Access matters. But contraception has to work beyond the moment someone gets a method.

By Dr. Caroline Moreau, WHGI Research Director

People start contraception, stop it, switch, experience side effects, change relationships, have pregnancies and revise their fertility intentions. Preferred options are not always available, and access to care can change.

Yet much of how we measure family planning still captures a single moment in time: who is using contraception, who has an unmet need, and which methods are available. Those measures remain essential. But they tell us less about what happens next.

Research from the William H. Gates Sr. Institute, much of it using longitudinal data from Performance Monitoring for Action, shows considerable movement beneath relatively stable levels of contraceptive prevalence. Method preferences change. Women discontinue contraception for many reasons. Some move quickly to another method; others who still want to avoid pregnancy stop using contraception altogether. Side effects, dissatisfaction with care and difficulty obtaining removal or another method can all shape these trajectories.

An important distinction is between stopping a method and losing contraceptive protection. A high rate of discontinuation can look like poor performance, but stopping a method is not necessarily a problem. People should be able to stop a method that no longer suits them. The more revealing question is what happens after they stop. If someone still wants to avoid pregnancy, can she move easily to another acceptable method? Or does stopping one method mean losing contraceptive protection altogether?

That ability becomes especially important when access to care is disrupted. The COVID-19 pandemic offered a real-world stress test. Health services were disrupted in many settings, yet longitudinal PMA data did not show the simple collapse in contraceptive use that might have been expected from service disruption alone. One reason is that contraceptive protection does not depend on a single point of care. Some people already had long-acting methods. Others had supplies at home, obtained contraception from pharmacies or community sources, changed where they sought care, or used methods they could manage themselves.

Together, these different pathways point to a broader goal: ensuring that people can continue to act on their reproductive goals, with the flexibility to stop, switch or change course as their needs evolve.

That means building contraceptive systems with more than one workable pathway: clinics, pharmacies, community distribution, telehealth, advance provision and self-management, with easy access back to clinical care when needed.

It also means rethinking what we measure. Our standard indicators tell us a great deal about contraceptive use at a point in time. They tell us less about whether people can act on their reproductive intentions as their needs and circumstances change.

Longitudinal research makes that gap visible. Current use tells us little about who will later discontinue, who will switch, whether that switch will be timely, or whether someone who still wants to avoid pregnancy will experience a gap in protection. Nor does receiving a preferred method at one point tell us whether that method will continue to fit as preferences and circumstances evolve.

If contraception is dynamic, our measures should capture more than status. They should tell us whether people can obtain an acceptable method, continue it when they want to, stop or switch when they need to, and move between different sources of care while remaining able to pursue their reproductive goals.

The next step is therefore not simply to measure contraceptive coverage, but to understand whether contraceptive systems can adapt with people over time.

Let's be clear what this means in this month where we celebrate World Contraception Day. It means building contraceptive systems with more than one workable pathway: clinics, pharmacies, community distribution, telehealth, advance provision and self-management, with easy access back to clinical care when needed.

The question remains: Can contraception keep up with life?