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