National Partnership for Women & Families

Monthly Women's Health Research Review

Study Examines Predictors of Contraceptive Discontinuation Rate Among Teens

Summary of "Predictors of Early Discontinuation of Effective Contraception by Teens at High-Risk of Pregnancy," Maslyanskaya et al., Journal of Pediatric and Adolescent Gynecology, Oct. 22, 2015.

Though teen pregnancy rates have "continued to decline over the past decade," driven by "an improvement in use of effective contraception by teens," the nation "still has the highest rate of teen pregnancy among high-income countries," according to Sofya Maslyanskaya, assistant professor of pediatrics at the Children's Hospital at Montefiore, and colleagues.

The researchers wrote, "A better understanding of factors that predict discontinuation of effective contraception by teens at high risk of pregnancy will help in promoting strategies to increase adherence and further decrease the teen pregnancy rate." Their study aimed "to assess predictors of early discontinuation of effective contraception during typical use by adolescents living in Bronx County," N.Y.

Methods

Between July 2012 and December 2013, the researchers recruited 145 "13-20 year-old females choosing a short-acting hormonal contraceptive method or an [intrauterine device] during a health care visit" at four health care centers in Bronx County. According to the researchers, the four centers provided IUDs, "depot medroxyprogesterone (DMPA), combined oral contraceptive pills (COCs), transdermal patch (Patch), and intravaginal ring (Ring)."

Although all methods could be provided on the participants' initial visit, "most participants choosing IUDs were given an appointment to return at a later date for insertion" because of a lack of available providers able to insert the device at the first visit.

According to the researchers, all participants completed a questionnaire that asked about parental acculturation, school achievement, health literacy and reproductive history. Participants also were interviewed to assess contraceptive continuation rates "at 3 and 6 months after enrollment." The researchers obtained continuation-rate data on "130/145 (90%) of [their] participants."

Results

The researchers found that of the 130 participants checked at six months, "34 (26%) chose [an] IUD, 10 (8%) chose DMPA, 63 (48%) chose COCs, 17 (13%) chose Patch, and 6 (5%) chose Ring." Overall:

  • 10 (29%) of the 34 participants who opted for an IUD had the device inserted at their initial visit, while 24 (71%) scheduled a follow-up appointment for insertion;
  • All 10 participants who chose DMPA received their first injection at their initial visit; and
  • 21 (24%) of the participants who chose COCs, Patch or Ring received a two- or three-month supply at their initial visit, while 65 (76%) were given a prescription for their preferred method.

According to the researchers, 49 of the 130 participants (38%) were "using their chosen contraceptive method at 6 months." Twenty-eight of the 130 participants (22%) said they never initiated their selected contraceptive method, and among the 78% of participants who initiated their selected method, 48% were still using the method at six months.

Comparison of Users and Non-Users

The researchers did not find any differences between contraceptive users and non-users at six months based on cultural and social characteristics, prior hormonal history, previous pregnancy or parental acculturation.

However, the researchers did find differences between users and non-users at six months based on contraceptive use. According to the researchers, "The IUD was the only method for which the proportion of 6-month users was higher than the proportion of non-users." Overall, among participants who selected a contraceptive method and were assessed at 6 months: "21/34 (62%) were using the IUD; 2/10 (20%) were using DMPA; 25/63 (40%) were using COCs; and 2/23 (9%) were using Patch or Ring."

Timing of initiation also had an effect on continuation rates. Overall, the 10 participants who opted for an IUD and had it inserted at their initial visit were still using it at six months. In contrast, "only 14/24 (58%) of those scheduled for insertion at a later date actually had the IUD inserted," and "only 11/24 (45%) who chose the IUD but had an appointment scheduled for insertion at a later date" were still using the method at six months. Meanwhile, "a very small proportion of participants (14%) who were given 2 or 3 month's supply of COCs, Patch, or Ring at their initial visit were using the method at 6 months compared with a larger proportion using the method at 6 months (35%) who were given a prescription to be filled at a pharmacy."

Timing of Discontinuation Over Six Months by Contraceptive Method

The researchers categorized users who did not initiate their contraceptive method as "day 1 discontinuers."

According to the researchers, day 1 discontinuers included:

  • 48% of participants who selected the Patch or Ring;
  • 29% of participants who selected an IUD; and
  • 1% of participants who selected COCs.

The researchers noted that no DMPA users were day 1 discontinuers. According to the researchers, the largest drop in continuation for DMPA users, as well as for COC users, occurred at 90 days.

Predictors of Contraceptive Discontinuation

According to the researchers, "all other methods" besides IUDs "predicted discontinuation" among the 102 participants who initiated a method. By six months:

  • Participants who used COCs were nearly seven times more likely to discontinue use than IUD users;
  • DMPA users were "almost 6 times more likely to discontinue the method" than IUD users;
  • Participants who previously used "hormonal contraceptives were almost twice as likely as first-time users to discontinue their method"; and
  • Users who left school prior to their high school graduation were more than eight times more likely to discontinue their contraceptive method than users who were currently in school or who had graduated high school.

Reasons for Not Initiating or Discontinuing the Chosen Contraceptive Method

The researchers also found that "[t]he reason most participants gave for not initiating their chosen method was that they had changed their mind." Further, 27% of participants using the Patch or Ring said they did not begin their method because of a lack of insurance, while 43% of those who opted for COCs but never initiated the method said they did not do so because they had read negative materials about the method.

Among reasons for discontinuing a given method, the researchers found:

  • Two of the three participants who initiated and discontinued an IUD cited side effects, while the third expelled the device;
  • 40% of the 30 participants who initiated but discontinued COCs said they did not remember to take the method, while 30% said they faced obstacles getting the method refilled; and
  • Those who initiated and discontinued DMPA, the Patch or the Ring cited side effects and refill difficulties.

Three participants became pregnant during the study, two of whom had never initiated their selected method.

Discussion

"In this population of Bronx teens at high-risk for pregnancy, nearly two thirds had either never initiated or discontinued their chosen method of effective contraception by 6 months," the researchers wrote. According to the researchers, the greatest predictor of discontinuation among those who initiated a method was the type of method selected, with "[a]ll short-acting hormonal contraceptive methods ... 6 to 12 times more likely to be discontinued by 6 months" in comparison with an IUD. Other factors associated with discontinuation were previous use of a hormonal contraceptive and having left school prior to high school graduation.

Overall, the researchers noted that the IUD had the highest rate of 6-month continuation, at nearly 90%, while COCs had a continuation rate of under 50% and all other methods had "much lower" rates. Further, the researchers found that "day 1 discontinuation was lowest for COCs with almost 90% of teens who were prescribed the method initiating it, intermediate for IUD with 71% initiating the method, and highest for Patch and Ring, with only 52% initiating the method." Meanwhile, the researchers wrote that teens who had an IUD inserted at their initial visit were more likely to be using the method at six months, compared with those who had to schedule a follow-up appointment for insertion. As result, they suggested that IUD initiation likely would be improved, and the teen pregnancy rate reduced further, if clinics offered IUD insertion the day the patient selected it.

Citing the association between previous hormonal contraceptive use and discontinuation, the researchers added that "clinicians might help teens who have discontinued in the past to be more likely to continue using an effective method if the clinician can make the case for not having to refill prescriptions or take daily medicine if the teen chooses a method that lasts for 3 years or longer such as an IUD." They also noted that as participants who had left school prior to high school graduation were more likely to discontinue their selected contraceptive method, "contraceptive discontinuation should be considered as another high-risk behavior associated with poor educational outcomes."

According to the researchers, their study affirms prior research showing that long-acting reversible contraception is "the least likely metho[d] to be discontinued" among teens. However, barriers to LARC use among teens includes a "lack of providers who are trained in IUD insertion" and reluctance among some providers to recommend IUDs to teens. The researchers wrote, "We provide evidence that the inability to provide same-day IUD insertions for teens is a significant barrier to initiation of this highly effective contraceptive method." They suggest that increasing provider training for IUD insertion, as well as "improved education about [the American Congress of Obstetricians and Gynecologists] and [the American Academy of Pediatricians] guidelines for IUD use as first line contraceptives for adolescents would help to improve utilization of the method in teens and, thus, to decrease teen pregnancy rates."