IJG-07956; No of Pages 5 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
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International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Postabortion contraception a decade after legalization of abortion in Nepal Corinne H. Rocca a,⁎, Mahesh Puri b, Cynthia C. Harper a, Maya Blum a, Bishnu Dulal b, Jillian T. Henderson a a b
Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, USA Center for Research on Environment Health and Population Activities (CREHPA), Kathmandu, Nepal
a r t i c l e
i n f o
Article history: Received 1 November 2013 Received in revised form 25 February 2014 Accepted 15 April 2014 Keywords: Abortion Counseling Nepal Postabortion contraception South Asia
a b s t r a c t Objective: To assess the contraceptive information received and methods chosen, received, and used among women having abortions one decade after legalization of abortion in Nepal. Methods: We examined postabortion contraception with questionnaires at baseline and six months among women obtaining legal abortions (n = 838) at four facilities in 2011. Multivariate regression analysis was used to measure factors associated with method information, choice, receipt, and use. Results: One-third of participants received no information on effective methods, and 56% left facilities without a method. The majority of women who chose to use injectables and pills were able to do so (88% and 75%, respectively). However, only 44% of women choosing long-acting reversible contraceptives and 5% choosing sterilization had initiated use of the method by six months. Levels of contraceptive use after medical abortion were on par with those after aspiration abortion. Nulliparous women were far less likely than parous women to receive information and use methods. Women living without husbands or partners were also less likely to receive information and supplies, or to use methods. Conclusion: Improvements in postabortion counseling and provision are needed. Ensuring that women choosing long-acting and permanent contraceptive methods are able to obtain either them or interim methods is essential. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The legalization of abortion in Nepal in 2002 and subsequent scaleup of safe abortion services were important steps toward reducing high pregnancy-related morbidity and mortality [1,2]. Legalization also presented new opportunities to offer postabortion contraceptive information and supplies—important for reducing repeat unintended pregnancy and abortion [3]. Abortion visits are occasions to reach women who may not otherwise access health and contraceptive services. Accordingly, Nepal’s Safe Abortion Policy has emphasized contraceptive counseling as integral to abortion care [4]. A systematic review found that postabortion contraceptive uptake in low-income countries was consistently higher among women receiving counseling and services (26%–67% increase) [5]. Willingness to adopt a method can be influenced by counseling content, including the range of methods discussed [6,7]. The one study evaluating the impact of counseling on repeat pregnancy and abortion found small beneficial effects [8].
⁎ Corresponding author at: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 335, Box 0744, San Francisco, CA 94143–0744, USA. Tel.: +1 415 476 6973; fax: +1 415 502 8479. E-mail address: [email protected] (C.H. Rocca).
After steady improvements, contraceptive prevalence in Nepal has plateaued since 2006 [9]. Only 43% of married women use modern methods, most commonly sterilization (23%) and injectables (9%), and women on average have almost one child more than desired [9]. Women seeking abortion are at elevated risk for repeat abortion; in a recent study, one-third of women at major abortion facilities in Nepal had experienced a prior abortion [10]. Empirical data on postabortion contraceptive services are needed to identify barriers to service delivery and method use. Data from Nepal’s Health Management Information System indicate that half of women obtaining abortions at public facilities from 2009 to 2011 received a contraceptive method at the visit [1]. However, these data are reported by public facilities only and by the facilities themselves, and do not provide information on methods discussed, women’s method preferences, or whether women use the methods they received. The objective of the present study was to examine the contraceptive services received by women after an abortion and to identify gaps in services. We assessed sociodemographic factors associated with receipt of method information and supplies, as well as method choice and use, to determine which women may be at highest risk for repeat abortion. 2. Materials and methods We used data from a prospective cohort study of 838 women obtaining legal, elective abortion at four health facilities in Nepal. The
http://dx.doi.org/10.1016/j.ijgo.2014.02.020 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
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C.H. Rocca et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
study sites—two nongovernmental clinics and two government hospitals—were selected to represent facilities across diverse geographies. The clinics are high-volume reproductive health facilities in the Western and Eastern regions. One hospital, in Kathmandu, is one of Nepal’s largest maternity hospitals and receives referrals from throughout Nepal. The other, in the populous agricultural Terai region bordering India, is an important referral facility for surrounding districts. All nonpermanent contraceptives were available free-of-charge, except clinic 1 that charged a small fee for intrauterine device (IUD) and implant insertions, and clinic 2 that charged a small fee for removals. From March 27 to May 13, 2011, we recruited women aged 16–35 years after an aspiration abortion or a medical abortion (MA) visit. (The Nepali MA protocol is mifepristone, followed 24 hours later by misoprostol, typically taken at home. At baseline, participants having medical abortions had taken mifepristone.) Before study initiation, female research assistants received intensive training on confidentiality, recruitment, and interviewing. Research assistants explained study procedures and obtained verbal informed consent. At three of the facilities, nearly all eligible women were enrolled (95% [604/635]). At clinic 2, 51% (234/460) were enrolled owing to high patient flow and limited staff. In private rooms at each facility, interviewers administered baseline questionnaires in Nepali including items on sociodemographics and abortion experience. Six-month follow-up interviews were carried out in a private location preferred by the participant: usually her home, sometimes a clinic, or elsewhere. Interviewers asked about contraceptive methods used since enrollment. Participants received small gifts after each interview. Data were kept confidential: surveys were assigned unique numbers and did not contain identifying information. The study was approved by the University of California, San Francisco, Committee on Human Research, and the Nepal Health Research Council. Participants were asked whether anyone had spoken to them about contraceptive methods at their abortion visit and which methods had been discussed. To measure the outcome receipt of contraceptive information, we created a variable indicating whether the woman had been told about any of the more effective contraceptive methods, defined as hormonal methods, long-acting reversible contraception (LARC: IUD and implant), and female or male sterilization. Condoms and other relatively less effective non-hormonal methods were not included as “effective methods.” We asked who had provided counseling and whether they had been told when they could become pregnant again. Our second outcome was effective method chosen, investigated using the question: “Did you choose/decide on a method of family planning today?” Women were asked which method(s) they had chosen or reasons for not choosing one. The third outcome was effective contraceptive supplies received at the abortion visit. We used data from the six-month interview to create a fourth outcome variable, effective method used at any time since baseline. Sociodemographic variables included age, marital status, education and husband’s education, and current cohabitation with husband or partner. We assessed socioeconomic status using a standardized scale of amenities (e.g. electricity) in women’s households. Reproductive characteristics included parity, desired timing of pregnancy, participant’s and husband’s happiness if she became pregnant within six months (not at all versus very/somewhat/a little/don’t know), and most effective contraceptive previously used. We calculated frequencies of participant characteristics and the four postabortion contraceptive outcomes: contraceptive information received, methods chosen, methods received, and methods used. For women choosing each effective method at baseline, we assessed the percentages who received that method, a different effective method, or no effective method. Similarly, using six-month data, we described contraceptive methods used by participants and assessed the percentages who used the method they chose after the abortion, a different effective method, or no effective method. Bivariate and multivariate logistic regression analyses were conducted to investigate factors associated with each contraceptive outcome. Husband’s education and
desired pregnancy timing were not included in multivariate models owing to correlation with participant education and parity, respectively. We compared the characteristics of participants who completed sixmonth interviews with those who did not using multivariate logistic regression. Analyses were conducted using Stata 12.1 (StataCorp, College Station, TX, USA). P b 0.05 was considered statistically significant.
3. Results The mean age of the 838 participants was 26.3 ± 4.6 years. Almost all were married (97%), but 16% of married women were not currently living with their husband (Table 1). No unmarried women were cohabitating. Most participants had children (87%). A majority (59%) did not want another child; 36% wanted to delay childbirth for at least two years; and 5% wanted a child within two years. Two-thirds of women reported receiving information on at least one effective method at their abortion visit, most commonly injectables (52%) or pills (45%) (Table 2). Approximately 31% received information about two methods, and 19% on three or more. Counseling was largely provided by nurses (69%) or counselors (20%). Half were told when they could become pregnant again. Women not currently living with their husband or cohabitating were less likely to receive contraceptive information than women living with husbands (57% vs 68%, P b 0.05), and nulliparous women were less likely to receive information than parous women (53% vs 68%, P b 0.01). Women having MA were no less likely to receive information than those having aspiration abortions (62% vs 67%, P = 0.24). Facility was strongly associated with contraceptive services: patients at the nongovernmental clinics were more likely to receive contraceptive information (82% and 97%) than women at public hospitals (67% and 40%, overall P b 0.001). In the multivariate analysis, receipt of effective contraceptive information did not vary by age, assets, education, or parity (Table 3). Noncohabitating women were less likely to receive counseling (aOR =
Table 1 Participant characteristics among 838 abortion patients in Nepal. Characteristics Marital status Currently married Never married, separated, or divorced Not living with husband or partner Greater than primary education Husband has greater than primary education (n = 830)a Rural residence Parity Nulliparous Parous Desired timing of next pregnancy Wants no more children More than 2 years Within 2 years Happy if became pregnant in next 6 months Husband happy if became pregnant in next 6 months (n = 832)a Prior use, most effective contraceptive method (n = 832) None or condoms Pills or injectable IUD or implant Abortion type Aspiration Medication Facility Clinic 1 Clinic 2 Hospital 1 Hospital 2 a
No.
(%)
810 28 134 579 702 345
(96.7) (3.3) (16.0) (69.1) (84.6) (41.2)
111 727
(13.3) (86.8)
495 301 42 123 203
(59.1) (35.9) (5.0) (14.7) (24.4)
307 475 50
(36.9) (57.1) (6.0)
671 167
(80.1) (19.9)
164 234 66 374
(19.6) (27.9) (7.9) (44.6)
Includes only currently married women.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
C.H. Rocca et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx Table 2 Postabortion contraceptive information, choice, and receipt at baseline and use at six months among 838 abortion patients in Nepal.
Received information on an effective method, baseline (n = 838) Methods discusseda Injectable Pills IUD Implant Female sterilization Male sterilization Chose an effective method, baseline (n = 838) Methods chosen Injectable Pills IUD Implant Female sterilization Male sterilization Received an effective method, baseline (n = 838) Methods received Injectable Pills IUD Implant Female sterilization Used an effective method, six months (n = 654) Methods useda Injectable Pills IUD Implant Female sterilization Male sterilization a
No.
(%)
554
(66.1)
433 375 196 125 46 40 520
(51.7) (44.8) (23.4) (14.9) (5.5) (4.8) (62.1)
270 130 53 35 33 15 371
(32.2) (15.5) (6.3) (4.2) (3.9) (1.8) (44.3)
231 104 29 6 1 409
(27.6) (12.4) (3.5) (0.7) (0.1) (62.5)
250 143 26 10 1 6
(38.2) (21.9) (4.0) (1.5) (0.2) (0.9)
Methods not mutually exclusive.
0.22; 95% CI, 0.13 − 0.39) than women living with a husband. Unlike in bivariate results, women having MA were less likely to obtain a method than women having aspiration abortion (aOR = 0.54; 95% CI, 0.32 − 0.92). Counseling varied significantly by facility. Sixty-two percent of women reported choosing an effective method at the abortion visit, most commonly the injectable (32%) or pills (16%) (Table 2). Fewer women chose the IUD (6%), implant (4%), female sterilization (4%), or male sterilization (2%). One-quarter reported not choosing a method, usually because their husband/partner was away
3
(37%) and/or she was having infrequent sex (19%). The proportion of women choosing an effective method who had received contraceptive information was 89% − 99% at three sites and 43% at hospital 2. In the multivariate analysis, not living with a husband/partner remained negatively associated with choosing a method (aOR = 0.16; 95% CI, 0.10 − 0.27) (Table 3). Parous women were more likely to choose an effective method (aOR = 6.52; 95% CI, 3.47 − 12.25), while older women (aOR = 0.93; 95% CI, 0.89 − 0.97) and those with higher education (aOR = 0.50; 95% CI, 0.33 − 0.77) were less likely to choose a method. Women who received contraceptive information were over twice as likely to choose an effective method (aOR = 2.50; 95% CI, 1.58 − 3.94). MA was not associated with choosing a method (aOR = 0.81; 95% CI, 0.51 − 1.28). Odds of choosing an effective method differed across facilities. Forty-four percent of participants received effective contraceptive supplies at their abortion visit, most commonly the injectable (28%) or pills (12%) (Table 2). Four percent had a LARC method placed. Factors associated with method receipt were similar to those associated with method choice (Table 3). One exception was that women having MA (who had initiated, but not completed, abortions) were less likely to receive a method than women having aspiration procedures (23% vs 50%, aOR = 0.28; 95% CI, 0.17 − 0.46). The large majority of women choosing the injectable or pill at baseline received the method (Fig. 1). However, only 40% of those selecting the IUD or implant had the method placed. Forty-eight percent of women choosing LARC and 83% of those selecting sterilization left the abortion clinic without an effective method. Overall, 78% of participants (n = 654) completed a six-month interview. Women lost-to-follow-up were younger, poorer, less educated, more rural, and less likely to live with husbands (P b 0.05 for each) than women completing follow-up. They were more likely to have had abortions at hospitals. Among participants completing a sixmonth interview, 63% reported using an effective contraceptive method since the abortion: 38% used injectables, 22% pills, 6% LARC, and 1% female or male sterilization (Table 2). Factors associated with use were similar to those associated with choosing a method post abortion (Table 3). Women who had MA were similarly likely to initiate a method by six months as women having aspiration procedures (58% vs 64%, aOR = 0.77; 95% CI, 0.47 − 1.26). Women who chose injectables or pills at their abortion visit were more likely to use them than women who chose LARC or sterilization (Fig. 2). While 88% of women choosing the injectable and 75% of those
Table 3 Characteristics associated with contraceptive outcomes after abortion (multivariate logistic regression models). Characteristics
Received information aOR (95% CI)
Age Not living with husband or partner Household assets Greater than primary education Rural residence (ref: urban) Parous (ref: nulliparous) Happy if became pregnant, in next 6 months Husband happy if pregnant, in next 6 months Ever use of effective method Received contraceptive information Medical abortion (ref: aspiration) Facility (ref: Clinic 1) Clinic 2 Hospital 1 Hospital 2 Number of observationsd P, Goodness-of-fit [17]
1.03 (0.99 0.22 (0.13 0.92 (0.75 0.84 (0.54 1.04 (0.70 1.06 (0.56 0.73 (0.37 0.87 (0.49 1.07 (0.69 – 0.54 (0.32
a b c d
− − − − − − − − −
1.08) 0.39)c 1.12) 1.30) 1.53) 2.03) 1.44) 1.53) 1.67)
− 0.92)a
7.32 (2.92 − 18.36)c 0.52 (0.24 − 1.12) 0.08 (0.05 − 0.15)c 827 0.48
Chose a method aOR (95% CI) 0.93 (0.89 0.16 (0.10 0.98 (0.82 0.50 (0.33 1.22 (0.82 6.52 (3.47 0.57 (0.32 0.97 (0.58 1.42 (0.97 2.50 (1.58 0.81 (0.51
− − − − − − − − − − −
0.97)c 0.27)c 1.18) 0.77)b 1.71) 12.25)c 1.02) 1.62) 2.07) 3.94)c 1.28)
0.36 (0.21 − 0.61)c 0.35 (0.17 − 0.72)b 1.74 (0.98 − 3.10) 827 0.56
Received a method aOR (95% CI)
Used a method aOR (95% CI)
0.92 (0.88 − 0.96)c 0.13 (0.07 − 1.09)c 0.91 (0.77 − 1.09) 0.65 (0.45 − 0.95)a 1.62 (1.15 − 2.28)b 5.10 (2.63 − 9.92)c 0.85 (0.48 − 1.53) 0.85 (0.52 − 1.41) 1.08 0.75 − 1.56) 2.21 (1.47 − 3.33)c 0.28 (0.17 − 0.46)c
0.92 (0.88 0.21 (0.12 0.90 (0.74 0.56 (0.35 1.32 (0.89 5.68 (2.68 0.62 (0.55 0.98 (0.55 1.89 (1.26 2.07 (1.29 0.77 (0.47
0.34 (0.20 − 0.57)c 0.22 (0.10 − 0.50)c 0.51 (0.30 − 0.86)a 827 0.62
0.48 (0.27 − 0.85)a 0.74 (0.34 − 1.1) 0.87 (0.48 − 1.59) 652 0.31
− − − − − − − − − − −
0.96)c 0.37)c 1.11) 0.88)a 1.96) 12.04)c 1.73) 1.73) 2.83)b 3.31)c 1.26)
P b 0.05. P b 0.01. P b 0.001. Number of observations varies with missing data on independent variables. Used a method measured at six-month visit.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
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C.H. Rocca et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
No. of participants (n=838)
85%
Received chosen method
200
Received a different method Received no effective method
78%
100
14%
22%
Injectable
83%
12%
0%
1%
0
48%
40%
Pill
2%
LARC
15%
Sterilization
Contraceptive method chosen at abortion visit Fig. 1. Contraceptive methods received at abortion visit, by method chosen at baseline.
choosing the pill used that method, 44% of those choosing LARC had the method placed, and two of 48 women choosing sterilization had (or their husband had) procedures, by six months. About 40% of LARC/ sterilization choosers relied on a different effective method. Primary reasons for non-use of the chosen method were the woman changed her mind about wanting the method (46%), medical/health reasons (18%), and concern over adverse effects (18%). A quarter of women who did not choose an effective method at baseline still adopted one, usually pills (47%) or injectables (40%). 4. Discussion
No. of participants at 6 months (n=654)
Despite Nepal’s policy commitment to postabortion contraception, data are lacking on the information women receive, the methods they choose and use, and barriers to adoption. The absence of data impedes evaluation and improvement of services. This study addresses this gap, using data from women obtaining abortions at diverse facilities to characterize women’s experiences with contraceptive services a decade after abortion legalization. Over half of the participants left abortion facilities without an effective contraceptive method. One-third received no information on effective methods. Few received information on the most effective reversible methods, IUDs and implants, and only 44% of women desiring these methods had them placed within six months. Similarly, 83% of women selecting female or male sterilization left the abortion facility without a method, and over half used no effective method over the first six
200
88%
Used chosen method Used a different method Used no effective method
100 75%
5% 7%
20%
Injectible
40%
17%
5%
Pill
Acknowledgments
44% 39%
55%
5%
0 LARC
months. Qualitative data from study sites indicated that inadequate time for counseling, limitations in space and privacy, and shortages in supplies and trained staff were service barriers [11]. Research assessing reasons for low LARC uptake and barriers to provision is needed, as there is likely room for improvement in use. Focusing on sociocultural barriers, participants whose husbands were away or reported infrequent sex were less likely to receive contraceptive information or to choose an effective method. Infrequent sex was also the most common reason for not choosing a method. The proportion of married women whose husbands migrate in Nepal is more than twice those of other South Asian countries [12]; in 2011, 37% of households had a male who migrated in the prior year [9]. A 2009 study found that 54% of women not using contraception reported “husband not living at home” as the reason for nonuse [12], which was also the most common reason for method discontinuation in the Demographic and Health Survey [9]. Women whose husbands are absent or who have infrequent sex may face sociocultural barriers to contraceptive use and likely have unique contraceptive preferences, warranting research into how abortion care can be adapted to better meet their needs. Increasing MA in Nepal, particularly since it became available through government-certified providers in 2009 [1], has fueled concerns about decreased contraceptive provision, given the need to return for injectables and long-acting methods. Although MA patients in the present study were no less likely than aspiration abortion patients to use an effective method, they were less likely to receive contraceptive information and supplies at their initial abortion visit. A recent study in India had somewhat similar findings: although six-month use rates were similar, MA patients experienced greater delays in contraceptive initiation and were more likely to rely on condoms than aspiration abortion patients [13]. Attention to contraceptive care for MA patients is needed, particularly considering evidence that MA is increasing, within and outside the legal system [9,14]. Insertion of an implant at the mifepristone visit is feasible [15]; likewise, scheduling IUD insertion a week after mifepristone, rather than 3–4 weeks later, may increase uptake without increasing expulsions [16]. Oral contraceptives can be given in case women do not return for follow-up. Regardless, provision of contraceptive information at the first MA visit should be encouraged. The study has limitations. Although the recruitment sites were diverse, they were not representative of abortion facilities in Nepal, limiting study generalizability. Data were self-reported, introducing social desirability bias. However, reports from women can provide important and otherwise unobtainable information on the contraceptive information retained by women and their method choice and use. Finally, participants who were more likely to be lost to follow-up were those less likely to choose or receive methods; thus the reported proportions using contraception at six months are likely overestimates. Legalized abortion in Nepal has presented an unprecedented opportunity for dispensing contraceptives to women at risk of unintended pregnancy. Considerable progress has been made to provide comprehensive family planning services after abortion [1], yet important challenges remain. Efforts to increase the range of methods discussed might improve uptake. Addressing barriers to LARC provision would alleviate the gap between selection and use of these methods. Ensuring that women choosing LARC or sterilization, which may not be immediately available, obtain these methods is essential.
Sterilization
Contraceptive method chosen at abortion visit Fig. 2. Contraceptive methods used six months after abortion, by method chosen at baseline.
This research was funded by a research grant and a career development grant from the Society of Family Planning. The views and opinions expressed are those of the authors and do not necessarily represent the views and opinions of the funding agency. Earlier versions of this article were presented at the FIGO World Congress and North American Forum for Family Planning, both held in October 2012.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
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Conflict of interest The authors have no conflicts of interest. References [1] Samandari G, Wolf M, Basnett I, Hyman A, Andersen K. Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care. Reprod Health 2012;7(9):1–11. [2] Henderson JT, Puri M, Blum M, Harper CC, Rana A, Gurung G, et al. Effects of abortion legalization in Nepal, 2001–2010. PloS One 2013;8(5):e64775. [3] International Federation of Gynecology and Obstetrics (FIGO), International Confederation of Midwives (ICM), International Council of Nurses (ICN), United States Agency for International Development (USAID). Family planning: a key component of post abortion care. http://www.figo.org/files/figo-corp/Joint%20Statement% 20FPPAC%20No%20Disclmr%2010Oct09%20%5B1%5D.pdf. Published September 25, 2009. Accessed January 17, 2013. [4] Ministry of Health and Population, Department of Health Services, Family Health Division. National Safe Abortion Policy, Final Draft. Kathmandu: Ministry of Health and Population; 2003. [5] Tripney J, Kwan I, Bird K. Postabortion family planning counseling and services for women in low-income countries: a systematic review. Contraception 2013;87: 17–25. [6] McDougall J, Fetters T, Clark KA, Rathavy T. Determinants of contraceptive acceptance among Cambodian abortion patients. Stud Family Plann 2009;40(2):123–32. [7] Gubhaju B. Barriers to sustained use of contraception in Nepal: Quality of care, socioeconomic status, and method-related factors. Biodemog Soc Biol 2009;55(1):52–70.
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[8] Johnson BR, Ndhlovu S, Farr SL, Chipato T. Reducing unplanned pregnancy and abortion in Zimbabwe through postabortion contraception. Stud Family Plann 2002;33(2): 195–202. [9] Ministry of Health and Population, New ERA, ICF International. Nepal Demographic and Health Survey, 2011. http://dhsprogram.com/pubs/pdf/FR257/FR257[13April2012].pdf . Published March 2012. Accessed March 26, 2012. [10] Thapa S, Neupane S. Risk factors for repeat abortion in Nepal. Int J Gynecol Obstet 2013;120(1):32–6. [11] Wang L, Puri M, Joshi D, Blum M, Henderson J. Post-abortion contraceptive services in Nepal: perspectives of abortion care stakeholders. Annual Meetings of the National Abortion Federation. New York, NY; April 27–30, 2013; 2013. [12] Ban B, Karki S, Shrestha A, Hodgins S. Spousal separation and interpretation of contraceptive use and unmet need in rural Nepal. Int Perspect Sex Reprod Health 2012;38(1):43–7. [13] Kalyanwala S, Acharya R, Zavier AJF. Adoption and continuation of contraception following medical or surgical abortion in Bihar and Jharkhand, India. Int J Gynecol Obstet 2012;118:S47–51. [14] Rocca C, Puri M, Dulal B, Bajracharya L, Harper C, Blum M, et al. Unsafe abortion after legalization in Nepal: a cross-sectional study of women presenting to hospitals. BJOG 2013;120(9):1075–83. [15] Sonalkar S, Hou M, Finneseth M, Petricone R, Arlos A, Kattan D, et al. Etonogestrel implant at the time of Mifepristone for medical abortion. Contraception 2012;86(3): 298. [16] Saav I, Stephansson O, Gemzell-Danielsson K. Early versus delayed insertion of intrauterine contraception after medical abortion - a randomized controlled trial. PLoS One 2012;7(11):e48948. [17] Hosmer DS, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley and Sons; 2000.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Postabortion contraception a decade after legalization of abortion in Nepal Corinne H. Rocca a,⁎, Mahesh Puri b, Cynthia C. Harper a, Maya Blum a, Bishnu Dulal b, Jillian T. Henderson a a b
Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, USA Center for Research on Environment Health and Population Activities (CREHPA), Kathmandu, Nepal
a r t i c l e
i n f o
Article history: Received 1 November 2013 Received in revised form 25 February 2014 Accepted 15 April 2014 Keywords: Abortion Counseling Nepal Postabortion contraception South Asia
a b s t r a c t Objective: To assess the contraceptive information received and methods chosen, received, and used among women having abortions one decade after legalization of abortion in Nepal. Methods: We examined postabortion contraception with questionnaires at baseline and six months among women obtaining legal abortions (n = 838) at four facilities in 2011. Multivariate regression analysis was used to measure factors associated with method information, choice, receipt, and use. Results: One-third of participants received no information on effective methods, and 56% left facilities without a method. The majority of women who chose to use injectables and pills were able to do so (88% and 75%, respectively). However, only 44% of women choosing long-acting reversible contraceptives and 5% choosing sterilization had initiated use of the method by six months. Levels of contraceptive use after medical abortion were on par with those after aspiration abortion. Nulliparous women were far less likely than parous women to receive information and use methods. Women living without husbands or partners were also less likely to receive information and supplies, or to use methods. Conclusion: Improvements in postabortion counseling and provision are needed. Ensuring that women choosing long-acting and permanent contraceptive methods are able to obtain either them or interim methods is essential. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The legalization of abortion in Nepal in 2002 and subsequent scaleup of safe abortion services were important steps toward reducing high pregnancy-related morbidity and mortality [1,2]. Legalization also presented new opportunities to offer postabortion contraceptive information and supplies—important for reducing repeat unintended pregnancy and abortion [3]. Abortion visits are occasions to reach women who may not otherwise access health and contraceptive services. Accordingly, Nepal’s Safe Abortion Policy has emphasized contraceptive counseling as integral to abortion care [4]. A systematic review found that postabortion contraceptive uptake in low-income countries was consistently higher among women receiving counseling and services (26%–67% increase) [5]. Willingness to adopt a method can be influenced by counseling content, including the range of methods discussed [6,7]. The one study evaluating the impact of counseling on repeat pregnancy and abortion found small beneficial effects [8].
⁎ Corresponding author at: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 335, Box 0744, San Francisco, CA 94143–0744, USA. Tel.: +1 415 476 6973; fax: +1 415 502 8479. E-mail address: [email protected] (C.H. Rocca).
After steady improvements, contraceptive prevalence in Nepal has plateaued since 2006 [9]. Only 43% of married women use modern methods, most commonly sterilization (23%) and injectables (9%), and women on average have almost one child more than desired [9]. Women seeking abortion are at elevated risk for repeat abortion; in a recent study, one-third of women at major abortion facilities in Nepal had experienced a prior abortion [10]. Empirical data on postabortion contraceptive services are needed to identify barriers to service delivery and method use. Data from Nepal’s Health Management Information System indicate that half of women obtaining abortions at public facilities from 2009 to 2011 received a contraceptive method at the visit [1]. However, these data are reported by public facilities only and by the facilities themselves, and do not provide information on methods discussed, women’s method preferences, or whether women use the methods they received. The objective of the present study was to examine the contraceptive services received by women after an abortion and to identify gaps in services. We assessed sociodemographic factors associated with receipt of method information and supplies, as well as method choice and use, to determine which women may be at highest risk for repeat abortion. 2. Materials and methods We used data from a prospective cohort study of 838 women obtaining legal, elective abortion at four health facilities in Nepal. The
http://dx.doi.org/10.1016/j.ijgo.2014.02.020 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
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C.H. Rocca et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
study sites—two nongovernmental clinics and two government hospitals—were selected to represent facilities across diverse geographies. The clinics are high-volume reproductive health facilities in the Western and Eastern regions. One hospital, in Kathmandu, is one of Nepal’s largest maternity hospitals and receives referrals from throughout Nepal. The other, in the populous agricultural Terai region bordering India, is an important referral facility for surrounding districts. All nonpermanent contraceptives were available free-of-charge, except clinic 1 that charged a small fee for intrauterine device (IUD) and implant insertions, and clinic 2 that charged a small fee for removals. From March 27 to May 13, 2011, we recruited women aged 16–35 years after an aspiration abortion or a medical abortion (MA) visit. (The Nepali MA protocol is mifepristone, followed 24 hours later by misoprostol, typically taken at home. At baseline, participants having medical abortions had taken mifepristone.) Before study initiation, female research assistants received intensive training on confidentiality, recruitment, and interviewing. Research assistants explained study procedures and obtained verbal informed consent. At three of the facilities, nearly all eligible women were enrolled (95% [604/635]). At clinic 2, 51% (234/460) were enrolled owing to high patient flow and limited staff. In private rooms at each facility, interviewers administered baseline questionnaires in Nepali including items on sociodemographics and abortion experience. Six-month follow-up interviews were carried out in a private location preferred by the participant: usually her home, sometimes a clinic, or elsewhere. Interviewers asked about contraceptive methods used since enrollment. Participants received small gifts after each interview. Data were kept confidential: surveys were assigned unique numbers and did not contain identifying information. The study was approved by the University of California, San Francisco, Committee on Human Research, and the Nepal Health Research Council. Participants were asked whether anyone had spoken to them about contraceptive methods at their abortion visit and which methods had been discussed. To measure the outcome receipt of contraceptive information, we created a variable indicating whether the woman had been told about any of the more effective contraceptive methods, defined as hormonal methods, long-acting reversible contraception (LARC: IUD and implant), and female or male sterilization. Condoms and other relatively less effective non-hormonal methods were not included as “effective methods.” We asked who had provided counseling and whether they had been told when they could become pregnant again. Our second outcome was effective method chosen, investigated using the question: “Did you choose/decide on a method of family planning today?” Women were asked which method(s) they had chosen or reasons for not choosing one. The third outcome was effective contraceptive supplies received at the abortion visit. We used data from the six-month interview to create a fourth outcome variable, effective method used at any time since baseline. Sociodemographic variables included age, marital status, education and husband’s education, and current cohabitation with husband or partner. We assessed socioeconomic status using a standardized scale of amenities (e.g. electricity) in women’s households. Reproductive characteristics included parity, desired timing of pregnancy, participant’s and husband’s happiness if she became pregnant within six months (not at all versus very/somewhat/a little/don’t know), and most effective contraceptive previously used. We calculated frequencies of participant characteristics and the four postabortion contraceptive outcomes: contraceptive information received, methods chosen, methods received, and methods used. For women choosing each effective method at baseline, we assessed the percentages who received that method, a different effective method, or no effective method. Similarly, using six-month data, we described contraceptive methods used by participants and assessed the percentages who used the method they chose after the abortion, a different effective method, or no effective method. Bivariate and multivariate logistic regression analyses were conducted to investigate factors associated with each contraceptive outcome. Husband’s education and
desired pregnancy timing were not included in multivariate models owing to correlation with participant education and parity, respectively. We compared the characteristics of participants who completed sixmonth interviews with those who did not using multivariate logistic regression. Analyses were conducted using Stata 12.1 (StataCorp, College Station, TX, USA). P b 0.05 was considered statistically significant.
3. Results The mean age of the 838 participants was 26.3 ± 4.6 years. Almost all were married (97%), but 16% of married women were not currently living with their husband (Table 1). No unmarried women were cohabitating. Most participants had children (87%). A majority (59%) did not want another child; 36% wanted to delay childbirth for at least two years; and 5% wanted a child within two years. Two-thirds of women reported receiving information on at least one effective method at their abortion visit, most commonly injectables (52%) or pills (45%) (Table 2). Approximately 31% received information about two methods, and 19% on three or more. Counseling was largely provided by nurses (69%) or counselors (20%). Half were told when they could become pregnant again. Women not currently living with their husband or cohabitating were less likely to receive contraceptive information than women living with husbands (57% vs 68%, P b 0.05), and nulliparous women were less likely to receive information than parous women (53% vs 68%, P b 0.01). Women having MA were no less likely to receive information than those having aspiration abortions (62% vs 67%, P = 0.24). Facility was strongly associated with contraceptive services: patients at the nongovernmental clinics were more likely to receive contraceptive information (82% and 97%) than women at public hospitals (67% and 40%, overall P b 0.001). In the multivariate analysis, receipt of effective contraceptive information did not vary by age, assets, education, or parity (Table 3). Noncohabitating women were less likely to receive counseling (aOR =
Table 1 Participant characteristics among 838 abortion patients in Nepal. Characteristics Marital status Currently married Never married, separated, or divorced Not living with husband or partner Greater than primary education Husband has greater than primary education (n = 830)a Rural residence Parity Nulliparous Parous Desired timing of next pregnancy Wants no more children More than 2 years Within 2 years Happy if became pregnant in next 6 months Husband happy if became pregnant in next 6 months (n = 832)a Prior use, most effective contraceptive method (n = 832) None or condoms Pills or injectable IUD or implant Abortion type Aspiration Medication Facility Clinic 1 Clinic 2 Hospital 1 Hospital 2 a
No.
(%)
810 28 134 579 702 345
(96.7) (3.3) (16.0) (69.1) (84.6) (41.2)
111 727
(13.3) (86.8)
495 301 42 123 203
(59.1) (35.9) (5.0) (14.7) (24.4)
307 475 50
(36.9) (57.1) (6.0)
671 167
(80.1) (19.9)
164 234 66 374
(19.6) (27.9) (7.9) (44.6)
Includes only currently married women.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
C.H. Rocca et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx Table 2 Postabortion contraceptive information, choice, and receipt at baseline and use at six months among 838 abortion patients in Nepal.
Received information on an effective method, baseline (n = 838) Methods discusseda Injectable Pills IUD Implant Female sterilization Male sterilization Chose an effective method, baseline (n = 838) Methods chosen Injectable Pills IUD Implant Female sterilization Male sterilization Received an effective method, baseline (n = 838) Methods received Injectable Pills IUD Implant Female sterilization Used an effective method, six months (n = 654) Methods useda Injectable Pills IUD Implant Female sterilization Male sterilization a
No.
(%)
554
(66.1)
433 375 196 125 46 40 520
(51.7) (44.8) (23.4) (14.9) (5.5) (4.8) (62.1)
270 130 53 35 33 15 371
(32.2) (15.5) (6.3) (4.2) (3.9) (1.8) (44.3)
231 104 29 6 1 409
(27.6) (12.4) (3.5) (0.7) (0.1) (62.5)
250 143 26 10 1 6
(38.2) (21.9) (4.0) (1.5) (0.2) (0.9)
Methods not mutually exclusive.
0.22; 95% CI, 0.13 − 0.39) than women living with a husband. Unlike in bivariate results, women having MA were less likely to obtain a method than women having aspiration abortion (aOR = 0.54; 95% CI, 0.32 − 0.92). Counseling varied significantly by facility. Sixty-two percent of women reported choosing an effective method at the abortion visit, most commonly the injectable (32%) or pills (16%) (Table 2). Fewer women chose the IUD (6%), implant (4%), female sterilization (4%), or male sterilization (2%). One-quarter reported not choosing a method, usually because their husband/partner was away
3
(37%) and/or she was having infrequent sex (19%). The proportion of women choosing an effective method who had received contraceptive information was 89% − 99% at three sites and 43% at hospital 2. In the multivariate analysis, not living with a husband/partner remained negatively associated with choosing a method (aOR = 0.16; 95% CI, 0.10 − 0.27) (Table 3). Parous women were more likely to choose an effective method (aOR = 6.52; 95% CI, 3.47 − 12.25), while older women (aOR = 0.93; 95% CI, 0.89 − 0.97) and those with higher education (aOR = 0.50; 95% CI, 0.33 − 0.77) were less likely to choose a method. Women who received contraceptive information were over twice as likely to choose an effective method (aOR = 2.50; 95% CI, 1.58 − 3.94). MA was not associated with choosing a method (aOR = 0.81; 95% CI, 0.51 − 1.28). Odds of choosing an effective method differed across facilities. Forty-four percent of participants received effective contraceptive supplies at their abortion visit, most commonly the injectable (28%) or pills (12%) (Table 2). Four percent had a LARC method placed. Factors associated with method receipt were similar to those associated with method choice (Table 3). One exception was that women having MA (who had initiated, but not completed, abortions) were less likely to receive a method than women having aspiration procedures (23% vs 50%, aOR = 0.28; 95% CI, 0.17 − 0.46). The large majority of women choosing the injectable or pill at baseline received the method (Fig. 1). However, only 40% of those selecting the IUD or implant had the method placed. Forty-eight percent of women choosing LARC and 83% of those selecting sterilization left the abortion clinic without an effective method. Overall, 78% of participants (n = 654) completed a six-month interview. Women lost-to-follow-up were younger, poorer, less educated, more rural, and less likely to live with husbands (P b 0.05 for each) than women completing follow-up. They were more likely to have had abortions at hospitals. Among participants completing a sixmonth interview, 63% reported using an effective contraceptive method since the abortion: 38% used injectables, 22% pills, 6% LARC, and 1% female or male sterilization (Table 2). Factors associated with use were similar to those associated with choosing a method post abortion (Table 3). Women who had MA were similarly likely to initiate a method by six months as women having aspiration procedures (58% vs 64%, aOR = 0.77; 95% CI, 0.47 − 1.26). Women who chose injectables or pills at their abortion visit were more likely to use them than women who chose LARC or sterilization (Fig. 2). While 88% of women choosing the injectable and 75% of those
Table 3 Characteristics associated with contraceptive outcomes after abortion (multivariate logistic regression models). Characteristics
Received information aOR (95% CI)
Age Not living with husband or partner Household assets Greater than primary education Rural residence (ref: urban) Parous (ref: nulliparous) Happy if became pregnant, in next 6 months Husband happy if pregnant, in next 6 months Ever use of effective method Received contraceptive information Medical abortion (ref: aspiration) Facility (ref: Clinic 1) Clinic 2 Hospital 1 Hospital 2 Number of observationsd P, Goodness-of-fit [17]
1.03 (0.99 0.22 (0.13 0.92 (0.75 0.84 (0.54 1.04 (0.70 1.06 (0.56 0.73 (0.37 0.87 (0.49 1.07 (0.69 – 0.54 (0.32
a b c d
− − − − − − − − −
1.08) 0.39)c 1.12) 1.30) 1.53) 2.03) 1.44) 1.53) 1.67)
− 0.92)a
7.32 (2.92 − 18.36)c 0.52 (0.24 − 1.12) 0.08 (0.05 − 0.15)c 827 0.48
Chose a method aOR (95% CI) 0.93 (0.89 0.16 (0.10 0.98 (0.82 0.50 (0.33 1.22 (0.82 6.52 (3.47 0.57 (0.32 0.97 (0.58 1.42 (0.97 2.50 (1.58 0.81 (0.51
− − − − − − − − − − −
0.97)c 0.27)c 1.18) 0.77)b 1.71) 12.25)c 1.02) 1.62) 2.07) 3.94)c 1.28)
0.36 (0.21 − 0.61)c 0.35 (0.17 − 0.72)b 1.74 (0.98 − 3.10) 827 0.56
Received a method aOR (95% CI)
Used a method aOR (95% CI)
0.92 (0.88 − 0.96)c 0.13 (0.07 − 1.09)c 0.91 (0.77 − 1.09) 0.65 (0.45 − 0.95)a 1.62 (1.15 − 2.28)b 5.10 (2.63 − 9.92)c 0.85 (0.48 − 1.53) 0.85 (0.52 − 1.41) 1.08 0.75 − 1.56) 2.21 (1.47 − 3.33)c 0.28 (0.17 − 0.46)c
0.92 (0.88 0.21 (0.12 0.90 (0.74 0.56 (0.35 1.32 (0.89 5.68 (2.68 0.62 (0.55 0.98 (0.55 1.89 (1.26 2.07 (1.29 0.77 (0.47
0.34 (0.20 − 0.57)c 0.22 (0.10 − 0.50)c 0.51 (0.30 − 0.86)a 827 0.62
0.48 (0.27 − 0.85)a 0.74 (0.34 − 1.1) 0.87 (0.48 − 1.59) 652 0.31
− − − − − − − − − − −
0.96)c 0.37)c 1.11) 0.88)a 1.96) 12.04)c 1.73) 1.73) 2.83)b 3.31)c 1.26)
P b 0.05. P b 0.01. P b 0.001. Number of observations varies with missing data on independent variables. Used a method measured at six-month visit.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
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C.H. Rocca et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
No. of participants (n=838)
85%
Received chosen method
200
Received a different method Received no effective method
78%
100
14%
22%
Injectable
83%
12%
0%
1%
0
48%
40%
Pill
2%
LARC
15%
Sterilization
Contraceptive method chosen at abortion visit Fig. 1. Contraceptive methods received at abortion visit, by method chosen at baseline.
choosing the pill used that method, 44% of those choosing LARC had the method placed, and two of 48 women choosing sterilization had (or their husband had) procedures, by six months. About 40% of LARC/ sterilization choosers relied on a different effective method. Primary reasons for non-use of the chosen method were the woman changed her mind about wanting the method (46%), medical/health reasons (18%), and concern over adverse effects (18%). A quarter of women who did not choose an effective method at baseline still adopted one, usually pills (47%) or injectables (40%). 4. Discussion
No. of participants at 6 months (n=654)
Despite Nepal’s policy commitment to postabortion contraception, data are lacking on the information women receive, the methods they choose and use, and barriers to adoption. The absence of data impedes evaluation and improvement of services. This study addresses this gap, using data from women obtaining abortions at diverse facilities to characterize women’s experiences with contraceptive services a decade after abortion legalization. Over half of the participants left abortion facilities without an effective contraceptive method. One-third received no information on effective methods. Few received information on the most effective reversible methods, IUDs and implants, and only 44% of women desiring these methods had them placed within six months. Similarly, 83% of women selecting female or male sterilization left the abortion facility without a method, and over half used no effective method over the first six
200
88%
Used chosen method Used a different method Used no effective method
100 75%
5% 7%
20%
Injectible
40%
17%
5%
Pill
Acknowledgments
44% 39%
55%
5%
0 LARC
months. Qualitative data from study sites indicated that inadequate time for counseling, limitations in space and privacy, and shortages in supplies and trained staff were service barriers [11]. Research assessing reasons for low LARC uptake and barriers to provision is needed, as there is likely room for improvement in use. Focusing on sociocultural barriers, participants whose husbands were away or reported infrequent sex were less likely to receive contraceptive information or to choose an effective method. Infrequent sex was also the most common reason for not choosing a method. The proportion of married women whose husbands migrate in Nepal is more than twice those of other South Asian countries [12]; in 2011, 37% of households had a male who migrated in the prior year [9]. A 2009 study found that 54% of women not using contraception reported “husband not living at home” as the reason for nonuse [12], which was also the most common reason for method discontinuation in the Demographic and Health Survey [9]. Women whose husbands are absent or who have infrequent sex may face sociocultural barriers to contraceptive use and likely have unique contraceptive preferences, warranting research into how abortion care can be adapted to better meet their needs. Increasing MA in Nepal, particularly since it became available through government-certified providers in 2009 [1], has fueled concerns about decreased contraceptive provision, given the need to return for injectables and long-acting methods. Although MA patients in the present study were no less likely than aspiration abortion patients to use an effective method, they were less likely to receive contraceptive information and supplies at their initial abortion visit. A recent study in India had somewhat similar findings: although six-month use rates were similar, MA patients experienced greater delays in contraceptive initiation and were more likely to rely on condoms than aspiration abortion patients [13]. Attention to contraceptive care for MA patients is needed, particularly considering evidence that MA is increasing, within and outside the legal system [9,14]. Insertion of an implant at the mifepristone visit is feasible [15]; likewise, scheduling IUD insertion a week after mifepristone, rather than 3–4 weeks later, may increase uptake without increasing expulsions [16]. Oral contraceptives can be given in case women do not return for follow-up. Regardless, provision of contraceptive information at the first MA visit should be encouraged. The study has limitations. Although the recruitment sites were diverse, they were not representative of abortion facilities in Nepal, limiting study generalizability. Data were self-reported, introducing social desirability bias. However, reports from women can provide important and otherwise unobtainable information on the contraceptive information retained by women and their method choice and use. Finally, participants who were more likely to be lost to follow-up were those less likely to choose or receive methods; thus the reported proportions using contraception at six months are likely overestimates. Legalized abortion in Nepal has presented an unprecedented opportunity for dispensing contraceptives to women at risk of unintended pregnancy. Considerable progress has been made to provide comprehensive family planning services after abortion [1], yet important challenges remain. Efforts to increase the range of methods discussed might improve uptake. Addressing barriers to LARC provision would alleviate the gap between selection and use of these methods. Ensuring that women choosing LARC or sterilization, which may not be immediately available, obtain these methods is essential.
Sterilization
Contraceptive method chosen at abortion visit Fig. 2. Contraceptive methods used six months after abortion, by method chosen at baseline.
This research was funded by a research grant and a career development grant from the Society of Family Planning. The views and opinions expressed are those of the authors and do not necessarily represent the views and opinions of the funding agency. Earlier versions of this article were presented at the FIGO World Congress and North American Forum for Family Planning, both held in October 2012.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
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Conflict of interest The authors have no conflicts of interest. References [1] Samandari G, Wolf M, Basnett I, Hyman A, Andersen K. Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care. Reprod Health 2012;7(9):1–11. [2] Henderson JT, Puri M, Blum M, Harper CC, Rana A, Gurung G, et al. Effects of abortion legalization in Nepal, 2001–2010. PloS One 2013;8(5):e64775. [3] International Federation of Gynecology and Obstetrics (FIGO), International Confederation of Midwives (ICM), International Council of Nurses (ICN), United States Agency for International Development (USAID). Family planning: a key component of post abortion care. http://www.figo.org/files/figo-corp/Joint%20Statement% 20FPPAC%20No%20Disclmr%2010Oct09%20%5B1%5D.pdf. Published September 25, 2009. Accessed January 17, 2013. [4] Ministry of Health and Population, Department of Health Services, Family Health Division. National Safe Abortion Policy, Final Draft. Kathmandu: Ministry of Health and Population; 2003. [5] Tripney J, Kwan I, Bird K. Postabortion family planning counseling and services for women in low-income countries: a systematic review. Contraception 2013;87: 17–25. [6] McDougall J, Fetters T, Clark KA, Rathavy T. Determinants of contraceptive acceptance among Cambodian abortion patients. Stud Family Plann 2009;40(2):123–32. [7] Gubhaju B. Barriers to sustained use of contraception in Nepal: Quality of care, socioeconomic status, and method-related factors. Biodemog Soc Biol 2009;55(1):52–70.
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[8] Johnson BR, Ndhlovu S, Farr SL, Chipato T. Reducing unplanned pregnancy and abortion in Zimbabwe through postabortion contraception. Stud Family Plann 2002;33(2): 195–202. [9] Ministry of Health and Population, New ERA, ICF International. Nepal Demographic and Health Survey, 2011. http://dhsprogram.com/pubs/pdf/FR257/FR257[13April2012].pdf . Published March 2012. Accessed March 26, 2012. [10] Thapa S, Neupane S. Risk factors for repeat abortion in Nepal. Int J Gynecol Obstet 2013;120(1):32–6. [11] Wang L, Puri M, Joshi D, Blum M, Henderson J. Post-abortion contraceptive services in Nepal: perspectives of abortion care stakeholders. Annual Meetings of the National Abortion Federation. New York, NY; April 27–30, 2013; 2013. [12] Ban B, Karki S, Shrestha A, Hodgins S. Spousal separation and interpretation of contraceptive use and unmet need in rural Nepal. Int Perspect Sex Reprod Health 2012;38(1):43–7. [13] Kalyanwala S, Acharya R, Zavier AJF. Adoption and continuation of contraception following medical or surgical abortion in Bihar and Jharkhand, India. Int J Gynecol Obstet 2012;118:S47–51. [14] Rocca C, Puri M, Dulal B, Bajracharya L, Harper C, Blum M, et al. Unsafe abortion after legalization in Nepal: a cross-sectional study of women presenting to hospitals. BJOG 2013;120(9):1075–83. [15] Sonalkar S, Hou M, Finneseth M, Petricone R, Arlos A, Kattan D, et al. Etonogestrel implant at the time of Mifepristone for medical abortion. Contraception 2012;86(3): 298. [16] Saav I, Stephansson O, Gemzell-Danielsson K. Early versus delayed insertion of intrauterine contraception after medical abortion - a randomized controlled trial. PLoS One 2012;7(11):e48948. [17] Hosmer DS, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley and Sons; 2000.
Please cite this article as: Rocca CH, et al, Postabortion contraception a decade after legalization of abortion in Nepal, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.02.020
