In contrast, where family planning services are made available to women who have had abortions, the women are likely to use family planning (179, 228). In the US, for example, undergoing an abortion, when followed by adequate family planning counseling and services, increased the likelihood that young women would consistently practice effective contraception in the future, one study found. Before their abortions only 25% of the women consistently used a modern contraceptive method, while one year afterward 77% did so (5).

Linking emergency care and family planning. All hospitals or clinics treating women for complications of unsafe abortion should consider starting a family planning program on-site as part of postabortion care. They can provide postabortion family planning counseling together with as full a range of contraceptive methods as possible. Reversible modern methods, such as condoms, spermicides, injectables, and oral contraceptives, can be offered to women before they are discharged from the medical facility (276). Where providers are trained to insert IUDs and Norplant® implants, these methods can be offered as well. In Nepal, for example, physicians trained in manual vacuum aspiration (MVA), as part of a postabortion care pilot project, also were trained to provide family planning counseling and services so that women could receive complete care in one place (177).

If no complications are present, sterilization services also can be offered to women and performed after postabortion treatment. Sterilization, of course, must always be fully voluntary. Counseling and informed choice are crucial. When it is unclear whether the woman has made an informed choice, she should be provided with a reversible method and a referral or follow-up appointment for sterilization later, after she has had more opportunity for consideration (33).

Setting up a postabortion family planning program requires (32, 33, 276):

• A private space for counseling women and providing reversible methods. The space could be an office that is rarely used, a corner of an examination or treatment room, or even a corridor or outdoor bench where the counselor and the woman can talk privately. A curtain can provide more privacy. In some settings counselors may be able to speak with women in the recovery room itself, once they feel well enough.
• A reliable supply of informational materials and range of contraceptive methods and an inventory system for ordering supplies in time to avoid running out.
• A secure but accessible space for storing contraceptives and informational materials. If the storage area is locked, at least one staff member per shift needs to have a key.
• If possible, an adequately equipped space for clinical procedures such as pelvic exams, insertion of IUDs and Norplant implants, and voluntary surgical sterilization, as well as a reliable supply of the materials and instruments needed for these methods and a system for equipment sterilization and infection prevention.
• Training for providers in family planning counseling and services. Training will need to inform clinicians about national and local policies on contraceptive services so that misunderstandings do not delay or deny services to women treated for abortion complications.
• Reliable funding, administration, and management. The program manager must monitor quality of services and coordinate hours of operation with other departments, ensuring that trained staff are available for all shifts, that new and rotating staff receive family planning training, and that sufficient supplies are stocked.

At the least, emergency care providers need to give every woman a clear, specific referral to an accessible family planning provider (200). At all levels of the health care system, providers can and should give each woman:

• The name of at least one family planning provider or clinic;
• Its location and the days and times that clients can receive services. Providing maps helps, especially if they are understandable to illiterate clients;
• A client brochure, where available, about family planning methods or about the family planning service.

Rapid return to fertility. All women treated for abortion complications need to receive certain key information about their rapid return to fertility and the availability of family planning and other reproductive health services. After abortion a woman's fertility returns almost immediately—usually within two weeks. The rapid return to fertility makes it especially important that women who will be sexually active and who want to avoid another pregnancy decide quickly whether to use a family planning method. Many women, however, do not know that they can become pregnant again soon after abortion. Many mistakenly believe that after abortion they will experience something similar to the usual postpartum delay in return to fertility (20, 161, 247).

Few women are told about their rapid return to fertility when they are treated for abortion complications. In Turkey, for example, survey data show that fewer than 10% of women undergoing abortion were told that they could become pregnant again within two weeks (262). In Kenya, at six hospitals where women were treated for postabortion complications, only 13% of patients were told about the rapid return to fertility (243).

To provide complete care and help women avoid future unintended pregnancies, all emergency staff need to be trained to discuss three key points about family planning with every woman (161, 279):

1 Fertility returns rapidly—
She could become pregnant again right away.
2 Modern family planning methods are safe and effective after treatment for abortion complications—
She can delay or avoid another pregnancy by using family planning.
3 Family planning information, services, and counseling are available—
Her health care provider can help her obtain and use family planning.

Which methods after abortion complications? In general, all modern family planning methods are safe and effective to use after treatment of abortion complications, but the appropriateness of each method varies with the individual woman's condition and her personal needs (161, 277, 279). Factors such as the severity and nature of the woman's complication and her current overall health influence which methods are most appropriate for her immediate use. For further information on contraceptive method choice, see the chart "Family Planning Following Postabortion Treatment," included with this issue of Population Reports, and sidebar, Additional Publications on Postabortion Care and Family Planning.)