Understanding Discontinuation: How Using Discontinuation Data Can Strengthen Family Planning Program Design
By: Rebecca Ross
Contraceptive use improves women’s health and is critical to achieving the Sustainable Development Goals — especially goal 3, to “ensure healthy lives and promote well-being for all at all ages.” The global health community gives particular attention and effort to reducing unmet need for contraception and expanding access to family planning services. However, it pays relatively little attention to understanding discontinuation from a data perspective or using that information to strengthen programmatic gaps. To help ensure the efficient use of scarce family planning resources, program managers need to understand the reasons for discontinuation and use available data to identify solutions that support women to achieve their reproductive goals.
Frequency of and Reasons for Discontinuation
FP2020 defines contraceptive discontinuation as starting contraceptive use and then stopping for any reason while still at risk of an unintended pregnancy. However, Demographic and Health Surveys (DHS) define contraceptive discontinuation among women age 15–49 who used a contraceptive method but stopped for any reason, such as desire to become pregnant or switch to a different method. Based on Demographic and Health Survey (DHS) data collected between 2010 and 2020 in USAID family planning and reproductive health priority and Ouagadougou Partnership countries, on average about one-third (38%) of women who start using a contraceptive method stop using it within one year. According to these surveys, the top reasons for contraceptive discontinuation include a desire to become pregnant (33%), health side effects/health concerns, including menopause and inconvenient use (26%), infrequent sexual activity and marital dissolution (11%), and becoming pregnant (i.e., method failure) (8%) (see Table 1).
While trends exist, the reasons for and frequency of discontinuation vary widely across countries and the method being used. A WHO multi-country analysis of method-specific reasons for discontinuation reported that the probability of discontinuing due to side effects was greatest for users of injection and pills, while method-related reasons were greatest for injections, but fairly high for all methods. Specifically, condoms and short-acting hormonal methods generally had the highest discontinuation rates (27–32%), while only about 10% of IUD and implant users discontinued in their first year. Understanding these nuances is critical to making programmatic enhancements that can reduce discontinuation.
Using Discontinuation Data to Understand Programmatic Challenges
Understanding contraceptive use dynamics is also important to meet women’s contraceptive needs, in addition to improving service delivery and achieving family planning objectives. Discontinuation may explain why countries observe increases in contraceptive use without subsequent decreases in fertility rates that they expect. Discontinuation rates and reasons can also be used as a measure of service and system quality; revealing problems in use of contraceptive technologies, gaps in service provision, availability of a user’s preferred contraceptive, and counseling. For example, in 2018 in Guinea, a high percentage (65%) of contraceptive users discontinued during the first year of use across all methods, with 27% of respondents reporting side effects as the reason for discontinuation. Qualitative analysis supports that side effects, interpersonal, sociocultural, and health system factors all present barriers in uptake and continued use of family planning among young people in Guinea. Together, these data point to programmatic issues, such as counselling or pressuring women to use a method they didn’t want, as well as the need to change contextual issues to create a stronger enabling environment for family planning use. In contrast to the Guinea example, only 22% of contraceptive users in Zimbabwe in 2015 discontinued in their first year of use, with the desire to get pregnant given as the key reason for discontinuing. Trends — which can vary between countries and within a country — may also reflect changes in how programs are designed and implemented. Greater quantitative and qualitative measurement and analysis of discontinuation rates can inform programmatic shifts and help ensure women’s reproductive needs are met throughout reproductive age.
Methodologies for Measuring Discontinuation
Most assessments of discontinuation rely on retrospective data, looking at contraceptive use historically. Demographic and Health Surveys (DHS) estimate the cumulative proportion of people that discontinued use over a 12 month-period using data collected from the contraceptive calendar in their women’s questionnaire. Studies in Myanmar, Egypt, and Ethiopia used DHS data to estimate prevalence of contraceptive discontinuation and associated factors. Based on these analyses with retrospective data, authors recommended programmatic changes, including increased availability of long-acting and permanent contraceptive methods and improved counseling to ensure clients’ informed and voluntary choice.
Other studies use prospective methodologies that aim to reduce recall bias of retrospective studies and offer more flexibility in exploring users’ experiences. The Evidence Project (2020) used a prospective cohort study to better understand contraceptive use dynamics in India; the results found the need to improve quality of care through routinely monitoring information exchanges about method selection, effective use, and continuity of use and care. Some studies, like this 2022 study in Mozambique and this 2015 study in northern rural Malawi, used data from family planning registry information and provider-recorded family planning cards, together with qualitative data, to better understand continuity of use and provide insights to improve quality of care and enhance family planning and reproductive health choices. Both studies advised adding questions to routine, cross-sectional surveys to provide more routine data on contraceptive use dynamics, that could then be used to adapt the program as appropriate.
Many resources are being put into strengthening family planning programs and increasing the uptake of modern contraception. Yet, a surprisingly large proportion of family planning users — estimated to be between 20–65% — stop using methods within the first year of starting. While deciding to become pregnant is a leading cause of discontinuing contraception, data suggest that the other key reasons for discontinuation can be addressed through improved program design related to communications, available funding, and supply chain. Looking forward, the opportunity exists to use data of all kinds to help explain why users discontinue contraceptive use and to strengthen the capacity of decisionmakers and program managers to use those data to reduce the frequency of discontinuation and to help women achieve their reproductive goals.
Rebecca Ross is a senior technical advisor with focus on quantitative data collection and analysis in health financing and economics on the USAID-funded Health Policy Plus project.