Elsevier

Contraception

Volume 87, Issue 1, January 2013, Pages 17-25
Contraception

Review article
Postabortion family planning counseling and services for women in low-income countries: a systematic review

https://doi.org/10.1016/j.contraception.2012.07.014Get rights and content

Abstract

Background

Unsafe abortion imposes heavy burdens on both individuals and society, particularly in low-income countries, many of which have restrictive abortion laws. Providing family planning counseling and services to women following an abortion has emerged as a key strategy to address this issue.

Study Design

This systematic review gathered, appraised and synthesized recent research evidence on the effects of postabortion family planning counseling and services on women in low-income countries.

Results

Of the 2965 potentially relevant records that were identified and screened, 15 studies satisfied the inclusion criteria. None provided evidence on the effectiveness of postabortion family planning counseling and services on maternal morbidity and mortality. One controlled study found that, compared to the group of nonbeneficiaries, women who received postabortion family planning counseling and services had significantly fewer unplanned pregnancies and fewer repeat abortions during the 12-month follow-up period. All 15 studies examined contraception-related outcomes. In the seven studies which used a comparative design, there was greater acceptance and/or use of modern contraceptives in women who had received postabortion family planning counseling and services relative to the no-program group.

Conclusions

The current evidence on the use of postabortion family planning counseling and services in low-income countries to address the problem of unsafe abortion is inconclusive. Nevertheless, the increase in acceptance and/or use of contraceptives is encouraging and has the potential to be further explored. Adequate funding to support robust research in this area of reproductive health is urgently needed.

Introduction

Unsafe abortion imposes serious health and economic costs on both individuals and society [1], [2]. As one of the easiest preventable causes of maternal mortality, it is estimated that 90% of abortion-related morbidity could be prevented by use of effective contraception; where effective contraceptive methods are available and widely used, the total abortion rate declines sharply [3], [4]. Globally, millions of women lack access to appropriate contraceptive methods; use in low- and middle-income countries is generally much lower than that in developed countries [5]. Over 80% of unintended pregnancies in developing countries occur among women who have an unmet need for modern contraception [6]. Whilst greater use of contraception will not produce direct, immediate effects on maternal mortality or morbidity, over time, it should reduce women's recourse to unsafe abortion, thereby putting women at less risk of lifelong injury or death [7], [8].

The 1994 Cairo Programme of Action placed a particular emphasis on the importance of postabortion counseling and family planning as part of a comprehensive package of postabortion care (PAC) [9]. Improving access to contraception information, services and supplies is now increasingly advocated by policymakers as the best way to reduce the demand for abortion and thus lower maternal mortality and morbidity overall [10], [11], [12]. The production and dissemination of systematic reviews are important steps in strengthening the international communities’ capacity for evidence-informed decision making [13]. Recent reviews in this area, however, either have been nonsystematic [14] or have included literature conducted in high-income countries only [15]. The objective of this systematic review was to gather and synthesize the available research evidence on the impacts of postabortion family planning counseling and services on women in low-income countries. An extended version of this article is available as a technical report [16].

Section snippets

Study identification

We searched PubMed, Popline, CINAHL, Cochrane database, Sociological abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Virtual Health Library and health research databases/specialist registers held at the EPPI-Centre [17]. The following Web sites were hand-searched: Ipas, Jhpiego, Family Health International, Marie Stopes International, Population Council, Postabortion Care Consortium, Gynuity Health Projects EngenderHealth, PRIME II and Eldis. In

Main results

A total of 2965 potentially relevant records were identified, of which 15 studies satisfied the inclusion criteria [19], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]. A summary of the characteristics and the findings of the included studies is shown in Table 1. Study designs varied: one matched controlled study [25], one unmatched controlled study [35], five separate pre–post samples design studies (i.e., those that compare a group of participants receiving

Discussion

Overall, there is a lack of good quality research in this area, and evidence regarding the impact of providing family planning services and contraception to postabortion women in low-income countries is sparse. This systematic review identified no evidence on the impact of such programs on maternal mortality and morbidity: a not altogether unexpected result since these outcomes are widely recognized as difficult and expensive to measure [36]. We found insufficient evidence regarding the impact

Conclusion

This review, initiated and funded by the UK Department for International Development, provides an important and timely contribution to efforts to address the gap in the provision of a systematic and unbiased assessment of evidence specific to developing countries. Given the high number of unsafe abortions in low-income countries and their wide-ranging impact on maternal health, the lack of conclusive evidence on the efficacy of family planning interventions provided to women following an

Acknowledgments

We wish to thank Josephine Kavanagh for her input to the grant application and protocol, Claire Stansfield for her contribution to the literature search and Professor Sandy Oliver for her comments on the final technical report.

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    Funding: UK Department for International Development (DFID).

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