Does Contraceptive Discontinuation Matter?: Quality of Care and Fertility Consequences

Author(s): Blanc A, Curtis S, Croft T

Year: 1999

Abstract:
Contraceptive discontinuation is often cited as an outcome that is associated with the quality of care provided by family planning programs. The primary objective of this study is to document levels of discontinuation across countries and to assess the utility of using this indicator as a reflection of the quality of the service environment. The study also examines contraceptive behavior following a discontinuation and the fertility consequences of contraceptive discontinuation and failure. The contraceptive histories collected in 15 DHS surveys are used to calculate a range of life table measures of discontinuation, including method and reason-specific rates. The 15 countries included in the study represent a diversity of situations with overall contraceptive prevalence among married women ranging from 31 to 77 percent. The most used method is the pill in six countries, the IUD in two countries, female sterilization in six countries, withdrawal in one country, and periodic abstinence in two countries. Hormonal methods (pill and injectables) are more likely to be discontinued as a result of side effects or health concerns than are other methods. Except for Zimbabwe, which has very low rates, the percentage discontinuing the pill for these reasons within a year ranges from 11 to 35 percent while for injectables, the percentage varies from 15 to 37 percent. For most countries, the 12-month cumulative rate of discontinuation of the IUD for side effects or health concerns is much lower, varying between 6 and 14 percent. Other method-related reasons (and contraceptive failure) are more important reasons for discontinuation of periodic abstinence, withdrawal, and condoms. Service-related reasons for discontinuation include cost of the method and lack of access to the method; these are rarely mentioned by women as the primary reason for discontinuing use of any method. In all but three of the countries, the most common action women take after discontinuing use of a modern reversible method for method or service related reasons is to switch to a different modern method. In these countries, between 29 and 58 percent of women begin using a different modern method within three months of discontinuation. Few women return to the method they had discontinued. In contrast, women who experience a contraceptive failure and resume using after the birth are most likely to return to the same method. All-method discontinuation rates, which measure the rate at which women stop using any method of contraception, are calculated separately for two groups of reasons: reduced need and quality related reasons. Overall, between 9 percent (Zimbabwe) and 34 percent (Dominican Republic) of women stop using contraception within 12 months for quality related reasons. The all-method discontinuation rate for quality related reasons accounts for between approximately a half and three quarters of the total rate at 12 months. This all-method rate for quality related reasons is inversely associated with overall Family Planning Program Effort (FPPE) scores; that is, strong programs tend to have relatively low quality related discontinuation rates. The relationship between the two indicators is statistically significant, but not particularly strong. The relationship between the all-method discontinuation rate for quality related reasons and the service related component of the FPPE score is also negative and statistically significant but stronger. However, contrary to expectation, two different indicators of method choice are not associated statistically with rates of method discontinuation for quality related reasons. Nevertheless, the study suggests that the measure of contraceptive discontinuation that most closely approximates an overall indicator of quality of care is the all-method rate for quality related reasons. The advantages of this measure over other types of discontinuation rates are, first, that it focuses on discontinuation of any method of contraception rather than on a specific method. It thus incorporates the notion that high rates of method switching are not necessarily negatively related to quality. Discontinuation of any method is of greater programmatic interest than discontinuation of a specific method because it leaves women unprotected from the risk of unwanted pregnancy. Second, this rate includes only those who discontinued for reasons other than a desire to get pregnant or reduced exposure to pregnancy risk; many of these reasons are ones that can effectively be addressed by improvements in the family planning program. One disadvantage revealed by a trend analysis is that change in this indicator over relatively short periods of time may not be possible to detect with sample sizes in the range utilized by DHS surveys. In addition, we hesitate to recommend this measure unequivocally as a summary indicator of quality of care because it does not have a consistent relationship with one of the core components of a high quality service environment - method choice. The study demonstrates clearly that contraceptive failure and discontinuation make a substantial contribution to overall fertility rates and to rates of unwanted fertility. In the 15 countries included in this analysis, the total fertility rate (TFR) would be between 4 and 29 percent lower in the absence of contraceptive failure. The average across all countries is 14 percent. Without other types of contraceptive discontinuation, the TFR would be reduced by between 20 (Indonesia) and 48 percent (Jordan). More than half of recent unwanted fertility was due to either a contraceptive failure or a contraceptive discontinuation in all countries except Guatemala. The total unwanted fertility rate would be between about 0.2 and 1.1 births lower in the absence of failure and discontinuation. This result implies that as fertility declines, family planning programs would profit from a shift in emphasis from providing methods to new clients towards providing services to existing clients, such as counseling, th at may help reduce failure and discontinuation rates.