Medium and long-term adherence to postabortion contraception among women having experienced unsafe abortion in Dar es Salaam, Tanzania

Post-abortion contraceptive utilization and associated factors among women who attended abortion services: A health facility cross-sectional study

Background: Post-abortion contraceptive utilization prevents unintended pregnancies, reduces the number of abortions, and lowers the morbidity and mortality related to obstetric complications. It plays a central role in improving maternal health and reducing child mortality. However, many women are suffering from unintended pregnancy and its complications after abortion care. Hence, the main objective of this study was to determine the magnitude of post-abortion contraceptive utilization and its associated factors in Bahir Dar City. Methods: Health-facility-based cross-sectional study was conducted in Bahir Dar city health facilities from April 1 to May 30, 2018. A systematic random sampling technique was used to select 354 eligible study participants. A pre-tested semi-structured questionnaire was used to collect the data. Data entry was done using Epi Data version 3.7 software and analyzed by SPSS v23 software. Descriptive statistics were done based on the nature of the data. A simple logistic regression model was used to identify the association and strength of exploratory variables and the outcome variables. Associations were announced at a 95% confidence interval and p-value <0.05 with adjusted odds ratio. Model fitness was checked by the Hosmer-Lemeshow goodness of fit test for logistic regression. Results: In this study, 348 aborted participants were involved with a mean age of 24.37 (±5.73) years. About 40% of the participants were not currently married and 12.9% were unable to read and write. The magnitude of post-abortion contraceptive utilization was 65.8%. The number of alive children (adjusted odds ratio: 7.0, 95% confidence interval: 1.54, 31.95), lower income (adjusted odds ratio: 0.14, 95% confidence interval: 0.03, 0.60), and (adjusted odds ratio: 0.11, 95% confidence interval: 0.02, 0.46), primary school education (adjusted odds ratio: 0.18, 95% confidence interval: 0.03, 0.97), and currently unemployed (adjusted odds ratio: 0.23, 95% confidence interval: 0.06, 0.85) were significantly associated with the post-abortion contraceptive utilization. Conclusion: The level of post-abortion contraceptive utilization is low as per the national plan. The number of alive children, lower income, lower education, and currently unemployed were the identified factors affecting post-abortion contraceptive utilization. Therefore, a collaborative effort is needed among stakeholders to increase the utilization and avoid factors that prevent the utilization of post-abortion contraceptive utilization.

Continuation of Contraception Following Termination of Pregnancy in a Canadian Urban Centre

OBJECTIVE

Minimal evidence exists on the continuation of contraception following termination of pregnancy. Continuation of effective contraception is important because it has been found to reduce unintended pregnancies. This study aims to determine the rate of continuation and choice of contraception following termination of pregnancy.

METHODS

A cross-sectional analytic study was undertaken of 400 patients undergoing termination of pregnancy over 2 years. Demographic information and contraception choice prior to, at time of, and 6 months following termination were collected. Data were analyzed to assess relationships between patient characteristics and contraceptive choice.

RESULTS

Prior to termination, 58.5% of patients were not using contraception and 22.4% used a less effective method (e.g., barrier or fertility awareness). Following termination, 99.7% of patients chose a method of contraception, and 95.2% chose a more effective method (e.g., long acting reversible contraception, permanent sterilization, combined hormonal contraceptives, progesterone-only contraceptive). Six months following termination, 85.8% of patients were using contraception. A more effective method was continued by 37.8%. There were no significant relationships between choice of contraception and age, previous pregnancies, or social determinants of health. Patients living with their sexual partner were significantly more likely to switch to a less effective method of contraception at 6 months.

CONCLUSIONS

Following termination of pregnancy, almost all patients chose a method of contraception and most continued using contraception 6 months following termination.

Post-abortion family planning use, method preference, and its determinant factors in Eastern Africa: a systematic review and meta-analysis

BACKGROUND

Utilization of post-abortion family planning is very critical to reduce high levels of unintended pregnancy, which is the root cause of induced abortion. In Eastern Africa, it is estimated that as many as 95% of unintended pregnancies occurred among women who do not practice contraception at all. Therefore, this meta-analysis aimed to assess post-abortion family planning utilization and its determinant factors in Eastern Africa.

METHODS

Published papers from Scopus, HINARI, PubMed, Google Scholar, and Web of Science electronic databases and grey literature repository were searched from database inception to January 30, 2020, with no restriction by design and date of publishing. We screened records, extracted data, and assessed risk of bias in duplicate. Cochrane I² statistics were used to check the heterogeneity of the studies. Publication bias was assessed by Egger and Biggs test with a funnel plot. A random-effects model was calculated to estimate the pooled prevalence of post-abortion family planning utilization.

RESULTS

A total of twenty-nine cross-sectional studies with 70,037 study participants were included. The overall pooled prevalence of post-abortion family planning utilization was 67.86% (95% CI 63.59-72.12). The most widely utilized post-abortion family methods were injectable 33.23% (95% CI 22.12-44.34), followed by implants 24.71% (95% CI 13.53-35.89) and oral contraceptive pills 23.42% (95% CI 19.95-26.89). Married marital status (AOR=3.20; 95% CI 2.02-5.05), multiparity (AOR=3.84; 95% CI 1.43-10.33), having a history of abortion (AOR=2.33; 95% CI 1.44-3.75), getting counselling on post-abortion family planning (AOR=4.63; 95% CI 3.27-6.56), and ever use of contraceptives (AOR=4.63; 95% CI 2.27-5.21) were factors associated with post-abortion family planning utilization in Eastern Africa.

CONCLUSIONS

This study revealed that the marital status of the women, multiparity, having a history of abortion, getting counselling on post-abortion family planning, and ever used contraceptives were found to be significantly associated with post-abortion family planning utilization.

Factors associated with seeking post-abortion care among women in Guangzhou, China

Background

In China, the vast majority of induced abortions are performed in public hospitals. However, post-abortion care (PAC) services are provided through the national network of family planning clinics, which are independent of the health care system. The integration of PAC services into abortion clinics in public hospitals is a new concept. This study aimed to assess PAC utilization among abortion patients, and identify the possible factors associated with PAC uptake in Guangzhou, China.

Methods

A cross-sectional survey was conducted among 431 women aged 15–43 years in Tianhe district of Guangzhou, China from June to September 2018. We estimated multivariate logistic regression model to examine the factors associated with utilization of PAC services.

Results

Less than half (42%) of the participants used PAC services. Married women were 2.7 times significantly more likely to use PAC services than their unmarried counterparts. Immigrants were 52% significantly less likely to use PAC services than non-immigrants. Women who perceived that their fertility could return later and those who did not know were 45 and 61% significantly less likely to use PAC services compared to those who knew that their fertility could return soon after an abortion. Women with limited decision-making autonomy regarding contraceptive use were 54% significantly less likely to use PAC services than those who made such decisions themselves.

Conclusions

The findings suggest the need for policies and programs to not only strengthen the provision of PAC services but also promote uptake among disadvantaged sub-groups of women in the study setting.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania

BACKGROUND

Unsafe abortion continues to be a major hazard for maternal health in Sub-Saharan Africa, where abortion remains highly controversial and access to safe abortion services is unequally distributed. Although national abortion laws are central in indicating women's potential for accessing safe abortion services, the character of an abortion law may alone say little about national discursive abortion landscapes and access scenarios. The article calls for the study and problematization of the relationship between legal abortion frameworks on the one hand, and discourses surrounding abortion on the other, in an attempt to move closer to an understanding of the complexity of factors that influence knowledge about and access to safer abortion services. With the restrictive abortion law in Tanzania as a starting point, the paper explores the ways in which the major global abortion discourses manifest themselves in the country and indicate potential implications of a hybrid abortion regime.

METHODS

The study combined a review of major legal and policy documents on abortion, a review of publications on abortion in Tanzanian newspapers between 2000 and 2015 (300 articles), and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health.

RESULTS

Tanzania's abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, and as such reflect the major global discourses. Fairclough's concepts interdiscursivity and recontextualization were drawn upon to develop an understanding of how the concepts health, rights and life emerge across the discourses, but are employed in contrasting lines of argumentation in struggles for hegemony and legitimacy.

DISCUSSION AND CONCLUSIONS

The paper demonstrates that a hybrid discursive regime relating to abortion characterizes the legally restrictive abortion context of Tanzania. We argue that such a complex discursive landscape, which cuts across the restrictive - liberal divide, generates an environment that seems to open avenues for enhanced access to abortion related knowledge and services.

Reducing Barriers to Postabortion Contraception: The Role of Expanding Coverage of Postabortion Care in Dar es Salaam, Tanzania

Expanding postabortion care (PAC) coverage to 64 public facilities over 30 months in Dar es Salaam, Tanzania, contributed to >6,000 women voluntarily adopting a contraceptive method, for an overall acceptance rate of about 81% and 78% adopting a long-acting method. Key interventions included clinical training and follow-up mentorship; PAC service reorganization, equipment provision, and an expanded method mix offering; standardized PAC documentation tools; and community linkages and referrals.

Background:

In Tanzania, limited access to postabortion care (PAC) contributes to high rates of maternal mortality. To address the issue, Pathfinder International and the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) introduced and expanded coverage of PAC in 64 public health facilities in Dar es Salaam, Tanzania.

Methods:

During a 30-month period, we implemented a multifaceted approach to introduce and expand PAC, including clinical training and mentorship for health care providers; service reorganization, equipment provision, and an expanded method mix offering; standardization of PAC reporting tools; and community engagement and referral. We assessed outcomes using PAC service statistics from 64 public health facilities in 4 districts of Dar es Salaam and health care provider mentorship data from 385 observed PAC visits.

Results:

From January 2016 to June 2018, voluntary postabortion contraceptive uptake increased steadily. A total of 6,636 PAC clients, including 2,731 young people (ages 10–24), adopted a method post-procedure. Average semesterly client volume per facility increased from 27 to 52.4 manual vacuum aspiration clients and 17.6 to 43.9 postabortion contraceptors between the first and last periods. Overall postabortion contraceptive uptake was 80.6% (6,636/8,230), with a method mix of 58.3% implant, 18.9% intrauterine device, 13.7% pills, 8.6% injectables, and 0.5% permanent methods. Adults and young people had comparable method mix. Mentored providers showed improvements in service quality indicators. During the last period, 92% counseled the client on contraception, 93% considered the client’s sexual and reproductive health intentions, 94% provided correct method information and supply, and 96% documented services on the client’s family planning card. Different provider types (mid- and senior-level) performed comparably.

Conclusions:

Expanding PAC coverage to primary- and secondary-level facilities led to high uptake of voluntary contraception among postabortion clients. Key interventions included PAC clinical training and mentorship; service reorganization, equipment provision, and an expanded method mix offering; use of standardized PAC registers; and community engagement for awareness building and linkage to PAC.

Women's Satisfaction With and Perceptions of the Quality of Postabortion Care at Public-Sector Facilities in Mainland Tanzania and in Zanzibar

BACKGROUND

In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of public sector provision of PAC. Accordingly, we carried out a mixed-method study between April and July 2016, using client surveys and in-depth interviews, both implemented immediately following PAC. Results were used to help guide the government's initiative.

METHODOLOGY

We assessed the quality of PAC in 25 public-sector facilities through a client survey of 412 women. Questions included satisfaction with client-staff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment. Based on responses, we developed and validated a scale representing women's overall satisfaction with the quality of care. We conducted bivariate analysis to identify the levels of care associated with clients' ranking of individual and composite measures of the quality of care. We used multivariate ordinal logistic models to assess the relative influence of multilevel factors on clients' overall satisfaction. We coupled our survey with qualitative analysis of in-depth interviews with 30 PAC clients.

RESULTS

Clients reported moderately high levels of satisfaction with the quality of PAC, with an overall mean score of 2.6 on a 4-point scale. Bivariate analysis identified several areas for improvement, including family planning counseling and provision, especially at regional hospitals; pain management; and reduced use of sharp curettage. The factors most strongly associated with satisfaction were advanced parity, receiving care at lower-level facilities, brief waiting periods, and manual vacuum aspiration for treatment of incomplete abortion. Qualitative analysis illuminated how client-provider interactions; pain; desire for counseling and information, especially on family planning; and congested facility environments shape clients' perceptions of the care they received.

CONCLUSIONS

Although clear areas for improvement in public-sector provision of PAC existed at all sites, women were less likely to report satisfaction with care at referral facilities owing primarily to inadequate counseling, delays in receiving PAC treatment after admission, and poor emphasis on postabortion fertility, family planning information, and contraceptive provision. PAC programs should ensure availability of a wide range of contraceptive methods and high-quality family planning counseling, especially at tertiary facilities.

Factors associated with uptake of post-abortion family planning in Shire town, Tigray, Ethiopia

Objectives

Post-abortion contraceptive service is pivotal for the prevention of unwanted pregnancy and alleviation of its complication. Worldwide half of the pregnancy is unplanned, whereas unwanted pregnancy ends up with abortion. This study assessed post-abortion contraceptive uptake and associated factors among abortion service users at health institution in Shire town, North Ethiopia. Institutional based cross-sectional study was conducted from December 15/2016 to March 15, 2017, in Shire town. Data were collected using systematic random sampling technique. Bivariate and multivariable analyses were done to determine the association of each independent variable with the dependent variable.

Results

Overall post-abortion contraceptive utilization in this study was 61.5%. Married [AOR 2.59, 95% CI (1.16, 5.65)], completed College education [AOR 5.69, 95% CI (1.61, 20.11)], previous contraceptive used [AOR 3.62, 95% CI (1.77, 7.40)], counseling of family planning [AOR 3.53 95% CI (1.69, 7.37)], grand multipara [AOR 7.91, 95% CI (1.66, 37.74)] and public health institution [AOR 5.95, 95% CI (3.03, 11.72)] were significantly associated with the post-abortion contraceptive utilization. In this study, post-abortion contraceptive utilization was about two-third. Being married, had been completing a college education, had been receiving family planning counseling, previous contraceptive usage, abortion care service at public health institution, and being grand multiparty were determinants of post-abortion contraceptive utilization.

Family planning utilization and factors associated among women receiving abortion services in health facilities of central zone towns of Tigray, Northern Ethiopia: a cross sectional Study

Background

Abortion remains among the leading causes of maternal death worldwide. Post-abortion contraception is significantly effective in preventing unintended pregnancy and abortion if provided before women leave the health facilty. However, the status of post-abortion family planning (PAFP) utilization and the contributing factors are not well studied in Tigray region. So, we conduct study aimed on family planning utilization and factors associated with it among women receiving abortion services.

Methods

A facility based cross-sectional study design was conducted among women receiving abortion services in central zone of Tigray from December 2015to February 2016 using a total of 416 sample size. Women who came for abortion services were selected using systematic random sampling technique.. The data were collected using a pre-tested interviewer administered questionnair. Data were coded and entered in to Epi info 7 and then exported to SPSS for analysis. Descriptive statisticslike frequencies and mean were computed to display the results. Both Bivariable and multivariable logistic regression was used in the analysis. Variables statistically significant at p < 0.05 in the bivariable analysis were checked in multivariable logistic regration to identify independently associated factors. Then variables which were significantly associated with post abortion family planning utilization at p-value < 0.05 in the multivariable analysis were declared as significantly associated factors.

Results

A total of 409 abortion clients were interviewed in this study with 98.3% of response rate. Majority 290 (70.9%) of study participants utilized contracepives after abortion. Type of health facility, the decision maker on timing of having child, knowledge that pregnancy can happen soon after abortion and husband’s opposition towards contraceptives were significantly associated with Post-abortion family planning ustilization.

Conclusions

About one-third of abortion women failed to receive contraceptive before leaving the facility. Private facilities should strengthen utilization of contraceptives on post abortion care service. Health providers should provide counseling on timing of fertility-return following abortion before women left the facility once they receive abortion care. Women empowerment through enhancing community’s awareness focusing on own decision making in the family planning utilization including the partner should be strengthened.

A cross-sectional analysis of Kenyan postabortion care services using a nationally representative sample

OBJECTIVE

To assess quality of postabortion care (PAC) offered by Kenyan healthcare facilities.

METHODS

A cross-sectional survey was conducted using data from the Incidence and Magnitude of Unsafe Abortions study, conducted among 326 PAC-providing healthcare facilities throughout Kenya from March 13 to June 30, 2012. Descriptive results with weighted proportions and an ordered probit model were used.

RESULTS

Overall, 408 (41.8%) first-trimester PAC cases were treated using appropriate technology versus 826 (82.6%) second-trimester cases. Private healthcare facilities lagged behind public healthcare facilities on the use of appropriate technology: 264 (47.5%) public and 144 (33.1%) private facilities used such technology for first-trimester abortion, and 664 (89.6%) public versus 162 (68.8%) private for second-trimester abortions). Most healthcare facilities (251, 70.7%) had at least one provider trained in PAC. A total of 273 (80.7%) healthcare facilities reported offering contraception to all PAC patients, mainly short-acting methods. Delivery of PAC services depended on the availability of separate evacuation room (public level 2-3: odds ratio [OR] 22.93; public level 4-6: OR 77.14), and the number of family planning methods offered within the facility (public level 2-3: OR 1.38; public level 4-6 OR 1.57; private level 2-3: OR 2.27; private level 4-5: 4.89).

CONCLUSION

Effective monitoring of PAC services, particularly among private healthcare facilities, might improve overall quality of services.

Contraceptive use following spontaneous and induced abortion and its association with family planning services in primary health care: results from a Brazilian longitudinal study

Background

Although it is well known that post-abortion contraceptive use is high when family planning services are provided following spontaneous or induced abortions, this relationship remains unclear in Brazil and similar settings with restrictive abortion laws. Our study aims to assess whether contraceptive use is associated with access to family planning services in the six-month period post-abortion, in a setting where laws towards abortion are highly restrictive.

Methods

This prospective cohort study recruited 147 women hospitalized for emergency treatment following spontaneous or induced abortion in Brazil. These women were then followed up for six months (761 observations). Women responded to monthly telephone interviews about contraceptive use and the utilization of family planning services (measured by the utilization of medical consultation and receipt of contraceptive counseling). Generalized Estimating Equations were used to analyze the effect of family planning services and other covariates on contraceptive use over the six-month period post-abortion.

Results

Women who reported utilization of both medical consultation and contraceptive counseling in the same month had higher odds of reporting contraceptive use during the six-month period post-abortion, when compared with those who did not use these family planning services [adjusted aOR = 1.93, 95 % Confidence Interval: 1.13–3.30]. Accessing either service alone did not contribute to contraceptive use. Age (25–34 vs. 15–24 years) was also statistically associated with contraceptive use. Pregnancy planning status, desire to have more children and education did not contribute to contraceptive use.

Conclusions

In restrictive abortion settings, family planning services offered in the six-month post-abortion period contribute to contraceptive use, if not restricted to simple counseling. Medical consultation, in the absence of contraceptive counseling, makes no difference. Immediate initiation of a contraceptive that suits women’s pregnancy intention following an abortion is recommended, as well as a wide range of contraceptive methods, including long-acting reversible methods, even in restrictive abortion laws contexts.

Incidence of Induced Abortion and Post-Abortion Care in Tanzania

BACKGROUND

Tanzania has one of the highest maternal mortality ratios in the world, and unsafe abortion is one of its leading causes. Yet little is known about its incidence.

OBJECTIVES

To provide the first ever estimates of the incidence of unsafe abortion in Tanzania, at the national level and for each of the 8 geopolitical zones (7 in Mainland plus Zanzibar).

METHODS

A nationally representative survey of health facilities was conducted to determine the number of induced abortion complications treated in facilities. A survey of experts on abortion was conducted to estimate the likelihood of women experiencing complications and obtaining treatment. These surveys were complemented with population and fertility data to obtain abortion numbers, rates and ratios, using the Abortion Incidence Complications Methodology.

RESULTS

In Tanzania, women obtained just over 405,000 induced abortions in 2013, for a national rate of 36 abortions per 1,000 women age 15-49 and a ratio of 21 abortions per 100 live births. For each woman treated in a facility for induced abortion complications, 6 times as many women had an abortion but did not receive care. Abortion rates vary widely by zone, from 10.7 in Zanzibar to 50.7 in the Lake zone.

CONCLUSIONS

The abortion rate is similar to that of other countries in the region. Variations by zone are explained mainly by differences in fertility and contraceptive prevalence. Measures to reduce the incidence of unsafe abortion and associated maternal mortality include expanding access to post-abortion care and contraceptive services to prevent unintended pregnancies.

Predictors of abortions in Rural Ghana: a cross-sectional study

Background

Abortion continues to be used as a method of family planning by many women. The complications of unsafe abortions are a major contributor to maternal mortality in sub-Saharan Africa, including Ghana. This study explored the influence of socio-demographic characteristics on abortions in 156 communities within the Kintampo Health and Demographic Surveillance System (KHDSS) area located in the middle part of Ghana.

Methods

A survey on Sexual and Reproductive Health among a representative sample of females aged 15–49 years was conducted in 2011. They were asked about the outcome of pregnancies that occurred between January 2008 and December 2011. Data on their socio-demographic characteristics including household assets were accessed from the database of the KHDSS. Univariate and multivariate random effects logistic regression models were used to explore the predictors of all reported cases of abortion (induced or spontaneous) and cases of induced abortion respectively.

Results

A total of 3554 women were interviewed. Of this total, 2197 women reported on the outcomes of 2723 pregnancies that occurred over the period. The number of all reported cases of abortions (induced and spontaneous) and induced abortions were 370 (13.6%) and 101 (3.7%) respectively.

Unmarried women were more likely to have abortion as compared to married women (aOR = 1.77, 95% CI [1.21-2.58], p = 0.003). Women aged 20–29 years were 43% less likely to have abortion in comparison with those within the ages 13–19 years (aOR = 0.57, 95% CI [0.34-0.95], p = 0.030). Women with primary, middle/junior high school (JHS) and at least secondary education had higher odds of having abortion as compared to women without education. Compared with the most poor women, wealthiest women were three-fold likely to have abortion.

Unmarried women had higher odds of having induced abortion as compared to married women (aOR = 7.73, 95% CI [2.79-21.44], p < 0.001). Women aged 20–29 years, 30–39 years and 40–49 years were less likely to have induced abortion as compared to those 13–19 years of age.

Conclusion

Extra efforts are needed to ensure that family planning services, educational programs on abortion and abortion care reach the target groups identified in this study.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1572-1) contains supplementary material, which is available to authorized users.

Preconception care: promoting reproductive planning

INTRODUCTION

Preconception care recognizes that many adolescent girls and young women will be thrust into motherhood without the knowledge, skills or support they need. Sixty million adolescents give birth each year worldwide, even though pregnancy in adolescence has mortality rates at least twice as high as pregnancy in women aged 20-29 years. Reproductive planning and contraceptive use can prevent unintended pregnancies, unsafe abortions and sexually-transmitted infections in adolescent girls and women. Smaller families also mean better nutrition and development opportunities, yet 222 million couples continue to lack access to modern contraception.

METHOD

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Comprehensive interventions can prevent first pregnancy in adolescence by 15% and repeat adolescent pregnancy by 37%. Such interventions should address underlying social and community factors, include sexual and reproductive health services, contraceptive provision; personal development programs and emphasizes completion of education. Appropriate birth spacing (18-24 months from birth to next pregnancy compared to short intervals <6 months) can significantly lower maternal mortality, preterm births, stillbirths, low birth weight and early neonatal deaths.

CONCLUSION

Improving adolescent health and preventing adolescent pregnancy; and promotion of birth spacing through increasing correct and consistent use of effective contraception are fundamental to preconception care. Promoting reproductive planning on a wider scale is closely interlinked with the reliable provision of effective contraception, however, innovative strategies will need to be devised, or existing strategies such as community-based health workers and peer educators may be expanded, to encourage girls and women to plan their families.

Group versus individual family planning counseling in Ghana: a randomized, noninferiority trial

BACKGROUND

Group, rather than individual, family planning counseling has the potential to increase family planning knowledge and use through more efficient use of limited human resources.

STUDY DESIGN

A randomized, noninferiority study design was utilized to identify whether group family planning counseling is as effective as individual family planning counseling in Ghana. Female gynecology patients were enrolled from two teaching hospitals in Ghana in June and July 2008. Patients were randomized to receive either group or individual family planning counseling. The primary outcome in this study was change in modern contraceptive method knowledge. Changes in family planning use intention before and after the intervention and intended method type were also explored.

RESULTS

Comparisons between the two study arms suggest that randomization was successful. The difference in change in modern contraceptive methods known from baseline to follow-up between the two study arms (group-individual), adjusted for study site, was -0.21, (95% confidence interval: -0.53 to 0.12) suggesting no difference between the two arms.

CONCLUSIONS

Group family planning counseling was as effective as individual family planning counseling in increasing modern contraceptive knowledge among female gynecology patients in Ghana.

Strategies for improving the acceptability and acceptance of the copper intrauterine device

BACKGROUND

Intrauterine devices (IUDs) are highly effective and are the most widely used reversible contraceptive method in the world. However, in developed countries IUDs are among the least common methods of contraception used. We evaluated the effect of interventions to increase uptake of the copper IUD, a long-acting, reversible contraceptive method.

OBJECTIVES

To determine effectiveness of interventions to improve uptake and continuation of the copper IUD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, PsycINFO, PubMed, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP) and OpenSIGLE. We also handsearched references of relevant reviews and included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled before and after studies of interventions which measured use and uptake of contraception including copper IUD as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search results for relevant studies and extracted data from included studies. We used RevMan 5.1 to calculate Peto odd ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes. We conducted meta-analysis by pooling data for similar types of intervention where possible. We used the GRADE system to evaluate the quality of evidence.

MAIN RESULTS

Nine studies representing 7960 women met our inclusion criteria, including seven randomised controlled trials and two controlled before and after studies that reported IUD uptake postintervention. We evaluated the quality of evidence as moderate to low. Three studies on contraceptive counselling and referrals by community workers showed an increase in uptake of the IUD among intervention groups (Peto OR 2.00; 95% CI 1.40 to 2.85). Two studies on antenatal contraceptive counselling also favoured the intervention groups (Peto OR 2.33; 95% CI 1.39 to 3.91). One study on postnatal couple contraceptive counselling also showed an increase in IUD uptake compared to control (Peto OR 5.73; 95% CI 3.59 to 9.15). The results of one study evaluating postnatal home visits and two studies on enhanced postabortion contraceptive counselling did not reach statistical significance.

AUTHORS' CONCLUSIONS

Community-based interventions and antenatal contraceptive counselling improved uptake of copper IUD contraception. Since the copper IUD is one of the most effective reversible contraceptive methods, primary care and family planning and practitioners could consider adopting these interventions. Although our review suggests these interventions are clinically effective, a cost-benefit analysis may be required to evaluate applicability.

Unsafe abortion and postabortion care - an overview

Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18-39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.

Choices on contraceptive methods in post-abortion family planning clinic in the northeast Brazil

BACKGROUND

In Brazil, a Ministry of Health report revealed women who underwent an abortion were predominantly in the use of contraceptive methods, but mentioned inconsistent or erroneously contraceptive use. Promoting the use of contraceptive methods to prevent unwanted pregnancies is one of the most effective strategies to reduce abortion rates and maternal morbidity and mortality. Therefore, providing post-abortion family planning services that include structured contraceptive counseling with free and easy access to contraceptive methods can be suitable. So the objective of this study is to determine the acceptance and selection of contraceptive methods followed by a post-abortion family planning counseling.

METHODS

A cross-sectional study was carried out from July to October 2008, enrolling 150 low income women to receive post-abortion care at a family planning clinic in a public hospital located in Recife, Brazil. The subjects were invited to take part of the study before receiving hospital leave from five different public maternities. An appointment was made for them at a family planning clinic at IMIP from the 8th to the 15th day after they had undergone an abortion. Every woman received information on contraceptive methods, side effects and fertility. Counseling was individualized and addressed them about feelings, expectations and motivations regarding contraception as well as pregnancy intention.

RESULTS

Of all women enrolled in this study, 97.4% accepted at least one contraceptive method. Most of them (73.4%) had no previous abortion history. Forty of the women who had undergone a previous abortion, 47.5% reported undergoing unsafe abortion. Slightly more than half of the pregnancies (52%) were unwanted. All women had knowledge of the use of condoms, oral contraceptives and injectables. The most chosen method was injectables, followed by oral contraceptives and condoms. Only one woman chose an intrauterine device.

CONCLUSION

The acceptance rate of post-abortion contraceptive methods was greater and the most chosen method was the best-known one. Implementing a specialized family planning post abortion service may promote an acceptance, regardless of the chosen method. Most important is they do receive contraception if they do not wish for an immediate pregnancy.

Health care providers' attitudes towards termination of pregnancy: a qualitative study in South Africa

Background

Despite changes to the abortion legislation in South Africa in 1996, barriers to women accessing abortion services still exist including provider opposition to abortions and a shortage of trained and willing abortion care providers. The dearth of abortion providers undermines the availability of safe, legal abortion, and has serious implications for women's access to abortion services and health service planning.

In South Africa, little is known about the personal and professional attitudes of individuals who are currently working in abortion service provision. Exploring the factors which determine health care providers' involvement or disengagement in abortion services may facilitate improvement in the planning and provision of future services.

Methods

Qualitative research methods were used to collect data. Thirty four in-depth interviews and one focus group discussion were conducted during 2006 and 2007 with health care providers who were involved in a range of abortion provision in the Western Cape Province, South Africa. Data were analysed using a thematic analysis approach.

Results

Complex patterns of service delivery were prevalent throughout many of the health care facilities, and fragmented levels of service provision operated in order to accommodate health care providers' willingness to be involved in different aspects of abortion provision. Related to this was the need expressed by many providers for dedicated, stand-alone abortion clinics thereby creating a more supportive environment for both clients and providers. Almost all providers were concerned about the numerous difficulties women faced in seeking an abortion and their general quality of care. An overriding concern was poor pre and post abortion counselling including contraceptive counselling and provision.

Conclusion

This is the first known qualitative study undertaken in South Africa exploring providers' attitudes towards abortion and adds to the body of information addressing the barriers to safe abortion services. In order to sustain a pool of abortion providers, programmes which both attract prospective abortion providers, and retain existing providers, needs to be developed and financial compensation for abortion care providers needs to be considered.