DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2017 No. 132

Mona Khalifa

Wafaa Abdel Aziz Hussein Soliman

Ehab Sakr

July 2017

This document was produced for review by the United States Agency for 

International Development.

Changes in Contraceptive Use Dynamics in Egypt:

Analysis of the 2008 and 2014 

Demographic and Health Surveys

Changes in Contraceptive Use Dynamics in Egypt: 

Analysis of the 2008 and 2014 

Demographic and Health Surveys 

Mona Khalifa1 

Wafaa Abdelaziz1 

Ehab Sakr1 

ICF 

Rockville, Maryland USA 

July 2017 

1

 Department of Biostatistics and Demography, Institute of Statistical Studies and Research, Cairo University 

Corresponding author: Mona Khalifa, Department of Biostatistics and Demography, Institute of Statistical 

Studies and Research, Cairo University, Egypt; email: monakhalifa2010@gmail.com
Acknowledgments 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through the 2017 DHS Fellows Program implemented by ICF. The authors 

would like to thank USAID for funding the DHS Fellows Program and also ICF for guidance and 

support received. Special thanks go to the facilitators Dr. Wenjuan Wang and Dr. Shireen Assaf 

and to the co-facilitators, Bupe Bwalya and Mulenga Chonzi. They were all very helpful, 

considerate, and supportive during the workshops and through all stages of writing this paper. Our 

special thanks go to our reviewers Dr. Kerry MacQuarrie and Dr. Trevor Croft for their valuable 

comments. Also, we would like to thank Mr. Bryant Robey who has given so generously of his 

time to edit the paper. His effort is much appreciated. 

Editor: Bryant Robey 

Document Production: Joan Wardell 

The DHS Working Papers series is a prepublication series of papers reporting on research in 

progress that is based on Demographic and Health Surveys (DHS) data. This research is carried 

out with support provided by the United States Agency for International Development (USAID) 

through The DHS Program (#AID-OAA-C-13-00095). The views expressed are those of the 

authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and 

evaluate population, health, and nutrition programs. For additional information about The DHS 

Program, contact DHS Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; 

Phone: +1 301-407-6500; Fax: +1 301-407-6501; Email: reports@dhsprogram.com; Internet: 

www.dhsprogram.com. 

Recommended citation: 

Khalifa, Mona, Wafaa Abdelaziz, and Ehab Sakr. 2017. Changes in Contraceptive Use Dynamics 

in Egypt: Analysis of the 2008 and 2014 Demographic and Health Surveys. DHS Working Papers 

No. 132. Rockville, Maryland, USA: ICF.
iii 

Abstract 

This study aims to provide an in-depth assessment of changes in contraceptive dynamics among 

ever-married Egyptian women based on calendar data from the 2008 and 2014 EDHS surveys. The 

sample from EDHS 2008 included 10,704 use segments and in EDHS 2014 it included 15,236. 

Single/multiple decrement life tables were built to examine net rates of discontinuation by reasons, 

and women’s status after discontinuation (no longer in need; method failure; switched to another 

method; abandoned use while in need). 

The 12 months discontinuation rate in the 2014 survey is 30%. The magnitude of the current 

increase is about 4.3 percentage points (2.3, 1.8, and 0.7 percentage points for the IUD, pill, and 

injectable segments). The increase occurred among all background groups, with only two 

exceptions: it dropped in urban Upper Egypt and among women in the highest wealth index 

quintile. 

Five main reasons for discontinuation are considered: contraceptive failure, side effects/health 

concerns, other method/service-related reasons, desire to get pregnant, and not exposed to 

pregnancy. While the highest reason-specific discontinuation rate remains “side effects/health 

concerns,” the second highest in EDHS 2008, “other method/service-related reasons,” has dropped 

significantly, and “desire to become pregnant” has emerged in EDHS 2014 as the new second 

highest reason-specific discontinuation rate. Discontinuation-specific rates due to method failure 

have significantly increased. 

The reasons were aggregated to reflect two main groups of factors: “method/service-related” and 

“reduced need.” The discontinuation rate for the former has remained almost unchanged at about 

18%, while the latter has significantly increased from 8% to 12% indicating a meaningful shift in 

the reasons for discontinuation away from method/service-related reasons and toward need-based 

reasons for all three methods. This trend is clear and significant across all background categories. 

The “method/service related” reasons rate decreased in Upper Egypt and especially in urban Upper 

Egypt. 

While reducing fertility is an essential component of Egypt’s development, the rise in the ideal 

family size and the discontinuation driven by the “desire to become pregnant” is a strong indicator 

that the strategic target of “avoiding unwanted births” may become a low priority consideration on 

the agenda. The main program related reasons for discontinuation suggest that better counseling 

might decrease failure rates and improve switching behavior. The findings suggest that there is a 

need to adopt strategies aiming to ensure better use compliance and longer duration of use together 

with strategies to increase contraceptive prevalence. 

1 

1. Introduction 

Since 1990, the total fertility rate (TFR) in Egypt has been slowly declining, from 4.1 in 1991 to 

3.5 in 2000 and 3.0 in 2008, but it unexpectedly increased to 3.5 in the Egypt 2014 Demographic 

and Health Survey (EDHS 2014). Between 2008 and 2014 the level of contraceptive use dropped 

slightly, from 60% to 58%. The proportion of IUD users declined from 36% to 30%, and the 

proportion of pill users increased from 12% to 16%. The United Nations Development Program 

(UNDP) concluded that “with the current decline in the level of usage (of contraception), it is 

unlikely for Egypt to achieve, on both the national and local levels, the MDG target relating to a 

contraceptive prevalence rate of 72%, which is the rate necessary to achieve the total fertility rate 

(TFR) of 2.1 children per woman by 2015 (UNDP and the Ministry of National Planning 2015).” 

Accordingly, the Strategic National Population Plan 2015-2030 in Egypt has called for accelerated 

efforts to reduce the TFR to 2.4 births per woman by the year 2030. Theoretically, such a fertility 

level can be achieved by increasing contraceptive prevalence from 58% in 2014 to 72%, reducing 

the discontinuation rate (within 12 months of use) from 30% in 2014 to 18%, and reducing the 

proportion of unmet need for family planning from 13% to 6% (National Population Council 

2015). In order to achieve this target, the family planning program must maintain good quality of 

family planning service provision and ensure that attitudes favorable to the use and acceptance of 

contraception are maintained. However, this target should be viewed as ambitious, considering the 

rising cost of ensuring contraceptive security as a result of the large increase in Egypt’s population. 

1.1. Background 

The family planning literature has emphasized that “contraceptive discontinuation is an important 

determinant of contraceptive prevalence, as well as unwanted fertility and other demographic 

impacts” (Bradley et al. 2009). The several types of contraceptive discontinuation that are often 

studied, such as method failure, switching, and abandonment, are behaviors that result from 

decisions contraceptive users take while already using a method. These decisions are determined 

by two groups of factors. First is the quality of family planning service provision. Although causal 

linkages between contraceptive discontinuation rates and the quality of family planning programs 

cannot be established in this analysis, earlier studies (e.g., Blanc et al. 2002) have indicated high 

correlations between evaluations of family planning efforts and discontinuation rates, particularly 

abandoning contraceptive use while still in need of family planning. Blanc et al. suggested, “The 

all-method discontinuation rate for quality-related reasons emerges as the most likely candidate 

for a summary measure of quality of care,” a result that highlights the importance of identifying 

the reasons of discontinuation for the purpose of program evaluation and finding solutions to 

reduce unmet need. 

The second group of factors is related to women’s background characteristics. “Along with the 

contraceptive method chosen, women’s demographic and socioeconomic characteristics have also 
2 

been found to be associated with contraceptive discontinuation and failure” (Bradley et al. 2009). 

In Egypt, all discontinuation studies have examined the discontinuation rates by background 

characteristics of women. In 1995, El Tawila showed that discontinuation is less likely among 

older women, women who had at least one living son, and women who did not intend to bear more 

children within 2 years (El Tawila 1995). Another study found that discontinuation rates were 

higher among rural women, those with no education, and the poorest group of women (Way 2003). 

Also, research has shown that women without education, younger women, women with one child, 

and poor women in rural Upper Egypt are more likely to discontinue by abandoning use while still 

in need of family planning than to switch to another method (Sayed and Abdel Aziz 2011). 

Choices that family planning users make may have an impact on contraceptive discontinuation, 

which is now considered a challenge facing the realization of the goals of the recent initiative 

FP2020. The initiative aims at reducing the level of unmet need for family planning. “When users 

discontinue use because of method- or service-related problems, they are at risk for unintended 

pregnancies. Improving continuation is a particular challenge because it requires advances in many 

areas simultaneously, including logistics, counseling, quality of care, and choice (Stover and 

Sonneveldt 2017). Women who continue to use a contraceptive method without interruption while 

they are in need are more likely to fulfill their goals of limiting or spacing births. Switching 

between contraceptive methods will have an effect on the level of fertility depending on the timing 

of adopting the destination method and whether the switching was to a more effective or to a less 

effective method. Also, the risk of getting pregnant while using a contraceptive method is 

determined by the effectiveness of the method and is also due to incorrect use of the method. El 

Tawila (1995) found that failure rates related to incorrect use were quite high among pill users in 

Egypt, since pills require more skill to be used effectively. 

All of these behaviors contribute to what Jain and colleagues have termed the “leaking bucket” 

that reduces the impact of family planning programs (Jain (2014a) in Castle and Askew 2015). In 

Egypt, the only estimate of this effect was made by Way (2003), who assessed the overall 

magnitude of the impact that contraceptive failure and abandonment has on fertility in Egypt. 

Using the calendar data of the EDHS 2000, she estimated that “If all births due to contraceptive 

failure or following a segment of use in which use of a method was abandoned because of methodor service-related issues had been prevented during the three–year period before the EDHS, the 

TFR would have dropped to 2.8 births, roughly 20 percent lower than the actual rate” (Way 2003). 

In addition, understanding the reasons behind these different patterns of behavior make the 

consideration of contraceptive dynamics, and addressing them effectively, an important 

component of family planning programs by introducing interventions that can complement the 

efforts aiming to reduce unmet need and increase the prevalence of modern contraceptive methods. 

Contraceptive discontinuation rates can help indicate how well the family planning program is 

achieving its goals, as evidenced by changes in the prevalence of unintended pregnancies. They 

also can indicate the extent to which a program is meeting users’ needs and addressing their 
3 

expectations and concerns, because the all-method discontinuation rate for quality-related reasons 

is associated with the quality of care a woman receives during her visit to the family planning 

center (Blanc et al. 2002). 

Quality of care can affect contraceptive discontinuation starting when the method is first prescribed 

and also during regular follow-up visits. Blanc et al. (2002) note that as fertility declines, it would 

be more beneficial if the family planning program shifted its emphasis from increasing the number 

of contraceptive users to improving services to reduce the discontinuation rates. This strategy has 

not been addressed by the Egypt family planning program. The above-mentioned national strategic 

objective of Egypt to reduce fertility was supported by six sub-objectives, among them improving 

the skills of family planning service providers. However, none of the programs and activities listed 

in the executive plan mentioned the need to improve the quality of counseling skills in order to 

influence contraceptive discontinuation and/or switching. 

The trend of the 12 months discontinuation rate in Egypt declined from 30% in 2000 to 26% in 

2008 but then noticeably increased to 30% in 2014 (EDHS 2008, 2014). This is calculated by 

constructing a life table to estimate the probability of stopping the use of the contraceptive method 

within 12 months of beginning use, measured during the 5-year period before the survey. At the 

same time, the percentage of users who experienced method failure within 12 months of beginning 

use was 3% in 2008 and increased to 4% in 2014 (EDHS 2008, 2014). 

The current research aims to provide an in-depth assessment of changes in contraceptive dynamics 

among ever-married Egyptian women based on data from the 2008 and 2014 EDHS surveys. 

Specifically, the study focuses on the following: 

1. Calculating contraceptive discontinuation and switching for each specific contraceptive 

method. 

2. Identifying differentials in contraceptive discontinuation and switching by user’s 

background characteristics. 

3. Determining women’s contraceptive use status after discontinuation according to 

background characteristics. 

1.2. Research Questions 

This study analyzes behaviors by women who reported use of contraception during the last 5 years 

before the survey. It assumes a relationship between their background characteristics and their 

dynamic family planning experience, demonstrated through the progressive segments of 

contraceptive use and non-use. Women who entered the family planning program and used a 

contraceptive method made different choices. While some continued to use their method, others 

switched to another method or abandoned contraceptive use. The discontinuation act could have 

happened among those using the first prescribed method and also among those who switched to 

another method. Discontinuation is a behavior that follows a decision that could be taken by those 
4 

who are no longer in need of family planning and also by those who abandon use while still having 

a need. Abandoning use of a method while in need of contraception will add to the existing level 

of unmet need and will have an effect on the TFR, as these women face the risk of becoming 

pregnant during the duration of the discontinuation period. 

Reasons women give for discontinuing contraceptive use, for switching, and for abandoning use 

while in need, whether for specific methods or overall, can guide the family planning program and 

help improve the efficiency of counseling services. Also, by identifying the specific background 

characteristics associated with contraceptive discontinuation, the program would be more able to 

satisfy women’s needs and ensure continuation of contraceptive use. However, these reasons are 

dynamic and differ across countries and over time. They are a product of differences and changes 

within the cultural, economic, social, and political environment in the country. Previous studies in 

Egypt regarding discontinuation dynamics were conducted during periods of increasing 

contraceptive prevalence and decreasing TFR. However, the current study will consider 

discontinuation dynamics during a period of unexpected increase in TFR and a drop in 

contraceptive prevalence within a mature family planning program. 

This study addresses the issue of contraceptive dynamics among Egyptian women and answers the 

following questions: 

1. What is the pattern of contraceptive discontinuation and switching (level and trend between 

2008 and 2014) for each contraceptive method? 

2. What are the main reasons for discontinuation/switching? Have these reasons changed over 

the study period? 

3. What are the differentials in the contraceptive use status after women discontinued a 

method, by women’s socioeconomic characteristics? 
5 

2. Data and Methods 

2.1. Data 

The analysis of this study is based on data from EDHS 2008 and EDHS 2014. The sample design 

of the two surveys ensures that information on various population and health indicators of interest 

are provided for the country as a whole and for six major subdivisions (Urban Governorates, urban 

Lower Egypt, rural Lower Egypt, urban Upper Egypt, rural Upper Egypt, and the Frontier 

Governorates). Both EDHS 2008 and EDHS 2014 have a multi-stage sample design. The sample 

for the 2014 EDHS was explicitly designed to allow for separate estimates of most key indicators 

at the governorate level (EDHS 2008, 2014). 

 A total of 16,571 in the 2008 EDHS and 21,903 women in the 2014 EDHS were identified as 

eligible to be interviewed. Among these women, 16,527 and 21,762 were successfully interviewed 

in the 2008 and 2014 EDHS, respectively. The response rate was 94.0% in 2008 and 99.7% in 

2014 (EDHS 2008, 2014). 

The study uses data from the contraceptive calendar of the 2008 EDHS and 2014 EDHS. The 

details of all segments of contraceptive use were recorded in the contraceptive calendar data as 

reported by women who used contraception during the last 5 years before the DHS survey. The 

calendar contains information about monthly contraceptive use and birth history for the previous 

5 years for ever-married women who used a contraceptive method. For each month, the respondent 

was requested to indicate whether she was pregnant or gave birth, had a terminated pregnancy, or 

used a contraceptive method. Women who used a method were asked to specify the contraceptive 

method used and, if more than one method was used during the month, the most effective method 

was recorded (ICF International 2012). If the respondent stopped using a method in that month, 

she was asked to give a reason for this discontinuation. 

The data files used are data of ever-married women age 15-49 from both EDHS 2008 and EDHS 

2014. The sample from EDHS 2008 included 7,597 women who experienced 10,704 use segments. 

The pill was used in 26% of these segments, the IUD in 45%, injectables in 15%, and other 

methods in 13% of the segments. In EDHS 2014, the sample included 10,570 women who 

experienced 15,236 use segments. The distribution of these segments by method was: 40% pills, 

36% IUD, 17% injectables, and 8% other methods. The segment of use is the unit of the analysis. 

The distribution of the segments by women’s background characteristics for 2008 and 2014 is 

presented in the Appendix 1. The table shows that there are enough segments to allow for the 

examination of discontinuation rates for all categories except for those in the Frontier Governorates 

in both EDHS 2008 and EDHS 2014. Therefore, these categories will be excluded. 
6 

2.2. Variables Used in the Analysis 

The key variables of interest are calendar data for pregnancies and contraception, reason for 

discontinuation, and century monthly code (CMC) start of calendar. The respondent characteristics 

are classified into two categories: 1) Characteristics at time of interview (we assumed they are the 

same at the time of discontinuation): highest educational level, region, type of place of residence, 

wealth index. 2) Characteristics at initiation of use: women’s age and total number of living 

children (changing across segments for the same woman). The date of initiation of use for each 

segment in CMC was calculated, and then women’s age at the initiation of use was calculated by 

subtracting the date of the initiation of use in CMC from her date of birth in CMC, and the outcome 

was divided by 12 months to obtain women’s age in years. The total number of living children at 

initiation of use was computed by summing the number of living children for those dates of birth 

in CMC that happened before the date of initiation of use in CMC. 

2.3. Statistical Analysis 

Single/multiple decrement life tables were built to examine various net rates of contraceptive 

discontinuation by reasons, and women’s behavior after discontinuation (no longer in need; 

method failure; switched to another method; abandoned use while in need). These reasons for 

discontinuation or status after discontinuation are treated as competing risks and discontinuation 

probabilities in months are additive across the reasons for discontinuation and status after 

discontinuation. If there are less than 125 unweighted segments of use for a method, rates for that 

method are not shown (Rutstein and Rojas 2006). 

The segments of contraceptive use used to construct life tables are those that began 3-59 months 

prior to the survey. The period 0-2 months prior to the interview is excluded from the analysis to 

eliminate any bias that might be introduced by unrealized pregnancy (Rutstein and Rojas 2006). 

Segments of use that started before the beginning of the calendar and 59 months prior to the survey 

are also excluded to ensure a consistent study time period between the 2008 and the 2014 surveys, 

since the segments of use began from 3-59 months prior to the survey in the 2008 survey, while it 

began from 3-62 months prior to the survey in 2014, and a woman may contribute more than one 

episode during the study period. The study used Greenwood’s formula to estimate the asymptotic 

standard error of S(t) “cumulative survival function” (Kalbfleisch and Prentice 2002) and used 

STATA command stcompet (Coviello and Boggess 2004) to estimate the standard error for each 

reason-specific 12 months discontinuation rate. The study used the estimated standard errors to 

test the null hypothesis that there is no significant difference in the discontinuation rates between 

the 2008 survey and the 2014 survey. 
7 

3. Results 

3.1. Trend in Discontinuation Rates by Contraceptive Method 

Since 1980, pills and the IUD have been the most commonly used contraceptive methods in Egypt, 

representing more than 80% of the method mix. In 1988, the IUD emerged as the most common 

method and has remained so from 1988 to 2014, in spite of a recent decrease in its share from 60% 

to 51% in the last inter-survey period (i.e., since EDHS 2008). In 1995, injectables were introduced 

and accounted for 11% of the method mix in the 2000 EDHS, increasing to 15% in EDHS 2014. 

Between 2008 and 2014, a little change in the method mix was observed with an increase in the 

use of hormonal methods (pills and injectables) and a decline in the IUD share, as Figure 1 shows. 

This study will focus on the discontinuation of the three most widely used contraceptive methods: 

IUD, pills, and injectables. These three methods together accounted for 92% of the method mix in 

EDHS 2008 and 93% in EDHS 2014, while other modern methods and traditional methods are not 

common, and the number of use segments does not allow for a life table analysis. The remaining 

methods in current use accounted for about 8% in EDHS 2008 (1% condoms, 2% female 

sterilization, 1% other modern methods, and 4% traditional methods including prolonged 

breastfeeding), and 7% in EDHS 2014 (1% condoms, 2% female sterilization, 1% other modern 

methods, and 3% traditional methods including prolonged breastfeeding) (EDHS 2008, 2014). It 

is clear that the changes in the method mix will have implications for discontinuation, as the overall 

discontinuation rate is a weighted average of the method-specific discontinuation rates, with the 

weights changing with changes in the method mix. 

Figure 1. Trend in the method mix 1980–2014 

One way of measuring the duration of a contraceptive segment is by looking at the median duration 

of use calculated from the life table as the time when 50% of the users had stopped using the 

15.9

41.8

59.2

63.3

61.7

59.9

51.5

68.6

40.5

27.4

16.9

16.7

19.7

27.4

0.0

0.3

1.1

10.9

11.8

12.3

14.5

15.5

17.5

12.3

8.9

9.8

8.1

6.7

1980

EFS

1988

EDHS

1992

EDHS

2000

EDHS

2005

EDHS

2008

EDHS

2014

EDHS

IUD Pill Injectables Other
8 

method. The median duration of contraceptive use was 24 months at the time of the 2008 DHS 

and dropped to 22 months at the time of the DHS 2014, as Figure 2 shows. The median time to 

discontinuation has dropped for all contraceptive methods. Although IUD users have the longest 

duration of use, the median duration of use has dropped from 35 months in the 2008 survey to 33 

months in the 2014 survey. For pill users, the median duration of use has dropped from 17 months 

to 16 months. Among injectable users, the median duration of use remained almost constant at 20 

months. 

Figure 2. Median duration of use by contraceptive method during 5 years 

preceding the survey, Egypt DHS 2008 and DHS 2014 

The other way of looking at the duration of use is by using the life table discontinuation rates, as 

Table 1 shows. The 12 months discontinuation rate in the 2014 survey is 30% for all methods. It 

is lowest for the IUD segments (14%), and highest for the pill segments (42%) followed by 

injectables (38%) The magnitude of the current increase is about 4.3 percentage points for all 

methods. The increase was 2.3, 1.8, and 0.7 percentage points for the IUD, pill, and injectable 

segments respectively. 

All life table discontinuation rates have significantly increased in the 2014 survey compared with 

the 2008 survey with the exception of injectables, which were unchanged or down at 6, 18, and 36 

months. By the end of the second year, more than one-third of the IUD segments, about 40% of 

the pill segments, and about 38% of the injectable segments were discontinued in both the 2008 

and 2014 surveys. By the end of 3 years, slightly more than half of the IUD segments, about twothirds of the pill segments, and about 70% of the injectables segments were discontinued. 

In both surveys the discontinuation rates for the hormonal methods (pills and injectables) are 

always higher than for the IUD, and the pattern of discontinuation for the IUD is different than for 

the hormonal methods. Discontinuation rates for the IUD segments by 12 months of use, although 

12.0

39.9

37.2

26.1

14.3

41.8

37.9

30.3

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

IUD Pills Injectables Any method

EDHS 2008 EDHS 2014
9 

lower for the hormonal methods, increase about 2.5 to 3 times by the end of the second year and 

almost four times by the end of the third year. On the other hand, discontinuation of the hormonal 

methods starts at high levels within the first year of use, increases about 50% in the second year, 

and reaches 85% by the end of the third year. It is common practice to use the 12 months 

discontinuation rate for comparison at the local level, and it will be used for the rest of this paper. 

Table 1. Discontinuation rates for 6, 12, 18, 24, and 36 months by contraceptive method during 5 years preceding 

the survey, Egypt DHS 2008 and DHS 2014 

Period 

IUD Pills Injectables All methods1

2008 2014 

∆ 

(2014-

2008) 

2008 2014 

∆ 

(2014-

2008) 

2008 2014 

∆ 

(2014-

2008) 

2008 2014 

∆ 

(2014-

2008) 

6 months 5.4 6.3 0.9*** 26.9 27.9 1.0*** 26.7 25.2 -1.5*** 15.4 18.3 2.9***

12 months 12.0 14.3 2.3*** 39.9 41.8 1.9*** 37.2 37.9 0.7*** 26.1 30.3 4.3***

18 months 21.7 26.4 4.7*** 52.6 55.0 2.4*** 47.3 46.8 -0.4*** 38.0 43.0 5.0***

24 months 34.0 37.3 3.3*** 63.6 65.7 2.1*** 55.2 56.3 1.1*** 50.1 53.6 3.5***

36 months 51.8 53.6 1.8*** 75.1 78.0 2.9*** 69.8 69.6 -0.2*** 64.5 67.4 2.9***

Total Segments 4833 5505 2880 6038 1609 2524 10704 15236 

* p<.05, ** p<.01, *** p<.001 

1 All methods include IUDs, pills, injectables, condoms, female sterilization, and other modern and traditional methods. 

Note: Figures are based on life table calculations using information on segments of use that began 3-59 months prior to the survey. 

3.2. Discontinuation Rates by Background Characteristics of Women 

Table 2 shows that the recent significant increase in the 12 months discontinuation rates between 

EDHS 2008 and EDHS 2014—with an overall average of 4.3 percentage points—has occurred 

among segments for all background groups, with only two exceptions: Discontinuation rates have 

dropped in urban Upper Egypt and among women in the highest wealth index quintile. Urban 

Upper Egypt is the only region where the discontinuation rate has dropped significantly (about 3 

percentage points), which could indicate improvement in the quality of family planning services. 

On the other hand, it is clear that the increase in the discontinuation rate has been greatest for 

women with one or two children, in rural areas, in Lower Egypt, in rural Upper Egypt, and in the 

lowest, low, and middle wealth index quintiles. 
10 

Table 2. Twelve months life table discontinuation rates by 

background characteristics1 during 5 years preceding the survey, 

Egypt DHS 2008 and DHS 2014 

Background 

characteristics 2008 2014 

∆ 

(2014-2008) 

Age 

15-24 30.3 35.0 4.7*** 

25-34 23.6 27.9 4.4*** 

35-49 22.7 26.1 3.4*** 

Number of living children

One 36.9 42.6 5.6*** 

Two 22.6 28.0 5.4*** 

Three 20.1 24.2 4.1*** 

Four or more 22.1 24.2 2.1*** 

Urban-rural residence 

Urban 24.3 25.0 0.8*** 

Rural 27.2 32.8 5.6*** 

Place of residence 

Urban Governorates 22.8 24.9 2.1*** 

Lower Egypt 23.3 28.5 5.2*** 

Urban 21.2 23.5 2.3*** 

Rural 23.9 29.7 5.8*** 

Upper Egypt 30.9 34.6 3.7*** 

Urban 29.2 26.6 -2.6*** 

Rural 31.6 37.7 6.1*** 

Level of education 

No education 24.7 28.3 3.7*** 

Less than primary 28.5 33.1 4.6*** 

Primary complete, some secondary 26.7 31.6 4.9*** 

Secondary/higher 26.1 30.3 4.2*** 

Wealth index quintiles 

Lowest 26.9 33.6 6.6*** 

Low 27.3 33.6 6.3*** 

Middle 26.5 32.0 5.5*** 

High 25.1 27.6 2.5*** 

Highest 24.6 24.2 -0.4*** 

Total 26.1 30.3 4.3*** 

* p<.05, ** p<.01, *** p<.001 1All methods include IUD, pills, injectables, condom, female sterilization and other modern and traditional methods. 

Note: Figures are based on life table calculations using information on segments of use that began 3-59 months prior 

to the survey. 

It is worth noting that changes by region of residence are extreme. The increase in the 12 months 

discontinuation rates between the two surveys is evident in the rural areas, at about 5.5 percentage 

points (from 27% to 33%) but very small in the urban areas (from 24% to 25%). In Lower Egypt, 

the rise in the 12 months discontinuation rate reached 5.3 percentage points (from 23% to 28%), 

while in Upper Egypt the increase was less, at 3.8 percentage points (from 31% to 35%). Within 

both regions, the urban-rural differential has increased. 

Differentials in the discontinuation rates by contraceptive method are shown in Appendix 2. In 

general, discontinuation rates have significantly changed among all categories, with a different 

pattern for each contraceptive method. Discontinuation rates among IUD segments have increased 
11 

significantly for all categories except among urban women, especially in urban Upper Egypt. 

Among pill segments, the 12 months discontinuation rates have significantly dropped among older 

women, women with three or more children, women in urban Lower Egypt and in urban Upper 

Egypt, and women in the highest wealth quintile. Among segments of injectables, the 

discontinuation rates have significantly dropped for women with two children, women in the 

Urban Governorates, women in Lower Egypt (both urban and rural areas), and women in the high 

and highest wealth quintiles. 

Appendix Table 2 shows that discontinuation rates have increased for segments in almost all age 

groups for all contraceptive methods. It is interesting to note the significant increase in 

discontinuation rates between the 2008 and 2014 surveys among IUD and pill segments for women 

with two children and the significant decrease among injectables segments. The increase is smaller 

among IUD segments (from 9% to 11%) than pill segments for women who have two children 

(from 31% to 39% in 2008 and 2014 respectively), while for injectables it decreased significantly 

for women with one or two children. 

Discontinuation rates have increased among segments for women in all education groups for all 

contraceptive methods, except among women with a secondary or higher education using 

injectables. The discontinuation rate for this group has decreased from 49% to 42%, a significant 

drop of 6.8 percentage points. Similarly, discontinuation rates have increased among women in all 

wealth quintiles; the only exception was among users of pills and injectables in the high and the 

highest wealth quintiles. Among women in the highest wealth category, the discontinuation rate 

for pill segments dropped from 42% to 34% and for injectable segments, from 47% to 36% among 

women in the high wealth quintile and from 54% to 43% in the highest quintile. 

From Appendix Table 2 we can also conclude that in the 2014 survey those IUD and pill users 

more likely to discontinue use within the first year of use are young, have one or two children, live 

in rural areas, especially in Upper Egypt, are less educated, and are in the lowest three wealth 

quintiles. The probability of discontinuing use for users of injectables within the first year is high 

among young women, women who have one or two children, women who live in urban areas, 

especially in urban Upper Egypt, and those in the highest wealth quintile. 

3.3. Reasons for Discontinuation of Contraceptives 

A classic conceptual framework for describing the impact of family planning programs on fertility 

was presented by Bertrand and others (Bertrand et al. 1996). The framework recognizes that 

fertility and other impacts are the consequence of both the demand for and supply of family 

planning services. Both the demand for children and demand for family planning services are 

affected by a number of political, socioeconomic, cultural, and individual factors. The family 

planning supply environment is also shaped by the political and administrative systems within 

which the program operates. Inputs to the family planning program are transformed through 
12 

program activities that collectively create the principal program outputs—accessibility, quality of 

care, and range of services. These outputs attract clients to the program and, jointly with demand 

for family planning, shape the behavior of family planning users and hence determine the impact 

of the program on the target population. 

The EDHS calendar data includes the reasons respondents give for discontinuing use for each 

segment. This allows us to analyze differences in trends of discontinuation for reasons related to 

both “supply” and “demand” factors in discontinuation. Five main reasons are considered in the 

analysis and each includes specific responses as follows: 

1. Contraceptive failure: became pregnant while using the method. 

2. Side effects/health concerns: had side effects or health concerns. 

3. Other method/service-related reasons1: wanted a more effective method, lack of access/too 

far, cost too much, inconvenient to use, husband disapproved, and up to God/fatalistic and 

other. 

4. Desire to get pregnant: wanted to become pregnant 

5. Not exposed to pregnancy: marital dissolution/separation, difficult to get 

pregnant/menopausal, infrequent sex/husband away. 

These five reasons for discontinuing contraceptive use can be further aggregated to reflect the two 

main groups of factors that influence a woman’s decision whether to stop or continue using a 

method. As family planning users assess the quality of the services they receive and the suitability 

of the method they are using, they also consider their needs and assess the level of their demand 

for these services. This process is dynamic, and therefore discontinuation decisions will shift 

accordingly. The first three reasons can be considered as “supply” factors, related to methods or 

services, while the last two can be considered as “demand” factors, related to reduced need for 

contraception. 

The first category, reasons related to methods and services includes: contraceptive failure, side 

effects/health concerns and other reasons such as the desire for a more effective method. The 

second category, reduced need for contraception, includes the woman’s desire to get pregnant or 

her personal assessment that she is not exposed to the risk of pregnancy. Although these two 

categories may seem broad, the categorization serves the purpose of simply differentiating between 

elements related to family planning service delivery and those related to women’s family planning 

desires and needs. 

 

1 Although the responses “husband disapproved” and “up to God” are not service-related, they were added to this 

reason because of their small share. “Husband disapproved” was 0.5% and 0.6% in the 2008 and 2014 surveys 

respectively, and “up to God” was 0.1% and 0.2%. 
13 

3.3.1 All-method discontinuation rates by reason for discontinuation 

Figure 3 presents the change in the all-method discontinuation rates by the two broad categories 

of reasons for discontinuation. The “method/service-related” category has remained almost 

unchanged, at about 18% in both surveys, while the “reduced need” category has significantly 

increased, from 8% in 2008 to 12% in 2014. There has been a meaningful shift in the reasons for 

discontinuation away from reasons related to contraceptive methods and services and toward needbased reasons. 

Figure 3. Grouped reason-specific 12 months discontinuation all-method rates, 5 

years preceding the survey, Egypt DHS 2008 and DHS 2014 

Table 3 presents the 12 months discontinuation rates by women’s reasons for discontinuing. It is 

clear that the ranking of the cited reasons for discontinuation has significantly changed between 

the surveys in 2008 and 2014. The first reason, which has the highest specific discontinuation rate, 

was side effects/health concerns, at 10% and 11% in 2008 and 2014 respectively. The second 

ranking reason reflects changing patterns between surveys, most notably in two specific reasons 

for discontinuation. In the 2008 survey the discontinuation rate for other method/service-related 

reasons was 6%, and it significantly dropped to 3% in 2014. At the same time, the largest observed 

increase was among segments that discontinued for a need-based reason, desire to get pregnant, 

which significantly increased from 4% in the 2008 survey to 6% in the 2014 survey, becoming the 

second-highest reason-specific discontinuation rate. 

The other component of the need-based discontinuation rate, not exposed to pregnancy, also 

significantly increased to become the third largest-reason for the increase in discontinuation rates 

between surveys. This result reflects a drop in the “demand” element of the family planning model. 

On the other hand, Table 3 shows that the almost unchanged discontinuation rates for segments 

due to method/service-related reasons is a result of an increase in contraceptive failure and in side 

8.1

17.9

11.8

18.5

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Reduced Need Method/Service related

All Methods

2008 2014
14 

effects/health concerns—both of which are related to the quality of counseling—offset by the drop 

in other method/service-related reasons—which are related to contraceptive logistics and 

accessibility. This result suggests that while the cost and accessibility of family planning methods 

and services have become less likely to cause discontinuation, counseling regarding side effects of 

contraceptive methods is still an issue that is likely to provoke discontinuation. Thus the overall 

effect of “supply” elements on discontinuation rates has remained unchanged. 

Table 3. Reason-specific 12 months discontinuation rates during 5 

years preceding the survey, Egypt DHS 2008 and DHS 2014

Reason 

All Methods 

2008 2014 

∆ 

(2014-2008) 

Method/service-related reasons 17.9 18.5 0.6***

Contraceptive failure 2.9 4.3 1.4*** 

Side effects/health concerns 9.5 10.8 1.4*** 

Other method/service-related reasons 5.6 3.4 -2.2*** 

Need-based reasons 8.1 11.8 3.7*** 

Desire to get pregnant 4.4 6.3 1.9*** 

Not exposed to pregnancy 3.7 5.5 1.8*** 

All reasons discontinuation rates 26.1 30.3 4.3***

Number of segments 10704 15236 

* p<.05, ** p<.01, *** p<.001 

3.3.2 Method-specific discontinuation rates by reason for discontinuation 

Figure 4 shows reasons for discontinuation for all segments of use that were discontinued within 

the first year by contraceptive method during the 5 years preceding the survey for the 2008 and 

2014 surveys. The figure highlights several points of interest. First, it shows that the segments of 

use are more likely to be discontinued due to method/service-related reasons than due to reasons 

of reduced need for all three contraceptive methods in both surveys. The second point of interest 

is that the “reduced need” reason has increased for all three methods. This increase is especially 

large among pill segments, which significantly increased from 16% to 18% between surveys, and 

for injectable users from 11% to 13%. 

Third, Figure 4 shows that the discontinuation rate for method/service-related reasons increased 

slightly for IUD use segments (from 8% to 9%), but decreased slightly for hormonal methods. For 

the pill segments, it dropped from 24.1%, to 23.5%, and for injectable segments there was a drop 

from 26% to 25%. This result may indicate that discontinuing the use of pills and injectables has 

become more responsive to demand factors, while discontinuation among IUD users has remained 

motivated by both demand and supply factors. 
15 

Figure 4. Grouped reason-specific 12 months discontinuation by contraceptive 

method, 5 years preceding the survey, Egypt DHS 2008 and DHS 2014 

 While Table 4 shows that the reported reasons for discontinuation differ among the methods, as 

might be expected, “side effects and health concerns” remain the major reason for discontinuation 

for all three contraceptive methods in both survey years. There has been a significant drop in 

discontinuation for this reason among pill and injectables segments, however, and a significant 

increase among IUD segments. On the other hand, “desire to get pregnant” has significantly 

changed, with a reason-specific discontinuation rate of 4%, 9%, and 6% in the 2014 survey among 

IUD, pill, and injectable segments respectively, compared with 3%, 7%, and 5% in the 2008 

survey. Discontinuation-specific rates due to method failure (becoming pregnant while using the 

method) have significantly increased for all methods, with the pill segments having the highest 

rates and the IUD segments having the lowest. 

Table 4. Reason-specific 12 months discontinuation rates during 5 years preceding the 

survey by contraceptive method, Egypt DHS 2008 and DHS 2014 

Reason 

IUD Pills Injectables 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008)

Method/service-related reasons 7.7 9.0 1.3*** 24.1 23.5 -0.6*** 26.1 24.5 -1.6***

Contraceptive failure 0.9 1.2 0.3*** 6.0 7.7 1.7*** 0.9 1.4 0.5***

Side effects/health concerns 6.1 7.5 1.5*** 12.3 11.1 -1.2*** 21.3 21.1 -0.2***

Other method/service-related 

reasons 0.7 0.3 -0.5*** 5.8 4.7 -1.1*** 3.9 2.0 -1.9***

Need-based reasons 4.2 5.3 1.1*** 15.8 18.3 2.5*** 11.1 13.4 2.4***

Desire to get pregnant 3.3 4.3 1.0*** 7.3 8.6 1.3*** 5.2 6.1 0.9***

Not exposed to pregnancy 0.97 1.0 0.04*** 8.6 9.7 1.2*** 5.9 7.3 1.4***

All reasons discontinuation rates 12.0 14.3 2.3*** 39.9 41.8 1.9*** 37.2 37.9 0.7***

Number of segments 4833 5505 2880 6038 1609 2524 

 * p<.05, ** p<.01, *** p<.001 

4.2

7.7

15.8

24.1

11.1

26.1

5.3

9.0

18.3

23.5

13.4

24.5

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Reduced Need Method/

Service

related

Reduced Need Method/

Service

 related

Reduced Need Method/

Service

related

IUD Pills Injectables

2008 2014
16 

3.4. Reasons for Discontinuation by Women’s Background Characteristics 

Table 5 presents reason-specific discontinuation rates for the two broad categories, classified by 

women’s background characteristics. In the 2008 survey, the all-method discontinuation rate due 

to method/service-related reasons was 18%, and remained almost constant in the 2014 survey. On 

the other hand, the all-method discontinuation rate due to reduced need for contraception increased 

from 8% to 12%. This trend is clear and significant across all background categories. Moreover, 

Table 5 shows that the increase in the all-method discontinuation rates due to reduced need is high 

(above average) among women with one or two children, women living in rural areas, women in 

rural Upper Egypt, women with primary education, and women in the lowest, low, and middle 

wealth index quintiles. 

Also, although the all-method discontinuation rate due to method/service-related reasons has 

changed only slightly, some increases have occurred among women with certain background 

characteristics: women age 25-34, women with three children, women in rural areas, women in 

urban and rural Lower Egypt, and women in the lowest wealth quintile. The rate has decreased in 

Upper Egypt and, especially, in urban Upper Egypt. 

Another concern is the high value of this indicator for the Urban Governorates, where family 

planning services are expected to be of the highest quality. About 17% of contraceptive users 

discontinue using the method within 1 year of initiating use because of method/service-related 

reasons. In 2008, urban Upper Egypt had the highest rate (22%), while urban Lower Egypt (14%) 

had the lowest rate. In 2014, an opposite pattern was evident, with the highest discontinuation rate 

due to method/service-related reasons found in rural Upper Egypt (22%) and the lowest rate in 

urban Lower Egypt (15%). This is a significant indication of a perceived improvement in the 

quality of family planning services in urban Upper Egypt, where discontinuation within the first 

year of contraceptive use due to method/service-related reasons became less likely than in the 

Urban Governorates. 

As mentioned, the current contraceptive method mix has an impact on the discontinuation rates. 

The grouped reason-specific discontinuation rates for each of the three main contraceptive 

methods are presented in Appendix 3, which can help establish whether the pattern discussed 

above exists among users of the three main contraceptive methods. 
17 

Table 5: All-method discontinuation rates by reason for discontinuation and 

background characteristics 5 years preceding the survey, Egypt DHS 2008 and 

DHS 2014 

Background 

characteristics 

Reduced need 

Method/Servicerelated 

Total 

discontinuation rates 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

Age 

15-24 9.1 14.3 5.1*** 21.2 20.7 -0.5*** 30.3 35.0 

25-34 7.3 9.8 2.5*** 16.2 18.1 1.8*** 23.6 27.9 

35-49 7.9 11.9 4.0*** 22.4 23.0 0.7*** 30.3 35.0 

Number of living children 

One 13.1 18.0 4.9*** 23.9 24.6 0.8*** 36.9 42.6 

Two 5.9 11.0 5.1*** 16.8 17.0 0.2*** 22.6 28.0 

Three 5.8 8.0 2.2*** 14.3 16.2 1.9*** 20.1 24.2 

Four or more 6.7 8.6 1.9*** 15.4 15.6 0.2*** 22.1 24.2 

Urban-rural residence 

Urban 6.6 8.7 2.1*** 17.6 16.3 -1.3*** 24.3 25.0 

Rural 9.1 13.2 4.1*** 18.1 19.6 1.4*** 27.2 32.8 

Place of residence 

Urban Governorates 6.2 8.0 1.8*** 16.6 16.8 0.3*** 22.8 24.9 

Lower Egypt 8.3 10.8 2.6*** 15.0 17.7 2.6*** 23.3 28.5 

Urban 7.2 8.0 0.8*** 14.0 15.5 1.5*** 21.2 23.5 

Rural 8.6 11.5 2.9*** 15.3 18.2 2.9*** 23.9 29.7 

Upper Egypt 8.9 14.3 5.5*** 22.0 20.3 -1.7*** 30.9 34.6 

Urban 6.9 10.2 3.3*** 22.2 16.4 -5.8*** 29.2 26.6 

Rural 9.7 15.9 6.2*** 21.9 21.8 -0.1*** 31.6 37.7 

Level of education 

No education 7.6 10.3 2.7*** 17.1 18.1 1.0*** 24.7 28.3 

Less than primary 7.9 11.8 3.9*** 20.6 21.3 0.6*** 28.5 33.1 

Primary complete, some 

secondary 8.0 12.8 4.8*** 18.7 18.8 0.1*** 26.7 31.6 

Secondary/higher 8.5 12.0 3.5*** 17.7 18.4 0.7*** 26.1 30.3 

Wealth index quintiles 

Lowest 6.8 12.0 5.1*** 20.1 21.6 1.5*** 26.9 33.6 

Low 9.0 14.5 5.5*** 18.3 19.1 0.8*** 27.3 33.6 

Middle 8.3 13.3 5.0*** 18.2 18.7 0.5*** 26.5 32.0 

High 7.6 9.7 2.2*** 17.5 17.9 0.4*** 25.1 27.6 

Highest 8.9 8.7 -0.2*** 15.7 15.5 -0.2*** 24.6 24.2 

Total 8.1 11.8 3.7*** 17.9 18.5 0.6*** 26.1 30.3 

 * p<.05, ** p<.01, *** p<.001 

3.5. Status after Discontinuation of Contraceptive Method 

In this section, the analysis is concerned with the contraceptive use status of women after 1 month 

of discontinuation. The main concern is whether the act of discontinuing a contraceptive method 

has left a user at risk of an unintended pregnancy. We assume that women who reported that they 

are no longer in need of using a contraceptive method (whether wanting to become pregnant or 

following their own assessment of inability to become pregnant) are not at risk of pregnancy. Those 
18 

who reported method failure are currently pregnant, and the resulting pregnancy is considered to 

be unintended. 

Women who reported discontinuing contraceptive use for reasons related to method/service have 

either abandoned use while in need of family planning and are therefore at risk of an unintended 

pregnancy or have discontinued use to switch to another contraceptive method and thus subject to 

a relative risk of unintended pregnancy depending on the effectiveness of the new method adopted. 

Switching to a more effective method will reduce the risk while switching to a less effective 

method will increase it. 

As the overall discontinuation rate increases to reach 30% in 2014, it becomes necessary to look 

into the probabilities that the discontinuers will belong to a particular status after discontinuation, 

which is, as mentioned above, an indication of the risk of unintended pregnancies. Table 6 displays 

the all-method status-specific 12 months discontinuation rates and those for the three main 

contraceptive methods. It shows that 8% of the use segments switched to another method in both 

surveys and that the “abandoned use while in need” status took place for 7.3% of the segments at 

the time of the 2008 survey and has significantly dropped to 6.5% at the time of the 2014 survey. 

Table 6. Status-specific 12 months discontinuation rates by contraceptive method 5 years preceding 

the survey, Egypt DHS 2008 and DHS 2014 

Status 

IUD Pills Injectables All Methods 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008)

No longer in need 4.2 5.3 1.1*** 15.8 18.3 2.5*** 11.1 13.4 2.4*** 8.1 11.8 3.7***

Switched in the 

following month 3.3 4.6 1.3*** 9.6 8.3 -1.3*** 11.5 11.0 -0.5*** 7.76 7.77 0.01***

Contraceptive failure 0.9 1.2 0.3*** 6.0 7.7 1.7*** 0.9 1.4 0.5*** 2.9 4.3 1.4***

Abandoned use while 

in need 3.5 3.2 -0.3*** 8.5 7.5 -1.0*** 13.7 12.1 -1.6*** 7.3 6.5 -0.8***

Discontinuation rates 12.0 14.3 2.3*** 39.9 41.8 1.9*** 37.2 37.9 0.7*** 26.1 30.3 4.3***

 * p<.05, ** p<.01, *** p<.001 

Almost the same trend is clear for all three methods of interest. The “no longer in need” rate has 

increased significantly, and the failure rate at which contraceptive discontinuation has left the user 

pregnant also has increased significantly, for all methods. It is interesting to note that among 

segments of all three methods, discontinuation has resulted in a decrease in the “abandoned while 

in need” status, which significantly decreased between the DHS surveys in 2008 and 2014. The 

“switched” rate significantly increased among the IUD users only, from 3% in 2008 to 5% in 2014. 

The switching status, while decreasing the percent of use of one method and increasing the percent 

of use of another, does not affect the overall contraceptive prevalence. However, as mentioned 

before, the impact of the switching status on fertility depends on whether the switching is to a more 

effective or less effective method. 
19 

The contraceptive methods have been ranked according to effectiveness2. Contraceptive methods 

effectiveness applied by the Spectrum Model (Avenir Health 2014) was used to rank all of the 

family planning methods used in Egypt. In 2008, about 43% of switchers switched to a less 

effective method and about 57% to a more effective method (Appendix 4). In 2014, a similar 

distribution was observed. About 46% switched to a less effective method and about 54% to a 

more effective method, as Figure 5 shows. The difference between those proportions was found to 

be non-significant, and a logistic regression model has shown that the women’s background 

characteristics do not explain the decision to choose a less effective or a more effective method 

(results not presented). 

Figure 5. Percent distribution of switchers during the first year of contraceptive 

initiation, by relative effectiveness of the destination method, 5 years preceding 

the survey, Egypt DHS 2008 and DHS 2014 

Table 7 shows that the same pattern described above applies to women in all background 

characteristics, with one exception. The pattern was slightly different for women in the highest 

wealth group where there was almost no change between the two surveys regarding the status of 

users after discontinuation. 

 

2

 Effectiveness is the extent by which a contraceptive method lowers the chances to become pregnant in a given 

month. This measure depends both on the ability of women to conceive and on the method’s failure rate. 

42.5%

45.6%

57.5%

54.4%

EDHS 2008

EDHS 2014

to less effective method to more effective method
20 

Table 7. Status-specific 12 months discontinuation rates by background characteristics 5 years preceding the survey, Egypt DHS 2008 

and DHS 2014 

Background characteristics 

No longer in need 

Switching in the 

following month Method failure 

Abandoned use while in 

need 

Discontinuation 

rate 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

Age 

15-24 9.1 14.3 5.1*** 8.7 8.9 0.2*** 3.3 4.9 1.5*** 9.2 6.9 -2.2*** 30.3 35.0 25-34 7.3 9.8 2.5*** 7.1 7.3 0.2*** 3.0 4.4 1.4*** 6.2 6.5 0.3*** 23.6 27.9 35-49 7.9 11.9 4.0*** 7.5 6.6 -0.9*** 1.5 2.3 0.8*** 5.8 5.3 -0.5*** 22.7 26.1 

Number of living 

children One 13.1 18.0 4.9*** 9.0 8.5 -0.5*** 4.3 7.5 3.2*** 10.6 8.6 -2.0*** 36.9 42.6 Two 5.9 11.0 5.1*** 7.8 7.8 0.1*** 3.1 3.7 0.6*** 5.9 5.4 -0.5*** 22.6 28.0 

Three 5.8 8.0 2.2*** 6.5 8.0 1.5*** 1.9 2.6 0.8*** 6.0 5.5 -0.4*** 20.1 24.2 

Four or more 6.7 8.6 1.9*** 7.5 6.6 -1.0*** 1.8 2.9 1.1*** 6.1 6.2 0.1*** 22.1 24.2 

Urban-rural residence 

Urban 6.6 8.7 2.1*** 7.6 7.2 -0.5*** 3.1 4.1 1.0*** 6.9 5.0 -1.9*** 24.3 25.0 Rural 9.1 13.2 4.1*** 7.9 8.1 0.2*** 2.7 4.3 1.6*** 7.6 7.2 -0.4*** 27.2 32.8 

Place of residence 

Urban Governorates 6.2 8.0 1.8*** 6.9 7.0 0.1*** 3.2 4.6 1.3*** 6.4 5.3 -1.2*** 22.8 24.9 

Lower Egypt 8.3 10.8 2.6*** 6.6 8.0 1.4*** 2.8 4.3 1.6*** 5.6 5.3 -0.4*** 23.3 28.5 Urban 7.2 8.0 0.8*** 5.2 7.1 1.9*** 3.1 3.8 0.7*** 5.7 4.6 -1.1*** 21.2 23.5 

Rural 8.6 11.5 2.9*** 7.1 8.3 1.2*** 2.7 4.5 1.8*** 5.6 5.5 -0.2*** 23.9 29.7 Upper Egypt 8.9 14.3 5.5*** 9.5 7.6 -1.9*** 2.8 4.1 1.3*** 9.7 8.6 -1.2*** 30.9 34.6 Urban 6.9 10.2 3.3*** 10.7 7.2 -3.5*** 2.9 4.0 1.2*** 8.7 5.2 -3.5*** 29.2 26.6 Rural 9.7 15.9 6.2*** 8.9 7.7 -1.2*** 2.8 4.2 1.4*** 10.2 9.9 -0.3*** 31.6 37.7 

Level of education 

No education 7.6 10.3 2.7*** 6.5 6.2 -0.3*** 2.8 3.7 0.9*** 7.8 8.2 0.3*** 24.7 28.3 Less than primary 7.9 11.8 3.9*** 9.2 8.8 -0.4*** 3.5 5.7 2.2*** 8.0 6.8 -1.2*** 28.5 33.1 Primary complete, some 

secondary 8.0 12.8 4.8*** 7.8 7.6 -0.1*** 2.5 4.2 1.6*** 8.4 7.0 -1.4*** 26.7 31.6 

Secondary/higher 8.5 12.0 3.5*** 8.16 8.2 0.04*** 2.9 4.4 1.4*** 6.6 5.8 -0.8*** 26.1 30.3 

Wealth index quintiles 

Lowest 6.8 12.0 5.1*** 7.6 7.2 -0.4*** 2.9 5.4 2.5*** 9.5 8.9 -0.6*** 26.9 33.6 Low 9.0 14.5 5.5*** 7.2 7.7 0.5*** 3.2 4.0 0.8*** 7.8 7.3 -0.5*** 27.3 33.6 

Middle 8.3 13.3 5.0*** 8.7 8.6 -0.1*** 2.7 3.4 0.7*** 6.8 6.7 -0.1*** 26.5 32.0 High 7.6 9.7 2.2*** 7.9 8.1 0.2*** 2.6 4.8 2.3*** 7.1 5.0 -2.1*** 25.1 27.6 

Highest 8.9 8.7 -0.2*** 7.2 6.8 -0.4*** 2.9 4.0 1.1*** 5.5 4.6 -0.9*** 24.6 24.2 

Total 8.1 11.8 3.7*** 7.76 7.77 0.01*** 2.9 4.3 1.4*** 7.3 6.5 -0.8*** 26.1 30.3 

* p<.05, ** p<.01, *** p<.001
21 

4. Discussion 

Within the context of the recent rise in fertility in Egypt, this paper has documented the 

accompanying rise in the discontinuation rates for all contraceptives and among subgroups of the 

population. “High rates of discontinuation stress the need to improve service quality, particularly 

counseling, so that women can make an informed choice and are forewarned about side-effects 

and reassured about health concerns. Timely and informed method-switching needs to be better 

recognized by the program in order to avoid unintended pregnancies, abortion and unwanted or 

mistimed births” (Ali, Cleland and Shah 2012). In the current paper we distinguish between two 

broad categories of reasons for discontinuation: “method/service-related” (supply) and “reduced 

need for contraception” (demand). Both affect user attitudes and behavior and are equally 

responsible, in our view, for changes in the dynamics of contraceptive use. This approach will also 

emphasize the importance of advocacy and raising awareness among women and family planning 

service providers. Anecdotal evidence indicates that some doctors have personal beliefs that may 

affect carrying out or recommending particular procedures for family planning clients. As 

members of the society, family planning service providers have been affected by the recent cultural 

and social change in the country, especially religious attitudes. 

The ranking of women’s cited reasons for discontinuation has significantly changed between 

surveys in 2008 and 2014. While “side effects/health concerns” remains the most common reason 

in both surveys for all three methods studied, the second-most cited reason for discontinuation 

changed from “other method/service-related reasons” in the 2008 survey to “desire to get 

pregnant” in the 2014 survey. 

In general, the grouped reason-specific discontinuation rate concerned with the contraceptive 

method itself and with family planning service provision (supply) has remained almost constant at 

18%, while the grouped reason-specific discontinuation rate related to less need for contraception 

(demand) has significantly increased, from 8% in 2008 to 12% in 2014. This pattern took place 

among users of hormonal methods, while among IUD users both grouped reason-specific 

discontinuation rates have increased significantly. 

The recent increase in the ideal family size in Egypt has been documented (Ministry of Health and 

Population, El Zanaty and Associates and ICF International 2015b), at 3.4 children among men 

and 3.1 among women of reproductive age, and could be a motive to get pregnant and stop using 

a family planning method. The report shows the highest ideal number of children to be among 

women who have two children, women living in rural areas, especially in rural Upper Egypt, and 

women in the middle wealth index quintile. We may conclude that the observed shift toward 

discontinuation for reasons of “reduced need” among contraceptive users is largely influenced by 

women’s attitudes, desires, and background characteristics rather than service delivery factors. 
22 

It is possible that these results for all methods could conceal differences by individual methods. In 

this paper, our focus was on each of the three main contraceptive methods that together form over 

nine-tenths of the total method mix in both surveys—IUD, pills, and injectables. This focus helps 

in understanding discontinuation, switching, and exposure to unintended pregnancies. 

The IUD is the most popular contraceptive method, at about half of the method mix (Ministry of 

Health and Population, El Zanaty and Associates, and ICF International 2015a). Although it is a 

long-term contraceptive method, it can be used for spacing because it is reversible, and this is 

common in Egypt. A comparative study about the discontinuation of IUD use (Ali, Mohamed, et 

al. 2011), which included data from the EDHS 2008, reported that in all countries studied, women 

were more likely to use modern methods other than IUDs to space births—with the exception of 

Egypt. 

Compared with the pill, IUD users are less likely to discontinue use within the first year of use, 

but discontinuation rates are high during the second and third years after initiation. IUD users 

experience a lower failure rate and are more likely to switch to another method compared with pill 

discontinuers. In our study, these rates increased slightly between 2008 and 2014 among all 

categories of women except women in urban areas, especially in urban Upper Egypt. 

Among discontinuers of the IUD the reason-specific 12 months discontinuation rate for “reduced 

need” increased from 3% in 2008 to 4% in 2014, compared with a drop from 0.7% to 0.3% for 

“other method/service-related reasons.” This pattern may reflect the aspiration of women—and 

their husbands—to achieve a higher ideal number of children. This pattern was more prominent 

for women in the lowest wealth index quintile. 

Researchers have pointed out the possibility that discontinuation of the IUD is especially 

significant in relation to the decision regarding desired family size. A policy brief by the World 

Health Organization concluded, “IUD users are distinguished by the relatively long duration of 

their IUD use and low failure rates. The reason is uncertain but the fact that discontinuation of this 

method typically requires a deliberate decision and a visit to a healthcare provider for removal is 

probably part of the explanation. In contrast, discontinuation of pills, injectables, and condoms is 

a passive act” (WHO 2012). 

 Concerning the switching behavior of the IUD users, the comparative study mentioned 

above studied switching behavior of IUD users within 3 months of removal (Ali et. al. 2011) and 

reported, “Switching back to an IUD (possibly a different type) was very rare except in Egypt and 

Kazakhstan.” In the current study we calculated switching within1 month of IUD removal and 

found that, in 2008, 26% of the IUD discontinuers were using injectables, 66% the pill, and 8% 

condoms or traditional methods. In 2014, after one month of removal, only 13% were using 

injectables, while use of the pill had risen to 75%, and 11% used condoms or traditional methods. 
23 

Women’s concerns about side effects and other health issues may be increasing, but it also appears 

that the decision to discontinue IUD use in order to get pregnant is increasing. 

The drop in the percentage of IUD discontinuers who believe they are not exposed to the risk of 

pregnancy may be due to the fact that IUD use is more popular among older women. The switching 

behavior of the IUD users can be described as “positive,” which leaves the woman in a state of 

reduced risk of pregnancy. Together with the results showing a significant drop in discontinuation 

rate for IUD users for the reason “abandoned use while in need,” we may conclude that the 

expected effect of IUD discontinuation on fertility is not large. 

Pill users have the highest discontinuation rates and the highest contraceptive failure rate of the 

three contraceptive methods studied in this report. The 12 months discontinuation rates have 

increased among pill users, especially among women who have two children, women in rural areas, 

especially in rural Upper Egypt, and women in the middle wealth index quintile. Pills form about 

a quarter of Egypt’s contraceptive method mix (Ministry of Health and Population, El Zanaty, and 

Associates, and ICF International 2015a), and thus the rise in discontinuation rates for pill use will 

have an impact on fertility rates in the future by increasing unintended pregnancies. 

Reason-specific discontinuation rates for pills have changed significantly. The rate for 

“method/service-related” reasons dropped slightly, from 24.1% in 2008 to 23.5% in 2014, while 

the rate for “reduced need” increased from 16% to 18% (Appendix 3.b). This indicates that the 

increase found overall for the “reduced need” discontinuation rates and the decrease in the 

“method/service” discontinuation rates applies to the pill users, and especially women who live in 

rural Upper Egypt, women with less than primary education, and women in the low wealth index 

quintile. 

Although the discontinuation rate of pill users who switch to another method within one month of 

stopping the pill has dropped, from 10% in 2008 to 8% in 2014, the large majority of pill users 

who reported switching to another method have switched to a more effective method. In the 2008 

survey 85% switched to the IUD and injectables, and 89% in the 2014 survey (Appendix 4). 

Injectables are a relatively recent addition to the method mix in Egypt, but injectable use has risen 

to 15% of total contraceptive use in the 2014 EDHS. Between the 2008 and 2014 surveys, the 

discontinuation rate of injectables has decreased among women in the urban governorates and in 

Lower Egypt, both in urban and rural areas, and among women in the high and highest wealth 

index quintiles, while it has increased in Upper Egypt in rural Upper Egypt and among the lowest 

wealth index quintiles. The changes in reasons for discontinuing injectable use are similar to those 

for the pill, with a much lower failure rate, and injectable users are more likely to abandon use 

while in need. Among those who switch from injectables to another method, about two-thirds 

switch to the pill, while the proportion switching to the IUD declined from 28% in 2008 to 17% in 

2014. 
24 

Appendix 5 presents a summary of the discontinuation rates, reasons for discontinuation, and the 

contraceptive status of women after discontinuation by the three most significant background 

characteristics (place of residence, wealth index, and number of children). Differentials by the 

mean ideal number of children are also included. This summary can guide the reader through the 

next section on policy implications. 
25 

5. Policy Implications 

The need for controlling fertility for Egypt’s development has long been established (Khalifa, 

DaVanzo, and Adamson 2000). Fertility levels declined between 1980 and 2008 but the TFR rose 

substantially during the 6-year period between 2008 and 2014 DHS surveys, from a level of 3.0 

births per woman to 3.5 births per woman (Ministry of Health and Population, El Zanaty and 

Associates, and ICF 2015a). Contraceptive prevalence rose rapidly in the 1980s, and continued to 

rise, reaching 60% in the 2003 EDHS, but has not changed significantly since then. The mean ideal 

number of children among men is about 10% higher than women’s ideal number (at 3.4 children 

and 3.1 children respectively) (Ministry of Health and Population, El-Zanaty and Associates, and 

ICF International 2015b). 

The results of this research may imply that while Egypt’s family planning program has continued 

to pursue an increase in contraceptive prevalence, strategies aiming to ensure better use 

compliance and longer durations of use have not been as effective. A general indicator of how well 

the family planning program is achieving its goals is the program effort score. This score declined 

from 66% in 1989 to 59% in 1994 and 57% in 1999 (Ross et al. 2001). There were great variations 

across regions and governorates (Khalifa et al. 1999), with a low score on services (58%) and on 

access (51%) (Ross et al. 2010). 

An analysis among countries that had once received technical and financial support from USAID 

presented conditions to ensure these “graduated” countries would continue their progress (Ross 

and Smith 2011). They cited “the balance among competing justifications that drive the programs” 

as a major consideration for directing national effort. It is important to note that the rise in the ideal 

family size is a strong indicator that may contribute to making the strategic target of avoiding 

unwanted births a low priority consideration on the agenda of the Egypt family planning program 

in the future. 

The results of this research highlight the fact that program-related factors such as cost or access 

remain reasons for discontinuing use of contraception. However, the main program-related reasons 

are users’ desire for a more effective method and side effects and health concerns. This result 

suggests that better counseling in these areas might have the potential to decrease failure rates and 

improve switching behavior, as it indicates that women are not well informed about contraceptive 

method effectiveness and possible side effects or about alternative methods that women might 

prefer. If these issues are not given due attention, many women may be at greater risk for having 

an unintended pregnancy because they may abandon a method without immediately adopting 

another. The dissemination of the study results among policymakers will highlight the potential 

impact of strategies that address better use compliance and longer duration of contraceptive use in 

Egypt and its relation to achieving the goal of fertility reduction, taking into account regional 

considerations. 
26 

A special issue in this regard is the high discontinuation rates of the two hormonal methods due to 

side effects and/or health concerns. The fact that switching between these two methods is common 

requires that switchers should be encouraged to move to the destination method as soon as possible 

so as to reduce the time of exposure to the risk of conception. It is an indication that women need 

forewarning about side effects and reassurance with regard to safety as well as advice that 

alternative methods are available if the initial method is found to be unsatisfactory. This is to 

ensure timely switching if needed. 

Contraceptive security remains a financial challenge for Egypt. It is clear that plans to avoid 

unintended pregnancies among contraceptive current users are likely to require an increased 

allocation of resources. However, the financial and health burden of unintended pregnancies may 

make program efforts to avoid unintended pregnancies quite cost effective. This argument can be 

verified by cost-effectiveness studies to be based on the estimates produced by this research 

regarding the number of births that can be averted by reducing discontinuation and switching. 

On the other hand, the research has shown that the recent increase in the mean ideal family size is 

starting to affect the impact of the family planning program on fertility. In order for this result to 

influence the national family planning strategy, further research is needed to quantify the effect of 

discontinuation on fertility. From a women’s needs/rights perspective, research is needed to 

address the impact of discontinuation on unmet need and especially regarding the feasibility of 

reaching the goals of FP2020. Qualitative research may be useful in understanding the process by 

which women formulate their fertility intentions, the reasons for wanting more children, the 

reasons driving women’s perception that they are no longer exposed to pregnancy, and reasons 

behind the increase in the failure rates. 
27 

Appendices 

Appendix 1. Number of segments of use, 5 years before the survey by contraceptive method 

and women’s background characteristics, Egypt DHS 2008 and DHS 2014 

Background 

characteristics 

DHS 2008 DHS 2014 

Injectable IUD Pills All 

methods

Injectable IUD Pills All 

methods

Age 

15-24 497 2027 1140 4132 553 2178 2290 5529 

25-34 759 2149 1233 4784 1049 2739 2957 7611 

35-49 353 657 507 1786 411 588 788 2092 

Number of living 

children 

None 2 13 14 35 7 14 31 58 

One 211 1499 884 2943 218 1555 1798 3845 

Two 410 1403 811 2947 728 1790 1853 4656 

Three 386 1096 546 2324 780 1288 1247 3597 

Four or more 602 822 625 2455 792 858 1110 3080 

Urban-rural residence 

Urban 453 2080 1088 4171 588 1925 1897 4807 

Rural 1156 2754 1792 6533 1936 3580 4141 10430 

Place of residence 

Urban Governorates 175 962 388 1755 180 737 586 1633 

Lower Egypt 679 2470 1281 4857 1172 3149 3049 7910 

Urban 118 580 327 1119 163 608 626 1535 

Rural 562 1890 954 3738 1009 2541 2423 6375 

Upper Egypt 737 1348 1168 3956 1155 1578 2342 5561 

Urban 150 501 344 1207 239 556 647 1560 

Rural 587 847 824 2750 916 1022 1695 4002 

Frontier Governorates 18 53 42 137 17 41 61 131 

Level of education 

No education 644 954 672 2684 842 752 907 2723 

Less than primary 202 344 190 866 161 239 317 777 

Primary complete, 

Some secondary 272 720 456 1663 483 940 977 2580 

Secondary/higher 492 2816 1562 5490 1039 3575 3837 9156 

Wealth index quintiles 

Lowest 481 664 459 1940 691 673 923 2526 

Low 394 835 567 2074 642 954 1195 3006 

Middle 375 1019 654 2316 604 1458 1588 3871 

High 239 1148 633 2247 402 1251 1293 3212 

Highest 120 1168 568 2128 185 1168 1039 2620 

Total 1609 4833 2880 10704 2524 5505 6038 15236 

 
28 

Appendix 2. Twelve months life table discontinuation rates by background characteristics for IUD, 

pills, and injectables segments during 5 years preceding the survey, Egypt DHS 2008 and DHS 2014 

Background 

characteristics 

IUD Pills Injectables 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 

Age 

15-24 15.9 18.8 2.9*** 44.1 46.1 1.9*** 46.9 44.6 -2.3*** 

25-34 10.5 12.2 1.7*** 35.0 39.6 4.6*** 32.8 34.2 1.4*** 

35-49 4.8 7.2 2.5*** 41.9 37.2 -4.7*** 31.9 37.9 6.0*** 

Number of living 

children 

One 22.0 26.2 4.2*** 51.5 52.9 1.4*** 63.7 63.3 -0.4*** 

Two 8.6 10.9 2.4*** 31.6 39.4 7.8*** 42.0 39.6 -2.4*** 

Three 6.4 7.3 0.9*** 36.8 35.3 -1.5*** 30.4 35.5 5.0*** 

Four or more 6.6 9.3 2.7*** 36.1 33.0 -3.0*** 28.0 31.0 2.9*** 

Urban-rural residence 

Urban 11.0 11.6 0.6*** 36.6 34.4 -2.2*** 38.7 38.4 -0.3*** 

Rural 12.7 15.8 3.1*** 41.9 45.2 3.3*** 36.6 37.8 1.2*** 

Place of residence 

Urban Governorates 11.9 12.9 1.0*** 34.3 35.1 0.8*** 36.2 36.0 -0.2*** 

Lower Egypt 9.8 13.1 3.2*** 40.1 42.2 2.1*** 36.8 34.5 -2.3*** 

Urban 7.5 10.3 2.7*** 37.8 35.0 -2.8*** 36.3 33.3 -3.0*** 

Rural 10.5 13.7 3.2*** 40.9 44.1 3.2*** 36.9 34.7 -2.2*** 

Upper Egypt 15.9 17.6 1.7*** 41.7 43.2 1.5*** 38.0 41.7 3.8*** 

Urban 13.4 11.3 -2.1*** 38.0 33.2 -4.8*** 44.5 43.5 -1.0*** 

Rural 17.3 20.9 3.6*** 43.2 47.0 3.7*** 36.3 41.3 5.0*** 

Frontier Governorates 15.0 12.2 -2.7*** 35.4 33.1 -2.3*** 28.7 30.3 1.6*** 

Level of education 

No education 11.5 14.2 2.8*** 38.3 38.0 -0.3*** 29.3 32.6 3.3*** 

Less than primary 11.6 10.8 -0.8*** 45.6 47.8 2.2*** 38.9 38.1 -0.8*** 

Primary complete, 

some secondary 14.5 16.4 2.0*** 38.7 42.8 4.0*** 33.4 38.5 5.1*** 

Secondary/higher 11.6 14.0 2.5*** 40.2 41.9 1.7*** 48.8 41.9 -6.8*** 

Wealth index quintiles 

Lowest 13.9 16.5 2.6*** 41.2 45.1 4.0*** 30.3 37.6 7.3*** 

Low 12.8 17.2 4.4*** 40.7 44.6 4.0*** 34.8 37.6 2.7*** 

Middle 13.3 14.8 1.6*** 37.7 45.5 7.7*** 37.9 38.0 0.1*** 

High 11.0 13.5 2.5*** 37.7 38.0 0.3*** 46.4 36.9 -9.5*** 

Highest 10.1 10.9 0.8*** 42.8 34.6 -8.2*** 52.1 41.9 -10.2*** 

Total 12.0 14.3 2.3*** 39.9 41.8 1.9*** 37.2 37.9 0.7*** 

* p<.05, ** p<.01, *** p<.001 
29 

Appendix 3.a. IUD discontinuation rates by reason for discontinuation and background 

characteristics five years preceding the survey, Egypt DHS 2008 and DHS 2014 

a. IUD 

Background 

characteristics 

Reduced need Method/Service related 

Total 

discontinuation 

rates 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

Age 

15-24 5.5 7.3 1.9*** 10.4 11.4 1.1*** 15.9 18.8 

25-34 3.9 4.1 0.2*** 6.5 8.1 1.6*** 10.5 12.2 

35-49 1.4 3.2 1.8*** 3.4 4.0 0.7*** 4.8 7.2 

Number of living 

children 

One 9.2 11.7 2.5*** 12.8 14.5 1.7*** 22.0 26.2

Two 2.4 3.7 1.2*** 6.1 7.3 1.1*** 8.6 10.9

Three 2.0 1.0 -1.0*** 4.4 6.3 1.9*** 6.4 7.3

Four or more 1.2 2.7 1.5*** 5.4 6.6 1.2*** 6.6 9.3

Urban-rural residence 

Urban 4.1 4.1 -0.1*** 6.9 7.5 0.7*** 11.0 11.6 

Rural 4.3 6.0 1.6*** 8.4 9.8 1.4*** 12.7 15.8 

Place of residence 

Urban Governorates 5.0 5.3 0.4*** 7.0 7.6 0.7*** 11.9 12.9 

Lower Egypt 3.8 4.9 1.1*** 6.0 8.2 2.2*** 9.8 13.1 

Urban 2.4 3.1 0.7*** 5.1 7.2 2.1*** 7.5 10.3 

Rural 4.2 5.3 1.1*** 6.3 8.4 2.1*** 10.5 13.7 

Upper Egypt 4.5 6.2 1.7*** 11.39 11.38 -0.01*** 15.9 17.6 

Urban 4.6 3.6 -1.0*** 8.8 7.7 -1.1*** 13.4 11.3 

Rural 4.5 7.6 3.2*** 12.9 13.3 0.4*** 17.3 20.9 

Level of education 

No education 4.1 5.3 1.2*** 7.4 8.9 1.6*** 11.5 14.2 

Less than primary 2.8 2.3 -0.5*** 8.9 8.5 -0.4*** 11.6 10.8 

Primary complete, some 

secondary 5.5 6.1 0.5*** 8.9 10.4 1.5*** 14.5 16.4 

Secondary/higher 4.1 5.3 1.2*** 7.4 8.7 1.3*** 11.6 14.0 

Wealth index quintiles 

Lowest 3.3 7.3 4.0*** 10.6 9.2 -1.5*** 13.9 16.5 

Low 5.0 5.2 0.2*** 7.8 12.0 4.2*** 12.8 17.2 

Middle 4.4 6.0 1.6*** 8.9 8.8 -0.1*** 13.3 14.8 

High 3.9 4.7 0.9*** 7.2 8.8 1.7*** 11.0 13.5 

Highest 4.5 4.0 -0.5*** 5.6 6.9 1.3*** 10.1 10.9 

Total 4.2 5.3 1.1*** 7.7 9.0 1.3*** 12.0 14.3 

* p<.05, ** p<.01, *** p<.001 

 
30 

Appendix 3.b. Pills discontinuation rates by reason for discontinuation and background 

characteristics 5 years preceding the survey, Egypt DHS 2008 and DHS 2014 

b. Pills 

Background 

characteristics 

Reduced Need Method/Service related 

Total 

Discontinuation 

Rates 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

Age 

15-24 15.8 20.6 4.7*** 28.3 25.5 -2.8*** 44.1 46.1 

25-34 14.9 16.2 1.3*** 20.1 23.3 3.2*** 35.0 39.6 

35-49 17.7 19.2 1.6*** 24.2 18.0 -6.3*** 41.9 37.2 

Number of living 

children 

One 20.7 23.0 2.3*** 30.8 29.9 -0.9*** 51.5 52.9

Two 11.9 18.0 6.1*** 19.7 21.4 1.7*** 31.6 39.4

Three 13.4 14.8 1.5*** 23.4 20.5 -2.9*** 36.8 35.3

Four or more 15.3 13.6 -1.7*** 20.8 19.4 -1.3*** 36.1 33.0

Urban-rural residence 

Urban 12.9 12.7 -0.1*** 23.7 21.7 -2.0*** 36.6 34.4 

Rural 17.6 20.9 3.3*** 24.3 24.3 0.0 41.9 45.2 

Place of residence 

Urban Governorates 12.9 11.3 -1.6*** 21.4 23.9 2.5*** 34.3 35.1 

Lower Egypt 17.0 18.0 1.1*** 23.1 24.1 1.1*** 40.1 42.2 

Urban 16.4 12.8 -3.6*** 21.4 22.2 0.8*** 37.8 35.0 

Rural 17.2 19.4 2.2*** 23.7 24.7 1.0*** 40.9 44.1 

Upper Egypt 15.8 20.6 4.8*** 25.9 22.5 -3.4*** 41.7 43.2 

Urban 10.2 14.1 3.9*** 27.8 19.1 -8.7*** 38.0 33.2 

Rural 18.1 23.1 5.0*** 25.1 23.9 -1.2*** 43.2 47.0 

Level of education 

No education 15.9 14.9 -1.0*** 22.4 23.2 0.7*** 38.3 38.0 

Less than primary 15.0 22.4 7.3*** 30.5 25.4 -5.1*** 45.6 47.8 

Primary complete, some 

secondary 14.3 17.6 3.4*** 24.5 25.1 0.7*** 38.7 42.8 

Secondary/higher 16.4 19.0 2.6*** 23.8 22.9 -0.9*** 40.2 41.9 

Wealth index quintiles 

Lowest 13.1 16.5 3.4*** 28.1 28.7 0.6*** 41.2 45.1 

Low 15.8 23.0 7.2*** 24.9 21.7 -3.2*** 40.7 44.6 

Middle 14.8 21.5 6.7*** 23.0 24.0 1.0*** 37.7 45.5 

High 14.7 15.0 0.3*** 22.95 22.99 0.04*** 37.7 38.0 

Highest 20.6 13.8 -6.8*** 22.2 20.8 -1.4*** 42.8 34.6 

Total 15.8 18.3 2.5*** 24.1 23.5 -0.6*** 39.9 41.8 

* p<.05, ** p<.01, *** p<.001 

 
31 

Appendix 3.c. Injectables discontinuation rates by reason for discontinuation and 

background characteristics 5 years preceding the survey, Egypt DHS 2008 and DHS 

2014 

c. Injectables 

Background 

characteristics 

Reduced need Method/Service related 

Total 

discontinuation 

rates 

2008 2014 

∆ 

(2014-

2008) 2008 2014 

∆ 

(2014-

2008) 2008 2014 

Age 

15-24 14.7 17.0 2.3*** 32.2 27.6 -4.6*** 46.9 44.6 

25-34 9.0 10.8 1.8*** 23.9 23.4 -0.5*** 32.8 34.2 

35-49 10.2 14.9 4.7*** 21.7 22.9 1.2*** 31.9 37.9 

Number of living 

children 

One 23.7 26.2 2.5*** 40.0 37.0 -2.9*** 63.7 63.3

Two 8.8 14.0 5.2*** 33.2 25.6 -7.6*** 42.0 39.6

Three 8.7 11.0 2.3*** 21.7 24.4 2.8*** 30.4 35.5

Four or more 9.2 11.4 2.1*** 18.8 19.6 0.8*** 28.0 31.0

Urban-rural residence 

Urban 8.3 12.8 4.4*** 30.3 25.6 -4.7*** 38.7 38.4 

Rural 12.1 13.6 1.5*** 24.5 24.2 -0.3*** 36.6 37.8 

Place of residence 

Urban Governorates 4.3 9.4 5.1*** 31.9 26.6 -5.3*** 36.2 36.0 

Lower Egypt 12.0 11.0 -1.0*** 24.8 23.6 -1.3*** 36.8 34.5 

Urban 9.1 11.3 2.2*** 27.2 22.1 -5.1*** 36.3 33.3 

Rural 12.6 10.9 -1.7*** 24.3 23.8 -0.5*** 36.9 34.7 

Upper Egypt 12.0 16.6 4.7*** 26.0 25.1 -0.9*** 38.0 41.7 

Urban 12.9 16.4 3.5*** 31.7 27.1 -4.6*** 44.5 43.5 

Rural 11.7 16.7 5.0*** 24.6 24.6 0.1*** 36.3 41.3 

Level of education 

No education 8.6 11.9 3.2*** 20.7 20.7 0.1*** 29.3 32.6 

Less than primary 13.8 9.3 -4.5*** 25.1 28.8 3.7*** 38.9 38.1 

Primary complete, some 

secondary 8.5 17.6 9.0*** 24.9 20.9 -4.0*** 33.4 38.5 

Secondary/higher 14.5 13.4 -1.0*** 34.3 28.5 -5.8*** 48.8 41.9 

Wealth index quintiles 

Lowest 9.7 13.8 4.1*** 20.6 23.8 3.2*** 30.3 37.6 

Low 13.0 15.1 2.1*** 21.8 22.4 0.6*** 34.8 37.6 

Middle 10.7 12.8 2.0*** 27.1 25.2 -1.9*** 37.9 38.0 

High 10.6 12.5 1.9*** 35.8 24.4 -11.4*** 46.4 36.9 

Highest 12.6 10.2 -2.4*** 39.5 31.8 -7.7*** 52.1 41.9 

Total 11.1 13.4 2.4*** 26.1 24.5 -1.6*** 37.2 37.9 

* p<.05, ** p<.01, *** p<.001 
32 

Appendix 4.a. Switching methods during 12 months of discontinuation, Egypt DHS 2008

a. Switching methods during 12 months of discontinuation 2008 

Destination method 

Discontinued 

method Injectables IUD Pill Condom Traditional Total 

Injectables 

0 68 156 4 13 240 

0.0% 28.2% 64.9% 1.5% 5.4% 100%

IUD 

70 0 174 8 9 262

26.8% 0.0% 66.6% 3.2% 3.4% 100.0%

Pill 

82 193 0 9 27 310

26.4% 62.2% 0.0% 2.8% 8.6% 100.0%

Condom 

2 14 3 0 6 25

6.1% 58.2% 13.0% 0.0% 22.7% 100.0%

Traditional 

74 112 95 5 8 294

25.2% 38.1% 32.3% 1.7% 2.7% 100.0%

All 

227 387 428 26 62 1130

20.1% 34.2% 37.9% 2.3% 5.5% 100.0%

to a less effective method 481 42.5%

to a more effective method 650 57.5%

Appendix 4.b. Switching methods during 12 months of discontinuation, Egypt DHS 2014

b. Switching methods during 12 months of discontinuation 2014 

Destination method 

Discontinued 

method Injectables IUD Pill Condom Traditional Total 

Injectables 

0 45 171 2 52 269 

0.0% 16.6% 63.4% 0.8% 19.3% 100.0%

IUD 

48 0 269 8 32 358

13.4% 0.0% 75.3% 2.3% 9.0% 100.0%

Pill 

124 362 0 9 77 572

21.6% 63.2% 0.0% 1.7% 13.5% 100.0%

Condom 

3 5 6 0 1 15

21.5% 34.5% 36.7% 0.0% 7.3% 100.0%

Traditional 

54 90 123 4 17 287

18.7% 31.2% 42.9% 1.3% 6.0% 100.0%

All 

229 501 569 24 180 1502

15.2% 33.4% 37.9% 1.6% 12.0% 100.0%

to a less effective method 684 45.6%

to a more effective method 818 54.4%
Appendix 5. Summary of differentials in discontinuation rates, reason for discontinuation, status after discontinuation, and the mean ideal 

number of children, by place of residence, wealth index, and number of children, Egypt DHS 2014 

12 months discontinuation rates1

Reason for 

discontinuation2 Status after discontinuation3

Mean ideal number 

of children4

Background characteristics IUD Pills Injectable 

Reduced 

need 

Method/

servicerelated No longer in need Switched Method failure 

Abandoned 

while in 

need 

Women 

15-49 

Men 

15-49 

Place of Residence 

Urban Governorates 12.9 35.1 36.0 8.0 16.8* 8.0 7.0 4.6 5.3 2.8 3.0 Lower Urban 10.3 35.0 32.3 8.0 15.5 8.0 7.1 3.8 4.6 2.8 3.1 Lower Rural 13.7 44.1 34.4 11.5 18.2 11.5 8.3 4.5 5.5 3.0 3.2 Upper Urban 11.3 33.2 43.7 10.2 16.4 10.2 7.2 4.0 5.2 3.0 3.5Upper Rural 20.9 47.1 41.6 15.9 21.8 15.9 7.7 4.2 9.9 3.4 3.9

Wealth index quintiles 

Lowest 16.5 45.1 37.6 12.0 21.6 12.0 7.2 5.4 8.9 3.3 3.7 Low 17.2 44.6 37.6 14.5 19.1 14.5 7.7 4.0 7.3 3.2 3.5Middle 14.8 45.5 38.0 13.3 18.7 13.3 8.6 3.4 6.7 3.1 3.4 High 13.5 38.0 36.9 9.7 17.9 9.7 8.1 4.8 5.0 2.9 3.3 Highest 10.9 34.6 41.9 8.7 15.5 8.7 6.8 4.0 4.6 2.8 3.1 

Number of living children 

One 26.2 52.9 63.3 18.0 24.6 18.0 8.5 7.5 8.6 - - Two 10.9 39.4 39.6 11.0 17.0 11.0 7.8 3.7 5.4 - - Three 7.3 35.3 35.5 8.0 16.2 8.0 8.0 2.6 5.5 - Four or more 9.3 33.0 31.0 8.6 15.6 8.6 6.6 2.9 6.2 - - 

Total 14.3 41.8 37.9 11.8 18.5 11.8 7.8 4.3 6.5 3.1 3.4 

1 Appendix 2 2 Table 5 3 Table 7 4 Ministry of Health and Population [Egypt], El-Zanaty and Associates [Egypt], and ICF International. 2015. Egypt Health Issues Survey 2015. 

* Bold figures are “above average.” 

33 

35 

References 

Ali, M. M., J. Cleland and I. Shah. 2012. Causes and Consequences of Contraceptive 

Discontinuation: Evidence from 60 Demographic and Health Surveys. World Health 

Organization: Geneva, Switzerland. 

Ali, M. M., R. Sadler, J. Cleland, T. Ngo, and I. Shah. 2011. Long-term Contraceptive Protection, 

Discontinuation and Switching Behavior: Intrauterine Device (IUD) Uses Dynamics in 14 

Developing Countries. London: World Health Organization and Marie Stopes 

International. 

Avenir Health. 2014. Spectrum Manual, Spectrum System of Policy Models: Resource Needs 

Model (RNM), in Avenir Health, ed. Spectrum Manual, Spectrum System of Policy 

Models: Glastonbury, CT. 

http://avenirhealth.org/Download/Spectrum/Manuals/SpectrumManualE.pdf. 

Awadalla, H. 2013. “Contraceptive Discontinuation among Egyptian Women: Results from Egypt 

Demographic and Health Survey 2005.” AF Preventive Medicine Bulletin 12(1):19-26. 

Bertrand, J. T., R. Magnani, and R. Naomi. “Evaluation Family Planning Programs: with 

Adaptations for Reproductive Health.” The Evaluation Project, USAID Contract Number: 

DPE-3060-C-00-1054-00 September 1996. 

Blanc, A.K., L. Sian, and N. Trevor. 2002. “Monitoring Contraceptive Continuation: Links to 

Fertility Outcomes and Quality of Care.” Studies in Family Planning 33(2):127-140. 

Bradley, S. E. K., M. Hilary, and K. Shan. 2009. Levels, Trends, and Reasons for Contraceptive 

Discontinuation. DHS Analytical Studies No. 20. 

Castle, S., and I. Askew. 2015. “Contraceptive Discontinuation: Reasons, Challenges, and 

Solutions.” Population Council. 

Coviello, V.. and M. Boggess. 2004. “Cumulative Incidence Estimation in the Presence of 

Competing Risks.” The Stata Journal, 2:103–112. 

El-Zanaty, F., and A. Way. 2009. Egypt Demographic and Health Survey 2008. Cairo, Egypt: 

Ministry of Health, El-Zanaty and Associates, and Macro International. 

El-Tawila, S. 1995. “Contraceptive Use Dynamics in Egypt” In Perspectives on Fertility and 

Family Planning in Egypt, ed. M. Mahran et al. Calverton, Maryland: National Population

Council (Arab Republic of Egypt), and Macro International Inc.

Jain, A. 2014. The Leaking Bucket Phenomenon in Family Planning. Champions for Choice. 

http://champions4choice.org/2014/09/the-leaking-bucket-phenomenon-infamilyplanning/1429 

Kalbfleisch, J. D., and R. Prentice. 2002. “The Statistical Analysis of Failure Time Data.” 2nd ed. 

New York: Wiley. 

Khalifa, M., E. Suliman, and J. Ross. 1999. “Family Planning Program Effort in Egypt’s 

Governorates.” Futures Group International, POLICY Project. [17] p. (USAID Contract 

No. CCP-C-00-95-00023-04). 
36 

Khalifa, M., J. DaVanzo, and D. Adamson. 2000. “Population Growth in Egypt: A Continuing 

Policy Challenge.” IP-183. RAND Issue Papers. 

Ministry of Health and Population [Egypt], El-Zanaty and Associates [Egypt], and ICF 

International. 2015a. Egypt Demographic and Health Survey 2014. Cairo, Egypt and 

Rockville, Maryland, USA. 

Ministry of Health and Population [Egypt], El-Zanaty and Associates [Egypt], and ICF 

International. 2015b. Egypt Health Issues Survey 2015. Cairo, Egypt and Rockville, 

Maryland, USA. 

National Population Council. 2015. “National Strategic Population Plan 2015-2030.” Cairo, 

Egypt. 

Ross, J., and E. Smith. 2011. “Trends in National Family Planning Programs.” International 

Perspectives on Sexual and Reproductive Health 37(3):125-33.

Ross, J., and E. Smith. 2010. The Family Planning Effort Index: 1999, 2004, and 2009. 

Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. 

Ross, J., and J. Stover. 2001. “The Family Planning Program Effort Index: 1999 Cycle.” 

International Family Planning Perspectives 27(3):119-129. 

Rutstein, O., and G. Rojas. 2006. Guide to DHS Statistics. Demographic and Health Surveys. ORC 

Macro: Calverton, Maryland. 

Sayed, H. and W. Abdel Aziz. 2011. “Trends of Contraceptive Discontinuation and Switching in 

Egypt during 2000-2008.” (paper presented at the Annual Conference of Statistics 

Department, Faculty of Economics and Political Sciences, Cairo University: Egypt). 

Stover, J., and E. Sonneveldt.2017 “Progress toward the Goals of FP2020.” Studies in Family 

Planning 48(1), March 2017. 

United Nations Development Program (UNDP) and the Ministry of National Planning. 2015. 

“Egypt’s Progress towards Millennium Development Goals (MDGs). Background paper 

produced for the 2015 National Human Development Report. Cairo, Egypt. 

Way, A. 2003. “Contraceptive Use Dynamics in Egypt: An In-depth Analysis.” In: Perspectives 

on Women’s and Children’s Health in Egypt, Results of Further Analysis of the 2000 Egypt 

Demographic and Health Survey. DHS Further Analysis Reports No. 42. Calverton, 

Maryland, USA. El-Zanaty and Associates [Egypt] and ORC Macro, Apr. 43-56 

World Health Organization (WHO). 2012. Contraception Discontinuation and Switching in 

Developing Countries. Research Policy Brief, June 2012 WHO/RHR/12.1.