J70 Contr discontinuation EJC (2007)

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Reasons and correlates of

contraceptive discontinuation in KuwaitN. M. Shah*, M. A. Shah{, R. I. Chowdhury{ and I. Menon*

*Department of Community Medicine & Behavioural Sciences, Faculty of Medicine, Kuwait University, Kuwait; and{Department of Health Information Administration, Faculty of Allied Health Sciences, Kuwait University, Kuwait

A B S T R A C T Objectives (1) To examine the probability of discontinuation of various methods within

1, 2, and three years of use and the reasons for discontinuation; 2) to analyse the socio-

demographic correlates of discontinuation.

Methods Data from a survey of Kuwaiti women in reproductive ages conducted in 1999

were used. Information on duration of use of modern and traditional methods, and reasons

for discontinuation during the 72 months before the survey were analysed. Probabilities of

discontinuation were estimated through multiple decrement life table analysis.

Results After 1 year, 30% of modern and 40% of traditional method users had

discontinued; after 3 years, discontinuation increased to 66 and 70%, respectively. After 36

months, only 40% of IUD users discontinued compared with 74% of oral contraceptive users.

The desire to become pregnant was the leading reason for discontinuation of most modern

methods, while method failure was an equally important reason for traditional methods.

Discontinuation was significantly more frequent among higher parity, non-working and

Bedouin women, and among those who said Islam disapproves of contraception.

Discussion Contraception is used largely for spacing. More than two-thirds of the women

studied had discontinued most methods after three years, except the IUD, which was used

only by about 10% of them. Traditional methods are often discontinued due to method

failure and may result in an unintended pregnancy. Better counselling is warranted for

traditional methods. Health care for managing side effects of modern methods also needs

improvement.

K E Y W O R D S Discontinuation rate, Kuwait, Contraception, Family planning, Methods

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I N T R O D U C T I O N

Kuwaiti women have now accumulated years of

experience with contraceptives, especially oral contra-

ceptives (OCs) and intrauterine devices (IUDs).

Previous research has analysed the level of use, charac-

teristics of users1-3, correlates of use and non-use4, and

unmet need for contraception5. The knowledge of

OCs and IUDs is almost universal while methods such

as vasectomy are known only by about 15% of

women6. About four-fifths of currently married

women report ever having used a contraceptive

Correspondence: Nasra M. Shah, Faculty of Medicine, PO Box 24923, Safat, 13110, Kuwait. Fax: 965 533-8948. E-mail: [email protected]

The European Journal of Contraception and Reproductive Health Care September 2007;12(3):260–268

ª 2007 European Society of Contraception

DOI: 10.1080/13625180701440560

MS 495

method and about half are currently using one.

Contraception in Kuwait is used primarily for spacing

purposes (60.8%) and is initiated by most women

after the first or second child. Unmet need for

contraception is estimated to be about 9.7%, based

on the percentage of women who experienced an

unwanted or mistimed birth5.

In addition to all the above facets related to

contraceptive use, it is important to determine the

pattern and reasons for method discontinuation among

women in order to understand and meet the contra-

ceptive needs of the population. The objectives of the

present paper, therefore, are:

. to examine the probability of discontinuation of

various methods over specified time periods of 12,

24 and 36 months;

. to analyse the reasons reported by women for

discontinuation of various methods during the

above time periods;

. to analyse the socio-demographic correlates of

discontinuation.

P R E V I O U S R E S E A R C H

A review of international research indicates that rates

of discontinuation vary widely across countries and

also according to the type of method used. A six

country study showed discontinuation rates to vary

from 28 to 42% after 24 months of use7. Another

comparison across countries showed discontinuation

of IUDs to vary from 0.18 in Sri Lanka to 0.53 in

Zimbabwe after 1 year of use8. Subdermal implants

were reported to have considerably lower disconti-

nuation than OCs or IUDs after 12 months of use in

the USA9.

Four main reasons have been reported as the major

ones given by respondents for discontinuing use.

These include the experience of side effects and health

concerns, the desire/intention to have another child,

failure of the method and the belief that contraception

was no longer needed. These four reasons were

reported from a wide range of countries such as

the USA9,10, New Zealand11, India12, Egypt13 and

China14.

Contraceptive discontinuation has been reported to

be more frequent among persons who were using a

method without their partner’s knowledge15 or in

cases where the husband disapproved of such use16.

Findings pertaining to discontinuation according to

respondent’s socioeconomic characteristics are not

consistent across countries. In a six country study,

for example, Ali and Cleland7 did not find any

appreciable influence of women’s schooling level on

discontinuation. In Ghana, on the other hand,

education as well as parity and ethnicity were found

to be strong determinants of discontinuation17.

M A T E R I A L S A N D M E T H O D S

This paper analyses the cumulative probability of

contraceptive discontinuation after specified periods

of time, and also examines the reasons and correlates of

discontinuation. The analysis is based on data from a

nationally representative household survey of ever-

married Kuwaiti women of reproductive age con-

ducted in 1999. A questionnaire very similar to the

1995 Egyptian Demographic and Health Survey was

used for data collection. As part of the survey,

information was collected on the contraceptive

history, by month, in terms of which method was

used, when its use was started and discontinued, and

the reason why it was discontinued. Retrospective

data on the above were collected for a total of 72

months covering the period January 1994 to

December 1999. Information on reasons for disconti-

nuation was regrouped by adding responses that

mentioned health concerns and side effects as a

category labelled in our analysis as ‘health reasons’.

Also, reasons such as husband’s disapproval, method

inconvenience, and difficulties in getting pregnant

were grouped under the category ‘other’ because of

the small number of responses in each of these

categories. A total of 1656 women were interviewed.

Of these, 1502 were currently married at the time of

survey. This article is based on the 1502 currently

married women who are the ones most likely to

demand contraception in the future.

The pattern of contraceptive discontinuation was

investigated using multiple-decrement life tables for

analysing competing risks emerging from retrospective

data. Inclusion of segments of method use that began,

but did not end, before the start of the calendar, can be

analysed using this type of life table. In addition, the

simultaneous consideration of multiple reasons for

discontinuation can be computed from this method18.

The hazard functions, the instantaneous risk of dis-

continuations, were first calculated in the construction

Contraceptive discontinuation in Kuwait Shah et al.

The European Journal of Contraception and Reproductive Health Care 261

of life tables. Using the estimated hazards, we

then calculated associated single-decrement and

competing-risk probabilities for discontinuation

(advantages and estimation procedure are presented

by Kost18). The associated single-decrement risks were

used to determine whether differences in the relative

importance of causes of discontinuation between the

groups being compared could substantially alter the

interpretation of the competing risks.

The discontinuation rates presented here excluded

the first and last 3-month periods of the retrospective

calendar data. Thus, of the total 72 months of

observation, only those comprised between the 4th

and the 69th months were included for the calcula-

tions. All segments of use during the period 4–69

months were analysed. A segment is an uninterrupted

period of use of a particular contraceptive method. All

segments of use that began before the 6-year period

are excluded from computations of discontinuation

rates, since inclusion of such segments complicates the

analyses; moreover, their omission has little effect on

piece-wise discontinuation rates for short durations of

less than 2 years. The month of interview and the two

preceding months are ignored to avoid the bias likely

to be introduced by an unrecognized pregnancy.

While calculating the probability of discontinua-

tion, women who were married throughout the

period under observation were included. Kuwait

being a traditional, Muslim society, questions about

contraception can be asked only to married women.

Widows and divorcees would not be asked questions

about their contraceptive behaviour since this would

be culturally highly inappropriate.

R E S U L T S

A socio-demographic profile of the women assessed in

this study is shown in Table 1. The average age of

currently married women was 33.2 years and their

average parity about 4. Kuwait has a rapidly develop-

ing society, where access to free public education has

been available to both sexes since the country’s

independence in 1961. Women in our study had

completed about 10 grades of schooling and 32% of

them were active participants in the labour force.

Approximately half belonged to the relatively more

conservative ethnic group with Bedouin background.

In terms of contraceptive use, about 81% women

reported to have ever used a family planning method

and 52% were using one at the time of survey

(Table 2). About two-thirds of the current users

resorted to a modern contraceptive, primarily an OC

or an IUD. The mean duration of use for all the

segments of use analysed from the calendar data was

17.9 months. Modern methods were reported to be

employed for a longer duration (18.7 months) than

traditional methods (15.5 months).

Table 3 shows the cumulative probability of

discontinuation of various methods. Six months after

initiation of a modern method one-tenth of the

women concerned had discontinued its use in

comparison with one-fifth of those employing a

Table 1 Socio-demographic profile of the currently

married women (n¼ 1502)

Characteristics %

Mean age 33.2

Mean age at marriage 20.1

Mean grades of education 9.9

Mean number of living children 4.08

% Bedouin 49.3

% Working 32.0

Table 2 Percentage ever use and current use of

contraception by methods for currently married women

Ever use

(n¼ 1219)*

Current use

(n¼ 773)*

Total 80.8 51.5

Modern methods 36.8 34.9

Pill 24.2 23.2

IUD 9.0 8.7

Condom 3.3 2.9

Other 2.9 0.1

Traditional methods 41.3 12.7

Rhythm 8.1 4.0

Withdrawal 15.3 5.6

Breastfeeding 17.9 3.0

Other methods 0.5 0.1

Mean duration of use of during 5 years prior to survey

All method 17.86 months

Modern method 18.86 months

Traditional method 15.48 months

*Excludes male and female sterilization.


262 The European Journal of Contraception and Reproductive Health Care

traditional method. The probability of discontinuation

increased substantially after 1 year of use; about 30% of

those resorting to modern methods had discontinued

compared with 40% of those using traditional

methods. Among the users of modern methods,

discontinuation of IUD was much less frequent

(13%) than that of other methods, especially condoms

(41.5%). Among users of traditional methods, about

half of those practising rhythm had stopped doing so

after 12 months. After 24 months, about 54% of

modern method users and 66% of traditional method

users had discontinued use. Contraceptive disconti-

nuation increased further after 36 months when about

two-thirds of the users of modern methods had

discontinued use compared with 70% of users of

traditional methods. The IUD had the lowest

probability of discontinuation after 36 months (40%)

compared with 74% for OCs. Among the users of

traditional methods discontinuation was close to 70%

or higher for all the methods.

With regard to the reasons for discontinuation after

12 months, desire to become pregnant was the major

reason for 47% of those using modern methods to

discontinue (Table 4). There were major differences

in the probability of discontinuation according to the

type of method being used. For example, a majority

of those who were using an OC (51%) stopped

because they wanted to conceive, while most of those

wearing an IUD had it removed because of health

reasons (66%). In case of condom use, other

unspecified reasons constituted the leading cause of

discontinuation (44%). A major reason for the

discontinuation of traditional methods, on the other

hand, was method failure (45%) followed by desire

for pregnancy (28%).

After 24 months, the reasons for discontinuation

remained roughly the same (Table 4). About 64% of

the pill users discontinued because they wanted to

become pregnant. In case of IUD, desire for

pregnancy emerged as the major reason for disconti-

nuation, followed by health reasons (46 and 41%).

Discontinuation of traditional methods resulted from

method failure in case of 39% users, while desire for

pregnancy was the reason for another 35%.

After 36 months, desire for pregnancy was the

leading reason for the discontinuation of the OC

(66%), IUD (54%) and withdrawal (44%), as shown in

Table 4. Health concerns were reported by 32% IUD

users and 22% pill users as the reason for discontinua-

tion. In case of traditional methods as a whole, method

failure was reported as the leading reason for

discontinuation (38%).

The frequency of discontinuation was also exam-

ined according to the socio-demographic character-

istics of women, as shown in Figure 1. The probability

of discontinuation was consistently greater among

those of lower parity. After 36 months, 73% of those

with 0–2 children had discontinued compared with

61% of those with six or more children. Women with

lower education had a higher probability of disconti-

nuation after 24 and 36 months; however, these

differences were not statistically significant. Women

who were employed had a lower probability of

stopping than non-working women at each point of

time examined. After 36 months, 72% non-working

women had discontinued use compared with only

57% working women. Ethnicity in terms of Bedouin

and non-Bedouin background also differentiated

women’s probability of discontinuation. After 36

months, 78% of Bedouin women no longer were

Table 3 Cumulative probability of discontinuation of contraceptive methods over 36 months

Methods 6 months 12 months 18 months 24 months 30 months 36 months

Modern methods 0.100 0.300 0.443 0.544 0.621 0.675

Pill 0.098 0.325 0.487 0.606 0.686 0.738

IUD 0.059 0.130 0.215 0.250 0.315 0.399

Condom 0.221 0.415 0.471 0.494 0.546 0.546

Traditional methods 0.201 0.400 0.544 0.663 0.683 0.702

Rhythm 0.235 0.495 0.584 0.689 0.697 0.707

Withdrawal 0.246 0.369 0.482 0.590 0.613 0.673

Breastfeeding 0.148 0.362 0.588 0.736 0.765 0.772



practising their contraceptive method, compared with

only 62% of the non-Bedouin women. After 24 and

36 months, women who believed that Islam dis-

approves of contraception more frequently had

stopped than those who believed that Islam approves

it. Finally, the probability of discontinuation did not

differ significantly according to whether the husband

approved or disapproved of contraception.

D I S C U S S I O N

Our analysis indicated that more than half the women

applying a modern method discontinued use after 24

months, while about two-thirds of those applying a

traditional method did so. After 36 months, the

probability of discontinuation increased to 68 and

70%, respectively. Thus, most Kuwaiti women take

up contraception for relatively short periods. Such

behaviour is explained by the fact that contraception is

started typically after the first or second child, and the

primary motivation for it is to space children in a

society that still has a high fertility1.

Kuwait had a total fertility rate of 4.3 children at the

time when our survey was conducted in 1999. The

current fertility rate still exceeds four children19. In

1999, the average number of children desired per

woman of reproductive age was 5.520. Previous

analyses led Shah and Nathanson20 to conclude that

the perceived need for children as social and national

capital is currently the most important driving force

Table 4 Discontinuation of different methods after 12, 24 and 36 months, by reason

Methods

Method

Failure

Wanted

pregnancy

Health

reasons Others Total

Probability

of discontinuation

12 months

Modern methods 10.3 46.7 28.3 15.0 100.0 0.300

Pill 8.6 51.4 27.1 12.9 100.0 0.325

IUD 14.6 14.6 66.2 4.6 100.0 0.130

Condom 18.1 27.0 10.6 44.1 100.0 0.415


Rhythm 47.5 32.3 1.4 18.8 100.0 0.495

Withdrawal 28.7 28.7 42.3 100.0 0.369

Breastfeeding 55.8 22.9 21.0 100.0 0.362

24 months

Modern methods 7.4 60.7 22.1 10.1 100.0 0.544

Pill 6.4 63.9 21.5 8.4 100.0 0.606

IUD 7.6 46.4 41.2 5.2 100.0 0.250

Condom 15.2 22.7 8.9 37.0 100.0 0.494


Rhythm 41.8 37.9 3.2 17.0 100.0 0.689

Withdrawal 25.9 40.7 0.0 33.2 100.0 0.590

Breastfeeding 43.8 29.1 1.0 26.4 100.0 0.736

36 months

Modern methods 5.9 63.1 21.8 9.2 100.0 0.675

Pill 5.3 65.7 21.5 7.6 100.0 0.738

IUD 4.8 53.6 31.8 9.5 100.0 0.399

Condom 17.2 28.2 8.1 37.0 100.0 0.546


Rhythm 43.4 36.9 3.1 16.5 100.0 0.707

Withdrawal 22.7 44.4 0.0 32.8 100.0 0.673

Breastfeeding 42.6 29.5 0.9 26.9 100.0 0.772



behind fertility desires and behaviour. Kuwaiti

nationals are a minority in their country constituting

about 37% of the population, and the perception that

the country needs more Kuwaitis is widespread20. In

view of the above, it is not surprising to find that the

leading reason given for the discontinuation of

contraception, especially by those using OCs, was to

become pregnant.

Among those using an IUD, discontinuation after

12 months was especially low (13%) and most had the

device removed for health reasons. Even after 36

months, about 60% of IUD users were still wearing it.

Characteristics of IUD users, analysed in a paper by

Shah et al.1, provide possible explanations for the low

discontinuation of IUDs. Compared with OC users,

women wearing an IUD were significantly older

(�X age¼ 31.8 and 34.2 years, respectively), had signi-

ficantly higher grades of education (�X grades¼ 10.4

and 11.1), and a significantly lower percentage were

Bedouin (49.1 and 60.3%, respectively). Also, IUD

Figure 1 Probability of discontinuation by socio-demographic characteristics*

*Associations were tested by using log-rank test



users had more living children than OC users (4.6

compared with 4.3)1. Thus, IUD users probably had a

higher motivation to limit further childbearing both

on account of their higher fertility and a relatively

higher socio-economic status. However, a substantial

percentage (32%) of women who had their IUD

removed after 36 months indicated health related

reasons. This calls for some action on the part of

authorities responsible for reproductive health since

discontinuation due to health reasons exposes the

woman to a possible unwanted pregnancy. It was

found in previous research that about 10% of Kuwaiti

women had an unmet need for contraception,

primarily to limit children5.

The major reason for discontinuation of OC use,

currently the leading method, was the desire for

another child. However, about 22% of those who

stopped after 36 months did so for health reasons.

Most OC users obtain the supplies from the pharmacy

where they are rarely told about side effects or how to

use the product. Also, about a quarter of the women

taking the pill did not consult a doctor before

initiating the method the first time21. Hence, health

care providers including pharmacists can play a role in

counselling OC users about their health concerns and,

thus, reduce the rate of discontinuation due to health

related reasons.

Discontinuation of traditional methods was more

frequent than that of modern methods. Failure of the

method was reported as the leading reason for

discontinuation of rhythm and breastfeeding at 12,

24 and 36 months. Among those practising with-

drawal, the desire for a pregnancy was the leading

reason at 24 and 36 months. When examined in a

historical context, the total share of the use of

traditional methods among all methods increased from

about 6% in a 1987 survey to 24% in the 1999 survey

analysed in this paper1. An increase in use of

traditional methods has accompanied the rise in

contraceptive use in Kuwait. However, the experi-

ence of frequent method failure may again result in

unwanted or mistimed pregnancy. Hence, for persons

seriously desirous of pregnancy spacing or limitation,

traditional methods are unlikely to be a good option in

Kuwait.

Since its independence in 1961, Kuwait has gone

through a very rapid transition in several social

indicators. Women’s literacy and education have

increased remarkably and almost all women aged less

than 40 have now had at least a few years of schooling

and more than one-fifth have completed high school

or higher levels of education22. Increased level of

education has also been a major facilitator of women’s

entry into the workforce. Almost 40% of all women

aged 15 and above were in the labour force in 2004,

compared with only 2% in 1965. We found that

women who were working had a significantly lower

probability of method discontinuation. Work partici-

pation is likely to result in higher continuation both

because of a possible conflict between the maternal

and work roles, and because of greater exposure of

working women to ideas that support spacing and

limitation of children.

We found that the probability of discontinuation

was higher among Bedouin than non-Bedouin

women. Ethnic background of Kuwaiti women has

repeatedly emerged as a significant variable in previous

analyses of desired fertility. A 1994 survey indicated

that Bedouin women had significantly higher desired

fertility23, as did a 1999 survey20. The number of

children desired by Bedouin women was 6.3 com-

pared with 4.8 desired by non-Bedouin women.

Furthermore, Bedouin women lag behind in educa-

tional attainment as well as participation in the labour

force. The mean grades of education attained by

Bedouin women was 7.6 compared with 12.2 among

non-Bedouin women; only 18% of the former group

was working compared with 46% of the latter (Shah

MA et al., unpublished data). Thus, commitment to

continuation in order to achieve their relatively lower

desired fertility seems to be higher among non-

Bedouin women.

Husband’s approval or disapproval of contraception

was not an important factor in discontinuation.

Previous analysis has shown, however, that negative

attitudes of respondents and husbands towards contra-

ception were significant predictors of non-use, as well

as lack of intentions for future use4. It seems that once

a respondent takes up contraception, other factors

such as desire for another child, health concerns and

method failure are the most important ones in

discontinuation.

The study has some limitations. The data are about

10 years old, covering the period 1995–1999, and the

findings may or may not represent the current

situation accurately. However, no recent survey has

been conducted on the subject to allow comparison.

Also, interpretation of discontinuation based on



retrospective data may be problematic since such data

may suffer from recall bias or reporting bias.

In summary, an analysis of contraceptive history of

Kuwaiti women indicates that after 36 months about

68% of those applying modern methods and 70% users

of traditional methods have discontinued them.

Among users of modern methods, three-quarters of

OC users and 40% of IUD users had discontinued at

36 months. Oral contraception accounts for 45% of all

current contraceptive use. Its relatively low continua-

tion rate suggests that it is resorted to mainly as a

method for spacing. Among women who had their

IUD removed within the first year, health concerns

such as fears about uterine perforation and bleeding

were the major reasons. Such concerns should be

addressed by health care providers when offering

services. Traditional methods have been more fre-

quently applied in Kuwait during the last two decades.

However, such methods have a high failure rate and

may result in unintended pregnancy. Finally, we

found that women of higher parity, working women

and non-Bedouin women had lower discontinuation

rates than their respective counterparts. In terms of

lessons learnt from this analysis, one might highlight

the following. First, better management of those who

discontinue for health reasons is likely to increase

continuation and reduce unmet need. Secondly, the

high failure rate of traditional methods points to a

need for better counselling for those who wish to rely

on such methods.

A C K N O W L E D G E M E N T S

The authors wish to thank the Kuwait Foundation for

Advancement of Sciences for funding this research

(project number KFAS 96-07-15).

R E F E R E N C E S

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and correlates of contraceptive use among Kuwaitis,

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