A fairly large body of literature on contraceptive discontinuation informs what we know already- that it is common, though rates vary by country. For example, a recent summary of 18 DHS countries by Vadnais et al. found that 20-50% of users of reversible modern methods discontinued during the first 12 months of use. Often, discontinuation is due to reasons other than to become pregnant. Blanc & Curtis et al. found that discontinuation due to “reduced need” ranged between 7-20% of discontinuations. Findings such as these suggest that the majority of contraceptive discontinuation is “premature,” leaving fertile women without protection. Indeed, discontinuation has been shown to be related to unmet need, unintended pregnancy, and unwanted births.
Notably, not all women who discontinue a contraceptive become nonusers; some women switch to another method. Having a range of methods available, knowledge of who may be at risk of discontinuation, and good counseling on methods can increase the likelihood that women switch rather than discontinue all use. Identifying individual characteristics related to switching and discontinuing can therefore be important for improving family planning service delivery and quality.
The data for this analysis come from a study conducted in 4 urban areas of Honduras. Honduras is in the central region of Central America- it has a population of about 7.2 million; a TFR of 3.3, and a CPR of 65% for married women. The most common method of contraception in the country is sterilization (33%), followed by injectables (21%), oral contraceptive pills (17%); and the IUD (10%).The cities included in the study are Tegucigalpa, San Pedro Sula, Santa Rosa de Copan, and Gracias
The data for the study come from a panel of 800 women, aged 15-44 at baseline, who were recruited after attending a FP appointment in one of the selected health facilities. The selected health facilities included 7 Secretary of Health clinics, one Secretary of Health hospital, and 5 clinics run by the Honduran Family Planning Association - these types of facilities were the most common providers of female reversible methods in the four cities visited according to the most recent data. All women enrolled in the study were initiating or using injectables, IUD, or the contraceptive pill, at the time of the baseline interview.About 200 women/city were enrolled between October-November 2006. The women were new to FP, new to a particular method, or continuing users.Baseline survey/exit interview- Collected detailed information on demographics, couple dynamics & FP decision-making, motivations to avoid pregnancy, and perceptions of service quality.After one year we conducted a follow-up interview with these women. We located and interviewed 671 women, (84%) of the original sample.Follow-up- Obtained detailed information on contraceptive use during the previous year in a month by month calendar, and included questions on the experience of side effects and any pregnancies or births during the year, etc.
A total of 273 women discontinued their baseline method during the 12 month study period (41%).
Of the 273 women who discontinued their baseline method, 117 (~43%) switched to another method without experiencing an episode of non-use (defined for this analysis as at least one-month of non-use). This group is referred to as “switchers” and those who experienced at least 1 month of non-use after discontinuation as “discontinuers”. In a bivariate analysis of whether women switched/discontinued by factors related to discontinuation, the distribution of a number of variables was significantly different between switchers and discontinuers. The variables include demographic characteristics, fertility desires, service quality at baseline, experience of side effects during the study period, communication with others, main reason for discontinuation, and method characteristics, such as type of method, and length of use at baseline. Some of the significant variables are shown in this table. (These variables are significant for chi-square statistics with a p-value <0.01).
In a further descriptive analysis, we look at differences in communication and treatment seeking among women experiencing the same side effect. This examination was done using the three most commonly mentioned side effects experienced by women in the study- amenorrhea, heavy bleeding, and headaches. A test of cross tabs was conducted to assess the relationships between the dependent and independent variables of interest; shown in this table are variables that were significant at p-value <.1 or less. However, results should be interpreted with caution due to the small sample sizes. These results suggest that there were no significant differences between perceived severity of the side effect, but that treatment, discussion of side effects, and discussing the decision to stop using the baseline method, are significantly related to whether women switch methods or not.
A multivariate regression analysis was conducted to assess the differences between women who switched methods and women who discontinued and experienced an episode of non-use. In any pair of variables with a correlation greater than +/- 0.6, a decision was made as to which variable to include in the model- mainly side effects/discussion variables were those that were not included.
In a multivariate analysis, fewer of the indicator variables maintained significance with the dependent variable than was seen in the bivariate analysis. This graph shows the Odds Ratios of significant demographic, side effects, and communication variables. An OR above 1 indicates an increased likelihood for switching methods, while an OR of less than 1 indicates a decreased likelihood for switching. Here we see that women residing in urban areas are almost 2.6 times more likely to have switched methods than discontinue all methods. Women who sought help with side effects from a clinic or health worker and women who discussed stopping the method with their partner before making a decision to stop were also significantly more likely to have switched to another method. Not shown in the graph, but also significantly related to switching, are new and recent method adopters and discontinuation of the baseline method due to problems with the method (in contrast to those with a reduced need, or other service or access reasons).In contrast, women who experienced amenorrhea were less likely to switch than discontinue.
There are some limitations to this analysis. First, we do not know the contraceptive behavior either before or after the 1 year observational period. We also limit the analysis to the month following the discontinuation, with the consequence that women categorized as ‘switcher’s may not necessarily have continued the new method for longer than a single month and women categorized as ‘discontinuers’ may not have experienced more than one month of non-use. A larger study population, particularly of new users, and a longer study period would help in addressing these censoring issues.This analysis does not focus on duration of use. As a result, another limitation is that it is possible that a woman who discontinued the baseline method early in the study period and then switched to another method and then discontinued a second time may have had fewer months of contraceptive use than another woman who discontinued at month 11 and did not adopt another method. With the data available from only a one-year period, it was not possible to examine contraceptive behavior in this depth. However, we were able to compare the mean time until discontinuation of the baseline method for both groups, and found that switchers had a mean time until discontinuation of 6.0 months and discontinuers a mean time until discontinuation of 6.4 months. The mean time until discontinuation of all methods extends beyond the observational period for ‘switchers’.
Despite these limitations, a number of interesting findings emerged from the study. For example, the multivariate analysis found that women living in urban areas were more likely to have been “switchers” than “discontinuers.” There are a number of potential factors contributing to this finding, including the fact that more women from urban areas were using IUDs, which require a decision to discontinue and an opportunistic visit to a clinic to remove the IUD; as well as the fact that women from urban areas were likely to benefit from easier access to family planning services, and especially in Tegucigalpa and San Pedro Sula, a better supply and broader variety of providers, and perhaps even higher diversity in available methods. Of all variables related to side effects, treatment seeking behavior (sought help from a health clinic) was found to be most significantly related to method switching. Though side effects are responsible for contributing to method discontinuation, their relationship with subsequent method use is less clear. Our findings suggest that only the experience of amenorrhea has a strong negative impact on switching behavior. Formative qualitative work in Honduras with current and previous users of contraception indicated that women discontinued when experiencing amenorrhea for two main reasons: to determine their pregnancy status and to re-establish what are considered “healthy” menstrual patterns. In the current study, amenorrhea was most commonly experienced by users of the injectable. Such findings highlight an opportunity for providers to counsel and educate about amenorrhea during the initiation of the injectable and to discuss the adoption of non-hormonal barrier methods with women who otherwise may “take a break” from contraception because they want to determine whether or not they are pregnant.Finally, another of the interesting findings from the study is in the significant influence of discussing the option to discontinue with the partner, before making the decision to discontinue the method. The study did not, however, determine what it is about discussions with the partner (and others) that are supportive of switching behavior. Do discussions represent a reinforcement of the decision to use family planning and encouragement to try a different method (i.e., is it the quality of the discussion)? Or does the indicator represent the value of being in supportive relationships, and being able to confide troubles and discuss family planning options with a partner/spouse or others (i.e., is it the quality of the relationship)? Definitive answers to these questions are beyond the scope of the present research, yet offer interesting avenues for further investigation. Based on our findings, however, we propose that the discussions are an approach to discontinuation that can be encouraged and supported by Honduran family planning programs seeking to improve the likelihood of contraceptive continuation.
What Characteristics Differentiate Method Switchers from Discontinuers?
What characteristicsdifferentiate method switchers from discontinuers? Janine Barden-O’Fallon, PhD Ilene Speizer, PhD University of North Carolina at Chapel Hill, USA 9 November 2010
Presenter Disclosure Janine Barden-O’Fallon(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose
Overview Findings from a one-year follow-up study with reversible method users conducted in Honduras, 2006-2007 The study was funded by USAID and implemented by MEASURE Evaluation in collaboration with Programas para el Desarollo de Infantes y Mujeres (PRODIM)
Contraceptive Discontinuation Common, though varies by country Most common during first 12 months of use 7-20% due to “reduced need” Contributes to unmet need Can lead to unplanned pregnancy and unwanted births, resulting in negative public health outcomes
Objective To examine differences between women who reinitiate contraceptive use immediately after a discontinuation (i.e. switch methods) and women who discontinue use and do not immediately begin another method (i.e. experience an episode of non-use). Factors included in analysis: -Demographic characteristics -Communication -Fertility desires -Method characteristics -Service quality -Reason for discontinuation -Experience of side effects
Data: Panel study collected in 2 rounds Baseline exit interviews with 800 women aged 15-44, attending a FP appointment in selected health facilities in which they received the injectable, IUD, or oral contraceptive pill Women were both new and continuing users There were no quotas by type of method Follow-up interviews completed with 671 (84%) 1 year later
Study sample (n=671)Compared to women who did not discontinue theirbaseline method (n=398), women who discontinued(n=273) were… At a lower parity (47.6% vs. 41.7% with 0/1 child) Not married at follow-up (15.7% vs. 7.3%) Living in rural area (25.3% vs. 20.8%) New to their method (53.1% vs. 45.0%) Using the injectable (77.7% vs. 68.8%)
Significant factors related to women’s contraceptivestatus after discontinuation of baseline method (n=273) Switchers Discontinuers Characteristic (n=117) (n=156)Service at Baseline Had all questions answered by provider 72.7 50.0Side Effects Had side effects during the study 89.7 69.9 Felt side effects interfered with daily activity 54.7 35.3 Sought help from clinic/health worker 55.6 28.2Communication with others Discussed side effects with 2 or more people 57.3 32.1 Discussed stopping BL method with partner 86.3 60.3 before making decision to discontinue
Significant factors related to women’s contraceptiveuse after discontinuation among womenexperiencing the same side effectSide effect experienced Switchers DiscontinuersAmenorrhea (N=66) (n=22) (n=44) Self-medicated/took home remedies 13.6 34.1 Sought help from a clinic/health worker 63.6 36.4 Discussed SE with 2 or more people 95.5 79.6Heavy bleeding (N=64) (n=36) (n=28) Discussed SE with 2 or more people 100.0 85.7 Discussed side effect with partner 80.6 46.4 Discussed stopping with partner 97.2 67.9Headaches (N=82) (n=36) (n=46) Self-medicated/took home remedies 36.1 56.5 Discussed stopping with partner 88.9 69.6
Multivariate logistic regression Dependent variable: switch vs. episode of non-use Independent variables: from bivariate analysis Women not experiencing side effects are included in null categories Correlated variables not included in model: experience of side effects during study period; discussion of side effects with 2 or more people; discussion of side effects with partner; and discussion of side effects with a health worker.
Odds Ratios for demographic, side effects, andcommunication variables significantly related tothe likelihood of switching methods; Honduras,2006-7, N=270**p<0.05 +new/recent method adopters**, +discontinuation due to method problems**
Limitations Right and left censoring of the data; analytical censoring Focus on switching behavior rather than duration of use
Conclusions There are significant differences between women who switch methods and women who discontinue, beyond the main reason for discontinuation Urban residence Treatment seeking for side effects Discussing discontinuation with partner
MEASURE Evaluation PRH is a MEASURE project funded bythe United States Agency for International Development(USAID) through Cooperative Agreement GHA-A-00-08-00003-00 and is implemented by the Carolina Population Center atthe University of North Carolina at Chapel Hill in partnershipwith Futures Group International, Management Sciences forHealth, and Tulane University. Views expressed in thispresentation do not necessarily reflect the views of USAID orthe U.S. Government. MEASURE Evaluation PRH supportsimprovements in monitoring and evaluation in population,health and nutrition worldwide.