STRENGTHS AND LIMITATIONS OF THIS STUDY

This study used a small sample size.

This study does not represent all women in the reproductive age groups because it is a single-centre study conducted in Debre Berhan town that excludes reproductive age group women in the community.

The cross-sectional nature of the study did not allow causal relationship between the demographic and clinical characteristics of study participants with modern contraceptive discontinuation.

Introduction

Contraceptive discontinuation is a termination of contraceptive use for any reason except desiring to become pregnant.1 Contraceptive discontinuation is the major contributor to an unplanned pregnancy and unsafe abortion.2

Contraceptive discontinuation is a worldwide problem that has negative consequences on maternal, neonatal and infant health.3 25 out of 74 million unintended pregnancies resulted from contraceptive discontinuation and it accounts for 33% of unintended birth and 35% of unintended pregnancies according to a study conducted in 36 developing countries.4 Over 40% of women were at risk of conception after 3 months of discontinuation.5 In addition to this, contraceptive discontinuation can increase infant mortality and morbidity by increasing preterm birth, small for gestational age and low birth weight which can be caused by unplanned pregnancy.6 Moreover, it leads to a high fertility rate that will affect the economic growth of most developing countries.6

The magnitudes of contraceptive discontinuation vary from region to region and from method to method. According to the WHO Demographic and Health Survey (DHS) data report in 2012, from 60 countries all contraceptive method discontinuation rates were 38%, 55% and 64% within the first, second and third years of use, respectively.5 Similarly, a survey conducted by Ali and Cleland in 19 developing countries showed that the oral contraceptive discontinuation rate ranged from 15% to 40%.7 Other studies conducted in different parts of the world also indicated contraceptive discontinuation rates ranging from 11% to 40% after 6 months of use and from 21% to 45% after 12 months of use.3 8–11 Data from 16 countries in sub-Saharan Africa indicated that around 50% of women who ever used contraceptive had discontinued their use.3

In Ethiopia, according to the Ethiopia Demographic and Health Survey 2016 report, around 33% of contraceptive users discontinued within the first 12 months, and more than 50% discontinued before 2 years.8 In another study conducted in the northwest part of Ethiopia, 12 monthly contraceptive discontinuation rates were 35% varied by the method of contraceptive; 70% for contraceptive pill/oral contraceptives and 38% for injectable methods.9 Similarly, a study conducted in Jimma town found that the discontinuation rate was 11.5% and 27.4% within 12 and 24 months, respectively, and pill discontinuation was highest (30.0%) for 12 months.10 As different studies showed, there are many possible reasons for contraceptive discontinuation and reasons vary from country to country and method to method.5 The major reasons for short-acting contraceptive discontinuation were dissatisfaction with the method and side effects, whereas the common reasons for discontinuation of long-acting contraceptives were wanting to become pregnant and husband displeasure.11

In Ethiopia, this high level of discontinuation can adversely affect the quality of family planning programmes, which is crucial for women and couples to attain their long-term fertility desires.3 Therefore, it is important to address issues related to the contraceptive discontinuation behaviour of women.12 There was no published article regarding the prevalence of modern contraceptive discontinuation and associated factors among married reproductive age group women in the study area. Additionally, most studies in Ethiopia were done only on early Implanon removal and they did not incorporate other contraceptives like pills, injectables and a coil or intrauterine contraceptive device (IUCD). Therefore, this study aimed to determine the prevalence and factors associated with modern contraceptive discontinuation among married reproductive age group women in Debre Berhan town, Ethiopia.

Methods and materialsStudy area, design and period

A community-based cross-sectional study was conducted from 15 March to 15 April 2019. The study was conducted at Debre Berhan town, North-Eastern, Ethiopia. Debre Berhan town is found in Amhara Region, North Shewa Zone. It is 130 km away from Addis Ababa, the capital city of Ethiopia.13 The town has nine administrative kebeles (kebele is the area where people live and the smallest administrative unit in Ethiopia). According to the information obtained from the Debre Berhan health office, in 2015 and 2016 population data, the total population size of the town was 92 887, out of which 50 883 (54.78%) were females. The number of households was estimated to be 22 014. In the town, there are 2 hospitals, 3 health centres, 9 health posts, 6 private clinics and 17 pharmacies that render health services for the community. Family planning service was also available in most of the above health institutions including health posts.

Patient and public involvement

Study participants did not participate in the initial conception and design of the current study. Study participants played a central role in the current study in assessing the use of modern contraceptives and associated factors.

PopulationSource population

All married reproductive age group women who used modern contraceptives in the last 5 years and who live in nine kebeles of Debre Berhan town.

Study population

Randomly selected married reproductive age group women who used modern contraceptives in the last 5 years at selected kebeles of Debre Berhan town.

Sample size determination

In this study, the sample size was calculated using a single population proportion formula based on the following assumptions: prevalence of contraceptive discontinuation (p) was used 27 %14, α=0.05, 95% CI, a margin of error (d) (5%). By considering the design effect of 1.5 and 10% non-response, a total of 500 women were recruited for the study.

Sampling procedures

Two-stage sampling procedures were employed to identify the study participants. In the first stage, four kebeles were randomly selected from nine kebeles in the town. In the second stage, systematic random sampling technique was applied to identify the required sample from selected kebeles. A list of contraceptive users was taken from the family planning and registration book of each selected kebele health post and health centre. Kebele administrative office of each selected kebele was used as the starting point for the selection of the first household, then the next household that contained women who used contraceptives in the last 5 years was selected by using systematic random sampling. For selected households with more than one eligible study participant, one was selected by using the lottery method.

Data collection tool

Data were collected using a semistructured face-to-face interview questionnaire. It had three parts: sociodemographic characteristics of study participants, reproductive characteristics (ever gave birth before, number of pregnancies before, encountered abortion, etc) and contraceptive discontinuation characteristics.

Data quality control and data collection procedure

Pretest was done on 5% of the study participants (25 study participants) at Kebele 09 of Debre Berhan town and data cleaning and coding was done before data analysis.

Four health extension workers were recruited and trained for data collection techniques and one supervisor was trained to supervise the data collectors and check for the completeness of the collected data.

Variables

Modern contraceptive discontinuation was the outcome variable, while sociodemographic characteristics, obstetric factors, method-related factors and quality of family planning services like counselling and appointment for follow-up were included in independent variables.

Operational definition

Modern contraceptives are contraceptives including pills, injectables, implants and IUCD.

Contraceptive discontinuation is the discontinuation of modern contraceptive use for any reason, at any time for pills and injectables and before the end of their use for implant and IUCD.

Methods of data analysis

Data were entered into EpiData V.4.2.0 and analysis was performed using SPSS V.25 software. Binary logistic regression was used to see the association between independent variables and the outcome variable. A p value <0.05 is considered statistically significant.

ResultsSociodemographic and economic characteristics of the respondent

The study was conducted among 500 married reproductive age group women and the response rate was 100%. The mean age of participants was 29 years (SD=7.3 years). Nearly one-third of 149 (29.8%) women were above 35 years old. Greater than two-thirds (69.6%) of the participants were Orthodox followers and 186 (37.2%) of women were government employees. The reported average family income of the participants was ETB4487 (Ethiopian birr) and two-thirds of participants (70%) were living with their husbands during the interview (table 1).

Table 1

Sociodemographic and economic characteristics of participants in Debre Berhan town, 2019 (n=500).

Reproductive characteristics of the respondent

Two-thirds of participants (66%) had birth before the date of the interview. Age at first birth ranged from 12 years to 38 years with a mean age of 22 years (SD=3.86). The average number of children per family was two (SD=1.34).

Of 330 study participants who ever gave birth, 66 (20%) had reported having a history of abortion and 38 (11.5%) had a history of child death.

Regarding decision-making in a number of children, 322 (64.4%) participants said that decisions were made by husband and wife together. However, 89 (17.8%) study participants said that the decision was made by the husband alone (table 2).

Table 2

Reproductive characteristics of the participant in Debre Berhan town, 2019 (n=500).

Prevalence of modern contraceptive discontinuation

In the current study, the prevalence of modern contraceptive discontinuation was 176 (35.2%) among married reproductive age group women. From those modern contraceptive methods, pills have the highest rate of discontinuation (59, 33.5%) in study participants while IUCD has the lowest rate of discontinuation (20, 11.4%) (figure 1).

Figure 1

Type of modern contraceptives discontinued within the last 5 years in Debre Berhan town, 2019. IUCD, intrauterine contraceptive device.

The major reasons for contraceptive discontinuation reported by study participants were needed to get pregnant (94, 53.4%), the occurrence of side effects of contraceptives (43, 24.4%) and husband going to another working area (39, 22.2%) (figure 2).

Figure 2

Reasons for contraceptive discontinuation in Debre Berhan town, 2019. MC, modern contraceptive.

135 (76.7%) study participants experience at least one side effect while using modern contraceptives. Irregular bleeding was the most (132, 48.4%) frequently reported side effect, followed by the absence of period (105, 38.6%) and weight loss (101, 37.1%) (figure 3).

Figure 3

Side effects experienced by participants while using modern contraceptives (MC) in Debre Berhan town, 2019.

Factors associated with modern contraceptive discontinuation

The reported demographic and clinical characteristics that fulfilled the multivariable logistic regression analysis were women’s educational status, living without their husbands, those who have been experiencing side effects of contraceptives, had not been receiving counselling service and not being accepted by their husbands for using contraceptives.

The results demonstrated that women who had primary educational status were about three times more likely to discontinue modern contraceptives compared with women who had college and above educational status (adjusted OR (AOR)=3.35, 95% CI 1.30 to 8.63). Women who had not lived with their husbands were three times more likely to discontinue contraceptives than women who lived with their husbands (AOR=3.27, 95% CI 1.78 to 6.00). Additionally, women who did not get acceptance from husbands were about four times more likely to discontinue contraceptives compared with women who did get acceptance from their husbands (AOR=3.90, 95% CI 1.65 to 9.22). Similarly, women who had experienced contraceptive side effects were three times more likely to discontinue contraceptives compared with women who had not experienced contraceptive side effects (AOR=3.28, 95% CI 1.89 to 5.71). In addition, women who did not receive counselling service from healthcare providers during contraceptive use were three times more likely to discontinue contraceptives compared with women who had received counselling service (AOR=3.12, 95% CI 1.77 to 5.49) (table 3).

Table 3

Factors associated with the discontinuation of modern contraceptives (n=500).

Discussion

The finding of this study indicated that the mean utilisation of modern contraceptives before discontinuation was found to be 2.6 (SD=2.1) months. Our finding implies that the modern contraceptive discontinuation rate was high. This finding is in line with studies done in Italy (34.9%).11 However, our finding is lower than a study done in Sweden (38.4%)15 and Nepal (62%).16 Likewise, a survey conducted by Ali and Cleland in 19 developing countries showed that oral contraceptive discontinuation rates ranged from 15% to 40%,7 and WHO DHS data report from 60 countries in 2012 revealed that all contraceptive method discontinuation rates were 38%, 55% and 64% within the first, second and third years of use, respectively.5 These inconsistencies may be due to differences in setting, sampling technique used, sample size and study participants’ characteristics.

In the current study, the 12-month contraceptive discontinuation rate was 12.6%. This result was similar to a study done in Jimma, Ethiopia (11.5%).10 This finding was lower than the studies done in Kenya (30.5%),17 Maryland, USA (21.9%),8 Senegal (34.7%)3 and Honduras, Central America (45%).3 This finding was also inconsistent with the DHS survey conducted in Armenia, Bangladesh, Colombia, the Dominican Republic, Egypt, Indonesia, Kenya and Zimbabwe, which showed that 12-month contraceptive discontinuation rates ranged from 18% to 63%.9 The variation could be the study design, size of the study participant, data collection method and nature of the study. For example, the study conducted in Kenya and Senegal used secondary data from DHS, used a large sample size and the study period in Senegal was too long (2010–2015).

In our study, the top three identified reasons for contraceptive discontinuation were study participants wanting a child, experiencing side effects and study participants’ husbands working in other areas. Around 55% of study participants reported that they experienced a side effect of contraceptives. So giving adequate counselling may fill this information gap and decrease modern contraceptive discontinuation. This finding is in line with other studies done in Maryland, USA and Italy.8 10 11 14

In the current study, the common side effects of contraceptives reported by study participants were irregular bleeding, absence of period, weight loss and headache. This finding is consistent with a study conducted in Italy which indicated that irregular bleeding (5.3%), weight gain (4.8%) and headache (3.8%) were the main reasons for contraceptive discontinuation.11 Similarly, the study done in Honduras, Central America revealed that the main reasons for contraceptive discontinuation were experiencing heavy bleeding (14.2%), weight gain (11%), dizziness (13%), headache (26.7%), amenorrhoea (22.1%) and abdominal pain (14.8%).3

In our study, the discontinuation rates of daily pills, injectables and IUCD were 38%, 32.7% and 18.4%, respectively. Likely, a study conducted in Nepal showed that the discontinuation rate of short-acting contraceptives (95%) was higher than long-acting contraceptives.16 Additionally, according to WHO DHS data report from 60 countries, discontinuation rates were higher for short-acting methods than long-acting methods.5

In the current study, the contraceptive discontinuation rate was higher among less educated women (primary education level) compared with more educated women (college and above education level). This finding was in line with studies done elsewhere.18–20

When women and their husbands are not living together, women may feel they do not need to use contraceptives because of the absence of a sexual relationship. Accordingly, contraceptive discontinuation among women who had not lived with their husbands was 3.81 times greater than those who lived with their husbands. This finding was comparable with a study conducted in Nepal.16

In the current study, study participants did not receive counselling from a healthcare provider about contraceptive methods, and side effects were one factor affecting modern contraceptive discontinuation. This is consistent with studies conducted in Bangladesh, Angola, Humera, Dale and Debre Tabor.14 16 21–25 Counselling will help women make an informed choice to be prepared for any possible side effects and be reassured about health concerns.5 According to a study done by Halpern et al, counselling enhances the continuation of contraceptive use through improvements in service quality.18 Proper contraceptive use counselling is expected to involve the women and husbands (partners) whose acceptance was found to decrease the contraceptive discontinuation rate.

This study assesses the prevalence of modern contraceptive discontinuation, which constitutes a quality indicator that can be used for improving the healthcare of family planning services. In the current study, some determinants affect the continuation of modern contraceptive use among women in the fertility age. However, due to the limitation of the study design the true cause-and-effect relationships could not be justified.

Conclusion

The findings of this study indicated that the prevalence of modern contraceptive discontinuation rate of all methods among married reproductive age group women was 35.2%. Similarly, the 12-month discontinuation rate of contraceptives was 12.6%.

Study participants who had low educational status, had experienced side effects, did not get counselling services and did not get acceptance from their husbands showed significant association with the occurrence of modern contraceptive discontinuation.

To reduce modern contraceptive discontinuation, mutually, it is important to create community awareness about the importance of the continued use of modern contraceptives, improve the quality of family planning service in the health institution, strengthen family planning counselling service and give adequate counselling on details of effectiveness and side effects.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Ethics statementsPatient consent for publication

Consent obtained directly from patient(s)

Ethics approval

This study involves human participants and was approved by the Institutional Review Board of Addis Ababa University (ERB/SON/110/07/2019). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We are very thankful to the study participants for their willingness to participate in this study.