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Contraceptive counselling in abortion care
Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Improving women’s knowledge about contraception, and their access to contraceptive methods, is central in order to strengthen their sexual and reproductive rights at the time of an abortion. Contraceptive counselling aims to support women’s reproductive control and prevent unintended pregnancies (UPs). It is unclear, however, how to provide contraceptive counselling and how to organise services at the time of an abortion, in order to achieve this.

Aim: The overall aim was to study women’s choices and use of contraceptive methods post-abortion. The research also aimed to describe contraceptive counselling in the context of an abortion from women’s and health professionals’ (HP’s) perspectives. Initial studies informed subsequent improvement efforts, also evaluated in the thesis, regarding contraceptive counselling and services at the time of an abortion.

Design and Methods: The studies in this thesis involve both quantitative (studies I and IV) and qualitative (studies II–IV) methods, performed at six departments in southeast Sweden. Study I had a quantitative and longitudinal design. The medical records of women (n=987) were reviewed regarding women’s choice of contraceptive method at the index abortion and the odds of repeat abortion within three to four years. Studies II and III were qualitative interview studies, in which 13 women (study II) and 21 healthcare professionals (HPs) (study III) described their experiences of contraceptive counselling at the time of an abortion. The interviews were analysed using interpretive phenomenology (study II) and conventional content analysis (study III). Study IV was a case study regarding a qualitative improvement collaborative (QIC), designed to improve contraceptive counselling and services. Three multi-professional teams involved in abortion care participated in the QIC and two women provided user-experience input. Both qualitative and quantitative data were collected and analysed.

Results: The findings of the thesis are organised into three themes: I) Women and HPs described contraceptive counselling at the time of an abortion as an often - complex meeting. There was scepticism about contraceptive methods and limited receptivity to information among women. Respectful counselling facilitated women’s choice of contraceptive method even if they were sceptical and found the situation emotionally charged. II) Women’s choices, need for guidance and access to the contraceptive methods was described in the second theme. Choice of oral contraceptives (OC) dominated. Overall, 25% of the women experienced repeat abortion during followup. Women who chose long-acting reversible contraception (LARC) experienced fewer repeat abortions compared to women who chose OC. Both women and HPs reported barriers in access to LARC post-abortion. III) In a Quality Improvement Collaborative (QIC), two volunteering women provided user-experience input. HPs participating in this QIC reported strengthened skills in counselling and enhanced ability to evaluate their performance. Despite the team’s prediction that they would reach the QIC goal that ≥50% of women would start LARC within 30 days post-abortion, and the fact that a majority of the women in QIC units chose LARC, none of the teams managed to reach the goal, primarily due to insufficient capacity for timely initiation of LARC.

Conclusion: The findings suggest that women need respectful counselling and guidance at the time of an abortion. Access to a range of contraceptive methods, particularly LARC, is important to prevent repeat UPs. There is room for further improvement in offering coordinated and timely access for women who choose LARC, and to evaluate counselling, in the present settings.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. , p. 106
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1631
Keywords [en]
Accessibility, Oral contraceptives, Collaboratives, Long Acting Reversible Contraception, Prevention, Repeat abortion, Respect, Reproductive control, Unintended pregnancy
National Category
Nursing Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-152875DOI: 10.3384/diss.diva-152875ISBN: 9789176852644 (print)OAI: oai:DiVA.org:liu-152875DiVA, id: diva2:1265729
Public defence
2018-11-23, Qulturum, Länssjukhuset Ryhovs, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-11-26 Created: 2018-11-26 Last updated: 2018-11-26Bibliographically approved
List of papers
1. Likelihood of repeat abortion in a Swedish cohort according to the choice of post-abortion contraception: a longitudinal study
Open this publication in new window or tab >>Likelihood of repeat abortion in a Swedish cohort according to the choice of post-abortion contraception: a longitudinal study
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2016 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 95, no 5, p. 565-571Article in journal (Refereed) Published
Abstract [en]

IntroductionDespite high access to contraceptive services, 42% of the women who seek an abortion in Sweden have a history of previous abortion(s). The reasons for this high repeat abortion rate remain obscure. The objective of this study was to study the choice of contraceptive method after abortion and related odds of repeat abortions within 3-4 years. Material and methodsThis is a retrospective cohort study based on a medical record review at three hospitals in Sweden. We included 987 women who had an abortion during 2009. We reviewed medical records from the date of the index abortion until the end of 2012 to establish the choice of contraception following the index abortion and the occurrence of repeat abortions. We calculated odds ratios (OR) with 95% CI. ResultsWhile 46% of the women chose oral contraceptives, 34% chose long-acting reversible contraceptives (LARC). LARC was chosen more commonly by women with a previous pregnancy, childbirth and/or abortion. During the follow-up period, 24% of the study population requested one or more repeat abortion(s). Choosing LARC at the time of the index abortion was associated with fewer repeat abortions compared with choosing oral contraceptives (13% vs. 26%, OR 0.36; 95% CI 0.24-0.52). Subdermal implant was as effective as intrauterine device in preventing repeat abortions beyond 3 years. ConclusionsChoosing LARC was associated with fewer repeat abortions over more than 3 years of follow up.

Place, publisher, year, edition, pages
WILEY-BLACKWELL, 2016
Keywords
Long-acting reversible contraception; post-abortion contraception; repeat abortion; subdermal implant; termination of pregnancy
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-128136 (URN)10.1111/aogs.12874 (DOI)000374349400012 ()26871269 (PubMedID)
Note

Funding Agencies|Futurum - the academy for healthcare; Jonkoping County Council; Medical Research Council of Southeast Sweden (FORSS)

Available from: 2016-05-19 Created: 2016-05-19 Last updated: 2018-11-26
2. Womens experiences of contraceptive counselling in the context of an abortion - An interview study
Open this publication in new window or tab >>Womens experiences of contraceptive counselling in the context of an abortion - An interview study
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2018 (English)In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 17, p. 103-107Article in journal (Refereed) Published
Abstract [en]

Objective: To identify and understand womens lived experiences of contraceptive counselling given at the same time as abortion counselling. Methods: We interviewed 13 women aged 20-39 who had experienced an abortion and the related counselling. The women were recruited from five hospitals in Sweden. Interviews were analysed using an interpretative phenomenological approach. Results: We identified two themes: need for respectful counselling and needs for guidance and access to contraceptives. The essence "Being in a state of limbo and feeling sceptical" was coalesced from the themes. The women described a state of limbo, as being caught in an unwanted and emotionally charged situation. They reported that respectful counselling and meeting a skilled health professional helped to dispel their scepticism and influenced their plans for contraceptive use post abortion. Furthermore, women who wanted an intrauterine device described difficulties in access post abortion. Conclusion: The women seem to have a limited receptivity to contraceptive counselling when they have an unwanted pregnancy and are sceptical about contraceptives. Women, who experience respect in the counselling, report being helped in contraceptive decision-making. To receive respectful counselling and to have good access to intrauterine devices emerged as central needs among women at the time of an abortion.

Place, publisher, year, edition, pages
ELSEVIER IRELAND LTD, 2018
Keywords
Accessibility; Contraception; Family planning; Intrauterine device; Pregnancy termination; Respect
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-152074 (URN)10.1016/j.srhc.2018.07.007 (DOI)000445980700018 ()30193713 (PubMedID)
Note

Funding Agencies|Futurum - the academy for healthcare in the Jonkoping County Council; Medical Research Council of Southeast Sweden (FORSS)

Available from: 2018-10-24 Created: 2018-10-24 Last updated: 2018-11-26
3. Contraceptive counselling of women seeking abortion - a qualitative interview study of health professionals experiences
Open this publication in new window or tab >>Contraceptive counselling of women seeking abortion - a qualitative interview study of health professionals experiences
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2017 (English)In: European journal of contraception & reproductive health care, ISSN 1362-5187, E-ISSN 1473-0782, Vol. 22, no 1Article in journal (Refereed) Published
Abstract [en]

Objectives: A substantial proportion of women who undergo an abortion continue afterwards without switching to more effective contraceptive use. Many subsequently have repeat unintended pregnancies. This study, therefore, aimed to identify and describe health professionalg experiences of providing contraceptive counselling to women seeking an abortion. Methods: We interviewed 21 health professionals (HPs), involved in contraceptive counselling of women seeking abortion at three differently sized hospitals in Sweden. The interviews were recorded and transcribed verbatim and analysed using conventional qualitative content analysis. Results: Three clusters were identified: Complex counselling, Elements of counselling and Finding a method. HPs often experienced consultations including contraceptive counselling at the time of an abortion as complex, covering both pregnancy termination and contraceptive counselling. Women with vulnerabilities placed even greater demands on the HPs providing counselling. The HPs varied in their approaches when providing contraceptive counselling but also in their knowledge about certain contraception methods. HPs described challenges in finding out if women had found an effective method and in the practicalities of arranging intrauterine device (IUD) insertion post-abortion, when a woman asked for this method. Conclusions: HPs found it challenging to provide contraceptive counselling at the time of an abortion and to arrange access to IUDs post-abortion. There is a need to improve their counselling, their skills and their knowledge to prevent repeat unintended pregnancies.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2017
Keywords
Contraception; decision-making; family planning; pregnancy termination; prevention; providers perspective; repeat abortion
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-136329 (URN)10.1080/13625187.2016.1238892 (DOI)000394925200002 ()27689407 (PubMedID)
Note

Funding Agencies|Futurum - the academy for healthcare, in the Jonkoping County Council [306501]; Medical Research Council of Southeast Sweden (FORSS) [467241]

Available from: 2017-04-10 Created: 2017-04-10 Last updated: 2018-11-26

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