In an area of Matlab, Bangladesh, where an intensive maternal and child health and family planning program has been delivering high-quality services since the late 1970s, about one in 10 unintended pregnancies end in abortion*--the same proportion as in a comparison area where women receive standard government services. However, unintended pregnancy is significantly less common in the program area; as a result, the proportion of all pregnancies that end in abortion is significantly lower there. Analysts who examined these trends observe that the high-quality longitudinal data from Matlab offer an unusual opportunity to study the effects of family planning services on abortion in the context of rapid fertility decline.1
The two areas are similar, but women in the program area have more contact with community health workers than women in the comparison area have with government workers; they also have a wider variety of contraceptive methods from which to choose. Contraceptive prevalence is rising in both areas, but use has been consistently higher and the unmet need for contraception consistently lower in the program area; moreover, women in the program area are more likely than those in the comparison area to use highly effective methods, such as the injectable. The birthrate per 1,000 women has fallen dramatically in both areas since 1979, but it has been consistently lower in the program area.
To assess trends in abortion, the analysts examined data on nearly 150,000 pregnancy outcomes, including 4,100 abortions, in the two areas between 1979 and 1998. (They note that abortion reporting in Matlab is likely to be complete because the health workers are trusted in the community and are likely to be aware of women's pregnancy status.) In addition, the researchers obtained information on women's pregnancy intentions and contraceptive use from 1984 and 1990 surveys of knowledge, attitudes and practice; by matching these data to pregnancy outcome data for about 10,000 women, they were able to examine separately intended and unintended pregnancies in the five years following each survey.
In 1979, the number of abortions per 1,000 women aged 15-49 was slightly but significantly higher in the program area than in the comparison area (probably, the analysts comment, because of the greater availability of menstrual regulation in the program area). Since 1983, however, the rate has fallen slightly in the program area and risen in the comparison area; the two rates have differed significantly every year. By the late 1990s, women in the program area averaged five fewer abortions per 1,000 annually than women in the comparison area.
In both areas in both survey years, about half of married women who were not pregnant and not relying on permanent contraception said that they wanted more children; about three-quarters of these women became pregnant within the five years following the survey. Among those reporting that they wanted no more children, the proportion who conceived within the next five years was significantly lower in the program area than in the comparison area--34% vs. 46% in 1984-1989 and 22% vs. 39% in 1990-1995. Within each area, the decline between periods was statistically significant. Similarly, unintended pregnancies made up a smaller proportion of all pregnancies in the program area than in the comparison area in the five years following both the 1984 survey (30% vs. 42%) and the 1990 survey (23% vs. 34%), and the declines between periods were statistically significant.
Few intended pregnancies ended in abortion, and the proportion did not change over time. However, in both periods, termination of an intended pregnancy was significantly less common in the program area (fewer than 1%) than in the comparison area (2%). By contrast, in each period, the proportions of unintended pregnancies ending in abortion were similar in the two areas (3-5% in 1984-1989 and 10-11% in 1990-1995), and the increase in each area between periods was statistically significant.
Between 1984-1989 and 1990-1995, the proportion of pregnancies ending in abortion rose in both areas. However, because unintended pregnancies and terminations of intended pregnancies were less common in the program area than in the comparison area, the proportion of pregnancies ending in abortion was likewise lower there (1% vs. 4% in the earlier period and 3% vs. 5% in the later period). Findings from the entire database are similar to those for survey respondents: Between 1984-1986 and 1996-1998, the abortion rate per 1,000 women increased minimally in the program area but substantially in the comparison area; in both periods, the rate was lower in the program area (2.2-2.3) than in the comparison area (5.2-6.8).
The analysts comment that as couples in developing countries increasingly wish to limit their family size, the incidence of abortion may rise. As illustrated in the Matlab program area, however, "widespread availability of quality family planning services...helps couples to space and limit their births and can result in much lower rates of abortion than would otherwise be the case." For countries undergoing fertility transition, the researchers conclude, keeping the number of abortions low will entail increasing contraceptive use and offering a variety of effective methods. By reducing the incidence of illegal abortion in particular, such strategies will have important public health benefits.--D. Hollander
REFERENCE
1. Rahman M, DaVanzo J and Razzaque A, Do better family planning services reduce abortion in Bangladesh? Lancet, 2001, 358(9287):1051-1056.