Expanding contraceptive choice in Ethiopia: a comparative analysis of method mixes in post-abortion contraception versus routine family planning

Introduction

According to an estimate in 2012, about 40% of pregnancies worldwide (85 million pregnancies) were unintended. Approximately half of these unintended pregnancies ended in induced abortion, and the remaining resulted in mistimed/unwanted birth or miscarriage¹. There was significant variation in the rate of unintended pregnancies across the world’s regions. For instance, the rate was as high as 108 per 1,000 women aged 15–44 years in Eastern and Middle Africa in 2012, but was very low in Western Europe (27 per 1,000 women). In addition, a study conducted to estimate the incidence and trend of induced abortion has revealed that the percentage of pregnancies ending in induced abortion declined in high-income countries (from 39% in 1990–94 to 28% in 2010–14), whereas in low-income countries it increased from 21% to 24%². This evidence highlight that more needs to be done to attain the SDG 2030 on reproductive health (RH) services in low-income countries, especially to address unmet need for contraception through comprehensive family planning service delivery strategies.

In areas where incidences of unintended pregnancy and abortion are very high and routine family planning services failed to reach all women who need contraception, post-abortion family planning service can play a significant role in addressing unmet of contraception. In developing worlds, women with an unmet need for modern contraceptives account for 81% of unintended pregnancies, and most women undergoing abortion have either mistimed or unwanted pregnancies². Therefore, women who have received induced abortion and are at risk of another unwanted pregnancy represent an important group with unmet family planning needs. This implies that in addition to routine contraceptive service, all family planning programs should give enough attention to post-abortion contraception to address unmet need of women who had induced abortion for unintended pregnancies³. In countries where abortion is legal, post-abortion family planning is provided as part of comprehensive abortion care, and whereas in those countries where abortion is illegal, the service is provided as part of post-abortion care⁴. Additionally, given that women seeking abortion services are a group with demonstrated unmet need for family planning, appropriate counseling and provision of effective contraceptive methods, such as long-acting revisable contraception (LARC), significantly contributes to prevention of repeat unintended pregnancies and induced abortions^5,6.

In Ethiopia, though the contraceptive prevalence rate (CPR) among currently married women progressively increased in the past years reaching 35% in 2016, the unmet need remains high, at 22%. Interestingly, only 27% of women used intrauterine devices (IUDs) and implants, which are highly effective methods, whereas a larger proportion (73%) of women received less effective, short-actingcontraception⁷. According to the 2014 abortion incidence study, the annual abortion rate was 28 per 1,000 women aged 15–49 years, an increase from 22 per 1,000 in 2008. About 77% of women accepted post-abortion contraception, but the majority (68%) of them received short-acting contraceptives⁸. The low CPR and high unmet need, coupled with the increasing trend of induced abortion and complications, clearly signify the need for comprehensive family planning delivery strategies, such as provision of contraception counseling and service for all women seeking abortion care.

Recognizing huge service delivery gaps, Ipas (US-based international NGO) has been working with Ethiopian Ministry of Health and Regional Health Bureaus to reduce maternal mortality and disability by preventing unwanted pregnancy and unsafe abortion through provision of safe, comprehensive abortion and contraceptive services. The ultimate goal of the intervention presented here was to increase contraception uptake and improve contraceptive method mix, with special attention to LARC methods. This analysis seeks to compare contraceptive method choice patterns in the routine (interval) and post-abortion contraception services and to suggest how multifaceted service delivery approaches can help address unmet need for LARC methods.

Description of the intervention

Although Ipas Ethiopia has been implementing the intervention in five major regional states of the country, this report presents only the achievements and lessons learned in the Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia between fiscal year (FY) 2010 (July 2009 to June 2010) and FY 2017 (July 2016 to June 2017). During this eight-year project period, Ipas has provided supports to the SNNP Regional Health Bureau (RHB) working in five zones (Guraghe, Siltie, Kaffa, Bench Maji and Sheka zones), Yem Special Woreda and Hawassa city council to strengthen systems and expand access to quality comprehensive abortion care (CAC) and comprehensive contraceptive (CC) services for women, including young women. By the end of FY 2017, Ipas has been supporting a total of 127 health facilities (13 hospitals and 114 health centers) in the project sites. Under the above main project goal, Ipas and health system partners have designed and implemented problem-focused interventions to improve the delivery and quality of routine (interval) and post-abortion family planning services that are acceptable to all clients. As a first step, a rapid baseline situational assessment was carried out in 346 health facilities in four major regions (106, 31% of facilities from SNNPR) in order to identify service delivery gaps in both routine and post-abortion contraception, with more emphasis on availability and accessibility to long-acting and permanent methods⁹. Major findings of the assessment include:

Ipas intervention focused on service delivery and program management gaps identified during baseline assessment. Similar components of the intervention were implemented in both interval (routine) and post-abortion family planning services to improve method mix and increase contraception uptake. Key components of the intervention include:

Methods

Results

Changes in the choice of method: Routine versus post-abortion family planning services

During the intervention period, the contraception method mix progressively improved in both routine and post-abortion family planning services. Expanding contraceptive choice contributes to increased uptake of LARC methods over time. Trend analysis of method choice patterns revealed that the share of method mix for LARCs rose from 3% in FY 2010 to 40% in FY 2017 in routine family planning service (Figure 1), whereas in the post-abortion family planning service, the share for LARCs climbed from 2% in FY 2010 to 62% in FY 2017 (Figure 2). Comparing LARCs acceptance in the routine family planning service with that of post-abortion contraception service in the same facilities indicates that the rate of LARCs uptake among post-abortion family planning clients, averaging 62%, was much higher than in the same facilities’ routine (interval) family planning program, where on average only 40% chose LARC methods (P<0.001).

Figure 1. Trends in use of short-acting and long-acting methods among routine contraceptive acceptors by year, Southern Nations, Nationalities, and Peoples’ Region, Ethiopia, fiscal year (FY) 2010–17 (N=864,303).

Figure 2. Trends in use of short-acting and long-acting methods among post-abortion contraceptive acceptors by year, Southern Nations, Nationalities, and Peoples’ Region, Ethiopia, fiscal year (FY) 2010–17 (N=54,773).

LARC uptake significantly increased in post-abortion contraception

Trend analysis of LARCs uptake in post-abortion family planning revealed that implant use rose from 2% in 2010 to 54% in 2017, while the use of IUDs increased from 0.1% in 2010 to 9% in 2017. A similar trend analysis in routine family planning program revealed that the proportion of interval contraceptive users relying on implant rose from 3% to 35% over eight years of the project period, while the share of method mix accounted for by use of IUD rose from 0.07% to 5% over the same period, with slow increase compared to post-abortion contraception service. Moreover, the percentage distribution of LARC acceptors by methods used showed that the proportion of clients opted for IUD (14%) was higher in post-abortion contraception than in routine family planning service, where only 11% of clients used the IUD. Figure 3 and Figure 4 illustrate and compare the method mix in routine family planning with post-abortion contraception. Uptake of LARCs was significantly improved in post-abortion contraception as compared to routine family planning. The percentage of women (couples) choosing short-acting methods were progressively declined and very few numbers of women have chosen the permanent method (tubal ligation) in both types of family planning the services.

Figure 3. Trends in the method mix among routine contraceptive acceptors by year, Southern Nations, Nationalities, and Peoples’ Region, Ethiopia, fiscal year (FY) 2010–17, (N=864,303).

*Values for tubal ligation were 0% in 2010, 2011 and 2012; 0.1% in 2013, 2014 and 2015; 0.07% in 2016 ; and 0.05 in 2017. IUDs, intrauterine devices; OCPs, oral contraceptive pills.

Figure 4. Trends in the Method Mix Among Post-abortion Contraception Acceptors by Year, Southern Nations, Nationalities, and Peoples’ Region, Ethiopia, fiscal year (FY) 2010–17, (N=54,773).

*Values for tubal ligation were 0% in 2010, 2011 and 2012; 0.03% in 2013; 0.2 in 2014 ; 0.05 in 2015; and 0% % in 2016 and 2017. IUDs, intrauterine devices; OCPs, oral contraceptive pills.

Discussion

Ipas, in collaboration with its partners, has implemented result-based and targeted interventions that significantly contributed to stronger post-abortion and routine (interval) family planning services. The successes of Ipas program intervention attributed to availability of a wide range of contraceptive methods, essential medical equipment and supplies; improvement of infrastructure; decentralization of the services and integration of abortion care and family planning services through training of mid-level providers (midwives, nurses and health officers) on comprehensive abortion care (CAC) and contraceptive services.

Studies have shown that access to a wide range of contraceptive methods, with the rights-based approach to informed consent and decision making, may contribute to the improvement of contraceptive prevalence rate. Though it is not a definitive indicator, a skewed method mix is a good signal of a limited range of available methods or service provider bias. In other instances, it may reflect cultural preferences or effect of national population policy of the country^14–16. However, it should be emphasized that improving contraceptive method mix does not mean balancing the method mix, with equal use of all available methods. Rather, it requires moving away from an obviously distorted method use patterns, without specifying precisely how fully balanced the mix should be, while expanding access to a wider variety of method choices, including new modern methods and underutilized effective contraceptives^17,18. This highlights that in addition to the CPR and unmet needs, change in contraceptive method mix (diversity of contraceptive methods used) is an important indicator of progress in family planning programs^16,19.

A strong family planning program, particularly in low-income countries, requires the implementation of effective service delivery strategies, such as the integration of family planning services with other maternal and child health services and offering methods tailored to the needs of users. Ipas and MOH partners have implemented various interventions to integrate abortion care with family planning service, which significantly contributed to the progressive improvement of post-abortion contraception acceptance. More importantly, the proportion of women who used LARC methods significantly increased in post-abortion service as compared to routine program (62% versus 40%)even though similar interventions were implemented in both service delivery programs. A number of studies and reports of program interventions indicate that such innovative strategies could help broadening the method mix and expanding contraceptive choice, letting women and couples choose the method that suits them best and change methods as their circumstances and need change^17,20,21. Programmatic interventions that contributed to effective integration of abortion care and contraception services were training of service providers on both abortion care and contraceptive services (with a focus on IUDs and implants), improving service setup and regular supply of wide range of contraceptive commodities and essential equipment to abortion room so that both abortion care and post-abortion contraception provided in the same place. Studies from various settings have shown that similar components of interventions implemented to strengthen the integration of abortion care and post-abortion contraception have significantly improved the uptake of contraception after abortion, with the number of women adopting effective long-acting methods increasing after the intervention^20,22,23.

Decentralization of the services, and task-shift in first-trimester abortion care and LARC services are also important interventions that contributed to our program successes and achievements. In Ethiopia, some serious challenges persisted despite the change in abortion law in 2005 to expand the indications under which abortion is allowed. Unavailability of trained mid-level providers in primary health care facilities and lack of facility-preparedness in terms of physical space, supplies, and equipment were the major challenges and obstacles to expanding the service to low-level facilities^8,10. Ipas, in collaboration with the government health system, has conducted cascade of clinical training on first-trimester abortion care and LARCs service for mid-level service providers (midwives, clinical nurses, health officers) which helped transferring tasks from high-level providers (gynecologists and general practitioners) to mid-level providers. Training of a large number of mid-level providers working in primary health care facilities and renovation and refurbishment of abortion/post-abortion family planning and routine family planning service areas were used as strategies to decentralize the services from few high-level facilities (secondary/tertiary levels) to accessible low-level facilities. Similar successful strategies were implemented in various parts of the world to decentralize abortion care and family planning services to low-level health facilities, which improved availability and accessibility of alternative methods and subsequently increased uptake of effective contraceptives, such as LARC methods^20,21,24.

Limitations of the study

Despite this intervention study revealing evidence for public health field to improve uptake of effective contraceptive methods and prevent maternal deaths and disabilities that resulted from unintended pregnancy and unsafe abortion, it suffers some limitations that are largely due to reasons related to program intervention. For instance, we could not conduct further analysis to investigate other factors that might contribute to method use patterns, since the tools used to collect family planning service data from the facilities do not capture socio-demographic and reproductive characteristics of both the routine and post-abortion contraceptive acceptors. This study presents contraceptive use patterns at the facility level, and no follow-up was done to investigate the continuation rate and method use patterns after the women left the facilities. Moreover, since our findings in this report are based on an intervention implemented in limited geographic areas and facilities, it may not be generalized to all facilities in the region or in the country.

Program implications and conclusion

In Ethiopia, as throughout the developing worlds, family planning remains an unfinished agenda. High unmet need contributes to a high fertility rate and uncontrolled population growth that adversely affects the economic development of the country. The current national family planning program in Ethiopia exclusively focuses on routine (interval) contraception service delivery, and no attention is given to increase access to quality contraceptive services after obstetric events and reduce the unmet need for family planning²⁵. Since evidence has shown that fertility may return as early as eight days after the completion of a first-trimester induced abortion, it is imperative that women are offered effective methods of contraception immediately after an abortion²⁶.

In Ipas intervention sites, one of the factors for a low level of CPR is a skewed method mix, with one or two methods (injectables and oral contraceptive pills) covers nearly three-fourths of all contraception use⁶. Our operation study has revealed that when the current mix is augmented by access to additional methods, choice of method expands and total contraceptive use tends to rise, with more women adopting effective methods. Integration of family planning with other maternal health services and offering wide-range of contraceptive methods can help the service to reach clients with a variety of needs, a key factor for a higher uptake of LARC methods by abortion clients in Ipas intervention sites. Multiple studies have shown that a comprehensive approach to family planning services may lead to an increase in the use of more effective contraceptive methods and user compliance among women or couples seeking services^17,20,27. Utilization of VSCs was very low in the intervention facilities, which could be due to lack of knowledge and misconception about permanent methods. A community-based study conducted in the northern part of the country revealed that significant number of married women had inadequate knowledge on permanent contraceptives, and more than half of the study participants had a negative attitude towards practicing of these methods²⁸.

Ipas and its partners have implemented similar intervention components in both routine family planning programs and post-abortion contraception services to expand contraceptive choice and improve uptake of effective methods, such as LARC methods. However, comparative trend analysis indicated that improvement in method mix and uptake of LARC methods were much better in post-abortion contraception service as compared to routine family planning program. This might be due to longer interactions between providers and clients, better counseling services, and high unmet to LARC methods among abortion clients as compared to routine program users. However, since evidence of the most acceptable method mix for post-abortion clients is scarce, more health systems research is needed to assess factors influencing women method preference in post-abortion contraception. Additionally, future research should investigate the integration of family planning with other services in more detail from the perspectives of service providers and clients and assess the cost-effectiveness of integration.

In conclusion, the intervention implemented in Southern region of the county can provide valuable lessons to other regions and countries, which do not require intensive resource inputs; and it can be replicable in any other family planning service delivery approaches, such as postpartum family planning services.

Data availability

Access to the data is restricted to protect the identities of those accessing services. Those wishing to access the data must confirm that:

To apply for access to the data, please contact the first author (samuelm@ipas.org). If the request is approved, the Associate Director of Program Evidence or their assigned delegate will create a Data Use Agreement that includes all components outlined in the global Data Use Agreement Template. Signatures of the relevant Ipas approvers and a representative of the relevant authority from the requestor should be obtained on the agreement.