Contraceptive dynamics in rural northern Malawi: a prospective longitudinal study

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 cross-sectional 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