Contraceptive discontinuation, reasons, and method switching among married women in Nepal: A life-table and survival analysis of the 2022 Nepal DHS contraceptive calendar

Abstract Background Nepal has invested in family planning for five decades, yet modern contraceptive prevalence among married women has barely moved since the mid-2000s. Why prevalence stalls while women continue to adopt methods is not well quantified at the national level. We examined how often Nepalese women stop contraception, why they stop, and what they do next, using the retrospective contraceptive calendar of the 2022 Nepal Demographic and Health Survey (NDHS). Methods The data source for the analysis was the NDHS’ individual recode file, which included data from 11,722 sexually-active married / in union women aged 15–49. The month-wise calendar strings were deconstructed into 60,389 contraceptive-related episodes, of which 13,819 were identified as contraception use episodes. The 12-month discontinuation rates were estimated using single-decrement life-table methods, specifically for episodes over the last five years before interview. Continuation was estimated using the Kaplan-Meier curves, and a weighted Cox proportional hazards model with robust standard error was fitted to explore the correlates of discontinuation. The post-discontinuation pathways were derived from the status in the month following each discontinued episode. Results Discontinuation at 12 months was 23.5% for the pill and 18.6% for the male condom, compared with 0.2% for the implant, 0.6% for injectables, and 0.9% for the IUD. The most commonly reported reasons for stopping short-acting methods were infrequent sex or husband being away, while side effect/health problems explained nearly all implant discontinuation and one-fifth of IUD discontinuation. Very few women switched methods where, 94.4% of modern-method discontinuations were followed by non-use and 2.1% by any other modern method. Comparing with the condom, the hazard of discontinuation was higher for the pill (adjusted hazard ratio [aHR] 1.38, 95% CI 1.14–1.67) and much lower for injectables (aHR 0.02, 95% CI 0.01–0.04), implants (aHR 0.01, 95% CI 0.003–0.06) and IUD (aHR 0.04, 95% CI 0.007-0.20). Discontinuation was more common among rural women (aHR 1.24, 95% CI 1.07–1.44) and women with secondary education (aHR 1.65, 95% CI 1.25–2.18). Conclusions Rather than non-adoption, the stagnation of contraceptive prevalence in Nepal is mainly attributable to early dropout of short-acting methods and a complete absence of switching. Counselling that anticipates side effects, accommodates spousal separation and proposes a long-acting option at the time of discontinuation could convert this revolving door into a source of sustained protection.