Effectiveness of a Contraceptive Education Program for Postabortion Patients in Chile

Author(s): Ellen Hardy and Karen Herud

Source: Studies in Family Planning, Vol. 6, No. 7 (Jul., 1975), pp. 188-191
Published by: Population Council
Stable URL: http://www.jstor.org/stable/1965270
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 ofa Contraceptive
Effectiveness Program
Education
inChile
Patients
forPostabortion
ELLEN HARDY and KAREN HERUD
As a group,women who are hospitalizedas a resultof com-
plicationsof abortionhave high fertility rates, are generally
highlymotivatedto avoid futurepregnancies,and run a great
riskof abortingagain if anotherpregnancyoccurs (Requena,
1965). Broad experienceindicatesthat patientshospitalized
fromcomplicationsof abortionare highlymotivatedto accept
a contraceptive,particularlythe intrauterinedevice (IUD).
Postabortioninsertionof an IUD does not entail an increase
in the riskof infectionand expulsionor a decrease in method
reliability(Rosenfieldand Castadot, 1974) .1
This paper evaluates the effortsof an educationalprogram
at the Barros Luco-Trudeau Hospital in Santiago, Chile, in-
tended to informwomen hospitalizedfor abortioncomplica-
tions about familyplanningand to persuade them to accept
contraceptives.The health objective of the hospital was to
reduce the incidence of induced abortion by offeringthese
women the alternativeof contraception.
For more than 15 years,the maternity ward of the Barros
Luco-Trudeau Hospital has recognizedthe seriousnessof the
problemof induced abortionand has taken steps toward its
prevention. In 1967, thehospitalinitiatedpostabortioninsertion
of IUDs for patientswho requestedit, but familyplanning
educationand information were providedonly individuallyby
physiciansor paramedicswho were personallyinterested in the
problem,and therewas no formaleducationalprogram.Post-
abortionpatientsdischargedwithoutan IUD were not referred
to or informedabout familyplanningclinics.
A reviewcompletedat theend of 1969 showed that12 per-
centof women comingto the hospitalwithabortioncomplica-
tionsreportedcontraceptive failureas thereasonforpregnancy,
with two-thirdsof them having used the IUD. It was to be
expectedthatmostof thosepatientswould not accept another
IUD insertion postabortionand would discourageotherpatients
who mighthave accepted withouttheirinfluence.
As a result,the hospitaldecided to institutea formalcon-
traceptiveeducationprogram;to offerothercontraceptives in
additionto theIUD; and to providefora morecarefulfollow-
up of all patients,not only for evaluationpurposes but as a
way to reinforceusers' motivationand to persuade nonusers
to enterthe program.
Recruiting and Training Volunteers
Because the use of professionalpersonnelwas beyond the
budget capacityof the hospital,volunteerswere recruitedfor
the educationalprogram.The Asociacion Chilena de Protec-
I See also: Andolsek,1972; Goldsmithet al., 1972; Tatum,1972; and
Viel and Lucerno,1970.
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cion de la Familia (APROFA) attractedand trainedwomen
of the middleand highsocioeconomicgroupswho were inter-
ested in participating
in educationalprogramson familyplan-
ning. All volunteershad secondary or universityeducation,
most were married,and theirage varied fromlate twentiesto
sixty.Many were close relativesof physicians.
Volunteersreceiveda two-weektrainingcourse on contra-
ceptivemethods,the possibleconsequencesof illegal abortion,
and the advantagesof familyplanning.Those wishingto par-
ticipatein the Barros-Luco's postabortioneducation program
receivedadditionalinstruction on theprogramobjectives,meth-
ods to be used in educatingpatients-includinginterviewpro-
cedures and use of audiovisual material-proceduresfor col-
lecting and recordingdata for evaluations,medical services
rendered,and procedures for follow-up.Before startingthe
programvolunteersinterviewed severalpatientsas a pretestof
thequestionnaires and of theirskills.
To keep thepersonnelparticipating in theprograminformed
and motivated,circularsreportingon the progressof the pro-
gramwerepublishedperiodicallyand displayedin theabortion
and familyplanningclinic sectionsof the hospital.At group
meetings,supervisorsand volunteersreportedon the goals
achieved,discussedthe work,and agreed on procedures.
Volunteers' Educational Activities
Every afternoon,from Monday to Friday, the volunteers
gave a recordedtalk, illustratedwith slides, in the abortion
ward whereall but the mostseriouslyill abortionpatientswere
located. Immediatelyafterthe talk,volunteersheld individual
interviewswith each patient in order to dissipate possible
doubts, reinforcemotivation,and obtain the data requested
for the evaluation.For thislast purpose,a precodedformwas
preparedincludingdata on name,address,age,education,mari-
tal status,numberof livingand dead children,previousabor-
tion(s), and interestin theuse of contraception.
A potentialproblemfaced was the social distancebetween
volunteersand patients,and the possibilitythis mightcause
problemsin communication.Some effortwas spenton trying
to avoid this.Volunteerswere instructedto treatpatientswith
respectand to avoid the familiar"tu," which is oftenused in
Chile when talkingto someone of lower status. No trouble
was reportedduringtheprogram,
arisingfromsocial differences
however.
The activevolunteers,numberingbetween20 and 25, were
divided in five groups, one for each weekday. Each volun-
teer'sdutywas limitedto two to threehours of work a week,
fromtwo to fivein the afternoon.The leader of each group-
also a volunteer-distributedamong them the different tasks
to be accomplished.
Prescription of Contraceptives of a given week and dischargednot later than noon of the
followingMonday. Both controland experimental groupswere
All personnelof theAbortionSectionwereinstructed to offer
offeredcontraceptionat the momentof discharge,referredto
contraceptivesto each patientat time of dischargefromthe thefamilyplanningclinic,and sentcontactlettersiftheydid not
hospital.To reinforcethis practice,the item "Contraception appear. However, only those who attendedMonday through
at Discharge"was includedon theclinicabortionrecord,which Friday received the educational talk and personal interview.
the doctor filledout when he signed the permissionfor dis- Because the patientswere in a large common ward of an old
charge. hospital,thisarrangementdid noteliminatethepossibleindirect
The contraceptivesofferedwere IUDs (Lippes Loop and influenceon thecontrolgroupthroughcontactwithpatientsin
Copper-T) and oral contraceptives.IUD insertionwas per- neighboring beds who receivedinformation and education.This
formedat the hospital,immediatelyafterdischargefromthe "contamination"riskwould tend to increasecontraceptiveac-
AbortionSection.In thecase of pill acceptance,thepatientwas ceptance among the women not interviewed(the control
given the firsttabletof a cycle at dischargeand took the re- group), and because of this,the differences in contraceptive
mainingtabletswithher. behaviorbetweentheinterviewed womenand thecontrolgroup
is a conservativeestimateof the influenceof the educational
Clinic Follow-Up program.
All patients,acceptors and nonacceptors,were given an
appointmentat the obstetricaland gynecologicaloutpatient Results
clinicof thehospitalone week afterdischarge.Withinthisclinic EVALUATION OF EDUCATIONAL PROGRAM
is a familyplanningclinic. The purpose of the appointment
was twofold:to controlany aftereffectsof abortionand to re- of the patientsby acceptanceof contracep-
The distribution
peat the offerof contraception. tion for interviewedand controlgroups,and for the total,is
All patientsreferredto thefamilyplanningclinic (including shownin Table 1. For all patients,63 percentacceptedcontra-
thosewho did notlive in thehealtharea servedby thehospital) ceptionat dischargeor at subsequentclinicvisits,27 percentde-
were followed up duringthe year followingtheirdischarge. clinedforunspecifiedreasons,and 10 percentdeclinedbecause
Patientswitha historyof repeatedabortionswerereferred to the theydesiredpregnancy.The difference in theproportionaccept-
fertilitysectionof the clinic. Because the numberof such pa-
tientsto be followedup was large,the servicesof a "matrona"2 TABLE 1 Percentage distributionof experimentaland control
were contractedfor two hours every afternoonespeciallyfor groups bycontraceptiveacceptance or nonacceptance
this group, and various doctors volunteeredtheirservicesas
Item Experimental Control Total
did all permanentpersonnelin the familyplanningsectionof
theclinic. Acceptors
On theinterviewcard, thevolunteerrecordedthedate of the Beforedischarge 42 36 40
clinic
On first
patient'sdischargefromthe hospital,the date of her appoint- visit 22 16 20
mentat the familyplanningclinic,and whethershe accepted On laterclinic
visit 3 3 3
contraceptionon discharge. Approximatelyten days aftera Nonacceptors
patient'sdischarge,the volunteereducatorvisitedthe clinic to Reasons unknown 22 36 27
ascertainwhetherthe patienthad kept the appointment.If the Wishingpregnancy 11 9 10
Total
patienthad come in,thevolunteerrecordedwhathad occurred Percent 100 100 100
at the visit,and the date of the nextappointment. Number 993 491 1,484
Follow-up letterswere mailed to all patientswho did not NOTE: (p = 0.05).
betweengroupsare significant
Differences
come to the clinicduringthe 15 days followingdischargefrom
thehospital.When a letterwas returnedbecause thewoman no
longerlived at thataddress,a searchwas made forthepatient's ingcontraception betweentheinterviewed women (67 percent)
addresswas found
card in thegeneralhospitalfile.If a different and the controlgroup (55 percent) is statistically significant
in thatfile,a second letterwas sent there. at the .05 level.3The differencein the proportiondesiringa
Informationregardingsubsequentvisitsthata patientmade subsequentpregnancyis not statistically in the two
significant
to the clinic was also recorded on the interviewcard by the groups.
personnelof theclinicInvestigation Center,whichwas in charge Table 1 also shows proportionsof patientsacceptingcon-
of programevaluation. traceptionby timeof acceptance.For bothgroups,themajority
of acceptancesoccurredat the time of discharge(42 percent
of theinterviewed and 36 percentof thecontrolgroup) or dur-
Control Group and
ing thefirstvisitto theclinic(22 percentof theinterviewed
To evaluatethepossibleinfluenceof theeducationalprogram 16 percentof the controlgroup). In the second, third,and
on contraceptiveacceptancelevels,a controlgroup of patients fourthclinicvisits,a smallerproportionbegan use.
was selected,consistingof thosehospitalizedafter5 pm Friday A largerproportionof interviewedwomen than noninter-

2
"Matrona" in Chile correspondsto a trainedmidwifeor obstetrical 3The statisticalanalysisof the differences
betweenthe groups was
nurse elsewhere. made usingthe testsof z or x2,accordingto the case.

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TABLE 2 Percentage distributionof experimental and control TABLE 3 Percentage distributionand number of cases of
groups by sociodemographic characteristics postabortion contraceptive acceptors and nonacceptors
among experimental and control groups, by sociodemographic
Characteristic Experimental Control Total characteristics
Age Experimental Control
Less than 20 13 14 13
20-29 53 53 53
30-49 34 33 34 Characteristic Acceptors Nonacceptors Acceptors Nonacceptors
Educationa Age
None 5 4 5
59 61 Under 20 10 (65) 19 (62) 12 (33) 17 (38)
Primary 62 55 (149) 49 (109)
37 34 20-29 56 (370) 49 (161)
Secondary or higher 33 30-49 34 (230) 32 (105) 33 (88) 34 (74)
Maritalstatus Maritalstatus
Married 81 81 81 84 (228) 76 (169)
19 Married 84 (560) 75 (245)
Single 19 19 16 (42) 24 (52)
Single 16 (105) 25 (83)
Livingchildren Livingchildren
Noneb 17 23 19
57 None 11 (72) 31 (103) 11 (30) 37 (82)
1 to 3 58 56 89 (240) 63 (139)
25 21 24 1 or more 89 (593) 69 (225)
4 or more Previous abor-
Previous abortions tions
None 53 52 53 48 (130) 57 (127)
47 None 51 (340) 56 (190)
1 or more 47 48 49 (325) 44 (138) 52 (140) 43 (94)
1 or more
Total
Percent 100 100 100 Total 100 (665) 100 (328) 100 (270) 100 (221)
Number 993 491 1,484
( ) = Number of cases.
a Educationwas unknown and 84 control.
in 223 women-139 experimental
b (p = 0.05).
Significant women were statistically both for women withand
significant
withoutchildren.
Similar proportionsof interviewedand controlgroups re-
viewed women (61 percentand 48 percent,respectively)at- portedpreviousabortions(47 percentand 48 percentrespec-
tendedthe clinic on the firstappointmentdate, withoutbeing tively).Examinationof therelationof previousabortionhistory
contactedby letter. to acceptanceshows thatproportionately fewerof the patients
who had had no previous abortionsbegan contraceptiveuse
thanof thosewithpreviousabortions(64 percentversus70 per-
INFLUENCES OF OTHER VARIABLES ON ACCEPTANCE
centin theinterviewed groupand 51 percentversus60 percent
To determinewhetherfactorsother than the educational in thegroupnotinterviewed),and thedifferences are statistically
talks mightbe influencing the contraceptiveacceptancelevels, significantin both interviewedand controlgroups.The differ-
thetwo groupswereclassifiedby age, maritalstatus,numberof ence in acceptancebetweentheinterviewed and controlgroups
livingchildren,and historyof past abortions,as shownin Table was significantin the group withno previousabortionsas well
2. The classification permitsa comparisonof the two groups, as in thegroupof patientswithone or morepreviousabortions.
whichis shownin Table 3.
The age distribution of the experimentaland controlgroups
USEFULNESS OF CONTACT BY MAIL
is almostidentical.In both theexperimental and controlgroup,
acceptancewas highestamong women aged 20-29 and lowest A contactletterwas sentto almost all the patientswho did
amongwomenunderage 20. Thereweresignificant differencesin not come to thefamilyplanningclinic.4Fifty-five patientswere
acceptancebetweenexperimentaland controlwomen aged 20 senttwo letters,and eightweresentthree.A greaterproportion
and overbut littledifference in acceptanceamongwomenunder of the letterssentto noninterviewed womenwere returnedbe-
age 20: in the experimentalgroup, 60 percent(600) of the cause of a wrong address compared with the lettersto inter-
women accepted, whereas in the control group, 48 percent viewedwomen (38 percentand 30 percent,respectively).If we
(237) accepted. assume thatthe lettersnot returnedby mail were receivedby
For the analysisof maritalstatus,the womenwere classified the patients,32 percentof the women who were givendefinite
as eithersingle (not currently livingwitha partner)or married appointments in theletterscame to theclinic.There was no dif-
(livingin legal or consenualunionwitha partnerpresent).There ferencein the proportionof interviewedand noninterviewed
was no difference in maritalstatusbetweenthe two groups.In womenwho came to theclinicbecause of an appointment made
both groups,marriedwomen accepted contraceptionin larger by letter.
proportions thanthosewithoutpartners.The acceptanceof con-
traceptiveswas higherfor the interviewed group thanthe con-
Conclusion
trol group among both women withoutspouses and women
with spouses, although for the women withoutspouses, the Althoughacceptance of contraceptiondoes not implycon-
difference was not statistically significant. tinuedfamilyplanningpractice(Faundes et al., 1968; Ramos,
The controlgroup had a somewhatgreaterproportionof of the educational
1972), it gives an idea of the effectiveness
womenwithno children.Since thewomenwithno childrenhad carriedout. Higheracceptancelevelsamong the women
efforts
a lower rate of acceptance,it was possible thatthisdifference receivingthe educationaltalkswere foundalmostconsistently
accountedfor much of the difference in acceptance levels be-
tweenthe two groups;however,the higherratesof contracep- 4No letterwas sentto 20 womenin the controlgroupand 10 in the
tive acceptance in the interviewedversus noninterviewed groupbecause of incompleteor no address.
interview

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whenthetwo groupswere brokendown by age, maritalstatus,
numberof livingchildren,and numberof abortions.Thus, on
the basis of the available data, it seems valid to conclude that
the educationalactivitiesand interviewsheld by thevolunteers
had a positiveeffecton the acceptanceof contraceptionby the
patients.
Consideringthe other factorsthat influenceacceptance, it
also maybe concludedthatthereis a greaterresistanceto using
contraceptiveson the part of the not marriedand younger
women, characteristics that are closely correlated.This resis-
tanceto acceptanceis made moreevidentby thefactthatthese
groupsof youngand singlewomenare theonlyones forwhom
differenceswere found betweenthe interviewed
no significant
and controlgroups;in otherwords,in thesegroups,the educa-
tional activitiesand the interviewdid not have the significant
positiveeffectstheyhad on therestof the patients.
Althoughwe do not have data on thisissue,our experience
with individualcases leads us to postulatethatthisresistance
derivesfromthehonestconvictionthat"I willneverhave sexual
relationsagain," no doubt caused by having been abandoned
by theboyfriend,or by reactionto the experienceof abortion.
The numerouscases of patientswiththesecharacteristics who
have been readmittedforsubsequentabortions,and thegreater
gravityof the abortionsin this group of women (Faundes,
1973), reveal thatwe must considerthissmallerlevel of ac-
ceptanceby singleand youngerwomen as a partialfailureof
theprogramand as an area in whichit is necessaryto redouble
the educationalefforts.
Anotherfindingis that the large majorityof patientswho
acceptcontraception do so at themomentof discharge,and that
the rateof acceptanceduringthe laterclinicvisitsis farlower.
This confirmsprevious findingsthat high risk women are
most motivatedto accept contraceptionduringhospitalization
(Potter and Masnick, 1971). To fullytake advantageof this
motivation,it is necessaryto make methodsotherthan IUDs
availablein theAbortionSection.5A relatedobservation,unfor-
tunatelynot properlydocumented,is thatpatientswho did not
receivea contraceptive duringtheirfirstvisitto thefamilyplan-
ningclinicbecause of lack of attentionor because the appoint-
mentcoincided with theirmenstrualperiod, seldom returned
for a subsequentappointment.
Finally,in reviewingthepracticeof settingup appointments
by mail, about one-thirdof the women who may have re-
ceiveda lettercame to the clinic.Althoughthisproportionmay
seem relativelysmall, we thinkthat the considerablysmaller
cost of contactby mail comparedwiththe alternativeof home
visitsmakessuch contacta worthwhile initialstepif a function-
ing postalsystemexists.
The resultspresentedshow theimportant rolevolunteersmay
play in a programof abortionpreventionand familyplanning.
The volunteersshowedgreatmotivationand dedicationto their
work,whichwas nurturedand reinforcedthroughinformative
meetingsand individualconversations.Even more importantis
the fact thatthe volunteerswere very aware thatthe hospital
personnel,fromthe head of the maternityward to the clinic
auxiliaries,recognizedthe importanceof the work that they
5To some extentthis was done at the time of the study.Oral con-
traceptives,among othermethods,were offered,but a breakdownby
methodwas not possiblein the analysis.
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carried out. Based on our experience,we suggestthatvolun-
teers should be under the supervisionof someone who will
motivatethem; observethe qualityof theirwork; assist them
when theyhave problems;and convince the staffof the con-
tributionthat the volunteersare making so that theirefforts
are recognized.
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ABOUT THE AUTHORS Ellen Hardy is a consultantforthe
DominicanRepublic'sNationalFertilitySurvey,whichis
partof theWorldFertility Survey.During1969-1973,she
at theCenterforResearchinReproduction,
was a sociologist
Barros Luco-TrudeauHospital in Santiago,Chile. Karen
was an assistantto Ms. Hardy
Herud,who is a sociologist,
at the CenterforResearchin Reproduction, BarrosLuco-
TrudeauHospitalduring1972-1973.
ACKNOWLEDGMENTS A studyon the effectof age, parity,
andthespacingofchildren on mother and
andchildmortality
morbidity,ofwhichtheresearchdescribedin thispaperwas
a part,was assistedby a grantfromthePopulationCouncil
to theUniversity ofChile.