Age matters: differential impact of service quality on contraceptive uptake among post-abortion clients in Kenya

This paper analyses the impact of high quality, user-friendly, comprehensive sliding-scale post-abortion services on clients' uptake of contraception in a Kenyan town. Data were drawn from detailed physician records in a private clinic that served 1080 post-abortion clients in 2006. All clients received confidential family planning counselling and were offered a complete range of contraceptives at no additional cost. One quarter of clients were below age 19. Prior to the abortion, no client aged 10–18 years reported having used contraception, as compared to 60% of clients aged 27–46 years. After the abortion and family planning counselling session, only 6% of clients aged 10–18 chose a method, as compared to 96% of clients aged 27–46, even though contraception was free, the provider strongly promoted family planning to everyone and all clients had just experienced an unwanted pregnancy. Significant predictors of contraceptive uptake post-abortion were: having a child, a previous termination, prior contraceptive use and being older than 21. These findings suggest that availability, affordability and youth-friendliness are not sufficient to overcome psycho-social barriers to contraceptive use for sexually-active young people in Kenya. To reduce unwanted pregnancies, more attention may be needed to developing youth-friendly communities that support responsible sexuality among adolescents.     

Does dedicated pre-abortion contraception counselling help to improve post-abortion contraception uptake?

OBJECTIVE: Many studies have shown a disappointing periabortion contraceptive uptake. This study investigated whether the provision of dedicated and targeted contraception counselling at the pre-abortion assessment visit can improve the post-abortion contraception uptake. METHODS: The study comprised a 3-month prospective reaudit of the abortion clinic. RESULTS: Of the 104 women seen during the re-audit period, 96% received post-abortion contraception. The majority (73%) of the women chose and received one of the less user-dependent contraceptive methods such as intrauterine contraceptive devices, the intrauterine contraceptive system, the progestogen injectable and subdermal implants. CONCLUSION: It was found that the provision of targeted contraception counselling by a dedicated team during the pre-abortion assessment visit can dramatically improve post-abortion contraception uptake.     

Service provider perspectives on post-abortion contraception in Nepal

The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility’s infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.     

年轻妇女重复人工流产状况及影响因素

目的:了解北京市年轻妇女(≤25岁)重复流产的基本状况、有关避孕态度行为,并探讨相关影响因素。方法:本研究采用以医院为基础的描述性流行病学研究,分析多次重复流产妇女的基本状况及相关影响因素。随机选取北京市8家医院,对6个月内到这8家医院进行早期人工流产的妇女(1980年8月1日以后出生)进行问卷调查并应用SPSS10.0统计软件进行分析。结果:在所有被调查的1008例流产妇女中,2次以上(包括2次)为330例,占所有流产妇女的比例为32.7%;在重复流产的妇女中,56.9%的人未使用任何避孕措施,43.1%的妇女怀孕原因是因为避孕失败。在所有因避孕失败怀孕者中,有36.9%为安全期避孕失败,29.8%是避孕套避孕失败所引起,26.2%是体外排精,19.1%是紧急避孕药。多元Logistic回归分析,最后进入模型的因素有职业、文化程度、避孕知识、本次流产避孕状况。结论:由于年轻妇女对避孕知识相对缺乏,未采取避孕措施的比例较高,安全期避孕的使用率仍然较高。职业、文化程度、对避孕知识的掌握程度以及本次流产是否避孕是妇女重复流产的影响因素。应加强对流产后避孕知识的宣教,特别是安全期避孕与体外排精的相关知识。     

深圳和眉山地区人工流产妇女对流产服务的评价及其比较

目的:评价深圳和眉山两地区不同部门和不同等级医疗机构人工流产服务质量,为进一步干预研究提供依据。方法:2005年10月~2006年3月,分别在深圳市和四川省眉山市对计划生育及卫生部门的市、县、乡三级开展人工流产服务机构,对完成流产手术离院前的妇女进行半结构式问卷调查,了解她们获得的相关服务及其对服务的评价。结果:术前医生对服务过程解释的比例为79%,术中对受术者不适进行处理的比例(61%),流产后避孕指导(67%)以及提供相应的宣教材料(52%)的水平均较低。深圳市流产服务在术后随访、性生活和避孕指导以及提供宣教材料方面高于眉山市,计划生育系统的人性化服务和流产后避孕服务好于卫生系统,县级机构术后指导和宣教以及人性化服务好于市级机构。总体上,流产妇女对服务的满意度为83%,其中对计划生育服务机构满意度(89%)高于卫生机构(76%),县级机构(93%)高于市级机构(72%)。结论:我国流产服务质量仍有很大的改善余地,尤其要加强以服务对象为中心的人性化服务和流产后避孕服务。经济欠发达地区和市一级服务机构是改进的重点。     

人工流产少女的性行为及避孕现状调查

目的:了解人工流产少女的性行为和避孕现状,找出存在的问题并提出相关建议。方法:以成都市锦江区妇幼保健院作为研究现场,于2009年5月～2010年4月,采用自填式问卷的方法对年龄≤20岁的人工流产少女525例进行调查和统计分析。结果:本次妊娠的主要原因是未避孕(67.6%)和避孕失败(25.2%)。未避孕的最主要原因是认为偶尔无避孕性行为不会妊娠,导致避孕失败的方法依次为体外射精、避孕套、安全期和紧急避孕药。在过去6个月内,每次性行为都使用避孕措施的占4.2%,25.2%研究对象从未使用过任何避孕措施。研究对象与男伴同居的比例非本市户籍(58.1%)高于本市户籍(41.1%),农村(59.8%)高于城镇(47.9%)(P<0.05)。采用逐步回归方法分析影响重复性流产的因素,发现年龄和收入具有统计学意义(P=0.04和P<0.01)。结论:未婚同居、收入水平低、年龄小、避孕措施使用率低和方法低效是非意愿妊娠的主要原因。应加强避孕知识的宣传教育,提高避孕药具可及性及流产后服务水平和能力。     

Peri-abortion contraception: a qualitative study of users' experiences

BACKGROUND: Contraceptive counselling is an essential element of induced abortion services but concerns remain about its effectiveness. OBJECTIVE: The issues that influence peri-abortion contraception were explored as part of a study on the experiences of women undergoing induced abortion. METHOD: In-depth interviews with 21 women of varying ages, gestations and ethnicity, 3-9 weeks after termination of their pregnancy, with qualitative analysis of data. RESULTS: Contraceptive risk-taking was high both before and after abortion. After abortion, only a few women had changed either to using some method, or moving to more reliable methods. Health professionals had not explored the issues around contraception with sufficient clarity or detail to be effective. Discussion of contraception was often deferred to the post-abortion follow-up visit, which only 12 respondents had attended at the time of interview. CONCLUSIONS: The effectiveness of peri-abortion contraception counselling was disappointing. We suggest that a family planning-trained outreach nurse attached to abortion providers with specific responsibility for contraception could improve uptake post-abortion.     

北京市西城区育龄妇女流产后综合服务现状调查

目的:了解城区育龄妇女人工流产术后接受综合服务的现状,为开展规范化流产后服务提供依据。方法:随机抽取在北京市西城区4家计划生育技术服务医疗机构中自愿要求人工流产的育龄妇女400例,进行现场问卷调查。结果:调查对象年龄28.9±6.89(18～48)岁;本次妊娠主要原因,42.6%未使用避孕方法,55.6%避孕失败,其他原因占1.8%;已婚育龄妇女重复流产率(68.05%)高于未婚育龄妇女(37.25%);既往避孕措施使用频率最高的是避孕套(68.1%),其次依次为安全期(38.7%)、体外排精(33.5%)、紧急避孕(19.4%)等;调查对象获得的宣教信息,最多的是流产后注意事项,其次是避孕方法的种类、避孕药具的使用方法等;95%能确定流产后使用哪种避孕方法,并愿意接受计划生育宣教服务;62.0%主动询问了有关避孕方法的问题,在咨询时医生介绍避孕方法占91.2%,咨询时间的中位数和众数均为10min,医生当场提供避孕药具占77.8%。结论:育龄妇女人工流产术后接受计划生育宣教和咨询服务意愿强,开展规范化流产后综合服务,有助于促进妇女生殖健康。     

医院服务提供者流产后服务现状

目的:了解郑州市医院服务提供者对流产后服务的知识、态度、行为及服务存在问题,为今后开展流产后服务提供科学依据。方法:采取整群抽样方式,对郑州市10家医院从事流产后服务的234名医护人员进行了调查,调查采用自填与询问相结合方式。结果:避孕方法知识水平较好者为72.2%,最需要的信息是如何生动进行计划生育宣教(70.94%)。仅有1.28%的服务提供者经常向流产妇女提供免费避孕药具。认为有必要向流产妇女提供避孕咨询服务和免费避孕药具的比例分别为89.75%和73.93%。对于今后推广实施流产后服务,认为亟需解决的问题依次是免费避孕药具的获得、妇女在流产手术后疼痛、能否抽出时间及计划生育宣教资料的获得等。结论:郑州市应加强对医院服务提供者的培训,提高医院服务提供者做好流产后服务的意识,计划生育和卫生部门应加强合作、共同推进流产后服务工作使其走向规范化。     

Contraceptive Use Among Clients of the Atlanta Feminist Women’s Health Center at Three to Five Weeks Post-Abortion

Little is known about women’s contraceptive use and sexual activity in the immediate post-abortion period although effective contraceptive use is paramount during this time because fertility returns almost immediately. This study sought to learn more about women’s contraceptive use and sexual behaviors to inform abortion providers and help them serve their clients better, potentially leading to a decline in the rates of unintended pregnancy and repeat abortion. Abortion clients of an Atlanta, GA clinic were surveyed over the telephone 3–5 weeks post-abortion. Background information was collected from clinic medical charts. Simple and stratified frequencies and logistic regression were used to describe women’s sexual activity and contraceptive use in the immediate post-abortion period and to determine if variables known at the time of the abortion could predict contraceptive use 3–5 weeks post-abortion. 54.2% (n = 39) of women had engaged in sexual intercourse in the immediate post-abortion period. Of these, 30.8% (n = 12) were not using a contraceptive method or were not using it effectively. Women who said they did not want or need information about birth control on their medical history form were less likely to be using contraception 3–5 weeks post abortion. Emphasizing the rapid return of fertility and risk of conception in pre-abortion counseling sessions could prevent future unintended pregnancies among abortion clients. Further research could explore the interaction between a willingness to talk about contraceptive methods at the time of abortion and method use post-abortion.     

人工流产后计划生育服务干预效果初探

目的:探讨人工流产后计划生育服务的实施效果。方法:在珠海市6家计划生育服务中心(站、所)选择1500名行人工流产妇女在流产术前进行初始问卷调查;然后将其随机分为流产后计划生育服务组(干预组)和对照组,对干预组进行流产后计划生育服务措施干预,对照组常规处理;1年期满后,对所有的研究对象采用与初始问卷相同的问卷再次进行问卷调查,重点调查避孕节育相关知识知晓情况,避孕措施实施情况,及再次非意愿妊娠情况。结果:随访1年后,收回有效问卷1146份,其中干预组577人,对照组569人。干预组和对照组的避孕相关知识得分分别为9.76和6.07(F=847.87,P0.001)。干预组采取主动避孕措施的比例(83.24%)高于对照组(59.93%),差异有统计学意义(χ2=114.86,P0.001)。干预组的非意愿妊娠率(9.71%)低于对照组(20.74%),差异有统计学意义(χ2=27.08,P0.001)。结论:流产后计划生育服务对育龄女性避孕节育相关知识的掌握,提高避孕措施使用比例,降低非意愿妊娠和人工流产率,提高生殖健康水平有一定的效果。     

Post-abortion contraception choices of women in Ghana: A one-year review

Low rates of contraception in much of sub-Saharan Africa result in unplanned pregnancies, which in young, unmarried women often result in unsafe abortion. Increasing the use of highly effective forms of contraception has the potential to reduce the abortion-related mortality and morbidity. In this cross-sectional study, information collected by the post-abortion family planning counsellor was analysed. De-identified data from one year (June 2012–May 2013) were extracted from the logbook. Multivariate linear and logistic regression was performed. A total of 612 women received care for post-abortion complications from June 2012 to May 2013. Young, unmarried women, and those who were being treated for complications arising from an induced versus spontaneous abortion were more likely to report they would use ‘abstinence’ as their method of contraception following their treatment. This vulnerable group could benefit from an increased uptake of long-acting reversible contraceptive methods to avoid repeated unplanned pregnancies and the potential of future unsafe abortions.     

1998～2007年负压吸引人工流产术人群特征回顾性分析

目的：探讨近年来人工流产人群特征及流行病学变化趋势。方法：采用流行病学系统抽样的研究方法,逐年抽取1998～2007年每个季度第3个月在本院施行人工流产手术者21869例进行回顾性分析。结果：受术者平均年龄28岁,其中以20～29岁者居多,占66.5%;未婚者占19.5%;未产者占64.2%;外地户籍者占30.7%;术前未采取避孕措施者占71.3%。随着年代递进,未婚、未产、术前未采取避孕措施及外地户籍的比例分别由1998～2002年的15.5%、58.6%、62.2%和23.6%上升至2003～2007年的22.1%、67.8%、77.2%和35.2%。结论：20～29岁年龄组以及未产妇女在此调查中所占比例最大,是进行流产后计划生育服务的重点人群,对未婚、未产及流动人口应加大服务力度。     

Contraceptive policies affect post-abortion provision of long-acting reversible contraception

Background

Placement of long-acting reversible contraceptives (LARC) — intrauterine devices (IUDs) and the implant — directly after an abortion provides immediate contraceptive protection and has been proven safe.

Study Design

We conducted a survey of National Abortion Federation member facilities (n=326; response rate 75%) to assess post-abortion contraceptive practices. Using multivariable logistic regression, we measured variations in provision of long-acting contraception by clinic factors and state contraceptive laws and policies.

Results

The majority (69%) of providers surveyed offered long-acting methods, but fewer offered immediate post-abortion placement of intrauterine devices (36%) or implants (17%). Most patients were provided with contraception; 6.6% chose LARC methods offering the highest level of protection. Post-abortion provision of these methods was lower in stand-alone abortion clinics (p≤.001), but higher with recent clinician training (p≤.001) and in the absence of clinic flow barriers (p≤.001). State policies had a significant impact on how women paid for contraception and the likelihood of LARC use. Patient use was higher in states with contraceptive coverage mandates (p≤.01) or Medicaid family planning expansion programs (p≤.05).

Conclusions

Use of the most effective contraceptives immediately post-abortion is rare in the United States. State policies, high cost to patients, and the ongoing need for clinician training in the methods hinder provision and patient uptake. Contraceptive policies are an important component of abortion patient access to the most effective methods.     

What contraception do women use after abortion? An analysis of 319,385 cases from eight countries

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.     

How commonly do US abortion clinics offer contraceptive services?

Background

About half of US women having abortions have already had at least one prior abortion. Facilitating access to contraception may help these women avoid subsequent unintended pregnancies. Information is needed to document the availability of contraceptive services in abortion care settings in the United States.

Study Design

Data for this cross-sectional mixed-methods study were collected between December 2008 and September 2009 and come from two sources: 15 semistructured telephone interviews and 173 structured questionnaires administered to a nationally representative sample of eligible facilities. Respondents were administrators at large (400+ abortions per year), nonhospital facilities that provide abortion services in the United States.

Results

Virtually all (96%) abortion clinics incorporate contraceptive education into abortion care, and the three most common methods reported to be distributed are the birth control pill (99%), the vaginal ring (61%) and Depo-Provera (58%). Almost one-third reported being able to offer post-abortion intrauterine device insertion. Most facilities (82%) accept some form of insurance for either contraceptive or abortion services, and those with a broader family planning focus are significantly more likely to do so. Administrators at the majority of facilities (56%) report that patients most commonly do not pay additional fees for contraceptive services because they are included in the cost of abortion services.

Conclusion

Although almost all large, non-hospital abortion providers in the United States are able to provide some level of contraceptive care to their abortion patients, the degree to which they are able to do so is influenced by a wide range of factors.     

Abortions in a hospital setting: hidden realities in Dar es Salaam, Tanzania.

This study investigates the extent of unwanted pregnancy, the use of illegally induced abortion, and the attitudes toward and practice of contraception among women admitted to a hospital with the diagnosis of abortion in Dar es Salaam, Tanzania. (In Tanzania, induced abortion is permitted only to save the mother's life.) A random sample of 300 women with early pregnancy loss admitted to Muhimbili Medical Centre, the teaching hospital in Dar es Salaam, were interviewed between September and November 1987, using a structured questionnaire. Among the 300 respondents, 155 said that their pregnancy had been unwanted: 94 of them presented with an illegally induced abortion and 61 with a spontaneous abortion. The number of spontaneous abortions of unwanted pregnancies increased with age and stability in a relationship. Having a small child to look after and having completed the family were the most common reasons for the pregnancy to be unwanted in this group. Induced abortion was more a problem of the young, unmarried woman. The 61 women with spontaneous abortion but unwanted pregnancy suggest that a much larger group of pregnant women continue to term with what are, at least initially, unwanted pregnancies--precisely the group of women family planning programs want to reach. The low prevalence of contraceptive use in this group indicates the failure of family planning clinics to motivate their target group. Recommendations are made for improved functioning of family planning clinics.     

护理专业女生避孕和意外妊娠认知状况

目的 了解护理专业女生避孕知识及对意外妊娠的认知情况,为制定有针对性的避孕教育策略提供依据.方法 采用自编问卷,对蚌埠医学院326名护理专业女生进行问卷调查,内容包括个人信息、对妊娠的认识、避孕知识及紧急事后避孕、对意外妊娠的担心和处理意愿等.结果 在326名女生中,分别有91.72％,76.07％,76.38％对妊娠的主要表现、早期预警及早期诊断有较好的认知.但对避孕相关知识(月经周期中最易受孕的时间、偶尔性交能否怀孕、避孕方法)及实际运用认知并不高.被调查对象中只有23.00％会计算安全期,13.50％意愿采纳避孕药避孕.一旦遭遇意外妊娠,83.74％担心的问题是流产(流产的危险48.77％、流产并发症34.97％),其中一半以上选择终止意外妊娠的方法是流产(人工流产31.90％,药物流产23.62％),意外妊娠后主要求助于家人(41.72％)和同学(26.07％),71.47％认为意外妊娠对心理有伤害,而对意外妊娠造成的远期影响如妇科炎症、不孕症认识不足.结论 护理专业的女生避孕知识有待提高,意外妊娠相关认知需全面加强.     

Do women and men consider abortion as an alternative to contraception in the United States? An exploratory study

The USA, a country with widespread access to the full range of modern methods of contraception, continues to have one of the highest abortion rates among developed countries. Forty-nine per cent of women reported ever experiencing an unintended pregnancy in 2001; 48% of these conceptions occurred during a month that contraception was used. We explored the extent to which people use contraception and abortion interchangeably to achieve their fertility goals via focus groups (n = 4) and semi-structured in-depth interviews (IDIs) (n = 18) with men and women between the ages of 18 and 35 in New York City in 2006. While there was a consensus that abortion cannot replace contraceptive use, poor couple communication, lack of planning, lack of acceptable contraceptive methods and the pleasures that people associate with having unprotected sex result in the perception that some individuals rely on abortion over contraception to prevent unintended births. Men and women both identified women as solely in charge of avoiding an unwanted pregnancy and resolving it should one occur. No one supported repeat abortions for themselves or others, and many respondents perceived multiple abortions to lead to infertility, which strengthens their position that substituting abortion for contraception is unacceptable.     

Contraception: short-term vs. long-term failure rates

Many couples will have a long period in which they will practice contraception as a family planning choice. Contraceptive failure rates recently published in the US by Elise Jones and Jacqueline Forest were based on short-term studies. This article extends these short-term failure rates by 3 differing models over a 10-year period. A 95% effective contraceptive method has a monthly 1% chance of failure. Taken over 10 years, this method has a 70% chance of failure. For many couples, 20 years of contraceptive usage is chosen and they may want to be able to choose their contraceptive according to its long-term efficiency. This article focuses on the individual and not on the group because the group's chance of unwanted pregnancy will rapidly decline as the most fecund become pregnant and drop out of subsequent analysis. The individual's risk will not diminish. The 3 models for extending short-term failure rates over 10 years are: 1) annual risk remains constant; 2) annual risk declines by 1/2 over 10 years; and 3) failure rates for various methods reduce to 0 over 10 years. Using the conservative 3 model, the risk of unwanted pregnancy over 10 years is still high for all forms of contraception outside of sterilization (e.g. Pill=27% failure, Condom=52% failure, Diaphragm=56% failure, Rhythm Method=57% failure, Spermicide=76% failure, and IUD=26% failure). There findings have implication for the occurrence of unwanted child bearing and abortion, and the need to look at long term risk is choosing a temporary contraceptive method.