Effectiveness of preabortion counseling on postabortion contraceptive use

Abstract

In a randomized trial, the effect of preabortion counseling was evaluated and contraceptive use postabortion described. The 420 women, who were assigned into either an intervention group (n = 210) or a control group (n = 210), were followed-up 4–6 months later, a total of 148 and 128 women in each respective group. No significant difference was found between the two groups regarding contraceptive use after abortion (86%, 85%), which indicates no immediate intervention effect. The women, in both groups, who had previously undergone abortion were less likely to use contraception. The main contraceptive methods used by intervention and control groups were oral contraceptives (61% and 58%, respectively) and injectables (12% and 11%). Choice of method was mainly based on women's prior perception of effectiveness and convenience of use. A majority of the women in both groups could not specify their contraceptive plans. A postrandomization inequality regarding age, education and parity in the two groups had, however, to be taken into account. Intensive contraceptive counseling before abortion may not be effective, but those who are at higher risk of unplanned pregnancy need special attention.

Introduction

Over the last several decades, the demand for abortion has been increasing, not least in the teenage population [1]. About one fourth of all abortions in Iceland occur among teenage women and half of all pregnancies among women aged 15–19 end in abortion [1]. These pregnancies are unwanted or mistimed, which indicates no or ineffective contraceptive use. The national abortion register shows that during 1976–1996, between 56 and 68% of the women in all age groups requesting abortion did not use any contraception around the time of conception [2]. A rise in the overall abortion rates over the last decades raises questions about availability, accessibility and quality of contraceptive services, especially for young people [2]. The quality of contraceptive services, especially counseling, has received little attention in Iceland. Until recently, contraceptive services for teenagers have not been prioritized and emergency contraception has not been made widely known or available [3], [4].

To counteract this, a team of healthcare professionals (a gynecologist, a nurse and a midwife) initiated, in 1997, the development of a contraceptive service for women who applied for abortion at Landspitali University Hospital in Reykjavik. The aim was to reach out to these women postabortion and provide them with improved counseling about contraception in order to facilitate their contraceptive use. Initially, it was not known if it was better to counsel women before, after or both before and after the abortion procedure. The main advantage of a preabortion service was considered to be the greater number of women who could be contacted, but the disadvantage was mainly the shortage of time because of admission interviews and the possibility of information overload. After the abortion, there was more time to provide information, at the cost of a higher drop-out rate.

There are few studies where the effectiveness of contraceptive counseling or client–provider interaction to improve contraceptive use has been evaluated [5], [6], [7], [8], [9], [10], [11], [12]. Only one of them [10] dealt with preabortion counseling and two were based on a randomized control trial design [6], [12]. One of those two studies showed effectiveness of contraceptive developmental counseling for adolescents [6], but the other study [12] among postpartum women showed no effect. Counseling about sexual and reproductive health, with emphasis on individual contraceptive needs, involves two-way communication. It is based on voluntary and informed decision-making and is supposed to enable the client to use contraception correctly [8], [13]. The aim of such counseling is to contribute to clients' satisfaction with the method of choice, which can lead to continued and successful method use [8], [14]. Few studies have focused on contraceptive counseling and even fewer have been based on randomized trial. The purpose of the present study was to evaluate the effectiveness of intensive preabortion contraceptive counseling on the postabortion contraceptive use among women and describe their contraceptive use after abortion.