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Contraception xxx (xxxx) xxx
Contents lists available at ScienceDirect
Contraception
journal homepage: www.elsevier.com/locate/contraception
Brief Research Article
Trajectories of method dissatisfaction among Kenyan women using
modern, reversible contraception: A prospective cohort study
Claire W. Rothschild
a , 1 , ∗, Barbra A. Richardson
b , c
, Brandon L. Guthrie
a , d
, Alison L. Drake
d
a
Department of Epidemiology, University of Washington, Seattle, WA, United St ates
b
Departments of Biostatistics and Global Health, University of Washington, Seattle, WA , United States
c
Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, WA , United States
d
Department of Global Health, University of Washington, Seattle, WA, United States
a r t i c l e i n f o
Article history:
Received 29 April 2022
Received in revised form 12 September
2022
Accepted 14 September 2022
Available online xxx
Keywo rds:
Contraception
Famil y planning
Patient satisfaction
Trajector y models
User experience
a b s t r a c t
Objectives: Evidence on method dissatisfaction among current contraceptive users is sparse. Group-based
trajectory modeling presents a novel approach to describing method dissatisfaction.
Study design: In a cohort of Kenyan women using modern contraception, we identified group-based tra-
jectories of method dissatisfaction over 24 weeks since clinic visit.
Results: Among 947 women, four trajectories were identified: consistent satisfaction (71%), increasing
dissatisfaction (18%), decreasing dissatisfaction (8%), and consistent dissatisfaction (3%).
Discussion: Method dissatisfaction was common in a cohort of Kenyan women. Group-based trajectory
models describe distinct and changing experiences of contraceptive use. Deeper understanding of trajec-
tories of contraceptive experience may be useful for advancing person-centered family planning care that
addresses users’ changing preferences and challenges.
©2022 The Author s. Published by Elsevier Inc.
This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )
1. Introduction
Adverse experiences using contraception, such as unwanted
side effects or problems with method use, are a major driver of
contraceptive discontinuation globally [ 1 , 2 ]. Several recent stud-
ies have found many women continue using contraception despite
being dissatisfied with their selected method [ 3 , 4 ]. However, few
studies have described dynamic patterns of method dissatisfac-
tion among current contraceptive users [ 4 , 5 ]. As a result, little is
known about distinct patterns of method dissatisfaction through-
out an episode of contraceptive use. Improved understanding of
method dissatisfaction is essential for advancing person-centered
family planning technologies, counseling, and care.
With new investments in longitudinal family planning data [6] ,
the field will have increased opportunity to apply longitudinal
methods such as trajectory modeling to contraceptive dynamics re-
search. Using data from a 2018 prospective cohort study of female
modern contraceptive users in Western Kenya, we illustrate how
∗Corresponding au thor.
E-mail address: cwatt2@uw.edu (C.W. Rothschild) .
1 Present address: Population Services International, Washington DC, United
States.
trajectory modelling can be applied to identify distinct trajecto-
ries in women’s experiences of contraceptive method dissatisfac-
tion over a 24-week-long period.
2. Materials and methods
2.1. Study population and data collection
We utilized data collected as part of a prospective cohort
study of women using modern contraception conducted in West-
ern Kenya in 2018. Study procedures have been described previ-
ously [4] . Women were recruited at public family planning (FP)
or maternal and child health clinics and eligible to participate if
they were ≥18 years old or ≥14 with a prior pregnancy, using
a modern, reversible contraceptive method [7] at enrollment, had
daily mobile phone access and a Safaricom SIM card, and could
read and respond to short message service (SMS) messages in En-
glish, Swahili, Luo, or Kisii themselves or with assistance. Partici-
pants were administered an in-person questionnaire at enrollment
and SMS-based questionnaires weekly for 24 weeks, in which they
self-reported current contraceptive use, method switching and dis-
continuation, and method satisfaction. Overall satisfaction with the
current method was assessed weekly via a single question with
https://doi.org/10.1016/j.contraception.2022.09.125
0010-7824/© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )
Please cite this article as: C.W. Rothschild et al., Trajectories of method dissatisfaction among Kenyan women using modern, reversible
contraception: A prospective cohort study, Contraception, https://doi.org/10.1016/j.contraception.2022.09.125
C.W. Rothschild et al. Contraception xxx (xxxx) xxx
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a five-point Likert scale response (very satisfied, satisfied, neu-
tral, dissatisfied, or very dissatisfied). For this analysis, we included
women with at least one complete observation of method satisfac-
tion over follow-up.
2.2. Statistical analysis
Method dissatisfaction was defined dichotomously as any
method dissatisfaction (“very dissatisfied” or “dissatisfied”) re-
ported in each four-week-long period of follow-up to account for
missing data at the week-level (4989/18,989 [26%] weekly surveys
had missing information on method satisfaction). Method dissatis-
faction for each interval was defined as missing if all weekly ob-
servations were missing (due to loss to follow-up, refusal, or if the
participant discontinued modern contraceptive use).
We identified distinct group-based trajectories of method dis-
satisfaction by fitting discrete logistic mixture models accounting
for non-random attrition [8] . We modeled attrition based on the
dissatisfaction response observed in the prior four-week period.
We selected a preferred group-based trajectory model (GBTM) by
fitting all models with one to four groups with each possible com-
bination of linear, quadratic, or cubic functional forms for each
group and identifying the best fit model based on the Bayesian In-
formation Criterion. We assessed adequacy of model fit by visualiz-
ing models graphically, assessing model convergence, and calculat-
ing average model-based posterior probabilities of group member-
ship with a minimum threshold of 0.70 [9] . We conducted several
sensitivity analyses in which we adjusted the primary model by FP
user type at enrollment (contraceptive initiator, method switcher,
or prevalent method user) and contraceptive method type at en-
rollment (categorized as long-term reversible method [implant or
intrauterine device], injectable, or other modern methods due to
small sample sizes among specific method types). In addition, we
repeated the procedure described above to identify distinct group-
based trajectories using a model adjusted by contraceptive use out-
come, which was dichotomized as switching/discontinuing versus
continuing the method used at enrollment over the study observa-
tion period.
3. Results
Of 1212 enrolled participants, 947 (78%) had at least one com-
plete observation of method satisfaction over follow-up and were
included in the analysis. Two percent (21/1212) of participants who
discontinued modern contraception in the first week of follow-up
were excluded because method satisfaction was not assessed.
The selected model identified 4 distinct trajectories of method
dissatisfaction: 71% of participants (n = 667/947) were char-
acterized by consistent satisfaction. The remaining three trajec-
tories were characterized by varying levels of method dissat-
isfaction, with 18% (n = 181/947) experiencing increasing and
8% (n = 71/947) decreasing levels of dissatisfaction, while 3%
(n = 28/947) were consistently dissatisfied ( Fig. 1 ). The selected
model identified a linear functional form for all groups except the
consistently satisfied group (which takes a quadratic functional
form). Average posterior probabilities of group membership ex-
ceeded the 0.70 threshold indicating adequate model fit for all but
the group characterized by increasing dissatisfaction (mean poste-
rior probability of 0.698). The primary GBTM was relatively robust
to adjustment by FP user type (Supplemental Material, Fig. S1).
Adjustment for contraceptive use outcome resulted in a selected
model that identified 3 rather than 4 distinct trajectories: 62% of
participants were characterized by consistent satisfaction, 32% by
a moderate level of dissatisfaction, and 7% by high but decreasing
dissatisfaction (Supplemental Material, Fig. S2).
Fig. 1. Group-based trajectories of dissatisfaction with current modern contracep-
tive method, Kenya (2018). Notes: Trajectories were generated using a discrete mix-
ture model with a Bernoulli (logistic) distribution (N = 947). The optimal model
identified using BIC values identified a linear functional form for all groups except
the consistently satisfied group (which takes a quadratic functional form). Method
dissatisfaction is defined as reporting overall satisfaction with the current contra-
ceptive method as "dissatisfied" or "very dissatisfied" via weekly survey. Dotted
lines indicate 95% confidence intervals. BIC, Bayesian Information Criterion.
4. Discussion
Method dissatisfaction was prevalent in a cohort of Kenyan
women using modern, reversible contraception: in the primary se-
lected model, nearly 30% experienced trajectories defined by some
level of dissatisfaction with their current contraceptive method,
and over one-fifth experienced either consistent or increasing dis-
satisfaction over 24 weeks. These findings build upon recent evi-
dence suggesting that adverse contraceptive experiences are com-
mon, even among continuing contraceptive users [ 3 , 4 ]. The GBTM
methodology allows for unique insight into dynamic contraceptive
experiences, identifying groups of users with increasing and de-
creasing probability of dissatisfaction who likely have unique needs
for ongoing contraceptive care and support.
Our study has several strengths, including a prospective co-
hort design and high-frequency data collection using participant-
reported SMS questionnaires; these features minimize measure-
ment error due to recall bias. Our study is also subject to limi-
tations. There is no existing, validated measure of method dissatis-
faction; we used a single question to assess dissatisfaction, which
may inadequately capture nuanced experiences of method use. We
modeled attrition based on dissatisfaction reported in the previ-
ous interval; however, model misspecification is possible. The av-
erage posterior probability for the increasing dissatisfaction group
did not meet the 0.70 threshold, indicating inadequacy of model
fit for this group. Small sample size resulted in relatively impre-
cise estimates with wide standard errors. Confirmation of these
distinct trajectories in larger samples of contraceptive users, ide-
ally sampled at initiation of contraceptive use, is needed to de-
scribe trajectories within and between key groups of users defined
by their sociodemographic characteristics, contraceptive method
type, contraceptive use history and quality of care of services re-
ceived, and their contraceptive use outcomes. Finally, our mod-
els did not incorporate 21 women who discontinued in the first
week of follow-up, resulting in possible underestimation of method
dissatisfaction.
The long-held assumption that contraceptive continuation is in-
dicative of user satisfaction is flawed. Understanding and meet-
ing the needs of dissatisfied contraceptive users should be a pri-
ority for the global sexual and reproductive health agenda. Statisti-
2
C.W. Rothschild et al. Contraception xxx (xxxx) xxx
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cal methods such as GBTM can be used to generate nuanced ev-
idence on the changing needs of people using contraception. In
addition, trajectories identified using statistical methods such as
GBTM could be useful as novel outcome measures for the moni-
toring and evaluation of person-centered contraceptive programs.
Disclosures and Funding
Conflicts of interest : The authors declare that there are no com-
peting interests.
Funding : Support for this research came from a Gates Grand
Challenges Explorations grant ( OPP1172004 ), the Eunice Kennedy
Shriver National Institute of Child Health & Human Development of
the National Institutes of Health ( F31HD097841 [CR]), and the Na-
tional Institute of Allergy and Infectious Diseases of the National
Institutes of Health ( K01AI11628 [ALD]). Funding for Online Open
publication was provided by the Bill & Melinda Gates Foundation .
The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of
Health or of the Bill & Melinda Gates Foundation.
Acknowledgments
The authors would like to wholeheartedly thank the mCUBE
Study research participants and study team for their invaluable
contributions. We would like to thank all mCUBE study co-
investigators at the University of Washington, Kenyatta National
Hospital, and PATH-Kenya. We would like to thank Anna Larsen
for her assistance in GBTM modeling. We would also like to ac-
knowledge the support of the Global Center for Integrated Health
of Women, Adolescents, and Children (Global WACh ) in the Univer-
sity of Washington Department of Global Health.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi: 10.1016/j.contraception.2022.09.
125 .
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