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Correlates of contraceptive use 4 months postabortion: findings from a prospective study in Bangladesh

Open AccessPublished:October 13, 2016DOI:https://doi.org/10.1016/j.contraception.2016.10.002

      Abstract

      Objectives

      Using the social determinants framework as a guide, this study sought to understand correlates of postabortion contraceptive use at the individual, family and abortion service delivery levels.

      Study design

      This prospective study assessed correlates of contraceptive use 4 months postabortion and timing of initiation using a facility-based sample of 398 abortion clients who selected pills, condoms, injectables or no method immediately following the procedure. We measured potential correlates immediately following abortion, inclusive of spontaneous or induced abortion, and assessed contraceptive use outcomes 4 months postabortion. Multivariable logistic regression models identified correlates at each level. Potential individual level correlates included contraceptive and abortion history and fertility intentions; family correlates included intimate partner violence (IPV), discordance in fertility intentions and household decision-making; and service delivery correlates included procedure type and postabortion contraceptive counseling.

      Results

      Reported contraceptive use 4 months postabortion was high (85.4%). Contraceptive use at the index pregnancy (resulting in abortion) was the primary correlate of contraceptive use 4 months postabortion (adjusted odds ratio=2.9; 95% confidence interval: 1.5–5.9). Delayed contraceptive initiation was more common among women who reported past year IPV (36.8% vs. 19.5%; p=.03) particularly with spousal accompaniment for abortion, those in relationships with discordant fertility intentions (44.4% vs. 21.9%; p=.04) and those receiving medication abortion (56.7%) or dilation and curettage (57.1%), compared to manual vacuum aspiration (12.6%; p<.01).

      Conclusions

      Contraceptive use at the index pregnancy was the primary correlate of contraceptive use 4 months postabortion. Abortion procedure type and relationship dynamics were correlated with delayed postabortion contraceptive initiation. Women who reported IPV delayed initiation when accompanied by their spouse for abortion.

      Implications

      Postabortion contraceptive counseling should assess previous use patterns and provide information on using contraception effectively. Delayed initiation among women reporting IPV could be addressed through comprehensive, confidential counseling that includes violence screening, support for contraceptive initiation and offer of woman-controlled methods.

      Keywords

      1. Introduction

      Fertility can return within 2 weeks of an abortion procedure, and the World Health Organization (WHO) recommends immediate contraceptive provision, on the day of the procedure, to reduce subsequent unwanted pregnancy [
      • World Health Organization (WHO)
      Safe abortion: technical and policy guidance for health systems.
      ]. However, contraceptive behavior is complex, and provision of contraception may not result in effective contraceptive use, as individual characteristics and an individual's social environment influence behavior [
      • McLeroy K.R.
      • Bibeau D.
      • Steckler A.
      • Glanz K.
      An ecological perspective on health promotion programs.
      ]. In Bangladesh, induced abortion is legally restricted, but menstrual regulation (MR) is a procedure permitted to establish nonpregnancy up to 10 weeks from the last menstrual period [
      • Bart Johnston H.
      • Oliveras E.
      • Akhter S.
      • Walker D.G.
      Health system costs of menstrual regulation and care for abortion complications in Bangladesh.
      ]. Both postabortion care (PAC) services for incomplete abortion and MR services are widely available in Bangladesh at all levels of the government health system [
      • Vlassoff M.
      • Hossain A.
      • Maddow-Zimet I.
      • Singh S.
      • Bhuiyan H.U.
      Menstrual regulation and postabortion care in Bangladesh: factors associated with access to and quality of services.
      ]. These services are offered free of charge by government policy, but quality is variable, and informal fees are often charged [
      • Vlassoff M.
      • Hossain A.
      • Maddow-Zimet I.
      • Singh S.
      • Bhuiyan H.U.
      Menstrual regulation and postabortion care in Bangladesh: factors associated with access to and quality of services.
      ,
      • Chowdhury S.N.M.
      • Moni D.
      A situation analysis of the menstrual regulation Programme in Bangladesh.
      ]. Postabortion contraceptive provision, inclusive of contraceptives provided immediately following MR or PAC procedures, varies considerably based on facility characteristics and method availability [
      • Vlassoff M.
      • Hossain A.
      • Maddow-Zimet I.
      • Singh S.
      • Bhuiyan H.U.
      Menstrual regulation and postabortion care in Bangladesh: factors associated with access to and quality of services.
      ]. However, less is known about the contextual factors associated with postabortion contraceptive use in the months following abortion.
      Social determinants frameworks identify social processes influencing reproductive behavior and inform intervention design to improve access, particularly for vulnerable groups [
      • Price N.L.
      • Hawkins K.
      A conceptual framework for the social analysis of reproductive health.
      ]. Evidence from Bangladesh suggests multiple levels of influence on women's postabortion contraceptive use. At the individual level, intentions to limit childbearing [
      • Akhter H.H.
      Predictors of contraceptive continuation among urban family planning acceptors of Bangladesh.
      ] and contraceptive history [
      • Schuler S.R.
      • Hashemi S.M.
      • Riley A.P.
      The influence of women's changing roles and status in Bangladesh's fertility transition: evidence from a study of credit programs and contraceptive use.
      ,
      • Koenig M.A.
      • Hossain M.B.
      • Whittaker M.
      The influence of quality of care upon contraceptive use in rural Bangladesh.
      ] are associated with contraceptive continuation. At the family level, women's power within the family is important, especially in rural Bangladesh where husbands' disapproval and dissatisfaction are cited as reasons for contraceptive discontinuation [
      • Ullah A.N.
      • Humble M.E.
      Determinants of oral contraceptive pill use and its discontinuation among rural women in Bangladesh.
      ]. Intimate partner violence (IPV) is considered highly relevant. Approximately 24% of women in Bangladesh report past year IPV [
      • National Institute of Population Research and Training (NIPORT)
      • Mitra and Associates
      • Macro International
      Bangladesh demographic and health survey 2007.
      ], and IPV is associated with unwanted pregnancy and induced abortion in Bangladesh and elsewhere [
      • Silverman J.G.
      • Gupta J.
      • Decker M.R.
      • Kapur N.
      • Raj A.
      Intimate partner violence and unwanted pregnancy, miscarriage, induced abortion, and stillbirth among a national sample of Bangladeshi women.
      ,
      • Rahman M.
      • Sasagawa T.
      • Fujii R.
      • Tomizawa H.
      • Makinoda S.
      Intimate partner violence and unintended pregnancy among Bangladeshi women.
      ,
      • Pallitto C.C.
      • Garcia-Moreno C.
      • Jansen H.A.F.M.
      • Heise L.
      • Ellsberg M.
      • Watts C.H.
      Intimate partner violence, abortion, and unintended pregnancy: results from the WHO multi-country study on women's health and domestic violence.
      ]. At the abortion service delivery level, high-quality postabortion contraceptive counseling [
      • Sultana F.
      • Nahar Q.
      • Marions L.
      • Oliveras E.
      Effect of post-menstrual regulation family planning service quality on subsequent contraceptive use in Bangladesh.
      ] and availability of contraceptive methods and skilled providers [
      • Vlassoff M.
      • Hossain A.
      • Maddow-Zimet I.
      • Singh S.
      • Bhuiyan H.U.
      Menstrual regulation and postabortion care in Bangladesh: factors associated with access to and quality of services.
      ] are correlated with use. Previous studies have assessed correlates separately, without simultaneously considering multiple levels of influence on women's postabortion contraceptive use.
      Studies typically focus on postabortion contraceptive continuation, defining contraceptive initiation within a timeframe ranging from 1 to 3 months postabortion [
      • Puri M.
      • Henderson J.T.
      • Harper C.C.
      • Blum M.
      • Joshi D.
      • Rocca C.H.
      Contraceptive discontinuation and pregnancy postabortion in Nepal: a longitudinal cohort study.
      ,
      • Kalyanwala S.
      • Acharya R.
      • Zavier A.J.F.
      Adoption and continuation of contraception following medical or surgical abortion in Bihar and Jharkhand, India.
      ,
      • Zavier A.J.F.
      • Padmadas S.S.
      Postabortion contraceptive use and method continuation in India.
      ]. However, health system interventions focus on immediate contraceptive provision, in line with WHO recommendations [
      • World Health Organization (WHO)
      Safe abortion: technical and policy guidance for health systems.
      ]. In Bangladesh, pills, injectables and condoms, which can be initiated immediately following any abortion procedure [
      • World Health Organization (WHO)
      Safe abortion: technical and policy guidance for health systems.
      ], account for approximately 85% of the contraceptive method mix in the postabortion and general populations [
      • National Institute of Population Research and Training (NIPORT)
      • Mitra and Associates
      • ICF International
      Bangladesh demographic and health survey 2014.
      ]. In this setting, it is more relevant to consider immediate as compared to delayed initiation to understand the determinants affecting implementation of WHO guidelines.
      The present study assessed correlates of contraceptive use 4 months postabortion and timing of initiation (immediate or delayed) at the individual, family and abortion service delivery levels among public sector abortion clients in Bangladesh.

      2. Material and methods

      2.1 Sample

      This prospective study used data from a parent study, which employed a stratified one-stage cluster sampling approach to select 498 women from 16 government and nongovernment organization (NGO) facilities receiving an intervention that trained providers in woman-centered abortion service provision. The parent study stratified facilities by type (primary, secondary, tertiary and NGO clinics) and randomly selected 16 using probability proportional to size sampling within facility-type strata. All facilities in the sample offered both MR services for women presenting with ongoing pregnancy and PAC services for women presenting with incomplete abortion. By policy, providers did not confirm pregnancy prior to an MR procedure [
      • Chowdhury S.N.M.
      • Moni D.
      A situation analysis of the menstrual regulation Programme in Bangladesh.
      ], but this study considered MR to be equivalent to induced abortion. Providers most commonly used manual vacuum aspiration (MVA) for both MR and PAC cases. Dilation and curettage (D&C) is not a WHO-approved abortion procedure, but some senior obstetrician–gynecologists still routinely used the procedure. In addition, some second trimester PAC cases required D&C because facilities primarily procured small MVA cannulae for MR procedures, which could not be used for PAC clients presenting at later gestational ages. At the time of data collection, medication abortion (MA) was newly available, primarily in the larger health facilities. All facilities provided at least two contraceptive methods, typically oral contraceptive pills and injectables. Inclusion criteria for participants were 18–49 years of age and selected pills, injectables or condoms as a postabortion contraceptive method or selected no method. The parent study focused on women who selected pills, injectables or condoms because they were of particular interest to the Bangladeshi government as they made up the majority of postabortion contraceptive users and because methods such as intrauterine devices (IUDs), implants and sterilization were not available to abortion clients in most government health facilities due to inadequate training and supplies [
      • Vlassoff M.
      • Hossain A.
      • Maddow-Zimet I.
      • Singh S.
      • Bhuiyan H.U.
      Menstrual regulation and postabortion care in Bangladesh: factors associated with access to and quality of services.
      ]. Thus, women who selected IUDs, implants or sterilization immediately following abortion (approximately 14% of abortion clients, most seen in specialized NGO-run abortion clinics) were ineligible for enrollment in the parent study. Women completed an interviewer-administered survey at the health facility after recovering from their abortion procedure and a follow-up survey 4 months later at a location of their choosing.
      The present analysis included all abortion clients who did not wish to become pregnant again soon, including miscarriage clients, as we expected postabortion contraceptive behavior to reflect current pregnancy intentions rather than abortion treatment type. Therefore, we included in the analysis miscarriage clients who intended to delay or limit childbearing. We excluded women from the analysis if on the day of the procedure they intended pregnancy in the next 4 months or, if at the 4-month follow-up, they intended pregnancy in the next month. We also excluded women if they were pregnant at the 4-month follow-up, missing data on contraceptive use at the 4-month follow-up or lost to follow-up.

      2.2 Measures

      The primary outcome of interest was contraceptive use 4 months postabortion, which included use of pills, condoms, injectables, implants, IUDs or sterilization. Even though women who selected IUDs, implants or sterilization immediately following abortion were ineligible for enrollment in the parent study, we included in the analysis women who initiated use of these methods over the 4-month follow-up period. We evaluated timing of postabortion contraceptive initiation (immediate or delayed), the secondary outcome of interest, among women who reported contraceptive use 4 months postabortion. Immediate postabortion contraceptive initiators selected a method (injectables, pills or condoms) at the health facility immediately following abortion, and delayed initiators did not select a method immediately following abortion, indicating contraceptive initiation after leaving the health facility.
      This study assessed all potential correlates on the day of the abortion procedure. At the individual level, we considered history of MR, contraceptive use at the index pregnancy (resulting in abortion) and fertility intentions for the index pregnancy. Contraceptive use at the index pregnancy included women who reported pregnancy resulting from contraceptive failure or inconsistent use. To measure intentions, interviewers asked women, “Right before you became pregnant, did you want to become pregnant then, did you want to wait until later, did you not want to have any (more) children, or did you not think about it?” [
      • Institut National D'etudes Demographiques
      FECOND survey "Fécondité - contraception - Dysfonctions sexuelles" en France métropolitaine - Volet population Générale (2009–2011).
      ]. We assessed discordance in fertility intentions between the woman and her husband/partner based on work by Schoen et al. [
      • Schoen R.
      • Astone N.M.
      • Kim Y.J.
      • Nathanson C.A.
      • Fields J.M.
      Do fertility intentions affect fertility behavior?.
      ]. We ordered the husband/partner's intentions from highest to lowest desire for fertility and created three categories relative to the woman's intentions: concordant, discordant–higher (indicating the husband had higher desire for fertility) and discordant–lower (indicating the husband had lower desire for fertility). We excluded discordant–lower from analyses due to the small number (n=7). We included three domains of women's power within the family: past year IPV, accompaniment to the health facility and women's involvement in household decision-making. Service delivery characteristics included abortion treatment and procedure type and postabortion contraceptive counseling. Interviewers asked women to report their abortion treatment type as MR, PAC for induced abortion or PAC for miscarriage.

      2.3 Data analysis

      We calculated the prevalence of the primary outcome, contraceptive use 4 months postabortion, for the sample and based on potential correlates in the three levels (individual, family and abortion service delivery). F-tests from simple logistic regression models assessed bivariate associations. We ran separate multivariable logistic regression models for each level, including potential correlates with bivariate significance at p<.05. Model 1 was the individual level model; Model 2 was the abortion service delivery level model; and Model 3 was a full model with potential correlates from both levels. All models adjusted for sociodemographic characteristics associated with the outcome (education, number of children and cohabitation with the husband/partner). We used a similar approach for the secondary outcome, timing of postabortion contraceptive initiation. We calculated the prevalence for the sample and by potential correlates in each level and assessed bivariate differences using an F-test. We conducted post hoc analysis of past year IPV experience by timing of initiation and stratified by accompaniment to the health facility to clarify whether the association varied by spousal accompaniment. Approximately 8% of observations were missing for past year IPV, and we generated 10 imputations with multivariate imputation using chained equations [
      • White I.R.
      • Carlin J.B.
      Bias and efficiency of multiple imputation compared with complete-case analysis for missing covariate values.
      ]. We analyzed the multiple imputation dataset using Stata/SE 14.0, accounting for the complex survey design.

      2.4 Ethical review

      Study procedures received ethical approval from the Bangladesh Medical Research Council in Dhaka and the Allendale Investigational Review Board in the United States.

      3. Results

      Interviewers approached a total of 555 women for participation in the parent study, enrolled 498 women (response rate: 498/555, 90%) and retained 457 women at the 4-month follow-up (follow-up rate: 457/498, 92%). The analytic sample for this study included 398 women who completed the follow-up survey and did not intend pregnancy soon (Fig. 1). Loss to follow-up was nondifferential by all sociodemographic characteristics except parity; loss to follow-up was more common among nulliparous women (16%), compared to parous women (6%; p<.01).
      Fig. 1
      Fig. 1Study eligibility and outcomes of interest.
      On average, women in the sample were 28 years old, more than half (56.0%) had secondary or higher education and 86.9% had at least one child (Table 1). At the 4-month follow-up 85.4% of women reported contraceptive use. Contraceptive use 4 months postabortion was associated with having at least one child (88.9% among women with 1–2 children and 83.8% among women with 3 or more children vs. 73.1% among women with no children; p<.01) and cohabitating with the husband/partner (86.7% vs. 67.0%; p=.01).
      Table 1Sociodemographic characteristics of study sample by contraceptive use 4 months postabortion (n=398)
      Total (n = 398)Not using (n=58)Using (n=340)
      n(%)(%)(%)p-value
      Contraceptive use 4 months postabortion398(100)(14.6)(85.4)
      Sociodemographic characteristics
      Age [mean (SE)]27.8(0.4)27.727.80.97
      Husband/Partner's age [mean (SE)]35.3(0.6)35.635.30.77
      Education0.50
       None55(13.8)(21.8)(78.2)
       Primary120(30.2)(15.0)(85.0)
       Secondary or higher223(56.0)(12.6)(87.4)
      Husband/Partner's education0.75
       None64(16.1)(18.8)(81.2)
       Primary116(29.1)(13.8)(86.2)
       Secondary or higher218(54.8)(13.8)(86.2)
      Religion0.44
       Islam356(89.4)(15.2)(84.8)
       Hinduism41(10.3)(9.8)(90.2)
       Buddhism1(0.3)(0)(100)
      Marital status
       Married397(99.7)(14.6)(85.4)
       Formerly married1(0.3)(0)(100)
      Number of children<0.01
       No children52(13.1)(26.9)(73.1)
       1–2 children235(59.0)(11.1)(88.9)
       3 or more children111(27.9)(16.2)(83.8)
      Household structure0.08
       Nuclear223(56.0)(12.6)(87.4)
       Extended175(44.0)(17.1)(82.9)
      Cohabitation with husband/partner0.01
       Cohabitating369(92.7)(13.3)(86.7)
       Not cohabitating29(7.3)(31.0)(69.0)
      Residence0.26
       Urban225(56.5)(12.9)(87.1)
       Rural173(43.5)(16.8)(83.2)
      Rural to urban migrant0.69
       Yes94(23.6)(13.8)(86.2)
       No304(76.4)(14.8)(85.2)
      Division0.66
       Dhaka190(47.7)(12.6)(87.4)
       Sylhet93(23.4)(14.0)(86.0)
       Chittagong50(12.6)(24.0)(76.0)
       Rajshahi65(16.3)(13.8)(86.2)
      Note: Original n, imputed percent and F-test p-value presented.
      Bivariate analysis demonstrated that contraceptive use 4 months postabortion was associated with individual and abortion service delivery characteristics but not family characteristics (Table 2). Ninety-two percent of women who reported contraceptive use at the index pregnancy reported contraceptive use 4 months postabortion, compared to only 76.9% of those who did not report use at the index pregnancy (p<.01). Eighty-eight percent of women who said that the pregnancy was mistimed or unwanted reported contraceptive use 4 months postabortion, compared to 76.3% who said the pregnancy was wanted then or they were ambivalent about the timing (p<.01). Abortion treatment type was also associated; 90.6% of women who received PAC services for induced abortion reported contraceptive use 4 months postabortion, compared to 87.3% of MR clients and 76.4% of PAC for miscarriage clients (p=.03).
      Table 2Bivariate associations between potential individual, family and abortion service delivery correlates and contraceptive use 4 months postabortion (n = 398)
      Total (n = 398)Not using (n = 58)Using (n = 340)
      n(%)(%)(%)p-value
      Contraceptive use at 4 months postabortion398(100)(14.6)(85.4)
      Potential correlates
      Individual characteristics
      History of MR0.06
       No history of MR284(71.4)(15.8)(84.2)
       Previous MR experience114(28.6)(11.4)(88.6)
      Contraceptive use at index pregnancy<0.01
       Not using contraception173(43.5)(23.1)(76.9)
       Using contraception225(56.5)(8.0)(92.0)
      Intentions at index pregnancy<0.01
       Wanted then or ambivalent93(23.4)(23.7)(76.3)
       Mistimed or unwanted305(76.6)(11.8)(88.2)
      Family characteristics
      Husband/Partner's relative intentions
      One category of husband/partner's relative intentions, discordant–lower (n=7), was excluded from the analysis due to the small sample size.
      0.80
       Concordant360(92.1)(15.0)(85.0)
       Discordant–Higher31(7.9)(12.9)(87.1)
      Physical or sexual IPV in past year
      Multiple imputation variable (original n≠398). Original n and imputed percent presented.
      0.75
       Did not experience IPV268(74.7)(14.3)(85.7)
       Experienced IPV95(25.3)(15.5)(84.5)
      Accompaniment to health facility for abortion0.95
       None/Alone42(10.5)(14.3)(85.7)
       Husband accompanied206(51.8)(15.0)(85.0)
       Someone else accompanied150(37.7)(14.0)(86.0)
      Decision-making for contraceptive use0.14
       Not involved25(6.3)(24.0)(76.0)
       Involved373(93.7)(13.9)(86.1)
      Decision-making for her healthcare0.70
       Not involved63(15.8)(12.7)(87.3)
       Involved335(84.2)(14.9)(85.1)
      Abortion service delivery characteristics
      Type of treatment received0.03
       PAC for miscarriage89(22.4)(23.6)(76.4)
       MR245(61.5)(12.7)(87.3)
       PAC for induced abortion64(16.1)(9.4)(90.6)
      Abortion procedure type0.33
       MVA294(73.9)(13.6)(86.4)
       MA33(8.3)(9.1)(90.9)
       D&C71(17.8)(21.1)(78.9)
      Time spent in postabortion contraceptive counseling0.70
       None95(23.9)(18.9)(81.1)
       Less than 5 min113(28.4)(12.4)(87.6)
       5 min or longer190(47.7)(13.7)(86.3)
      Immediate initiation of postabortion contraception0.11
       No102(25.6)(20.6)(79.4)
       Yes296(74.4)(12.5)(87.5)
      a One category of husband/partner's relative intentions, discordant–lower (n = 7), was excluded from the analysis due to the small sample size.
      b Multiple imputation variable (original n ≠ 398). Original n and imputed percent presented.
      In multivariable analyses (Table 3), Model 1 demonstrated that women who reported contraceptive use at the index pregnancy had three times higher odds of reported contraceptive use 4 months postabortion, compared to women who did not report contraceptive use at the index pregnancy (95% confidence interval (CI): 1.5–6.1). Model 2 showed that abortion service delivery characteristics were not associated with contraceptive use 4 months postabortion after adjusting for sociodemographic characteristics. The full model (Model 3) demonstrated that after adjusting for all correlates with bivariate associations with the outcome, only contraceptive use at the index pregnancy was correlated with contraceptive use 4 months postabortion (adjusted odds ratio (AOR)=2.9; 95% CI: 1.5–5.9).
      Table 3Logistic regression results of association between contraceptive use 4 months postabortion and potential correlates (n = 398)
      Model 1: individual characteristicsModel 2: abortion service delivery characteristicsModel 3: full model
      Potential correlatesAOR(95% CI)AOR(95% CI)AOR(95% CI)
      Individual characteristics
      Contraceptive use at index pregnancy
       Not using contraception (ref)1.01.0
       Using contraception3.0
      p<0.05.
      (1.5–6.1)2.9
      p<0.05.
      (1.5–5.9)
      Intentions at index pregnancy
       Wanted then or ambivalent (ref)1.01.0
       Mistimed or unwanted1.6(0.9–2.6)1.5(0.8–2.8)
      Abortion service delivery characteristics
      Type of treatment received
       PAC for miscarriage (ref)1.01.0
       MR1.7(0.9–3.1)1.2(0.6–2.3)
       PAC for induced abortion2.6(0.9–7.7)2.0(0.5–7.6)
      Logistic regression models adjust for education, number of children, cohabitation with husband/partner and all variables listed in column.
      low asterisk p < 0.05.
      Timing of postabortion contraceptive initiation was associated with characteristics at the family and abortion service delivery levels (Table 4). At the family level, 44.4% of women whose husband/partner had a higher desire for fertility delayed initiation, compared to only 21.9% of women who reported intentions concordant with their husband/partner's (p=.04). Delayed initiation was also associated with reported past year IPV; 36.8% of women who reported IPV delayed initiation, compared to 19.5% of women who did not report past year IPV (p=.03). At the abortion service delivery level, 56.7% of MA clients and 57.1% of D&C clients delayed initiation, compared to only 12.6% of MVA clients (p<.01).
      Table 4Bivariate associations between potential individual, family and abortion service delivery correlates and timing of postabortion contraceptive initiation (n = 340)
      Total (n = 340)Immediate initiation (n = 259)Delayed initiation (n = 81)
      n(%)(%)(%)p-value
      Timing of initiation340(100)(76.2)(23.8)
      Potential correlates
      Individual characteristics
      History of MR0.35
       No history of MR239(70.3)(77.8)(22.2)
       Previous MR experience101(29.7)(72.3)(27.7)
      Contraceptive use at index pregnancy0.81
       Not using contraception133(39.1)(75.2)(24.8)
       Using contraception207(60.9)(76.8)(23.2)
      Woman's intentions at index pregnancy0.18
       Wanted then or ambivalent71(20.9)(64.8)(35.2)
       Mistimed or unwanted269(79.1)(79.2)(20.8)
      Family characteristics
      Husband/Partner's relative intentions
      One category of husband/partner's relative intentions, discordant–lower (n=7), was excluded from the analysis due to the small sample size.
      0.04
       Concordant306(91.9)(78.1)(21.9)
       Discordant–Higher27(8.1)(55.6)(44.4)
      Physical or sexual IPV in past year
      Multiple imputation variable (original n≠340). Original n and imputed percent presented.
      0.03
       Did not experience IPV228(75.0)(80.5)(19.5)
       Experienced IPV80(25.0)(63.2)(36.8)
      Accompaniment to health facility for abortion0.77
       None/Alone36(10.6)(83.3)(16.7)
       Husband accompanied175(51.5)(74.3)(25.7)
       Someone else accompanied129(37.9)(76.7)(23.3)
      Decision-making for contraceptive use0.27
       Not involved19(5.6)(89.5)(10.5)
       Involved321(94.4)(75.4)(24.6)
      Decision-making for her healthcare0.22
       Not involved55(16.2)(89.1)(10.9)
       Involved285(83.8)(73.7)(26.3)
      Abortion service delivery characteristics
      Type of treatment received0.30
       PAC for miscarriage68(20.0)(60.3)(39.7)
       MR214(62.9)(86.0)(14.0)
       PAC for abortion58(17.1)(58.6)(41.4)
      Abortion procedure type<0.01
       MVA254(74.7)(87.4)(12.6)
       MA30(8.8)(43.3)(56.7)
       D&C56(16.5)(42.9)(57.1)
      a One category of husband/partner's relative intentions, discordant–lower (n = 7), was excluded from the analysis due to the small sample size.
      b Multiple imputation variable (original n ≠ 340). Original n and imputed percent presented.
      We analyzed the interaction between reported past year IPV experience and spousal accompaniment on timing of initiation to explore a possible explanation for delayed initiation. Among women whose husband/partner accompanied them for the abortion procedure, 49.6% of women who reported past year IPV delayed initiation, compared to 19.6% of women who did not report IPV (p=.03) (Table 5). We did not observe significant differences among women who attended the facility alone or were accompanied by someone other than their husband/partner.
      Table 5Timing of postabortion contraceptive initiation by past year IPV, stratified by accompaniment to the health facility for the abortion procedure (n = 340)
      Total (n=340)Immediate initiation (n=259)Delayed initiation (n = 81)
      n(%)n(%)n(%)p-value
      Attended facility alone36(10.6)
       Physical or sexual IPV in past year
      Multiple imputation variable (original n≠340). Original n and imputed percent presented.
      0.44
      Did not experience IPV20(83.3)17(86.7)3(13.3)
      Experienced IPV13(16.7)10(77.7)3(22.3)
      Husband accompanied175(51.5)
       Physical or sexual IPV in past year
      Multiple imputation variable (original n≠340). Original n and imputed percent presented.
      0.03
      Did not experience IPV122(74.3)98(80.4)24(19.6)
      Experienced IPV34(25.7)17(50.4)17(49.6)
      Someone else accompanied129(37.9)
       Physical or sexual IPV in past year
      Multiple imputation variable (original n≠340). Original n and imputed percent presented.
      0.34
      Did not experience IPV86(76.7)68(79.2)18(20.8)
      Experienced IPV33(23.3)23(70.5)10(29.5)
      a Multiple imputation variable (original n ≠ 340). Original n and imputed percent presented.

      4. Discussion

      In this prospective study of abortion clients, reported contraceptive use 4 months postabortion was prevalent (85.4%), and contraceptive use at the index pregnancy was the primary correlate. Our analysis of timing of postabortion contraceptive initiation extended past analyses that used a 1- to 3-month initiation window and identified correlates of delayed compared to immediate initiation. Delayed contraceptive initiation was more common among women who received MA or D&C, women who reported discordant pregnancy intentions and women who reported past year IPV, particularly with spousal accompaniment for the abortion procedure. Though these women were equally likely to report contraceptive use 4 months postabortion, findings highlight ways health system interventions can prevent delays in postabortion contraceptive initiation.
      The primary correlate of contraceptive use 4 months postabortion was contraceptive use at the index pregnancy. Findings echo results from other settings demonstrating that contraceptive history predicts postabortion contraceptive use [
      • Tavrow P.
      • Withers M.
      • McMullen K.
      Age matters: differential impact of service quality on contraceptive uptake among postabortion clients in Kenya.
      ]. In Bangladesh some pill users believe it necessary to take “short breaks” for health reasons [
      • Ullah A.N.
      • Humble M.E.
      Determinants of oral contraceptive pill use and its discontinuation among rural women in Bangladesh.
      ], and postabortion contraceptive counseling provides an opportunity to assess previous contraceptive use patterns and provide accurate information on using contraception effectively.
      Timing of postabortion contraceptive initiation varied by family and abortion service delivery characteristics. At the abortion service delivery level, MA and D&C clients delayed initiation compared to MVA clients, suggesting providers differentially offered postabortion contraception based on procedure type. In practice, providers often ask MA and D&C clients to return for a follow-up visit to ensure that the abortion is complete and that there are no complications. Providers may prefer to provide postabortion contraception during follow-up visits, but women may miss the opportunity for contraceptive initiation before fertility returns.
      This study identified discordant fertility intentions and past year IPV as correlates of delayed initiation, particularly with spousal accompaniment for abortion. Though there were no differences in contraceptive use 4 months postabortion, the timing of initiation differed. This suggests that women reporting IPV are equally able to use contraception by 4 months postabortion but are less likely to initiate postabortion contraception on the day of the procedure. Delayed initiation among women reporting IPV is particularly concerning as studies from a variety of settings demonstrate less power within relationships to negotiate contraceptive use [
      • Miller E.
      • Jordan B.
      • Levenson R.
      • Silverman J.G.
      Reproductive coercion: connecting the dots between partner violence and unintended pregnancy.
      ,
      • Emenike E.
      • Lawoko S.
      • Dalal K.
      Intimate partner violence and reproductive health of women in Kenya.
      ] and restricted mobility [
      • Garcia-Moreno C.
      • Jansen H.A.F.M.
      • Ellsberg M.
      • Heise L.
      • Watts C.H.
      Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence.
      ], which could result in delays beyond the 2-week period of natural protection from pregnancy after an abortion procedure. This study identified spousal accompaniment as a potential explanation for delayed initiation among women reporting past year IPV. While husband/partner accompaniment to abortion services is seen as positive and supportive for some women in the South Asian context [
      • Ganatra B.
      • Kalyanwala S.
      • Elul B.
      • Coyaji K.
      • Tewari S.
      Understanding women's experiences with medical abortion: in-depth interviews with women in two Indian clinics.
      ], it may be experienced as controlling or coercive when violence is present. Abortion service providers should be trained to provide confidential counseling in a private place within the health facility to screen for violence [
      • World Health Organization (WHO)
      Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.
      ] and identify women's reproductive goals in comparison to her husband/partner's [
      • Silverman J.G.
      • Raj A.
      Intimate partner violence and reproductive coercion: global barriers to women's reproductive control.
      ]. Women reporting IPV may have a greater need for woman-controlled methods such as injectables that can be used covertly [
      • Steinauer J.E.
      • Upadhyay U.D.
      • Sokoloff A.
      • Harper C.C.
      • Diedrich J.T.
      • Drey E.A.
      Choice of the levonorgestrel intrauterine device, etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion.
      ], and postabortion contraceptive counseling provides an opportunity for providers to assess women's needs, match postabortion contraceptive recommendations to these needs and provide information on available support services [
      • Silverman J.G.
      • Raj A.
      Intimate partner violence and reproductive coercion: global barriers to women's reproductive control.
      ].

      4.1 Limitations

      The primary limitations of this study were the small sample size and short follow-up period. Similar studies have used 6-month or 1-year follow-up periods, which provide greater power to assess outcomes such as subsequent pregnancy [
      • Puri M.
      • Henderson J.T.
      • Harper C.C.
      • Blum M.
      • Joshi D.
      • Rocca C.H.
      Contraceptive discontinuation and pregnancy postabortion in Nepal: a longitudinal cohort study.
      ,
      • Kalyanwala S.
      • Acharya R.
      • Zavier A.J.F.
      Adoption and continuation of contraception following medical or surgical abortion in Bihar and Jharkhand, India.
      ]. Despite the small sample size, a major strength of this study was the low rate of loss to follow-up. Loss to follow-up was nondifferential by most sociodemographic characteristics, but we note potential for selection bias in that nulliparous women were more likely to be lost to follow-up. Contraceptive use 4 months postabortion was likely lowest among nulliparous women, and differential loss could overestimate contraceptive use 4 months postabortion. We relied on self-reported contraceptive use, which is subject to social desirability bias. Calendar data on contraceptive use over the follow-up period would provide more nuanced information on timing of postabortion contraceptive initiation, including whether women used the contraceptive method selected immediately following abortion. We also lacked data on pregnancy risk after abortion, such as sexual activity and resumption of menses. The parent study focused on government and NGO facilities receiving an intervention to improve abortion services; the extent to which findings generalize to other settings, women under age 18 and women who selected long-acting or permanent methods immediately following abortion is unclear.

      4.2 Conclusions

      Contraceptive use at the index pregnancy was the primary correlate of postabortion contraceptive use 4 months postabortion. Postabortion contraceptive counseling should assess contraceptive failure and inconsistent contraceptive use and empower women with accurate information to use contraception effectively. This study also found that women “catch up” in terms of contraceptive use over the 4 months following abortion, but delayed initiation may indicate a need for postabortion contraception not met immediately following abortion, potentially putting women at risk of unwanted pregnancy. This gap in contraceptive coverage is particularly concerning for women reporting IPV, who were more likely to delay initiation, especially if accompanied by a husband/partner for abortion. Interventions should improve confidential counseling to screen for violence and appropriately match postabortion contraceptive provision with women's needs.

      Acknowledgements

      We are grateful to our funding sources, including Ipas, the National Institute of Child Health and Human Development T32 predoctoral traineeship on preventing and addressing violence in families and the Sommer Scholars program at the Johns Hopkins Bloomberg School of Public Health. We are also grateful to our partners at the Directorate General of Family Planning and Directorate General of Health Services for supporting this study and to Altaf Hussain and the Bangladesh Association for Prevention of Septic Abortion for collecting study data.

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