Journal Pre-proofs

Original Research Article

Reasons for discontinuation of contraception among women with a current un-

intended pregnancy in 36 low and middle-income countries

S. Bellizzi, P. Mannava, M. Nagai, H.L. Sobel

PII: S0010-7824(19)30430-5
DOI: https://doi.org/10.1016/j.contraception.2019.09.006
Reference: CON 9335

To appear in: Contraception

Received Date: 12 October 2018

Revised Date: 16 September 2019
Accepted Date: 17 September 2019

Please cite this article as: S. Bellizzi, P. Mannava, M. Nagai, H.L. Sobel, Reasons for discontinuation of
contraception among women with a current unintended pregnancy in 36 low and middle-income countries,
Contraception (2019), doi: https://doi.org/10.1016/j.contraception.2019.09.006

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 1 Reasons for discontinuation of contraception among women with a current

2 unintended pregnancy in 36 low and middle-income countries

5 Authors: Bellizzi S1, Mannava P2, Nagai M3, Sobel HL2

6
7
8 1Partnership of Maternal, Newborn, Child and Adolescent Health, Geneva, Switzerland
9 2World Health Organization, Western Pacific Regional Office, PO Box 2932 (United
10 Nations Avenue), 1000 Manila, Philippines
11 3National Center for Global Health and Medicine, Tokyo, Japan
12
13
14 Corresponding author:
15 Howard Sobel; sobelh@who.int
16
17
18 Key words: Family planning, Demographic Health Survey, Developing countries,
19 unwanted pregnancies.
20
21

22 Funding: No funding was utilized for this work.

23

24 Conflict of Interest: None declared.

25 Abstract word count: 250

26 Text word count: 2,440

27

1
28 Abstract

29

30 OBJECTIVES: To explore the reasons for discontinuation of the last contraceptive

31 method used in women with a current unintended pregnancy.

32

33 STUDY DESIGN: We conducted a retrospective analysis using contraceptive calendar

34 data from Demographic and Health Surveys from 36 low- and middle-income countries

35 from 2005 through 2014. The prevalence of contraception utilization and the contribution

36 of each reason for contraceptive discontinuation was calculated, at country level as well

37 as for the pooled dataset, for 10 901 women aged 15-49 before the current unintended

38 pregnancies.

39

40 RESULTS: Unintended pregnancies ranged from 5.5 % of all pregnancies in the Kyrgyz

41 Republic to 60.0 % in Colombia and Peru. In Central Asian and in six African countries,

42 over 80% of women with a current unintended pregnancy had not used any

43 contraceptives in the previous five years. Use of long-acting modern methods remained

44 consistently low across all countries. Among women who last used a traditional method,

45 83.8% discontinued due to failure. Among women who last used a long-acting modern

46 method, 40.2% discontinued because of side effects.

47

48 CONCLUSIONS: Our findings confirm that more than 65.0% of women with an

49 unintended pregnancy in 36 low and middle-income countries were either non-users or

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50 using traditional methods. An additional 31.2% were using short-acting modern methods.

51 Long-acting methods would have prevented the overwhelming majority of unintended

52 pregnancies.

53

54 IMPLICATIONS: This paper shows the need for the health system to support use of

55 suitable methods, reduce switching failure and identify early when women are having

56 concerns about the method they are using.

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60

61

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66

67

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69 Introduction

70

71 Globally, 74 million women living in low and middle-income countries have unintended

72 pregnancies annually [1]. Unintended pregnancies lead every year to 25 million unsafe

73 abortions [2] and 47,000 maternal deaths [3]. Reduced antenatal care seeking and

74 delivery assistance sought by women having unintended pregnancies [4] also contribute

75 to the 2.7 million neonatal deaths [5] and the 2.6 million stillbirths occurring annually [6].

76 Unintended pregnancies are the consequence of a wide range of factors including non-use

77 of contraception, contraceptive discontinuation, contraceptive failure [7], and inconsistent

78 and incorrect use of contraception [8]. Contraceptive discontinuation, defined as starting

79 contraceptive use and then stopping for any reason while still at risk of an unintended

80 pregnancy [9], is a frequent event [10].

81 Analysis of the reasons for contraceptive discontinuation is important to improve service

82 delivery and user uptake of contraception. For example, fear of side effects, health

83 concerns and underestimation of risk of conception were found to account for two-thirds

84 of discontinuation among sexually active women who did not desire another pregnancy

85 [11]. Discontinuation because of side effects, may suggest the need for improved

86 counselling and communication [12]. Other reported reasons for discontinuation include

87 accessibility to contraceptives, cost of services, opposition and religious beliefs as well as

88 misunderstanding of how to use the contraceptives [13]. In addition, as discontinuation

89 rates vary according to the type contraceptive method, knowing reasons for

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 90 discontinuation helps to determine how to tailor interventions accordingly. For example,

91 women using user-dependent methods such as oral contraceptives are more likely to

92 discontinue than women using intrauterine devices (IUD) [7].

93 Our previous findings, also based on Demographic and Health Survey (DHS) data,

94 showed 11.3% of pregnant women who did not desire a pregnancy had stopped using a

95 modern method. This prompted us to further investigate contraceptive histories among

96 women with a current unintended pregnancy [11]. We sought to explore the proportional

97 contribution of the reasons for discontinuation of the last contraceptive method used.

98

99 Methods

100

101 Data source

102 Demographic and Health Surveys (DHS) are large, nationally representative household

103 surveys conducted since 1984 in over 90 low- and middle-income countries worldwide.

104 The standard DHS survey consists of a household questionnaire and a women’s

105 questionnaire. The latter is administered to women of reproductive age (15 – 49 years)

106 and includes a contraceptive history calendar for the five years prior to the survey [14].

107 We explored all available datasets and analysed data from all the 36 latest country DHS

108 conducted from 2005 with data on desire for pregnancy among currently pregnant women

109 (Table 1), the last method of contraception used and reasons for discontinuation. Fifty

110 percent (N=18) of the surveys were from Sub-Saharan Africa, 22% (N=8) from South

111 and East Asia, 8% (N=3) from East Europe, 8% (N=3) from Latin America, 6% (N=2)

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112 from Middle East and North Africa, and 6% (N=2) from Central Asia. Quality and risk of

113 bias were evaluated by using the Newcastle-Ottawa Scale (NOS) [15] for observational

114 studies. Quality of each survey was evaluated through a system of points (stars) given to

115 the eligible categories. Since all studies included in the analysis were cross-sectional, the

116 NOS with a total scale of six was used and a total of four or above was utilized to

117 categorize surveys of high quality [16].

118

119 Variables

120 The DHS women’s questionnaire asks whether currently pregnant women intended to

121 become pregnant at the time, wait until a later time, or did not want pregnancy at all.

122 Based on responses, current pregnancies were respectively categorized as “intended”,

123 “wanted to wait”, and “not wanted at all”. We combined pregnancies that “wanted to wait”

124 and “not wanted at all” into the variable “unintended” current pregnancies. Data on last

125 method of contraception used prior to or at the time of the current pregnancy and reasons

126 for contraception discontinuation were extracted from the contraceptive history calendar.

127 As per the DHS methodology, only one contraceptive method is recorded per month. For

128 women reporting using two methods concurrently, the method selected is the one that

129 appears first in the list in the DHS questionnaire (which corresponds to the more effective

130 method being used).

131 Last method of contraception used prior to the current pregnancy was classified into four

132 main categories: “no contraception”, “traditional methods of contraception”, “short-

133 acting modern methods of contraception” and “long-acting modern methods of

134 contraception” based on definitions of the World Health Organization. Traditional

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135 methods included “withdrawal”, “periodic abstinence” and the “calendar rhythm method”;

136 short-acting modern methods included “pills”, “injections”, “lactational amenorrhea

137 (LAM)”, “diaphragms”, male and female “condoms”; long-acting modern methods

138 included “intra-uterine device (IUD)”, “implant”, female and male “sterilization”.

139 Reasons for discontinuing contraception were grouped into (1) reported failure (the

140 respondent became pregnant while using the method), (2) method-related reasons: side

141 effects and health concerns, cost, and other supply and demand factors consisting of

142 inconvenient to use, infrequent sex/marital dissolution, unavailability, husband’s

143 disapproval, fatalism, wanting a more effective method, (3) Other reasons comprising

144 difficult pregnancy, don’t know and other unspecified reasons. Method-related reasons

145 apply to all women who were using a method of contraception over the last five years but

146 were not using it in the month immediately prior to conception.

147

148 Statistical analysis

149 Country datasets were downloaded from the DHS program website and imported into

150 Stata/MP v.14 for analysis. We estimated the prevalence of use of contraception by type

151 of method for all current unintended pregnancies for each country, accounting for

152 stratification and clustering in the sample design. Also, we conducted the same analysis

153 for the pooled 36 country dataset to have a more global perspective, and to have broader

154 results that are “often obscured by the noise of individual data sets” [17]. Cross-

155 tabulations were conducted to examine the contribution of each reason for contraceptive

156 discontinuation to country and pooled unintended pregnancies. Each category of

157 contraception method and reasons for discontinuation were also stratified by residence

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158 (urban or rural), education (no education, primary, secondary, and higher), and wealth

159 (poor, middle and rich based on the DHS wealth factor score) [18].

160 In country specific analyses, the svytab command was used to adjust for stratification, the

161 cluster-sampling design and sampling weights as per standard methodology for analyses

162 of DHS data. The svytab function automatically produces a design-based F statistics

163 when tabulating categorical variables. The Metaprop syntax [19] was used in the pooled

164 analysis of all country datasets, which generated weighted subgroup and overall pooled

165 estimates with inverse-variance weights obtained from a random-effects model. In this

166 model, no residual heterogeneity is assumed.

167 To ensure reliability of findings, we conducted a sensitivity analysis taking into

168 consideration the last method of contraception used and reasons for discontinuation

169 during the two years prior to the interview.

170 Formal approval to use the data was obtained from the DHS program through the

171 following link: https://dhsprogram.com/data/available-datasets.cfm.

172

173 Results

174

175 Desirability of pregnancy

176 Of the 663,622 women of reproductive age in the pooled dataset, 43,763 (6.5%) women

177 were pregnant. Of these women, 10,901 (25.0%) had an unintended pregnancy. Three out

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178 of four unintended pregnancies were wanted at a later time, and one out of four not

179 wanted at all.

180 In individual country analyses, unintended pregnancies ranged from 5.5 % of all

181 pregnancies in the Kyrgyz Republic to 60.0 % in Colombia and Peru (Table 1).

182 In the pooled sample estimates within socio-economic groups around 20% or more of

183 pregnancies were unintended irrespective of place of residence or education and wealth

184 status (Table 2). The differences between urban and rural and by education were found to

185 be significant.

186

187 History of contraception use

188 Of women with an unintended pregnancy, 56.3% used no contraception in the last 5 years,

189 whilst 9.9% last used traditional methods, 31.2% short-acting modern methods, and 2.6%

190 long-acting modern methods of contraception (Figure 1). Eight percent of unintended

191 pregnancies were due to failure of traditional methods, 12.9% due to failure of short-

192 acting modern methods, and 1.0% from failure of long-acting modern methods.

193 Two percent of unintended pregnancies were due to discontinuation of traditional

194 methods, 18.0% were due to discontinuation of short-acting modern methods, and 2.0%

195 were due to discontinuation of long-term modern methods at any time in the last five

196 years.

197 The sensitivity analysis showed that 60.4% of women used no contraception in the last

198 two years, whilst 9.3% used traditional methods, 27.9% short-acting modern methods and

199 2.4% long-acting modern methods of contraception. The sensitivity analysis confirmed

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200 the same failure percentages above-reported (8.3% for traditional methods, 12.9% for

201 short-acting modern methods and 0.9% for long-acting modern methods of

202 contraception).

203 One percent of unintended pregnancies were due to discontinuation of traditional

204 methods, 15.0% were due to discontinuation of short-acting modern methods, and 1.5%

205 were due to discontinuation of long-term modern methods at any time in the last five

206 years.

207

208

209 Reasons for discontinuation

210 Reasons for discontinuation of methods differed by the last method used in the past 5

211 years among women with a current unintended pregnancy. Among women who last used

212 a traditional method, the primary reason for discontinuation was failure (becoming

213 pregnant, 83.8%) followed by inconvenience of use (5.2%). Other supply and demand

214 factors were less frequently reported as reasons: disapproval of the husband (3.9%),

215 infrequent sex (1.8%), fatalism (0.9%) and marital dissolution (0.9%), whilst 3.5% did

216 not know why the method was discontinued. Among women who last used short-acting

217 modern method, 41.3% discontinued due to side-effects and health concerns and over a

218 quarter (25.1%) discontinued due to failure. Small percentages of women reported cost

219 (1.5%), unavailability (6.8%), inconvenience to use (6.5%), disapproval by husband

220 (5.7%), infrequent sex (3.8%), wanting a more effective method (1.7%), marital

221 dissolution (0.8%), and fatalism (0.5%) as a reason. Other unspecified reasons accounted

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222 for 6.3% of unintended pregnancies among women who last used short-acting methods.

223 Among women who last used a long-acting modern method, 40.2% discontinued because

224 of side effects and health concerns, 22.5% from failure, 14.8% due to cost, 14.1%

225 inconvenient to use, 1.6% disapproval by husband, 1.4% unavailability of the

226 contraceptive, and 5.4% unspecified factors as reasons for discontinuation.

227 The sensitivity analysis yielded very similar findings with failure as primary reason for

228 discontinuation among women who last used a traditional method (becoming pregnant,

229 89.4%). Among women who last used short-acting modern method, 45.2% discontinued

230 due to side-effects and health concerns and over a quarter (26.8%) discontinued due to

231 failure. Among women who last used a long-acting modern method, 39.0% discontinued

232 because of side effects and health concerns and 20.1% from failure.

233

234 Variation by country and socio-economic factors

235 Countries varied considerably in contraceptive usage (Figure 2). Non-use of

236 contraceptives in the last five years exceeded 80,0% of current unintended pregnancies in

237 the Central Asian countries (Kyrgyz Republic and Tajikistan) and six African countries

238 (Benin, Comoros, Gambia, Mali, Mozambique, and Senegal). In Bangladesh, Colombia,

239 Egypt, Honduras, Indonesia, Namibia, and Zimbabwe, over half of women with a current

240 unintended pregnancy last used a short-acting modern method. Pregnancy due to all-

241 method failures ranged from 2.2% of unintended pregnancies in Tajikistan to 54.0% in

242 Bangladesh. Use of long-acting modern methods remained consistently low among

243 women who reported an unintended pregnancy across all countries.

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244 In the 5 years previous to the surveys, non-use was higher among women living rural

245 areas, in the poorest wealth quintile, and with no education (Table 3). Only 0.6% of the

246 poorest, 0.4% of least educated and 0.4% of rural respondents identified cost as a reason

247 for non-use.

248 A higher proportion of traditional method users were urban dwellers (13.3% versus 7.8%

249 in rural areas), in the richest wealth quintile (12.4% versus 8.7% for the poorest wealth

250 quintile), and had the highest level of education (23.0% versus 4.7% for no education).

251 Across all socioeconomic strata, the vast majority of women using traditional methods

252 (over 78.0%) discontinued due to failure (i.e., became pregnant).

253 The proportion of women who used modern methods of contraception prior to the current

254 unintended pregnancy (Table 3) was higher among those living in urban areas, and

255 increased with wealth and level of education. Estimates for the proportion of women

256 using short-term methods ranged from 17.7% and 26.3% in women with no education

257 and in the poorest quintile respectively to 38.6% and 36.6% in the highest education

258 category and richest quintile. Proportions stopping due to side-effects or health concerns

259 were around 7.0% in all wealth categories, and ranged between 5.0% - 10.0% across

260 educational levels. Less than 5.0% of women in all strata last used a long-term method.

261

262

263

264

265

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266 Discussion

267

268 More than half of women who had an unintended pregnancy were not using any

269 contraception. This is the classical "unmet need" [20]. However, 9.9% had last used

270 traditional methods which pose a high risk of unintended pregnancy [11]. Another 31.2%

271 had used short-acting methods. Long-acting methods would have prevented the

272 overwhelming majority of unintended pregnancies.

273 Rich or poor, educated or uneducated, rural or urban around or above 20% of the total

274 pregnancies were undesired. Large country variation existed with two countries having

275 60% of all pregnancies unintended, the non-use of any contraceptive method before the

276 current unintended pregnancy exceeded 80% in several Central-Asian and African

277 Countries.

278 Side effects are common reasons for discontinuation of pills, injectables and IUDs in

279 low-income settings [21]. In our study, among women with an unintended pregnancy

280 who last used a short-acting modern method, 41% discontinued because of health

281 concerns and side effects. It is well-known that short-acting methods do not require

282 provider involvement to stop using and are thus more easily discontinued [22].

283 Discontinuation of long acting modern methods contributed to 2.9% of the total

284 unintended pregnancies, mainly due to the side effects and health concerns. However,

285 two countries exceeded 30% of the unintended pregnancies among women using long-

286 acting methods due to failure. Higher than expected failure rates for intrauterine devices

287 (IUD) has been found in other multi-country analysis [23].

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288 As reported in literature [24, 25], unintended pregnancies often occur during periods

289 when women engage in contraceptive switching, often to less effective methods, or

290 abandoning contraception. The rate of switching to no method is of particular importance

291 because 85 out of 100 will become pregnant in the first year after stopping [26]. Among

292 women who experienced an unintended pregnancy leading to an abortion, half had

293 discontinued their contraceptive methods due to a method-related reason [27]. Our

294 findings substantiate the current evidence and highlight the need to ensure correct use of

295 contraception and address client concerns namely with side-effects to prevent

296 discontinuation of contraceptive use.

297 Though DHS use standardized procedures for collection of data, several limitations are

298 noted. While underreporting of certain methods such as condoms and other short-acting

299 methods has been documented, especially in West Africa [28], other reports suggest the

300 opposite, with women who have unintended pregnancies over-reporting consistent and

301 correct use of contraception as it is more socially acceptable [29, 30]. Reasons for

302 discontinuation may be subject to recall bias [31] and this may vary across countries.

303 Also, even if a woman did stop for a specific reason, there are potentially many other

304 reasons a woman did not then take up a different method in the interim which are not

305 captured in our analyses. Lastly, method failure is classified as women who say they

306 “became pregnant while using” but this does not necessarily allow for the fact that

307 women may have used inconsistently or improperly because of other concerns, such as

308 side effects. Thus, using this classification alone may be underestimating the impact of

309 side effects/health concerns.

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310 Post-event rationalization bias [32] on the intention status of pregnancies should be

311 minimized in the current study since we are dealing with current pregnancies.

312 Researchers have also questioned the validity of current measures of unintendedness,

313 especially when assessing the contradictions between pregnancy intention and woman

314 happiness or unhappiness at discovering she is pregnant [33]; a report highlighted how

315 among the 32% of women who reported a contraceptive failure as an intended pregnancy,

316 90% had been happy or very happy [34]. While families may feel compelled to love their

317 new child, the socio-economic effect of unintended pregnancies must be considered [35].

318 Another complicating factor is the considerable heterogeneity within the category of

319 unintended pregnancy, with unwanted and mistimed pregnancies representing different

320 life-choice considerations [36].

321 In our analysis we included data from countries from different parts of the world and

322 different points in time across ten years, thus possibly reflecting important differences in

323 the attitudes. We may have missed women who are most motivated to avoid a pregnancy

324 and had an abortion [37]; however, it is difficult to judge this effect on the study results

325 [38]. Although we are considering only the last discontinued method, women or couples

326 may have used several methods during the 5 years interval covered by the questionnaire,

327 thus limiting a more comprehensive understanding of reasons of discontinuation. A

328 longitudinal study would help to minimize these limitations and better understand

329 contraceptive use and discontinuation among couples.

330 The high levels of unintended pregnancies due to non-use of contraception were most

331 prevalent among the least educated (76%), poorest (63%) and rural respondents (62%);

332 however, even among the most educated (33.3%), richest (47.3%) and urban respondents

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333 (46.7%), non-use is very high and a major issue that needs to be tackled. That one in ten

334 used traditional methods raises similar concerns. Compared with modern methods of

335 contraception, non-use of contraception or use of traditional methods increases the odds

336 of an unintended pregnancy by respectively 14 and 3 times [11]. Side effects and health

337 concerns reinforce the need of wider access to family planning services coupled with

338 detailed information on mechanisms of action, safety and ease of use of modern methods

339 of contraception [39]. Availability of a range of contraceptive methods, especially long-

340 acting reversible methods would allow an appropriate choice according to personal needs

341 and would enhance continuous long-term use [40].

342 Our findings build on previous reports, which emphasize the central role the health

343 system can have on recognition and treatment of common adverse effects [11,41],

344 enabling women to change modern methods while remaining protected [11,41], and

345 increasing use of long-acting methods to reduce failure rates [11]. Health systems should

346 improve effective counselling for women who are using suboptimal methods, who are at

347 risk of stopping modern methods because they are having side effects or health concerns

348 or underestimating their risk of getting pregnant. Eliminating missed opportunities for

349 family planning counselling is also key [42].

350 Millennium Development Goal target 5b targeting universal access to reproductive health

351 was unfinished business, and thus remains in Sustainable Development Goal 3.7. Focus

352 should go beyond increasing contraceptive usage. Health systems need to support use of

353 suitable methods, reduce switching failure and identify early when women are having

354 concerns about the method they are using. This means frontline health workers need to be

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355 armed with factually correct information, be facilitative to help women to choose the

356 most suitable method from the start and support correct usage.

357

358 Authors’ role

359 S.B., P.M., M.N. and H.S. contributed equally to the study idea, the development of the
360 study, the writing of the manuscript and the review all the versions.

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361 References

362 [1] Singh S, Darroch JE, Ashford LS. Adding it up: The cost and benefits of investing in
363 sexual and reproductive health 2014. Guttmacher Institute report. New York, NY, The
364 Alan Guttmacher Institute; 2014.
365 [2] Ganatra B, Gerdts C, Rossier C, Johnson BR Jr, Tuncalp O, Assifi A, et al. Global,
366 regional and subregional classification of abortions by safety, 2010-14: estimates from a
367 Bayesian hierarchical model. Lancet 2017 Nov 25; 390(10110): 2372-2381.
368 [3] World Health Organization (WHO). Unsafe abortion: global and regional estimates of
369 the incidence of unsafe abortion and associated mortality in 2008. 6th ed. World Health
370 Organization, Geneva; 2011.
371 [4] Gipson JD, Koenig MA, Hindin MJ. The effect of unintended pregnancy on infant,
372 child, and parental health: a review of the literature. Stud Fam Plann 2008 Mar;39(1):18-
373 38.

374 [5] Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of under-5
375 mortality in 2000-15: an updated systematic analysis with implications for the
376 Sustainable Development Goals. Lancet 2016; 388: 3027-3035.

377 [6] Blencowe H, Cousens S, Jassir FB, et al, for The Lancet Stillbirth Epidemiology
378 Investigator Group. National, regional, and worldwide estimates of stillbirth rates in
379 2015, with trends from 2000: a systematic analysis. Lancet Glob Health 2016; 4: e98-
380 108.

381 [7] Barden-O’Fallon JL, Speizer IS, White JS. Association between contraceptive
382 discontinuation and pregnancy intentions in Guatemala. Rev Panam Salus Publica. 2008
383 Jun; 23(6); 410-7.
384 [8] Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al.
385 Effectiveness of long-acting reversible contraception. N Engl J Med 2012 May 24;
386 366(21): 1998-2007.
387 [9] Castle S, Askew I. Contraceptive discontinuation: reasons, challenges, and solutions.
388 New York: Population Council 2015.
389 http://www.familiyplanning2020.org/microsite/contraceptive-dicontinuation [accessed 23
390 June 2018]

18
391 [10] Cleland J, Ali MM. Reproductive consequences of contraceptive failure in 19
392 developing countries. Obstet Gynecol 2004 Aug; 104(2):314-20.
393 [11] Bellizzi S, Sobel HL, Obara H, Temmerman M. Underuse of modern methods of
394 contraception: underlying causes and consequent undesired pregnancies in 35 low- and
395 middle-income countries. Hum Reprod 2015 Apr; 30(4):973-86.
396 [12] Hossain MB, Phillips JF. The impact of outreach on the continuity of contraceptive
397 use in rural Bangladesh. Stud Fam Plann 1996 Mar-Apr; 27(2):98-106.
398 [13] Casterline J, El-Zanaty F, El-Zeini L. Unmet need and unintended fertility:
399 longitudinal evidence from upper Egypt. Int Fam Plan Perspect 2003; 29(4):158-166.
400 [14] Rustein SO, Rojas G. Guide to DHS Statistics. Calverton, MD: ORC Macro,
401 MEASURE DHS+; 2003.
402 [15] Wells G, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of non
403 randomised studies in meta-analyses.
404 http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. [5 September 2019, date
405 last accessed].
406 [16] Sum G, et al. Multimorbidity and out-of-pocket expenditure on medicines: a
407 systematic review. BMJ Global Health. 2018;3(1):e000505.
408 [17] Hatt LE, Waters HR. Determinants of child morbidity in Latin America: a pooled
409 analysis of interactions between parental education and economic status. Soc Sci Med.
410 2006; 62:375-86.
411 [18] Rustein SO, Johnson K. The demographic and health survey wealth index.
412 Calverton: ORC Macro; 2004.
413 [19] Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-
414 analysis of binomial data. Arch Public Health. 2014; 72:39.
415 [20] Unmet need for family planning
416 http://www.who.int/reproductivehealth/topics/familyplanning/unmetneedfp/en [8 April
417 2018, date last accessed].
418 [21] Mumah JN, Machiyama K, Mutua M, Kabiru CW, Cleland J. Contraceptive
419 adoption, discontinuation, and switching among postpartum women in Nairobi’s Urban
420 Slums. Stud Fam Plann 2015 Dec; 46(4):369-86.

19
421 [22] Thanel K, Garfinkel D, Riley C, Esch K, Girma W, Kebede T, et al. Leveraging long
422 acting reversible contraceptives to achieve FP2020 commitments in sub-Saharan Africa:
423 The potential of implants. PLoS One 2018 Apr 9; 13(4):e0195228.
424 [23] Polis C, Bradley S, Bankole A, Onda T, Croft T, Singh S. Contraceptive failure rates
425 in the developing world: an analysis of Demographic and Health Survey data in 43
426 Countries. Guttmacher Institute report. New York, NY, The Alan Guttmacher Institute;
427 2017.
428 [24] Hossain MB. Analysing the relationship between family planning worker’s contact
429 and contraceptive switching in rural Bangladesh using multilevel modelling. J Biosoc Sci
430 2005 Sep; 37(5):529-54.
431 [25] Vaughan B, Trussel J, Kost K, Singh S, Jones R. Discontinuation and resumption of
432 contraceptive use: results from the 2002 National Survey of Family Growth.
433 Contraception 2008 Oct; 78(4):271-83.
434 [26] Trussell J. Contraceptive failure in the United States. Contraception 2011 May;
435 83(5):397-404.
436 [27] Moreau C, Bouyer J, Bajos N, Rodriguez G, Trussel J. Frequency of discontinuation
437 of contraceptive ise: results from a French Population-based cohort. Hum Reprod 2009
438 Jun; 24(6):1387-92.
439 [28] Calverton, MD, USA: 2015. Contraceptive use and perinatal mortality in the DHS:
440 an assessment of the quality and consistency of calendars and histories.
441 https://www.dhsprogram.com/pubs/pdf/MR17/MR17.pdf [9 April 2018, date last
442 accessed].
443 [29] Stuart G, Grimes D. Social desirability bias in family planning studies: a neglected
444 problem. Contraception. 2009;80(2):108–112.
445 [30] Hillard PJA. Contraception: adherence? Compliance? Successful use? And how do
446 we know? J Women’s Heal. 2010;19(12):2157–2158.
447 [31] Strickler J, Magnani R, McCann H, Brown L, Rice J. The reliability of reporting of
448 contraceptive behavior in DHS calendar data: evidence from Morocco. Stud Fam Plan
449 1997; 28(1):44-53.

20
450 [32] Curtis S, Evens E, Sambisa W. Contraceptive discontinuation and unintended
451 pregnancy: an imperfect relationship. Int Perspect Sex Reprod Health 2011 Jun;37(2):58-
452 66. https://doi.org/10.1363/3705811.
453 [33] Santelli J, Rochat R, Hatfield-Timajchy K, Gilbert BC, Curtis K, Cabral R, et al. The
454 measurement and meaning of unintended pregnancy. Perspect Sex Reprod Health 2003.
455 Mar-Apr;35(2):94-101.
456 [34] Trussell J, Vaughan B, Stanford J. Are all contraceptive failures unintended
457 pregnancies? Evidence from the 1995 National Survey of Family Growth. Fam Plann
458 Perspect 1999. Sep-Oct; 31(5):246-7,260.
459 [35] Klima CS. Unintended pregnancy. Consequences and solutions for a worldwide
460 problem. J Nurse Midwifery 1998 Nov-Dec; 43(6):483-91.
461 [36] Luker KC. A reminder that human behavior frequently refuses to conform to models
462 created by researchers. Fam Plann Perspect 1999. Sep-Oct; 31(5):248-9.
463 [37] Santelli JDL, Lindberg MG, Orr LB, Speizer I. Towards a multidimensional measure
464 of pregnancy intentions: evidence from the United States. Stud Fam Plan 2009 Jun;
465 40(2):87-100.
466 [38] Marston C, Cleland J. Relationship between contraception and abortion: a review of
467 the evidence. Int Fam Plan Perspect 2003; 29(1):6-13.
468 [39] Sedgh G, Ashford L, Hussain R. Unmet need for contraception in developing
469 countries: examining women’s reasons for not using a method. Guttmacher Institute
470 report. New York, NY, The Alan Guttmacher Institute; 2016.
471 [40] Leahy E, Akitobi E. A Case study of reproductive Health supplies. Washington, DC:
472 Population Action International, 2009.
473 http://apps.who.int/medicinedocs/documents/s18425en/s18425en.pdf [10 April 2018,
474 date last accessed].
475 [41] Grossman Barr N. Managing adverse effects of hormonal contraceptives. Am Fam
476 Physician 2010; 82: 1499-1506.
477 [42] Nagai M, Bellizzi S, Murray J, Kitong J, Cabral EI, Sobel HL. Opportunities lost:
478 Barriers to increasing the use of effective contraception in the Philippines. PLoS One
479 2019 Jul 25; 14(7):e0218187.

480

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481 Figure 1. Last method of contraception used and reasons for discontinuation among

482 women with a current unintended pregnancy (N=10,901), pooled data from 36 countries

483

02%
01%
No contraception

18%
Traditional methods failure

Traditional methods other

reasons

Short-term modern methods

failure

13%
Short-term modern methods 56%
other reasons

Long-term modern methods

failure 02%

Long-term modern methods 08%

other reasons

484

485 *Other reasons: Side effects and health concerns, cost, inconvenient to use, infrequent

486 sex/marital dissolution, unavailability, husband’s disapproval, fatalism, wanting a more

487 effective method, difficult pregnancy, don’t know and unspecified reasons

488

489

490

491

492

493
22
494 Figure 2. Last method of contraception used and reasons for discontinuation among
495 women with a current unintended pregnancy (N=10,901), by country

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Armenia
Azerbaijan
Bangladesh
Benin
Burkina Faso
Burundi
Cambodia
Colombia
Comoros
Egypt
Gambia
Ghana
Honduras
India
Indonesia
Jordan
Kyrgyz Republic
Liberia
Maldives
Mali
Moldova
Mozambique
Namibia
Nepal
Niger
Nigeria
Pakistan
Peru
Philippines
Rwanda
Senegal
Sierra Leone
Tajikistan
Uganda
Zambia
Zimbabwe

Stopped using modern long-term method for any reason other than pregnancy
Failure modern long-term method
Stopped using modern short-term method for any reason other than pregnancy
Failure modern short-term method
Stopped using traditional method for any reason other than pregnancy
Failure traditional method
No contraception
496

23
497 *Other reasons: Side effects and health concerns, cost, inconvenient to use, infrequent

498 sex/marital dissolution, unavailability, husband’s disapproval, fatalism, wanting a more

499 effective method, difficult pregnancy, don’t know and unspecified reasons

500

24
 501 Table 1. Distribution of current pregnancies by intention in 36 countries, Demographic and

502 Health Surveys 2005 to 2014.

Total pregnancies Intended pregnancies Wanted later Not wanted at all

N n % n % n %
Armenia 2010 172 154 89.5 14 8.5 4 2.0
Azerbaijan 2005 285 238 83.5 30 10.5 17 6.0
Bangladesh 2011 1,048 739 70.5 207 20.4 102 9.1
Benin 2011/12 1,575 1,181 75.0 301 19.1 93 5.9
Burkina Faso 2010 1,667 1,477 88.6 171 10.2 19 1.2
Burundi 2010 920 532 57.8 318 34.6 70 7.6
Cambodia 2014 913 789 86.4 63 6.9 61 6.7
Colombia 2010 1,931 773 40.0 708 36.7 450 23.3
Comoros 2012 334 234 70.0 83 24.8 17 5.2
Egypt 2014 2,190 1,828 83.5 183 8.3 179 8.2
Gambia 2013 814 693 85.1 106 13.0 15 1.9
Ghana 2014 668 436 65.3 168 25.1 64 9.6
Honduras 2011/12 1,215 744 61.2 328 27.0 143 11.8
India 2005/06 5,655 4,415 78.1 728 12.9 512 9.0
Indonesia 2012 2,021 1,815 89.8 122 6.0 84 4.2
Jordan 2012 1,097 794 72.4 205 18.7 98 8.9
Kyrgyz Republic 2012 562 531 94.5 23 4.1 8 1.4
Liberia 2013 817 496 60.7 210 25.7 111 13.6
Maldives 2009 531 440 82.9 49 9.2 42 7.9
Mali 2012/13 1,154 953 82.6 165 14.3 36 3.1
Moldova 2005 167 132 79.0 31 18.6 4 2.4
Mozambique 2011 1,371 1,045 76.2 253 18.4 73 5.4
Namibia 2013 544 274 50.4 214 39.3 56 10.3
Nepal 2011 605 400 65.0 118 18.5 87 15.5
Niger 2012 1,446 1,322 91.4 108 7.5 16 1.1
Nigeria 2013 4,243 3,817 89.9 323 7.6 103 2.5
Pakistan 2012/13 1,429 1,167 81.7 141 9.9 121 8.4
Peru 2012 942 376 39.9 361 38.3 205 21.8
Philippines 2013 724 527 72.8 130 17.9 67 9.3

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Rwanda 2014 930 556 59.8 261 28.1 113 12.1
Senegal 2014 774 579 74.8 177 22.9 18 2.3
Sierra Leone 2013 1,381 1,067 77.3 199 14.4 115 8.3
Tajikistan 2012 654 608 93.0 31 4.7 14 2.3
Uganda 2011 946 528 55.8 298 31.5 120 12.7
Zambia 2013 1,346 777 57.7 467 34.7 102 7.6
Zimbabwe 2010/11 692 425 61.4 202 29.2 65 9.4
Total 43,763 32,862 75.1 7,496 17.1 3,405 7.8
503

504

26
506 Table 2. Intention of pregnancy among currently pregnant women in 36 low and middle

507 income countries by socio-economic characteristics, Demographic and Health Surveys 2005

508 to 2014.

Characteristics Intended pregnancies Unintended pregnancies χ2 test

n % n % P-value
Age
15-24 14,486 73.9 5,125 26.1 0.2
25-49 18,362 73.3 6,683 26.7
Education
No education 11,553 79.8 2,742 19.2 <0.001
Primary 7,110 67.6 3,406 32.4
Secondary 11,139 73.6 4,000 26.4
Higher 3,047 79.2 752 19.8
Missing 13 92.8 1 7.1
Wealth
Poor 13,407 75.5 4,354 24.5 0.2
Middle 10,998 74.9 3,682 25.1
High 8,038 77.0 2,405 23.0
Missing 419 47.7 460 52.3
Residence
Urban 11,491 72.9 4,278 27.1 <0.001
Rural 21,371 76.4 6,623 23.6

Total 32,862 75.1 10,901 24.9

509

27
Table 3. Reason for discontinuation of contraception by method and socioeconomic
characteristics among women with a current unintended pregnancy from 36 low and
middle income countries, Demographic and Health Surveys 2005 to 2014.
Method of Tota Residence n Wealth n (%) Education n (%)
contraceptio l (%)
n and reason N
for (%)
discontinuat
ion
Urba Rur Poo Midd Ric Non Prima Seconda High
n al r le h e ry ry er
No 6,134 1998 4136 2751 2035 1140 2090 1896 1897 251
(56.3 (46.7) (62.4 (63. (54.9) (47. (76. (55.7) (47.4) (33.3)
contraceptio
) ) 2) 3) 2)
n
Traditional 1,086 570 516 379 393 299 129 312 471 174
(10.0 (13.3) (7.8) (8.7) (10.6) (12. (4.7) (9.2) (11.8) (23.2)
) 4)
Became 904 479 425 308 331 251 104 246 396 158
pregnant (8.3) (11.2) (6.4) (7.2) (9.0) (10. (3.8) (7.2) (9.9) (21.0)
4)
Other 182 91 91 71 62 48 25 66 75 16
supply/dema (1.7) (2.1) (1.4) (1.5) (1.6) (2.0) (0.9) (2.0) (1.9) (2.2)
nd factors*
Short-term 3,401 1564 1837 1147 1143 882 485 1127 1498 290
(31.2 (36.6) (27.7 (26. (30.9) (36. (17. (33.1) (37.4) (38.6)
modern
) ) 3) 6) 7)
Became 1,404 697 707 403 500 416 168 393 671 171
pregnant (12.9 (16.3) (10.7 (9.3) (13.6) (17. (6.1) (11.5) (16.8) (22.7)
) ) 3)
Side- 834 308 526 316 265 175 146 354 298 36
effects/health (7.7) (7.2) (7.9) (7.3) (7.2) (7.3) (5.4) (10.4) (7.3) (4.8)
concerns
Cost 51 23 28 25 14 11 12 15 21 3
(0.5) (0.5) (0.4) (0.6) (0.4) (0.4) (0.4) (0.4) (0.5) (0.3)
Other 1,002 461 541 392 352 275 151 360 499 49
supply/dema (9.2) (10.8) (8.6) (9.0) (9.6) (11. (5.5) (10.6) (12.5) (6.5)
nd factors* 4)
Others** 110 75 35 11 12 5 8 5 9 31
(1.0) (1.8) (0.1) (0.1) (0.1) (0.2) (0.1) (0.2) (0.3) (4.1)
Long-term 280 146 134 77 111 84 38 71 134 37
(2.6) (3.4) (2.0) (1.8) (3.0) (3.5) (1.4) (2.2) (3.3) (4.9)
modern

28
Became 105 55 50 33 35 34 13 27 50 14
pregnant (0.9) (1.3) (0.7) (0.8) (1.0) (1.4) (0.5) (0.8) (1.2) (1.8)
Side- 112 57 55 28 53 27 19 31 49 13
effects/health (1.0) (1.3) (0.9) (0.6) (1.4) (1.1) (0.6) (0.9) (1.2) (1.8)
concerns
Cost 40 16 24 24 12 4 12 10 9 9
(0.4) (0.3) (0.2) (0.2) (0.4) (0.4) (0.1) (0.2) (0.5) (1.0)
Other 17 13 4 7 5 5 5 6 4 2
supply/dema (0.2) (0.3) (0.1) (0.1) (0.1) (0.4) (0.1) (0.2) (0.3) (0.2)
nd factors*
Others** 6 5 1 3 1 1 2 1 1 1
(0.1) (0.2) (0.1) (0.1) (0.1) (0.2) (0.1) (0.1) (0.1) (0.1)
Total 10,90 4278 6107 4354 3682 2405 2742 3406 4000 752
1
*Inconvenient to use, infrequent sex/marital dissolution, unavailability, fatalism, husband disapproval, and

wanting a more effective product.

**Difficult pregnancy, don’t know, and other unspecified reasons.

29