We found that about one-third of women experienced side effects while using hormonal methods, and that their associations with switching and discontinuation varied substantially based on the nature of side-effects. Experiencing more bleeding was strongly associated with discontinuation, while irregular bleeding, physical discomfort, and changes to sexual experience were associated with discontinuation. These results underscore the importance of examining the unique influence of specific side effects, instead of broad singular category of “side effects and health concerns”, in studies of contraceptive practices. Failure to investigate specific contraceptive side effects inhibits understanding of nuanced relationships between women’s experiences and their adaptive responses to contraceptive behaviors.
Our finding that increased menstrual bleeding was associated with discontinuation aligns with a growing body of literature, highlighting the importance of contraceptive-induced bleeding changes (1, 11). Excessive bleeding arose as a major barrier to contraceptive use in previous qualitative research in Uganda (22, 35, 36); that excessive bleeding was strongly associated with discontinuation, but not with switching, indicates that women who experience this side effect may be reluctant to switch to new methods, instead preferring to discontinue use altogether. The experience of excessive bleeding may be additionally problematic in environments like Uganda, where myths and misperceptions around the harmful impacts of contraception, including effects on future fertility and on overall health, are widespread (22, 37, 38). In strongly pronatalist cultures such as Uganda, where concerns of fertility are paramount, excessive bleeding may not be viewed simply as an inconvenience, but as a prequel to infertility. This belief carries profound social consequences and, therefore, may greatly reduce motivation to use contraception (17, 39)
We did not find significant effects with discontinuation or switching among women who reported less bleeding, although irregular bleeding was shown to reduce the risk of switching. Evidence from qualitative studies in Africa suggests that amenorrhea and irregular bleeding are often viewed negatively and associated with concerns about future fertility, particularly among nulliparous women (11), however recent qualitative evidence in Uganda found that the potential for lighter periods as a side effect of contraception was viewed favorably by women (36). Zimmerman and colleagues found that two-thirds of sexually active women in Uganda strongly agreed that not having a menstrual period as a result of contraceptive use was unhealthy, but agreement was not strongly associated with either discontinuation or switching (Under Review). This supports the current findings and suggests that while concerns about amenorrhea are prevalent, they did not seem to motivate contraceptive discontinuation in this sample. Of note, however, we did not distinguish between less bleeding and cessation of bleeding. Future research should attempt to distinguish between these two bleeding patterns, as complete cessation may engender different behavioral responses than a lighter, but consistent, menstrual period.
Though experiencing changes to sexual experience and physical discomfort were only marginally statistically significant, both were associated with increased risk of switching; changes to sexual experience demonstrated a particularly large effect size. One explanation for why these are related to switching rather than discontinuation is that these side effects may be perceived as less related to fertility risk; women may thus be willing to try another method, rather than discontinue use altogether. Very little research has explored either quantitatively or qualitatively how changes to sexual experience induced by contraceptive use affect contraceptive dynamics, despite evidence that changes to sexual experience and enjoyment for both the woman and her partner are critical (12, 20, 22, 40). Similarly, physical discomfort, which here included headache, nausea, weakness, and cramping, have generally not been included in studies that assess the impact of side effects. Unlike our findings, Barden-O’Fallon and colleagues found that abdominal cramping was not associated with the decision to switch versus stop method use. However, the authors did not assess whether cramping increased the overall risk of either relative to continuation (31). Some qualitative research in low-income countries has identified cramping as a concern (20), but the majority of research that has explored this side effect has been conducted in high income countries, thereby limiting comparison with countries like Uganda (41, 42). This limits our ability to compare our findings to other studies and underscores the critical need to explore these areas of contraceptive use and experience more fully.
A secondary objective of this paper was to gain a better understanding of the characteristics of women who continue, discontinue, and switch methods after experiencing side effects, in order to explore how life circumstances influence contraceptive decision-making. Due to sample size limitations, we could not limit our analyses to only women who reported experiencing a side effect, however, we were able to identify several relevant sociodemographic characteristics associated with discontinuation and switching, after adjusting for the experience of specific side effects. Women who wanted to delay or limit childbearing by more than two years were significantly less likely to discontinue use, but these same motivations had little relationship with switching; indicating that fertility desires impact whether a method is used but may have less influence on what method specifically is chosen. Qualitative evidence from Uganda highlights the significant role that motivation to avoid pregnancy plays on contraceptive continuation, even when negative side effects are experienced (22). Barden-O’Fallon found that fertility intentions did not differentiate switchers from discontinuers, which seems to contradict our findings, but less research has examined what role, if any, fertility intention may play on the decision to switch methods when side effects are experienced (31).
Interestingly, we also found that wealth was associated with decreased relative risk of discontinuation, while education was associated with an increased risk of switching, indicating that social privilege may influence contraceptive dynamics in different ways. For example, social disadvantages that inhibit poorer women from seeking healthcare services to adopt new methods, in the presence of side effects, may result in higher discontinuation among this population. In contrast, wealthier women who have greater access to contraceptive services, and perhaps enhanced counseling from providers, may be less likely to discontinue their methods. Additionally, educated women may be more knowledgeable about a range of contraceptive methods than less educated women, allowing them greater opportunity to switch methods if they are dissatisfied. Despite experience of side effects, education and knowledge may translate into use of preferred methods and continuation of these methods.
A potential limitation of our study is that women were asked to spontaneously report side effects that they were experiencing, rather than replying directly to a list of potential side effects. To do so, women needed to consider what they were experiencing as a side effect of their contraceptive method and, in the case of amenorrhea and loss of libido, recognize the absence or reduction of these experiences as being currently experienced. It is possible that women are less likely to report something that is not happening as being “currently experienced”, relative to something that has increased or newly presented, but this requires further investigation. Reading a list of potential side effects and requiring a response may be a more effective way to gather information on prevalence of side effects, but may also result in over-reporting (43, 44). Under-reporting, in addition to our lower than expected retention, may have contributed to our limited analytical sample size. The limited absolute numbers of women, particularly for switching, restricted our ability to explore relationships across the full range of side effects. However, even with our limited sample, one in three women in Uganda who were current users of hormonal contraceptive indicated that they were experiencing some form of side effects, underscoring how common these experiences are. Additionally, our retention at study level was 67%, with higher attrition amongst certain sub-groups (reported in Zimmerman et al, Under Review). The application of propensity scores to adjust for loss-to-follow-up allowed us to construct weights that generated estimates of sample characteristics that did not differ between the full baseline and the sample of women who successfully completed follow-up. While we believe we thus adjusted for the majority of demographic and economic characteristics that may be related to contraceptive continuation, it is possible that there are unadjusted confounders that differ between these groups and may affect the overall generalizability of our findings. Finally, we defined switching and discontinuation only based on baseline and follow-up and were unable to account for events that occurred between the two time points. Though we included a contraceptive calendar for this purpose, we found that recall of starting and ending dates of methods when reported retrospectively was inconsistent and rendered the calendar data unusable for this purpose.
Despite these limitations, our study has several important strengths. First, we were able to identify and assess the effect of a range of side effects, including some, such changes to sexual experience and physical discomfort, which have not been extensively studied in the literature. Additionally, we used longitudinal data, following up with women one year after the baseline survey, enabling us to assess how these specific side effects related to discontinuation and switching independently, providing additional insight into contraceptive behaviors.
Women do not experience generalized “side effects and health concerns”; they experience specific side effects and contraceptive behavior is influenced based on both the side effect and on the woman’s unique circumstances and context. Identifying which side effects are commonly experienced and strongly associated with discontinuation and switching, in addition to identifying some of the socio-demographic characteristics that may be associated with these behaviors, has valuable programmatic purposes. Counseling that incorporates discussions about individualized suitability for specific side effects and more discussion about the possibility of switching methods when side effects do occur may improve continuation rates. Additional research should explore in greater detail the role that context, including partner support, plays in the decision to stop or switch methods.