Journal Pre-proof

Adolescent women with unintended pregnancy in low- and middle-income countries:

reasons for discontinuation of contraception

S. Bellizzi, F. Palestra, G. Pichierri

PII: S1083-3188(19)30355-9
DOI: https://doi.org/10.1016/j.jpag.2019.11.004
Reference: PEDADO 2419

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 17 September 2019

Revised Date: 31 October 2019
Accepted Date: 4 November 2019

Please cite this article as: Bellizzi S, Palestra F, Pichierri G, Adolescent women with unintended
pregnancy in low- and middle-income countries: reasons for discontinuation of contraception, Journal of
Pediatric and Adolescent Gynecology (2019), doi: https://doi.org/10.1016/j.jpag.2019.11.004.

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Gynecology.
1 Adolescent women with unintended pregnancy in low- and middle-income countries:
2 reasons for discontinuation of contraception

5 Authors: Bellizzi S,1 Palestra F,2 Pichierri G3

7
1
8 Partnership of Maternal, Newborn, Child and Adolescent Health, Geneva, Switzerland
2
9 World Health Organization, Addis Ababa, Ethiopia
3
10 NHS, Galsworthy Road, Kingston upon Thames, KT27QB, UK

11

12 Corresponding author:

13 Saverio Bellizzi; bellizzis@who.int

14

15

16 Key words: Family planning, Adolescent Health, Demographic Health Survey,

17 Developing countries, unwanted pregnancies.

18

19

20 Funding: No funding was utilized for this work.

21 Conflict of Interest: None declared.

22 Abstract word count: 213

23 Text word count: 2,392

24
1
25 Abstract

26

27 Study Objective: To investigate the reasons for discontinuation of the last contraceptive
28 method used among adolescent women with a current unintended pregnancy.

29 Design Demographic and Health, Cross Sectional, Surveys (DHS).

30 Setting: 35 low- and middle-income countries.

31 Participants: 2,173 girls aged 15-19 years with a current unintended pregnancy, selected
32 by a multistage cluster random sampling method.

33 Interventions: A questionnaire administered by trained interviewers, which included

34 socio-demographic as well as individual maternal and contraceptive history was used to
35 collect data.

36 Main Outcome Measure(s): The prevalence of contraception utilization and the

37 contribution of each reason for contraceptive discontinuation before the current
38 unintended pregnancies.

39 Results: Almost three fourth of adolescent women was not using any contraception prior
40 to the current unintended pregnancy, and less than 1 in 100 was using a long-acting
41 modern method. Among girls who last used a traditional method, 74.0% discontinued due
42 to failure. Among girls who last used a long-acting modern method, 63.6% discontinued
43 because of health concerns and side effects.

44 Conclusion: This study highlights that around 80.0% of adolescent women with an
45 unintended pregnancy in 35 low and middle-income countries were either non-users or
46 using traditional methods. An additional 20.4% were using short-acting modern method.
47 Long-acting methods would have prevented the overwhelming majority of unintended
48 pregnancies, including the vast numbers from contraceptive failure.

49

50

51

2
52 INTRODUCTION

53 Nearly half of the 21 million pregnancies that occurred among adolescent women in 2016
54 globally were unintended.1 About 20% of the unintended pregnancies in Asia, and about
55 50% of the unintended pregnancies in Latin America and the Caribbean and in Africa end
56 in unsafe abortions.1 Specifically, compared with older women, adolescents are more
57 likely to seek abortions from untrained providers or to have a self-induced abortion.2

58 Unintended pregnancies among adolescent girls are influenced by a wide range of factors
59 including barriers to obtaining sexual and reproductive health services at individual,
60 family, and community levels.3,4 Girls of age between 15-19 , especially in Sub-Saharan
61 Africa and South Asia, often face bias and negative attitudes from providers, who refuse
62 to provide contraceptive information and services because they do not approve premarital
63 sexual activity.5 Contraceptive discontinuation, defined as starting contraceptive use and
64 then stopping for any reason while still at risk of an unintended pregnancy,6 is a
65 particularly frequent event in adolescents.6

66 Analysis of the reasons for contraceptive discontinuation is important to improve service

67 delivery and user uptake of contraception. For example, fear of side effects, health
68 concerns and underestimation of risk of conception were found to account for two-thirds
69 of discontinuation among sexually active (age 15-49) women who did not desire another
70 pregnancy.7 Discontinuation because of side effects, may suggest the need for improved
71 counselling and communication.8 Other reported reasons for discontinuation among
72 sexually active women include accessibility to contraceptives, cost of services, opposition
73 and religious beliefs as well as misunderstanding of how to use the contraceptives.9 In
74 addition, as discontinuation rates vary according to the type contraceptive method,
75 knowing reasons for discontinuation helps to determine how interventions need to be
76 tailored to reduce these rates. For example, women using user-dependent methods such as
77 oral contraceptives are more likely to discontinue than women using intrauterine devices
78 (IUD).10

79 Using data from the Demographic and Health Survey (DHS) program, we sought to
80 explore the proportional contribution of the reasons for discontinuation of the last
81 contraceptive method used in young girls with a current unintended pregnancy.

3
 82 METHODS

83

84 Data source

85 DHS are nationally representative household surveys carried out in over 90 low- and
86 middle-income countries since 1984. The standard DHS survey consists of women’s
87 questionnaire and a household questionnaire. The first one is administered to women of
88 reproductive age (15 – 49 years) and includes a contraceptive history calendar for the five
89 years prior to the survey.11 We explored all available datasets with data on desire for
90 pregnancy among women aged 15-19 years (Table 1), the last method of contraception
91 used and reasons for discontinuation. Based on these eligibility criteria, we finally
92 analysed data from all the 35 latest country DHS conducted from 2005. The majority of
93 surveys were from Sub-Saharan Africa (N=18), followed by from South and East Asia
94 (N=8), East Europe (N=3), Latin America (N=3), Middle East and North Africa (N=2),
95 and Central Asia (N=1).

96

97 Participants

98 All women age 15-49 who were either permanent residents of the household, randomly
99 selected from a list done for different country areas drawn from national census, or
100 visitors who stayed in the household the night before the survey were eligible to be
101 interviewed. For this analysis, we restricted our sample to girls aged 15-19, which
102 represented around the 20% of the total 10,657 women of reproductive age (15-49), with
103 a current unintended pregnancy, interviewed and included in the pooled database.

104 As far as the socio-demographic characteristics are concerned, around 50% of

105 participants (N= 1,054) belonged to the lowest wealth category, more than 50% (N=1,237)
106 had at least completed secondary school and 3 out of 5 young girls were living in rural
107 settings (Table 2).

108

109

4
110 Variables

111 Based on the DHS questionnaire structure, current pregnancies were respectively
112 categorized as “wanted to wait”, and “not wanted at all”. We combined pregnancies that
113 “wanted to wait” and “not wanted at all” into the variable “unintended” current
114 pregnancies. The contraceptive history calendar was utilized to extract the last method of
115 contraception used prior to or at the time of the current pregnancy as well as reasons for
116 contraception discontinuation. As per the DHS methodology, only one contraceptive
117 method is recorded per month.

118 In light of the definitions provided by the World Health Organization, the last method of
119 contraception used prior to the current pregnancy was classified into four main categories:
120 “no contraception”, “traditional methods of contraception”, “short-acting modern
121 methods of contraception” and “long- acting modern methods of contraception”.
122 Traditional methods included “withdrawal”, “periodic abstinence” and the “calendar
123 rhythm method”; short-acting modern methods included “pills”, “injections”, “lactational
124 amenorrhea (LAM)”, “diaphragms”, male and female “condoms”; long-acting modern
125 methods included “intra-uterine device (IUD)”, “implant”, female and male
126 “sterilization”.

127 Reasons for discontinuing contraception were grouped into (1) reported failure (the
128 respondent became pregnant while using the method), (2) method-related reasons: side
129 effects and health concerns, access and availability, and cost, (3) Other reasons
130 comprising difficult pregnancy, marital dissolution, fatalism, husband’s disapproval,
131 don’t know and other unspecified reasons. Method-related reasons apply to all women
132 who were using a method of contraception over the last five years but were not using it in
133 the month immediately prior to conception.

134

135 Statistical analysis

136 Datasets were downloaded from the DHS program website and imported into Stata/MP
137 v.14 for analysis. We tabulated the distribution of unintended pregnancies by country as
138 well as for the pooled 35 country dataset to have to have broader results and a more

5
139 global perspective”.12 To explore the contribution of each reason for contraceptive
140 discontinuation, cross-tabulation of data was one for the pooled unintended pregnancies.
141 Each category of contraception method and reasons for discontinuation were also
142 stratified by residence (urban or rural), education (no education, primary, secondary, and
143 higher), and wealth (poor, middle and rich based on the DHS wealth factor score).13
144 Statistical difference, using the Chi Squared Test and the Chi Squared Test for Trend,
145 was calculated for the following groups: 1) use of contraception versus non-use of
146 contraception across residence, education and wealth; 2) use of traditional methods of
147 contraception versus use of modern methods of contraception across residence, education
148 and wealth; and use of short-acting modern methods of contraception versus short-acting
149 modern methods of contraception across residence, education and wealth.

150 The Metaprop syntax14 was used in the pooled analysis to adjust for the cluster-sampling
151 design as well as stratification and sampling weights as per standard methodology for
152 analyses of DHS data; this function generates weighted subgroup and overall pooled
153 estimates with inverse-variance weights obtained from a random-effects model.

154 Formal approval to use the data was obtained from the DHS program through the
155 following link: https://dhsprogram.com/data/available-datasets.cfm.

156

157

158 RESULTS

159

160 In the pooled dataset, 2,173 had an unintended pregnancy. Nine out of ten unintended
161 pregnancies were wanted at a later time, and one out of ten not wanted at all.

162 As for individual country, unintended pregnancies ranged from two in Armenia up to 315
163 Colombia (Table 1).

164 Of all the adolescent women with an unintended pregnancy, 1,569 (72.2%) used no
165 contraception in the last 5 years, whilst 150 (6.9%) last used traditional methods, 443
166 (20.4%) short-acting modern methods, and 11 (0.5%) long-acting modern methods of

6
167 contraception (Figure 1). Five percent (N=111) of unintended pregnancies were due to
168 failure of traditional methods, 7.2% (N=158) due to failure of short-acting modern
169 methods, and 0.1% (N=3) from failure of long-acting modern methods.

170 Around two percent (N=39) of unintended pregnancies were due to discontinuation of
171 traditional methods, 13.2% (N=283) were due to discontinuation of short-acting modern
172 methods, and 0.4% (N=8) were due to discontinuation of long-term modern methods at
173 any time in the last five years.

174 Reasons for discontinuation of methods differed by the last method used in the past 5
175 years among women with a current unintended pregnancy. Among women who last used
176 a traditional method, the primary reason for discontinuation was failure (becoming
177 pregnant) (N=111; 74.0%) whilst among women who last used a short-acting modern
178 method, 35.6% (N=158) discontinued due to failure and almost 20% (N=83) discontinued
179 due to side-effects and health concerns. Among women who last used a long-acting
180 modern method, 63.6% (N=7) discontinued because of side effects and health concerns
181 and a quarter (N=3) discontinued because of failure.

182 In the 5 years previous to the surveys, non-use was significantly higher among women
183 living rural areas [χ2 (1, N=2173)= 12.13, p<.05] and with no education [χ2 (3, N=2173)=
184 14.09, p<.05](Table 3).

185 Across all socioeconomic strata, the vast majority of women using traditional methods
186 discontinued due to failure (i.e., became pregnant).

187 The proportion of women who used modern methods of contraception prior to the current
188 unintended pregnancy (Table 3) was higher among those living in urban areas and
189 increased with wealth and level of education. Estimates for the proportion of women
190 using short-term methods ranged from 7.0% and 21.0% in women with no education and
191 in the poorest quintile respectively to 43.3% and 21.4% in the highest education category
192 and richest quintile. Proportions stopping due to side-effects or health concerns were
193 ranged between 14.0% and 25.0% across wealth levels while it substantially decreased
194 with more years of educations (from around 25.0% among women with no education to

7
195 less than 1.0% in women with higher educations). Less than 1.0% of women in all strata
196 last used a long-term method.

197

198

199 DISCUSSION

200

201 In this study we attempted to investigate on the different reasons for discontinuation of
202 the last contraceptive method used in young girls of age 15-19 currently pregnant. Almost
203 three quarters of adolescent women who had an unintended pregnancy were not using
204 any contraception during the five years prior to the current unintended pregnancy. This is
205 the consequence of the classical "unmet need", pointing to the gap between women’s
206 reproductive intention (not wanting anymore children or wanting to delay next child) and
207 their contraceptive behaviours (sexually active but not using any method of
208 contraception).15 However, 6.9% had last used traditional methods which pose a high risk
209 of unintended pregnancy.10 Another 20.4% had used short-acting methods. Long-acting
210 methods would have prevented the majority of unintended pregnancies.

211 Side effects are common reasons for discontinuation of pills, injectables and IUDs in
212 low-income settings.16 In our study, among adolescent women with an unintended
213 pregnancy who last used a short-acting modern method, almost 20% discontinued
214 because of health concerns and side effects. It is well-known that short-acting methods
215 are more easily discontinued due to the fact they do not require provider involvement to
216 stop using.17

217 Discontinuation of long acting modern methods contributed to less than 1.0% of the total
218 unintended pregnancies; however, more than half adolescent women discontinued long
219 acting modern methods because of side effects and health concerns.

220 As documented by other reports,8,18 unintended pregnancies often occur during periods
221 when women engage in contraceptive switching, often to less effective methods, or
222 abandoning contraception. Our findings add to the current evidence and highlight the

8
223 need to address client concerns namely with side-effects to prevent discontinuation of
224 contraceptive use.

225 In spite of the fact DHS use standardized procedures for collection of data, several
226 limitations are noted. While underreporting of certain methods such as condoms and
227 other short-acting methods has been documented, especially in West Africa,19 other
228 reports suggest the opposite, with women who have unintended pregnancies over-
229 reporting consistent and correct use of contraception as it is more socially acceptable.20,21
230 Reasons for discontinuation may be subject to recall bias and this may vary across
231 countries.22 Method failure is classified as women who say they “became pregnant while
232 using” but this does not necessarily allow for the fact that women may have used
233 inconsistently or improperly because of other concerns, such as side effects. Thus, using
234 this classification alone may be underestimating the impact of side effects/health
235 concerns.

236 Also, even if a woman did stop for a specific reason, there are potentially many other
237 reasons a woman did not then take up a different method in the interim which are not
238 captured in our analyses.

239 Post-event rationalization bias on the intention status of pregnancies should be minimized
240 in the current study since we are dealing with current pregnancies.23 Researchers have
241 also questioned the validity of current measures of unintendedness, especially when
242 assessing the contradictions between pregnancy intention and woman happiness or
243 unhappiness at discovering she is pregnant.24

244 Another complicating factor is the considerable heterogeneity within the category of
245 unintended pregnancy, with unwanted and mistimed pregnancies representing different
246 life-choice considerations.25

247 In consideration of the very small sample size of some country-surveys, generalizability
248 is another important limitation of the current study.

249 In our analysis we included data from countries from different parts of the world and
250 different points in time across ten years, thus possibly reflecting important differences in
251 the attitudes. We may have missed women who are most motivated to avoid a pregnancy

9
252 and had an abortion,24 although it is difficult to judge its effect on the study results.26
253 Although we are considering only the last discontinued method, women or couples may
254 have used several methods during the 5 years interval covered by the questionnaire, thus
255 limiting a more comprehensive understanding of reasons of discontinuation.

256 Side effects and health concerns reinforce the need of wider access to family planning
257 services coupled with detailed information on mechanisms of action, safety and ease of
258 use of modern methods of contraception.27 Availability of a range of contraceptive
259 methods, especially long-acting reversible methods would allow an appropriate choice
260 according to personal needs and would enhance continuous long-term use.28

261 Our findings build on previous reports, which emphasize the central role the health
262 system in investing on sexual education, proper counselling as well as on provision of
263 sexual health services.29 Long-acting reversible contraception (LARC), including both
264 intrauterine contraception and implants are safe and highly effective, therefore well suited
265 for adolescents.30 However, the uptake of LARC should be complemented with
266 messages about condom use specifically for sexually transmitted infection prevention.30

267 Health systems need to support use of suitable methods, reduce switching failure and
268 identify early when women are having concerns about the method they are using. This
269 means frontline health workers need to be armed with factually correct information, and
270 be facilitative to help women to choose the most suitable method from the start.

271 Additionally, as highlighted by recent studies,31 involving local stakeholders in

272 addressing structural and socio-cultural barriers to women’s free access to family
273 planning programs can positively influence quality of service and method mix as well as
274 knowledge and attitudes surrounding family planning use, hence improving uptake of
275 suitable methods of contraception.

276 Authors’ role

277 S.B., F.P. and G.P. contributed equally to the study idea, the development of the study,
278 the writing of the manuscript and the review all the versions.

279 Funding: No funding was utilized for this work.

10
280 Conflict of Interest: None declared.

281

11
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365

14
1 Table 1. Distribution of unintended pregnancies among adolescent women in 35 countries,

2 Demographic and Health Surveys 2005 to 2014.

Total unintended pregnancies Wanted later Not wanted at all

N n % n %
Armenia 2010 2 2 0.1 0 0.0
Azerbaijan 2005 7 4 0.2 3 1.8
Bangladesh 2011 74 73 3.6 1 0.6
Benin 2011/12 43 39 1.9 4 2.4
Burkina Faso 2010 31 31 1.5 0 0.0
Burundi 2010 21 20 1.0 1 0.6
Cambodia 2014 13 10 0.5 3 1.8
Colombia 2010 315 257 12.8 58 34.5
Comoros 2012 42 39 1.9 3 1.8
Egypt 2014 45 39 1.9 6 3.6
Gambia 2013 57 57 2.8 0 0.0
Ghana 2014 107 107 5.8 0 0.0
Honduras 2011/12 131 119 5.9 12 7.1
India 2005/06 203 186 9.3 17 10.1
Indonesia 2012 15 14 0.7 1 0.6
Jordan 2012 11 8 0.4 3 1.8
Kyrgyz Republic 2012 2 2 0.1 0 0.0
Liberia 2013 88 77 5.3 1 0.6
Maldives 2009 4 2 0.1 2 1.2
Mali 2012/13 23 21 1.1 2 1.2
Moldova 2005 8 8 0.4 0 0.0
Mozambique 2011 103 96 4.8 7 4.2
Namibia 2013 70 62 3.5 8 4.8
Nepal 2011 41 38 1.9 3 1.8
Niger 2012 13 12 0.6 1 0.6
Nigeria 2013 79 71 3.5 8 4.8
Pakistan 2012/13 11 11 0.6 0 0.0
Peru 2012 113 104 5.2 9 5.4
Philippines 2013 40 38 1.9 2 1.2

1
 Rwanda 2014 24 24 1.2 0 0.0
Senegal 2014 42 40 2.0 2 1.2
Sierra Leone 2013 113 99 4.9 14 8.3
Tajikistan 2012 45 31 4.7 14 2.3
Uganda 2011 77 76 3.8 1 0.6
Zambia 2013 113 111 6.5 2 1.2
Zimbabwe 2010/11 47 45 2.2 2 1.2
Total 2,173 2,005 100,0 168 100,0
3

4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

2
26 Table 2. Intention of pregnancy among currently pregnant young girls in 35 low and middle

27 income countries by socio-economic characteristics, Demographic and Health Surveys 2005 to

28 2014.

Characteristics Unintended pregnancies

n %
Education
No education 241 11.1
Primary 695 32.0
Secondary 1,177 54.2
Higher 60 2.7
Wealth
Poor 1,054 48.5
Middle 506 23.3
High 613 28.2
Residence
Urban 883 40.6
Rural 1,290 59.4

Total 2,173 100,0

29

30
31
32
33
34
35
36

3
37 Table 3. Reason for discontinuation of contraception by method and socioeconomic characteristics among adolescent women with a
38 current unintended pregnancy from 35 low and middle-income countries, Demographic and Health Surveys 2005 to 2014.
Method of contraception and Total Residence n χ² Wealth n (%) χ² Education n (%) χ²
reason for discontinuation N (%) (%)
Urban Rural Poor Middle Rich None Primary Secondary Higher
No contraception 1,568 571 997 <0.05 747 378 443 0.3 218 543 777 30 <0.05
(72.2) (64.8) (77.3) (70.9) (73.0) (72.3) (90.5) (78.1) (66.0) (50.0)
Traditional 150 84 66 0.09 81 33 36 0.08 6 25 115 4 0.1
(6.9) (9.5) (5.1) (7.7) (8.2) (5.9) (2.5) (3.6) (9.8) (6.7)
Became pregnant 111 67 44 65 23 23 4 17 86 4
(5.1) (7.6) (0.3) (6.2) (5.7) (3.7) (1.6) (2.4) (7.3) (6.7)
Others 39 17 22 16 10 13 2 8 28 1
(1.8) (1.9) (0.2) (1.5) (2.5) (2.2) (0.9) (1.2) (2.5) (0.1)
Short-term modern 444 225 219 0.08 221 92 131 0.07 17 122 279 26 0.1
(20.4) (25.4) (17.0) (21.0) (18.2) (21.4) (7.0) (17.5) (23.7) (43.3)
Became pregnant 158 74 84 80 28 50 8 28 107 13
(7.2) (8.2) (6.5) (7.6) (4.4) (8.1) (2.9) (4.0) (10.6) (25.1)
Side-effects/health concerns 83 40 43 37 13 33 4 32 41 1
(3.4) (4.2) (3.3) (3.5) (2.6) (5.4) (1.8) (4.5) (4.4) (1.7)
Access/availability 41 21 20 27 10 4 0 11 29 1
(1.9) (2.3) (1.5) (2.5) (2.4) (0.6) (0.0) (1.5) (3.1) (1.7)
Cost 8 5 3 4 1 3 0 3 4 1
(0.5) (0.6) (0.2) (0.3) (0.2) (0.5) (0.0) (0.3) (0.6) (1.7)
Others 151 90 81 64 47 50 5 52 41 10
(7.4) (10.1) (6.3) (6.1) (8.4) (6.8) (2.3) (7.2) (5.0) (13.1)

4
 Long-term modern 11 3 8 5 3 3 0 5 6 0
(0.5) (0.3) (0.6) (0.4) (0.6) (0.4) (0.0) (0.8) (0.5) (0.0)
Became pregnant 3 1 2 2 1 0 0 1 2 0
(0.1) (0.1) (0.2) (0.2) (0.2) (0.0) (0.0) (0.1) (0.2) (0.0)
Side-effects/health concerns 7 2 5 2 2 3 0 3 4 0
(0.3) (0.2) (0.3) (0.2) (0.4) (0.4) (0.0) (0.6) (0.3) (0.0)
Others 1 0 1 0 0 0 0 1 0 0
(0.1) (0.0) (0.1) (0.0) (0.0) (0.0) (0.0) (0.1) (0.0) (0.0)
Total 2,173 883 1290 1054 506 613 241 695 1177 60
39
40
41
42
43
44
45
46
47

5
1 Figure 1. Last method of contraception used and reasons for discontinuation among adolescent women with a current unintended

2 pregnancy (N=2,173), pooled data from 35 countries

0.5%
13.2%
No contraception

Traditional methods
failure
7.2%
Traditional methods
other reasons 1.8%

Short-term modern
methods failure 5.1%

Short-term modern
methods other reasons

Long-term modern
methods failure
72.2%
Long-term modern
methods other reasons