Contraceptive Method Choice in Nepal and Mexico
October 1999

Background

A key concern for family planning programs is the rate at which users discontinue contraception and the reasons for such discontinuation, particularly dissatisfaction with new contraceptive methods or the quality of services provided. Clients have many reasons for discontinuing contraception. Family planning programs can influence some of these, such as concern over side effects. Others, such as desire to become pregnant, are beyond programs' control.

A prospective study in Indonesia (Pariani et al., 1991) showed that discontinuation can be related to contraceptive choice. Women initiating contraception were asked about their preference for contraceptive methods before entering the clinic and what method they subsequently received. They were reinterviewed 12 months later to determine method continuation. In this study, 86% of users were given their chosen methods. Nearly three-fourths of those whose choice was denied discontinued in the first year, compared with only 9% discontinuation for women who received the method they wanted.

To determine whether lack of choice may be a significant factor in programs elsewhere in the world, FHI conducted an exploratory study in Mexico and Nepal that examined family planning client method selection and the factors influencing clients' ability to obtain their desired method.

All 418 women who participated in the study had a method preference when they came to the clinic. Ninety-three percent of the women (390) received their preferred method.

All but eight of the clients informed clinic staff of their method choice upon arrival. The method preferences were for injectables (51.9%), female

sterilization (19.9%), implants (14.4%), male sterilization (7.7%), the intrauterine device or IUD (4.3%), oral contraceptives or OCs (1.7%), and condoms (0.2%).

Clinic staff suggested a method to 413 of the clients, or 98.8 percent. The suggested methods very closely matched the methods preferred and received.

Thirty clients (7.2 percent) did not receive their preferred method. Of these clients, 10 (33%) received no method at all, leaving these women unprotected against unwanted pregnancy. The reasons given by providers for not providing a method to these 10 clients was that pregnancy was suspected (70%) or the woman was not menstruating (30%).

Twenty clients received a method different from their choice. The main reasons given by providers were that the client changed her mind during the visit (55%), there were medical contraindications (20%), or the client was not menstruating (15%).

Ninety-six percent ? 553 of the 575 clients participating in the study ? had a method preference upon entering the clinic. Of those with a preference, 87.3 percent (483 clients) received the method they wanted.

Slightly more than 92 percent of clients with a choice informed the clinic staff of their choice. The methods most preferred were the IUD (58.3%) and OCs (25.7%); injectables and condoms were the other two methods wanted, though by far fewer clients (6.6% and 5.6% respectively).

Clinic staff suggested a method to less than half of the clients, primarily the IUD (suggested to 62.4%) and OCs (29.6%).

Seventy women (12.7 percent) did not receive their method of choice. Of these clients, 26 (37%) received no method, leaving these women unprotected against unwanted pregnancy. The primary reasons providers gave for not supplying a method were that the woman was not menstruating (38.5%), the method was unavailable (23.1%), and pregnancy was suspected (19.3%).

Forty-four clients received a method different from their first choice. The primary reasons given by providers were that the client was not menstruating (34.3%), the method was not available (14.3%), and pregnancy was suspected (8.6%).

In these geographically diverse study sites, the issue of contraceptive choice does not seem to be a substantial problem. Most women did receive the method they wanted.

The results suggest, however, that provider misinformation is a primary reason that women do not receive their chosen method. Twenty-six clients in Mexico and 10 in Nepal did not receive any method, most because they were not menstruating at the time of the visit, an invalid reason for denying contraception. FHI has developed a simple checklist

to enable providers to be reasonably certain that a woman is not pregnant. Using the checklist can help prevent clients from being sent home without a contraceptive method. In countries where clients' resources are few and transportation to clinics difficult, providers should offer appropriate services when clients do come to the clinic.

In conclusion:

• Most women have a particular contraceptive method in mind when they come to the family planning clinic.

• Most women in these settings are receiving their method of choice ? which is important for user satisfaction and possibly for continuation.

• When women do not receive their method of choice, the reason is often because of unnecessary medical barriers, primarily unfounded suspicion of pregnancy if a woman is not menstruating.
  
  
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