Effect of a mobile phone-based intervention on post-abortion contraception: a

randomized controlled trial in Cambodia

7,12

13,14

1517

Chris Smith , Thoai D Ngo , Judy Gold , Phil Edwards , Uk Vannak , Ly Sokhey , Kazuyo
Machiyama , Emma Slaymaker , Ruby Warnockd, Ona McCarthy & Caroline Free

Oleh:
Galuh Rahmita Mufti
16014101084
Masa KKM 5 Desember 2016 15 Januari 2017
 Dosen Pembimbing:
dr. Benecditus S. Lampus, M.Kes, PKK

BAGIAN ILMU KEDOKTERAN KOMUNITAS

FAKULTAS KEDOKTERAN
UNIVERSITAS SAM RATULANGI
MANADO
2016
 LEMBAR PENGESAHAN

World Health Organization (WHO) Journal

Ilmu Kedokteran Komunitas
Dengan Judul:

Effect of a mobile phone-based intervention on post-abortion contraception: a

randomized controlled trial in Cambodia
Chris Smith , Thoai D Ngo , Judy Gold , Phil Edwards , Uk Vannak , Ly Sokhey , Kazuyo
Machiyama , Emma Slaymaker , Ruby Warnockd, Ona McCarthy & Caroline Free
WHO 2015;93:842-850A

Oleh:
Galuh Rahmita Mufti
16014101084
Masa KKM 5 Desember 2016 15 Januari 2017

Mengetahui,
Dosen Pembimbing

dr. Benecditus S. Lampus, M.Kes, PKK

Research

Effect of a mobile phone-based intervention on post-abortion

contraception: a randomized controlled trial in Cambodia
Chris Smith,a Thoai D Ngo,b Judy Gold,c Phil Edwards,a Uk Vannak,d Ly Sokhey,d Kazuyo
Machiyama,a Emma Slaymaker,a Ruby Warnock,d Ona McCarthya & Caroline Freea

Objective To assess the effect of a mobile phone-based intervention (mHealth) on post-abortion contraception use by
women in Cambodia. Methods The Mobile Technology for Improved Family Planning (MOTIF) study involved women who
sought safe abortion services at four Marie Stopes International clinics in Cambodia. We randomly allocated 249 women to a
mobile phone-based intervention, which comprised six automated, interactive voice messages with counsellor phone support,
as required, whereas 251 women were allocated to a control group receiving standard care. The primary outcome was the
self-reported use of an effective contraceptive method, 4 and 12 months after an abortion.
Findings Data on effective contraceptive use were available for 431 (86%) participants at 4 months and 328 (66%) at 12 months. Significantly
more women in the intervention than the control group reported effective contraception use at 4 months (64% versus 46%, respectively;
relative risk, RR: 1.39; 95% confidence interval, CI: 1.171.66) but not at 12 months (50% versus 43%, respectively; RR: 1.16; 95% CI: 0.92
1.47). However, significantly more women in the intervention group reported using a long-acting contraceptive method at both follow-up times.
There was no significant difference between the groups in repeat pregnancies or abortions at 4 or 12 months.
Conclusion Adding a mobile phone-based intervention to abortion care services in Cambodia had a short-term effect on the overall
use of any effective contraception, while the use of long-acting contraceptive methods lasted throughout the study period.

ily planning in countries like Cambodia where over 90% of

Introduction
Unmet need for contraception can result in unintended preg-
nancy and avoidable maternal and infant deaths. 1 It has been
estimated that, if the need for modern contraception methods
were met, 52 million unintended pregnancies, 24 million abor-
tions (over half of which would be unsafe) and 70000 maternal
deaths would be prevented among women in low- income
countries each year. Nevertheless, 225 million women in these
countries had an unmet need for contraception in 2014. 2
Women who seek an abortion are likely to have an unmet
need for contraception and the time after an abortion provides a
key opportunity to offer family planning services. 3 Typically,
women are counselled on family planning before discharge from
clinical care after seeking abortion services. 4 However, quality
of service provision varies and evidence on the ability of
enhanced counselling interventions to improve post-abortion
family planning is inconclusive.5,6
In Cambodia, despite the total fertility rate declining
from 3.4 births per woman in 2005 to 3.0 births per woman
in 2010, there remains an unmet need for contraception: in
2010, 81% of women of reproductive age reported wanting
to delay their next child or to have no more children but only
35% reported currently using a modern contraceptive
method.7 The abortion rate in the country was estimated to be
50 per 1000 women, compared to a global average of 28 per
1000,8 and 26% of women who sought abortion services had
had more than one abortion.7
Interventions delivered by mobile phone could help
increase the uptake and continuation of post-abortion fam-
the 2066 women surveyed report owning a mobile phone. 9
Health interventions delivered by mobile phone can utilize
different approaches (e.g. text messages, voice messages or
smartphone applications) depending on the literacy of the
population and the devices available. 10 Compared with face-
to-face interventions, mobile phone-based interven-tions
have the advantage that they can provide interactive,
personalized support inexpensively wherever the person is
located and whenever needed. Our research suggested that
women in Cambodia often found it difficult to make deci-
sions about contraception at the time of seeking abortion
services; they needed more time, to wait for their health to
improve or to speak with family or friends. 11 Hence, in this
setting, where 80% of the population live in a rural area and
geographical distances can restrict access to services, mobile
phone-based interventions may provide an effective method
for maintaining communication with clients after
they leave the clinic. Interventions delivered by mobile
phone have been shown to be effective in other health areas,
such as smoking cessation and adherence to treatment for
human immunodeficiency virus infection. However, the
evidence from three small trials in which a mobile phone-
based intervention was used to increase contraceptive use
has been inconclusive. The objective of our study was
to evaluate the effectiveness of a mobile phone-based inter-
vention designed to support post-abortion contraception in
Cambodia. The specific aims were to increase the uptake of
effective contraceptive methods and to reduce contraceptive
discontinuation.

a
Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England.
b
Innovations for Poverty Action, New Haven, United States of America.
c
Independent consultant, London, England.
d
Marie Stopes International, Phnom Penh, Cambodia.
Correspondence to Chris Smith (email: christopher.smith@lshtm.ac.uk).
(Submitted: 18 June 2015 Revised version received: 3 September 2015 Accepted: 16 September 2015 Published online: 15 October 2015)

842 Bull World Health Organ 2015;93:842850A | doi: http://dx.doi.org/10.2471/BLT.15.160267


Chris Smith et al.
Methods
Our study the Mobile Technology for
Improved Family Planning (MOTIF)
study was a single-blind, randomized
trial of a personalized, mobile phone-
based intervention designed to support
post- abortion family planning. The pro-
tocol was published in 2013. 18,19 The trial
was undertaken at four Marie Stopes
International clinics in Cambodia that
provided safe abortion services: two
served peri-urban populations around
Phnom Penh city (i.e. Chbar Ambov and
Takmao) and two served provincial
towns with a predominantly rural popu-
lation (i.e. Battambang and Siem Reap).
All women older than 17 years who
sought an induced abortion were eligible
for inclusion if they had a mobile phone
primarily for their own use, reported not
wanting to become pregnant and were
willing to receive automated voice
messages about contraception. Research
assistants interviewed women after they
had received post -abortion family plan-
ning counselling at the clinic to assess
their eligibility for the study and to col-
lect baseline data. Participants provided
consent by written signature or thumb-
print. Ethical approval was obtained from
ethics committees at the London School
of Hygiene & Tropical Medicine and
Marie Stopes International and the
Cambodia Human Research ethics com-
mittee. The trial was registered through
ClinicalTrials.gov with the identifier
NCT01823861.
Research assistants provided a
written list of participants, each with a
unique identification number, to coun-
sellors delivering the intervention. The
project statistician at the London School
of Hygiene & Tropical Medicine, Lon-
don, United Kingdom of Great Britain
and Northern Ireland, received only the
identification number and the urban or
rural clinic classification of each
participant. The statistician allocated
participants to the intervention or con-trol
group on a 1:1 basis using Minim
(https://www-users.york.ac.uk/~mb55/
guide/minim.htm), a computer ran-
domization program that stratified them
according to whether their clinic was
urban or rural. The identification
numbers of participants allocated to the
intervention were sent to the counsel-lors
between 1 May and 27 September 2013.
Researchers who undertook data
collection and analysis were blinded to
the treatment allocation.
Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267
Research
Contraceptive use, Cambodia
Box 1. The mobile phone-based intervention
The conceptual framework for the intervention used in the MObile Technology for Improved
Family Planning (MOTIF) study was based on literature reports on the determinants of
contraceptive use and on links between contraceptive use and fertility. 18 The intervention
comprised six automated voice messages sent to participants mobile phones, at the time of
their preference, during the 3 months following an abortion. Participants received the first
message within 1 week of using abortion services and every 2 weeks thereafter. The
message, recorded in the Khmer language, was as follows:
Hello, this is a voice message from a Marie Stopes counsellor. I hope you are doing fine. Contraceptive
methods are an effective and safe way to prevent an unplanned pregnancy. I am waiting to provide free
and confidential contraceptive support to you. Press 1 if you would like me to call you back to discuss
contraception. Press 2 if you are comfortable with using contraception and you do not need me to call you
back this time. Press 3 if you would prefer not to receive any more messages.
Participants who pressed 1 or who did not respond received a phone call from a counsellor. The
phone calls were intended to encourage contraceptive use by increasing the clients capability of
using contraception by: (i) providing individualized information on a range of contraceptive
methods; (ii) increasing the participants opportunity to use contraception, for example, by
informing her where she could access specific methods near her residence; and (iii) increasing
motivation by reinforcing knowledge of the benefits of contraception. At the participants request,
the counsellor would also discuss contraception with her husband or partner.
Participants were also able to call the service and ask to speak to a counsellor. Those who
chose to receive an oral or injectable contraceptive could opt to receive additional reminder
messages appropriate to their method (e.g. on when to start a new packet of pills or when
to receive a new injection). The sixth and final voice message was similar but also reminded
the participant that this was the last message they would receive.
The intervention was delivered by trained counsellors at Marie Stopes International Cambodia.
Voice messages were scheduled and sent using the open-source software program Verboice
(InSTEDD, Palo Alto, United States of America). The cost of outgoing communications from the
provider to the participant was met by Marie Stopes International Cambodia and the cost of calling
into the service (i.e. a local call) was incurred by participants.
All participants received existing subdermal implants, intrauterine de-vices
standard care, which included post- and permanent methods, such as
abortion family planning counselling at sterilization or vasectomy.20 ,21 A partici-
the clinic in accordance with national pant was regarded as using an effective
guidelines, the offer of a follow-up ap- method if she reported that she: (i) cur-
pointment at the clinic and details of the rently had a contraceptive implant or an
clinics phone number and of a hotline intrauterine device in place; (ii) had
number operated by counsellors at Marie received a contraceptive injection within
Stopes International Cambodia. Those the previous 3 months; (iii) had under-
allocated to the intervention, which lasted gone sterilization or her husband or
3 months, also received six automated, partner had had a vasectomy; or (iv) had
interactive voice messages and were taken an oral contraceptive within 24
provided with phone support from a hours of the interview or according to
counsellor depending on their responses instructions. Secondary outcomes were:
to the messages (Box 1). Par-ticipants (i) use of a long-acting contracep-tive
who chose to receive oral or injectable method (i.e. an intrauterine device,
contraceptives could opt for additional implant or permanent method); (ii) re-
reminder phone messages ap-propriate to peat pregnancy; (iii) repeat abortion; (iv)
their method. Participants in the control effective contraceptive use for more than
group did not receive voice messages. 80% of the 4 or 12 months after the
The formative research carried out to abortion; (v) road traffic accidents asso-
develop the intervention will be reported ciated with the intervention (e.g. caused
elsewhere. by driving while using the phone); and
The primary outcome was the self- (vi) domestic abuse associated with the
reported use of an effective contracep- intervention (e.g. after the womans
tion method, 4 and 12 months after an husband or partner had listened to the
abortion. Effective methods were de- messages). Research assistants contacted
fined as those that have been associated participants by phone and collected
with a 12-month pregnancy rate below information on these outcomes using a
10% (a common criterion in developing standardized questionnaire. The effect of
countries), such as oral contraceptives, 3- the intervention was examined in pre-
monthly contraceptive injections, specified subgroups categorized by age,
843
 Research
Contraceptive use, Cambodia
Fig. 1. Flowchart of participants in a mobile phone-based intervention for post-abortion contraception, Cambodia, 20132014
249 women allocated to intervention group
38 women lost to
follow up:
3 withdrew
35 could not be reached
At four months:
211 women followed
up and analyzed
42 women lost to
follow up:
42 could not be reached
At 12 months:
169 women followed
up and analyzed
Note: The intervention comprised six automated, interactive voice messages by mobile phone and phone support from a
counsellor, as required, during the 3 months following an abortion (Box 1).
urban or rural residence, educational
level and socioeconomic status
access to a motorized vehicle was used
as a proxy measure of socioeconomic
status. The 4-month follow-ups were
conducted between 13 August 2013
and 31 Janu-ary 2014 and the 12
-month follow-ups, between 24 July
and 16 November 2014. An assessment
of the validity of the self-reported data
collected after 4 months in 50
participants will be reported elsewhere.
Statistical analysis
The statistical analysis plan was speci-
fied before the study was unblinded and
was reported in the trial protocol. 18 We
estimated that 35% of the control group
would be using an effective contraception
method after 4 months and that a sample
size of 500 would be required to detect a
13% increase in contraceptive use with a
90% power at the 5% level of
significance.18 Analyses were undertaken
on an intention-to-
844
915 women assessed for eligibility
500 women randomized
251 women allocated to control group
At four months:
220 women followed
up and analyzed
At 12 months:
159 women followed
up and analyzed
treat basis using Stata version 13.1
(StataCorp. LP, College Station, United
States of America). The effect of the
intervention was expressed as a relative
risk (RR) or hazard ratio (HR); a 95%
confidence interval (CI) was used for
primary and secondary outcomes and a
99% CI for subgroup analyses. The
contraceptive discontinuation rate was
assessed using KaplanMeier sur-vival
analysis techniques: for 4-month follow-
up data, discontinuation was assessed in
participants who started us-ing an
effective contraception method during the
first 4 weeks after an abor-tion and, for
12-month follow-up data, discontinuation
was assessed in those who started the
method during the 3 months after an
abortion. Discon-tinuation was defined as
stopping the method for 1 week or more
before the 4-month follow- up or for 1
month or more before the 12-month
follow -up. If the participant switched
from one effective method to another
effective
Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267
Chris Smith et al.
209 women did not meet inclusion criteria:
199 had no phone
5 had a miscarriage (not an abortion)
5 wanted to have another child
206 women eligible but declined:
163 had no time
14 separated from husband/partner
11 husband/partner working away
14 planning to work abroad
3 no space to interview client
1 deaf
31 women lost to
follow up:
3 withdrew
28 could not be reached
61 women lost to
follow up:
2 withdrew
59 could not be reached
method this was not considered dis-
continuation.
Results
We excluded 199 potential participants
because they did not own a mobile
phone. Of the 500 participants, 249
were assigned to the intervention group
and 251 to the control group (Fig. 1).
The participants baseline characteris-
tics are shown in Table 1. Data on the
primary outcome were available for
431 (86%) participants at 4 months and
for 328 (66%) at 12 months. Over 75%
(133/172) of losses to follow-up by 12
months were due to the participants
phone being either switched off or not
in use, as indicated by an automated
message. Less frequently the phone
number had been reassigned to another
user or the participant had reportedly
moved abroad for work. The proportion
of women in the intervention group
who reported effective contraception
 Research
Chris Smith et al. Contraceptive use, Cambodia

Table 1. Baseline characteristics of participants in a mobile phone-based 1.041.70) . There was some evidence
that fewer women in the intervention than
intervention for post-abortion contraception, Cambodia, 20132014
the control group had discontin-ued
Characteristic Intervention Control group contraceptive use by the 4-month follow-
up (7% versus 16%, respectively; HR:
group (n=249) (n=251)
0.45; 95% CI: 0.201.01; Table 2) but not
No. (%) No. (%) by the 12 -month follow-up (26% versus
Age, years 30%, respectively; HR: 0.82; 95% CI:
<25 88(35) 69(27) 0.481.40; Fig. 2, avail-able at:
25 161 (65) 182 (73) http://www.who.int/bulletin/
Residence volumes/93/12/15-160267). There was no
Rural 164 (66) 157 (63) significant difference between the groups
in the proportion of women who had a
Urban 85(34) 94(37)
repeat pregnancy or an abortion by 4 or
Educational level
12 months and there were no reports that
None or primary school 93(37) 103 (41)
the intervention had been associated with
Secondary school or higher 156 (63) 148 (59)
a road traffic accident or domestic abuse
Socioeconomic status at 4 months (Table 2). The subgroup
Access to a motorized vehicle 221 (89) 214 (85) analysis found no evidence that either
No access to a motorized vehicle 28(11) 37(15) age, urban or rural residence, educational
Marital status level or so-cioeconomic status influenced
Married or cohabiting 231 (93) 233 (93) the effect of the intervention on
Never married or cohabited 15(6) 14(6) contraception use at 12 months (Fig. 3).
Divorced or separated 3(1) 4(2)
Literacy
Able to recognize numbers 246 (99) 250 (100) Discussion
Not able to recognize numbers 3(1) 1(>1)
Our mobile phone-based intervention
Number of living children
was associated with an increase in the
0 79(32) 68(27)
self-reported use of an effective contra-
1 or 2 122 (49) 131 (52)
ceptive method 4 months after an abor-
3 48(19) 52(21) tion but not 12 months after. However,
Previous abortions more participants in the intervention
0 144 (58) 155 (62) than the control group reported using a
1 69(28) 65(26) long-acting contraceptive method at 4
2 36(15) 31(12) and 12 months. The intervention had no
Type of abortion before study entry significant effect on the repeat preg-
Medical 102 (41) 105 (42) nancy or abortion rate and there were
Surgical 147 (59) 146 (58) no reports of adverse effects.
Woman planned to use contraception at time of This study has several strengths.
randomization First, all analyses were carried out on an
Yes 91(37) 96(38) intention-to- treat basis. Few trials of
No 18(7) 24(10) post-abortion family planning have a
Undecided 140 (56) 131 (52) longer observation period than our study.5
Womans mobile phone access The follow-up rate at 4 months was high
Shares phone 123 (49) 118 (47) and there was no evidence of any
difference in losses to follow-up between
Never shares phone 126 (51) 133 (53)
the treatment groups. However, the
Note: The intervention comprised six automated, interactive voice messages by mobile phone and phone
follow-up rate at 12 months was only
support from a counsellor, as required (Box 1). Inconsistencies arise in some values due to rounding.
66%, which decreased the statistical
power of our assessment of the long-
use was significantly higher than in the Table 2) and at 12 months (25% versus term effects of the intervention. This low
control group at 4 months (64% versus 12%, respectively; RR: 2.08; 95% CI: rate was probably due to participants
46%, respectively; RR: 1.39; 95% CI: 1.273.42). In addition, significantly migrating for work and/or changing
1.171.66; Table 2 ) but not at 12 more women in the intervention than the phone numbers, which is recognized as a
months (50% versus 43%, respectively; control group reported effective challenge for mobile phone-based
RR: 1.16; 95% CI: 0.921.47). contraceptive use for more than 80% of interventions in Cambodia.22
Significantly more women in the the 4 months after the abortion (54% One limitation of the study was
intervention than the control group re- versus 40%, respectively; RR: 1.35; 95% that, since the intervention involved
ported using a long-acting contraceptive CI: 1.101.67) and for more than 80% of behavioural change, it was not possible
method at 4 months (29% versus 9%, re- the 12 months after (51% versus 38%, to blind participants to their treatment
spectively; RR: 3.35; 95% CI: 2.075.40; respectively; RR: 1.33; 95% CI: allocation and they may have passed on

Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267 845

 Research
Contraceptive use, Cambodia Chris Smith et al.

information to the research assistants at

follow-up. In addition, the use of self

1.16 (0.921.47)

2.08 (1.273.42)

1.33 (1.041.70)

0.82b (0.481.40)

0.68 (0.281.66)

0.88 (0.691.12)
0.60 (0.152.50)
0.74 (0.441.24)
-report measures of contraceptive use has
(95% CI) the potential for detection bias. Although
they are standard in contra-ceptive

NA
NA
research, self-report measures have been
RR

shown to overestimate contra-ceptive use

and underestimate abortion rates.23
However, it seems unlikely that
participants would over-report using one
Twelve-month follow-up

particular long-acting method rather than

another (e.g. intrauterine devices versus
respondents (%)
No./total no. of

implants). It was not feasible to measure

Control group

61/159 (38)
68/159 (43)

19/159 (12)

92/251 (37)
28/159 (18)
objective contracep-tion use in this setting
25/83 (30)

11/159 (7)

5/251 (2)
and electronic medication monitors and

months following an abortion (Box 1).

hormonal assays have limited reliability

ND
ND
and valid-ity.24, 25 Oral and injectable
contracep-tives can be obtained from
pharmacists without prescriptions in
Intervention group

respondents (%)

Cambodia, so clinic records may not

No./total no. of

accurately reflect contraceptive use. The

86/169 (51)

28/107 (26)
84/169 (50)

42/169 (25)

80/249 (32)
22/169 (13)
8/169 (5)

3/249 (1) most commonly reported reason for

ineligibility was not having a mobile
ND
ND

phone. Although we did not record the

characteristics of the 199 potential
Note: The intervention comprised six automated, interactive voice messages by mobile phone and phone support from a counsellor, as required, during 3
participants in our study who did not have
a phone, it is a concern that mobile phone
-based interventions may not reach the
1.35 (1.101.67)thefollow-upperiod
1.39 (1.171.66)contraceptivemethodSecondaryoutcome

3.35 (2.075.40)method

people most in need. We did not give

0.45 (0.201.01)a

participants mobile phones because of

RR (95% CI)
Effect of mobile phone-based intervention on post-abortion contraception, Cambodia, 20132014Table2.a

1.24 (0.801.92)b
1.01 (0.214.95)

possible implications for the

2.10 (0.1922.9)
1.25 (0.394.06)

NA

sustainability of the intervention and

NA

because there could have been negative

consequences for a participant if she was
asked where she obtained a new phone.
Study participants were similar to clients
0/220 (0)

seeking abortion services at the four

Control group

16/101 (16)

0/220 (0)
respondents (%)

Marie Stopes International Cambodian

Four-month follow-up

No./total no. of

19/220 (9)

study clinics during 2013. Most of these

31/251 (12)
3/251 (1)
1/220 (0.5)

women are married and multiparous, had

81/203 (40)

5/220 (2)

attended secondary school, are aged over

25 years and have previously paid for
CI: confidence interval; NA: not applicable; ND: not determined; RR: relative risk.Thevalueforcontraceptivediscontinuationisthehazardratio,nottherelative risk.a

The number lost to follow-up includes participants who withdrew from the study.b
101/220 (46)

reproductive health services at a clinic

0/210 (0)

run by a nongovernmental orga-nization.

Intervention group

0/210 (0)

However, sex workers known to have a

61/211 (29)

9/123 (7)
respondents (%)
No./total no. of

high unmet need for contra-ception and a

108/200 (54)

3/249 (1)
38/249 (15)

high abortion rate26 and young women,

135/211 (64)

6/210 (3)
2/210 (1)

were not well represented in our study

population. The effect of mobile phone
Involvement in a road traffic accident

-based interventions on post- abortion

family planning among these groups
Effective contraceptive use for >80% of
Use of a long-acting contraceptive
Primary outcomeSelf-reporteduseof an effective

requires further evaluation.

Experience of domestic abuse
Contraceptive discontinuation

There are few trials of mobile

phone-based interventions to increase
Withdrawal from study

contraception use. Two small trials

found no effect,16,17 whereas one trial
Repeat pregnancy

Lost to follow-up

found improved self-reported

Repeat abortion

adherence to oral contraceptive use.15

Service providers often define post-
Outcome

abortion family planning as the

initiation of contraceptive use within 2
weeks of an abortion but we did not

846 Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267

 Research
Chris Smith et al. Contraceptive use, Cambodia

Fig. 3. Contraceptive use in different subgroups after a mobile phone-based effective contraceptive use was higher in
the intervention than the control group
intervention for post-abortion contraception, Cambodia, 20132014
(84% (227/271) versus 64% (165/258),
respectively; P<0.001) and repeat un-
Subgroup Intervention Control Relative risk of intended pregnancy was lower (15%
group group contraceptive use at (42/276) versus 34% (96/281), respec-
(n = 169) (n = 159) 12 months (99% CI) tively; P<0.001) but repeat abortions
No. using contraceptives No. using contraceptives were not significantly lower (3% versus
at 12 months/total at 12 months/total 5%; P =0.23).30 At 12 months in our
no. of respondents (%) no. of respondents (%)
study, 13% (22/169) of participants in the
Age intervention group reported a repeat
Age < 25 years 20/53 (37.7) 11/40 (27.5) 1.37 (0.623.06)
Age 25 years 64/116 (55.2) 57/119 (47.9) 1.15 (0.831.60) pregnancy compared with 18% (28/159)
in the control group; the corresponding
Residence figures for a repeat abortion were 5%
Rural 61/116 (52.6) 46/96 (47.9) 1.10 (0.771.57)
Urban 23/53 (43.4) 22/63 (34.9) 1.24 (0.682.26) (8/169) and 7% (11/159), respectively.
However, the study was not powered to
Access to a
detect differences in these outcomes.
motorized vehicle
Yes 77/156 (49.4) 59/138 (42.8) 1.15 (0.831.60) Nevertheless, the increased use of long-
No 7/13 (53.9) 9/21 (42.9) 1.26 (0.503.17) acting methods and the increased duration
of all effective contraceptive use would
Educational level
None or primary 30/59 (50.9) 30/60 (50.0) 1.02 (0.641.62) be expected to result in a decrease in
Some secondary 54/110 (49.1) 38/99 (38.4) 1.28 (0.851.93) unintended pregnancies and repeat
or above abortions over time. A larger study may
be able to detect differences in these
All participants 84/169 (49.7) 68/159 (42.8) 1.16 (0.921.47) outcomes.

0.75 1 2 3 4 Conclusion
Favours control Favours intervention
Our results indicate that the addition of
CI: confidence interval. a mobile phone- based intervention to
Note: The intervention comprised six automated interactive voice messages by mobile phone and phone existing abortion care services could
support from a counsellor, as required, during 3 months following an abortion ( Box 1). Contraceptive use increase the use of long-acting contra-
was defined as the self-reported use of an effective contraception method 12 months after an abortion. ceptives. The overall use of effective
contraceptive methods was increased
identify any trials reporting follow-up at the uptake of long-acting methods. It is 4 months after an abortion but not at
this time point. We decided to assess plausible, though, that a relatively 12 months. In practice, the duration,
contraception use at 4 months, after the intensive intervention delivered over a language and mode of communication
intervention had been completed, because short period of time could influence the (i.e. text or voice) could be adapted to
we recognized that side-effects and decision to adopt a long- acting method different settings, though voice messages
discontinuation are common in the first (i.e. a single behavioural change) but be will be most useful in populations with
few months.27 The 12-month follow-up less effective in influencing continued limited literacy. We estimated the main
was intended to assess the long-term adherence to an oral contraceptive, which cost of delivering the intervention (i.e. for
effects of the intervention. Although at 12 requires sustained repetitive behaviour. In voice messages, phone calls and the
months there was no evidence of fact, the literature sug-gests that counsellors time) to be 6 United States
increased contraceptive use overall or of interventions encouraging medication dollars per client. A costeffectiveness
less frequent discontinuation, our inter- adherence are more effective for short- analysis will be reported elsewhere. Al-
vention was associated with an increase term rather than long-term treatments. though our intervention was delivered in
in the use of long-acting contraceptive Furthermore, long-acting contraceptive addition to post-abortion family plan-ning
methods in a context where a wide range methods are associated with lower support at a clinic, future research could
of post-abortion family planning methods discontinuation rates than short-acting assess the effect of a similar inter-vention
is available but the immediate uptake of hormonal methods.2729 We plan to in settings with more limited support: for
contraception is low (data available from publish a separate report on the results of example, where medical abortions are
corresponding author). The increase qualitative interviews with participants provided by the private sector.
occurred because partici-pants returned to about their experience of the intervention.
the clinic for a contra-ceptive implant or
an intrauterine device and is consistent Few studies have examined con- Acknowledgements
with our findings that some clients traceptive use for an extended period We thank all clients and clinic staff who
preferred to make decisions about post- after an abortion in a low-income set- participated in the study; BBC Media
abortion family planning after discharge ting. One matched, controlled study in Action Cambodia; Channe Suy at the
from clinical care.11 As our intervention Zimbabwe assessed the effect of InSTEDD iLab South East Asia; Javier
was complex, it was not clear which counselling and free contraception be- Sola at the Open Institute; Naomi Bryne-
component influenced fore hospital discharge. At 12 months, Soper, Sieklot Chinn, Thou Chum,

Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267 847

 Research
.Chris Smith et al Contraceptive use, Cambodia

collection or analysis. The UK Medical
Research Council ( MRC ) funded the
data analysis but had no influence on
the analysis or reporting. Chris Smith
was supported by an MRC Population
.Scientist Fellowship
.Competing interests: None declared
URC, Cambodia; Deborah Constant at
the University of Cape Town ; and Ali
-Flaming, Antoinette Pirie, Chris Vick
.ery, Tung Rathavy and Richard Lester
Funding: The Marie Stopes International
Innovation Fund funded the study for 15
months from October 2012 and had some
influence on the study design (authors JG
and TN) but not on data
Melissa Cockcroft, Sarah Cooper, Nicky
Jurgens, Seaklong Keam, Michelle Phil-
lips, Sras Thorng and Stefanie Wallach at
Marie Stopes International Cambo-dia;
Isolde Birdthistle, Tim Clayton, John
Cleland, Anna Glasier, Richard Hayes
and Susannah Mayhew at the London
School of Hygiene & Tropical Medicine ;
Azeem Majeed at Imperial College
London; Jerker Liljestrand at

:
) mHealth(
.
%46 %64 (4

1.39 : ) MOTIF(
(12 95%: 1.17 1.66(
1.16 : %43 50%249 .
%95: 0.921.47(.

.
. 251
. 12 4
. 12 4

328 4 %86( (431
. . 12 %66( (

64% 46% RR 1.39 95%
(Marie CI 1.17-1.66 12
Stopes International) 50% 43% RR 1.16 95%
(MOTIF) CI 0.921.47).
249 4
6 12
251
4 12

4 431 (86%)
12 328 (66%)4

Rsum

Effet dune intervention par t

Objectif valuer leffet dune intervention par tlphone portable mdicalis dans quatre cliniques Marie Stopes International du
sur lutilisation de mthodes contraceptives aprs (sant sur mobile) Cambodge. Nous avons alatoirement affect 249 femmes au groupe
.un avortement par les femmes au Cambodgebnficiant dune intervention par tlphone portable, laquelle
Mthodes Ltude MOTIF (Mobile Technology for Improved Family ,comprenait six messages vocaux automatiss et interactifs et, au besoin
(Planning Technologie mobile pour une meilleure planification familiale lassistance tlphonique dun conseiller, et 251 femmes au groupe de
a mobilis des femmes ayant eu recours des services davortement contrle recevant une prise en charge standard. Le critre dvaluation

Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267 848

 Research
Chris Smith et al. Contraceptive use, Cambodia

principal tait lutilisation autodclare dune mthode
contraceptive efficace, 4 et 12 mois aprs un avortement.
Rsultats Les donnes relatives lutilisation de contraceptifs efficaces
taient disponibles pour 431 (86%) participantes 4 mois et pour 328
(66%) 12 mois. Les femmes appartenant au groupe ayant bnfici de
lintervention sont beaucoup plus nombreuses que les femmes du groupe
de contrle avoir mentionn lutilisation de contraceptifs efficaces 4
mois (64% pour les premires contre 46% pour les secondes; risque relatif,
RR: 1,39; intervalle de confiance, IC, 95%: 1,17-1,66), ce qui nest pas le
cas 12 mois (50% contre 43%; RR: 1,16; IC 95%: 0,92-1,47).
Cependant, un nombre beaucoup plus lev de femmes ayant bnfici de
lintervention a indiqu avoir utilis une mthode contraceptive long terme
sur ces deux priodes de suivi. Aucune diffrence notable na t constate
entre les deux groupes concernant des grossesses ou des avortements
rpts 4 ou 12 mois.
Conclusion Ladjonction dune intervention par tlphone portable
aux services de soins aprs avortement au Cambodge a produit un
effet court terme sur lutilisation gnrale de contraceptifs efficaces,
tandis que lutilisation de mthodes contraceptives long terme sest
poursuivie tout au long de la priode dtude.

,
, ,
, 4 328 (66%) 12 .
(mHealth), ,
, 4 , ,

. ,
(64 46%
,
(MOTIF) , : 1,39; 95% ,
, : 1,171,66), 12
Marie Stopes International, (50 43% , : 1,16;
95% :
. 249 0,921,47).

,

,

,
.

, 251 4 12 ,
, .
.

4 12 ,

. - ,

431 (86%) .

Resumen
El efecto de una intervencin basada en la telefona mvil en los mtodos
anticonceptivos postaborto: un ensayo controlado aleatorizado en Camboya
Objetivo Evaluar el efecto de una intervencin basada en la 431 (86%) de las participantes y al cabo de 12 meses en el caso de 328
telefona mvil (mHealth) en el uso de mtodos (66%). Significativamente ms mujeres del grupo de la intervencin
anticonceptivos postaborto entre las mujeres de Camboya.
Mtodos El estudio Mobile Technology for Improved Family Planning
(MOTIF) involucr a mujeres que recurrieron a servicios de aborto seguros
en cuatro clnicas Marie Stopes International de Camboya. Se asignaron
de forma aleatoria 249 mujeres a una intervencin basada en la telefona
mvil que consista en seis mensajes de voz interactivos y automatizados y
el apoyo de un asesor a travs del telfono, cuando fuera necesario, y 251
mujeres a un grupo de control que reciba atencin estndar. El resultado
principal fue el uso autodeclarado de un mtodo anticonceptivo efectivo 4 y
12 meses despus de sufrir un aborto.
Resultados Los datos sobre el uso efectivo de los mtodos
anticonceptivos estuvieron disponibles al cabo de 4 meses en el caso de
que del grupo de control informaron de un uso efectivo de los
mtodos anticonceptivos al cabo de 4 meses (64% frente a 46%
respectivamente; riesgo relativo, RR: 1,39; intervalo de confianza (IC)
del 95%: 1,171,66) pero no al cabo de 12 meses (50% frente a 43%
respectivamente; RR: 1,16 (IC del 95%: 0,921,47). Sin embargo,
ms mujeres del grupo de la intervencin informaron sobre el uso de
mtodos anticonceptivos de larga duracin en los dos momentos del
seguimiento. No hubo una diferencia importante entre los grupos en
cuanto a embarazos futuros o abortos al cabo de 4 o 12 meses.
Conclusin Aadir una intervencin basada en la telefona mvil
a los servicios de atencin al aborto en Camboya tuvo un efecto a
corto plazo en el uso general de cualquier mtodo anticonceptivo
efectivo, mientras que el uso de mtodos anticonceptivos a largo
plazo perdur a lo largo de todo el periodo de estudio.

Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267 849

 Research
Contraceptive use, Cambodia
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Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267
 Research
Chris Smith et al. Contraceptive use, Cambodia

Fig. 2. KaplanMeier survival curves for contraceptive

discontinuation, in a mobile phone-based intervention
for post-abortion contraception, Cambodia, 2013 2014

100
Control group
90 Intervention group
Cumulativeproportionofparticipantsdiscontinuingcontraception(%)

20
80

70
60
50
40
30

10
0 1 2 3 4 5 6 7 8 9 10 11
Time from randomization (months)
Number at risk
Control group 83 83 80 78 72 71 70 66 65 65 61 60
Intervention 107 107 106 105 100 97 95 92 90 90 85 85
group

Note: The intervention comprised six automated, interactive voice messages by mobile phone and
phone support from a counsellor, as required, during 3 months following an abortion (Box 1).
Discontinuation, defined as stopping for 1 month, was assessed at 12 months in the 190
participants who started an effective method of contraception in the 3 months after an abortion. At
the 12-month follow up, data were collected on self-reported contraception use during each month
following the abortion. The number at risk is the number of contraception users at each time point.

Bull World Health Organ 2015;93:842850A| doi: http://dx.doi.org/10.2471/BLT.15.160267

 Effect of a mobile phone-based intervention on post-abortion contraception: a
randomized controlled trial in Cambodia
Pengaruh intervensi berbasis telepon seluler pada pasca aborsi kontrasepsi: uji
coba terkontrol secara acak di Kamboja

Baru-baru ini analisis yang lebih telah diusahakan untuk mengatasi kekuatan global dan arus
yang mempengaruhi patters/fungsi dari kesenjangan kesehatan antara jarak (Labonte et al.,
2007). Paul Farmer berpendapat dalam tradisi terbaik dari Rudolf Virchow ketika menganalisis
situasi di Haiti ia berbicara tentang "kekerasan struktural" yang mencerminkan asimetri
kekuasaan dan perlu jenis yang sangat berbeda dari analisis dari pemetaan koefisien Gini. Hal
ini juga menggarisbawahi bahwa kesehatan masyarakat global harus peduli dengan lanskap
global ini, dengan arus global dan dengan penentu politik yang menghasilkan mereka.
Tujuan Untuk menilai efek dari ponsel intervensi berbasis telepon (mHealth) pada pasca aborsi
penggunaan kontrasepsi oleh wanita di Kamboja.
Metode Mobile Technology untuk Peningkatan Keluarga Berencana (MOTIF) Penelitian ini
melibatkan wanita yang mencari layanan aborsi yang aman di empat klinik Marie Stopes
International di Kamboja. Kami secara acak mengalokasikan 249 perempuan untuk intervensi
berbasis telepon seluler, yang terdiri enam, pesan suara interaktif otomatis dengan dukungan
konsuler telepon, seperti yang diperlukan, sedangkan 251 perempuan yang dialokasikan untuk
kelompok kontrol yang menerima perawatan standar. Hasil utama adalah penggunaan yang
dilaporkan dengan metode lapor-sendiri dengan kontrasepsi yang efektif, 4 dan 12 bulan setelah
aborsi.
Temuan Data penggunaan kontrasepsi yang efektif yang tersedia untuk 431 (86%) peserta pada
4 bulan dan 328 (66%) pada 12 bulan. Secara signifikan lebih banyak perempuan dalam
intervensi dari kelompok kontrol melaporkan penggunaan kontrasepsi yang efektif pada 4 bulan
(64% berbanding 46%, masing-masing; risiko relatif, RR: 1,39; 95% confidence interval, CI: 1,17-
1,66) tetapi tidak pada 12 bulan ( 50% berbanding 43%, masing-masing; RR: 1,16; 95% CI: 0,92-
1,47). Namun, secara signifikan lebih banyak perempuan dalam kelompok intervensi dilaporkan
menggunakan metode kontrasepsi long-acting di kedua tindak lanjut kali. Tidak ada perbedaan
yang signifikan antara kelompok pada kehamilan berulang atau aborsi pada 4 atau 12 bulan.
Kesimpulan Menambahkan intervensi ponsel berbasis layanan perawatan aborsi di Kamboja
memiliki efek jangka pendek dari keseluruhan penggunaan setiap alat kontrasepsi yang efektif,
sedangkan penggunaan metode kontrasepsi long-acting (tindakan yang lama) berlangsung
selama periode penelitian.

Kata Pengantar
Kebutuhan yang tidak tercukupi untuk kontrasepsi dapat mengakibatkan kehamilan yang
tidak diinginkan dan kematian ibu dan bayi yang tidak dapat dihindarkan. Diperkirakan bahwa,
jika kebutuhan untuk metode kontrasepsi modern ditemukan/dilakukan, 52 juta kehamilan yang
tidak diinginkan, 24 juta aborsi (lebih dari setengah dari yang tidak aman) dan 70 000 kematian
ibu dapat dicegah di kalangan perempuan di negara-negara berpenghasilan rendah setiap tahun
. Namun demikian, 225 juta perempuan di negara-negara ini memiliki kebutuhan yang belum
terpenuhi untuk kontrasepsi pada tahun 2014.
 Wanita yang mencari aborsi cenderung memiliki kebutuhan yang belum terpenuhi untuk
kontrasepsi dan waktu setelah aborsi memberikan kesempatan kunci untuk menawarkan
layanan keluarga berencana. Biasanya, perempuan dinasehati untuk mengdakan keluarga
berencana sebelum pulang dari perawatan klinis setelah mencari layanan aborsi. Namun,
kualitas penyediaan layanan bervariasi dan bukti kemampuan intervensi konseling ditingkatkan
untuk meningkatkan KB pasca aborsi tidak meyakinkan.
Di Kamboja, meskipun total dari tingkat kelahiranl menurun dari 3,4 kelahiran per
perempuan di 2.005-3,0 kelahiran per perempuan pada tahun 2010, masih ada kebutuhan yang
belum terpenuhi untuk kontrasepsi: pada tahun 2010, 81% dari wanita usia reproduksi
dilaporkan ingin menunda anak mereka berikutnya atau tidak memiliki anak lagi tetapi hanya
35% dilaporkan sedang menggunakan metode kontrasepsi modern. Tingkat aborsi di negara itu
diperkirakan 50 per 1000 wanita, dibandingkan dengan rata-rata global 28 per 1000, dan 26%
dari wanita yang mencari layanan aborsi telah melakukan lebih dari satu aborsi.
Intervensi yang tersampaikan oleh ponsel dapat membantu meningkatkan penyerapan
dan kelanjutan keluarga berencana pasca-aborsi di negara-negara seperti Kamboja di mana
lebih dari 90% dari 2.066 wanita yang disurvei dalam laporan memiliki ponsel. intervensi
kesehatan yang tersampaikan oleh ponsel dapat dimanfaatkan dengan pendekatan yang
berbeda (pesan teks misalnya, pesan suara atau aplikasi smartphone) tergantung pada
keaksaraan (kemampuan membaca dan menulis) penduduk dan perangkat yang tersedia.
Dibandingkan dengan intervensi secara tatap muka (langsung), intervensi ponsel berbasis
telepon memiliki keuntungan dimana ponsel dapat memberikan/menyediakan dukungan
interaktif, personal dan murah dan di mana pun orang berada dan kapan saja diperlukan.
Penelitian kami menunjukkan bahwa perempuan di Kamboja sering merasa sulit untuk membuat
keputusan tentang kontrasepsi pada saat mencari layanan aborsi; mereka membutuhkan lebih
banyak waktu, untuk menunggu kesehatan mereka untuk meningkatkan atau untuk berbicara
dengan keluarga atau teman-teman. Oleh karena itu, dalam pengaturan ini, di mana 80%
penduduk tinggal di daerah pedesaan dan jarak geografis dapat membatasi akses ke layanan,
ponsel intervensi berbasis telepon dapat memberikan metode yang efektif untuk menjaga
komunikasi dengan klien setelah mereka meninggalkan klinik. Intervensi disampaikan oleh
ponsel telah terbukti efektif di bidang kesehatan lainnya, seperti program berhenti merokok dan
kepatuhan terhadap pengobatan untuk infeksi virus human immunodeficiency. Namun, bukti-
bukti dari tiga percobaan kecil di mana intervensi berbasis ponsel digunakan untuk
meningkatkan penggunaan kontrasepsi belum meyakinkan. Tujuan dari studi kami adalah untuk
mengevaluasi efektivitas mobile/ponsel intervensi berbasis ponsel yang dirancang untuk
mendukung kontrasepsi pasca aborsi di Kamboja. Tujuan khusus adalah untuk meningkatkan
penyerapan metode kontrasepsi yang efektif dan untuk mengurangi penghentian kontrasepsi.

Metode-Metode
Studi kami - the Mobile Technology for Improved Family Planning (MOTIF)Studi - adalah
intervensi single-blind (tidak terarah secara satu putaran), uji coba acak dari pribadi/ukuran
tertentu, berbasis ponsel yang dirancang untuk mendukung keluarga berencana pasca-aborsi.
Protokol ini diterbitkan pada 2013. percobaan ini dilakukan di empat klinik Marie Stopes
International di Kamboja yang memberikan pelayanan aborsi yang aman: dua berada di populasi
peri-urban di sekitar kota Phnom Penh (yaitu Chbar Ambov dan Takmao) dan lainnya berada di
kota provinsi dengan didominasi penduduk pedesaan (yaitu Battambang dan Siem Reap).
Semua wanitaberumur lebih dari 17 tahun yang berusaha melakukan aborsi yang memenuhi
syarat untuk dimasukkan jika mereka memiliki ponsel terutama untuk mereka gunakan sendiri,
dilaporkan tidak ingin hamil dan bersedia untuk menerima pesan suara otomatis tentang
kontrasepsi. asisten peneliti mewawancarai wanita setelah mereka menerima konseling pasca
aborsi KB di klinik untuk menilai kelayakan mereka untuk penelitian dan untuk mengumpulkan
data dasar. Peserta memberikan persetujuan oleh tanda tangan tertulis atau cap jempol.
persetujuan etis diperoleh dari komite etika di London School of Hygiene & Tropical Medicine dan
Marie Stopes International dan Kamboja Manusia Penelitian komite etik. Percobaan ini terdaftar
melalui ClinicalTrials.gov dengan identifier NCT01823861.
Asisten peneliti memberikan daftar tertulis dari peserta, masing-masing dengan nomor
identifikasi yang unik, untuk konselor yang memberikan/membawakan intervensi. Proyek
statistik di London School of Hygiene & Tropical Medicine, London, Kerajaan Inggris Raya dan
Irlandia Utara, menerima hanya nomor identifikasi dan klasifikasi klinik perkotaan atau
pedesaan dari masing-masing peserta. statistik yang dialokasikan peserta untuk intervensi atau
kelompok kontrol pada 1: dasar 1 menggunakan Minim (https://www-users.york.ac.uk/~mb55/
panduan / minim.htm), sebuah program pengacakan komputer yang dikelompokkan apakah
klinik mereka masuk kriteria perkotaan atau pedesaan. Nomor identifikasi peserta dialokasikan
untuk intervensi dikirim ke konselor antara 1 Mei dan 27 September 2013. Para peneliti yang
melakukan pengumpulan data dan analisis tidak mengetahui (blinded) untuk alokasi
pengobatan.
Semua peserta menerima perawatan standar, termasuk konseling KB pasca-aborsi di
klinik sesuai dengan pedoman nasional, tawaran janji tindak lanjut di klinik dan rincian nomor
telepon klinik dan dari nomor hotline yang dioperasikan oleh konselor di Marie Stopes
International Kamboja. Mereka dialokasikan untuk intervensi, yang berlangsung selama 3 bulan,
juga menerima enam, pesan suara interaktif otomatis dan dilengkapi dengan dukungan telepon
dari seorang konselor tergantung pada tanggapan mereka terhadap pesan (Kotak 1). Peserta
yang memilih untuk menerima kontrasepsi oral atau suntik bisa memilih untuk tambahan pesan
telepon pengingat tepat untuk metode mereka. Peserta pada kelompok kontrol tidak menerima
pesan suara. Penelitian formatif dilakukan untuk mengembangkan intervensi akan dilaporkan di
tempat lain.

Hasil utama adalah laporan sendiri (self-reported) penggunaan metode kontrasepsi yang
efektif, 4 dan 12 bulan setelah aborsi. metode yang efektif didefinisikan sebagai mereka yang
telah dikaitkan dengan tingkat kehamilan 12 bulan di bawah 10% (kriteria umum di negara-
negara berkembang), seperti kontrasepsi oral, suntikan kontrasepsi 3-bulanan, implan
subdermal, intrauterine device dan metode permanen, seperti sebagai sterilisasi atau
vasectomy. seorang peserta dianggap menggunakan metode yang efektif jika dia melaporkan
bahwa dia: (i) saat ini memiliki implan kontrasepsi atau alat kontrasepsi yang ditempatkan
dalam rahim; (Ii) telah menerima suntikan kontrasepsi pada 3 bulan sebelumnya; (Iii) menjalani
sterilisasi atau suaminya atau pasangan memiliki vasektomi; atau (iv) telah mengambil
kontrasepsi oral dalam waktu 24 jam dari wawancara atau sesuai dengan instruksi. Hasil
sekunder adalah: (i) penggunaan metode long-acting kontrasepsi (yaitu alat kontrasepsi dalam
rahim, implan atau metode permanen); (Ii) kehamilan berulang; (Iii) ulangi aborsi; (Iv)
penggunaan kontrasepsi yang efektif selama lebih dari 80% dari 4 atau 12 bulan setelah aborsi;
(V) kecelakaan lalu lintas jalan terkait dengan intervensi (misalnya disebabkan oleh mengemudi
sambil menggunakan telepon); dan (vi) kekerasan dalam rumah tangga yang terkait dengan
intervensi (misalnya setelah suami wanita atau pasangan telah mendengarkan pesan). asisten
peneliti dihubungi peserta melalui telepon dan mengumpulkan informasi tentang hasil ini
menggunakan kuesioner standar. Pengaruh intervensi diperiksa dalam subkelompok
prespecified dikategorikan oleh usia, tempat tinggal perkotaan atau pedesaan, tingkat
pendidikan dan status sosial ekonomi - akses ke kendaraan bermotor yang digunakan sebagai
ukuran proksi dari status sosial ekonomi. 4 bulan follow-up yang dilakukan antara 13 Agustus
2013 dan 31 Januari 2014 dan 12 bulan follow-up, antara 24 Juli dan 16 November 2014.
Penilaian terhadap validitas data yang dilaporkan sendiri dikumpulkan setelah 4 bulan di 50
peserta akan dilaporkan di tempat lain.
 Kotak 1. Ponsel intervensi berbasis hp (mobile/telephone)
Kerangka konseptual untuk intervensi yang digunakan dalam studi teknologi mobile
untuk Peningkatan Keluarga Berencana (MOTIF) berdasarkan laporan literatur tentang
faktor-faktor penentu penggunaan kontrasepsi dan hubungan antara penggunaan
kontrasepsi dan kesuburan. intervensi terdiri enam pesan suara otomatis yang dikirim ke
ponsel peserta, pada saat preferensi mereka, selama 3 bulan setelah aborsi. Peserta
menerima pesan pertama dalam waktu 1 minggu dari menggunakan layanan aborsi dan
setiap 2 minggu sesudahnya. Pesan, dicatat dalam bahasa Khmer, adalah sebagai
berikut:
Halo, ini adalah pesan suara dari konselor Marie Stopes. Saya harap Anda baik-baik saja.
metode kontrasepsi merupakan cara yang efektif dan aman untuk mencegah kehamilan
yang tidak direncanakan. Saya menunggu untuk memberikan layanan/dukungan
kontrasepsi gratis dan rahasia untuk Anda. Tekan 1 jika Anda ingin saya untuk
menghubungi Anda kembali untuk membahas kontrasepsi. Tekan 2 jika Anda merasa
nyaman dengan menggunakan kontrasepsi dan Anda tidak perlu saya untuk menelepon
Anda kembali saat ini. Tekan 3 jika Anda memilih untuk tidak menerima pesan lagi.
Peserta yang menekan 1 atau yang tidak merespon menerima panggilan telepon dari
seorang konselor. Panggilan telepon dimaksudkan untuk mendorong penggunaan
kontrasepsi dengan meningkatkan kemampuan klien menggunakan kontrasepsi dengan
cara: (i) memberikan informasi individual pada berbagai metode kontrasepsi; (Ii)
meningkatkan kesempatan peserta untuk menggunakan kontrasepsi, misalnya, dengan
memberitahukan di mana dia bisa mengakses metode khusus dekat tempat tinggalnya;
dan (iii) meningkatkan motivasi dengan memperkuat pengetahuan tentang manfaat
kontrasepsi. Atas permintaan peserta, konselor juga akan mendiskusikan kontrasepsi
dengan suaminya atau pasangan.
Peserta juga dapat menghubungi layanan dan meminta untuk berbicara dengan seorang
konselor. Mereka yang memilih untuk menerima kontrasepsi oral atau suntik bisa memilih
untuk menerima pesan pengingat tambahan yang sesuai untuk metode mereka
(misalnya pada saat untuk memulai sebuah paket baru dari pil atau ketika menerima
suntikan baru). Pesan suara keenam dan terakhir adalah serupa tetapi juga
mengingatkan peserta bahwa ini adalah pesan terakhir yang akan mereka terima.

Intervensi tersebut disampaikan oleh konselor terlatih di Marie Stopes International

Kamboja. pesan suara dijadwalkan dan dikirim menggunakan Verboice (InSTEDD, Palo
Alto, Amerika Serikat) program perangkat lunak open source. Biaya komunikasi keluar
dari penyedia ke peserta dipenuhi dengan Marie Stopes International Kamboja dan biaya
219 wanitaoleh
menelepon ke layanan (yaitu panggilan lokal) dikeluarkan tidakpara
memenuhi criteria
peserta.
199 tidak memiliki ponsel
Gambar 1. Flowchart dari peserta dalam intervensi ponsel berbasis
5 wanita pasca-aborsi kontrasepsi,
mengalami keguguran Kamboja,
(bukan
2013-2014. aborsi)
914 wanita yang dinilai layak 5 ingin memiliki anak lagi
(untuk percobaan)
206 wanita layak namun menolak/ditolak
163 tidak memiliki waktu
3114wanita
61 terpisah
wanita hilang
dari dengan
hilang dengan rincian
suami/partner
rincian
berikut
berikut :
11 suami/partner
: berkerja ditempat yang
Dalam 12 bulan :jauh 3 mengundurkan diri
Dalam 4 bulan : 2 mengundurkan diri
159 wanita
14 berencana
28
220 wanita 59tidak
tidak dapat
kerja diluar negeri
dapat
dikutidan 3 tidak dihubungi/dijangkau
memiliki tempat
dihubungi/dijangkauuntuk
dikuti dan
500 wanita diacak dianalisa wawancara klien
215 wanita dialokasikan ke grup kontrol
dianalisa
1 tuli
249 wanita dialokasikan di grup intervensi
38 wanita hilang dengan
rincian berikut :
3 mengundurkan diri
35 tidak dapat
dihubungi/dijangkau
Dalam 4 bulan :

211 wanita
dikuti dan 42 wanita hilang dengan
dianalisa rincian berikut :
59 tidak dapat
dihubungi/dijangkau
Dalam Catatan
12 bulan :
: intervensi terdiri enam pesan suara otomatis, interaktif melalui telepon seluler dan telepon dari seorang konselor, seperti
168diperlukan,
yang wanita selama
dikuti
3 bulan setelah aborsi (Kotak 1).
dan dianalisa
Analisis statistik.

Rencana analisis statistik ditentukan sebelum penelitian ini adalah unblinded dan dilaporkan
dalam protokol siding/percobaan. Kami memperkirakan bahwa 35% dari kelompok kontrol akan
menggunakan metode kontrasepsi efektif setelah 4 bulan dan ukuran sampel 500 akan
diperlukan untuk mendeteksi peningkatan 13% dalam penggunaan kontrasepsi dengan
kekuatan 90% pada tingkat signifikansi 5% . Analisis dilakukan secara intention-to-treat
(perlakuan sesuai tujuan) menggunakan Stata versi 13.1 (StataCorp. LP, College Station,
Amerika Serikat). Efek dari intervensi itu dinyatakan sebagai risiko relatif (RR) atau rasio hazard
(HR); 95% confidence interval (CI) digunakan untuk hasil primer dan sekunder dan CI 99% untuk
analisis subkelompok. Tingkat penghentian kontrasepsi dinilai menggunakan teknik analisis
survival Kaplan-Meier: selama 4 bulan follow-up data, penghentian dinilai dalam peserta yang
mulai menggunakan metode kontrasepsi efektif selama 4 minggu pertama setelah aborsi dan,
selama 12 bulan follow Data-up, penghentian dinilai pada mereka yang mulai pada metode
selama 3 bulan setelah aborsi. Penghentian didefinisikan sebagai menghentikan metode untuk 1
minggu atau lebih sebelum 4 bulan follow-up atau selama 1 bulan atau lebih sebelum 12 bulan
follow-up. Jika peserta beralih dari satu metode yang efektif untuk ke metode efektif yang lain,
ini tidak dianggap sebagai penghentian.

Hasil
Kami mengeluarkan 199 calon peserta karena mereka tidak memiliki ponsel. Dari 500
peserta, 249 ditugaskan untuk kelompok intervensi dan 251 untuk kelompok kontrol (Gambar.
1). Karakteristik dasar peserta ditunjukkan pada Tabel 1. Data hasil primer yang tersedia untuk
431 (86%) peserta pada 4 bulan dan untuk 328 (66%) pada 12 bulan. Lebih dari 75% (133/172)
dari kerugian untuk menindaklanjuti dengan 12 bulan adalah karena telepon peserta dimatikan
atau tidak digunakan, seperti yang ditunjukkan oleh pesan otomatis. Sering nomor telepon telah
dipindahkan ke pengguna lain atau peserta telah dilaporkan pindah ke luar negeri untuk
bekerja. Proporsi perempuan dalam kelompok intervensi yang melaporkan penggunaan
kontrasepsi yang efektif secara signifikan lebih tinggi daripada di kelompok kontrol pada 4 bulan
(64% berbanding 46%, masing-masing; RR: 1,39; 95% CI: 1,17-1,66; Tabel 2) tetapi tidak pada
12 bulan (50% berbanding 43%, masing-masing; RR: 1,16; 95% CI: 0,92-1,47).
 Secara signifikan lebih banyak perempuan dalam kelompok intervensi daripada kelompok
kontrol yang dilaporkan menggunakan metode kontrasepsi long-acting pada 4 bulan (29%
berbanding 9%, masing-masing; RR: 3,35; 95% CI: 2,07-5,40; Tabel 2) dan pada 12 bulan ( 25%
berbanding 12%, masing-masing; RR: 2,08; 95% CI: 1,27-3,42). Selain itu, secara signifikan lebih
banyak perempuan dalam kelompok intervensi daripada kelompok kontrol melaporkan
penggunaan kontrasepsi yang efektif selama lebih dari 80% dari 4 bulan setelah aborsi (54%
berbanding 40%, masing-masing; RR: 1,35; 95% CI: 1,10-1,67) dan lebih dari 80% dari 12 bulan
setelah (51% berbanding 38%, masing-masing; RR: 1,33; 95% CI: 1,04-1,70). Ada beberapa
bukti bahwa lebih sedikit perempuan intervensi dari kelompok kontrol telah mengehntikan
penggunaan kontrasepsi dengan 4-bulan follow-up (masing-masing 7% dibandingkan 16%,; HR:
0,45; 95% CI: 0,20-1,01; Tabel 2) tapi tidak dengan 12 bulan follow-up (26% berbanding 30%,
masing-masing; HR: 0.82; 95% CI:. 0,48-1,40; Gambar 2, tersedia di: http://www.who.int/bulletin/
volume / 93/12 / 15-160267). Tidak ada Perbedaan yang signifikan antara kelompok dalam
proporsi perempuan yang memiliki kehamilan berulang atau aborsi antara 4 atau 12 bulan dan
tidak ada laporan bahwa intervensi telah dikaitkan dengan kecelakaan lalu lintas atau kekerasan
dalam rumah tangga pada 4 bulan (Tabel 2). Analisis subkelompok tidak menemukan bukti
bahwa baik usia, tempat tinggal perkotaan atau pedesaan, tingkat pendidikan atau status sosial
ekonomi mempengaruhi efek intervensi pada penggunaan kontrasepsi pada 12 bulan (Gambar.
3).

karakteristik
usia, tahun
<25 thn
25 thn
tempat tinggal

Daerah kota

Diskusi
intervensi berbasis telepon seluler kami dikaitkan dengan peningkatan penggunaan yang
dilaporkan sendiri pada metode kontrasepsi yang efektif selama 4 bulan setelah aborsi tapi tidak
setelah 12 bulan . Namun, lebih banyak peserta dalam kelompok intervensi daripada kelompok
kontrol dilaporkan menggunakan metode kontrasepsi long-acting pada 4 dan 12 bulan.
Intervensi tidak berpengaruh signifikan pada kehamilan berulang atau tingkat aborsi dan tidak
ada laporan efek samping.

Penelitian ini memiliki beberapa kekuatan/kelebihan. Pertama, semua analisis dilakukan

secara intention-to-treat. Beberapa percobaan keluarga berencana pasca-aborsi memiliki
periode observasi lebih lama dari penelitian kami. Tingkat tindak lanjut pada 4 bulan tinggi dan
tidak ada bukti dari perbedaan kerugian untuk menindaklanjuti antara kelompok perlakuan.
Namun, tingkat tindak lanjut pada 12 bulan hanya 66%, yang mengalami penurunan kekuatan
statistik dari penilaian kami tentang efek jangka panjang dari intervensi. tingkat rendah ini
mungkin karena peserta bermigrasi untuk bekerja dan / atau mengubah nomor telepon, yang
diakui sebagai tantangan untuk mobile intervensi berbasis telepon di Kamboja.
Salah satu keterbatasan dari studi ini adalah bahwa, karena intervensi yang melibatkan
perubahan perilaku, itu tidak mungkin untuk membutakan peserta pada alokasi pengobatan
mereka dan mereka mungkin telah lulus untuk mengidentifikasi setiap percobaan dan
melaporkan tindak lanjut pada titik waktu ini. Kami memutuskan untuk menilai penggunaan
kontrasepsi pada 4 bulan, setelah intervensi telah selesai, karena kami menyadari bahwa efek
samping dan penghentian yang umum di beberapa bulan pertama. 12 bulan follow-up
dimaksudkan untuk menilai efek jangka panjang dari intervensi. Meskipun pada 12 bulan tidak
ada bukti dari peningkatan penggunaan kontrasepsi secara keseluruhan atau sering kurangnya
penghentian, intervensi kami dikaitkan dengan peningkatan penggunaan metode kontrasepsi
long-acting dalam konteks di mana berbagai metode keluarga berencana pasca-aborsi (data
tersedia dari penulis yang sesuai) tersedia tetapi penyerapan langsung kontrasepsi masih
rendah. Peningkatan ini terjadi karena peserta kembali ke klinik untuk implan kontrasepsi atau
alat kontrasepsi dalam rahim dan konsisten dengan temuan kami bahwa beberapa klien lebih
suka membuat keputusan tentang keluarga berencana pasca-aborsi setelah keluar dari
perawatan klinis. Karena intervensi kami kompleks/rumit, tidak jelas komponen mana yang
mempengaruhi penyerapan metode long-acting. Hal ini masuk akal, meskipun, bahwa intervensi
yang relatif intensif disampaikan selama periode waktu yang singkat dapat mempengaruhi
keputusan untuk mengadopsi metode long-acting (yaitu perubahan perilaku tunggal) tetapi
kurang efektif dalam mempengaruhi kepatuhan lanjutan untuk kontrasepsi oral, yang
membutuhkan perilaku berulang yang berkelanjutan. Bahkan, literatur menunjukkan bahwa
intervensi mendorong kepatuhan pengobatan yang lebih efektif untuk jangka pendek daripada
perawatan jangka panjang. Selanjutnya, long-acting metode kontrasepsi yang dikaitkan dengan
tingkat penghentian lebih rendah dari metode hormonal short-acting. Kami berencana untuk
menerbitkan sebuah laporan terpisah pada hasil wawancara kualitatif dengan peserta tentang
pengalaman mereka dari intervensi.
Beberapa studi telah meneliti penggunaan kontrasepsi untuk jangka setelah aborsi dalam
setting berpenghasilan rendah. Satu cocok, studi terkontrol di Zimbabwe menilai pengaruh
konseling dan kontrasepsi gratis sebelum pulang dari rumah sakit. Pada 12 bulan, penggunaan
kontrasepsi yang efektif lebih tinggi pada intervensi dari kelompok kontrol (84% (227/271)
dibandingkan 64% (165/258), masing-masing; P <0,001) dan kehamilan berulang yang tidak
diinginkan lebih rendah (15% (42 / 276) dibandingkan 34% (96/281), masing-masing; P <0,001)
tetapi aborsi berulang tidak signifikan lebih rendah (3% dibandingkan 5%; P = 0,23) 0,30 pada
12 bulan dalam penelitian kami, 13% (22 / 169) dari peserta dalam kelompok intervensi
melaporkan kehamilan berulang dibandingkan dengan 18% (28/159) pada kelompok kontrol;
yang sesuai angka untuk aborsi berulang adalah 5% (8/169) dan 7% (11/159), masing-masing.
Namun, penelitian ini tidak didukung untuk mendeteksi perbedaan hasil ini. Namun demikian,
peningkatan penggunaan metode long-acting dan peningkatan durasi semua penggunaan
kontrasepsi yang efektif diharapkan akan menghasilkan penurunan kehamilan yang tidak
diinginkan dan aborsi berulang dari waktu ke waktu. Sebuah studi yang lebih besar mungkin
dapat mendeteksi perbedaan hasil ini.

Kesimpulan
Hasil kami menunjukkan bahwa penambahan intervensi berbasis telepon seluler untuk
layanan perawatan aborsi yang ada dapat meningkatkan penggunaan kontrasepsi long-acting.
Keseluruhan penggunaan metode kontrasepsi yang efektif meningkat 4 bulan setelah aborsi
tetapi tidak pada 12 bulan. Dalam prakteknya, durasi, bahasa dan cara komunikasi (yaitu teks
atau suara) bisa disesuaikan dengan pengaturan yang berbeda, meskipun pesan suara akan
sangat berguna pada populasi dengan aksara terbatas. Kami memperkirakan biaya utama
memberikan intervensi (pesan suara i.e.for, panggilan telepon dan waktu konselor ') menjadi 6
dollar Amerika Serikat per klien. Analisis efektivitas biaya akan dilaporkan di tempat lain.
Meskipun intervensi kami disampaikan dengan tambahan dukungan keluarga berencana pasca-
aborsi di klinik, penelitian di masa depan bisa menilai efek dari intervensi yang sama dalam
pengaturan dengan dukungan lebih terbatas: misalnya, di mana aborsi medis disediakan oleh
sektor swasta.
Pernyataan
Kami berterima kasih kepada semua klien dan staf klinik yang berpartisipasi dalam penelitian
ini; BBC Media Action Kamboja; Channe Suy di InSTEDD iLab Asia Tenggara; Javier Sola di Open
Institute; Naomi Bryne Soper, Sieklot Chinn, Engkau Chum, Melissa Cockcroft, Sarah Cooper,
Nicky Jurgens, Seaklong Keam, Michelle Phillips, Sras Thorng dan Stefanie Wallach di Marie
Stopes International Kamboja; Isolde Birdthistle, Tim Clayton, John Cleland, Anna Glasier,
Richard Hayes dan Susannah Mayhew di London School of Hygiene & Tropical Medicine; Azeem
Majeed di Imperial College London; Jerker Liljestrand di URC, Kamboja; Deborah Constant di
University of Cape Town; dan Ali Flaming, Antoinette Pirie, Chris Vickery, Tung Rathavy dan
Richard Lester.
Pendanaan: Marie Stopes International Dana Inovasi mendanai studi selama 15 bulan dari
Oktober tahun 2012 dan memiliki beberapa pengaruh pada desain studi (penulis JG dan TN)
tetapi tidak pada pengumpulan data atau analisis. Inggris Medical Research Council (MRC) yang
didanai analisis data tetapi tidak mempengaruhi analisis atau pelaporan. Chris Smith didukung
oleh MRC Penduduk Scientist Fellowship.

Bersaing kepentingan: Tidak dinyatakan.

850A