Rethinking Contraceptive Discontinuation: Reflections on a Blog Series and Policy Forum
By Jay Gribble and Sara Stratton
Contraceptive discontinuation is a complex issue, in part because there are many reasons it happens. Understanding and measuring discontinuation is especially challenging because it is a fluid process over the course of a woman’s life — she can start, discontinue, and switch contraceptive methods many times. Work carried out by PRB on contraceptive dynamics graphically highlights this complexity using Sankey diagrams that show transitions from non-use to method-specific use over time. These graphics help us grasp what happens in the aggregate, they don’t help us understand why discontinuation occurs and how it can be reduced.
To reduce discontinuation, we need to understand its underlying reasons and how policies, programs, and systems can be modified to make it a less frequent event. Taken together, the Health Policy Plus blog series and the comments shared in an online policy forum illuminated three key approaches that could reduce discontinuation: empowering women, understanding context, and strengthening health systems.
“Women’s empowerment needs to be a broader cross-sectoral initiative that will advance not only health, but education, employment, and virtually every other aspect of the social fabric.”
One of the take-away messages from the policy forum was the essential role of women’s empowerment in reducing discontinuation. With greater empowerment, many women are more willing to use contraception in the first place. Empowered women are better able to address some of the primary and secondary reasons for discontinuation. For example, they’re likely more comfortable navigating the healthcare system and standing up to providers who have poor interpersonal skills and paternalistic or ageist attitudes. They may also engage more often in community discussions that address and help change social and gender norms through participating in community groups and taking on community leadership roles.
In our discussion on digital solutions, a couple of participants brought up the use of WhatsApp groups at the community level as a vehicle for sharing information about methods and managing their side effects. This type of communication platform can reinforce empowerment by giving women a safe space to talk about personal issues and seek advice that helps them continue using their contraceptive. Empowerment can come through having the support of other women to step up and voice an opinion or concern.
While empowerment may help reduce discontinuation, creating an enabling environment that empowers women is not easy. Women’s empowerment needs to be a broader cross-sectoral initiative that will advance not only health, but education, employment, and virtually every other aspect of the social fabric. We talk about empowerment in the context of family planning, but efforts to incorporate gender-transformative approaches need to be integrated into development sector initiatives across the board. Each program and sector can undertake its own approach to gender transformation and women’s empowerment, and the synergy across sectors will improve women’s lives — as well as development sector outcomes.
Policy and program efforts do not happen in a vacuum, and when we forget to think about the context in which discontinuation is being addressed, we run the risk of not effectively making the most of program efforts related to both the uptake of family planning and the reduction of discontinuation. The supply chain challenge of getting to the last mile, for example, requires an understanding of the context in which discontinuation takes place and how it might contribute to discontinuation — including understanding the difficulties of getting products to the right place, the preferences of these underserved women, and the combination of opportunity and real costs that these women bear in starting, and continuing, family planning use. The discussion held during the policy forum included an example of women health workers in communities in Pakistan who visit women in their homes, provide contraceptives, and serve as a trusted source of information. While this type of provider may not be needed in an urban setting, their importance in rural Pakistan — where conservative social and gender norms prevail — cannot be underestimated.
Often policymakers and program designers move forward without gathering community input and understanding of context. One of our policy forum discussants talked about needing to, at times, take off our “policy hat” and seek diverse types of input before developing policies and programs to ensure they will fit the specific context and help women continue to use contraception when the want to avoid an unintended pregnancy. There is no substitute for obtaining input from the people who are the focus of the program. The concept of “human-centered design” came up in our discussion of new method development, but that input is also needed to help design policies and programs that align with cultural and social priorities. Getting context right is essential to both the methods and programs that support women with contraceptive use — and to help reduce discontinuation.
“…we need to focus greater attention on helping women find and successfully use the contraceptive method that suits their life courses…”
Strengthening Health Systems
A third approach that can help reduce discontinuation is strengthening health systems. This issue receives a lot of attention these days as a focus of making health systems more responsive to people’s needs. A strengthened health system often requires increased financing, which is as important for family planning as it is for any other health area. In the policy forum, one participant mentioned that the policy area in need of the greatest revision is financing so that family planning programs have the funds they need to support program efforts, such as quality services, sufficient procurement of commodities and supplies, and efforts to combat rumors and misinformation. Sufficient funding would permit the various cadres of providers engaged in providing family planning services to be trained, not only in the clinical aspects of their jobs, but in the interpersonal skills that can undermine a woman’s desire to continue using contraception. Sufficient funding can also ensure that community health workers aren’t overwhelmed with dozens of tasks so that they can provide follow-up visits and address users’ concerns about side effects and correct method use; it can also help ensure effective referral systems are in place so that if a woman wants to switch to a different method, she is able to access it when she needs it.
Too many women discontinue using family planning while not wanting to become pregnant. They may not all have unintended pregnancies, but their risks increase dramatically when they discontinue use because of side effects, health concerns, and — sadly — method failure. Many of these reasons can be addressed through directing greater attention and resources to different aspects of the policy and program environment. The “Rethinking Contraceptive Discontinuation” blog series and policy forum were designed to help draw attention to high levels of discontinuation and different ways discontinuation can be addressed. Whether working through the health system, ensuring the context is appropriately included in policy and program development, or advancing women’s empowerment to have a more meaningful voice for themselves and for their communities, we need to focus greater attention on helping women find and successfully use the contraceptive method that suits their life courses so that they and their partners are able to have the number of children they want, when they want them.
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+.