For decades, research on contraceptive discontinuation has reported that the key reasons women stop using contraception are stock outs, service delivery issues, and “method-related concerns” — which can include health concerns, side effects, problems of cost or access, or desire for a more effective method. In fact, a 2012 World Health Organization (WHO) 60-country survey found that about 20 percent of women discontinue their family planning method within a year for method-related reasons, including side effects or health concerns. But the levels of and reasons for discontinuation vary by method. Short-acting hormonal methods like pills and injectables may be discontinued for method-related reasons within the first year by 25–35 percent of women, while only about 9 percent of IUD users discontinue for method-related reasons in their first year. While these data are older, more recent Demographic and Health Surveys from Nigeria (2019), Rwanda (2020), and Senegal (2019) echo these findings, with side effect-related discontinuation among pill and injectable users ranging from 15–36 percent but only 5–10 percent for implant and IUD users.
As family planning practitioners, we tend to make broad generalizations about these data. For example, although in most countries fewer women use IUDs and implants, those that do often use them for longer. We sometimes attribute this to stronger motivation to avoid pregnancy (i.e., they are often “limiters”) and better access to higher-quality services (urban-based, higher education, higher income levels). In contrast, pills, condoms, and injectables are more prevalent, easier to access, easier to “try” and abandon, and might even be more often promoted by healthcare workers because they’re easier and faster to offer. While uptake may be easier for pills and injectables, one conclusion is that many users abandon pills and injectables due to the unpleasant side effects. We assume that the problem is with the method, regardless of how it is provided, but is that necessarily true?
“Have we underestimated how much women are willing trade off other method characteristics…for increased convenience?”
My thinking about side effects, method source, and discontinuation was challenged a few years ago when a friend published research that showed discontinuation among women in Malawi who self-injected DMPA-SC was half that of women who had DMPA-SC administered from a community health worker (health surveillance assistants in Malawi) or facility-based provider. I found this highly curious. Here we have the same method, so presumably these women were experiencing the same side effects. So why did women who self-inject continue to use DMPA-SC at such significantly higher rates? A 2019 systematic review confirmed two other studies, both from the United States and published in Contraception in 2014 and 2017, found similar results. Perhaps discontinuation isn’t only about the method, but also how the method is provided.
Could it be that contraceptive convenience plays a much bigger role in method satisfaction than we thought? Have we underestimated how much women are willing trade off other method characteristics (e.g., side effects) for increased convenience? This certainly fits with the data about higher continuation rates for IUDs and implants — methods that users can “get and forget” until users want them removed. If convenience really has that much influence on discontinuation, perhaps we need to rethink what we think we know about discontinuation.
The research in Malawi on DMPA-SC suggests that if we try making access to contraceptives more convenient, then discontinuation rates might decrease. Improving contraceptive convenience means embracing self-care — individuals promoting and maintaining health, preventing disease, and coping with illness and disability with or without the support of a healthcare provider. This will require targeted policy, service delivery, and behavior change interventions to increase women’s autonomy, agency, access, and health literacy. The WHO has rolled out extensive guidance on self-care approaches to family planning. This includes making hormonal pills available over the counter (or if obtaining from a health provider, advance provision of a year’s supply) and recommending providers train clients in self-injection and provide them with an ample supply of DMPA-SC. One way that countries addressed family planning needs during the COVID-19 pandemic was to implement WHO self-care approaches so that women would not have to visit providers, facilities, and pharmacies as often. For example, in December 2020, Burkina Faso issued new directives and operational guidance that allowed providers to dispense pills in sufficient quantities (i.e., could accommodate a 12-month supply), and also allowed pharmacists and community health workers to resupply pills without a prescription. These types of policies increasing contraceptive convenience need to be the norm, not only a response to emergencies.
Beyond more convenient access through self-care, women can use digital technology to empower themselves to use contraception and make access and use more convenient. As digital health applications flourish, opportunities abound to intersect client-based applications with self-care, whether through a basic digital reminder, an app to geo-locate your nearest family planning service delivery point, or ordering refills from online pharmacies or personal care sites for direct delivery. Digital solutions need to be developed with local context, infrastructure, and equity in mind, but the promise is there. Interactive “chatbots” delivered through common platforms such as WhatsApp or Facebook, or through text messaging, can not only educate clients on a range of methods, but also support them to manage any undesirable side effects or link them to services to switch to a different method. Supporting self-care through digital technologies will be particularly effective for reaching young people, who tend to be more plugged in and appreciate the privacy digital tools can offer.
By putting in place the policy and programmatic approaches needed to bolster self-care and combining self-care approaches with digital health technology, we can take contraceptive convenience to a new level. This may, in turn, be the missing solution to significantly decreasing contraceptive discontinuation rates. There are three ways countries can begin contributing to contraceptive convenience: (1) make pills available over the counter, or if a client is obtaining from a provider, provide a year’s supply in advance; (2) integrate self-injection of DMPA-SC into family planning programs, ensuring that both the private and public sector offer it and that refills are available from drug shops/pharmacies; (3) incorporate digital reminder apps into programming — reminders for follow-up appointments, to refill prescriptions, and to take pills or self-inject — with links to services in case clients need additional counseling or wish to switch methods. These changes will require coordination and increased investment, but the trade-off in the form of increased contraceptive convenience and lower discontinuation rates, will be worth it.