In Nepal, postabortion contraceptive use is low and characterized by high levels of discontinuation.¹ According to a study that used population-based data, only 56% of women who had had an abortion initiated contraceptive use in the 12 months following the procedure. Although women who had had abortions were more likely than those who had given birth to initiate contraceptive use earlier in the year after the procedure (hazard ratio, 2.3), they were also more likely than women who had given birth to discontinue use of a temporary method earlier during that period (1.3).

Since 2002, abortion has been legal and available without restriction in Nepal. In general, women who have had abortions are motivated to use contraceptives to prevent future unintended pregnancies; however, little is known about postabortion contraceptive uptake at the national level in Nepal or how it compares with postpartum contraceptive uptake. To address this gap, researchers used calendar data from the 2011 Nepal Demographic and Health Survey to examine the timing of contraceptive initiation and the rates of method discontinuation after an abortion or delivery.

The survey collected monthly data on contraceptive use and pregnancy outcomes during the five years preceding the survey, as well as data on women’s socioeconomic and demographic characteristics. The current analysis examined initiation of a modern or traditional contraceptive method among married women who had had an abortion, live birth or stillbirth; it was restricted to married women because childbearing in Nepal typically occurs within marriage. Women who had had abortions were considered to require contraception immediately, while those who had had a live birth were allowed a six-month lag to account for such factors as amenorrhea, postpartum abstinence and exclusive breast-feeding. Kaplan-Meier cumulative hazard plots were estimated to determine rates of contraceptive use by pregnancy outcome and discontinuation rates by method type, and discrete-time hazard models were fitted to determine the timing of postabortion or postpartum contraceptive uptake and discontinuation by pregnancy outcome and method type, after adjustment for demographic and socioeconomic characteristics. Analyses of discontinuation examined whether a woman who had initiated a temporary method after her pregnancy outcome was still using the same method. The final sample included 3,190 women—2,506 in the postpartum group (live births and stillbirths) and 684 in the postabortion group.

Overall, 56% of women in the postabortion group initiated contraceptive use in the 12 months following the procedure, while 34% of postpartum women initiated use in the 12 months following the return of fecundity. Among women who initiated contraception in the postabortion group, 28% used injectables, 20% used the pill, 20% a traditional method (primarily withdrawal), 19% condoms, 6% female sterilization, 4% implants and 3% IUDs. The method mix was slightly different for women who starting using contraceptives after a live birth or stillbirth: 40% used injectables, 16% condoms, 16% traditional methods, 15% the pill, 10% female sterilization, 3% IUDs and 2% implants. Among women who had had an abortion, 45% initiated contraceptive use within three months of their procedure; this proportion rose to about 50% at four months and increased only slightly in the next eight months. By contrast, contraceptive uptake was much more gradual in the postpartum group; fewer than 20% initiated contraceptive use within six months of becoming fecund, and the proportion slowly climbed to 34% by the 12th month.

In the multivariate discrete-time models, women in the postabortion group were more likely than those in the postpartum group to have initiated contraceptive use earlier within 12 months (hazard ratio, 2.3). Earlier contraceptive initiation was more likely among women who had used traditional methods or modern methods before the index pregnancy than among those who had not used a method (3.4 and 1.8, respectively). Women aged 25–30 or 30–34 had a greater likelihood of earlier contraceptive initiation than did those aged 15–24 (1.2–1.3). Compared with women with other family compositions, women with two sons were more likely to have initiated contraceptive use earlier (1.2). Women reporting autonomy in household decision making had a higher likelihood of earlier contraceptive initiation than women without autonomy (1.5). Earlier method initiation was positively associated with wealth and education (1.4–2.1), and negatively associated with having a husband who migrated for work (0.6). Unexpectedly, compared with women in the relatively remote and economically deprived midwestern region, those in the eastern, central and western regions were less likely to initiate contraceptive use earlier within 12 months (0.7–0.8).

Overall, 44% of women who had initiated any temporary method of contraception discontinued use within 12 months; this proportion was higher among women in the postabortion group than among those in the postpartum group (48% vs. 44%). Modern method users were more likely to discontinue use earlier than were traditional method users, especially among women who had had abortions. For example, at six months, about 50% of postabortion injectable users had discontinued use, compared with 40% of postpartum injectable users. Overall, by 12 months, only 30% of modern method users and 60% of traditional method users were still using their method.

Women in the postabortion group had a higher rate of earlier method discontinuation in the first 12 months than did women in the postpartum group (hazard ratio, 1.3). Those with at least a secondary education were more likely than those with no education to have discontinued their method earlier (1.3–1.4). Women whose husbands were migrants had a higher risk of earlier discontinuation than women whose husbands lived at home (2.2). Users of traditional methods had a lower rate of earlier discontinuation than users of modern methods (0.5), and women in older age-groups were less likely to discontinue their method earlier than were women aged 15–24 (0.6–0.8). Finally, women from the eastern and central regions had a lower rate of earlier discontinuation than did women from the midwestern region (0.7–0.8).

The researchers note that the data did not permit examination of the reasons for contraceptive nonuse or discontinuation, and that the sample size for the analysis on discontinuation precluded disaggregation by method type. They conclude that "there is a dire need [in Nepal] to strengthen the abortion program and ensure effective family-planning counseling and user follow-up,…[especially for] marginalized groups living in hard-to-reach and remote locations." Moreover, "given the diverse topography and service delivery challenges in the country, context-specific innovations in policy and programs are warranted to increase the use of [postabortion family planning] services." —L. Melhado

REFERENCE

1. Padmadas SS et al., Contraceptive behavior among women after abortion in Nepal, International Journal of Gynecology and Obstetrics, 2014, doi: 10.1016/ j.ijgo.2014.05.012, accessed Nov. 3, 2014. Increased Use of Facilities Helped Reduce Maternal Mortality in Bangladesh