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369
Contraceptive Adoption, Discontinuation,
and Switching among Postpartum Women
in Nairobi’s Urban Slums
Joyce N. Mumah, Kazuyo Machiyama, Michael Mutua, Caroline W. Kabiru,
and John Cleland
Unmet need for contraception is highest within 12 months post-delivery, ac-
cording to research. Using longitudinal data from the Nairobi Urban Health
and Demographic Surveillance System, we assess the dynamics of contraceptive
use during the postpartum period among women in Nairobi’s slums. Results
show that by 6 months postpartum, 83 percent of women had resumed sexual
activity and 51 percent had resumed menses, yet only 49 percent had adopted a
modern contraceptive method. Furthermore, almost half of women discontin-
ued a modern method within 12 months of initiating use, with many likely to
switch to another short-term method with high method-related dissatisfaction.
Women who adopted a method after resumption of menses had higher discon-
tinuation rates, though the effect was much reduced after adjusting for other
variables. To reduce unmet need, effective intervention programs are essential
to lower high levels of discontinuation and encourage switching to more effec-
tive methods. (S F P 2015; 46[4]: 369–386)
Estimates indicate that more than 215 million women who wish to postpone childbearing
in low- and middle-income countries are not using any form of modern contraception
(Singh et al. 2009). Discounting the partial protection from lactational amenorrhea,
unmet need for family planning is particularly high among postpartum women (Ross and
Winfrey 2001). Factors associated with nonuse of contraception include low educational and
socioeconomic status, rural residence, and fertility goals (Westoff 2001). The consequences
are high levels of unintended pregnancies, especially in low- and middle-income countries,
with an estimated 73 million such pregnancies in 2012 (Sedgh and Hussain 2014). Unintended
pregnancies have implications for the health and well-being of women and children, because
a woman’s risk of death increases with each successive pregnancy.
Joyce N. Mumah is Associate Research Scientist, Michael Mutua is Data Analyst, and Caroline W.
Kabiru is Research Scientist, African Population and Health Research Center, Population Dynamics and
Reproductive Health Program, APHRC Campus, 2nd Floor Manga Close, Off Kirawa Road, Nairobi,
Kenya. Email: jmumah@aphrc.org. Kazuyo Machiyama is Research Fellow and John Cleland is Emeritus
Professor of Medical Demography, Faculty of Epidemiology and Population Health, London School of
Hygiene & Tropical Medicine, London, United Kingdom.
© 2015 The Authors. Studies in Family Planning published by Wiley Periodicals, Inc. on behalf of The Population Council.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
370 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
In Kenya, according to the 2008–09 Kenya Demographic and Health Survey (KDHS)
(KNBS and ICF Macro 2010), 17 percent of births were unwanted and an additional 26 percent
were mistimed. Low use of contraception and high levels of unmet need for family planning are
largely responsible for the country’s high incidence of unintended pregnancies. Unmet need for
family planning in Kenya is higher within the extended postpartum period than at other times
(Machiyama and Cleland 2014a), perhaps because women are still breastfeeding and the range
of methods available after giving birth is limited. The 2008–09 KDHS shows that 23 percent of
non-first births in Kenya occur less than 24 months apart, because by 12 months postpartum
92 percent of women had resumed sexual activity, 80 percent had resumed menses, yet only 44
percent were using any form of contraception (MCHIP and USAID 2012). It is well established
that such short intervals pose a risk to the survival and health of infants (Tsui and Creanga 2009).
Similarly, Ndugwa and colleagues (2011) investigated the degree to which women in Nairobi’s
urban slums protected themselves against pregnancy during the postpartum period and found
that although women resumed sexual relations early—usually by the third month—many were
not using any form of contraception up to 6 months postpartum. Furthermore, about 12 percent
of these women were pregnant within 12 months of giving birth.
The range of contraceptive methods available after childbirth is a key determinant of
adoption and use, as is the timing of return of menses (Salway and Nurani 1998a; Ali and Shah
2004; Gebreselassie, Rutstein, and Mishra 2008; Borda and Winfrey 2010; Rutstein and Win-
ter 2014). A multicountry analysis by Ali and Shah (2004) showed that less than 30 percent of
women adopt a method before the return of menses, while a study in Dhaka’s slums showed
that women were more likely to adopt a method after the resumption of menses (Salway and
Nurani 1998a). In Peru and Indonesia, only half of modern methods were available to couples,
and this factor was likely the reason for high use of periodic abstinence (Becker and Ahmed
2001). In Swaziland, half of the women who had reported use of condoms during the postpar-
tum period had an unintended pregnancy (Warren, Abuya, and Askew 2013), indicating that
use of short-term methods was often not effective in avoiding pregnancy. In Kenya, the vast
majority of women practicing contraception used short-term hormonal methods (i.e., inject-
ables and pills). Discontinuation of these methods is high, with a median duration of use of
9.8 and 15.4 months, respectively (Ali, Cleland, and Shah 2012). Moreover, only 30 percent of
women who discontinued for method-related reasons switched to a modern method within
three months of discontinuation (ibid.). Thus, both adoption of postpartum family planning
and continuation of use have important policy and program implications.
Studies on postpartum contraceptive use have relied on cross-sectional data, with the nota-
ble exception of Salway and Nurani (1998a and 1998b) in Bangladesh. Moreover, most previous
research on postpartum family planning focuses on the timing of contraceptive adoption, with
limited examination of continuation of contraceptive use or switching after discontinuation. Our
study draws on longitudinal data to address these gaps in evidence and to answer the following
questions: (1) To what extent does postpartum contraceptive use overlap with lactational pro-
tection or postnatal abstinence? (2) Is the timing of contraceptive adoption (e.g., before or after
resumption of menses) among women in urban slums related to length of use? (3) To what extent
do baseline fertility preferences (e.g., want another child or not) predict successful prolonged use?
and (4) To what extent do women promptly switch to another method after discontinuation?
The longitudinal nature of our data is well suited for examining the dynamics of postpartum
Mumah et al. 371
December 2015 Studies in Family Planning 46(4)
contraception and also implies greater accuracy in the dating of events than most other analyses
that use retrospective data. Our data allow us to ascertain the temporal sequence of events—that
is, resumption of sex and adoption of contraception in relation to resumption of menses.
METHODS
Study Setting
This study focuses on two Nairobi slums—Viwandani and Korogocho—where the African
Population and Health Research Center (APHRC) runs the Nairobi Urban Health and Demo-
graphic Surveillance System (NUHDSS). As of December 2012, the NUHDSS—which collects
and monitors health and demographic data among residents living in the two slums—covered
approximately 66,000 people in about 27,000 households. Residents of these two slums face chal-
lenges that are often triggered by pervasive poverty and unmet service-provision needs, including
poor housing, poor sanitation facilities, and poor health services. Of particular relevance to our
study, the sexual and reproductive health outcomes on some indicators for women in slums are
worse compared with their counterparts in broader Nairobi. For example, the maternal mortality
ratio (MMR) in slums is estimated at 709 deaths per 100,000 live births (APHRC 2002), almost
double the national ratio, estimated at 488 per 100,000. A study by Ziraba and colleagues (2009)
found that most maternal deaths in slums occurred because labor and abortion were not man-
aged properly, with less than 50 percent of women seeking care at a health facility.
Data
Our study draws on data from the Maternal and Child Health component of a broader project
entitled ‘‘Urbanization, Poverty, and Health Dynamics,’’ which was nested in the NUHDSS.
All women residing in NUHDSS sites who gave birth since September 2006 and their children
were enrolled in the project. Follow-up visits were carried out every four months. Our study
uses data on women who were interviewed at least three times and thus provide a minimum
of 12 months of information. The first baseline observations (Cohort 1 and Wave 1) took
place between February and April 2007, with follow-up visits and new recruitments made
routinely thereafter. Overall, 5,345 women were recruited by the end of the study in October
2010. Data on reproductive events such as breastfeeding, postpartum amenorrhea and absti-
nence, contraceptive use, sexual behavior, and fertility intention were collected since the birth
of the index child using a monthly calendar method. Interviews were conducted in Swahili,
and trained fieldworkers recruited mothers and their children during each visit; these moth-
ers formed new cohorts, while updated information was obtained from mothers recruited in
the previous cohort. We use data from seven cohorts of women collected since February 2007.
Table 1 shows relatively high attrition across the waves, an expected feature of surveillance in
a slum population. For example, of the 363 women who were enrolled in the first cohort, only
148 were reinterviewed during the tenth visit. In this regard, out of the 10 cohorts of women
interviewed during 2007–10, only 7 cohorts (1–6 and 8) had sufficient numbers of women
with 12 months of continuous calendar data to be included in our analysis (N=3,579). As a
result of attrition and our selection criterion, we assessed the sample to ascertain whether
372 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
women retained for analysis were statistically different from those excluded. After checking
for differences, we found that the characteristics of women retained in our analysis were not
very different from those of the women not included (not shown). However, a slightly higher
proportion of women reported being Kamba, had completed primary education, and were
primiparous, compared with the women retained for analysis.
Ethical approval for the NUHDSS and Urbanization, Poverty, and Health Dynamics
(UPHD) research programs was received from the Ethical Review Board of the Kenya Medi-
cal Research Institute.
Analysis
Survival analysis was used to estimate the probability of adoption of first contraceptive method
in the first 12 months postpartum. We further computed discontinuation rates based on all
women who adopted a family planning method. While survival analysis on time to adoption
uses woman-months since the birth of the index child observed, cumulative discontinuation
rates are based on episodes of use of any contraceptive method. An episode in this study is
defined as a period of uninterrupted use (in months) that might still be ongoing (Ali, Cleland,
and Shah 2012). Discontinuation rates are presented at 3, 6, and 12 months postpartum. We
compute hazards of adopting a modern contraceptive method and of discontinuation of any
contraceptive method using the Cox proportional hazard model. In analyzing adoption of
the first modern method, we use mother’s age at birth of index child, marital status at recruit-
ment, level of education at recruitment, parity, baseline fertility intention, site, and ethnicity
as explanatory variables. In analyzing discontinuation, in addition to the above-mentioned
explanatory variables, we also use timing of contraceptive adoption, type of contraception,
and breastfeeding status as explanatory variables. To assess possible problems of collinearity,
we ran separate discontinuation analyses with fertility intention and parity. Results showed
no significant differences, so we present the results with both variables included. We used life
table methods to estimate the reproductive status of women at 1, 3, and 6 months after dis-
continuation due to method-related or unspecified reasons, thereby excluding cases where
discontinuation reflected the desire for another child. For the switching analysis, among the
844 women who discontinued the first postpartum contraceptive method for method-related
or unstated reasons, data were missing for 128 women at 6 months after discontinuation and
were therefore excluded from the analysis, leaving 716 women.
TABLE 1 Number of women interviewed during 2007–10, with at least 12 months of continuous
calendar data since birth of index child
Wave 1a Wave 2a Wave 3 Wave 4 Wave 5 Wave 6 Wave 7 Wave 8 Wave 9 Wave 10 Total
Cohort 1a 363 374 370 337 296 262 220 198 177 148 2,745
Cohort 2 — 281 280 274 254 237 224 211 184 167 2,112
Cohort 3 — — 481 475 463 438 414 391 360 398 3,420
Cohort 4 — — — 696 689 670 608 549 423 379 4,014
Cohort 5 — — — — 331 332 331 303 261 208 1,766
Cohort 6 — — — — — 606 609 601 534 414 2,764
Cohort 8 — — — — — — — 478 479 446 1,403
Total 363 655 1,131 1,782 2,033 2,545 2,406 2,731 2,418 2,160 18,224
aCohort 1 (Waves 1 and 2): 11 women interviewed in Wave 2 did not have calendar data in Wave 1.
NOTE: Cohorts 7, 9, and 10 had very few women recruited into the study and few women with 12 months of continuous data.
Mumah et al. 373
December 2015 Studies in Family Planning 46(4)
To assess the timing between contraceptive use and resumption of menses and of sexual
activity since birth of the index child, we classify the monthly calendar into ordinal month
since the birth of the index child, using the classifications of mutually exclusive categories of
protection and risk with regard to contraceptive use as defined by Ndugwa and colleagues
(2011). Protection and risk categories include the following. Protected: Months a woman is
considered protected if she has not yet resumed sexual activity (irrespective of whether she is
amenorrheic). Partially protected: A woman is considered to have partial protection during
months she is amenorrheic but sexually active, since she is at risk of getting pregnant. Exposed:
Months of exposure includes months where a woman is not amenorrheic and is sexually active.
These months are considered protected if the woman was using any type of modern contracep-
tive method. Currently pregnant: Defined as months of pregnancy after birth of the index child.
RESULTS
Table 2 shows the summary of selected background characteristics for the 3,579 women with
12 months of continuous data from the seven cohorts in our sample. About 53 percent of the
TABLE 2 Background characteristics of women at recruitment during 2007–10, based on all
women having at least 12 months of continuous calendar data since birth of index child
Characteristic Percent Number of women
Site
Korogocho 52.9 1,892
Viwandani 47.1 1,687
Mother’s age at birth
15–24 55.9 1,999
25–34 36.7 1,315
35–49 7.4 265
Mother’s marital status at recruitment
Currently married/cohabiting 83.4 2,986
Previously married 6.1 220
Never married 10.4 373
Mother’s level of education at recruitment
No education/incomplete primary 29.8 1,066
Complete primary 46.4 1,660
Secondary + 23.3 833
Missing 0.6 20
Ethnicity
Kikuyu 26.5 950
Kamba 19.6 700
Luo 18.9 676
Luhya 17.8 636
Other 17.2 617
Parity
1 28.9 1,034
2 25.2 903
3 15.8 564
4 and above 20.5 732
Missing 9.7 346
Baseline fertility intentionsa
Wanted more 56.7 2,021
Wanted no more 32.1 1,145
Undecided/missing/not askeda 11.2 399
Total 100.0 3,579
aBaseline prospective fertility intention was not asked of pregnant women.
374 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
women resided in Korogocho. The majority of women were between ages 15 and 24 (56 per-
cent), and most women reported being in a marital union or living with a partner at the time
of recruitment (83 percent). Nearly half had completed primary school (46 percent). The most
common ethnic group was Kikuyu (27 percent). About 29 percent of women were primipa-
rous, 25 percent had two children, and 21 percent had 4 or more children. At the first inter-
view, more than half (57 percent) wanted more children.
Time to Menstrual, Sexual, and Contraceptive Use Resumption
Using survival analyses, we employ monthly calendar data to estimate the first occurrence of
modern contraceptive use, initiation of sexual activity, and resumption of menses since the
birth of the index child. Figure 1 shows the survival curves for time to first menses, first use of
modern contraception, and sexual resumption by ordinal postpartum month. By 6 months
postpartum, about 49 percent of women in our sample had resumed menstruation. About 56
percent to 83 percent of women had resumed sexual relations by 3 and 6 months postpartum,
respectively, suggesting that sexual activity typically preceded resumption of menses. Finally,
49 percent of women in the sample initiated modern contraceptive use at 6 months postpar-
tum. Survival probabilities for all three events show that by 12 months postpartum, more than
90 percent of the women had resumed sexual relations, only 30 percent had not yet resumed
menses, and about 60 percent had initiated use of modern contraception.
Menstrual Resumption, Sexual Activity, and Contraceptive Use
by Months Since Birth
Table 3 provides summary data for various categories of monthly postpartum protection and
pregnancy risk, defined by contraceptive use, sexual activity, and menstrual and pregnancy sta-
01234567 8910 11 1201234567 8910 11 12
MonthsMonths
FIGURE 1 Number of months to menstrual resumption, rst use of modern contraception,
and resumption of sexual relations among postpartum women in Nairobi’s slums, 2007–10
Resumption of menses
Sexual resumption
First modern FP use
0
0.2
0.4
0.6
0.8
1
2
4
6
0.
8
1
Survival probability
0.1
0.3
0.5
0.7
9
Mumah et al. 375
December 2015 Studies in Family Planning 46(4)
tus, for the first 12 months since the birth of the index child. A total of 42,948 woman-months
were observed. Only 0.6 percent of the woman-months comprised pregnancy, though this is
likely be an underestimate because of underreporting of first-trimester pregnancies. Over the
whole 12-month postpartum period, 36 percent of months were protected by contraception
and 36 percent by sexual abstinence. Partial protection from amenorrhea accounted for about
18 percent of months, and 10 percent were unprotected. As expected, the roles of contracep-
tion, abstinence, and amenorrhea change radically during the 12-month period. In the first
three months postpartum, sexual abstinence (without contraception) dominates, accounting
for more than 80 percent of woman-months. By months 10–12, this contribution has shrunk
to about 16 percent. The contribution of partial protection from lack of menses after resump-
tion of sex peaks at 26 percent of woman-months at 4–6 months postpartum and falls to about
18 percent by months 10–12. The proportion of woman-months protected by use of contra-
ception increases steadily from 11 percent in the first three months to 49 percent in the final
three months. Despite this rise in contraceptive protection, full exposure to risk of pregnancy
grows from less than 1 percent in the first three months to about 9 percent, 14 percent, and 16
percent over succeeding three-month segments.
Table 3 also shows overlaps between different protective states. As noted earlier, contra-
ceptive use accounts for about 36 percent of all months in the first postpartum year. Of this
total, 5 percent was redundant because of protection from abstinence and a further 10 percent
partially redundant because of amenorrhea. Thus, out of the total of 15,238 woman-months
of contraception (sum of last column in rows 1–4), 6,113 months, or 40 percent, were totally
or partially redundant. This total or partial redundancy is removed when contraceptive use
does not overlap with protection from abstinence or amenorrhea.
Timing of First Contraceptive Adoption and Menstrual Resumption
during the Postpartum Period
The timing of contraceptive adoption in relation to resumption of sexual intercourse and men-
ses has implications for avoiding pregnancy during the postpartum period. Figure 2 shows
that initiation of contraception during the postpartum period peaked during the month of the
first menstrual cycle. About 22 percent of all adopters of a modern method started use in this
TABLE 3 Percent distribution of woman-months of exposure to and protection against pregnancy
among postpartum women in Nairobi’s slums, by months since birth of index child, 2007–10
Total woman-
1–3 4–6 7–9 10–12 months of
months months months months Total observation
1. FP + No menses + No sex [protected] 4.9 2.3 0.9 0.6 2.2 932
2. FP + No menses + Sex [protected] 2.3 13.1 12.6 10.6 9.7 4,148
3. FP + Menses + No sex [protected] 2.2 2.8 2.2 2.5 2.4 1,033
4. FP + Menses + Sex [protected] 1.9 19.2 29.0 34.9 21.3 9,125
5. No FP + No menses + No sex [protected] 78.7 21.4 10.5 7.0 29.4 12,619
6. No FP + No menses + Sex [partial protection] 4.8 25.7 22.7 17.8 17.8 7,627
7. No FP + Menses + No sex [protected] 4.5 6.5 7.5 8.9 6.8 2,938
8. No FP + Menses + Sex [exposed] 0.8 8.9 14.0 15.9 9.9 4,252
9. Currently pregnant 0.0 0.1 0.6 1.9 0.6 274
Total 100.0 100.0 100.0 100.0 100.0 42,948
Number of woman-months 10,737 10,737 10,737 10,737 42,948
376 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
month, compared with less than 5 percent in the months preceding or following first menses.
Although initiation of sexual activity also tended to peak around menstrual resumption, the
peak was lower compared with contraceptive use, and initiation of sexual activity was more
likely than contraceptive use to precede resumption of menses.
Results (not shown) indicate that, overall, injectables and pills were the most common
choice of contraception during the postpartum period, especially after resumption of menses.
Use of traditional methods was about the same during amenorrhea and after resumption of
menses, with slight uptake observed after resumption of menses. Condom use was quite low dur-
ing the 12 months postpartum, with only 6 percent reporting use during the post-amenorrhea
periods. Long-acting methods such as implants, IUDs, and female sterilization were the least
adopted methods during the 12-month postpartum period.
Analysis showed that the correlates of postpartum uptake of all methods, including tradi-
tional ones, were very similar to the correlates of uptake of a modern method. Thus the results
presented here relate to modern methods. Table 4 provides the unadjusted and adjusted odds
of modern contraceptive adoption at any time in the first year following childbirth. Results
show that compared with women in Korogocho, women in Viwandani were about 1.3 times
more likely to have adopted a modern contraceptive method during the 12-month postpartum
period. Significant differences were observed by marital status: formerly married women and
never-married women were 49 percent and 68 percent less likely, respectively, to adopt a mod-
ern contraceptive method during the 12-month postpartum period. Similarly, women aged
35–49 years had significantly lower odds of adopting a contraceptive method than women aged
15–24 years. Women with secondary or higher education and women who completed primary
education were 1.3 times and 1.2 times more likely, respectively, to adopt a modern contracep-
tive method compared with women having incomplete primary or no formal education. With
respect to parity, only women with four or more children reached the threshold for statistical
significance and were 32 percent less likely to have adopted a method compared with women
who had only one child. Significant differences were also observed by ethnic group: compared
–6 –5 –4 –3 –2 –1 0123456789
0
5
10
15
20
25
Percent
Menstrual months (1st = 0)
FIGURE 2 Resumption o
f
menses an
d
timing o
f
f
irst mo
d
ern contraception
and first sexual intercourse
First modern contraception
after birth
First sex after birth
Mumah et al. 377
December 2015 Studies in Family Planning 46(4)
to Kikuyu women, women from all other ethnic groups had significantly lower odds of adopt-
ing a contraceptive method during the 12-month postpartum period. Women who reported
having no desire for more children at baseline were 1.1 times more likely to adopt a modern
contraceptive method compared with women who reported a desire for more children.
Discontinuation of First Postpartum Contraceptive Method
Self-reported reasons for stopping use of the first method showed that method-related factors,
such as side effects and health concerns, were dominant (50 percent; results not shown). Just
over 10 percent stopped because of infrequent sex, 4 percent reported method failure, and 3
percent had no further need for protection because of the desire for another child or other
reasons. We further assess the dynamics of contraceptive use following the initiation of any
contraceptive method to estimate the length of use of methods. Table 5 shows the cumulative
discontinuation rate for all reasons, per 100 episodes of first contraceptive use, by selected
respondent characteristics among women who had adopted any method. Overall, 19 percent
of women had discontinued their first contraceptive method within 3 months of starting, 32
percent within 6 months, and 49 percent within 12 months. Women who adopted a method
after resumption of menses had higher discontinuation rates, especially within 12 months (54
percent), compared with women who adopted a method before (47 percent) or at the same
TABLE 4 Odds of adopting a modern method of contraception 12 months aer birth among
all women recruited during 2007–10, based on women with at least 12 months of continuous
calendar data
Hazard ratio
Bivariate Multivariate
model Cox PH model
Site (r = Korogocho)
Viwandani 1.519*** 1.266***
Mother’s age at birth (r = 15–24)
25–34 0.982 0.980
35–49 0.529*** 0.585***
Mother’s marital status at recruitment (r = Currently married/cohabiting)
Previously married 0.526*** 0.509***
Never married 0.366*** 0.323***
Mother’s level of education at recruitment (r = No education/incomplete primary)
Complete primary 1.499*** 1.157**
Secondary+ 1.678*** 1.245***
Ethnicity (r = Kikuyu)
Luhya 0.824** 0.766***
Luo 0.591*** 0.596***
Kamba 0.944 0.730***
Other 0.606*** 0.571***
Baseline fertility intention (r = Wanted more)
Wanted no more 0.940 1.137*
Undecided/missing/not asked 0.945 1.020
Parity (r = 1)
2 1.103 0.977
3 1.079 0.916
4 and above 0.674*** 0.680***
Missing 0.815* 0.991
*Significant at p < 0.05; **p < 0.01; ***p < 0.001. (r) = Reference category. PH = Proportional hazards.
378 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
time as resumption of menses (48 percent). Users of condoms and pills had the highest discon-
tinuation rates, while implants were the least discontinued. For example, 51 percent of women
who adopted condoms had discontinued use by 3 months, with the level reaching 84 percent
TABLE 5 Discontinuation of any rst contraceptive method used postpartum, based on women
with at least 12 months of continuous calendar data
Cumulative discontinuation rate
per 100 episodes (percent) Number of
3 months 6 months 12 months FP adopters
Timing of contraceptive adoption
Before resumption of menses 19.2 32.0 46.5 1,178
Same time as resumption of menses 17.3 28.9 48.3 736
Aer resumption of menses 19.6 34.9 53.8 713
Type of contraception
Pills 30.6 48.7 64.2 561
Injectables 13.6 24.0 39.7 1,480
Traditional methods 16.6 34.5 60.1 346
Implants 2.0 5.3 13.2 98
Condoms 50.9 65.4 84.2 118
Other 8.3 26.7 50.4 24
Breastfeeding status at rst adoptiona
Not breastfeeding 22.3 37.7 62.0 142
Breastfeeding 18.5 31.6 48.3 2,477
Site
Korogocho 17.9 30.9 51.1 1,230
Viwandani 19.6 32.5 46.7 1,397
Mother’s age at birth
15–24 20.9 34.2 51.2 1,494
25–34 16.5 28.9 46.7 984
35–49 12.9 28.3 38.9 149
Mother’s marital status at recruitment
Currently married/cohabiting 17.5 30.5 46.6 2,332
Previously married 33.2 47.9 69.2 122
Never married 26.6 38.9 67.7 173
Mother’s level of education at recruitmentb
No education/incomplete primary 20.6 33.8 54.0 660
Complete primary 17.7 30.9 47.9 1,279
Secondary + 19.1 32.1 45.5 681
Ethnicity
Kikuyu 18.5 30.9 46.0 734
Luhya 16.5 30.2 50.4 478
Luo 16.9 30.9 54.1 433
Kamba 22.0 34.4 48.1 582
Other 19.2 32.5 47.7 400
Baseline fertility intentionc
Wanted more 18.8 32.8 50.2 1,502
Wanted no more 18.2 29.4 44.1 836
Undecided/missing/not asked 21.2 34.9 53.6 284
Parity
1 22.3 34.6 51.3 752
2 18.9 34.2 48.7 708
3 14.3 27.3 46.2 445
4 and above 15.6 28.2 44.7 484
Missing 22.5 32.5 54.3 238
Total 18.8 31.9 48.8 2,627
NOTE: Male/female sterilization (n=27), IUD users (n=11), and emergency contraceptive users (n=5) were excluded from the sample.
aEight episodes do not have data on breastfeeding status at discontinuation.
bSeven episodes do not have data on education.
cFive episodes do not have data on baseline fertility intention.
Mumah et al. 379
December 2015 Studies in Family Planning 46(4)
by 12 months. Similarly, about 31 percent of women who had adopted pills had discontinued
by 3 months, with the level reaching 64 percent by 12 months. Compared with the pill, dis-
continuation of the most commonly used method, injectables, is low, 40 percent by month 12.
Women who were not breastfeeding at the time of adoption had higher discontinuation
rates than women who were breastfeeding. Compared with their married counterparts, for-
merly married and never-married women had substantially higher discontinuation rates. By
3 months, 33 percent of formerly married women and 27 percent of never-married women
had discontinued a method, compared with 18 percent of married women. Similarly, by 12
months, 68 percent of never-married and 69 percent of formerly married women had discon-
tinued a method, compared with 47 percent of their married counterparts. With regard to edu-
cational groups, discontinuation rates were similar at 3 and 6 months. However, at 12 months
a higher discontinuation level was observed among women with incomplete primary or no
formal education (54 percent), especially compared with women with secondary and higher
education (46 percent). No substantial differences were observed by ethnicity, parity, and site.
With regard to mother’s age at birth, women aged 15–24 had substantially higher discontinu-
ation probabilities at 12 months (51 percent) than women aged 35–49 years (39 percent).
Table 6 shows the hazard ratios of discontinuation of the first postpartum method. After
controlling for other variables, women who adopted a method after resumption of menses
were 13 percent more likely to discontinue, compared with women who adopted before re-
sumption of menses. Results for marital status remained significant. After controlling for other
variables, formerly married and never-married women were 2.4 times and 1.7 times more like-
ly to discontinue a contraceptive method, compared with married women. Condoms had the
highest odds of discontinuation, with women 1.7 times more likely to discontinue the method
after adoption compared with pills. All other methods (injectables and traditional) were less
likely to be discontinued, compared with pills. Women with secondary education and higher
had slightly lower odds of discontinuing a method compared with their counterparts having
no formal or incomplete primary education. Women who gave birth between ages 25 and 34
and ages 35 and 49 were also less likely to discontinue compared with women who gave birth
between ages 15 and 24.
Switching aer Discontinuation for Method-Related
or Unspecied Reasons
We analyzed method switching among women who reported discontinuing for reasons that
implied dissatisfaction with their method, or for an unspecified reason, and who therefore still
had a need for contraception. More than half (54 percent) switched within one month of stop-
ping, 63 percent within three months, and 70 percent within six months (results not shown).
Table 7 presents detailed results of method switching at three months after discontinuation
for women who had discontinued for method-related or unspecified reasons, by contraceptive
method used before and after discontinuation. Table 8 shows switching by selected respon-
dent characteristics. Results show that overall, three months after discontinuation, 32 percent
of women were at risk (had not switched to any other method) and 5 percent had become
pregnant. Reproductive consequence for method-related discontinuation was highest for
women who discontinued traditional methods, with 12 percent reporting a pregnancy (Table
380 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
7). Failure to switch to another method (combining women at risk and pregnant) was highest
for injectable users (51 percent), followed by traditional method users (32 percent). The main
choice for women who discontinued pills, condoms, and traditional methods was injectables.
Injectable discontinuers mainly switched to pills (Table 7). Table 8 shows that switching was
TABLE 6 Hazard ratio of discontinuation of rst postpartum method, based
on women with at least 12 months of continuous calendar data
Hazard ratio
Timing of contraceptive adoption
Before resumption of menses 1.000
Same time as resumption of menses 1.024
Aer resumption of menses 1.128
Type of contraception
Pills 1.000
Injectables 0.417***
Traditional methods 0.757**
Implants 0.100***
Condoms 1.692***
Other 0.564
Breastfeeding status at rst adoptiona
Not breastfeeding 1.000
Breastfeeding 0.966
Site
Korogocho 1.000
Viwandani 0.965
Mother’s age at birth
15–24 1.000
25–34 0.848*
35–49 0.677**
Mother’s marital status at recruitment
Currently married/cohabiting 1.000
Previously married 2.407***
Never married 1.710***
Mother’s level of education at recruitmentb
No education/incomplete primary 1.000
Complete primary 0.924
Secondary + 0.840*
Ethnicity
Kikuyu 1.000
Luhya 1.189
Luo 1.121
Kamba 1.076
Other 1.070
Baseline fertility intention
Wanted more 1.000
Wanted no more 0.917
Undecided/missing/not asked 1.092
Parity
1 1.000
2 0.970
3 0.944
4 and above 1.008
Missing 1.036
*Significant at p < 0.05; **p < 0.01; ***p < 0.001.
NOTE: Male/female sterilization (n=27), IUD users (n=11), and emergency contraceptive users (n=5) were
excluded from the sample.
aEight episodes do not have data on breastfeeding status at discontinuation.
bSeven episodes do not have data on education.
Mumah et al. 381
December 2015 Studies in Family Planning 46(4)
lower among women who adopted a contraceptive method after resumption of menses and
highest among women with secondary or higher education. The probability of switching was
unrelated to fertility intentions.
DISCUSSION
Many of the results from our study in two Nairobi slums are encouraging. Calibrated in terms
of woman-months, protection from pregnancy by use of any method of contraception rose
from the low level of 11 percent in the first three months to 37 percent in the following three
months, and further to 45 percent and 49 percent. Postpartum contraceptive use in the Nai-
robi slums is considerably higher than national levels, estimated at 38 percent in the final
three months of the first postpartum year (Winfrey and Rakesh 2014). The results from our
study are lower than the estimate of 34 percent at three months postpartum for Kenya’s urban
population (ibid.).
TABLE 7 Status at three months aer discontinuing any method for method-related or unstated
reasons, by contraceptive method used before discontinuation
Status at 3 months (%)
Contraceptive method Switched to:
used before At Preg- Inject- Con- Traditional Other
discontinuation risk nant Pills ables doms Implants methods methods Total (N)
Pills 20.7 2.5 2.9 60.6 0.4 3.3 6.2 3.3 100 (241)
Injectables 47.1 3.9 29.1 2.6 2.6 5.2 4.6 4.9 100 (306)
Condoms 16.3 7.0 9.3 37.2 11.6 4.7 9.3 4.7 100 (43)
Traditional methods 20.5 11.6 8.9 43.8 3.6 1.8 6.3 3.6 100 (112)
Other 42.8 0.0 21.4 7.1 7.1 14.3 0.0 7.1 100 (14)
Total 32.1 4.7 15.8 30.7 2.6 4.2 5.6 4.2 100 (716)
(N) (230) (34) (113) (220) (19) (30) (40) (30) (716)
TABLE 8 Status at three months aer discontinuing any method for method-related or unstated
reasons, by women’s characteristics
Status at 3 months (%) p-value for
Characteristic At risk Pregnant Switched Total (N) chi-square test
Timing of contraceptive adoption
Before resumption of menses 31.5 2.5 65.9 100 (355)
Same time as resumption of menses 29.7 7.0 63.2 100 (185) 0.076
Aer resumption of menses 35.1 7.0 57.9 100 (171)
Missing (5)
Baseline fertility intention
Wanted more 31.1 5.7 63.2 100 (424)
Wanted no more 34.6 2.0 63.4 100 (205) 0.027
Undecided/not asked 31.8 5.9 62.4 100 (85)
Missing (2)
Mother’s level of education at recruitment
No education/incomplete primary 40.3 5.8 53.9 100 (191)
Complete primary 33.1 4.4 62.5 100 (344) 0.001
Secondary+ 20.7 4.5 74.9 100 (179)
Missing (2)
Total 32.1 4.7 63.1 100 (716)
382 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
Few women adopted a method before resumption of sex, and, in common with ear-
lier analyses, we found that many awaited the return of menses before initiating use. At 4–6
months postpartum, the largest exposure category (26 percent of woman-months) was sexu-
ally active, amenorrheic women who were using no method. In the following three-month
segments, the size of this category drops only modestly to 23 percent and then to 18 percent
at months 10–12. Prevailing postpartum protocols recommend contraceptive protection for
such women, except for those observing exclusive breastfeeding in the first six months post-
partum. The risks of pregnancy during lactational amenorrhea are low, however, even in the
second half of the postpartum year (Kennedy and Visness 1992).
Estimating the level of unmet need among postpartum women in Nairobi slums on the
reasonable assumption that few women wish to become pregnant again within 12 months of
a birth depends on the acceptability of the small, but not negligible, risks of conception before
the return of menses. If these risks are deemed unacceptable, then unmet need is high. Over
one-third (36 percent) of all woman-months were contributed by sexually active amenorrheic
women who were using no method of contraception. However, only 10 percent of months
were contributed by sexually active, menstruating women who were nonusers.
The complexity of postpartum contraception is increased by consideration of double
or redundant protection and early discontinuation of use. In this slum population, menses
certainly acted as a signal to start using a method, but contraceptive initiation before the re-
turn of menses was nevertheless common. We estimate that 40 percent of all contracepting
months were totally or partially redundant because of sexual abstinence or amenorrhea. This
high degree of overlap severely dilutes the impact of contraceptive practice on birth interval
lengths.
If contraceptive use, once started, was prolonged, particularly among women initiating
use before menses, overlap would be of little concern. However, contraceptive discontinua-
tion rates were high, with almost half of women who adopted a method during the postpartum
period discontinuing within 12 months, and with only a small difference between those who
adopted before and after resumption of menses. The estimate from our study is much higher
than the national estimate of 32 percent documented by the 2008–09 KDHS. The reason for
this difference is unknown but in part may reflect differences in data collection. A prospective
approach should be better suited than the retrospective approach used by the DHS to identify
short episodes of use.
Unless followed by prompt method switching, this very high level of contraceptive discon-
tinuation indicates that past users of contraception account for a large fraction of unmet need
for contraception among women in the Nairobi slums. According to the recently published
Nairobi Cross-Sectional Slum Survey, about 24 percent of women reported unmet need for
contraception (APHRC 2014). Jain and colleagues (2013) argue that to effectively reduce un-
met need, especially in low- and middle-income countries, programs must not only focus on
attracting new users but also need to pay attention to current users and past users who have
stopped. Through the “leaking bucket” analogy, Jain (2014) further argues that if the hole in
the bucket (past users with unmet need) is not plugged, then the number of women who have
abandoned use could exceed the number of current users. Moreover, if method dissatisfac-
tion is not addressed, these concerns might spread to nonusers (Jain 2014; Machiyama and
Cleland 2014b).
Mumah et al. 383
December 2015 Studies in Family Planning 46(4)
Choice of contraceptive method after birth in the Nairobi slums was similar to the national
method mix. Injectables accounted for 56 percent of all episodes of reversible method use, fol-
lowed by pills and traditional methods. Implants represented only 4 percent of all episodes,
and IUD adoption was even less common. Continued use of injectables is notably higher than
use of pills or traditional methods. Nevertheless 40 percent of injectables users had stopped
within a year of starting, mainly because of side effects or health concerns. The corresponding
figure for pills and traditional methods exceeds 60 percent. This finding echoes that from a
national study showing that about 61 percent of married women having unmet need in Kenya
had used a modern method in the past, predominantly pills or injectables, and had discontin-
ued the methods because of health concerns or side effects (Machiyama and Cleland 2014a).
Because of the poor environment that characterizes the slums, we had expected that access-
related factors (including cost, supply, and distance) would be a common reason for discon-
tinuation. However, access-related factors were the least-cited reason (2 percent), which sug-
gests that client-side factors that impede successful use of contraceptive methods also need to
be addressed in program planning.
The reproductive consequences of high probability of discontinuation can be offset by
prompt switching to an alternative method. Overall, 63 percent of women in our study who
stopped using a method because of dissatisfaction or an unspecified reason switched to an-
other method within three months. This estimate is much higher than the national estimate
of 35 percent, based on data from the 2003 KDHS (Ali, Cleland, and Shah 2012), a difference
that may reflect a high motivation to postpone pregnancy among slum couples. The majority
of women who discontinued use of pills, traditional methods, and condoms switched to the
dominant method, injectables. Clearly, dissatisfaction with one hormonal method does not
discourage women from trying another hormonal method. It is disconcerting that women who
stopped using injectables were appreciably less likely to switch than those who discontinued
other methods. While 29 percent switched to pills and another 20 percent to other methods,
47 percent of women discontinuing injectables had not switched by month three and 4 per-
cent had become pregnant.
This worrisome trend adds to the growing evidence that the method mix available to
women, especially during the postpartum period, may be inadequate to meet their contracep-
tive needs and hence achieve their fertility goals. The results also suggest inadequate provider
counseling on anticipated side effects and choice of method at the point of initiation of a con-
traceptive method. Expanding the range of methods available and improving client–provider
interaction through adequate counseling on potential side effects and management of effects
are therefore warranted, especially at the point of initiation, even with switching levels this high.
Our results suggest that encouraging women to adopt long-acting methods may be an ef-
fective strategy not only for limiting but also for spacing (Fotso et al. 2013). Our finding that
women with four or more living children and those who gave birth at ages 35–49 years were
less likely to adopt a method during the 12-month postpartum period underscores the need
to provide long-acting or permanent methods (with less method-related dissatisfaction) to
regulate fertility, since many of these women may want no more children. The evidence con-
cerning implants is encouraging. Although only 98 episodes of use of this method were ob-
served, discontinuation was markedly lower than for all other methods. Moreover, 4 percent
of discontinuers of other methods switched to implants.
384 Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women
Studies in Family Planning 46(4) December 2015
Some of the differentials in postpartum behavior are of note. It is surprising that few differ-
ences in contraceptive adoption, discontinuation, or switching were observed between women
who wanted no more children and those who wanted to postpone the next birth. It appears
that both postponement and spacing provide motivation for fertility regulation equal to that
of limitation. Less surprising is that better-educated women are more likely than less-educated
women to adopt a modern method and more likely to switch after discontinuation. Education-
al differences in discontinuation were small, suggesting that greater awareness of reproduc-
tive biology that is likely associated with length of schooling does not reduce concerns about
side effects. Similar results have been reported in other populations (Ali and Cleland 2010).
Nonbreastfeeding women had higher discontinuation rates than women who were breast-
feeding at the time of method adoption. Furthermore, women who adopted a method after
resumption of menses were also slightly more likely to discontinue than others, perhaps be-
cause their motivation was weaker. The concern of many women with the regularity of their
menstrual periods and the disruptions that accompany the use of hormonal methods may ex-
plain why they stop using these methods (Hindin, McGough, and Adanu 2014; Machiyama
and Cleland 2014b).
The need for additional counseling on postpartum fertility was evident in our findings.
Survival probabilities show that, by 6 months postpartum, 83 percent of women were sexually
active while only 49 percent of women had adopted a method and 49 percent had not resumed
menses. These results suggest that many women were partially or fully exposed to the risk of
pregnancy but were not using any modern method of contraception. As Ndugwa and colleagues
(2011) noted in the baseline analyses for this group of women, special attention needs to be paid
to meeting the contraceptive needs of postpartum women, more than half of whom, although
sexually active by the sixth month, were not using any contraceptive method but rather awaiting
the return of menses to adopt a method. Further, tightly focused research is needed to better un-
derstand the link between menses and contraception, which may stem in part from insistence by
providers that women prove nonpregnancy by waiting until they are menstruating before seek-
ing a method. It is uncertain whether women understand the small risks of conception during
lactational amenorrhea and are prepared to accept them, as Salway and Nurani (1998a, 1998b)
found in Bangladesh, or whether they believe that they are fully protected. The postpartum pe-
riod provides an avenue for intervention as women frequent health centers for child-related care
(Rossier and Hellen 2014). The evidence therefore suggests that integrating postpartum family
planning with antenatal care and postnatal services is a useful means to reach women and pro-
vide accurate information on postpartum fertility, breastfeeding, and options for timing of con-
traceptive uptake (Townsend 1990; Becker and Ahmed 2001; Borda and Winfrey 2010; Rossier
and Hellen 2014). Family planning services that are offered to women at every contact point dur-
ing antenatal and postnatal periods can be effective in increasing awareness of, demand for, and
practice of contraception (Lopez et al. 2012). Integration of postpartum services during antenatal
and postnatal visits, if carried out properly, can be an efficient tool to streamline service delivery.
Findings from this study should be interpreted in light of some limitations. Because of the
high loss to follow-up, only seven of the ten cohorts had sufficient numbers of women who had
12 months of continuous calendar data. The effect of this attrition is, however, mitigated by the
use of 12 months of continuous calendar data. Furthermore, the characteristics of women not
retained for analysis due to attrition were not significantly different from the characteristics of
Mumah et al. 385
December 2015 Studies in Family Planning 46(4)
women retained for analysis. Second, we assessed only the dynamics of first modern contracep-
tive use. It is therefore possible that many women who promptly switched to another method
have different contraceptive-use dynamics.
Women in Nairobi’s slums were generally more likely to discontinue a contraceptive
method than other Kenyan women, but they were more likely to switch to an alternative
short-acting method. What remains to be investigated is whether switchers experience the
same high discontinuation rate as documented for adopters of their first postpartum method.
Method-related dissatisfaction explains the high discontinuation rates. Effective interventions
that address the health concerns of women with regard to method choice and management of
side effects are essential and may increase uptake and continuous use of contraception among
women in Nairobi’s slums.
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ACKNOWLEDGMENTS
We drew upon data from the Maternal and Child Health Survey, part of the broader study on Urbanization, Pov-
erty, and Health Dynamics funded by the Wellcome Trust (Grant No. GR 07830M). Writing and analysis time
for authors was supported by the Strengthening Evidence for Programming on Unintended Pregnancy project
(STEP UP, Grant No. SR1109D-6), and general support grants to APHRC from Sida (Grant No. 2011-001578)
and the William and Flora Hewlett Foundation (Grant No. 2012–7612).
