DHS ANALYTICAL 

STUDIES 54

Uptake and Discontinuation

of Long-Acting Reversible

Contraceptives (LARCs) in

Low-Income Countries

September 2015

This publication was produced for review by the United States Agency for International Development. It was prepared by 

Sarah Staveteig, Lindsay Mallick, and Rebecca Winter of ICF International.

DHS Analytical Studies No. 54 

Uptake and Discontinuation of Long-Acting Reversible 

Contraceptives (LARCs) in Low-Income Countries 

Sarah Staveteig1

Lindsay Mallick1

Rebecca Winter2

ICF International 

Rockville, Maryland, USA 

September 2015 

1

 The DHS Program, Avenir Health 

2

 The DHS Program, ICF International 

Corresponding author: Sarah Staveteig, The DHS Program, ICF International, 530 Gaither Road, 

Suite 500, Rockville, MD 20850, USA; telephone: +1 301-572-0577; fax: +1 301-407-6501; email: 

Sarah.Staveteig@icfi.com 
Acknowledgments: The authors are grateful to Shireen Assaf for technical assistance with modeling, to 

Trevor Croft for data support, and to our external reviewer Iqbal Shah for his insightful comments. We 

also wish to thank Kerry MacQuarrie for conceptual suggestions, supervising tasks in an earlier iteration 

of the project, and a helpful review; Tom Pullum, Emily Sonneveldt, Wenjuan Wang, and Sarah Bradley 

for valuable input and suggestions at various stages of the project; Jennifer Yourkavitch for initial 

research assistance; and Inday Zosa-Feranil, Bernice Kuang, Emily Sonneveldt, and Shipra Srihari for 

sharing Family Planning Effort Scores. 

Editor: Diane Stoy 

Document Production: Natalie La Roche 

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

Development (USAID) through The DHS Program (#AIDOAA-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 International, 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: 

Staveteig, Sarah, Lindsay Mallick, and Rebecca Winter. 2015. Uptake and Discontinuation of LongActing Reversible Contraceptives (LARCs) in Low-Income Countries. DHS Analytical Studies No. 54. 

Rockville, Maryland, USA: ICF International. 
iii 

Contents 

Tables ......................................................................................................................................................... v 

Figures ......................................................................................................................................................... v 

Preface ....................................................................................................................................................... vii 

Abbreviations ............................................................................................................................................... ix 

Abstract ........................................................................................................................................................ xi 

Executive Summary ................................................................................................................................... xiii 

1. Background ............................................................................................................................................... 1 

1.1 Long-acting and Permanent Contraceptive Methods ................................................................. 2 

1.2 Discontinuation .......................................................................................................................... 4 

1.3 Programmatic Environment ....................................................................................................... 5 

2. Data and Methods ..................................................................................................................................... 7 

2.1 Data ............................................................................................................................................ 8 

2.2 Methods ................................................................................................................................... 11 

3. Starting and Using LARCs ..................................................................................................................... 13 

3.1 Current use of LARCs ............................................................................................................. 13 

3.2 Adoption of LARCs ................................................................................................................. 15 

4. Stopping LARCs ..................................................................................................................................... 23 

4.1 Discontinuation Rates .............................................................................................................. 23 

4.2 Reasons for discontinuation ..................................................................................................... 30 

4.3 Status after discontinuation ...................................................................................................... 37 

5. Policy and Programmatic Linkages ........................................................................................................ 45 

6. Discussion and Conclusions ................................................................................................................... 55 

References ................................................................................................................................................... 59 

v 

Tables 

Table 2.1. Total population size and DHS sample size of currently married women 15-49, 

by country ........................................................................................................................... 8 

Table 3.1. Family planning method mix, by country ......................................................................... 13

Table 3.2. Arrival at IUD use ............................................................................................................. 17 

Table 3.3. Arrival at implant use ....................................................................................................... 18 

Table 3.4. Arrival at injectable use .................................................................................................... 19 

Table 3.5. Arrival at non-LARC modern method use ........................................................................ 20 

Table 3.6. Arrival at traditional/folkloric use .................................................................................... 21 

Table 4.1. Reasons for discontinuing IUDs ....................................................................................... 32 

Table 4.2. Reasons for discontinuing implants .................................................................................. 33 

Table 4.3. Reasons for discontinuing injectables ............................................................................... 34 

Table 4.4. Reasons for discontinuing non-LARC modern methods .................................................. 35 

Table 4.5. Reasons for discontinuing traditional and folkloric methods ........................................... 36 

Table 4.6. Status 3 months after discontinuing IUDs ........................................................................ 39 

Table 4.7. Status 3 months after discontinuing implants ................................................................... 40

Table 4.8. Status 3 months after discontinuing injectables ................................................................ 41

Table 4.9. Status 3 months after discontinuing non-LARC modern methods ................................... 42 

Table 4.10. Status 3 months after discontinuing traditional or folkloric methods ............................... 43 

Table 5.1. Selected Family Planning Effort (FPE) scores, focal countries ........................................ 46 

Table 5.2. Pooled multilevel hazard model of discontinuing IUDs while still in need ..................... 49 

Table 5.3. Pooled multilevel hazard model of discontinuing implants while still in need ................ 51 

Table 5.4. Pooled multilevel hazard model of discontinuing injectables while still in need ............. 52 

Appendix Table A1. List of FP2020 focus countries ................................................................................ 57 

Figures 

Figure 2.1 Map of study countries ....................................................................................................... 7 

Figure 3.1. Share of LARCs in method mix ........................................................................................ 14 

Figure 3.2. Composition of non-LARC modern methods excluding female sterilization .................. 15 

Figure 3.3. Arrival at method use: Pooled results ............................................................................... 16 

Figure 4.1. 12, 24 and 36-month failure and discontinuation rates by method type: 

Pooled results .................................................................................................................... 24 

Figure 4.2. 12, 24 and 36-month failure and discontinuation rates, IUDs .......................................... 25 

Figure 4.3. 12, 24 and 36-month failure and discontinuation rates, implants ..................................... 26 

Figure 4.4. 12, 24 and 36-month failure and discontinuation rates, injectables .................................. 27 

Figure 4.5. 12, 24 and 36-month failure and discontinuation rates, non-LARC modern methods, 

excluding female sterilization ........................................................................................... 28 

Figure 4.6. 12, 24 and 36-month failure and discontinuation rates, traditional and folkloric 

methods ............................................................................................................................. 29 

Figure 4.7. Reasons for discontinuation: Pooled results ..................................................................... 31 

Figure 4.8. Status 3 months after method discontinuation: Pooled results ......................................... 38 
vi 

Figure 5.1. IUD share of method mix versus FPE IUD Access Score (2009), focal countries ........... 47 

Figure 5.2. Implant share of method mix versus FPE implant Access Score (2014), 

focal countries ................................................................................................................... 47 

Figure 5.3. Injectable share of method mix versus FPE Injectable Access Score (2009), 

focal countries ................................................................................................................... 48
vii 

Preface 

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services. 

One of the objectives of The DHS Program is to analyze DHS data and provide findings that will be 

useful to policymakers and program managers in low- and middle-income countries. DHS Analytical 

Studies serve this objective by providing in-depth research on a wide range of topics, typically including 

several countries and applying multivariate statistical tools and models. These reports are also intended to 

illustrate research methods and applications of DHS data that may build the capacity of other researchers. 

The topics in the DHS Analytical Studies series are selected by The DHS Program in consultation with 

the U.S. Agency for International Development. 

It is hoped that the DHS Analytical Studies will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries. 

Sunita Kishor 

Director, The DHS Program 

ix 

Abbreviations 

DWSIN Discontinuation (of family planning) while still in need 

FPE Family Planning Effort (Index) 

IUD Intrauterine device 

LAM Lactational Amenorrhea Method 

LARC Long-acting reversible contraceptive 

PPA Postpartum abstinence 

RE Random effects

xi 

Abstract 

Long-acting reversible contraceptive (LARC) methods—intrauterine devices (IUDs), implants, and 

injectables—together comprise a growing share of contraceptive use in low-income countries. Using DHS 

contraceptive calendar data this paper examines married women’s adoption and discontinuation of 

LARCs, other modern methods, and traditional/folkloric methods in 21 low-income countries. The two 

methods that require provider removal, IUDs and implants, have the lowest discontinuation rates. The 

discontinuation rate of injectables is on par with that of traditional methods and is lower than that of other 

non-LARC modern methods combined. Cost or access is infrequently cited as an issue in discontinuation 

of any method. Failure rates of LARC methods are low, but four in ten episodes of LARC discontinuation 

are attributed to side effects or health concerns, more than double that of other modern methods 

combined. Three months after discontinuing while still in need (DWSIN), 15 to 20 percent of LARC 

users are at risk of an unwanted pregnancy. We model the hazard of DWSIN based on individual and 

country-level characteristics. Adjusted hazard models find that starting an IUD or injectable after birth, 

postpartum abstinence, or LAM significantly reduces the hazard of DWSIN. Additionally, living in a 

country with greater access to the method being used and higher-quality family planning programs 

reduces the hazard of DWSIN. These findings point to the benefits that postpartum family planning 

efforts and a supportive programmatic environment confer on sustained LARC use. 

xiii 

Executive Summary 

The proportion of women using a long-acting reversible contraceptive (LARC) method—IUD, implants, 

or injectables—has increased in low-income countries over the past few decades (Bertrand et al. 2014; 

Darroch 2013). Although LARCs are not medically indicated for all women or the appropriate choice for 

all couples, they offer an important form of protection for those who want to delay pregnancy for a longer 

time or limit births altogether but who are not committed to a permanent method. 

This paper focuses on the contraceptive dynamics of LARC use among married women in low-income 

countries. It uses a life cycle approach to understand how women start these methods, how and why they 

stop, and what their status is three months after stopping. It also examines how individual and country 

characteristics affect the risk of discontinuation while still in need (DWSIN). High levels of DWSIN 

suggest method dissatisfaction and may leave women vulnerable to unwanted pregnancies if they do not 

start a new method. 

Among FP2020’s list of 69 focus countries, 21 countries with a DHS survey fielded during or after 2010 

that included a contraceptive calendar with the reasons for discontinuation were selected for this study. 

With the exception of contraceptive method mix, the unit of the analysis in this study is a continuous 

episode of contraceptive use. Computations of discontinuation rates are based on multi-decrement life 

tables from episodes 3 to 62 months prior to the survey. Using multilevel hazard models, we analyze how 

individual and country characteristics affect the hazard of DWSIN. 

Results show that the total share of LARCs in a method mix varies widely across countries and regions. 

Among users, LARC methods comprise the majority of the method mix among married women in more 

than half of these countries. By far, the largest overall proportions of any one LARC method are 

injectables; they comprise the largest share of any method in 8 of 21 countries studied. The share of IUD 

use is typically less than 10 percent in most countries but surpasses 50 percent in three countries: Egypt, 

Kyrgyz Republic, and Tajikistan. Implants comprise only 10 percent or less of all methods used in most 

countries. 

Across focal countries, IUDs and traditional/folkloric methods were the methods most commonly started 

after birth, LAM/extended breastfeeding, or PPA. Meanwhile, the majority of episodes of injectable use 

were started after non-use. Previous LARC use more commonly preceded implants and non-LARC 

modern methods. The proportion whose modern method use was immediately preceded by a more 

effective (LARC) method was strikingly high in Indonesia (47 percent), and was also high in Rwanda (18 

percent) and Egypt (15 percent). 

On average, within the first year of use, 9 percent of women discontinue using implants, 15 percent 

discontinue IUDs, and 32 percent discontinue injectables. While these rates are less than the 40 percent of 

women who discontinue non-LARC modern methods in the first year, the 12 month discontinuation rate 

for injectables (32 percent) is on par with the 28 percent of women who discontinue traditional methods 

within the first year. Access and/or cost were not heavily cited as reasons for discontinuation among all 

countries for IUDs and implants but were more prominent among reasons for discontinuing injectables. 

IUD discontinuation rates range from 20 percent at the end of three years in Indonesia to 76 percent in 

Sierra Leone. Method failure is higher than expected in Burundi, Zambia, and Pakistan, but was almost 

imperceptible in Cambodia, Indonesia, and Nepal. The share of discontinuations due to method failure is 
xiv 

lowest for IUD, implants, and injectables; higher for non-LARC modern methods; and highest for 

traditional/folk methods (at nearly 30 percent). In comparisons of reasons for discontinuation across the 

method types, desire for a more effective method is most common among traditional or folk method 

discontinuations, and lowest among IUD discontinuations. Side effects or health concerns were the reason 

given for four of ten episodes of LARC discontinuation. 

Discontinuation while still in need is particularly problematic when it leaves women at risk of an 

unwanted pregnancy, which was true for 15 to 20 percent of the pooled sample of former LARC users in 

this study three months after discontinuation. Some level of method dissatisfaction and side effects are to 

be expected with any method, but high levels of DWSIN can indicate method dissatisfaction and service 

quality or gaps that put women at risk of an unintended pregnancy. This is somewhat counterbalanced by 

the low failure rates of LARC methods. 

Comparing across the five FP method types, women are most likely to be at risk of an unwanted or too 

closely-spaced pregnancy three months after discontinuing injectables. Women who discontinued 

traditional methods are least likely to still be at risk, but this is largely because they are now pregnant. 

We model the hazard of DWSIN for each of the three LARC method types using pooled multilevel 

Weibull survival models that incorporate country random effects. The results indicate that women are 

significantly more likely to continue a method if its adoption is immediately preceded by a birth, LAM, or 

PPA. Additionally, we use these models to quantify the dimension of experience related to supply, 

programs, and policies using scores from the Family Planning Effort (FPE) Index, which measures the 

strength of national FP programmatic efforts within low-income countries. The FPE scores used in this 

report indicate the quality of overall FP programs as well as access to the three LARC methods: IUDs, 

implants, and injectables. We find that LARC users in countries with greater access to their method and in 

countries with higher-quality FP programs have a significantly lower hazard of DWSIN. 

The finding that among injectable and IUD users, women were significantly at less risk of discontinuation 

if they started the episode of use after birth, PPA, or LAM indicates the importance of postpartum FP 

efforts designed to help women space and limit births. The inverse relationship between quality of FP 

programs and the hazard of DWSIN suggests the importance that method choice, counseling, and safe 

clinical procedures have on sustained use. Access to the method is also inversely related to the hazard of 

DWSIN, but when access and quality scores are combined it appears that quality is the more important of 

the two. Collectively, these findings suggest that increasing service readiness and access to LARC 

methods is not enough to sustain use: national FP efforts should focus on offering a wide array of options 

for informed choice and high-quality provision of client-centered services. More research on the specific 

elements of programmatic quality that support continued use is needed to focus policy efforts. 
1 

1. Background 

In recent decades, contraceptive prevalence has increased in low-income countries, become more 

diversified, and shifted toward a stronger reliance on modern methods (Bertrand et al. 2014; Seiber, 

Bertrand, and Sullivan 2007). As new methods are introduced, men and women have more options to 

choose a method that meets their preferences throughout the family planning (FP) life cycle, and 

contraceptive prevalence tends to increase (Ross and Stover 2013). 

Despite increased use of FP, unmet need for contraception is still strikingly high, and is estimated at about 

222 million women and approximately 1 in every 4 women in developing1

 countries in 2012 (Ross and 

Stover 2013; Singh and Darroch 2012). The World Health Organization (WHO) recommends waiting at 

least two years after delivery before attempting to conceive again (WHO 2005) because the risks for 

adverse health outcomes for both mothers and children are greatest when the interval between one birth 

and the next is either less than 27 months or greater than 60 months (Conde-Agudelo, Rosas-Bermúdez, 

and Kafury-Goeta 2006; Conde-Agudelo, Rosas-Bermúdez, and Kafury-Goeta 2007; Rutstein 2005; 

Rutstein 2008). Long-term contraceptive methods enable women and couples to cost-effectively avert 

pregnancy during these risky time periods by allowing women to space and/or limit births. 

Long-acting reversible contraceptive methods (LARCs) typically include intrauterine devices (IUDs) and 

implants. There is no firm agreement on whether injectables are considered LARCs: they are not as longacting as IUDs or implants, but they share the trait of not requiring user action after being taken. For this 

reason we include injectables in our definition of LARCs. In low-income countries, IUD use has been 

declining while injectable use has rapidly increased; as a group, LARCs represent a growing share of the 

method mix in most low-income countries (Darroch 2013; Bertrand et al. 2014). 

Although LARCs are not medically indicated for all women or the appropriate choice for all couples, 

these three methods offer an important form of protection for couples to space and limit births for longer 

periods of time than most other modern methods. LARC methods may be a good option for couples who 

want to delay pregnancy for a longer time or limit any future pregnancies but who are not committed to a 

permanent method. Since most LARCs do not contain estrogen, they are generally compatible with 

breastfeeding. 

This paper focuses on the contraceptive dynamics of LARC use in low-income countries. It uses a life 

cycle approach to understand how women start these methods, how and why they stop, and what their 

status is after stopping. It also examines how women’s individual characteristics and the national context 

in which LARC uptake and discontinuation take place affect the risk of discontinuation while still in need 

(DWSIN). High levels of DWSIN suggest method dissatisfaction and may leave women vulnerable to 

unwanted pregnancies if they do not start a new method. 

 

1

 The definition of ‘developing countries’ varies by international body and author. This report focuses on ‘lowincome countries’ since they are the focus of FP2020 efforts and are more objectively defined. Low-income 

countries largely overlap with the group of countries considered ‘developing’; as such, the literature on developing 

countries is considered broadly applicable to our study population. 
2 

1.1 Long-acting and Permanent Contraceptive Methods 

IUDS

Intrauterine devices (IUDs) were first used in the beginning of the 20th century (Ali et al. 2011). They are 

T-shaped devices that must be inserted into a woman’s uterus by a health care provider. The types of 

IUDs available differ by country. Three examples of popular, widely available brands of IUDs are 

Mirena, TCu 380A, and ParaGard. Mirena is hormonal (containing progestin) and lasts up to 5 years 

while TCu 380A and ParaGards’ copper content prevents pregnancy for up to 12 years (Ali et al. 2011). 

At the end of this time, a provider must remove the IUD. The failure rate is below 1 percent in the first 

year of use (Hatcher, Trussell, and Nelson 2007). Evidence supports IUD insertion immediately after 

delivery (ideally within 10 minutes, but also up to 48 hours of placental delivery2

) because of the 

convenience of a woman being present at a health facility and the guarantee that she is not currently 

pregnant. This practice is common in Egypt, China, and Mexico (Grimes et al. 2003; WHO 2015). 

Among all reversible modern methods, IUDs are the most cost-effective and the most effective at 

preventing pregnancy (Ali et al. 2011; Hatcher, Trussell, and Nelson 2007). After the IUD is removed, 

fecundity immediately returns; the 12-month post-removal pregnancy rate is comparable to non-IUD 

users (Mansour et al. 2011). 

Worldwide, the use of IUDs has increased in the past few decades and, despite recent declines in 

prevalence, IUDs remain the most widely used reversible method (Ali et al. 2011; Seiber, Bertrand, and 

Sullivan 2007). China has the largest proportions of IUD users among all married women (33 percent) 

while the lowest use is in sub-Saharan Africa (0.8 percent); the IUD is the dominant method in seven lowincome countries, five in Central Asian Republics, as well as Egypt and Vietnam (Ali et al. 2011). Several 

studies, however, are reporting a decrease or stagnation in the use of IUDs, particularly in sub-Saharan 

Africa and other low-income countries, although no significance testing was reported in these studies 

(Bertrand et al. 2014; Darroch and Singh 2013; Seiber, Bertrand, and Sullivan 2007). 

Implants 

Implants are also long-acting and extremely effective at preventing pregnancy, with a clinical failure rate 

less than 1 percent (Hatcher, Trussell, and Nelson 2007; Rademacher et al. 2014). Implants are progestincontaining rods that are inserted under the skin and can prevent pregnancy for up to five years 

(Ramchandran and Upadhyay 2007). The first implant, Norplant, was licensed in 1983 although global 

production was discontinued in 2008 after a lawsuit accused Norplant of causing scarring, pain upon 

removal, and other side effects (Rademacher et al. 2014; Ramchandran and Upadhyay 2007). Newer 

generations of implants are smaller, offer easier insertion and removal, and have fewer complications 

(Ramchandran and Upadhyay 2007). These include Implanon, Jadelle (Norplant 2), Nexplanon, and SinoImplant. Although newer implants are less expensive, they are still more cost-effective than other modern 

methods and become less expensive with continued use (Bertrand et al. 2014; Power, French, and Cowan 

2007; Singh and Darroch 2012). Like IUDs, fertility returns rapidly upon discontinuation of implants; 

they can also be safely inserted immediately after giving birth (Espey and Ogburn 2011; Power, French, 

and Cowan 2007). 

Use of implants has faced barriers of cost and their reputation for side effects and painful insertion or 

removal (Rademacher et al. 2014). Implants are not the dominant or modal method in any country and are 

used by less than 1 percent of married women in low-income countries (Ross, Keesbury, and Hardee 

 

2

 The IUD can also be inserted safely after 4 weeks postpartum; however, delayed postpartum (between 48 hours 

and 4 weeks after delivery) insertion is not recommended (WHO 2015). 
3 

2015). In the majority of countries where the share of implants in the method mix is the highest—above 

10 percent among all methods in sub-Saharan Africa—there is an increase in use, particularly after the 

introduction of newer, less expensive implants; however, the share is still low (Bertrand et al. 2014). 

Bertrand et al. note the potential to improve the method mix with the introduction of the implant which 

can satisfy the need to both limit and space pregnancies (2014). 

Injectables 

Injectables are clinically very effective against pregnancy and also are the shortest-acting of the three 

LARC methods. There are several types of injectables. The first, depot medroxyprogesterone acetate 

(DPMA, brand name: Depo Provera), which was licensed and marketed in 1960s (Seth, Nagrath, and 

Deoghare 2012) is a progestin-only injectable which protects against pregnancy for up to three months 

with a two-week grace period (Adetunji 2011; Seth, Nagrath, and Deoghare 2012). Norethindrone 

enanthate (NET-EN) is another progestin-only injectable which lasts for two months (Adetunji 2011; 

Seth, Nagrath, and Deoghare 2012). Combined injectable contraceptives (CICs), such as Cyclofem, 

Mesigyna and Deladroxate, contain both estrogen and progestin and are only effective for preventing 

pregnancy for up to 30 days (Seth, Nagrath, and Deoghare 2012). These CICs, however, are not 

recommended for use while breastfeeding within the first six months postpartum (Seth, Nagrath, and 

Deoghare 2012; WHO 2015). The failure rate of injectables like DPMA is less than 1 percent (Hatcher, 

Trussell, and Nelson 2007). Injectables are the least cost effective of the three long-acting methods (Singh 

and Darroch 2012) and are the only method of the three LARCs that can be passively discontinued. 

However, injectables cannot be discontinued until the effectiveness period expires, although the return of 

fertility is delayed, particularly for DPMA and NET-EN (Seth, Nagrath, and Deoghare 2012; 

WHO 2015). 

Injectable use is rising rapidly, particularly in sub-Saharan Africa, because of convenience of use and 

provision, length of effectiveness, and discretion (Adetunji 2011; Bertrand et al. 2014; Seiber, Bertrand, 

and Sullivan 2007). Adetunji (2013) found that use of injectables among married women in six recent 

DHS surveys in sub-Saharan African countries ranged from 6.2 percent in Ghana to 25.8 percent in 

Malawi, while a larger study of national surveys from 123 countries found that the contraceptive 

prevalence rate of injectables in all of sub-Saharan Africa was 7.3 percent (Ross, Keesbury, and Hardee 

2015). Not having to take a daily pill is a benefit for many women, while others see an advantage to the 

absence of menses with Depo Provera. Adetunji (2011) reported, tested, and confirmed the theory that 

secrecy is also a major factor in the use of injectables. The injectable can be easily administered to a 

woman at a health clinic or through mobile outreach efforts without the permission from her spouse or 

other family members who may disapprove. These advantages may be responsible for the dramatic 

increase in injectables during the last 20 years. Bertrand et al (2014) found that this increase was as high 

as 42 percentage points in Chad and over 25 percentage points in six other countries. 

Sterilization 

In addition to the three LARC methods described above, sterilization (male or female) is the only other 

long-term method of preventing pregnancy. For couples wishing to limit births, sterilization is the most 

cost-effective method when assessing cost over the duration of effectiveness (Seth, Nagrath, and 

Deoghare 2012). Female sterilization, in particular, is permanent and thus cannot be discontinued. Female 

sterilization is the most commonly used method across all developing countries (Mansour et al. 2011; 

Seiber, Bertrand, and Sullivan 2007), although it constitutes a declining share of the method mix in most 

countries (Bertrand et al. 2014). Female sterilization is a predominant practice in many countries in Latin 

America, the Caribbean, and Asia (Mansour et al. 2011; Seiber, Bertrand, and Sullivan 2007) and 

accounts for 31-64 percent of the method share in some countries in those regions (Mansour et al. 2011). 
4 

In the Middle East, North Africa and sub-Saharan Africa, sterilization is not common because it is a 

surgical procedure that requires infrastructure and properly trained providers which are challenging for 

poor countries (Ross, Keesbury, and Hardee 2015; Seiber, Bertrand, and Sullivan 2007). Use of male 

sterilization is low at less than three percent of the method share in many low-income countries (Seiber, 

Bertrand, and Sullivan 2007). In this paper, we group male sterilization with other modern methods. Since 

we are interested in the life cycle of contraceptive use, female sterilization is not examined further. 

1.2 Discontinuation 

Of course, no single method is appropriate for all women. Despite their advantages, LARCs have key 

drawbacks. The use of synthetic progesterone, progestin, in all LARCs is associated with breast pain, 

weight gain, bloating, and acne or greasy skin (Espey and Ogburn 2011; Lethaby et al. 2015). Changes in 

menstruation can also occur with LARCs. Some injectables such as Depo Provera suspend menses (Seth, 

Nagrath, and Deoghare 2012). Implants can cause irregular bleeding and/or amenorrhea (Power, French, 

and Cowan 2007). Expulsion of IUDs is another potential complication. If an IUD is inserted within 10 

minutes of placental delivery, the risk of expulsion is lower than if the IUD is inserted between 10 

minutes and 48 hours after delivery, and is lowest when inserted weeks after (The ACQUIRE Project 

2008). Serious complications are rare but sometimes occur with IUDs, including perforation of the uterus 

(Espey and Ogburn 2011). Injectables can cause a loss of bone mineral density, although this side effect is 

not serious and is also reversible (Seth, Nagrath, and Deoghare 2012). Finally, since LARCs are not 

barrier methods, they do not prevent sexually transmitted infections (STIs) or HIV (Ali et al. 2011). 

Since LARC methods—IUDs, implants, and injectables—comprise an increasing share of contraceptive 

use, it is important to examine how often and why women discontinue these methods, particularly in lowincome countries. Discontinuation of a method occurs when there is method failure (pregnancy), when a 

woman no longer has a need for contraception (because of a desire to become pregnant, infrequent sex, 

husband away, marital dissolution, or menopause), or when a woman is dissatisfied with her method or 

cannot access or afford it. Discontinuation may result in pregnancy, switching to another method, or 

abandonment of all contraception. 

The majority of contraceptive failures result in unwanted births (Ali, Cleland, and Shah 2012; Bradley, 

Croft, and Rutstein 2011). It is also of concern when contraceptive users DWSIN by switching to a less 

effective method or abandoning contraception entirely. These latter situations place a woman at risk of 

unintended and/or unwanted pregnancy. Unintended pregnancy can then lead to potentially unsafe 

induced abortions where access to safe abortion is restricted, births that pose a risk to the health of the 

mother and child, and ultimately reduced educational attainment of children (Blanc, Curtis, and Croft 

2002; Montgomery et al. 1997; Singh, Sedgh, and Hussain 2010). 

Research has repeatedly found that method type is the most important factor in discontinuation (Bradley, 

Schwandt, and Khan 2009; Montgomery et al. 1997). Properties of methods differ; some, such as 

condoms, diaphragm, and jelly, are coitus-dependent and must be used continually. Other methods such 

as pills must be actively continued on a daily basis. Implants and IUDs are designed to be removed with 

assistance of a provider, which makes discontinuation more difficult. Empirically, traditional and short 

acting methods have the highest rates of discontinuation; LARCs, such as IUDs, have the lowest rate 

(Bradley, Schwandt, and Khan 2009; Curtis and Blanc 1997; Montgomery et al. 1997). In 2009, Bradley 

et al. found the 12-month discontinuation rate of IUDs in 11 Demographic and Health Survey (DHS) 

surveys to be less than 18 percent in one year while another, more recent study of 60 DHS countries 

found the 12-month discontinuation rate of IUDs to be even less—13 percent (Montgomery et al. 1997). 
5 

In areas where women have informed choice about contraceptive methods, there is presumably some 

endogeneity between method choice and intention. Married women who are looking to space or limit 

births might find LARC methods more appropriate than shorter-term or coitus-dependent methods. For 

these reasons, this report analyzes discontinuation by method type, and treats LARC methods separately 

from traditional/folkloric methods and all other modern methods. 

Reasons for discontinuation also differ by method. General reasons include dissatisfaction or methodrelated reasons such as health concerns or side effects; lack of access by cost or distance to a facility; or 

husband/family disapproval (Ali, Cleland, and Shah 2012; Bradley, Schwandt, and Khan 2009; Curtis and 

Blanc 1997; Moreau, Cleland, and Trussell 2007). Side effects and health concerns are the most common 

reason for discontinuing short acting methods, while reasons for discontinuing condoms or traditional 

methods include unintended pregnancy or the desire for a more effective method. Reasons for 

discontinuation of IUDs vary but frequently include dissatisfaction with the method or side effects (Ali et 

al. 2011; Bradley, Schwandt, and Khan 2009). When discontinuing IUDs for method-related reasons, half 

of the women switched to another modern method, with over 10 percent to traditional methods (Ali et 

al. 2011). 

Because of low use, implant discontinuation rates are less well studied. One review found that the 5 year 

cumulative continuation rate was just over 50 percent (Power, French, and Cowan 2007). Injectables are 

unique because they are the shortest-acting of all the long-acting methods (one, two, or three months) and 

they cannot be voluntarily discontinued before expiration. Users must actively seek out another injection 

in order to continue use. Varying discontinuation rates for injectables have been found. Twelve month 

rates of discontinuations range from 18 to 67 percent (Bradley, Schwandt, and Khan 2009), although this 

range could be the result of the higher likelihood of discontinuation of one-month injectables versus 

three-month injectables, which were not differentiated in this report. Ali, Cleland and Shah (2012) found 

an average discontinuation rate to be 41 percent over 12 months with a large range across countries 

as well. 

Prior studies have also shown that rates of discontinuation also vary by women’s characteristics. Slower 

time to discontinuation is associated with age (over 25 compared to 15-24), higher education, and in some 

case, higher parity (Bradley, Schwandt, and Khan 2009). 

1.3 Programmatic Environment 

Although LARCs are not appropriate for every woman or every couple, they are the most cost-effective 

and long-term reversible means of preventing unintended pregnancy. As such, LARCs comprise an 

important part of total method choice. To support use of IUDs and implants, countries must ensure that 

women have access to competent health services that can safely provide insertion and removal services 

(Singh and Darroch 2012). Beyond individual preferences, variations in use may indicate differences in 

policy, national promotion of the method, or provider bias (Ali et al. 2011). When the share of IUDs in 

the method mix ranges from less than 1 percent to 66 percent, it seems likely that availability and service 

provision are influencing use. 

Nearly all low-income countries have established programs to improve family planning services, although 

the quality and availability of these programs vary widely. Convened in London in July 2012, the Family 

Planning Summit 2020 designated the funding and political support for reaching a goal that would 

improve women’s right to—and availability of—contraceptive information, access, and commodities 

among 120 million more women in the poorest countries by 2020 (FP2020 2015). Family Planning 2020 

(FP2020) is a partnership born from this summit and created to facilitate these improvements and to draw 
6 

attention to the supply and service provision of contraceptive methods. This report focuses on 21 of the 

FP2020 focus countries. 

Previous studies have found that increasing method choice and availability have the potential to improve 

both rates of DWSIN and unmet need while reducing the risks associated with unintended pregnancy 

(Ross and Stover 2013). Less is known about how the policy environment relates to discontinuation. How 

do access and availability of specific methods and overall programmatic quality affect discontinuation 

and failure rates for those methods? 

This paper focuses on uptake and discontinuation of LARC methods in low-income, FP2020 priority 

countries. The paper begins with how women start these methods, the extent of current use, 

discontinuation rates in past 5 years, reasons for discontinuation, and status following discontinuation. 

The focus then moves to testing the importance of women’s characteristics, method availability, and 

quality of FP programs on the risk of DWSIN. 
7 

2. Data and Methods 

Study countries were selected from among FP2020’s list of 69 focus countries, as shown in Appendix A. 

These are the 69 poorest countries in the world: in 2010, these countries were estimated to have less than 

$2,500 gross domestic product (GDP) per capita. From these 69 countries, we selected all countries with a 

DHS survey fielded during or after 2010 that included a contraceptive calendar with the reasons for 

discontinuation. There were 23 such countries. All 21 of 23 viable surveys3

 were included in this study. 

Figure 2.1 indicates the 21 study countries in red and the 48 other FP2020 focus countries in blue. 

Figure 2.1 Map of study countries 

The DHS sample size of married4

 women for each survey is listed in Table 2.1, along with contraceptive 

prevalence (any method) among married women. Countries are sorted by world region: 6 in West Africa, 

6 in East and Southern Africa, 2 in North Africa and West Asia, 2 in Central Asia, and 5 in South and 

Southeast Asia. The weighted sample size of married FP users ranged from 632 (Comoros) to 20,704 

(Indonesia). Table 2.1 also lists the overall population size of the country in 2010 (in thousands). Pooled 

estimates in later chapters normalize the DHS weights relative to overall population size.5

 The countries 

range in size from less than one million to more than two hundred million. The most populous countries 

studied in this report are Indonesia, Pakistan Nigeria, and Bangladesh. The least populous countries 

studied are Comoros, Liberia, and Kyrgyz Republic. 

 

3

 The Mozambique 2010 DHS had an insufficient number of episodes for most analysis and was excluded. The 

2011-12 Benin DHS was excluded due to hundreds of missing calendar entries. 

4

 Includes married and living with a man as if married. 5

 Note that the number of married women age 15 to 49 in each country is not perfectly proportional to national 

population size, as this will depend on age structure and nuptiality. Nonetheless it was the best option to provide 

relative scaling of the weights. 
8 

Table 2.1. Total population size and DHS sample size of currently married women 15-49, 

by country 

Country 

Total population 

size 2010 

(thousands)1

Year of DHS 

survey 

Sample size of 

currently married 

women2

 age 

15-49 

Total 

Contraceptive 

Prevalence (%)3

Sample size of 

currently married 

family planning 

users age 15-49 

West Africa 

Burkina Faso 15,632 2010 13,563 16.2 2,194 

Liberia 3,958 2013 5,386 20.2 1,090 

Niger 16,292 2012 9,881 13.9 1,374 

Nigeria 159,425 2013 27,830 15.1 4,216 

Senegal 12,957 2014 5,500 22.2 1,219 

Sierra Leone 5,776 2013 10,903 16.6 1,813 

East and Southern Africa 

Burundi 9,461 2010 5,421 21.9 1,185 

Comoros 699 2012 3,261 19.4 632 

Rwanda 10,294 2010 6,897 51.6 3,558 

Uganda 33,149 2011 5,418 30.0 1,626 

Zambia 13,917 2013-14 9,859 49.0 4,832 

Zimbabwe 13,974 2010-11 5,703 58.5 3,338 

North Africa and West Asia 

Egypt 82,041 2014 20,460 58.5 11,974 

Yemen 23,592 2013 15,566 33.5 5,213 

Central Asia 

Kyrgyz Republic 5,465 2012 5,256 36.3 1,907 

Tajikistan 7,582 2012 6,504 27.9 1,816 

South and Southeast Asia 

Bangladesh 151,617 2011 16,635 61.2 10,183 

Cambodia 14,364 2010 11,626 50.5 5,876 

Indonesia 241,613 2012 33,465 61.9 20,704 

Nepal 26,876 2011 9,608 49.7 4,774 

Pakistan 170,044 2012-13 12,937 35.4 4,581 

1

 United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 

2015 Revision, custom data acquired via website. 

2

 Here and throughout the report, currently married means married or living with a man as if married 3

 The percent of married women age 15-49 using any method of family planning. 

Per DHS convention, sample sizes are weighted 

2.1 Data 

2.1.1 Survey data 

In the DHS surveys analyzed in this report, women were asked about all episodes of contraceptive use 

that extended back at least five years6

 preceding the date of interview. These ‘contraceptive calendar’ data 

are retrospective records of births, pregnancies, and family planning use. The calendar allows one event 

per month: a pregnancy, birth, or termination; if none of these applies, it indicates whether family 

planning was used, and if so, which method.7

 In the countries we studied, the calendar also included a 

 

6

 Women are frequently asked about slightly longer periods of time, up to 70 or 80 months, but those earlier entries 

were truncated as indicated in order to standardize the length across surveys. 7

 Interviewers are asked to first fill in the pregnancies and births from the birth history, then to probe episodes of use 

and non-use. Interviewers receive extensive training on the calendar. Illustrative questions provided to interviewers 

in the questionnaire include: When was the last time you used a method? Which method was that? When did you 

start using that method? How long after the birth of (NAME)? How long did you use the method then? Why did you 

stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or 

did you stop for some other reason? 
9 

second column where women were asked to identify the main reason for every episode of contraceptive 

discontinuation.

There are possible concerns about the calendar data. First is the issue of recall (particularly for short-term 

and coitus-dependent methods) and underreporting of prior method use. Previous studies have found 

broad consistency in calendar data compared to retrospective contraceptive prevalence (Bradley, 

Schwandt, and Khan 2009; Curtis and Blanc 1997; Strickler et al. 1997). A more recent study found that 

in more than one-fourth of countries, injectables, pills, and traditional methods appear to be signficantly 

underreported in the calendar and in more than half of countries LAM and male condom use appears to be 

significantly underreported (Bradley, Winfrey, and Croft 2015). Second, dual use of methods such as both 

injectables and condoms are not recorded in the calendar. Interviewers are instructed to record the most 

effective method used by the woman. Third, even with perfect recall, rounding to the nearest whole 

month introduces some measurement issues. Women do not generally stop and start methods in whole 

month intervals; a period of one week would be recorded as one month, while a period of five weeks 

would necessarily span two months. This is one reason why we avoid making estimates of median 

duration of use. An additional concern for estimates of median use is left-censoring of longer-term 

methods that started before the calendar. IUDs are designed to be used for ten to twelve years while the 

calendar only spans five years. Despite data concerns, these data are the most complete, representative, 

and accurate picture of cross-country contraceptive dynamics. 

With the exception of contraceptive method mix in Chapter 3, the unit of the analysis in this study is a 

continuous episode of contraceptive use. We only include episodes among women currently married or in 

union at the time of survey whose date of first union was at or prior to the date the episode began. Each of 

these episodes that are discontinued (versus ongoing at the time of the survey) are associated with a 

discontinuation code. Women may contribute more than one episode over the course of the five years 

prior to the survey, or zero episodes if they have not used any method. In addition, we exclude episodes 

from women who are currently unmarried or had not yet had a first union at or prior to the date of starting 

contraceptive use. 

The sample size of episodes depends on the type of analysis. In some cases such as reasons for 

discontinuation, only episodes that ended during the period are considered. In other cases such as 

discontinuation rates, episodes must be started in the period but right-censoring (ongoing use) is allowed. 

For discontinuation rates, it is standard to consider the 3 to 62 months prior to the calendar: the month of 

interview and the two preceding months are ignored to avoid the bias that might be introduced by an 

unrecognized pregnancy. When possible, we have maintained this convention in order to standardize the 

number of cases. Sample size is listed for each analysis separately. 

For the purpose of this paper, family planning methods are divided into five categories: 

• IUD, implants, and injectables are the three LARC methods that each comprise their own 

category. Except in very rare circumstances, the type of IUD (hormonal or non-hormonal) and the 

duration of the injectable (1 to 3 months) is unspecified. In older surveys, the brand name of 

implants was frequently specified as Norplant; several more recent surveys ask only about 

implants. 

• Non-LARC modern methods excluding female sterilization are combined into a reference 

group because the focus of the paper is LARCs. These other modern methods include pill, male 

condoms, female condoms, foam/jelly, diaphragm, emergency contraception, lactational 
10 

amenorrhea method (LAM), standard days, male sterilization, and other unspecified modern 

methods. The composition of these methods varies by country and is described in Chapter 3. 

Female sterilization is excluded from episodic analysis since it cannot be discontinued. 

• Traditional/folkloric methods. This category primarily includes traditional methods such as 

periodic abstinence and withdrawal, but may also inlcude herbs, massage, and other folkloric 

methods. 

Reasons for discontinuation are mutually exclusive. Women are asked about the main reason for 

discontinuation of each method. Response options include failure (became pregnant while using), 

method-related reasons (side effects and health concerns, inconvenient to use, desire for more effective 

method), access/cost, and perceived lack of need (desire to become pregnant, marital dissolution, 

infrequent sex/husband away, and menopause). Individual questionnaires for each survey provide the full 

range of responses. 

For the purposes of this report: 

• Discontinuation while still in need (DWSIN) includes becoming pregnant while using the 

method (failure), method-related reasons, cost/access, opposition, and other reasons unrelated to 

lack of need. DWSIN does not necessarily refer to ‘unmet need,’ a term which is based on a fixed 

set of criteria for fecundity, fertility preferences, and non-use. Instead, DWSIN means that, from 

a number of mutually-exclusive choices that describe her reason for stopping use, a respondent 

said that she stopped for reasons other than not needing contraception. 

• Discontinuation due to no further need includes desire to become pregnant, marital dissolution, 

infrequent sex/husband away, and menopause. As with DWSIN, ‘no further need’ refers the 

respondent’s perception of her need rather than to unmet need. For example, a husband’s absence, 

even long-term, is not considered exclusionary from the DHS definition of unmet need, since the 

husband may return at any time. 

2.1.2 Family Planning Effort Scores 

One measure of the strength of national FP programmatic efforts within low-income countries is the 

Family Planning Effort (FPE) Index scores, which have been calculated periodically since 1972 (Ross and 

Smith 2010). 

The FPE Index scores are calculated from questionnaires completed by local country experts within each 

country. Experts rate aspects of FP programmatic efforts within four domains—Policies, Services, 

Environment, and Method Access. Specific questions include the overall quality of FP programs and the 

availability of particular methods (Ross and Smith 2010; Ross and Hardee 2012). Some items have been 

added to the index over time to account for new methods being added to the method mix, such as the 

injectables in 2004 and implants in the 2014 round (Ross and Stover 2013). 

The FPE scores used in this report are availability scores for the three LARC methods: IUDs, implants, 

and injectables. The scores for IUDs and injectables are from 2009, a year which overlaps with the time 

period of survey in every country studied. Implant scores were first measured in 2014. The scores are 

designed to gauge the “extent to which the entire population and ready and easy access” to each of the 
11 

LARC methods within a given country. The quality metric is based on experts’ rating of the general 

quality of family planning services. The questionnaire states that “good quality includes a focus on client 

needs, with counseling, full information, wide method choice, and safe clinical procedures” (Ross and 

Smith 2010). 

2.2 Methods 

Descriptive statistics are computed among the episodes that occurred to currently married or in union 

women whose date of first marriage was at or prior to the date the episode began. For pooled estimates, 

we re-normalize DHS weights to population size, based on 2010 UN population estimates. Computations 

of discontinuation rates are based on multi-decrement life tables from episodes 3 to 62 months prior to the 

survey. The month of interview and the two preceding months are ignored to avoid the bias that might be 

introduced by an unrecognized pregnancy. The rates represent the probability of discontinuing use of a 

method within 12, 24, or 36 months of starting. 

The regression models are multilevel hazard models, which analyze time to an outcome by using country 

random effects. This enables clustering based on country characteristics. We analyze women within 

countries and their hazard of discontinuing a particular method while still in need. All other types of 

discontinuations (including no further need) are considered right-censored. We use a multilevel Weibull 

regression model, which is a more flexible alternative to the exponential hazard model (BoxSteffensmeier and Jones 2004). A Weibull model of contraceptive discontinuation has advantages over a 

Cox model because it allows for accelerated levels of failure over time in contraceptive use (Ali, 

Marshall, and Babiker 2001; Creanga et al. 2007). Population-level weights are used to ensure 

consistency with descriptive analysis. The multilevel models allow for fixed effects by characteristics and 

random intercepts by country. We first model unadjusted coefficients with country random effects; 

adjusted models incorporate individual characteristics, FPE access scores, overall method prevalence, and 

FP program quality scores. 

13 

3. Starting and Using LARCs 

3.1 Current use of LARCs 

LARCs are an important source of method choice for women and couples motivated to plan and space 

births for the minimum amount of time recommended by WHO. Table 3.1 illustrates the overall 

composition of method mix by country among currently married women. There is enormous diversity in 

LARC use across countries. The share of IUD use is typically less than 10 percent in most countries and it 

is not used at all in Liberia. However, the proportion of IUD use alone surpasses 50 percent in three 

countries: Egypt, Kyrgyz Republic, and Tajikistan. In these countries, implant use is practically nonexistent, although implant use is low in most countries. Implants comprise only 10 percent or less of the 

proportion of all methods used in 16 of the 21 countries. The proportion of implants is the most 

substantial in Burkina Faso and Senegal—over 20 percent of each country’s method mix. 

By far, the largest overall proportions of any one LARC method are injectables in most countries. 

Injectables dominate the method mix in Indonesia, Rwanda, and Liberia and hold the largest share of any 

method in five other countries: Zambia, Uganda, Sierra Leone, Burundi, and Senegal. The lowest shares 

of injectables are in Kyrgyz Republic, Tajikistan, and Pakistan. Other modern methods dominate in 

Zimbabwe, Niger, and Bangladesh, while traditional methods hold the largest share in Nigeria and 

Cambodia. The highest proportions of female sterilization are seen in Nepal and Pakistan. 

Table 3.1. Family planning method mix, by country

Among married women age 15-49, the percent of all users who use specified method 

Country IUD Implants 

Injectables 

Female 

sterilization Pill Condom

Male 

sterilization 

Other 

modern 

methods 

Traditional/ 

Folkloric Total 

Number of 

family 

planning 

users 

West Africa 

Burkina Faso 1.6 21.3 38.6 1.1 19.7 9.7 0.0 1.0 7.0 100.0 2,194 

Liberia 0.0 10.2 55.4 1.4 24.7 2.1 0.0 0.7 5.5 100.0 1,090 

Niger 0.5 2.2 15.4 1.0 40.2 0.3 0.0 28.2 12.2 100.0 1,374 

Nigeria 7.1 2.5 21.0 2.3 12.1 13.8 0.0 5.7 35.5 100.0 4,216 

Senegal 3.8 21.6 37.7 1.7 23.3 2.8 0.0 0.8 8.3 100.0 1,219 

Sierra Leone 0.7 14.6 45.2 2.8 23.4 1.4 0.1 5.6 6.2 100.0 1,813 

East and Southern Africa 

Burundi 12.5 2.6 47.5 2.7 11.2 4.4 0.3 0.3 18.9 100.0 1,185 

Comoros 0.3 8.1 29.1 4.3 16.1 11.1 4.2 4.2 26.9 100.0 632 

Rwanda 0.9 12.2 50.9 1.6 13.8 5.6 0.1 2.2 12.5 100.0 3,558 

Uganda 1.8 8.9 46.8 9.6 9.7 9.0 0.3 0.6 13.3 100.0 1,626 

Zambia 2.4 11.3 39.4 3.8 24.0 8.2 0.1 2.1 8.7 100.0 4,832 

Zimbabwe 0.3 4.7 14.2 1.9 70.6 5.3 0.0 0.9 2.2 100.0 3,338 

North Africa and West Asia 

Egypt 51.4 0.9 14.5 2.1 27.4 0.8 0.0 1.9 1.0 100.0 11,974 

Yemen 17.7 1.7 12.5 6.8 34.7 1.6 0.2 12.0 12.9 100.0 5,213 

Central Asia 

Kyrgyz Republic 60.9 0.0 1.4 4.4 4.2 21.1 0.0 0.8 7.2 100.0 1,907 

Tajikistan 66.4 0.2 7.1 2.1 8.2 8.0 0.0 0.5 7.5 100.0 1,816 

South and Southeast Asia 

Bangladesh 1.2 1.9 18.3 8.1 44.5 9.0 2.0 0.0 15.0 100.0 10,183 

Cambodia 6.1 0.9 20.6 4.7 30.4 5.4 0.1 0.8 31.0 100.0 5,876 

Indonesia 6.3 5.4 51.6 5.2 21.9 2.8 0.3 0.1 6.5 100.0 20,704 

Nepal 2.6 2.4 18.5 30.5 8.3 8.7 15.8 0.0 13.2 100.0 4,774 

Pakistan 6.5 0.2 7.8 24.4 4.5 24.9 0.7 4.7 26.3 100.0 4,581 

Notes: Other modern methods include foam/jelly, diaphragm, female condom, emergency contraception, LAM, standard days, and other 

unspecified modern methods. Percentages may not sum to 100 due to rounding. 
14 

Figure 3.1 shows the distribution of methods, particularly LARC methods, among married women who 

currently use any modern or traditional method in 21 DHS countries at the time of the most recent survey. 

Among users, the three LARC methods combined dominate the method mix (over 50 percent) in more 

than half of these countries. The smallest proportion of LARC use among contraceptives users appears in 

Pakistan (15 percent), while the largest proportion appears in Tajikistan (over 70 percent). 

Figure 3.1. Share of LARCs in method mix 

Among currently married women age 15-49, by country, in increasing order of LARC method use 

Notes: Non-LARC modern methods include pill, condom, foam/jelly, diaphragm, female condom, emergency contraception, LAM, 

standard days, male sterilization, and other unspecified modern methods. 

Figure 3.2 depicts the distribution of other modern methods among contraceptive users, excluding LARCs 

and female sterilization. These non-LARC modern methods are later grouped, and their composition will 

influence results such as discontinuation rates. The pill holds the largest share of other modern methods in 

most countries and comprises approximately 90 percent of non-LARC modern methods in Zimbabwe, 

Egypt and Liberia as well as approximately half of the share in 17 countries. The pill is used least among 

all modern methods in Pakistan, where condoms dominate the other modern method’s share. The condom 

0% 20% 40% 60% 80% 100%

Pakistan

Niger

Zimbabwe

Bangladesh

Nepal

Cambodia

Nigeria

Yemen

Comoros

Zambia

Uganda

Sierra Leone

Burkina Faso

Kyrgyz Republic

Burundi

Senegal

Indonesia

Rwanda

Liberia

Egypt

Tajikistan

IUD

Implants

Injectables

Female

sterilization

Non-LARC modern

methods

Traditional/

Folkloric
15 

is also a widely used other modern method in the Kyrgyz Republic, Tajikistan, and Uganda. Male 

sterilization is dominant in Nepal, where it is almost half of the proportion of all other modern methods. It 

is relatively non-existent in all other countries. 

Figure 3.2. Composition of non-LARC modern methods excluding female sterilization 

Among currently married women 15-49, by country, in order of Figure 3.1 

Note: ‘Other modern’ includes foam/jelly, diaphragm, female condom, emergency contraception, LAM, standard days, and otherunspecified. 

3.2 Adoption of LARCs 

While method mix and women’s current use of family planning is a heavily-researched area, less is 

known about how and when women adopt a method. A full picture of contraceptive dynamics requires an 

understanding of method adoption as well as discontinuation. Switching methods may indicate problems 

with the previous method, or—for LARCs in particular—women’s desire for a more effective or longerterm method. Starting a modern method during the postpartum period may reflect specific postpartum 

0% 20% 40% 60% 80% 100%

Pakistan

Niger

Zimbabwe

Bangladesh

Nepal

Cambodia

Nigeria

Yemen

Comoros

Zambia

Uganda

Sierra Leone

Burkina Faso

Kyrgyz Republic

Burundi

Senegal

Indonesia

Rwanda

Liberia

Egypt

Tajikistan

Pill

Condom

Male

Sterilization

Other modern

methods
16 

programs in place, and counseling during the antenatal period and at the time of delivery if women 

received services from trained providers and facilities.8

 

Figure 3.3 depicts the pooled and re-weighted average, across all 21 countries, of the event immediately 

preceding uptake in the past five years, by method type. Women are classified as switching from another 

method, as coming from an episode of non-use (including termination of a pregnancy), or as coming from 

birth, postpartum abstinence (PPA), lactational amenorrhea (LAM), or extended breastfeeding. In the 

latter category, birth, LAM, and extended breastfeeding are whole month calendar entries and thus 

mutually exclusive with other contraceptive method use. However, the calendar does not indicate sexual 

activity. In the case of PPA, the duration of abstinence is recorded separately from the calendar. Women 

are classified as coming from PPA if the period of PPA co-occurred during the start of method use, or in 

the month immediately prior to the start of method use, and the woman was not using any other method 

immediately prior to adoption of the new method. 

Across focal countries, IUDs and traditional/folkloric methods were the methods most commonly started 

after birth, LAM/extended breastfeeding, or PPA. Meanwhile, the majority of episodes of injectable use 

were started after non-use. Previous LARC use more commonly preceded implants and non-LARC 

modern methods. 

Figure 3.3. Arrival at method use: Pooled results 

Event prior to starting an episode of method use, all episodes among married women begun in past five years, by method type. 

Notes: Pooled results are averaged across all 21 countries, using DHS weights normalized relative to national population size 

according to United Nations (2010) estimates shown in Table 2.1. Computed among episodes of use begun 0 to 59 months before 

interview among women 15-49 currently married or in union whose date of first union occurred at or prior to the start of the episode. 

Women are classified as coming from birth, post-partum abstinence (PPA), lactational amenorrhea method (LAM), and extended 

breastfeeding if any of these events immediately preceded the month that they started the event, or--in the case of PPA--if it cooccurred during the month a woman started contraception. PPA may be any self-reported length, from 1 to 60 months. If a woman 

reported both PPA and switching from another method, preference was given to switching from the other method. 

 

8

 Because the contraceptive calendar spans the same five-year time period as questions about place of delivery, skill 

of delivery provider, and antenatal care it was not possible to pinpoint recency of health services surrounding a birth 

for episodes very early in the calendar. Therefore we opted to examine births, PPA, LAM, and extended 

breastfeeding as being sources of transition to a method. 

0 20 40 60 80 100

IUD

Implant

Injectable

Non-LARC Modern

Traditional/folk

From Birth, PPA, or LAM

Switched from LARC

Switched from other

modern method

Switched from traditional

or folkloric method

From non-use
17 

Tables 3.2 to 3.6 indicate the event immediately preceding adoption of each method by country. Table 3.2 

shows arrival at IUD use. In five countries, there was insufficient sample size (fewer than 25 unweighted 

cases) to calculate reliable estimates; in five additional countries, a small sample size (25-49 unweighted 

cases) means that estimates should be interpreted with caution. Across the remaining countries, over half 

of all episodes of IUD use started immediately after birth, LAM, or during/after postpartum abstinence. 

Notably, the percentage of women in that category was highest in Egypt (73 percent) and above 40 

percent in Indonesia, Zambia, and Tajikistan. The percentage of women starting an IUD after birth, LAM, 

or PPA was lowest in Uganda, Nepal, Burundi, and Bangladesh. 

Table 3.2. Arrival at IUD use 

Event immediately prior to starting an episode of IUD use, episodes among married women begun in past five years, by country. 

Country 

From Birth, 

PPA, or 

LAM1

Switched 

from other 

LARC 

(implant or 

injectable) 

Switched 

from other 

modern 

method 

Switched 

from 

traditional or 

folkloric 

method 

From 

non-use Total 

Number of 

episodes 

West Africa 

Burkina Faso 2010 22.1 7.7 3.7 1.6 64.9 100.0 (47) 

Liberia 2013 * * * * * 2 

Niger 2012 * * * * * 12 

Nigeria 2013 23.1 4.3 3.7 5.1 63.8 100.0 282 

Senegal 2014 14.5 1.3 11.1 0.0 73.1 100.0 (42) 

Sierra Leone 2013 * * * * * (24) 

East and Southern Africa 

Burundi 2010 18.0 17.3 1.2 2.3 61.2 100.0 176 

Comoros 2012 * * * * * 2 

Rwanda 2010 22.9 15.2 1.7 2.6 57.5 100.0 (33) 

Uganda 2011 12.3 12.7 0.0 0.0 75.0 100.0 (42) 

Zambia 2013-14 48.0 5.6 11.7 4.4 30.3 100.0 134 

Zimbabwe 2010-11 * * * * * 10 

North Africa and West Asia 

Egypt 2014 72.5 1.7 8.8 0.1 16.9 100.0 5,660 

Yemen 2013 20.2 2.8 18.2 3.1 55.7 100.0 1,143 

Central Asia 

Kyrgyz Republic 2012 18.0 0.5 3.3 1.3 76.9 100.0 1,005 

Tajikistan 2012 36.6 0.2 2.2 0.5 60.5 100.0 1,004 

South and Southeast Asia 

Bangladesh 2011 10.1 11.3 36.9 3.9 37.9 100.0 125 

Cambodia 2010 18.5 4.6 11.5 3.9 61.5 100.0 339 

Indonesia 2012 47.2 19.5 9.6 1.0 22.6 100.0 798 

Nepal 2011 8.1 16.7 9.0 8.7 57.5 100.0 122 

Pakistan 2012-13 34.1 2.5 7.1 3.9 52.3 100.0 503 

TOTAL 53.3 4.9 9.2 1.4 31.2 100.0 11,503 

Notes: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in 

parentheses are based on 25-49 unweighted cases. Computed among episodes of use begun 0 to 59 months before interview 

among women 15-49 currently married or in union whose date of first union occurred at or prior to the start of the episode. Total is 

an average across all 21 countries, using DHS weights normalized relative to national population size according to United Nations 

(2010) estimates shown in Table 2.1. 

1

 Women are classified as coming from birth, post-partum abstinence (PPA), lactational amenorrhea (LAM), and extended 

breastfeeding if any of these events immediately preceded the month that they started the event, or--in the case of PPA--if it cooccurred during the month a woman started contraception. PPA may be any self-reported length, from 1 to 60 months. If a woman 

reported both PPA and switching from another method, preference was given to switching from the other method. 

Table 3.2 shows the event immediately preceding an episode of implants by country. This indicates that 

implants were more commonly preceded by non-use or another modern method than IUDs. In Egypt, 

Senegal, and Niger, however, at least 40 percent of episodes began after birth, postpartum abstinence, or 

LAM/ extended breastfeeding. The most common event preceding an implant was non-use. 
18 

According to Table 3.3, which shows arrival at injectable use, the portion of episodes begun after birth, 

LAM, or PPA was particularly high in Indonesia, Egypt, Niger, Zimbabwe, and Senegal. In Bangladesh 

more than one-third of injectable episodes were immediately preceded by another modern method. 

Table 3.3. Arrival at implant use 

Event immediately prior to starting an episode of implant use, episodes among married women begun in past five years, by country 

Country 

From Birth, 

PPA, or LAM 

Switched 

from other 

LARC (IUD or 

injectable) 

Switched 

from other 

modern 

method 

Switched 

from 

traditional or 

folkloric 

method 

From 

non-use Total 

Number of 

episodes 

West Africa 

Burkina Faso 2010 34.2 2.3 1.6 0.5 61.3 100.0 489 

Liberia 2013 23.3 1.6 0.0 0.0 75.1 100.0 114 

Niger 2012 41.5 3.0 19.0 1.8 34.8 100.0 (37) 

Nigeria 2013 30.6 1.5 1.2 1.7 65.0 100.0 103 

Senegal 2014 48.8 1.1 1.9 0.1 48.0 100.0 296 

Sierra Leone 2013 22.8 1.7 8.0 0.0 67.5 100.0 316 

East and Southern Africa 

Burundi 2010 34.0 13.5 0.3 1.4 50.9 100.0 (36) 

Comoros 2012 30.5 0.7 1.6 0.0 67.1 100.0 67 

Rwanda 2010 8.9 33.3 4.5 1.9 51.4 100.0 491 

Uganda 2011 25.6 10.7 8.3 1.5 53.9 100.0 177 

Zambia 2013-14 35.1 7.4 9.6 2.6 45.3 100.0 640 

Zimbabwe 2010-11 28.3 12.8 29.5 0.0 29.3 100.0 153 

North Africa and West Asia 

Egypt 2014 51.9 13.9 11.9 0.0 22.3 100.0 180 

Yemen 2013 18.3 6.8 21.7 0.6 52.7 100.0 182 

Central Asia 

Kyrgyz Republic 2012 * * * * * 0 

Tajikistan 2012 * * * * * 5 

South and Southeast Asia 

Bangladesh 2011 13.9 15.3 31.9 3.1 35.7 100.0 206 

Cambodia 2010 12.1 0.5 18.6 9.4 59.3 100.0 60 

Indonesia 2012 26.7 37.2 10.3 1.3 24.4 100.0 1,167 

Nepal 2011 7.8 14.9 8.4 5.1 63.8 100.0 101 

Pakistan 2012-13 * * * * * 10 

TOTAL 26.9 23.9 11.9 1.5 35.7 100.0 4,831 

Notes: See Table 3.2 
19 

Table 3.4. Arrival at injectable use 

Event immediately prior to starting an episode of injectable use, episodes among married women begun in past five years, by country 

Country 

From Birth, 

PPA, or LAM 

Switched 

from other 

LARC (IUD or 

implant) 

Switched 

from other 

modern 

method 

Switched 

from 

traditional or 

folkloric 

method 

From 

non-use Total 

Number of 

episodes 

West Africa 

Burkina Faso 2010 33.3 0.8 1.9 0.4 63.6 100.0 1,387 

Liberia 2013 22.6 0.0 1.7 0.3 75.3 100.0 901 

Niger 2012 47.3 0.0 10.2 0.2 42.3 100.0 552 

Nigeria 2013 30.1 0.2 3.0 1.7 65.0 100.0 1,221 

Senegal 2014 39.5 0.8 2.8 0.2 56.6 100.0 828 

Sierra Leone 2013 22.9 0.6 3.7 0.4 72.4 100.0 1,205 

East and Southern Africa 

Burundi 2010 22.0 0.4 4.1 0.6 72.9 100.0 1,126 

Comoros 2012 25.9 0.6 0.3 0.0 73.3 100.0 285 

Rwanda 2010 12.7 0.4 8.1 1.3 77.6 100.0 2,866 

Uganda 2011 23.1 0.2 3.7 1.0 72.1 100.0 1,611 

Zambia 2013-14 33.9 1.5 9.4 2.8 52.5 100.0 3,204 

Zimbabwe 2010-11 47.7 0.5 21.2 0.6 30.0 100.0 749 

North Africa and West Asia 

Egypt 2014 57.9 10.0 10.2 0.0 21.9 100.0 2,685 

Yemen 2013 13.6 2.6 12.1 1.3 70.5 100.0 1,435 

Central Asia 

Kyrgyz Republic 2012 7.4 8.8 8.1 0.5 75.2 100.0 50 

Tajikistan 2012 15.9 5.0 5.2 0.8 73.1 100.0 197 

South and Southeast Asia 

Bangladesh 2011 17.2 1.2 35.2 3.3 43.1 100.0 2,694 

Cambodia 2010 19.9 0.6 7.5 2.5 69.5 100.0 1,570 

Indonesia 2012 58.3 2.1 11.6 0.8 27.2 100.0 12,601 

Nepal 2011 18.5 1.0 4.4 1.3 74.8 100.0 1,716 

Pakistan 2012-13 33.4 3.2 4.1 1.5 57.8 100.0 966 

TOTAL 43.2 2.2 12.8 1.3 40.6 100.0 39,845 

Notes: See Table 3.2 

Non-LARC modern methods, excluding female sterilization, and traditional methods are the two 

reference groups considered in this study. Table 3.5, which shows arrival at non-LARC modern methods 

combined, indicates that in six countries—Niger, Nigeria, Zimbabwe, Egypt, Tajikistan, and Pakistan—

more than half of women began a non-LARC modern method directly after a birth, or from LAM, 

extended breastfeeding, or PPA. Meanwhile, more than 12 percent of episodes of non-LARC modern 

methods in Bangladesh and Indonesia began after an episode of LARC use. The proportion whose 

modern method use was immediately preceded by a more effective (LARC) method was strikingly high 

in Indonesia (47 percent), and was also high in Rwanda (18 percent) and Egypt (15 percent). 

In 11 of 21 countries considered, more than half of the episodes of traditional or folkloric method use 

were arrived at after birth, extended breastfeeding, PPA or LAM (Table 3.6). Traditional and folkloric 

methods were arrived at more commonly from non-use in Burkina Faso, Sierra Leone, Burundi, Rwanda, 

and Nepal. They are more heavily favored by women switching from a LARC or other modern method in 

Bangladesh and Indonesia. 
20 

Table 3.5. Arrival at non-LARC modern method use 

Event immediately prior to starting an episode of non-LARC modern methods (excluding female sterilization), episodes among married 

women begun in past five years, by country 

Country 

From Birth, 

PPA, or LAM 

Switched 

from LARC 

Switched 

from other 

modern 

method 

Switched 

from 

traditional or 

folkloric 

method 

From 

non-use Total 

Number of 

episodes 

West Africa 

Burkina Faso 2010 35.7 4.1 1.0 0.2 58.9 100.0 1,002 

Liberia 2013 24.7 3.1 0.0 0.0 72.2 100.0 470 

Niger 2012 75.0 1.8 0.1 0.4 22.8 100.0 2,760 

Nigeria 2013 63.0 1.4 0.8 0.8 34.0 100.0 2,595 

Senegal 2014 41.3 4.5 1.1 0.9 52.2 100.0 752 

Sierra Leone 2013 36.6 5.4 0.5 0.2 57.2 100.0 903 

East and Southern Africa 

Burundi 2010 22.1 12.6 0.4 1.5 63.4 100.0 431 

Comoros 2012 31.7 4.6 0.0 1.1 62.7 100.0 262 

Rwanda 2010 20.8 17.5 1.5 1.2 58.9 100.0 1,415 

Uganda 2011 33.7 12.3 0.8 1.9 51.2 100.0 675 

Zambia 2013-14 44.6 6.3 2.7 2.5 43.8 100.0 3,335 

Zimbabwe 2010-11 68.4 4.2 3.1 0.5 23.8 100.0 3,764 

North Africa and West Asia 

Egypt 2014 62.3 14.6 0.4 0.1 22.5 100.0 6,538 

Yemen 2013 43.2 4.7 0.7 1.5 49.9 100.0 7,583 

Central Asia 

Kyrgyz Republic 2012 26.1 6.1 2.5 2.3 63.0 100.0 869 

Tajikistan 2012 40.5 7.6 2.2 1.5 48.3 100.0 576 

South and Southeast Asia 

Bangladesh 2011 23.7 9.6 8.9 1.7 56.1 100.0 8,675 

Cambodia 2010 19.7 5.9 1.7 3.8 68.9 100.0 2,800 

Indonesia 2012 27.3 46.5 1.9 0.8 23.5 100.0 7,091 

Nepal 2011 14.4 8.4 2.4 1.6 73.3 100.0 2,403 

Pakistan 2012-13 60.9 4.5 2.2 2.1 30.3 100.0 3,178 

TOTAL 40.0 15.3 3.8 1.3 39.6 100.0 58,079 

Notes: See Table 3.2 
21 

Table 3.6. Arrival at traditional/folkloric use 

Event immediately prior to starting an episode of traditional or folkloric family planning, episodes among married women begun in past 

five years, by country 

Country 

From Birth, 

PPA, or LAM 

Switched 

from LARC 

Switched 

from other 

modern 

method 

Switched 

from 

traditional or 

folkloric 

method 

From 

non-use Total 

Number of 

episodes 

West Africa 

Burkina Faso 2010 38.8 4.4 2.6 0.0 54.2 100.0 219 

Liberia 2013 53.3 2.5 0.0 0.0 44.2 100.0 53 

Niger 2012 84.2 0.5 3.2 0.0 12.0 100.0 350 

Nigeria 2013 66.3 1.1 0.9 0.8 30.9 100.0 2,150 

Senegal 2014 48.8 3.2 5.9 1.5 40.6 100.0 159 

Sierra Leone 2013 41.1 3.0 0.0 0.0 55.9 100.0 130 

East and Southern Africa 

Burundi 2010 30.0 2.6 1.5 0.0 65.9 100.0 382 

Comoros 2012 53.4 0.0 3.6 0.4 42.6 100.0 192 

Rwanda 2010 24.8 8.8 5.1 0.5 60.8 100.0 654 

Uganda 2011 42.6 4.8 3.4 0.6 48.7 100.0 369 

Zambia 2013-14 67.3 3.2 4.6 0.4 24.6 100.0 927 

Zimbabwe 2010-11 66.9 4.3 11.4 0.0 17.4 100.0 137 

North Africa and West Asia 

Egypt 2014 91.6 2.4 2.0 0.0 4.0 100.0 774 

Yemen 2013 19.6 6.6 20.1 1.1 52.5 100.0 1,199 

Central Asia 

Kyrgyz Republic 2012 20.2 7.2 10.8 1.3 60.5 100.0 209 

Tajikistan 2012 42.4 8.0 3.6 0.0 45.9 100.0 164 

South and Southeast Asia 

Bangladesh 2011 22.4 11.5 24.5 1.1 40.5 100.0 1,495 

Cambodia 2010 39.2 2.7 6.3 0.2 51.7 100.0 1,966 

Indonesia 2012 46.6 21.6 13.7 0.9 17.2 100.0 1,357 

Nepal 2011 19.1 8.7 7.5 0.3 64.4 100.0 1,040 

Pakistan 2012-13 55.4 5.4 6.9 0.1 32.1 100.0 1,714 

TOTAL 48.1 7.8 9.8 0.6 33.8 100.0 15,638 

Notes: See Table 3.2 

23 

4. Stopping LARCs 

4.1 Discontinuation Rates 

Figure 4.1 shows pooled discontinuation rates grouped by reason and method type. These cumulative 

discontinuation rates represent the proportion of women who discontinue using a method within 12, 24, 

and 36 months of starting the method across the 21 countries studied, adjusted for population weights. On 

average, within the first year of use, 9 percent of women discontinue using implants, 15 percent 

discontinue IUDs, and 32 percent discontinue injectables. While these rates are less than the 40 percent of 

women who discontinue non-LARC modern methods in the first year, the 12 month discontinuation rate 

for injectables (32 percent) is on par with the 28 percent of women who discontinue traditional methods 

within the first year. 

By year three, only a minority of women are still using non-LARC modern methods, injectables, and 

traditional or folkloric methods, as compared to two-thirds of implant users and about half of IUD users 

who remain with their original method. Interestingly, traditional methods were discontinued less often 

than both injectables and other modern methods over the course of all periods. 

In Figure 4.1, discontinuation rates by reason are indicated by color. The darkest shade reflects method 

failure with increasingly lighter shades representing other reasons including method-related reasons, such 

as side effects and health concerns, inconvenience, and desire for a more effective method; cost, access, 

and other reasons such as lack of availability, husband opposed, and other; and no need, which means that 

either the woman wanted to become pregnant, had infrequent sex or husband/partner away, became 

menopausal, was unable to become pregnant, or experienced dissolution of her marriage or union. 

The rates of discontinuation due to failure depicted in Figure 4.1 are broadly consistent with existing 

clinical knowledge about contraceptive efficacy: traditional and folk methods are the most likely to fail, 

followed by other modern methods. Perhaps surprisingly, IUDs appear to have a failure rate equal to that 

of injectables and double that of implants. This could reflect data quality issues, such as imperfect recall, 

or it could suggest problems with training, quality of supplies, provision, counseling, and support that 

occur ‘on the ground’ in low-income countries. 

The finding that IUD and implant discontinuation rates are lowest makes sense. With adequate counseling 

and provision, it is presumed that women who elect for an IUD or implant intend to use it for a sustained 

period of time. IUDs and implants are also provider-discontinued methods, whereas injectables and some 

modern methods can be discontinued passively, require continuous renewal, or are coitus-dependent. One 

major area of concern in supporting continued use is the frequency with which women discontinue 

because of method properties, cost and access, since these may indicate inadequate counseling and 

provision or supply chain failures. Figure 4.1 indicates that discontinuation rates for method-related 

reasons such as side effects and health concerns are highest for injectables, over 30 percent over the 

course of three years. Meanwhile, IUDs, implants, and other modern methods have on average around 20 

percent discontinuation rate due to method-related reasons by the end of three years. Additionally, cost 

and access issues for IUDs and implants were cited much less often than method-related reasons. Issues 

of cost and access, however, appear to be fairly substantial for injectables and other modern methods that 

require more frequent renewal. 
24 

Figure 4.1. 12, 24 and 36-month failure and discontinuation rates by method type: Pooled results 

Among married women age 15 to 49 who began using contraception 3 to 62 months preceding the survey, the percentage who 

experienced failure (pregnancy) or discontinued within the specified interval, by method and reason for discontinuation 

Notes: Pooled results are averaged across all 21 countries, using DHS weights normalized relative to national population size 

according to United Nations (2010) estimates shown in Table 2.1. Computed among married women 15-49 at time of survey, whose 

date of first union is at or before the start of episode. Reasons are mutually exclusive. Computations based on multi-decrement life 

tables from episodes 3 to 62 months prior to the survey. Grey boxes indicate unweighted number of episodes is less than 50, results 

suppressed. Method reasons include health, side effects, inconvenience, and wanting a more effective method. Cost, access, and 

other reasons include lack of availability, husband opposed, and other. No need means that the woman wanted to become 

pregnant, she became menopausal or unable to become pregnant, infrequent sex or husband/partner away, or her marriage or 

union dissolved. 

Figure 4.2 shows cumulative IUD discontinuation rates disaggregated by reason and by country for 12, 

24, and 36 month periods. In seven countries, all in sub-Saharan Africa, there was insufficient sample size 

to estimate discontinuation rates. In the remaining countries, we see that IUD discontinuation ranges from 

20 percent at the end of three years in Indonesia to 76 percent in Sierra Leone. Method failure is a 

substantial factor in Burundi, Zambia, and Pakistan, but almost imperceptible in Cambodia, Indonesia, 

and Nepal. Access and/or cost were not frequently cited as primary reasons for discontinuation in any 

country. 

15.0

32.6

46.3

8.5

17.3

33.3 31.9

48.0

60.4

40.2

59.8

71.2

28.6

52.1

64.2

0

10

20

30

40

50

60

70

80

90

100

12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m

IUD Implant Injectable Other modern Traditional/ Folk

Failure Discontinue: Method reasons Discontinue: Access/ Cost/ Other Discontinue :No need Discontinue: DK/ Missing
25 

Figure 4.2. 12, 24 and 36-month failure and discontinuation rates, IUDs 

Among married women age 15 to 49 who began using IUDs 3 to 62 months preceding the survey, the percentage who experienced 

failure (pregnancy) or who discontinued within the specified interval, by country and reason for discontinuation 

Notes: Grey boxes indicate unweighted number of episodes is less than 50, results suppressed. Results computed among married 

women 15-49 at time of survey, whose date of first union is at or before the start of episode. Reasons are mutually exclusive. 

Computations based on multi-decrement life tables from episodes 3 to 62 months prior to the survey. Method reasons include side

effects and health concerns, inconvenience, and wanting a more effective method. Cost, access, and other reasons include lack of 

availability, husband opposed, and other. No need means that the woman wanted to become pregnant, she became menopausal or 

unable to become pregnant, infrequent sex or husband/partner away, or her marriage or union dissolved. 

10

23

28

52

71

76

15

32

51

7

18

29

0

10

20

30

40

50

60

70

80

90

12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m

Burkina Faso Liberia Niger Nigeria Senegal Sierra Leone Burundi Comoros Rwanda Uganda Zambia

Failure Discontinue: Method reasons Discontinue: Access/ Cost/ Other Discontinue :No need Discontinue: DK/ Missing

14

37

53

18

31

47

10

22

34

10

22

30

24

30

42

7

15

21

6

12

20 22

33

49

26

42

55

0

10

20

30

40

50

60

70

80

90

100

12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m

Zimbabwe Egypt Yemen Kyrgyz

Republic

Tajikistan Bangladesh Cambodia Indonesia Nepal Pakistan
26 

Figure 4.3. 12, 24 and 36-month failure and discontinuation rates, implants 

Among married women age 15 to 49 who began using implants 3 to 62 months preceding the survey, the percentage who 

experienced failure (pregnancy) or discontinued within the specified interval, by country and reason for discontinuation 

Notes: See Figure 4.2. 

3

13

26

14

23 23

11

16

41

7

10

46

11

17

34

6

25

40

4

13

23

12

34

56

4

13

28

0

10

20

30

40

50

60

70

80

90

100

12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m

Burkina Faso Liberia Niger Nigeria Senegal Sierra Leone Burundi Comoros Rwanda Uganda Zambia

Failure Discontinue: Method reasons Discontinue: Access/ Cost/ Other Discontinue :No need Discontinue: DK/ Missing

9

13

29

14

36

60

27

43

69

8

18

30

12

45 46

8

15

30

12

17

26

0

10

20

30

40

50

60

70

80

90

100

12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m12m24m36m

Zimbabwe Egypt Yemen Kyrgyz Republic Tajikistan Bangladesh Cambodia Indonesia Nepal Pakistan
27 

Figure 4.4. 12, 24 and 36-month failure and discontinuation rates, injectables 

Among married women age 15 to 49 who began using injectables 3 to 62 months preceding the survey, the percentage who 

experienced failure (pregnancy) or discontinued within the specified interval, by country and reason for discontinuation 

Notes: See Figure 4.2. 

28

55

72

27

46

65

58

81

90

22

42

56

42

64

74

29

46

59

40

66

85

26

48

58

23

45

62

45

69

81

25

53

72

0

10

20

30

40

50

60

70

80

90

100

12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m

Burkina Faso Liberia Niger Nigeria Senegal Sierra Leone Burundi Comoros Rwanda Uganda Zambia

Failure Discontinue: Method reasons Discontinue: Access/ Cost/ Other Discontinue :No need Discontinue: DK/ Missing

33

50

67

38

56

69

48

66

79

46

69

81

42

51

60

36

50

61

30

43

56

24

39

51

56

71

77

61

74

86

0

10

20

30

40

50

60

70

80

90

100

12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m

Zimbabwe Egypt Yemen Kyrgyz Republic Tajikistan Bangladesh Cambodia Indonesia Nepal Pakistan
28 

Figure 4.5. 12, 24 and 36-month failure and discontinuation rates, non-LARC modern methods, 

excluding female sterilization 

Among married women age 15 to 49 who began using non-LARC modern methods (excluding female sterilization) 3 to 62 months 

preceding the survey, the percentage who experienced failure (pregnancy) or discontinued within the specified interval, by country 

and reason for discontinuation 

Notes: See Figure 4.2.

22

47

67

33

50

62

42

85

95

45

66

79

39

65

78

30

53

66

57

82

94

23

46

63

42

61

70

44

65

76

34

62

78

0

10

20

30

40

50

60

70

80

90

100

12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m

Burkina Faso Liberia Niger Nigeria Senegal Sierra Leone Burundi Comoros Rwanda Uganda Zambia

Failure Discontinue: Method reasons Discontinue: Access/ Cost/ Other Discontinue :No need Discontinue: DK/ Missing

21

41

60

41

65

77

48

77

88

35

56

72

45

61

72

39

54

65

28

44

55

40

53

62 62

72

78

41

68

80

0

10

20

30

40

50

60

70

80

90

100

12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m

Zimbabwe Egypt Yemen Kyrgyz

Republic

Tajikistan Bangladesh Cambodia Indonesia Nepal Pakistan
29 

Figure 4.6. 12, 24 and 36-month failure and discontinuation rates, traditional and folkloric methods 

Among married women age 15 to 49 who began using traditional or folkloric methods 3 to 62 months preceding the survey, the 

percentage who experienced failure (pregnancy) or discontinued within the specified interval, by country and reason for 

discontinuation 

Notes: See Figure 4.2. 

 

18

44

58

2

16 16

26

75

96

26

55

68

33

64

74

15

32

44

40

65

78

13

41

44

27

50

65

40

66

78

29

73

87

0

10

20

30

40

50

60

70

80

90

100

12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m

Burkina Faso Liberia Niger Nigeria Senegal Sierra Leone Burundi Comoros Rwanda Uganda Zambia

Failure Discontinue: Method reasons Discontinue: Access/ Cost/ Other Discontinue :No need Discontinue: DK/ Missing

31

68

85

41

86

92

36

56

71

29

59

74

31

47

56

23

40

51

16

35

50

21

40

53 50

63

75

32

55

67

0

10

20

30

40

50

60

70

80

90

100

12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m 12m 24m 36m

Zimbabwe Egypt Yemen Kyrgyz Republic Tajikistan Bangladesh Cambodia Indonesia Nepal Pakistan
30 

Discontinuation rates for implants are shown in Figure 4.3. At the end of three years, the probability of 

discontinuation ranges from 23 percent in Liberia to 69 percent in Yemen. In Yemen, method-related 

reasons such as side effects and health concerns largely drive the high discontinuation rate. Failure rates 

are highest in Nigeria, Comoros, Uganda, and Cambodia and lowest in most remaining countries in subSaharan Africa as well as in Nepal. Again, access and cost were relatively uncommon reasons for 

discontinuation compared to other reasons. 

Injectables are the only LARC that do not require provider removal; as might be expected, injectables 

have the highest discontinuation rates of the three LARC methods. Injectable discontinuation rates by 

country, as shown in Figure 4.4, reflect higher rates than IUDs and implants, but also show more diverse 

reasons for discontinuation than injectables. For the first time, cost, access, and opposition are a nonnegligible share of discontinuation rates of a method. This is found most prominently in Niger and 

Senegal but also in Burundi, Pakistan and Zimbabwe, although less frequently in the North Africa and 

Asian countries (except Pakistan) as compared to sub-Saharan countries. In addition, method-related 

reasons were a substantial cause of discontinuation in Pakistan, Yemen, Bangladesh, Egypt, Tajikistan, 

and most of sub-Saharan Africa (particularly Uganda, Rwanda, Burundi, Senegal, Liberia, and 

Zimbabwe). 

The one year discontinuation rate for non-LARC modern methods (Figure 4.5) ranges from 21 percent in 

Zimbabwe to 62 percent in Nepal; by three years the rate reaches 88 percent in Yemen, 94 percent in 

Burundi, and 95 percent in Niger. Method-related causes of discontinuation were considerable in Pakistan 

and Yemen. Discontinuation rates due to failure are an important source of discontinuation in Kyrgyz 

Republic and in Pakistan, Yemen, Egypt, Uganda and Burundi. Access and cost issues were also more 

frequently cited as a reason for discontinuation in sub-Saharan Africa compared to Asia and North Africa. 

Figure 4.6 shows the discontinuation rates by reason for traditional/folkloric methods. The 36-month 

discontinuation rate spans a wide range from 16 percent in Liberia to 96 percent in Nigeria. As expected, 

the failure rate is high; traditional/folkloric methods are least effective. The failure rate is highest in 

Uganda, Burundi, Zambia, and Zimbabwe. Discontinuation rates for method-related reasons and for 

access/cost/other reasons are also low. Discontinuation due to no need is high among traditional method 

users in Niger, Nigeria, Senegal, Burundi, Nepal, and Pakistan; it may be that women who use traditional 

methods in these countries intend to use them for the short-term to space pregnancies. However, results 

should be interpreted with caution due to the underreporting of traditional methods in the DHS calendar 

(Bradley, Winfrey, and Croft 2015).

4.2 Reasons for discontinuation 

The discontinuation rates computed in section 4.1 were standardized for the duration of the specified time 

interval and computed among episodes begun in the 3 to 62 months prior to the survey regardless of 

whether they ended. Discontinuation reasons, detailed in this section, are based on all intervals 

discontinued in the past 3 to 62 months, regardless of length or start date. The section provides insight 

into the detailed reasons for discontinuation by method type. We classify these detailed reasons into two 

major categories: discontinuation while still in need (DWSIN) and discontinuation due to lack of need 

(see Chapter 2 for a discussion of this categorization). 

Figure 4.7 highlights differences in the distribution of reasons for discontinuation across the five method 

types, based on the pooled survey results. In the figure, reasons for discontinuations for women who were 

still in need of contraception are shaded in red and pink, while reasons for women no longer in need are in 

green. The share of discontinuations to women still in need of contraception ranges from 50 percent for 

traditional/folk method to over 70 percent for implant discontinuations. 
31 

Across all modern method types, there are two reasons given for the majority of discontinuations: interest 

in becoming pregnant, and side effects/health concerns. The percentage of women who discontinued 

because they wanted to become pregnant is highest for IUD discontinuations and lowest for implant 

discontinuations, although the differences across method types are not very large. In contrast, the 

percentage of discontinuations for which side effects/health concerns were given as the reason is 

markedly lower for non-LARC modern methods than for LARC methods and is lowest for traditional or 

folk methods. 

The share of discontinuations due to method failure is lowest for IUD, implants, and injectables; higher 

for non-LARC modern methods; and highest for traditional/folk methods (at nearly 30 percent). In 

comparisons of reasons for discontinuation across the method types, desire for a more effective method is 

most common among traditional or folk method discontinuations and lowest among IUD 

discontinuations. 

Figure 4.7. Reasons for discontinuation: Pooled results 

Distribution of the main reason for discontinuation, episodes of contraceptive use among married women age 15-49 discontinued in 

the 3 to 62 months preceding the survey, by method type 

Notes: Pooled results are averaged across all 21 countries, using DHS weights normalized relative to national population size 

according to United Nations (2010) estimates shown in Table 2.1. Episodes among currently married women age 15 to 49 whose 

date of first marriage or union was before the date the episode started. 

Tables 4.1-4.5 show the distribution of the reason for discontinuation for each method separately by 

country. Table 4.1 shows this distribution among IUD discontinuations that occurred among married 

women in the 3 to 62 months prior to interview. In the pooled sample, just over half of IUD 

discontinuation episodes were to women still in need of contraception. Among women still in need, the 

most frequent reason for discontinuing was side effects or health concerns (38 percent in the pooled 

sample). This percentage ranged widely across countries, from 16 percent in Burundi to over 60 percent 

in Pakistan and Bangladesh. Becoming pregnant while using FP was the second most common reason for 

women still in need; this reason was given for 5 percent of IUD discontinuations in the pooled sample, 

and ranged from 1 percent in Nepal and Cambodia to 14 percent in Burundi (note the small sample size in 

that country). In the pooled sample, only a small percentage of IUD discontinuations were due to wanting 

a more effective method, inconvenience, access or cost, or opposition or other reasons (under 5 percent 

for each reason). However, in Burundi and Cambodia, inconvenience was given as a reason for 18 percent 

and 12 percent, respectively, of discontinuations. 

For the other half of IUD discontinuations, women stopped using an IUD because they were no longer in 

need of contraception. In the pooled sample, 44 percent of discontinuation episodes were a result of 

0 10 20 30 40 50 60 70 80 90 100

IUD

Implant

Injectable

Non-LARC Modern

Traditional/folk

Became pregnant while using

Side effects/ health concerns

Wanted more effective method

Inconvenient to use

Access / cost

Opposition/ other

Wanted to become pregnant

No/ infrequent sex/ husband away

Marital dissolution/ separation

Difficult to get pregnant/

menopause

Don't know/ Missing
32 

women wanting to become pregnant. This percentage ranged from just 5 percent in Nepal to 60 percent in 

Nigeria. An additional three percent of IUD discontinuations in the pooled sample were due to either no 

or infrequent sex, the husband being away (2 percent) or menopause/difficulty getting pregnant 

(1 percent). Nepal had the highest percentage of IUD discontinuations due to no or infrequent sex or the 

husband being away (25 percent). 

Because of the small number of cases of IUD discontinuations in most of West, East, and Southern 

Africa, we were not able to examine the reasons for discontinuations in these regions. 

Table 4.1. Reasons for discontinuing IUDs 

Distribution of the main reason for discontinuation, IUD episodes among married women age 15-49 discontinued in the 3 to 62 months preceding the survey, 

by country 

Still in need1 Not in need 

Became 

pregnant 

while 

using 

Side 

effects/ 

health 

concerns 

Wanted 

more 

effective 

method 

Inconvenient 

to use 

Access/ 

cost 

Opposition/ 

other 

Wanted 

to 

become 

pregnant 

No/ infrequent 

sex/ 

husband 

away 

Marital 

dissolution/ 

separation 

Difficult 

to get 

pregnant/ 

menopause 

Don’t 

know/ 

Missing Total 

Number 

of episodes 

West Africa 

Burkina Faso 2010 * * * * * * * * * * * 18 

Liberia 2013 * * * * * * * * * * * 2 

Niger 2012 * * * * * * * * * * * 13 

Nigeria 2013 4.3 23.4 0.0 1.9 1.6 2.1 60.1 0.7 0.0 1.4 4.6 100.0 124 

Senegal 2014 * * * * * * * * * * * 9 

Sierra Leone 2013 * * * * * * * * * * * 21 

East and Southern Africa 

Burundi 2010 14.0 15.8 0.0 17.6 0.0 12.3 40.3 0.0 0.0 0.0 0.0 100.0 (34) 

Comoros 2012 * * * * * * * * * * * 2 

Rwanda 2010 * * * * * * * * * * * 9 

Uganda 2011 * * * * * * * * * * * 16 

Zambia 2013-14 12.5 57.5 6.7 0.0 0.0 2.5 20.8 0.0 0.0 0.0 0.0 100.0 (38) 

Zimbabwe 2010-11 * * * * * * * * * * * 9 

North Africa and West Asia 

Egypt 2014 6.3 32.4 0.1 0.6 0.0 0.7 56.5 2.1 0.3 0.9 0.0 100.0 4,766 

Yemen 2013 5.0 50.5 1.9 3.0 0.1 2.6 28.6 3.7 0.1 0.5 4.1 100.0 781 

Central Asia 

Kyrgyz Republic 2012 7.0 33.5 2.0 1.5 0.0 3.4 49.0 2.3 0.0 1.4 0.0 100.0 628 

Tajikistan 2012 4.5 28.1 1.8 8.9 0.2 3.3 34.6 5.2 0.3 0.9 12.1 100.0 461 

South and Southeast Asia 

Bangladesh 2011 2.5 66.0 4.8 1.2 0.4 7.6 12.3 0.0 0.0 3.2 1.9 100.0 80 

Cambodia 2010 0.9 24.4 2.5 12.2 3.9 6.6 34.1 3.9 0.1 0.3 11.1 100.0 89 

Indonesia 2012 4.4 29.0 4.0 5.1 0.9 19.9 30.8 1.2 0.1 2.4 2.3 100.0 552 

Nepal 2011 0.5 58.5 3.1 6.7 0.0 1.6 5.0 24.6 0.0 0.0 0.0 100.0 53 

Pakistan 2012-13 3.7 63.0 0.9 2.1 0.4 5.6 18.7 2.8 0.0 1.8 0.9 100.0 400 

TOTAL2 5.4 38.2 1.0 1.8 0.2 4.3 44.4 2.2 0.2 1.3 1.0 100.0 8,102 

Notes: Episodes among currently married women age 15 to 49 whose date of first marriage or union was before the date the episode started. 

Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been 

suppressed. 

1 ‘Still in need’ does not necessarily refer to unmet need. See chapter 2 for additional discussion of this distinction. 

2 Pooled average across all 21 countries, using DHS weights normalized relative to national population size according to United Nations (2010) estimates shown in 

Table 2.1. 

Table 4.2 shows the distribution of reasons for discontinuing the use of an implant, among all implant 

discontinuations that occurred among married women in the 3 to 62 months before the interview. Overall 

in the pooled sample, more than 70 percent of these discontinuations were among women still in need of 

contraception. Side effects/health concerns was the most common reason given for discontinuing implants 

(44 percent in the pooled sample), ranging from 19 percent in Cambodia to 66 percent in Bangladesh. 

Overall, opposition or other reasons were given for 13 percent of implant discontinuations; this reason 
33 

was particularly high in South and Southeast Asia, and specifically in Cambodia (19 percent), Indonesia 

(20 percent), and Nepal (17 percent). 

The remaining 10 percent of implant discontinuations among women still in need was due to becoming 

pregnant while using (3 percent), wanting a more effective method (4 percent), and access or cost (4 

percent). Wanting a more effective method was especially common in Bangladesh (9 percent), and access 

or cost was especially common in Zimbabwe (8 percent). 

Among women who no longer needed a method, wanting to become pregnant was the most common 

reason given for discontinuing use of an implant. This reason was given for 23 percent of implant 

discontinuations in the pooled sample, with ranges from 11 percent in Rwanda and Bangladesh to 50 

percent in Burkina Faso. All other reasons were given for less than 5 percent of discontinuations in the 

pooled sample and in every country, except that no or infrequent sex or husband being away was provided 

as a reason for 13 percent of implant discontinuations in Nepal. 

Table 4.2. Reasons for discontinuing implants 

Distribution of the main reason for discontinuation, implant episodes among married women age 15-49 discontinued in the 3 to 62 months preceding the survey, 

by country 

Still in need No further need 

Became 

pregnant 

while 

using 

Side 

effects/ 

health 

concerns 

Wanted 

more 

effective 

method 

Inconvenient 

to use 

Access/ 

cost 

Opposition/ 

other 

Wanted 

to 

become 

pregnant 

No/ infrequent 

sex/ 

husband 

away 

Marital 

dissolution/ 

separation 

Difficult 

to get 

pregnant/ 

menopause 

Don’t 

know/ 

Missing Total 

Number 

of episodes 

West Africa 

Burkina Faso 2010 0.9 23.4 5.1 0.7 0.9 9.8 49.7 1.4 0.6 0.0 7.5 100.0 163 

Liberia 2013 * * * * * * * * * * * 10 

Niger 2012 * * * * * * * * * * * 8 

Nigeria 2013 * * * * * * * * * * * 12 

Senegal 2014 10.7 30.0 1.6 6.6 0.0 14.1 33.6 0.0 0.0 3.4 0.0 100.0 58 

Sierra Leone 2013 2.0 58.2 0.9 0.7 3.2 9.2 23.6 0.0 0.0 0.0 2.2 100.0 67 

East and Southern Africa 

Burundi 2010 * * * * * * * * * * * 4 

Comoros 2012 * * * * * * * * * * * 20 

Rwanda 2010 2.0 66.2 5.0 1.3 0.0 3.1 10.6 1.7 0.0 0.0 10.2 100.0 70 

Uganda 2011 5.0 47.6 0.0 0.0 2.7 4.3 37.7 0.0 1.8 1.0 0.0 100.0 47 

Zambia 2013-14 2.4 60.5 1.6 0.0 0.0 2.7 30.2 0.0 0.0 0.2 2.6 100.0 177 

Zimbabwe 2010-11 7.0 38.1 1.4 0.0 8.2 6.8 31.7 2.3 0.0 0.0 4.6 100.0 47 

North Africa and West Asia 

Egypt 2014 2.3 58.7 3.1 4.6 3.1 1.2 20.5 4.4 0.1 2.0 0.0 100.0 150 

Yemen 2013 2.2 63.5 1.7 9.9 1.9 1.1 16.8 1.9 0.0 0.0 1.0 100.0 120 

Central Asia 

Kyrgyz Republic 2012 * * * * * * * * * * * 0 

Tajikistan 2012 * * * * * * * * * * * 1 

South and Southeast Asia 

Bangladesh 2011 1.4 66.1 8.6 0.9 3.5 2.9 10.7 2.9 0.0 2.8 0.3 100.0 108 

Cambodia 2010 9.1 19.0 2.3 5.7 0.0 19.3 31.2 4.6 0.0 8.8 0.0 100.0 25 

Indonesia 2012 2.8 37.0 4.2 3.5 4.5 19.8 22.7 1.7 0.7 1.2 1.8 100.0 654 

Nepal 2011 0.0 40.9 5.8 3.3 1.7 16.7 15.8 12.9 0.0 2.9 0.0 100.0 49 

Pakistan 2012-13 * * * * * * * * * * * 10 

TOTAL 2.8 44.4 4.3 2.9 3.7 13.4 22.6 2.1 0.5 1.4 1.9 100.0 1,799 

Notes: See Table 4.1. 

The distribution of reasons given for discontinuing use of injectables is similar to those described above 

for implants, as Table 4.3 shows. Across all countries in the pooled sample, 61 percent of injectable 

discontinuations were to women still in need of a method. Among reasons that indicate that the woman is 

still in need, side effects or health concerns is the most common reason given (40 percent), followed by 
34 

opposition or other reasons (9 percent), becoming pregnant while using (4 percent), access or cost (3 

percent), and inconvenience (2 percent). Two countries are noteworthy for distinct distributions of 

reasons: in Tajikistan, a relatively large percentage of discontinuations are due to inconvenience of use 

(21 percent), and in Kyrgyz Republic a relatively high percentage of discontinuations are due to becoming 

pregnant while using (15 percent). 

For the remaining 39 percent of injectable discontinuations, the woman was no longer in need. 

Overall in the pooled sample, 29 percent of injectable discontinuations were due to wanting to become 

pregnant; this ranged from 10 percent in Nepal to 54 percent in Burkina Faso. Also in the pooled sample, 

6 percent of injectable discontinuations were due to no or infrequent sex or the husband being away, 

although this percentage varied widely across countries. While in 13 countries the percentage was under 5 

percent, in Kyrgyz Republic, Tajikistan, and Nepal, this reason was given for 21 percent, 15 percent, and 

31 percent of injectable discontinuations, respectively. Marital dissolution and menopause/difficult 

getting pregnant were infrequent reasons (under 3 percent) in all countries, except that in Bangladesh and 

Cambodia, 6 percent and 4 percent of injectable discontinuations were due to menopause or difficulty 

getting pregnant. Finally, in two countries, Niger and Tajikistan, information on reasons was either 

unknown or missing for more than 10 percent of injectable discontinuations. 

Table 4.3. Reasons for discontinuing injectables 

Distribution of the main reason for discontinuation, injectable episodes among married women age 15-49 discontinued in the 3 to 62 months preceding the survey, 

by country 

 Still in need No further need 

Don’t 

know/ 

Missing Total 

Number 

of 

 episodes

Became 

pregnant 

while 

using 

Side 

effects/ 

health 

concerns 

Wanted 

more 

effective 

method 

Inconve

nient to 

use 

Access/ 

cost 

Oppositi

on/ other

Wanted 

to 

become 

pregnant 

No/ 

infrequent 

sex/ 

husband 

away 

Marital 

dissolution/ 

separation 

Difficult 

to get 

pregnant/ 

menopa

use 

West Africa 

Burkina Faso 2010 1.0 24.2 2.8 0.8 5.3 3.2 53.8 2.7 0.1 0.4 5.5 100.0 725 

Liberia 2013 6.0 54.4 2.9 0.9 6.2 4.1 19.6 1.3 0.0 0.4 4.1 100.0 382 

Niger 2012 0.5 11.6 5.0 0.5 6.7 11.6 42.6 8.0 0.3 0.2 13.0 100.0 403 

Nigeria 2013 10.3 26.7 1.9 1.2 0.8 3.7 45.4 2.5 0.2 0.1 7.3 100.0 673 

Senegal 2014 1.7 34.5 2.4 0.9 1.1 19.0 33.2 6.6 0.4 0.0 0.0 100.0 506 

Sierra Leone 2013 4.3 45.2 4.1 1.1 3.2 5.4 32.0 1.7 0.6 0.3 2.1 100.0 516 

East and Southern Africa 

Burundi 2010 4.5 34.2 2.8 4.0 4.1 10.0 35.8 2.1 1.0 1.2 0.3 100.0 637 

Comoros 2012 7.0 37.2 2.5 0.8 2.6 1.9 37.5 1.2 1.6 0.0 7.6 100.0 157 

Rwanda 2010 5.4 45.1 9.2 1.7 1.0 6.8 22.8 2.8 0.1 0.3 4.8 100.0 1,320 

Uganda 2011 7.6 47.3 1.6 1.9 3.1 7.7 28.1 1.7 0.6 0.2 0.2 100.0 1,143 

Zambia 2013-14 6.6 31.4 2.9 0.8 3.9 5.7 41.2 1.2 0.3 0.3 5.6 100.0 1,778 

Zimbabwe 2010-11 6.1 33.7 5.3 3.2 7.6 2.5 36.5 2.8 0.3 0.5 1.6 100.0 582 

North Africa and West Asia 

Egypt 2014 3.9 52.5 1.0 1.0 0.2 1.6 28.3 9.9 0.3 1.4 0.0 100.0 2,236 

Yemen 2013 4.9 48.9 2.7 4.3 3.0 6.0 15.7 8.6 0.0 0.1 5.8 100.0 1,122 

Central Asia 

Kyrgyz Republic 2012 14.5 28.6 7.4 1.6 1.8 0.0 22.2 21.1 0.0 0.9 1.9 100.0 42 

Tajikistan 2012 3.1 26.3 4.1 20.6 2.9 1.4 13.2 14.6 0.0 0.4 13.5 100.0 112 

South and Southeast Asia 

Bangladesh 2011 5.4 52.8 2.2 1.8 4.7 1.5 18.5 4.6 0.2 5.6 2.8 100.0 2,010 

Cambodia 2010 6.6 36.5 2.8 9.1 4.2 2.8 26.2 2.8 0.0 3.5 5.5 100.0 869 

Indonesia 2012 3.5 32.8 3.7 2.5 2.2 12.9 32.1 5.4 1.0 1.2 2.8 100.0 10,264 

Nepal 2011 1.5 47.3 4.0 0.2 0.9 3.3 10.4 31.4 0.1 0.6 0.1 100.0 1,568 

Pakistan 2012-13 4.1 53.7 2.6 1.0 4.3 5.9 18.7 3.1 0.0 0.9 5.6 100.0 801 

TOTAL 4.3 39.6 3.1 2.1 2.7 8.8 28.5 5.8 0.6 1.6 2.9 100.0 27,844 

Notes: See Table 4.1. 
35 

Table 4.4 shows the distribution of reasons for discontinuing non-LARC modern family planning 

methods. Across all countries in the pooled sample, 53 percent of these discontinuations are among 

women still in need of a method. Among reasons that indicate the woman is still in need, side 

effects/health concerns was the most common reason given (20 percent). Looking across the countries, 

side effects/health concerns ranged from under 5 percent in Niger, Nigeria, and Tajikistan, to over 30 

percent in Liberia and Rwanda. Compared with the three LARC methods, a higher percentage of nonLARC discontinuation episodes were due to the respondent becoming pregnant while using (15 percent). 

This percentage was particularly high in Kyrgyz Republic, where becoming pregnant while using was 

given as a reason for nearly one third of these discontinuations (32 percent). Wanting a more effective 

method was given as a reason for 6 percent of non-LARC discontinuations in the pooled sample; this 

ranges from 2 percent in Liberia to 15 percent in Rwanda. Access or cost was given as a reason for just 1 

percent of discontinuations in the pooled sample; the share is under 5 percent in all countries. Opposition 

or other reasons were given for 7 percent of non-LARC modern FP discontinuations, and this percentage 

ranges from 2 percent in both Bangladesh and Egypt to 16 percent in Burundi. 

Table 4.4. Reasons for discontinuing non-LARC modern methods 

Distribution of the main reason for discontinuation, non-LARC modern method episodes (excluding female sterilization) among married women age 15-49 

discontinued in the 3 to 62 months preceding the survey, by country 

 Still in need No further need 

Don’t 

know/ 

Missing Total 

Number 

of 

 episodes

Became 

pregnant 

while 

using 

Side 

effects/ 

health 

concerns 

Wanted 

more 

effective 

method 

Inconve

nient to 

use 

Access/ 

cost 

Oppositi

on/ other

Wanted 

to 

become 

pregnant 

No/ 

infrequent 

sex/ 

husband 

away 

Marital 

dissolution/ 

separation 

Difficult 

to get 

pregnant/ 

menopa

use 

West Africa 

Burkina Faso 2010 6.0 14.3 5.0 2.4 2.1 3.7 51.0 7.8 1.8 0.5 5.4 100.0 610 

Liberia 2013 16.0 31.1 2.2 9.8 3.8 10.7 19.5 0.6 0.0 0.0 6.3 100.0 251 

Niger 2012 1.7 3.2 5.8 0.2 1.7 20.1 45.7 9.6 0.2 0.5 11.2 100.0 2,104 

Nigeria 2013 11.1 4.0 9.6 2.9 1.0 4.1 40.6 2.7 0.2 0.2 23.6 100.0 1,694 

Senegal 2014 7.5 26.9 5.4 0.5 1.1 15.6 30.3 11.7 1.0 0.0 0.1 100.0 506 

Sierra Leone 2013 9.8 21.2 13.8 1.9 4.4 11.9 27.5 3.0 0.0 0.1 6.6 100.0 481 

East and Southern Africa 

Burundi 2010 11.2 17.7 6.1 13.9 3.7 15.9 30.3 1.0 0.0 0.2 0.0 100.0 280 

Comoros 2012 11.3 8.1 2.9 0.7 3.2 2.6 42.2 2.9 0.0 0.0 26.2 100.0 120 

Rwanda 2010 15.6 30.6 15.3 8.4 0.7 7.2 15.5 1.3 0.4 0.3 4.7 100.0 769 

Uganda 2011 17.7 27.4 2.6 9.0 3.4 11.2 24.1 3.8 0.5 0.1 0.3 100.0 450 

Zambia 2013-14 12.6 16.4 10.9 3.1 3.2 5.2 35.5 1.1 0.4 0.2 11.4 100.0 2,684 

Zimbabwe 2010-11 13.8 12.6 5.5 3.3 2.7 4.5 49.1 4.6 0.5 0.4 3.0 100.0 2,564 

North Africa and West Asia 

Egypt 2014 18.8 22.2 4.8 1.2 0.5 1.4 37.0 13.4 0.1 0.7 0.0 100.0 5,217 

Yemen 2013 18.1 21.6 12.5 2.6 3.3 5.2 20.9 9.9 0.1 0.1 5.8 100.0 6,635 

Central Asia 

Kyrgyz Republic 2012 32.0 6.4 9.9 4.6 1.4 8.8 32.5 4.0 0.0 0.1 0.3 100.0 613 

Tajikistan 2012 13.3 4.8 5.8 6.4 4.1 8.7 21.5 6.3 0.0 1.4 27.6 100.0 400 

South and Southeast Asia 

Bangladesh 2011 16.7 25.6 4.5 4.1 1.1 1.8 30.2 11.3 0.1 2.1 2.5 100.0 7,496 

Cambodia 2010 8.9 25.3 5.3 10.4 1.2 3.6 38.3 1.7 0.2 0.2 5.0 100.0 1,647 

Indonesia 2012 11.7 22.8 7.8 3.5 0.7 13.4 29.9 4.0 0.6 1.3 4.2 100.0 5,495 

Nepal 2011 8.2 14.9 6.4 3.1 0.5 3.5 15.1 47.6 0.2 0.3 0.3 100.0 1,803 

Pakistan 2012-13 18.5 12.8 6.2 2.9 2.2 11.7 36.6 3.5 0.0 1.6 3.9 100.0 2,495 

TOTAL 15.3 20.3 6.3 3.4 1.4 6.6 32.4 8.6 0.2 1.3 4.3 100.0 44,313 

Notes: See Table 4.1. 

Among reasons that indicate that the woman is no longer in need, wanting to become pregnant is the most 

common reason for discontinuing (32 percent) in the pooled sample; this ranges from 15 percent in Nepal 

to over 50 percent in Burkina Faso. This is followed by no or infrequent sex or the husband being away (8 

percent), which ranges from under 2 percent in five countries to 48 percent in Nepal. Marital dissolution 

and menopause/difficult getting pregnant are infrequent reasons (under 2 percent) in all countries. For 
36 

over 20 percent of non-LARC modern FP discontinuations in Nigeria, Comoros, and Tajikistan, 

information on the reason is either missing or the respondent did not know the reason. 

Table 4.5 shows the distribution of reasons for discontinuing traditional or folkloric family planning 

methods. Exactly half of these discontinuations were to women still in need of a method. Most common 

among these reasons is becoming pregnant while using (28 percent in the pooled sample). While in Niger 

this percentage is just 3 percent, in Burundi, Rwanda, Uganda, and Cambodia, at least 40 percent of 

traditional/folkloric discontinuations were due to becoming pregnant. For another 11 percent of 

discontinuations in the pooled sample, wanting a more effective method was given as the reason; for 6 

percent, opposition or other reasons were given. Access or cost was provided for less than 1 percent of 

discontinuations in all countries, and only in Rwanda and Egypt (6 percent and 19 percent, respectively) 

was inconvenience cited as a reason for more than 5 percent of discontinuation episodes. 

Table 4.5. Reasons for discontinuing traditional and folkloric methods 

Distribution of the main reason for discontinuation, traditional and folkloric episodes among married women age 15-49 discontinued in the 3 to 62 months preceding 

the survey, by country 

 Still in need No further need 

Don’t 

know/ 

Missing Total 

Number 

of 

 episodes

Became 

pregnant 

while 

using 

Side 

effects/ 

health 

concerns 

Wanted 

more 

effective 

method 

Inconve

nient to 

use 

Access/ 

cost 

Oppositi

on/ other

Wanted 

to 

become 

pregnant 

No/ 

infrequent 

sex/ 

husband 

away 

Marital 

dissolution/ 

separation 

Difficult 

to get 

pregnant/ 

menopa

use 

West Africa 

Burkina Faso 2010 30.8 0.5 7.4 1.0 0.0 1.3 44.3 3.8 0.0 2.8 8.1 100.0 137 

Liberia 2013 * * * * * * * * * * * 29 

Niger 2012 2.6 0.0 3.5 0.4 1.0 18.2 48.1 3.3 0.0 0.9 22.1 100.0 237 

Nigeria 2013 24.2 0.2 4.5 0.2 0.0 1.8 53.2 2.2 0.1 0.6 13.1 100.0 1,242 

Senegal 2014 16.1 8.6 10.7 0.0 0.0 20.8 39.2 4.7 0.0 0.0 0.0 100.0 76 

Sierra Leone 2013 31.5 10.9 2.4 4.6 0.8 10.3 30.3 0.0 2.3 0.0 7.0 100.0 56 

East and Southern Africa 

Burundi 2010 39.7 0.0 7.2 2.1 0.0 13.2 33.5 1.9 0.0 0.1 2.3 100.0 193 

Comoros 2012 21.1 0.6 5.1 0.0 1.0 1.8 43.8 2.1 1.0 0.0 23.5 100.0 86 

Rwanda 2010 41.2 0.3 13.1 5.8 0.0 3.8 27.3 1.5 0.3 0.3 6.4 100.0 358 

Uganda 2011 47.2 0.2 9.4 1.2 0.0 7.8 31.1 1.5 0.9 0.7 0.0 100.0 280 

Zambia 2013-14 32.6 0.0 19.5 1.1 0.0 4.2 31.9 0.6 0.2 0.2 9.6 100.0 774 

Zimbabwe 2010-11 33.7 0.9 18.2 0.0 1.6 9.5 26.2 3.5 0.7 0.0 5.7 100.0 103 

North Africa and West Asia 

Egypt 2014 26.9 2.9 27.5 19.2 0.1 3.0 18.8 1.4 0.0 0.3 0.0 100.0 552 

Yemen 2013 37.5 2.1 14.2 2.4 0.4 7.7 25.3 5.0 0.1 0.2 5.1 100.0 897 

Central Asia 

Kyrgyz Republic 2012 30.2 2.8 19.9 1.6 0.0 12.3 29.6 1.9 0.0 1.3 0.5 100.0 137 

Tajikistan 2012 28.4 0.0 7.0 1.4 0.0 10.0 20.8 8.9 0.0 0.0 23.6 100.0 113 

South and Southeast Asia 

Bangladesh 2011 31.4 2.1 19.6 3.4 0.0 3.5 23.6 3.4 0.2 7.0 5.9 100.0 984 

Cambodia 2010 40.8 0.9 13.1 2.8 0.0 1.4 32.4 0.7 0.6 0.0 7.2 100.0 981 

Indonesia 2012 26.9 5.4 10.0 2.6 0.2 12.5 31.5 1.5 0.1 1.0 8.3 100.0 888 

Nepal 2011 16.3 0.4 10.0 0.7 0.1 2.7 16.1 52.6 0.0 0.8 0.3 100.0 732 

Pakistan 2012-13 25.7 2.4 6.3 1.3 0.5 5.8 48.7 4.5 0.0 0.5 4.4 100.0 1,046 

TOTAL 28.1 2.1 11.1 2.6 0.2 5.6 36.9 5.1 0.1 1.8 6.4 100.0 9,900 

Notes: See Table 4.1. 

Among reasons that indicate that the woman is no longer in need of contraception, wanting to become 

pregnant is the most common for discontinuing traditional/folkloric methods (37 percent) in the pooled 

sample; this percentage ranges from 19 percent in Egypt to 49 percent in Pakistan. No or infrequent sex or 

the husband being away was given as a reason for 5 percent of discontinuations, and is most prevalent in 

Nepal (53 percent) and Tajikistan (9 percent). Marital dissolution and menopause/difficult getting 

pregnant were given for under 3 percent of discontinuations in all countries. In three countries, Niger, 
37 

Comoros, and Tajikistan, information on the reason is missing or was not known by the respondent for 

more than 20 percent of traditional/folkloric discontinuations. 

4.3 Status after discontinuation 

To gain insight into what happens after women discontinue using a method, we examined the status of 

women three months after they discontinued an episode of contraceptive use. Figure 4.8 summarizes these 

results, separately for each of the five method types, based on the pooled survey results. In the figure, 

women are either pregnant after a method failure, pregnant after discontinuing for reasons other than 

wanting to become pregnant, not using a method (at risk), using a family planning method (sterilization, 

LARC, other modern, traditional/folkloric), or pregnant after wanting to become pregnant. Women who 

are ‘at risk’ three months after discontinuing are further divided into two categories: those whom we 

consider at risk of an unwanted or too closely-spaced pregnancy, and those we consider to be at low or no 

risk. Women are at risk if they were not using family planning but discontinued while still in need– that 

is, due to a method-related reason or access/inconvenience. While these women may have had a change in 

fertility intentions and are not using three months later, they discontinued the method for reasons other 

than lack of need. Women are considered at low or no risk if they discontinued because they were subfecund or infecund, menopausal, or due to marital dissolution or the husband being away. In this category 

there is still some risk. For example, women who discontinued because their husbands are away may 

indeed be at high risk of unintended pregnancy when he returns, or women may incorrectly perceive 

themselves to be infecund. Indeed, a small proportion of those who are pregnant 3 months after 

discontinuation are women who originally discontinued because they perceived themselves to be at low 

risk of pregnancy. 

When we look specifically at women who are pregnant either after a method failure or after discontinuing 

for reasons other than wanting to become pregnant, as expected the percentage is highest for women who 

were using traditional/folk methods. Three months after discontinuing traditional/folk methods, nearly 

one third of women fall in these two categories (32 percent), compared to 12 percent for IUD 

discontinuations, less than 10 percent for implant and injectable discontinuations, and 19 percent for nonLARC modern method discontinuations. However, if we add women still at risk to this total (see all red 

categories in Figure 4.8), there is remarkable consistency across method types. The main difference 

between LARCs and other modern methods or traditional/folk methods is the percent of women who are 

pregnant after method failure. 

Comparing the five method types, women are most likely to be at risk of an unwanted or too closelyspaced pregnancy three months after discontinuing injectables. Women who discontinued traditional 

methods are least likely to still be at risk, but this is largely because they are now pregnant. Nearly 60 

percent of women using traditional/folk methods are pregnant three months after discontinuing, compared 

to less than 20 percent for both implants and injectables, and 37 percent for both IUD and non-LARC 

modern methods. 

The percentage of women who are using a family planning method three months after a discontinuation 

episode is highest for implant discontinuations, at 50 percent. Most of these women are using a LARC or 

non-LARC modern method three months later. For the other four methods, 33 percent or fewer are using 

any contraceptive method three months later. 
38 

Figure 4.8. Status 3 months after method discontinuation: Pooled results 

Notes: Pooled results are averaged across all 21 countries, using DHS weights normalized relative to national population size 

according to United Nations (2010) estimates shown in Table 2.1. At risk means not using FP and discontinued while still in need 

(method failure, method-related reasons, inconvenience, access/cost, and opposition). Low/no risk means not using FP but 

discontinued due to a desire to become pregnant, marital dissolution, husband away, or perceived sub-fecund/menopause. 

Tables 4.6-4.10 show women’s status three months after they discontinued an episode of contraceptive 

use, for each method separately by country. Discontinuation is particularly problematic if DWSIN 

resulted in method failure, pregnancy for reasons other than wanting to become pregnant, or leaves 

women vulnerable to unintended pregnancy. Table 4.6 shows this distribution for women following IUD 

discontinuations, among discontinuation episodes to married women age 15 to 49 that ended 3 to 62 

months preceding the survey, by country. Three months later, 12 percent of women are pregnant in the 

pooled sample either after a method failure (5 percent) or after discontinuing for a reason other than 

wanting to get pregnant (7 percent). Another 26 percent are pregnant after wanting to become pregnant, 

and nearly one quarter is using a method of family planning. Of the remaining 39 percent who are not 

using a family planning method, 16 percent are at risk of an unwanted or too closely-spaced pregnancy, 

while 22 percent are at no or low risk. The percentage of women at risk is highest in Pakistan, Tajikistan, 

and Zambia (31 percent, 29 percent, and 26 percent, respectively), and is lowest in Bangladesh and Egypt, 

at 11 percent in both countries. 

0 10 20 30 40 50 60 70 80 90 100

IUD

Implant

Injectable

Non-LARC Modern

Traditional/folk

Pregnant after method failure

Pregnant after discontinuing for any reason

besides wanting to become pregnant

At risk (discontinued while still in need)

Low/no risk (discontinued due to no need)

Using sterilization

Using LARC method

Using other modern method

Using traditional/ folkloric method

Pregnant after wanting to become pregnant
39 

Table 4.6. Status 3 months after discontinuing IUDs 

Status 3 months after discontinuing IUDs, episodes among married women age 15 to 49 that ended 3 to 62 months preceding the survey, by country 

 Pregnant Not using FP Using FP 

Total 

Number 

of 

 episodes

After 

method 

failure 

After 

wanting to 

become 

pregnant 

After 

discontinuing for 

any other 

reason 

At risk 

(discontinued while 

still in need)

Low/no risk 

(discontinued due to 

no need) 

Using 

sterilization 

Using 

LARC 

method 

Using 

other 

modern 

method 

Using 

traditional/ 

folkloric 

method 

West Africa 

Burkina Faso 2010 * * * * * * * * * 18 

Liberia 2013 * * * * * * * * * 2 

Niger 2012 * * * * * * * * * 13 

Nigeria 2013 4.0 34.5 4.4 17.1 26.9 0.0 3.0 4.6 5.5 100.0 124 

Senegal 2014 * * * * * * * * * 9 

Sierra Leone 2013 * * * * * * * * * 21 

East and Southern Africa 

Burundi 2010 14.0 30.5 15.1 12.8 9.8 0.0 8.3 3.2 6.3 100.0 (34) 

Comoros 2012 * * * * * * * * * 2 

Rwanda 2010 * * * * * * * * * 9 

Uganda 2011 * * * * * * * * * 16 

Zambia 2013-14 12.5 17.5 6.3 25.5 3.3 0.0 15.3 19.6 0.0 100.0 (38) 

Zimbabwe 2010-11 * * * * * * * * * 9 

North Africa and West Asia 

Egypt 2014 5.8 33.4 5.6 11.1 26.3 0.1 6.1 11.3 0.3 100.0 4,766 

Yemen 2013 4.9 15.3 12.3 18.5 17.1 0.5 7.6 18.8 5.0 100.0 781 

Central Asia 

Kyrgyz Republic 2012 4.4 23.9 6.3 21.1 28.7 0.2 3.9 8.9 2.6 100.0 628 

Tajikistan 2012 2.8 22.6 11.6 29.0 18.5 0.2 6.7 5.9 2.7 100.0 461 

South and Southeast Asia 

Bangladesh 2011 2.5 4.5 5.3 11.3 10.3 6.1 20.3 36.2 3.4 100.0 80 

Cambodia 2010 0.0 2.2 1.6 22.7 35.9 0.0 12.2 19.5 5.8 100.0 89 

Indonesia 2012 4.0 15.6 3.8 18.4 18.5 1.6 20.7 14.9 2.4 100.0 552 

Nepal 2011 0.0 5.0 4.8 14.5 24.1 7.0 17.9 22.3 4.4 100.0 53 

Pakistan 2012-13 2.5 10.0 13.2 31.4 12.8 1.0 10.7 10.3 8.1 100.0 400 

TOTAL 4.8 25.5 7.0 16.4 22.3 0.6 9.0 12.1 2.3 100.0 8,102 

Notes: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has 

been suppressed. Discontinued while still in need includes method failure, discontinued for method-related reasons, inconvenience, access/cost, and opposition. 

Low/no risk means the woman is not using family planning but stated her reason for discontinuation was a desire to become pregnant, because she was subfecund or infecund, menopause, marital dissolution, and husband away. Pooled total results are averaged across all 21 countries, using DHS weights normalized 

relative to national population size according to United Nations (2010) estimates shown in Table 2.1. 

Table 4.7 shows women’s status three months after discontinuing implants. One half of women are using 

an FP method three months after discontinuing implants in the pooled sample, primarily LARC or nonLARC modern methods. One-third of women are not using any method three months later; 16 percent are 

considered at risk of an unwanted or too closely-spaced birth, while 17 percent are considered at low or 

no risk. The percentage of women at risk ranges from 11 percent in Zimbabwe to 53 percent in Sierra 

Leone. An additional 7 percent are pregnant either after a method failure (3 percent) or discontinuing for 

reasons other than wanting to get pregnant (5 percent). The remaining 10 percent of women in the pooled 

sample are pregnant three months after an implant discontinuation because they wanted to get pregnant; 

this percentage is highest in Cambodia, at 26 percent, and lowest in Bangladesh and Yemen, at 4 percent. 
40 

Table 4.7. Status 3 months after discontinuing implants 

Status 3 months after discontinuing implants, episodes among married women age 15 to 49 that ended 3 to 62 months preceding the survey, by country 

 Pregnant Not using FP Using FP 

Total 

Number 

of 

 episodes

After 

method 

failure 

After 

wanting to 

become 

pregnant 

After 

discontinuing for 

any other 

reason 

At risk 

(discontinued while 

still in need)

Low/no risk 

(discontinued due to 

no need) 

Using 

sterilization 

Using 

LARC 

method 

Using 

other 

modern 

method 

Using 

traditional/ 

folkloric 

method 

West Africa 

Burkina Faso 2010 0.9 13.0 4.1 25.3 38.7 0.0 10.5 6.4 1.1 100.0 163 

Liberia 2013 * * * * * * * * * 10 

Niger 2012 * * * * * * * * * 8 

Nigeria 2013 * * * * * * * * * 12 

Senegal 2014 10.7 4.8 13.0 25.3 32.3 0.0 1.2 12.7 0.0 100.0 (58) 

Sierra Leone 2013 2.0 13.5 3.6 53.3 10.1 0.7 9.7 6.5 0.4 100.0 67 

East and Southern Africa 

Burundi 2010 * * * * * * * * * 4 

Comoros 2012 * * * * * * * * * 20 

Rwanda 2010 2.0 4.6 13.9 22.5 7.7 0.0 17.5 23.7 8.2 100.0 70 

Uganda 2011 3.5 20.1 11.0 24.0 20.3 0.0 14.5 6.7 0.0 100.0 47 

Zambia 2013-14 2.4 16.2 4.8 28.8 14.1 0.0 23.0 7.6 3.1 100.0 177 

Zimbabwe 2010-11 7.0 22.2 11.7 10.9 11.7 0.0 7.0 29.5 0.0 100.0 47 

North Africa and West Asia 

Egypt 2014 2.3 10.6 6.6 21.5 16.3 0.0 20.8 21.9 0.0 100.0 150 

Yemen 2013 2.2 4.1 7.3 28.8 14.6 0.0 10.2 25.5 7.3 100.0 120 

Central Asia 

Kyrgyz Republic 2012 * * * * * * * * * 0 

Tajikistan 2012 * * * * * * * * * 1 

South and Southeast Asia 

Bangladesh 2011 1.4 4.3 3.4 11.9 10.3 5.7 19.3 35.3 8.3 100.0 108 

Cambodia 2010 4.7 26.1 0.0 14.7 14.3 1.7 6.4 20.5 11.7 100.0 25 

Indonesia 2012 2.6 9.1 2.6 13.2 17.0 2.4 32.5 18.0 2.6 100.0 654 

Nepal 2011 0.0 12.1 3.3 15.7 19.6 6.1 28.5 4.0 10.7 100.0 49 

Pakistan 2012-13 * * * * * * * * * 10 

TOTAL 2.6 9.5 4.6 16.1 16.7 2.2 26.1 18.9 3.2 100.0 1,799 

Notes: See Table 4.6.

Table 4.8 is similar to Tables 4.6 and 4.7 above, but shows women’s status three months after 

discontinuing injectables. Compared with the IUD and implant, a higher percentage of women who 

discontinued injectables are at risk of an unwanted or too closely-timed pregnancy three months later (22 

percent). This percentage is especially high in Liberia (60 percent), and is moderately high (40-50 

percent) in Sierra Leone, Uganda, and Pakistan. The percentage of women who are not using any method 

but who are considered to be at low or no risk is also higher for injectables than for implants or IUDs in 

the pooled sample (27 percent). 

Similar to the distribution for implants, one-third of women are using a FP method three months later in 

the pooled sample; most often it is a non-LARC modern method (21 percent). The percentage of women 

using a FP method three months later is notably lower in West Africa and in some East and Southern 

African countries, as compared with North Africa and West Asia, Central Asia, and South and Southeast 

Asia. 
41 

Table 4.8. Status 3 months after discontinuing injectables 

Status 3 months after discontinuing injectables, episodes among married women age 15 to 49 that ended 3 to 62 months preceding the survey, by country 

 Pregnant Not using FP Using FP 

Total 

Number 

of 

 episodes

After 

method 

failure 

After 

wanting to 

become 

pregnant 

After 

discontinuing for 

any other 

reason 

At risk 

(discontinued while 

still in need)

Low/no risk 

(discontinued due to 

no need) 

Using 

sterilization 

Using 

LARC 

method 

Using 

other 

modern 

method 

Using 

traditional/ 

folkloric 

method 

West Africa 

Burkina Faso 2010 0.6 10.0 2.7 31.1 47.1 0.0 1.8 5.6 1.1 100.0 725 

Liberia 2013 5.5 5.3 7.1 60.5 16.0 0.0 0.4 4.3 0.9 100.0 382 

Niger 2012 0.5 9.5 6.3 30.9 40.1 0.0 0.3 11.7 0.7 100.0 403 

Nigeria 2013 9.9 20.4 3.8 26.9 27.8 0.1 3.0 4.5 3.6 100.0 673 

Senegal 2014 0.8 13.1 12.9 34.3 27.1 0.0 2.9 7.8 1.0 100.0 506 

Sierra Leone 2013 4.3 13.7 9.0 43.2 19.2 0.0 1.9 7.9 0.8 100.0 516 

East and Southern Africa 

Burundi 2010 4.5 8.2 6.9 34.5 31.9 0.2 6.3 6.6 0.9 100.0 637 

Comoros 2012 5.4 14.4 9.7 35.5 22.7 0.0 2.8 8.3 1.3 100.0 157 

Rwanda 2010 5.3 8.7 8.5 26.0 16.5 0.2 14.0 16.6 4.2 100.0 1,320 

Uganda 2011 7.3 9.8 12.4 40.5 20.3 0.4 2.4 5.2 1.7 100.0 1,143 

Zambia 2013-14 6.6 21.0 10.1 26.7 21.7 0.1 3.6 8.9 1.3 100.0 1,778 

Zimbabwe 2010-11 6.1 19.6 5.5 19.9 20.2 0.0 5.0 22.7 1.1 100.0 582 

North Africa and West Asia 

Egypt 2014 3.8 8.8 4.5 25.8 30.8 0.1 10.0 15.7 0.4 100.0 2,236 

Yemen 2013 4.6 7.3 11.2 35.9 16.5 0.2 4.9 16.9 2.5 100.0 1,122 

Central Asia 

Kyrgyz Republic 2012 11.5 3.5 4.3 6.8 40.8 0.0 19.0 8.5 5.5 100.0 42 

Tajikistan 2012 0.9 9.4 16.0 36.6 18.8 0.0 3.9 12.9 1.5 100.0 112 

South and Southeast Asia 

Bangladesh 2011 4.7 5.0 3.4 17.8 21.5 2.3 6.6 30.9 7.7 100.0 2,010 

Cambodia 2010 5.0 5.0 4.6 33.0 26.4 1.0 3.6 16.3 5.2 100.0 869 

Indonesia 2012 3.3 7.8 3.4 16.3 31.0 0.3 10.1 25.3 2.6 100.0 10,264 

Nepal 2011 1.3 3.1 4.1 27.7 38.1 3.2 4.6 12.4 5.6 100.0 1,568 

Pakistan 2012-13 3.9 9.0 6.7 41.9 13.6 0.5 2.4 12.9 9.2 100.0 801 

TOTAL 4.0 8.3 4.7 22.2 27.4 0.6 7.9 21.3 3.6 100.0 27,844 

Notes: See Table 4.6.

Table 4.9 shows women’s status three months after discontinuing non-LARC modern methods. In the 

pooled sample, 26 percent are using any FP method three months later (14 percent are using a LARC 

method, 7 percent a non-LARC modern method, 4 percent a traditional/folk method, and 1 percent using 

sterilization). Among the 37 percent not using a method, 13 percent are considered at risk while 24 

percent are not at risk in the pooled sample. The percentage of women at risk is particularly high in 

Liberia (41 percent) and is lowest in Bangladesh and Egypt (9 percent and 10 percent, respectively). An 

additional 19 percent in the pooled sample are pregnant after either a method failure (14 percent) or 

discontinuing for a reason other than wanting to become pregnant (6 percent). The remaining 17 percent 

of women in the pooled sample are pregnant after discontinuing because they wanted to become pregnant, 

and this ranges from 8 percent in Nepal to 33 percent in Zimbabwe. 
42 

Table 4.9. Status 3 months after discontinuing non-LARC modern methods 

Status 3 months after discontinuing non-LARC modern methods (excluding female sterilization), episodes among married women age 15 to 49 that ended 3 to 62 

months preceding the survey, by country 

 Pregnant Not using FP Using FP 

Total 

Number 

of 

 episodes

After 

method 

failure 

After 

wanting to 

become 

pregnant 

After 

discontinuing for 

any other 

reason 

At risk 

(discontinued while 

still in need)

Low/no risk 

(discontinued due to 

no need) 

Using 

sterilization 

Using 

LARC 

method 

Using 

other 

modern 

method 

Using 

traditional/ 

folkloric 

method 

West Africa 

Burkina Faso 2010 5.5 18.5 5.7 18.9 41.2 0.3 6.4 2.8 0.6 100.0 610 

Liberia 2013 14.3 11.5 17.2 40.9 8.5 0.0 7.0 0.3 0.4 100.0 251 

Niger 2012 1.7 18.0 14.5 19.9 35.5 0.0 4.8 4.5 1.0 100.0 2,104 

Nigeria 2013 10.7 24.7 5.8 22.7 17.9 0.0 4.6 6.1 7.5 100.0 1,694 

Senegal 2014 6.6 16.4 10.5 27.5 25.3 0.0 9.7 2.0 2.0 100.0 506 

Sierra Leone 2013 9.4 12.8 9.4 30.6 16.8 0.0 19.8 1.2 0.1 100.0 481 

East and Southern Africa 

Burundi 2010 11.2 13.8 10.9 22.8 17.8 0.0 19.7 1.1 2.7 100.0 280 

Comoros 2012 11.3 15.1 15.5 20.3 27.7 0.0 0.8 1.6 7.7 100.0 120 

Rwanda 2010 15.3 9.7 9.0 14.9 7.5 0.0 34.7 3.5 5.6 100.0 769 

Uganda 2011 16.6 14.7 12.2 22.2 12.6 0.5 15.9 2.1 3.2 100.0 450 

Zambia 2013-14 12.4 23.2 9.8 18.0 13.6 0.1 15.3 5.5 2.0 100.0 2,684 

Zimbabwe 2010-11 13.5 32.5 6.6 12.3 20.8 0.1 7.6 6.2 0.5 100.0 2,564 

North Africa and West Asia 

Egypt 2014 17.4 20.8 4.3 10.4 29.4 0.1 15.6 1.8 0.4 100.0 5,217 

Yemen 2013 17.3 11.8 9.4 18.2 18.0 0.3 10.4 9.2 5.3 100.0 6,635 

Central Asia 

Kyrgyz Republic 2012 16.5 17.0 4.9 12.3 19.1 0.4 8.3 17.5 3.9 100.0 613 

Tajikistan 2012 9.9 14.2 6.1 30.5 14.4 0.7 13.0 8.7 2.5 100.0 400 

South and Southeast Asia 

Bangladesh 2011 14.0 14.5 3.0 9.0 27.7 1.3 13.9 11.9 4.6 100.0 7,496 

Cambodia 2010 5.5 16.1 8.0 22.9 23.9 0.9 10.7 4.4 7.6 100.0 1,647 

Indonesia 2012 11.4 13.1 6.3 11.2 22.2 0.2 28.8 3.6 3.2 100.0 5,495 

Nepal 2011 5.5 7.9 2.6 13.0 49.7 1.6 6.8 8.3 4.6 100.0 1,803 

Pakistan 2012-13 16.1 24.0 8.4 16.9 16.3 1.2 4.8 5.8 6.5 100.0 2,495 

TOTAL 13.6 17.3 5.7 13.0 23.9 0.7 14.4 7.1 4.1 100.0 44,313 

Notes: See Table 4.6.

Lastly in this series, Table 4.10 shows women’s status three months after discontinuing traditional or 

folkloric methods. Nearly 60 percent of women in the pooled sample are pregnant three months after 

discontinuing traditional methods (57 percent), ranging from 21 percent in Nepal to 77 percent in Nigeria. 

Among these, in the pooled sample 25 percent are pregnant after a method failure, 7 percent are pregnant 

after discontinuing for reasons other than wanting to become pregnant, and 26 percent are pregnant after 

discontinuing because they wanted to become pregnant. Of the remaining 43 percent, 19 percent are using 

a family planning method, and 24 percent are not using any method three months later. Among the 24 

percent not using a method, 6 percent are considered at risk of an unwanted or closely-spaced pregnancy 

within three months, while the remaining 18 percent are considered at low or no risk. The percentage of 

women at risk is highest in Niger at 21 percent and lowest in Nigeria and Zambia, at 4 percent. 
43 

Table 4.10. Status 3 months after discontinuing traditional or folkloric methods 

Status 3 months after discontinuing traditional or folkloric episodes, episodes among married women age 15 to 49 that ended 3 to 62 months preceding the survey, 

by country 

 Pregnant Not using FP Using FP 

Total 

Number 

of 

 episodes

After 

method 

failure 

After 

wanting to 

become 

pregnant 

After 

discontinuing for 

any other 

reason 

At risk 

(discontinued while 

still in need)

Low/no risk 

(discontinued due to 

no need) 

Using 

sterilization 

Using 

LARC 

method 

Using 

other 

modern 

method 

Using 

traditional/ 

folkloric 

method 

West Africa 

Burkina Faso 2010 26.8 29.4 4.1 9.6 20.7 0.0 7.1 1.8 0.5 100.0 137 

Liberia 2013 * * * * * * * * * 29 

Niger 2012 2.6 25.7 21.2 20.5 25.3 0.0 0.6 4.1 0.0 100.0 237 

Nigeria 2013 23.4 42.5 10.8 3.7 13.4 0.0 2.5 1.7 2.0 100.0 1,242 

Senegal 2014 15.3 26.5 13.8 9.2 17.3 0.0 8.6 8.7 0.6 100.0 76 

Sierra Leone 2013 31.5 13.6 13.6 14.2 16.6 0.0 8.6 1.9 0.0 100.0 56 

East and Southern Africa 

Burundi 2010 38.2 25.3 9.3 8.7 9.9 0.3 5.6 2.0 0.8 100.0 193 

Comoros 2012 18.4 29.3 17.9 9.4 15.5 0.0 2.5 4.7 2.4 100.0 86 

Rwanda 2010 39.8 23.6 6.3 5.1 5.8 0.0 12.5 4.7 2.2 100.0 358 

Uganda 2011 44.7 27.6 3.8 6.1 5.8 0.5 6.2 3.8 1.5 100.0 280 

Zambia 2013-14 32.2 24.5 7.5 4.2 8.2 0.1 13.5 9.1 0.6 100.0 774 

Zimbabwe 2010-11 31.7 21.3 2.1 13.4 7.3 0.0 5.8 17.5 1.0 100.0 103 

North Africa and West Asia 

Egypt 2014 25.4 10.9 7.0 10.8 9.5 0.0 22.8 13.0 0.6 100.0 552 

Yemen 2013 35.1 18.7 6.4 6.4 11.3 0.3 6.5 9.4 5.9 100.0 897 

Central Asia 

Kyrgyz Republic 2012 18.6 19.3 1.9 9.1 13.3 0.0 13.0 18.1 6.7 100.0 137 

Tajikistan 2012 23.6 17.7 8.2 14.2 11.4 0.0 8.8 9.7 6.3 100.0 113 

South and Southeast Asia 

Bangladesh 2011 26.7 15.3 2.5 6.9 18.5 2.3 10.5 12.8 4.6 100.0 984 

Cambodia 2010 25.4 19.7 3.6 10.8 13.9 0.5 6.6 10.4 9.3 100.0 981 

Indonesia 2012 24.3 22.6 13.7 4.9 11.0 0.0 12.0 6.5 5.0 100.0 888 

Nepal 2011 9.4 10.6 1.2 4.6 55.9 1.8 5.6 5.0 5.9 100.0 732 

Pakistan 2012-13 21.2 31.5 5.4 6.2 21.7 1.4 3.6 5.5 3.6 100.0 1,046 

TOTAL 24.5 25.8 6.8 6.2 17.6 0.9 7.5 7.1 3.7 100.0 9,900 

Notes: See Table 4.6.

45 

5. Policy and Programmatic Linkages 

Women and couples select, start, and stop contraceptive methods within particular local and national 

supply and care environments. Cultural and societal norms influence overall method mix. Skews in mix 

may not be problematic if a broad spectrum of options is available (Bertrand et al. 2014). Women’s 

preferences certainly differ from country to country. On the other hand, when 67 times as many women 

use a method like IUD in one country (Tajikistan) versus another (Bangladesh), the disparity probably 

reflects underlying variations in access, availability, and programs available to women. Differences in 

method use are partly a product of disparities in access to health care, method choice, and provider 

training (Sullivan et al. 2006), as well as individual preferences and culture. Side effects, for example, are 

known clinically but their incidence, significance, and tolerability may be related to the quality of 

provision and counseling, and informed choice. Some studies have shown that higher-quality counseling 

and provision reduces discontinuation rates (Ali, Marshall, and Babiker 2001; Creanga et al. 2007). 

In this section, we quantify the dimension of experience related to supply, programs, and policies to 

understand what influences discontinuation. Is popularity of a method, access to that method, or quality of 

FP programs overall significantly related to discontinuation? As a proxy for unobserved variation in the 

programmatic environment between countries, we use Family Planning Effort (FPE) scores, which are 

available individually for the three LARC methods by country, along with overall quality scores. As 

described in Chapter 2, these scores range from 0 to 100, and are based on average assessments by local 

experts of the degree to which the entire population has ready and safe access to a particular method or of 

the overall quality of FP services. 

The FPE access scores are meant to indicate the “ready and easy access” to a particular method in a given 

country. In areas where access is greater, providers may be better-educated about guidelines for use and 

better able to advise about possible side effects. However, access is not the same as demand. Availability 

and use may not be correlated. Part of method choice is giving women the right not to opt for a particular 

method. The percent of users, rather than access, may also be a good proxy for actual support of a method 

or for provider bias. Women who are using a popular method may be more supported in their choice, 

while women using a minority method may feel more isolated and have more difficulty with the method. 

For this reason, we test the effects of FPE access scores, share of method mix, and overall programmatic 

quality in our models of discontinuation. Women and couples who have the opportunity to make wellinformed method choices, and who receive better counseling on their method may be more aware of 

potential side effects and how to cope with them. Higher-quality provision of services and safe clinical 

procedures for methods that require provider insertion, like IUDs and implants, may also reduce the 

failure rate. 

Table 5.1 lists FPE scores for access to injectables and IUDs from 2009, and implant FPE scores from 

2014, which was the first year they became available. Although a few of the DHS surveys analyzed in this 

report were fielded in 2014, 2009 scores are preferable because they overlap with retrospective five-year 

time period from every survey used. Quality scores are listed for 2009. Comoros is not rated for scores in 

any year; Rwandan scores from 2009 were missing; and implant scores from 2014 were not produced for 

Sierra Leone, Burkina Faso, or Cambodia. 

Of the remaining countries, the average access score is 45 for IUDs, 51 for implants, and 57 for 

injectables. The IUD scores are lowest in Western and Eastern Africa as a whole, with ranges from 16 to 

44 in those countries, and highest in Egypt and Central Asia (Kyrgyz Republic and Tajikistan). Implant 

scores show tremendous regional diversity, with the highest scoring four focal countries spanning all four 
46 

regions studied (Rwanda, Senegal, Tajikistan, and Bangladesh). Injectable scores are above 40 in all 

countries and as high as 80 in Indonesia. The FP program quality score for focal countries ranges from 25 

in Yemen to 72 in Zimbabwe; its average is 50. 

Table 5.1. Selected Family Planning Effort (FPE) scores, focal countries 

IUD Access 

Score, 2009

Implant 

Access 

Score, 2014 

Injectable 

Access Score, 

2009 

Overall 

Quality of FP 

Programs 

Score, 2009 

West Africa 

Burkina Faso 2010 44.4 na 62.2 37.8 

Liberia 2013 16.2 43.3 43.4 33.3 

Niger 2012 41.4 58.7 58.6 60.6 

Nigeria 2013 27.8 30.6 34.3 38.9 

Senegal 2014 43.7 69.8 65.2 60.7 

Sierra Leone 2013 25.3 na 46.5 44.4 

East and Southern Africa 

Burundi 2010 35.9 57.3 54.8 42.7 

Rwanda 2010 na 77.8 na na 

Uganda 2011 30.2 49.6 57.9 45.2 

Zambia 2013-14 22.2 38.9 44.4 43.3 

Zimbabwe 2010-11 39.5 50.5 76.7 72.2 

North Africa and West Asia 

Egypt 2014 85.9 46.2 77.8 60.0 

Yemen 2013 45.2 33.3 44.4 25.4 

Central Asia 

Kyrgyz Republic 2012 71.3 44.4 45.4 46.3 

Tajikistan 2012 83.7 72.2 62.2 70.6 

South and Southeast Asia 

Bangladesh 2011 52.3 61.1 62.1 54.9 

Cambodia 2010 50.0 na 60.0 51.9 

Indonesia 2012 52.5 52.5 80.0 62.6 

Nepal 2011 45.3 42.6 69.2 55.6 

Pakistan 2012-13 37.0 31.6 40.7 42.2 

AVERAGE, FOCAL COUNTRIES 44.7 50.6 57.1 49.9 

Notes: na indicates score was not measured. Implant access not measured in 2009; 2014 scores were 

used instead. 

For information about 2009 scores, see Ross and Smith (2010); for information about 2014 implant access 

scores, see Kuang and Weinberger (2015). 

Figures 5.1-5.3 are scatter plots representing the relationship between the use of each LARC method and 

the method’s respective FPE access score, with a regression line of best fit for each method. Figure 5.1 

shows that the use of IUDs (at the time of survey) is positively correlated with IUD access (based on 2009 

access scores). Three main outliers with very high access and use are Egypt, Kyrgyz Republic, and 

Tajikistan. The implant FPE access score, measured in 2014, is very weakly correlated with use (Figure 

5.2). Injectables as a share of method mix is also weakly related to access in 2009 (Figure 5.3). As Ross 

and Hardee (2013) found, the relationship between access and method use appears to vary by method 

type. In our country sample, the use of IUDs tends to be strongly correlated with access while the use of 

implants and injectables is not. 
47 

Figure 5.1. IUD share of method mix versus FPE IUD Access Score (2009), focal countries 

Figure 5.2. Implant share of method mix versus FPE implant Access Score (2014), focal countries 

 

0 20 40 60

IUD use among contraceptive users

0 20 40 60 80 100

FPE IUD Access Score- 2009

0 20 40 60

Implant use among contraceptive users

0 20 40 60 80 100

FPE Implant Access Score- 2014
48 

Figure 5.3. Injectable share of method mix versus FPE Injectable Access Score (2009), focal 

countries 

To quantify the effects of women’s individual characteristics while accounting for within-country 

clustering in unobserved effects as well as country programmatic environments, we model the hazard of 

discontinuing a given LARC method while still in need using pooled multilevel Weibull survival 

regression models. Duration of use in months is input into the model. Failure is defined as DWSIN 

(experiencing method failure, discontinuing for side effects, method-related reasons, cost/access, or other 

reasons unrelated to lack of need); ongoing use at time of survey and discontinuation for any other 

reasons is considered right censoring. It is important to note that survival models do not necessarily imply 

that the risk of the ultimate event (DWSIN) itself is higher or lower. Instead they measure the rate of 

progress: when the hazard is lower, users progress more slowly towards DWSIN. In other words, they 

sustain use while still in need for a longer period of time. The key individual factors considered in the 

multilevel model are women’s age and parity at the time the method was started, current education and 

residence, and how women arrived at method use (from birth/PPA/LAM, switching from another method, 

or starting from non-use). At the country level we consider the FPE access score of the LARC method the 

woman is using, the share of that method in the method mix, and the overall quality score of FP 

programs. 

Table 5.2 shows the results for pooled multilevel hazard models of IUD discontinuation. Unadjusted 

coefficients with country-level random effects show that higher age, greater parity, urban residence, and 

more education significantly reduce the hazard of DWSIN. Additionally, if the episode of IUD use is 

immediately preceded by use of another method or by birth/LAM/PPA, the hazard of DWSIN is greatly 

reduced. IUD access scores, the share of method mix, and overall quality of family planning programs are 

each inversely related to the hazard of DWSIN. 

The second IUD model in Table 5.2, an adjusted model of individual characteristics, finds that these 

individual characteristics each remain statistically significant even when considered jointly. Model 3, 

which incorporates IUD access scores, finds a significant effect of IUD access on the hazard of DWSIN 

even after controlling for other factors. Each additional point of score reduces the hazard of DWSIN by 3 

0 20 40 60

Injecatables use among contraceptive users

0 20 40 60 80 100

FPE Injectables Access Score- 2009
49 

percent. The country’s IUD share of method mix is not statistically significant in the adjusted model 

(Model 4). The overall quality of FP programs (Model 5) is, however, significant. Women who live in 

countries with higher-quality FP programs have longer sustained use of IUDs while still in need. 

The combined model of access and share of method mix (Model 6) finds that access and share of method 

mix are inversely related, and the two nearly cancel each other out. This is likely the result of high 

collinearity between access scores and use of IUDs. The final combined model of access and quality 

(Model 7) finds that the quality of FP programs is more important than access to IUDs. Even after 

controlling for individual characteristics and for overall access to IUDs, for every point of increase in the 

quality score, the hazard of discontinuing an IUD while still in need is reduced by 4 percent. 

Table 5.2. Pooled multilevel hazard model of discontinuing IUDs while still in need 

Among married women age 15 to 49 who began using an IUD 3 to 62 months preceding the survey, using weights normalized to relative 

population size and country-level random effects (RE) 

Model 1: 

Unadjusted 

Coefficients 

Model 2: 

Individual 

factors 

Model 3: 

Access 

Model 4: 

Use 

Model 5: 

Quality 

Model 6: 

Access and 

Use 

Model 7: 

Access and 

Quality 

Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio 

Age at start of use 

<24 (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

25-34 0.12*** 0.53*** 0.61*** 0.63*** 0.74*** 0.70*** 0.72*** 

35-49 0.10*** 0.36*** 0.41*** 0.37*** 0.54*** 0.44*** 0.51*** 

Parity at start of use 

0-1 (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

2-3 0.10*** 0.28*** 0.41*** 0.71** 0.45*** 0.64*** 0.46*** 

4+ 0.14*** 0.26*** 0.35*** 0.97 0.39*** 0.71*** 0.39*** 

Residence 

Rural (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

Urban 0.14*** 0.78*** 0.72** 0.93 0.78 0.92 0.77 

Education 

None (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

Primary 0.16*** 0.42** 0.70 1.03 0.76 1.10 0.80 

Secondary+ 0.09*** 0.21*** 0.55** 0.71* 0.71* 0.85* 0.75*** 

Event immediately 

preceding use 

From non-use (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

from use 0.16*** 0.66*** 0.88** 1.14 1.11 1.27 1.08 

from birth, PPA, 

LAM 0.11*** 0.30*** 0.70*** 0.76*** 0.76*** 0.81*** 0.81*** 

Country’s IUD 

Access Score, 

2009 0.95*** 0.97*** 0.95** 0.99 

Country’s IUD share 

of method mix 

among married 

women 15-49 0.94*** 0.99 1.04* 

Country's overall FP 

quality score, 2009 0.93*** 0.95*** 0.96* 

Observations 10,946 10,946 10,946 10,946 10,946 10,946 10,946 

Countries1 19 19 19 19 19 19 19 

* p<0.05, ** p<0.01, *** p<0.001 

Notes: Share of method mix and FPE scores are continuous variables from 0 to 100. Discontinuation while still in need means the woman 

became pregnant due to method failure, or discontinued due to side effects, method-related reasons, cost/access, opposition, or other. 

1

 Models exclude Comoros and Rwanda which lacked 2009 FPE scores. 
50 

Pooled multilevel hazard models of implant discontinuation are shown in Table 5.3. As with IUDs, the 

unadjusted coefficients are each statistically significant: higher age, higher parity, urban residence, more 

education, and starting a method from use or from birth/PPA/LAM each reduce the hazard of DWSWIN. 

Additionally, living in a country with better access to implants, with a higher share of implants in the 

method mix, or with higher-quality FP programs overall reduces the hazard of DWSIN. In the adjusted 

model of individual factors (Model 2), individual characteristics remain statistically significant. 

Interestingly, urban residence changes from a negative to a positive effect on the hazard. In other words, 

after adjusting for other individual characteristics, urban residents have a 10 percent higher hazard of 

discontinuing implants while still in need than rural residents. However, in models that include country 

characteristics (Models 3 to 7), none of the individual factors, including residence, are statistically 

significant. 

Country-level access to implants (Model 3) and overall quality of FP programs (Model 5) each reduce the 

hazard of DWSIN even after controlling for other characteristics; living in a country where implants are 

more common (Model 4) does not. A joint model of access to and use of implants (Model 6) finds that 

when both are considered, neither is significant. However the adjusted model of access and quality finds 

that both are important: better access to implants and higher-quality FP programs significantly reduce the 

hazard of discontinuing implants while still in need. 
51 

Table 5.3. Pooled multilevel hazard model of discontinuing implants while still in need 

Among married women age 15 to 49 who began using implants 3 to 62 months preceding the survey, incorporating weights normalized to 

relative population size and country-level random effects (RE) 

Model 1: 

Unadjusted 

Coefficients 

Model 2: 

Individual 

factors 

Model 3: 

Access 

Model 4: 

Use 

Model 5: 

Quality 

Model 6: 

Access and 

Use 

Model 7: 

Access and 

Quality 

Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio 

Age at start of use 

<24 (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

25-34 0.12*** 0.62*** 0.60 0.69 0.69 0.84 0.68 

35-49 0.11*** 0.56* 0.59 0.72 0.72 0.97 0.71 

Parity at start of use 

0-1 (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

2-3 0.11*** 0.25*** 1.00 0.96 0.96 0.77 0.96 

4+ 0.12*** 0.21*** 1.11 1.03 1.03 0.75 1.03 

Residence 

Rural (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

Urban 0.18*** 1.10* 0.99 1.01 1.01 1.06 1.01 

Education 

None (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

Primary 0.07*** 0.14*** 0.64 0.86 0.86 0.97 0.85 

Secondary+ 0.09*** 0.14*** 0.89 1.21 1.21 1.37 1.20 

Event immediately 

preceding use 

From non-use (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

from use 0.11*** 0.37*** 0.94 1.00 1.00 0.95 0.99 

from birth, PPA, 

LAM 0.17*** 0.54*** 1.10 1.19 1.19 1.22 1.18 

Country's implant 

access score, 2014 0.89*** 0.90*** 0.99 0.94*** 

Country's implant 

share of method 

mix among married 

women 

15-49 0.53*** 1.03 1.01 

Country's overall FP 

quality score, 2009 0.90*** 0.90*** 0.95*** 

Observations 3,257 3,257 3,257 3,257 3,257 3,257 3,257 

Countries1 15 15 15 15 15 15 15 

* p<0.05, ** p<0.01, *** p<0.001 

Notes: Share of method mix and FPE scores are continuous variables from 0 to 100. Discontinuation while still in need means the woman 

became pregnant due to method failure, or discontinued due to side effects, method-related reasons, cost/access, opposition, or other. 

1

 Models exclude Comoros, Burkina Faso, Sierra Leone, and Cambodia, which lacked 2014 FPE implant access scores; Kyrgyz Republic, which 

lacked implant users; and Rwanda, which lacked 2009 FPE scores. 

Table 5.4 presents the results of multilevel hazard models of discontinuing injectables while still in need. 

Unadjusted coefficients are again statistically significant, except for urban residence and switching to 

injectables from another method (Model 1). When individual characteristics are modeled together (Model 

2), parity, education, and starting a method after birth/PPA/LAM remain significant predictors of the 

hazard of DWSIN. Adjusted models of access to injectables (model 3), country-level use of injectables 

(Model 4), and overall quality of FP programs (Model 5) find that each of these factors significantly 

reduces the hazard of DWSIN. Even after controlling for individual characteristics, each percentage point 

of increased injectable share in the method mix reduced the hazard of DWSIN by 3 percent. However, 

access and use considered jointly (Model 6) are not significant. 
52 

Table 5.4 also shows that when access to injectables and overall quality of FP programs are considered 

jointly (Model 7), we find that women who live in countries with higher-quality FP programs have slower 

time-to-discontinuation while still in need. This effect was statistically significant after controlling for 

women’s characteristics, country effects, and access to injectables. Additionally, in this model, women 

who start a method after birth/PPA/LAM have a 21 percent lower hazard of DWSIN. Interestingly, the 

adjusted models find that women who have switched to injectables after discontinuing another method 

have a higher hazard of DWSIN. 

Table 5.4. Pooled multilevel hazard model of discontinuing injectables while still in need 

Among married women age 15 to 49 who began using injectables 3 to 62 months preceding the survey, incorporating weights normalized to 

relative population size and country-level random effects (RE) 

Model 1: 

Unadjusted 

Coefficients 

Model 2: 

Individual 

factors 

Model 3: 

Access 

Model 4: 

Use 

Model 5: 

Quality 

Model 6: 

Access and 

Use 

Model 7: 

Access and 

Quality 

Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio Hazard ratio 

Age at start of use 

<24 (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

25-34 0.18*** 0.70*** 1.03 0.91 0.98 1.03 1.02 

35-49 0.20*** 0.72 1.12 1.04 0.95 1.10 1.09 

Parity at start of use 

0-1 (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

2-3 0.17*** 0.40*** 0.60*** 0.38*** 0.96 0.71** 0.71* 

4+ 0.20*** 0.28*** 0.37*** 0.24*** 0.94 0.49*** 0.50*** 

Residence 

Rural (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

Urban 0.95 0.87 0.92 0.97 1.04 0.96 0.96 

Education 

None (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

Primary 0.12*** 0.19*** 0.59** 0.42*** 0.80 0.70** 0.70** 

Secondary+ 0.13*** 0.19*** 0.65 0.41*** 0.95 0.82 0.82 

Event immediately 

preceding use 

From non-use (ref) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 

from use 1.62 0.94 1.58 0.92 1.68 1.73* 1.74* 

from birth, PPA, 

LAM 0.72*** 0.43*** 0.79*** 0.56*** 0.76*** 0.80*** 0.79*** 

Country's 

injectables access 

score, 2009 0.95*** 0.96*** 0.99 1.00 

Country's 

injectables share 

of method mix 

among married 

women 15-49 0.94*** 0.97*** 0.99 

Country's overall FP 

quality score, 2009 0.94*** 0.94*** 0.94* 

Observations 34,141 34,141 34,141 34,141 34,141 34,141 34,141 

Countries1 19 19 19 19 19 19 19 

* p<0.05, ** p<0.01, *** p<0.001 

Notes: Share of method mix and FPE scores are continuous variables from 0 to 100. Discontinuation while still in need means the woman 

became pregnant due to method failure, or discontinued due to side effects, method-related reasons, cost/access, opposition, or other. 

1

 Models exclude Comoros and Rwanda which lacked 2009 FPE scores. 
53 

Overall, the results from multilevel survival models indicate that women are significantly more likely to 

continue a LARC method while still in need if its adoption is immediately preceded by a birth, LAM, or 

PPA. When access and share of method mix are considered jointly, they are not significant and in the 

same direction for any of the three LARC methods. The quality of FP programs is inversely related to 

DWSIN. Access and quality are key for method continuation, but quality seems to be the more important 

of the two. 

55 

6. Discussion and Conclusions 

The proportion of women using LARC methods—IUD, implants, and injectables—has increased 

worldwide over the last few decades (Bertrand et al. 2014; Darroch 2013). However, the use of the 

individual long-acting reversible contraceptive methods varies substantially across and within regions. 

Among married women in low-income countries, IUDs are more predominant in Asia than sub-Saharan 

Africa (Ali et al. 2011; Bertrand et al. 2014; Mansour et al. 2011; Seiber, Bertrand, and Sullivan 2007). 

This was true of our 21 country sample as well. The highest proportions of use of both implants and 

injectables are found in sub-Saharan Africa, where they also constitute a growing share of the method mix 

(Bertrand et al. 2014; Mansour et al. 2011; Seiber, Bertrand, and Sullivan 2007). 

We examined the contraceptive dynamics of LARC methods among married women in 21 low-income 

countries by using DHS calendar episodes to examine adoption, discontinuation, and status after 

discontinuation. Additionally, we modeled the hazard of discontinuation based on women’s individual 

characteristics, country effects, and access scores. 

There are important limitations to our analysis. First, the quality of calendar data is not well-studied. 

Although some studies have found relative consistency of the data (Bradley, Schwandt, and Khan 2009; 

Curtis and Blanc 1997), a more recent study found substantial underreporting in the calendar, particularly 

among short-term and traditional methods (Bradley, Winfrey, and Croft 2015). Second, the sample sizes 

for some methods in countries were limited, particularly for implants and IUDs. Third, although the 

decision may have involved several factors, women were required to select one main reason for 

discontinuation. Little detail is given for lack of need or side effects and health concerns. Fourth, the type 

of IUD (hormonal or non-hormonal) or the duration of injectable was generally not available. Fifth, 

implant accessibility scores were only available for 2014; in most cases, this was after the survey was 

fielded. Finally, quality and accessibility scores are not available at subregional levels; national numbers 

may not reflect the local environment or individual experience. Despite these limitations, the results 

enable us to draw some conclusions from the study. 

In terms of method adoption, IUDs are the method most commonly preceded by a birth, LAM, or PPA. 

This is particularly the case in Egypt, Indonesia, and Zambia, and may reflect the success of postpartum 

FP efforts in those countries. Implants are most frequently preceded by discontinuation of IUDs or 

injectables, which—in countries where IUDs are rarely used—may reflect a desire for a longer-term 

method among those switching from injectables. 

In terms of failure and discontinuation, our results are broadly consistent with clinical data and previous 

studies, which indicate that failure rates are much lower for LARCs than for other modern or traditional 

methods. There is some evidence of higher failure rates than expected for IUDs which deserve additional 

investigation. While most methods of FP can be passively discontinued, IUDs and implants are two 

methods designed to be discontinued with the assistance of a provider. As expected, we find that IUDs 

and implants have the lowest overall rates of discontinuation. In addition, given appropriate counseling 

and provision, women who choose a long-term method may intend to use it for a more sustained duration 

of time. Injectable discontinuation rates are only slightly lower than for other modern methods and on par 

with discontinuation of traditional/folkloric methods. However, the composition of discontinuation is 

different across the three methods, with failure much higher for other modern and traditional/folk and 

method dissatisfaction higher for injectables. 
56 

When discontinuation is disaggregated by specific reasons across all episodes, regardless of length, we 

find around 4 in 10 discontinuations of each type of LARC were for method-related reasons such as side 

effects and health concerns. This is more than double that of other modern methods combined. Access 

and cost were not frequently given as a main reason for the discontinuation of IUDs or implants. 

However, it was more frequent for injectables, particularly in sub-Saharan Africa. This is an area of 

concern for a method rising in popularity. Overall, the share of discontinuations to women still in need of 

contraception ranged from 50 percent for traditional/folk methods to over 70 percent for implant 

discontinuations. 

DWSIN is particularly problematic when it leaves women at risk of an unwanted pregnancy, which was 

true for 15 to 20 percent of the pooled sample of former LARC users in this study three months after 

discontinuation. Some level of method dissatisfaction/side effects are to be expected with any method, but 

high levels of DWSIN can indicate method dissatisfaction and service quality or gaps that put women at 

risk of an unintended pregnancy. This is somewhat counterbalanced by the low failure rates of LARC 

methods. 

When we modeled the risk of DWSIN by method type across a pooled sample, using country-level 

random effects and women’s characteristics, we found that among injectable and IUD users, women had 

significantly lower hazards of DWSIN if they started the episode of use after birth, PPA, or LAM. This 

suggests the importance of postpartum FP efforts designed to help women space births. 

The share of IUDs and implants in the national method mix was not significantly related to the hazard of 

discontinuing either method while still in need. For injectable users, even after controlling for individual 

characteristics, each percentage point of increased injectable share in the method mix reduced the hazard 

of DWSIN by 3 percent. However, the relationship did not hold once access was included in the model. 

The other two country-level factors considered—access to LARC method and overall quality of FP 

programs, as measured by FPE scores—significantly reduced the hazard of DWSIN. Access scores are 

designed to reflect the “extent to which the entire population and ready and easy access” to a specific 

LARC method. This implies that having sufficient supplies on hand is not enough; counselors and 

providers should also be trained in that particular method. Quality scores, on the other hand, are a 

reflection of the entire FP program irrespective of method: full information, wide method choice, 

counseling, and safe clinical procedures (Ross and Smith 2010). The significant relationship between 

quality and discontinuation may indicate that users of the particular method have made a better-informed 

choice of method type and were counseled in-depth on a method’s possible side effects. Additionally, 

because the quality score reflects safe clinical practices, it is conceivable that in countries with higherquality FP programs, users receive better clinical insertion of their method in such a way that reduces the 

possibility of failure. Joint models for each LARC method that include access and quality of FP programs 

found that access remained significant only for one method (implants), but quality remained significant 

for all three methods. In other words, although method access and programmatic quality are important 

factors in method continuation, programmatic quality seems to be the more important of the two. 

Collectively these models suggest that increasing service readiness and access to LARC methods helps 

sustain their use. But supplying particular LARC methods is not enough: programs should focus on 

overall method choice and increasing quality of services. Married women and couples living in countries 

with broader access to a full range of methods, better counseling to make an appropriate method choice, 

and safer clinical procedures have lower hazards of discontinuing their LARC method while still in need 

of contraception. More research on the specific components of programmatic quality that act to sustain 

use is needed to help focus policy efforts. 
57 

Appendix Table A1. List of FP2020 focus countries 

The 69 poorest countries in the world by region and sub-region 

AFRICA ASIA 

Eastern Africa Eastern Asia 

Burundi Korea, Dem. Rep. of 

Comoros Mongolia 

Djibouti 

Eritrea Central Asia 

Ethiopia Kyrgyzstan 

Kenya Tajikistan 

Madagascar Uzbekistan 

Malawi 

Mozambique South Asia 

Rwanda Afghanistan 

Somalia Bangladesh 

Uganda Bhutan 

Tanzania India 

Zambia Nepal 

Zimbabwe Pakistan 

 Sri Lanka 

Middle Africa 

Cameroon South-eastern Asia 

Central African Republic Cambodia 

Chad Indonesia 

Congo Lao People’s Dem. Rep. 

Dem. Rep. of the Congo Myanmar 

Sao Tome and Principe Philippines 

Timor-Leste 

Southern Africa Viet Nam 

Lesotho 

 Western Asia 

Western Africa Iraq 

Benin Palestinian Territory, Occupied 

Burkina Faso Yemen 

Cote d’Ivoire 

Gambia LATIN AMERICA & THE CARIBBEAN 

Ghana Caribbean 

Guinea Haiti 

Guinea-Bissau 

Liberia Central America 

Mali Honduras 

Mauritania Nicaragua 

Niger 

Nigeria South America 

Senegal Bolivia 

Sierra Leone 

Togo OCEANIA 

Melanesia 

Northern Africa Papua New Guinea 

Egypt Solomon Islands 

Sudan 

Sudan, South 

Western Sahara 

Source: FP2020 (2015). 

Note: Countries with 2010 gross national per capita annual income less than or equal to US $2,500. 

South Africa made a commitment to FP2020 at the 2013 International Conference on Family Planning but is 

not a low-income country. 

59 

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