/. biosoc. Sci. (1979) 11,65-75
EPIDEMIOLOGICAL ANALYSIS AND REPRODUCTIVE CHARACTERISTICS OF INCOMPLETE ABORTION PATIENTS IN KHARTOUM, THE SUDAN HAMID RUSHWAN University of Khartoum, Khartoum, The Sudan Summary. A study of 2447 patients treated for incomplete abortion in three major hospitals in Khartoum, the Sudan, was carried out from 1974 to 1976. Analysis focused particularly on socio-demographic variables, reproductive history and contraceptive behaviour before and after the abortion. This paper presents the epidemiological analysis and reproductive characteristics of these patients in an attempt to show the value of such service oriented research in evaluating clinical problems. Introduction
Induced abortion is illegal in the Sudan except where strong medical indications exist. However, admissions to hospital for incomplete and inevitable abortion are a cause for concern. Incomplete abortion may occur when a woman has a spontaneous abortion (miscarriage) or a poorly performed induced abortion. In an inevitable abortion the process of uterine emptying has begun and the cervix has usually begun to dilate and some bleeding to occur. Treatment is by evacuating the uterus. A basic analysis of the type offered in this paper can form the foundation of an epidemiological study of the incidence of incomplete abortion, although it is not possible to produce an exact sociodemographic profile. Attention is focused on gross differences among the hospitals inasmuch as the data collection period extended for less than a year and a half. The significance of any differences found in such a short period would be indeterminate in that they may represent 'real' differences or be due to the operation of spurious influences, such as sampling fluctuation. The sample Khartoum is the capital of the Sudan (population 18 million) and is a rapidly expanding city, due to migration from the mainly rural population of the country. The city is divided by the Nile rivers into three distinct areas and the medical 65
66
H.Rushwan
facilities are: Omdurman Hospital, mainly serving a middle class population of approximately 299,000 people; Khartoum North Hospital, in a rural lower socioeconomic catchment area (pop. 155,000); and Khartoum General hospital, whose predominantly middle and lower class patients are drawn from the towns and adjacent villages (pop. 344,000). Of the total sample of 2447 patients, 707 were from Omdurman Hospital, 931 from Khartoum General and 809 from Khartoum North (Table 1). The Khartoum population is described on the basis of socio-economic factors, such as education, employment and urban and rural residence, thought to be most closely related to ultimate pregnancy outcome. Socio-economic, biological, attitudinal and behavioural aspects of fertility form a functional chain whose ends are linked. Even from a narrow hospital sample of incomplete abortion patients it is possible to build a behaviour model using routinely available data. In Fig. 1 a 'core model' of patient characteristics is organized sequentially in groups from socioeconomic, biological-reproductive, employment and residence data, moves on to pregnancy outcome events, and ends with the woman's desire for additional children and her contraceptive practices. The core model shows how obstetrics and gynaecology relate to community health and paediatrics. A study of this type is a step towards understanding interaction between family and community health. Results and discussion Demographic indices Table 2 shows the distribution of the sample by age and employment; the differences between hospitals are not great but there are minor trends between the three locations. The median age for the entire sample was 27-0 years. There is an age gradient from Khartoum General (median = 25-3) to Khartoum North (26-9) to Omdurman (28-1). Khartoum North, however, reported the highest proportion (14-1%) of women under 20 years of age. Data for gainful employment show a similar order: Khartoum General reported the greatest proportion of gainfully employed (5-8%), followed by Khartoum North (4-7%) and Omdurman (1-3%). Table 1. Distribution of sample at admission, by abortion type Omdurman Type of abortion Incomplete/inevitable Induced Inevitable/incomplete with systemic condition Total
Khartoum General
Khartoum North
Total sample
No.
%
No.
%
No.
%
683 96-6 20 2-8 4 0-6
921 7 3
98-9 0-8 0-3
791 6 12
97-8 0-7 1-5
2395 33 19
97-9 1-3 0-8
707
931
No.
%
809
2447
Characteristics of abortion patients in Khartoum
67
Rurality
Education
Socio-Economic
Gainful employment \ /
FAMILY AND COMMUNITY HEALTH
Pregnancy Spontaneous abortion
Induced abortion
OBSTETRICS
Stillbirth Bio-Reproductive
> PAEDIATRICS
Attitude
I
Practice
Additional children desired
Contraception
Fig. 1. Core model of patient characteristics.
Figure 2 shows education and residence data together in order to examine the relationship between these two variables. The urban-rural gradient from Omdurman to Khartoum North is evident and data on education reflect the same pattern. If, however, one selects for analysis only those patients with 4 or more years of education, a different pattern emerges. The data for Omdurman remain virtually unchanged: 92% of women with 4 or more years of education are from urban areas. For Khartoum General, however, 78-2% of these women are from
68
H. Rushwan
Table 2. Distribution of 2447 hospitalized abortion patients, by age and gainful employment Omdurman Patient characteristic Age 32
(b)
Omdurman
28 0% 8 0,
64 0%
Khartoum General
26 2%
•52 0%
7ZA 21 5%
///A Khartoum North
22 3%
Fig. 2. Percentage distribution by area of residence (a) for each hospital sample and (b) for those within each sample having 4 or more years of education: urban local, 9; urban outside, • ; rural, 0. Table 3. Distribution of 2447 hospitalized abortion patients, by parity Omdurman Parity 0 1 2 3 4 5 6 7 8 9 10
11 + Unknown Median
Khartoum General
Khartoum North
Total sample
No.
%
No.
%
No.
%
No.
95 111 96 105 84 65 53 40 25 19 8 3 3
13-4 15-7 13-6 14-9 11-9
124 132 143 118 110 97 89 44 41 20 10 1 2
13-3 14-2 15-4 12-7 11-8 10-4
141 103 100 85 96 92 71 46 38 22 6 3 6
17-4 12-7 12-4 10-5 11-9 11-4
360 346 339 308 290 254 213 130 104 61 24 7 11
9-2 7-5 5-7 3-5 2-7 11 0-4 0-4 3 •0
9-6 4-7 4-4 2-1 11 01 0-2 31
8-8 5-7 4-7 2-7 0-7 0-4 0-7 3-2
%
14-7 141
13-9 12-6 11-9 10-4 8-7 5-3 4-3 2-5 10 0-3 04 3•
1
70
H. Rushwan 400 375 On 367 6 ^ y
300 282 10.
Q.
O O O
\ V \ \
o
\
T3
SPONTANEOUS ABORTION
\\209 6
200 \ai.8i-8T
179-50, N
c o o
v
X
N N
.2 100 -
^ ^ ^ O 157-1
1695^;
N
^ v '^-g121-9 X
X Ny
x
82 9
CHILD LOSS ~~~~~-O602
44 1 O 31 2 O ^ ^~ _ _ _ ^ ^ i
-19
o 1
O24 6 ^
20-29
30-39
Age (years)
Fig. 3. Previous abortions and child loss, by age: Omdurman, . ; Khartoum North,
; Khartoum General,
There are clear differences in offspring loss between locations: the highest offspring loss rates recorded at Omdurman (31 -2/1000 live births) and at Khartoum General (44-1/1000 live births) are less than the lowest offspring loss rate recorded at Khartoum North (60-2/1000 live births). Furthermore, the rate of 5-9/1000 live births among women aged 30-39 in Omdurman is remarkably low. Women younger than 20 at all three locations have a higher rate of previous abortion. In addition, Omdurman (375-0/1000 pregnancies) and Khartoum General (367-6/1000 pregnancies) report higher rates of previous abortions than Khartoum North (282-1/1000 pregnancies). In an effort to detect any meaningful relationship between education and residence and abortion/offspring loss, a subanalysis was performed. For women with 4 or more years of education there was no discernible departure from the main group with respect to previous abortion or offspring loss rates. However, urbanrural variations provide a clue for further study. Sample sizes become too small to draw firm conclusions but there are indications, for all three locations, that
Characteristics of abortion patients in Khartoum
71
150 -
124 0 q^ \
V)
.c
r
"S > 100 o o o
O
50 - 50 -2«s.
38 5 a..
\
\
\
\
\
,X>95 6
>»57 2
58 8 38
\s^ \25
•\^s' ^
4 - - - 2 4 1 ...•••-• o-' ^>O19 1
'•••a
11 8o
..O46 8
..••"•'
17 4 ^ 3 - 0
3 1 ^ — I
1-2
3-4 5-6 No. of live births
Fig. 4. Child loss, by parity: total sample, I
7+
t; other symbols as for Fig. 3.
previous abortion rates for rural women below the age of 20 are markedly higher than those of their urban counterparts. Further data are required to confirm or refute this finding. Offspring loss may also be examined in relation to parity (Fig. 4) and interesting differences emerge between locations. Although there is a pattern of decline and increase at all three places, the trend for Khartoum North is different from those for Omdurman and Khartoum General. Comparing the rates for parity groups 1-2 and 3-4 there is a 75% reduction at Omdurman, a 55% reduction at Khartoum General and a 53% reduction at Khartoum North. For parity 7 or more, offspring loss shows slight increase at Khartoum North (18%) but a substantial increase at both Khartoum General (94%) and Omdurman (516%). The changes in offspring loss rates at all three hospitals appear to merit further study. The Sudan is still largely a traditional society but modernizing influences are entering the life of city dwellers in Khartoum. There is approximately one abortion case admitted to hospital for every two babies born in hospital in the three institutions included in this study and it is the impression of clinicians that a substantial number of incomplete abortions are deliberately provoked. However,
72
H. Rushwan 100
405
188 100
2 3 No. of living children
5+
Fig. 5. Desire for additional children among women aged 20-29 years, by parity: Omdurman, ; Khartoum General, ; Khartoum North, .
unlike Latin America, septic abortions make up only a small proportion of cases, suggesting that most induced abortions are performed relatively satisfactorily. Khartoum North, which caters for the low income groups, has the highest child loss, irrespective of parity, and also the highest rate of abortion complications. Desiredfamily size and contraceptive practice The women in this study were asked how many additional children they wanted, without regard to timing or intention. Figure 5 presents the results, by number of living children, for the age group 20-29 at each of the three hospitals. Pooled data for the age groups 20-29 and 30-39 are given in Fig. 6. A more accurate measure of future fertility behaviour can be obtained by asking specific questions about the number of children an individual intends to have in a particular time period. Thus, the data to be discussed here should be viewed as less than optimal indicators of intended fertility behaviour. Nevertheless, an increasing gradient of desired family size emerges across the three hospitals (Fig. 5). The ideal family size at Omdurman was approximately three children, at Khartoum General about four and at Khartoum North around five. In other words, desired family size in the sample decreased with increasing urbanization. The desire for additional children decreases sharply with the number of living children (Fig. 6). In both age groups, approximately 80% of the women
73
Characteristics of abortion patients in Khartoum 100
1
2
3 No. of living children
4
Fig. 6. Desire for additional children, by parity and age: 20-29 years, years, . Pooled data for total sample.
5+
; 30-39
with two living children wanted additional children, as contrasted to 20% for women with five or more living children. The overall figure for ideal family size for the entire sample is about four children. An overall presentation of contraceptive practice before and after the abortion is given in Fig. 7. Only 10% of the women had practised some form of fertility control in the month of this conception. At follow-up, however, 46-8% were using fertility control and, of these, 98-3% had accepted highly effective contraceptive methods. The greatest change from before to after the abortion occurred at Khartoum General where 3-4% were using it at follow-up. Khartoum North reported 9-4% in the month of conception and 41-5% at follow-up. Slightly less change was reported at Omdurman with 19-4% using contraception in the month of conception and 48% at follow-up. It may be that more effort is devoted to the family planning programme at Khartoum General or that a particular population may be more receptive to motivational programmes. Also, a relatively high proportion of the women at Omdurman were already using contraception in the month of conception, and this may be related to their desired family size of only three. Khartoum North reported the next highest percentage of pre-abortion contraceptive use (9-4%). Their ideal family size was not an invariant five, but rather a range of values from two through more than five with a statistical mean of five. There was probably a subgroup of women at Khartoum North who wanted
74
H. Rushwan BEFORE /V = 2447) Total sample
AFTER V = 2232)
00
Vasectomy
0 0
0 0
Tubectomy
14
Pill
9
03
IUD
]52
06
Conventional*
08
None
90
Omdurman
0 \
Vasectomy
00
0 0
Tubectomy
0 2
04
IUD
]3 9
0 1
Conventional*
02
None
80 6 L BEFORE (/V = 931)
J52 0 AFTER V=
0 0
Vasectomy
0 1
00
Tubectomy
0 1
2 9[
Pill
0 3
IUD
0 2
Conventional* None
96
00
Vasectomy
0 1
Tubectomy
7.6C
J40 4 13
J49 6 AFTER / = 728)
EPIDEMIOLOGICAL ANALYSIS AND REPRODUCTIVE CHARACTERISTICS OF INCOMPLETE ABORTION PATIENTS IN KHARTOUM, THE SUDAN HAMID RUSHWAN University of Khartoum, Khartoum, The Sudan Summary. A study of 2447 patients treated for incomplete abortion in three major hospitals in Khartoum, the Sudan, was carried out from 1974 to 1976. Analysis focused particularly on socio-demographic variables, reproductive history and contraceptive behaviour before and after the abortion. This paper presents the epidemiological analysis and reproductive characteristics of these patients in an attempt to show the value of such service oriented research in evaluating clinical problems. Introduction
Induced abortion is illegal in the Sudan except where strong medical indications exist. However, admissions to hospital for incomplete and inevitable abortion are a cause for concern. Incomplete abortion may occur when a woman has a spontaneous abortion (miscarriage) or a poorly performed induced abortion. In an inevitable abortion the process of uterine emptying has begun and the cervix has usually begun to dilate and some bleeding to occur. Treatment is by evacuating the uterus. A basic analysis of the type offered in this paper can form the foundation of an epidemiological study of the incidence of incomplete abortion, although it is not possible to produce an exact sociodemographic profile. Attention is focused on gross differences among the hospitals inasmuch as the data collection period extended for less than a year and a half. The significance of any differences found in such a short period would be indeterminate in that they may represent 'real' differences or be due to the operation of spurious influences, such as sampling fluctuation. The sample Khartoum is the capital of the Sudan (population 18 million) and is a rapidly expanding city, due to migration from the mainly rural population of the country. The city is divided by the Nile rivers into three distinct areas and the medical 65
66
H.Rushwan
facilities are: Omdurman Hospital, mainly serving a middle class population of approximately 299,000 people; Khartoum North Hospital, in a rural lower socioeconomic catchment area (pop. 155,000); and Khartoum General hospital, whose predominantly middle and lower class patients are drawn from the towns and adjacent villages (pop. 344,000). Of the total sample of 2447 patients, 707 were from Omdurman Hospital, 931 from Khartoum General and 809 from Khartoum North (Table 1). The Khartoum population is described on the basis of socio-economic factors, such as education, employment and urban and rural residence, thought to be most closely related to ultimate pregnancy outcome. Socio-economic, biological, attitudinal and behavioural aspects of fertility form a functional chain whose ends are linked. Even from a narrow hospital sample of incomplete abortion patients it is possible to build a behaviour model using routinely available data. In Fig. 1 a 'core model' of patient characteristics is organized sequentially in groups from socioeconomic, biological-reproductive, employment and residence data, moves on to pregnancy outcome events, and ends with the woman's desire for additional children and her contraceptive practices. The core model shows how obstetrics and gynaecology relate to community health and paediatrics. A study of this type is a step towards understanding interaction between family and community health. Results and discussion Demographic indices Table 2 shows the distribution of the sample by age and employment; the differences between hospitals are not great but there are minor trends between the three locations. The median age for the entire sample was 27-0 years. There is an age gradient from Khartoum General (median = 25-3) to Khartoum North (26-9) to Omdurman (28-1). Khartoum North, however, reported the highest proportion (14-1%) of women under 20 years of age. Data for gainful employment show a similar order: Khartoum General reported the greatest proportion of gainfully employed (5-8%), followed by Khartoum North (4-7%) and Omdurman (1-3%). Table 1. Distribution of sample at admission, by abortion type Omdurman Type of abortion Incomplete/inevitable Induced Inevitable/incomplete with systemic condition Total
Khartoum General
Khartoum North
Total sample
No.
%
No.
%
No.
%
683 96-6 20 2-8 4 0-6
921 7 3
98-9 0-8 0-3
791 6 12
97-8 0-7 1-5
2395 33 19
97-9 1-3 0-8
707
931
No.
%
809
2447
Characteristics of abortion patients in Khartoum
67
Rurality
Education
Socio-Economic
Gainful employment \ /
FAMILY AND COMMUNITY HEALTH
Pregnancy Spontaneous abortion
Induced abortion
OBSTETRICS
Stillbirth Bio-Reproductive
> PAEDIATRICS
Attitude
I
Practice
Additional children desired
Contraception
Fig. 1. Core model of patient characteristics.
Figure 2 shows education and residence data together in order to examine the relationship between these two variables. The urban-rural gradient from Omdurman to Khartoum North is evident and data on education reflect the same pattern. If, however, one selects for analysis only those patients with 4 or more years of education, a different pattern emerges. The data for Omdurman remain virtually unchanged: 92% of women with 4 or more years of education are from urban areas. For Khartoum General, however, 78-2% of these women are from
68
H. Rushwan
Table 2. Distribution of 2447 hospitalized abortion patients, by age and gainful employment Omdurman Patient characteristic Age 32
(b)
Omdurman
28 0% 8 0,
64 0%
Khartoum General
26 2%
•52 0%
7ZA 21 5%
///A Khartoum North
22 3%
Fig. 2. Percentage distribution by area of residence (a) for each hospital sample and (b) for those within each sample having 4 or more years of education: urban local, 9; urban outside, • ; rural, 0. Table 3. Distribution of 2447 hospitalized abortion patients, by parity Omdurman Parity 0 1 2 3 4 5 6 7 8 9 10
11 + Unknown Median
Khartoum General
Khartoum North
Total sample
No.
%
No.
%
No.
%
No.
95 111 96 105 84 65 53 40 25 19 8 3 3
13-4 15-7 13-6 14-9 11-9
124 132 143 118 110 97 89 44 41 20 10 1 2
13-3 14-2 15-4 12-7 11-8 10-4
141 103 100 85 96 92 71 46 38 22 6 3 6
17-4 12-7 12-4 10-5 11-9 11-4
360 346 339 308 290 254 213 130 104 61 24 7 11
9-2 7-5 5-7 3-5 2-7 11 0-4 0-4 3 •0
9-6 4-7 4-4 2-1 11 01 0-2 31
8-8 5-7 4-7 2-7 0-7 0-4 0-7 3-2
%
14-7 141
13-9 12-6 11-9 10-4 8-7 5-3 4-3 2-5 10 0-3 04 3•
1
70
H. Rushwan 400 375 On 367 6 ^ y
300 282 10.
Q.
O O O
\ V \ \
o
\
T3
SPONTANEOUS ABORTION
\\209 6
200 \ai.8i-8T
179-50, N
c o o
v
X
N N
.2 100 -
^ ^ ^ O 157-1
1695^;
N
^ v '^-g121-9 X
X Ny
x
82 9
CHILD LOSS ~~~~~-O602
44 1 O 31 2 O ^ ^~ _ _ _ ^ ^ i
-19
o 1
O24 6 ^
20-29
30-39
Age (years)
Fig. 3. Previous abortions and child loss, by age: Omdurman, . ; Khartoum North,
; Khartoum General,
There are clear differences in offspring loss between locations: the highest offspring loss rates recorded at Omdurman (31 -2/1000 live births) and at Khartoum General (44-1/1000 live births) are less than the lowest offspring loss rate recorded at Khartoum North (60-2/1000 live births). Furthermore, the rate of 5-9/1000 live births among women aged 30-39 in Omdurman is remarkably low. Women younger than 20 at all three locations have a higher rate of previous abortion. In addition, Omdurman (375-0/1000 pregnancies) and Khartoum General (367-6/1000 pregnancies) report higher rates of previous abortions than Khartoum North (282-1/1000 pregnancies). In an effort to detect any meaningful relationship between education and residence and abortion/offspring loss, a subanalysis was performed. For women with 4 or more years of education there was no discernible departure from the main group with respect to previous abortion or offspring loss rates. However, urbanrural variations provide a clue for further study. Sample sizes become too small to draw firm conclusions but there are indications, for all three locations, that
Characteristics of abortion patients in Khartoum
71
150 -
124 0 q^ \
V)
.c
r
"S > 100 o o o
O
50 - 50 -2«s.
38 5 a..
\
\
\
\
\
,X>95 6
>»57 2
58 8 38
\s^ \25
•\^s' ^
4 - - - 2 4 1 ...•••-• o-' ^>O19 1
'•••a
11 8o
..O46 8
..••"•'
17 4 ^ 3 - 0
3 1 ^ — I
1-2
3-4 5-6 No. of live births
Fig. 4. Child loss, by parity: total sample, I
7+
t; other symbols as for Fig. 3.
previous abortion rates for rural women below the age of 20 are markedly higher than those of their urban counterparts. Further data are required to confirm or refute this finding. Offspring loss may also be examined in relation to parity (Fig. 4) and interesting differences emerge between locations. Although there is a pattern of decline and increase at all three places, the trend for Khartoum North is different from those for Omdurman and Khartoum General. Comparing the rates for parity groups 1-2 and 3-4 there is a 75% reduction at Omdurman, a 55% reduction at Khartoum General and a 53% reduction at Khartoum North. For parity 7 or more, offspring loss shows slight increase at Khartoum North (18%) but a substantial increase at both Khartoum General (94%) and Omdurman (516%). The changes in offspring loss rates at all three hospitals appear to merit further study. The Sudan is still largely a traditional society but modernizing influences are entering the life of city dwellers in Khartoum. There is approximately one abortion case admitted to hospital for every two babies born in hospital in the three institutions included in this study and it is the impression of clinicians that a substantial number of incomplete abortions are deliberately provoked. However,
72
H. Rushwan 100
405
188 100
2 3 No. of living children
5+
Fig. 5. Desire for additional children among women aged 20-29 years, by parity: Omdurman, ; Khartoum General, ; Khartoum North, .
unlike Latin America, septic abortions make up only a small proportion of cases, suggesting that most induced abortions are performed relatively satisfactorily. Khartoum North, which caters for the low income groups, has the highest child loss, irrespective of parity, and also the highest rate of abortion complications. Desiredfamily size and contraceptive practice The women in this study were asked how many additional children they wanted, without regard to timing or intention. Figure 5 presents the results, by number of living children, for the age group 20-29 at each of the three hospitals. Pooled data for the age groups 20-29 and 30-39 are given in Fig. 6. A more accurate measure of future fertility behaviour can be obtained by asking specific questions about the number of children an individual intends to have in a particular time period. Thus, the data to be discussed here should be viewed as less than optimal indicators of intended fertility behaviour. Nevertheless, an increasing gradient of desired family size emerges across the three hospitals (Fig. 5). The ideal family size at Omdurman was approximately three children, at Khartoum General about four and at Khartoum North around five. In other words, desired family size in the sample decreased with increasing urbanization. The desire for additional children decreases sharply with the number of living children (Fig. 6). In both age groups, approximately 80% of the women
73
Characteristics of abortion patients in Khartoum 100
1
2
3 No. of living children
4
Fig. 6. Desire for additional children, by parity and age: 20-29 years, years, . Pooled data for total sample.
5+
; 30-39
with two living children wanted additional children, as contrasted to 20% for women with five or more living children. The overall figure for ideal family size for the entire sample is about four children. An overall presentation of contraceptive practice before and after the abortion is given in Fig. 7. Only 10% of the women had practised some form of fertility control in the month of this conception. At follow-up, however, 46-8% were using fertility control and, of these, 98-3% had accepted highly effective contraceptive methods. The greatest change from before to after the abortion occurred at Khartoum General where 3-4% were using it at follow-up. Khartoum North reported 9-4% in the month of conception and 41-5% at follow-up. Slightly less change was reported at Omdurman with 19-4% using contraception in the month of conception and 48% at follow-up. It may be that more effort is devoted to the family planning programme at Khartoum General or that a particular population may be more receptive to motivational programmes. Also, a relatively high proportion of the women at Omdurman were already using contraception in the month of conception, and this may be related to their desired family size of only three. Khartoum North reported the next highest percentage of pre-abortion contraceptive use (9-4%). Their ideal family size was not an invariant five, but rather a range of values from two through more than five with a statistical mean of five. There was probably a subgroup of women at Khartoum North who wanted
74
H. Rushwan BEFORE /V = 2447) Total sample
AFTER V = 2232)
00
Vasectomy
0 0
0 0
Tubectomy
14
Pill
9
03
IUD
]52
06
Conventional*
08
None
90
Omdurman
0 \
Vasectomy
00
0 0
Tubectomy
0 2
04
IUD
]3 9
0 1
Conventional*
02
None
80 6 L BEFORE (/V = 931)
J52 0 AFTER V=
0 0
Vasectomy
0 1
00
Tubectomy
0 1
2 9[
Pill
0 3
IUD
0 2
Conventional* None
96
00
Vasectomy
0 1
Tubectomy
7.6C
J40 4 13
J49 6 AFTER / = 728)
