Does contraceptive discontinuation matter? : quality of care and fertility consequences

The study also examines contraceptive behavior following a discontinuation and the fertility consequences of contraceptive discontinuation and failure. Hormonal methods (pills and injectables) are more likely to be discontinued due to side effects or health concerns than are other methods. Other method-related reasons (and contraceptive failure) are more important reasons for discontinuing periodic abstinence, withdrawal, and condoms. Service-related reasons for CD include cost and lack of access; these are rarely the primary reason for CD. In all but three countries, women who discontinue a modern reversible method for method- or service-related reasons most commonly switch to a different modern method; few return to a discontinued method. In contrast, women who experience a contraceptive failure and resume use after birth are most likely to return to the same method. The all-method discontinuation rate was calculated separately for reduced need and for quality-related reasons. Overall, 9-34% of women stop using contraception completely within 12 months on quality grounds. This latter rate is inversely associated with overall Family Planning Program Effort (FPPE) scores as well as with FPPE"s service-related component, although, contrary to expectation, two different indicators of method choice are not associated statistically with rates of CD for quality-related reasons. Nevertheless, the study suggests that the closest approximation to an overall indicator of quality of care is the all-method rate for quality-related reasons, since this indicator: (1) focuses on all methods and not any specific method and thus incorporates the notion that high rates of method switching are not necessarily negatively related to quality; and (2) includes only those who discontinued for reasons other than a desire to get pregnant or reduce exposure to pregnancy risk. On the negative side, short-term changes in this indicator may not be possible to detect with sample sizes in the range utilized by DHS surveys. The indicator also lacks 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 contribute substantially to overall rates of fertility and unwanted fertility. This implies that as fertility declines, FP programs would profit from a shift in emphasis from providing methods to new clients towards providing services to existing clients, such as counseling, that may help reduce failure and CD rates. (Author abstract, modified)