Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial
Our study shows that there is no difference in contraceptive use 3 months post-abortion among women whose abortion outcome was assessed in-clinic compared with women who assessed their abortion at home, bearing in mind that women in the 3-month follow-up mainly resided in urban areas where health care is easier to access. The post-abortion contraceptive use at 3 months seen in our study corresponded with results from previous studies in similar settings [11]. Interestingly, at the 2 week follow-up we found a higher overall contraceptive use (33 %) after medical abortion than was previously seen in similar settings in India (9 %) [10, 11]. This was true regardless of study group allocation and in spite of that most of the study participants in the RCT belonged to disadvantaged social groups and where the majority of participants resided in rural areas. However, there was a difference in method use between study groups. A larger proportion of women (53 %) in the clinic follow-up group had initiated contraception in comparison with women in the home-assessment group (25 %). A Nordic RCT investigating home-assessment post-medical abortion indicated higher (55 %) overall use 2 weeks post-abortion than was seen in our study, and with no difference between the study groups [19]. In spite of the Nordic setting being different from our study setting, our findings from the 3-month follow-up and the Nordic RCT suggest that with comprehensive contraceptive counseling and available contraception, women may be motivated to initiate contraception post-abortion irrespective of location of outcome assessment in both high- and low-resource settings. Even though the 3-month follow-up was carried out among women, who were mostly residing in urban areas, it is important to highlight that most study participants belong to underprivileged social groups with a relatively low socio-economic status, with women recruited at the rural sites having the lowest status. Our study shows that the contraceptive intentions reported by women at 2 weeks in the sub-set of women and in the total study population are comparable. Moreover we show that social group, educational attainment and residency do not affect women’s contraceptive use. Based on this we suggest that the observed 3-month contraceptive use in the sub-set of women can be used to indicate an overall trend of contraceptive use at 3 months in general, bearing in mind that the women in the sub-set had a slightly higher socio-economic status and resided in urban areas where health care is easier to access. The slightly postponed use of contraception among the home-assessment women is similar to what was previously observed when comparing contraceptive use after medical versus surgical abortion [11]. Thus, the delay in our study may be an effect of sub-optimal contraceptive counseling and provision rather than the course of abortion, whether home- or clinic-based.
To optimize contraceptive provision in medical abortion we need to understand what factors contribute to contraception use in low-resource settings. The WHO safe abortion guidelines state that contraceptive counseling must be provided on day one of abortion, and that most contraceptive methods are feasible to initiate on day one or three of the medical abortion [2]. Our study enforces this statement by showing that contraceptive counseling on day one, provision of a method on day three, and having an actual plan to initiate on day 14 were associated with contraceptive use at 2 weeks and 3 months. In line with this finding, previous research shows that having a reproductive intention, with regard to spacing or limiting childbearing, motivates women to adopt contraception [18]. We believe that effective provision of intra-abortion contraception could circumvent much of the decreased use at 2 weeks that was seen in the home-assessment group in our study, because there were no differences in the women’s intentions to initiate contraception between the study groups.
Women in our study preferred reversible or barrier methods and rarely desired sterilization. This finding is in sharp contrast to the widespread use of female sterilization, representing two-thirds of contraceptive use in India [24]. Interestingly, the 3-month injection was the overall preferred method, especially among the rural residents, supporting a trend documented in recent studies from similar settings [6, 12], and arguing for the inclusion of the 3-month injection under the NRHM family planning initiative. Additionally, hormonal IUDs and implants should be included as contraceptive options, given their long-acting nature, to avoid discontinuation soon after initiation [25, 26]. Such methods may also be preferable for the women because their use could be kept secret from other family and community members, and hence increases the feasibility of using the method [9]. Similarly, it has been argued that women in situations of dependence are more likely to avoid jeopardizing their social relationships, in this case by using contraception, to avoid the risk of rejection and loss of support [27]. Another study showed that Nepali women who received condom and oral pill post-abortion were more likely to discontinue within 12 months [28], supporting the importance of focusing on long-acting reversible contraceptive methods. In the total study population, women in the in-clinic follow-up group were more likely to prefer condoms at 2 weeks. This finding may be attributed to the patient-provider power-dynamic, putting women in a vulnerable position where they do not want to disobey the provider who is offering contraception, combined with women’s lack of autonomy resulting in their unlikeliness to act on their own preference [29]. This indicates the importance of empowering women to choose their method of preference from a range of different methods as well as encouraging them to return to the clinic if they want to discontinue or switch methods. In line with previous studies [6, 30, 31], our study showed that a woman’s age, existing family size, and whether the woman had any sons influenced contraceptive use. This supports the persisting misconceptions and fear of infertility related to contraceptive use. However, with the observed changes in the childbearing norms in India, young women living in rural areas have new opportunities to negotiate their reproduction [9]. The young women’s self-identified need for effective contraception, and their wish to space between and limit the number of children, provides the health care system with an excellent opportunity to motivate and increase women’s adoption of modern contraception [9].
Our study emphasized the importance of effectively offering contraception with a focus on the 3-month injection, the copper-IUD and other LARCs, intra-abortion. Early initiation of contraception is crucial to avoid repeat unintended pregnancies. Research shows a rapid return of ovulation post-abortion and most women ovulate before returned menses, however, ovulation may occur as early as 10 days post-abortion [32]. Hence, to wait to initiate contraception beyond 10 days post-abortion puts women at risk of unintended pregnancies, however, increasingly so if contraceptive provision is postponed until after the next menses [32]. Most LARCs and the 3-month injection, can be initiated on the same day as misoprostol, or after the confirmed expulsion of the pregnancy [33, 34]. Moreover, early insertion of hormonal IUD reduces the number of days of heavy bleeding post-abortion [34], which is beneficial in settings where anemia is common [35]. In line with these findings, Nepali women who adopted LARC post-abortion were less likely to discontinue or experience unplanned pregnancies within 1 year [6, 28]. Unfortunately, copper-IUDs or injectables were rarely provided on day three of the abortion in our study, primarily due to lack of routine and providers’ reluctance to do so. This can partly explain the lesser use of these methods in the home-assessment group at 2 weeks, and 3 months. However, the difference in use of IUD and injectables at 3 months must be further investigated to understand how to facilitate women’s initiation of long-acting methods, if they assess their abortion outcome at home, particularly because more women in the home-assessment group had expressed their preference towards the IUD or the injectable at the 2-week follow-up compared with women in the in-clinic follow-up group. Moreover, providers’ attitudes to and knowledge of contraceptive services are crucial for the provision of contraception. A study of Indian medical students identified that they possessed poor knowledge and had misconceptions with regard to modern contraception [36]. Hence, more research and clear clinical guidelines are required to support health care providers in their provision of contraceptive methods in medical abortion, especially with regard to early initiation of LARCs and the 3-month injection. In-service training of contraception in abortion care is crucial and should be combined with training in ‘simplified early medical abortion’ as this has proven to be effective and acceptable in low-resource settings [18, 20, 37].
To our knowledge, no previous RCT has investigated contraceptive use post-simplified-follow-up after medical abortion in a low-resource setting. However, there is a need for research on rural women’s contraceptive use and continuation over time as well as a more extensive study on urban women’s contraceptive use over time due to the small sample size in our study. Moreover, studies should preferably investigate contraceptive use over a longer time period than 3 months post-abortion. Another limitation of our study was that women in the home-assessment group could not return to the clinic for contraceptive initiation before their scheduled follow-up. This may have resulted in fewer women reporting contraceptive use by the time of their follow-up appointment, and may have affected the difference in contraceptive use between study groups. Moreover, women in the clinic follow-up group were reimbursed for their travel costs to decrease the dropout rate [23]. This encouraged women to return to the clinic and offered a better opportunity for contraception provision than is commonly seen [21]. These scenarios could have been circumvented by the provision of contraception on day one or three; however, this was not the clinical practice in most of the study sites. Finally, the risk of recall bias must be taken into account. At the 2-week follow-up, women were asked whether they had received contraceptive counseling on day one, and whether or not they had initiated a method before the 2-week follow-up. One can argue that women who had initiated a method were more motivated to report that they had received counseling, however, judging from the data and that most women reported contraceptive counseling regardless of contraceptive use at 2-weeks, indicates the validity of our findings. Moreover, if necessary, the research assistant could carefully probe for information about different aspects of the contraceptive counseling session, such as whether the woman remembered that the doctor spoke of methods to avoid pregnancy, this was to help the woman remember the encounter. However, and more importantly, for the women who were followed-up after 3 months, we asked when they had initiated the method of contraception. To facilitate these responses, the research assistant referred to actual events, such as ‘at follow-up’, ‘after next menstruation’ etc., rather than asking for time intervals in weeks. These events were then translated into number of weeks for the purpose of the survival analysis.