FACTORS ASSOCIATED WITH DISCONTINUATION OF HORMONAL
CONTRACEPTIVES
by
Kathleen J. Ly
B.A., University of Pittsburgh, 2012
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2014
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Kathleen J. Ly
on
August 8, 2014
and approved by
Essay Advisor:
Martha Ann Terry, PhD
___________________________________
Assistant Professor
Department of Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Elizabeth M. Felter, DrPH
___________________________________
Visiting Assistant Professor
Department of Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Tammy M. Haley, PhD
Associate Professor
Department of Nursing
University of Pittsburgh, Bradford
___________________________________
ii
Copyright © by Kathleen J. Ly
2014
iii
Martha Ann Terry, PhD
FACTORS ASSOCIATED WITH DISCONTINUATION OF HORMONAL
CONTRACEPTIVES
Kathleen Ly, MPH
University of Pittsburgh, 2014
ABSTRACT
Family planning is considered one of the top 10 public health achievements of
the 20th century by the Centers for Disease Control and Prevention (CDC), and use of
hormonal contraceptives has only increased since its invention in the 1960s. Yet there
is a noticeable lack of research and discussion on how to encourage patients to
continue their use of contraception. Discontinuation of contraception is an issue of
public health significance, since it often leads to unintended pregnancies that are costly
to the individual and public as a whole. This literature review examines the extant
literature on rates of discontinuation of the following hormonal methods of
contraception: oral contraceptives, intrauterine devices, injectable contraceptives,
vaginal rings, patches, and implant contraceptives. In addition, the review also
examines demographic factors that have been associated with discontinuation, such as
age, intimate partner violence, reproductive coercion, ethnicity, and socioeconomic
status. Based on the literature reviewed, it appears that the most common reason for
discontinuation is side effects. While providers usually cannot mitigate side effects of
hormonal contraceptives, as they are often unpredictable, other studies have shown
that discussing these side effects and other concerns that patients may have about the
contraceptive that they are beginning or are currently taking can increase continuation
as well as compliance with their regimen.
iv
TABLE OF CONTENTS
1.0
INTRODUCTION .............................................................................................. 1
2.0
BACKGROUND ............................................................................................... 4
2.1
3.0
UNINTENDED PREGNANCY – TRENDS, COSTS, AND OUTCOMES .. 8
METHODS ..................................................................................................... 12
3.1
4.0
DESCRIPTION OF STUDIES ................................................................. 12
RESULTS ...................................................................................................... 16
4.1
REASONS
GIVEN
FOR
DISCONTINUATION
OF
HORMONAL
CONTRACEPTIVES .............................................................................................. 16
4.2
DISCONTINUATION OF HORMONAL METHODS ............................... 18
4.2.1 ORAL CONTRACEPTION (COMBINED AND PROGESTIN-ONLY) . 19
4.2.2 INTRAUTERINE DEVICES (HORMONAL AND COPPER) ............... 24
4.2.3 INJECTABLE
CONTRACEPTION
(DEPOT
MEDROXYPROGESTERONE [DMPA] AND COMBINED) ........................... 28
4.2.4 VAGINAL RING .................................................................................. 32
4.2.5 PATCH ................................................................................................ 35
4.2.6 IMPLANT ............................................................................................ 37
4.3
OTHER
FACTORS
ASSOCIATED
WITH
CONTRACEPTIVE
DISCONTINUATION ............................................................................................. 40
v
4.3.1 AGE .................................................................................................... 40
4.3.2 INTIMATE PARTNER VIOLENCE AND REPRODUCTIVE COERCION
............................................................................................................ 41
4.3.3 SOCIOECONOMIC STATUS AND ETHNICITY ................................. 41
5.0
DISCUSSION ................................................................................................. 43
5.1
DISCONTINUATION OF CONTRACEPTION ........................................ 43
5.2
IMPLICATIONS FOR PRACTICE: CLIENT-PROVIDER INTERACTIONS
AND COUNSELING .............................................................................................. 45
6.0
CONCLUSION ............................................................................................... 51
6.1
LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH ............ 53
6.2
PUBLIC HEALTH SIGNIFICANCE ........................................................ 54
BIBLIOGRAPHY ........................................................................................................... 55
vi
LIST OF TABLES
Table 1. Choice of contraceptive methods among US women in 2010, listed by
popularity......................................................................................................................... 6
Table 2. Failure rates of various types of contraception over one year, by method, listed
by effectiveness of perfect use ........................................................................................ 7
Table 3. Summary of oral contraceptive studies reviewed, with most common reason
given for discontinuation................................................................................................ 19
Table 4. Other reasons for discontinuation of oral contraceptive .................................. 21
Table 5. Summary of oral contraception articles reviewed, with no reason for
discontinuation given in study ....................................................................................... 22
Table 6. Summary of copper intrauterine device articles reviewed ............................... 24
Table 7. Summary of hormonal intrauterine device articles reviewed ........................... 26
Table 8. Summary of articles reviewed, intrauterine device (type not stated) ............... 27
Table 9. Summary of injectable contraceptive (DMPA) articles reviewed, with most
common reason for discontinuation............................................................................... 29
Table 10. Summary of injectable contraceptive (DMPA) articles reviewed, with no
reason for discontinuation given in study ...................................................................... 30
Table 11. Summary of injectable contraceptive (combined or type not stated) articles
reviewed ........................................................................................................................ 32
vii
Table 12. Summary of vaginal ring articles reviewed, with most common reason reason
for discontinuation ......................................................................................................... 33
Table 13. Summary of vaginal ring articles reviewed, with no reason for discontinuation
given in study ................................................................................................................ 34
Table 14. Summary of patch contraceptive articles reviewed ....................................... 36
Table 15. Summary of implant contraceptive articles reviewed, with most common
reason for discontinuation ............................................................................................. 37
viii
LIST OF FIGURES
Figure 1. Results of literature search............................................................................. 13
Figure 2. Reasons given for discontinuation of contraceptives given in studies reviewed
...................................................................................................................................... 18
Figure 3. Discontinuation rates of oral contraception, by time (months) and percentage
...................................................................................................................................... 23
Figure 4. Discontinuation rates of copper intrauterine device, by time (months) and
percentage .................................................................................................................... 25
Figure 5. Discontinuation rates of hormonal intrauterine device, by time (months) and
percentage .................................................................................................................... 26
Figure 6. Discontinuation rates of intrauterine device, type not stated, by time (months)
and percentage ............................................................................................................. 28
Figure 7. Discontinuation rates of injectable DMPA, by time (months) and percentage 31
Figure 8. Discontinuation rates of vaginal ring contraceptive, by time (months) and
percentage .................................................................................................................... 35
Figure 9. Discontinuation rates of implant contraceptives, by time (months) and
percentage .................................................................................................................... 39
Figure 10. 24 Indicators of Care Assessed by RamaRao et al., 2003 ........................... 47
ix
1.0
INTRODUCTION
The Centers for Disease Control and Prevention (CDC) consider family planning
to be one of the greatest public health achievements of the 20 th century (CDC, 1999).
The ability for families to decide when to have children and to determine family size
without sexual abstinence has been key to improving the health of children and women.
The birth control movement in America began in the 20 th century, and the science
behind contraception has only improved since. In the 1960s, the first major hormonal
contraceptive became available: the birth control pill. Since then, many other hormonal
methods have been invented and used to great success.
The advantage of hormonal contraception over barrier methods of birth control is
that use does do not disrupt foreplay, and it is considerably more effective and reliable
in preventing pregnancy when properly used. The fact that use does not necessarily
coincide with sexual intercourse also makes hormonal methods useful in the case of
unexpected sexual intercourse or sexual assault. The advantages of barrier methods
are that they do not require a doctor’s visit and prescription, are readily available and
affordable to most, and they do not produce the physiological side effects of hormonal
methods, which are often off-putting to users. Additionally, besides abstinence, barrier
methods are the only reliable way to prevent transmission of sexually transmitted
diseases. Natural methods, such as the rhythm or withdrawal method, breastfeeding,
1
and the basal temperature method, are less reliable at preventing pregnancy and may
require more user action than either barrier methods or hormonal methods. Lastly, male
and female sterilization are extremely effective at preventing pregnancy, but are not
considered reversible, and are not preferred by many couples for this reason.
This paper explores the reasons that women discontinue use of hormonal
methods. Often, healthcare practitioners and educators discuss how to encourage
women to begin using contraception, to promote women’s health and socioeconomic
future. However, the CDC has estimated (Daniels, Mosher, & Jones. 2013) that 30% of
American women have tried five or more contraceptive methods, indicating that
discontinuation is common. Public health practitioners and healthcare providers rarely, if
ever, discuss how to encourage women to stay on their contraception once they begin
using it; this is an equally important issue since consistency is the key to contraceptive
success.
Because the mechanisms, behavioral components, and costs of contraceptive
methods vary so greatly, this paper examines only hormonal contraceptive use: oral
contraceptives, intrauterine devices, injectable contraceptives, vaginal rings, dermal
adhesive patch contraceptives, and implantable contraceptives. Though it is a form of
hormonal contraception, emergency contraception such as the morning-after pill is not
included in this review, since it is not a form of birth control that requires continuation.
For the purposes of this paper, discontinuation is defined as stopping usage of that
method of birth control, with or without a lapse in contraceptive coverage.
Following this introductory section, the background section discusses the
contraceptive usage and needs of American women, as well as the failure rates of the
2
contraceptive methods discussed in this paper. The background section also discusses
the public impact and current trends, individual and public costs, and outcomes of
unintended pregnancies in the United States. A short discussion of the Healthy People
2020 objectives related to reducing unintended pregnancy and increasing use of
contraception is also included in the background section. Next, in the methods section,
we describe the methods and criteria used to gather the studies reviewed in this
literature synthesis, followed by a description of the studies.
In the following results section, we discuss the reasons given for discontinuation
of hormonal contraceptives, as well as the rates of discontinuation. In this section, we
discuss each method reviewed in this synthesis, ordered by popularity of use in the
United States: oral contraception (combined and progestin-only), intrauterine devices
(hormonal and copper), injectable contraception (depot medroxyprogesterone [DMPA]
and combined), vaginal ring, patch, and implant. This section also includes a discussion
of demographic factors that are associated with contraceptive discontinuation: age,
intimate partner violence and reproductive coercion, and socioeconomic status and
ethnicity.
The following discussion section includes a discussion of the factors that may be
positively or negatively associated with discontinuation in specific methods. This is
followed by a discussion of client-provider interactions and counseling, which is shown
to significantly improve contraceptive continuation. Lastly, this paper concludes with a
discussion of limitations and directions for future research, and the public health
significance of this topic.
3
2.0
BACKGROUND
The Guttmacher Institute points out that the average number of children desired
by American families is two; as the average reproductive lifespan is considered to be
roughly ages 15-44, women spend at least three decades of their lives trying to avoid
pregnancy (Guttmacher Institute, 2000). It is likely that the length of time that women
want to avoid pregnancy is growing as marriage and childbearing are becoming
increasingly delayed, leading to greater use of contraceptives. The Guttmacher Institute
(2013) also estimates that in 2010, there were 66 million American women of
reproductive age (13-44). More than half of these women (37 million) were sexually
active and fertile, but were not and did not want to become pregnant; therefore, 37
million women were in need of contraceptives. The CDC contends that the need for
contraception among sexually active women may be even greater; they estimated that
43 million of these women of childbearing age (70% of the total) are sexually active and
do not want to become pregnant, but could if they do not use contraception or their
contraception fails (Jones, Mosher, & Daniels, 2012). Hormonal contraception may be
preferred over sterilization by a majority of sexually active couples due to its
reversibility, and over barrier methods due to hormonal contraceptives’ greater reliability
in preventing pregnancy. Another important additional consideration that increases
4
couples’ preference for hormonal methods is that use does not interrupt sexual
intercourse.
Contraceptive use is generally widespread among sexually active couples in the
United States. Approximately 99% of sexually active women have used at least one
contraceptive method (Daniels, Mosher, & Jones, 2013), and it is estimated that 62%
are using a method at any given time (Jones, Mosher, & Daniels, 2012). Of women who
have used at least one method, approximately 80% have used oral contraceptives
(Daniels, Mosher, & Jones, 2013), while the popularity of other hormonal methods is
increasing. For instance, the rate of women who had ever used injectable
contraceptives increased from 4.5% in 1995 to 23% by 2010, while the rate of women
who had ever used the contraceptive patch increased from <1% in 2002 to 10% by
2010 (Jones, Mosher, & Daniels, 2012).1 Table 1 shows the prevalence of hormonal
contraceptive methods used in the United States in 2010, as estimated by the
Guttmacher Institute, with male and female sterilization, male condoms, and no method
included for comparison’s sake.
1Depot
medroxyprogesterone, an injectable contraceptive, was approved by the FDA in
1992 and the patch did not come on the market until early in the 2000s.
5
Table 1. Choice of contraceptive methods among US women in 2010, listed by
popularity
Method
# of users, by
thousands
No method
Oral contraceptive (combined and
progestin-only)
Female sterilization (tubal ligation)
Male condom
Male sterilization (vasectomy)
Intrauterine device (copper &
hormonal)
Injectable (depot
medroxyprogesterone & combined)
Vaginal ring
Contraceptive patch
Implant
% of all women
15-44
% of
contraceptive
users, overall
23,360
10,540
37.8
17.1
-27.5
10,200
6,280
3,860
2,140
16.5
10.2
6.2
3.5
26.6
16.3
10.0
5.6
1,450
2.4
3.8
830
290
180
1.3
0.5
0.3
2.2
0.7
0.5
Source: Guttmacher Institute. (2013). Contraceptive use in the United States. Retrieved from
http://www.guttmacher.org/pubs/fb_contr_use.html.
When used correctly and consistently, hormonal contraceptives are extremely
effective in preventing pregnancy; in fact, some are more reliable than male or female
sterilization. For instance, implants have a 0.05% failure rate with both perfect and
typical use, meaning that 1 in 2000 users will become pregnant over one year, while
male sterilization has double the implant failure rate at .10% with perfect use (1 in 1000)
and triple the implant failure rate of 0.15% with typical use (1 in 666) (see Table 1 for
failure rates). Compared to implantable contraceptives and male sterilization, female
sterilization (tubal ligation) is much less reliable, with a perfect use failure rate of 0.5%
with typical and perfect use (1 in 200); in other words, ten times the failure rate of
implants, and at least three times the failure rate of male sterilization). Table 2 (below)
shows the proportion of women who will become pregnant over one year, sorted by
method, with male and female sterilization, male condoms, and no method included for
6
comparison’s sake. It is clear from the discrepancy between perfect use and typical use
that for most hormonal methods that require a timed regimen, method failure or user
failure is extremely common.
Table 2. Failure rates of various types of contraception over one year, by method,
listed by effectiveness of perfect use
Method
Perfect use %
Implant
0.05
Male sterilization (vasectomy)
0.10
Intra-uterine device (hormonal)
0.20
Injectable (depot medroxyprogestrone acetate
0.20
and combined)
Oral contraceptive (progestin-only, combined)
0.30
Contraceptive patch
0.30
Vaginal ring
0.30
Female sterilization (tubal ligation)
0.50
Intra-uterine device (copper)
0.60
Male condom
2.00
No method
85.0
(Types of contraception not included in this review are italicized)
Typical use %
0.05
0.15
0.20
6.00
9.00
9.00
9.00
0.50
0.80
18.0
85.0
Source: Guttmacher Institute. (2013). Contraceptive use in the United States. Retrieved from
http://www.guttmacher.org/pubs/fb_contr_use.html.
Family planning is not only a personal issue, but also has public impact. It has
been estimated that the total public expenditures for family planning services in 2010
were $2.37 billion, with Medicaid accounting for 75% of the total ($1.8 billion) (Sonfield
& Gold, 2012). With the help of these publicly funded family planning services, 2.2
million unintended pregnancies were avoided, which would have resulted in 1.1 million
unintended births and 760,000 abortions in 2010 (Guttmacher Institute, 2010). Avoiding
unintended pregnancies saved a total of $7.6 billion in public expenditures; the
Guttmacher Institute estimates that for every $1.00 invested in family planning services,
7
$5.68 was saved in Medicaid expenditures that would have been used to support these
unintended pregnancies (2010).
2.1
UNINTENDED PREGNANCY – TRENDS, COSTS, AND OUTCOMES
Unintended pregnancy is a widespread and highly visible public health issue in
the United States, despite public prevention efforts. In 2008, 3.4 million pregnancies, or
roughly half of the 6.6 million total pregnancies, in the United States were unintended.
and the rate of unintended pregnancies increased from 2001 to 2008 while the rate of
intended pregnancies decreased from 52% to 49% in that same period (Finer & Zolna,
2014). More than half of all American women have or will become pregnant without
having intended to do so by the age of 45, and more than three in 10 will have had an
abortion (Jones & Kavanaugh, 2011). Another estimate found that about 37% of births
in the United States were unintended at conception (Mosher, Jones, & Abma, 2012).
Each year, about 5% of women of reproductive age have an unintended pregnancy;
40% of unintended pregnancies in 2008 ended in abortion (Finer & Zolna, 2014).
Approximately 40% of women who experienced an unintended pregnancy
between 1998 and 2002 were using contraception (Mosher, Jones, & Abma, 2012). Of
the 60% who were not using contraception at the time of conception, 36% stated that
they believed they could not get pregnant, 23% said that they “really didn’t mind if they
got pregnant” (p11), 17% did not expect to have sex, 14% did not use contraception
because they were concerned about the side effects of birth control, 8% stated that their
8
partner did not want to use birth control, and 5.3% stated that their partner did not want
them to use birth control (Mosher, Jones, & Abma, 2012).
Unintended pregnancy is a pressing public health issue in the United States,
because it is a far too common and costly event, at an individual/personal level and at
the public level. It is worth noting that the rate of unintended pregnancy in the United
States is significantly higher than that of many other developed countries (Singh,
Sedgh, & Hussain, 2010). The estimated public cost of unintended pregnancies in 2008
alone was approximately $12.5 billion in government expenditures (Trussell, 2007). (For
comparison’s sake, the CDC’s 2008 budget was about $9.2 billion [CDC, 2008].) As
stated above, 60% of the unintended pregnancies that occurred in 2008 ended in birth;
of these pregnancies, 65% were paid for by public insurance programs, compared to
48% of all pregnancies and 36% of intended pregnancies (Sonfield & Kost, 2013).
Sonfield and Kost (2013) also found that a publicly funded unintended pregnancy cost
$12,613 for prenatal care, labor and delivery, postpartum care, and one year of care for
the infant.
Publicly funded family planning services are a cost-effective and efficient way to
prevent these unintended pregnancies: without these programs, it has been estimated
that the rate of unintended pregnancies and abortions would be nearly 2/3 higher overall
(Sonfield & Kost, 2013). Sonfield and Kost (2013) estimate that public spending on
these family planning programs totaled $1.9 billion in 2008, resulting in $7 billion in
savings from preventing unintended pregnancies and the resulting births. Furthermore,
the Guttmacher Institute (Sonfield & Kost, 2013) has estimated that without public family
planning programs, the public cost of unintended pregnancies would have been $12.7
9
billion, more than that of the unintended pregnancies that did occur, and doubling the
potential overall cost to more than $25 billion in 2010.
On an individual level, unintended pregnancy is associated with negative social
and health outcomes. Mothers whose pregnancies are unintended are more likely to
delay seeking prenatal care or to receive inadequate prenatal care, which greatly
increases the likelihood of negative health outcomes (Dibaba, Fantahun, & Hindin,
2013; Mayer, 2008). Prenatal care includes screening for congenital or birth conditions,
maternal health screening, especially for concurrent health issues such as sexually
transmitted diseases and alcohol, tobacco, and drug use, breastfeeding preparation,
parenting skills preparation, birth preparation and more. The Maternal and Child Health
Bureau at the Human Resources and Services Administration estimates that babies
born to mothers who received no prenatal care are three times more likely to be low
birthweight and five times more likely to die (Maternal and Child Health Bureau, n.d.).
Low birthweight is well-known as a significant risk factor for neonatal mortality. Another
study found that unintended pregnancies that were reported during the first trimester
were more than twice as likely to result in neonatal mortality (Bustan & Coker, 1994).
Unintended pregnancy is also linked to a higher likelihood of alcohol and tobacco
use during pregnancy (DePersio, Chen, Blose, & Lorenz, 1992), as well as increased
intimate partner violence towards the mother (Gazmararian et al., 1995). Delayed
psychosocial development and emotional disturbances in children have also been
linked to unintended pregnancies (Kubicka et al., 1995), as well as lower educational
attainment by the child (Myhrman, Olsen, Rantakallio, & Laara, 1995). However, it is
important to keep in mind that many of these outcomes may be confounded by poverty.
10
In 2008, the rate of unintended pregnancy among women whose incomes were at or
below the federal poverty line (137/1,000) was more than five times that of women at
the highest income level (26/1,000); likewise, women who did not complete high school
had the highest unintended pregnancy rate across all educational levels (Finer & Zolna,
2014).
Several of Healthy People 2020’s family planning objectives are related to
contraceptive use and the reduction of unintended pregnancy. For this essay, the two
most salient objectives are FP-1 and FP-6 (Healthy People 2020, 2014). FP-1’s
objective is to increase the proportion of intended pregnancies overall from 51% (2002
statistic) to 56%. Data from 2006 on unintended pregnancy showed an increase of .3%
(51.0 to 51.3) compared to the 2002 data; this is not a statistically significant increase,
nor is it an improvement. FP-6’s objective is to increase contraceptive use by females at
risk of unintended pregnancy or their partners, at most recent sexual intercourse.
Healthy People 2020 data reported for 2006-2010 show that 83.3% of females at risk of
unintended pregnancy or their partners used contraception at the most recent sexual
intercourse; FP-6 aims to increase this proportion by 10% to 91.6%.
11
3.0
METHODS
Although family planning and contraception are both important public health
topics, there is a noticeable lack of literature that reports and analyzes patients’ selfreported reasons for discontinuation of contraception. Discontinuation of contraception
puts women at risk of unintended pregnancy, especially if another reliable and effective
method of contraception is not adopted immediately after discontinuation. This paper
seeks to identify and describe the reasons for women’s discontinuation of their
hormonal contraceptives, which can then be addressed by public health practitioners
and women’s healthcare providers.
3.1
DESCRIPTION OF STUDIES
All searches were completed between May 1 and May 7, 2014, with the following
search phrase: “contraceptive compliance OR contraceptive discontinuation OR
contraceptive continuation.” Google Scholar yielded 34,200 results, Science Direct
yielded 7,465 results, PubMed yielded 2,939 results, GenderWatch yielded 2,513
results, Web of Science yielded 2,162 results, Medline yielded 2,162 results, and
Women’s Studies International yielded 373 results. All of the databases listed were
12
accessed through the University of Pittsburgh’s Library Services, with the exceptions of
Google Scholar and Science Direct. Many of the results were excluded although they fit
the search parameters due to lack of quantitative information regarding patients’
reasons for discontinuation. Figure 1 describes the search parameters, number of
search results by database, reasons for exclusion of some studies from this review, and
the number of studies included by contraceptive type. Some studies included several
types of contraception in their analyses.
Figure 1. Results of literature search
13
Many of the studies appearing in the database searches were not included
because they discussed use of contraception but did not include method-specific rates
of discontinuation, which was one of the criteria for inclusion in this review. They may
have included qualitative data on discontinuation, but this review primarily examines
quantitative data, i.e. rates of discontinuation. Other criteria for selecting these articles
included: (1) a sample size of greater than 100; (2) publication date within the last 20
years (i.e. later than 1994); (3) evaluation of contraceptives to prevent pregnancy, rather
than explicitly treating other gynecological disorders such as pre-menstrual dysphoric
disorder or endometriosis. International studies were acceptable, while barrier methods
were not evaluated in this review. Certain studies measured use in cycles rather than
months; cycles were coded as months in the literature summary tables, since the typical
menstrual cycle approximately corresponds with a month.
For the purposes of this literature synthesis, 58 research articles published in
peer-reviewed journals were reviewed. All articles included reported discontinuation
rates of various hormonal contraceptives and patients’ reasons for discontinuing their
hormonal contraceptive. The hormonal contraceptives included in this review are: (1)
oral contraceptives, including combined pills and progestin-only pills (many brand
names for both); (2) intrauterine devices (IUDs), including hormone-releasing systems
(brand name Mirena) and copper systems (brand name Paragard); though copper
systems are technically not hormonal contraception, they are often grouped with
hormonal contraceptives because they are effective, long-lasting, and reversible; (3)
injectable contraceptives, including depot medroxyprogesterone acetate (DMPA; brand
name Depo-Provera) and combination injectables (brand name Lunelle); (4) vaginal ring
14
contraceptives (brand name NuvaRing); (5) contraceptive adhesive dermal patches
(brand name Ortho-Evra); and (6) contraceptive upper arm implants (brand names
Implanon, Nexplanon, Norplant). Some of the 58 articles reviewed more than one type
of contraceptive; not all articles listed the reasons for discontinuation of drugs.
15
4.0
4.1
RESULTS
REASONS GIVEN FOR DISCONTINUATION OF HORMONAL
CONTRACEPTIVES
There was very little consistency between studies for typifying or naming the
reasons given by study subjects for discontinuation of the study medication. In some
studies, no reasons were given, while in others the reason was brief and non-specific
(e.g., “side effects” rather than “menorrhagia”). By far, the most common reason given
for discontinuation was discomfort with the side effects associated with hormonal
contraception. Other reasons for discontinuation common to all the methods were that
the contraceptive was no longer needed, either due to pregnancy (which we may
assume meant failure of the method or pregnancy that occurred before the
contraceptive regimen), a desire for pregnancy, or a change in sexual habits (e.g. no
longer having sex). These reasons for discontinuation cannot necessarily be addressed
by public health or healthcare practitioners. Reasons for discontinuation given in the
studies were grouped as follows by this author (Figure 2):
16
17
Figure 2. Reasons given for discontinuation of contraceptives given in studies
reviewed
4.2
DISCONTINUATION OF HORMONAL METHODS
Fifty-eight articles that reviewed discontinuation of hormonal contraceptives and
reasons for discontinuation were identified and reviewed. The studies differed widely in
the contraceptives covered, time period studied, and reasons given for discontinuation.
Overall, and overwhelmingly, the most common reason for discontinuing any method
was side effects. Many studies did not elucidate “side effects,” but of those that did, the
side effects that were found to be most off-putting were irregular or increased bleeding
and pain.
18
4.2.1 ORAL CONTRACEPTION (COMBINED AND PROGESTIN-ONLY)
Twenty eight articles that reviewed discontinuation of oral contraceptives were
identified and reviewed. The rates of and reasons for discontinuation given in these
studies are summarized below in Tables 3, 4, and 5, and Figure 3. By far the most
popular contraceptive method in the United States and world-wide, oral contraceptives
overall displayed a disappointing rate of continuation, compared to other methods. Only
13 of the 28 total studies listed reasons for discontinuation; most often, the reason was
side effects. Other common reasons included no further need for contraception, user
dissatisfaction, access issues, and failure of the method. Other reasons for
discontinuation that were given are listed in Table 4. These were widely variable,
ranging from vague and non-specific (e.g., “Patient preference” or “Other”) to the very
specific (e.g., “Unacceptable vaginal bleeding”).
Table 3. Summary of oral contraceptive studies reviewed, with most common
reason given for discontinuation
Study
Time
(months)
Discontinuation
rate
Most common reason for
discontinuation
Range: 8.0% -88.0%
Rosenberg & Waugh,
1998
Khan, 2001
Ali & Cleland, 2010
6
27.7%
Side effects
6
6
43.0%
48.1%
Westhoff et al., 2007
Rakhshani &
Mohammadi, 2004
Suhonen et al., 2004
Lete et al., 2012
Raine et al., 2011
Ahrendt et al., 2006
Oddsson et al., 2005
6
12
57.0%
8.0%
Side effects
Side effects and medical
reasons or health concerns
Access issues
User dissatisfaction
12
12
12
13
13
27.0%
54.1%
66.9%
25.4%
29.8%
Side effects
Side effects
Side effects
Side effects, adverse event
Side effects, adverse events
19
Table 3 continued.
Colli et al., 1999
24
42.0%
Contraceptive no longer
needed
Side effects
Rosenberg, Waugh,
24
51.0%
& Meehan, 1995*
Rosenberg, Waugh,
24
72.0%
Side effects
& Meehan, 1995**
Rosenberg, Waugh,
24
73.0%
Side effects
& Meehan, 1995***
Rosenberg, Waugh,
24
82.0%
Side effects
& Meehan, 1995****
Rosenberg, Waugh,
24
88.0%
Side effects
& Meehan, 1995*****
Moreau, Cleland, &
Lifetime
29.2%
Side effects
Trussell, 2007
*Italy; **United Kingdom; ***Denmark; ****Portugal; *****France
Continuation rates were highly variable, ranging from 8.0% after 12 months
(Rakhshani & Mohammadi, 2004) to 88.0% after 12 months (Zibners, Cromer, & Hayes,
1999) and 24 months (Rosenberg, Waugh, & Meehan, 1995). Rosenberg, Waugh, and
Meehan (1995) also found that the occurrence of multiple side effects greatly increased
the likelihood of discontinuation: one side effect increased the risk of discontinuation by
50%, two side effects by 220%, and three side effects by 320%.
As noted above, only 13 of the 28 studies reviewed listed patients’ reasons for
discontinuation of their oral contraceptive. The 15 studies that did not list reasons for
discontinuation are summarized below in Table 5. A visual representation of the
discontinuation rates given in all 28 studies is given in Figure 3, which charts
discontinuation rates by time (months) and percentage. There does not seem to be any
pattern in rates of discontinuation, which may be attributed to several factors such as a
wide variety of oral contraceptive formulations (see Discussion).
20
Table 4. Other reasons for discontinuation of oral contraceptive
Reason for discontinuation
Studies in which patients reported
reason for discontinuation
Ahrendt et al., 2006
Colli et al., 1999
Ahrendt et al., 2006
Khan, 2001
Lete et al., 2012
Raine et al., 2011
Rosenberg & Waugh, 1998
Westhoff et al., 2007
Ali & Cleland, 2010
Khan, 2001
Lete et al., 2012
Raine et al., 2011
Rosenberg & Waugh, 1998
Ahrendt et al., 2006
Ali & Cleland, 2010
Khan, 2001
Lete et al., 2012
Moreau, Cleland, & Trussell, 2007
Lete et al., 2012
Moreau, Cleland, & Trussell, 2007
Raine et al., 2011
Rosenberg & Waugh, 1998
“Not willing to cooperate”
“Patient preference”
“Other”
Contraceptive no longer needed:
Change in sexual habits
Pregnancy desired
Failure of method
User dissatisfaction:
Did not like changes in menstrual period
Lack of protection against STIs
Method decreased sexual pleasure
Poor cycle control
Too difficult to use
Too messy to use
Worried about effectiveness in preventing
pregnancy
Partner dissatisfaction
Ahrendt et al., 2006
Khan, 2001
Moreau, Cleland, & Trussell, 2007
Access issues
Khan, 2001
Insufficient supply
Moreau, Cleland, & Trussell, 2007
Too difficult to obtain
Raine et al., 2011
Too expensive
Rosenberg & Waugh, 1998
Medical reasons of health concerns
Ahrendt et al., 2006
Concern about hormones
Khan, 2001
Worried about side effects
Moreau, Cleland, & Trussell, 2007
Raine et al., 2011
Rosenberg & Waugh, 1998
Side effects
Ahrendt et al., 2006
Unacceptable vaginal bleeding
Westhoff et al., 2007
21
Table 5. Summary of oral contraception articles reviewed, with no reason for
discontinuation given in study
Study
Time (months)
Discontinuation rate
Range: 13.0% - 88.0%
Kalagian et al., 1998
Murphy & Brixner, 2008
Moreau et al., 2009.
Vaughn et al., 2008
Gilliam et al., 2010
Rosenstock et al., 2012*
Rosenstock et al., 2012**
Rosenstock et al., 2012***
Kalagian et al., 1998
Moreau et al., 2009.
Trussell, 2011
O'Neil-Callahan et al., 2013
Melhado, 2011
Peipert et al., 2011
Stuart et al., 2013
Vaughn et al., 2008
Barden-O’Fallon et al., 2011
Zibners, Cromer, & Hayes, 1999
Ali & Cleland, 1999
Moreau et al., 2009.
O'Neil-Callahan et al., 2013
Rosenberg, Waugh, & Meehan, 1995
Moreau et al., 2009.
Moreau et al., 2009.
*Age <26; **Age 20-25; *** Age 14-19
3
3
6
6
6
12
12
12
12
12
12
12
12
12
12
12
12
12
24
24
24
24
36
48
22
13.0%
45.0%
19.6%
31.1%
71.0%
46.1%
48.4%
53.3%
23.0%
30.7%
33.0%
41.0%
44.0%
44.9%
47.0%
47.4%
48.9%
88.0%
40.7%
49.0%
56.9%
72.0%
59.9%
68.5
Discontinuation rates of oral contraceptives,
by time (months) and percentage
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
0
3
6
9
12
15
18
21
24
*Figure does not include Moreau, Cleland, & Trussell (2007), which provided a lifetime discontinuation
percentage
Figure 3. Discontinuation rates of oral contraception, by time (months) and
percentage
23
4.2.2 INTRAUTERINE DEVICES (HORMONAL AND COPPER)
Seven studies identified reasons for discontinuation of hormonal intrauterine
devices, and another seven identified reasons for discontinuation of copper devices.
Ten studies were also identified that did not differentiate between the two types of
systems.
The rates of and reasons for discontinuation given in these studies are
summarized below in Tables 6 (copper), 7 (hormonal), and 8 (type not given), and
Figures 4 (copper), 5 (hormonal), and 6 (type not given). Often, studies were not clear
or did not differentiate between hormone-releasing systems and copper systems. The
hormonal intrauterine device (also called intrauterine system or IUS) was more popular
than the copper device, due to fewer and/or less severe side effects.
Table 6. Summary of copper intrauterine device articles reviewed
Study
Time (months)
Discontinuation rate
Range: 6.7% - 58.3%
Sivin et al., 1997
6
Garbers et al., 2013
6
Sivin et al., 1997
12
Rosenstock et al., 2012*
12
O'Neil-Callahan et al., 2013 12
Peipert et al., 2011
12
Rosenstock et al., 2012**
12
Trussell, 2011
12
Rosenstock et al., 2012***
12
O'Neil-Callahan et al., 2013 24
Lara-Torre et al., 2011
36
*Age >26; **Age 20-25; ***Age 14-19
6.7%
11.0%
11.9%
14.1%
14.9%
16.0%
17.5%
22.0%
24.4%
26.7%
58.3%
24
Discontinuation rates of copper intrauterine device,
by time (months) and percentage
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
0
6
12
18
24
30
36
Figure 4. Discontinuation rates of copper intrauterine device, by time (months)
and percentage
Discontinuation ranged between 6.7% at six months (Sivin et al., 1997) to 58.3%
at 36 months (Lara-Torre, Spotswood, Correia, & Weiss, 2011) for copper systems, and
9.2% at 12 months (Behringer, Reeves, Rossiter, Chen, & Schwarz, 2011) to 70.2% at
36 months (Lara-Torre et al., 2011) for hormonal systems. For studies that did not
differentiate between the types, the discontinuation rate ranged from 10.2% at six
months (Moreau, Bouyer, Bajos, Rodriguez, & Trussell, 2009) to 70.2% of ever-users
(Modey, Aryeetey, & Adanu, 2014). It is notable that only studies of two copper IUD
stated reasons for discontinuation (Lara-Torre et al., 2011; Peipert et al., 2011), and
only four hormonal IUD studies did so as well (Behringer et al., 2011; Lara-Torre et al.,
2011; Peipert et al., 2011; Suhonen et al., 2004) with side effects being the most
common reason for discontinuation in all of the above.
25
Table 7. Summary of hormonal intrauterine device articles reviewed
Study
Time (months)
Discontinuation rate
Range: 9.2% - 32.6%
Behringer et al., 2011
12
O'Neil-Callahan et al., 2013 12
Rosenstock et al., 2012*
12
Rosenstock et al., 2012**
12
Rosenstock et al., 2012***
12
Trussell, 2011
12
Suhonen et al., 2004
12
Peipert et al., 2011
12
Behringer et al., 2011
24
O'Neil-Callahan et al., 2013 24
Lara-Torre et al., 2011
36
*Age 20-25; **Age <26; ***Age 14-19
9.2%
11.9%
13.2%
13.4%
19.4%
20.0%
20.0%
22.5%
15.1%
21.1%
32.6%
Discontinuation rates of hormonal intrauterine device,
by time (months) and percentage
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
0
12
24
36
Figure 5. Discontinuation rates of hormonal intrauterine device, by time (months)
and percentage
Three studies that did not differentiate between the types of IUDs also identified
the most common reasons: contraceptive was no longer needed (Colli et al., 1999);
failure of method (expulsion) (Teal & Sheeder, 2012); and side effects (Tewari & Kay,
26
2006). All studies that further elaborated on side effects identified bleeding and/or
cramping/pain (Peipert et al., 2011; Suhonen et al., 2004; Tewari & Kay, 2006). Two
studies identified failure of the method as a reason for discontinuation (Lara-Torre et al.,
2011; Teal & Sheeder, 2012), and two identified “contraceptive no longer needed” as a
reason for discontinuation (Colli et al., 1999; Lara-Torre et al., 2011).
Table 8. Summary of articles reviewed, intrauterine device (type not stated)
Study
Time (months)
Discontinuation rate
Range: 10.2% - 70.2%
Moreau et al., 2009.
Moreau et al., 2009.
Rakhshani & Mohammadi, 2004
Tewari & Kay, 2006
Melhado, 2011
Barden-O'Fallon et al., 2011
Teal & Sheeder, 2012
Moreau, et al., 2009.
Ali & Cleland, 1999
Colli et al., 1999
Moreau et al., 2009.
Rakhshani & Mohammadi, 2004
Moreau et al., 2009.
Moreau, Cleland, & Trussell, 2007
Modey, Aryeetey, & Adanu, 2014
6
12
12
12
12
12
12
24
24
24
36
36
48
Lifetime
Lifetime
27
10.2%
15.0%
18.0%
23.0%
31.0%
37.9%
45.0%
26.2%
37.3%
44.0%
36.4%
40.0%
43.4%
36.4%
70.2%
Discontinuation rates of intrauterine device, type not stated,
by time (months) and percentage
50.0%
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
0
6
12
18
24
30
36
42
48
*Figure does not include the 2 studies (Moreau, Cleland, & Trussell, 2007; Modey, Aryeetey, & Adanu,
2014) which provided lifetime estimates for discontinuation
Figure 6. Discontinuation rates of intrauterine device, type not stated, by time
(months) and percentage
Intrauterine devices were second only to the implant in terms of highest rates of
continuation. Other commonly given reasons for discontinuation included failure of
method (including expulsion or ectopic pregnancy) and no further need for
contraception.
4.2.3 INJECTABLE CONTRACEPTION (DEPOT MEDROXYPROGESTERONE
[DMPA] AND COMBINED)
Fifteen studies reviewing injectable depot medroxyprogesterone (DMPA)
contraceptives were identified, in addition to six that either identified a combined
injectable or did not identify a type at all The rates of and reasons for discontinuation
28
given in these studies are summarized below in Tables 9, 10, and 11, and Figures 7 and
8. Side effects of menstrual irregularities or disturbances were listed as the most
common reason for discontinuation, when a reason was given. Rates of discontinuation
for injectables were especially high; all of the studies identified had discontinuation rates
of at least 33%. The highest rate of discontinuation was 88.6% at 12 months (Raine et
al., 2011).
Table 9. Summary of injectable contraceptive (DMPA) articles reviewed, with most
common reason for discontinuation
Study
Time
Discontinuation
(months)
rate
Polaneczky & Liblanc, 1998
Rakhshani & Mohammadi,
2004
Paul, Skegg, & Williams, 1997
Davidson et al., 1997
Polaneczky & Liblanc, 1998
6
12
52.0%
47.0%
Most common reason
for discontinuation, if
given
Side effects
User dissatisfaction
12
12
12
53.0%
58.0%
73.0%
Side effects
Side effects
Side effects
Raine et al., 2011
Colli et al., 1999
Rakhshani & Mohammadi,
2004
Moreau, Cleland, & Trussell,
2007
12
24
36
88.6%
48.0%
56.0%
Side effects
"Patient preference"
User dissatisfaction
Lifetime
43.3%
Side effects
Range: 43.4% - 88.6%
Five studies identified reasons for discontinuation other than side effects as the
most common reason. Moreau, Cleland, and Trussell (2007) found the following
reasons for discontinuation of DMPA: access issues (too expensive, too difficult to
obtain), user dissatisfaction (too difficult to use, too messy to use, worried about
effectiveness in preventing pregnancy, lack of protection against STIs, method
decreased sexual pleasure), partner dissatisfaction, medical reasons or health concerns
29
(worried about side effects, other health problems, doctor’s advice), failure of method,
and “other.”
Table 10. Summary of injectable contraceptive (DMPA) articles reviewed, with no
reason for discontinuation given in study
Study
Time (months)
Discontinuation rate
Range: 33.0% - 77.0%
Hubacher et al., 2000
O'Neil-Callahan et al., 2013
Rosenstock et al., 2012
Peipert et al., 2011
Trussell, 2011
Rosenstock et al., 2012
Hubacher et al., 2000
Rosenstock et al., 2012
Zibners, Cromer, & Hayes,
1999
Beksinksa, Rees, & Smit, 2001
Westfall, Maine, & Barnard,
1996
O'Neil-Callahan et al., 2013
6
12
12
12
12
12
12
12
12
33.0%
42.5%
42.9%
43.5%
44.0%
46.6%
49.0%
52.7%
55.0%
12
12
58.0%
77.0%
24
62.0%
30
Discontinuation rates of injectable DMPA, by time (months)
and percentage
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
0
6
12
18
24
30
36
Figure 7. Discontinuation rates of injectable DMPA, by time (months) and
percentage
Raine et al. (2011) found the following reasons for discontinuation of DMPA:
access issues, contraceptive no longer needed (“pregnancy-related” or pregnancy
desired), user dissatisfaction (too difficult to use), medical reasons or health concerns,
and “other” (unknown). Colli et al. (1999) found that the contraceptive was no longer
needed, while Hubacher et al. (2000) found that side effects (weight gain, other),
contraceptive no longer needed (pregnancy desired), failure of method, medical
reasons or health concerns, and “other” were reasons given for discontinuation by
patients. Lastly, Polaneczky and Liblanc (1998) found that side effects (weight gain) and
access
issues
(appointment
noncompliance)
were
other
reasons
given
for
discontinuation. Only one study (Moreau, Cleland, & Trussell, 2007) reviewed a
combined injectable contraceptive (Lunelle); no reason was given for discontinuation,
31
which is not surprising as the drug is no longer available in the United States due to
concerns about its effectiveness in preventing pregnancy. Table 11 below lists the
discontinuation rates for various studies in which the type of injectable contraceptive
was not given, in addition to the one study on Lunelle.
Table 11. Summary of injectable contraceptive (combined or type not stated)
articles reviewed
Study
Vaughn et al., 2008
Barden-O’Fallon et al., 2011
Melhado, 2011
Vaughn et al., 2008
Ali & Cleland, 1999
Moreau, Cleland, & Trussell,
2007
Modey, Aryeetey, & Adanu,
2014.
Time
(months)
Discontinuation
Type
Rate
6
12
12
12
24
Lifetime
34.5%
43.6%
50.0%
55.3%
40.5%
33.1%
[not stated]
[not stated]
[not stated]
[not stated]
[not stated]
[combined]
Lifetime
50.1%
[not stated]
Range: 33.1%-55.3%
4.2.4 VAGINAL RING
Seventeen studies reviewing vaginal ring contraceptives were identified. The
rates of and reasons for discontinuation given in these studies are summarized below in
Tables 12 and 13, and Figure 9. As with all the other methods reviewed, side effects
were the most common reason identified for discontinuation. Rates of discontinuation
were high compared to other methods; the lowest rate of discontinuation was 15.7% at
three months (Roumen, op ten Berg, & Hoomans, 2006), while the highest was 76.5%
at 12 months (Sivin et al., 1997). Five of 15 studies reported a discontinuation rate of
above 50%, and nine had above a 40% discontinuation rate. Two studies identified
32
“nonmedical” or “nondevice” reasons for discontinuation (Dieben, Roumen, & Apter,
2002; Novak et al., 2003).
Table 12. Summary of vaginal ring articles reviewed, with most common reason
reason for discontinuation
Study
Time period
(months)
Discontinuation
rate
Most common reason for
discontinuation
Roumen, op ten
Berg, & Hoomans,
2006
Brucker, Karck, &
Merkle, 2008
Oddsson et al., 2005
3
15.7%
Side effects
6
22.0%
Side effects
12
29.1%
Roumen et al., 2001
12
29.6%
Dieben, Roumen, &
Apter, 2002
Lete et al,., 2012
Raine et al.,2011
Novak et al.,2003
12
35.4%
Side effects, adverse
events
Side effects, adverse
events
"Nonmedical reasons"
12
12
13
57.7%
70.0%
25.4%
Ahrendt et al., 2006
13
29.8%
Range: 15.7%-70.0%
Side effects
Side effects
"Nonmedical, nondevice
reasons"
Side effects, adverse
events
Several studies listed reasons for discontinuation other than side effects, that
were not the most common reason. Lete et al. (2011) identified these: “other,”
contraceptive no longer needed (change in sexual habits or pregnancy desired), user
dissatisfaction (poor cycle control), and failure of method. Ahrendt et al. (2006) identified
the following reasons: “other,” partner dissatisfaction (felt ring during intercourse), side
effects (unacceptable vaginal bleeding), failure of method, contraceptive no longer
needed, and “not willing to cooperate”. Raine et al. (2011) identified the following
33
reasons: user dissatisfaction (too difficult to use), access issues (too expensive, too
difficult to obtain), contraceptive no longer needed (pregnancy desired or “pregnancyrelated”), medical reasons or health concerns, and “other” (unknown). Roumen, op ten
Berg, and Hoomans (2006) identified partner dissatisfaction (felt ring during intercourse)
and “other” as reasons. Novak et al. (2003) identified side effects (adverse events not
necessarily related to study medication) as another reason for discontinuation.
Table 13. Summary of vaginal ring articles reviewed, with no reason for
discontinuation given in study
Study
Time (months)
Discontinuation rate
Range: 22.2%-76.5%
Merki-Feld & Hund, 2010
4
Sivin et al., 1997
6
Gilliam et al., 2010
6
Trussell, 2011
12
O'Neil-Callahan et al., 2013 12
Peipert et al., 2011
12
Rosenstock et al., 2012*
12
Rosenstock et al., 2012**
12
Stuart et al., 2013
12
O'Neil-Callahan et al., 2013 12
Rosenstock et al.,2012***
12
Sivin et al., 1997
12
O'Neil-Callahan et al., 2013 24
*Age >26; **Age 20-25; *** Age 14-19
22.2%
47.5%
74.0%
33.0%
44.0%
45.8%
46.9%
47.8%
49.0%
44.0%
69.0%
76.5%
58.9%
34
Figure 8. Discontinuation rates of vaginal ring contraceptive, by time (months)
and percentage
4.2.5 PATCH
Nine studies were identified that reviewed discontinuation rates of the
contraceptive patch. The rates of and reasons for discontinuation given in these studies
are summarized below in Table 14. The small number of studies available is not
surprising due to the patch’s status as the second-least popular hormonal method of
contraception in the United States. Overall, rates of continuation were highly variable,
ranging from 19.8% in all women who had ever used the method (Moreau, Cleland, &
Trussell, 2007) to 87.1% after 12 months (Raine et al., 2011). While side effects were
35
the most common reason for discontinuation, user dissatisfaction was also common as
was no longer needing contraception.
Table 14. Summary of patch contraceptive articles reviewed
Study
rate
Time period (months) Discontinuation
Range: 19.8% - 87.1%
Trussell, 2011
12
Peipert et al., 2011
12
O'Neil-Callahan et al., 2013
12
Stuart et al., 2013
12
Rosenstock et al., 2012*
12
Rosenstock et al., 2012**
12
Rosenstock et al., 2012***
12
Lete et al., 2012
12
Raine et al., 2011
12
O'Neil-Callahan et al., 2013
24
Moreau, Cleland, & Trussell, 2007 Lifetime
*Age 14-19; **Age >26; ***Age 20-25
33.0%
50.1%
50.4%
58.0%
59.1%
59.3%
60.3%
74.0%
87.1%
60.1%
19.8%
Only two studies (Lete et al., 2012; Raine et al., 2011) listed reasons for
discontinuation; both found that the most common reason was side effects. In addition
to side effects, these two studies also found other reasons for discontinuation: “other,”
contraceptive no longer needed (pregnancy desired or change in sexual habits), user
dissatisfaction (poor cycle control), and failure of method (Lete et al., 2012). Raine et al.
(2011) found the following reasons for discontinuation: user dissatisfaction (too difficult
to use), “pregnancy-related,” access issues, contraceptive no longer needed (pregnancy
desired or change in sexual habits), medical reasons or health concerns, and “other”
(unknown).
36
4.2.6 IMPLANT
Fourteen studies were identified that reviewed the discontinuation rates of
contraceptive implants. The rates of and reasons for discontinuation given in these
studies are summarized below in Table 15 and Figure 10. Several types of implants
were studied, including levonorgestrel rods (generic and Norplant) and etonorgestrel
(Implanon). Of all the hormonal methods reviewed in this paper, implants were the
most likely to be continued. Only five studies calculated discontinuation rates above
30%. Eleven of the studies showed discontinuation rates below 20%, and the lowest
rate of discontinuation was 3.5% at six months (Peers, Stevens, Graham, & Davey,
1996).
Table 15. Summary of implant contraceptive articles reviewed, with most common
reason for discontinuation
Study (and type of implant, if
identified)
Time
(months)
Peers et al., 1996 [Norplant]
Kalmuss et al., 1996
Croxatto et al., 1999
Lakha & Glasier, 2006
Rakhshani & Mohammadi,
2004 [levonorgestrel rod]
Peers et al., 1996 [Norplant]
Rosenstock et al., 2012*
Trussell, 2011 [Implanon]
O'Neil-Callahan et al., 2013
Peipert et al., 2011
Sivin et al., 1998a
Rosenstock et al., 2012**
Zibners, Cromer, & Hayes,
1999
Rosenstock et al., 2012***
6
6
6
6
3.5%
7.6%
10.0%
11.0%
Most common
reason for
discontinuation, if
given
Side effects
Side effects
Side effects
Side effects
12
14.0%
Side effects
12
12
12
12
12
12
12
14.8%
15.6%
16.0%
16.6%
16.7%
17.3%
17.8%
Side effects
12
18.0%
12
19.9%
37
Discontinuation
rate
Range: 3.5%-41.0%
Side effects
Side effects
Table 15 continued.
Croxatto et al., 1999
12
Lakha & Glasier, 2006
12
Sivin et al., 1998a
24
Croxatto et al., 1999
24
O'Neil-Callahan et al., 2013
24
Lakha & Glasier, 2006
24
Rakhshani & Mohammadi,
36
2004 [levonorgestrel rod]
Sivin et al., 1998a
36
Sivin et al., 1998b [Norplant]
36
Sivin et al., 1998b
36
[levonorgestrel rod]
Modey, Aryeetey, & Adanu,
Lifetime
2014
*Age >26; **Age 14-19; ***Age 20-25
20.0%
25.0%
20.0%
31.0%
31.5%
41.0%
Side effects
Side effects
Side effects
Side effects
22.0%
Side effects
25.1%
28.9%
Side effects
Side effects
29.4%
Side effects
Side effects
40.3%
Most studies identified side effects as the leading cause of discontinuation; most
of the side effects were either irregular, prolonged, increased, or otherwise
“unacceptable” bleeding, as well as headaches and changes in menstrual periods.
Other reasons for discontinuation were given in two studies. Moreau, Cleland, and
Trussell (2007) listed the following reasons: side effects (changes in menstrual periods),
access issues (too expensive, too difficult to obtain), user dissatisfaction (too messy to
use, too difficult to use, worried about effectiveness in preventing pregnancy, lack of
protection against STIs, method decreased sexual pleasure), partner dissatisfaction,
medical reasons or health concerns (worried about side effects, other health problems,
or doctor’s advice), and “other.”
38
Discontinuation rates of implant contraceptives,
by time (months) and percentage
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
0
6
12
18
24
30
36
Figure 9. Discontinuation rates of implant contraceptives, by time (months) and
percentage
Kalmuss and colleagues (1996) listed the following reasons for discontinuation:
side effects (implant site discomfort, implant site infection, weight change, mood
changes, hair loss, chest pain), “other/unknown,” and “negative media reports” (the only
article in this review to list that as a reason for discontinuation, for any type of hormonal
contraceptive).
39
4.3
OTHER FACTORS ASSOCIATED WITH CONTRACEPTIVE
DISCONTINUATION
4.3.1 AGE
Age is a particularly relevant factor of concern for non-compliance or
discontinuation due to the increased fertility of younger women. A 2008 study by
Whitaker and Giliam estimated that 82% of pregnancies in females aged 15-19 were
unintended. Rosenstock and colleagues (2012) found that continuation of contraception
was negatively associated with age for all contraceptives studied. This conclusion is
common to other studies as well. Mahdy and el-Zeiny (1999) found that women who
were older and those with several children were significantly more likely to continue and
comply with their oral contraceptive regimen. Archer, Cullins, Creasy and Fisher (2004)
found that perfect dosing with the Patch was about equal across all age groups but
compliance with oral contraceptives was significantly better in the above-30 age group
compared to those aged 18-20. Another study reviewing intrauterine device use found
that women aged 13-19 were more likely to request early discontinuation (Aoun et al.,
2014). In a review of data from the 1995 National Survey of Family Growth, Trussell and
Vaughn (1999) found that women over the age of 30 were 28% less likely to discontinue
a reversible method of contraception.
40
4.3.2 INTIMATE PARTNER VIOLENCE AND REPRODUCTIVE COERCION
While there is a lack of statistical data lacking regarding contraceptive
discontinuation or noncompliance due to intimate partner violence or reproductive
coercion, the issue is so pressing that the American College of Obstetricians and
Gynecologists (ACOG) released a set of recommendations, guidelines, and suggestions
for screening patients for intimate partner violence and reproductive coercion that could
potentially lead to unintended pregnancies (ACOG, 2013). Use and continuation of
hormonal contraception are important in situations such as these, since it is controlled
by the woman (rather than male-controlled methods such as condoms) and much more
reliable in preventing unwanted pregnancies than other methods. Miller et al. (2010)
found that birth control sabotage and reproductive coercion were associated with
unintended pregnancy in a population of women aged 16-29 seeking care in a public
family planning clinic. The CDC's National Intimate Partner and Sexual Violence Survey
2010 Summary Report found that approximately 8.6% of women (about 10.3 million)
reported ever having an intimate partner who tried to get them pregnant when they did
not want to, or refused to wear a condom. About 4.8% had an intimate partner who tried
to get them pregnant against their wishes.
4.3.3 SOCIOECONOMIC STATUS AND ETHNICITY
Some evidence suggests that ethnicity and socioeconomic status are linked to
discontinuation of contraception, and unintended pregnancy. Trussell and Vaughn’s
review of data (1999) from the 1995 National Survey of Family Growth found that
41
Hispanic and Black women had a 28% higher rate of method-related discontinuation
than their White counterparts, while low-income women had a 39% higher rate of
method-related discontinuation than higher-income women. (Method-related reasons
include side effects and user dissatisfaction, while non-method-related reasons may
include no longer needing the contraceptive due to a change in sexual habits, access
issues, or desire to become pregnant.) The groups that were most likely to experience
an unintended pregnancy were minority women and poor and low-income women, as
well as women aged 18-24 and cohabiting women (Finer & Zolna, 2014). Daniels,
Mosher, and Jones (2013) found that Hispanic and Asian women were less likely than
their Black and White counterparts to have ever used a highly effective reversible
method of contraception. Stuart et al. (2013) found that Black women and women who
received public assistance were more likely to discontinue oral contraception, the patch,
or the ring.
42
5.0
5.1
DISCUSSION
DISCONTINUATION OF CONTRACEPTION
While this review of literature on hormonal contraceptive discontinuation has
made clear that by far, side effects are the most common reason for discontinuation of
contraception, there is little that public health practitioners and healthcare providers can
do to physiologically prevent, mitigate, or eliminate side effects without discontinuing the
method altogether. This is especially true of hormonal contraceptives because
hormones interact differently with each individual to produce unpredictable side effects.
It
remains incumbent
on
the
pharmaceutical industry to develop
hormonal
contraceptives that provide a better user experience, which would go a very long way in
promoting contraceptive continuation.
In addition to side effects, several studies named access issues such as expense
or difficulty obtaining as one reason for discontinuation of contraception. With the
introduction of the Affordable Care Act’s family planning mandate, requiring insurance
plans to cover contraceptive methods at no out-of-pocket cost to patients (including the
methods covered in this essay), as well as contraceptive counseling, it is possible that
many financially-related access issues will be mitigated or eliminated. However, serious
challenges remain to preventing unintended pregnancy through the use of hormonal
43
contraceptives, including access issues and the need to improve support from
healthcare providers for contraceptive users, especially concerning issues of side
effects.
One possible explanation for the highly variable rates of continuation of oral
contraception that were found in this review, is the different combinations and
formulations of pills available, many of which are not named in the studies reviewed.
The highly variable rates of discontinuation of oral contraception are particularly
troubling, since over 1 million unplanned pregnancies in the United States each year are
attributed to oral contraception non-compliance (mostly missing pills) or discontinuation
(Black et al., 2010).
It is possible that the relatively low rates of discontinuation of IUDs and implants
could be due to the extensive counseling and examinations that must take place before
insertion, guaranteeing a motivated and educated patient. In addition to this, the system
can be placed and removed only by a trained practitioner during an appointment, and it
is a “forgettable” method (Grimes, 2009). Another possible reason for the hormonal
IUDs popularity is its potential to cause fewer side effects; since the effective dose for
IUDs is lower because the hormone is released directly into the uterus, there is a
lessened chance of side effects (Guttmacher, 2007). Other reasons may include
marketing; for instance, Mirena was marketed as a birth spacer for parous women, so it
is not surprising that desire for a pregnancy was a common reason for discontinuation.
It is quite interesting that while implants are the least popular method of hormonal
contraception, they were also the least likely to be discontinued after placement.
44
5.2
IMPLICATIONS FOR PRACTICE: CLIENT-PROVIDER INTERACTIONS AND
COUNSELING
The need to improve client-patient interactions and communication was
underlined in Isaacs and Creinin’s 2003 study of pregnant women seeking in-office
abortions, which found that 14% of the study population was using a less effective
method of contraception than previously used, or no method at all, due to a
communication failure.
Thirty nine percent of the study population reported that they had their
contraceptive method switched by the provider and were not offered an equally or more
effective method; 22% were using an oral contraceptive, provided antibiotics (which
negate the effect of oral contraceptives2) and were not warned to use a back-up
method; 20% had their oral contraceptive stopped for a contraindication and were
switched to a less effective method; 12% experienced difficulty obtaining emergency
contraception or were incorrectly instructed on the use of emergency contraception; and
6% were prescribed a method that they did not want, while not being offered any other
methods by the provider. Only one of the 77 women in the study who knew about
emergency contraception and could have used it actually did use emergency
contraception. It is clear that unintended pregnancy and abortion could have been
2It
should be noted that more recent studies have found that broad speum
antibiotics do not reduce the efficacy of oral contraceptives. (Archer & Archer, 2002;
Helms et al., 1997.)
45
avoided in many of these cases if client-provider interaction had been tailored to the
patients’ needs (Isaacs & Creinin, 2003).
Tailored contraceptive health counseling is also useful for helping women select
a method that they feel suits them, which improves contraceptive compliance and
continuation. In a 2012 study, Garbers, Meserve, Kottke, Hatcher, and Chiasson
created a computer-based contraceptive assessment module and individually tailored
health materials that assessed clients’ contraceptive needs; one group received the
assessment module and tailored materials, another group received the assessment
module and generic materials, and the last group did not receive the special
assessment module and only generic materials (control group). There was no significant
difference between the group that received the module and generic materials and the
control group that received only generic materials, but there was a significant difference
between the group that received the special assessment module and tailored materials
and the control group. Continuation of use and adherence to the contraceptive regimen
were 95% and 86%, respectively, in the experimental group that received the special
assessment module and tailored materials, while the control group continued use only
77% of the time and adhered to their regimen 69% of the time.
Several studies show that high-quality client-provider interactions do improve
contraceptive compliance and continuation. While the following studies discussed were
not conducted in the United States, it remains clear that high-quality care is key to
providers’ promotion of contraceptive continuation. RamaRao and colleagues (2003)
report a positive association between quality of care and contraceptive use; the study
assessed 1,728 women in the Philippines who were new users of family planning care.
46
Those women who received low-quality care at the time of contraceptive adoption had a
55% probability of using contraception at follow-up, compared to 67% of those who
received high-quality care. In this study, quality of care was assessed using 24
indicators (Figure 10). The respondents reported that an average of 18.5 of the 24
indicators were assessed. The medium-quality level of care was defined as falling within
one-half of a standard deviation of that mean; low-quality care was below one-half of the
standard deviation from the mean, while high-quality care was above one-half of the
standard deviation from the mean.
Figure 10. 24 Indicators of Care Assessed by RamaRao et al., 2003
One 36-month study of 3,611 women using oral contraceptives, IUDs,
injectables, and other non-hormonal methods of birth control in Bangladesh used seven
47
indicators of care: (1) was the fieldworker responsive to questions? (2) did the
fieldworker appreciate the privacy of their client? (3) was the fieldworker helpful with
problems? (4) was the fieldworker sympathetic to his/her client's needs? (5) did the
fieldworker provide enough information about contraceptives? (6) did the fieldworker
spend enough time with the client? and (7) did the fieldworker discuss and offer the
client a choice of contraceptives? The results were positive when client-provider
interactions were high-quality: women who reported a high level of care from their
fieldworker were 27% more likely to adopt a method of contraception subsequently
(after controlling for client characteristics), and 72% more likely to continue their method
of contraception (Koenig, Hossain, & Whittaker, 2003).
Similarly, a study in Senegal assessed five indicators of care: “whether the client
was provided choice, had her needs assessed, was provided information, was treated
well by the provider, and whether she was linked to future services” (Sanogo et al.,
2003, p. 63). Based on these indicators, women who received high-quality care were
1.3 times more likely to use contraception than those who did not.
Receiving routine information at care and follow-up visits is not as effective as
personalized counseling. In a study of 350 Mexican women using DMPA, 43.4% of
women in the control group who received only routine information on the side effects of
DMPA discontinued use (Canto de Cetina, Canto, & Ordonez Luna, 2001). In contrast,
the experimental group of women received pretreatment counseling that described
DMPA’s mode of action and discussed common side effects including irregular or heavy
bleeding and menstrual periods, spotting, and amenorrhea. They were also told that the
side effects were not detrimental to their health, and were encouraged to visit their
48
provider if they had any concerns about DMPA’s effect on their health. Only 17% of the
experimental group discontinued use of DMPA; the authors concluded that explaining
the contraceptive’s effectiveness and mode of action, preparing clients for the potential
side effects, and assuring them that the side effects were not detrimental to their health
but that they could seek care if they were concerned, were all instrumental in improving
the continuation rate of DMPA.
A similar study of 811 women in China using DMPA reached comparable
conclusions: 11% of women who received structured counseling discontinued the
contraceptive, while 42% of women who received only routine counseling discontinued
use (Lei et al., 1996). Both the Mexican and Chinese studies utilized audio-visual aids in
the structured counseling group; the Mexican study did not describe the audiovisual
aids in detail, while the Chinese group’s aid depicted American women discussing their
use of DMPA.
However, an assessment of 74 articles about contraceptive counseling revealed
that the extant literature on contraceptive counseling is unreliable in its determination on
the effects of counseling on unintended pregnancy in the United States (Moos,
Bartholomew, & Lohr, 2003). The authors of this literature review concluded that,
collectively, the body of literature did not provide “definitive guidance about effective
counseling strategies” (Moos, Bartholomew, & Lohr, 2003, abstract) and the studies
themselves differed widely in methodology, population, and outcomes measured. This is
true of the studies examined in this review as well: each study included different
indicators of quality of care, and while there was much overlap, there was also a wide
variety of populations and methodologies. But as Moos, Bartholomew, and Lohr (2003)
49
point out, the overlap in many of these studies indicates a future direction for research
on the contribution of quality of care and counseling to contraceptive continuation and
compliance.
50
6.0
CONCLUSION
The Guttmacher Institute (2012) estimates that 37 million American women are
sexually active and fertile but are not and do not desire pregnancy, while the CDC’s
estimate is even higher, at 43 million American women (Jones, Mosher, & Daniels,
2012). While the exact number may be unclear, it is certainly clear that there are
millions of American women who are in need of contraception to avoid an unintended
pregnancy; it is estimated that more than half of all American women have or will
become pregnant without having intended to do so by the age of 45 (Jones &
Kavanaugh, 2011). Hormonal contraception is a reliable, long-term, and highly effective
way to prevent unintended pregnancies, but it must be taken or used consistently to be
highly effective. Contraceptive discontinuation is therefore a major risk factor that may
lead to unintended pregnancy. As this paper has shown, contraceptive discontinuation
is a widespread phenomenon that has not been widely addressed by researchers or
practitioners.
This paper’s introduction discussed the advantages of hormonal contraception
over barrier methods, natural methods, and sterilization, as well as the public health
importance of the topic of contraceptive discontinuation. The following background
section discussed the contraceptive usage and needs of American women. The failure
rates of the contraceptive methods discussed in this paper were also reviewed, as well
51
as the public impact and current trends, individual and public costs, and outcomes of
unintended pregnancies in the United States. This section concluded with a short
discussion of the Healthy People 2020 objectives related to reducing unintended
pregnancy and increasing use of contraception. In the next section, the methods and
criteria used to gather and determine the studies reviewed in this literature synthesis
were described; the studies were also described.
The results section, organized by method and ordered by popularity of use in the
United States, discussed the rates and reasons for discontinuation given by patients in
the studies. The results section concluded with a discussion of demographic factors that
are also associated with contraceptive discontinuation. This was followed by the
discussion section, which included a method-specific discussion of the method-related
factors that may be positively or negatively associated with discontinuation. This section
concluded with a discussion of client-provider interactions and contraceptive counseling,
shown to significantly support and improve contraceptive continuation. Lastly, this paper
concludes with this section, a discussion of this paper’s limitations, suggestions and
directions for future research, and the public health significance of contraceptive
discontinuation.
This literature review examined the extant literature on discontinuation of the
following hormonal methods of contraception: oral contraceptives, copper intrauterine
devices, hormonal intrauterine devices, injectable contraceptives, including depot
medroxyprogesterone and combined type, vaginal rings, patches, and implant
contraceptives. In addition, the review also examined demographic factors that have
been associated with discontinuation, including age, intimate partner violence,
52
reproductive coercion, ethnicity, and socioeconomic status. Based on the review of
studies examining discontinuation of hormonal contraceptives, it appears that the most
common reason for discontinuation is side effects. While providers usually cannot
mitigate side effects of hormonal contraceptives, as they are often unpredictable, other
studies have shown that discussing these side effects and other concerns that patients
may have about the contraceptive that they are beginning or are currently taking can
increase continuation as well as compliance with their regimen.
6.1
LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH
There are several limitations to this literature review. First, the meta-analysis
included only studies that provided quantitative results for discontinuation. Adding
qualitative results would improve the quality and depth of a review of reasons why
women choose to discontinue their methods of contraception. Second, the populations
studied varied widely demographically. Therefore, conclusions are not generalizable to
any specific population. Third, many of the studies used only provided rates of
discontinuation, and did not provide specific reasons for discontinuation. It would be
very instructive for future studies to include reasons for discontinuation, so that these
may be addressed in client interventions. Fourth, many of the studies regarding
contraceptive counseling only defined counseling in terms of talking to clients around
specific objectives, without any theoretical basis. Future studies examining the use of
counseling to improve contraceptive compliance or continuation may wish to incorporate
behavioral theories of health decision-making, which may increase contraceptive
53
adherence and decrease unwanted pregnancies. Lastly, this review only examined
studies published in English.
6.2
PUBLIC HEALTH SIGNIFICANCE
Given that increasing the proportion of intended pregnancies and increasing
contraceptive use by females (or their partners) at risk of unintended pregnancy at most
recent sexual intercourse are Healthy People 2020 objectives, improving maternal
health and reducing child mortality are United Nations Millennium Development Goals,
and the CDC considers family planning one of the top 10 public health achievements of
the 20th century, family planning remains a very significant public health issue. By
increasing continuation of contraceptive use, the proportion of unintended pregnancies
can be reduced, rates of neonatal/infant/child mortality can be reduced, and women’s
health as a whole can be improved. In addition, because contraceptive use puts women
in control of their fertility, it also improves their social and economic opportunities.
It is clear from this review that while there is little that healthcare providers can do
to prevent or eliminate side effects, contraceptive compliance or continuation can be
improved by discussing the advantages and disadvantages of each method, providing
care with quality interpersonal interaction, and discussing the preferences and worries
of each patient. The extant meta-analytical literature on contraceptive discontinuation is
extremely scarce, especially for such an important public health topic.
54
BIBLIOGRAPHY
Ahrendt, H. J., Nisand, I., Bastianelli, C., Gómez, M. A., Gemzell-Danielsson, K., Urdl,
W., ... & Milsom, I. (2006). Efficacy, acceptability and tolerability of the
combined contraceptive ring, NuvaRing, compared with an oral contraceptive
containing 30μg of ethinyl estradiol and 3 mg of drospirenone.
Contraception, 74(6), 451-457.
Ali, M.M. & Cleland, J. (1999). Determinants of contraceptive discontinuation in six
developing countries. Journal of Biosocial Science, (31)3, 343-360.
Ali, M.M. & Cleland, J. (2010). Oral contraceptive discontinuation and its aftermath in
19 developing countries. Contraception, 81(1), 22-29.
American College of Obstetricians and Gynecologists, Committee on Health Care for
Underserved Women. (2013). Reproductive and sexual coercion. Committee
opinion no. 554. Retrieved from
http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20Hea
lth%20Care%20for%20Underserved%20Women/co554.pdf?dmc=1&ts=2013020
6T0531420146
Aoun, J., Dines, V. A., Stovall, D. W., Mete, M., Nelson, C. B., & Gomez-Lobo, V.
(2014). Effects of age, parity, and device type on complications and
discontinuation of intrauterine devices. Obstetrics & Gynecology, 123(3), 585592.
Archer, D. F., Cullins, V., Creasy, G. W., & Fisher, A. C. (2004). The impact of improved
compliance with a weekly contraceptive transdermal system (Ortho Evra®) on
contraceptive efficacy. Contraception, 69(3), 189-195.
Archer, J. S., & Archer, D. F. (2002). Oral contraceptive efficacy and antibiotic
interaction: A myth debunked. Journal of the American Academy of Dermatology,
46(6), 917-923.
Barden-O’Fallon, J., Speizer, I.S., Calix, J., & Rodriguez, F. (2011). Contraceptive
discontinuation among Honduran women who use reversible methods. Studies in
Family Planning, 42(1), 11-20.
55
Behringer, T., Reeves, M.F., Rossiter, B., Chen, B.A., & Schwarz, E.B. (2011).
Duration of use of a levonorgestrel IUS among nulliparous and adolescent
women. Contraception, 84(5), e5-e10.
Beksinska, M.E., Rees, H.V., & Smit, J. (2001). Temporary discontinuation: A
compliance issue in injectable users. Contraception, 64(5), 309-313.
Black, K. I., Gupta, S., Rassi, A., & Kubba, A. (2010). Why do women experience
untimed pregnancies? A review of contraceptive failure rates. Best Practice &
Research Clinical Obstetrics & Gynaecology, 24(4), 443-455.
Brucker, C., Karck, U., & Merkle, E. (2008). Cycle control, tolerability, efficacy, and
acceptability of the vaginal contraceptive ring, NuvaRing®: Results of clinical
experience in Germany. European Journal of Contraception and Reproductive
Health Care, 13(1), 31-38.
Bustan, M. N., & Coker, A. L. (1994). Maternal attitude toward pregnancy and the risk of
neonatal death. American Journal of Public Health, 84(3), 411-414.
Canto De Cetina, T. E., Canto, P., & Ordoñez Luna, M. (2001). Effect of counseling to
improve compliance in Mexican women receiving depot-medroxyprogesterone
acetate. Contraception, 63(3), 143-146.
Centers for Disease Control and Prevention. (1999). Achievements in public health,
1900-1999: Family planning. Morbidity and Mortality Weekly Report, 48(47),
1073- 1080. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm
Centers for Disease Control and Prevention. (2008). State of CDC, 2008. Retrieved
from http://www.cdc.gov/about/pdf/resources/socdc2008.pdf.
Centers for Disease Control and Prevention. (2011). National intimate partner and
sexual violence survey: 2010 summary report. Retrieved from
http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf
Colli, E., Tong, D., Penhallegon, R., & Parazzini, F. (1999). Reasons for contraceptive
discontinuation in women 20–39 years old in New Zealand. Contraception, 59(4),
227-231.
Cotten, N., Stanback, J., Maidouka, H., Taylor-Thomas, J. T., & Turk, T. (1992). Early
discontinuation of contraceptive use in Niger and The Gambia. International
Family Planning Perspectives, 18(4), 145-9.
Croxatto, H. B., Urbancsek, J., Massai, R., Bennink, H. C., & van Beek, A. (1999). A
multicentre efficacy and safety study of the single contraceptive implant
Implanon®. Human Reproduction, 14(4), 976-981.
56
Daniels, K., Mosher, W.D., & Jones, J. (2013). Contraceptive methods women have
ever used: United States, 1982-2010. National Health Statistics Reports (Centers
for Disease Control and Prevention National Center for Health Statistics), U.S.
Department of Health and Human Services. Retrieved from
http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf
Davidson, A. R., Kalmuss, D., Cushman, L. F., Romero, D., Heartwell, S., & Rulin,
M. (1997). Injectable contraceptive discontinuation and subsequent unintended
pregnancy among low-income women. American Journal of Public Health, 87(9),
1532-1534.
DePersio, S.R., Chen, W., Blose, D., & Lorenz, R. (1992). Unintended pregnancy and
its consequences on live birth outcomes and maternal behaviors during
pregnancy. Oklahoma City Department of Health.
Dibaba, Y., Fantahun, M., & Hindin, M. J. (2013). The effects of pregnancy intention on
the use of antenatal care services: Systematic review and metaanalysis. Reproductive Health, 10(1), 50.
Dieben, T.O.M., Roumen, F.J.M.E., & Apter, D. (2002). Efficacy, cycle control, and
user acceptability of a novel combined contraceptive vaginal ring. Journal of
Obstetrics and Gynecology 100(3), 585-593.
Finer, L.B. & Zolna, M.R. (2014). Shifts in intended and unintended pregnancies in
the United States, 2001-2008. American Journal of Public Health, 104(S1), S4348.
Garbers, S., Haines-Stephan, J., Lipton, Y. Meserve, A., Spieler, L., & Chiasson, M.A.
(2013). Continuation of copper-containing intrauterine devices at 6 months.
Contraception, 87(1), 101-106.
Garbers, S., Meserve, A., Kottke, M., Hatcher, R., & Chiasson, M.A. (2012). Tailored
health messaging improves contraceptive continuation and adherence: Results
from a randomized controlled trial. Contraception, 86(5), 536-542.
Gazmararian, J. A., Adams, M. M., Saltzman, L. E., Johnson, C. H., Bruce, F. C.,
Marks, J. S., ... & PRAMS Working Group. (1995). The relationship between
pregnancy intendedness and physical violence in mothers of
newborns. Obstetrics & Gynecology, 85(6), 1031-1038.
Gilliam, M.L., Neustadt, A., Kozloski, M., Mistretta, S., Tilmon, S., & Godfrey, E.
(2010). Adherence and acceptability of the contraceptive ring compared with the
pill among students. Journal of Obstretics and Gynecology, 115(3), 503-510.
Gold, R. B., Sonfield, A., Richards, C. L., & Frost, J. J. (2009). Next steps for
America's family planning program: Leveraging the potential of Medicaid and
57
Title X in an evolving health care system. Guttmacher Institute. Retrieved from
http://www.guttmacher.org/pubs/NextSteps.pdf
Grimes, D.A. (2009). Forgettable contraception. Contraception, 80(6), 497-499.
Hubacher, D., Goco, N., Gonzalez, B., & Taylor, D. (2000). Factors affecting
continuation rates of DMPA. Contraception, 60(6), 345-351.
Guttmacher Institute. (2000). Fulfilling the promise: Public policy and U.S. family
planning clinics. Retrieved from http://www.guttmacher.org/pubs/fulfill.pdf
Guttmacher Institute. (2010). Contraceptive needs and services. Retrieved from
http://www.guttmacher.org/pubs/win/contraceptive-needs-2010.pdf
Guttmacher Institute. (2013). Contraceptive use in the United States. Retrieved from
http://www.guttmacher.org/pubs/fb_contr_use.html
Helms, S. E., Bredle, D. L., Zajic, J., Jatjoura, D., Brodell, R. T., & Krishnarao, I. (1997).
Oral contraceptive failure rates and oral antibiotics. Journal of the American
Academy of Dermatology, 36(5), 705-710.
Isaacs, J. N., & Creinin, M. D. (2003). Miscommunication between healthcare providers
and patients may result in unplanned pregnancies. Contraception,68(5), 373-376.
Jones, J., Mosher, W., & Daniels, K. (2012). Current contraceptive use in the United
States, 2006-2010, and changes in patterns of use since 1995. National Health
Statistics Reports (Centers for Disease Control and Prevention National Center
for Health Statistics), U.S. Department of Health and Human Services. Retrieved
from http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf
Jones, R.K. & Kavanaugh, M.L. (2011). Changes in abortion rates between 2000 and
2008 and lifetime incidence of abortion. Obstetrics & Gynecology, 117(6), 13581366.
Kalagian, W., Loewen, I., Delmore, T., & Busca, C. (1998). Adolescent oral
contraceptive use: Factors predicting compliance at 3 and 12 months. The
Canadian Journal of Human Sexuality, 7(1), 1-8.
Kalmuss, D., Davidson, A.R., Cushman, L.F., Heartwell, S. & Rulin, M. (1996).
Determinants of early implant discontinuation among low-income women. Family
Planning Perspectives, 28, 256-260.
Khan, M.A. (2001). Side effects and oral contraceptive discontinuation in rural
Bangladesh. Contraception, 64(3), 161-167.
58
Koenig, M. A., Hossain, M. B., & Whittaker, M. (1997). The influence of quality of care
upon contraceptive use in rural Bangladesh. Studies in Family Planning, 278289.
Kost, K., Singh, S., Vaughan, B., Trussell, J., & Bankole, A. (2008). Estimates of
contraceptive failure from the 2002 National Survey of Family Growth.
Contraception, 77(1), 10-21.
Kubička, L., Matějček, Z., David, H. P., Dytrych, Z., Miller, W. B., & Roth, Z. (1995).
Children from unwanted pregnancies in Prague, Czech Republic revisited at age
thirty. Acta Psychiatrica Scandinavica, 91(6), 361-369.
Lakha, F. & Glasier, A. (2006). Continuation rates of Implanon® in the UK: Data from
an observation study in a clinical setting. Contraception, 74(4), 287-289.
Lara-Torre, E., Spotswood, L., Correia, N., & Weiss, P. M. (2011). Intrauterine
contraception in adolescents and young women: a descriptive study of use,
side effects, and compliance. Journal of Pediatric and Adolescent Gynecology,
24(1), 39-41.
Lei, Z. W., Chun Wu, S., Garceau, R. J., Jiang, S., Yang, Q. Z., Wang, W. L., & Vander
Meulen, T. C. (1996). Effect of pretreatment counseling on discontinuation rates
in Chinese women given depo-medroxyprogesterone acetate for
contraception. Contraception, 53(6), 357-361
Lete, I., Pérez-Campos, E., Correa, M., Robledo, J., de la Viuda, E., Martínez, T., ...
& Lobo, P. (2012). Continuation rate of combined hormonal contraception: a
prospective multicenter study. Journal of Women's Health, 21(5), 490-495.
Mahdy, N. H., & El-Zeiny, N. A. (1999). Probability of contraceptive continuation and its
determinants. Eastern Mediterranean Health Journal, 5(3), 526-539.
Mayer, J. P. (1997). Unintended childbearing, maternal beliefs, and delay of prenatal
care. Birth, 24(4), 247-252.
Melhado, L. (2011). More than four in 10 Honduran women discontinue their
contraceptive method within the first year of use. International Perspectives on
Sexual and Reproductive Health, 37(2), 104-105.
Merki-Feld, G. & Hund, M. (2010). Clinical experience with the combined contraceptive
vaginal ring in Switzerland, including a subgroup analysis of previous hormonal
contraceptive use. European Journal of Contraception and Reproductive Health
Care 15(6), 413-422.
59
Miller, E., Decker, M. R., McCauley, H. L., Tancredi, D. J., Levenson, R. R., Waldman,
J., ... & Silverman, J. G. (2010). Pregnancy coercion, intimate partner violence
and unintended pregnancy. Contraception, 81(4), 316-322.
Modey, E.J., Aryeetey, R., & Adanu, R. (2014). Contraceptive discontinuation and
switching among Ghanian women: Evidence from the Ghana Demographic and
Health Survey, 2008. African Journal of Reproductive Health, 18(1), 84-92.
Moreau, C., Bouyer, J., Bajos, N., Rodriguez, G., & Trussell, J. (2009). Frequency of
discontinuation of contraceptive use: results from a French population-based
cohort. Human Reproduction, 24(6), 1387-1392.
Moreau, C., Cleland, K., & Trussell, J. (2007). Contraceptive discontinuation
attributed to method dissatisfaction in the United States. Contraception, 76(4),
267-272.
Mosher, W.D., Jones, J., & Abma, J.C. (2012). Intended and unintended births in the
United States: 1982-2010. National Health Statistics Reports. Retrieved from
http://www.cdc.gov/nchs/data/nhsr/nhsr055.pdf
Murphy, P.A. & Brixner, D. (2008). Hormonal contraceptive discontinuation patterns
according to formulation: Investigation of associations in an administrative claims
database. Contraception 77(4), 257-263.
Myhrman, A., Olsén, P., Rantakallio, P., & Laara, E. (1995). Does the wantedness of a
pregnancy predict a child's educational attainment? Family Planning
Perspectives, 27(3), 116-119.
Novak, A., de la Loge, C., Abetz, L., & van der Meulen, E.A. (2003). The combined
contraceptive vaginal ring, NuvaRing®: An international study of user
acceptability. Contraception, 67(3), 187-194.
Oddsson, K., Leifels-Fischer, B., de Melo, N. R., Wiel-Masson, D., Benedetto, C.,
Verhoeven, C. H., & Dieben, T. O. (2005). Efficacy and safety of a contraceptive
vaginal ring (NuvaRing) compared with a combined oral contraceptive: A 1-year
randomized trial. Contraception, 71(3), 176-182.
O'Neil-Callahan, M., Peipert, J. F., Zhao, Q., Madden, T., & Secura, G. (2013). Twentyfour–month continuation of reversible contraception. Obstetrics &
Gynecology, 122(5), 1083-1091.
Paul, C., Skegg, D.C.G, & Williams, S. Depot medroxyprogesterone acetate:
Patterns of use and reasons for discontinuation. Contraception, 56(4), 209214.
60
Peers, T., Stevens, J. E., Graham, J., & Davey, A. (1996). Norplant® implants in the
UK: First year continuation and removals. Contraception, 53(6), 345-351.
Peipert, J. F., Zhao, Q., Allsworth, J. E., Petrosky, E., Madden, T., Eisenberg, D., &
Secura, G. (2011). Continuation and satisfaction of reversible contraception.
Obstetrics and Gynecology, 117(5), 1105-1113.
Polaneczky, M. & Liblanc, M. (1998). Long-term depot medroxyprogesterone acetate
(Depo-Provera) use in inner-city adolescents. Journal of Adolescent Health,
23(2), 83-88.
Raine, T. R., Foster-Rosales, A., Upadhyay, U. D., Boyer, C. B., Brown, B. A.,
Sokoloff, A., & Harper, C. C. (2011). One-year contraceptive continuation and
pregnancy in adolescent girls and women initiating hormonal contraceptives.
Obstetrics and Gynecology, 117(2 Pt 1), 363.
Rakhshani, F. & Mohammadi, M. (2004). Contraception continuation rates and reasons
for discontinuation in Zahedan, Islamic Republic of Iran. Eastern Mediterranean
Health Journal, 10(3), 260-267.
Rosenberg, M.J. & Waugh, M.S. (1998). Oral contraceptive discontinuation: A
prospective evaluation of frequency and reasons. American Journal of
Obstetrics and Gynecology, 179(3), 577-582.
Rosenberg, M.J., Waugh, M.S., & Meehan, T.E. (1995). Use and misuse of oral
contraceptives: Risk indicators for poor pill taking and discontinuation.
Contraception, 51(5), 283-288.
Rosenstock, J.R., Peipert, J.F., Madden, T., Zhao, Q. & Secura, G.M. (2012).
Continuation of reversible contraception in teenagers and young women. Journal
of Obstetrics and Gynecology, 120(6), 1298-1305.
Roumen, F.J.M.E., Apter, D., Mulders, T.M.T., & Dieben, T.O.M. (2001). Efficacy,
tolerability, and acceptability of a novel contraceptive vaginal ring releasing
etonogestrel and ethinyl oestradiol. Human Reproduction, 16(3), 469-475.
Roumen, F.J.M.E., op ten Berg, M.M.T., & Hoomans, E.H.M. (2006). The combined
contraceptive vaginal ring (NuvaRing®): First experience in daily clinical practice
in The Netherlands. European Journal of Contraception and Reproductive
Healthcare, 11(1), 14-22.
Sanogo, D., RamaRao, S., Jones, H., N'diaye, P., M'bow, B., & Diop, C. B. (2003).
Improving quality of care and use of contraceptives in Senegal. African Journal of
Reproductive Health, 7(2).
61
Singh, S., Sedgh, G., & Hussain, R. (2010). Unintended pregnancy: worldwide levels,
trends, and outcomes. Studies in Family Planning, 41(4), 241-250.
Sivin, I., Alvarez, F., Mishell Jr, D. R., Darney, P., Wan, L., Brache, V., ... & Stern, J.
(1998). Contraception with two levonorgestrel rod implants: a 5-year study in the
United States and Dominican Republic. Contraception, 58(5), 275-282.
Sivin, I., Campodonico, I., Kiriwat, O., Holma, P., Diaz, S., Wan, L., ... & Stern, J.
(1998). The performance of levonorgestrel rod and Norplant® contraceptive
implants: a 5 year randomized study. Human Reproduction, 13(12), 3371-3378.
Sivin, I., Díaz, S., Croxatto, H. B., Miranda, P., Shaaban, M., Sayed, E. H., ... &
Jackanicz, T. (1997). Contraceptives for lactating women: a comparative trial of a
progesterone-releasing vaginal ring and the copper T 380A IUD. Contraception,
55(4), 225-232.
Sonfield, A. (2007). Popularity disparity: Attitudes about the IUD in Europe and the
United States. Guttmacher Institute. Retrieved from
http://www.guttmacher.org/pubs/gpr/10/4/gpr100419.html.
Sonfield, A., & Gold, R.B. (2012). Public funding for family planning, sterilization, and
abortion services, FY 1980-2010. Guttmacher Institute. Retrieved from
http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf
Sonfield, A. & Kost. K. (2013). Public costs from unintended pregnancies and the
role of public insurance programs in paying for pregnancy and infant care:
Estimates for 2008. Guttmacher Institute. Retrieved from
http://www.guttmacher.org/pubs/public-costs-of-UP.pdf
Stuart, J. E., Secura, G. M., Zhao, Q., Pittman, M. E., & Peipert, J. F. (2013). Factors
associated with 12-month discontinuation among contraceptive pill, patch, and
ring users. Obstetrics & Gynecology, 121(2, Part 1), 330-336.
Suhonen, S., Haukkamaa, M., Jakobsson, T., & Rauramo, I. (2004). Clinical
performance of a levonorgestrel-releasing intrauterine system and oral
contraceptives in young nulliparous women: A comparative study.
Contraception, 69(5), 407-412.
Teal, S.B. & Sheeder, J. (2012). IUD use in adolescent mothers: Retention, failure,
and reasons for discontinuation. Contraception, 85(3), 270-274.
Tewari, R. & Kay, V.J. (2006). Compliance and user satisfaction with the intrauterine
contraceptive device in Family Planning Service: The results of a survey in Fife,
Scotland, August 2004. European Journal of Contraception and Reproductive
Health Care, 11(1), 28-37.
62
Trussell, J. (2007). The cost of unintended pregnancy in the United States.
Contraception, 75(3), 168-170.
Trussell, J. (2011). Contraceptive failure in the United States. Contraception, 70(2),
397-404.
United States Department of Health and Human Services, Health Resources and
Services Administration, Maternal and Child Health Bureau. Prenatal services.
(n.d.) Retrieved from http://mchb.hrsa.gov/programs/womeninfants/prenatal.html
United States Department of Health and Human Services, Healthy People 2020. (2011).
Family planning: Objectives. Retrieved from
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topi
cId=13
Vaughan, B., Trussell, J., Kost, K., Singh, S. & Jones, R. (2008). Discontinuation and
resumption of contraceptive use: Results from the 2002 National Survey of
Family Growth.
Westfall, J.M., Main. D.S., & Barnard, L. (1996). Continuation rates among injectable
contraceptive users. Family Planning Perspectives, 28(6), 275-277.
Westhoff, C. L., Heartwell, S., Edwards, S., Zieman, M., Stuart, G., Cwiak, C., ... &
Kalmuss, D. (2007). Oral contraceptive discontinuation: do side effects matter?
American Journal of Obstetrics and Gynecology, 196(4), e1-e7.
Whitaker, A. K., & Gilliam, M. (2008). Contraceptive care for adolescents. Clinical
Obstetrics and Gynecology, 51(2), 268-280.
Zibners, A., Cromer, B.A., & Hayes, J. (1999). Comparison of continuation rates for
hormonal contraception among adolescents. Journal of Pediatric Adolescent
Gynecology, 12(2), 90-94.
63