Theme 1: Factors influencing the abortion-services sought and obtained by women
The National Strategy for Reproductive and Sexual Health in Cambodia 2017–2020 identifies “information” as a key area to address in order to continue making progress in strengthening safe abortion services (20). Theme 1 describes the findings to understand the reasons that lead women to seek healthcare provider services, what was their prior level of abortion-related information, the availability of abortion services and associated costs which can affect abortion seeking behaviour. ‘M’ is used for women and ‘P’ for providers.
Sub-theme 1–1. Reasons for abortion
Birth-spacing and financial constraints were the main reasons for abortion reported among study participants
M11: I wish to have one more but not now… may be at the next two years… I just said I already have a small baby and don’t want to keep this foetus now…
M12: I think that I don’t have much money and I now have to pay for my daughter’s milk…
Sub-theme 1–2. Information sources of abortion
Interviewees generally asked their peers, older family members, or relatives for information about abortion; in particular, whether to have medical or surgical abortion, and where. Women also asked friends, close co-workers, or listened to the conversations of others about experiencing an abortion. Hearing about other women’s experiences strongly shaped the expectations, positively or negatively, of women seeking abortion, and what kind of services they required. Only two women said that they never sought information but went directly to the clinic. No woman said that they searched the internet for abortion information, though smartphones are widely used among factory workers.
M08: My friend who experienced abortion told me about abortion…I asked her what and where she did, and she took me to here…
M23: My sister in-law experienced abortion before, and she accompanied me to come here.
Sub-theme 1–3. Available abortion methods
Providers reported medical abortion was available at all study sites; except for infirmaries, which by law do not provide this service. Based on provider reports and researcher observations pharmacies, clinics, and cabinets had available one or more of three pills: Medabon, Mifeso, and a ‘Chinese pill’ (Zizhu Pharmaceutical company). Medabon and Mifeso follow the World Health Organization approved regimen which is 200 mg mifepristone and 800 µg misoprostol (4 tablets of 200 µg) (21). The regimen of the ‘Chinese pill’ is two tablets of mifepristone (25 mg per tablet) for three days and three tablets of misoprostol (0.2 mg per tablet) on the third day. As a surgical method, Manual Vacuum Aspiration (MVA), was available at clinics and cabinets.
Sub-theme 1–4. Cost for abortion
According to women Medabon or Mifeso cost between 12 and 20 US dollars (USD
), with an additional cost of 5 to 30 USD for vitamin injections. MVA was provided for 60 to 200 USD. One woman reported paying 200 USD, including both medical and surgical abortion, but was satisfied with the quality of services.
M21: I feel ok… not so painful… strong enough after got service here… I thought 200 USD is not important (costly) if I am better like this…
To put these amounts in context, the minimum monthly wage of a factory worker in Cambodia is USD170 (22).
Sub-theme 1–5. Selection of abortion methods
In this study half of the women received MVA, for the following reasons: over nine weeks pregnant, incomplete abortion, health care providers’ advice or it was automatically included in the abortion service. Some women preferred MVA because they thought that it was cleaner and safer than medical abortion, or they did not want to come back for a follow-up or in the case of complications.
M07: The provider said it is better to use vacuum aspiration...For medical abortion, I might have some difficulties when I face some problem after using it … it will be difficult to come back again if it doesn’t work well… such as bleeding and not well done
Theme 2: Women's experiences of abortion mapped against the CAC observation checklist for medical abortion
The national protocol for CAC is the latest and most important protocol that providers must adhere to provide safe abortion services. Theme 2 describes women’s experiences alongside the standards set by CAC.
Sub-theme 2 − 1. CAC task 1 – “Greets woman with respect and kindness, helps her feel comfortable and ensures privacy”
Interviewees felt privacy was an important factor in selecting providers for abortion; for instance, they preferred larger providers because they felt smaller ones may not be able to maintain confidentiality and would be less safe. Some younger and unmarried women sought a provider away from their living or working area, so that they would not encounter anyone they knew. Providers said that women never openly asked for an abortion, rather, the subject was broached indirectly.
P05: They just ask for a pregnancy test… and they added that “after I did the pregnancy test, may I see you again…I always inform them that “if you are pregnant and don’t want to keep that baby, please come back and then I will find a solution for you...”
They also occasionally refused to take any written instruction for abortion, again for fear that other people would find out that they had an abortion. Conversely, providers occasionally did not offer the written instructions to clients, to make sure they came back to them for further instruction.
Sub-theme 2–2. CAC task 2 – “Assesses the woman’s health: medical and reproductive history, estimates gestation based on date of last menstruation period, assess vital signs.”
In this study, all women who used medical abortion were less than nine weeks pregnant and thus allowed to use it. Most of the women were aware of their menstruation period and confirmed the pregnancy immediately after they missed their period or felt morning sickness. The most common way to estimate a women's gestational age was ultrasound, but some declined it due to the cost. Four women were asked about their last menstruation. No woman had a pelvic examination.
M13: I didn't do ultrasound…because I missed period about 10 days…I think it was fine not to do ultrasound…he (provider) asked me to do ultrasound… but I rejected as I didn't want to spend lots of money ($5 USD)
One provider said that some clients who were over two months pregnant came to get a medical abortion whilst pretending to be less than two months pregnant, or they asked someone else to buy the medical abortion drugs.
Sub-theme 2–3. CAC task 3 – “Discuss reproductive goals, including pregnant options and family planning options”
Most women had already decided, together with their husband or family, to have an abortion when they came to providers. One provider recommended one woman to keep the baby because the woman was young (21 years) and did not have a child.
M24: The provider said I should have a baby now because I am young and have more energy now… If I have a baby when I am older … it might be more difficult…she wants me to keep the baby rather than to have abortion…
Sub-theme 2–4. CAC task 4 – “Provide detailed information about medication-abortion side effects, warning signs, required visits and action in the event of failure of procedure”
Some women knew the side effects of medical abortion such as fever, exhaustion, diarrhoea, vomiting, and pain; and they received that information from providers, friends, or relatives. Most women knew that they would bleed for a few days after inserting misoprostol and needed to contact providers in case of severe bleeding. Two women experienced serious haemorrhaging and both visited a provider.
M19(Note): she returned to doctor on next day of inserting pills because a lot of black bleeding and much pain, used sanitary pad every hour, was very exhausted and could not eat well.
Infirmary workers encountered factory workers who came to the infirmary with serious abdominal pain, probably caused by an incomplete abortion. Those women tried to be discreet and asked for painkillers for menstruation, although the bleeding was far heavier than a normal menstruation.
P02: Some women came with pain, but we could notice that the abdominal pain and bleeding was because of incomplete abortion not menstruation…we asked them “if you took medical abortion” … but they said they had menstruation period...
Sub-theme 2–5. CAC task 5 – “Explains all aspects of the medication administration regimen, including pain management”
A pharmacy provider said that women typically took mifepristone on Friday or Saturday, and inserted misoprostol over the weekend, in anticipation of returning to work on Monday to avoid losing income. A booklet with instructions, side effects, and warning signs was available at some facilities, but it was not accepted by women since if seen by others it could reveal that they had an abortion. Only four women were provided with pain medication.
Sub-theme 2–6. CAC task 6 – “Provides emergency contact information in case the woman has questions or needs care”
Most providers gave their phone number to women and told them to call if they had a problem or needed more information. Some women went back or called providers when they were afraid of bleeding or pain.
Sub-theme 2–7. CAC task 9 – “Schedules follow-up visit to confirm completion of the medication abortion”
Most interviewed women did not come back for a follow-up visit if they did not encounter a problem after a medical or surgical abortion. Some women who used medical abortion asked providers to have a surgical abortion to ensure the completion of abortion.
P04: Clients came here seeking for cleaning (surgical abortion) to make sure if it is completed since they just saw bleeding without anything
Only a few women knew the signs of completion of medical abortion, and their knowledge was based on their previous abortion or miscarriage.
M13: I noticed it had serious bleeding and it came out along with tissue…as remembered, when there is a miscarriage there are also coagulated blood come out and the size is about the size of a toe…
Sub-theme 2–8. CAC task 8 – “Ensures contraceptive counselling and a method are provided if requested”
Not all women received contraceptive counselling after abortion. Some said they were informed about pills, injection, and IUD, and a few women reported being advised to use traditional methods such as abstinence and timing. Instead of gaining this information from providers, women sought it from family members, friends, or elders in their community. Some women received contraceptive counselling at the health centre in their province when they gave birth.
Of the seven women who could be followed up after abortion, three women started to use modern contraception; one started using the pill, one injection, and one an intrauterine device (IUD). Two reasons given for not using modern contraception after abortion were still feeling weak or rarely having sex with a partner due to separation.
M07: No, I have not used any contraception yet...I thought my health is still weak...we are not too often having sex...
Some women said that they continued using traditional methods since they were afraid of infertility caused by using modern contraception, particularly by pills. This rumour and fear discouraged women from starting or continuing using pills.
M24: I have learnt that one of my neighbours who used pills had uterus problem…when she wanted to have a baby, she could not have a baby for about ten years…
Women's partners sometimes objected to using modern contraception because they thought that it may negatively affect the women's health or cause uterus problems.
M24: Actually, my husband uses the natural method (withdrawal)… and he doesn't want me to use any other methods because we’ve just newly married…he is worried that it affects my health....