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Side-effects of contraceptives the main cause of discontinued use: Colombo study

  • Survey of expecting mothers highlights factors in family planning preferences
  • User discomfort and partner’s satisfaction also cited as reasons for not using contraceptives

By Ruwan Laknath Jayakody

Among antenatal mothers who were not planning to use a contraceptive method following the current pregnancy, the side-effects of the contraceptive methods were considered as the main reason by the majority, followed by those who considered the satisfaction of the partner and those who cited discomfort as a reason for discontinuing the use of certain methods in the future, a study conducted in Colombo found.

These findings were made in a research article on the “Prevalence of unplanned pregnancies and their family planning preferences among antenatal clinic attendees in the Thimbirigasyaya Divisional Secretariat (DS) Division” which was authored by P.S. Nagendran (Medical Officer at the Health Promotion Bureau) and S.P. Godakandage (Consultant Community Physician at the Family Health Bureau) and published in the Sri Lanka Journal of Obstetrics and Gynaecology 43 (3) in November 2021.

There are planned or wanted pregnancies and unplanned pregnancies, with the latter being a major public health issue, particularly among certain ethnic and racial groups and low income females owing to induced abortions. In such cases there is an increased risk of abortion-related death and morbidity, especially in countries where abortion is illegal, per “Sexual and reproductive health: A matter of life and death” by A. Glasier, A. Gulmezoglu, G. Schmid, C. Moreno, and P.V. Look. In addition, there are outcomes such as poor maternal and child health, negative physical, emotional, and financial impacts on females, and the immense burden on the national healthcare system due to unplanned pregnancies.

There are two types of unplanned pregnancies; namely unwanted pregnancies where the pregnancy occurred when no more children were desired, and mistimed pregnancies where the pregnancy occurred before the desired time as the conception was expected later. The common cause of unplanned pregnancies has been identified in N. Baydar’s “Consequences for children of their birth planning status”, as not using contraception, or due to not using a contraceptive method consistently and/or correctly.

While unplanned pregnancies have been caused due to factors such as the failure of contraceptive methods and contraception techniques, in “Estimates of contraceptive failure from the 2002 National Survey of Family Growth” by K. Kost, S. Singhe, B. Vaughan, J. Trussell, and A. Bankole, it is noted that due to the high unmet need for contraception, there is a reduction in the use of a contraceptive method or technique, and that the failure of the contraceptive method includes technical issues on the part of the couple and the failure of the method itself.

Therefore, as explained by A. Daponte, F. Guidozzi, and A. Marineanu in “Maternal mortality in a tertiary centre after the introduction of free antenatal care”, effective, equitable, and easy access to effective contraception methods, especially to long acting reversible contraception, would help address this issue. Between 2015 to 2019, there have been 121 million unplanned pregnancies per annum the world over, which corresponded to a global rate of 64 unplanned pregnancies per 1,000 females between the ages of 15 to 49 years, out of which, 61% ended in abortions, which accounted for a rate of 39 abortions per 1,000 females, as mentioned in “Unintended pregnancy and abortion by income, region, and the legal status of abortion: Estimates from a comprehensive model for 1990-2019” by J. Bearak, A. Popinchalk, B. Ganatra, A.B. Moller, O. Tuncalp, C. Beavin, L. Kwok, and L. Alkema.

According to the World Health Organisation (WHO) estimates, almost half of the pregnancies between 2015 to 2019 in low and low-middle income countries had been unplanned, with women living in the poorest regions almost three times more likely to have unplanned pregnancies than women from wealthier regions. In Sri Lanka, approximately 360,000 women become pregnant annually, of which one in three (33.3%) are estimated to have an unplanned pregnancy.

The Demographic and Health Survey (DHS) of 2016, by the Census and Statistics Department, reported that 35% of married women in Sri Lanka do not use any form of contraception. The prevalence of unplanned pregnancies is related to, per “Unsafe abortion: The preventable pandemic” by D.A. Grimes, J. Benson, S. Singh, M. Romero, B. Ganatra, F.E. Okonofua, and I.H. Shah, the choice and use of contraceptive methods, and females’ expectations, knowledge, and behaviours. Effective family planning is medical advice to prevent unplanned pregnancies.

Towards this end, P. Dixit, F. Ram, and L.K. Dwivedi noted in “Determinants of unwanted pregnancies in India using matched case control designs” that when there is a need and understanding for the use of contraceptives, and if they are made available, accessible, and used correctly and consistently, unplanned pregnancy is preventable. Furthermore, access to family planning and the use of modern methods of contraception is a human right where individuals have the right to choose their preferred method of contraception and to decide freely as to whether and when to have children and their family size.

That said, due to the lack of understanding and limited access to effective contraception, higher rates of contraceptive failure can occur, as noted by I. Sawhill, A. Thomas, and E. Monea in “An ounce of prevention: Policy prescriptions to reduce the prevalence of fragile families”. Therefore, the danger of such, as pointed out by D. Habte, S. Teklu, T. Melese, and M.G.M.D. Magafu in “Correlates of unintended pregnancy in Ethiopia: Results from a national survey” and Y. Tebekaw, B. Aemro, and C. Teller in the “Prevalence and determinants of unintended child birth in Ethiopia”, is lower if the knowledge of family planning and technical skills on the use of family planning methods is sufficient among the vulnerable population. Family planning is an approach to give the right to the couple to decide on the desired number of children to have, the adequate timing of the pregnancies, and the right to choose a contraceptive method of their choice.

Hence, Nagendran and Godakandage’s study conducted among a selected cohort of antenatal mothers within a community-setting (as it is at community-based clinics that grassroots-level healthcare workers follow up on the majority of antenatal mothers), analysed family planning methods used in the past, the reason for using the method, future family planning preferences and choices, and the reason for not using a family planning method in the past and future.

A cross-sectional study was performed using an interviewer administered questionnaire in three randomly selected antenatal clinics (Borella, Kirula, and Wellawatte) in the Thimbirigasyaya DS Division of the Colombo Municipal Council between April 2020 and January 2021. A total of 425 antenatal mothers who fulfilled the inclusion and exclusion criteria were included and this meant all antenatal mothers in their first, second, or third trimester who were attending the antenatal clinics at Borella, Kirula, and Wellawatte of the Districts Three, Four, and Five Medical Officer of Health (MOH) areas of the Thimbirigasyaya DS Division. A consecutive sampling method was used. More information on the current pregnancy and related factors were looked into through the pregnancy records of each mother.

The 425 antenatal mothers who took part belonged to the age range of 15 to 44 years, with the majority (354 – around 83%) falling between the ages of 22 to 34 years. In terms of ethnicity/race, the majority were Sinhalese (158 – 37.2%), followed by Moors (144 – 33.9%), and Tamils (123 – 28.9%). In terms of religion, the majority were Buddhists (146 – 34.4%), followed by Muslims (144 – 33.9%), Hindus (89 – 20.9%), and Christians and Catholics (46 – 10.8%). In terms of marital status, the majority were married (408 – 96%) while 16 (3.8%) were unmarried.

The prevalence of unplanned pregnancies was calculated to be 139 (32.7%) which included antenatal mothers who responded saying that they never wanted to be pregnant (41 – 9.6%) and those who wanted to be pregnant later (98 – 23.1%). With regard to family planning practices, 33% had used some form or method of contraception in the past, with the majority of them (80%) having used it for the spacing of the pregnancy, to widen the inter-pregnancy interval, with half of the 33% who had used such a method in the past (70 – approximately 50%), having chosen barrier methods like condoms (22.5%) or hormonal methods like the depot-medroxyprogesterone acetate (DMPA – a contraceptive injection that contains the hormone progestin, which is given every three months, and which suppresses ovulation, thereby keeping the ovaries from releasing an egg and also thickening the cervical mucus in order to keep sperm from reaching the egg) (28.3%) as their preferred method of contraception, while 45%, approximately 15% each who had used such in the past, preferred the use of combined oral contraceptive pills, implants, and intrauterine devices, and only four (3%) had used traditional and natural methods.

Advice received from healthcare workers and clinics was the main reason to choose a method of contraception in the past among 63% while around one-third had considered the side-effects before choosing their method of choice. Among the two-thirds (287 – 67%) who had not used a contraceptive method in the past, more than half (165 – 57.6%) said that they were not willing to use a method, while 102 (35.5%) were expecting to get pregnant (predominantly compromised of primiparous females (those who have been pregnant and given birth once and those without a child due to bad obstetric history), and 20 (7%) claimed ignorance of family planning or contraceptive methods.

Among those who were not willing to use a method in the past, the side-effects of contraceptive methods were considered the major reason (71 – 43.1%), while 56 (33.9%) noted that they had refrained from the use of such due to their spouses not being happy about it. Looking at future contraceptive practices and preferences following the current pregnancy, 58.6% were planning to use a contraception method following the current pregnancy while 41.4% were not planning to do so.

Among the mothers who were planning to use a method, the majority (28.5%) had decided to use DMPA as their method of choice, followed by barrier methods such as condoms (23.7%), implants (18.9%), intrauterine devices (12%), and combined oral contraceptive pills (10.4%). Regarding the time to start using the contraceptive method following the current pregnancy, the numbers were almost equally distributed among the three categories; immediately after delivery, within six weeks of delivery (around 36.2%), and after six weeks of delivery.

Advice received from healthcare workers was the major factor in deciding the type of contraception method to be used in the future (61%). Side-effects were considered by 32.1% when selecting a contraception method for the future. Among future users, half of them were planning to use their chosen method of contraception for two to five years following the current pregnancy (51%), while around 37.4% had decided to use the chosen method of contraception for more than five years. Among those who were not planning to use a contraception method following the current pregnancy (41.4%), the side-effects of the contraception methods were considered as the main reason by the majority (48.3%), followed by the satisfaction of the partner being considered by 23.3%, and 10.8% citing discomfort as a reason for not using a method in the future.

According to the WHO, in 2020, the prevalence of modern contraceptive methods has increased by 2.1% to 57.1% among married women of reproductive age. Per G. Sedgh, L.S. Ashford, and R. Hussain’s “Unmet need for contraception in developing countries: Examining women’s reasons for not using a method” which cited demographic and health surveys conducted in 52 countries between 2005 and 2014 on the common reasons given by married women for not using a contraceptive method; 26% had expressed concerns about the contraceptive-related side- effects and health risks, 24% had reported having infrequent sexual intercourse or not at all, 23% stated that they or others close to them reject contraception, and 20% mentioned breast feeding and not having resumed menstruation since giving birth.

A community-based cross-sectional study using multi-stage sampling done in Ethiopia (W. Ashebir and T. Tadesse’s “Associated factors of postpartum modern contraceptive use in the Burie District, Amhara region, Ethiopia”), revealed that 59.1% of postnatal mothers had started using a modern contraceptive method within 12 months of delivery and that 71.5% of them preferred injectables as a contraceptive method, with postpartum use of modern contraceptives being significantly associated with the maternal education level, discussing family planning methods with a partner, being aware about modern family planning methods (having heard of such at least once), and contacting healthcare professionals.