Could New Contraceptive Methods Help Reduce Discontinuation?
By Sara Stratton
Worldwide, there are over 13 contraceptive methods with numerous variations in doses and brands, but not all countries offer all methods to women and men. For a woman to find the “right” contraceptive, and continue using it, different aspects of the health system need to function well. The supply chain must ensure the product is at the right place, at the right time; her partner needs to be supportive; and she needs reassurance and consultation to overcome any health concerns and side-effects. That said, people’s needs and reasons for using contraceptives can change over their lifetime — and so can their method choice. Other blogs in this series have highlighted that, on average, about one-third (34 percent) of women who start using a contraceptive method stop using it within one year. Other data indicates that women may try 3.5 different contraceptives before finding one that works well for her and her reproductive intentions at the time, e.g., spacing or limiting pregnancies. This starting-stopping-switching behavior over the course of an individual’s reproductive lifetime is part of the cycle of contraceptive discontinuation.
Attempts to expand the range of contraceptive methods available to women have been made over the last decade. Variations on existing contraceptives have been introduced, including DMPA-SC, hormonal IUDs, the Caya diaphragm, newer vaginal rings, and implants of different durations. But I’m not aware of any brand new methods that have come to the market. So, what can be done to increase options for contraception users, and what if anything is in the contraceptive research and development (R&D) pipeline?
What is involved in bringing a new contraceptive to market?
Developing a new contraceptive, or even a variation on an existing one, takes many years. These products are not the most lucrative for the pharmaceutical industry thus, often, fewer resources are invested compared to other products (such as treatments for chronic or acute diseases). Even for existing methods, getting them registered and incorporated into provider training curricula and clear policies established to maximize access can take years (for example, oral birth control pills are still not available over the counter in the United States). USAID is a long-time investor in new contraceptive development, with increasing numbers of contraceptive R&D firms helping to bring new or adapted methods to market. The Bill & Melinda Gates Foundation is a newer investor in contraceptive development (think DMPA-SC).
As of June 2022, there were over 200 methods in the R&D pipeline. The majority are “revisions” to existing contraceptive technologies — implants, injections, pills. There are some contraceptive methods being designed to deliver protection against pregnancy through different mechanisms, such as a patch with many small needles and male-oriented methods such as those that would affect sperm mobility. Traditionally, research is conducted in North American or European contexts in a non-diverse population. Historically, this process hasn’t directly incorporated the perspectives of contraceptive users or the realities of supply chains in low- and middle-income countries. However, this is starting to change.
“…reproductive health advocates emphasize the adoption of a human-centered design approach…”
What are some user considerations for new methods under development?
We know that side-effects are a significant reason women discontinue their contraceptive. To address this, reproductive health advocates emphasize the adoption of a human-centered design approach, arguing that considering contraception users’ perspective and the context of use, including who influences women’s use of methods (e.g., husbands/partners and mothers-in-law) is important to expand access and encourage continuation. Also, it is important to understand that contraceptive users would like methods that do more than just prevent pregnancy, such as offer dual protection against HIV and sexually transmitted infections (STIs) or contraceptive induced menstrual changes to address other health issues. In parts of the world where HIV and STIs are significant health issues, multipurpose prevention technologies are important developments for contraceptive users as they address HIV/STI prevention together with unintended pregnancy prevention.
Program implementers and service delivery providers are also exploring shifting the messaging around perceived “side-effects” to be more positive, e.g., the “side-benefits.” Providers can accentuate the benefits of avoiding unwanted or poorly timed pregnancy in lieu of describing only the side-effects. Also, the benefits may be contraceptive-induced menstrual changes, such as fewer, shorter, and/or less painful periods. This line of argument may be challenging in some low- and middle-income countries, particularly across Africa where menstruating regularly can be culturally important. Recently, the high first-year continuation rates for the Caya diaphragm — almost 77 percent after six months — were recognized, in part, because the method responds to what women have said for many years: they don’t want side-effects from hormonal methods or menstruation changes. The on-demand, non-hormonal (and thus no side-effects) characteristics of Caya, along with how advance insertion doesn’t interrupt sexual intercourse, really appealed to Nigerien women.
Several factors are evolving that can help decrease discontinuation rates.
Other considerations that researchers and programmers are adopting include: “on-demand” use (women can use it only when needed, like Caya or a condom); methods that are more amenable for self-care (e.g., self-injection, self-removal of IUDs, and patches); and modifying the duration of a method as a woman’s need for contraception changes over her lifecycle (using longer-lasting IUDs or implants that limit, versus space, future pregnancies). All of these could lead to less discontinuation as women have more control over how the method works for them. The field of precision medicine is exploring designing methods that will be specific to an individual woman, incorporating her own variability in hormone levels, duration of menstruation, and other health conditions and/or life factors. When a contraceptive is adapted specifically to an individual woman, theoretically discontinuation should decrease.
What about systems considerations?
Designing contraceptives to be more user-controlled has the advantage that they can reduce demands on the health system. Women who can access their preferred contraceptive via pharmacies and community health workers, or online, means that facility-based health workers can respond to more complex cases or deliver provider-dependent methods (e.g., inserting IUDs). Developers using the “begin with the end in mind” philosophy are planning for supply and logistics aspects: how heat will affect a contraceptive, what packaging works well and has less environmental impact, and how best to transport to the last mile. Other developers are anticipating the time required for introduction and registration of a new method, and how this timeline might affect the eventual market for the “new” method. These considerations can help reduce stockouts with more easily transported contraceptives with extended shelf lives so that women can select their preferred method.
Contraceptive users have a long wait for brand new methods, but researchers continue to learn from each adaptation that is introduced, evolving their approach to developing contraceptives, making them more responsive to what women (and men) say they want. An even wider range of contraceptives is needed, and new methods need to reach facilities and community health workers at the last mile to help women (and men) find the method that works best for them. Eventually, we may even have ways to tailor methods to a specific individual or identify methods that work best with their genetic profile, which could be very exciting. Several factors are evolving that can help decrease discontinuation rates. These include: (1) contraceptive users are gaining more confidence about providing feedback on how a particular method worked or didn’t, and to request a different method from their provider; (2) options are increasing for user-controlled methods and self-care delivery; and (3) users’ are gaining an understanding of the side-benefits of using contraceptives. As these factors continue to advance, we hope that more contraceptive users will have their demand truly satisfied.
Sara Stratton is a director of family planning and maternal and child health at Palladium, where she leads activities on the USAID-funded Health Policy Plus project and serves as project director for the Uganda Health Systems Strengthening and Malawi MOMENTUM projects.