Abortion and Repeat Abortion In Grampian A report for the Sexual Health and Blood Borne Virus Managed Care Network (MCN) NHS Grampian March 2015 This document is also available in large print and other formats and languages upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245. Contents Page Acknowledgements 1 Glossary 2 Foreword 3 Recommendations 4 Introduction 5 Section 1: Abortions in Grampian (2009-2013) 6 1. Background 6 2. Overview of abortion rates in Grampian: ISD Data 6 2.1 Grounds for abortion 7 2.2 Abortion rates and deprivation 8 3. Abortion rates by age and local authority area 9 3.1 Aberdeen City 9 3.2 Aberdeenshire 9 3.3 Moray 11 4. Abortion rates by intermediate zone 11 4.1 Aberdeen City 11 4.2 Aberdeenshire 12 4.3 Moray 13 5. Abortion rates by deprivation 15 5.1 Aberdeen City 15 5.2 Aberdeenshire 15 5.3 Moray 15 6. Abortion rates by GP cluster zone 17 6.1 Aberdeen 17 6.2 Aberdeenshire 17 6.3 Moray 17 7. Travel times to Aberdeen Royal Infirmary and Dr Grays 19 8. Key Findings 22 Section 2: Repeat abortions in Grampian (2010-2013) 23 1. Background 23 2. Results: Analysis of the Grampian TOP Database 23 2.1 Comparison of characteristics of women with 24 single and multiple abortions 2.2 Multivariate analysis 24 Section 3: International Systematic Review – Determinant 29 factors of repeat abortion 1. Background 29 1.1 Definitions 30 2. Systematic review 30 2.1 Systematic review methods 30 2.2 Scope of the review 30 2.3 Search strategy 31 2.4 Inclusion Criteria 31 2.5 Exclusion Criteria 31 2.6 Data extraction and assessment for study inclusion 31 3. Results 32 4. Data synthesis 38 4.1 Familial factors 38 4.1.1 Socioeconomic status 38 4.1.2 Ethnicity 39 4.1.3 Education 39 4.2 Urbanisation and rurality 40 4.3 Individual level factors 40 4.3.1 Age 40 4.4 Age at first pregnancy 41 4.5 Marital status 41 4.6 Relationship 42 4.7 Previous obstetric history 42 4.8 Contraception usage 43 4.8.1 Comparison with one abortion 43 4.8.2 Contraceptive method 43 4.8.3 Comparison with no abortion 44 4.8.4 Emergency contraception 45 4.8.5 Contraceptive usage post abortion 45 4.9 Sexual behaviour 45 4.9.1 Intentions and motivations 45 4.10 Psychosocial 46 4.10.1 Mental illness 46 4.10.2 Abuse 46 4.10.3 Substance abuse 47 4.10.4 Smoking 47 4.10.5 Adverse life events 47 4.10.6 Sexual health and past medical history 48 4.10.7 Intervention studies 48 5. Discussion 48 5.1 Principle findings 48 5.1.1 Systematic review 48 5.1.2 Secondary data analysis 50 5.2 Strengths and limitations 50 5.2.1 Systematic review 50 5.2.2 Secondary data analysis 51 5.3 Context of findings from secondary analysis 51 References 53 Appendices Acknowledgements This report is produced on behalf of the Grampian Managed Care Network for Sexual Health and Blood Borne Viruses led by Executive Lead, Dr Emmanuel Okpo. Data on Abortions in Grampian were compiled by Rochelle Morgan, Senior Analyst, NHS Grampian and Sarah Shanks, Public Health Locum Associate Specialist, NHS Grampian. Data on repeat abortions and investigation into the determinants of repeat abortion were compiled by a team based at the University of Aberdeen. Thanks are therefore expressed to the principle investigator Dr Sohinee Bhattacharya and co-investigators Dr Mari Imamura and Dr Gillian Flett. Mr Stephen McCall, Dr Umi Nursheila Nur Ibrahim and Dr Emmanuel Okpo are also noted for their contribution as authors. Finally, special thanks to Dr Sue Brechin, Consultant in Sexual and Reproductive Health for reviewing the report and Lisa Allerton, Public Health Researcher for reviewing and compiling the final report. 1 Glossary AOR Adjusted Odds Ratio ARI Aberdeen Royal Infirmary BBV(s) Blood Borne Virus(es) CI Confidence Interval CMO Chief Medical Officer COC Combined Oral Contraception EMBASE Excerpta Medica dataBase ISD Information Services Division HIS Health Improvement Scotland IUD Intrauterine Device IUS Intrauterine System LARC Long Acting Reversible Contraception MEDLINE Medical Literature Analysis and Retrieval System Online MeSH Medical Subject Heading NHS National Health Service RCOG Royal College of Obstetrics and Gynaecology SH&BBV(s) Sexual Health and Blood Borne Virus(es) SIMD Scottish Index of Multiple Deprivation SMR1 Scottish Morbidity Record STI(s) Sexually Transmitted Infection(s) TOP Termination of Pregnancy UK United Kingdom US United States WHO World Health Organization 2 Foreword The Managed Care Network (MCN) for Sexual Health and Blood Borne Viruses in Grampian brings together partners from across the NHS, local authorities and the third sector. The overall objective of the MCN is to plan and review actions to promote health, prevent, diagnose and treat ill health as a result of sexually transmitted infections, blood borne viruses and unintended pregnancies. Abortion and repeat abortion are a direct consequence of unintended and unwanted pregnancy. In order to better understand the current patterns and trends of abortion and repeat abortion in Grampian, a review, culminating in this report, was undertaken. In Grampian, we are fortunate to have excellent data collection on abortions locally through the Grampian Termination of Pregnancy (TOP) Database. This database collects rich data which allows us to look further than nationally collected data which is published annually by NHS Information Services Division (ISD). Moreover, our academic colleagues at the University of Aberdeen have also assisted us with adding to our knowledge base by looking at factors associated with repeat abortions, something which is of particular concern to us here in Grampian. Our review has confirmed that abortion is linked to deprivation and younger women (15-24) are more likely to attend for abortion. We also know that the contextual factors surrounding abortion and repeat abortion are multifaceted with family stability, education, contraceptive use, relationship stability and psychosocial factors all impacting on increased risk of abortion. However, this report provides us with an evidence base from which we can set our direction for the future starting with the recommendations for improvement and further investigation. There is a lot of information contained in this report and it is the responsibility of the MCN, within the context of the Grampian Sexual Health and Wellbeing and Blood Borne Virus Strategy, to consider this and take forward the recommendations. The MCN manager can be contacted on (01224) 558569. We would like to thank everyone who contributed to this needs assessment and all those who gave freely of their time. Susan Webb, Emmanuel Okpo, Deputy Director of Public Health Consultant in Public Health Medicine 3 Recommendations 1. Results suggest that some intermediate zones have increased rates of abortion which is at odds with our local knowledge of population demographics and deprivation. Therefore rates of abortion by intermediate zone warrants further investigation. 2. In Grampian, abortion rates are highest in the age group 15-24 years and women are more likely to have a repeat abortion if they had their first abortion at a young age (under 20 years old). Being sexually active at a younger age therefore may expose women to an increased risk of conception and subsequent abortions during their reproductive years. Consideration should be given to how best to engage with young women who are sexually active at a young age to assist them in planning pregnancies and to reduce the risk of unplanned pregnancy. 3. Literature suggests that there is a strong association between older age and repeat abortion. It is unclear whether this is because by definition women at a repeat abortion will be older or if this represents a group of women who are more likely to attend for further abortion(s) due to other factors such as increased parity which has been shown to increase repeat abortion. This requires further investigation. 4. Results indicate that most women use a form of contraception prior to their repeat abortion. Although ‘self-reported method failure’ is collected locally, detailed information on the circumstances of failure and whether the repeat abortion was due to ‘true method failure’ or ‘ presumed user failure’ would be useful to collect to assist in developing tailored contraceptive advice and counselling following repeat abortion. 5. There was some evidence in the literature that the use of LARC post abortion reduces the risk of further abortions. Evidence from our local dataset contradicted this. Women attending for repeat abortion in Grampian who had left with a LARC method following a first abortion were significantly more likely to have a repeat abortion. Investigation into LARC uptake, continued use and reasons for discontinuation following abortion in Grampian is required. 6. There appears to be an association between psychosocial factors and repeat abortion. At present psychosocial factors are not recorded in the TOP database. This should be considered for future research purposes. 7. Studies suggest that women from lower socioeconomic quintiles have an increased likelihood of repeat abortion. This is consistent with our own local data and ISD data. This has public health implications in terms of addressing inequalities in health and wellbeing in addition to accessing sexual health services. As such, careful thought should be given to how best to target women who are considered to be at increased risk of repeat abortion, particularly those who live in the most deprived quintiles. 8. Further clarification and investigation is required to establish actual versus indicated travel time to specialist sexual health services for women undergoing an abortion. 4 Introduction Reducing the number of abortions is central to achieving the national outcomes as outlined in the Sexual Health and Blood Borne Virus (SH& BBV) Framework for Scotland (Scottish Government, 2011).