Association between history of abortion and current use of contraceptives among Mongolian Women

Background: Understanding the factors associated with the adoption of contraceptive methods among women of childbearing age is imperative to improving maternal health outcomes. This study aimed at exploring the association between history of abortion and contraceptive use among Mongolian women. Materials and methods: We analyzed cross-sectional data of 8373 women aged 15–49 years from the 2018 Mongolian Social Indicator Sample Survey (MSISS). Binary logistic regression models were used to assess the association between abortion history and current contraceptive use while accounting for both individual- and community- level factors. Results: A total of 4347 (51.92%) and 2525 (30.16%) reported current use of various contraceptive methods and a history of abortion in their lifetime, respectively. Women with a history of abortion were less likely to report current use of contraceptives (adjusted odds ratio (AOR) = 0.72, 95% confidence interval (CI) [0.58–0.89]). Specifically, women with a history of abortion were less likely to report use of IUD (AOR = 0.79, 95% CI [0.71–0.90)]) and injectables (AOR = 0.59, 95% CI [0.41–0.84]). History of abortion was associated with increased likelihood of using abstinence (OR = 1.82, 95% CI [1.31–2.53]) as a contraceptive method. Conclusion: Our results demonstrated a significant association between history of abortion and contraceptive use. Public health interventions aiming to improve maternal health outcomes through contraceptive use should target women with a history of abortion to improve their uptake. This was a cross-sectional survey that analyzed secondary data from the 2018 Mongolian Social Indicator Sample Survey (MSISS) [28]. Mongolia has a population of about 2.8 million, with close to 69% of its population believed to occupy the capital, Ulaanbaatar [3].. The MSISS complements the earlier Multiple Cluster Indicator Surveys (MCIS) conducted every five years dating back to 1996. The MSISS was first introduced in 2013 with support from United Nations Children’s Emergency Fund (UNICEF) and United Nations Population Fund (UNFPA). A total of 14,500 households were sampled. All women aged 15–49 years from the sampled provinces were eligible to participate in the survey. A total of 11,737 women were interviewed. In the current study, participants with complete information on all the selected variables were analyzed (n = 8373). Information on the design, methodology, and sampling techniques of the MSISS have been detailed elsewhere [28]. In brief, the MSISS is a household survey with the final sampling units being individuals at each enlisted household. The 2018 MSISS was designed to cover the largest number of indicators than other previous surveys. The 2018 survey covered five geographical regions (Eastern, Western, Central, Khangai and Ulaanbaatar) both in rural and urban areas aimed at providing a large number of estimates of indicators on the situation of women, children and men. The selection of the survey sample was based on a two-stage stratified cluster sampling technique, employing the 2017 Population and Household Database sampling frame. A total of 8 targeted provinces/districts were singled out from the five regions (Bayan-Ulgii, Bay ankhongor, Gobi-Altai, Zavkhan, Umnugovi, Khuvsgul, Bayanzurkh and Nalaikh) from which samples were drawn. Data was collected through the completion of questionnaires using computer assisted personal interview. Paper and pencil interviewing was employed during pretesting, which resulted in the modification of wording and coherence of a couple of items in the questionnaire. All the people involved in the data collection went through rigorous training on interviewing techniques, contents of the questionnaire and other vital elements. The MSISS questionnaire was designed to collect data on characteristics of households, women, men and children. The data used in this study comprised of self-reported responses. The questionnaire had several sections including women’s socio-demographic information, contraception use, unmet need for contraception, access to mass and social media and or technology, fertility, miscarriage, stillbirth and abortion, maternal and newborn health, attitudes towards domestic violence, adult function and many more. The data extracted for this study was obtained from the women’s socio-demographic information, contraception use and miscarriage, stillbirth and abortion sections. The outcome variable was current use of contraceptives by women of reproductive age (15–49 years). Contraception methods were defined as devices, medications or methods used to avoid pregnancy [29]. First, we assessed overall contraceptive use (i.e., whether participant reported to be using any contraceptive method (yes/no)). Women were asked the following question “Are you currently doing something or using any method to delay or avoid getting pregnant?”. Second, we assessed the use of specific contraceptive method. Participants were asked to report the type of contraceptive method using the following question “what type of method are you using?”. This was a “yes/no” question. Participants reported using different types of contraceptive methods (i.e. permanent non-reversible methods [male and female sterilization], long acting reversible contraception (LARC) [IUD or Implants], any other modern contraceptive methods [i.e., injections, pills, male or female condoms, foam/jelly], and traditional or natural methods [lactational amenorrhea method (LAM), periodic abstinence/rhythm/calendar, withdrawal] or any other method) they were using at the time of the interview. We created a variable ‘use of specific contraceptive method’ with nine mutually exclusive categories (i.e., ‘0’ no contraceptive use, ‘1’ female sterilization, ‘2’ IUD, ‘3’ injection, ‘4’ implants, ‘5’ pills, ‘6’ male condom, ‘7’ female condom, ‘8’ abstinence). Even though the question regarding contraceptive use may have been affected with the potential of social desirability bias (in which women may have wanted to report use of contraceptives when they are not using hence resulting in overestimation of contraceptive use), the data collectors were well trained to assure participants of the confidentiality of their responses to ensure participants provide accurate information. Our main independent variable was history of abortion (Yes or No). During the survey, women of reproductive age were asked whether they had ever experienced any case of their pregnancy ending up with miscarriage, stillbirth, missed abortion or abortion [28]. The responses were self-reported based on the respondent’s total lifetime number of history of abortions. The variable was coded ‘Yes’ (for those with a history of abortion) and ‘No’ (for those with no abortion history). Variables considered as covariates were selected and classified as individual or community- level factors based on literature [30, 31]. Based on our outcome of interest, history of abortion, missing cases from each of the covariates used in this study were dropped. Age of the women (15–19, 20–24, 25–34, 35+), their marital status (married, formerly married/divorced, never married), highest educational level (secondary[lower/upper], vocational or training center, and university/institute/collected), age at first marriage (10–19, 20–29, 30+), currently pregnant (yes/no), ever given birth (yes/no), alcohol use (yes/no), age at first use of alcohol (10–19, 20–29, 30+, Never), the total number of children (Less or equal 2, Less or equal 4, Equal or more than 5, None) and age of the husband (15–24, 25–34, 35+) were the sociodemographic and individual-level factors included in this study. Community-level factors included were area of residency (rural/urban), area of origin (Khangai, Central, Eastern, Ulaanbaatar, Western), ethnicity (Khalkh, Kazakh, Other), religion (Buddhist, Islam, Other, No Religion), and wealth index score (Richest, Fourth, Middle, Second, Poorest). Chi-square test was used to examine the distribution of study characteristics according to history of abortion and contraceptive use, respectively. We used binary logistic regression to report the association between the outcome and the independent variables. Variables assessed in the current analysis were selected based on their importance in literature [30, 31]. Univariable models were constructed and variables with a p < 0.1 were included in the multivariable models [32]. In our final analyses, four models were run. Model 1 was the unadjusted model between history of abortion and contraceptive use. In models 2 and 3, we adjusted for individual and community level factors, respectively. To check for multicollinearity of the models, variance inflation factor and tolerance were used with VIF < 10 and tolerance > 0.1 indicating no multicollinearity problems in our models. Furthermore, we used receiver-operating characteristic (ROC) analysis to compare and evaluate the accuracy of the four statistical models employed [33, 34]. The higher the value of the AUC or the larger the area under curve, the better the performance of the model. The strength of association was reported as adjusted odds ratio (AOR) and their 95% confidence intervals. The statistical significance was set at p < 0.05. All analyses were carried out using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). The MSISS was approved by order number A/67 2018 of Chairperson of NSO in 2018.The order A/67 2018 had details relating to the potential risks and mitigation of same through the lifecycle of the survey under its Protection Protocol. Informed consent was obtained before commencement of the survey from each of the participants or their legal guardian. The participants were assured of the confidentiality and anonymity of any information they had provided. The survey was conducted in accordance with approved guidelines and regulations.