Knowledge, attitude and practice of post abortion contraception among MTP Seekers in a tertiary care hospital of North India

Introduction: Medical termination of pregnancy (MTP), despite legalization, is a greatly neglected health care problem of women in their reproductive age group and is not free from complications. Therefore, the present study was undertaken to study the factors influencing MTPs & the subsequent adoption of contraceptive methods following MTP. Materials and Methods: This cross-sectional study was conducted over one year and included 148 women who underwent MTP at the hospital. The details regarding their socio-demographic profile, reason for seeking abortion and acceptance of post abortal contraception were taken and analyzed by SPSS software. Results: Majority of women (93.92%) were aware of the various contraceptive methods available and awareness was maximum for condom (87.16%). The main source of information was television (76.35%). 85.81% women had no knowledge about emergency contraception. 89.20% patients came early for termination of pregnancy below 8 weeks. Completed family was the most common reason (62.84%). Post abortion contraception was accepted by 92.56% women. IUCD was the most preferred choice (51.35%). Decision regarding contraception was taken by both husband and wife in 45.95% cases. Conclusions: There is need to counsel women of reproductive age group that MTP is not a way to control unwanted birth and it is not free from risk. Eligible couples have to be educated regarding the availability of different methods of contraception and their proper use to avoid pregnancy.


Introduction
The term 'Medical termination of pregnancy' is defined as the willful termination of pregnancy before theperiod of viability of the fetus (20 weeks for all practical purposes).Although abortion has been legalized for more than four decades in India, still a major proportion of abortions are conducted by untrained persons at unauthorized place. 1 This practice of unsafe abortion remains one of the most neglected reproductive and sexual health problems in the world today. 2 It is estimated that 21.6million women experience an unsafe abortion worldwide each year. Of this, 18.5 million occur in developing countries. 3 In India, complications of unsafe abortion account for an estimated 9% of all maternal deaths. 4 Safe and legal abortion is considered a key intervention for improving women's reproductive health and quality of life. With the legislation of the MTP Act in 1971, India became one of the first countries legalizing abortion on moderately liberal grounds -particularly "failure of contraceptive use" for termination of pregnancy. 5 A strong motivation to seek an abortion rests on the widespread desire for smaller families, the need to control the timing of births and the failure or inconsistent use of contraception. Misinformation and apprehension about the different contraceptive options prevent widespread contraceptive use and abortion is used as an alternative to contraception. Encouraging eligible couples to use effective contraceptive methods is an effective way to reduce MTP.
The aim of the present study was to investigate the socio-demographic profile of pregnant women seeking MTP, the reasons for procuring abortion, the subsequent adoption of contraceptive methods following MTP and reasons for not adopting contraceptive methods.

Materials and Methods
The cross-sectional study was conducted in the department of Obstetrics and Gynecology, Santosh Medical College and Hospital, Ghaziabad, India, over a period of one year from January 2018 to December 2018. Total 153 women came for MTP in this period, out of which 148 women who consented for the participation in study were included. Subjects included all consenting married and unmarried women seeking MTP at the hospital during the study period. Women who did not consent or who self medicated MTP pills and reported to the hospital with some complications were excluded. Ethical approval was taken from the Institutional Ethics committee.
Detailed information regarding socio-demographic profile, obstetric history, duration of pregnancy and factors influencing MTP was collected through a pre designed structured questionnaire; and information regarding subsequent use of contraceptive methods, reasons for not adopting contraception were also collected. The pregnancies were confirmed by urine pregnancy test and the gestation age was confirmed by doing per vaginal examination and Ultrasonography.
The data obtained was statistically analyzed using percentage distribution and chi square test. P value < 0.05 was considered statistically significant.

Results
Out of 148 women who sought termination of pregnancy in the hospital during the study period, majority were less than 30 years of age (n=108, 72.98%), Hindu by religion, housewife, married and belonged to low-mid socioeconomic status (n=138, 93.2%). This data was highly statistically significant (p<0.0001). The socio-demographic characteristics of the women who underwent MTP (Table  1).  Table 2 depicts the obstetric history of the study subjects. Majority of the patients had two or more living children and at least one or more previous induced abortion (p<0.0001). 89.20% patients (n=132) came early for termination of pregnancy below 8 weeks (p<0.0001). The reasons for the termination of the current pregnancy are detailed in Table 3. Completed family was the most common reason (n= 93, 62.84%) for terminating the pregnancy. One patient (0.68%) was unmarried. Nine women (6.08%) did not give any reason for MTP. Post abortion contraception was accepted by 92.56% (n=137) women. Eleven women did not accept any contraception after MTP due to lack of support from the family (Fig. 1).
Only 14.19% (n=21) of the women were having knowledge of emergency contraception. 85.81% women (n=127) had no knowledge about it, and the data was highly statistically significant (p<0.0001).
Most of the participants obtained the information regarding contraception from multiple sources. The main source of information was television (n= 113, 76.35%) followed by friends and relatives (n=105, 70.95%), health personal/doctors (n=52, 35.14%) and social media like newspaper, internet etc (n=31, 20.95%).

Discussions
The medical termination of pregnancy act was passed by the Indian parliament to safeguard the life of women from illegal abortions, which is considered an important strategy under the Reproductive and Child health program II. In the present study, maximum abortions (n=108, 72.98%) were noted among women of 21-30 years age group. Similar findings were noted in a study conducted by Sathikumar M, 1 Yadav A 4 and Uma Maheswari R et al. 6 This shows that younger women seeks termination of pregnancy more frequently rather than the older women, which may be attributed to lack of maturity and decision making among younger women for accepting contraceptive measures either to postpone pregnancy or after the family is completed.
In the present study, 56.76% patients belonged to urban area and 43.24% to rural area. The high number of rural population could be because our hospital caters to patients from many surrounding villages that do not have facility of MTP at the PHCs. Majority of the study subjects belonged to urban area in study by Sathikumar M (80.3%) 1 and Uma Maheswari R. (75%). 6 Maximum numbers of MTP seekers were Hindus (94.59%). The results were comparable to other studies where 77.8% 4 patients were Hindus. Increased prevalence of abortion in Hindus may be because of their greater population. Moreover, Hindus are more liberal and easily opt for family planning measures including abortion. Muslim women have both less access to and less demand for induced abortion owing to religious norms.
46.62% of the women were either illiterate or had primary education. Similar results were seen in study by Yadav A (29.6%). 4 However, the results were higher in studies by Uma Maheswari R 6 and Patniak M 7 (72.3% and 65.6% respectively), indicating that the lower educational status makes the women more vulnerable to unwanted pregnancies. The highly educated women might be using appropriate contraceptive methods to space or avoid their pregnancies.
Maximum number (93.24%) of women who had come for MTP belonged to the lower or lower-middle socioeconomic status. Similar results were seen in other studies (94% & 84.4%. 6,7 Lower educational and lower social status of the women are the reasons for their repeated and unwanted conceptions making them vulnerable to all the possible risks of morbidity and mortality due to abortions. Working women seemed to be more aware of contraceptive methods and their needs as they constituted only 10.14%. Our results were comparable to other studies (6.48% & 16%). 4,7 The present study showed that 77.70% MTP seekers had two or more living children. Similarly, other studies also showed comparable results (84.25%, 88.6%), 4,6 revealing the fact that in spite of the completed family size, these women got unwanted pregnancy and came for MTP. There is a need to make these women aware of and to motivate them for accepting various contraceptive measures available.
Majority of the women (89.20%) came in early pregnancy (< 8weeks) for MTP and only 2.70% came beyond 12 weeks. Yadav A 4 also observed majority of abortions (97.22%) before 12 weeks of pregnancysuggesting a better awareness towards the family planning programme.
In present study, most common reason for MTP was completed family (62.84%), followed by previous baby too young (20.27%) and contraception failure (5.41%) in the form of forgotten pill or rupture of condom. Our findings were consistent with other studies (62.96%, 85.90%), 4,6 where completed family was the commonest cause for MTP. This supported the fact that many women consider termination of pregnancy as a method of contraception. The emphasis of family planning measures should be laid upon these target couples.
In our study, 51.35% patients accepted IUCD as the post abortal contraceptive method, followed by barrier method (20.95%), female sterilization (18.24%) and OC pills (2.02%). 7.44% did not agree to use any contraception. Another study also had similar results where 70% patients accepted IUCD. 1 The reason for poor acceptance for permanent sterilization may be attributed to lack of family support and poor knowledge regarding the contraceptive measures. Our findings were not consistent with the studies done by Yadav A 4 and Uma Maheswari 6 where maximum women (58.33% and 87.5% respectively) accepted permanent method as a mode of contraception after MTP.
In the present study, in 45.95% cases both husband and wife were decision maker for post MTP contraception. It shows good spousal communication; but only in 11.48% cases women herself was decision maker. It seeks empowerment of women. Husband alone took decision in only 16.22% cases, which was in contrast with another study in which decision regarding choice of contraceptive method was taken by husband alone in 40.74%. 4 This implies that, for many, the decision for family planning often involves a women's spouse and in-laws.
In our study, only 14.19% had knowledge about emergency contraceptivepill. The awareness about emergency contraceptive pill was very low in other studies also (12.03%, 0%). 4,6 This reflects that emergency contraception is an area which needs to be promoted so that unwanted pregnancy can be avoided safely and conveniently, particularly for those who are inconsistent contraceptive users as well as those who have never used a contraceptive method. But emergency contraceptive pill should definitely not be considered or promoted as an alternative to regular contraceptive methods.

Conclusion
Abortion despite legalization is a greatly neglected health care problem of women in their reproductive age-group.
There is a need to counsel women of reproductive age group that MTP is not a way to control unwanted birth and it is not free from risk. Counseling for post-abortal contraceptive should be provided to the couple so that they can make an informed choice. Contraceptive services should also include emergency contraceptives to prevent unwanted pregnancy due to unprotected sex.