Contraceptive Dynamics in Rural Northern Malawi: A Prospective Longitudinal Study

Abstract

Context-Increased use of contraceptives in Malawi has not translated into a commensurate reduction in fertility, but the reason is unknown. Insight into contraceptive switching and discontinuation may shed light on this conundrum and on whether the commonly used modern contraceptive prevalence rate (mCPR) is the best indicator of family planning program performance.Methods-A one-year prospective longitudinal data set was created from patient-held family planning cards of 4,678 reproductive-age women living in a demographic surveillance site in rural northern Malawi. Contraceptive service data recorded on the women's cards by providers were linked to their socioeconomic, demographic and health data. Contraceptive point prevalence estimates calculated from these data were compared with mCPR estimates from cross-sectional surveys. Survival analyses examined contraceptive adherence.Results-The contraceptive point prevalence of 35% was slightly lower than comparable crosssectional estimates of mCPR. Only 51% of users of the injectable-the most widely used modern method-received their first reinjection on time, and just 15% adhered to the method for 12 months. Although various study variables were associated with contraceptive use, none were associated with adherence.Conclusions-Gaps in and discontinuation of use of the injectable may play a role in the discrepancy between mCPR and fertility. Interventions to help women adhere to injectable use and to promote long-acting methods should be strengthened.Malawi is a poor country in Sub-Saharan Africa that has made attempts to address its population and fertility problems,1-5 by initiating programs to encourage birthspacing6 and by organizing conferences on population and development.1,7-9 Such activities may be showing some results. Malawi's modern contraceptive prevalence rate (mCPR)-the proportion of women of reproductive age who report that they (or their partner) are currently using a modern contraceptive-was six times as high in 2010 as it was in 1992 (42% vs. 7%),10 a remarkable achievement and a higher level of use than in other countries in the region.11 During that period, the percentage of married women using the injectable rose from 1.5% to nearly 26%.10 Present author contact: dasgupta@un.org. The mCPR is the most widely used measure of success of contraception programs.12,13 It is typically captured in Demographic and Health Surveys (DHS), the Multiple Indicator Cluster Survey and other large-scale national surveys with the question "Are you currently doing something or using any method to delay or avoid getting pregnant?" If the reply is "yes," the woman is asked what method she is using; nonmodern methods (e.g., withdrawal, the calendar method) are excluded for calculation of mCPR. Europe PMC Funders GroupGiven Malawi's high mCPR, the country has been heralded by the international community as a success story.14 However, the country's total fertility rate (TFR) has decreased only marginally, from 6.7 births per woman in 1992 to 5.7 in 2010,10 and r...

Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial

“…For example, in a prospective longitudinal study that used patient-held records, researchers found an 85% discontinuation rate among users of injectable contraception in rural northern Malawi. 9 However, the point estimate of the prevalence of modern contraceptive use that these researchers calculated using their longitudinal data was lower than modern contraceptive use estimates reported from other cross-sectional surveys for this population. This suggests that conventional estimates of contraceptive use might be overestimates if, when responding to survey questions about past use, women consider themselves to be contraceptive users even if they were late for re-injection.…”

“…8 Injectables are the most widely used modern method in Malawi: nearly a third of currently married women (30%) who practised modern family planning in 2015-16 used injectables. However, according to findings from a study in rural Malawi, 9 only half of new users received their first follow-up injection within 13 weeks, and method switching is not common among women who discontinue for method-related reasons. 5 In a study from 2012, 38% of women in Malawi who did not switch to another method after discontinuing for method-related reasons became pregnant and more than half of those pregnancies were either mistimed or unwanted.…”

Postpartum uptake of contraception in rural northern Malawi: A prospective study

“…Elsewhere we show high discontinuation of short-term methods in northern Malawi [16]. Therefore, provision of short-term methods in the immediate postpartum period is unlikely to be effective, given the low risk of pregnancy for women during this time and high probability of discontinuation by the time the woman resumes sexual activity and menstruation [17].…”

Incidence of induced abortion in Malawi, 2015

“…However, recent increases in contraceptive use in Malawi have not translated into lower fertility rates [26]. Several plausible explanations for this seeming disconnect have been put forward, including that contraceptive increases may be occurring among women at lower risk of pregnancy, or potentially due to contraceptive discontinuation [32]. Furthermore, simultaneous increases in contraception and abortion can occur in the context of concurrent increases in desire for smaller family size [33].…”