Greater efforts are needed to improve contraceptive counseling and provision after abortion in Nepal, finds a prospective cohort study conducted in 2011, a decade after the country legalized the procedure.1 Overall, one-third of the women who underwent a legal abortion did not receive any information afterward on effective contraceptive methods (hormonal methods, the IUD, implants and female or male sterilization), and more than half did not receive such contraceptives. While about eight in 10 women who opted for the injectable or pill had used their chosen method six months after their abortion, only four in 10 who chose long-acting reversible contraceptives (LARCs) and fewer than one in 10 who chose sterilization had used those methods. Parous women had sharply elevated odds of having chosen and having used an effective method (odds ratios, 6.5 and 5.7, respectively), whereas women who were not living with their husband or partner had dramatically reduced odds (0.2 for each).
Study participants were women aged 16–35 who had just undergone a legal elective abortion at one of four reproductive health facilities in geographically diverse areas of Nepal. The facilities generally provided nonpermanent contraceptives at no cost, although some charged small fees for IUDs. After their abortion, women provided information about their social and demographic characteristics, contraceptive history and fertility plans, as well as about the abortion visit itself. They also indicated whether, at their abortion visit, they had received information on effective contraceptive methods, chosen an effective method and received a method. At a six-month follow-up interview, women reported whether they had used an effective method at any time since the abortion. The researchers computed frequencies of the women’s characteristics and the four contraceptive outcomes, and performed bivariate and multivariate analyses to identify characteristics associated with each outcome.
At the time of their abortion, the 838 women studied were 26 years old, on average. Most were married (97%) and had children (87%). About one-third had never used an effective contraceptive method. Fifty-nine percent did not want another child, 36% wanted to postpone childbearing for at least two years and 5% wanted a child within two years.
Overall, 66% of women received information about one or more effective contraceptive methods at their abortion visit; they were most commonly counseled about the injectable (52%) and pill (45%). Multivariate analyses indicated that women who did not live with their husband or partner had greatly reduced odds of receiving counseling (odds ratio, 0.2), and that women who had had a medication abortion were less likely to be counseled than were their counterparts who had had an aspiration abortion (0.5).
Sixty-two percent of women reported choosing an effective method at the abortion visit; most often they selected the injectable (32%) or pill (16%). The majority of those who did not choose an effective contraceptive said they opted not to do so because their husband or partner was away (37%) or they had sex infrequently (19%). In multivariate analyses, women had reduced odds of having chosen an effective method if they did not live with a husband or partner (odds ratio, 0.2) or had more than a primary education (0.5); moreover, the odds of having chosen a method fell with each additional year of age (0.9). Parous women and those who had received contraceptive information had elevated odds of having chosen an effective method (6.5 and 2.5, respectively).
Forty-four percent of all women reported receiving an effective method at their abortion visit; they most commonly received the injectable (28%) or pill (12%). In multivariate analyses, women had reduced odds of having received an effective method if they were not living with a husband or partner (odds ratio, 0.1), had more than a primary education (0.7) or had had a medication abortion (0.3); the odds also declined with increasing age (0.9). Women had an elevated likelihood of receiving an effective method if they were parous (5.1), lived in a rural area (1.6) or had received information on these methods (2.2). The majority of women who chose the injectable or pill received their preferred method (85% and 78%, respectively); in contrast, only 40% of those who selected LARC (the IUD) or implant had one placed at that visit.
Of the 654 women interviewed six months after their abortion, 63% reported having used an effective contraceptive method at some time since the procedure; they most commonly had used the injectable (38%) or pill (22%). Women had reduced odds of having used an effective method if they were not living with a husband or partner (odds ratio, 0.2) or had more than a primary education (0.6); again, the likelihood fell with increasing age (0.9). Women had elevated odds of use if they were parous (5.7), had used an effective method prior to their abortion (1.9) or had received information on effective contraceptives (2.1). Among women who had selected a method at their abortion visit, the proportion who subsequently used their chosen method was higher among those who had chosen the injectable (88%) or pill (75%) than among those who had chosen a LARC (44%) or sterilization (5%). Roughly 40% of those who had initially selected a LARC or sterilization had relied on a different effective method during follow-up. Women who had not used their chosen method most commonly attributed their nonuse to having changed their mind about the method (46%), to medical or health reasons (18%) or to concerns about side effects (18%). On the other hand, 28% of women who had not chosen an effective method at their abortion visit had used one during follow-up, most often the pill (47%) or injectable (40%).
The study identifies important gaps in postabortion contraceptive care in Nepal and potentially modifiable correlates, according to the researchers. In particular, women who had had a medication abortion were less likely than other women to receive contraceptive information and supplies at their initial abortion visit, possibly because they needed to wait for a return visit to receive a LARC or the injectable; the authors recommend that efforts be made to provide information and supplies at the initial abortion visit and to explore other strategies for improving provision. Study limitations include a possible lack of generalizability to other health facilities in Nepal, reliance on self-reported data, and the higher rate of loss to follow-up among women who did not choose or receive a method, the researchers note. "Improvements in postabortion counseling and provision are needed," they conclude. "Ensuring that women choosing long-acting and permanent contraceptive methods are able to obtain either them or interim methods is essential."—S. London
1. Rocca CH et al., Postabortion contraception a decade after legalization of abortion in Nepal, International Journal of Gynecology & Obstetrics, 2014, 126(2):170–174.