Contraceptive discontinuation, reasons, and method switching among married women in Nepal: A life-table and survival analysis of the 2022 Nepal DHS contraceptive calendar
This study analyzes the 2022 Nepal Demographic and Health Survey data to reveal that the stagnation of contraceptive prevalence is driven primarily by high discontinuation rates of short-acting methods due to side effects and spousal separation, combined with a near-total lack of method switching, rather than a failure to adopt contraception initially.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
For decades, family planning programs have worked to help couples decide when to have children, aiming to prevent unintended pregnancies and improve maternal health. A key measure of success in these efforts is the contraceptive prevalence rate, which simply counts the percentage of women who are currently using a method to prevent pregnancy. However, a high number of women starting a method does not guarantee a high number of women staying on it. Many women begin using contraception but stop before their need for it ends. When a woman stops using a method but does not immediately start a new one, she enters a period of unprotected sex, which can lead to unplanned pregnancies. Understanding why women stop, and what they do next, is just as important as knowing how many start.
In Nepal, a country that has invested heavily in family planning for fifty years, the number of married women using modern contraception has remained stubbornly flat since the mid-2000s. Despite falling birth rates, better education for women, and widespread knowledge of how to prevent pregnancy, the percentage of users has hovered around 43 percent for nearly two decades. This plateau suggests that while programs are good at getting women to try a method, something is causing them to leave the pool of users as quickly as they enter. To solve this puzzle, researchers turned to a detailed record of women's lives rather than just a snapshot of the present. They analyzed the 2022 Nepal Demographic and Health Survey, which asked thousands of married women to reconstruct their month-by-month history of contraceptive use over the previous five years. This approach allowed them to see not just who was using a method, but how long they kept using it, why they stopped, and what happened in the very next month.
The researchers found that the reason for the stagnant numbers lies in the behavior of women using short-term methods, such as the daily pill or the male condom. These methods are highly effective when used correctly, but they require daily or weekly attention. The data showed that within one year of starting the pill, nearly one in four women had stopped using it. For the male condom, the rate was nearly one in five. In stark contrast, women using long-acting methods, such as implants placed under the skin or intrauterine devices, rarely stopped. Less than one percent of women using these long-term methods discontinued within a year. The difference is so pronounced that the long-acting methods act as a stable foundation for the national statistics, while the short-acting methods create a constant leak.
When the researchers asked women why they stopped, the answers revealed a pattern tied to daily life rather than medical failure. For those using the pill or condoms, the most common reason for stopping was simply that they were not having sex often, usually because their husbands were away for work. Nepal has a large population of men who migrate for employment, leaving their wives behind for months or years at a time. When a husband leaves, a wife may stop taking her daily pill or stop using condoms because the immediate need for protection seems to have vanished. When he returns, she often does not restart the method immediately. For the small number of women who stopped using long-acting methods like implants, the reasons were almost entirely related to side effects or health concerns, suggesting that when these methods are used, they are generally trusted until a physical issue arises.
The most critical finding of the study, however, was what happened after a woman stopped. The data revealed a near-total absence of switching. When a woman stopped using a modern method, 94 percent of the time she did not start a different one; she simply stopped using contraception altogether. Only about two percent of women who stopped one modern method immediately began using a different modern method. This lack of switching means that every time a woman stops her pill because her husband is away, she is not just pausing her protection; she is effectively leaving the family planning system entirely. The system succeeds in getting her to start, but fails to keep her in the loop when her circumstances change.
The study also looked at who was most likely to stop. Women living in rural areas were more likely to discontinue use than those in cities, and women with secondary education were more likely to stop than those with no education. This pattern suggests that the issue is not a lack of knowledge or access, but rather the difficulty of managing a daily method over the long term, especially when life is unpredictable. The researchers noted that women who had already completed their families tended to stay on long-acting methods, which further supports the idea that the problem is specific to the management of short-term methods.
The implications of these findings are clear for how family planning services are delivered. The current model often treats stopping a method as a failure or a sign that the woman no longer needs care. Instead, the data suggests that stopping is a normal part of the process, often triggered by predictable life events like migration. The researchers propose that health workers should treat every time a woman stops a method as an opportunity to switch. If a woman stops her pill because her husband is away, a counselor could offer her a long-acting method that will remain effective even when he is gone, or provide a supply of condoms for when he returns. By anticipating these interruptions and offering a seamless transition to a different method, programs could turn these moments of discontinuation into moments of continued protection.
Ultimately, the stagnation in Nepal's contraceptive use is not caused by a lack of interest or a failure to start. It is caused by a revolving door where women enter the system with short-term methods and exit when their lives change, only to remain outside the system. The solution lies in recognizing that the goal is not just adoption, but sustained use. By understanding that the most common reason for stopping is a change in sexual activity due to migration, and by ensuring that women have a plan for what to do when that happens, the country can transform its family planning efforts from a series of starts and stops into a continuous, reliable source of protection.
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