Population Council Research that makes a difference

2011 International Conference on Family Planning
29 November–2 December 2011

Abstract

"Postabortion contraception patterns following medical and surgical abortion in India"
Shveta Kalyanwala, Rajib Acharya, and A.J. Francis Zavier

Background
Post-abortion contraception is a key component of comprehensive abortion care, yet, in India, little is known about the extent to which post-abortion contraception is practised, whether, if adopted, there is a preference for any particular method, and whether patterns of post-abortion contraception adoption and continuation differ among women who undergo surgical and medical abortion. We hypothesize, on the one hand, that since such methods as sterilisation and IUCDs cannot be adopted together with medical abortion but can be adopted concurrently with surgical abortion, post-abortion contraception may be more widely practised by women undergoing surgical abortion. At the same time, it is possible that because of the rapport gained and opportunities made available by the three visits required for medical abortion (as opposed to a single visit, in most cases, for surgical abortion), women who undergo medical abortion are more likely than those who opt for surgical abortion to receive contraceptive counselling and therefore adopt a method of contraception.

Main question
The objective of this paper is to compare post abortion adoption and continuation of contraception among women who have undergone medical abortion and surgical abortion and assess factors that pose obstacles to the continuation of contraception up to six months following the abortion.

Methodology
Data come from a study undertaken in four high volume facilities of Janani, an NGO in Bihar and Jharkhand which is responsible for a range of reproductive health services, including abortion, in the two states. All women undergoing abortion at these facilities from November 2009 to May 2010 were invited to participate in the study (N=800), and those who consented were interviewed on or around the time of their abortion and six months thereafter. A total of 82 women were lost to follow-up, and our analysis excludes 39 women who were unmarried or widowed at the time of interview. Hence, this paper focuses on data from 679 currently married women aged 15 years and above (308 who had undergone medical abortion and 371 who had undergone surgical abortion) and 598 women who did not adopt sterilisation and were interviewed again about 6 months later (306 who had undergone medical abortion and 292 who had undergone surgical abortion). Post-abortion contraception was measured as contraception adopted within 4 weeks of the abortion procedure. Data were analysed using SPSS 18 and Stata 10. In order to estimate contraceptive discontinuation rate for acceptors of different methods of abortion and contraception, Kaplan-Meier survival estimates were computed using spell data generated from post-abortion contraception histories. Logistic regression and Cox regression models were used to assess the effect of different factors on adoption and continuation of contraceptive methods, respectively.

Key findings
Findings from preliminary analysis indicate that women who had undergone medical abortion were considerably less likely than those who had undergone surgical abortion—58% and 86% respectively—to have adopted contraception within a month of the abortion. A total of 81 women opted to be sterilised concurrently with the surgical abortion procedure (an option not available to those opting for medical abortion). Omitting this group from further analysis, wide differences persist for overall contraceptive adoption as well as method-specific adoption; for example while 36% of those who had undergone medical abortion had opted for an IUD, almost half (48%) of those who had undergone surgical abortion opted for this method. Factors associated with post abortion contraception adoption include parity, and, in the case of women adopting surgical abortion, post abortion contraception increased significantly with education. Among both groups of women, moreover, associations with such other characteristics as age, work status, and quality of care received were not observed. Multivariate analysis confirms that these associations persist even when confounding factors are controlled. While non-terminal method adoption differed significantly between the two groups, findings suggest that continuation rates are similar among women who underwent medical and surgical abortion. The 24-week discontinuation rate for women who adopted a non-terminal contraceptive method was 15% for those who underwent surgical abortion and 14% for those who underwent medical abortion. Method-wise break-up indicates that irrespective of the method of abortion, IUCD users were, not surprisingly, less likely to discontinue using the method than were those who had adopted other non-terminal method. Method discontinuation ranged from 8% and 5% among women who had adopted an IUCD following medical and surgical abortion, respectively, to 27% and 22% of those who had adopted other non-terminal methods.

Knowledge contribution
Findings of this study advance what is known about post-abortion contraception uptake and continuation in India and highlight that women undergoing surgical and medical abortion display different patterns of adoption but similar patterns of continuation. These findings highlight the need for programmes to consider ways of enhancing the contraceptive choices of women who undergo MA in ways that respond to the constraints they may face in making multiple visits to the facility.

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