Reducing Contraceptive Discontinuation Among Youth
by Jay Gribble, Amy Uccello, and Sara Stratton
In 2022, the Health Policy Plus project’s blog series on Rethinking Contraceptive Discontinuation focused primarily on ways to strengthen the enabling environment through health system and community level interventions to avoid discontinuation, intentionally avoiding method- and age-specific issues. However, given the importance of responding to youth reproductive health needs, we take this opportunity to examine how we might help reduce the high levels of contraceptive discontinuation we see among youth.
First, some facts
Much valuable research has been carried out on youth, contraceptive use, and discontinuation. As noted by the PACE project, youth (ages 15–24) discontinue contraceptive use at a higher rate than their older counterparts. They also experience a contraceptive failure rate that is 25 percent higher than that of older women. While these two groups share some of the same reasons for discontinuing contraceptives, e.g., method-related concerns and fear of not being fertile after use, other factors, such as infrequent sex and changes in reproductive intentions, and facilities that are often inhospitable to youth clients — such as inaccessible hours and days of operation, concerns about treatment and counseling, and long waiting times — are particularly significant reasons for young women to discontinue. Quality of care can be poor, as exemplified by youth being stigmatized by facility staff and lack of confidentiality. Youth are more likely to be offered and use short-term methods — pills, condoms, and injectables — and obtain them from pharmacies and drug shops, sources that often provide inadequate counselling.
But there are positive programmatic efforts that we can put in place to support youth’s contraceptive use and reduce unnecessary discontinuation.
Establish healthy lifelong behaviors
Youth is a time of transition, and many behaviors that start during this stage of life have long-term health implications. When youth enter adulthood in good health with established, positive health behaviors, they are more likely to become healthy, productive adults. For this to work effectively, we need to remove barriers to adopting and practicing these healthy behaviors and create a positive and supportive environment that support youth to take up those behaviors. Key to this positive environment is helping youth to trust the health system and its providers. In thinking about contraceptive use by youth, programs need to reinforce the positive behavior of contraceptive use to avoid unintended pregnancies, focusing on the roles of both male and female youth in achieving this goal. Establishing contraceptive use as a healthy behavior during adolescence or young adulthood can reinforce it as a regular practice later in life. For this to be successful however, youth’s access to high-quality counselling to make an informed decision, coupled with a full range of contraceptive options that match their reproductive health intentions, is key.
Engage the community
While starting a contraceptive method may happen with a provider, discontinuing one does not typically happen in a clinical setting. Improving youth’s contraceptive access through strengthening the supply side of programs is key, but so too is ensuring there is a supportive demand. For that to happen, youth need to have access to information, and to have the confidence to ask for that information when they need it. When the time is right, young people may decide to use contraception, but they also need support to follow through on the decision and continue using the method. Community support can come in a variety of ways. One increasingly popular way is private channels for sharing information, such as through a WhatsApp discussion group, as discussed during a recent policy forum on contraceptive discontinuation. This type of network can be a lifeline for understanding side effects and concerns when deciding to use a method as well as when thinking about discontinuing. These support systems can also help contraceptive users to realize that there are other sexually active young people who also need support to avoid unintended pregnancies. Support can come in other ways, too. Work in Mali, Niger, and Burkina Faso found that friends, sisters, neighbors, aunts, mothers, and others can provide support and information to new younger and older users alike.
While youth’s use of contraception is primarily focused on young women, community support also needs to focus on young men’s sexual behavior — responding to their needs for information. Gender norms may limit support for young women being sexually active, but sexual activity among young men is not shunned in the same way. Young men and women both can benefit from open discussion on issues of consent, couple communication, and what healthy relationships require, and this may lead to lower levels of discontinuation due to insufficient understanding of side effects, myths, and barriers. Work in male engagement in family planning considers three complementary roles: users, supportive partners, and change agents. Efforts to engage young men in understanding these roles should begin while they are young — when the opportunity to create healthy, lifelong behaviors can more easily be established.
Address barriers that affect youth uptake, use, and discontinuation
Finally, to discontinue the use of a contraceptive method, a person must first start using one. Many of the same issues that limit the uptake of a method also contribute to discontinuation. While many countries have policies that are supportive of youth’s use of contraception, it is in the implementing of those policies that things breakdown. Low quality of services and negative provider attitudes keep many youth from initiating contraceptive use. Those same factors can also encourage youth not to return to providers. Waiting time at facilities is one of the key reasons youth report as negatively affecting their use of contraception.
Providers can play an important role in preventing discontinuation. A follow-up phone call or visit is more effective than counselling alone in supporting continued use. Similarly, incorporation of the NORMAL counselling tool and similar instruments into provider-based counselling may help young women better anticipate changes in menstrual bleeding and help them avoid discontinuing use. Providers can also play an important role in changing community understanding and promoting positive social norms around menstruation. Data indicate that young women who use contraception are much more likely to experience method failure than older women. With better counselling and follow-up, these young women are more likely to use contraception correctly and avoid method failure.
Enable youth to act
Not only does the size of youth cohorts around the world warrant a special consideration of youth needs in contraception use and discontinuation, but the missed opportunities that occur to young women who experience an unintended pregnancy also adversely affects their and their children’s health, as well as education and economic opportunities. Youth face many challenges in beginning to use contraception — from issues of self-efficacy and overcoming personal stigma to lack of social support and services that discourage them from returning. To reduce contraception discontinuation among youth, we must first strengthen the environment that encourages them to use modern contraception in the first place, while also focusing on quality information and services so that they are encouraged to access services; ask questions; and choose, start, and continue a contraceptive method that works for them.
Jay Gribble is a senior director at Palladium with expertise in policy, research, and communication, and more than 25 years of experience in international family planning.
Amy Uccello is a senior youth and reproductive health technical advisor with USAID’s Office of Population and Reproductive Health.
Sara Stratton is a director of family planning and maternal and child health at Palladium.
