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Some individuals or couples select a contraceptive method and
continue using it throughout their reproductive lives. Others will
change methods several times.
There are many reasons why people switch methods. Their contraceptive
needs may change over time. They may want greater effectiveness. Or,
they may be dissatisfied with side effects, have problems getting a
method, or have previously followed poor advice from clinic staff. Some
may simply wish to experiment, if various contraceptive options are
available.
Often, women and men first try methods that are easy to get or use,
but may be less effective than other methods. Later, when they feel more
urgency to limit their fertility, they tend to switch to more effective
methods.
In Sri Lanka, 40 percent of some 300 users of reversible modern
methods switched within two years to a more effective method, with
switching mainly occurring as women approached their desired family
size.1
In a retrospective survey of contraceptive use over four years among
715 rural Kenyan women of reproductive age, women tended to adopt
long-term or permanent methods as they became older and had more
children. Many were "casual" family planners at first. That
is, they used a method to delay pregnancy and, if the method failed,
they tended to view an unintended pregnancy simply as a matter of poor
timing. However, once women had had three or four children, unintended
pregnancies were less acceptable and the women were more likely to adopt
long-term or permanent methods.2
In Jordan, the rhythm method, withdrawal and the lactational
amenorrhea method (LAM) were considered by married couples who
participated in focus group discussions to be both safe and in keeping
with Islamic religious principles. However, researchers noted that,
while widely used, these methods were often used incorrectly, leading to
failure. Changing to modern methods tended to occur only after one of
these traditional methods had failed, several children were born, or the
couple faced money problems. "We started by planning, using the
rhythm method," recalled one urban woman. "After two children,
we continued to use it, but it did not work. I had a third child, then
had an intrauterine device (IUD) inserted."3
On the other hand, side effects associated with some modern methods
may cause women to change to other methods, some of which may be less
reliable.
In the Jordanian study, side effects from IUDs and oral
contraceptives were identified as the main reason for switching from
modern to traditional family planning. "Sometimes we used pills,
sometimes the rhythm method," said an urban man. "When my wife
suffered the side effects of the pill, she stopped using them and
shifted to the rhythm method for three, four, five or six months. I used
withdrawal when I feared there had been a mistake in our counting."
High discontinuation rates for the IUD and the pill, largely due to
fear of adverse health effects, were also observed in a survey involving
some 900 married Turkish women. Authors of the study noted that many
couples seemed to resort to withdrawal in order to escape the perceived
or actual side effects of modern methods.4
In an FHI study conducted in Indonesia in collaboration with the
Population Studies Center, Gadjah Mada University, nearly a fifth of 720
contracepting women reported health problems with contraceptive use.
Side effects usually led to method switching. For example, a rural
29-year-old mother of three told an interviewer that she originally used
an IUD, but an infection that she believed was related to her IUD led
her to begin using condoms instead, which are less effective. After a
couple of months of condom use, this woman switched back to the IUD.
Further problems with the IUD, however, caused her to use an injectable
contraceptive, which she abandoned after three injections because it
caused the side effect of spotting (intermenstrual bleeding). Finally,
she switched to Norplant subdermal implants.5
A survey of 800 women from Lampung and South Sumatra, Indonesia,
conducted by FHI in collaboration with Atma Jaya Catholic University,
also revealed that many women changed contraceptive methods after
experiencing side effects, particularly those associated with hormonal
methods and the IUD.6
"The amount of method switching due to side effects among women
in these two studies was surprising and underscores the importance of
providers fully informing clients about possible effects," says Dr.
Karen Hardee, who was FHI's monitor of the two Indonesian studies and is
currently with The Futures Group International. "Some providers
worry that if they fully inform clients about possible side effects,
clients will not even begin using the methods. But a client who is
ill-informed and experiences a side effect may discontinue the method
out of fear, not realizing that the effect is normal and probably
transient."
Inappropriate medical advice or practices by clinic staff and
periodic unavailability of some methods, supplies or services can also
lead to switching. Inconvenience can be another reason. In an FHI study
conducted in collaboration with Xavier University in the Philippines,
only a fifth of some 900 current users of family planning and 350 past
users had ever changed methods. However, when switching occurred, it was
often associated with distant locations of clinics, limited clinic
service or long waits at clinics.7
Range of options
Research in developing countries has shown that offering a variety of
modern methods and encouraging dissatisfied clients to try another
method results in higher contraceptive continuation rates. However,
greater awareness and availability of a wide range of methods also may
result in more method switching. In Indonesia, the Demographic and
Health Surveys program found that educated contraceptive users were more
likely to change methods than uneducated users, and urban users were
found to be more likely to switch than rural users. Researchers
concluded that educated users were probably more aware of available
methods, likely to find an alternative method, and willing to experiment
until they found a method that suited them. Similarly, urban women may
have had more access to contraceptive information, increasing their
awareness of choices.8
"Efforts should be made to prevent unnecessary switching -- for
example, switching due to a lack of understanding about side
effects," says Dr. Hardee. "However, switching in itself is
not a bad thing. Women need to be allowed to switch. In fact, when
providers have denied women the right to switch provider-controlled
methods, women have justifiably felt coerced. The result is that a safe
and effective method can get a bad reputation."
An FHI study in Senegal of women's experience with Norplant removal
showed that women who wished to have implants removed commonly
complained that they were forced to return to the clinic many times for
counseling and treatment before their request was granted.9
"Because a Norplant client must rely upon a trained provider to
remove the implants, guaranteed access to removal upon the woman's
request is essential if Norplant is to be a method that expands
reproductive choices, instead of curtailing women's freedom of
choice," says Elizabeth Tolley of FHI, who coauthored the study.
"Since requests for removal are usually due to an intolerance of
side effects or a desire to get pregnant, they may be kept to a minimum
if potential clients are well counseled about side effects and do not
intend to have more children within five years of accepting
Norplant."
Encouraging couples who are dissatisfied with a modern method to
change to a traditional family planning method can be a good choice as
long as both partners are determined to use the traditional method
correctly and consistently. For example, a couple interviewed in a study
conducted in the Philippines reported successfully using the calendar
rhythm method for a total of 10 years. For the four years following the
birth of their first child, they rigorously kept track of the woman's
menstrual cycle and abstained from intercourse during fertile periods.
But the husband wanted a break from this regimen and his wife switched
to the pill. After three months, she developed a pill-related rash,
abandoned the method, and became pregnant again. After the birth of this
child, the couple resumed the calendar rhythm method, using it
successfully for years.10
A user's choice
To discourage frequent method switching, providers should give
clients the method they ask for as long as it is medically appropriate.
There is a strong association between granting a woman's choice of a
method, especially when her partner agrees, and her sustained use of it.11
Clinic counselors should provide full information about the chosen
method, thoroughly addressing the problems and side effects of the
method before use begins.
Providers should also be able to explain fully the correct use of
periodic abstinence, withdrawal or LAM. A couple may prefer such methods
for many reasons, including religious beliefs, but may not understand
how to use the methods effectively. Using traditional methods
successfully requires an understanding of a woman's fertile cycle, for
example. An unintended pregnancy may result in a couple feeling forced
to change to a more effective modern method, although they believe its
use is inappropriate.
The first clinic visit can affect contraceptive behavior. This was
illustrated in a U.S. study in which nearly half of some 200 diaphragm
users and two-thirds of some 325 oral contraceptive users had switched
from these methods only five months after beginning to use them. Women
who switched were more likely to have had inaccurate expectations about
the methods and a poor experience during their first clinic visit.12
Among some 800 acceptors of the progestin-only injectable
depot-medroxyprogesterone acetate (DMPA) in the Philippines, those women
who were told they might experience side effects were more than three
times as likely to continue using the method as those who had not
received such counseling. Those who felt they had been treated in a
caring and polite manner were 10 times as likely to continue using DMPA
as those treated discourteously.13
If a client plans to discontinue a method and begin using another,
the provider should urge her to do so immediately. Otherwise, she risks
an unintended pregnancy. An analysis of contraceptive use by 1,000
Peruvian women, for example, indicated that those who stopped using a
method without starting another method were likely to become pregnant
before either returning to the abandoned method or switching to another.14
Providers recommending that a client change methods because of a
medical condition should be sure their concern is justified. The World
Health Organization's (WHO) medical eligibility criteria for safe use of
contraceptives can help them do so.15
If a client wishes to switch to another method because of side
effects, providers should consider better alternatives. For example, if
a woman likes the highly effective, progestin-only injectable DMPA but
wishes to discontinue the method because of irregular bleeding, a
provider might suggest an equally effective combined injectable, such as
Cyclofem or Mesigyna, that would produce more regular menstrual
bleeding.
Providers should not forget the male partners of women clients. Men
can play a significant role in contraceptive method switching by
discouraging use of particular methods. In the Philippines, DMPA
acceptors whose husbands were opposed to the method were twice as likely
to discontinue the method as women who had supportive husbands.16
Men may oppose the use of condoms, believing that the method reduces
sexual sensation. Or, they may hold misconceptions about a method's
mechanism of action or health effects. Other men may discourage their
partners' use of a method if they think it can affect a woman's sex
drive or physical appearance.
Although emergency contraception should not be used as a routine
contraceptive, its use may prompt couples to begin or switch to a
reliable, long-term method. Nearly two-thirds of 119 U.S. women who
sought and used emergency contraceptive pills cited condom failure as
the reason for using emergency contraception. In a follow-up survey
conducted two to three weeks later, over half reported that they
intended to change or had already changed their contraceptive methods,
most to hormonal methods.17
Providing fertility control counseling to some 450 Irish female
students who visited a university health center for emergency
contraception was found to result in many students adopting more
reliable contraceptive methods. At follow-up one to 36 months after the
initial visit, 42 percent of the women had changed to a more reliable
method than the one they had been using at the time they sought
emergency contraception.18
Data about contraceptive switching among adolescents are limited.
However, "adolescents tend to use easily obtainable, short-term,
barrier methods, such as condoms, if they use any contraception at
all," says Dr. Cindy Waszak, an FHI principal research scientist
who has evaluated adolescent programs in the United States, Jamaica,
Nepal and Africa. "A pregnancy scare often prompts adolescents
either to initiate use of a method or to switch to a more reliable
method. However, switching may be more difficult for adolescents than
for adults. Adolescents are often reluctant to approach a family
planning clinic because they are unfamiliar with the medical system and
fear stigmatization for being sexually active."
Thus, it is important that family planning workers treat adolescents
with respect. Counseling about side effects is essential because youth
are more likely than adults to abandon a method if they are
dissatisfied.
In many cases, the ideal contraceptive method for an adolescent is
the condom. When used correctly and consistently, the condom is highly
effective in preventing both pregnancy and sexually transmitted
diseases. Counseling can help young, inexperienced people to use condoms
correctly, as well as to negotiate condom use with partners.
Adolescents' sexual activity tends to be irregular and often
unplanned, so the condom is a practical method that is often easy to
obtain. Adolescents also face greater risks of infection from sexually
transmitted diseases because they change partners more often than older
adults. Also, younger women are more vulnerable than older women to
infections such as chlamydia because of different anatomical and
physiological characteristics of the cervix due to age.
-- Kim Best
References
- Hamill DN, Tsui AO, Thapa S. Determinants of
contraceptive switching behavior in rural Sri Lanka. Demography 1990;27(4):559-78.
- Ferguson AG. Fertility and contraceptive adoption
and discontinuation in rural Kenya. Stud Fam Plann 1992;23(4):257-67.
- Farsoun M, Khoury N, Underwood C. In Their Own
Words: A Qualitative Study of Family Planning in Jordan, IEC Field
Report Number 6. Baltimore, MD: Johns Hopkins University School
of Public Health, Center for Communication Programs, 1996.
- Breslin M. Fearing side effects, many Turkish
women choose traditional contraceptives. Int Fam Plann Perspect 1997;23(3):139-40.
- Dwiyanto A, Faturochman, Suratiyah K, et al. Family
Planning, Family Welfare and Women's Activities in Indonesia.
(Research Triangle Park, NC: Population Studies Center, Gadjah Mada
University and Family Health International, 1997)18-20.
- Irwanto, Poerwandari EK, Prasadja H, et al. In
the Shadow of Men: Reproductive Decision-making and Women's
Psychological Well-being in Indonesia. (Research Triangle Park,
NC: Atma Jaya Catholic University and Family Health International,
1997)49.
- Cabaraban MC, Morales BC. Social and Economic
Consequences of Family Planning Use in Southern Philippines.
Research Triangle Park, NC: Xavier University and Family Health
International, 1998.
- Fathonah S. Contraceptive Use Dynamics in
Indonesia, DHS Working Papers Number 20. Calverton, MD: Macro
International, 1996.
- Tolley E, Nare C. Women's experiences with
Norplant removal in four clinics in Dakar. Unpublished paper. Family
Health International, 1997.
- Avila JL. When Fate and Husbands Prevail: The
Dynamics of Women's Reproductive Decisions in the Philippines.
Cebu City, Philippines: University of San Carlos and Family Health
International, 1998.
- Pariani S, Heer DM, Van Arsdol MD Jr. Does choice
make a difference to contraceptive use? Evidence from East Java. Stud
Fam Plann 1991;22(6):384-90.
- Jaccard J, Helbig DW, Gage TB, et al. Social and
situational factors associated with contraceptive switching:
implications for practitioners. J Applied Soc Psychology 1995;
25(20): 1765-89.
- Population Council. Focus on the Philippine DMPA
reintroduction program: continuing users vs. drop-outs. Population
Council Research News: Asia and Near East Operations Research and
Technical Assistance Project 1996;(7):1-2.
- Kost K. The dynamics of contraceptive use in Peru.
Stud Fam Plann 1993;24(2):109-19.
- World Health Organization. Improving Access to
Quality Care in Family Planning, Medical Eligibility Criteria for
Contraceptive Use. Geneva: World Health Organization, 1996.
- Population Council.
- Breitbart V, Castle MA, Walsh K, et al. The impact
of patient experience on practice: the acceptability of emergency
contraceptive pills in inner-city clinics. JAMWA 1998;53(5):255-58.
- Ni Riain A. Increasing the effectiveness of
contraceptive usage in university students. European J Contracept
and Reprod Health Care 1998;3(3):124-28.
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