Volume 123, Issue S1 p. e38-e42
Family planning
Open Access

Effect of post-menstrual regulation family-planning service quality on subsequent contraceptive use in Bangladesh

Farhana Sultana

Corresponding Author

Farhana Sultana

Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia

Corresponding author at: Melbourne School of Population and Global Health, Level 4, 207 Bouverie Street, University of Melbourne, Melbourne, Victoria 3010, Australia. Tel.: + 61 390353504; fax: + 61 93495815.Search for more papers by this author
Quamrun Nahar

Quamrun Nahar

International Centre for Diarrhoeal Disease Research, Bangladesh, Mohakhali, Bangladesh

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Lena Marions

Lena Marions

Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden

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Elizabeth Oliveras

Elizabeth Oliveras

Pathfinder International, Watertown, USA

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First published: 02 August 2013
Citations: 5
This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Objective

To determine whether the quality of post-menstrual regulation family-planning services (post-MRFP) affected contraceptive use at 3-month follow-up.

Methods

915 women who received post-MRFP in 2 public and 1 NGO clinics in a district in Bangladesh were interviewed to obtain information on service quality and other characteristics. Quality was scored based on 21 items and the score divided into 3 categories: low (0–6); medium (7–11); and high (12–21). Three months after menstrual regulation, 902 of the women were interviewed at their residence or a clinic and contraceptive status was recorded. Adjusted odd ratios (aORs) for using contraception were calculated via multivariate logistic regression.

Results

Contraceptive use was positively correlated with the level of service quality, with 78% use among women who received the lowest-quality care and 92% use among women who received the highest-quality care. The aOR for contraceptive use was 1.80 (95% confidence interval [CI], 1.11–2.93) among women who received moderate-quality services and 3.01 (95% CI, 1.43–6.37) among women receiving high-quality services compared with those who received poor-quality services.

Conclusion

Good-quality post-MRFP increases contraceptive use, at least in the short term.

1 Introduction

Globally, women experience 76 million unwanted pregnancies annually, 42 million of which are terminated through induced abortion [1]; approximately 48% of those are unsafe, performed by unskilled people or in unhygienic conditions [2]. Overall, 97% of unsafe abortions occur in low-resource countries and these are responsible for 13% of maternal deaths globally [2]. The experience of unintended pregnancy and abortion, with its related risks, is not a singular event for many women. Studies show that 25%–50% of women seeking abortions report at least 1 past abortion [3], indicating that many women are at risk for the consequences of unintended pregnancy more than once. Although circumstances vary, repeat abortion can be attributed to non-use of contraception, inconsistent or incorrect use, or method-related failure [4]. This cycle of unintended pregnancy and abortion is likely to continue if provision of information and services to prevent future pregnancies is neglected.

Postabortion family planning (PAFP)—provision of a range of contraceptive methods, accurate information, sensitive counseling, and referral for ongoing care [5], all of which reflect dimensions of service quality [6]—has been promoted as a means of increasing contraceptive use and decreasing repeat abortion [7,8]. Postabortion family planning is effective in ensuring contraceptive acceptance by over 70% of women who attend facilities for abortion services [9–13]. However, contraceptive acceptance following abortion does not mean continued contraceptive use.

Evidence of the effect of PAFP on continued contraceptive use is inconclusive. While a few studies show increased uptake of contraception and continuation of methods for up to 12 months [12–14], others find no such effects [15,16]. For instance, in a prospective intervention study of PAFP in Zimbabwe, a significantly larger proportion of women in the intervention arm (which included provider training, counseling, and provision of free contraception) than in the control arm adopted a highly effective method of contraception (96% vs 5%) and fewer had unplanned pregnancies (15% vs 34%) during the year-long follow-up [12]. By contrast, a study testing an intervention to improve PAFP counseling failed to show either a decrease in the rate of repeat abortions or an increase in contraceptive use at 4-month follow-up [15]. Other studies have shown that providing women their preferred method, especially when there is husband–wife agreement on the method [17], and informing women about method use and adverse effects are associated with higher continuation rates [18,19]. In addition, the setting [20] and provider's communication skills [21] are key to achieving good-quality family-planning services. Although important, quality of PAFP and factors affecting continuation of contraceptive use by women after abortion have received less attention.

Bangladesh offers a unique setting in which to assess whether the quality of counseling affects contraceptive continuation. In Bangladesh, abortion is prohibited except to save a woman's life but menstrual regulation is provided in both public and non-governmental sectors. According to an official government circular, menstrual regulation is the evacuation of the uterus by vacuum aspiration within 6–10 weeks of a missed period in a woman with a previously normal cycle [22,23]. Menstrual regulation is officially performed without a pregnancy test [23] because it is considered to be an “interim method to establish a state of non-pregnancy in a woman who is at risk of being pregnant” [24]. In terms of post-menstrual regulation family planning (post-MRFP), although contraception is provided by both public and non-governmental organization (NGO) facilities, counseling varies markedly by setting. One analysis found that post-MRFP counseling in public facilities was almost non-existent, whereas NGOs emphasized counseling because they had targets for long-term and permanent methods [23].

Using these naturally occurring differences, we conducted a longitudinal study to examine whether the quality of post-MRFP affected contraceptive continuation among women attending clinics for menstrual regulation services in a district in Bangladesh.

2 Materials and methods

The present study was conducted during 2009 and 2010 in 2 public and 1 NGO clinics in a district in central Bangladesh. An NGO facility located in a public medical college hospital was selected; it was believed that its location might lessen differences between women from public and those from NGO facilities. The public facilities were selected based on their reported patient flow, to ensure an adequate sample size, and because of their accessibility. Women seeking their first menstrual regulation were eligible for participation if they were over 18 years of age, resided in the study district, and did not desire pregnancy within 2 years.

Trained female interviewers conducted exit interviews with 915 women who underwent menstrual regulation and who were provided post-MRFP. The questionnaires, which were adapted from tools developed for the Quick Investigation of Quality for Clinic-based Family Planning Programs, captured information on sociodemographic and reproductive characteristics, contraceptive history, and services received during the visit. Reproductive characteristics included number of living children, the woman and her husband's fertility intentions, and whether or not the woman had discussed family planning with her husband. Women who did not want to have a/another child were classified as wanting to limit births, while those who wanted to wait more than 2 years to have another child were considered to want to space births. Contraceptive history included method used and regularity of use before menstrual regulation, with regularity defined according to method-specific effective-use patterns (e.g. daily use for pill users). Principal component analysis was used to predict wealth scores based on assets and used the resulting quintiles as a measure of relative economic wellbeing. Personal contact information was recorded separately and only study researchers had access to the information.

If the woman agreed at exit interview, she was contacted before follow-up through phone calls or informal household visits. Women had the option of calling the study team to reschedule a visit or to tell the team not to contact them.

Three months after menstrual regulation, follow-up interviews were conducted at a location the woman identified during the initial interview. The follow-up interview asked about current contraceptive use, including regularity of use, and a pregnancy test was carried out. At follow-up, contraceptive use was recorded regardless of whether it was the same method that the participant accepted at study enrollment.

Written informed consent was obtained from each woman at baseline and follow-up. The study was approved by the Ethical Review Committee at the International Centre for Diarrhoeal Disease Research, Bangladesh.

Quality was defined based on whether recommended components of care were provided, using a composite score based on the Bruce/Jain framework for quality of family-planning services [6]. The score was derived from 21 items reflecting 4 dimensions of quality: needs assessment (0–4); choice of method (0–4); information on method use and follow-up (0–6); and interpersonal relations (0–7) (Table 1). The scores were categorized as low- (0–6), medium- (7–11), and high- (12–21) quality post-MRFP services.

Table 1. Quality dimensions (score range) and items measured at baseline to assess the quality of post-MRFP services in selected public and NGO clinics in Bangladesh.
Quality dimensions (score range) Percentage of women (n = 902)
Needs assessment (0–4)
 Whether she has any living children 83
 Whether she wanted to conceive a child 45
 How long she wanted to wait before conceiving 62
 Previous contraceptive use 37
Method choice (0–4)
 Any preference for a method 57
 Discussed at least 1 method 76
 Received a method today 44
 Received her preferred method 24
Information on method use and follow-up (0–6)
 Method use 30
 Adverse effects 20
 Where to seek help in case of problem 21
 Method does not protect against STIs 1
 Return to fertility on stopping method use 22
 When to return for follow-up 52
Interpersonal relations (0–7)
 Did she feel comfortable asking questions? 80
 Did provider encourage her to ask questions? 14
 Was privacy ensured during her counseling? 37
 Did provider assure her confidentiality of information? 2
 Did provider treat her with respect? 95
 Was the content of counseling adequate? 42
 Was the duration of counseling adequate? 37
Total quality (0–21)
 Low (score 0–6) 38
 Medium (7–11) 30
 High (12–21) 32
  • Abbreviations: MRFP, menstrual regulation family planning; NGO, non-governmental organization; STI, sexually transmitted infection.

Bivariate methods were used to explore the association between various factors and contraceptive use. The 10 women who were lost to follow-up were excluded. Multivariate logistic regression was used to test for associations between the quality of post-MRFP services and contraceptive use at 3-month follow-up, after adjusting for factors known to be related to contraceptive continuation. All analyses were performed using STATA version 11 (StataCorp, College Station, TX, USA).

3 Results

All women in the sample were married and the majority were 20–39 years of age (84%), unemployed (62%), and Muslim (94%) (Table 2). More than half had primary or no education. Two-thirds of the women had 2 or more living children; 57% wanted to stop childbearing, while 42% were planning to postpone childbearing for more than 2 years. The majority (89%) of women reported similar fertility intentions to those of their husband but 28% had never discussed family planning with their husband.

Table 2. Percentage distribution of users and non-users of contraception at 3 months following MR, by selected characteristics.a
Characteristics Users (n = 767) Non users (n = 135) Total (n = 902)
Type of facilityb
 Public 64 79 67
 NGO 36 21 33
Age group, y
 ≤ 19 13 14 13
 20–39 84 84 84
 ≥ 40 3 2 3
Religion
 Muslim 94 96 94
 Hindu 6 4 6
Education level
 No education 23 25 23
 Primary (1–5 y) 28 39 28
 Secondary (6–10 y) 39 40 39
 Higher secondary and above (> 10 y) 10 5 10
Employment status
 Unemployed 62 64 62
Wealth quintiles
 Poorest 22 22 22
 Lower middle 19 19 19
 Middle 20 19 20
 Upper middle 20 25 21
 Richest 19 16 18
Number of living childrenb
 0 6 16 7
 1 29 25 29
 ≥ 2 65 59 64
Fertility intentions
 Limit births 58 54 57
 Space births 41 43 42
 Unsure 1 3 1
Fertility intention similar to husband's
 Yes 89 87 89
 No 9 7 8
 Unsure 2 6 3
Discuss family planning with husbandc
 Never 27 31 28
 Sometimes 47 53 48
 Often 26 16 24
  • Abbreviations: NGO, non-governmental organization; MR, menstrual regulation.
  • a Values are given as percentages.
  • b P ≤ 0.001.
  • c P ≤ 0.05.

At follow-up, contraceptive users and non-users differed. A larger proportion of non-users than users underwent menstrual regulation in public clinics (79% vs 64%; P ≤ 0.001) and non-users had fewer children (16% had none vs 6% of users). Furthermore, more users often discussed contraception with their husband (26% vs 16%).

Based on the quality scores, 32% of women had received high-quality services, 38% received poor-quality services, and the rest received moderate-quality services (Table 1). Contraceptive use increased from 43% before menstrual regulation to 85% at 3-month follow-up (Table 3). Modern method use increased by 44%, with an increase from 5% to 29% in injectable use and from 0% to 6% in use of intrauterine devices. Among users not accepting a permanent method, regularity of use increased from 10% to 69%. Seven non-contraceptive users and 4 users had a positive pregnancy test at follow-up (1.2% of all women).

Table 3. Percentage distribution of contraceptive use before and 3 months after MR.a
Method Before MR
(n = 902)
3 months after MR
(n = 902)
No method 57 15
Traditional methods 7 5
Modern contraceptive methods 36 80
(n = 391) (n = 767)
 Pills 59 45
 Condoms 36 19
 Injectables 5 29
 Permanent methods 0.3 1
 IUD 6
 Implant
Regularity of method use (n = 902) (n = 893)b
 Non-user 57 15
 Irregular user 33 16
 Regular user 10 69
  • Abbreviations: IUD, intrauterine device; MR, menstrual regulation.
  • a Values are given as percentages.
  • b Excludes those who received a permanent method.

Neither sociodemographic characteristics nor fertility intentions were associated with contraceptive use at follow-up in the unadjusted model (Table 4). However, women who had at least 1 living child were significantly more likely to be users, as were those who discussed family planning with their husband (odds ratio [OR] 1.89; P ≤ 0.05). Contraceptive use before menstrual regulation was also positively associated with post-menstrual regulation continuation, as were receiving post-MRFP services from an NGO (OR 2.11; P ≤ 0.001) and visiting a satellite clinic in the past 3 months (OR 1.76; P ≤ 0.05).

Table 4. Effect of the quality of post-MRFP services and other selected factors on contraceptive use at 3 months.
Factors No. Percentage using a method Crude odds ratio (95% CI) Adjusted odds ratio (95% CI)
Age group, y
 ≤ 19b 115 84
 20–40 760 85 1.13 (0.67–1.93) 0.48 (0.23–1.00)d
 ≥ 40 27 89 1.58 (0.43–5.79) 0.78 (0.18–3.38)
Religion
 Hindub 55 89
 Muslim 847 85 1.46 (0.62–3.49) 0.98 (0.39–2.47)
Education level
 No educationb 207 84
 Primary school (1–5 y) 258 85 1.07 (0.65–1.76) 1.06 (0.62–1.85)
 Secondary school (6–10 y) 351 85 1.08 (0.68–1.73) 1.35 (0.72–2.56)
 High school or more 86 92 2.22 (0.94–5.22) 3.27 (1.12–9.55)d
Employment status
 Not employedb 563 85
 Employed 339 86 1.10 (0.76–1.62) 1.05 (0.68–1.62)
Wealth quintiles
 Poorestb 200 85 - -
 Lower middle 171 85 1.07 (0.58-1.83) 1.07 (0.58 -1.97)
 Middle 180 86 1.09 (0.61-1.94) 1.02 (0.54 – 1.93)
 Upper middle 185 82 0.78 (0.46-1.34) 0.66 (0.35 -1.25)
 Richest 166 87 1.21 (0.67-2.22) 0.82 (0.40 -1.70)
Number of living children
 0 b 66 68
 1 260 87 3.1 (1.65–5.83)c 4.39 (1.91–10.10)c
 ≥ 2 576 86 2.9 (1.63–5.11)c 6.69 (2.42–18.45)c
Fertility intentions
 Limit birthb 517 86
 Space > 2 y 374 85 0.89 (0.61–1.30) 1.25 (0.68–2.29)
 Unsure 11 64 0.29 (0.08–1.01) 1.06 (0.19–5.20)
Similar fertility intentions to husband's
 Nob 74 86
 Yes 802 85 0.91 (0.46–1.83) 0.78 (0.37–1.62)
 Unsure 26 69 0.35 (0.12–1.02) 0.48 (0.14–1.62)
Discuss family planning with husband
 Neverb 250 83
 Sometimes 434 83 1.02 (0.67–1.54) 0.69 (0.43–1.10)
 Mostly 218 90 1.89 (1.08–3.31)d 1.20 (0.65–2.26)
Method use before MR
 Noneb 511 81
 Irregular use 296 87 1.84 (1.21–2.82)d 1.56 (1.00–2.47)d
 Regular use 95 94 3.43 (1.46–8.08)d 2.90 (1.21–7.12)d
Type of facility
 Publicb 601 82
 NGO 301 91 2.11 (1.36–3.28) c 1.40 (0.71–2.80)
Visit to a satellite clinic in the past 3 months
 Nob 684 84
 Yes 218 90 1.76 (1.10–2.86)d 1.83 (1.10–3.10)d
Total quality
 Low (0–6)b 342 78
 Moderate (7–11) 269 87 1.85 (1.19–2.85)d 1.80 (1.11–2.93)d
 High (12–21) 291 92 3.33 (2.02–5.47) c 3.01 (1.43–6.37) d
  • Abbreviations: CI, confidence interval; MR, menstrual regulation; MRFP, menstrual regulation family planning; NGO, non-governmental organization.
  • b Reference group.
  • c P ≤ 0.001.
  • d P ≤ 0.05.

Better-quality services were associated with contraceptive use at follow-up; women who received moderate-quality services were almost twice as likely to be using contraception compared with women who received poor-quality services (OR 1.85; 95% confidence interval [CI], 1.19–2.85), and women who received high-quality services were 3 times as likely to be users (OR 3.33; 95% CI, 2.02–5.47) (Table 4). This relationship remained after adjusting for potential confounders. Number of living children, having attended high school, using a method regularly before menstrual regulation, and visiting a satellite clinic were all independent predictors of contraceptive use in the multivariate model.

4 Discussion

The present results indicate that high-quality post-MRFP services increase short-term contraceptive use. Three months after menstrual regulation, 80% of all women were using a modern method, and the proportion of women using a method ranged from 78% among those reporting low-quality services to 92% among those reporting high-quality services. This relationship persisted after controlling for the effects of potential confounders. These results are consistent with those from an intervention study in Zimbabwe that showed significantly higher levels of contraceptive use among women who received the intervention, which is presumed to be higher-quality care [12]. However, they contradict a study that found no difference in rates of contraceptive use at 4-month follow-up after abortion. That study had high rates of loss to follow-up and potential contamination because the same staff implemented both the intervention and the control approaches, which may have biased the results toward the null [15].

The fact that some participants, particularly those with 1 or more children and those who were using a method regularly prior to menstrual regulation, were more likely to use contraception at 3 months indicates that some women may be particularly motivated to use family planning following menstrual regulation or abortion. Others may need special attention to encourage continued contraceptive use.

The present study was designed to address some of the common critiques of past studies of PAFP. In particular, every effort was made to limit loss to follow-up. Participants were contacted by phone and home visits in order to build rapport and encourage their continued participation in the study. For women who chose to have the follow-up interview outside their home, travel costs were reimbursed. As a result, just 1% of the original sample was lost at 3 months. In addition, by asking women about the services they received during an exit interview just after the menstrual regulation procedure, recall bias was minimized. Although there was a potential for bias because women reported on quality and may have felt that their answers would affect future care, a sample of cases were observed and interviewed independently; a comparison of the items using κ correlations showed moderate–good agreement for most items (data not shown). Although women with repeat menstrual regulation were excluded by design, underreporting of repeat menstrual regulation is likely and it is difficult to anticipate how this would have affected the results. Every effort was made to ensure accurate reporting, particularly by careful probing from the trained interviewers.

Furthermore, while prior studies in low-income countries have tended to combine women with spontaneous and induced abortion—who may respond quite differently because of different fertility preferences [25]—the present study assessed counseling among women who opted for pregnancy termination. Although, officially, pregnancy tests are not conducted prior to menstrual regulation, women in fact come for such services when they believe that they are pregnant.

Unlike most other studies of PAFP, the present investigation used naturally occurring variation in the quality of services rather than a controlled intervention [12]. As a result, the present findings are more likely to reflect what would happen during the course of normal practice. However, because of differences in the length of follow-up and intensity of the intervention, the results are not directly comparable to those from other studies.

Although 3-month follow-up shows only short-term use, it is an improvement on past studies that looked only at immediate uptake of contraception at the time of abortion. One potential bias of the follow-up period was that women who used injectables may not yet have had their second injection by the time of the interview. In fact, the interviews were scheduled to take this into account; more than 90% of follow-up visits were conducted 2 weeks after the date on which the next injection was scheduled. A sensitivity analysis excluding injectable users showed a strong association between quality of care and contraceptive use at 3 months (results not shown), indicating that these results are robust. In addition, given the uptake of long-acting methods (e.g. intrauterine device), longer-term follow-up is needed to assess continuation fully.

An additional concern was selection bias. Quality of services is likely to be affected by patient characteristics, and the women most likely to receive higher-quality service are also more likely to use contraception. While women who received high-quality services were somewhat different from those who received lower-quality services (e.g. more educated and of higher wealth quintiles), there was no significant difference in pre-menstrual regulation contraceptive use by level of quality (results not shown).

The results of the present study highlight the importance of providing post-MRFP services in accordance with recognized parameters of quality. Taking steps to ensure that all women receive the highest-quality services is important for increasing contraceptive continuation and avoiding repeat abortion. Exploring longer-term continuation of contraceptive use by the same population would provide more insight into the duration of the effect of quality of services on contraceptive continuation. It may also be useful to identify those components of services that are most important to contraceptive continuation. In conclusion, the quality of post-MRFP services is a key factor affecting continuation of contraceptive use, at least in the short term. In Bangladesh and in other settings, improving quality of services and ensuring it across providers can improve contraceptive use and potentially decrease repeat unintended pregnancy and repeat menstrual regulation.

Acknowledgments

The present study was funded by the Department for Research Cooperation, Swedish International Development Cooperation Agency.

Conflict of interest

The authors have no conflicts of interest.