Predictors of contraceptive discontinuation in Rwanda: evidence from demographic and health survey 2019-2020

BACKGROUND

Despite advancements, Rwanda continues to face challenges regarding contraceptive discontinuation. The 2019-2020 Rwanda Demographic and Health Survey (DHS) reported a 30% discontinuation rate among women within the first year of use. This study analyses predictors of discontinuation using this DHS data, with the goal of strengthening Rwanda's family planning programs.

METHODS

Data from the 2019-20 Rwanda DHS (14,634 women aged 15-49) was examined. A two-stage sampling design informed the survey. Life table methods and Cox proportional hazard models were used to analyze discontinuation rates, median usage duration across contraceptive methods, and the influence of demographic and other factors.

RESULTS

Results indicated a progressive rise in contraceptive discontinuation over different period: 16.69% at 6 months, 29.29% at 12 months, and 47.21% at 24 months. Pills and male condoms showed higher discontinuation probabilities early on. While injectables and LAM initially showed lower discontinuation, rates rose significantly by the 24th month. Health concerns and side effects were the primary reasons cited for discontinuation. The Cox proportional hazards analysis revealed significant factors influencing discontinuation: contraceptive method, desire for pregnancy, husband's disapproval, access/availability, and the desire for a more effective method.

CONCLUSION

This study highlights substantial contraceptive discontinuation rates in Rwanda, particularly for pills and injectables. Method type, health concerns, side effects, and method failure were associated with discontinuation. Interventions should focus on improving contraceptive continuation and investigating alternative methods with lower discontinuation tendencies.

Comparing the reasons for contraceptive discontinuation between parenting adolescents and young women in sub-Saharan Africa: a multilevel analysis

BACKGROUND

Adolescent sexual and reproductive health remains a major public health and development issue of global importance. Given that adolescents and young people are heterogenous groups in terms of many characteristics, this study expands the literature by comparing the reasons for contraceptive discontinuation between parenting adolescents (aged 15-19) and parenting young women (aged 20-24) in sub-Saharan Africa (SSA).

METHODS

Data for the study came from Demographic and Health Surveys of 22 SSA countries. The outcome variable was reasons for discontinuation. We performed multilevel binary logistic regression on analytic samples comprising 1485 parenting adolescents and 10,287 parenting young women across the selected SSA countries.

RESULTS

Findings show that the proportion of respondents who used modern contraceptives was lower among parenting adolescents (35%) relative to their 20-24-year-old counterparts (43%). Higher percentages of parenting adolescents than young women discontinued contraceptives because of reasons such as pregnancy or method failure (i.e., 9.9% and 8.17% accordingly), husband disapproval, access or availability issues, wanting more effective methods, and inconvenience in using methods. The multilevel analysis further highlighted disparities between parenting adolescents and parenting young women who discontinued contraceptives. For instance, parenting young women had 30% lower odds of discontinuing contraceptives due to pregnancy or method failure than parenting adolescents.

CONCLUSION

The study established disparities in the reasons for contraceptive discontinuation between parenting adolescents and parenting young women, with adolescents demonstrating greater vulnerabilities and higher risks. Considerable attention must be given to parenting adolescents in the efforts to achieve equity goals such as the Sustainable Development Goals and universal health coverage in SSA.

Prediction of contraceptive discontinuation among reproductive-age women in Ethiopia using Ethiopian Demographic and Health Survey 2016 Dataset: A Machine Learning Approach

BACKGROUND

Globally, 38% of contraceptive users discontinue the use of a method within the first twelve months. In Ethiopia, about 35% of contraceptive users also discontinue within twelve months. Discontinuation reduces contraceptive coverage, family planning program effectiveness and contributes to undesired fertility. Hence understanding potential predictors of contraceptive discontinuation is crucial to reducing its undesired outcomes. Predicting the risk of discontinuing contraceptives is also used as an early-warning system to notify family planning programs. Thus, this study could enable to predict and determine the predictors for contraceptive discontinuation in Ethiopia.

METHODOLOGY

Secondary data analysis was done on the 2016 Ethiopian Demographic and Health Survey. Eight machine learning algorithms were employed on a total sample of 5885 women and evaluated using performance metrics to predict and identify important predictors of discontinuation through python software. Feature importance method was used to select top predictors of contraceptive discontinuation. Finally, association rule mining was applied to discover the relationship between contraceptive discontinuation and its top predictors by using R statistical software.

RESULT

Random forest was the best predictive model with 68% accuracy which identified the top predictors of contraceptive discontinuation. Association rule mining identified women's age, women's education level, family size, husband's desire for children, husband's education level, and women's fertility preference as predictors most frequently associated with contraceptive discontinuation.

CONCLUSION

Results have shown that machine learning algorithms can accurately predict the discontinuation status of contraceptives, making them potentially valuable as decision-support tools for the relevant stakeholders. Through association rule mining analysis of a large dataset, our findings also revealed previously unknown patterns and relationships between contraceptive discontinuation and numerous predictors.

The association between depression and contraceptive behaviors in a diverse sample of new prescription contraception users

OBJECTIVE

Among women initiating new prescription contraception, we investigated the relationship between recent depression and a range of contraceptive behaviors.

STUDY DESIGN

We used medical and pharmacy records of 52,325 women ages 19 to 29 who initiated prescription contraception (pills, patches or rings, injectables, and long-acting reversible contraceptives) in 2014-2016 at a large integrated healthcare system in Northern California. Women had continuous enrollment for a year before and after initiating, and no records of prescription contraceptive use in the year before initiating. Depression in the year prior to initiation was dichotomized into (1) no depression indicator (reference group) or (2) depression diagnosis or redeemed antidepressant. Multinomial logistic regression models examined the associations between depression and method type initiated, and contraceptive patterns, timing of discontinuation, inconsistent use, and switching methods over a year after initiating, adjusting for sociodemographics and testing for interactions between depression and having a recent birth or abortion.

RESULTS

Women with recent depression were more likely to initiate methods other than the pill, and the association was stronger for patches or rings vs pills among those with a recent birth compared to those without. Among women initiating all methods and the pill, those with depression were more likely to discontinue their method, use it inconsistently, and switch from it than use it continuously for a year.

CONCLUSION

Women with recent depression were less likely to initiate the pill; and when the pill was initiated, those with depression were more likely to discontinue use, use it inconsistently, and switch from it.

IMPLICATIONS

Women with recent depression indicators should be followed closely to ensure they have the support they need to meet their reproductive goals. Those who wish to avoid pregnancy may benefit from methods that do not require daily use.

Return to pregnancy after contraceptive discontinuation to become pregnant: a pooled analysis of West and East African populations

BACKGROUND

The fear of infertility or delayed return to fertility is a common barrier to contraceptive use in sub-Saharan Africa, particularly among young or nulliparous women. Global evidence on return to pregnancy after method discontinuation suggests these fears may be misplaced; yet the topic has not been widely studied in sub-Saharan Africa nor by age and parity group.

METHODS

Reproductive calendar data from recent Demographic and Health Surveys of 15 sub-Saharan African countries were used to analyze time-to-pregnancy following discontinuation of a contraceptive method with the reason to become pregnant. The probability of pregnancy at 12 months was estimated using single-decrement life tables run by type of method discontinued, age and parity. Results are presented by region: francophone West Africa, anglophone West Africa and East Africa.

RESULTS

The 12-month probability of pregnancy after discontinuation of contraception to become pregnant was 73.0% in francophone West Africa, 78.8% in anglophone West Africa, and 82.0% in East Africa. Our results showed significant regional differences in return to pregnancy by 12 months, with probabilities in francophone West Africa being significantly lower than in anglophone West Africa or East Africa. A lower return to pregnancy by 12 months was seen among women ages 35-49 years and was lowest after discontinuation of a hormonal method for all age groups. Differences by parity group were only evident after discontinuation of hormonal methods in francophone West Africa.

CONCLUSIONS

Sustainable gains in increasing contraceptive uptake, especially among youth, may be difficult to achieve without information and counseling that address concerns about infertility and potential delays in return to pregnancy following use of hormonal methods.

A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya

BACKGROUND

Addressing the unmet need for modern contraception underpins the goal of all family planning and contraception programs. Contraceptive discontinuation among those in need of a method hinders the attainment of the fertility desires of women, which may result in unintended pregnancies. This paper presents experiences of contraceptive use, reasons for discontinuation, and future intentions to use modern contraceptives.

METHODS

Qualitative data were collected in two rural counties in Kenya in 2019 from women with unmet need for contraception who were former modern contraceptive users. Additional data was collected from male partners of some of the women interviewed. In-depth interviews and focus group discussions explored previous experience with contraceptive use, reasons for discontinuation, and future intentionality to use. Following data collection, digitally recorded data were transcribed verbatim, translated, and coded using thematic analysis through an inductive approach.

RESULTS

Use of modern contraception to prevent pregnancy and plan for family size was a strong motivator for uptake of contraceptives. The contraceptive methods used were mainly sourced from public health facilities though adolescents got them from the private sector. Reasons for discontinued use included side effects, method failure, peer influence, gender-based violence due to covert use of contraceptives, and failure within the health system. Five reasons were provided for those not willing to use in the future: fear of side effects, cost of contraceptive services, family conflicts over the use of modern contraceptives, reduced need, and a shift to traditional methods.

CONCLUSION

This study expands the literature by examining reasons for contraceptive discontinuation and future intentionality to use among women in need of contraception. The results underscore the need for family planning interventions that incorporate quality of care in service provision to address contraceptive discontinuation. Engaging men and other social influencers in family planning programs and services will help garner support for contraception, rather than focusing exclusively on women. The results of this study can inform implementation of family planning programs in Kenya and beyond to ensure they address the concerns of former modern contraception users.

Short-acting hormonal contraceptive continuation among low-income postpartum women in Texas

OBJECTIVE

The objective was to assess continuation of the pill, patch, ring or injectable (i.e., short-acting hormonal contraception); characteristics associated with discontinuation; and subsequent method use among low-income postpartum women in Texas.

STUDY DESIGN

Using a 24-month cohort study of 1700 women who delivered in eight Texas hospitals and were uninsured or publicly insured at the time of delivery, we focused on 456 women who used short-acting hormonal contraception within 6 months after delivery. We classified this sample according to characteristics and method preference, and estimated rates of discontinuation and associated predictors using life tables and Cox models. We assessed reasons for discontinuation and subsequent contraceptive use among those who discontinued.

RESULTS

Roughly half used the pill and half used the injectable. One hundred seventy-eight (39%) expressed a baseline preference for the method they used, 162 (36%) preferred a long-acting reversible contraception method, and 41 (9%) preferred sterilization. After 1 year, 72% had discontinued [95% confidence interval (CI) 67.1-75.7]. Foreign-born Hispanic women were less likely to discontinue than U.S.-born Hispanics [adjusted hazard ratio (aHR), 0.65; 95% CI 0.50-0.84]. Those who wanted a more effective method (aHR, 1.44; 95% CI 1.12-1.85) and those who lost insurance coverage (aHR, 1.47; 95% CI 1.12-1.92) were more likely to discontinue. The most common reasons for discontinuation were side effects and access/cost. Of those who discontinued, 243 (68%) switched to a less effective or no method. Only 47 (13%) switched to their preferred method.

CONCLUSIONS

Short-acting hormonal contraceptive discontinuation is high in this population. Many switch to less effective methods after discontinuation despite preferring methods at least as effective as the pill, patch, ring or injectable.

IMPLICATIONS

Expanding contraceptive coverage in the 2 years after delivery should be a state and federal policy priority. In clinics, providers should discuss contraceptive preferences throughout pregnancy and the interpregnancy interval.

Share of current unmet need for modern contraceptive methods attributed to past users of these methods in India

Despite persistent efforts, unmet need for contraceptives in India has declined only slightly from 14% to 13% between 2005-06 and 2015-16. Many women using a family planning method discontinue it without switching to another method and continue to have unmet need. This study quantified the share of current unmet need for modern contraceptive methods attributed to past users of these methods in India. Data were drawn from two rounds of the National Family Health Survey conducted in 2005-06 and 2015-16. Using information on women with current unmet need, and whether they used any modern method in the past, the share of past users with current unmet need for modern methods was calculated. Bivariate and multivariate analyses were performed. Among 46 million women with unmet need, 11 million were past users of modern methods in 2015-16. The share of current unmet need attributed to past users of modern contraceptive methods declined from 27% in 2005-06 to 24% in 2015-16. Share of current unmet need attributed to past users was associated with reversible method use. This share rose with increased use of modern reversible methods. With the Indian family planning programme's focus on increasing modern reversible method use, the share of unmet need attributed to past users of modern methods is likely to increase in the future. The programme's emphasis on continuation of contraceptive use, along with bringing in new users, could be one of the key strategies for India to achieve the FP2020 goals.

Measures of family planning service quality associated with contraceptive discontinuation: an analysis of Measurement, Learning & Evaluation (MLE) project data from urban Kenya

Introduction: Several measures to assess family planning service quality (FPQ) exist, yet there is limited evidence on their association with contraceptive discontinuation. Using data from the Measurement, Learning & Evaluation (MLE) Project, this study investigates the association between FPQ and discontinuation-while-in-need without switching in five cities in Kenya. Two measures of FPQ are examined - the Method Information Index (MII) and a comprehensive service delivery point (SDP) assessment rooted in the Bruce Framework for FPQ. Methods: Three models were constructed: two to assess MII reported in household interviews (as an ordinal and binary variable) among 1,033 FP users, and one for facility-level quality domains among 938 FP users who could be linked to a facility type included in the SDP assessment. Cox proportional hazards ratios were estimated where the event of interest was discontinuation-while-in-need without switching. Facility-level FPQ domains were identified using exploratory factor analysis (EFA) using SDP assessment data from 124 facilities. Results: A woman's likelihood of discontinuation-while-in-need was approximately halved whether she was informed of one aspect of MII (HR: 0.45, p < 0.05), or all three (HR: 0.51, p < 0.01) versus receiving no information, when MII was assessed as an ordinal variable. Six facility-level quality domains were identified in EFA. Higher scores in information exchange, privacy, autonomy & dignity and technical competence were associated with a reduced risk of discontinuation-while-in-need (p < 0.05). Conclusions: The MII has potential as an actionable metric for FPQ monitoring at the health facility level. Furthermore, family planning facilities and programs should emphasize information provision and client-centered approaches to care alongside technical competence in the provision of FP care.

Contraceptive discontinuation: frequency and associated factors among undergraduate women in Brazil

Background

In Brazil, high contraceptive prevalence rates coexist with high rates of unintended pregnancies. Contraceptive discontinuation may explain this context, but few studies have focused on highly educated young women in countries with low unmet need for modern contraception. This paper explores frequency and associated factors of contraceptive discontinuation among undergraduate students in Brazil within 12-months.

Methods

This retrospective cohort study was conducted among a probability sample of 1679 undergraduates of São Paulo University. Data were collected online using a contraceptive calendar. We examined factors related to monthly discontinuation of oral pills and male condoms using Generalized Estimating Equation models.

Results

Altogether, 19% of oral pill users and 48% of male condom users discontinued their method for method-related reasons within 12-months, and 18% of oral pill users and 15% of male condom users abandoned/or switched to less effective methods. Women in casual relationships were at increased odds of oral pill (OR = 1.4 [1.1–1.8]) and male condom discontinuation (OR = 1.3 [1.0–1.7]), and at increased odds of switching from oral pill to less effective or no method (OR = 1.4 [1.1–1.7]). Other associated factors were method specific. Women from lower socioeconomic status or who had multiple lifetime partners were more likely to discontinue or abandon the oral pill, while more sexually experienced women were less likely to discontinue the male condom.

Conclusion

Frequent method discontinuation in Brazil calls for greater attention to the difficulties women face when using short acting methods. Discontinuation was associated with type of partner and sexual experience highlighting the changing contraceptive needs of women at the early stages of their professional careers.

Side effects and the need for secrecy: characterising discontinuation of modern contraception and its causes in Ethiopia using mixed methods

BACKGROUND

Contraceptive discontinuation is a major barrier to reducing global unmet needs for family planning, but the reasons why women discontinue contraception are poorly understood. Here we use data from Ethiopia to investigate (i) the magnitude of contraceptive discontinuation in 2005-2011, (ii) how the risk of discontinuation varies with method type and education level and (iii) the barriers to continuation. Our main hypothesis is that contraceptive discontinuation is driven by the experience of physiological side-effects associated with the use of hormonal contraception, rather than a lack of formal education.

METHODS

We used a mixed methods explanatory sequential design to explain the quantitative results in more details through the qualitative data. First, we analysed quantitative data from the 2011 Ethiopian Demographic and Health Survey to study patterns of contraceptive discontinuation and method choice using multilevel multiprocess models. Second, we conducted semi-structured interviews and focus group discussions in the 3 most populated regions of Ethiopia with individuals of reproductive age and health professionals.

RESULTS

The analysis of EDHS data shows that the rate of discontinuation has not reduced in the period 2005-2011 and remains high. Discontinuation mainly takes the form of abandonment, and is a function of method type, age and wealth but not of educational level. Interviews with women and health professionals reveal that the experience of debilitating physiological side effects, the need for secrecy and poverty are important barriers to continuation.

CONCLUSIONS

Our findings together suggest that physiological and social side-effects of contraceptive use, not a lack of formal education, are the root causes of contraceptive abandonment in Ethiopia.

"Just Wear Dark Underpants Mainly": Learning from Adolescents' and Young Adults' Experiences with Early Discontinuation of the Contraceptive Implant

STUDY OBJECTIVE

Long-acting reversible contraception, including the contraceptive implant, is recommended for teens and young women. However, some young women discontinue the implant early, and we seek to better understand their experiences.

DESIGN, SETTING, AND PARTICIPANTS

We conducted interviews with 16 young women ages 14 to 24 who presented for removal of the contraceptive implant within 6 months after placement at outpatient adolescent, family medicine, and obstetrics and gynecology clinics. We coded and analyzed transcripts to identify themes and develop a thematic framework.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We explored decision-making regarding placement and removal of the implant, differences between anticipated and experienced side effects, and recommendations for counseling.

RESULTS

The participants reported experiencing significant side effects that led to removal, most often frequent or heavy bleeding or mood changes. These healthy young women were unprepared for these symptoms, despite remembering being told about possible side effects. Participants wanted more concrete examples of possible side effects, and personal stories of side effects experienced by others, rather than general terms such as irregular bleeding or mood changes. Few discussed problems with their providers; instead, they relied on the Internet or friends to help decide when to remove the implant. Nearly half of the participants did not start new contraception after removal, although they voiced a continued desire to avoid pregnancy.

CONCLUSION

We identified a need for more descriptive counseling about side effects experienced by individuals, and guidance on what to do about problems encountered after placement.

Contraceptive behavior among women after abortion in Nepal

OBJECTIVE

To investigate the timing of contraceptive use and estimate the discontinuation rates of temporary methods among women after abortion, or a live birth or stillbirth.

METHODS

A sample of married women with detailed pregnancy and contraceptive histories was analyzed in a population-based cross-sectional study based on calendar data extracted from the 2011 Nepal Demographic and Health Survey. Kaplan-Meier cumulative and discrete-time hazard models were used to estimate the timing of contraceptive use and discontinuation rates among users of temporary methods.

RESULTS

The final analysis sample included 3190 women. Of 684 women who had had an abortion, 298 (43.6%) had not initiated any contraceptive use in the 12 months afterwards. Women initiated contraceptive use significantly earlier after abortion (hazard ratio [HR] 2.25; 95% CI, 1.96-2.59; P<0.001). The rate of discontinuation among contraceptive users was significantly higher in the postabortion group (HR 1.32; 95% CI, 1.05-1.65; P<0.05). Women who were educated, wealthier, had used contraceptives before the index pregnancy, had two sons and had autonomy initiated contraceptive use significantly earlier in the post-abortion period than their counterparts.

CONCLUSION

Postabortion contraceptive use is low in Nepal. Postabortion family-planning counseling and related services should be strengthened with systematic monitoring and follow-up interventions.

Levels and determinants of switching following intrauterine device discontinuation in 14 developing countries

OBJECTIVE

To examine the levels and determinants of switching to any reversible modern contraceptive method following intrauterine device (IUD) discontinuation due to method-related reasons among women in developing countries.

STUDY DESIGN

We analysed 5-year contraceptive calendar data from 14 Demographic and Health Surveys, conducted in 1993-2008 (n=218,092 women; 17,151 women contributed a total of 18,485 IUD episodes). Life-table methods were used to determine overall and cause-specific probabilities of IUD discontinuation at 12 months of use. For IUD episodes discontinued due to method-related reasons, the probability of switching to another reversible modern method within 3 months was estimated, overall and by place of residence, education level, motivation for use, age category and wealth tertiles. Country-specific rate ratios (RR) were estimated using generalized linear models, and pooled RRs using meta-analyses.

RESULTS

The median duration of uninterrupted IUD use was 37 months. At 12 months, median probability of discontinuation was 13.2% and median probability of discontinuation due to method-related reasons was 8.9%. Within 3 months of discontinuation due to method-related reasons, half of the women had switched to another reversible modern method, 12% switched to traditional methods, 12% became pregnant, and 25% remained at risk for pregnancy. More educated women were more likely to switch to another reversible modern method than women with primary education or less (pooled RR 1.47; 95% CI 1.10-1.96), as were women in the highest wealth tertile (pooled RR 1.38; 95% CI 1.04-1.83) and women who were limiting births (pooled RR 1.35; 95% CI 1.08-1.68).

CONCLUSION

Delays to switching and switching to less reliable methods following IUD discontinuation remain a problem, exposing women to the risk of unwanted pregnancy. Family planning programmes should aim to improve quality of services through strengthening of counselling and follow-up services to support women's continuation of effective methods.

IMPLICATIONS

The risk of unintended pregnancy following IUD discontinuation remains high in developing countries. The quality of family planning services may be an important factor in switching to alternative modern contraceptive methods. Service providers should focus on counselling services and follow-up of women to support the continued use of effective methods.