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| Journal of the New Zealand Medical Association,
21-November-2003, Vol 116 No 1186
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Contraception before and after termination of pregnancy: can
we do it better?
Felicity Goodyear-Smith and Bruce Arroll
The general abortion rate (per 1000 estimated mean number of
women aged 15 to 44 years) has been rising steadily in New Zealand, from 14 in
1990 to 16.2 in 1995, and 19.4 in 2001.1 This
is a significantly higher rate than found in a number of other counties in the
Western world; for example, in 1999 the Netherlands recorded a rate of 7.4 and
Germany 7.7; in 2000 Finland recorded 10.7. On the other hand, some Western
countries have even higher rates: in 1996 in Australia and 1997 in the United
States, the rate was about 22. Sexual health education including accurate
information on contraceptive methods and access to reliable contraception should
reduce the need for termination of unwanted pregnancies resulting from either
the failure of contraceptives or the lack of their use.
The grounds considered permissible for legal abortion under
New Zealand law are that the mother’s physical or mental health is
endangered by the pregnancy. Abortion law reform came into place in 1977 whereby
termination of pregnancies subsisting for no more than 12 weeks were legalised
to be performed in licensed premises if two certifying consultants authorised by
the Abortion Supervisory Committee assessed the woman and determined that she
had grounds for the procedure to
occur.2
New Zealand law does not allow ‘abortion on
demand’. The Act stipulates that the decision of whether or not an
abortion is performed cannot be a matter entirely ‘for the woman and a
doctor to decide’, but rests solely on whether or not the woman meets the
specified grounds. Generally, it is determined on the grounds of fears for her
mental rather than physical health should the pregnancy continue. Women who have
suffered the emotional distress of an unwanted pregnancy and who meet the
grounds for termination are given comprehensive contraceptive advice to minimise
the chance of subsequent unplanned conception.
Contraceptive information is freely available in New Zealand
and is included in the secondary school
curriculum.3 New Zealanders have access to
contraception through general practitioners and family planning clinics
throughout the country. Condoms are available over the counter (OTC) at
pharmacies and supermarkets, as well as from vending machines in some locations.
Recently, the emergency contraceptive pill (0.75 mg levonorgesterol) has also
been available OTC.
Unwanted pregnancies result either from lack of
contraceptive use, or failure of the chosen method. Relative use of
contraceptive methods is influenced by a number of factors, including the
availability, cost and perceived effectiveness and safety of each method. It is
of interest to determine whether the use, or lack of use, of various
contraceptive methods by women presenting for termination is changing over
time.
The aim of this study was to compare contraceptive use prior
to unplanned conception and following therapeutic abortion in the years 1995,
1999 and 2002 in women presenting to a New Zealand abortion clinic.
MethodsA retrospective review was
conducted of 200 consecutive cases of women attending a New Zealand clinic for
assessment for termination of pregnancy in mid-1995, 400 in mid-1999, and 400 in
mid-2002. The initial audit (1995) was of 200 cases, but in 1999 it became
apparent that ‘panic-stopping’ of the pill was contributing unwanted
pregnancies, and the sample size was increased to 400 to more accurately
evaluate the significance of this effect. The sample size of 400 was repeated in
2002 to improve the ability to compare samples.
Information collected included demographic details
(age, ethnicity, parity, number of previous terminations); contraception used at
the time of conception (if any); and post-termination contraception. Where
pre-conception contraception was documented, the reason given for failure was
recorded.
Methods of contraception include combined and
progesterone-only pills, Depo-Provera injection, intrauterine contraceptive
devices, sterilisation (tubal ligation and vasectomy), condoms, diaphragms, use
of the emergency contraceptive pill and ‘natural’ family planning.
Where natural family planning is combined with condom use, it is categorised as
condom use; where no condom is used it is categorised as ‘no
contraception’.
Anonymous data were collected retrospectively from
patient records by either a certifying consultant or a nurse counsellor who had
access to these records in their normal work situation. Researchers worked from
an aggregated data set containing no identifiable details of individual
patients.
ResultsThe age of the women presenting at
the clinic were of similar proportions in 1995, 1999 and 2002, with about 80%
aged between 20 and 39 years, and two thirds between 20 and 34 years. Their
marital status was also similar, with just over half identifying as single.
Similar percentages had had previous terminations in each of the three years,
with just over two thirds (67–69%) having their first
termination.
However, the women attending the clinic in 2002 differed
from those attending in 1999 and 1995 in several regards. First, they were much
less likely to already have children (65% were nulliparous, compared with 41%
and 48% respectively). They were far more likely to be students (43% compared
with 16% and 18%) and there were correspondingly far fewer primarily involved in
home duties or child care (7% compared with 30% and 32%). The most significant
change was the ethnicity of the presenting women (Table 1). In 1995, 62% of the
women were New Zealand European, which dropped to 55% in 1999 and down to 33% in
2002. Numbers of Maori also significantly reduced, from 22% in 1995 and 26% in
1999 down to 8% in 2002. The majority of the women (55%) seen by the clinic in
the 2002 sample were of Asian ethnicity, increased from 12% in 1995 and 13% in
1999. While ‘Asian’ includes a number of ethnicities, including
Korean, Japanese, Indian and Thai, the overwhelming majority of these women were
ethnic Chinese, mostly young, non-resident women in New Zealand as students, or
recent immigrants.
Table 1. Ethnicity of women presenting to abortion
clinic in 1995, 1999 and 2002
The data show that women presenting to the clinic for
termination of pregnancy were far less likely to have been using contraception
at conception in 2002 (30.5%) than those in 1999 (51.5%) or 1995 (54.5%), see
Table 2. Condom use declined from 35% in 1995, to 26.5% in 1999, down to 22% in
2002. Of particular interest is the changing use of oral contraceptives, with
16.5% using contraceptive pills prior to conception in 1995, rising to 23% in
1999, and dropping to 8% in 2002.
Throughout the study period, over 90% of the women left the
clinic following the termination of pregnancy with some form of contraception
(Table 3). The condom has become the most popular method, increasing from 10.5%
in 1995, through 14.75% in 1999, to 38% in 2002. The oral contraceptive has
become correspondingly less popular, with nearly half (48.5%) choosing this
method in 1995, declining to 39.75% in 1999, and down to under one third (31%)
in 2002. The contraceptive injection Depo-Provera shows a similar decline in
popularity, from 21% in 1995 down to 6.75% in 2002.
Table 2. Contraceptive use at time of
conception
NFP = natural family planning; ECP = emergency
contraceptive pill; IUCD = intrauterine contraceptive device; TL = tubal
ligation
*includes second- and third-generation combined pills and progesterone-only pills Table 3. Contraceptive use following termination of
pregnancy (TOP)
NFP = natural family planning; ECP = emergency
contraceptive pill; IUCD = intrauterine contraceptive device; TL = tubal
ligation
*IUCD insertion and Depo-Provera injection occur immediately post-TOP; †includes second- and third-generation combined pills and progesterone-only pills We wished to explore factors contributing to the dramatic
drop in pre-conception pill use (from 23% in 1999 to 8% in 2002). One of the
possibilities was a general fear of the pill, resulting in the use of
alternative methods or disillusionment with contraceptive use. In our 1999
sample, 23% of pregnancies were due to pill failure, and nearly half of
combined-pill users claimed their pregnancy resulted from panic-stopping because
of media-promoted fear of health risks, especially
‘clots’.4 In 1995 and 1999, the
majority of women attending the clinic were New Zealand European. In 2002 this
group had dropped to one third. However, New Zealand Europeans were still the
highest users of the pill, with a slightly increased use (31%) in 2002 compared
with 1999 (28%).
In 1999, 74% of women had been using either no contraception
(48%) or condoms (26%), which some women were using only intermittently. In 2002
this had increased to 91.5% (69.5% having used no contraception and 22% condoms
only).
Asian women, particularly non-resident Chinese students, are
now the predominant ethnic group attending the clinic. The Asian women are
younger on average than the European patients (average age 22 compared with 29.9
years for Europeans), more likely to be single (135/221, 61% compared with
59/131, 45%, p = 0.003) and much more likely to be nulliparous (174/221, 79%
compared with 68/131, 52%, p <0.00001).
One hundred and seventy seven (80%) of the 221 Asian women
assessed in 2002 had been using no pre-conception contraception; a further 38
(17%) claimed to have been using condoms, and only six (2.7%) had been using
more reliable methods (five pill users, one intrauterine contraceptive device).
A much higher percentage left the clinic with reliable contraception (Table 4)
– pills 52/221 (24%); intrauterine contraceptive device 20/221 (9%);
Depo-Provera 10/221 (4.5%) – or planning to seek sterilisation 2/221
(0.9%), but 62% were still determined to rely on condoms only (123/221, 56%) or
abstinence (14/221, 6.3%).
Table 4. Use of contraception by Asian women in 2002
pre- and post-termination of pregnancy (TOP)
NFP = natural family planning; IUCD = intrauterine
contraceptive device; TL = tubal ligation
The use of oral contraceptive pills by European and Asian
women is significantly different both pre-termination (25/131 compared with
5/221; Fisher’s exact test p = 0.0001) and post-termination (61/131
compared with 52/221; chi-square test p = 0.00001) (Table 5).
Table 5. Use of oral contraceptive pills by ethnicity
pre- and post-termination of pregnancy (TOP)
*Fisher’s exact test for European versus Asian
women pre-termination p = 0.00001;
†chi-square test for European versus
Asian women post-termination p = 0.00001
DiscussionWhat do these data tell us? First,
despite the panic-stopping of oral contraceptives in 1999, when a higher rate of
venous thromboembolism was linked to third-generation
pills,4 the use of this form of contraception
does not appear to have significantly changed among New Zealand European women.
The majority of combined pills prescribed in 2002, however, are second- and not
third-generation formulations. Prescription data from the Pharmaceutical
Management Agency of New Zealand (PHARMAC) indicate that in 1995
third-generation pills represented 76% (356 959/471 282) of all prescribed
combined oral contraceptives, but in 2002 only 18% (68 864/383
954).5
In 1996, four studies indicated that third-generation oral
contraceptive pill use correlated with an increased risk for venous thrombosis
compared with second-generation pills (weak odds ratio ranging from 1.5 to
2.3).6–9 The publicity related to this
research led to panic-stopping of the pill in Europe at that time, and a
subsequent, similar reaction in New Zealand women in
1999.4 Clinic data analysis of the 1999 cohort
in our study found that nearly 50% of women citing combined oral contraceptive
use prior to conception had stopped their pill through media-generated fear of
risks to their health in the form of clots.4 In
contrast, none of the women in 2002 gave a history of panic-stopping the
pill.
A potential weakness of this study is that the data rely on
retrospective reporting of contraceptive methods used prior to unwanted
pregnancies. It is clinic policy to record for all patients what pre-conception
contraception was used, if any, and reasons for its failure. It is possible that
women might claim contraceptive failure rather than admit to lack of use,
through embarrassment or from fear that this admission might jeopardise their
access to an abortion. However, given that a high percentage of women (up to 69%
in 2002) freely acknowledged that they were using no contraception prior to this
pregnancy, it seems likely that responses to questions regarding contraceptive
use prior to conception were reasonably accurate and overestimate rather than
underestimate use.
While it is encouraging that over 90% of women left the
clinic after their abortion with their elected form of contraception, this may
well reflect the encouragement given by the clinic staff (doctors and nurse
counsellors) that the women avoid unprotected sexual intercourse in the future.
There is no coercion to accept contraception but all women are provided with
accurate information on, and access to, the full range of contraceptive methods
available.
Unfortunately, while patients may select a form of birth
control following a therapeutic abortion, this does not ensure that they will
continue to use contraception in the future. One study of adolescent girls found
that while 93% chose a reliable form of contraception following their
termination, only 28% reported using contraception at a follow-up visit within
the following year.10
A further issue raised by our data is that Asian women, who
are now the predominant ethnic group attending the clinic, are not using
reliable methods of contraception either before or after termination. The
changing ethnicity of the clinic population reflects social and health provision
changes within New Zealand. Many small-town or rural Maori women used to attend
the clinic because therapeutic abortion services were not available in their
localities, and this deficiency has now been remedied. New Zealand has also seen
a large influx of young Asians, especially Chinese, entering the country as
students, and it is the presence of mostly nulliparous Chinese students that is
demonstrated by the changed demographics of the women using the clinic
services.
The lack of contraceptive use by Asian women presenting for
termination of pregnancy, and their reliance on condoms post-termination, are
matters of particular concern. These women are predominantly non-resident or
recently immigrant Chinese, many of whom are students away from their families,
lacking exposure to contraceptive education normally available to young New
Zealanders. They demonstrate a profound reluctance to try any form of
contraception other than the condom, and will seldom consider using oral
contraceptives, which they believe will be harmful to them. This attitude is
consistently reported by clinic staff, both nurse counsellors and doctors,
including the two ethnic Chinese nurses employed by the clinic who meet with
similar resistance from Asian patients to consideration of oral contraceptive
use. A study of ethnic Chinese women presenting for abortion in Canada found a
negative attitude toward oral contraceptives.11
Although a formal assessment of reasons for contraceptive choice was not
conducted, the subjective impressions of our clinic staff would support this
view.
Condom use certainly will reduce the chance of unwanted
pregnancy as well as offering protection against some sexually transmitted
diseases. A case-control study found that consistent condom use reduced
fecundity by 88.9%, compared with diaphragm use by 89.3%, the pill by 97.8%,
IUCD use by 97.6%, vasectomy by 99.5%, and female sterilisation by
99.8%.12 Our concern regarding condom choice
relates more to failure of use rather than condom failure per se. Asian women
attending the clinic frequently decline an offer of free samples, express the
opinion that it is the man’s role to provide the prophylactic, and hold a
widespread, misinformed belief that the use of condoms is not necessary for the
first week following menstruation. While overall evidence indicates that the
benefits of contraceptive pills for women far outweigh the
risks,13 these women hold the opinion that the
pill is ‘bad’ for them.
While there are legal restrictions and ethical concerns
about abortion in New Zealand, its use is actively promoted in the
People’s Republic of China, in line with its one-child policy to reduce
population growth.14 It is also culturally
unacceptable in China for unmarried women to bear and raise children. A study of
unmarried abortion patients in Sichuan province, China, indicated that these
women were relying on abortion as a family planning method rather than as a
back-up method in case of contraceptive
failure.15
The percentage of Asian women having termination of
pregnancies nationwide has doubled from 6.5% in
199416 to 13.2% in
2001.17 The last decade has seen an influx of
young Chinese arriving in New Zealand. These include both immigrating families
and large numbers of non-residents coming to New Zealand to attend secondary and
tertiary educational institutions. The latter are often without family support,
and may take advantage of the relative sexual freedom they experience in
comparison with the situation in their home country. These young people require
immediate sexual health education including accurate information on
contraceptive options, and advice not to consider abortion as a contraceptive
method.
We recommend that liaison should be established between the
primary healthcare sector and policy makers of immigration and other services
that assist overseas students to develop and provide culturally appropriate
education for this population.
Author information:
Felicity A Goodyear-Smith, Senior Lecturer; Bruce Arroll, Associate
Professor, Department of General Practice and Primary Health Care, Faculty of
Medical and Health Sciences, University of Auckland
Acknowledgements:
Thanks to the clinic staff for their assistance with data collection.
Correspondence: Dr
Felicity A Goodyear-Smith, Department of General Practice and Primary Health
Care, Faculty of Medical and Health Sciences, University of Auckland, Private
Bag 92019, Auckland. Fax: (09) 373 7006; email: f.goodyear-smith@auckland.ac.nz
References:
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