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Risk factors for repeat abortion in Nepal
International Journal of Gynecology and Obstetrics 120 (2013) 32–36
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Risk factors for repeat abortion in Nepal Shyam Thapa a, b, c,⁎, Shailes Neupane d a
Public Health Institute, Washington, USA Geneva Foundation for Medical Education and Research, Geneva, Switzerland c Patan Academy of Health Sciences, Lalitpur, Nepal d Valley Research Group, Lalitpur, Nepal b
a r t i c l e
i n f o
Article history: Received 22 March 2012 Received in revised form 9 July 2012 Accepted 13 September 2012 Keywords: Contraception Repeat abortion Risk factors Nepal
a b s t r a c t Objective: To examine the incidence of and risk factors for repeat abortion in Nepal. Methods: Data were analyzed from a survey of 1172 women who had surgical abortions between December 2009 and March 2010 in 2 clinics in Kathmandu, Nepal. Bivariate and multivariate logistic regressions were performed to estimate odds ratios for the risk factors. Results: Among the respondents, 32.3% (95% confidence interval, 29.6–34.9) had repeat abortions. This incidence rose sharply with age and parity, and was higher among those with no intention of having a future child, those attaining primary or secondary level education, and those attending the non-governmental sector clinic. Women with repeat abortion were similar to those with 1 abortion in terms of contraceptive practice. Among women not using contraceptives at the time of the unintended pregnancy, the 3 most commonly cited reasons were ill health, non-compliance with the method intended for use, and dislike of the method. Women with repeat abortion showed a pattern of contraceptive acceptance immediately after the procedure similar to that of women who had 1 abortion. Conclusion: Repeat abortion is emerging as a major public health issue in Nepal, with implications for counseling and provision of abortion, and for family planning services. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction As of 2008, women in 56 countries (constituting 60 million or 39% of women aged 15–44 years worldwide) had legal access to abortion on demand (i.e. without restrictions regarding the reason) [1]. It is well established that, after liberalization of abortion laws, repeat abortion in a given population increases over time and then stabilizes [2,3]. In the United States, for example, repeat abortion increased from just under 20% in the mid-1970s, to approximately 40% in the mid-1980s, and then began stabilizing at just under 50% in the 1990s [4]. In some countries in Europe in the early 2000s, the prevalence of repeat abortion varied between 32% and 38% [5]. Even if only a quarter of all abortions taking place in the 56 countries were assumed to be repeat abortions, the incidence of repeat abortion would run into millions. Despite the high incidence of repeat abortion, there seems to be relatively little research on it, especially in low-income countries. In 2006, a search by the Guttmacher Institute found 71 articles on repeat abortion, and most of the studies came from high-resource or high-income countries [4]. A similar PubMed search in early 2010 found an additional 9 articles published since 2006, again mostly focusing on high-income countries (unpublished observations).
⁎ Corresponding author at: Public Health Institute, 1201 Pennsylvania Avenue, Suite 200, Washington DC 20004, USA. Tel.: +1 703 966 0758; fax: +1 202 808 3742. E-mail address: [email protected] (S. Thapa).
Epidemiologically, repeat abortion is associated with low birth weight and preterm delivery [6], fetal loss [7], and ectopic pregnancy [8]. Aside from the adverse effects on pregnancy outcomes, less is known about the socio-psychologic costs to the women and the monetary costs of providing services. For these reasons, especially in countries with legalized abortion where the incidence of repeat abortion continues and remains high, repeat abortion is a major public health issue. Previous research—mainly in high-income countries—has identified common risk factors for repeat abortions, including higher age, higher parity, and lower socioeconomic status [4,5,9]. Evidence from the United States clearly showed that the women with repeat abortion were as likely as those with 1-time abortion to use contraception [4]. Abortion was legalized in 2002 in Nepal [10]. Services were initiated in 2004 and have continued to expand over the years. As of December 2009, 286 clinics, representing the public, non-governmental, and private/commercial sectors, were providing abortion (surgical evacuation) services. A total of 606 physicians and 98 staff nurses had been trained to provide these services via manual vacuum aspiration. In addition, 313 561 women had obtained these services since abortion was legalized in the country [11]. Previous research in Nepal has shown that most abortions are provided for married women, and the primary reason for having an abortion is not wanting more children [12,13]. With the increasing incidence of abortion, repeat abortion is also expected to rise. However, very little is known about the risk factors associated with repeat abortion in Nepal. The aim of the present study was, therefore, to
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.07.016
S. Thapa, S. Neupane / International Journal of Gynecology and Obstetrics 120 (2013) 32–36
identify risk factors for repeat abortion, compared with 1-time abortion, in Nepal. 2. Materials and methods A survey was carried out between December 23, 2009, and March 5, 2010, in 2 abortion clinics in Kathmandu: a clinic at the Maternity Hospital (MH; officially renamed Paripakar Maternity and Women's Hospital), the largest women's public hospital in Nepal; and a non-governmental sector franchised clinic of Marie Stopes International (MSI) in Chabel. These 2 clinics were selected for the study because they had the highest attendance of women among all of the clinics (including public, private, and non-governmental) certified by the Ministry of Health to provide abortion services, as per the new abortion law [10]. The study protocol was approved by the Nepal Health Research Council—the local Protection of Human Subjects Committee. An informed consent document was read to each potential respondent, and verbal consent was obtained from each woman before she was interviewed. Eligible study participants were defined as all women who presented themselves with a pregnancy of up to 12 gestational weeks and who opted for surgical abortion upon screening by the attending nurse. Everyone who met the eligibility criteria were asked to participate in the study. The minimal sample size was pre-determined in proportion to the numbers of women attending each clinic. The study was powered to test differences among women between the 2 clinics with respect to 3 variables: age, literacy, and modern contraceptive use around the time of the unplanned pregnancy. The parameter (base) value for each of these variables was based on a similar survey in 2005 [13]. For a power of 90%, a confidence level of 95%, and a margin of error (difference) of 10%, the minimum number of women was determined to be 352 and 703 at the MH clinic and the MSI clinic, respectively. These numbers included compensation for a non-response level of 5%. Interviews in each clinic were stopped on the day that the minimum required number of participants was reached. The interviews took an average of 20 minutes. Seven women conducted the interviews under the guidance of 1 on-site female supervisor. All of the interviewers were given training on the survey content and on techniques of interviewing with sensitivity to women seeking abortion counseling and services. After preliminary analysis of the data, the clinic staff (excluding physicians) and survey interviewers were consulted in order to better understand the results and to clarify selected issues that emerged from the data. The relevant materials are described and incorporated in the interpretation of the data. The incidence of repeat abortions was calculated among all women undergoing surgical abortion. The variables included in the assessment of risk factors were age of the woman, number of living children, educational attainment, intention to have a child or another child sometime in the future, use of public or private clinic for the abortion services, and contraceptive use during the month of the unintended pregnancy. The primary reasons for not using contraception were based on responses to an open-ended question. For all regression results, repeat and 1-time abortions were coded as 1 and 0, respectively. Repeat abortion referred to more than 1 induced abortion obtained at any time in the past. Bivariate and multivariate logistic regressions [14] were performed to obtain odds ratios to assess the effects of risk factors and differences between the 2 groups of women. Data were analyzed using SPSS version 18 (IBM, Armonk, NY, USA). A P value of 0.05 or less was considered to be statistically significant. 3. Results In total, 392 and 780 eligible women at the MH clinic and MSI clinic, respectively, consented to participate in the survey. Only 8 women
33
declined to participate, and no respondent withdrew after the interview was initiated. The analysis was, therefore, based on 1172 women. There were significant differences between women with repeat abortion and those with 1-time abortion in terms of their background profile for all but 1 characteristic. The mean ± SD age of women with repeat abortion (29.4 ± 5.5 years) was significantly older than that of women with 1-time abortion (26.2 ± 5.5 years) (P b 0.001). The mean ± SD number of living children was also significantly higher among women with repeat abortion (1.95 ± 1.23) than among women with 1-time abortion (1.39 ± 1.16) (P b 0.001). Almost all women with repeat abortion (99.5%) were currently married, whereas a significantly lower percentage of women with 1-time abortion (95.3%) were currently married (P b 0.01). The percentage of women with high school or higher education was significantly lower among those with repeat abortion than among those with 1-time abortion (29.6% vs 37.6%; P b 0.01). Significantly more women with repeat abortion indicated that they would consider having another abortion in the future compared with their 1-time counterparts (48.9% vs 37.3%; P b 0.001). By contrast, there was no significant difference between the 2 groups with respect to the use of any method of family planning during the time of unintended pregnancy (43.4% of women with repeat vs 39.8% with 1-time abortion). Table 1 presents the incidence of repeat abortion among all women having abortion stratified by selected factors. Overall, nearly one-third (32.3%; 95% CI, 29.6–34.9) of all of the women interviewed were having a repeat abortion. The percentage increased from 18.6% among women aged 16–24 years to 50.0% among those aged 35–48 years. Similarly, it increased from 13.7% among those with no living child to 42.6% among those with 2 or more children. The relationship between the incidence of repeat abortion and the education of the women was an inverted U shape: the incidence increased from 30.3% among those with no education to 38.5% among those with secondary education (grades 6–10), and then decreased among those with higher education.
Table 1 Repeat abortion among all women who underwent abortion, according to demographic and behavioral characteristics. Variable/characteristic
No. (%) of women
Total Age, y 16–24 25–29 30–34 35–48 No of living children 0 1 2+ Education Illiterate Primary (grades 1–5) Secondary (grades 6–10) High school College or higher Intention for future child Yes Not sure No Type of clinic Public Non-government Contraception at the time of pregnancy None Rhythm Withdrawal Condom Pill Injectable/vasectomy/minilap
378/1172 (32.3) 78/420 122/355 99/239 79/158
(18.6) (34.4) (41.4) (50.0)
32/233 (13.7) 88/334 (26.3) 258/605 (42.6) 94/310 58/154 115/299 55/188 56/221
(30.3) (37.7) (38.5) (29.3) (25.3)
68/413 (16.5) 38/115 (33.0) 272/644 (42.2) 82/392 (20.9) 296/780 (37.9) 214/692 23/64 51/161 54/140 31/87 5/28
(30.9) (35.9) (31.7) (38.6) (35.6) (17.9)
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S. Thapa, S. Neupane / International Journal of Gynecology and Obstetrics 120 (2013) 32–36
The incidence of repeat abortion was 16.5% among those women who intended to have a child in the future, but 42.2% among those who had no intention to have either a first child or additional children in the future. Among those women who used a private clinic for abortion services, the incidence of repeat abortion was approximately twice as high as the incidence of 1-time abortion (37.9% vs 20.9%). Among the women who had not used any form of contraception during the month of unintended pregnancy, 30.9% were having a repeat abortion. For those using contraception, the proportion of women with repeat abortion ranged from 17.9% for those using long-term methods (e.g. injectable contraceptives or vasectomy) to 38.6% for those using condoms. Table 2 shows the odds ratios of repeat abortion based on multivariate logistic regression. The odds of having a repeat abortion increased linearly with age: among women aged 30–34 years, the odds of having a repeat abortion was 1.77 times higher than that among woman aged 16–24 years. The odds increased 2.61-fold for those in the higher age group (35–48 years). The odds ratio of repeat abortion also increased to 2.24 for women with 2 or more living children relative to those with no children. In addition, the odds ratio of repeat abortion increased with level of education: it was highest among those with secondary (grades 6–10) education at 2.37. Women who did not intend to have another child in the future were 2 times more likely to have a repeat abortion than those who intended to have a child sometime in the future. Similarly, women attending a private clinic were 2.84 times more likely to have a repeat abortion than those attending a public clinic. Women with repeat abortion were no less likely to have used a specific method of contraception compared with women with 1-time abortion. Among women who did not use any contraceptive to avoid the unintended pregnancy, differences between women with 1-time abortion and those with repeat abortion were analyzed with respect to their primary reason for non-use of contraceptive (Table 3). On the basis of coding of the open-ended responses, the 4 most
Table 2 Odds ratios of repeat abortion based on multivariate logistic regression. Variable Age, y 16–24 25–29 30–34 35–48 No of living children 0 1 2+ Education Illiterate Primary (grades 1–5) Secondary (grades 6–10) High school or higher Intention for future child Yes Not sure No Type of clinic Public Non-government Contraception at the time of pregnancy None Rhythm Withdrawal Condom Pill Injectable/vasectomy/minilap a b c
P b 0.05. P b 0.01. P b 0.001.
Odds ratio (95% CI) 1.00 1.56 (1.06–2.30)a 1.77 (1.13–2.78)a 2.61 (1.58–4.31)c 1.00 1.59 (0.93–2.72) 2.24 (1.13–4.45)a 1.00 1.80 (1.16–2.81)b 2.37 (1.62–3.47)c 1.71 (1.16–2.52)b 1.00 1.65 (0.97–2.81) 2.01 (1.18–3.42)a
Table 3 Comparison of primary reason for non-use of contraception during the month of pregnancy between 1-time and repeat abortion.a Reason (multiple response)
No. of women
First-time abortion (%)
Repeat abortion (%)
Gross odds ratiob
Net odds ratio
Health Forgot to use (self or partner) Dislike method (self or partner) Perceived low risk of pregnancy Infrequent sex Youngest child too small Other Total
247 148 137 97 42 33 41 692
31.4 20.3 20.7 16.5 6.3 5.6 7.3 100
45.3 23.8 17.8 8.4 5.6 2.8 2.8 100
1.81e 1.23 0.83 0.46d 0.89 0.48 0.37c
1.63d 1.35 0.86 0.46d 0.71 0.52 0.40
a
Among all women not using a contraceptive method (n = 692). Gross odds ratio refers to bivariate results; net odds ratio controls for age, number of living children, and type of clinic variable. c P b 0.05. d P b 0.01. e P b 0.001. b
commonly mentioned reasons were health, forgot to use the intended method (either the woman herself or her partner/husband), dislike of a method (either by herself or by her partner/husband), and perceived low risk of pregnancy. Among these 4 reasons, health was by far the most frequently mentioned. Women with repeat abortion were significantly (P b 0.001) more likely to report health as a primary reason for not using contraception compared with their 1-time counterparts. In addition, they were significantly (P b 0.01) less likely to mention low risk of pregnancy as a primary reason for not using contraception. Women with 1-time and repeat abortion were similar with respect to other reasons for not using contraceptives to avoid the unintended pregnancy. Data regarding the contraceptive method dispensed at the time of discharge from the clinic were analyzed as an indicator of patterns of contraceptive use in the post-abortion period (Table 4). Among all women having an abortion, a fifth (20.6%) left the clinic without any method. Among women who received contraception (79.4%), injectable contraceptives and condoms were the 2 most frequently prescribed and accepted methods. Controlling for age, number of living children, and clinic type, women with repeat abortion were 1.45 times more likely to have received condoms at discharge than were women with 1-time abortion. They were significantly (P b 0.01) less likely to have received 3-month injectable contraceptives. The patterns of contraceptive dispensing and acceptance were similar for other methods. 4. Discussion Nearly one-third of all women undergoing surgical abortion in the 2 high-volume clinics were having a repeat abortion. This incidence of repeat abortion has been reached approximately 6 years after the Table 4 Comparison of specific contraceptive method dispensed at the time of discharge between 1-time and repeat abortion. Method
No. of women
One-time abortion (%)
Repeat abortion (%)
Gross odds ratioa
Net odds ratioa
Condom Pill Injectable Other (vasectomy/minilap) No method Total
332 206 333 60 241 1172
25.7 17.4 30.5 3.9 22.5 100
33.9 18.0 24.1 7.7 16.4 100
1.48c 1.04 0.72b 2.05c 0.67b
1.45b 1.29 0.62c 1.72 0.74
1.00 2.84 (2.08–3.88)c 1.00 1.46 1.00 1.46 1.18 0.40
(0.80–2.66) (0.66–1.51) (0.96–2.22) (0.71–1.97) (0.14–1.13)
a Gross odds ratio refers to bivariate results; net odds ratio controls for age, number of living children, and type of clinic variable. b P b 0.05. c P b 0.01.
S. Thapa, S. Neupane / International Journal of Gynecology and Obstetrics 120 (2013) 32–36
abortion service was first introduced after legalization of abortion on demand in Nepal. As noted earlier, by December 2009 more than 313 000 women had accessed and obtained abortion services from the various abortion facilities throughout the country. Even if we assume that only half of the incidence found in the present study is likely to prevail nationally, it means more than 50 000 women may have undergone repeat abortions cumulatively thus far. As mentioned earlier, if the experience of other countries is any guide, both the incidence and volume are likely to continue to rise in the foreseeable future. The risk factors for repeat abortions were found to be age, number of living children (parity) of 2 or more, intention to have no more children in the future, and primary or secondary level of educational attainment. The effects of age and parity are consistent with findings from high-income countries, but a parity of 2 or higher is a risk factor only among women with repeat abortion in Nepal. The study also showed that proportionately more women coming to the nongovernmental clinic were likely to be having a repeat abortion. The main reason for this seems to be that, although the sociodemographic characteristics of women having an abortion at the public and non-governmental clinics were similar, the latter group had considerably lower peri-contraceptive use compared with the former group (35.0% vs 52.8%; P b 0.001) and significantly more of them had used withdrawal as their method [15]. The present study also found that women with repeat abortion were equally likely to have used contraception as those with 1-time abortion. Similar to research elsewhere [4], this refutes the often-made assumption that women with repeat abortion are less motivated to use contraception. However, women with repeat abortion may be self-selected to use less effective methods for various reasons. Health was the most commonly cited primary reason for not having used contraceptives among both women with 1-time and those with repeat abortion. The contraceptive method dispensed and accepted immediately after the abortion procedure was not a good indicator of medium and long-term contraceptive use patterns among the women. Nevertheless, women with repeat abortion did not have a significantly different pattern of contraceptive use with the exception of condoms and injectable contraceptives: that is, compared with those with 1-time abortion, they were significantly more likely to use condoms and less likely to use injectable contraceptives. A strong message that emerges is that health clinics and/or facilities providing abortion services (and family planning) need to pay special attention to women with repeat abortion. Failing to address their needs appropriately and effectively might mean, in many situations, that they will return for another abortion. Indeed, nearly half of the women with repeat abortion said that they would consider having abortion again if they were to have another unintended pregnancy. The incidence of repeat abortion is also likely to be exacerbated by the fact that medical abortion (mifepristone/misoprostol) has been introduced and access is being expanded in the country [16,17]. At present in the MSI clinic, family planning services are provided on the same premises where the abortion (surgical evacuation) service is provided. In the MH clinic, by contrast, services for longacting contraceptives are provided at a separate clinic on the hospital premises without a systematic and well-functioning referral system. As a result, those women having an abortion who are referred for family planning are often “lost” between the abortion clinic and the family planning clinic. Even at the MSI clinic, a lack of regular, consistent, and adequate supplies of contraceptives was reported to be a recurrent problem. Notably, the IUD, which is an effective and appropriate long-term method, particularly for women having an abortion [4,5], was not accepted by even 1 woman in the study. In subsequent discussions with service providers at the 2 clinics, it became apparent that supplies of IUDs had been erratic and at times IUDs were simply not available.
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Approximately 1 in 5 of all women left the clinic without a method. During post-survey discussions with the clinic staff, we were informed that a considerable proportion of these women did not wish to accept any method because they did not plan to have intercourse (e.g. on account of their own or their husband's or partner's travel). For some women, the reason was ill health or advice by their healthcare provider against the use of any contraceptive method. For others, it was the need to consult with their husband before they accepted or used any method. Involving males in family planning decisions remains a big challenge. It is a critical factor, especially in Nepal, where gender and power relations have been slow to change. Strengthening quality family planning services has most probably not received the attention that it needs within the health services system where abortion services are introduced and established. The results of the present study, together with previous data [13], underscore the need to critically revisit and recalibrate family planning counseling and the provision of services. A more effective system needs to be put in place to address these needs. Efforts are also needed beyond the strengthening or recalibration of existing family planning services. As the present study has shown, poor compliance with the contraceptive methods intended to be used and use of less efficacious methods were some of the reasons for having an unintended pregnancy. Family planning programs still have a long way to go toward addressing these issues. Furthermore, ill health was found to be a major reason for not using contraceptives. How can these needs be addressed? How much can be accomplished by investing in both improving counseling and engaging media more effectively? These questions need to be considered and explored. The situation is likely to be more challenging in rural and remote areas. In conclusion, the present study indicates that, after liberalization of the abortion law and the subsequent availability and expansion of services, repeat abortion is emerging as a major public health problem in Nepal. This fact should be taken into account in the planning and provision of abortion and family planning services. Although the study is limited to Nepal, the issues are likely to be relevant to many other societies where abortion is legal. Acknowledgments Ipas/Nepal provided support for implementing the survey, data analysis, and preparation of the manuscript as part of its support for health services research and program evaluation in Nepal. The views expressed are those of the authors only and do not necessarily reflect the views of Ipas/Nepal or other organizations with which the authors are affiliated. Conflict of interest The authors have no conflicts of interest. References [1] Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion Worldwide: A Decade of Uneven Progress. http://www.guttmacher.org/pubs/Abortion-Worldwide.pdf. Published 2009. [2] Tietze C. The “problem” of repeat abortions. Fam Plann Perspect 1974;6(3): 148-50. [3] Tietze C, Jain AK. The mathematics of repeat abortion: explaining the increase. Stud Fam Plann 1978;9(12):294-9. [4] Jones RK, Singh S, Finer LB, Frohwirth LF. Repeat Abortion in the United States. Occasional Report No. 29. http://www.guttmacher.org/pubs/2006/11/21/or29.pdf. Published November 2006. [5] Heikinheimo O, Gissler M, Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. Contraception 2008;78(2): 149-54. [6] Brown Jr JS, Adera T, Masho SW. Previous abortion and the risk of low birth weight and preterm births. J Epidemiol Community Health 2008;62(1):16-22. [7] Infante-Rivard C, Gauthier R. Induced abortion as a risk factor for subsequent fetal loss. Epidemiology 1996;7(5):540-2.
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[8] Parazzini F, Ferraroni M, Tozzi L, Ricci E, Mezzopane R, La Vecchia C. Induced abortions and risk of ectopic pregnancy. Hum Reprod 1995;10(7):1841-4. [9] St John H, Critchley H, Glasier A. Can we identify women at risk of more than one termination of pregnancy? Contraception 2005;71(1):31-4. [10] Thapa S. Abortion law in Nepal: the road to reform. Reprod Health Matters 2004;12(24 Suppl.):85-94. [11] Health Information Management System, Department of Health Services, Ministry of Health. Kathmandu: Ministry of Health; March 2010. [12] Thapa S, Padhye SM. Induced abortion in urban Nepal. Int Fam Plan Perspect 2001;27(3):144-7. [13] Thapa S, Malla K, Basnett I. Safe Abortion Services in Nepal: Initial Years of Availability and Utilization. A Study Report. Kathmandu: Ipas/Nepal; 2007.
[14] Retherford RD, Choe MK. Statistical Models for Causal Analysis. New York: Wiley; 1993. [15] Thapa S, Neupane S, Basnett I. A Comparison of Clients having Abortion in Public and Non-government Clinics in Urban Nepal. A Study Report. Kathmandu: Ipas/Nepal; 2011. [16] Ministry of Health and Population. Medical Abortion Scale up Strategy and Implementation Guide 2009. Kathmandu: Ministry of Health and Population; 2009. [17] Ipas/Nepal. A Comprehensive Report on Implementation of Medical Abortion Services in Six Pilot Districts of Nepal. Kathmandu: Ipas/Nepal; 2009.
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Risk factors for repeat abortion in Nepal Shyam Thapa a, b, c,⁎, Shailes Neupane d a
Public Health Institute, Washington, USA Geneva Foundation for Medical Education and Research, Geneva, Switzerland c Patan Academy of Health Sciences, Lalitpur, Nepal d Valley Research Group, Lalitpur, Nepal b
a r t i c l e
i n f o
Article history: Received 22 March 2012 Received in revised form 9 July 2012 Accepted 13 September 2012 Keywords: Contraception Repeat abortion Risk factors Nepal
a b s t r a c t Objective: To examine the incidence of and risk factors for repeat abortion in Nepal. Methods: Data were analyzed from a survey of 1172 women who had surgical abortions between December 2009 and March 2010 in 2 clinics in Kathmandu, Nepal. Bivariate and multivariate logistic regressions were performed to estimate odds ratios for the risk factors. Results: Among the respondents, 32.3% (95% confidence interval, 29.6–34.9) had repeat abortions. This incidence rose sharply with age and parity, and was higher among those with no intention of having a future child, those attaining primary or secondary level education, and those attending the non-governmental sector clinic. Women with repeat abortion were similar to those with 1 abortion in terms of contraceptive practice. Among women not using contraceptives at the time of the unintended pregnancy, the 3 most commonly cited reasons were ill health, non-compliance with the method intended for use, and dislike of the method. Women with repeat abortion showed a pattern of contraceptive acceptance immediately after the procedure similar to that of women who had 1 abortion. Conclusion: Repeat abortion is emerging as a major public health issue in Nepal, with implications for counseling and provision of abortion, and for family planning services. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction As of 2008, women in 56 countries (constituting 60 million or 39% of women aged 15–44 years worldwide) had legal access to abortion on demand (i.e. without restrictions regarding the reason) [1]. It is well established that, after liberalization of abortion laws, repeat abortion in a given population increases over time and then stabilizes [2,3]. In the United States, for example, repeat abortion increased from just under 20% in the mid-1970s, to approximately 40% in the mid-1980s, and then began stabilizing at just under 50% in the 1990s [4]. In some countries in Europe in the early 2000s, the prevalence of repeat abortion varied between 32% and 38% [5]. Even if only a quarter of all abortions taking place in the 56 countries were assumed to be repeat abortions, the incidence of repeat abortion would run into millions. Despite the high incidence of repeat abortion, there seems to be relatively little research on it, especially in low-income countries. In 2006, a search by the Guttmacher Institute found 71 articles on repeat abortion, and most of the studies came from high-resource or high-income countries [4]. A similar PubMed search in early 2010 found an additional 9 articles published since 2006, again mostly focusing on high-income countries (unpublished observations).
⁎ Corresponding author at: Public Health Institute, 1201 Pennsylvania Avenue, Suite 200, Washington DC 20004, USA. Tel.: +1 703 966 0758; fax: +1 202 808 3742. E-mail address: [email protected] (S. Thapa).
Epidemiologically, repeat abortion is associated with low birth weight and preterm delivery [6], fetal loss [7], and ectopic pregnancy [8]. Aside from the adverse effects on pregnancy outcomes, less is known about the socio-psychologic costs to the women and the monetary costs of providing services. For these reasons, especially in countries with legalized abortion where the incidence of repeat abortion continues and remains high, repeat abortion is a major public health issue. Previous research—mainly in high-income countries—has identified common risk factors for repeat abortions, including higher age, higher parity, and lower socioeconomic status [4,5,9]. Evidence from the United States clearly showed that the women with repeat abortion were as likely as those with 1-time abortion to use contraception [4]. Abortion was legalized in 2002 in Nepal [10]. Services were initiated in 2004 and have continued to expand over the years. As of December 2009, 286 clinics, representing the public, non-governmental, and private/commercial sectors, were providing abortion (surgical evacuation) services. A total of 606 physicians and 98 staff nurses had been trained to provide these services via manual vacuum aspiration. In addition, 313 561 women had obtained these services since abortion was legalized in the country [11]. Previous research in Nepal has shown that most abortions are provided for married women, and the primary reason for having an abortion is not wanting more children [12,13]. With the increasing incidence of abortion, repeat abortion is also expected to rise. However, very little is known about the risk factors associated with repeat abortion in Nepal. The aim of the present study was, therefore, to
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.07.016
S. Thapa, S. Neupane / International Journal of Gynecology and Obstetrics 120 (2013) 32–36
identify risk factors for repeat abortion, compared with 1-time abortion, in Nepal. 2. Materials and methods A survey was carried out between December 23, 2009, and March 5, 2010, in 2 abortion clinics in Kathmandu: a clinic at the Maternity Hospital (MH; officially renamed Paripakar Maternity and Women's Hospital), the largest women's public hospital in Nepal; and a non-governmental sector franchised clinic of Marie Stopes International (MSI) in Chabel. These 2 clinics were selected for the study because they had the highest attendance of women among all of the clinics (including public, private, and non-governmental) certified by the Ministry of Health to provide abortion services, as per the new abortion law [10]. The study protocol was approved by the Nepal Health Research Council—the local Protection of Human Subjects Committee. An informed consent document was read to each potential respondent, and verbal consent was obtained from each woman before she was interviewed. Eligible study participants were defined as all women who presented themselves with a pregnancy of up to 12 gestational weeks and who opted for surgical abortion upon screening by the attending nurse. Everyone who met the eligibility criteria were asked to participate in the study. The minimal sample size was pre-determined in proportion to the numbers of women attending each clinic. The study was powered to test differences among women between the 2 clinics with respect to 3 variables: age, literacy, and modern contraceptive use around the time of the unplanned pregnancy. The parameter (base) value for each of these variables was based on a similar survey in 2005 [13]. For a power of 90%, a confidence level of 95%, and a margin of error (difference) of 10%, the minimum number of women was determined to be 352 and 703 at the MH clinic and the MSI clinic, respectively. These numbers included compensation for a non-response level of 5%. Interviews in each clinic were stopped on the day that the minimum required number of participants was reached. The interviews took an average of 20 minutes. Seven women conducted the interviews under the guidance of 1 on-site female supervisor. All of the interviewers were given training on the survey content and on techniques of interviewing with sensitivity to women seeking abortion counseling and services. After preliminary analysis of the data, the clinic staff (excluding physicians) and survey interviewers were consulted in order to better understand the results and to clarify selected issues that emerged from the data. The relevant materials are described and incorporated in the interpretation of the data. The incidence of repeat abortions was calculated among all women undergoing surgical abortion. The variables included in the assessment of risk factors were age of the woman, number of living children, educational attainment, intention to have a child or another child sometime in the future, use of public or private clinic for the abortion services, and contraceptive use during the month of the unintended pregnancy. The primary reasons for not using contraception were based on responses to an open-ended question. For all regression results, repeat and 1-time abortions were coded as 1 and 0, respectively. Repeat abortion referred to more than 1 induced abortion obtained at any time in the past. Bivariate and multivariate logistic regressions [14] were performed to obtain odds ratios to assess the effects of risk factors and differences between the 2 groups of women. Data were analyzed using SPSS version 18 (IBM, Armonk, NY, USA). A P value of 0.05 or less was considered to be statistically significant. 3. Results In total, 392 and 780 eligible women at the MH clinic and MSI clinic, respectively, consented to participate in the survey. Only 8 women
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declined to participate, and no respondent withdrew after the interview was initiated. The analysis was, therefore, based on 1172 women. There were significant differences between women with repeat abortion and those with 1-time abortion in terms of their background profile for all but 1 characteristic. The mean ± SD age of women with repeat abortion (29.4 ± 5.5 years) was significantly older than that of women with 1-time abortion (26.2 ± 5.5 years) (P b 0.001). The mean ± SD number of living children was also significantly higher among women with repeat abortion (1.95 ± 1.23) than among women with 1-time abortion (1.39 ± 1.16) (P b 0.001). Almost all women with repeat abortion (99.5%) were currently married, whereas a significantly lower percentage of women with 1-time abortion (95.3%) were currently married (P b 0.01). The percentage of women with high school or higher education was significantly lower among those with repeat abortion than among those with 1-time abortion (29.6% vs 37.6%; P b 0.01). Significantly more women with repeat abortion indicated that they would consider having another abortion in the future compared with their 1-time counterparts (48.9% vs 37.3%; P b 0.001). By contrast, there was no significant difference between the 2 groups with respect to the use of any method of family planning during the time of unintended pregnancy (43.4% of women with repeat vs 39.8% with 1-time abortion). Table 1 presents the incidence of repeat abortion among all women having abortion stratified by selected factors. Overall, nearly one-third (32.3%; 95% CI, 29.6–34.9) of all of the women interviewed were having a repeat abortion. The percentage increased from 18.6% among women aged 16–24 years to 50.0% among those aged 35–48 years. Similarly, it increased from 13.7% among those with no living child to 42.6% among those with 2 or more children. The relationship between the incidence of repeat abortion and the education of the women was an inverted U shape: the incidence increased from 30.3% among those with no education to 38.5% among those with secondary education (grades 6–10), and then decreased among those with higher education.
Table 1 Repeat abortion among all women who underwent abortion, according to demographic and behavioral characteristics. Variable/characteristic
No. (%) of women
Total Age, y 16–24 25–29 30–34 35–48 No of living children 0 1 2+ Education Illiterate Primary (grades 1–5) Secondary (grades 6–10) High school College or higher Intention for future child Yes Not sure No Type of clinic Public Non-government Contraception at the time of pregnancy None Rhythm Withdrawal Condom Pill Injectable/vasectomy/minilap
378/1172 (32.3) 78/420 122/355 99/239 79/158
(18.6) (34.4) (41.4) (50.0)
32/233 (13.7) 88/334 (26.3) 258/605 (42.6) 94/310 58/154 115/299 55/188 56/221
(30.3) (37.7) (38.5) (29.3) (25.3)
68/413 (16.5) 38/115 (33.0) 272/644 (42.2) 82/392 (20.9) 296/780 (37.9) 214/692 23/64 51/161 54/140 31/87 5/28
(30.9) (35.9) (31.7) (38.6) (35.6) (17.9)
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The incidence of repeat abortion was 16.5% among those women who intended to have a child in the future, but 42.2% among those who had no intention to have either a first child or additional children in the future. Among those women who used a private clinic for abortion services, the incidence of repeat abortion was approximately twice as high as the incidence of 1-time abortion (37.9% vs 20.9%). Among the women who had not used any form of contraception during the month of unintended pregnancy, 30.9% were having a repeat abortion. For those using contraception, the proportion of women with repeat abortion ranged from 17.9% for those using long-term methods (e.g. injectable contraceptives or vasectomy) to 38.6% for those using condoms. Table 2 shows the odds ratios of repeat abortion based on multivariate logistic regression. The odds of having a repeat abortion increased linearly with age: among women aged 30–34 years, the odds of having a repeat abortion was 1.77 times higher than that among woman aged 16–24 years. The odds increased 2.61-fold for those in the higher age group (35–48 years). The odds ratio of repeat abortion also increased to 2.24 for women with 2 or more living children relative to those with no children. In addition, the odds ratio of repeat abortion increased with level of education: it was highest among those with secondary (grades 6–10) education at 2.37. Women who did not intend to have another child in the future were 2 times more likely to have a repeat abortion than those who intended to have a child sometime in the future. Similarly, women attending a private clinic were 2.84 times more likely to have a repeat abortion than those attending a public clinic. Women with repeat abortion were no less likely to have used a specific method of contraception compared with women with 1-time abortion. Among women who did not use any contraceptive to avoid the unintended pregnancy, differences between women with 1-time abortion and those with repeat abortion were analyzed with respect to their primary reason for non-use of contraceptive (Table 3). On the basis of coding of the open-ended responses, the 4 most
Table 2 Odds ratios of repeat abortion based on multivariate logistic regression. Variable Age, y 16–24 25–29 30–34 35–48 No of living children 0 1 2+ Education Illiterate Primary (grades 1–5) Secondary (grades 6–10) High school or higher Intention for future child Yes Not sure No Type of clinic Public Non-government Contraception at the time of pregnancy None Rhythm Withdrawal Condom Pill Injectable/vasectomy/minilap a b c
P b 0.05. P b 0.01. P b 0.001.
Odds ratio (95% CI) 1.00 1.56 (1.06–2.30)a 1.77 (1.13–2.78)a 2.61 (1.58–4.31)c 1.00 1.59 (0.93–2.72) 2.24 (1.13–4.45)a 1.00 1.80 (1.16–2.81)b 2.37 (1.62–3.47)c 1.71 (1.16–2.52)b 1.00 1.65 (0.97–2.81) 2.01 (1.18–3.42)a
Table 3 Comparison of primary reason for non-use of contraception during the month of pregnancy between 1-time and repeat abortion.a Reason (multiple response)
No. of women
First-time abortion (%)
Repeat abortion (%)
Gross odds ratiob
Net odds ratio
Health Forgot to use (self or partner) Dislike method (self or partner) Perceived low risk of pregnancy Infrequent sex Youngest child too small Other Total
247 148 137 97 42 33 41 692
31.4 20.3 20.7 16.5 6.3 5.6 7.3 100
45.3 23.8 17.8 8.4 5.6 2.8 2.8 100
1.81e 1.23 0.83 0.46d 0.89 0.48 0.37c
1.63d 1.35 0.86 0.46d 0.71 0.52 0.40
a
Among all women not using a contraceptive method (n = 692). Gross odds ratio refers to bivariate results; net odds ratio controls for age, number of living children, and type of clinic variable. c P b 0.05. d P b 0.01. e P b 0.001. b
commonly mentioned reasons were health, forgot to use the intended method (either the woman herself or her partner/husband), dislike of a method (either by herself or by her partner/husband), and perceived low risk of pregnancy. Among these 4 reasons, health was by far the most frequently mentioned. Women with repeat abortion were significantly (P b 0.001) more likely to report health as a primary reason for not using contraception compared with their 1-time counterparts. In addition, they were significantly (P b 0.01) less likely to mention low risk of pregnancy as a primary reason for not using contraception. Women with 1-time and repeat abortion were similar with respect to other reasons for not using contraceptives to avoid the unintended pregnancy. Data regarding the contraceptive method dispensed at the time of discharge from the clinic were analyzed as an indicator of patterns of contraceptive use in the post-abortion period (Table 4). Among all women having an abortion, a fifth (20.6%) left the clinic without any method. Among women who received contraception (79.4%), injectable contraceptives and condoms were the 2 most frequently prescribed and accepted methods. Controlling for age, number of living children, and clinic type, women with repeat abortion were 1.45 times more likely to have received condoms at discharge than were women with 1-time abortion. They were significantly (P b 0.01) less likely to have received 3-month injectable contraceptives. The patterns of contraceptive dispensing and acceptance were similar for other methods. 4. Discussion Nearly one-third of all women undergoing surgical abortion in the 2 high-volume clinics were having a repeat abortion. This incidence of repeat abortion has been reached approximately 6 years after the Table 4 Comparison of specific contraceptive method dispensed at the time of discharge between 1-time and repeat abortion. Method
No. of women
One-time abortion (%)
Repeat abortion (%)
Gross odds ratioa
Net odds ratioa
Condom Pill Injectable Other (vasectomy/minilap) No method Total
332 206 333 60 241 1172
25.7 17.4 30.5 3.9 22.5 100
33.9 18.0 24.1 7.7 16.4 100
1.48c 1.04 0.72b 2.05c 0.67b
1.45b 1.29 0.62c 1.72 0.74
1.00 2.84 (2.08–3.88)c 1.00 1.46 1.00 1.46 1.18 0.40
(0.80–2.66) (0.66–1.51) (0.96–2.22) (0.71–1.97) (0.14–1.13)
a Gross odds ratio refers to bivariate results; net odds ratio controls for age, number of living children, and type of clinic variable. b P b 0.05. c P b 0.01.
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abortion service was first introduced after legalization of abortion on demand in Nepal. As noted earlier, by December 2009 more than 313 000 women had accessed and obtained abortion services from the various abortion facilities throughout the country. Even if we assume that only half of the incidence found in the present study is likely to prevail nationally, it means more than 50 000 women may have undergone repeat abortions cumulatively thus far. As mentioned earlier, if the experience of other countries is any guide, both the incidence and volume are likely to continue to rise in the foreseeable future. The risk factors for repeat abortions were found to be age, number of living children (parity) of 2 or more, intention to have no more children in the future, and primary or secondary level of educational attainment. The effects of age and parity are consistent with findings from high-income countries, but a parity of 2 or higher is a risk factor only among women with repeat abortion in Nepal. The study also showed that proportionately more women coming to the nongovernmental clinic were likely to be having a repeat abortion. The main reason for this seems to be that, although the sociodemographic characteristics of women having an abortion at the public and non-governmental clinics were similar, the latter group had considerably lower peri-contraceptive use compared with the former group (35.0% vs 52.8%; P b 0.001) and significantly more of them had used withdrawal as their method [15]. The present study also found that women with repeat abortion were equally likely to have used contraception as those with 1-time abortion. Similar to research elsewhere [4], this refutes the often-made assumption that women with repeat abortion are less motivated to use contraception. However, women with repeat abortion may be self-selected to use less effective methods for various reasons. Health was the most commonly cited primary reason for not having used contraceptives among both women with 1-time and those with repeat abortion. The contraceptive method dispensed and accepted immediately after the abortion procedure was not a good indicator of medium and long-term contraceptive use patterns among the women. Nevertheless, women with repeat abortion did not have a significantly different pattern of contraceptive use with the exception of condoms and injectable contraceptives: that is, compared with those with 1-time abortion, they were significantly more likely to use condoms and less likely to use injectable contraceptives. A strong message that emerges is that health clinics and/or facilities providing abortion services (and family planning) need to pay special attention to women with repeat abortion. Failing to address their needs appropriately and effectively might mean, in many situations, that they will return for another abortion. Indeed, nearly half of the women with repeat abortion said that they would consider having abortion again if they were to have another unintended pregnancy. The incidence of repeat abortion is also likely to be exacerbated by the fact that medical abortion (mifepristone/misoprostol) has been introduced and access is being expanded in the country [16,17]. At present in the MSI clinic, family planning services are provided on the same premises where the abortion (surgical evacuation) service is provided. In the MH clinic, by contrast, services for longacting contraceptives are provided at a separate clinic on the hospital premises without a systematic and well-functioning referral system. As a result, those women having an abortion who are referred for family planning are often “lost” between the abortion clinic and the family planning clinic. Even at the MSI clinic, a lack of regular, consistent, and adequate supplies of contraceptives was reported to be a recurrent problem. Notably, the IUD, which is an effective and appropriate long-term method, particularly for women having an abortion [4,5], was not accepted by even 1 woman in the study. In subsequent discussions with service providers at the 2 clinics, it became apparent that supplies of IUDs had been erratic and at times IUDs were simply not available.
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Approximately 1 in 5 of all women left the clinic without a method. During post-survey discussions with the clinic staff, we were informed that a considerable proportion of these women did not wish to accept any method because they did not plan to have intercourse (e.g. on account of their own or their husband's or partner's travel). For some women, the reason was ill health or advice by their healthcare provider against the use of any contraceptive method. For others, it was the need to consult with their husband before they accepted or used any method. Involving males in family planning decisions remains a big challenge. It is a critical factor, especially in Nepal, where gender and power relations have been slow to change. Strengthening quality family planning services has most probably not received the attention that it needs within the health services system where abortion services are introduced and established. The results of the present study, together with previous data [13], underscore the need to critically revisit and recalibrate family planning counseling and the provision of services. A more effective system needs to be put in place to address these needs. Efforts are also needed beyond the strengthening or recalibration of existing family planning services. As the present study has shown, poor compliance with the contraceptive methods intended to be used and use of less efficacious methods were some of the reasons for having an unintended pregnancy. Family planning programs still have a long way to go toward addressing these issues. Furthermore, ill health was found to be a major reason for not using contraceptives. How can these needs be addressed? How much can be accomplished by investing in both improving counseling and engaging media more effectively? These questions need to be considered and explored. The situation is likely to be more challenging in rural and remote areas. In conclusion, the present study indicates that, after liberalization of the abortion law and the subsequent availability and expansion of services, repeat abortion is emerging as a major public health problem in Nepal. This fact should be taken into account in the planning and provision of abortion and family planning services. Although the study is limited to Nepal, the issues are likely to be relevant to many other societies where abortion is legal. Acknowledgments Ipas/Nepal provided support for implementing the survey, data analysis, and preparation of the manuscript as part of its support for health services research and program evaluation in Nepal. The views expressed are those of the authors only and do not necessarily reflect the views of Ipas/Nepal or other organizations with which the authors are affiliated. Conflict of interest The authors have no conflicts of interest. References [1] Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion Worldwide: A Decade of Uneven Progress. http://www.guttmacher.org/pubs/Abortion-Worldwide.pdf. Published 2009. [2] Tietze C. The “problem” of repeat abortions. Fam Plann Perspect 1974;6(3): 148-50. [3] Tietze C, Jain AK. The mathematics of repeat abortion: explaining the increase. Stud Fam Plann 1978;9(12):294-9. [4] Jones RK, Singh S, Finer LB, Frohwirth LF. Repeat Abortion in the United States. Occasional Report No. 29. http://www.guttmacher.org/pubs/2006/11/21/or29.pdf. Published November 2006. [5] Heikinheimo O, Gissler M, Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. Contraception 2008;78(2): 149-54. [6] Brown Jr JS, Adera T, Masho SW. Previous abortion and the risk of low birth weight and preterm births. J Epidemiol Community Health 2008;62(1):16-22. [7] Infante-Rivard C, Gauthier R. Induced abortion as a risk factor for subsequent fetal loss. Epidemiology 1996;7(5):540-2.
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[14] Retherford RD, Choe MK. Statistical Models for Causal Analysis. New York: Wiley; 1993. [15] Thapa S, Neupane S, Basnett I. A Comparison of Clients having Abortion in Public and Non-government Clinics in Urban Nepal. A Study Report. Kathmandu: Ipas/Nepal; 2011. [16] Ministry of Health and Population. Medical Abortion Scale up Strategy and Implementation Guide 2009. Kathmandu: Ministry of Health and Population; 2009. [17] Ipas/Nepal. A Comprehensive Report on Implementation of Medical Abortion Services in Six Pilot Districts of Nepal. Kathmandu: Ipas/Nepal; 2009.