Investigating contraceptive use and continuation among women obtaining legal abortion services in Nepal
Awarded 2010
Large Research Grants
Jillian Henderson, PhD
University of California, San Francisco

Background: With the historic legalization of abortion in Nepal in 2002, descriptive data on the prevalence of legal abortion services are now available, but little is known about access to contraception and method use, or reproductive behaviors and intentions following abortion. Our mixed-method study examined women’s contraceptive use and continuation after obtaining a legal abortion, with attention to method access, the contraceptive counseling experience, and personal and contextual factors influencing contraceptive use and availability in Nepal. Methods: We conducted a prospective cohort study of women obtaining abortions at 4 clinics (2 public and 2 private) within the Kathmandu Valley and in rural areas. Participants were interviewed at the clinic on the day of abortion services (n=838) and at 6-months (n = 654) and 12-months (n=624). In addition, in-depth interviews with abortion service providers and managers were conducted to characterize health care structure and process barriers to contraceptive use (n = 24). Results: One-third of women receiving an abortion did not receive any contraceptive counseling (34%), and only half received counseling on 2 or more methods. At baseline, 62% of women selected a modern method of contraception. The most common method used was the injectable (28%); the oral contraceptive pill was next most common (14%). The overall contraceptive continuation rate for female controlled effective modern methods was 58.2 per 100 person years. The 12-month continuation rate for the injectable was 49.6 per 100 person years and for the pill was 63.8 per 100 person years. Although few women initiated use of long-acting reversible contraception (3.5%), continuation rates were higher for these methods than for the pill or injectable (92.3 per 100 person years, p <.01). Contraceptive use varied significantly varied by age, level of education, number of living children, the type of facility, desired timing of future pregnancy, and the availability of contraceptive counseling at the clinic. The most common reasons for discontinuation were husband away or infrequent sex, side effects of contraception, ran out of method, and partner objection. Qualitative interviews with providers revealed supply side barriers, including shortages of long-acting reversible contraceptives, the need for more trained providers and counselors, and challenges to providing quality counseling. Factors affecting demand included individual factors, including concerns over side effects, and socio-cultural factors such as family influence. Conclusion: Low adoption of modern methods of contraception post-abortion and high discontinuation rates in the following year were observed in this study. Our findings will contribute to the scientific literature by examining multiple levels influencing contraceptive use and reproductive health of women seeking legal abortion. Results are useful to advocates working to improve and expand access to contraception and improve the quality of reproductive health care for women in Nepal and in similar countries. Addressing supply and service delivery issues could improve post-abortion contraceptive service delivery in Nepal.