Factors associated with the discontinuation of modern contraceptive methods among lactating women in nine West African high-fertility countries: findings of the most recent demographic and health surveys

Family planning (FP) includes all practices that enable individuals or couples to avoid unwanted pregnancies, regulate the time between two pregnancies, and decide when to have children and how many to have, depending on their age and socioeconomic characteristics [1]. Appropriate use of family planning not only helps to avoid unwanted pregnancies but also reduces maternal mortality due to unsafe abortions and prevents sexually transmitted diseases [2, 3]. Modern contraception is, therefore, an important mechanism for controlling high fertility and improving the physical and economic well-being of women and their families [4, 5]. In addition to these benefits, it contributes to healthy and productive families, food security, and sustainable development in low- and middle-income countries [5].

Despite these benefits, contraceptive use among women of childbearing age is low in low-income countries [6, 7]. This is reflected in the high fertility rate in this part of the world. In 2021, the World Bank identified ten countries in sub-Saharan Africa with fertility rate above 5, higher than the world and African averages of 2.47 and 4.44, respectively [8].

The situation is the most worrying because, despite these low levels of use, a significant proportion of women discontinue modern contraception prematurely [9, 10]. The word "discontinuation" is used to refer to women who have started a contraceptive method and stopped using it for any reason while they are still at risk of getting pregnant [11]. According to Family Planning 2020, more than one-third of women who started using a modern contraceptive method stopped using it within the first year, and more than half stopped before two years [11]. According to the WHO, after three months of use, 40% of women in Egypt, 51% in Kenya, 73% in Malawi, 56% in Tanzania, and 47% in Zimbabwe were at risk of becoming pregnant [12].

The issue of women discontinuing contraception, in general, is so worrying that several authors have studied the topic. In 2016, Fekadu et al. concluded that majority of women in Ethiopia had stopped using contraception after three years [13]. Ouédraogo et al. reported similar findings in Burkina Faso, Mali, and Niger in a multi-country study in 2021 [14]. The problem is even more worrying for breastfeeding women with a live child under 24 months. This group of women is exposed to the potential risk of an imminent pregnancy, with all the possible severe complications. This means that stopping contraception exposes these women to a new pregnancy with a birth interval of less than 33 months, which is below the WHO recommendations of at least 24 months to avoid a very high risk of morbidity and mortality for the woman and her child [15, 16].

To the best of our knowledge, no study has examined contraceptive discontinuation among breastfeeding women with a child under 24 months of age. The rationale for conducting this study in breastfeeding women is that, firstly, particularly in sub-Saharan Africa, discontinuation of modern contraception in women of childbearing age or young women has been widely studied in the literature [12, 15, 17‐20]. Secondly, one of the reasons women give for stopping contraception is the desire to have a child, and finally, according to the World Health Organisation, a woman who becomes pregnant less than 24 months after her last birth is exposed to several health risks [15, 16]. We therefore wanted to study the factors associated with contraceptive discontinuation in breastfeeding women with an under 24-months child.

The interest of our study is, therefore, to examine modern contraceptive methods discontinuation among breastfeeding women and its associated factors using the DHS data from nine West African countries with high fertility rates.

We identified factors associated with modern contraceptive discontinuation among breastfeeding women with a live child under 24 months of age. Overall, the prevalence of modern contraceptive discontinuation was 13.1%. We find this prevalence quite worrying because of the consequences that discontinuation can have on women’s reproductive health. Contraceptive discontinuation among breastfeeding women, who would be exposed to short birth intervals if they became pregnant, is associated with high rates of unintended pregnancies, leading to unsafe abortion and maternal and infant morbidity and mortality [26‐31]. Our finding may be explained by the fact that breastfeeding women's specific family planning needs are not considered. Also, the methods available may not be adapted to their needs, and the follow-up of women who are using modern contraception is ineffective in our context. Women do not receive enough information about the possible side effects of the methods they choose [32]. All this contributes significantly to contraceptive discontinuation. In addition, several studies have previously reported a large number of women who stopped using contraception when they were at risk of getting pregnant [13, 14, 27, 28, 33].

This study found that side effects were the most common reason for discontinuation (29.1%). This worrying result means that a significant proportion of women stopped using contraception for reasons other than wanting to become pregnant. In other words, these women will become pregnant early and have unwanted pregnancies. However, the findings on side effects as the most common reason for discontinuation aligns with previous studies [30, 34, 35]. On the other hand, other studies have shown that wanting to become pregnant is the most common reason for stopping modern contraception [28, 36, 37]. This difference could be explained in our context by the prevalence of misconceptions about contraception, as reported by Tran et al. in Burkina Faso and the Democratic Republic of Congo in 2018 [38] and Alvergne et al. in Ethiopia in 2017 [39]. A literature review of factors influencing contraceptives use in sub-Saharan Africa between 2005 and 2015, published in 2017, also found that the negative factors reducing contraceptives use were women misconceptions about the side effects of contraception [40]. Awareness campaigns should be conducted to minimise the extent of these misconceptions about contraception. Husbands' reluctance to women's contraception use is also an important reason why breastfeeding women do not use contraception (6.7%). Several studies have found similar results [31, 38, 40]. It is therefore necessary to develop awareness-raising and information campaigns aimed at men so that they accept their wives use of contraceptive methods. In fact, a systematic review has shown that men related interventions are effective in increasing contraceptive use [41].

In this study, the final multilevel multivariate model showed that the type of method used, being the head of the household, lack of sexual activity, desire for children, and country of origin were the most important factors associated with contraceptive discontinuation.

Users of long-acting contraceptive methods, such as IUDs and implants, were less likely to stop using contraception than users of short-acting methods, such as the pill and injectables. These findings are similar to those of previous studies [28, 34, 39, 42‐45]. In contrast to short-acting contraceptives, the lower discontinuation rate for long-acting methods may be explained by the fact that they are more difficult to discontinue and that their discontinuation requires the intervention of health professionals and sometimes has financial implications [44, 46, 47]. Women who were heads of household are more likely to discontinue modern contraception than women who were not heads of household. According to Wayack and Moussa (2015), the conditions for a woman to become head of household are, firstly, that she is a widow (40%), then that she is married to a migrant (26%), or that she is single (22%) [48]. Furthermore, according to the same authors, married women with a cohabiting partner do not identify themselves as the head of their household [49]. The lack of sexual activity among this category of women could explain their tendency to stop using modern contraception.

This study shows that despite government efforts to achieve national family planning goals and despite low contraceptive prevalence, a significant proportion of breastfeeding women discontinue contraception. Information on contraception, communication about side effects, access to information through the media, and regular monitoring would enable women to overcome barriers to contraceptives use. This will improve the design and implementation of family planning programs for breastfeeding women.

The study's main strength is its use of information from the reproductive calendar (monthly information). This study has several limitations. The first limitation is recall bias due to the retrospective nature of reproductive calendar data collection and social desirability bias. Regarding recall bias, some authors have explored the reliability score of the reproductive calendar data [50, 51]. For example, Tumlinson and Curtis stated that when using retrospective calendar data, attention must be paid to the potential for individual reporting errors. Anglewicsz et al., used population-based longitudinal data from nine settings in seven countries (Burkina Faso, Nigeria (Kano and Lagos States), Democratic Republic of Congo (Kinshasa and Kongo Central Provinces), Kenya, Uganda, Cote d'Ivoire, and India) to evaluate the reliability score and found that overall, the reliability of the calendar is in the “moderate/substantial” range for nearly all geographies and tests (Kappa statistics between 0.58 and 0.81). These results imply that some recall bias could affect the results of the reproductive calendar data. To mitigate some data quality concerns when using the reproductive calendar data, Bradley et al. [52], suggested that consistent recall of contraceptive use earlier in the six-year calendar period is better, for example, analyzing a shorter period of calendar data (e.g., 2–3 years rather than six years). Given this suggestion, we think these data quality concerns are addressed in this study because we limited the analysis to the last 24 months.

The second limitation is the heterogeneity of the years the DHS was carried out. Unfortunately, this limits the comparability of the results between countries. Although the DHSs used in this study were conducted between 2018 and 2019, we note that the Niger DHS was conducted in 2012 and the Burkina DHS in 2021.

The third limitation of this study is the unavailability of the type of breastfeeding in the databases, which could be a confounding factor. Indeed, as Bryant et al. reported milk supply concerns among women who started hormonal contraception [53], women may be confused as to what impact hormonal contraception has on lactation and infant growth, and so could stop the contraceptive method even if evidence from randomized controlled trials on the effect of hormonal contraceptives on lactation and infant growth is not consistent across trials [54, 55].

The last limitation is related to the data collection techniques. The responses were obtained from women by direct interview and are therefore subject to social desirability biases: women may voluntarily under-report contraceptive discontinuation.

Our study found a contraceptive discontinuation prevalence of 13.1% among lactating women in nine countries in sub-Saharan Africa. Factors associated with contraceptive discontinuation were the type of method used, being the head of the household, lack of sexual activity, desire for children, and country of origin. To help achieve the Sustainable Development Goals and ensure that breastfeeding women continue to use contraception, West African countries should focus on contraceptives education, communication about their side effects, dissemination of family planning messages through the media, and regular monitoring of women using contraception.