Duration and Predictors of "In-Need" Contraceptive Discontinuation in Ethiopia: A Competing Risks Analysis Using the Fine-Gray Subdistribution Hazards Model.

BACKGROUND

Contraceptive discontinuation while a need for pregnancy prevention persists, often termed "in-need" discontinuation, remains a significant barrier to achieving reproductive health goals in Ethiopia. Traditional survival analyses often overestimate this risk by failing to account for competing events, such as discontinuation due to an intentional desire for pregnancy.

METHODS

This study utilized nationally representative data from the 2016 Ethiopian Demographic and Health Survey (EDHS). A total of 1617 contraceptive episodes among currently married women were analyzed. To identify predictors of "in-need" discontinuation while strictly accounting for the competing risk of "desire for pregnancy," a Fine-Gray subdistribution hazards model was employed as the primary inferential framework.

RESULTS

The overall 12-month-adjusted cumulative incidence of "in-need" discontinuation was heterogeneous across sociodemographic strata. Women in the 35-49 age cohort exhibited a significantly higher subdistribution hazard (2.91%) compared with those aged 15-24 (1.58%; aSHR: 1.85; 95% CI: 1.26-2.71). Secondary education was protective, reducing the 12-month incidence to 1.27% compared with 1.85% for those with no formal education (aSHR: 0.62; 95% CI: 0.40-0.96). Conversely, women engaged in manual labor faced an increased probability of discontinuation (1.97%) compared with professional workers (1.29%; aSHR: 1.56; 95% CI: 1.08-2.25). Notably, women with undecided fertility preferences showed the highest persistence, with a 12-month probability of only 1.03% (aSHR: 0.55; 95% CI: 0.32-0.93). Religious affiliation remained a strong predictor, with Catholic users exhibiting a higher subdistribution hazard (aSHR: 4.65; 95% CI: 2.06-10.49).

CONCLUSION

"In-need" discontinuation in Ethiopia is driven by a complex interplay of age, educational attainment, and occupational physical demands. The finding that older and less-educated women are at higher risk suggests that national family planning programs should move beyond adolescent-focused strategies to include targeted clinical counseling for long-term users. Furthermore, the economic impact of side effects on manual laborers necessitates more flexible, community-based follow-up care to ensure contraceptive security for Ethiopia's most economically vulnerable women.