Studying linkages between provision of Emergency Contraceptive Pills as Prophylactic and Continuation of Contraception among Post Abortion Clients Not Accepting Any Long Acting Contraceptive Method (Completed 2008)

This study conducted by the PHD Group for Planned Parenthood Federation of America, Inc. and the Family Planning Association of Nepal (FPAN) documents the increasing demand for Emergency Contraception Pills (ECP) in Nepal and its link with the use of contraceptive method other than long acting contraceptive methods.

In Nepal Emergency Contraception Pills (ECP) are available over the counter (OTC) which means that women do not need a prescription to obtain the ECP. It is hoped that women who have unprotected sex would be able to obtain and use ECP to prevent unintended pregnancies. However, such women would still have to go to the pharmacy or a family planning (FP) clinic to obtain the ECP and this may cause a delay in using them, which may lead to an unintended pregnancy. This may cause a delay in using the pills, thereby making ECP less or ineffective in protecting women from unwanted pregnancy. Hence it is important to find out “does provision of ECP prophylactic increase its utilization and more importantly, would it contribute to continuation of regular contraceptives than when ECP is supplied only on demand?”

In the present study impact of ECP use on continuation of contraception has been assessed in the context of women who after undergoing abortion, either did not accept any contraceptive method or accepted temporary contractive methods like condoms, OCP and contraceptive injection.

Many situations such as unprotected sex, improper use of regular contraceptives, failure of barrier methods, sexual violence, etc. lead to unwanted pregnancy. In all such cases ECP gives one last chance to women to protect themselves from unwanted pregnancy. This could also help in reducing need for abortion and thereby abortion complications and maternal deaths. ECP contain increased doses of regular contraceptive pills and should be taken within 72 hours of unprotected intercourse.

The study is based on sequential experimental-control design, with post-test only. Those women who registered in the first two months of the study formed the Control Group (CG). The clients registered in the following two months formed the Intervention Group (IG).

The study was conducted at five family planning clinics of FPAN- two clinics Kathmandu valley, one each in Chitwan, SunsariJhapa districts. These clinics are supported by The Asia Regional Office of the Planned Parenthood Federation of America – International (PPFA- International). All postabortion women of the five clinics who did not accept an IUCD, Norplant or sterilization formed the universe of the study and were invited to join the study. Those willing to participate in the study were asked to sign a consent form indicating their willingness to be contacted after three months.

In five study sites, there were 440 clients enrolled for CG of which only 260 clients were followed-up. Similarly, 440 clients were enrolled for IG and of them 246 clients were followed-up. There was no significant difference between CG and IG with respect to age of respondents. The average age was about 28 years.

Overall, 10 percent women in the baseline study reported experiencing spontaneous abortion and there was no significant difference between CG and IG. Of those who had experienced spontaneous abortion, 9 percent had experienced two spontaneous abortions.  Also 20 percent of all study clients in the baseline who came for abortion had already had induced abortions. Nearly one in four women who had experienced induced abortion has had more than one induced abortion in life. In other words, about 5 percent women had repeat abortions in life.

Women who have had abortion for two times or more were asked what situation led them to have unplanned pregnancy which they eventually decided to abort. Important causes for repeat abortions were forced sex by husband, intercourse without using any FP method, withdrawal method failed, condom leakage, failure to take OCPs continuously for 3 days.

Women who visited FPAN study clinics for abortion at baseline were asked what caused unprotected sex that ended in unwanted pregnancy. The study has found 8 major causes of unprotected sex in the context of Nepal.

Sex without using any family planning method was a major cause of unprotected sex among baseline clients in both CG and IG as about 30 percent of them reported it. Other major causes of unprotected sex that ended in unwanted pregnancy were failed coitus interruptus/ in withdrawal, forced sex by husband/other, failure to take OCPs continuously for 3 days and condom leakage/Vasectomy/IUCD failure. Lesser important causes of unprotected sex mentioned were delayed in taking Depo, miscalculation of infertile period and unexpected visit by husband.

Women from both the CG and IG were asked what a woman could do to protect herself from getting pregnant from unprotected sex and 45 percent from CG and 39 percent from the IG reported using EC to prevent pregnancy. High proportion of women (11.6 percent) from IG mentioned abortion and 5.5 percent of their counterparts from the CG mentioned this reason. In the baseline study, very high proportion of women (45 percent) from both Groups lacked knowledge of preventing conception from unprotected sex.

The proportions of women participating in the follow-up mentioning the use of ECP to prevent pregnancy from unprotected sex have increased substantially since the baseline from 45 percent to 72 percent among the CGs and from 39 percent to 71 percent in the IG. The proportions mentioning “do not know” have slashed down from around 44 percent at baseline to less than five percent in the follow-up. The change in knowledge on ECP use in follow-up group after the baseline is seen vividly in Figure 1 which shows that percent change in knowledge of ECP use in the IG is higher (79.6 percent) than in the CG (60.9 percent).

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