Long-term contraceptive protection,
discontinuation and switching behaviour
Intrauterine device (IUD) use dynamics in 14 developing countries
Marie Stopes International
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Marie Stopes International delivers quality family planning and reproductive
healthcare to millions of the world’s poorest and most vulnerable women.
Mohamed M. Ali, Rachael K. Sadler, John Cleland, Thoai D. Ngo and Iqbal H. Shah
02
(IUD)
Intrauterine
Authors
andDevice
acknowledgements
Marie Stopes International
This publication was produced by Marie Stopes International and the World Health Organization
Marie Stopes International delivers quality family planning
and reproductive healthcare to millions of the world’s poorest
and most vulnerable women.
Established in 1948, WHO works to make the enjoyment
of the highest attainable standard of health a reality for
every human being.
Authors
Mohamed M. Ali1, Rachael K. Sadler1, John Cleland2, Thoai D. Ngo3 and Iqbal H. Shah4
1.Evidence-Based Health Situation and Trends Assessment, Division of Health Systems and Services
Development, Regional Office for the Eastern Mediterranean, World Health Organization, Cairo, Egypt.
2. Department of Population Studies, London School of Hygiene and Tropical Medicine, London, United Kingdom.
3. Research and Metrics, Health System Department, Marie Stopes International, London, United Kingdom.
4. Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
The authors declare that they have no conflicts of interest.
For citation purposes
Ali, Mohamed M; Sadler, Rachael K; Cleland, John; Ngo, Thoai D and Shah, Iqbal H. Long-term contraceptive
protection, discontinuation and switching behaviour: intrauterine device (IUD) use dynamics in 14 developing
countries. London: World Health Organization and Marie Stopes International, 2011.
Contents
Marie Stopes International
Contents
1. Executive summary
06
2. Introduction
08
3.Data, materials and methods
3.1 Data
3.2 Contraceptive calendar
3.3 Selection of IUD episodes
3.4 Reasons for discontinuation and switching
3.5 Covariates
3.6 Methods of analysis
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4. Results
4.1 Background information for the 14 countries
4.2 Women’s characteristics
4.3 IUD discontinuation
a. Reported failure
b. Method-related reasons
c. Probabilities of discontinuation by duration of use
d. Differentials in discontinuation
4.4 Method-switching following method-related discontinuation
a. Time to switching
b. Differentials
4.5 Comparison of IUD and other modern methods
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5. Discussion and conclusions
5.1 Data limitations
5.2 Main findings
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6. Appendix
34
7. Glossary and References
48
Acknowledgements
This report was written by Mohamed M. Ali, Rachael K. Sadler, John Cleland, Thoai D. Ngo and Iqbal H. Shah.
All authors contributed equally to the conceptualising and writing of the report. Mohamed M. Ali and Rachael K.
Sadler were in charge of data handling and analysis. The report was reviewed by the Department of
Reproductive Health and Research of the World Health Organization (WHO).
The publication of this report was made possible by support from the American people through the United
States Agency for International Development (USAID). The contents are the responsibility of Marie Stopes
International and the World Health Organization and do not necessarily reflect the views of USAID or the
United States Government.
The authors would like to thank Catherine d’Arcangues of WHO’s Department of Reproductive Health and
Research and the following individuals from Marie Stopes International (MSI) for their critical review of the
report: Tania Boler, Louise Lee-Jones, Nicole Gray, Geraldine Ellis, Chris Duncan and Dana Hovig.
Thanks are also due to Vicky Anning, who edited the report.
Cover photograph
© Marie Stopes International
Support for this research was provided by Marie Stopes International (MSI).
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Intrauterine Device (IUD)
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Intrauterine Device (IUD)
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Tables and figures
Figure 1: Percentage of contraceptive users by types of contraceptive method used, by year
08
Table 1: P
ercentage using any method of contraception that are using the IUD among women
who are married or in union aged 15-49 and those using IUD among the users of any
method of contraception, 2009
Figure 2a: IUD all-cause discontinuation probabilities at 12 months by country
20
10
Figure 2b: IUD all-cause discontinuation probabilities at 24 months by country
20
Table 2: Country background information
14
Figure 2c: IUD all-cause discontinuation probabilities at 36 months by country
20
Table 3: All contraceptive methods and IUD episodes reported in the calendar, by surveys
16
Figure 3a: IUD discontinuation probabilities due to method dissatisfaction at 12 months by country
21
Figure 3b: IUD discontinuation probabilities due to method dissatisfaction at 24 months by country
21
Table 4: P
ercentage of IUD and other modern method (MM) episodes contributed
by women of specified characteristics
17
Figure 3c: IUD discontinuation probabilities due to method dissatisfaction at 36 months by country
21
Table 5: Reasons for IUD discontinuation, by country
18
Figure 4a: IUD method-related discontinuation probabilities at 12 months, by residence 22
Table 6: Median cumulative cause-specific discontinuation probabilities per 100 episodes
19
Figure 4b: IUD method-related discontinuation probabilities at 12 months, by education
22
Table 7: Median conditional cause-specific discontinuation probabilities per 100 episodes
19
Figure 4c: IUD method-related discontinuation probabilities at 12 months, by motivation for use
23
Table 8: Status at three months after discontinuing IUD for method-related reasons
24
Figure 4d: IUD method-related discontinuation probabilities at 12 months, by wealth
23
Table 9: Duration of modern methods and IUD episodes
28
Figure 5: Switching behaviours three months post IUD discontinuation
25
Figure 6a: Switching to a modern FP method within three months of IUD discontinuation, by residence
26
Box 1: Facts about the intrauterine device (IUD)
08
Figure 6b: Switching to a modern FP method within three months of IUD discontinuation, by education
26
Figure 6c: Switching to a modern FP method within three months of IUD discontinuation, by motivation for use
27
Table A.1: Cumulative cause-specific discontinuation probabilities (per 100 episodes)
34
Figure 6d: Switching to a modern FP method within three months of IUD discontinuation, by wealth
27
Table A.2: Conditional 12-month cause-specific discontinuation probabilities (per 100 episodes)
36
Figure 7: All-cause discontinuation rates at 12 months for the four main modern, reversible methods
29
Figure 8: Discontinuation rates at 12 months due to failure of the four main modern, reversible methods
29
Table A.3: M
ethod-related discontinuation probabilities (per 100 episodes), disaggregated
by selected characteristics
36
Table A.4: Status at three months after discontinuing IUD for method-related reasons
38
Table A.5: Status at three months after discontinuing IUD for method-related reasons: by residence
40
Table A.6: Status at three months after discontinuing IUD for method-related reasons: by education
42
Table A.7: Status at three months after discontinuing IUD for method-related reasons: by motivation for use
44
Table A.8: Status at three months after discontinuing IUD for method-related reasons: by wealth status
46
Figure 9: P
ercentage of women who switched to any modern method within three months
post discontinuation due to method-related reasons, by method
30
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Executive summary
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Executive summary
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1. Executive summary
The intrauterine device (IUD) is one of the most widely
used, reversible contraceptive methods in the world.
Women living in China constitute about 70% of the
106 million global users. Modern IUDs are a safe, highly
effective and cost-effective method of contraceptive.
However, IUD uptake varies significantly across the
globe. Some countries have wide usage and others
have very little or no usage.
For instance, use among all married women of
reproductive age is highest in China (where 33% of all
married women use IUDs, as well as the Scandinavian
countries (18%), Asian nations (13%) and the Near East
and North Africa (12%). Approximately seven percent
of all married European and Russian women and
about five percent of women from Australia and New
Zealand rely on the IUD as a method of contraception.
Overall IUD use is lowest in Northern America (1.5%)
and sub-Saharan Africa (0.8%). These figures reveal
that IUDs remain underutilised, especially in Northern
America, Oceania, South Asia and sub-Saharan
Africa, in spite of the IUD’s many benefits.
The aim of this report is to provide an in-depth assessment
of IUD use-dynamics in developing countries, with a
focus on discontinuation and method-switching, and
to compare users of IUDs with users of other methods
in these regards. Contraceptive calendar data from
14 nationally representative surveys were used for the
analysis. All but two of the surveys were conducted
between 1998 and 2008. All major developing regions
are represented with the exception of sub-Saharan
Africa, for which no suitable survey data were available.
Most analyses focused on contraceptive-use episodes,
with particular attention to length of use, reasons for
stopping and method-switching following stopping.
Even within the 14 study countries, which were selected
for reasonably high overall contraceptive use and a
minimum of 300 IUD use-episodes, the contribution
of the IUD to contraceptive protection is immensely
variable. It accounts for about two percent of users in
some countries but over half of users in other countries.
This variability probably reflects policy choices about
which methods to promote and preference biases in
family planning services. In view of the advantages
of the IUD over alternative reversible methods in terms
of its low failure rate and high continuation, the virtual
absence of IUDs from the overall method mix in many
countries is deeply unfounded.
While the IUD, along with other long-acting methods
such as implants, is well suited to the needs of couples
who have all the children that they desire, about half
of all IUD use appears to be motivated by the wish to
space or postpone childbearing. IUD use is compatible
with breastfeeding and thus has a potentially valuable
role in postpartum contraceptive protection.
In terms of urban-rural residence and household wealth,
IUD users differ little from users of other modern
methods. In five of the 14 countries, IUD users were
less well educated than other method users. However,
in the majority of countries, this difference was
negligible or reversed.
© Marie Stopes International / Peter Barker
The main reasons for stopping IUD use imply
dissatisfaction with the method. However, more intensive
studies are needed to gain more insight into precise
concerns. The probability of abandoning IUDs for
method-related reasons is approximately constant
over the three years following adoption, though this
pattern varies between countries.
Huge inter-country variations in the probability of
stopping IUD use were observed. After 24 months
more than 40% of women had stopped use in three
countries compared with 20% or less in another three
countries. The reasons for variation in the willingness
or ability of women to persist with the method are
unclear. In contrast to pronounced inter-country
differences, discontinuation does not vary appreciably
by women’s schooling, household wealth or urbanresidence. Thus the method is equally suitable for
all socio-economic and residential strata.
Thus, an IUD offers, on average,
three times the length of contraceptive
protection offered by other modern
reversible methods.
© Marie Stopes International / Peter Caton
Following IUD discontinuation for method-related
reasons, half of all women on average switched to
another reversible modern method within three months
and an additional 11.5% switched to a traditional
method. In most countries the pill was the most
common destination method and voluntary sterilisation
was rare except in three Latin American countries.
The percentage who switched methods ranges from
40% to 80% across the 14 countries, indicating very
great variability in access to, or acceptability of,
alternatives to the IUD. Switching to another method
following discontinuation is more common for those
who stopped IUD use than those who stopped use
of other modern methods.
The analysis confirms the huge advantages of the
IUD over alternative (mainly hormonal) spacing methods
in terms of reported failure and discontinuation in all
14 countries. Whereas more than 40% of users of the
pill, injectable methods and condoms stopped use within
12 months, the equivalent figure for IUDs was only 13%.
Similarly, while the median length of uninterrupted use
of IUDs is typically 30 or more months, the median
for other methods is typically ten months. Thus an
IUD offers, on average, three times the length of
contraceptive protection offered by other modern
reversible methods.
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Introduction
Marie Stopes International
In sub-Saharan Africa, the use of the
IUD is less common. Only two percent
of users rely on the IUD.
Introduction
Marie Stopes International
2. Introduction
Intrauterine devices (IUDs) for preventing pregnancy
were first introduced more than a century ago. In 1909,
the first paper reporting the use of a ring made of
silkworm gut was published1.
Advances in contraceptive technologies over the last
35 years have resulted in the availability of copperbearing and levonorgestrel-releasing IUDs, which are
easier to insert and remove. Safety and effectiveness
vary by type of IUD. Copper T380A IUD was found
to be the most effective copper-containing device 2.
Among IUD users, contraceptive failure is below
one percent by the end of the first year 3.
The use of IUDs has increased over the past 25
years and it is now the most widely used reversible
contraceptive method globally (Figure 14-5). In 2007,
22.6% of 721 million users of any method of
contraception worldwide relied on IUDs to prevent
pregnancy 5. Among all women aged 15-49 who were
married or in union in 2007, female sterilisation was
used by 20.3% and IUDs by 14.2%. Thus, the IUD
is the leading reversible method and the second most
commonly used method when all reversible and
irreversible methods are considered.
%
World
Developing
90
Injectable
80
IUD
70
Condom
Withdrawal/Rhythm
Other
The Fourth Edition of Medical Eligibility Criteria
for Contraceptive Use (MEC) 6 considered more
than 100 personal characteristics and reproductive
history aspects to examine the suitability of IUDs
for each one.
60
IUDs can be safely and effectively used by women
under most conditions. However, IUDs do not
protect against sexually transmitted infections (STI)
or the human immunodeficiency virus (HIV). MEC
recommended the correct and consistent use of
condoms, either alone or with another contraceptive
method, if there is a risk of STI/HIV, including during
pregnancy or post-partum.
50
40
30
20
10
1983
2007
1983
2007
1983
The figure of 16% for Africa is influenced by the relative
dominance of IUDs in Northern Africa, where 37% of all
users rely on the IUD. In Egypt and Tunisia, one in two
contraceptive users has an IUD. In sub-Saharan Africa,
the use of the IUD is less common. Only two percent
of users rely on the IUD.
Medical eligibility criteria for IUDs
Developed
Male sterilisation
Pill
Both the global figure and the figure for Asia reflect
the predominance of the IUD in China, where this
method accounts for one in two contraceptive users.
Excluding China from the global estimates of users
of any method and IUD users, IUDs account for only
12% of all use, halving the percentage of users of
IUDs among all users worldwide.
BOx 1: Facts about the intrauterine device (IUD)
FIGURE 1: Percentage of contraceptive users by types of contraceptive method used, by year
Female sterilisation
The overall worldwide trends and levels mask the
variation in use of any contraceptive method, and
of IUD use by region and sub-region, as well as by
country and within countries. The latest update of
World Contraceptive Use 20095 indicates that the
prevalence of IUD use is highest in Asia, where one
in four users of any method of contraception relies
on the IUD, followed by Europe with about one
IUD user among five (Table 1).
2007
Source: United Nations, 2009
BOx 1: Facts about the intrauterine device (IUD)
What is an IUD?
The letters IUD stand for ‘intrauterine device’. IUDs are small, T-shaped devices made of flexible plastic.
A health-care provider inserts an IUD into a woman’s uterus to prevent pregnancy. There are two popular
brands of IUD available globally – ParaGard and Mirena. The ParaGard IUD contains copper and is effective
for 12 years. The Mirena IUD releases a small amount of the hormone progestin and is effective for five years.
It also recommended that copper-containing
IUD (Cu-IUD) or levonorgestrel-releasing IUD
(20 μg per 24 hours) or both should not be
used under the following conditions:
a.during pregnancy;
b.immediately after septic abortion;
c. post-partum puerperal sepsis;
d.before evaluating unexplained vaginal bleeding;
e.persistently elevated β-human chorionic
gonadotropin (β-HCG) levels or malignant disease;
f.cervical cancer (while awaiting treatment);
g.current breast cancer (for initiating levonorgestrel
IUD (LNG-IUD));
h.endometrial cancer;
i.uterine fibroids with distortion of the uterine cavity;
j.distorted uterine cavity (any congenital
or acquired uterine abnormality distorting the
uterine cavity in a manner that is incompatible
with IUD insertion);
k.current pelvic inflammatory disease (PID);
l.current purulent cervicitis or chlamydial infection
or gonorrhoea; and
m.pelvic tuberculosis.
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Introduction
Marie Stopes International
Introduction
Marie Stopes International
In spite of this method’s attractive features, IUDs
remain underutilised, especially in Northern America,
Oceania, South Asia and sub-Saharan Africa. IUD
use exceeds 30% among all women who are married
or in union in just 11 countries (China, Cuba, Estonia,
Egypt, Kazakhstan, Kyrgyzstan, Mongolia, Tajikistan,
Turkmenistan, Uzbekistan and Viet Nam) 5.
As contraceptive prevalence in a population increases,
success in avoiding unwanted pregnancy depends less
on initial contraceptive uptake and more on effective
and persistent use. Once a method is adopted, it is
important that couples have quick and easy access
to other methods, should the initial one be deemed
unsuitable. Contraceptive method use dynamics
therefore becomes an important determinant
of success in achieving reproductive intentions.
In spite of this method’s attractive
features, IUDs remain underutilised,
especially in Northern America, Oceania,
South Asia and sub-Saharan Africa.
This report aims to provide detailed information on the
dynamics of IUD use in developing countries, using
data from the most recent Demographic and Health
Surveys (DHSs). More specifically, it provides the
socio-demographic profile of IUD users, continuation
of use and reasons for the discontinuation of use at 12,
24 and 36 months. In addition, it provides information
on method-switching following discontinuation for
method-related reasons.
The ultimate aim of this report is to provide information
for policies and programmes to strengthen services for
improving the continuation of IUD use and shortening
the time for switching to a modern method for women
who do not want another child.
TABLE 1: Percentage using any method of contraception that are using the IUD among women who are
married or in union aged 15-49 and those using IUD among the users of any method of contraception, 2009
Region
% using any method
% using IUD
% of all users relying on IUD
World
62.9
14.2
22.6
More developed
69.7
9.1
13.1
Europe
70.5
13.6
19.3
Northern America
72.9
1.7
2.3
Less developed
61.7
15.1
24.5
Africa
28
4.5
16.1
Asia
67
17.7
26.4
Latin America & the Caribbean
71.7
7.2
10
Oceania
58.6
1
1.7
Source: United Nations, 2009
© Marie Stopes International
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Data, materials and methods
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Data, materials and methods
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3. Data, materials and methods
3.1 Data
3.4 Reasons for discontinuation and switching
3.6 Methods of analysis
The data used in this analysis come from 14 Demographic
and Health Surveys (DHSs) conducted between 1993
and 2008. The main criterion for inclusion in this report
is the availability of at least 300 IUD episodes that allows
disaggregated analysis. Five of the surveys come from
Latin America & the Caribbean, five from North Africa/
West Asia and four from South-Central/South-East Asia.
The lack of surveys in sub-Saharan Africa reflects
the generally low contraceptive prevalence rate
and particularly the low use of IUDs (Table 1).
The reasons given for discontinuation were grouped
into the following four categories:
•reported method failure (i.e. the respondent
became pregnant while using the IUD)
• a desire to become pregnant
•no further need (i.e. sexual abstinence due
to illness or marital dissolution)
• method-related reasons.
Reasons for discontinuation were analysed using
single-decrement life-table methods and reported
per 100 episodes of use. These rates give hypothetical
cause-specific probabilities of discontinuing use for
users who do not stop for any other reason. Life-table
methods were also used to calculate the median duration
of use. Cumulative cause-specific discontinuation rates
at 12, 24 and 36 months of use are presented. It is also
of interest to investigate the probability of discontinuing
with the IUD due to method-related reasons by time
elapsed since starting the method. The analysis
investigated the probability of discontinuing between
12 and 24 months and between 24 and 36 months.
3.2 Contraceptive calendar
As of 1990, the DHS programme has included a
contraceptive calendar for countries where contraceptive
prevalence is considered to be relatively high (≥40%).
During the interview, previous births and current
pregnancies are entered into a grid spanning five
years preceding the survey. Abortions are also entered
into the calendar, although it is not possible to distinguish
between spontaneous and induced abortions. Around
these reproductive events, dates of contraceptive use
are entered and reasons for discontinuation are noted.
Calendars of contraceptive use have been found to
generate more complete and accurate data on past
contraceptive use than other formats7-9.
3.3 Selection of IUD episodes
The units of analysis in this study are episodes of IUD
use and the time to first event following discontinuation
of IUD for method-related reasons. An episode is
defined as a period of uninterrupted use (in months)
that may or may not have ended. A switch to a new
method (or a break between methods) indicates the
start of a new episode. The episodes analysed in this
report were contributed by women who were either
married or in union at the time of use. Calendar data
for the three months prior to the interview data were
omitted to avoid the problem of under-reporting of first
trimester pregnancies10, as including these would
underestimate the reported IUD failure rate.
This final category includes reasons that imply some
degree of dissatisfaction with the IUD, such as side
effects, health concerns, medical advice, access and
availability, desire to switch to a permanent method,
inconvenience of use and cost. While women may
discontinue with their IUD for multiple reasons, the
survey only recorded the main reason. For the purposes
of this report, the categories for discontinuation of interest
were ‘reported IUD failure’ and ‘method-related reasons’,
as other reasons are driven by user desires and are
not related to the method itself.
3.5 Covariates
Four covariates are used in this analysis. Women’s usual
place of residence is either rural or urban. Education
level was re-grouped into two: primary schooling or less,
and secondary schooling or higher. Motivation for use
(i.e. using the IUD to limit births or to space them) was
derived by comparing the total number of children desired
and number of living children at the start of the episode.
If total desired size is less than the number of living
children, the motive for use is inferred to be limitation.
If desired size equals or exceeds actual size, the motive
is classified as spacing. The DHS wealth quintiles,
based on household possessions and characteristics,
were re-coded into tertiles, with those in the top third
(the richer) compared with those in the bottom third
(the poorer).
Multiple-decrement life-table methods were employed
to estimate the status of women three months after
having discontinued the IUD due to method-related
reasons. It was assumed that these women would
still require contraception as they had not stopped
due to a desire to become pregnant but because of
dissatisfaction with the IUD. The three month mark
was chosen because few women switch to another
method after this length of time.
All analyses were done using STATA 10.1 (StataCorp.
2009. College Station, TX: StataCorp LP) and
appropriate adjustments for the survey weights
and clusters were made.
For the purposes of this report, the
categories for discontinuation of
interest were ‘reported IUD failure’
and ‘method-related reasons’.
© Marie Stopes International
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Results
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4. Results
Results
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TABLE 2: Country background information
Country
(abbreviation)
Date of fieldwork Number of women
4.1 Background information for the 14 countries
As can be seen in Table 2, current use of any
contraceptive method among currently married
women in the 14 study countries ranges from 44.6%
in Bangladesh to 78.5% in Viet Nam, while current
use of modern methods ranges from 17.7% in Bolivia
to 68.2% in Colombia. The use (popularity) of the IUD
varies from 2.2% in both Bangladesh and the Dominican
Republic to 42% in Kazakhstan. While current use of
modern methods is high in the Dominican Republic
(65.8%), use of the IUD is low (2.2%). Conversely, the
level of modern contraceptive prevalence in Kazakhstan
(52.7%) is mainly a result of IUD use (42%). Median
use of IUD is 8.6% across the 14 countries studied.
In addition to contraceptive use, Table 2 presents
the total fertility rate (TFR) and unmet need for family
planning (contraception). TFR and unmet need ranges
from 1.9 to 4.8% in Viet Nam and 4.8 to 24.3% in
Bolivia, respectively. Levels of TFR and unmet need
are significantly correlated with current use of any
method and modern method (TFR: -0.78 and -0.64,
respectively and unmet need: -0.91 and -0.79).
% currently using:*
Any method Modern method
IUD
TFR (15-49) Unmet need %
Latin America & the Caribbean
Bolivia
(BO)
1993/1994
8,603
45.3
17.7
8.1
4.80
24.3
Colombia
(CO)
2004/2005
41,344
78.2
68.2
11.2
2.40
5.8
Dominican Republic
(DR)
2002
23,384
69.8
65.8
2.2
3
10.9
Nicaragua
(NC)
1997/1998
13,634
60.3
57.4
9.1
3.90
14.7
Peru (1)
(PE)
2003/2005
11,717
71.3
47.6
5.6
2.60
8.1
Egypt
(EG)
2008
16,527
60.3
57.6
36.1
3
9.2
Jordan
(JO)
2007
10,876
57.1
41.9
22.3
3.60
11.9
Morocco
(MA)
2003/2004
16,798
63
54.8
5.4
2.50
10
Turkey
(TR)
1998
8,576
63.9
37.7
19.8
2.61
10.1
Bangladesh
(BD)
1993/1994
9,640
44.6
36.2
2.2
3.44
19.4
Indonesia
(ID)
2007
32,895
61.4
57.4
4.9
2.60
9.1
Kazakhstan
(KK)
1999
4,800
66.1
52.7
42
2.05
8.7
Philippines
(PH)
2003
13,633
48.9
33.4
4.1
3.50
17.3
Viet Nam
( VN)
2002
5,665
78.5
56.7
37.7
1.87
4.8
12,675
62.2
53.8
8.6
2.81
10.1
Northern Africa/Western Asia
South central/South-eastern Asia
Total (Median)
*among currently-married women aged 15-49, for Bangladesh (10-49) (1) Peru is a continuous survey
© Marie Stopes International
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Results
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Results
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4.2 Women’s characteristics
Table 3 shows the total number of women who
contributed at least one episode and number of episodes
used of any method. It also shows those who reported
IUD episodes during the five-year calendar, as well
as the mean number of episodes reported, by survey.
Overall 137,884 contraceptive episodes started during
the five-year period of the calendar, 18,484 (13.4%)
of which were IUD episodes. The mean number of
IUD episodes per woman was slightly more than one
(1.05), which was lower than the mean number of
all contraceptive method episodes (1.61).
Table 4 compares the characteristics of IUD users with
those of users of other modern contraceptive methods.
In terms of urban-rural residence, on average across all
14 countries, there is little difference between IUD users
and users of other modern methods: 71% of IUD episodes
were recorded in urban women compared with 67% for
other methods. Differences were observed, however, in
Peru, Nicaragua and Indonesia, where more IUD episodes
were contributed by women in urban settings than was
the case for users of other modern methods. The opposite
was found in Kazakhstan, Viet Nam and the Philippines.
Nearly one-third (30%) of the IUD episodes in the 14
surveys combined were contributed by women educated
to at least secondary school level. The corresponding
figure for other modern methods was higher (42%) and
this pattern was observed in the majority of the 14 countries.
However, this difference was pronounced in only five
countries (Dominican Republic, Egypt, Indonesia,
Nicaragua and Peru).
In terms of motivation for IUD use, women appeared
to use the IUD equally for both spacing and for limiting
births, with each motivational factor contributing 50%
of the episodes. In all countries, women were more
likely to use modern methods other than IUDs to space
births (a median of 59%), with the exception of Egypt.
Around 40% of IUD episodes were contributed by
women from more affluent households, and the same
finding was observed for women using other modern
methods. However, there were mixed findings within
the countries. Wealthier women in Viet Nam and
Kazakhstan contributed fewer IUD episodes than
episodes of other modern methods, whereas the
opposite was found in Indonesia, Peru and Egypt.
© Marie Stopes International / Susan Schulman
TABLE 4: Percentage of IUD and other modern method (MM) episodes contributed by women
of specified characteristics
TABLE 3: All contraceptive methods and IUD episodes reported in the calendar, by surveys
Country
All methods
Women
episodes
IUD
Women
n
mean
episodes
n
mean
Bangladesh
4,253
6,806
1.60
358
369
1.03
Bolivia
2,797
4,435
1.59
464
495
1.07
Colombia
18,127
30,415
1.68
2,768
2,843
1.03
Dominican Republic
8,896
14,879
1.67
652
684
1.05
Egypt
7,346
10,024
1.36
4,394
5,008
1.14
Indonesia
14,668
20,341
1.39
663
682
1.03
Jordan
6,079
10,270
1.69
2,381
2,624
1.10
Kazakhstan
1,856
3,253
1.75
1,030
1,125
1.09
Morocco
5,428
10,126
1.87
490
506
1.03
Nicaragua
5,122
7,866
1.54
1,228
1,291
1.05
Peru
2,671
5,186
1.94
248
267
1.07
Philippines
3,764
5,783
1.54
298
304
1.02
Turkey
3,034
4,909
1.62
1,007
1,046
1.04
Viet Nam
2,451
3,551
1.45
1,170
1,241
1.06
Median
(4,688)
(7,336)
(1.61)
(835)
(865)
(1.05)
Country
% Urban
MM
IUD
% Secondary +
MM
IUD
% Spacing
MM
IUD
% Upper third (wealth)
MM
IUD
Bangladesh
17
17
73
72
42
36
46
41
Bolivia
90
87
26
21
58
51
65
66
Colombia
80
78
22
26
67
51
48
42
Dominican Republic
70
76
44
30
77
73
48
59
Egypt
36
43
42
31
50
52
22
42
Indonesia
42
67
44
19
64
49
37
71
Jordan
86
87
7
7
60
57
41
47
Kazakhstan
70
53
n/a
n/a
77
66
41
25
Morocco
59
69
77
72
58
47
37
46
Nicaragua
64
77
55
41
63
58
43
45
Peru
77
90
21
10
60
48
41
64
Philippines
51
40
24
28
55
44
24
17
Turkey
73
73
67
71
53
40
47
41
Viet Nam
25
13
32
34
42
40
48
22
Total (median)
(67)
(71)
(42)
(30)
(59)
(50)
(42)
(43)
MM= Modern methods (include pill, injections, vaginal methods, condom and Norplant)
17
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4.3 IUD discontinuation
Table 5 shows the number of IUD episodes and the
percentage discontinued by reason across the 14
countries during the five-year period. On average for
the 14 study countries, 66% of IUD episodes were
still continuing at the time of the survey. The dominant
reason for stopping was health concerns or side effects
(15.7%); 2.5% episodes were discontinued because of
reported method failure, 5.9% due to a desire for a child
and 3.5% because of no further need. Bangladeshi
women showed the highest levels of discontinuation
due to health concerns at 39.8% with Indonesia
showing the lowest at 8.2%.
Table 6 presents the medians of the country-specific,
cumulative overall and cause-specific discontinuation
rates at 12, 24 and 36 months, per 100 episodes. (See
appendix Table A1 for country-specific rates.) Across
all 14 countries, the median probability of discontinuing
an IUD for all reasons was 13.2% at 12 months, 27.5%
at 24 months and 41.5% at 36 months.
b. Method-related reasons. Across all countries and
at all time periods, the main reasons for discontinuation
were related to the method itself; the median methodrelated discontinuation rates were 8.9% at 12 months,
16.7% at 24 months and 27% at 36 months. The highest
method-related discontinuation rate at 12 months was
observed in Bangladesh (32.2%), while rates of around
18% were found in the Dominican Republic, Peru and
Nicaragua (Figures 3a, 3b and 3c). At 36 months, over
one-third of all episodes in the Dominican Republic
(46.5%), Nicaragua (40.9%) and Peru (34.4%) had
been discontinued due to dissatisfaction with the
method, and over half in Bangladesh (53.6%).
In terms of inter-country variability, three countries
showed consistently low probabilities of IUD
discontinuation at all time periods, namely Indonesia,
Turkey and Kazakhstan, while Bangladesh and the
Dominican Republic showed the highest (Figures
2a, 2b and 2c, please see overleaf ).
a. Reported failure. Discontinuation due to reported
method failure (i.e. the user became pregnant while
using the IUD) was low across the 14 countries. Just
over one per 100 episodes (1.3) failed in the first year,
rising slightly to nearly four out of 100 at three years of
use (Table A1). At 12 months of use, the reported failure
rate was lowest in Bangladesh (0.4%) and highest in
Kazakhstan (3.2%). At 24 months, the median reported
failure rate was 2.3%, with the lowest rate observed in
the Philippines (0.6%) and the highest in Kazakhstan
(5.8%). By 36 months, the median overall reported failure
rate was 3.9%. The lowest rate at this time point was
found again to be in the Philippines (0.6%) and the
highest in Colombia (6.9%).
In terms of inter-country variability, three
countries showed consistently low
probabilities of IUD discontinuation
at all time periods, namely Indonesia,
Turkey and Kazakhstan.
TABLE 5. Reasons for IUD discontinuation, by country
Country
Total IUD episodes
Currently using (%)
c. Probabilities of discontinuation by duration of use.
Table 7 shows overall and cause-specific probabilities
of discontinuing the IUD between 12 and 24 months
(denoted in the table as 24 | 12) and between 24 and
36 months (shown as 36 | 24). (See appendix Table
A2 for country-specific findings.) The median reported
failure rate remained low at 1.4% in the second year
of use, with little discernible increase in the third year
(1.5%). While the reported failure rate in the majority
of countries remained either stable or decreased,
the rates in both Indonesia and Jordan doubled in
the third year of use compared with the second year
(1.3% to 3% and 1.6% to 3.1% respectively).
TABLE 6. Median cumulative cause-specific discontinuation probabilities
per 100 episodes. (Median values for the 14 countries)
Discontinued (%):
Method failure
Health concens Other reasons
Want a child
No further need
Month
All reasons
Failure
Methodrelated
Want
a child
No further
need
12
13.2
1.3
8.9
1.4
1.6
Bangladesh
369
44.5
0.8
39.8
2.4
5.2
7.3
Bolivia
495
71.9
1.4
15.6
1
5.7
4.4
Colombia
2,843
68.2
4.3
20
2.2
3.4
1.9
24
27.5
2.3
16.7
5.2
2.8
Dominican Republic
684
47.8
2.8
27.9
5.1
8.3
7.9
36
41.5
3.9
27
11.1
4.9
Egypt
5,008
63.3
2.1
11.6
0.4
19.6
3
Indonesia
682
77.8
2.8
8.2
1.9
5.6
3.8
Jordan
2,624
63.6
2.8
13.5
1.4
17.3
1.5
Kazakhstan
1,125
73
5.2
12
1.2
6.8
2
Morocco
506
60.7
1.6
22.5
1
11.1
3.2
Nicaragua
1,291
52.4
3.3
26.6
4.3
6.2
7.4
Peru
267
63.8
2.3
26.3
0.4
5.6
1.5
Philippines
304
73.1
0.7
15.8
3.9
2
4.6
Turkey
1,046
72.9
2.1
12.9
0.6
5.4
6.1
Viet Nam
1,241
75.2
3.1
12.7
0.6
6.8
1.5
Total (median)
865
66
2.5
15.7
1.3
5.9
3.5
TABLE 7. Median conditional cause-specific discontinuation probabilities
per 100 episodes. (Median values for the 14 countries)
Month
All reasons
Failure
Methodrelated
Want
a child
No further
need
12 | 24
15.6
1.4
8.5
3.4
1.1
36 | 24
17.5
1.5
8
5.4
1.7
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Figure 2a: IUD all-cause discontinuation probabilities at 12 months by country
Figure 3a: IUD discontinuation probabilities due to method dissatisfaction at 12 months by country
Percent
37.3
Figure 2B: IUD all-cause discontinuation probabilities at 24 months by country
19.7
Dominican
Republic
Colombia
Nicaragua
12.7
Peru
11.4
Morocco
Viet Nam
6.8
Philippines
6.4
8.9
18
Percent
46.5
53.9
12.6
12.7
20
20.2
Bangladesh
11.7
17.5
32.6
Dominican
Republic
Bangladesh
Dominican
Republic
Nicaragua
Egypt
Peru
Morocco
Colombia
Jordan
Bolivia
Philippines
Kazakhstan
Viet Nam
Turkey
Indonesia
Figure 2C: IUD all-cause discontinuation probabilities at 36 months by country
10.1
15.9
Morocco
10
10
8.3
14
Jordan
20
29.3
Nicaragua
30
33.5
Colombia
32.6
Egypt
23.2
29.7
Viet Nam
22.3
27.7
Kazakhstan
20.4
27.3
Indonesia
15.3
17.7
25.7
Turkey
30
27.8
Philippines
40
40
Peru
44
48.5
Bolivia
50
Figure 3C: IUD discontinuation probabilities due to method dissatisfaction at 36 months by country
Percent
Percent
Bangladesh
Dominican
Republic
20.3
Nicaragua
18.4
28.4
Colombia
16.4
27.2
Philippines
10.9
16.1
27.1
Morocco
Bangladesh
Dominican
Republic
Nicaragua
Egypt
Jordan
Peru
Morocco
Bolivia
Colombia
Philippines
Turkey
10
15.4
26.9
Bolivia
20
Jordan
30
24.6
Viet Nam
34.4
Egypt
40
40.9
40
Viet Nam
38.8
51.2
46.5
Turkey
33.3
53.6
50
Kazakhstan
30.8
48.2
66
Indonesia
30.5
30.6
43
47.1
63.1
Peru
58.1
Kazakhstan
60
50
40
30
20
10
6.3
8.8
17.5
Figure 3B: IUD discontinuation probabilities due to method dissatisfaction at 24 months by country
Percent
20
6
8.1
Bolivia
Bangladesh
Dominican
Republic
Nicaragua
Peru
Colombia
Morocco
10
7.5
Jordan
20
Indonesia
20.1
Turkey
15.5
16.7
28.2
Egypt
13.8
Philippines
12.5
Viet Nam
12
Jordan
11.9
Bolivia
11.8
Egypt
11.4
Kazakhstan
10.4
Indonesia
10
9.6
Turkey
20
24.2
32.2
30
Kazakhstan
30
Bangladesh
Percent
Indonesia
20
21
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Across all 14 countries, the probability of stopping for
method-related reasons declines over time. In the first
12 months of use, 8.9% of episodes were terminated
for this reason. For women who continued with use for
12 months or more, the probability of discontinuing in
the second year fell to 8.5%. For those who completed
24 months or more of use, it fell further to 8% in the third
year. However, examination of country-specific results
reveals a variety of patterns. In some countries (e.g. Egypt
and Jordan) discontinuation was rather constant over
the three years. In Indonesia and Viet Nam, the rate was
relatively high in the first 12 months but low in the second
and third year. In other countries (e.g. Nicaragua and
Turkey), it was high in the first year, fell in year two
but rose in the third year.
Figure 4a shows that IUD discontinuation was marginally
higher on average among rural than urban women, but
the country-specific results in Table A3 indicate a fair
number of exceptions (notably Philippines and Viet Nam)
where discontinuation among urban women was
about twice as high as among rural women.
d. Differentials in discontinuation. It is of interest to
know whether or not women with different characteristics
also vary in their propensity to discontinue IUD use
for method-related reasons. This topic is addressed
in Figures 4a, 4b, 4c and 4d. Results are summarised
by box and whisker plots for discontinuation at 12 months.
The height of each box indicates the range within which
half of estimates for the 14 countries fall and the horizontal
line in the box shows the median value. The vertical lines
protruding from each box (the whiskers) show the predicted
range within which 90% of national estimates fall. Finally,
dots lying beyond the end of the whiskers represent
outliers. In this analysis, all outliers represent Bangladesh.
As expected, motivation for use (Figure 4c) influenced
discontinuation, with a higher 12 month risk of stopping
among spacers than limiters (11.4% versus 7.9%). This
contrast was most pronounced in Peru (25.2% versus
9.9%) but, conversely, was negligible or slightly reversed
in Bolivia, Dominican Republic and Morocco.
The average differences by women’s education were
small; the overall median was slightly lower for those
with secondary or higher schooling than for the less
well educated, but the two boxes in Figure 4b shows a
great degree of overlap. The big exception is Indonesia,
where the probability of stopping was ten times greater
among better educated women than among the less
well educated.
Differences according to household wealth tended
to be small (Figure 4d).
© Marie Stopes International / Peter Caton
FIGURE 4A: IUD method-related discontinuation
probabilities at 12 months, by residence
Discontinuation rate per 100 episodes
FIGURE 4B: IUD method-related discontinuation
probabilities at 12 months, by education
Discontinuation rate per 100 episodes
FIGURE 4C: IUD method-related discontinuation
probabilities at 12 months, by motivation for use
Discontinuation rate per 100 episodes
FIGURE 4D: IUD method-related discontinuation
probabilities at 12 months, by wealth
Discontinuation rate per 100 episodes
30
30
30
30
20
20
20
20
10
10
10
10
rural
urban
<primary
secondary+
spacer
limiter
poor
rich
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4.4 Method-switching following
method-related discontinuation
Table 8 displays contraceptive status at three months
following discontinuation. Across all 14 countries
the median percentage of women who were already
pregnant was 12.4% three months after discontinuation.
The highest observed value in the analysis was
in Bolivia (23.7%), while the lowest was observed
in Morocco (2.8%). It is likely that most of these
pregnancies were unintended.
A quarter of women were still at risk of becoming pregnant
three months after method-related discontinuation.
This indicates that, although they had not become
pregnant, they had not switched to any other method
of birth control. As switching is uncommon after three
months, these women were at high risk of an unintended
pregnancy. The highest rate was found in Kazakhstan
(42.3%) and the lowest was in Peru (11.6%). This indicates
that, across all countries, between 10-40% of women
who discontinued their IUD due to dissatisfaction
with the method were left without another method
of family planning.
a. Time to switching. The overall median estimate of
switching to another modern method of contraception
within three months of discontinuation was 49.9%.
(See appendix Table A4 for country-specific rates).
High levels of switching to another modern method
were noted in Peru (70.5%) and Morocco (69.8%),
with Bolivia and Kazakhstan both showing lower
levels (16.7% and 25.2%, respectively), (Figure 5).
The most popular destination method was the
contraceptive pill in all countries except Indonesia
and Peru where around 30% of women chose to switch
to injectable contraception within three months of
discontinuing with their IUD. Sterilisation was a popular
choice for women in Latin America, namely Colombia
(9.3%), Nicaragua (7.5%) and the Dominican Republic
(5.7%). Switching back to an IUD (possibly a different
type) was very rare except in Egypt and Kazakhstan.
FIGURE 5: Switching behaviours three months post IUD discontinuation
Percent
80
60
40
20
KK
traditional
DR
BO
EG
modern
TABLE 8: Status at three months after discontinuing IUD for method-related reasons. (Median values for the 14 countries)
At risk
Became pregnant
Switched to:
Modern methods
All episodes
23.9
12.4
IUD
Pill
Injectable
Barrier
All modern reversible
0.5
24.6
8.8
8.2
49.9
Sterilisation
Traditional
0.5
11.5
Place of residence
Urban
27.1
13.9
0
26
6.5
5.4
48.4
0.7
11.5
Rural
24
10
0
23.9
7.4
8.8
50.3
0
12.3
Primary or less
24.7
13.6
0
22.9
8.5
2.8
42.7
0.1
7.5
Secondary+
20.6
10.2
1.3
25.6
9.4
8.7
52.9
0
14.4
Spacers
25.8
14.8
0
23.5
6.9
6.9
48.3
0
13.7
Limiters
25.3
8.4
0.7
26.5
10.5
6.4
48.3
0.9
12.6
Poor
24.5
12.1
0
22.6
5.1
5.6
42.9
0
9
Rich
23.6
11.2
0
25
9.9
7.5
52.3
0
14.2
Women education
Motivation
Wealth index
*Note row percentages sum to 100% at the country level (see Appendix Tables A.5-A.8)
JO
NC
CO
PH
TR
BD
VN
ID
MA
PE
Source: Demographic and Health Surveys
A preference for switching from an IUD to another modern
method after three months rather than to a traditional
method was found to occur in all countries except
in Bolivia and Turkey, where the opposite behaviour
was observed. Across the 14 countries, the median
percentage of switching to traditional methods was
11.5%. Three months after IUD discontinuation, around
a third of women who had switched method in Bolivia,
Turkey and Viet Nam were relying more on less
effective traditional methods to control their fertility.
b. Differentials. On average, urban women were more
likely to be pregnant already or at risk of conception
compared with women in rural areas. Of urban women,
27.1% had discontinued the IUD yet not taken up any
other method, with this figure standing at 24% amongst
rural women (Table A5). The corresponding figures for
pregnancy were 10% and 13.9% for rural and urban
women, respectively. Results from rural Egypt, rural
and urban Kazakhstan and urban Dominican Republic
indicated that around 40% of those who discontinued
the IUD remained at risk three months later.
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FIGURE 6A: Switching to a modern FP method within
three months of IUD discontinuation, by residence
FIGURE 6B: Switching to a modern FP method within
three months of IUD discontinuation, by education
FIGURE 6C: Switching to a modern FP method within
three months of IUD discontinuation, by motivation for use
Percent
Percent
60
60
60
60
60
40
40
40
40
40
20
20
20
20
20
rural
urban
Figure 6a shows very slightly higher levels of switching
to another modern method in rural areas than in urban
areas (50.3% and 48.4% respectively). In rural areas of
Bolivia, switching to a modern method was particularly
low (18.2%), due to higher rates of non-use, pregnancy
and use of traditional methods. Rural areas of Morocco,
Indonesia and Peru saw switching of over 70% and
lower levels of non-use. In urban areas, high levels
of switching were observed in Philippines, Peru and
Morocco (around 60% or above). While there were
higher occurrences of switching to traditional methods
in urban Bolivia (54.9%), there was no reported
switching to modern methods, although it must be
noted that the number of episodes in this category
was very small.
Of the less educated women, 24.7% on average
reported remaining at risk of pregnancy following
discontinuation compared with 20.5% of their better
educated counterparts (Table A6). Similarly, the
proportion of women already pregnant was higher
among the less well educated women than among
the better educated (13.6% versus 10.2%). At the
country level, almost half of the lesser educated
women in Dominican Republic and 41.7% of more
educated women in Kazakhstan were at risk of
pregnancy. Around 45% of less educated women
in Bolivia and a fifth in the Philippines fell pregnant
in the three months following discontinuation, with
around 17% of more educated women in Bolivia,
Jordan and Kazakhstan also reporting pregnancy.
Percent
FIGURE 6D: Switching to a modern FP method
within three months of IUD discontinuation, by wealth
primary or less
secondary or more
The levels of switching to modern methods of
contraception was 10% higher among women who
had received secondary level education compared
with women who had only received primary education
or less (52.9% and 42.7% respectively), (Figure 6b).
Also, more educated women reported switching to
traditional methods than less educated women (14.4%
and 7.5% respectively). Among women who had only
received primary education or less, the highest levels
of switching to a modern method were observed in
Peru (77.1%) and Indonesia (72.2%). While in Peru
this high level of switching was accompanied by a low
level of women reportedly being at risk of pregnancy,
Indonesia saw more women discontinuing but not
switching to any other method. Higher levels of
switching to a new IUD within three months were
observed in more educated women.
A quarter of both spacers and limiters reported being
at risk of conception three months after discontinuing the
IUD, with levels above 40% observed amongst spacers
in Dominican Republic and Kazakhstan (Table A7).
Pregnancies were more common amongst spacers
(14.8%) than limiters (8.4%), with levels particularly
high amongst Kazakhstani spacers (20.9%) and
limiters, and Bolivian limiters (27.2%).
Percent
spacer
limiter
The probability of switching to a modern method was
found to be similar for both switchers and limiters with
the median for the 14 countries lying at 48.3% in both
groups (Figure 6c).
Limiters in Peru and Morocco were particularly likely
to switch quickly to modern methods (74.4% and 74%
respectively). Bolivian and Turkish women who were
motivated to limit family size favoured less effective
traditional methods above modern methods. In Bolivia,
10.8% of limiters switched to a modern method of
contraception, yet switching levels to a traditional
method were more than double, at 25.2%. In Turkey,
30.4% of limiters switched to a modern method, but
38.3% were relying on a less effective traditional
method. High rates of sterilisation post-discontinuation
were observed among limiters in three Latin American
countries, namely Colombia (20.9%), Dominican
Republic (18.1%) and Nicaragua (18.9%). These were
also the only countries to report sterilisation rates among
women who were reportedly only spacing their births.
poorer
richer
On average, little difference was observed between
richer and poorer women in the probability of becoming
pregnant after IUD discontinuation or remaining at risk
of pregnancy (Table A8). Overall, Figure 6d indicates
higher levels of switching to a modern method among
wealthier women compared with their poorer counterparts
(50.4% and 42.9% respectively). The same pattern was
observed for switching to traditional methods, with 14.2%
of wealthier women turning to these methods compared
with 9% of poorer women. Country-specific results
are difficult to interpret because of the small number
of episodes reported, particularly by poorer women.
If attention is restricted to countries with 50 or more
episodes in both groups, it may be noted that in Egypt
and Nicaragua, richer women were more likely to switch
to a modern method than poorer women but the
reverse was true in Bangladesh and Jordan.
In urban areas, high levels of switching
were observed in Philippines, Peru
and Morocco (around 60% or above).
27
28
Results
Marie Stopes International
Results
Marie Stopes International
4.5 Comparison of IUD and other modern methods
In this section, IUD discontinuation, reported failure
and switching is compared to these indicators for the
other main modern reversible methods, pills, injectables
and condoms, using data from the 14 study countries.
Figure 7 shows all cause discontinuation at 12 months
for these methods. Similar results were obtained for
method-related discontinuation (not shown). A huge
difference is apparent between IUDs and the other three
methods. Whereas a little over 10% of women stopped
using their IUD in the first 12 months of use, the
corresponding estimate for the other methods was over
40%. The height of the box for IUDs is also lower than
those for other methods, indicating less inter-country
variability for the IUD.
An alternative way of representing discontinuation is to
estimate the median length of episodes and the results
are shown in Table 9. In all 14 countries, the length of IUD
episodes vastly exceeds that of other modern methods.
For these other reversible methods, the median length
of use was typically about ten months, although longer
in Indonesia (33 months) and Viet Nam (22 months).
In comparison, median lengths of IUD use exceeded
50 months in half the 14 countries and were less
than 30 months in only three of them: Bangladesh
(20 months), Dominican Republic (25.5 months)
and Nicaragua (27 months).
The comparison is extended in Figure 8, which shows
12-month reported failure rates. As noted earlier, the
failure rate for IUDs for all 14 countries was 1.3 per
hundred episodes. The equivalent median value for
injectables was not much higher, but the height of the box
for this method indicates a much greater range of failure
rates across countries. For pills and condoms, failure
rates were much higher, close to eight per 100 episodes.
Finally, it is of interest to ascertain whether methodswitching differs between discontinuers of IUDs and
of other modern methods (Figure 9). Half of IUD
discontinuers switched to another modern method
within three months compared with a little over 40%
of discontinuers of other modern methods. The heights of
the boxes for IUD and other method users indicate greater
inter-country variability in switching for the former than
the latter group. Thus generalisations about differences
in switching behaviour should be made with caution.
TABLE 9: Duration of modern methods and IUD episodes
FIGURE 7: All-cause discontinuation rates at 12 months for the four main modern, reversible methods
Rate per 100 episodes
80
70
60
50
40
30
20
Method failure
IUD
Pill
IUD
Pill
Injectables
Condom
10
Injectables
Condom
All reasons
FIGURE 8: Discontinuation rates at 12 months due to failure of the four main modern, reversible methods
Rate per 100 episodes
Country
Modern methods (MM)
no. of episodes median use (months)
IUD
no. of episodes
median use (months)
Bangladesh
4,802
11.8
369
20
Bolivia
996
6.1
495
50.3
Colombia
17,676
11.8
2,843
53.6
Dominican Republic
8,910
10.1
684
25.5
Egypt
4,811
18
5,008
35.1
Indonesia
18,191
33.2
682
60+
Jordan
3,334
14.4
2,624
37.3
Kazakhstan
990
8.2
1,125
59.5
Morocco
6,856
17.6
506
42.3
Nicaragua
4,713
11
1,291
27.4
Peru
2,940
10
267
36.7
Philippines
2,958
14.8
304
60+
Turkey
1,555
11.4
1,046
50.7
Viet Nam
923
21.7
1,241
60+
Total (median)
(4,024)
(12)
(865)
(37)
Modern methods include pill, injections, vaginal methods, condom and Norplant
16
12
8
4
IUD
Pill
Injectables
Method failure
Condom
29
30
Discussion and conclusions
Marie Stopes International
5. Discussion and conclusions
5.1 Data limitations
The main limitations of this analysis stem from the narrow
range of available data. The decision was made to use
nationally representative data from DHS enquires that
collected contraceptive calendars. The number of
countries that could be included was further narrowed
by the need to have a minimum number of IUD episodes
for each country in order to justify detailed analysis.
The net result of these requirements was that only 14
countries could be studied. Though their geographical
spread was reasonable, global generalisations need to
be made with caution. It is particularly regrettable that
China, which accounts for about half of all IUD users,
could not be included in the study because no DHS has
yet been conducted in China. It is also regrettable that
no data were available for any industrialised country.
While DHS data are generally considered to be of high
quality, they inevitably have limitations. The main limitation
in respect of this report concerns the recording of reasons
for stopping a method. Motivations for stopping may be
complex and multi-faceted and it is difficult to capture
such complexity in a large, structured interview survey.
Moreover, the recording of only one reason for
stopping is obviously not ideal.
The most significant limitation is the lack of countryspecific information on the nature and quality of family
planning services and on the types of IUD that are
used. Huge variations between countries in IUD use
dynamics are apparent. However, in the absence
of contextual information on services, interpretation
is impossible. The report can identify countries with,
for instance, unusually poor IUD use continuation
but cannot proffer reasons or propose remedies.
FIGURE 9: Percentage of women who switched to any
modern method within three months post discontinuation
due to method-related reasons, by method
% switched to any modern methods
70
60
50
40
30
20
IUD
Other modern
© Marie Stopes International
The case for vigorous promotion
of IUDs is particularly strong
in sub-Saharan Africa, the one
remaining region where contraceptive
prevalence remains low but where
large future increases are projected.
5.2 Main findings
This analysis has served to confirm and elaborate
results that were already established from earlier
studies, such as the low reported failure rate of IUDs
and low discontinuation compared with alternative
methods. It has also generated useful new evidence,
for instance, by examining IUD use dynamics among
women of different characteristics and by analysing
discontinuation in the second and third year following
IUD adoption. The main results are summarised
and discussed below:
a. Even within the 14 study countries, which were
selected for reasonably high overall contraceptive
use and a minimum of 300 IUD use-episodes, the
contribution of the IUD to contraceptive protection
is immensely variable. It accounts for about two
percent of users in some countries but more than half
of users in others. It is most unlikely that any biological
or cultural factor can account for this variability. Rather,
it reflects the policy choices about which methods
to promote and biases in family planning services.
Discussion and conclusions
Marie Stopes International
In view of the advantages of the IUD over alternative
reversible methods in terms of its low failure rate and
high continuation, the virtual absence of IUDs from
the overall method mix in so many countries is deeply
regrettable. The case for vigorous promotion of IUDs
is particularly strong in sub-Saharan Africa, the one
remaining region where contraceptive prevalence remains
low but where large future increases are projected. It is
equally strong in a country such as Bangladesh, where
women typically reach their desired family size in their
mid-twenties and ideally require long-acting methods
for the next two decades in preference to hormonal
methods that currently dominate contraceptive provision.
b. While the IUD, along with voluntary sterilisation and
implants, is well suited to the needs of couples who have
all the children they desire, an important finding from this
analysis is that about half of all IUD use appears to be
motivated by the wish to space or postpone childbearing.
In only one of the 14 countries did the proportion
of episodes attributable to women who still had not
reached their desired size of family fall below 40%.
31
32
Discussion and conclusions
Marie Stopes International
Discussion and conclusions
Marie Stopes International
IUD use is compatible with breastfeeding and thus has
a potentially valuable role in post-partum contraceptive
protection. Women with infants often have unusually
frequent contact with health services and thus, to the
extent that family planning is integrated with maternal
and child health services, abundant opportunities
exist for IUD counselling and provision in the
post-partum period.
c. In terms of urban-rural residence and household
wealth, IUD users differ little from users of other modern
methods. In five of the 14 countries, IUD users were
less well educated than other method users. However,
in the majority of countries, this difference was negligible
or reversed. Any suspicion that family planning staff
target under-privileged and less educated women for
IUD insertions because they cannot be ‘trusted’ to use
hormonal methods receives no support from these results.
d. The main reasons for stopping IUD use imply
dissatisfaction with the method, but more intensive
studies are needed to gain further insight into precise
concerns. In view of the high proportion of women who
are using the method for postponement of births, the
percentage of women who say they stopped in order
to have another child is surprisingly low. As noted
above, the reliability of self-reported reasons is
uncertain. One might have expected high levels of
discontinuation in the early months following insertion,
succeeded by a long period of low discontinuation.
However, the evidence suggests that this is not the
case. The probability of abandoning IUDs for methodrelated reasons is approximately constant over the
three years following adoption, although this pattern
varies between countries.
e. Huge inter-country variations in the probability
of stopping IUD use were observed. After 24 months,
more than 40% had stopped use in three countries
compared with 20% or less in another three countries.
No obvious link to the overall ‘popularity’ of IUDs and
discontinuation is apparent and thus the reasons for
variation in the willingness or ability of women to
persist with the method are unclear.
f. In contrast to pronounced inter-country differences,
discontinuation does not vary appreciably by women’s
schooling, household wealth or urban-residence. It may
be concluded that the method is equally suitable for all
socio-economic and residential strata.
© Marie Stopes International
© Marie Stopes International
g. Following IUD discontinuation for method-related
reasons, half of all women on average switched to
another reversible modern method within three months
and an additional 11.5% switched to a traditional
method. In most countries, the pill was the most
common destination method and voluntary sterilisation
was rare except in three Latin American countries.
The proportion of women who switch ranges from 40%
to 80% across the 14 countries, indicating very great
variability in access to, or acceptability of, alternatives
to the IUD. Better educated women and those from
wealthier households were more likely to switch than
their counterparts. Very few women readopted an IUD.
IUD discontinuers were slightly more likely, on average,
to switch to another modern method than those who
discontinued another modern method.
IUD users experience fewer side
effects and worries about the possible
effect of the method on their health
than other users.
h. The analysis confirms the huge advantages of
the IUD over alternative (mainly hormonal) methods
in terms of reported failure and discontinuation in
all 14 countries. Its low failure rate implies a marked
advantage over other methods in countries where
abortion is illegal and often unsafe. Whereas more
than 40% of users of the pill, injectable methods and
condoms stopped use within 12 months, the equivalent
figure for IUDs was only 13%. Similarly, while the
median length of uninterrupted use of IUDs is typically
30 or more months, the median for other methods is
typically ten months. Thus an IUD offers, on average,
three times the length of contraceptive protection
offered by other modern reversible methods.
The reasons for this contrast do not appear to stem
from differences in the characteristics of women who
choose specific methods nor are they readily explained
by variations in spacing versus limitation motives.
It is possible that women who decide to use an IUD are
more committed to avoiding pregnancy than those who
choose another method. It is also likely that IUD users
experience fewer side effects and worries about the
possible effect of the method on their health than other
users. However, the most significant reason may be the
obvious one. A user of pills, injectables or condoms has
to make a conscious effort to persist with use, whereas
an IUD user has to make a conscious effort to stop.
Long-term adherence to any drug regime that requires
regular pill-taking or injections is known to be poor and,
in this regard, contraception may be no different.
33
34
Appendix
Marie Stopes International
Appendix
Marie Stopes International
6. Appendix
TABLE A.1: Cumulative cause-specific discontinuation probabilities (per 100 episodes)
At 12 months
All reasons
Failure
Method-related
Want a child
No further need
At 36 months
All reasons
Failure
Method-related
Want a child
No further need
Bangladesh
37.3
0.4
32.2
2.5
4.4
Bangladesh
66
1.2
53.6
12.4
14.4
Bolivia
11.9
1.7
8.1
1.1
1.4
Bolivia
40
1.9
26.9
9.6
7.2
Colombia
16.7
2.7
12.7
0.9
1
Colombia
38.8
6.9
28.4
5.3
2.8
Dominican Republic
28.2
2.5
19.7
2.7
5.5
Dominican Republic
63.1
4
46.5
18.4
11.4
Egypt
11.8
1
6.3
3.4
1.4
Egypt
51.2
3.5
18.4
34.6
4.6
Indonesia
10.4
0.7
6.8
0.7
1.7
Indonesia
24.6
4.9
10.9
6.8
3.2
Jordan
12
0.8
7.5
3.6
0.5
Jordan
48.2
5.5
20.3
28.7
3.2
Kazakhstan
11.4
3.2
6
1.5
1.2
Kazakhstan
30.5
6.3
15.4
9.9
2.7
Morocco
15.5
1.5
11.4
0.9
2.2
Morocco
43
1.9
27.1
16.9
3.8
Nicaragua
24.2
1.8
18
2.9
3
Nicaragua
58.1
6.1
40.9
11.7
13.7
Peru
20.1
0.7
17.5
2.1
0.4
Peru
47.1
3.8
34.4
11
5.7
Philippines
13.8
0.6
8.8
0.4
4.4
Philippines
33.3
0.6
27.2
2.7
5.2
Turkey
9.6
1
6.4
0.5
1.9
Turkey
30.8
3.3
16.1
7.3
7.8
Viet Nam
12.5
1.8
8.9
1.3
0.8
Viet Nam
30.6
4.9
16.4
11.1
1.7
Median
13.2
1.3
8.9
1.4
1.6
Median
41.5
3.9
27
11.1
4.9
At 24 months
All reasons
Failure
Method-related
Want a child
No further need
Bangladesh
53.9
1.2
46.5
6
6.8
Bolivia
25.7
1.9
15.9
5.5
4.6
Colombia
27.7
4.8
20
2.9
2.1
Dominican Republic
48.5
4
32.6
11.3
9.8
Egypt
33.5
2.4
12.7
19.3
2.9
Indonesia
15.3
1.9
8.3
2.2
2.6
Jordan
27.3
2.4
14
12.4
1
Kazakhstan
22.3
5.6
11.7
4.5
2.1
Morocco
29.7
1.9
20.2
7.7
2.6
Nicaragua
44
4.6
29.3
8.2
9
Peru
32.6
1.1
27.8
4.9
0.5
Philippines
23.2
0.6
17.5
1.1
5.2
Turkey
17.7
2.2
10.1
2.3
4.1
Viet Nam
20.4
3.6
12.6
4.3
1.2
Median
27.5
2.3
16.7
5.2
2.8
© Marie Stopes International
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Appendix
Marie Stopes International
Appendix
Marie Stopes International
TABLE A.2: Conditional 12-month cause-specific discontinuation probabilities (per 100 episodes)
Still using at 12 months
All reasons
Failure
Method-related
Want a child
No other need
Still using at 24 months
All reasons
Failure
Method-related
Want a child
No other need
Bangladesh
26.5
0.8
21
3.6
2.5
Bangladesh*
-
-
-
-
-
Bolivia
15.6
0.2
8.5
4.5
3.2
Bolivia
19.2
0
13.1
4.3
2.8
Colombia
13.2
2.2
8.4
2
1.1
Colombia
15.3
2.1
10.5
2.5
0.7
Dominican Republic
28.2
1.6
16
8.8
4.5
Dominican Republic
28.5
0
20.6
8
1.8
Egypt
24.6
1.4
6.9
16.4
1.6
Egypt
26.6
1.1
6.5
19
1.7
Indonesia
5.5
1.3
1.7
1.6
0.9
Indonesia
11
3
2.8
4.7
0.6
Jordan
17.4
1.6
7
9.2
0.5
Jordan
28.8
3.1
7.4
18.6
2.2
Kazakhstan
12.2
2.5
6.1
3.1
1
Kazakhstan
10.6
0.7
4.2
5.6
0.6
Morocco
16.9
0.4
10
6.9
0.3
Morocco
18.9
0
8.6
10
1.3
Nicaragua
26.1
2.9
13.8
5.4
6.2
Nicaragua
25.1
1.5
16.4
3.8
5.2
Peru
15.6
0.5
12.5
2.9
0.1
Peru*
-
-
-
-
-
Philippines
10.9
0
9.5
0.7
0.8
Philippines
13.2
0
11.8
1.6
0
Turkey
8.9
1.2
3.9
1.8
2.3
Turkey
16
1.1
6.8
5.1
3.9
Viet Nam
9.1
1.8
4
3.1
0.4
Viet Nam
12.8
1.4
4.4
7.1
0.5
Median
15.6
1.4
8.5
3.4
1.1
Median
17.5
1.1
8
5.4
1.5
*Rates of less than 100 episodes were suppressed
TABLE A.3: Method-related discontinuation probabilities (per 100 episodes), disaggregated by selected characteristics
At 12 months
Residence
Rural
Urban
Education
Primary or less
Secondary or more
Motivation
Spacer
Limiter
Wealth
Poor
Rich
Bangladesh
­-
33
34.5
26.1
38.1
29
33.9
28.6
Bolivia
9.2
­-
8.9
7.9
7.9
8.2
­-
9.6
Colombia
11.8
15.8
10.5
13.4
15.6
9.6
17.7
10.8
Dominican Republic
18.4
24.3
26.3
16.9
20
19.3
­-
14.2
Egypt
5.2
7.2
6
6.4
8.6
3.8
7.7
4.7
Indonesia
8.6
3
0.8
8.1
11
2.8
­-
8.5
Jordan
7.2
8.9
6.2
7.5
8.2
6.5
8.1
6.9
Kazakhstan
5.2
6.9
­-
6
6.9
4.3
7.4
5.5
Morocco
10.8
12.7
11.7
10.5
11.7
11.1
10.2
11.3
Nicaragua
18.2
17.1
17.6
18.2
19.9
15.4
18
17.8
Peru
17.6
­-
­-
18
25.2
9.9
­-
13.7
Philippines
4.8
11.7
­-
9
13.1
5.6
9.2
­-
Turkey
5.9
7.9
6.6
5.9
8
5.3
7.5
5.1
Viet Nam
5.6
9.4
12
7.4
11.1
7.5
10.9
4.2
Median
8.6
10.6
10.5
8.6
11.4
7.9
9.7
9.6
Note: Rates of less than 100 episodes were suppressed
© Marie Stopes International
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Appendix
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Appendix
Marie Stopes International
TABLE A.4: Status at three months after discontinuing IUD for method-related reasons
All episodes
No. episodes*
At risk
Became pregnant
Switched to:
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Sterilisation
Traditional method
Total %
Bangladesh
184
24.8
8.7
0.5
35.7
10.4
9
55.6
0.9
10
100
Bolivia
82
31
23.7
1.3
12
2
1.5
16.7
1.5
27.1
100
Colombia
599
21
7.9
0
23.4
17.6
10.7
51.7
9.3
10.2
100
Dominican Republic
183
39.7
12.6
0
26.1
7.2
3.6
36.8
5.7
5.1
100
Egypt
654
34.1
16.3
4.4
31
12.3
1.1
48.7
0
0.9
100
Indonesia
64
21.2
8.6
0
25.7
28.1
9.2
63.1
0
7.2
100
Jordan
432
28.3
17.2
1.7
23.6
0.8
9.2
35.1
0.1
19.3
100
Kazakhstan
178
42.3
17.3
6
8.9
2.2
8.2
25.2
0
15.1
100
Morocco
143
16.8
2.8
0
57.8
6.6
5.4
69.8
0.2
10.5
100
Nicaragua
366
26.5
8
0.5
37
13.9
2.9
54.3
7.5
3.7
100
Peru
68
11.6
5.1
0
21.4
30.5
18.5
70.5
0
12.8
100
Philippines
62
22.5
14.1
0
32.3
17.2
1.5
51
0
12.4
100
Turkey
155
23.1
12.2
1.9
19.9
1.8
8.1
31.7
0.9
32.1
100
Viet Nam
194
16.5
14.6
2.4
19
0.3
16.2
37.8
1.6
29.5
100
Median
181
23.9
12.4
0.5
24.6
8.8
8.2
49.9
0.5
11.5
*Discontinued due to method-related reasons
© Marie Stopes International
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Appendix
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Appendix
Marie Stopes International
TABLE A.5: Status at three months after discontinuing IUD for method-related reasons: by residence
Rural
No. episodes*
At risk
Became pregnant
Switched to:
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Sterilisation
Traditional method
Total %
Bangladesh
29
17.9
9.1
0
28.1
8.8
14.4
51.3
0
21.8
100
Bolivia
75
31.4
25.8
1.5
13
2.1
1.6
18.2
0
24.6
100
Colombia
436
18.6
7.8
0
23.2
16.4
12
51.5
9.7
12.3
100
Dominican Republic
122
37.8
10.9
0
25.2
10.7
4.5
40.4
4
7
100
Egypt
259
37.2
11.3
8.5
30.7
7.4
2.7
49.3
0
2.2
100
Indonesia
42
15.8
3
0
22.4
37.9
10.3
70.6
0
10.6
100
Jordan
367
26.3
17.2
1.4
24.6
0.9
9.8
36.7
0
19.8
100
Kazakhstan
100
40.8
19.1
5.1
11.9
0.6
11.2
28.8
0
11.3
100
Morocco
103
14.6
2.2
0
59.2
8.8
5.5
73.5
0
9.7
100
Nicaragua
282
24.7
8.9
0.4
37.1
15.2
3.2
55.9
6
4.6
100
Peru
58
13.3
3.5
0
22.3
30.1
17.7
70.1
0
13.2
100
Philippines
21
35.3
18.1
0
30.1
4.2
0
34.3
0
12.3
100
Turkey
107
23.3
11.7
1.4
21.5
1
7.9
31.7
1.3
32.1
100
Viet Nam
17
21.2
7.1
0
20.6
0
32.6
53.2
0
18.5
100
Median
102
24
10
0
23.9
8.1
8.8
50.3
0
12.3
Urban
No. episodes*
At risk
Became pregnant
Switched to:
Sterilisation
Traditional method
Total %
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Bangladesh
154
26.1
8.7
0.6
37.1
10.7
8
56.4
1.1
7.7
100
Bolivia
7
26.9
0
0
0
0
0
0
18.2
54.9
100
Colombia
163
27.3
8
0
24.1
21
7.3
52.3
8
4.3
100
Dominican Republic
61
43.6
16.1
0
27.8
0
1.8
29.7
9.2
1.4
100
Egypt
395
32.1
19.6
1.7
31.1
15.5
0.1
48.4
0
0
100
Indonesia
22
31.9
19.3
0
32.3
9
7.1
48.4
0
0.4
100
Jordan
65
39.1
17.2
2.8
18
0
5.8
26.5
0.8
16.4
100
Kazakhstan
78
44.3
15.1
7.1
5
4.1
4.5
20.7
0
20
100
Morocco
41
22.3
4.2
0
54.3
1.1
5.1
60.5
0.5
12.5
100
Nicaragua
84
32.7
4.9
1
36.4
9.7
1.9
49
12.7
0.8
100
Peru
11
2.7
14.3
0
16.9
32.7
23
72.6
0
10.5
100
Philippines
41
16
12
0
33.5
23.8
2.3
59.6
0
12.5
100
Turkey
49
22.6
13.4
3.2
16.4
3.7
8.5
31.8
0
32.2
100
Viet Nam
177
16.1
15.3
2.6
18.8
0.3
14.6
36.3
1.8
30.5
100
Median
63
27.1
13.9
0.3
26
6.5
5.4
48.4
0.7
11.5
*Discontinued due to method-related reasons
41
42
Appendix
Marie Stopes International
Appendix
Marie Stopes International
TABLE A.6: Status at three months after discontinuing IUD for method-related reasons: by education
Primary or less
No. episodes*
At risk
Became pregnant
Switched to:
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Sterilisation
Traditional method
Total %
Bangladesh
132
27.7
8.5
0
36.7
11
7
54.8
1.3
7.7
100
Bolivia
17
14.3
45.9
0
7.2
7.2
0
14.3
0
25.4
100
Colombia
156
22.6
13.5
0
20.9
15.6
6.3
42.8
12.4
8.7
100
Dominican Republic
64
48.4
14.4
0
24
0
1.1
25
8.8
3.4
100
Egypt
204
38.9
18.6
1.8
23
17.2
0.6
42.5
0
0
100
Indonesia
5
27.8
0
0
22.8
30.4
18.9
72.2
0
0
100
Jordan
20
34.4
13.6
0
19.8
5
0
24.8
0
27.3
100
Kazakhstan
2
100
0
0
0
0
0
0
0
0
100
Morocco
105
22.4
2.8
0
56.4
6.8
4.1
67.3
0.2
7.3
100
Nicaragua
159
24.2
11.3
0
40.4
9.9
1.5
51.7
10.9
1.8
100
Peru
12
1.8
11.9
0
4
73.1
0
77.1
0
9.3
100
Philippines
18
30.4
21.2
0
28.1
9.9
5.2
43.2
0
5.1
100
Turkey
124
25.2
15.1
1.3
19.9
2
5.5
28.7
1.1
29.9
100
Viet Nam
82
20.3
17.4
1
23.7
0.6
16.1
41.4
2.1
19
100
Median
73
26.5
13.6
0
22.9
8.5
2.8
42.7
0.1
7.5
Secondary or more
No. episodes*
At risk
Became pregnant
Switched to:
Sterilisation
Traditional method
Total %
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Bangladesh
52
17.3
9.3
1.8
33
8.8
14
57.6
0
15.8
100
Bolivia
65
35.4
17.9
1.7
13.2
0.6
1.9
17.4
1.9
27.5
100
Colombia
443
20.5
5.9
0
24.3
18.3
12.2
54.8
10.7
8.2
100
Dominican Republic
119
35.1
11.7
0
27.2
11
5
43.1
4.1
6
100
Egypt
450
31.9
15.2
5.6
34.6
10
1.4
51.6
0
1.3
100
Indonesia
60
20.7
9.2
0
26
27.9
8.5
62.4
0
7.7
100
Jordan
412
28
17.4
1.7
23.7
0.6
9.6
35.6
0.1
18.9
100
Kazakhstan
176
41.7
17.5
6
9
2.2
8.3
25.5
0
15.3
100
Morocco
39
1.6
2.6
0
61.6
6.1
9
76.7
0
19.2
100
Nicaragua
207
28.3
5.4
0.9
34.3
17.1
3.9
56.2
4.9
5.2
100
Peru
56
13.7
3.7
0
25.1
21.6
22.4
69.1
0
13.5
100
Philippines
43
19.2
11.1
0
34.1
20.2
0
54.3
0
15.4
100
Turkey
31
14.5
1.1
4.7
19.7
1.1
18.1
43.6
0
40.8
100
Viet Nam
113
13.8
12.6
3.4
15.6
0
16.2
35.2
1.4
37.1
100
Median
89
20.6
10.2
1.3
25.6
9.4
8.7
52.9
0
15.4
*Discontinued due to method-related reasons
43
44
Appendix
Marie Stopes International
Appendix
Marie Stopes International
TABLE A.7: Status at three months after discontinuing IUD for method-related reasons: by motivation for use
Spacer
No. episodes*
At risk
Became pregnant
Switched to:
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Sterilisation
Traditional method
Total %
Bangladesh
65
24.8
17.2
0
37.1
4.7
9.9
51.7
0
6.3
100
Bolivia
41
28.1
20.2
0
15.9
4
3
22.8
0
29
100
Colombia
360
22
8.5
0
26.9
19.4
10.5
56.8
1.4
11.4
100
Dominican Republic
141
44.7
14.8
0
20.6
9.2
3.9
33.7
2.1
4.8
100
Egypt
409
34
18.8
2.3
30.7
12.1
1.5
46.6
0
0.7
100
Indonesia
49
19.3
11.3
0
17.2
42
8.6
67.9
0
1.5
100
Jordan
281
28.1
19.2
1.6
20.9
0.7
11.1
34.3
0
18.4
100
Kazakhstan
125
41
20.9
3.3
11.1
1.1
6.7
22.2
0
15.9
100
Morocco
74
13.7
4.5
0
57
4.3
4.6
65.9
0
15.9
100
Nicaragua
224
27
9.1
0.5
39.2
14.2
3
56.9
2.2
4.9
100
Peru
39
7.6
2.6
0
20.4
27.2
19.9
67.5
0
22.3
100
Philippines
29
18.5
20.4
0
40.9
9.1
0
50
0
11.2
100
Turkey
73
26.9
14.8
0
26.1
0
7.1
33.2
0
25.1
100
Viet Nam
86
19
11.2
1.3
18.8
0
18.1
38.2
0
31.6
100
Median
80.3
25.8
14.8
0
23.5
6.9
6.9
48.3
0
13.7
Limiter
No. episodes*
At risk
Became pregnant
Switched to:
Sterilisation
Traditional method
Total %
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Bangladesh
119
24.8
4.1
0.8
34.9
13.5
8.5
57.7
1.5
12
100
Bolivia
41
33.9
27.2
2.6
8.1
0
0
10.8
2.9
25.2
100
Colombia
243
19.1
6.8
0
17.9
16.4
10.8
45
20.9
8.1
100
Dominican Republic
42
22.9
5.3
0
44.8
0
2.7
47.5
18.1
6.2
100
Egypt
253
33.3
11.8
7.7
30.5
15.1
0.5
53.7
0
1.2
100
Indonesia
26
36.2
0
0
30.9
11.8
6.6
49.2
0
14.6
100
Jordan
151
28.6
13.4
1.7
28.4
0.9
5.6
36.6
0.4
21.1
100
Kazakhstan
53
45.4
8.8
12.4
3.6
4.7
11.9
32.5
0
13.2
100
Morocco
69
20.1
0.9
0
58.6
9.1
6.2
74
0.3
4.7
100
Nicaragua
142
25.8
6.3
0.6
33.4
13.6
2.7
50.2
15.9
1.9
100
Peru
29
17.1
8.5
0
22.8
35
16.6
74.4
0
0
100
Philippines
32
26.2
8.4
0
24.5
24.5
2.9
51.9
0
13.5
100
Turkey
82
19.7
9.9
3.7
14.4
3.5
9
30.4
1.6
38.3
100
Viet Nam
108
14.5
17.3
3.3
19.1
0.5
14.7
37.5
3
27.8
100
Median
75.7
25.3
8.4
0.7
26.5
10.5
6.4
48.3
0.9
12.6
*Discontinued due to method-related reasons
45
46
Appendix
Marie Stopes International
Appendix
Marie Stopes International
TABLE A.8: Status at three months after discontinuing IUD for method-related reasons: by wealth status
Poorer
No. episodes*
At risk
Became pregnant
Switched to:
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Sterilisation
Traditional method
Total %
Bangladesh
51
19.7
7.2
0
38.1
16.1
7.9
62
3.4
7.7
100
Bolivia
2
25.5
0
0
0
0
0
0
0
74.5
100
Colombia
192
23.5
8.7
0
26.5
19.2
8
53.7
8.1
6.1
100
Dominican Republic
25
68.3
10.4
0
21.3
0
0
21.3
0
0
100
Egypt
179
37.9
19.6
1.5
21.6
18.8
0.6
42.6
0
0
100
Indonesia
3
23.6
0
0
18.8
20.6
33.7
73.1
0
3.4
100
Jordan
98
27.9
26.4
1.9
26.8
1.2
10.1
40
0
5.6
100
Kazakhstan
82
42.4
20.9
6.7
3.1
3.9
0.7
14.4
0
22.3
100
Morocco
29
14.7
5.9
0
63.9
1.5
3.7
69.1
0
10.3
100
Nicaragua
61
41.6
5.2
0
34.3
6.2
1.1
41.6
11.7
0
100
Peru
8
0.7
19.4
0
13.1
40.9
11.6
65.6
0
14.2
100
Philippines
30
20.4
13.8
0
35.6
15.9
3.1
54.6
0
11.2
100
Turkey
46
28.6
21.7
3.4
11.8
3.9
7.4
26.4
0
23.3
100
Viet Nam
103
18
17.9
4.6
23.5
0.5
14.7
43.3
2.2
18.6
100
Median
48.5
24.5
12.1
0
22.6
5.1
5.6
42.9
0
9
Richer
No. episodes*
At risk
Became pregnant
Switched to:
Sterilisation
Traditional method
Total %
Modern methods
IUD
Pill
Injectable
Barrier
All modern reversible
Bangladesh
73
22
7.4
1.3
31.9
6.6
13.3
53.1
0
17.5
100
Bolivia
64
32.2
20.5
1.7
15.3
2.5
1.9
21.4
1.9
24
100
Colombia
238
17.5
2.9
0
24.6
13.4
13.5
51.5
14.1
14
100
Dominican Republic
104
34.6
12.1
0
25.5
12.5
5.7
43.7
4.7
5
100
Egypt
239
34.7
13.5
7.6
33.7
5.9
2.3
49.4
0
2.4
100
Indonesia
51
16.1
10.8
0
29.3
28.8
6.7
64.9
0
8.2
100
Jordan
182
27.7
15.7
0.1
23.3
0.3
8.2
31.9
0
24.7
100
Kazakhstan
49
35.7
11.6
8.4
17.8
1.3
14.7
42.2
0
10.6
100
Morocco
67
18.1
1.5
0
53.9
7.2
8.3
69.4
0
11.1
100
Nicaragua
155
25.2
4.8
0.7
35.2
22.2
0.8
58.9
6.4
4.8
100
Peru
34
13
0
0
27.5
26.8
18.2
72.5
0
14.5
100
Philippines
14
29.3
8.1
0
16.8
21.8
0
38.6
0
24
100
Turkey
50
19.4
12.1
0
23.4
0
3.3
26.7
0
41.8
100
Viet Nam
25
16.3
15.1
0
18.3
0
35.5
53.8
0
14.8
100
Median
66
23.6
11.2
0
25
6.9
7.5
50.4
0
14.2
*Discontinued due to method-related reasons
47
48
Appendix
Marie Stopes International
7. Glossary
Definitions
IUD episode: The duration in months of uninterrupted
use of IUD that may or may not have ended by the
time of the interview.
Contraceptive calendar: This takes the form of a grid
in which contraceptive status is recorded for each calendar
month over a five year period preceding the survey.
Time to first event: The time from start of use
to discontinuation of the IUD.
The single-decrement life-table: A hypothetical
cause-specific probabilities in the absence of competing
reasons for stopping also know as gross rates.
Cu-IUD Copper-containing intrauterine device (IUD)
DHS
Demographic Health Survey
FP
Family planning
hCG
Human chorionic gonadotropin
HIV
Human immunodeficiency virus
IUD
Intrauterine device
MEC Medical Eligibility Criteria for Contraceptive Use
MM
Modern methods
PID
Pelvic inflammatory disease
STI
Sexually transmitted infection
TFR
Total fertility rate
WHO World Health Organization
The multiple-decrement life table: The observed
probabilities of cause-specific discontinuation in the
presence of competing reasons, also known as net rates.
Acronyms
References
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