From the global public health perspective, repeat abortion remains a severe challenge to women’s reproductive health, which needs increased attention and research. This study provides relevant evidence from northwestern China to the growing body of international literature on the repeat abortion of women and associated factors from both the perspectives of women and their sexual partners.
Our study found that approximately six in ten (56.6%) participants seeking an abortion with unintended pregnancies were undergoing a repeat abortion, which was similar to previous studies in China that reported that the prevalence of repeat abortion among women ranged from 43.0 to 65.2% [45, 49, 52]. However, these findings about the prevalence of repeat abortion among Chinese women were much higher than that of female abortion seekers elsewhere in the world [4,5,6,7,8,9,10,11, 13,14,15,16,17,18, 20,21,22,23,24,25,26,27,28]. No direct evidence has been found about why Chinese women have a higher prevalence of repeat abortion; however, this difference might be relevant to the gap in sexual education and contraceptive practice in China compared with other, especially developed, countries [48]. To some extent, these results in China may also be related to the universal two-child policy implemented since Jan. 1st, 2016. In summary, our findings reveal the seriousness of this reproductive health problem for women in China, and more attention and action should be taken on how to reduce the risks of unintended pregnancy and repeat abortion among Chinese women.
In terms of contraceptive use at the time of conception, 58.3% had used contraception measures and 41.7% were nonuse of contraception, which was consistent with that in previous studies in China [45, 53]. Meanwhile, we found that a significantly higher percentage (61.2%) of women undergoing a repeat abortion had used contraception measures at the time of conception than those receiving their first abortions (54.4%). The results of multivariate analysis further showed that participants who had used contraception measures at the time of conception, such as condom, withdrawal, and emergency contraception, were 1.33–1.48 times more likely to undergo a repeat abortion than those who did not use contraceptives. These findings have also been reported in previous studies [11, 40, 41, 54]; however, McCall et al. [8] and Thapa et al. [25] did not identify a significant association between contraceptive use at the time of conception and repeat abortion among women in Scotland and Nepal, respectively. In addition, although we did not find a significant association of contraceptive use during the 6 months preceding the survey with repeat abortion of women, a slightly higher percentage of women undergoing a repeat abortion had used at least one contraception measure than those receiving their first abortions in this study. As noted by Kabiru et al. [40] and Cohen [54], these results all cast doubt on the often-made assumption that some women rely on abortions as a means to prevent unintended pregnancies and unplanned births, and women having experienced an abortion and even a repeat abortion are less motivated to use contraception. Instead, women having had a previous abortion might be more likely to use contraception but may need counseling for correct and effective contraceptive use and access to a wider range of effective contraception measures, such as the long-acting measures, to minimize the risks of contraceptive failure [40, 45, 46, 54].
Besides, with respect to the participants themselves, their age, education, occupation, parity, and cognition of the possible adverse health effects of having an abortion were significantly associated with the repeat abortion. First, in line with prior studies [4,5,6,7, 10,11,12,13, 19, 23,24,25,26, 28, 41, 44, 49, 52], we found that an increased age of women was strongly associated with a higher risk of having repeat abortions. This association is not surprising and reflects the longer exposure to sexual intercourse and thereby increased risks of unintended pregnancies for these older women. Second, we found that the lower the level of education women attained, the higher their risks of having a repeat abortion, which was consistent with prior studies [4,5,6, 9, 11, 12, 16, 18, 19, 21, 23, 26, 27, 39, 40, 43, 53]. One possible explanation is that women with a higher-level education might have higher levels of health literacy, especially contraceptive knowledge, and better contraceptive practice, which allow them to better avoid unintended pregnancies and subsequent abortions. However, a few studies conducted in Ghana [20], Nepal [25], and the Netherlands [13] reported a contrary finding with the positive association between a higher-level education of women and the repeat abortion. Third, consistent with prior studies [11, 40, 43, 46, 48, 49], we found that jobless women were 2.46 times more likely to undergo a repeat abortion. This finding might be related to their poor contraceptive knowledge and limited access to contraceptive measures [48]. In addition, Makenzius et al. [43] pointed out that women suffering from poverty caused by unemployment might have reduced motivation to practice safe sexual intercourse.
Parity was the fourth factor associated with repeat abortion. In line with a great deal of evidence in prior studies [4, 5, 8, 9, 11,12,13,14,15, 19, 21, 24,25,26, 39, 41, 43, 44, 46, 48, 49], our study showed that participants having a child were 1.54 times more likely to under a repeat abortion than nulliparous participants. Jones et al. reported that women having children were demonstrably fertile and therefore at continued risk of pregnancy after the first abortion [4]. In the opinion of Kirkman et al. [55], parous women, especially those with higher parity, sought abortions because they did not want to look after another child. In our study, the association between parity and repeat abortion might also be related to the change in the family planning policy in China. To some extent, the implementation of the universal two-child policy in China since 2016 might weaken the contraceptive awareness of women, especially those having already had one child, as they could legally have a second child, even if it might be an unwanted birth. Fifth, we found that participants’ cognition of potential adverse health effects of having an abortion was significantly associated with repeat abortion. Not surprisingly, we found that the lower the cognitive level among women, the higher the risk of having a repeat abortion. This finding may reflect the weak sex education system in China, and women still have limited access to counseling for relevant reproductive health knowledge; however, no related evidence has been reported in prior studies.
In addition to the above factors, our study identified four more factors that were significantly associated with the repeat abortion from the perspective of abortion seekers’ sexual partners, including their age, education, income, and attitudes toward contraceptive use. Few similar studies and findings have been reported. First, we found that the participants whose sexual partners were older than 30 years were 1.33–2.13 times more likely to undergo a repeat abortion. This is similar to the finding on women’s age as a factor associated with the repeat abortion, and it reflects the longer exposure to sexual intercourse of older sexual partners and thereby higher risks of unintended pregnancies for women. Second, our study reported that abortion seekers whose sexual partners attained a lower-level education were 1.38–1.66 times more likely to undergo a repeat abortion. This is also similar to that of the participants themselves, and their sexual partners with a lower-level education might have less contraceptive knowledge and poorer contraceptive practice. Zhang et al. found that women with a repeat abortion had a higher percentage of sexual partners with a low- and middle-level education compared to those who experienced only one abortion; however, they did not identify a significant association between them [52].
Besides, participants whose sexual partners had the highest-level income per month were 1.34 times more likely to undergo a repeat abortion than those with the lowest-level income per month. One possible explanation is that, in the current structure and relationship of Chinese couples and families, it is still men who carry the most of the economic responsibility; and for these couples or families where men receive a high-level income, they may have the financial ability to take care of a child whose birth is unplanned [40], thereby they are at a higher risk of poor contraception practices. Fourth, our study identified that participants’ sexual partners’ attitudes toward contraception was strongly associated with participants’ repeat abortions. Compared with participants whose sexual partners presented a very strong willingness to use contraception, those with a sexual partner who had a weak or very weak willingness were 6.84 times more likely to undergo a repeat abortion. As we found that the male condom was the most common method participants used at the time of conception or during the 6 months preceding the survey, the negative attitudes toward contraceptive use by sexual partners would not surprisingly increase risk of unintended pregnancy for women. Although no similar evidence about the significant association has ever been reported, Zhang et al. also found that compared with women undergoing a first abortion, those with a repeat abortion had a higher percentage of sexual partners who had negative attitudes toward contraception [52]. These findings highlight the significant role of women’s sexual partners in reducing women’s risks of unintended pregnancy and subsequent abortion, even the repeat abortion, by improving their awareness and practice of contraception.
There are several limitations to our study. First, as the study was conducted in Xi’an, a northwestern city in China, the results could not be generalized very well to all women in other regions in China. Second, although our study focused on both the perspectives of participants and their sexual partners, we could not identify and report all factors associated with the repeat abortion, as there were many other aspects that we did not collect and review. Third, as the survey was self-reported by women seeking abortions themselves, though anonymous, this might bring a bias of social desirability. For example, women who were undergoing a repeat abortion might especially feel like that they should report having used contraception. Fourth, as this was based on a cross-sectional survey, we could not conclude any causal relationships of repeat abortion of women with the factors identified in our study. Fifth, the use of convenience sampling, rather than probability sampling, is a weakness of the study.