Original article

Uptake of long-acting reversible contraceptives among post abortion clients in

Sargodha, Pakistan

Abstract

Objective: To determine uptake of long acting reversible contraceptive methods (LARC) and

their influencing factors in post abortion clients

Methodology: This analytical cross-sectional study was conducted in three public and three

private hospitals of Sargodha from February 2018 to October 2018. The study included 160 post

abortion clients using two stage sampling technique. First part of a self- structured questionnaire

was filled to record socio demographic details and the second part to assess LARC uptake. Data

were analyzed using SPSS version 22. Chi square test/ Fischer exact test and logistic regression

analysis was applied, p-value < 0.05 was considered significant.

Results:

Mean age of participants was 28.4 ± 6.04 years. Only 10% clients adopted LARC within one

month. Significant association of LARC was noted in clients who were managed by manual

vacuum aspiration (p value 0.04), clients having three or more living children (p value 0.006),

clients served by private sector (p value 0.004), clients more than 24 years of age (p value 0.03)

and clients who received counseling (p value 0.006).

Conclusion: Post abortion LARC uptake was low; however, private sector, age more than 24

years, management by manual vacuum aspiration, three or more live children and counseling by
health care providers were significantly associated factors with LARC uptake by post abortion

clients.

Keywords: Contraception; Long acting reversible contraceptive method; Post abortion

contraception

Introduction

World Health Organization recommends at least 6 month interval to next pregnancy after

miscarriage or induced abortion.1 Post abortion contraceptive provision is an important

component of comprehensive post abortion care.2

Due to rapid return of fertility and early resumption of sexual intercourse, post abortion clients

are exposed to the risk of subsequent pregnancy with short interval. 3 High quality counseling and

provision of effective contraceptive method can protect post abortion client from these undesired

outcomes.

Post abortion women are the potential candidates for contraception and they must receive

comprehensive information and counseling about a range of contraceptive methods including

short acting, long acting and permanent method.4 LARC such as intrauterine contraceptive

device (IUCD) and sub dermal implants are safe, highly effective, user independent and cost

effective methods.5 Uptake of LARC by post abortion clients is a high impact practice which

reduces the rate of repeat abortions and unintended pregnancies. 6 In Pakistan, contraceptive

prevalence rate is only 34% and unmet need for contraception is as high as 17%. Incidence of

miscarriage and abortions is still alarming and about 15% pregnancies had to face this outcome. 7

According to a study, 2.2 million abortions took place in Pakistan in 2012. 8 Strategies for
effective counseling and service provision of LARC must be implemented to address the

contraceptive needs of post abortion clients. 9

Determination of post abortion LARC uptake is essential to know what percentage of post

abortion clients get long term reversible protection from the risk of unintended pregnancies, poor

maternal outcome or repeat abortions. Assessment of factors which affect post abortion LARC

uptake would be helpful in addressing the high unmet need of contraception. 10 There was paucity

of data regarding post abortion LARC uptake in Pakistan. This study is aimed to determine

uptake of LARC among post abortion clients along with factors influencing the uptake.

Methodology

This study was conducted at three public and three private sector hospitals of district Sargodha

from February 2018 to October 2018. The sample size of 160 was estimated by using Raosoft

sample size calculator with 5% margin of error, 95% confidence level and adding 30% increase

to cover the lost to follow-up. Two stage Sampling Technique was used by obtaining list of all

hospitals providing reproductive health care from District Health Officer followed by sampling

frames construction for private and public sector hospital strata. Selection of hospitals was done

by stratified sampling technique using lottery method from each stratum. In the second phase,

simple random sampling technique utilizing computer generated random number was used to

select hospital for that day to collect data. Total of 160 post abortion clients (78 from public

sector and 82 from private sector hospitals) were enrolled who fulfilled the eligibility criteria

after taking written voluntary informed consent. Inclusion criteria were women aged 15–49 years

who reported any type of abortion before 20 weeks gestation and gave written consent. Women
with a plan or desire for next pregnancy within 6 months and who developed life threatening

complications were excluded.

Research questionnaire was designed after extensive literature search based upon questions used

in previous studies. The questionnaire was piloted on 20 post abortion clients and received

approval from research committees of Army Medical College. First part of questionnaire was

filled to record socio-demographic characteristics of the client and the second part of

questionnaire was filled after one month of abortion to record LARC uptake.

Data were entered and analyzed in SPSS Version 22. Descriptive statistics like frequency and

percentage were used for categorical variables. Mean and standard deviation were calculated for

continuous variables. Chi square test and Fischer exact test were applied where ever applicable

to determine the association between categorical variables followed by application of logistic

regression. A p-value < 0.05 was considered statistically significant.

Results

The mean age of 160 study participants was 28.4 ± 6.04 years. Seventy eight clients (48.7%)

received healthcare by public and 82 clients (51.2%) from private sector hospitals. Details are in

table 1.
Table I: Socio demographic characteristics of the participants (n=160) and uptake of

LARC

Demographic variables Frequencies n LARC uptake n (%) p value

(%)

Age

Less than 24 years 37 (23.1) 0 0.036*

25-35 years 103 (64.4) 12 (11.7)

36-49 years 20 (12.5) 4 (20)

Years of education

Illiterate 33 (20.6) 6 (46.1) 0.10

1-5 years 38 (23.8) 6 (15.8)

6-10 years 64 (40) 2 (3.1)

11-14 years 20 (12.5) 2 (10)

More than 14 years 5 (3.1) 0

Years of marriage

Less than one year 8 (5) 0 0.12

1-5 years 52 (32.5)

6-10 years 58 (36.3) 3(5.8)

11-15 years 27 (16.9)

15 (9.4) 5 (8.6)
More than 15 years
4 (14.8)
 4 (26.7)

No of living children

No living child 20 (12.5) 0 0.006*

1-2 78 (48.8) 4 (5.1)

3 or more 62 (38.7) 12 (19.4)

Type of abortion

Missed 60 (37.5) 9 (15) 0.51

Incomplete 75 (46.9) 5 (6.7)

Complete 5 (3.1) 0

Induced 19 (11.9) 2 (10.5)

Recurrent 1 (0.6) 0

Mode of treatment

Dilation and curettage (D&C) 80 (50) 7 (8.8) 0.04*

Manual Vacuum Aspiration 23 (14.4) 6 (26)

Medical Treatment 53 (33.1) 3 (5.7)

No Treatment 4 (2.5) 0

Previous contraceptive method

use 47 (29.4) 6 (12.8) 0.45

Yes 113 (70.6) 10 (8.8)

No
 Counseling received

Yes 112 (70) 16(14.3) 0.006*

No 48 (30) 0

*Statistically significant

Out of 160 clients, only 16 clients (10%) reported LARC uptake within one month after abortion.

Among LARC adopters, 14(87.5 %) clients adopted IUCD while only two (12.5%) adopted sub-

dermal implants.

Uptake of LARC was significantly higher among clients served by private sector facilities (p

value = 0.04). Twelve clients (14.6%) of private sector and four clients (5.1%) of public sector

adopted LARC (Figure1). Significant association was observed between long term contraceptive

uptake and having ≥3 living children (p value = 0.006) as 12(19.4%) clients adopted LARC.

LARC adoption was observed only in women more than 24 years with highest percentage (20%)

among women of age 36-49 years (p value =0.036). Highest percentage of LARC adoption

6(26%) was observed among clients who were managed by manual vacuum aspiration (p value =

0.04). LARC uptake was reported in the clients who received counseling (p value = 0.006)

Logistic regression analysis showed that adoption of LARC was significantly associated with

having 3 and more alive children (Table 2).

Figure 1: Total Contraceptive uptake along with LARC uptake in both sectors (n=160) (p

value=0.004)

60.00%

50.00% 48.70%

40.00%

30.00% 26.90% FP method adopters

LARC adopters
20.00%
14.60%

10.00%
5.10%

0.00%
Private sector Public sector

Table 2: Logistic Regression within Study Groups

Variable p-value β p-value Adjusted OR (CI-95%)

Age (Years) 0.036 -0.462 0.407 0.630 (0.211-1.879)

Alive Children 0.006 -1.438 0.022* 0.237 (0.069-0.816)

Facility Type 0.045 -1.203 0.055 0.300 (0.088-1.027)

Treatment Mode 0.040 -0.136 0.674 0.873 (0.462-1.648)

*Significant Value
Discussion

Findings revealed that 161 (10%) clients adopted LARC which is higher than the adoption of

LARC in Pakistan (2.5%).11 Higher uptake could be due to increased felt need for long term

contraception following an abortion.

Among 61 contraceptive adopters, IUCD was the choice of more clients (22.9%) as compared to

implants which was opted by 3.2%. Azmat K et al conducted a study in Pakistan in which results

are comparable as most of contraceptive adopters preferred IUCD (31.6 %) and only 1.9%

implants adopted sub-dermal implants.12

In this study uptake of LARC was significantly higher among clients served by private sector

facilities. Analysis of a study conducted at Addis Ababa by Ndola P et al., also suggested that

post abortion clients served by private sector have higher odds (OR=2.34, p=0.01) to accept

LARC.13

No women younger than 24 years of age adopted long term methods. LARC adoption was noted

in age groups more than 25 years with highest uptake among women more than 36 year (20%).

These results are similar to a study conducted in Australia which also revealed high uptake

among women ≥ 30 years of age, and lowest among women under 19 years of age.14

In this study, uptake of LARC was more among clients who had induced abortion (10.5%).

Findings of a study conducted in Ethiopia also showed, women who had induced abortion were

more likely to opt for LARC method.15

This study revealed higher uptake of LARC in clients treated by MVA (26%). Study conducted

at Tanzania also showed that clients receiving vacuum aspiration had higher odds of adopting a

LARC or permanent method.16

It was found that uptake of LARC was higher in women with three or more living children. A

study conducted in New Zealand similarly reported higher LARC uptake in women with parity 3

or more.17 The motivation of women with higher parity to adopt contraception might be much

stronger than those who had lower parity.

LARC uptake was higher in clients who used contraception in the past. Study conducted in

China also concluded that previous use of contraceptive is a predictor for intention to use LARC

in post abortion period.18

LARC uptake were noted in clients who were counseled and is consistent with the study by

Pfitzer A et al which stated that uptake of LARC was more in clients who received contraceptive

counseling.19

Conclusion

Uptake of LARC within one month after abortion was low reflecting the unmet need although it

was higher than the contraceptive prevalence rate of Pakistan. Higher uptake of LARC was

found in clients served by private sector. Factors positively influencing post-abortion LARC

uptake were age more than 24 years, having >3 living children, history of induced abortion and

counseling regarding contraception.

Conflict of Interest
There is no conflict of interest to be declared.

Acknowledgment

The authors are grateful to Dr Nusrat Javaid, Dr Ayesha Wajid and Dr Ikram for their support

and facilitation.

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