Prevalence and associated factors of modern contraceptive discontinuation among sexually active married women in Nigeria

doi:10.21203/rs.3.rs-2123371/v1

Background

Contraceptive discontinuation for reasons other than the desire for pregnancy is associated with a high rate of unintended pregnancies leading to unsafe abortions, maternal morbidity and mortality. In Nigeria, little is known about modern contraceptive discontinuation using the calendar data. Thus, this study examined the prevalence and associated factors of modern contraceptive methods discontinuation among sexually active married women in Nigeria.

Methods

Out of the total sample of 41,821 women (15–49 years) in the individual recode (IR) dataset of the 2018 Nigeria Demographic and Health Surveys (NDHS) with reproductive calendar history, this study analysed a weighted sample size of 3,433 currently sexually active married or in union women who have ever used a modern contraceptive 5 years before the survey and with complete reproductive histories and are not sterilised or declared infecund. The outcome variable was modern contraceptive discontinuation (Pill, IUD, Injections, diaphragm, male condom, female sterilization, male sterilization, implants, female condom, foam/jelly, and lactational amenorrhea) which was disaggregated based on whether discontinuation occurred even though they are still at risk of unwanted pregnancy or not. The explanatory variables examined are the socio-demographic characteristics of the respondents (age, wealth index, religion, education, marital duration, media exposure, and visitation to health facilities in the last 12 months). Data were analysed and displayed using frequency tables and charts, Pearson's chi-square test, and the binary logistic regression model.

Results

Among the sampled women, 35.8% discontinued using modern contraceptives with 45.8% of the women discontinuing using modern contraceptives while at risk of pregnancy. The most modern method discontinued was Injections (25.2%) while the commonest reason for modern method discontinuation was because they wanted to become pregnant (36.1%). Associated factors of modern contraceptive discontinuation among Nigerian women were: marital duration (AOR = 3.47; 95%CI: 2.0–6.0), visitation to a health facility in the last 12 months (AOR = 0.58; 95%CI: 0.4–0.8), education (AOR = 2.00; 95%CI: 1.2–3.4), wealth quintile (AOR = 0.81; 95%CI: 0.4–1.9) and region of residence (AOR = 2.73; 95%CI: 1.6–4.7).

Conclusion

This study concluded that modern contraceptive discontinuation was high. Region of residence, health facility visitation and marital duration were significantly related to modern contraceptive discontinuation. The study suggests that policymakers should recognise women's ability to visit a health facility, marital duration, and region of residence are significantly associated with modern contraceptives. Policymakers must recognise these factors to increase modern contraceptive use in the country.

Modern contraceptive discontinuation

sexually active

married women

Nigeria

The interruption of contraceptive use for one month or longer by women who had used a contraceptive method in the past 12 months but discontinued at least once without switching to another method has been identified as a clog in achieving maternal and child health-related Sustainable Development Goals (SDG) [1, 2, 3]. Discontinuation of contraceptive use, while women are still at risk of becoming pregnant without switching to any other contraceptive methods, has adverse reproductive health consequences [4, 5]. It has adverse effects on family planning programmes as well as grave implications for demographic growth [4]. According to the WHO, contraceptive discontinuation for reasons other than the desire for pregnancy is associated with a high rate of unintended pregnancies leading to unsafe abortions, maternal morbidity and mortality [2, 6]. Globally, as of 2019, about 270 million women who were sexually active and wanted to avoid pregnancies and/or postponed births were not using modern contraceptives [7, 8, 9]. In developing countries, every year, about 74 million unintended pregnancies occur particularly among a great number of women who are not using any contraceptive [8, 9, 10]. However, consistent and effective use of modern methods of contraception could prevent unintended pregnancies and deaths of women from pregnancy-related causes [11, 12, 10]. For instance, globally in 2019, about 85% of women who were not using any contraceptive method became pregnant during the first year of discontinuation of contraception [13]. Subsequently, at least one in four pregnancies was unintended in the year [14, 15, 16]. Despite these negative reproductive health consequences of not using a contraceptive method, a large number of sexually active women who intend to avoid pregnancy are not using any contraceptive method for various reasons [17, 18]. These include the fear of contraceptive side effects, method failure, menstrual disruption, husband/spousal disapproval, menopause, fear of infertility, and desire for more children [19, 20]. Extant literature has shown that 65% of sexually active women (15–49) who have an unmet need for contraception in 2018, stopped using contraception because of the fear of side effects, and health risks/concerns [2, 12]. Meanwhile, contraceptive discontinuation while still at risk of becoming pregnant has a wide range of health risks for the mother and child [21]. These include high-risk pregnancies and childbirths, unsafe abortions, and low educational and employment opportunities, among others [22, 23, 24]. According to the World Health Organisation (WHO), the consistent and effective use of modern methods of contraception offers a better opportunity for couples to limit and space the number of children they want [25]. It also helps in reducing maternal morbidity and mortality [26]. Studies on maternal mortality have shown that about 44% of maternal deaths were prevented through the consistent use of contraceptives [21, 27]. In the last two decades in Nigeria, among currently married women of reproductive age (15–49), the overall use of contraception has increased from 15–17% [28]. Within the same period, the use of any modern method of contraception has increased by 2% (from 10–12%) with a noticeable rise in the use of implants and injectables from 0–3% [28]. Despite the overall increase in modern contraceptive use in the 5 years preceding the 2018 Demographic and Health Survey [DHS] in Nigeria, two out of every five contraceptive users (40.6%) discontinued the method within 12 months [28]. In addition to this, the proportion of women who switched to another method after discontinuation of the previous method has reduced from 4.8% in 2013 to 4.5% in 2018 [28]. This high rate of modern contraceptive discontinuation could cause Nigeria to lose the progress made in increasing contraceptive use over the past 20 years.

There have been several studies [29, 6, 5, 30, 31] on why contraceptive users decide to continue or discontinue contraception. However, successive studies on factors influencing modern contraceptive discontinuation in Nigeria using national data is limited. This study, therefore, tries to fill this gap by using the 2018 NDHS calendar data and raising two research questions. What is the prevalence of modern contraceptive method discontinuation, and what are the associated factors influencing modern contraceptive discontinuation among sexually active married women in Nigeria? The 2018 NDHS calendar data covers month-by-month information on episodes of contraceptive use for the five years preceding the survey. Thus, this study examines the prevalence and associated factors of modern contraceptive method discontinuation among sexually active married women in Nigeria. The finding will inform achieving maternal and child health-related Sustainable Development Goals (SDG) [32], and the Family Planning Blueprint (scale-up plan) in Nigeria [33] by reducing maternal morbidity and mortality as well as unintended pregnancies.

Theoretical Framework

The theory of the Health Belief Model (HBM) [34] provides theoretical support for this study. The HBM is a good framework for explaining and predicting contraceptive behaviour (i.e. probability of modern contraceptive continuation or discontinuation). The theory postulates that health-related behaviour hinges on perceived susceptibility and severity of becoming ill with a disease or health condition. Perceived benefits of preventive behaviour, perceived barriers to preventive behaviour, cues to action, and self-efficacy for preventive behaviour. The concepts of HBM as applied to modern contraceptive behaviour are to be achieved through activities involved in the process of health decision-making such as identifying and using a modern contraceptive method to prevent unwanted pregnancy. This process of health decision-making includes; Perceived susceptibility; knowledge, belief and the risk of getting pregnant). Perceived severity; beliefs about the social and medical consequences of pregnancy and childbirth. Perceived benefits; knowledge and belief about contraceptive efficacy and long-term convenience. Perceived barriers; beliefs about the side effect, risks and costs of accepting a new health behaviour. Cues to action; both internal and external stimuli such as counselling, media exposure, and missed menstrual period after intercourse could trigger the health behaviour). Self-efficacy; contraceptive decision-making and the probability of modern contraceptive continuation or discontinuation (35). The combination of these factors together with the modifying and enabling factors (socio-demographic, psychological, structural, and reproductive) interact and triggers a reaction that repeatedly exhibits the likelihood of modern contraceptive continuation or discontinuation (36, 37). In Nigeria, women's use of FP services particularly modern contraceptives is low. Thus, HBM provides the path to understanding the factors influencing modern contraceptive behaviour and the strategies to prevent unintended pregnancy.

Study Design and Data Source

The 2018 NDHS data used for this study adopted a cross-sectional research design. The women’s individual recode (IR) data extracted from the survey was used for the study. The data is accessible at https://dhsprogram.com/data/available-datasets.cfm.

Participants

The 2018 DHS was a national representative data of approximately 42,000 selected households. The survey targeted women aged 15–49 across the country. The sample was selected using a two-stage stratified random sampling technique. A multi-stage sampling technique was employed in the survey. Firstly, the country was stratified into urban and rural areas and then the primary sampling units were selected using a two-stage procedure. The selection of households was done through systematic random sampling. In all, 41,821 women were completely interviewed in the survey. Details information about the sampling procedure is available in the survey report and on the DHS website (https://dhsprogram.com).

Study Context

Nigeria has 36 States, the Federal Capital Territory (Abuja), and 774 constitutionally recognised local government areas across the six geo-political zones. It has 374 identifiable ethnic groups and three major ethnic groups (Hausa, Yoruba, and Igbo) [32, 33]. The country has a fast-growing population, with an estimated population of over 180 million [18]. About 46 million of this population are women of reproductive age with a total fertility rate (TFR) of 5.3 and low use of family planning services [18]. In addressing the fast-growing population and unintended pregnancies, as well as preventing maternal, infant, and child mortality, the Federal Government of Nigeria (FGoN), through the Federal Ministry of Health (FMoH), has set a target of increasing women’s use of FP services from the 2013 contraceptive prevalence rate (CPR) of 15–36% by 2018 [38]. In addition, a scale-up plan; the revised National Family Planning Blueprint (2020–2024), was also set up with the main goal of increasing the modern contraceptive prevalence rate (mCPR) to 27% by the year 2024 [38], representing a projected 3% annual growth from the 2018 national mCPR [32]. This blueprint is expected to avert around 400,000 infants, 700,000 child deaths and 1.6 million unintended pregnancies [18]. However, extant literature has shown that in the last two decades in Nigeria, among currently married women of reproductive age (15–49), the overall use of contraception has increased from 15–17% [28]. Within the same period, the use of any modern method of contraception has increased by 2% (from 10–12%) with a noticeable rise in the use of implants and injectables from 0–3% (NPC [28]. Despite the overall increase in modern contraceptive use in the 5 years preceding the 2018 Demographic and Health Survey [DHS] in Nigeria, two out of every five (40.6%) contraceptive users discontinued the method within 12 months [28]. In addition, the proportion of women who switched to another method after discontinuation of the previous method has reduced from 4.8% in 2013 to 4.5% in 2018 [28].

Data Collection

The DHS’s reproductive calendar data derived from the women’s questionnaire was used for this study. The data captured reliable and valid information on contraceptive use (Callahan & Becker, 2012). The data covers month-by-month strong retrospective information among women aged 15–49 on episodes of contraceptive use and non-use for five years preceding the DHS survey [31, 39, 40, 41]. Hence, it provides strong historical information on contraceptive discontinuation. The reproductive calendar data are recorded in a series of string variables (vcal variables) for each of the columns in the calendar [42, 43]. These string variables were converted into event data files to make each reproductive event (duration in months) become one observation in the dataset. These event variables were then used to calculate a contraceptive discontinuation rate and the number of episodes. The string functions command in Stata 14 that transform and restructure the calendar data into a single month was used to create event data files.

The discontinuation rate was calculated using a life table that generated the net discontinuation rates. The rate was calculated by dividing the number of episodes discontinued in a month by the total number of episodes that complete the duration. A 12-month duration for each of the discontinuation reasons was also calculated. In this study, a woman may contribute more than one episode to the calculation. Episodes in the last two months of the interview and the month of the interview were left out to avoid bias that may be introduced by unrecognized or unnoticed pregnancy in the analysis [42]. The duration of the episodes of contraceptive use was also calculated by examining each position in sequential order (starting at the end of the string and moving towards the beginning) for a contraceptive code. The first code following a position without that code indicates the start of a new episode of use. The last position (e.g., January 2013) is ignored in this examination, since a code in that position may represent an episode of use that began before the calendar start date. The number of continuous positions with the same contraceptive code indicates the number of months of use in the episode. An episode ends if the following month does not have the same contraceptive code (discontinuation) or corresponds to the month of the interview (a censored duration). The episodes are then tabulated by duration and reasons for ending for each contraceptive method and all methods combined. Standard life table calculations are then applied to the terminations to calculate months of exposure and the number of discontinuations by month of an episode. The cumulative proportion that is discontinued by 12 months is taken as the 12-month discontinuation rate. The unit of analysis in this study is the episodes of modern contraceptives used from 3–62 months preceding the date of the survey. Thus, the first episode of contraceptive use in the observation period was analysed.

Inclusion And Exclusion Criteria

Women who were not sexually active and not married/in-union, women who had never used contraceptives, women who had indicated that they were pregnant at the time of the survey, infecund women who were self-reported, and women with incomplete contraceptive information were excluded in this study. Also, out of the total sample of 41,821 women (15–49 years) in the IR data file, a weighted sample size of 3,433 currently sexually active married or in the union who were using a modern contraceptive and not sterilised or declared infecund were included and analysed.

Handling of missing values

In DHS, the use of contraception is generally not allowed to be missing in any month in the calendar. In the few surveys where it is missing, they are treated as months of non-use of contraception. Thus, missing and unknown reasons for discontinuation are treated as “Other” reasons in this study.

Definition And Measurement Of Variables

Dependent variable

The dependent variable is the modern contraceptive discontinuation (Pill, IUD, Injections, diaphragm, male condom, female sterilisation, male sterilisation, implants, female condom, foam/jelly, and lactational amenorrhea). Discontinuation refers to the disruption of the use of modern contraceptive methods for at least 12 months before the survey. It was operationalised as a dichotomous variable, coded as '1' for currently married women who are using contraception 12 months before the survey, but discontinue before the end of the 12 months and coded as '0' otherwise. However, we are not concerned with all contraceptive discontinuation because the fertility desires of currently married women change over time. Therefore, in this analysis, discontinuation was further disaggregated based on whether discontinuation occurred even though they are still at risk of unwanted pregnancy or not. Thus, discontinuation while still at risk was coded as “1” and as ‘0’ if otherwise.

Independent Variables

The independent variables considered in this study were: age, household wealth, region, and education. Others include the history of visiting a health facility in the last 12 months, media exposure and marital duration. Age was categorised into 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, and 45–49. Household wealth; women’s household ownership of assets, was classified into the poorest, poorer, middle, richer and richest. The region of residence in which respondents were interviewed was grouped into North West, North East, North Central, South West, South East and South-South. Women’s highest level of education attained was grouped into no education, primary, secondary, and higher. The history of visiting health facilities in the last 12 months was grouped as yes and no. Media exposure was defined based on the use of at least one of the news outlets. It was grouped as exposed and not exposed. Finally, marital duration was calculated by subtracting the age at the time of marriage from the age at the time of the survey, in completed years. It was categorised as 0–4, 5–9, 10–14, 15–19, 20 years or more. The variables were included in the study and used to build models based on evidence from existing literature regarding factors associated with contraceptive discontinuation and/or based on a theoretical association

Data Analysis

Data were analysed in three stages (univariate, bivariate and multivariable) using the Stata statistical package version 14 [44]. First, frequencies and percentages were used to describe the categorical variables while the mean values were used for the continuous variables. In the second stage, Pearson's Chi-square goodness of fit test was performed to examine predictors that had a statistically and meaningfully crude association with contraceptive discontinuation using the confidence interval (CI) and the p-values. In addition to this, tests for multi-collinearity among variables were performed using the variance inflation factor threshold of < 5 [45]. A threshold means a score of 3.12 was obtained. Thus, all predictor variables that were significantly correlated with contraceptive discontinuation were kept in the logistic regression model in the third stage. Furthermore, sample weights and the Stata complex survey (svy) commands were also employed to cater for stratified sample design and the effect of oversampling or under-sampling of some regions or areas as recommended by DHS [18]. Finally, in the multivariable analysis, a logistic regression model with a 95% confidence interval was used to examine the determinants of contraceptive discontinuation up to 12 months. In this study, we focused on women who discontinued using modern contraceptive methods (pills, IUDs, injectables, implants, female condoms, and male condoms). To avoid bias as a result of the failure of some women to realise that they are pregnant in their first trimester, we censored discontinuation on the month of the interview or two months before the survey.

Univariate Analysis

Table 1 presents the percentage distribution of the selected socio-demographic characteristics of the respondents. The mean age of the respondents was 32.4. Slightly more than half (55%) were aged 25-34, while to some extent, more than a third (36.7%) were aged 35-49. A high proportion of respondents (44.4%) were in the richest households' quintile, and more than a quarter (27.5%) were in the richer households’ quintile. Almost one-third of the respondents (32.3%) were from South West geo-political zone. The majority of the respondents (74.6%) had secondary school and above. On marital duration, more than half (55.6%) of the respondents had between 5-9 and 10-14 marital duration (33.9% and 21.7% respectively). About a third of the respondents (31.1%) claimed to have had media exposure to family planning messages. Almost three of every five respondents (59.3%) had visited a health facility in the last 12 months.

Table 1: Percent Distribution of Respondent by socio-demographic Characteristics

Variables

Number of Women (%)

Not At Risk

At Risk

Total

1199 (100.00)

650

549

Age (in years)

15-19

20-24

25-29

30-34

35-39

40-44

45-49

Mean = 32.4

8 (0.7)

92 (7.7)

325 (27.1)

334 (27.9)

277 (23.1)

122 (10.2)

41 (3.4)

1.2

7.8

30.9

29.6

21.5

6.9

2.3

0.2

7.5

22.6

25.9

25.0

14.1

4.7

Wealth Index

Poorest

Poorer

Middle

Richer

Richest

51 (4.2)

108 (9.0)

178 (14.8)

330 (27.5)

532 (44.4)

4.3

10.1

14.2

26.1

45.2

4.1

7.7

15.6

29.2

43.5

Region

North Central

North East

North West

South East

South South

South West

146 (12.2)

138 (11.5)

177 (14.8)

185 (15.5)

165 (13.8)

387 (32.3)

14.3

12.8

11.6

17.1

13.6

30.6

9.7

10.0

18.6

13.6

14.0

34.2

Education

No education

Primary

Secondary

Tertiary

140 (11.7)

165 (13.7)

620 (51.7)

274 (22.9)

12.8

13.1

50.4

23.6

10.4

14.4

53.2

21.9

Marital duration

0-4

5-9

10-14

15-19

20+

186 (15.5)

407 (33.9)

260 (21.7)

196 (16.3)

150 (12.5)

18.1

37.5

22.0

14.4

8.0

12.5

29.7

21.3

18.6

17.9

Media exposure

No

Yes

826 (68.9)

372 (31.1)

70.8

29.2

66.7

33.3

Visited Health Facility in the Last 12 Months

No

Yes

488 (40.7)

711 (59.3)

34.2

65.8

48.5

51.5

Modern Contraceptive Discontinuation

The commonest reasons for modern contraceptive discontinuation (see Fig. 5) were the need to become pregnant (36.1%), followed by the need for a more effective method (19.1%), side effects/health concerns (14.1%), and became pregnant while using (13.4%).

Bivariate And Multivariable Analyses

The unadjusted bivariate results in Table 2 show a statistically significant relationship between modern contraceptive discontinuation and the time respondents last visited a health facility. The data revealed that women who visited a health facility in the last 12 months before the survey were 45% less likely to discontinue modern contraceptive methods compared to women who have not visited a health facility in the last 12 months before the survey (OR = 0.55, p < 0.001, CI: 0.41–0.75). The data also revealed a positive association between modern contraceptive discontinuation and marital duration. Marital duration increases consistently with modern contraceptive discontinuation. That is, the higher the marital duration, the higher the odds of modern contraceptive discontinuation. This relationship is statistically significant among women whose marital duration is 15–19 (OR = 1.86, p < 0.005, CI: 1.13–3.07) and 20 years and above (OR = 3.23, p < 0.001, CI: 1.92–5.42). Also, the region of residence is significantly associated with modern contraceptive discontinuation. The data revealed that women in the North West (OR = 2.37, p < 0.001, CI: 1.37–4.12) and women in the South West (OR = 1.65, p < 0.005, CI: 1.03–2.65) have a higher odds of modern contraceptive discontinuation than women in the Northern Central (RC). Furthermore, as regards education, the results showed a significant inverse relationship between educational level and modern contraceptive discontinuation. The higher the educational level, the lower the modern contraceptive discontinuation. On the wealth quintile, the analysis showed a positive relationship between the wealth quintile and modern contraceptive discontinuation.

Table 2: Logistic Regression analysis of determinants of modern contraceptive discontinuation

Variables

Crude Odd Ratio (OR)

95% CI

Adjusted Odd Ratio (aOR)

95% CI

Visited Health Facility in the Last 12 Months

No

Yes

RC

0.55

0.41-0.75*

RC

0.58*

0.43-0.78

Media exposure

No

Yes

RC

1.22

0.89-1.67

RC

1.17

0.83-1.63

Marital duration

0-4

5-9

10-14

15-19

20+

RC

1.14

1.39

1.86

3.23

0.73-1.76

0.88-2.20

1.13-3.07**

1.92-5.42*

RC

1.13

1.30

1.65

3.02*

0.70-1.82

0.79-2.16

0.91-2.98

1.48-6.16

Region

North Central

North East

North West

South East

South South

South West

Wealth Index

Poorest

Poorer

Middle

Richer

Richest

Education

No education

Primary

Secondary

Tertiary

Age

15-19

20-24

25-29

30-34

35-39

40-44

45-49

RC

1.15

2.37

1.18

1.52

1.65

0.81

1.17

1.20

1.03

1.36

1.31

1.15

7.14

5.36

6.44

8.56

15.07

15.36

0.69-1.94

1.37-4.12*

0.71-1.95

0.89-2.58

1.03-2.65**

0.38-1.70

0.62-2.20

0.65-2.22

0.56-1.89

0.77-2.40

0.82-2.09

0.69-1.92

0.80-63.64

0.64-45.01

0.76-54.87

1.01-72.64**

1.74-130.45**

1.63-145.22**

RC

1.42

2.73*

1.13

1.55

1.69*

0.62

0.81*

0.81

0.69**

1.51

2.00**

1.97*

5.80

3.86

4.35

5.04

6.42

5.95

0.79-2.57

1.58-4.72

0.55-1.95

0.83-2.72

1.03-2.76

0.24-1.58

0.35-1.87

0.35-1.86

0.29-1.66

0.82-2.77

1.16-3.43

1.09-3.58

0.59-56.99

0.42-35.89

0.45-41.88

0.52-48.78

0.64-64.03

0.53-66.83

* p< 0.001, **p < 0.05, RC Reference Category, OR Odds Ratio, CI Confidence Interval, aOR Adjusted Odds Ratio

In the multivariable results, the adjusted odds ratio results in Table 2 show that women who visited a health facility in the last 12 months before the survey were 42% less likely to discontinue modern contraceptive methods than women who have not visited a health facility in the last 12 months before the survey (aOR = 0.58, p < 0.001, CI: 0.43–0.78). The data also revealed that the likelihood of modern contraceptive discontinuation increases consistently with marital duration. Women whose marital duration was 15–19 years were 65% more likely to discontinue modern contraceptive methods than women whose marital duration was 0–4 (RC) (aOR = 1.65, p < 0.005, CI: 0.91–2.98). Similarly, women whose marital duration was 20 years and above were 3.02 times more likely to discontinue modern contraceptive methods than women whose marital duration was 0–4 (RC) (aOR = 3.02, p < 0.001, CI: 1.48–6.16). Also, women from the North West region of the country were found to be 2.73 times more likely to discontinue modern contraceptive methods than North Central women (aOR = 2.73, p < 0.001, CI: 1.58–4.72). Likewise, women in South West region were 69% more likely to discontinue modern contraceptive methods than their counterparts from the North Central. (aOR = 1.69, p < 0.005, CI: 1.03–2.76).The data also revealed that women in the middle and the richest wealth quintile were 19% and 31% respectively to be less likely to discontinue modern contraceptive methods than their counterparts in the poorest wealth quintile. As regards the level of education, the data showed that women with secondary education and women with tertiary education were 2 times and 1.97 times respectively to be more likely to discontinue modern contraceptive methods than their counterparts with no education. Age and media exposure did not appear to be significantly associated with modern contraceptive methods discontinuation.

This study examined the prevalence and associated factors of modern contraceptive discontinuation. We sought to provide a better understanding of related factors influencing modern contraceptive discontinuation in Nigeria. The study found a significant number of women who discontinued using contraceptives while at risk of pregnancy. Previous studies have also reported this finding of contraceptive discontinuation in the 12 months among women at risk of pregnancy [5, 19, 50]. This, however, has serious negative reproductive health consequences. This is because contraceptive discontinuation for reasons other than the desire for pregnancy is associated with high rates of unintended pregnancies leading to unsafe abortions, maternal morbidity and mortality in Nigeria [25]. This pattern of results (high rate of contraceptive discontinuation for women at risk) is unexpected and challenging because a substantial proportion of women discontinued contraception for purposes beyond the desire to be pregnant. Other plausible reasons found in this study responsible for a high rate of contraceptive discontinuation included infrequent sex, inconvenient use, ineffective methods, methods failure, and side effects, among others, which were established in our study in its actual sense.

Just as established by mounting evidence in scholarly literature that a higher proportion of women are short–term contraceptive users globally, our study found that short-term contraceptive methods (injectable, pills and condoms) are the most discontinued modern contraceptive method. This finding corroborated existing findings [5, 47, 48]. The observable fact attributed to this is that it is easier to discontinue short-term contraception without professional service of medical/health providers unlike the Implant and IUD, or other long-acting reversible contraceptives (LARC). This might have accounted for the reason why women discontinued short-term contraceptive methods more often.

On the reason for modern contraceptive discontinuation, this study found that the intention to be pregnant is the commonest reason for modern contraceptive discontinuation. This finding aligns with what one would expect of women of reproductive age who wanted to be pregnant [17, 19, 21, 29]. However, side effects/health concerns and contraceptive failure were also mentioned as reasons why women discontinued modern contraceptive methods. This is consistent with previous studies [6, 29, 30] and lends credence to the need for adequate and accurate information and counselling on the failure and side effects of modern contraceptives. Our study also argues for the need to encourage long-acting and reversible methods which cannot be changed abruptly without the service of health providers.

Furthermore, our study established some significant correlates of modern contraceptive discontinuation among women aged 15–49. These include; a visit to a health facility in the 12 months, marital duration, education, wealth quintile and region of residence. The study found low discontinuation among women who visited a health facility in the last 12 months before the survey. This is consistent with a previous study [29]. The probable explanation for this is that women who visited health facilities in the reference period have a higher tendency to adhere to counselling and information on the benefits of using contraceptive methods as this could be easily assessed in the health facilities thus, reducing discontinuation. Even with other proximate barriers that drive contraceptive discontinuation, health facility visitation is likely the single most important variable that reduces contraceptive discontinuation among women at risk. The instructive message for policymakers is to increase both health facility and community-based family planning outreach and/or integrate family planning programmes in maternal health care services.

As expected, the study also found that marital duration influenced modern contraceptive discontinuation, especially short-term contraceptive methods. Women with longer marital duration may have discontinued contraception than their counterparts who are younger in marriage. Other studies [6, 17, 29, 49] have indicated that a longer duration of marriage may affect contraceptive use. This finding may be attributable to a reduced need for contraception by women who no longer desire to have more children or are older in marriage thereby using a long-acting and reversible contraceptive (LARC) method rather than short-term contraceptive methods. In like manner, married women with long years in marriage may have reached menopause or be less fertile. Furthermore, findings showed that women living in the North West had higher odds of modern contraceptive discontinuation. This finding corroborates existing findings [6, 29]. Though there is high contraceptive discontinuation across all the regions as it is nationally, a higher rate in North-West, for example, could be because of low knowledge of family planning, the predominant effect of Islamic pronatalist and religious doctrines. Also, it could be attributed to higher odds of discontinuation of contraception in the whole country. Policymakers should design and implement regional-specific policies to reduce contraceptive discontinuation, especially among women at risk in Nigeria

The data used for the study is quantitative and provides reliable nationally representative estimates that are generalizable for modern contraceptive discontinuation in Nigeria. The study also departs from previous studies as it considered the calendar year episodes of contraception history. Thus, as a consequence, the result is robust and can be used as evidence for policy formulation and design of family planning programmes for improved contraceptive use in the context of Nigeria and similar settings. However, it should be noted that the survey design is cross-sectional. Thus, causal inferences cannot be established. In addition to this, there is a possibility of recall bias due to the retrospective nature of the study.

The study found a high number of women who discontinued modern contraception while still at risk of becoming pregnant. Associated factors of modern contraception discontinuation were women's visitation to a health facility in the last 12 months of the observation period, marital duration, and region of residence. To increase modern contraceptive use in Nigeria, it is imperative for policymakers to address the discontinuation of contraception, particularly among short-term users as well as strengthen the use of contraception among those who are still at risk of becoming pregnant. Government should employ strategies to prevent discontinuation by dissuading users from seeing discontinuation as an option while still at risk.

SDG: Sustainable Development Goals, WHO: World Health Organization,

NPC: National Population Commission,

ICF: ICF International

DHS: Demographic and Health Survey,

NDHS: Nigeria Demographic and Health Survey,

UNFPA: United Nations Population Fund,

UNICEF: United Nations Children’s Fund,

IRB: Institutional Review Board,

IUD: FP: Family Planning,

CI: Confidence Interval, OR:

Crude Odds Ratio,

AOR: Adjusted Odds Ratio

Availability of data and materials

The datasets are available in the Nigeria Demographic and Health repository, http://dhsprogram.com/data/available-datasets.cfm. Permission to use the data was obtained at the Measure DHS website www.measuredhs.com upon request.

Acknowledgements

The author is grateful to ICF Macro, Calverton USA for the data used for this study.

Author’s contributions

JAK and BLS conceptualized and analysed the study. JAK, BLS OMA and JOA contributed to drafting the manuscript and interpreted the findings. All authors reviewed, edited and approved the final manuscript.

Funding

The authors did not obtain any funding for this research.

Consent for Publication

Not applicable.

Ethics approval and consent to participate

Ethical procedures and questionnaires for the 2018 DHS were approved by ICF Institutional Review Board (IRB) in the United States and the National Ethics Committee in the Federal Ministry of Health of Nigeria. The ICF IRB in the United States and Nigeria ensures that the survey complies with the laws and norms of both countries. Written and signed informed consent were obtained from the participants before they participated in the survey. Information was collected anonymously and confidentially [28]. Furthermore, the NDHS Individual recode (IR) data file used in this study was de-identified. It is no longer possible to identify the participants because all personally identifiable information has been removed. Therefore, no further ethics approval was required because the study used secondary data. However, permission to use the data was obtained from Measure DHS/ICF International, USA.

Competing interests

The authors declare that they have no competing interests.

Author Information

^{1.2.3, 4} Department of Demography and Social Statistics, Faculty of Social Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria

Corresponding author

Correspondence: [email protected]

Department of Demography and Social Statistics, Faculty of Social Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria

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No competing interests reported.

Prevalence and associated factors of modern contraceptive discontinuation among sexually active married women in Nigeria

Status:

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Abstract

Background

Methods

Results

Conclusion

Figures

Background

Theoretical Framework

Methods

Study Design and Data Source

Participants

Study Context

Data Collection

Inclusion And Exclusion Criteria

Handling of missing values

Definition And Measurement Of Variables

Dependent variable

Independent Variables

Data Analysis

Results

Univariate Analysis

Modern Contraceptive Discontinuation

Bivariate And Multivariable Analyses

Discussion

Strengths And Limitations Of The Study

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1