Over the course of their lives, women may choose to start, stop, or switch family planning methods to meet their reproductive needs and preferences. By understanding the dynamics of contraceptive use, health policy and program decisionmakers can better deliver high-quality, client-centered services that enable women and couples to make the best family planning choices for themselves.
Follow the trajectory of ages in .
What’s a Sankey Diagram?
Sankey diagrams are a type of flow diagram that shows the direction and relative size of flows from one category, or “node”, to another. This Sankey diagram visualizes trends in contraceptive discontinuation and switching over a two-year period. Each node represents a category of family planning users or non-users. In the diagram, nodes at the top are more-effective family planning categories while those at the bottom are less-effective, or non-users.
The connections between each node are called flow lines. The flow lines show the proportion of women who started and ended in each category during the time period. The bigger the flow line, the larger the number of women who “flowed” from one node to another.
You can click on each node to lock it in place, and hover over each flow line to see how many women transitioned from one node to the next. Your first view of this Sankey shows trends for all women across long-action reversible contraceptives (LARC), short-acting modern (SAM) methods, traditional/folk methods, pregnant women, and non-use. LARCs include IUDs and implants. SAMs include injectables, pills, and other modern methods. When you explore the data for family-planning users and non-users, data are disaggregated by method. In this view, other modern methods include male and female condom, emergency contraception, diaphragm, foam or jelly, lactational amenorrhea, and standard days methods.
Go ahead, check it out!Discontinued while
still in need
LARC: Long-acting reversible contraceptives (IUD and implant)
SAM: Short-acting modern methods (injectable, pill, other modern)
Other modern: male and female condom, emergency contraception, diaphragm, foam or jelly, lactational amenorrhea, standard days method
N/A: Some samples are under the display threshold and do not appear
Women choose to discontinue family planning for a variety of reasons, such as starting a family, onset of menopause, or separation from a partner. But for many women, the decision is driven by method-related reasons such as concerns about side effects or lack of access to their preferred method. Others may find a method to be inconvenient or lack information about the full range of family planning options. Understanding the reasons women stop using contraception enables policy and program decisionmakers to improve health service delivery to better meet the needs and preferences of family planning clients.
Explore the reasons women age report for discontinuing family planning during the year of use in .
Analysis based on episodes of contraceptive use. Methods based on fewer than 100 episodes are not shown.
Even among women who wish to avoid or delay pregnancy, contraceptive discontinuation is often high. In some countries, over 60 percent of pregnancies that begin within 12 months of discontinuation while still in need are unintended. Investments to improve comprehensive counseling, reduce financial and other barriers to access, and expand the family planning method mix may help enhance contraceptive continuation and reduce unintended pregnancy.
Wantedness of pregnancies within 12 months of discontinuation while still in need
Policy and program decisionmakers’ efforts to address barriers to contraceptive continuation should be tailored to the unique national and subnational drivers of discontinuation. Several countries consider these barriers in their Costed Implementation Plans, which outline how they will achieve their family planning goals and commitments. To accelerate progress, decisionmakers can incorporate the following evidence-based approaches to support women who wish to delay or avoid pregnancy in family planning policies and programs.
Recommendations
Studies suggest that comprehensive counseling on side effects during the initial client visit can significantly increase the likelihood of continued use. Comprehensive counseling ultimately ensures that a patient has accurate expectations of their chosen method and an understanding that they may select a different option if a method proves unsuitable. Providers should be trained on all such components to support each patient in choosing the best method for their needs, thereby decreasing the risk of discontinuation. Tools such as job aids for health providers appear to facilitate increased continuation rates: One intervention showed that use of job aids and appointment cards yielded a discontinuation rate 10 percent lower than the control arm, which used neither.
Guidelines to improve counseling should address:
- Potential side effects, ways to manage side effects, expected menstrual bleeding changes, and alternative available methods if the one selected is no longer wanted.
- Alternate methods prior to discussing full discontinuation for patients reporting dissatisfaction with their method if the patient’s goal is still to prevent pregnancy.
- The patient’s level of literacy, using a model in-person or providing illustrations for take-home information for patients who cannot read.
- Provider motivation and/or bias, a known barrier in family planning program implementation. Job aids may have a protective effect against provider bias if they follow a transparent algorithm. Utilizing a job aid may ensure customized, unbiased method selection and comprehensive counseling.
Evidence of Impact: High
Fifteen sources including two Cochrane reviews and three randomized trials provided strong supporting evidence for this recommendation.
Syed Khurram Azmat et al., “Rates of IUCD Discontinuation and Its Associated Factors Among the Clients of a Social Franchising Network in Pakistan,” BMC Women's Health 12, no. 1 (2012). doi.org/10.1186/1472-6874-12-8.
Syed Khurram Azmat et al., “IUD Discontinuation Rates, Switching Behavior, and User Satisfaction: Findings From a Retrospective Analysis of a Mobile Outreach Service Program in Pakistan,” International Journal of Women's Health 19 (2013). doi.org/10.2147/ijwh.s36785.
Joy Noel Baumgartner et al., “Impact of a Provider Job Aid Intervention on Injectable Contraceptive Continuation in South Africa,” Studies in Family Planning 43, no. 4 (2012): 305-14. doi.org/10.1111/j.1728-4465.2012.00328.x.
Francesca L. Cavallaro et al., “A Systematic Review of the Effectiveness of Counselling Strategies for Modern Contraceptive Methods: What Works and What Doesn’t?” BMJ Sexual & Reproductive Health (2019). doi.org/10.1136/bmjsrh-2019-200377.
Nirali M. Chakraborty et al., “Association Between the Quality of Contraceptive Counseling and Method Continuation: Findings From a Prospective Cohort Study in Social Franchise Clinics in Pakistan and Uganda,” Global Health: Science and Practice 7, no. 1 (2019): 87-102. doi.org/10.9745/ghsp-d-18-00407.
Nabamallika Dehingia et al., “Family Planning Counseling and Its Associations With Modern Contraceptive Use, Initiation, and Continuation in Rural Uttar Pradesh, India,” Reproductive Health 16, no. 1 (2019). doi.org/10.1186/s12978-019-0844-0.
Karla Feeser et al., “Measures of Family Planning Service Quality Associated With Contraceptive Discontinuation: An Analysis of Measurement, Learning & Evaluation (MLE) Project Data From Urban Kenya,” Gates Open Research 3 (2019): 1453. doi.org/10.12688/gatesopenres.12974.1.
Ana Laura Carneiro Gomes Ferreira, Mariana Moreira Boa-Viagem, and Ariani Impieri Souza, “Contraceptive Continuation, Pregnancy, and Abortion Rate Two Years After Post Abortion Counselling,” Open Journal of Obstetrics and Gynecology 5, no. 3 (2015): 135-41. doi.org/10.4236/ojog.2015.53018.
Lisa Haddad et al., “Contraceptive Discontinuation and Switching Among Couples Receiving Integrated HIV and Family Planning Services in Lusaka, Zambia,” AIDS 27 (2013). doi.org/10.1097/qad.0000000000000039.
Waqas Hameed et al., “Determinants of Method Switching Among Social Franchise Clients Who Discontinued the Use of Intrauterine Contraceptive Device,” International Journal of Reproductive Medicine 2015 (2015): 1-8. doi.org/10.1155/2015/941708.
Waqas Hameed et al., “Continuation Rates and Reasons for Discontinuation of Intra-Uterine Device in Three Provinces of Pakistan: Results of a 24-Month Prospective Client Follow-Up,” Health Research Policy and Systems 13, no. S1 (2015). doi.org/10.1186/s12961-015-0040-9.
Ali Mehryar Karim et al., “Application of Behavioral Economics Principles to Reduce Injectable Contraceptive Discontinuation in Rural Ethiopia: A Stratified-Pair, Cluster-Randomized Field Trial,” Gates Open Research 3 (2019): 1494. doi.org/10.12688/gatesopenres.12987.1.
Natasha Mack et al., “Strategies to Improve Adherence and Continuation of Shorter-Term Hormonal Methods of Contraception,” Cochrane Database of Systematic Reviews, 2019.
Ellen Maclachlan et al., “Continuation of Subcutaneous or Intramuscular Injectable Contraception When Administered by Facility-Based and Community Health Workers: Findings From a Prospective Cohort Study in Burkina Faso and Uganda,” Contraception 98, no. 5 (2018): 423-29. doi.org/10.1016/j.contraception.2018.08.007.
Chris Smith et al., “Mobile Phone-Based Interventions for Improving Contraception Use,” Cochrane Database of Systematic Reviews, 2015. doi.org/10.1002/14651858.cd011159.pub2.
Contraceptive methods require different adherence timelines, with action required by users at intervals ranging from daily to monthly to quarterly to several years. To continue their selected method, women must be able to access and use it consistently, which can be difficult when usage depends on clinic or pharmacy visits to receive or purchase the method. Improving reminder mechanisms—such as appointment cards or mobile text messages—can help women better plan for their next opportunity to seek family planning care (for example, to receive an injection) or re-stock their own supply (for example, for oral contraceptives). Through these reminders, providers also have the opportunity to offer follow-up care or counseling remotely. Some studies suggest daily educational text messages can improve continued use of the pill.
Supporting consistent and correct method use through follow-up mechanisms can include:
- Voicemail or text messages to follow up with women on post-appointment care and interim health concerns, and/or to notify clients of upcoming appointments.
- A wide range of tools available online, via mobile device, and in hard copy to help providers determine and follow up on the best method for the patient. Tools should be holistic, factoring in physical, emotional, and financial components to guide deciding on and adhering to a family planning method.
- Appointment cards provided at the time of care to remind clients about future appointments. Appointment cards may also provide critical information on what to do if a woman cannot make it to her next appointment or experiences health concerns in the interim (and is unable to access a provider for immediate consult).
Evidence of Impact: Moderate
Seven sources, including a two Cochrane reviews and a field trial, provide moderate evidence supporting this recommendation.
Syed Khurram Azmat et al., “Rates of IUCD Discontinuation and Its Associated Factors Among the Clients of a Social Franchising Network in Pakistan,” BMC Women's Health 12, no. 1 (2012). doi.org/10.1186/1472-6874-12-8.
Francesca L. Cavallaro et al., “A Systematic Review of the Effectiveness of Counselling Strategies for Modern Contraceptive Methods: What Works and What Doesn’t?” BMJ Sexual & Reproductive Health (2019). doi.org/10.1136/bmjsrh-2019-200377.
Jane Cover et al., “Continuation of Self-Injected Versus Provider-Administered Contraception in Senegal: A Nonrandomized, Prospective Cohort Study,” Contraception 99, no. 2 (2019): 137-41. doi.org/10.1016/j.contraception.2018.11.001.
Waqas Hameed et al., “Determinants of Method Switching Among Social Franchise Clients Who Discontinued the Use of Intrauterine Contraceptive Device,” International Journal of Reproductive Medicine 2015 (2015): 1-8. doi.org/10.1155/2015/941708.
Ali Mehryar Karim et al., “Application of Behavioral Economics Principles to Reduce Injectable Contraceptive Discontinuation in Rural Ethiopia: A Stratified-Pair, Cluster-Randomized Field Trial,” Gates Open Research 3 (2019): 1494. doi.org/10.12688/gatesopenres.12987.1.
Natasha Mack et al., “Strategies to Improve Adherence and Continuation of Shorter-Term Hormonal Methods of Contraception,” Cochrane Database of Systematic Reviews, 2019. doi.org/10.1002/14651858.cd004317.pub5.
Chris Smith et al., “Mobile Phone-Based Interventions for Improving Contraception Use,” Cochrane Database of Systematic Reviews, 2015. doi.org/10.1002/14651858.cd011159.pub2.
Women with the full range of contraceptive options available to them have lower rates of discontinuation. While findings on the relationship between method availability and overall modern contraceptive prevalence rate (mCPR) are mixed, studies do suggest that method choice is associated with higher continuation rates, perhaps because offering other method options allows a woman to switch methods rather than discontinue altogether. Access to the full range of options encompasses not only physical availability (supply), but also logistical and financial availability. Minimizing these common barriers through autonomous care can further improve access. Across three countries in Sub-Saharan Africa, the 12-month continuation rate for women who practiced the autonomous approach of self-injection was 73 percent, almost 25 percent higher than those who received injection from a provider, suggesting that self-injection can improve continuation.
Broadening access to the full complement of methods, particularly to encourage autonomy through self-care, can include:
- Task-shifting approaches that bring more methods, including self-care options, closer to the community, and allow women greater control over their use of a chosen method. One particularly effective self-care mechanism is self-injection. In reducing the number of return visits to a clinic, self-injection alleviates the transportation and economic burdens associated with travel, which decreases late or missed appointments—putting control of service provision back in the woman’s hands.
- Provider training on how to counsel patients on successful self-injection including: Needle insertion, activation, knowledge of steps, knowledge of reinjection dates.
- Reminder mechanisms to prompt women when it is time to self-administer an injection—ensuring they have purchased the syringe and are prepared to use it.
- Integrated support for self-care into the health system. This may
include:
- Provision of accessible information and resources (digital or hard copy) on correct product usage, including low literacy options.
- Facilitation of remote ordering and remote provider interactions through electronic and digital technologies.
- National self-care guidelines to generate acceptance and clear best practices for empowering patients.
- Incorporating self-care into existing family planning surveillance systems to ensure accurate understanding of use.
Evidence of Impact: Emerging
Four sources of, primarily, prospective cohort studies and a randomized trial provided strong supporting evidence for this recommendation.
Select emerging evidence from gray literature provided supplemental recommendations for integrating support for self-care into health systems.
Holly M. Burke et al., “Effect of Self-Administration Versus Provider-Administered Injection of Subcutaneous Depot Medroxyprogesterone Acetate on Continuation Rates in Malawi: A Randomised Controlled Trial,” Lancet Global Health 6, no. 5 (2018).doi.org/10.1016/s2214-109x(18)30061-5.
Jane Cover et al., “Continuation of Injectable Contraception When Self-Injected vs. Administered by a Facility-Based Health Worker: A Nonrandomized, Prospective Cohort Study in Uganda,” Contraception 98, no. 5 (2018): 383-88. doi.org/10.1016/j.contraception.2018.03.032.
Jane Cover et al., “Continuation of Self-Injected Versus Provider-Administered Contraception in Senegal: A Nonrandomized, Prospective Cohort Study,” Contraception 99, no. 2 (2019): 137-41. doi.org/10.1016/j.contraception.2018.11.001.
Ellen Maclachlan et al., “Continuation of Subcutaneous or Intramuscular Injectable Contraception When Administered by Facility-Based and Community Health Workers: Findings From a Prospective Cohort Study in Burkina Faso and Uganda,” Contraception 98, no. 5 (2018): 423-29. doi.org/10.1016/j.contraception.2018.08.007.
Population Services International, “A New Quality of Care Framework to Measure and Respond to People's Experience with Self-Care.” Knowledge SUCCESS, September 23, 2020. https://knowledgesuccess.org/2020/07/23/a-new-quality-of-care-framework-to-measure-and-respond-to-peoples-experience-with-self-care/.
When cost is not a decisionmaking factor, women are able to select (or switch to) the method that best fits their lifestyle without the influence of affordability, which may improve long-term continuation. Vouchers can be used as a demand-focused financing tool to improve access and equity for women seeking contraceptive methods.
Strategies to increase contraceptive equity and overcome cost barriers can consider:
- Implementing a voucher system/scheme, which is most effective when targeting specific households and women for whom cost is a significant barrier.
- Providing a financial subsidy for contraceptive services at public and/or private facilities including pre-paid consultations, follow up visits, side effect management, and/or removal of selected method.
- Providing vouchers or subsidies directly to the patient (as opposed to the head of household, if not the same).
Evidence of Impact: Moderate
Five sources, using a variety of methodological approaches including a program evaluation, cross-sectional survey, and prospective cohort study, provide moderate supporting evidence of this recommendation.
Moazzam Ali et al., “Are Family Planning Vouchers Effective in Increasing Use, Improving Equity, and Reaching the Underserved? An Evaluation of a Voucher Program in Pakistan,” BMC Health Services Research 19, no. 1 (2019). doi.org/10.1186/s12913-019-4027-z.
Syed Khurram Azmat et al., “Rates of IUCD Discontinuation and Its Associated Factors Among the Clients of a Social Franchising Network in Pakistan,” BMC Women's Health 12, no. 1 (2012). doi.org/10.1186/1472-6874-12-8.
Luke Boddam-Whetham et al., “Vouchers in Fragile States: Reducing Barriers to Long-Acting Reversible Contraception in Yemen and Pakistan,” Global Health: Science and Practice 4, no. Supplement 2 (2016). doi.org/10.9745/ghsp-d-15-00308.
Waqas Hameed et al., “Determinants of Method Switching Among Social Franchise Clients Who Discontinued the Use of Intrauterine Contraceptive Device,” International Journal of Reproductive Medicine 2015 (2015): 1-8. doi.org/10.1155/2015/941708.
Waqas Hameed et al., “Continuation Rates and Reasons for Discontinuation of Intra-Uterine Device in Three Provinces of Pakistan: Results of a 24-Month Prospective Client Follow-Up,” Health Research Policy and Systems 13, no. S1 (2015). doi.org/10.1186/s12961-015-0040-9.
Often more concerned with avoiding pregnancy than their male partners, women tend to seek out information on contraceptive options more often than men. However, male counterparts (boyfriends, partners, spouses) may have significant decisionmaking power in a household, including over the contraceptive method choice of their female partners. Studies suggest that the presence of supportive male counterparts is associated with lower rates of discontinuation, with one study reporting that having a partner who approved of contraceptive use lowered the rate of discontinuation by 52 percent. Similarly, evidence in several studies cites “male disapproval” as a common reason for method discontinuation. Couple-level agreement supports method continuation.
Strategies to prioritize male partner involvement should consider:
- Training providers and community health workers specifically in couples counseling.
- Adapting contraceptive counseling approaches to better accommodate couples as a means to establish patient-partner agreement on a selected method. Such approaches could include introducing comprehensive contraceptive counseling into HIV education for concordant couples.
- Encouraging women to engage male partners in their contraceptive method choice, if/when the woman finds it appropriate and safe.
- Employing strict consent procedures for all options to ensure that the female client is amendable to the inclusion of her male partner in counseling and to set clear boundaries on what patient information remains confidential.
- Connecting male partners to male providers/health workers to inform them on contraceptive options best for their joint fertility goals. Additionally, framing this contraceptive discourse in terms of the economic/financial costs of parenting or an unwanted pregnancy also appeared to effectively encourage buy-in.
Evidence of Impact: Moderate
Five sources, including one Cochrane review and several prospective cohort studies, provide moderate supporting evidence for this recommendation.
Francesca L. Cavallaro et al., “A Systematic Review of the Effectiveness of Counselling Strategies for Modern Contraceptive Methods: What Works and What Doesn’t?” BMJ Sexual & Reproductive Health (2019). doi.org/10.1136/bmjsrh-2019-200377.
Jane Cover et al., “Continuation of Injectable Contraception When Self-Injected vs. Administered by a Facility-Based Health Worker: A Nonrandomized, Prospective Cohort Study in Uganda,” Contraception 98, no. 5 (2018): 383-88. doi.org/10.1016/j.contraception.2018.03.032.
Jane Cover et al., “Continuation of Self-Injected Versus Provider-Administered Contraception in Senegal: A Nonrandomized, Prospective Cohort Study,” Contraception 99, no. 2 (2019): 137-41. doi.org/10.1016/j.contraception.2018.11.001
Lisa Haddad et al., “Contraceptive Discontinuation and Switching Among Couples Receiving Integrated HIV and Family Planning Services in Lusaka, Zambia,” AIDS 27 (2013). doi.org/10.1097/qad.0000000000000039.
Ellen Maclachlan et al., “Continuation of Subcutaneous or Intramuscular Injectable Contraception When Administered by Facility-Based and Community Health Workers: Findings From a Prospective Cohort Study in Burkina Faso and Uganda,” Contraception 98, no. 5 (2018): 423-29. doi.org/10.1016/j.contraception.2018.08.007.