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ABSTRACT

Family planning is considered one of the top 10 public health achievements of the 20th century by the Centers for Disease Control and Prevention (CDC), and use of hormonal contraceptives has only increased since its invention in the 1960s. Yet there is a noticeable lack of research and discussion on how to encourage patients to continue their use of contraception. Discontinuation of contraception is an issue of public health significance, since it often leads to unintended pregnancies that are costly to the individual and public as a whole. This literature review examines the extant literature on rates of discontinuation of the following hormonal methods of contraception: oral contraceptives, intrauterine devices, injectable contraceptives, vaginal rings, patches, and implant contraceptives. In addition, the review also examines demographic factors that have been associated with discontinuation, such as age, intimate partner violence, reproductive coercion, ethnicity, and socioeconomic status. Based on the literature reviewed, it appears that the most common reason for discontinuation is side effects. While providers usually cannot mitigate side effects of hormonal contraceptives, as they are often unpredictable, other studies have shown that discussing these side effects and other concerns that patients may have about the contraceptive that they are beginning or are currently taking can increase continuation as well as compliance with their regimen.

TABLE OF CONTENTS

1.0 introduction 1

2.0 Background 4

2.1 UNINTENDED PREGNANCY – TRENDS, COSTS, AND OUTCOMES 8

3.0 METHODS 12

3.1 DESCRIPTION OF STUDIES 12

4.0 RESULTS 16

4.1 REASONS GIVEN FOR DISCONTINUATION OF HORMONAL CONTRACEPTIVES 16

4.2 DISCONTINUATION OF HORMONAL METHODS 18

4.2.1 ORAL CONTRACEPTION (COMBINED AND PROGESTIN-ONLY) 19

4.2.2 INTRAUTERINE DEVICES (HORMONAL AND COPPER) 24

4.2.3 INJECTABLE CONTRACEPTION (DEPOT MEDROXYPROGESTERONE [DMPA] AND COMBINED) 28

4.2.4 VAGINAL RING 32

4.2.5 PATCH 35

4.2.6 IMPLANT 37

4.3 OTHER FACTORS ASSOCIATED WITH CONTRACEPTIVE DISCONTINUATION 40

4.3.1 AGE 40

4.3.2 INTIMATE PARTNER VIOLENCE AND REPRODUCTIVE COERCION 41

4.3.3 SOCIOECONOMIC STATUS AND ETHNICITY 41

5.0 DISCUSSION 43

5.1 DISCONTINUATION OF CONTRACEPTION 43

5.2 IMPLICATIONS FOR PRACTICE: CLIENT-PROVIDER INTERACTIONS AND COUNSELING 45

6.0 CONCLUSION 51

6.1 limitations and directions for future research 53

6.2 PUBLIC HEALTH SIGNIFICANCE 54

bibliography 55

List of tables

Table 1. Choice of contraceptive methods among US women in 2010, listed by popularity 6

Table 2. Failure rates of various types of contraception over one year, by method, listed by effectiveness of perfect use 7

Table 3. Summary of oral contraceptive studies reviewed, with most common reason given for discontinuation 19

Table 4. Other reasons for discontinuation of oral contraceptive 21

Table 5. Summary of oral contraception articles reviewed, with no reason for discontinuation given in study 22

Table 6. Summary of copper intrauterine device articles reviewed 24

Table 7. Summary of hormonal intrauterine device articles reviewed 26

Table 8. Summary of articles reviewed, intrauterine device (type not stated) 27

Table 9. Summary of injectable contraceptive (DMPA) articles reviewed, with most common reason for discontinuation 29

Table 10. Summary of injectable contraceptive (DMPA) articles reviewed, with no reason for discontinuation given in study 30

Table 11. Summary of injectable contraceptive (combined or type not stated) articles reviewed 32

Table 12. Summary of vaginal ring articles reviewed, with most common reason reason for discontinuation 33

Table 13. Summary of vaginal ring articles reviewed, with no reason for discontinuation given in study 34

Table 14. Summary of patch contraceptive articles reviewed 36

Table 15. Summary of implant contraceptive articles reviewed, with most common reason for discontinuation 37

List of figures

Figure 1. Results of literature search 13

Figure 2. Reasons given for discontinuation of contraceptives given in studies reviewed 18

Figure 3. Discontinuation rates of oral contraception, by time (months) and percentage 23

Figure 4. Discontinuation rates of copper intrauterine device, by time (months) and percentage 25

Figure 5. Discontinuation rates of hormonal intrauterine device, by time (months) and percentage 26

Figure 6. Discontinuation rates of intrauterine device, type not stated, by time (months) and percentage 28

Figure 7. Discontinuation rates of injectable DMPA, by time (months) and percentage 31

Figure 8. Discontinuation rates of vaginal ring contraceptive, by time (months) and percentage 35

Figure 9. Discontinuation rates of implant contraceptives, by time (months) and percentage 39

Figure 10. 24 Indicators of Care Assessed by RamaRao et al., 2003 47

introduction

The Centers for Disease Control and Prevention (CDC) consider family planning to be one of the greatest public health achievements of the 20th century (CDC, 1999). The ability for families to decide when to have children and to determine family size without sexual abstinence has been key to improving the health of children and women. The birth control movement in America began in the 20th century, and the science behind contraception has only improved since. In the 1960s, the first major hormonal contraceptive became available: the birth control pill. Since then, many other hormonal methods have been invented and used to great success.

The advantage of hormonal contraception over barrier methods of birth control is that use does do not disrupt foreplay, and it is considerably more effective and reliable in preventing pregnancy when properly used. The fact that use does not necessarily coincide with sexual intercourse also makes hormonal methods useful in the case of unexpected sexual intercourse or sexual assault. The advantages of barrier methods are that they do not require a doctor’s visit and prescription, are readily available and affordable to most, and they do not produce the physiological side effects of hormonal methods, which are often off-putting to users. Additionally, besides abstinence, barrier methods are the only reliable way to prevent transmission of sexually transmitted diseases. Natural methods, such as the rhythm or withdrawal method, breastfeeding, and the basal temperature method, are less reliable at preventing pregnancy and may require more user action than either barrier methods or hormonal methods. Lastly, male and female sterilization are extremely effective at preventing pregnancy, but are not considered reversible, and are not preferred by many couples for this reason.

This paper explores the reasons that women discontinue use of hormonal methods. Often, healthcare practitioners and educators discuss how to encourage women to begin using contraception, to promote women’s health and socioeconomic future. However, the CDC has estimated (Daniels, Mosher, & Jones. 2013) that 30% of American women have tried five or more contraceptive methods, indicating that discontinuation is common. Public health practitioners and healthcare providers rarely, if ever, discuss how to encourage women to stay on their contraception once they begin using it; this is an equally important issue since consistency is the key to contraceptive success.

Because the mechanisms, behavioral components, and costs of contraceptive methods vary so greatly, this paper examines only hormonal contraceptive use: oral contraceptives, intrauterine devices, injectable contraceptives, vaginal rings, dermal adhesive patch contraceptives, and implantable contraceptives. Though it is a form of hormonal contraception, emergency contraception such as the morning-after pill is not included in this review, since it is not a form of birth control that requires continuation. For the purposes of this paper, discontinuation is defined as stopping usage of that method of birth control, with or without a lapse in contraceptive coverage.

Following this introductory section, the background section discusses the contraceptive usage and needs of American women, as well as the failure rates of the contraceptive methods discussed in this paper. The background section also discusses the public impact and current trends, individual and public costs, and outcomes of unintended pregnancies in the United States. A short discussion of the Healthy People 2020 objectives related to reducing unintended pregnancy and increasing use of contraception is also included in the background section. Next, in the methods section, we describe the methods and criteria used to gather the studies reviewed in this literature synthesis, followed by a description of the studies.

In the following results section, we discuss the reasons given for discontinuation of hormonal contraceptives, as well as the rates of discontinuation. In this section, we discuss each method reviewed in this synthesis, ordered by popularity of use in the United States: oral contraception (combined and progestin-only), intrauterine devices (hormonal and copper), injectable contraception (depot medroxyprogesterone [DMPA] and combined), vaginal ring, patch, and implant. This section also includes a discussion of demographic factors that are associated with contraceptive discontinuation: age, intimate partner violence and reproductive coercion, and socioeconomic status and ethnicity.

The following discussion section includes a discussion of the factors that may be positively or negatively associated with discontinuation in specific methods. This is followed by a discussion of client-provider interactions and counseling, which is shown to significantly improve contraceptive continuation. Lastly, this paper concludes with a discussion of limitations and directions for future research, and the public health significance of this topic.

Background

The Guttmacher Institute points out that the average number of children desired by American families is two; as the average reproductive lifespan is considered to be roughly ages 15-44, women spend at least three decades of their lives trying to avoid pregnancy (Guttmacher Institute, 2000). It is likely that the length of time that women want to avoid pregnancy is growing as marriage and childbearing are becoming increasingly delayed, leading to greater use of contraceptives. The Guttmacher Institute (2013) also estimates that in 2010, there were 66 million American women of reproductive age (13-44). More than half of these women (37 million) were sexually active and fertile, but were not and did not want to become pregnant; therefore, 37 million women were in need of contraceptives. The CDC contends that the need for contraception among sexually active women may be even greater; they estimated that 43 million of these women of childbearing age (70% of the total) are sexually active and do not want to become pregnant, but could if they do not use contraception or their contraception fails (Jones, Mosher, & Daniels, 2012). Hormonal contraception may be preferred over sterilization by a majority of sexually active couples due to its reversibility, and over barrier methods due to hormonal contraceptives’ greater reliability in preventing pregnancy. Another important additional consideration that increases couples’ preference for hormonal methods is that use does not interrupt sexual intercourse.

Contraceptive use is generally widespread among sexually active couples in the United States. Approximately 99% of sexually active women have used at least one contraceptive method (Daniels, Mosher, & Jones, 2013), and it is estimated that 62% are using a method at any given time (Jones, Mosher, & Daniels, 2012). Of women who have used at least one method, approximately 80% have used oral contraceptives (Daniels, Mosher, & Jones, 2013), while the popularity of other hormonal methods is increasing. For instance, the rate of women who had ever used injectable contraceptives increased from 4.5% in 1995 to 23% by 2010, while the rate of women who had ever used the contraceptive patch increased from 26; ***Age 20-25

Only two studies (Lete et al., 2012; Raine et al., 2011) listed reasons for discontinuation; both found that the most common reason was side effects. In addition to side effects, these two studies also found other reasons for discontinuation: “other,” contraceptive no longer needed (pregnancy desired or change in sexual habits), user dissatisfaction (poor cycle control), and failure of method (Lete et al., 2012). Raine et al. (2011) found the following reasons for discontinuation: user dissatisfaction (too difficult to use), “pregnancy-related,” access issues, contraceptive no longer needed (pregnancy desired or change in sexual habits), medical reasons or health concerns, and “other” (unknown).

6 IMPLANT

Fourteen studies were identified that reviewed the discontinuation rates of contraceptive implants. The rates of and reasons for discontinuation given in these studies are summarized below in Table 15 and Figure 10. Several types of implants were studied, including levonorgestrel rods (generic and Norplant) and etonorgestrel (Implanon). Of all the hormonal methods reviewed in this paper, implants were the most likely to be continued. Only five studies calculated discontinuation rates above 30%. Eleven of the studies showed discontinuation rates below 20%, and the lowest rate of discontinuation was 3.5% at six months (Peers, Stevens, Graham, & Davey, 1996).

Table 15. Summary of implant contraceptive articles reviewed, with most common reason for discontinuation

|Study (and type of implant, if identified) |Time (months) |Discontinuation rate |Most common reason for |

| | |Range: 3.5%-41.0% |discontinuation, if given |

|Peers et al., 1996 [Norplant] |6 |3.5% |Side effects |

|Kalmuss et al., 1996 |6 |7.6% |Side effects |

|Croxatto et al., 1999 |6 |10.0% |Side effects |

|Lakha & Glasier, 2006 |6 |11.0% |Side effects |

|Rakhshani & Mohammadi, 2004 [levonorgestrel rod] |12 |14.0% |Side effects |

|Peers et al., 1996 [Norplant] |12 |14.8% |Side effects |

|Rosenstock et al., 2012* |12 |15.6% | |

|Trussell, 2011 [Implanon] |12 |16.0% | |

|O'Neil-Callahan et al., 2013 |12 |16.6% |  |

|Peipert et al., 2011 |12 |16.7% |Side effects |

|Sivin et al., 1998a |12 |17.3% |Side effects |

|Rosenstock et al., 2012** |12 |17.8% | |

|Zibners, Cromer, & Hayes, 1999 |12 |18.0% | |

|Rosenstock et al., 2012*** |12 |19.9% | |

|Table 15 continued. | | | |

|Croxatto et al., 1999 |12 |20.0% |Side effects |

|Lakha & Glasier, 2006 |12 |25.0% |Side effects |

|Sivin et al., 1998a |24 |20.0% |Side effects |

|Croxatto et al., 1999 |24 |31.0% |Side effects |

|O'Neil-Callahan et al., 2013 |24 |31.5% |  |

|Lakha & Glasier, 2006 |24 |41.0% |Side effects |

|Rakhshani & Mohammadi, 2004 [levonorgestrel rod] |36 |22.0% |Side effects |

|Sivin et al., 1998a |36 |25.1% |Side effects |

|Sivin et al., 1998b [Norplant] |36 |28.9% |Side effects |

|Sivin et al., 1998b [levonorgestrel rod] |36 |29.4% |Side effects |

|Modey, Aryeetey, & Adanu, 2014 |Lifetime |40.3% | |

*Age >26; **Age 14-19; ***Age 20-25

Most studies identified side effects as the leading cause of discontinuation; most of the side effects were either irregular, prolonged, increased, or otherwise “unacceptable” bleeding, as well as headaches and changes in menstrual periods. Other reasons for discontinuation were given in two studies. Moreau, Cleland, and Trussell (2007) listed the following reasons: side effects (changes in menstrual periods), access issues (too expensive, too difficult to obtain), user dissatisfaction (too messy to use, too difficult to use, worried about effectiveness in preventing pregnancy, lack of protection against STIs, method decreased sexual pleasure), partner dissatisfaction, medical reasons or health concerns (worried about side effects, other health problems, or doctor’s advice), and “other.”

Kalmuss and colleagues (1996) listed the following reasons for discontinuation: side effects (implant site discomfort, implant site infection, weight change, mood changes, hair loss, chest pain), “other/unknown,” and “negative media reports” (the only article in this review to list that as a reason for discontinuation, for any type of hormonal contraceptive).

4 OTHER FACTORS ASSOCIATED WITH CONTRACEPTIVE DISCONTINUATION

1 AGE

Age is a particularly relevant factor of concern for non-compliance or discontinuation due to the increased fertility of younger women. A 2008 study by Whitaker and Giliam estimated that 82% of pregnancies in females aged 15-19 were unintended. Rosenstock and colleagues (2012) found that continuation of contraception was negatively associated with age for all contraceptives studied. This conclusion is common to other studies as well. Mahdy and el-Zeiny (1999) found that women who were older and those with several children were significantly more likely to continue and comply with their oral contraceptive regimen. Archer, Cullins, Creasy and Fisher (2004) found that perfect dosing with the Patch was about equal across all age groups but compliance with oral contraceptives was significantly better in the above-30 age group compared to those aged 18-20. Another study reviewing intrauterine device use found that women aged 13-19 were more likely to request early discontinuation (Aoun et al., 2014). In a review of data from the 1995 National Survey of Family Growth, Trussell and Vaughn (1999) found that women over the age of 30 were 28% less likely to discontinue a reversible method of contraception.

2 INTIMATE PARTNER VIOLENCE AND REPRODUCTIVE COERCION

While there is a lack of statistical data lacking regarding contraceptive discontinuation or noncompliance due to intimate partner violence or reproductive coercion, the issue is so pressing that the American College of Obstetricians and Gynecologists (ACOG) released a set of recommendations, guidelines, and suggestions for screening patients for intimate partner violence and reproductive coercion that could potentially lead to unintended pregnancies (ACOG, 2013). Use and continuation of hormonal contraception are important in situations such as these, since it is controlled by the woman (rather than male-controlled methods such as condoms) and much more reliable in preventing unwanted pregnancies than other methods. Miller et al. (2010) found that birth control sabotage and reproductive coercion were associated with unintended pregnancy in a population of women aged 16-29 seeking care in a public family planning clinic. The CDC's National Intimate Partner and Sexual Violence Survey 2010 Summary Report found that approximately 8.6% of women (about 10.3 million) reported ever having an intimate partner who tried to get them pregnant when they did not want to, or refused to wear a condom. About 4.8% had an intimate partner who tried to get them pregnant against their wishes.

3 SOCIOECONOMIC STATUS AND ETHNICITY

Some evidence suggests that ethnicity and socioeconomic status are linked to discontinuation of contraception, and unintended pregnancy. Trussell and Vaughn’s review of data (1999) from the 1995 National Survey of Family Growth found that Hispanic and Black women had a 28% higher rate of method-related discontinuation than their White counterparts, while low-income women had a 39% higher rate of method-related discontinuation than higher-income women. (Method-related reasons include side effects and user dissatisfaction, while non-method-related reasons may include no longer needing the contraceptive due to a change in sexual habits, access issues, or desire to become pregnant.) The groups that were most likely to experience an unintended pregnancy were minority women and poor and low-income women, as well as women aged 18-24 and cohabiting women (Finer & Zolna, 2014). Daniels, Mosher, and Jones (2013) found that Hispanic and Asian women were less likely than their Black and White counterparts to have ever used a highly effective reversible method of contraception. Stuart et al. (2013) found that Black women and women who received public assistance were more likely to discontinue oral contraception, the patch, or the ring.

DISCUSSION

1 DISCONTINUATION OF CONTRACEPTION

While this review of literature on hormonal contraceptive discontinuation has made clear that by far, side effects are the most common reason for discontinuation of contraception, there is little that public health practitioners and healthcare providers can do to physiologically prevent, mitigate, or eliminate side effects without discontinuing the method altogether. This is especially true of hormonal contraceptives because hormones interact differently with each individual to produce unpredictable side effects. It remains incumbent on the pharmaceutical industry to develop hormonal contraceptives that provide a better user experience, which would go a very long way in promoting contraceptive continuation.

In addition to side effects, several studies named access issues such as expense or difficulty obtaining as one reason for discontinuation of contraception. With the introduction of the Affordable Care Act’s family planning mandate, requiring insurance plans to cover contraceptive methods at no out-of-pocket cost to patients (including the methods covered in this essay), as well as contraceptive counseling, it is possible that many financially-related access issues will be mitigated or eliminated. However, serious challenges remain to preventing unintended pregnancy through the use of hormonal contraceptives, including access issues and the need to improve support from healthcare providers for contraceptive users, especially concerning issues of side effects.

One possible explanation for the highly variable rates of continuation of oral contraception that were found in this review, is the different combinations and formulations of pills available, many of which are not named in the studies reviewed. The highly variable rates of discontinuation of oral contraception are particularly troubling, since over 1 million unplanned pregnancies in the United States each year are attributed to oral contraception non-compliance (mostly missing pills) or discontinuation (Black et al., 2010).

It is possible that the relatively low rates of discontinuation of IUDs and implants could be due to the extensive counseling and examinations that must take place before insertion, guaranteeing a motivated and educated patient. In addition to this, the system can be placed and removed only by a trained practitioner during an appointment, and it is a “forgettable” method (Grimes, 2009). Another possible reason for the hormonal IUDs popularity is its potential to cause fewer side effects; since the effective dose for IUDs is lower because the hormone is released directly into the uterus, there is a lessened chance of side effects (Guttmacher, 2007). Other reasons may include marketing; for instance, Mirena was marketed as a birth spacer for parous women, so it is not surprising that desire for a pregnancy was a common reason for discontinuation. It is quite interesting that while implants are the least popular method of hormonal contraception, they were also the least likely to be discontinued after placement.

2 IMPLICATIONS FOR PRACTICE: CLIENT-PROVIDER INTERACTIONS AND COUNSELING

The need to improve client-patient interactions and communication was underlined in Isaacs and Creinin’s 2003 study of pregnant women seeking in-office abortions, which found that 14% of the study population was using a less effective method of contraception than previously used, or no method at all, due to a communication failure.

Thirty nine percent of the study population reported that they had their contraceptive method switched by the provider and were not offered an equally or more effective method; 22% were using an oral contraceptive, provided antibiotics (which negate the effect of oral contraceptives[2]) and were not warned to use a back-up method; 20% had their oral contraceptive stopped for a contraindication and were switched to a less effective method; 12% experienced difficulty obtaining emergency contraception or were incorrectly instructed on the use of emergency contraception; and 6% were prescribed a method that they did not want, while not being offered any other methods by the provider. Only one of the 77 women in the study who knew about emergency contraception and could have used it actually did use emergency contraception. It is clear that unintended pregnancy and abortion could have been avoided in many of these cases if client-provider interaction had been tailored to the patients’ needs (Isaacs & Creinin, 2003).

Tailored contraceptive health counseling is also useful for helping women select a method that they feel suits them, which improves contraceptive compliance and continuation. In a 2012 study, Garbers, Meserve, Kottke, Hatcher, and Chiasson created a computer-based contraceptive assessment module and individually tailored health materials that assessed clients’ contraceptive needs; one group received the assessment module and tailored materials, another group received the assessment module and generic materials, and the last group did not receive the special assessment module and only generic materials (control group). There was no significant difference between the group that received the module and generic materials and the control group that received only generic materials, but there was a significant difference between the group that received the special assessment module and tailored materials and the control group. Continuation of use and adherence to the contraceptive regimen were 95% and 86%, respectively, in the experimental group that received the special assessment module and tailored materials, while the control group continued use only 77% of the time and adhered to their regimen 69% of the time.

Several studies show that high-quality client-provider interactions do improve contraceptive compliance and continuation. While the following studies discussed were not conducted in the United States, it remains clear that high-quality care is key to providers’ promotion of contraceptive continuation. RamaRao and colleagues (2003) report a positive association between quality of care and contraceptive use; the study assessed 1,728 women in the Philippines who were new users of family planning care. Those women who received low-quality care at the time of contraceptive adoption had a 55% probability of using contraception at follow-up, compared to 67% of those who received high-quality care. In this study, quality of care was assessed using 24 indicators (Figure 10). The respondents reported that an average of 18.5 of the 24 indicators were assessed. The medium-quality level of care was defined as falling within one-half of a standard deviation of that mean; low-quality care was below one-half of the standard deviation from the mean, while high-quality care was above one-half of the standard deviation from the mean.

[pic]

Figure 10. 24 Indicators of Care Assessed by RamaRao et al., 2003

One 36-month study of 3,611 women using oral contraceptives, IUDs, injectables, and other non-hormonal methods of birth control in Bangladesh used seven indicators of care: (1) was the fieldworker responsive to questions? (2) did the fieldworker appreciate the privacy of their client? (3) was the fieldworker helpful with problems? (4) was the fieldworker sympathetic to his/her client's needs? (5) did the fieldworker provide enough information about contraceptives? (6) did the fieldworker spend enough time with the client? and (7) did the fieldworker discuss and offer the client a choice of contraceptives? The results were positive when client-provider interactions were high-quality: women who reported a high level of care from their fieldworker were 27% more likely to adopt a method of contraception subsequently (after controlling for client characteristics), and 72% more likely to continue their method of contraception (Koenig, Hossain, & Whittaker, 2003).

Similarly, a study in Senegal assessed five indicators of care: “whether the client was provided choice, had her needs assessed, was provided information, was treated well by the provider, and whether she was linked to future services” (Sanogo et al., 2003, p. 63). Based on these indicators, women who received high-quality care were 1.3 times more likely to use contraception than those who did not.

Receiving routine information at care and follow-up visits is not as effective as personalized counseling. In a study of 350 Mexican women using DMPA, 43.4% of women in the control group who received only routine information on the side effects of DMPA discontinued use (Canto de Cetina, Canto, & Ordonez Luna, 2001). In contrast, the experimental group of women received pretreatment counseling that described DMPA’s mode of action and discussed common side effects including irregular or heavy bleeding and menstrual periods, spotting, and amenorrhea. They were also told that the side effects were not detrimental to their health, and were encouraged to visit their provider if they had any concerns about DMPA’s effect on their health. Only 17% of the experimental group discontinued use of DMPA; the authors concluded that explaining the contraceptive’s effectiveness and mode of action, preparing clients for the potential side effects, and assuring them that the side effects were not detrimental to their health but that they could seek care if they were concerned, were all instrumental in improving the continuation rate of DMPA.

A similar study of 811 women in China using DMPA reached comparable conclusions: 11% of women who received structured counseling discontinued the contraceptive, while 42% of women who received only routine counseling discontinued use (Lei et al., 1996). Both the Mexican and Chinese studies utilized audio-visual aids in the structured counseling group; the Mexican study did not describe the audiovisual aids in detail, while the Chinese group’s aid depicted American women discussing their use of DMPA.

However, an assessment of 74 articles about contraceptive counseling revealed that the extant literature on contraceptive counseling is unreliable in its determination on the effects of counseling on unintended pregnancy in the United States (Moos, Bartholomew, & Lohr, 2003). The authors of this literature review concluded that, collectively, the body of literature did not provide “definitive guidance about effective counseling strategies” (Moos, Bartholomew, & Lohr, 2003, abstract) and the studies themselves differed widely in methodology, population, and outcomes measured. This is true of the studies examined in this review as well: each study included different indicators of quality of care, and while there was much overlap, there was also a wide variety of populations and methodologies. But as Moos, Bartholomew, and Lohr (2003) point out, the overlap in many of these studies indicates a future direction for research on the contribution of quality of care and counseling to contraceptive continuation and compliance.

CONCLUSION

The Guttmacher Institute (2012) estimates that 37 million American women are sexually active and fertile but are not and do not desire pregnancy, while the CDC’s estimate is even higher, at 43 million American women (Jones, Mosher, & Daniels, 2012). While the exact number may be unclear, it is certainly clear that there are millions of American women who are in need of contraception to avoid an unintended pregnancy; it is estimated that more than half of all American women have or will become pregnant without having intended to do so by the age of 45 (Jones & Kavanaugh, 2011). Hormonal contraception is a reliable, long-term, and highly effective way to prevent unintended pregnancies, but it must be taken or used consistently to be highly effective. Contraceptive discontinuation is therefore a major risk factor that may lead to unintended pregnancy. As this paper has shown, contraceptive discontinuation is a widespread phenomenon that has not been widely addressed by researchers or practitioners.

This paper’s introduction discussed the advantages of hormonal contraception over barrier methods, natural methods, and sterilization, as well as the public health importance of the topic of contraceptive discontinuation. The following background section discussed the contraceptive usage and needs of American women. The failure rates of the contraceptive methods discussed in this paper were also reviewed, as well as the public impact and current trends, individual and public costs, and outcomes of unintended pregnancies in the United States. This section concluded with a short discussion of the Healthy People 2020 objectives related to reducing unintended pregnancy and increasing use of contraception. In the next section, the methods and criteria used to gather and determine the studies reviewed in this literature synthesis were described; the studies were also described.

The results section, organized by method and ordered by popularity of use in the United States, discussed the rates and reasons for discontinuation given by patients in the studies. The results section concluded with a discussion of demographic factors that are also associated with contraceptive discontinuation. This was followed by the discussion section, which included a method-specific discussion of the method-related factors that may be positively or negatively associated with discontinuation. This section concluded with a discussion of client-provider interactions and contraceptive counseling, shown to significantly support and improve contraceptive continuation. Lastly, this paper concludes with this section, a discussion of this paper’s limitations, suggestions and directions for future research, and the public health significance of contraceptive discontinuation.

This literature review examined the extant literature on discontinuation of the following hormonal methods of contraception: oral contraceptives, copper intrauterine devices, hormonal intrauterine devices, injectable contraceptives, including depot medroxyprogesterone and combined type, vaginal rings, patches, and implant contraceptives. In addition, the review also examined demographic factors that have been associated with discontinuation, including age, intimate partner violence, reproductive coercion, ethnicity, and socioeconomic status. Based on the review of studies examining discontinuation of hormonal contraceptives, it appears that the most common reason for discontinuation is side effects. While providers usually cannot mitigate side effects of hormonal contraceptives, as they are often unpredictable, other studies have shown that discussing these side effects and other concerns that patients may have about the contraceptive that they are beginning or are currently taking can increase continuation as well as compliance with their regimen.

1 limitations and directions for future research

There are several limitations to this literature review. First, the meta-analysis included only studies that provided quantitative results for discontinuation. Adding qualitative results would improve the quality and depth of a review of reasons why women choose to discontinue their methods of contraception. Second, the populations studied varied widely demographically. Therefore, conclusions are not generalizable to any specific population. Third, many of the studies used only provided rates of discontinuation, and did not provide specific reasons for discontinuation. It would be very instructive for future studies to include reasons for discontinuation, so that these may be addressed in client interventions. Fourth, many of the studies regarding contraceptive counseling only defined counseling in terms of talking to clients around specific objectives, without any theoretical basis. Future studies examining the use of counseling to improve contraceptive compliance or continuation may wish to incorporate behavioral theories of health decision-making, which may increase contraceptive adherence and decrease unwanted pregnancies. Lastly, this review only examined studies published in English.

2 PUBLIC HEALTH SIGNIFICANCE

Given that increasing the proportion of intended pregnancies and increasing contraceptive use by females (or their partners) at risk of unintended pregnancy at most recent sexual intercourse are Healthy People 2020 objectives, improving maternal health and reducing child mortality are United Nations Millennium Development Goals, and the CDC considers family planning one of the top 10 public health achievements of the 20th century, family planning remains a very significant public health issue. By increasing continuation of contraceptive use, the proportion of unintended pregnancies can be reduced, rates of neonatal/infant/child mortality can be reduced, and women’s health as a whole can be improved. In addition, because contraceptive use puts women in control of their fertility, it also improves their social and economic opportunities.

It is clear from this review that while there is little that healthcare providers can do to prevent or eliminate side effects, contraceptive compliance or continuation can be improved by discussing the advantages and disadvantages of each method, providing care with quality interpersonal interaction, and discussing the preferences and worries of each patient. The extant meta-analytical literature on contraceptive discontinuation is extremely scarce, especially for such an important public health topic.

bibliography

Ahrendt, H. J., Nisand, I., Bastianelli, C., Gómez, M. A., Gemzell-Danielsson, K., Urdl, W., ... & Milsom, I. (2006). Efficacy, acceptability and tolerability of the combined contraceptive ring, NuvaRing, compared with an oral contraceptive containing 30μg of ethinyl estradiol and 3 mg of drospirenone. Contraception, 74(6), 451-457.

Ali, M.M. & Cleland, J. (1999). Determinants of contraceptive discontinuation in six developing countries. Journal of Biosocial Science, (31)3, 343-360.

Ali, M.M. & Cleland, J. (2010). Oral contraceptive discontinuation and its aftermath in 19 developing countries. Contraception, 81(1), 22-29.

American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women. (2013). Reproductive and sexual coercion. Committee opinion no. 554. Retrieved from lth%20Care%20for%20Underserved%20Women/co554.pdf?dmc=1&ts=2013020 6T0531420146

Aoun, J., Dines, V. A., Stovall, D. W., Mete, M., Nelson, C. B., & Gomez-Lobo, V. (2014). Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstetrics & Gynecology, 123(3), 585- 592.

Archer, D. F., Cullins, V., Creasy, G. W., & Fisher, A. C. (2004). The impact of improved compliance with a weekly contraceptive transdermal system (Ortho Evra®) on contraceptive efficacy. Contraception, 69(3), 189-195.

Archer, J. S., & Archer, D. F. (2002). Oral contraceptive efficacy and antibiotic interaction: A myth debunked. Journal of the American Academy of Dermatology, 46(6), 917-923.

Barden-O’Fallon, J., Speizer, I.S., Calix, J., & Rodriguez, F. (2011). Contraceptive discontinuation among Honduran women who use reversible methods. Studies in Family Planning, 42(1), 11-20.

Behringer, T., Reeves, M.F., Rossiter, B., Chen, B.A., & Schwarz, E.B. (2011). Duration of use of a levonorgestrel IUS among nulliparous and adolescent women. Contraception, 84(5), e5-e10.

Beksinska, M.E., Rees, H.V., & Smit, J. (2001). Temporary discontinuation: A compliance issue in injectable users. Contraception, 64(5), 309-313.

Black, K. I., Gupta, S., Rassi, A., & Kubba, A. (2010). Why do women experience untimed pregnancies? A review of contraceptive failure rates. Best Practice & Research Clinical Obstetrics & Gynaecology, 24(4), 443-455.

Brucker, C., Karck, U., & Merkle, E. (2008). Cycle control, tolerability, efficacy, and acceptability of the vaginal contraceptive ring, NuvaRing®: Results of clinical experience in Germany. European Journal of Contraception and Reproductive Health Care, 13(1), 31-38.

Bustan, M. N., & Coker, A. L. (1994). Maternal attitude toward pregnancy and the risk of neonatal death. American Journal of Public Health, 84(3), 411-414.

Canto De Cetina, T. E., Canto, P., & Ordoñez Luna, M. (2001). Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate. Contraception, 63(3), 143-146.

Centers for Disease Control and Prevention. (1999). Achievements in public health, 1900-1999: Family planning. Morbidity and Mortality Weekly Report, 48(47), 1073- 1080. Retrieved from

Centers for Disease Control and Prevention. (2008). State of CDC, 2008. Retrieved from .

Centers for Disease Control and Prevention. (2011). National intimate partner and sexual violence survey: 2010 summary report. Retrieved from

Colli, E., Tong, D., Penhallegon, R., & Parazzini, F. (1999). Reasons for contraceptive discontinuation in women 20–39 years old in New Zealand. Contraception, 59(4), 227-231.

Cotten, N., Stanback, J., Maidouka, H., Taylor-Thomas, J. T., & Turk, T. (1992). Early discontinuation of contraceptive use in Niger and The Gambia. International Family Planning Perspectives, 18(4), 145-9.

Croxatto, H. B., Urbancsek, J., Massai, R., Bennink, H. C., & van Beek, A. (1999). A multicentre efficacy and safety study of the single contraceptive implant Implanon®. Human Reproduction, 14(4), 976-981.

Daniels, K., Mosher, W.D., & Jones, J. (2013). Contraceptive methods women have ever used: United States, 1982-2010. National Health Statistics Reports (Centers for Disease Control and Prevention National Center for Health Statistics), U.S. Department of Health and Human Services. Retrieved from

Davidson, A. R., Kalmuss, D., Cushman, L. F., Romero, D., Heartwell, S., & Rulin, M. (1997). Injectable contraceptive discontinuation and subsequent unintended pregnancy among low-income women. American Journal of Public Health, 87(9), 1532-1534.

DePersio, S.R., Chen, W., Blose, D., & Lorenz, R. (1992). Unintended pregnancy and its consequences on live birth outcomes and maternal behaviors during pregnancy. Oklahoma City Department of Health.

Dibaba, Y., Fantahun, M., & Hindin, M. J. (2013). The effects of pregnancy intention on the use of antenatal care services: Systematic review and meta- analysis. Reproductive Health, 10(1), 50.

Dieben, T.O.M., Roumen, F.J.M.E., & Apter, D. (2002). Efficacy, cycle control, and user acceptability of a novel combined contraceptive vaginal ring. Journal of Obstetrics and Gynecology 100(3), 585-593.

Finer, L.B. & Zolna, M.R. (2014). Shifts in intended and unintended pregnancies in the United States, 2001-2008. American Journal of Public Health, 104(S1), S43- 48.

Garbers, S., Haines-Stephan, J., Lipton, Y. Meserve, A., Spieler, L., & Chiasson, M.A. (2013). Continuation of copper-containing intrauterine devices at 6 months. Contraception, 87(1), 101-106.

Garbers, S., Meserve, A., Kottke, M., Hatcher, R., & Chiasson, M.A. (2012). Tailored health messaging improves contraceptive continuation and adherence: Results from a randomized controlled trial. Contraception, 86(5), 536-542.

Gazmararian, J. A., Adams, M. M., Saltzman, L. E., Johnson, C. H., Bruce, F. C., Marks, J. S., ... & PRAMS Working Group. (1995). The relationship between pregnancy intendedness and physical violence in mothers of newborns. Obstetrics & Gynecology, 85(6), 1031-1038.

Gilliam, M.L., Neustadt, A., Kozloski, M., Mistretta, S., Tilmon, S., & Godfrey, E. (2010). Adherence and acceptability of the contraceptive ring compared with the pill among students. Journal of Obstretics and Gynecology, 115(3), 503-510.

Gold, R. B., Sonfield, A., Richards, C. L., & Frost, J. J. (2009). Next steps for America's family planning program: Leveraging the potential of Medicaid and Title X in an evolving health care system. Guttmacher Institute. Retrieved from

Grimes, D.A. (2009). Forgettable contraception. Contraception, 80(6), 497-499.

Hubacher, D., Goco, N., Gonzalez, B., & Taylor, D. (2000). Factors affecting continuation rates of DMPA. Contraception, 60(6), 345-351.

Guttmacher Institute. (2000). Fulfilling the promise: Public policy and U.S. family planning clinics. Retrieved from

Guttmacher Institute. (2010). Contraceptive needs and services. Retrieved from

Guttmacher Institute. (2013). Contraceptive use in the United States. Retrieved from

Helms, S. E., Bredle, D. L., Zajic, J., Jatjoura, D., Brodell, R. T., & Krishnarao, I. (1997). Oral contraceptive failure rates and oral antibiotics. Journal of the American Academy of Dermatology, 36(5), 705-710.

Isaacs, J. N., & Creinin, M. D. (2003). Miscommunication between healthcare providers and patients may result in unplanned pregnancies. Contraception,68(5), 373-376.

Jones, J., Mosher, W., & Daniels, K. (2012). Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995. National Health Statistics Reports (Centers for Disease Control and Prevention National Center for Health Statistics), U.S. Department of Health and Human Services. Retrieved from

Jones, R.K. & Kavanaugh, M.L. (2011). Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstetrics & Gynecology, 117(6), 1358- 1366.

Kalagian, W., Loewen, I., Delmore, T., & Busca, C. (1998). Adolescent oral contraceptive use: Factors predicting compliance at 3 and 12 months. The Canadian Journal of Human Sexuality, 7(1), 1-8.

Kalmuss, D., Davidson, A.R., Cushman, L.F., Heartwell, S. & Rulin, M. (1996). Determinants of early implant discontinuation among low-income women. Family Planning Perspectives, 28, 256-260.

Khan, M.A. (2001). Side effects and oral contraceptive discontinuation in rural Bangladesh. Contraception, 64(3), 161-167.

Koenig, M. A., Hossain, M. B., & Whittaker, M. (1997). The influence of quality of care upon contraceptive use in rural Bangladesh. Studies in Family Planning, 278- 289.

Kost, K., Singh, S., Vaughan, B., Trussell, J., & Bankole, A. (2008). Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception, 77(1), 10-21.

Kubička, L., Matějček, Z., David, H. P., Dytrych, Z., Miller, W. B., & Roth, Z. (1995). Children from unwanted pregnancies in Prague, Czech Republic revisited at age thirty. Acta Psychiatrica Scandinavica, 91(6), 361-369.

Lakha, F. & Glasier, A. (2006). Continuation rates of Implanon® in the UK: Data from an observation study in a clinical setting. Contraception, 74(4), 287-289.

Lara-Torre, E., Spotswood, L., Correia, N., & Weiss, P. M. (2011). Intrauterine contraception in adolescents and young women: a descriptive study of use, side effects, and compliance. Journal of Pediatric and Adolescent Gynecology, 24(1), 39-41.

Lei, Z. W., Chun Wu, S., Garceau, R. J., Jiang, S., Yang, Q. Z., Wang, W. L., & Vander Meulen, T. C. (1996). Effect of pretreatment counseling on discontinuation rates in Chinese women given depo-medroxyprogesterone acetate for contraception. Contraception, 53(6), 357-361

Lete, I., Pérez-Campos, E., Correa, M., Robledo, J., de la Viuda, E., Martínez, T., ... & Lobo, P. (2012). Continuation rate of combined hormonal contraception: a prospective multicenter study. Journal of Women's Health, 21(5), 490-495.

Mahdy, N. H., & El-Zeiny, N. A. (1999). Probability of contraceptive continuation and its determinants. Eastern Mediterranean Health Journal, 5(3), 526-539.

Mayer, J. P. (1997). Unintended childbearing, maternal beliefs, and delay of prenatal care. Birth, 24(4), 247-252.

Melhado, L. (2011). More than four in 10 Honduran women discontinue their contraceptive method within the first year of use. International Perspectives on Sexual and Reproductive Health, 37(2), 104-105.

Merki-Feld, G. & Hund, M. (2010). Clinical experience with the combined contraceptive vaginal ring in Switzerland, including a subgroup analysis of previous hormonal contraceptive use. European Journal of Contraception and Reproductive Health Care 15(6), 413-422.

Miller, E., Decker, M. R., McCauley, H. L., Tancredi, D. J., Levenson, R. R., Waldman, J., ... & Silverman, J. G. (2010). Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception, 81(4), 316-322.

Modey, E.J., Aryeetey, R., & Adanu, R. (2014). Contraceptive discontinuation and switching among Ghanian women: Evidence from the Ghana Demographic and Health Survey, 2008. African Journal of Reproductive Health, 18(1), 84-92.

Moreau, C., Bouyer, J., Bajos, N., Rodriguez, G., & Trussell, J. (2009). Frequency of discontinuation of contraceptive use: results from a French population-based cohort. Human Reproduction, 24(6), 1387-1392.

Moreau, C., Cleland, K., & Trussell, J. (2007). Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception, 76(4), 267-272.

Mosher, W.D., Jones, J., & Abma, J.C. (2012). Intended and unintended births in the United States: 1982-2010. National Health Statistics Reports. Retrieved from

Murphy, P.A. & Brixner, D. (2008). Hormonal contraceptive discontinuation patterns according to formulation: Investigation of associations in an administrative claims database. Contraception 77(4), 257-263.

Myhrman, A., Olsén, P., Rantakallio, P., & Laara, E. (1995). Does the wantedness of a pregnancy predict a child's educational attainment? Family Planning Perspectives, 27(3), 116-119.

Novak, A., de la Loge, C., Abetz, L., & van der Meulen, E.A. (2003). The combined contraceptive vaginal ring, NuvaRing®: An international study of user acceptability. Contraception, 67(3), 187-194.

Oddsson, K., Leifels-Fischer, B., de Melo, N. R., Wiel-Masson, D., Benedetto, C., Verhoeven, C. H., & Dieben, T. O. (2005). Efficacy and safety of a contraceptive vaginal ring (NuvaRing) compared with a combined oral contraceptive: A 1-year randomized trial. Contraception, 71(3), 176-182.

O'Neil-Callahan, M., Peipert, J. F., Zhao, Q., Madden, T., & Secura, G. (2013). Twenty- four–month continuation of reversible contraception. Obstetrics & Gynecology, 122(5), 1083-1091.

Paul, C., Skegg, D.C.G, & Williams, S. Depot medroxyprogesterone acetate: Patterns of use and reasons for discontinuation. Contraception, 56(4), 209- 214.

Peers, T., Stevens, J. E., Graham, J., & Davey, A. (1996). Norplant® implants in the UK: First year continuation and removals. Contraception, 53(6), 345-351.

Peipert, J. F., Zhao, Q., Allsworth, J. E., Petrosky, E., Madden, T., Eisenberg, D., & Secura, G. (2011). Continuation and satisfaction of reversible contraception. Obstetrics and Gynecology, 117(5), 1105-1113.

Polaneczky, M. & Liblanc, M. (1998). Long-term depot medroxyprogesterone acetate (Depo-Provera) use in inner-city adolescents. Journal of Adolescent Health, 23(2), 83-88.

Raine, T. R., Foster-Rosales, A., Upadhyay, U. D., Boyer, C. B., Brown, B. A., Sokoloff, A., & Harper, C. C. (2011). One-year contraceptive continuation and pregnancy in adolescent girls and women initiating hormonal contraceptives. Obstetrics and Gynecology, 117(2 Pt 1), 363.

Rakhshani, F. & Mohammadi, M. (2004). Contraception continuation rates and reasons for discontinuation in Zahedan, Islamic Republic of Iran. Eastern Mediterranean Health Journal, 10(3), 260-267.

Rosenberg, M.J. & Waugh, M.S. (1998). Oral contraceptive discontinuation: A prospective evaluation of frequency and reasons. American Journal of Obstetrics and Gynecology, 179(3), 577-582.

Rosenberg, M.J., Waugh, M.S., & Meehan, T.E. (1995). Use and misuse of oral contraceptives: Risk indicators for poor pill taking and discontinuation. Contraception, 51(5), 283-288.

Rosenstock, J.R., Peipert, J.F., Madden, T., Zhao, Q. & Secura, G.M. (2012). Continuation of reversible contraception in teenagers and young women. Journal of Obstetrics and Gynecology, 120(6), 1298-1305.

Roumen, F.J.M.E., Apter, D., Mulders, T.M.T., & Dieben, T.O.M. (2001). Efficacy, tolerability, and acceptability of a novel contraceptive vaginal ring releasing etonogestrel and ethinyl oestradiol. Human Reproduction, 16(3), 469-475.

Roumen, F.J.M.E., op ten Berg, M.M.T., & Hoomans, E.H.M. (2006). The combined contraceptive vaginal ring (NuvaRing®): First experience in daily clinical practice in The Netherlands. European Journal of Contraception and Reproductive Healthcare, 11(1), 14-22.

Sanogo, D., RamaRao, S., Jones, H., N'diaye, P., M'bow, B., & Diop, C. B. (2003). Improving quality of care and use of contraceptives in Senegal. African Journal of Reproductive Health, 7(2).

Singh, S., Sedgh, G., & Hussain, R. (2010). Unintended pregnancy: worldwide levels, trends, and outcomes. Studies in Family Planning, 41(4), 241-250.

Sivin, I., Alvarez, F., Mishell Jr, D. R., Darney, P., Wan, L., Brache, V., ... & Stern, J. (1998). Contraception with two levonorgestrel rod implants: a 5-year study in the United States and Dominican Republic. Contraception, 58(5), 275-282.

Sivin, I., Campodonico, I., Kiriwat, O., Holma, P., Diaz, S., Wan, L., ... & Stern, J. (1998). The performance of levonorgestrel rod and Norplant® contraceptive implants: a 5 year randomized study. Human Reproduction, 13(12), 3371-3378.

Sivin, I., Díaz, S., Croxatto, H. B., Miranda, P., Shaaban, M., Sayed, E. H., ... & Jackanicz, T. (1997). Contraceptives for lactating women: a comparative trial of a progesterone-releasing vaginal ring and the copper T 380A IUD. Contraception, 55(4), 225-232.

Sonfield, A. (2007). Popularity disparity: Attitudes about the IUD in Europe and the United States. Guttmacher Institute. Retrieved from .

Sonfield, A., & Gold, R.B. (2012). Public funding for family planning, sterilization, and abortion services, FY 1980-2010. Guttmacher Institute. Retrieved from

Sonfield, A. & Kost. K. (2013). Public costs from unintended pregnancies and the role of public insurance programs in paying for pregnancy and infant care: Estimates for 2008. Guttmacher Institute. Retrieved from

Stuart, J. E., Secura, G. M., Zhao, Q., Pittman, M. E., & Peipert, J. F. (2013). Factors associated with 12-month discontinuation among contraceptive pill, patch, and ring users. Obstetrics & Gynecology, 121(2, Part 1), 330-336.

Suhonen, S., Haukkamaa, M., Jakobsson, T., & Rauramo, I. (2004). Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: A comparative study. Contraception, 69(5), 407-412.

Teal, S.B. & Sheeder, J. (2012). IUD use in adolescent mothers: Retention, failure, and reasons for discontinuation. Contraception, 85(3), 270-274.

Tewari, R. & Kay, V.J. (2006). Compliance and user satisfaction with the intrauterine contraceptive device in Family Planning Service: The results of a survey in Fife, Scotland, August 2004. European Journal of Contraception and Reproductive Health Care, 11(1), 28-37.

Trussell, J. (2007). The cost of unintended pregnancy in the United States. Contraception, 75(3), 168-170.

Trussell, J. (2011). Contraceptive failure in the United States. Contraception, 70(2), 397-404.

United States Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Prenatal services. (n.d.) Retrieved from

United States Department of Health and Human Services, Healthy People 2020. (2011). Family planning: Objectives. Retrieved from cId=13

Vaughan, B., Trussell, J., Kost, K., Singh, S. & Jones, R. (2008). Discontinuation and resumption of contraceptive use: Results from the 2002 National Survey of Family Growth.

Westfall, J.M., Main. D.S., & Barnard, L. (1996). Continuation rates among injectable contraceptive users. Family Planning Perspectives, 28(6), 275-277.

Westhoff, C. L., Heartwell, S., Edwards, S., Zieman, M., Stuart, G., Cwiak, C., ... & Kalmuss, D. (2007). Oral contraceptive discontinuation: do side effects matter? American Journal of Obstetrics and Gynecology, 196(4), e1-e7.

Whitaker, A. K., & Gilliam, M. (2008). Contraceptive care for adolescents. Clinical Obstetrics and Gynecology, 51(2), 268-280.

Zibners, A., Cromer, B.A., & Hayes, J. (1999). Comparison of continuation rates for

hormonal contraception among adolescents. Journal of Pediatric Adolescent Gynecology, 12(2), 90-94.

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[1]Depot medroxyprogesterone, an injectable contraceptive, was approved by the FDA in 1992 and the patch did not come on the market until early in the 2000s.

[2]It should be noted that more recent studies have found that broad speum antibiotics do not reduce the efficacy of oral contraceptives. (Archer & Archer, 2002; Helms et al., 1997.)

-----------------------

FACTORS ASSOCIATED WITH DISCONTINUATION OF HORMONAL CONTRACEPTIVES

by

Kathleen J. Ly

B.A., University of Pittsburgh, 2012

Submitted to the Graduate Faculty of

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh

2014

UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

This essay is submitted

by

Kathleen J. Ly

on

August 8, 2014

and approved by

Essay Advisor:

Martha Ann Terry, PhD ___________________________________

Assistant Professor

Department of Behavioral and Community Health Sciences

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Elizabeth M. Felter, DrPH ___________________________________

Visiting Assistant Professor

Department of Behavioral and Community Health Sciences

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Tammy M. Haley, PhD ___________________________________

Associate Professor

Department of Nursing

University of Pittsburgh, Bradford

Copyright © by Kathleen J. Ly

2014

Martha Ann Terry, PhD

FACTORS ASSOCIATED WITH DISCONTINUATION OF HORMONAL CONTRACEPTIVES

Kathleen Ly, MPH

University of Pittsburgh, 2014

Figure 1. Results of literature search

*Figure does not include Moreau, Cleland, & Trussell (2007), which provided a lifetime discontinuation percentage

Figure 3. Discontinuation rates of oral contraception, by time (months) and percentage

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Figure 9. Discontinuation rates of implant contraceptives, by time (months) and percentage

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