Women's post-abortion contraceptive use: Are predictors the same for immediate and future uptake of contraception? Evidence from Ghana.

This study seeks to identify the socio-demographic, reproductive, partner-related, and facility-level characteristics associated with women's immediate and subsequent use of post-abortion contraception in Ghana. Secondary data from the 2017 Ghana Maternal Health Survey were utilized in this study. The weighted data comprised 1,880 women who had ever had an abortion within the five years preceding the survey. Binary logistic regression analyses were performed to examine the associations between the predictor and outcome variables. Health provider and women's socio-demographic characteristics were significantly associated with women's use of post-abortion contraception. Health provider's counselling on family planning prior to or after abortion and place of residence were associated with both immediate and subsequent post-abortion uptake of contraception. Among subsequent post-abortion contraceptive users, older women (35-49), women in a union, and women who had used contraception prior to becoming pregnant were strong predictors. Partner-related and reproductive variables did not predict immediate and subsequent use of contraception following abortion. Individual and structural/institutional level characteristics are important in increasing women's acceptance and use of contraception post abortion. Improving and intensifying family planning counselling services at the health facility is critical in increasing contraceptive prevalence among abortion seekers.

Introduction

Studies indicate that women who have ever terminated a pregnancy are at risk of having more than two abortions in their lifetime [1] and with the risks to women that induced abortions pose, reducing these experiences is important for improving maternal morbidity and mortality globally. The provision of post-abortion contraception immediately following an induced abortion is essential to reducing repeat unwanted pregnancies and induced abortions among women [2]. Evidence from multiple studies indicate that integrating post-abortion services into health care systems increases the contraceptive prevalence rate among women having an abortion [3-8].

In Ghana, contraceptive knowledge is universal, yet less than half of all reproductive aged women (15–49) are using a modern contraceptive method [9]. For instance, according to the 2014 Ghana Demographic and Health Survey (GDHS), the proportion of both married and unmarried women using a modern method of contraception differs. About 18.2% of all women were currently using a modern method of contraception [9].

The 2007 and 2017 Ghana Maternal Health Surveys (GMHS) provide relevant information on maternal, and child health indicators as well as the reproductive histories of women five years preceding the survey [10,11]. From both surveys, the proportion of reproductive aged women (15–49) who had an induced abortion in the five years preceding the survey was relatively unchanged between 5% in 2007 and 7% in 2017. The 2007 GMHS report indicates that, out of the 28% of women who used a contraceptive method prior to the pregnancy resulting in an abortion, 20% reported using a modern type of contraceptive. On the other hand, of the women who had an induced abortion during the five-year period preceding the 2017 GMHS, only 20% used some form of contraception before becoming pregnant and undergoing a subsequent abortion [11]. Additionally, both surveys report the contraceptive prevalence rate among women who had an induced abortion. In 2017, 36% of women received a contraceptive method after induced abortion by a health personnel while this figure was lower (5%) in 2007 [10,11]. The findings from these nationally representative health surveys suggest that multiple factors account for the low use of modern contraceptive methods before and after women’s induced abortion experiences. It is possible that among women who underwent an induced abortion, few may have encountered health personnel at the point of abortion care where family planning services were offered; hence, the increased uptake of contraception post abortion during the ten-year period. For women who have ever had unplanned pregnancies that resulted in abortion, the imperative to use contraception to prevent another unplanned pregnancy may be greater.

To the best of our knowledge, no studies to date have used nationally representative data to investigate the range of factors that would predict women’s use of contraception following an abortion in Ghana. Thus, it is not clear whether demographic factors alone predict family planning use after abortion among women in Ghana. There is also sparse literature from the Ghanaian context that indicate which reproductive factors, partner-related and health facility-related characteristics influence such contraceptive practices among women who have had an abortion in their lifetime. Previous studies that examine post-abortion contraception tend to use qualitative methods, eliciting data from abortion seekers, healthcare providers and community members on experiences and perceptions of post-abortion contraceptive uptake [12] or use health facility data focusing on facility related variables [8,13]. These studies we believe, are insufficient in unravelling the multiple factors that may be critical in improving women’s uptake of contraception following abortion.

Using the 2017 GMHS, we investigate the factors that account for women’s immediate and subsequent or future use of contraception following abortion, considering socio-demographic, reproductive, partner-related, and facility-level factors. Several studies have investigated factors associated with contraceptive use among women in reproductive ages [14-18] but, abortion seekers have unique characteristics that put them at risk of experiencing multiple abortions. Abortion seekers in Ghana are younger, reside in urban areas, have a higher socio-economic status, and have no child or few children [19]. On the other hand, women who undergo unsafe abortions are typically rural residents, less educated, and have a lower socio-economic status [19,20].

This study provides a novel means to examine the determinants associated with contraceptive uptake post-abortion in order to highlight the multiple factors needed to increase opportunities for post-abortion women to have access to family planning services with the ultimate goal of reducing the risk of repeat abortions. In a context where unmet need for contraception is high [21,22] and abortions occur repeatedly, especially, among young women who are more likely to induce abortions unsafely [19], it is important to investigate the multiple level characteristics associated with the adoption of post-abortion contraception among abortion seekers.

Socio-ecological model explaining contraceptive behavior among abortion seekers

Previous studies on the determinants of contraceptive use after abortion reveal varying results due to contextual differences, study designs and outcomes of interests [5,23-26]. Research also shows that contraceptive uptake is highest when immediately offered on-site, or within less than six months or up to a year [23,26-29]. For instance, Adelman, Free and Smith [29] examined the predictors of post-abortion contraception at four and 12 months among Cambodian women. They found that previous contraceptive use, intention to use contraception, and number of living children were strongly associated with post-abortion contraception use. Occupation was significantly associated at four months whilst abortion method predicted post-abortion contraception at 12 months.

In an intervention study conducted by Johnson and colleagues [23], their results showed that women who received post-abortion family planning services during an intervention programme had significantly lower unplanned pregnancies and few repeat abortions during a 12 month follow-up period compared to post-abortion women who were not included in the intervention programme. In addition, Delvaux and colleagues [30] found that post-abortion contraceptors were more likely to be older, married, have at least one child and use contraception before the abortion.

Similarly, other studies have reported greater acceptance and/or use of modern contraceptives among women who received PAFP counselling [31] and services if they attended health centers or maternity homes compared to hospitals [32,33], and if women attended urban hospitals compared to rural hospitals or attended Protestant hospitals compared with Catholic hospitals [34]. Women were also more likely to use modern contraception after abortion if the family planning counselling and services was provided by gynaecological ward staff compared to other models of provision [3].

The socio-ecological model can best explain factors associated with contraceptive uptake among women with abortion experiences. Studies have explored factors associated with contraceptive use at the individual (intrapersonal), partner (interpersonal) and institutional or structural levels [35]. Age, education, religion, marital status, ethnicity, number of living children, number of abortions and personal motivation for abortion are individual-centred factors that can determine use among women. While some studies have found that older women are more likely than younger women to use contraception, especially long-acting methods, because of prior experience and the desire to limit childbearing [13], others have found that younger women are more likely to adopt contraception post-abortion [8,30,36]. Also, women with some level of education may have a greater likelihood of contraceptive adoption than uneducated women while women belonging to all other religious affiliations other than Catholics and all other ethnic group other than Mole-Dagbanis are predisposed to use a contraceptive method [12,13].

Important interpersonal factors have included those associated with the male-partner. The few studies on this have discussed that financial, communicative, and emotional support are predictors of contraception uptake immediately post-abortion [37]. Men’s participation and support during the abortion process may be linked to women’s acceptance and use of contraception post abortion [12,37,38]. In the literature, institutional level factors are characterized by facility-level factors and these are also key to understanding contraceptive use. The abortion procedure, facility type and type of provider may determine use through these mechanisms [13]. Structural level factors may also determine access to facilities for contraceptive use [28].

The two aims of this study are to examine the key factors associated with immediate post-abortion contraceptive use, as well as those associated with subsequent or future use, suggesting sustained use. We argue that abortion seekers in Ghana may use post-abortion contraception when partner support and health provider or facility-level factors are available.

Materials and methods

Study design and setting

The 2017 Ghana Maternal Health Survey dataset is a publicly accessible document which was obtained from www.DHSprogram.com [11]. The survey was jointly implemented by the Ghana Statistical Service (GSS) and the Ghana Health Service (GHS) with technical assistance from the ICF (originally Inner City Fund) through the DHS program. Participants in the survey provided written informed consent and participation in the survey was voluntary. The dataset was completely anonymized, de-identified and aggregated before we were provided with access to it for analysis. The identities of participants were therefore, not linked to the data. The 2017 GMHS is the second nationally representative household two-stage cluster survey which comprises comprehensive information on maternal and reproductive health issues, maternal mortality, and specific causes of death among women in Ghana [11]. The survey protocols and biomarkers were reviewed and approved by the ICF Institutional Review Board. The data that were collected comprised events within five years preceding the survey. The women’s individual dataset used for this study was limited to a weighted sample of 1,880 women (both married and unmarried) who had ever had an abortion within the five years preceding the survey.

Measures

The primary outcome variables were immediate and subsequent or later post-abortion family planning or contraceptive use. In the dataset, immediate post-abortion contraceptive use was captured by two questions. The first question asked respondents, ‘After this abortion, did the doctor or health worker give you a method of contraception, prescribed a method of contraception, or refer you to a family planning clinic?’ with responses as either ‘Yes’ or ‘No’. a subsequent question for those responding in the affirmative was “Did they give you the method of contraception, give you a prescription, or give you a referral?” and the corresponding options were ‘Gave method’, ‘Prescribed a method’, ‘Gave a referral’ or ‘Don’t know’. Respondents who chose the option ‘gave method’ were categorised as immediate users and were coded as ‘Yes’ while all the other options were categorised as ‘No’. Given the data limitation of questions on the immediacy of actual contraceptive use post-abortion, we assume that those ‘given a method’ suggests acceptance of and actual uptake of a contraceptive method after the abortion. Subsequent post-abortion uptake of contraception was measured by women’s current use of contraception at the time of the survey. In this study, modern contraceptive users should be using implants, intrauterine device (IUD), oral contraceptive pills, injectables, male and female condoms. All others were coded as ‘No’.

The predictor variables in the study included socio-demographic, reproductive, and abortion-related service characteristics, partner factors, and health facility indicators. The socio-demographic characteristics examined include age, highest educational status, religious affiliation, ethnicity, marital status, and place of residence. The reproductive factors were number of abortions (1, 2, 3+) and contraceptive use at index pregnancy (No/Yes). Abortion-related service delivery characteristics consisted of pre-or post-abortion health provider counselling and services (No/Yes) and abortion method (Safe/Unsafe). Respondents’ abortion method was categorised as safe or unsafe based on the WHO classification (place abortion was performed, category of health provider who performed the abortion and equipment used). Partner-related factors were measured based on three variables: attitude towards the abortion (Favourable/Opposed), provision of financial support for the abortion (Yes/No), and partner-related reasons for the abortion (Health-related, Partner-related and Other-related).

Data analysis

The data were analysed in three stages. First, we employed univariate techniques to explore frequencies of the categorical variables. Second, for the bivariate analyses, descriptive statistics were reported for all categorical and continuous predictor variables with their differences assessed by selected characteristics using cross-tabulations and chi-square tests. Third, multivariate analyses were conducted using two binary logistic regression models to ascertain the odds of all the factors significantly associated with immediate and subsequent post-abortion contraceptive use. All analyses were performed using STATA version 13.

There were few limitations which pertained to restrictions with the dataset in measuring some variables. First, we were unable to measure immediate post-abortion contraceptive use due to the limited questions on actual contraceptive use immediately post-abortion; hence, the assumption that ‘given method’ is actual immediate contraceptive use. Second, another limitation was our inability to measure some individual characteristics such as occupation and number of surviving children. In addition, the type of health facility—primary, secondary, or tertiary—where women obtained induced abortion could not be ascertained more specifically for and considered in the analysis since it was not captured in the data.

Results

Among the sample of women who had ever had an abortion in the five years preceding the survey, the majority were more than 25 years old. The mean age of respondents was 27 years. Most respondents (89%) had received formal education with only 11% having never had any formal education. The study population was predominantly Christians and exactly half of the sample belonged to the Pentecostal/Charismatic faith. Concerning ethnicity, the majority were Akans (55%) and the least represented ethnic group was Ga (7%). Less than one-third of women had been using a contraceptive method prior to the index pregnancy that ended in the abortion. Only 30% of the sample practiced a safe abortion as their last pregnancy termination method. About 6.9% of women used contraception immediately after the abortion while women who delayed uptake until later were 48%. The percentage of women using specific contraceptive methods post-abortion subsequently varied: 49% were using short-acting contraceptives; 21% were using long-acting reversible contraception, and 19% preferred traditional methods. The remaining were currently using emergency contraceptive pills as their main method of pregnancy prevention (specific methods not shown in table). The key characteristics of the sample are presented in Table 1.

Table 1

Participants’ characteristics (N = 1880).

Variables	Categories	N	Percent (%)
Socio-demographic factors
Age	15–24	694	36.9
	25–34	867	46.1
	35–49	319	17.0
Highest educational level	No education	161	8.6
	Primary	298	15.9
	Junior High School	874	46.5
	Senior High School	410	21.8
	Tertiary	137	7.3
Religious affiliation	Catholic	164	8.7
	Orthodox	241	12.8
	Charismatic/Pentecostal	1043	55.5
	Islam	266	14.1
	Other Christian	128	6.8
	No religion	38	2.1
Ethnicity	Akan	1133	60.3
	Ga	171	9.1
	Ewe	286	15.2
	Mole Dagbani	142	7.6
	Other ethnic groups	148	7.9
Marital status	Not in union	760	40.5
	In union	1120	59.6
Place of residence	Urban	1229	65.4
	Rural	651	34.6
Reproductive factors
Number of abortions	1	1269	67.5
	2	455	24.2
	3+	156	8.3
Contraceptive use at index pregnancy	No	1528	81.3
	Yes	352	18.7
Abortion-related service delivery factors
Type of abortion	Safe	657	34.9
	Unsafe	1223	65.1
Health provider counselling on family planning before/ after abortion	Yes	596	31.7
	No	1284	68.3
Partner-related factors
Partner attitude towards abortion	Opposed	887	47.2
	Favourable	993	52.8
Partner paid for abortion	Yes	844	44.9
	No	1036	55.1
Main reason for abortion	Health-related	143	7.6
	Partner-related	278	14.8
	Other reasons	1459	77.6
Outcome variables
Immediate post-abortion contraceptive use	No	1750	93.1
	Yes	130	6.9
Subsequent post-abortion contraceptive use	No	989	52.6
	Yes	891	47.4
Total		1880	100.0

Results from the bivariate analysis (Table 2) showed seven factors associated with subsequent uptake of contraception post-abortion. A little over half the proportion of women aged 15–24 years reported that they used contraception subsequently post-abortion while less than half of women in older age groups reported the same. More than half (55%) of women in rural areas and 44% of urban women adopted contraception following abortion subsequently. Also, exactly half the proportion of women in union reported using contraception subsequently after the abortion (p-value = 0.04), while over four out of ten women currently not in union used contraception. Contraceptive use at index pregnancy was the only reproductive history factor associated with women’s subsequent use of contraception. About 6 in 10 respondents who used contraception at index pregnancy also reported that they used contraceptives later post-abortion (p-value = <0.001).

Table 2

Distribution of predictor variables by immediate and subsequent post-abortion family planning (PAFP) uptake.

Variables	Categories	Immediate PAFP			Subsequent PAFP
Socio-demographic factors		Yes	χ2	p-value	Yes	χ2	p-value
Age	15–24	.07	1.339	.57	.53	32.719	.000
	25–34	.06			.49
	35–49	.07			.31
Highest educational level	No education	.06	7.336	.13	.46	.722	.97
	Primary	.11			.46
	Junior High School	.07			.47
	Senior High School	.06			.49
	Tertiary	.03			.49
Religious affiliation	Catholic	.05	2.515	.69	.54	4.006	.69
	Orthodox	.07			.51
	Charismatic	.08			.46
	Islam	.06			.47
	Other Christian	.06			.48
	No religion	.03			.46
Ethnicity	Akan	.07	2.787	.63	.46	7.778	.21
	Ga	.08			.55
	Ewe	.05			.42
	Mole Dagbani	.08			.55
	Other ethnic groups	.09			.49
Residence	Urban	.05	14.398	.00	.44	10.288	.007
	Rural	.10			.53
Marital status	Not in union	.07	.227	.67	.44	5.927	.04
	In union	.07			.50
Reproductive factors
Number of abortions	1	.07	1.839	.46	.49	3.002	.29
	2	.06			.45
	3+	.09			.43
Contraceptive use at index pregnancy	No	.06	.806	.40	.45	17.108	.000
	Yes	.08			.59
Abortion service delivery factors
Type of abortion	Safe abortion	.08	2.392	.14	.43	5.214	.06
	Unsafe abortion	.06			.49
Health provider counselling on FP before/ after abortion	Yes	.19	161.05	.000	.51	4.208	0.10
	No	.01			.45
Partner-related factors
Partner attitude towards abortion	Opposed	.07	.05	.83	.44	6.721	.02
	Favourable	.07			.51
Partner paid for abortion	Yes	.07	.022	.88	.52	9.844	.03
	No	.07			.44
Main reason for abortion	Health-related	.06	.355	.82	.36	9.716	.04
	Partner-related	.08			.42
	Other reasons	.07			.49

All the partner-related characteristics were significantly associated with women’s uptake of contraception after the abortion subsequently. For instance, results indicate that 45% of women who reported that their partners had favourable attitudes towards the abortion used contraception subsequently following the abortion (p-value = 0.02). Further, more than half (52%) the proportion of women who indicated that their partners paid for the abortion used contraception subsequently after the abortion. Regarding the main reason for the abortion, about 42% of women who stated that some partner related reasons were the main reasons for the abortion used contraception subsequently post-abortion. The smallest proportion of respondents using contraception were in the ‘health-related’ reason category (36%).

Health provider counselling on family planning prior to or before the abortion, and place of residence were the only variables significantly associated with women’s uptake of immediate post-abortion contraception. Ten percent of women in rural areas reported use of contraception immediately while five percent of rural respondents reported the same. In addition, close to one in five women who received counselling on family planning before/after abortion from a health provider reported using contraception immediately after the abortion, while only one percent of women with no counselling used contraception immediately post-abortion.

Table 3 shows the results of the multivariate regression analyses for immediate and subsequent post-abortion family planning use. Among immediate post-abortion contraceptive users, only place of residence and counselling on a family planning method by a health provider before or after abortion was significant (Model 1). Women residing in rural areas were more likely to use contraception immediately following an abortion compared to women in urban areas (OR = 1.79; 95% CI = 1.088–4.249). Women were less likely to use family planning immediately after the pregnancy termination if they did not receive family planning counselling from a health professional before or after the abortion compared to women who were counselled by a health professional prior to or post abortion (OR = 0.04; 95% CI = 0.021–0.079).

Table 3

Associations between predictor variables and immediate and subsequent post-abortion family planning (PAFP) uptake.

Variables	Categories	Model 1 Immediate PAFP		Model 2 Subsequent PAFP
Socio-demographic factors		OR	95 CI%	OR	95 CI%
Age	15–24 [RC]	1.00		1.00
	25–34	0.60	.322–0.121	0.84	.645–1.092
	35–49	0.65	.309–1.353	0.38**	.253-.572
Highest educational level	No education [RC]	1.00		1.00
	Primary	2.03	.901–4.581	0.96	.540–1.689
	Junior High School	1.03	.470–2.242	0.91	.524–1.586
	Senior High School	0.73	.309–1.709	0.91	.517–1.601
	Tertiary	0.51	.128–2.066	1.04	.513–2.126
Religious affiliation	Catholic [RC]	1.00		1.00
	Orthodox	1.54	.530–4.453	0.84	.512–1.367
	Charismatic	1.53	.648–3.638	0.70	.454–1.081
	Islam	1.13	.431–2.945	0.77	.463–1.278
	Other Christian	1.00	.334–2.970	0.74	.361–1.413
	No religion	0.43	.038–4.902	0.64	.241–1.696
Ethnicity	Akan [RC]	1.00		1.00
	Ga	1.00	.403–2.464	1.50*	.956–2.349
	Ewe	0.71	.323–1.564	0.94	.653–1354
	Mole Dagbani	1.43	.672–3.043	1.27	.746–2.178
	Other	1.43	.482–4.249	1.02	.604–1.736
Residence	Urban [RC]	1.00		1.00
	Rural	1.79**	1.088–2.954	1.35**	1.021–1.784
Marital status	Not in union [RC]	1.00		1.00
	In union	1.00	.601–1.677	1.41**	1.086–1.834
Reproductive factors
Number of abortions		1.10	.859–1.419	1.00	.872–1.135
Contraceptive use at index pregnancy	No [RC]	1.00		1.00
	Yes	1.17	.632–2.169	1.74**	1.215–2.507
Abortion service delivery factors
Type of abortion	Safe [RC]	1.00		1.00
	Unsafe	1.07	.661–1.726	1.32*	.986–1.762
Health provider counselling on FP before/ after abortion	Yes [RC]	1.00		1.00
	No	0.04**	.021-.079	0.73**	.542-.990
Partner-related factors
Partner attitude towards abortion	Opposed [RC]	1.00		1.00
	Favourable	1.08	.626–1.851	1.25	.950–1.657
Partner paid for abortion	Yes [RC]	1.00		1.00
	No	0.93	.540–1.605	0.84	.605–1.177
Main reason for abortion	Health-related [RC]	1.00		1.00
	Partner-related	1.56	.548–4.442	1.22	.644–2.306
	Other reasons	1.28	.572–2.870	1.49	.889–2.486

**p<0.05

*p<0.1.

Results from Model 2 in Table 3 show that the determinants significantly associated with subsequent post-abortion contraceptive uptake include age, marital status, place of residence, contraceptive use at index pregnancy, and receipt of pre or post FP counselling by a health provider. The results indicate that compared to young women (aged 15–24 years), older women (between 35–49 years) were less likely to initiate post-abortion contraception in future (OR = 0.38; 95% CI = 0.253–0.572). Also, compared to single women, women in a union were 1.41 times as likely to adopt a post abortion contraceptive method subsequently (OR = 1.41; 95% CI = 1.086–1.834). Prior use of contraception before the abortion (contraceptive use at index pregnancy) predicted subsequent use following abortion (OR = 1.74; p<0.05). Like immediate post abortion contraceptors, if women were not offered FP counselling pre/post abortion by a health professional, they were less likely to use FP subsequently after the abortion (OR = 0.73; p<0.05).

Discussion

In this study, we examined the factors associated with immediate and subsequent or future use of modern contraception following induced abortion among a retrospective cohort of women. The study findings are discussed below on the levels within the socio-ecological framework which guided the study.

Individual level factors of post-abortion contraceptive use

At the individual/intrapersonal level, age, marital status, place of residence, and contraceptive use before pregnancy were associated with subsequent/future post-abortion contraceptive use. Age as a determinant of post-abortion contraception use has been found in other studies [8,30,36] and these findings are consistent with our study which showed that older women (>35 years) were less likely to use contraception subsequently after abortion compared to adolescents and young women. Attitudinal resistance and prior experience with contraceptive use may account for older women’s unwillingness to initiate contraception following an abortion. Fertility intentions and reproductive goals of women differ. Similarly, continuation rates of contraception uptake after abortion may vary for younger and older women. Young women (including adolescents) may be more willing to accept family planning to prevent future unplanned pregnancies because they may have educational aspirations and other life achievement goals to pursue. It is also likely that young women are inexperienced with modern contraception and perhaps more susceptible to ‘subtle directives’ from health providers to accept post-abortion family planning counselling services compared to older women.

The findings also show that, compared to women who were not in a union, women in a union were more likely to use contraception at any time following termination of pregnancy. This finding is somewhat unexpected although there is evidence to demonstrate that married women initiate post-abortion contraception with their partners’ approval [39]. It is plausible that married women have reached their fertility goals and aspirations, therefore, they prefer using contraception to regulate or stop childbearing [40]. On the other hand, unmarried women may have fears or anxieties about adopting contraception if they believe that using contraceptives will make them infertile before they get married. Support and involvement of male partners at the time of the abortion could also influence the use of contraception after abortion [37].

From the results of the study, place of residence is an important factor in women’s use of modern contraception immediately and subsequently following induced abortion. We found that compared to women residing in urban areas, women living in rural settings were more likely to use modern family planning methods post-abortion. Similar findings have been reported in other contexts among women in their reproductive ages [41,42]. In Ghana for instance, the 2007 GMHS evidences slight differences in modern family planning use by women living in urban and rural areas. Aviisah and colleagues [43] used the 2003, 2008 and 2014 demographic and health surveys to examine patterns in the use of modern contraceptive methods among married women. They found an increase in modern methods of contraceptive use among married women in rural areas compared to urban dwellers. Women living in rural settings in Ghana have greater avenues and opportunities to access, use, and choose from a variety of modern family planning methods due to the implementation of the Community-based Health Planning and Services (CHPS) concept at the district levels which expands and integrates the provision of child and maternal care with reproductive health services [44].

Prior contraceptive use before pregnancy termination is necessary to sustaining efforts aimed at avoiding future unplanned pregnancies. We found that women were more likely to use contraception not immediately but, subsequent after an induced abortion, if they had used contraceptives prior to becoming pregnant. Findings echo results from other settings indicating that contraceptive history predicts post abortion contraceptive use [26,45,46]. These findings can be explained considering women’s desire and intention to reduce their fertility or stop having children as well as discontinuing future unplanned pregnancies. By implication, the previous contraceptive practices of women present an opportunity for health providers to counsel women on the efficacy and benefits of effective long-acting contraceptive methods at the time of abortion.

Interpersonal factors associated with post-abortion contraceptive use

According to the socio-ecological model, an individual’s decision is shaped not only by their own characteristics, but by others including significant others. Kayi [37] and Rominski et al [12] demonstrated that attributes of male partners shaped women’s reproductive decisions. Our results, however, show that partner-related characteristics such as male partner attitude, financial support of male partner and partner-related reasons for the abortion were not associated with immediate and subsequent post-abortion contraception use. These findings provide insights for discussions on autonomy in contraceptive decision-making among post-abortion women who have varying degrees of vulnerability [20]. Though evidence exists to demonstrate male dominance in women’s contraceptive decisions, male power appears to be overshadowed during abortion care.

Structural/Institutional level- health system factors

The findings show that structural level factors specifically, the provision of family planning counselling by health providers before or after abortion is strongly associated with immediate and future use of post-abortion contraception. Our study found that, women were less likely to use contraception following abortion if family planning counselling was not provided by a health provider. This finding suggests that, abortion method, type of facility, and location (or access) are not as important as the role played by health professionals in the delivery of abortion care and family planning services. Health care providers form an integral part of the healthcare system particularly where maternal and reproductive health services are concerned. To a large extent, confidence in the medical expertise of health professionals coupled with a change in provider attitudes on abortion, training and provider skills [47] may have served as strong motivating factors to encourage women’s adoption and uptake of a contraceptive method post-abortion. The results are consistent with existing studies [3,13,32,33,48].

Conclusions

This study contributes to the growing body of post-abortion research, specifically, on the determinants of contraceptive uptake in the immediate post-abortion period and subsequently within a five-year period among Ghanaian women. We find that individual (intrapersonal) and structural/institutional level characteristics are significant in predicting women’s use of contraception following abortion either immediately or in future. Except for woman’s age, marital status, and place of residence, all the other individual level factors are not associated with post-abortion FP use. Structural/institutional level factors have the potential to influence women’s intention and continued use of FP, but health professionals’ provision of pre/post abortion FP counselling is a sine qua non. Findings from this study are relevant and informative in building the evidence base of institutional relevant factors influencing post-abortion care in Ghana. Policy makers involved in comprehensive abortion care delivery need to target young women when designing programmes to increase the contraceptive prevalence rate among post-abortion women. Expanding access to and availability of post-abortion FP counselling and services, equipping health providers on abortion care, in addition to the availability of a variety of modern contraceptives at the time of abortion care are key to increasing the contraceptive prevalence rate among post-abortion women.

21 Oct 2020

PONE-D-20-22759

Women’s post-abortion contraceptive use: are predictors the same for immediate and future uptake of contraception? Evidence from Ghana.

PLOS ONE

Dear Dr. Esinam Afi Kayi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Kindly revise your manuscript taking into cognisance the comments of Reviewer 2.

Please submit your revised manuscript by 21st November. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Eugene Kofuor Maafo Darteh, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please change your reference to "p=0.000" to "p<0.001" or as similarly appropriate, as p values cannot equal zero.

3. In ethics statement in the manuscript and in the online submission form, please provide additional information about the database used in your retrospective study. Specifically, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have their data used in research, please include this information.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper was generally well written

The background information was well researched and unambiguous. The socio-ecological model used to underpin the study was appropriate and commendable.The objectives set were to examine key factors associated with immediate post-abortion contraceptive use and those associated with subsequent or future use. These are clear and unambiguous

Secondary data was used in this study. The methods used in the primary data collection were summarised in the paper. A multi-stage sampling technique was employed. The logistic regression analysis employed was appropriate and rigorous.

Findings generally reflected objectives set, however, the finding that about 9% of women used contraception immediately after the abortion was wrongly reported. It is 6.9% and not 9% (see table 1).

The conclusions drawn and recommendations made generally reflected the objectives set and gaps respectively observed.

Reviewer #2: 1. In the abstract, the recommendation is not specific. Again, the study did not focus on access to modern contraceptives and so the related recommendation is misplaced. Similarly, the study did not look into access to post-abortion contraceptives, hence, a wild recommendation.

2. At line 72 and 73, the statement that less than one-quarter of women in the reproductive ages (15-49) use any method of contraception is misleading: The key variable is women currently married. Again, figure is not less than one-quarter. More so, it is not ‘any method’ of contraceptive. The authors could rather include evidence of contraceptive use and induced abortion among such cohort.

3. Data on the contraceptive 78 prevalence rate (CPR) of women who have ever had an abortion is lacking’ – this statement made on line 77 was not supported with any evidence. Apart from the GDHS (1988-2014), the GMHS (2007 and 2017) data are available.

4. The justification for the study is presented at line 77-88. The authors admit they did not have any nationally representative study on the subject. What about other jurisdictions – especially Africa, and other regions - Asia, Europe, Americas? Again, they reported that there are qualitative studies; they need to explore further to raise justifiable arguments.

5. There is no commentary on the findings based on the GMHS 2007 and 2017 at the introduction section. This makes the section scanty on relevant issues.

6. In discussing the subject with the socio-ecological model (Lines 132-160), the authors indicated three levels of interests: individual (intrapersonal), partner (interpersonal) and institutional or structural levels. The authors must therefore put the discussion under each of these interests to interpret it within the context of the model.

7. At Lines 154-156, the authors indicate that the study is an explanatory study. This is questionable because there are not additional qualitative information to complement the predictor information.

8. Information at Lines 158-160 defeat the earlier position of the author with regard to the justification of the study at Lines 77-88.

9. There are no references under the Material and Methods section; not even the source of the data sets. This is unethical or suggests plagiarism.

10. The socio-ecological model should be discussed with the findings. This was not done at the discussion level.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

25 Jan 2021

Reviewer #1:

The paper was generally well written

The background information was well researched and unambiguous. The socio-ecological model used to underpin the study was appropriate and commendable. The objectives set were to examine key factors associated with immediate post-abortion contraceptive use and those associated with subsequent or future use. These are clear and unambiguous

Response: We are grateful to the reviewer for these positive comments

Secondary data was used in this study. The methods used in the primary data collection were summarised in the paper. A multi-stage sampling technique was employed. The logistic regression analysis employed was appropriate and rigorous.

Findings generally reflected objectives set, however, the finding that about 9% of women used contraception immediately after the abortion was wrongly reported. It is 6.9% and not 9% (see table 1).

The conclusions drawn and recommendations made generally reflected the objectives set and gaps respectively observed.

Response: We are grateful for the reviewer catching this error. This has been rectified in table 1.

Reviewer #2:

1. In the abstract, the recommendation is not specific. Again, the study did not focus on access to modern contraceptives and so the related recommendation is misplaced. Similarly, the study did not look into access to post-abortion contraceptives, hence, a wild recommendation.

Response: The recommendation in the abstract has been rephrased to suit the findings from the study. We are grateful for this observation. Please see lines 59-62.

2. At line 72 and 73, the statement that less than one-quarter of women in the reproductive ages (15-49) use any method of contraception is misleading: The key variable is women currently married. Again, figure is not less than one-quarter. More so, it is not ‘any method’ of contraceptive. The authors could rather include evidence of contraceptive use and induced abortion among such cohort.

Response: The misleading information has been corrected based on evidence from the relevant references. The study consists of all reproductive aged (15-49) women (both married and unmarried) with an induced abortion in the 5 years preceding the survey. The suggestion for evidence of contraceptive use and induced abortion among the subgroup of women has been incorporated into the manuscript at lines 74-77.

3. Data on the contraceptive 78 prevalence rate (CPR) of women who have ever had an abortion is lacking’ – this statement made on line 77 was not supported with any evidence. Apart from the GDHS (1988-2014), the GMHS (2007 and 2017) data are available.

Response: We are grateful to the reviewer for this critical observation. The statement that the contraceptive prevalence rate (CPR) of women who have ever had an abortion is lacking has been removed. Data from the 2007 and 2017 Ghana Maternal and Health Surveys have been incorporated into the introduction sections of the manuscript. We agree that the data are available.

4. The justification for the study is presented at line 77-88. The authors admit they did not have any nationally representative study on the subject. What about other jurisdictions – especially Africa, and other regions - Asia, Europe, Americas? Again, they reported that there are qualitative studies; they need to explore further to raise justifiable arguments.

Response: To address this comment we have included a paragraph in the Introduction Section (line 65-72) that further argues the rationale for the study. Despite there not being any nationally representative studies on the subject, we do comment on the gaps of existing studies the reviewer suggested we mention. We have commented on studies conducted in other contexts – both quantitative and qualitative. This additional paragraph arguing the justification of our study is seen between lines 104-109.

5. There is no commentary on the findings based on the GMHS 2007 and 2017 at the introduction section. This makes the section scanty on relevant issues.

Response: A commentary on relevant findings based on the 2007 and 2017 GMHS have been included in the introduction section from lines 78-97.

6. In discussing the subject with the socio-ecological model (Lines 132-160), the authors indicated three levels of interests: individual (intrapersonal), partner (interpersonal) and institutional or structural levels. The authors must therefore put the discussion under each of these interests to interpret it within the context of the model.

Response: We appreciate this suggestion. The discussion has been placed under the individual (intrapersonal), partner (interpersonal) and institutional or structural levels in the context of the socio-ecological model at lines 308-379.

7. At Lines 154-156, the authors indicate that the study is an explanatory study. This is questionable because there are not additional qualitative information to complement the predictor information.

Response: We understand the reviewer’s concern about our description of the study as explanatory. We mentioned this due to the fact that our study’s aim was to examine relationships between the various factors associated with immediate and subsequent contraceptive use among abortion seekers in Ghana. By examining associations between the various independent and dependent variables we apply nomothetic explanation principles. The idiographic explanations are not possible since the data are secondary and quantitative and cannot fully get all the in-depth factors associated with immediate and subsequent use of contraception post-abortion.

8. Information at Lines 158-160 defeat the earlier position of the author with regard to the justification of the study at Lines 77-88.

Response: We admit that the information provided to justify the study on lines 158-160 contradicts the justification provided on lines 77-88. This error was not intended and has been removed accordingly.

9. There are no references under the Material and Methods section; not even the source of the data sets. This is unethical or suggests plagiarism.

Response: We regret this oversight and have included a reference of the 2017 Ghana Maternal and Health Survey report on line 182.

10. The socio-ecological model should be discussed with the findings. This was not done at the discussion level.

Response: We are grateful for this observation. The discussion of findings has been sectioned under the individual (intrapersonal), partner (interpersonal), and structural or institutional levels now from lines 308-379.

Submitted filename: RESPONSE TO REVIEWERS.docx

Click here for additional data file.

19 Apr 2021

PONE-D-20-22759R1

Women’s post-abortion contraceptive use: are predictors the same for immediate and future uptake of contraception? Evidence from Ghana.

PLOS ONE

Dear Dr. Kayi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 03 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Eugene Kofuor Maafo Darteh, Ph.D.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Women’s post-abortion contraceptive use: are predictors the same for immediate and future uptake of contraception? Evidence from Ghana.

General Comments

Abortion (Safe and unsafe) generally have arisen from unintended pregnancies. These unintended pregnancies could have been prevented by use of contraceptives. Post –abortion family planning is another window of opportunity to improve CPR. Finding predictors of immediate and later post-abortion contraceptive usage would go a long way to target interventions appropriately.

This study is important for various reasons including the use of socio-ecological model which enables determination of predictors from individual to structural levels. Additionally the use of nationally representative data enables generalization of findings across the country.

The use of secondary DHS data is acceptable. DHS methodologies are robust and standardized across countries over the years to enable comparison of results of similar studies across different countries.

The authors however need to address the following concerns:

1. The assumption that “Given method of contraception at time of abortion as directed by a health provider” is assumed to be:

a. the same as actual contraceptive use and;

b. a measure of immediate post-abortion contraceptive use,

need to be further explained.

2. What post abortion time intervals define immediate and subsequent or later contraceptive use

3. The authors assume current contraceptive use at the time of study to be equivalent to subsequent or later contraceptive use. However, some further clarifications need to be made concerning:

a. How many of the 1750 immediate PAFP users continued or discontinued contraceptive use? Of those who continued use, would the authors still include them as later or subsequent PAFP users?

b. Of those 1750 who discontinued use (If data is available), how many went on to re-use contraceptives subsequently?

c. Did some of the 130 non-users of PAFP (immediate) go on subsequently to use contraceptives or not?

4. In the binary logistic regression analysis, the authors did not specify whether it was a bivariate or multivariate.

5. Further information could have been derived from a multivariate

Reviewer #2: After comparing the revised manuscript with the review comments, It is satisfactory to say that the authors have incorporated all the suggestions and comments into the revision. this makes the article scientifically appropriate for acceptance.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Sebastian Eliason

Reviewer #2: Yes: Kobina Esia-Donkoh

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Re-Review of Article_Womens Post Abortion.docx

Click here for additional data file.

3 Jun 2021

The Academic Editor

PLOS ONE

Dear Dr Darteh,

My co-authors and I are grateful for the opportunity to revise and resubmit our manuscript titled, “Women’s post-abortion contraceptive use: are predictors the same for immediate and future uptake of contraception? Evidence from Ghana” with manuscript number, PONE-D-20-22759R1.

We are writing to address the comments of the reviewers and provide your office with the revised manuscript. Please see the responses to the comments below.

Best regards,

Dr Esinam Kayi (Corresponding Author)

Reviewer #1:

1. The assumption that “Given method of contraception at time of abortion as directed by a health provider” is assumed to be:

a. the same as actual contraceptive use

Response: We made this assumption on the basis of the question in the dataset “did they give you the method of contraception, give you a prescription, or give you a referral?” and the corresponding options were ‘gave method’, ‘prescribed a method’, ‘gave a referral’ or ‘don’t know’. We therefore used ‘gave method’ as our measure of immediate post-abortion contraceptive use and assumed it to be actual contraceptive use and acceptance of contraception at the time of post-abortion care. Furthermore, among all the questions on post-abortion contraception, this was the only closely related and direct question asked of the post-abortion women. From these options, ‘gave method’ presupposes that the woman initiated/adopted/accepted a family planning method prior to being discharged after the abortion procedure. Given the data restrictions on the measurement of actual immediate contraceptive use after abortion, we have included this limitation in the manuscript on page 20 and modified the measures section related to immediate post-abortion contraceptive use on page 8.

b. a measure of immediate post-abortion contraceptive use

Response: In our study, immediate post-abortion contraceptive use was measured by the question “did they give you the method of contraception, give you a prescription, or give you a referral?” (we paraphrased the question as “given method of contraception after abortion”). According to the World Health Organization (2006, 2010), immediate use of post-abortion family planning is measured as a woman’s receipt of family planning immediately after abortion at the health facility before discharge; and or use of contraception within six months post abortion before a subsequent pregnancy. We chose to use WHO’s recommendation of immediate post-abortion contraceptive use as the dataset does not specify the timing of women’s initiation and acceptance of contraceptive use after abortion. Again, the question that most closely measures the immediacy of initiation or use of a contraceptive method is “did they give you the method of contraception, give you a prescription, or give you a referral?” We find that other studies such as Delvaux et al (2008) and McDougall et al (2009) also measure immediate post-abortion contraceptive use based on WHO’s recommendation of post-abortion contraceptive use.

2. What post-abortion time intervals define immediate and subsequent or later contraceptive use?

Response: The time intervals that define immediate contraceptive use after abortion is initiation or adoption of family planning immediately after abortion at the health facility before discharge; and or use of contraception within six months post abortion before a subsequent pregnancy; and subsequent or later contraceptive use after abortion is contraceptive use 6 months after abortion. For this study, From the 2017 GMHS dataset we used, the century month code for the most recent abortion was not included so we were unable to identify how many months ago women had an abortion prior to their use of contraception at the time of the survey. The information we were able to calculate was limited to the number of years ago the women had the last abortion. We found that 12.6% of women reported having an abortion within a year (or 0 years) preceding the survey. Out of this, 12.6% (or 30 women) were immediate users and 39.2% (or 93 women) were currently using a contraceptive method at the time of the survey (subsequent users). Due to this limitation of not being able to detect the actual period in months, we decided to still include these women as subsequent users of contraception as they reported current use at the time of the survey.

3. The authors assume current contraceptive use at the time of study to be equivalent to subsequent or later contraceptive use. However, some further clarifications need to be made concerning:

a. How many of the 1750 immediate PAFP users continued or discontinued contraceptive use? Of those who continued use, would the authors still include them as later or subsequent PAFP users?

Response: We were interested in the women who initiated contraception after abortion for the immediate users. From the analysis, 1750 women did not qualify to be categorized as immediate contraceptive users post abortion as only 130 women reported being given a method of contraception post-abortion. Therefore, if they continued or discontinued contraceptive use, they would be classified as subsequent PAFP users which was considered a separate event.

b. Of those 1750 who discontinued use (if data is available), how many went on to re-use contraceptives subsequently?

Response: From our categorization of immediate and subsequent post-abortion contraceptive users, 1750 of these women did not qualify to be classified as immediate contraceptive users following abortion. Unfortunately, the data does not allow us to analyze the proportion of women who discontinued contraceptive use in detail. From the dataset, we are only able to identify those reporting use of a method immediately and then subsequently. We found that out of the 1750 women who were not immediate users of contraception, 809 (or 46.2%) were subsequent users of post-abortion contraception.

c. Did some of the 130 non-users of PAFP (immediate) go on subsequently to use contraceptives or not?

Response: The 130 women were immediate PAFP users and of this number, 62.9% (82 out of 130) continued contraceptive use (subsequent users) while 37.1% (48 out of 130) were not subsequent users.

4. In the binary logistic regression analysis, the authors did not specify whether it was a bivariate or multivariate.

Response: In the data analysis section of the paper on page 9, we stated that we carried out multivariate analysis using two binary logistic regression models to ascertain the odds adjusting for all the factors which we deemed to be associated with immediate and subsequent post-abortion contraceptive use. However, we have modified and clarified the sentence slightly on page 14 to highlight that the results are from multivariate analyses.

5. Further information could have been derived from a multivariate

Response: We performed two separate multivariate regression models to examine the predictors (or factors) associated with the two primary outcome variables (immediate and subsequent post abortion contraceptive use). We believe this satisfies the information derived from the multivariate analyses.

Reviewer #2:

After comparing the revised manuscript with the review comments, it is satisfactory to say that the authors have incorporated all the suggestions and comments into the revision. This makes the article scientifically appropriate for acceptance.

Response: We are grateful to the reviewer for these positive comments.

Submitted filename: RESPONSE TO REVIEWERS.docx

Click here for additional data file.

23 Nov 2021

Women’s post-abortion contraceptive use: are predictors the same for immediate and future uptake of contraception? Evidence from Ghana.

PONE-D-20-22759R2

Dear Dr. Kayi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Zelalem Nigussie Azene, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In my opinion the authors have responded to the concerns raised. The statistically analysis has been satisfactorily done

Reviewer #2: Article Type: Research Article

Manuscript #: PONE-D-20-22759

Title: Women’s post-abortion contraceptive use: are predictors the same for immediate and future uptake of contraception? Evidence from Ghana.

Authors: Esinam Afi Kayi, PhD; Adriana Andrea Ewurabena Biney; Naa Dodua Dodoo; Charlotte Abra Esime Ofori; Francis Nii-Amoo Dodoo

If the article type is not Research Article, please view this page for more information on other article types: https://journals.plos.org/plosone/s/other-article-types

Abstract

The study recommends an improvement in health system level factors to meet the needs of women at the point of abortion care delivery. However, the results did not point to poor health system factor with respect to the subject.

Socio-ecological model explaining contraceptive behavior among abortion seekers

The content on Lines 130-152 are useful. However, these could have come at the introduction section, immediately after the sentence on Lines 98-99.

Results and discussion

Individual level factors of post-abortion contraceptive use

The discussion was well done. However, it was not discussed with the ecological model.

Structural /institutional level- health system factors

The discussion was well done. However, it was not discussed with the ecological model.

Conclusion

Three issues are found in the Conclusion – conclusion, recommendation and challenges. I think they should stand alone. However, the challenges could come after data analysis.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

10 Dec 2021

PONE-D-20-22759R2

Women’s post-abortion contraceptive use: are predictors the same for immediate and future uptake of contraception? Evidence from Ghana.

Dear Dr. Kayi:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Zelalem Nigussie Azene

Academic Editor

PLOS ONE