title: Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial.
abstract: Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion.
  
  
  
  A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114).
  
  
  
  There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use.
  
  
  
  Simplified follow-up after early medical abortion will not change women's opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women's postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods.
  
  
  
  Clinicaltrials.gov NCT01827995.
authors.affiliation: Department of Women's and Children's health / International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Uppsala, Sweden. mandira.paul@kbh.uu.se.
authors.forename: Mandira
authors.identifier: 0000-0002-5841-5984
authors.initials: M
authors.lastname: Paul
authors.affiliation: Action Research & Training for Health (ARTH), 313011, Udaipur, Rajasthan, India.
authors.forename: Sharad D
authors.initials: SD
authors.lastname: Iyengar
authors.affiliation: Department of Women's and Children's health / International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Uppsala, Sweden.
authors.forename: Birgitta
authors.initials: B
authors.lastname: Essén
authors.affiliation: Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet and Karolinska University Hospital, WHO collaborating Centre, SE-17176, Stockholm, Sweden.
authors.forename: Kristina
authors.initials: K
authors.lastname: Gemzell-Danielsson
authors.affiliation: Action Research & Training for Health (ARTH), 313011, Udaipur, Rajasthan, India.|Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet and Karolinska University Hospital, WHO collaborating Centre, SE-17176, Stockholm, Sweden.
authors.forename: Kirti
authors.initials: K
authors.lastname: Iyengar
authors.affiliation: Statisticon, SE-10136, Stockholm, Sweden.
authors.forename: Johan
authors.initials: J
authors.lastname: Bring
authors.affiliation: Statisticon, SE-10136, Stockholm, Sweden.|School of Education, Health and Social Studies, Dalarna University, SE-791 88, Falun, Sweden.
authors.forename: Marie
authors.initials: M
authors.lastname: Klingberg-Allvin
mesh_terms: D000028:Abortion, Induced / Q000523:psychology*; D000293:Adolescent; D000328:Adult; D000359:Aftercare / Q000523:psychology*; D000554:Ambulatory Care Facilities; D002985:Clinical Protocols; D003267:Contraception / Q000523:psychology* / Q000706:statistics & numerical data*; D003270:Contraceptive Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D005500:Follow-Up Studies; D006699:Home Care Services; D006801:Humans; D007194:India; D008875:Middle Aged; D011247:Pregnancy; D055815:Young Adult
chemical_list: D003270:Contraceptive Agents