptive within a month, the transition from one method to another is characterized by an increased risk of unintended pregnancy for many women. For example, hormonal contraceptive users often switch to less effective, coitus-dependent methods.9,10,15,16
Need for New Service Models
In addition to our own studies and experience, the peer-reviewed literature6,17–22 provides compelling evidence that advances in contraceptive service delivery have failed to keep pace with advances in contraceptive technologies. Despite the methodological pitfalls of comparing studies separated by 70 years, we believe the juxtaposition of unintended birth estimates from service delivery–based research in the early 1930s and a more recent investigation of national birth data lends credence to this assertion. Researchers at the Birth Control Clinic Research Bureau in New York City found that half of all births to family planning patients seen in 1931–1932 were “accidental.”23 A 2001 estimate mirrors that finding—women using contraceptives at the time of conception accounted for almost half of all unintended births in the United States that year24—and therefore suggests that the prevalence of unintended pregnancy will not be addressed simply by the emergence of a range of more effective contraceptive options.
Given that contraceptive counseling represents the hallmark of family planning care, we believe that systematic research into contraceptive cycling could yield critical information for the development of evidence-based counseling models that promote informed contraceptive decisions. Such research could lead to counseling interventions that provide routine guidance on the management of side effects and the development of proactive contingency plans (e.g., use of emergency contraception in the event of contraceptive failure or safe switching plans in the event of method dissatisfaction).6,9,25 In addition, it might help identify how best to configure and deliver counseling interventions that include a systematic review of issues such as pregnancy desires, contraceptive attitudes and beliefs, advantages and disadvantages of different methods, and the potential influence of contextual factors on method selection and use. For instance, one contextual aspect that is often overlooked in counseling is the extent to which a male partner’s lack of familiarity with method options may influence a woman’s contraceptive decisions and subsequent behavior. The following comment by a 24-year-old male participant in one of our recent studies exemplifies this point:26
“She took her clothes off, and I said, ‘You lied, I thought you didn’t smoke.’ She said, ‘I didn’t lie, this is a pregnancy patch.’ I said, ‘You’re a crock. There’s no such thing.’”
Although the potential influence of a male partner on contraceptive choice and uptake represents just one contextual factor, it highlights the challenges that family planning providers face in providing information and guidance that are salient for an individual client, maximize consistent and correct use, and minimize method switching and attendant periods of exposure to pregnancy risk.
Implications for Research and Practice
Current approaches to the delivery of family planning care have done little to reduce the nation’s high rate of unintended pregnancy. In the coming decade, whether by chance or by design, the service delivery system is certain to face a multitude of direct care, technological, economic and structural challenges and opportunities. New contraceptive technologies may emerge—including one or two options for men—and oral contraceptives may become available over the counter; service demands may increase as a result of health care reform and expansions in Medicaid family planning waivers; and ever-expanding social networking technologies may provide new opportunities, as well as challenges, for influencing the contraceptive decision-making process and subsequent behaviors. Yet there is no cohesive body of research that provides a basic understanding of a fundamental issue involved in the delivery of family planning services: contraceptive cycling.
Writing from the vantage point of family planning service providers, we urge researchers to undertake a systematic and rigorous examination of the patterns of contraceptive use and corresponding influences that emerge over a person’s reproductive life span and are amenable to intervention. In addition to the potential to strengthen the organization, content and delivery of family planning services, findings from such seminal research might contribute to rethinking the current approaches and content of sex education curricula related to abstinence and contraceptive decision making among the nation’s youth.
Contraceptive cycling is a multifaceted, dynamic phenomenon that merits increased attention from the family planning research and service community.