Original research articleOral contraceptive discontinuation and its aftermath in 19 developing countries☆
Introduction
In developing countries, the percentage of married or cohabiting couples using any method of contraception has risen from an estimated 10% in 1950 to 63% in 2003 [1]. As contraceptive practice becomes more widespread, the avoidance of unintended pregnancies becomes less dependent on contraceptive nonuse and more dependent on the ability and willingness of couples to use methods with maximum effectiveness, to use them persistently and to switch quickly to alternative methods as and when the need arises. In industrialized countries, unintended pregnancies are of social, economic and emotional concern but do not constitute a serious health hazard because safe abortion is usually accessible and obstetric mortality is low. In contrast, unintended pregnancies in developing countries are a major health hazard because access to safe abortion is often limited and maternal mortality is high. A recent analysis showed that 30% of the half-million maternal deaths per year in developing countries could be averted by use of effective contraception among women wishing to delay or cease childbearing [2]. This figure underscores the practical importance of studying contraceptive-use dynamics (failure, discontinuation and switching) and their relevance to an understanding of the ability of couples in developing countries to achieve their reproductive intentions.
The focus of this article was on one component of use dynamics, namely, discontinuation of oral contraceptive (OC) use for reasons that imply dissatisfaction and method switching following discontinuation of use of this method. OCs were selected for analysis because, globally, they are the second most widely used method after IUDs and, if China with her massive population and high prevalence of IUD use is excluded, OCs are the most commonly used reversible method. In 2003, an estimated 8.5% of all married or cohabiting couples of reproductive age were using OCs [1]. A second reason for this method-specific focus is that discontinuation of OCs, unlike IUDs, is known to be high in both developing and developed countries [3], [4], [5]. Pill discontinuation has already been documented in multicountry studies [4], [6], [7], [8]. The main contribution of this article to existing knowledge on discontinuation is to assess for 19 developing countries the effect of two factors, women's education and motive for use (birth spacing vs. total cessation of childbearing), on the probability of OC discontinuation. Women's education is well established as the strongest correlate of contraceptive use in developing countries, and it is thus of interest to establish the extent to which this link reflects lower discontinuation and/or greater switching among better than less educated women. Motive for use was selected for study because the adverse consequences of an unintended pregnancy are likely to be more severe for a woman wanting no more children than for a woman wanting to delay the next birth. It is expected therefore that discontinuation probabilities will be lower and switching probabilities higher for limiters than for spacers. In exploratory analysis, it was found that these two factors were more powerful predictors of the outcomes of interest than other available covariates such as urban–rural residence, woman's age and parity.
Despite a fair number of country-specific studies on switching, less is known about this topic in developing countries than about discontinuation. Two of the three multicountry studies of switching grouped methods into modern and traditional categories, which is far from ideal for the analysis of intercountry differences because of variations in method mix [4], [7]. The third article presented method-specific switching probabilities for six countries but did not document the destination method [8]. The focus in this article on a single method facilitates intercountry comparisons as well as provides new information on methods used after OC discontinuation.
In the final part of the article, an attempt is made to explain observed intercountry differences in OC discontinuation and switching by using independent national data on the overall quality of family planning provision and a measure of method availability and by survey data on method mix and prevalence. Specifically, we hypothesize that OC discontinuation will be lower and switching higher in countries whose family planning programs are rated highly, and that probabilities of switching to a modern method will be high where availability of alternative methods is thought to be good. We also expect discontinuation to be low in settings where use of oral OCs is high, because widespread use implies that health concerns and side effects are tolerated. Similarly, we expect switching to another modern method will be higher where reversible methods other than OCs are commonly used.
Section snippets
Materials and methods
Data from 19 Demographic and Health Surveys (DHSs), conducted between 1990 and 2005, were used in the analysis. The geographical distribution of countries is as follows: Latin America, 8; Asia, 4; North Africa and Near East, 4; Sub-Saharan Africa, 3. They are reasonably representative of low- and low–middle income countries with at least moderate levels of contraceptive use. Contraceptive prevalence in married couples ranges from 26% in Tanzania to 78.5% in Vietnam. In most of these countries,
National
Table 1 shows the fieldwork date of each of the 19 surveys, the number of women who contributed episodes of OC use, the number of OC episodes per survey by education and motive for use, and the mean number of episodes per woman. The total number of episodes ranges from about 500 in Bolivia, Guatemala and Vietnam to over 5000 in Colombia and Morocco. The mean number of episodes per woman varies from 1.0 to 1.5 with a median of 1.2 in the 19 surveys. For all surveys combined, the number of
Discussion and conclusion
Interventions to enhance continuation of contraceptive use through improvements in service quality, such as more intensive counselling, have an unconvincing record of success [7], [16], [17]. In this regard, contraception may be no different from other long-term preventive or therapeutic drug regimens where poor compliance or discontinuation is also commonly reported [18], [19]. It may be inevitable that a large minority of women will abandon their chosen reversible contraceptive method rather
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The views expressed in the article are those of the authors and do not necessarily reflect those of WHO.