Baynes et al. BMC Women's Health (2019) 19:22 https://doi.org/10.1186/s12905-018-0687-9 RESEARCHARTICLE Open Access What contraception do women use after experiencing complications from abortion? an analysis of cohort records of 18,688 postabortion care clients in Tanzania Colin Baynes1* , J. Kahwa2, G. Lusiola2, F. Mwanga2, J. Bantambya2, L. Ngosso2 and M. Hiza3 Abstract Background: The family planning component of postabortion care (PAC) is critical, as it helps women to prevent unintended pregnancies and reduce future incidence of life-threatening unsafe abortion. In Tanzania, PAC was recently decentralized from tertiary-level district hospitals to primary health care dispensaries in four regions of the country. This analysis describes interventions used to improve access to high quality PAC services during decentralization; examines results and factors that contribute to PAC clients’ voluntary uptake of contraception; and develops recommendations for improving postabortion contraceptive services. Methods: This analysis uses service delivery statistics of 18,688 PAC clients compiled from 120 facilities in Tanzania between 2005 and 2014. Results: This study suggests that efforts to integrate postabortion family planning into treatment for incomplete abortion contributed to higher postabortion contraceptive uptake (86%). Results indicate that variables associated with significant differences in contraceptive uptake were facility level, age, gestational age at the time of treatment, and uterine evacuation technology used. Conclusion: The experience of expanding PAC services in Tanzania suggests that integrating contraceptive services with treatment for abortion complications can increase family planning use. Keywords: Postabortion care, Family planning, Contraceptive uptake, Decentralization, Tanzania Background from the uterus and family planning services (FP). The In 2012, approximately 213 million pregnancies occurred latter component of PAC includes discussion of post- worldwide, of which 85 million (40%) were unintended. abortion fertility, optimal and desired timing of future Half of these ended in induced abortions [1] . During childbearing after the evacuation procedure, contracep- this year, 7 million women who had induced abortions tion, and, if the client chooses, the actual provision of a received lifesaving treatment for complications from contraceptive method. Over time, a holistic program- unsafe pregnancy termination. This treatment, postabor- ming model was developed that includes community tion care (PAC), is a service package that addresses the sensitization and mobilization to address demand-side emergency treatment and preventive health care needs barriers to access to PAC services (Fig. 1). In spite of of women experiencing complications from early preg- global progress in this regard, estimates made by health nancy termination, both spontaneous and induced. This professionals (averaged across several surveys conducted includes evacuation of residual products of conception between 2000 and 2008) indicate that only 60% of women experiencing complications from abortion were expected to have accessed PAC, with the remaining * Correspondence: [email protected] 1EngenderHealth, 440 Ninth Avenue, New York City, NY 10001, United States two-fifths of women with postabortion complications Full list of author information is available at the end of the article not receiving such care [2, 3]. It follows that unsafe © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Baynes et al. BMC Women's Health (2019) 19:22 Page 2 of 12 Fig. 1 The Postabortion Care (PAC) Model abortion accounts for a sizeable proportion of all Accordingly, contraceptive services are an essential maternal deaths globally (8%), mostly in developing component of PAC. Various international technical countries [4]. working groups and organizations have concluded that a Strengthening contraceptive provision during PAC is range of contraceptive methods, accurate information, critical, as it helps women to prevent unintended preg- counseling, and referral for ongoing care should be nancies and reduce future incidence of unsafe abortion. made available to women who have received PAC, and Women seeking postabortion emergency care are par- that this should start before they are discharged from a ticularly in need of contraceptive services: These clients facility [9, 13]. The U.S. Agency for International Devel- are sexually active and at risk for subsequent pregnancy, opment (USAID) has offered guidance on high-impact not currently pregnant, and often highly desirous of practices for operationalizing these recommendations in avoiding childbearing. They are in contact with the health service delivery and management settings [14]. health system, are often disinclined to return to the facil- Furthermore, multiple studies have shown that women ity for a follow-up visit [5–7], and, according to global who receive PAC services that include FP have high recommendations, are advised to delay a subsequent contraceptive uptake [15, 16]. Studies in developed and pregnancy for at least six months, for optimal health of developing countries assessing facility-level interven- the woman and her future newborn [8, 9]. tions, such as providing contraception in the same loca- Fertility can return 1–2 weeks after vacuum aspiration tion and the same time as PAC, show that offering a of the uterus or medical treatment for abortion compli- wide range of methods and using obstetric and midwif- cations [10, 11]. All contraceptive methods are safe to ery staff to provide contraception improves overall use after PAC emergency treatment, whether it is per- uptake of a contraceptive method [17]. formed medically, through uterotonic drugs, via vacuum This paper describes the process and effects of aspiration, or surgically to remove residual products of expanding access to PAC, including postabortion FP ser- conception. When treated medically, a PAC client may vices, in mainland Tanzania. The legal status of abortion start using hormonal methods—including oral contra- in Tanzania is ambiguous: the penal code is broadly ceptives, injectables, and implants—immediately after understood to authorize abortion to save a woman’s life, the onset of treatment, and an intrauterine device (IUD) but provisions for this, or allowance for it in the case of may be placed when it is certain that the uterus is rape or incest, are not incorporated into national law empty. After vacuum aspiration, all methods, including that prohibits the practice. The lack of clarity creates IUDs and implants, may be started immediately follow- confusion amongst providers and women who fear ing a first- or second-trimester procedure. Only women persecution, which, in turn, pushes women to seek abor- who have had a septic abortion or evacuation with sharp tion clandestinely. In 2013, women obtained just over curettage should wait until they are healed before having 405,000 abortions, for a national rate of 36 abortions per an IUD inserted, but they may start any other method of 1000 women aged 15–49 and ratio of 21 abortions per contraception. Providing voluntary methods at the time 100 live births. For each woman treated for an induced of PAC, rather than at a follow-up visit, increases abortion complication, 6 times as many had an abortion, contraceptive uptake and reduces future risk of unin- but did not receive care [18]. According to the Ministry tended pregnancy [12]. of Health, Community Development, Gender, Elderly Baynes et al. BMC Women's Health (2019) 19:22 Page 3 of 12 and Children (MOHCDGEC), 19% of maternal deaths in PAC treatment as per MOHCDGEC policy in mainland Tanzania are due to abortion complications [19]. Tanzania. Lastly, the model used to expand PAC cover- From 2005 to 2014, the MOHCDGEC implemented age included community awareness raising and facility-based, provider-focused, and community-level mobilization. For this, service providers, convened health system interventions to improve the accessibility community meetings in their catchment communities and quality of PAC services, with technical assistance during outreach events that centered on other primary from EngenderHealth, an international nongovernmental health care issues. During these occasions, providers organization. Global guidance on the design and delivery educated communities on complications from early ter- of PAC was tailored into implementation approaches mination of pregnancy and forged linkages with commu- that were contextually appropriate to the cultural, health nity health volunteers, whom educated them on FP and care delivery, and broader environmental context of PAC and encouraged to convene community discussion rural and peri-urban Tanzania, where this work was con- groups on these issues. For clients that extended their ducted. Between 2005 and 2014, the MOHCDGEC and permission to do so, volunteers would conduct home health care providers in Tanzania decentralized