Rethinking Contraceptive Discontinuation: Are Solutions Being Overlooked?
By: Jay Gribble and Sara Stratton
The launch of the FP2030 partnership provides a renewed focus on the importance of responding to the family planning needs of women and couples. Much attention is given to reducing unmet need by ensuring that women who do not want to become pregnant are using modern contraception. These efforts include innovative ways of providing services; ensuring availability of contraceptives and method choice; and prioritizing informed choice, voluntarism, and rights-based approaches. While a focus on the uptake of family planning is important for increasing the number of women and men who use contraception, an alarming number of users discontinue their use of family planning each year, leaving many of them at risk of unplanned pregnancy. A recent study examined data from Senegal and reported that, when considering the uptake of all family planning methods, 35 percent of acceptors had discontinued use within 12 months of starting, escalating to 54 percent discontinuing by 24 months. Of course, this average doesn’t reflect trends related to specific methods, age groups, places of residence, and other factors that might influence both the uptake and discontinuation of contraceptive use. However, it does drive home an important point: many women who do not want to get pregnant discontinue using effective contraception for a variety of reasons, and not too long after they start. Given the investment made in helping women and couples to begin using contraception, these high levels of discontinuation warrant closer examination so that the global health community can better understand why discontinuation is so high and identify solutions to reduce it.
Reasons for Discontinuation. While reasons for discontinuation vary across countries and among individuals, some of the key reasons women stop using a family planning method are related to the health system. While the leading reason for discontinuation is reduced need for contraception (such as the desire to become pregnant, infrequent sex/husband away, and marital dissolution/separation), other reasons reflect issues related to available methods and services and break downs in the supply chain. Health concerns and side effects are also common reasons for discontinuation and may reflect inadequate counselling about how contraceptives affect the body, including effects on menstruation. Method failure is also common and can result from incorrect use; in addition, even clinical methods such as vasectomy and tubal ligations have a failure rate. Discontinuation due to method-related issues — such as wanting to use a more effective method or inconvenience in using a method — may reflect supply chain failures or insufficiently distributed service delivery points that didn’t allow the client to obtain the method wanted or opportunity cost of having to return to the provider for additional commodities. Cost and access to contraception, also stated as a reason for discontinuation, may reflect poor health financing schemes and insufficient outreach by community health workers. Other issues, such as lack of approval by a spouse or society at large, may reflect insufficient community mobilization, awareness raising, and social and behavior change. While the reasons for discontinuation are diverse, more important is identifying solutions that can reduce the frequency of discontinuation and help women avoid unintended pregnancies.
A Blog Series on Contraceptive Discontinuation. To help advance thinking about how to address causes of discontinuation, Palladium is launching a blog series that reflects creative and emerging approaches about how family planning programs can better help women and men remain satisfied users of contraception. Over the course of the next few months, we will share some of our experiences and insights into how health systems and program components might better respond to the challenge of contraceptive discontinuation. Currently, we are thinking about a handful of diverse ways to address the different underlying causes of discontinuation and will draw on experts to share their thoughts, insights, and experiences on the following topics:
- Understanding discontinuation: To reach solutions, we must first understand the breadth of the problem. A summary of data will highlight some of the experiences of different countries, how discontinuation varies by contraceptive methods, age group, and other characteristics that can help decisionmakers better understand how to address these challenges. This blog lays out a summary of discontinuation data from different countries, some of the data challenges, and the impacts on cost of, and outcomes from, high levels of discontinuation.
- Improving counselling, service delivery, and follow up: Several key reasons for discontinuation are linked to users’ inadequate understanding of how the method functions and its potential side effects. This blog will consider how improved service delivery might better help women and men to get the method they want, understand side effects, and continue using the method.
- Strengthening the supply chain to avoid stockouts: Supply chains are complex systems that rely on capable individuals to provide input at every step along the way. A well-functioning supply chain can help ensure that the right products, in the right condition, reach the right clients at the right time and at the right place. Without a functioning supply chain, there’s no product to respond to contraceptive users’ needs. Supply chain failure is an important reason for contraceptive discontinuation that can be addressed through strategic investments in family planning programs.
- Financing to ensure sustained access to contraceptives: Between donor phase-out and efforts to increase domestic resources, sustainable financing for family planning — especially commodities — remains a priority and is key to reducing discontinuation. Funding gaps can affect discontinuation in a variety of ways, including insufficient stock levels of commodities, inadequately trained providers, and insufficient access to facilities and providers — to mention only a few. In addition, the many countries with nascent insurance programs and an underdeveloped private sector place additional burden on the public sector to shoulder the responsibility of financing and responding to family planning needs.
- Changing community ideas around family planning: For family planning to be more acceptable by communities and spouses, efforts are needed to change attitudes and beliefs so that the practice of family planning use can become more acceptable. A key aspect to this is changing norms around gender and youth, which can, for example, empower women to use contraception and more effectively engage men and boys in family planning.
- Responding with self-care and digital solutions: As self-care and digital solutions become more prominent forms of responding to the needs of family planning users, programs will need to consider the required inputs to help women understand the methods they choose and access to follow-up care to avoid discontinuation because of side effects or other reasons. Self-care and digital solutions present important opportunities and need to be developed in ways that provide accurate information so that women fully understand methods and can make informed choices.
- Developing new methods: Since one of the key reasons for discontinuation is side effects and health concerns, a long-standing issue is whether methods currently in development adequately address those concerns. Human-centered design is important to ensure the acceptability of a new contraceptive method. So, we ask, what do women (and men) want and what is in the pipeline to help ensure the continued use of emerging contraceptives?
This blog series is designed to stimulate thinking about how to address the challenge of contraception discontinuation. We look forward to sharing our thoughts and hope that you will provide comments and raise the importance of discontinuation in the multiple contexts in which it can be addressed.
This blog series is co-edited by Palladium’s Jay Gribble, a senior director and deputy director of family planning and reproductive health on the USAID-funded Health Policy Plus (HP+) project, and Sara Stratton, a director of family planning and maternal and child health, who also leads activities on HP+.