Long-acting reversible contraceptive use in the post-abortion period among women seeking abortion in mainland China: intentions and barriers

Long-acting reversible contraceptives (LARCs) are the most cost-effective contraceptives for the prevention of unintended pregnancies, and the use of these medications during the post-abortion period reduces the rate of repeat abortions. However, the willingness of women to use LARCs during the post-abortion period remains uncertain; intentions and potential barriers to their use therefore require further investigation. This study explores the intentions and barriers to the use of LARC in the post-abortion period among pregnant women seeking abortion in mainland China.

Information was collected using a field questionnaire survey by convenience sampling methods. The survey contained 18 questions including socio-demographic information, sexual and reproductive health history, awareness, experience, intention, and barriers to use for each type of LARC in the immediate post-abortion period.

Of the 381 women seeking abortion with unintended pregnancy, approximately 42.5% were interested in using LARCs during the post-abortion period. 35.2% intended to use intra-uterine device (IUDs), while nearly 13.9% of the women intended to use the implant method during the post-abortion period, which suggested that this cohort of women preferred IUDs over implants. Intention to use LARCs was predicted by marital status, frequency of sexual activity, number of children, planned timing of the next pregnancy, and previous LARC use. Impaired future fertility, being harmful to health, irregular bleeding, risk of complications, and lack of awareness were the main barriers to the use of LARC. In order to increase access to LARCs in order to reduce unintended pregnancies in women, education and communication should focus on alleviating barriers to the use of LARCs.

Unintended pregnancy is an important public health challenge cross the world, as well as in mainland China. Unintended pregnancy has negative effects on the health of the mother and baby, leading to a sizeable, and potentially avoidable, cost burden [1]. According to the Chinese ‘health and family planning statistics annual publication’ (2014), unintended pregnancy results in 6.62 million abortions in mainland China [2]. Moreover, the rate of repeat induced abortions due to unintended pregnancies is also high in mainland China, with nearly half of the women seeking abortion having had at least one previous induced abortion [3]. Unintended pregnancy usually occurs due to contraceptive issues including emergency contraception failure (33.1%), incorrect use of contraception or a lack of condoms (28.6%) and use of the rhythm method (21.9%). Short-term family planning methods are less effective, and have a higher risk of contraceptive failure [4].

Long-acting reversible contraceptives (LARCs) are a type of contraceptive that is easily reversed and do not rely on the user to maintain efficacy for at least three years. Typical examples include intra-uterine devices (IUDs) and implants [5]. These are user-independent and exhibit higher compliance than short-acting methods [6]. Almost all women of reproductive-age who use LARCs can return to a fertile state, as the effects are reversible [5]. The mean time until return to fertility following the use of implants or IUDs is within days of cessation; faster than all progestogen-only oral contraceptives [5]. Trussell and Hassan et al. conducted a study to estimate the relative costs of short-acting reversible methods and LARC methods, and reported that LARCs were more cost-effective than short-acting reversible methods such as oral contraceptives, the ring, the patch, or injections over a three-year period [7]. The American College of Obstetricians recommends LARCs as an effective method with which to reduce the risk of unintended pregnancy and abortion [8].

Previous evidence has also shown that the use of LARCs during the post-abortion period reduces repeat abortion rates [9, 10]. However, LARC methods have been under-utilized during the immediate post-abortion period in mainland China [11, 12]. To provide a wider choice of more effective methods, and to encourage the continuation of this method, it is important to understand the intentions and barriers to LARC use in women seeking abortion, so that effective counseling practices and promotional policies can be implemented. However, little is known about the intentions and barriers to LARC use in Chinese women seeking abortion. Thus, the present study explored the intentions for LARC use and the factors associated with contraceptive choices among women with unintended pregnancy and seeking abortion in mainland China. Barriers to LARC use in the immediate post-abortion period were also identified.

This study identified that only around two-fifths of Chinese women seeking abortion were interested in using a LARC. One-third intended to use IUDs, while only one in seven intended to use the implant method during the post-abortion period. These findings were consistent with a previous study conducted in China [26], which suggested that consultation may enhance access to LARCs. Wei and Liu [26] found that only 11.1 and 1.8% of women seeking abortion chose IUDs and contraceptive implants during the immediate post-abortion period prior to consultation with health professionals. After consultation, the intended use of IUDs and implants increased to 19.7 and 2.7%, respectively.

The findings of the present study also indicated that women seeking abortion preferred IUDs to contraceptive implants. The one-child policy was introduced to control population in mainland China in 1979 [27]; however, since 2016, women in mainland China have been allowed to give birth to two children. During the period in which the one-Child policy was enforced, immediate post-placental insertion of an IUD was practiced as part of the standard care package received by all women following the birth of their first child [28]. This may have led to a high general level of acceptance of IUDs in China, while implants were relatively less known or under-used [26, 29].

Frequency of intercourse, marital status, number of living children, previous LARC use and excepted timing of next pregnancy were all shown to be significant predictors of a woman’s intention to use a LARC. In contemporary mainland China, having sex before marriage is widely accepted among unmarried Chinese women, and this cohort showed a high intercourse frequency, as well as a high rate of induced abortion [30]. Research has also shown that the rate of IUD use among unmarried women is low (6304, 7.42%) [31] and that the majority of these women use short-acting contraceptives after abortion instead of LARCs [12]. However, post-placental insertion of an IUD is usually recommended to married women by health professionals [32]. The use of LARCs during the immediate post-abortion period is not the standard form of care. This indicates that LARCs might be under-utilized among unmarried women who have a high frequency of intercourse, and it is therefore important to address the barriers to LARC usage among unmarried women with high intercourse frequency and to promote its use among this group in order to reduce the risk of unintended pregnancy and repeated induced abortion.

Furthermore, the present study found that women with no or only one child, or planned to have a child within two years were found to have less intent to use a LARC. A previous study by Fleming and Sokoloff also showed that women with more than one child were more likely to be interested in using IUDs than nulliparous women [22]. A study conducted by Anguzu and Tweheyo similarly indicated that women who had living children were 1.5-times more likely to use a LARC compared to nulliparous women [20].

Previous LARC use was associated with whether participants were interested in LARC use in the post-abortion period. Evidence indicated that LARC users had a high degree of satisfaction with respect to this type of contraceptive [33]. Women who had previously used LARCs were 1.49-times more likely to intend to use a LARC [34].

Finally, this study indicated that barriers to the use of LARCs during the immediate post-abortion period included “worry about future fertility”, “fear of harm to health”, “may cause irregular bleeding”, “fear of complications”, and “lack of awareness about the methods”. A previous study indicated that because women believed that LARC use would negatively impact upon their future fertility, they did not choose a LARC [35]. We similarly found that worry about future fertility was the main reason that women seeking abortion did not intend to use a LARC in the immediate post-abortion period. It is obvious that worries about the risk and side effects of LARCs was one of the main reasons preventing women from using LARCs. A study that surveyed women aged 16 to 25 years showed that factors influencing contraceptive technology choices included “familiarity with the methods”, “whether or not the method contained hormones”, “likely effect on periods”, and “other side effects” [36]. A population of women who desired sterilization also had concerns about the side effects of LARCs [21].

Another barrier was a lack of awareness with regards to these methods. An internet-based study of 1982 female undergraduates at a large mid-western university in the United States found that lack of education about LARCs was the primary reason participants rejected this method [37]. Whitaker et al. [23] found that women aged 14–24 were likely to have positive attitudes around IUD methods after undergoing a three-minute educational intervention, suggesting that such interventions may improve positive attitudes towards LARC use among women seeking abortions [9]. There remain many myths regarding the use of LARCs, particularly regarding its potential effect on future fertility, which may prevent women of reproductive age using it to avoid unwanted pregnancy [38]. In order to help women to make informed decisions, health care professionals should pay significant attention to providing women with information relating to LARCs, especially with regards to alleviating the barriers.

Our study has some limitations which should be taken into consideration. Firstly, this investigation was conducted in only one hospital and most participants were employed women of Han ancestry. These findings may not therefore be representative of other settings or apply to those who are not of Han ancestry or are unemployed. In addition, this study relied upon a questionnaire that relied upon self-reporting by the respondents. Thus, there was the potential for recall bias in these data. Finally, adding qualitative study questions could provide additional insights into these findings in future research.

This study has significant clinical utility for health care professionals working with Chinese women seeking abortion. To identify women seeking abortion who intend not to use LARCs, health care professionals should asses their marital status, frequency of sexual activity, number of children, planned timing of the next pregnancy, and previous LARC use.

Impaired future fertility, being harmful to health, irregular bleeding risk of IUD failure and lack of awareness with regards to LARCs were the main barriers to LARC use. It is important to promote the use of LARCs among unmarried Chinese women; particularly during the post-abortion period to reduce the risk of unintended pregnancy and repeated induced abortion. Health care professionals could develop strategies to enhance women’s intentions to use LARCs, such as providing information to alleviate the barriers to LARC use.