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Every woman should have the opportunity to make an informed choice about the contraceptive method that’s right for her. However, when it comes to family planning following an abortion, we know that not every woman has that choice.
To better support women following an abortion, at Marie Stopes International we have worked to understand: Which approaches enable quality post-abortion contraception counselling, and which don’t?
In this article, we’ll share three of the key lessons we’ve learned, in the hope that these learnings will help other implementers to roll out quality post-abortion contraception elsewhere too.
The challenge: how to support every woman with high-quality contraceptive counselling
To enable women to determine their own futures, it’s essential that effective contraception and supportive counselling is available. It’s been found that including this counselling within a safe abortion and post-abortion care service, also known as post-abortion contraception or post-abortion family planning, can help in reducing future unwanted pregnancies.
In recognition of this, we wanted to establish whether women served across MSI’s country programmes are receiving supportive counselling in tandem with their services, or whether there was something holding them back from accessing effective contraception. These barriers can arise at a number of levels:
- At the facility level, for example, from a lack of family planning commodities or trained providers
- At the provider level, for example, if the provider delivers no counselling, or their counselling is biased
- At the client level, for example, if the woman is concerned about contraceptive side effects.
Since 2012, MSI evaluated several interventions to see how we can deconstruct these barriers and expand access to more women. Below we’ve shared what we found worked.
3 lessons on providing balanced post-abortion family planning counselling
Lesson 1: Make family planning counselling a central element of your safe abortion and post-abortion care training and quality monitoring
Although it’s been found that counselling women on family planning following an abortion can reduce client-level barriers in low-income countries, we also know there’s no silver bullet.
Every woman is different and contraceptive counselling should always be tailored to needs and preferences – including medical eligibility, fertility desires and lifestyle. Balanced contraceptive counselling takes time and skill, so providing post-abortion contraceptive counselling needs to be a key component of training and quality monitoring.
To ensure providers are delivering post-abortion counselling, MSI made it a priority across our channels, including our social franchise clinics where we upskill private providers to scale up access to safe services.
In 2015, we tested approaches to upskill and monitor independent private providers delivering safe abortion and post-abortion care. The interventions included:
- A one day training orientation for providers on post-abortion contraception, including balanced counselling, values clarification, method-specific counselling and data management
- A job aid to support a step-by-step provision process for post-abortion contraception with a focus on balanced family planning counselling
- Monthly structured supervision visits using a checklist to verify social franchise data quality, monitor post-abortion contraception uptake and ensure adequate stock.
By upskilling providers to deliver balanced, supportive counselling and providing them with the tools and support to track this provision on a regular basis, clinics involved in one intervention extended access to contraception considerably. The number of women choosing to take up contraceptive following a post-abortion care service increased from 19 to 31%.
Lesson 2: Expect high-quality counselling for 100% of women
In 2014, it was identified that the current method mix in Nepal was suboptimal, with 71% of post-abortion clients choosing to take-up either no contraception or a short-term method. Findings from Sunaulo Parivar Nepal, an implementing partner of Marie Stopes International, confirmed this too.
Sunaulo Parivar Nepal provide around 40,000 safe abortions every year. Half of the women served shared that they would like to delay their next pregnancy by at least two years. However, despite the clinics offering reliable long-acting reversible contraceptive methods (LARCs) at an affordable price, uptake of LARCs following an abortion remained low overall, with one in four women choosing to take one.
To understand how we could better serve the women who do not intend to get pregnant again soon, by increasing access to LARCs, we collaborated with Ideas42 to undertake a behavioural economics intervention. The aim was to ensure clinics offered tailored contraceptive counselling and a good method mix to all women visiting their clinics.
Following in-depth interviews with providers, we established that although providers are well-trained and well-motivated, they faced two key provider-level barriers:
- As no performance data was shared between clinics, they found it difficult to benchmark their service delivery against others
- In larger clinics, role sharing and diffusion of responsibility made it easier to assume that another colleague had provided the client with post-abortion family planning counselling.
The outcome was a lack of accountability and consistency in post-abortion contraceptive counselling. This meant women were not receiving the counselling they need to make an informed choice on onward contraception, leading to an imbalance in method mix.
To address this shortfall, we began sharing analytics between the clinics. We sent monthly posters to each clinic comparing contraceptive uptake in their clinic with other similar clinics in the network. This set the aim of providing client-centred contraceptive counselling to all safe abortion clients, to provide women with an informed choice over their onward contraceptive options.
The intervention presented a low-tech and cost-effective solution that was successful in extending access to women. Uptake of LARCs grew from 22.6% to 29.6% as providers shared that the posters helped them to shift their focus to providing consistent post-abortion contraceptive counselling to all clients and a good method mix, including both short-term methods and LARCs.
Lesson 3: Provide family planning counselling that fits your client’s schedule
On our Cambodia programme, we identified that many women feel unprepared to decide on a family planning method on the same day as their safe abortion or post-abortion care services.
The 2010 DHS survey found that 81% of women of reproductive age either reported wanting to delay their next child or to have no more children, but that only 35% were using contraception. In many cases, women wished to complete the abortion process first or consult with their partners, friends and family before accessing contraception.
As our research also revealed that 90% of women owned a mobile phone, we spotted an opportunity. We decided that our post-abortion counselling should be more tailored, so began providing follow-up information regarding post-abortion contraception via voice messages, sent to the mobile phones of participants.
The mHealth phone messages provided information on contraceptive options, linking women to a Marie Stopes call centre for personalised counselling or to schedule an appointment. With 80% of the population living in rural areas, the messages enabled us to maintain contact and provide contraceptive counselling that better fitted our clients’ schedules.
Participants received the first message within 1 week of using abortion services and every 2 weeks thereafter. An example message, recorded in the Khmer language, read:
Hello, this is a voice message from a Marie Stopes counsellor. I hope you are doing fine. Contraceptive methods are an effective and safe way to prevent an unplanned pregnancy. I am waiting to provide free and confidential contraceptive support to you. Press 1 if you would like me to call you back to discuss contraception. Press 2 if you are comfortable with using contraception and you do not need me to call you back this time. Press 3 if you would prefer not to receive any more messages.
The intention of the phone calls was to enable effective use of contraception by:
- Providing personalised advice from a trained counsellor at Marie Stopes International Cambodia on a range of contraceptive methods
- Increasing their opportunity to access contraception, for example, by sharing where she could access contraceptive methods near her
- Increasing motivation by reinforcing the benefits of contraception. At the participant’s request, the counsellor could also discuss contraception with her husband or partner.
The impact of the trial was significant. By linking women with information and counselling through their mobile phone, Marie Stopes Cambodia increased access to women in both rural and urban areas. 4 months into the trial, 29% of women in the study reported using a LARC, versus only 9% in the control group.
As with most family planning services, there is no silver bullet when it comes to contraceptive counselling following an abortion service. Every woman is different and it’s only through knowledge of her medical eligibility, fertility plans, lifestyle choices and preferences that services can effectively advise on the most appropriate post-abortion contraceptive options.
There are, however, several approaches that can help along the way. From providing thorough training on family planning counselling, including useful job aids for safe abortion and post-abortion care providers, to delivering follow-up care and advice that fits around your client’s schedule, we can work towards ensuring that every woman receiving safe abortion and post-abortion care services has access to an informed choice on her future contraceptive options.
In this article, we shared a few of the lessons we’ve learned through our safe abortion and post-abortion care programming at Marie Stopes International. However, it would be great to know if you’ve trialled any approaches to improving post-abortion contraception counselling too. If you have any questions or suggestions, please do share them in the comments below.