Original research article Contraceptive discontinuation and pregnancy postabortion in Nepal: a longitudinal cohort study ☆,☆☆ Mahesh Puri a , Jillian T. Henderson b,c , Cynthia C. Harper b , Maya Blum b , Deepak Joshi a , Corinne H. Rocca b, ⁎ a Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, PO Box 9626, Kathmandu, Nepal b Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, 3333 California Street, Suite 335, Box 0744, San Francisco, CA 94143-0744, USA c Kaiser Permanente Center for Health Research, Northwest, 3800 N. Interstate Avenue, Portland, OR 97227, USA Received 14 May 2014; revised 17 December 2014; accepted 22 December 2014 Abstract Objective: To examine postabortion contraceptive discontinuation and pregnancy in Nepal, where abortion was decriminalized in 2002. Study Design: We conducted an observational cohort study of 654 women obtaining abortions from four public and nongovernmental facilities in 2011. Patients completed questionnaires at their abortion visit and 6 and 12 months later. We used Cox proportional hazards models to assess contraceptive discontinuation and pregnancy by method initiated postabortion and other sociodemographic and reproductive factors. Results: Among the 78% (508/654) of women who initiated a modern contraceptive method within 3 months postabortion, the 1-year contraceptive discontinuation rate was 62 per 100 person-years. Discontinuation was far lower among the 5% of women using long-acting reversible methods (21/ 100 person-years) than among those using condoms (74/100 person-years), pills (61/100 person-years) and the injectable [64/100 person-years; adjusted hazard ratio (aHR)=0.32 (0.15–0.68)]. Unmarried women and those not living with their husband experienced higher contraceptive discontinuation [aHR=2.16 (1.47–3.17)]. The 1-year pregnancy rate for all women was 9/100 person-years. Pregnancy was highest among those who initiated no modern method postabortion (13/100 person-years) and condoms (12/100 person-years), and pregnancy was lowest among users of long- acting reversible methods (3/100 person-years). The poorest women were at increased pregnancy risk [aHR=2.31 (1.32–4.10)]. Conclusion: Women using intrauterine devices and implants experienced greatly reduced contraceptive discontinuation and pregnancy within a year postabortion, although initiation of these long-acting methods was low. Increased availability of long-acting methods in Nepal and similar settings may help to prevent unwanted pregnancy and attendant maternal mortality and morbidities. Implications: Initiation of modern contraception was high postabortion; however, 1-year discontinuation was high for the condom, pill and injectable, the methods most commonly used. Rates for intrauterine devices and implants were low. Results support efforts to facilitate patient knowledge and access to the full range of contraceptives, including long-acting reversible methods. © 2015 Elsevier Inc. All rights reserved. Keywords: Postabortion contraception; Continuation; Pregnancy; Long-acting reversible contraception 1. Introduction Since abortion was legalized in 2002, Nepal has experienced a rapid expansion of safe services [1]. The country's Safe Abortion Policy includes a mandate that abortion facilities provide comprehensive contraceptive care [2]. Effective contraceptive use, including after abortion, is critical to reducing unintended pregnancy and improving women's reproductive autonomy and health [3]. Contracep- tion is also an important intervention to address maternal mortality, which, despite improvements, remains high in many regions of Nepal [4,5]. Contraception 91 (2015) 301 – 307 ☆ Acknowledgement of funding: This research was funded by the Society of Family Planning. The views and opinions expressed are those of the authors and do not necessarily represent the views and opinions of the funding agency. ☆☆ Conflicts of interest: We have no conflicts of interests to disclose. ⁎ Corresponding author. Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, 3333 California Street, Suite 335, Box 0744, San Francisco, CA 94143-0744, USA. Tel.: + 1 415 476 6973; fax: + 1 415 502 8479. E-mail address: roccac@obgyn.ucsf.edu (C.H. Rocca). http://dx.doi.org/10.1016/j.contraception.2014.12.011 0010-7824/© 2015 Elsevier Inc. All rights reserved.