ORIGINAL�ARTICLE ABSTRACT Objective: To determine uptake of contraceptive methods by post abortion clients along with factors influencing the uptake. Study Design: Descriptive cross sectional study. Materials and Methods: The study included 160 post abortion clients using two stage sampling technique. A questionnaire was designed based upon questions used in previous studies. Part A of questionnaire was filled to record socio demographic details and part B to assess contraceptive uptake. Chi square test was applied to determine association between independent and dependent variables. Data were analyzed using SPSS version 22. P-value < 0.05 was considered significant. Results: Mean age of participants was 28.4 ± 6.04 years. Only 38.1% clients adopted contraceptive method within one month. Short term methods were adopted by 62.2% and long acting reversible contraceptives by 26.2% clients. Male condom was the most frequently chosen method, adopted by 24.5% clients. Fifty four percent clients having > 3 living children, 48.7% clients served by private sector, 61.7% clients reporting previous contraceptive use and 50.9% clients who received counseling, adopted the method. Association between these factors and contraceptive uptake was statistically significant (p value <0.05). Key Words: Contraception, Contraceptive Method, Family Planning, Post Abortion Contraception. Conclusion: Post abortion contraceptive uptake was low. However private sector health facilities, previous contraceptive method use and counseling by health care providers were significantly affecting contraceptive uptake. Place and Duration of Study: The study was conducted in three public and three private hospitals of Sargodha from February to October 2018. important part of reproductive health care. Healthy Timing and Spacing of Pregnancy (HTSP) is an intervention which enables women and couples delay or space their pregnancies, and hence ensure 3 healthiest outcomes for mother and neonate. In context to HTSP, World Health Organization recommends at least 6 month interval to next 4 pregnancy after miscarriage or induced abortion. Due to rapid return of fertility and early resumption of sexual activity, post abortion clients are exposed 5,6 to the risk of closely spaced pregnancy. Counseling and provision of effective contraceptive method can protect post abortion client from this undesired 7 occurence. In Pakistan, unmet need for contraception is as high as 17% and contraceptive prevalence rate is only 8 34%. Incidence of abortions is also high and more 9 than 2 million pregnancies end annually. Strategies for effective counseling and service provision must be implemented to address the contraceptive needs of post abortion clients. Introduction Access to comprehensive reproductive health care services enables women to pass through pregnancy and labour safely and to accomplish the best 1 reproductive outcomes. Reproductive health care is one of the core components of the 3rd Sustainable Development Goal which emphasizes on universal access to sexual and reproductive health-care services, including family planning, information and 2 education. Contraception is an essential and Contraceptive Uptake among Post Abortion Clients in Local Population of Sargodha District, Pakistan 1 2 3 Saadia Maqbool , Hina Shan , Lubna Shaheen Correspondence: Dr. Saadia Maqbool Former Head of Training Department Green Star Social Marketing, Pakistan E-mail: maqboolsaadia@yahoo.com 1 Green Star Social Marketing, Pakistan 2 Department of Community Medicine HBS Medical and Dental College, Islamabad 3 Department of Pathology Sargodha Medical College, Sargodha Funding Source: NIL; Conflict of Interest: NIL Received: April 17, 2019; Revised: August 10, 2019 Accepted: August 14, 2019 Post Abortion Contraceptive UptakeJIIMC 2019 Vol. 14, No.4 174 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 I and Table II. the study. Clients coming to hospital were assessed for eligibility criteria and those fulfilling the criteria were enrolled in the study after taking written voluntary informed consent. Results 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 was applied to determine the association between categorical variables. A p- value < 0.05 was taken as statistically significant. Section A of questionnaire was filled on first contact with the client to record socio-demographic information and section B was filled after one month to record contraceptive uptake. Research questionnaire was designed after extensive literature search by modifying the questions used in previous studies by Pearson et al, Abrah P, Uwera D.J and Thapa A. After review by two gynecologists and a public health specialist, questionnaire was piloted on 23 post abortion clients. Research committees of National University of Medical Sciences and Army Medical College also approved it. Gaps exist regarding awareness about post abortion contraception at client and health care provider's level. Determination of post abortion contraceptive uptake is essential to know what percentage of post abortion clients get protection from the risk of unplanned pregnancies, poor perinatal outcome or repeat abortions. Assessment of factors which affect post abortion contraceptive uptake would be helpful i n a d d r e s s i n g t h e h i g h u n m e t n e e d o f 11 contraception. There was paucity of data regarding post abortion contraceptive uptake in Pakistan. The purpose of the study was to determine uptake of contraceptive methods by post abortion clients along with factors influencing the uptake. After obtaining approval from the ethical review committee of Army Medical College, this study was conducted at three public and three private sector hospitals of district Sargodha from February 2018 to October 2018. Study participants were 160 post abortion client, 78 from public sector hospital and 82 from private sector hospital. Raosoft sample size calculator was used for sample size estimation. Keeping 4% margin of error, 95% confidence level, a sample size of 115 was calculated initially. After adding 30% increase to cover the lost to follow-up and rounding off, sample size of 160 was finalized. Two stage Sampling Technique was used. Firstly, list of all hospitals providing reproductive health care was obtained from District Health Officer and sampling frames were constructed for private and public sector hospital strata. Three hospitals were selected by simple random sampling technique using lottery method from each stratum. In the second stage of sampling, simple random sampling technique using computer generated random number was used to select hospital for that day to collect data. Women aged 15–49 years who reported abortion before 20 weeks gestation and gave written consent were included and women with a desire for next pregnancy within 6 months and who developed life threatening complications were excluded from Materials and Methods Post abortion woman must get the opportunity for discussion about contraceptive needs and her reproductive goals. She has a right to get comprehensive information and counseling about the benefits, usage, effectiveness and side effects of 10 a range of contraceptive methods. Table I: Socio Demographic Characteris�cs of the Par�cipants (N=160) and their Contracep�ve Method Uptake Post Abortion Contraceptive UptakeJIIMC 2019 Vol. 14, No.4 175 Uptake Uptake of contraception was significantly higher among clients served by private sector facilities (p value = 0.004). Forty clients (48.7%) of private sector and 21 clients (26.9%) of public sector adopted the method. Significant association was observed between contraceptive uptake and having >3 living children (p value < 0.001) as 33(54%) clients adopted the method. Among 47 previous FP users 29 (61.7%) initiated contraceptive method while 32(28.3%) clients among 113 previous non users adopted contraception (p value < 0.001). Fifty seven clients (96.4.7%) who received counseling while only 4 (8.3%) who received no counseling reported method uptake (p value < 0.001). Dilation and curettage: D&C, Manual vacuum aspiration: MVA, Medical Treatment: MT, No treatment: NT,*Statistically significant Out of 160 clients, only 61 clients (38.1%) reported contraceptive method uptake within one month after abortion. Among method adopters, 38(62.2%) clients adopted short term method while 16(26.2%) adopted LARC. Male condom was chosen by 15 (24.5%), IUCD by 14 (22.9%) and pills by 12 (19.6%) clients. Table II: Obstetric Details of the Par�cipants (N=160) and their Contracep�ve Method Uptake Fig 1: Uptake of various Contracep�ve Methods (n=61) Fig 2: Contracep�ve Method Uptake in both Sectors (n=160) (p value=0.004) Majority of contraceptive method adopters have chosen the short term method. Male condoms followed by pills were the most frequently chosen method. A Brazilian study also indicated similar Findings revealed that 38.1% clients adopted a contraceptive method which is higher than the 12 contraceptive prevalence rate in Pakistan (34%). Higher uptake could be due to increased felt need of contraception following an abortion. Discussion Post Abortion Contraceptive UptakeJIIMC 2019 Vol. 14, No.4 176 2. Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. The Lancet. 2018;391(10140):2642-92. use and counseling regarding contraception are significantly affecting contraceptive uptake. There is a need to strengthen post-abortion contraceptive services which can contribute in increasing the country's contraceptive prevalent rate. Strategies for post abortion contraceptive provision as a part of post abortion care must be developed and implemented. Capacity building of health care providers and availability of a range of contraceptive methods are essential to increase post abortion contraceptive uptake. REFERENCES 5. Gemzell-Danielsson K, Kallner HK. Post abortion contraception. Women's Health. 2015; 11(6):779-84 6. G e m ze l l - D a n i e l s s o n K , Ka l l n e r H K , Fa ú n d e s A . Contraception following abortion and the treatment of incomplete abortion. International Journal of Gynecology & Obstetrics. 2014; 126:S52-5. 7. Roe AH, Bartz D. Contraception after surgical and medical abortion: a review. Obstetrical & gynecological survey. 2017; 72(8):487-93 9. Sathar Z, Singh S, Rashida G, Shah Z, Niazi R. Induced abortions and unintended pregnancies in Pakistan. Studies in family planning. 2014; 45(4):471-91. 10. Stanback J, Steiner M, Dorflinger L, Solo J, Cates W. WHO tiered-effectiveness counseling is rights-based family planning. Global health: science and practice. 2015; 3(3):352-57. 11. Samuel M, Fetters T, Desta D. Strengthening post abortion family planning ser vices in Ethiopia: expanding contraceptive choice and improving access to long-acting reversible contraception. Global Health: Science and Practice. 2016;4(Supplement 2):S60-72. Recommendations 3. Allison A, Basikoro EE. Why World Vision supports healthy timing and spacing of pregnancies to improve maternal and child health: a faith-based perspective. Christian Journal for Global Health. 2017;4(2):75-9. 1. Dunn JT, Lesyna K, Zaret A. The role of human rights litigation in improving access to reproductive health care and achieving reductions in maternal mortality. BMC pregnancy and childbirth. 2017; 17(2):367. 4. Agida TE, Akaba GO, Ekele BA, Isah D. Practice of healthy timing and spacing of pregnancy (HSTP), experience from a low resource setting. Tropical Journal of Obstetrics and Gynecology. 2016;33(1):57-63. 8. National Institute of Population Studies (NIPS) and ICF. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF; 2018. Available at https://dhsprogram.com /publications/publication-fr354-dhs-final-reports.cfm Uptake of contraceptive method within one month after abortion is low although many clients express desire to limit fertility. However private sector health facilities, previous history of contraceptive method Higher percentage of method adoption was noted in age groups more than 24 years with highest uptake among women more than 35 year (55%). These results are comparable to another study. Benson et al. who also reported high uptake among women ≥25 15 years of age. In our study, uptake of contraceptive method was more among clients who had induced abortion (57.8%). Findings of a study conducted in eight countries described higher odds of contraceptive method uptake in clients who had induced 16 abortion. choice of contraceptive methods. Condom was the most frequently adopted method, followed by the 13 contraceptive pills. Higher uptake of method was noted in women with more than 3 living children. Another study also reported higher post abortion contraceptive use 17 among women with 3 or more children (83.8%). In our study uptake of contraception was significantly higher among clients served by private sector facilities Results suggest that in private sector, clients are counseled and offered method provision more effectively. This finding is not similar with the study conducted at Ethiopia. Analysis of Ethiopian study suggested that post abortion clients served in private health facilities were 72.4% less likely to adopt contraceptive method as compared to the 14 public facilities. Different quality standards of private sector in both countries may be explain this disparity. Conclusion Most of clients who have been counseled, reported contraceptive uptake. Very low adoption of FP method (8.3%) was seen among clients who received no counseling at all. In an Ethiopian study, respondents who received contraceptive counseling were 4 times more likely to have post abortion 19 contraceptive method. Contraceptive uptake was higher among clients who reported previous use of contraceptive method. 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Predictors of Post abortion Family Planning Uptake in the New Juaben Municipality (Doctoral dissertation). Ghana: Kwame Nkrumah University of Science and Technology; 2015 15. Benson J, Andersen K, Healy J, Brahmi D. What factors contribute to Post abortion contraceptive uptake by young women? A program evaluation in 10 countries in Asia and sub-Saharan Africa. Global Health: Science and Practice. 12. National Institute of Population Studies (NIPS) and ICF. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF; 2018. Available at https://dhsprogram.com /publications/publication-fr354-dhs-final-reports.cfm 13. Borges AL, Monteiro RL, Hoga LA, Fujimori E, Chofakian CB, Santos OA. Post-abortion contraception: care and practices. Revista latino-americana de enfermagem. 2014; 22(2):293- 300. 14. Hagos G, Tura G, Kahsay G, Haile K, Grum T, Araya T. Family planning utilization and factors associated among women receiving abortion services in health facilities of central zone towns of Tigray, Northern Ethiopia: a cross sectional Study. BMC women's health. 2018; 18(1):83. Post Abortion Contraceptive UptakeJIIMC 2019 Vol. 14, No.4 178