At the end of this analysis, we noted that postpartum interventions (Yam Daabo project) did not have a significant effect on modern contraceptive method discontinuation and switching. We also noted different results between the two countries. Indeed, while women in the intervention group in Burkina Faso switched contraceptive methods less than those in the control group, in the DRC the situation was the opposite (more frequent method switching in the intervention group). The main reported reason of the first method switching was method-related reasons, although some women also cited partner opposition as a reason for discontinuation or switching contraceptive methods.
Effect of PP interventions on contraceptive methods discontinuation and associated factors
the results showed no effect of PP (Yam Daabo) interventions on contraceptive methods discontinuation. Instead, these events were associated with the type of contraceptive methods used. Weldemariam et al, showed that the method related problems were found to contribute for more than half of the contraceptive use discontinuation by studying the reasons and multilevel factors associated with unscheduled contraceptive use discontinuation in Ethiopia [7]. In their study, they found that IUD and implant discontinuation rates were lowest compared to others. In our study, we had the same finding. Indeed, compared to implants or IUDs, we noticed many discontinuations among women using pills and injectables, which could be explained by the complexity of their intake (daily intake). The woman may either forget to take the pull several times or not be able to take the pill at the specified times. These types of events can lead to a switch to a method that is more practical to use, especially to long-acting methods (implant and IUD), but also to injectables (to a lesser extent). These results, obtained in the multivariate analysis, are consistent with the reasons given by women to explain the discontinuation of the methods. According to them, the method-related issues were the main reason for discontinuation of the first method with 141 episodes stopped over 199 (70.8%). The periodicity of injectable renewal exposes women to the forgetfulness in the same way as pills. So, this can lead to switching or discontinuation. The other reason for the low likelihood of women using a long-acting method to switch or stop is the fact that these methods are administered by qualified staff, and discontinuing or switching also requires the same type of staff. Women who return to interrupt her long-acting method could receive explanations (discussions on the reasons for the discontinuation) from health workers. They may convince her not to stop the method; this is unlike the pill or injectables, for which a woman does not need to see a health worker stop the method. All of these reasons explain why, in almost all studies, such as the Casey et al., study in the DRC (86.1% versus 78.0%) the rate of continuation of methods is higher in users of long-acting methods (implants and IUDs) than in users of short-acting methods (pills and injectables) [17]. In Senegal, in 2015, a study of 6927 women of childbearing age living in six urban sites showed that implants had the lowest 12-month discontinuation rate (6.3%), followed by intrauterine devices (IUDs) (18.4%). Higher rates were observed for injectable contraceptives (32.7%), pills (38%), and condoms (62.9%) [10]. Similar results were reported by the Diedrich's study, which, after adjustment, showed a risk of discontinuation that was three times higher among users of other methods compared to long-acting methods users (HRa = 3.08, 95% CI = 2.80–3.39) [18].
In this study, discontinuation and switching were more frequently observed among women using LAM. Indeed, this method is ineffective after six months postpartum, and the women who were using are supposed to know that they must change to another method after six months postpartum. The counselling made with our new tool could have contributed to reassure the women for these switching. Also, regarding the data on discontinuation among injectables users, we noted that the control group had many women who gave method-related reasons to discontinue the method compared to the intervention group, that could also be explained by the counselling tool. Indeed, before adopting the given method, health workers had to explain the side effects to a woman so that she was prepared to accept any symptom that she might experience while using the method. Health care providers might be updated on contraceptives side-effects, indications, contraindications, and mechanisms of action. In Benin, for instance, it has been proven that among women who chose a modern method (excepted condoms), health care providers informed only 57% of women on methods side effects at the initiation, and 88% of them were instructed on how to manage these effects [19].
Effect of PP (Yam Daabo) interventions on contraceptive methods switching
regarding the switching of methods, we noted that switching of methods varied according to the study group. Being part of the control group was associated with a decreased likelihood of switching to a less or equal effectiveness method, especially in RD Congo. This shows a beneficial effect of PP interventions on switching.
Reason of contraception discontinuation or switching
lastly, regarding the reason of contraception discontinuation or switching, some women did not indicate their reasons for the discontinuation and switching of methods (17 women in total, similar repartition between the study's group). This lack of clear reason raises questions, especially in an African context, marked by misconceptions about contraception, as shown in the first phase of this trial [20]. In Benin, for example, Chae et al. showed in 2014 that, among married women with unmet needs, opposition to contraceptive methods is one of the main reasons for not using contraception. In their study, a quarter of the women rejected contraception themselves, while 58% reported opposition from their husbands and 5% reported opposition from other people. The remaining 12% referred to a religious ban as the reason for their opposition [19]. Another reason for discontinuation given by women is the partner's opposition. This has already been reported in several studies [20–23] as one of the inhibitors for contraception use by women in general and especially by married women. The opposition from partners calls for more targeted action towards men to gain a better commitment from them to facilitate the use of contraceptive methods by women. In particular, family planning is part of women's rights, and husbands should not prevent them from adopting the method of their choice. In this study, we noted a different distribution of women who gave their partner's opposition as the reason for discontinuation even if the statistical significance was not explored (in the control group, 14 women (16.3%) against 6(5.3%) in the intervention group).
Limitations: for the analysis of switching, we did not consider the time for which women used the first modern methods if they used more one modern contraceptive method.