Reasons for discontinuing contraception among women in Bangkok.

Bulletin ofthe World Health Organization, 61 (5): 861-865 (1983) .World Health Organization 1983 Reasons for discontinuing contraception among women in Bangkok* S. SUNYAVIVAT,' T. CHUMNIJARAKIJ,2 y. ONTHUAM,3 A. H. MEHYAR,4 B. BUSCA,5 & B. CHRISTIAN6 In an attempt to investigate in detail clients' reasons for discontinuing use of a particular contraceptive, a study was undertaken (i) to develop and test a system of classification that would allow precise categorization of individuals in the study, and (ii) to ascertain detailed medical and social reasons for discontinuing contraception. A total of 666 women, who had accepted a family planning method from one of 14 health clinics administered by the Bangkok Metropolitan Health Authority over a 6-month period in 1977, were traced and interviewed one year later. Of these, 46% were still using their initial method of contraception and their original supply source. A further 29% had changed either their method or their source ofsupply or both, and 26% were not using any contra- ception. The most frequent reason given for discontinuation referred to medical side- effects; the second mostfrequent reason was the woman 'sfeeling that she had no needfor contraception. However, the study indicated that preconceived ideas of a contraceptive method, rather than the side-effects experienced, may play a leading role in determining whether the method will continue to be used. Although high contraceptive discontinuation rates are recognized as a major problem facing family plan- ning programmes (1, 2), two recent reviews have concluded that published reports on the subject are of uneven quality, frequently methodologically weak, and provide insufficient information to answer the practical questions raised by programme adminis- trators (3, C. Bleathman, unpublished observations, 1978). Reasons for contraceptive discontinuation are usually highly complex but research publications often group them under broad headings such as "medical" and "other". The term "discontinu- ation" itself often means different things in different studies. In an attempt to investigate in more detail clients' reasons for discontinuing a particular contra- ceptive, a study was undertaken in Bangkok at the * Requests for reprints should be sent either to Dr Sunyavivat or to the Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1211 Geneva 27, Switzerland. ' Associate Professor, Faculty of Political Science, Chulalong- korn University, Bangkok, Thailand. 2 Associate Professor, Department of Preventive and Social Medicine, Chulalongkorn University, Bangkok, Thailand. 3Statistician, Chulalongkorn University, Bangkok, Thailand. 4Professor of Psychology, Shiraz University, Shiraz, Islamic Republic of Iran. s Programmer Analyst, Information Systems Support, World Health Organization, Geneva, Switzerland. 6 Social Scientist, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland (Deceased). request of the Thai National Family Planning Pro- gramme. The study had two main objectives: (a) to develop and test a precise system of classification that would allow categorization of the individuals in the study; and (b) to ascertain detailed reasons for dis- continuing contraception and to classify these reasons into precise categories of use to family planning authorities. A particular effort was made to include psychosocial as well as medical and service-related reasons for discontinuation. SAMPLING AND METHODOLOGY A previous WHO-supported study, conducted in Bangkok health clinics (4), found that 59% of women taking oral contraceptives, 45% of those using inject- able contraceptives, and 59% of those using an intra- uterine device (IUD) were still using their original method one year after adoption. In addition, 67%, 76%, and 79%, respectively, were using some method of contraception at the one-year follow-up. These groups of protected women included those who had been sterilized or whose husband had had a vasec- tomy. The present study was carried out on a sub- group of the original study group. Women who had accepted a family planning method from one of 14 health clinics administered by the Bangkok Metropolitan Authority over a 6-month 4350 -861- S. SUNYAVIVAT ET AL. period in 1977 were traced and interviewed one year later. The 14 clinics chosen were representative of the 35 family planning clinics in Bangkok, and there was no significant difference between the study group and the total clinic patient population. It was calculated that a sample of about 650 women would be necessary for the analysis. To allow for the possibility that some women would not be traceable, a total of 900 subjects were selected for inclusion in the study: 300 who had originally chosen the IUD, 300 who had accepted oral contraceptives, and 300 who had received an injectable contraceptive, depot- medroxyprogesterone acetate (DMPA). This distri- bution of subjects underrepresents pill-users and overrepresents users of injectable contraceptives. The data were collected between May and Novem- ber 1978 by a group of 10 women with postsecondary schooling, who had been given 3 days' training in administering the 130-item questionnaire. The inter- viewers worked in teams of two, with one person ask- ing the questions and the other recording the responses. Three factors were taken into consideration: (a) whether the subject was using some form of contraception at the time of the interview; (b) if using contraception, whether the method being used was the one adopted 12 months previously; (c) if using contraception, whether supplies were still being obtained from the clinic attended 12 months previously. In this way, the women could be categorized into five classes: those continuing with the same method, and attending the same clinic; those continuing with the same method, but using a different source of supply; - those using a different method, but attending the same clinic; those using a different method and a different source of supply; those who were not using contraception. This classification system is thought to be more useful than those used in most previous studies, since it differentiates between women who had dis- continued their initial method of contraception and those who had changed their source of supply. RESULTS A total of 666 women were traced; of these, 270/o had initially chosen the IUD, 32% oral contra- ceptives, and 41% injectable contraceptives. This compares with proportions of 1507, 61% and 240%, respectively, in all Bangkok clinics (4). The sample was homogeneous. Virtually all women were Buddhist and married; 750%o had 4 or fewer years of schooling, and were between 20 and 29 years old; 44%o had more than 2 children (Table 1). At the time of the interview, 74%o of the women were using some form of contraception; 4607o were still using their original method and attending the same clinic. This latter group comprised 5507o of those originally accepting an IUD, 4607o of those taking oral contraceptives, and 4007o of those using DMPA (Table 2). Only 6%o of the 666 women had changed their supply source while retaining their original method of contraception; 1007o had changed the method used but not the supply source, and 1307o had changed both. Over two-thirds of the women who changed their source of supply also changed their method. This may be because women who want to change methods pre- fer to visit another clinic to receive the new method or because women were given another method when they changed clinics. Four women said they changed clinic because their initial doctor had refused to remove their IUD. There were rather more women who continued with the same method and service among IUD users (55 07o) than in the other two groups. As would be expected, none of the IUD users had changed clinic without also changing method, since there was no need for them to return to the clinic at all. On the other hand, adopters of oral contraceptives had the highest rate of changing supply source while maintaining the initial method because pills are easily obtained from drug Table 1. Characteristics of study group according to method of contraception used Oral IUD' contracep- DMPA Total (178) tive (216) (272) 1666) Mean age (years) 26.2 25.7 27.2 26.4 Mean age at 20.2 20.1 20.4 20.2 marriage (years) Mean length of schooling 5.0 5.2 4.9 5.0 (years) Mean length of husband's 6.5 7.0 6.9 6.8 schooling (years) Percentage in 36 47 42 41 employment Mean no. of sons 1.0 0.8 1.1 1.0 Mean no. of 2.1 1.7 2.1 2.0 children a Figures in brackets give no. of women in each group. 862 CONTRACEPTIVE DISCONTINUATION IN BANGKOK 863 Table 2. Distribution of women at one-year follow-up, according to contraceptive method adopted initially Contraceptive method adopted initially Status at follow-up IUD Oral DMPA Total Same method, same source 55 46 40 46 (%) Same method, different source 0 14 2 6 (%) Different method, same source 1 1 2 15 10 (%) Different method, different source 1 2 7 18 1 3 (%) No contraception 22 31 25 26 (%) stores. This group also had the highest discontinu- ation rates. DMPA acceptors had the highest rate of change of both method and service, but a relatively small proportion had changed their source while con- tinuing with the method. This may be because of the difficulty of obtaining DMPA in other settings. The women who had changed method were asked for their reasons; two-thirds mentioned medical side- effects, the remainder generally giving vague re- sponses such as "inconvenience". Further question- ing to determine the possible influence of husbands, relatives, or clinic personnel produced few positive responses. As for the women who changed supply source, it has previously been noted that most (6807o) also switched methods, with one-third explicitly citing method-related reasons for the change. However, women who had originally used DMPA were more likely to mention side-effects (75%) than were IUD or pill users (about 50%o). Other problems were as- sociated with the clinic itself: distance from home (27%), inconvenience of hours (1907o), and crowding or husband's objection to the clinic (907o). Further evi- dence of dissatisfaction was seen in the responses to questions that asked the women to compare the initial and the subsequent clinic. Distance from home and the convenience of clinic hours were clearly more favorable in the new clinic (60% and 790o, respec- tively, found these factors to be more suitable in the second clinic). No differences were found in personal relations with clinic personnel: about one-third perceived the staff in the first clinic as more friendly, one-third the second, and one-third saw no difference between them. Further, 97Wo claimed that neither their husbands nor relatives objected to the clinic. Discontinuation of contraception A total of 174 women were not using a contracep- tive method at the time of the interview. Both open- ended and closed-format questions were asked to obtain reasons for this discontinuation. After exam- ination of the responses to these questions, it was decided to classify the replies according to the follow- ing system: medical reasons (including side-effects of the method), dissatisfaction with the clinic, lack of need for contraception, and psychosocial influences. Age and education were taken into account in the analysis. Half of the 174 women cited medical side-effects as their major reason for discontinuation. An additional 60/o gave medically related reasons, e.g., fear of an allergic reaction. The second most frequent reason for abandoning contraception (cited by over 2507o of the group) was the woman's feeling that she had no need for contraception; 10% had become pregnant since discontinuing,a another 10% were trying to become pregnant, and 5Vo had lost their husbands. In response to direct questioning, one-third of the 174 women said they believed they would not become pregnant when they ceased using contraception. A total of 54 women, therefore, were fecund, sexually active, desiring not to become pregnant, but using no contraceptive method. These women jusitified their behaviour in terms of fear of side-effects (36%), laziness (21 %), low perceived risk of pregnancy (15%), and clinic inaccessibility (10%o). Discriminant analysis In an attempt to ascertain the factors that distin- guish the women who continued with their initial method and source from the other groups, a dis- criminant analysis was performed using age, age at marriage, occupation, number of years of schooling, previous use of contraceptives, number of living sons and daughters, tolerance to the inconvenience as- sociated with contraceptive use, perceptions of the method, perceptions of the clinic, need for protec- tion, social support, and an index of modernization (a single figure reflecting demographic, socioeconomic, and behavioural features) as the independent vari- ables. The discriminant analysis correctly classified 73.4% of those still using their initial method and source, and 68.2% of the remainder; overall, 70.6% of the women were classified correctly; The main dis- criminating factor was the woman's attitude to the method; the other indices were only weakly related to continuation status. Similar analyses were conducted a Only 2 women admitted involuntary pregnancy. S. SUNYAVIVAT ET AL. on the individual groups; again, the only significant variable was the woman's attitude to the method. DISCUSSION One of the aims of this project was to devise a scheme that could be adopted in diverse settings and would permit precise classification of the status of women as regards contraception. A second aim was to determine the important factors associated with dis- continuation of contraception. These two goals were only partly realized; the classification of the women was felt to be useful and could, if widely adopted, help clarify the findings of research. The attempt to devise a scheme for identifying the major reasons for discontinuation of contraception was, however, less successful. The clinical and psychosocial variables considered were found to be mostly unrelated to continuation status. A recent WHO multinational study of the "paper" pill and conventional oral contraceptives (5) found that the major influence on the woman's attitude was her perception of the method at th.e time she arrived at the family planning clinic, i.e., before using the method. This study tends to confirm the conclusion that preconceived ideas of a contraceptive method, rather than the side-effects experienced, may play a leading role in determining whether the method will continue to be used. As would be expected, the findings of this study are similar to those of the earlier project in Bangkok (4). The percentage of women continuing with the IUD was 55%o in the present study and 59Wo in the earlier one; for women using oral contraceptives, the respective proportions were 4607o and 510Wo, and for DMPA users, 4O07o and 4507o. In both studies, side- effects were the major reason cited for discorTtinuing a particular method. ACKNOWLEDGEMENTS The authors wish to thank Dr J. M. Stycos, Cornell University, NY, USA, and Dr J. Marshall, formerly with the World Health Organization, Geneva, Switzerland, who helped prepare the manuscript. The study was supported financially by the Special Programme of Research, Development, and Research Training in Human Reproduction of the World Health Organization. RESUME ENQUETE SUR LA CONTRACEPTION FEMININE A BANGKOK: CAUSES DES ABANDONS CONSTATES Les taux eleves d'abandon sont l'un des problmes majeurs auxquels se heurtent les programmes de planifi- cation familiale; le terme (<abandon>> ne veut d'ailleurs pas toujours dire la meme chose suivant les contextes. Afin d'etudier plus en detail les raisons pour lesquelles les utilisa- trices abandonnent un moyen contraceptif donne, on a entrepris a Bangkok un projet de recherche qui comportait deux objectifs principaux: 1) elaborer et mettre a l'essai un systeme de classification permettant de caracteriser avec precision les sujets inclus dans l'etude; et 2) verifier dans le detail les raisons (medicales, liees aux prestations et psycho- sociales) de I'abandon du moyen contraceptif. Un total de 666 femmes qui avaient accepte d'utiliser un dispositif intra- uterin (DIU), un contraceptif oral ou un contraceptif injectable fourni par l'un des 14 dispensaires de Bangkok sur lesquels portait le projet ont et suivies et interrogees au bout d'un an. Trois facteurs ont et pris en consideration: 1) la femme utilisait-elle une methode contraceptive au moment de l'entretien? 2) si oui, etait-ce celle qui avait e adoptee a l'origine? 3) si la femme utilisait la contraception, etait-elle approvisionnee par la meme source? On a ainsi pu classer les femmes en cinq categories: - celles qui continuaient d'utiliser la meme methode et de se rendre dans le meme dispensaire; - celles qui continuaient d'utiliser la meme methode mais avec une autre source d'approvisionnement; - celles qui utilisaient une autre methode tout en se rendant dans le meme dispensaire; - celles qui utilisaient une autre methode et une autre source d'approvisionnement; - celles qui n'avaient pas recours a la contraception. Au moment de l'enquete, 74% des femmes utilisaient une forme ou une autre de contraception; 46% des femmes qui ont repondu continuaient d'utiliser la methode initiale et de se rendre dans le meme dispensaire. Parmi elles, 55%o utili- saient un DIU, 46% prenaient des contraceptifs oraux et 40%7 des contraceptifs injectables. Seules 6% des 666 femmes avaient change de source d'approvisionnement tout en continuant a utiliser la methode contraceptive initiale; 10%1o avaient change de methode mais pas de source d'approvisionnement et 137o avaient change les deux. Sur les 174 femmes qui n'utilisaient pas de methode contraceptive au moment de l'enquete, la moitie a evoque les effets medicaux secondaires comme principale raison de l'abandon. D'autre part, 6% ont donne des raisons d'ordre paramedical, par exemple crainte d'une reaction allergique. La deuxieme raison la plus frequente d'abandon de la methode contraceptive etait l'impression de ne pas avoir besoin de la contraception. Repondant a des questions 864 CONTRACEPTIVE DISCONTINUATION IN BANGKOK 865 directes, un tiers des femmes ayant abandonne ont dit etre convaincues qu'elles ne seraient pas enceintes si elles cessaient d'utiliser un moyen contraceptif. Mis a part les femmes qui voulaient un enfant, 54 femmes etaient fecondes, sexuellement actives et ne voulaient pas se retrouver enceintes. Ces femmes ont justifie leur comporte- ment en evoquant la crainte d'effets secondaires (3607o), la paresse (21 Vo), la perception tr&s vague du risque de grossesse (15%) et la difficulte d'acces du dispensaire (10%). L'etude a neanmoins montre que les idees preconques sur une methode contraceptive, plus que les effets secondaires ressentis, jouaient sans doute un r6le majeur dans la decision de continuer ou non a utiliser la methode. REFERENCES 1. MAULDIN, P. Experience with contraceptive methods in less developed countries. Center for Policy Studies, Working Paper No. 30, New York, Population Council, 1978. 2. ZEIDENSTEIN, G. The user perspective: an evolutionary step in contraceptive service programs. Studies infamily planning, 11: 24-29 (1980). 3. KREAGER, P. Family planning dropouts reconsidered. London, International Planned Parenthood Feder- ation, 1977. 4. CHUMNIJARAKIJ, T. ET AL. A study of contraceptive choice and use in Bangkok metropolis health clinics. Contraception, 24: 245-258 (1981). 5. WHO SPECIAL PROGRAMME OF RESEARCH, DEVELOP- MENT AND TRAINING IN HUMAN REPRODUCTION. A comparison of an oral contraceptive tablet and paper pill: the results of a multicentred clinical trial. Studies in family planning (in press).