1. Contraceptive discontinuation in urban Honduras Janine Barden-O’Fallon, PhD Ilene Speizer, PhD University of North Carolina at Chapel Hill, USA 29 September 2009
2. Overview Results from a one-year follow-up study with reversible method users conducted in Honduras, 2006-2007 The study was funded by USAID and implemented by MEASURE Evaluation in collaboration with Programaspara el Desarollo de Infantes y Mujeres (PRODIM)
3. Contraceptive Discontinuation Common, though varies by country Most common during first 12 months of use Contributes to unmet need Can lead to unplanned pregnancy and unwanted births, resulting in negative public health outcomes
4. Objective To determine how multiple factors affect contraceptive discontinuation among users of temporary methods over a one-year period Demographic characteristics Fertility motivations Partner engagement Quality of FP services Experience of side effects Method characteristics
6. Data: Panel study collected in 2 rounds Baseline exit interviews with 800 women aged 15-44, attending a FP appointment in selected health facilities in which they received the injectable, IUD, or oral contraceptive pill Women were both new and continuing users There were no quotas by type of method Follow-up interviews completed with 671 (84%) 1 year later
7. Study sample at baseline (n=671) Young (94% under age 35) Educated (30% reached secondary or higher) Parity ≥ 1 Married/in union (89%) Urban residents (77%) Desire to space a birth 2+ years (50%) or no more children (34%)
11. Multivariate analysis: Cox proportional hazards models Model 1: Time until discontinuation of baseline method Model 2: Time until first episode of non-use of any method (Model 2) Covariates: demographic characteristics, fertility motivations and family engagement, experience of side effects, baseline service quality, and user status at baseline Stratified by baseline method
16. Discussion More than 4 out of 10 women discontinued the baseline method Living in rural areas may limit women’s ability to successfully switch methods Service quality had little effect on discontinuation Family and friends may support continuation
17. Thank you MEASURE Evaluation is funded by the U.S. Agency for International Development and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill in partnership with Futures Group International, ICF Macro, John Snow, Inc., Management Sciences for Health, and Tulane University. The views expressed in this presentation do not necessarily reflect the views of USAID or the United States Government.
Editor's Notes
In-country collaborators- Javier Calix, Francisco Rodriguez, and Sadith Caceres, of PRODIM
A fairlylarge body of literatureon contraceptive discontinuation informs what we know already- that it is common (estimates vary by country; a recent summary of 18 DHS countries by Vadnais et al. found that 20-50% of users of reversible modern methods discontinued during the first 12 months of use). Often, discontinuation is due to reasons other than to become pregnant. In other research, Blanc & Curtis et al. found that discontinuation due to “reduced need” ranged between 7-20%. Findings such as these indicate that the majority of contraceptive discontinuation is “premature,” leaving fertile women without protection. Indeed, discontinuation has been shown to be related to unmet need, unintended pregnancy, and unwanted births.
Understanding the factors that contribute to discontinuation of family planning use is crucial to ensuring that women and couples can attain their long-term fertility goals. Weused an unpublished framework by Curtis and colleagues to identify a number of factors related to contraceptive discontinuation to include in the study. The objective was to…The factors which were included in the are:
The study was conducted in 4 urban areas of Honduras: Honduras is in the central region of Central America- it has a population of about 7.2 million; a TFR of 3.3, and a CPR of 65%. The most common method of contraception in the country is sterilization (33%), followed by injectables (21%), oral contraceptive pills (17%); and the IUD (10%).The cities included in the study are Tegucigalpa (capital, most populous), San Pedro Sula (large, industrial city in the north); and two regional cities, Santa Rosa de Copan and Gracias (in the Western, less developed region of the country)
The data for the study come from a panelof 800 women, aged 15-44 at baseline, who were recruited after attending a FP appointment in one of the selected health facilities. The selected health facilities included 7 Secretary of health clinics, one Secretary of Health hospital, and 5 clinics run by the Honduran Family Planning Association (ASHONPLAFA)- these types of facilities were the most common providers of female reversible methods in the four cities visited according to the most recent data. All women enrolled in the study were initiating or using injectables, IUD, or the contraceptive pill at the time of the baseline interview.About 200 women/city were enrolled between October-November 2006. The women were new to FP, new to a particular method, or what we call continuing (or returning) users.Baseline-Collected detailed information on contraceptive history, experience with side effects, couple dynamics & decision-making, motivations to avoid pregnancy, and service qualityAfter one year we conducted a follow-up interview with these women. We located and interviewed 671 women, (84%) of the original sample.Follow-up-Obtained detailed information on contraceptive use during the previous year in a month by month calendar, and included questions on the experience of side effects, pregnancies or births during the year, etc.
Read slide.There were no significant differences between the women interviewed at follow-up and the full sample of 800 women interviewed at baseline.
As you can see by this slide, the majority of women enrolled in the study at baselinewere using the injectable (72%); 21% of women were using the IUD and only 7% were using the Pill. We believe the low rate of pill users is reflective of the fact that women do not need to go to a clinic or get a prescription in order to obtain pills, and can purchase them at pharmacies.Herewomen are categorized into three groups based on contraceptive use status at the time of the baseline interview. About 52% were either getting a refill or having a consult about a method they were already using (“continuing users”). New adopters=new to FP (13%)New ‘switchers’=new to the method, reinitiating a method after a period of non-use (35%)
Life tables were used to construct discontinuation rates for women initiating a method at baseline. In this slide we see that among the 324 women initiating a method at baseline, 45% had stopped using their method by 12 months. Discontinuation during the first 12 months was most common for the injectable (at 50%) and Pill (at 44%- though it is a very small sample size).So discontinuation was common…
…But many women switched to another method without missing an episode of use (we define an episode of use as one month).This table shows us that discontinuation leading to at least one month of non-use was actually much lower, at 25% overall (compared to 45%). So, while 50% of women discontinued use of the injectable by 12 months, only 30% transitioned to a month or more of non-use.
Next to look at factors associated with contraceptive discontinuation in a multivariate analysis, we used Cox proportional hazards models. We ran two Models- the first, which will be presented in yellow, for the time until discontinuation of the baseline method; the second, which will be presented in lavender, for the time until the first episode of non-use of any method. Model 2, therefore, takes into consideration successful method switching.The covariates are those groups of factors that were outlined previously, including: demographics, fertility motivations, partner and family engagement, experience of side effects, baseline service quality, and user status at baseline.Baseline method type is used as a strata variable to allow for differences in the baseline hazard functions.
I’m going to present the covariate results by group to make the presentation easier to follow. What you see on this slide are the hazard ratios for demographic covariates that are significantly related to discontinuation (three asterisks=p<0.01; two asterisks=p<0.05; and the carot symbol=p<0.1; ). Note that a hazard ratio (HR) below 1.0 indicatesthat increases in the covariate reduce the hazard (or “likelihood”) of the indicated event, while a HR above 1.0 increase the likelihood of the event occurring. Again, Model 1, shown in yellow, are the hazard ratios for discontinuation of the baseline method while Model 2, in lavender, are the hazard ratios for experiencing an episode of non-use.Here we see that among demographic characteristics, being in the age group over 25, having a low parity and not being married or in union are associated with an increased likelihood of discontinuation, whereas only marital status and residence are related to an episode of non-use. While residing in an urban area is not significantly related to method discontinuation, it was found to be moderately related to a 26% reduction in the likelihood of experiencing an episode of non-use.
This slide has the covariates related to fertility motivations and family engagement.As would be expected, women who desired a child within 2 years had an increased likelihood of discontinuing the baseline method and of experiencing an episode of non-use as compared to women who wanted to wait more than 2 years, not have any more children, or who were undecided.Discussing side effects or health concerns with family members or friends in recent months was related to a 25% reduction in the likelihood of discontinuing and of experiencing an episode of non-use.There were no significant effects of discussing FP with the partner during the year or of feeling that the partner wanted more children than she, which were also included in the model.
This slide shows the covariates related to the experience ofside effects. Included in the model were heavy bleeding, weight gain, dizziness, headaches, amenorrhea, abdominal pain, and whether side effects had interfered with daily life or personal relationships.We see that a number of side effects are associated with an increased likelihood of method discontinuation, however this is not the case for transitioning to a period of non-use. Of women experiencing side effects, only women who experienced heavy bleeding had an increased risk of transitioning to an episode of non-use.
Finally, though this slide looks rather empty, it conveys some important information. Among a number of factors assessed for service quality at baseline, only four were included in the multivariate models, mainly because there was little variation in responses among many of the measures. The 4 included measures were: whether the woman had ever been informed by a health care provider about the side effects of her method; whether she was told at the baseline clinic appointment how to use the method effectively; whether she felt that all her questions had been answered by the provider; and whether the provider discussed 2 or more methods at her appointment. None of these factors were shown to be associated with the likelihood of discontinuation; however, women who felt that their provider had answered all their questions were 24% less likely to transition to a period of non-use than women who did not feel this way. (at p<0.1)
