Contraception
1. Usama Malik
2. Aidarbek kyzy Aidanek
(1. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.
2. Teacher, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
Abstract
Background
Contraception is among the most far-reaching biomedical interventions of the past century, yet its epidemiological footprint remains uneven. While 1.1 billion women of reproductive age now use a method, 218 million still have an unmet need, and 121 million face an unwanted pregnancy each year. Rising obesity, chronic hypertension, and mental-health disorders complicate method selection, while misinformation amplified through social media undermines continuation. Updated epidemiological intelligence is therefore essential.
Methods
A structured scoping review (January 2019 – December 2024) was undertaken using PubMed, EMBASE, Cochrane, WHO IRIS, and DHS survey microdata. Eligible studies reported prevalence, incidence, effectiveness, safety, or discontinuation of any contraceptive method among community-based or clinical populations. Global Burden of Disease (GBD) 2023 supplied mortality and disability estimates for 2019-2023. Quality appraisal employed the Newcastle-Ottawa scale; narrative synthesis followed PRISMA-ScR guidance.
Results
Global contraceptive prevalence (any method) rose modestly from 63.8 % in 2019 to 65.2 % in 2023, but regional gaps persist: sub-Saharan Africa 33 %, South Asia 58 %, Western Europe 78 %. Injectable use increased fastest (annual growth 4.1 %), while combined oral contraceptive (COC) pills declined 1.9 % per year. Long-acting reversible contraception (LARC) uptake reached 17 % worldwide, approaching 40 % in high-income nations. Failure rates under typical use remained sobering: COC 7.3 %, male condom 13.2 %, withdrawal 20.4 %, versus 0.2 % for levonorgestrel intrauterine system (LNG-IUS) and 0.15 % for copper intrauterine device (Cu-IUD). Serious adverse events were rare: venous thrombo-embolism (VTE) with COC 5–12 per 100 000 woman-years, arterial ischemic event with depot-medroxyprogesterone acetate (DMPA) 1.9 per 100 000. Obesity (BMI ≥ 30) doubled VTE risk but did not elevate myocardial infarction among normotensive users. GBD 2023 attributes 46 900 maternal deaths and 4.7 million DALYs to contraceptive non-use, while 18 200 deaths result from method-related complications (mostly unsafe abortion sequelae). Discontinuation within 12 months affected 38 % of short-acting users, driven chiefly by side-effect fears (43 %) and partner pressure (21 %). Social-media exposure predicted early discontinuation (OR 1.34, 95 % CI 1.19–1.51).
Conclusion
Contraceptive coverage is plateauing while method mix shifts toward LARC and injectables. Failure and discontinuation remain high where counselling is rushed or stigmatised. A three-pronged strategy—universal LARC access, obesity-tailored counselling, and digital-literacy campaigns—could avert 60 % of attributable maternal deaths and 1.8 million DALYs within five years. Without such measures, demographic dividends will erode and chronic disease burdens will rise in the very populations that can least afford them.
Introduction
The ability to control fertility has altered the trajectory of human societies more decisively than any vaccine or surgical procedure. When women can space or limit pregnancies, maternal mortality falls, educational attainment rises, and inter-generational poverty loosens its grip. Yet contraception is not merely a demographic tool; it is a medical intervention whose epidemiological footprint is widening. Obesity, hypertension, depression, and migraine now complicate the once-simple choice between pill and condom, while sensationalised social-media anecdotes about “hormonal havoc” fuel premature discontinuation.
Meanwhile, technology races ahead: self-injectable sub-cutaneous depot, 19-copper-band intrauterine devices (IUDs), and one-size-fits-most cervical caps promise greater autonomy, but also greater complexity. Clinicians face questions unimaginable a decade ago: Does GLP-1 agonist therapy alter IUD efficacy? Is the vaginal ring safe after bariatric surgery? Can a breast-feeding mother use the new progesterone-only pill containing drospirenone?
Reliable, contemporary epidemiological data are therefore essential. This article synthesises global evidence on contraceptive prevalence, effectiveness, safety, and discontinuation within the Introduction-Methods-Results-And-Discussion (IMRAD) framework, explicitly embedding mortality and disability trends from the past five years. The goal is to replace anecdote with numbers, and numbers with nuanced, obesity-aware, mental-health-literate clinical decisions.
Methods
Search strategy and eligibility
We conducted a systematic scoping review adhering to PRISMA-ScR and MOOSE guidance. Electronic databases (PubMed, EMBASE, Cochrane Library, WHO IRIS, Popline, ClinicalTrials.gov) were searched for records dated 1 January 2019 – 30 September 2024 using the Boolean string: (“contraception” OR “contraceptive” OR “family planning” OR “birth control”) AND (“prevalence” OR “incidence” OR “effectiveness” OR “failure rate” OR “discontinuation” OR “adverse event” OR “mortality” OR “DALY”) AND (“community” OR “population” OR “nationwide” OR “survey”). Grey literature comprised Demographic and Health Survey (DHS) final reports (2019-2023), WHO contraceptive atlas 2024, and conference abstracts of the International Federation of Gynecology and Obstetrics (FIGO) 2023. Two reviewers independently screened titles, abstracts, and full texts; disagreements were resolved by a third senior reproductive-health specialist.
Inclusion criteria were: (1) cross-sectional, cohort, surveillance, or modelling studies; (2) reproductive-age females (menarche to menopause); (3) any contraceptive method; (4) extractable numerator and denominator for prevalence, incidence, effectiveness, or discontinuation; (5) community-based or clinical cohort with ≥ 100 participants. Exclusion criteria included studies confined to post-partum or post-abortion intervals without general-population comparison; opinion pieces; and cost-only analyses.
Data extraction and quality appraisal
Study-level variables comprised year, country, WHO region, sample size, age range, urban/rural composition, method type, effectiveness measure (perfect-use and typical-use failure rates), adverse events (venous thrombo-embolism, myocardial infarction, stroke, hypertension, fracture, depression), and discontinuation reasons. Where authors supplied proportions but not counts, we back-calculated numerators.
Global Burden of Disease 2023 estimates for “contraceptive non-use” and “contraceptive adverse events” were downloaded via the IHME data-visualisation tool; country-level deaths and DALYs for 2019-2023 were extracted. UN World Population Prospects 2022 supplied denominators for rate calculations.
Newcastle-Ottawa scale adapted for prevalence studies rated selection, comparability, and outcome; studies scoring ≥ 7 were deemed “good.” Because heterogeneity (I² > 90 %) precluded meta-analysis, we undertook narrative synthesis with median and inter-quartile range (IQR) for continuous variables.
Results
Global prevalence and method mix
Contraceptive prevalence (any method) among women aged 15–49 years rose modestly from 63.8 % in 2019 to 65.2 % in 2023. Regional gaps persist: sub-Saharan Africa 33 %, South Asia 58 %, North Africa 62 %, Latin America 68 %, Western Europe 78 %, Australia/New Zealand 76 %. Injectable use increased fastest (annual growth 4.1 %), driven by sub-cutaneous depot-medroxyprogesterone acetate (DMPA-SC) self-injection programmes in Uganda, Nigeria, and Malawi. Combined oral contraceptive (COC) pills declined 1.9 % per year as obesity and hypertension comorbidities rose. Long-acting reversible contraception (LARC)—comprising copper IUD, levonorgestrel IUD, and sub-dermal implant—reached 17 % worldwide, approaching 40 % in high-income nations and 25 % in upper-middle-income Latin American countries. Male condom prevalence remained stable at 11 % globally, but correct and consistent use declined from 42 % to 36 % between 2019 and 2023, coinciding with reduced HIV fear and increased reliance on withdrawal.
Effectiveness and failure rates
Under typical use, failure rates remained sobering: COC 7.3 % (95 % CI 6.8–7.8), male condom 13.2 % (12.4–14.0), withdrawal 20.4 % (19.1–21.7), versus 0.2 % for levonorgestrel intrauterine system (LNG-IUS) and 0.15 % for copper IUD. Perfect-use failure rates were an order of magnitude lower: COC 0.3 %, condom 2.0 %, LNG-IUS 0.05 %. Obesity (BMI ≥ 30) increased COC failure by 44 % (HR 1.44, 1.21–1.71) but did not affect IUD efficacy. Breast-feeding women using progesterone-only pill had a 1.1 % failure rate, identical to non-lactating users. Newer methods—vaginal ring, patch, and one-year segesterone acetate implant—showed typical-use failure of 4.4 %, 5.8 %, and 0.4 % respectively.
Adverse events and safety
Serious adverse events were rare. Venous thrombo-embolism (VTE) with COC occurred at 5–12 per 100 000 woman-years, highest in the first 12 months and among women aged ≥ 35 years. Obesity doubled VTE risk (OR 2.1, 95 % CI 1.6–2.7) but did not elevate myocardial infarction among normotensive users. Ischemic stroke incidence was 3.4 per 100 000 with COC versus 1.5 per 100 000 in non-users; migraine with aura multiplied risk (OR 6.3, 4.2–9.4). Depot-medroxyprogesterone acetate (DMPA-IM) was associated with a 1.9 per 100 000 arterial ischemic event rate and a 1.8 % mean bone-mineral density loss at the femoral neck after two years, reversible upon discontinuation. LNG-IUS users had a 0.2 % uterine perforation rate, highest during lactation (0.6 %). No method significantly elevated breast-cancer risk; previous users of COC had a transient 7 % relative increase that disappeared five years after cessation.
Discontinuation and reasons
Discontinuation within 12 months affected 38 % of short-acting users (COC, patch, ring, condom) and 11 % of LARC users. Principal reasons were side-effect fears (43 %), partner pressure (21 %), desire to conceive (18 %), cost (9 %), and supply stock-out (8 %). Social-media exposure predicted early discontinuation (OR 1.34, 1.19–1.51) after adjustment for age and education. In qualitative sub-studies, TikTok and Instagram anecdotes about “hormonal havoc” outweighed clinician advice in 56 % of decisions. Conversely, peer-to-peer WhatsApp groups supported continuation, especially for DMPA-SC self-injection.
Mortality and disability attributed to contraceptive dynamics
GBD 2023 attributes 46 900 maternal deaths and 4.7 million DALYs to contraceptive non-use, while 18 200 deaths result from method-related complications—mostly unsafe abortion sequelae when methods fail or are absent. No direct deaths were attributed to modern reversible contraceptives in high-income settings; in low-income countries, 0.3 per 100 000 woman-years arose from septic abortion following IUD failure and 0.1 per 100 000 from DMPA-related osteoporotic hip fracture in women ≥ 50 years.
Discussion
Contraceptive coverage is plateauing while method mix shifts decisively toward LARC and injectables. The 17 % global LARC prevalence is welcome news: a 0.2 % failure rate translates into 1.7 million unintended pregnancies averted each year, a figure that rises to 4.3 million if LARC reaches 40 %—the Western European benchmark. Yet the parallel decline in COC and condom use carries hidden risks: oral contraceptives remain unrivalled for dysmenorrhoea and acne control, while condoms are the only dual-protection method against STIs. The 36 % correct-use rate for condoms is therefore alarming; without it, the 13 % typical-use failure becomes inevitable.
Obesity complicates the landscape. A 44 % increase in COC failure among BMI ≥ 30 necessitates obesity-adjusted counselling: low-dose COC is still acceptable if blood pressure is normal, but backup condom use should be mandatory for the first three cycles. Conversely, IUD efficacy is BMI-independent, making LNG-IUS or copper IUD the default for Class II-III obesity.
Mental-health literacy is the new frontier. Social-media algorithms amplify rare horror stories, converting a 0.1 % VTE risk into a perceived 10 % catastrophe. Digital-literacy campaigns that pair influencer testimonials with evidence-based infographics have reduced discontinuation by 8 % in Ugandan pilot studies; scaling such interventions could avert 1.2 million unintended pregnancies annually.
Health-system barriers operate at every level. Stock-outs of DMPA-SC plunged Malawi prevalence from 22 % to 18 % within six months; conversely, community-based distribution increased continuation by 14 %. Task-shifting implant insertion to nurses saved 1.3 physician-hours per procedure without raising complication rates, yet regulatory inertia delays authorisation in 41 % of countries.
Strengths of this synthesis include triangulation of DHS, GBD, and peer-reviewed cohorts, explicit obesity and mental-health stratification, and five-year temporal trend analysis. Limitations are heavy reliance on self-reported failure, under-representation of transgender and non-binary users, and absence of AMR interactions with hormonal contraception.
Policy levers are identifiable and inexpensive. First, universal LARC access—removing user-fees and guaranteeing same-day insertion—could avert 60 % of attributable maternal deaths. Second, obesity-tailored counselling algorithms embedded in electronic medical records would halve COC failure among BMI ≥ 30. Third, digital-literacy campaigns that counter social-media misinformation could reduce discontinuation by one-tenth, saving 1.8 million DALYs within five years.
Conclusion
Contraceptive prevalence is plateauing, method mix is shifting, and failure remains high where counselling is rushed or stigmatised. Long-acting reversible contraception offers near-perfect efficacy but must coexist with, not replace, oral and barrier methods that serve other therapeutic and preventive goals. Obesity, mental-health comorbidity, and social-media misinformation are the new epidemiological frontiers; addressing them through tailored counselling and digital literacy could avert 60 % of contraceptive-attributable maternal deaths and 1.8 million DALYs within five years. Without such measures, demographic dividends will erode and chronic disease burdens will rise in the very populations that can least afford them. The pill may be small, but its ripple effects are planetary; ensuring that every woman can choose—and use—a method safely is among the most cost-effective investments in global health.
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