Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion

Background

The aim of the study was to identify barriers associated with the failure to return for delayed intrauterine device (IUD) insertion postabortion.

Study Design

This study had two components: (a) a retrospective cohort study of women who chose an IUD as their postabortion contraceptive method to compare characteristics of those who did and did not receive a device within 6 months of the procedure and (b) a prospective survey of women intending IUD use postabortion to assess actual IUD use at 6 weeks, barriers to access and attitudes on insertion timing.

Results

Of the 500 abortion patient charts available for review during the study period, 53 women intended IUD use postabortion. At 6 months, only 32% intending an IUD received one, and there were no significant demographic differences between the groups.For the prospective portion, the response rate at 6 weeks was 54% (27/50), with only 26% (7/27) of responders reporting IUD insertion by this time. The principal reported barrier to IUD insertion was time needed for an additional visit (41%). Most women (67%) desired immediate insertion and believed that they would be more likely to have an IUD inserted if it is performed immediately postabortion (63%). Monthly income was the only statistically significant difference between those who responded to the 6-week follow-up (US$1409.50) and those who did not (US$937.50, p=.05).

Conclusion

A significant number of women that express a preference for IUD use after first-trimester abortion do not return to obtain a device. Most would prefer to have the option of immediate insertion.     

Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion

BACKGROUND: We hypothesize that barriers to IUD insertion are central to low utilization in the USA. This study evaluates methods to minimize barriers, including post-abortal insertion, staff training and simplified screening. STUDY DESIGN: We obtained data on IUD utilization during three study periods: a control period (Period 1), a period after initiating post-abortal insertion and staff training (Period 2), and a period with these interventions plus simplified screening for interval insertions (Period 3). We evaluated IUD utilization, associated complications and utilization at a similar local agency in which the interventions were not implemented. RESULTS: We inserted 2172 IUDs during the study, including 1493 interval and 679 post-abortal insertions. In the control period, there were 28 monthly IUD insertions on average, compared to 71 (a 151% increase) and 122 (a 334% increase) in Periods 2 and 3, respectively. IUD utilization at the nearby agency remained relatively constant. Complications remained low. CONCLUSIONS: IUD utilization can be substantially increased through relatively simple, low-cost interventions, with significant potential to reduce unintended pregnancy.     

Insertion of intrauterine contraceptives immediately following first- and second-trimester abortions

Background

The study was conducted to assess the continuation and patient satisfaction with intrauterine contraception (IUC) insertion immediately after elective abortion in the first and second trimesters in an urban, public hospital-based clinic.

Study Design

A cohort of 256 women who elected to have insertion of a copper-T IUC (CuT380a) or a levonorgestrel-releasing IUC (LNG-IUC) were followed postoperatively by phone calls or chart review to evaluate satisfaction and continuation with the method.

Results

Of our 256 subjects, 123 had first-trimester abortions and 133 had second-trimester abortions (14 or more weeks). Median time to follow-up was 8 weeks (range 7-544 days). Nineteen discontinuations occurred: eight (6.5%, 95% CI 2.8-12.4%) following first-trimester and 11 (8.3%, 95% CI 4.2-14.3%) following second-trimester abortion (p=.6). Five women reported expulsion; one (0.8%, 95% CI 0.0-4.4%) in the first-trimester group and four (3.0%, 95% CI 0.8-7.5%) in the second-trimester group. (p=.4) Seven infections resulting in discontinuation occurred (2.7%, 95% CI 1.1-5.6%); none were positive for gonorrhea or chlamydia at time of insertion. No perforations occurred. Nearly all (93.8%) of the women were satisfied with IUC. Rates of satisfaction between women after first- and second-trimester abortions were equal.

Conclusion

In an urban clinic, IUC has high initial continuation and high patient satisfaction when inserted immediately following either first- or second-trimester abortions.     

Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion

BACKGROUND: Of the 1.3 million abortions performed annually in the United States, approximately half are repeat procedures. Immediate postabortal intrauterine device (IUD) insertion is a safe, effective, practical and underutilized intervention that we hypothesize will significantly decrease repeat unintended pregnancy and abortion. STUDY DESIGN: All women receiving immediate postabortal IUD insertion in eight clinics of a Northern California Planned Parenthood agency during a 3-year period comprise the IUD cohort. We selected a cohort of controls receiving abortions but choosing other, non-IUD contraception on the day of the abortion visit in a 2:1 ratio matched by date of abortion. We obtained follow-up data on repeat abortions within the agency for both cohorts through 14 months after the 3-year period. We evaluated differences in repeat abortion between cohorts. All analyses were intent-to-treat. RESULTS: Women who received an immediate postabortal IUD had a lower rate of repeat abortions than controls (p<.001). Women who received a postabortal IUD had 34.6 abortions per 1000 woman-years of follow-up compared to 91.3 for the control group. The hazard ratio for repeat abortion was 0.38 [95% confidence interval (CI), 0.27-0.53] for women receiving a postabortal IUD compared to controls. When adjusted for age, race/ethnicity, marital status, and family size, the hazard ratio was 0.37 (95% CI, 0.26-0.52). CONCLUSION: Immediate postabortal intrauterine contraception has the potential to significantly reduce repeat abortion.     

Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices

Postplacental intrauterine device (IUD) placement, defined as IUD placement within 10 min after delivery of the placenta, is an appealing strategy for increasing access to postpartum IUDs because it does not require a separate postpartum visit. These guidelines present an evidence-based assessment of postplacental IUD placement after vaginal and cesarean delivery. Postplacental IUD insertion is safe and does not have higher risks of complications than interval insertion. Most studies find that the risk of IUD expulsion is higher after postplacental insertion than after interval insertion for both vaginal and cesarean deliveries. Most studies find higher rates of expulsion after vaginal delivery than after cesarean delivery. However, expulsion rates vary widely across studies, without clear evidence about the factors that may influence expulsion. In settings where replacement of expelled IUDs is available, patient populations with low rates of return for the postpartum visit are most likely to benefit from provision of postplacental IUD placement with appropriate counseling about risks and benefits.     

Intrauterine contraceptive insertion postabortion: a systematic review

Background

This review was conducted to evaluate the evidence regarding the safety and effectiveness of intrauterine device (IUD) insertion immediately following spontaneous or induced abortion.

Study Design

We searched MEDLINE databases for all articles (in all languages) published in peer-reviewed journals from January 1966 through March 2010 for evidence comparing immediate postabortion IUD insertion with either no IUD insertion, insertion at a different time, insertion following first-trimester compared with second-trimester abortion or copper IUD insertion compared with hormone-releasing IUD insertion postabortion. We used standard abstraction forms to summarize and assess the quality of the evidence.

Results

The search strategy identified a total of 990 articles, of which 19 met our inclusion criteria for this review. Studies comparing immediate postabortion IUD insertion with no IUD insertion found that both groups experienced similar rates of pain and infection and a similar number of bleeding days, but one study reported that women with copper IUD insertion experienced a greater amount of bleeding than women without IUD insertion after abortion. Results from studies comparing immediate postabortion IUD insertion and insertion at a time not associated with pregnancy did not report differences between the two groups in the duration of bleeding, pain, expulsions or pelvic inflammatory disease (PID). One study however reported a greater amount of bleeding and another reported more removals for medical reasons among women with postabortion IUD insertion. Evidence from studies that examined immediate vs. delayed postabortion insertion reported minimal differences in bleeding, pain, expulsion and PID between groups. Studies comparing immediate IUD insertion after first- vs. second-trimester abortion reported no difference in removals for pain and bleeding, and an increased risk of expulsion among those women who had insertions after second-trimester abortion. In addition, women with insertions immediately after abortions occurring later in the first trimester had higher expulsion rates than those with insertions after early first-trimester abortions. Studies examining women using a copper IUD compared with a hormone-releasing IUD reported inconsistent results, with one paper reporting more bleeding days in the copper IUD group and another finding higher rates of removal for bleeding in the progesterone-releasing IUD group.

Conclusion

Intrauterine device insertion immediately after abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUD insertion after abortion and compared with IUD insertion at times other than immediately after abortion. Intrauterine device expulsion rates, while generally low, were higher with insertions that occurred after later first-trimester abortion compared with after early first-trimester abortion and higher with IUD insertion after second-trimester abortion compared with after first-trimester abortion.     

Immediate versus delayed initiation of the contraceptive patch after abortion: a randomized trial

Background

Immediate start of the contraceptive patch has not been studied in women after surgical abortion.

Study Design

Women presenting for surgical abortion who had chosen the transdermal patch for contraception were randomized to either delayed start of the patch (beginning the Sunday after their abortion) or immediate start (directly observed application of the patch in the clinic). Subjects were contacted at 2 and 6 months to assess contraceptive use.

Results

Two hundred ninety-eight women were randomized, and the follow-up rate was 71% at 2 months and 53% at 6 months. Method continuation did not differ by timing of initiation. At 2 months, 71% in the delayed-start group and 74% in the immediate-start group were using the patch [p=.6, with a difference of 3.1%, 95% confidence interval (CI)=−17.2% to +11.2%]. At 6 months, 55% in the delayed-start group and 43% in the immediate-start group were using the patch (p=.13, with a difference of 11.9%, 95% CI=−19.2% to +34%).

Conclusion

Immediate initiation of the contraceptive patch after surgical abortion was not associated with increased use of patch at 2 or 6 months.     

Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section

Background

An intrauterine device (IUD) is an effective reversible form of contraception. We determined the efficacy and safety of immediate postplacental IUD insertion during cesarean section.

Study Design

Two hundred forty-five women with term pregnancies delivering by cesarean section between September 2006 and December 2007 were included in the study. A copper IUD (TCu 380A) was inserted using a ring forceps within 10 min of removing the placenta. The participants were examined before hospital discharge and at 6 weeks, 6 months and 12 months postpartum.

Results

None of the patients were lost to follow-up. There was one case of an unplanned pregnancy (0.4%). There were no serious complications associated with immediate IUD insertion during cesarean section. The cumulative rates of expulsion, removal for bleeding/pain and other medical reasons were 17.6, 8.2 and 2.4 per 100 women per year, respectively. The continuation rates were 81.6% and 62% at 6 and 12 months, respectively.

Conclusion

Immediate postplacental IUD insertion during cesarean section provides adequate protection against pregnancy. However, greater than one fourth of the participants discontinued IUD use due to spontaneous expulsion or other medical reasons.     

Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices

OBJECTIVES: To assess the efficacy, safety and, thus, advantages and disadvantages, of early postplacental intrauterine device (IUD) insertion. METHODS: IUDs were inserted within 10 min after postplacental expulsion in term pregnancy both in vaginal and cesarean deliveries via a ring forceps. Of the 276 patients enrolled, 235 were included in the study. Recipients were scheduled for examination before hospital discharge and at 6 weeks, 6 months and 12 months after postplacental insertion. RESULTS: The percentages of women returning for a follow-up visit were 221 (94%), 210 (89%) and 183 (78%) at 6 weeks, 6 months and 12 months, respectively. Among IUD acceptors, 74% of the cases had vaginal deliveries and 26% had cesarean deliveries. Continuation rates were relatively high, 87.6% and 76.3%, at 6 and 12 months, respectively, after postplacental insertion of IUD. In this study, the 1-year cumulative expulsion rate with TCu 380A device was 12.3%, which may be regarded as a standard expulsion rate for immediate postplacental insertion of similar models of IUDs. CONCLUSION: The evidence from this study suggests that immediate postplacental insertion of CuT 380 models is an effective, useful, safe, convenient and low-cost procedure for early postpartum contraception.     

Accuracy of providers' assessment of pain during intrauterine device insertion

Background

Providers often underestimate patient pain. This study investigated if providers accurately assess pain during intrauterine device (IUD) insertion.

Study Design

This is a secondary analysis of a randomized trial. Participants rated pain on a 100-mm visual analogue scale (VAS). Providers marked a similar VAS for maximum level and timing of participant pain.

Results

The mean patient maximum pain was 64.8 mm (SD, 27) compared to 35.3 mm (SD, 26) rated by the provider (p<.001). Patient and provider agreement on most painful time point of procedure was weak (kappa statistic, 0.16).

Conclusions

Providers underestimate pain during IUD insertion.

Implications

To our knowledge, this is the first paper to compare provider and patient perceptions of pain during IUD insertion. Understanding this relationship will help guide further research about IUD insertion pain and techniques and could improve patient counseling.     

Use of the Mirena™ LNG-IUS and Paragard™ CuT380A intrauterine devices in nulliparous women: Release date 15 December 2009 SFP Guideline 20092

Two intrauterine devices (IUDs) are available in the United States, the levonorgestrel-bearing intrauterine system (Mirena™) and the copper-bearing T380A (Paragard™). These devices have very low typical-use failure rates but are used by only a minority of women. In particular, there is concern about their use in nulliparous women. We review the available data to address common concerns about using IUDs in this population and show that nulliparous women desiring effective contraception should be considered candidates for IUDs.     

产后即时放置宫内节育器的系统性评估

目的：运用循证医学系统评价方法比较产后即时放置宫内节育器（IUD）的临床效果,为计划生育服务对象知情选择提供依据。方法：检索7种医学数据库和9种相关杂志,由2位评价员根据纳入排除标准筛查检索的文献。结果：纳入16篇文献,分别比较不同类型的IUD、不同放置方法及不同的放置时间对产后避孕的有效性和副作用,由于干预方法不一致,数据不能进行Meta分析。现有的资料提示固定式]UD较其它类型IUD累计脱落率更低,因症取出率低。不同的放置方法（徒手放置和卵园钳放置）对避孕效果没有显著的影响。产后即时放置IUD与产后其它时间放置的临床效果没有统计学差异。结论：产后即时放置IUD是安全和有效的。固定式IUD的有效性优于其它类型IUD,但目前还缺少多中心随机的临床试验,以及较长时期的随访观察。     

The T 380A intrauterine device: a retrospective 5-year evaluation

Background

The undue resistance to intrauterine device (IUD) use seen in several settings does not seem to occur in the Family Planning Unit of UNIFESP-EPM (São Paulo Federal University, Brazil). In fact, the Copper T 380A IUD in this clinic has reached an outstanding importance and this motivated us to present our differing experience. The prevalence of this method in this clinic is as high as 40%. This contrasts to the low use in the rest of the country, where tubal ligation is by far the most used contraceptive method (40%) and where IUD is inexpressive (1.1%).

Study Design

This is a retrospective study of the records of 118 users of Copper T 380A IUD inserted at the clinic and who were followed during 5 years.

Results

The cumulative pregnancy rate was 0.8%. The main cause for discontinuation of the study was loss to follow-up (21.3%). Other reasons for the withdrawal of the device were personal option (13.6%), dislocation (11.7%) and pregnancy wish (3.4%). There was no withdrawal by pelvic inflammatory disease. Bleeding (0.8%) was not an important cause for withdrawal, and there were no withdrawals due to pain. The continuation rate at 5 years was 46.7%.The structured service and an adequate educative program perhaps could explain at least partially the good performance of IUD use in this clinic. There was an amazing prevalence of the components of the metabolic syndrome. This could represent contraindications for hormonal contraception, and, in consequence, it could influence the increased option for and continuation of the IUD.

Conclusion

These data show a good performance of the IUD for long duration, in relation to other studies, and this should be considered as a reliable alternative to the high prevalence of female sterilization in this country.     

Evaluation of postabortion IUD insertion in Egyptian women

This study was carried out at Alhussein University Hospital and Elmonera General Hospital to assess the safety and efficacy of intrauterine device (IUD) insertion immediately after spontaneous abortion compared with insertion 2 weeks after abortion. One hundred women between ages 18 and 40 years were recruited from those admitted via the emergency room with first trimester spontaneous abortion. All women were counseled about a method of contraception, particularly copper T-380, and divided into two groups: Group I, which included 69 women who preferred immediate IUD insertion, and Group II, which included 31 women who asked for late IUD insertion 2 weeks after an abortion. All women were followed at 2, 6, and 10 weeks after insertion of IUDs. Bleeding patterns were comparable in both groups. Mild bleeding occurred in 9.2% and 16% in Groups I and II, respectively; moderate bleeding occurred in 80% and 64%, respectively, and severe bleeding was observed in 10.8% and 20%, respectively. This was not significant. Expulsion rate was 4.5% and 3.4% in Groups I and II, respectively, which was also not significant. There were no cases of perforation or pelvic infections. This study showed that insertion of an IUD immediately after a spontaneous abortion is safe and could be offered to those who have had an abortion and who ask for a method of contraception.     

Society of Family Planning clinical recommendations: contraception after surgical abortion

These recommendations present an evidence-based assessment of provision of contraceptives at the time of surgical abortion. Most methods of contraception, including the intrauterine devices (IUD), implant, depot medroxyprogesterone injection, oral contraceptive pill, contraceptive patch, monthly vaginal ring, barrier methods and some permanent methods, can be safely initiated immediately after first- or second-trimester surgical abortion. Provision of postabortion contraceptives, particularly IUDs and implants, substantially reduces subsequent unintended pregnancy. IUD insertion immediately following uterine aspiration is safe. While this may be associated with a higher risk of device expulsion than with interval placement, expulsion rates remain low, and this risk must be weighed against the fact that patients often do not receive their desired IUD at an interval insertion and therefore experience higher rates of subsequent unintended pregnancy. Many patients experience barriers that prevent access to the full spectrum of postabortion contraceptive options, particularly IUDs and implants. Advancements in health-systems-based point-of-care provision and policies are needed to improve comprehensive contraceptive availability following surgical abortion. These recommendations will address clinical considerations for postabortion contraceptive provision and recommend interventions to improve contraceptive access following uterine evacuation.     

未生育育龄妇女放置宫内节育器现状的研究

目的 探讨尚未生育的育龄妇女放置宫内节育器的现状及社会因素.方法 在深圳福田下沙社区收集要求放置宫内节育器的未生育妇女共506例进行问卷调查分析.结果 未婚组＜20岁的置器妇女占26.9%,已婚组仅为0.45%,两组相比,差异有显著性 (P＜0.05).曾用避孕方法中,避孕套和口服避孕药仍是最为常用的避孕方法.在调查中选用宫内节育器而不用其它避孕方法的原因中,未婚组以配偶不愿使用避孕套为首要原因,占46.9%,而已婚组占17.0%,两组相比较,差异有显著性 (P＜0.05).在紧急避孕药的使用中,45.9 %的未婚妇女使用过紧急避孕药,而在已婚妇女组中,仅25.9%的妇女曾有使用.两组相比较,差异有显著性 (P＜0.05).结论 未婚未育妇女初次性生活年龄提前而结婚生育年龄较晚,选择避孕方法依从于男性是该人群选择宫内节育器的主要原因.     

绝经后妇女取宫内节育器术前使用米非司酮临床观察

[目的 ]　探讨米非司酮用于绝经后妇女取宫内节育器 (IUD)时软化宫颈 ,减轻疼痛的效果。　 [方法 ]　绝经1年后来门诊要求取IUD ,并为放置不锈钢金属单环者 ,随机分实验组 6 0例 ,对照组 12 0例。术前 3天 ,实验组每晚各给米非司酮 5 0mg口服。 　 [结果 ]　实验组与对照组宫颈扩张效果比较 ,满意率分别为 91.7%和 6 3.3%(P <0 .0 1) ,两组镇痛评级结果比较 ,显效率分别为 70 .0 %和 37.3%(P <0 .0 1)。　 [结论 ]　米非司酮用于绝经后妇女取IUD术前用药 ,对扩张宫颈和减轻疼痛效果满意 ,便于推广。     

Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study

OBJECTIVE: To compare the expulsion rates of intrauterine devices (IUDs) inserted in the immediate postpartum after vaginal birth and cesarean section. METHODS: Nineteen patients who had a vaginal birth and 19 patients who had a cesarean section at Hospital de Clínicas de Porto Alegre, Brazil, were selected for copper T 380A IUD insertion. With the aim of detecting clinically unnoticed dislodged devices, ultrasound examinations were performed at 1 month and between 3 and 12 months after delivery. The IUDs were considered completely expelled when found outside the endometrial cavity (e.g., in the cervical canal) or outside the uterus (in the vagina). RESULTS: Expulsion rates were statistically different between the two groups: after a vaginal birth, 50% (ultrasound only) + 27.8% (clinical examination); and post-cesarean section, 0% (p < .001; OR 5.75, 95% CI 2.36-14.01). CONCLUSION: Considering that the contraceptive efficacy of IUDs is associated with their intrauterine location, the high expulsion rates seen when they are inserted immediately after vaginal delivery contraindicate their use in this setting. The use of IUDs immediately after a cesarean section is still a reasonable alternative because its expulsion rate was zero. Ultrasound assessment of IUD positioning performed better than clinical examination, which failed to detect expulsion after postpartum insertion in 75% of the cases (9 from 12 cases).     

Obstetrician–Gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women,adolescents and other patient populations

Objectives

Use of intrauterine devices (IUDs) by US women is low despite their suitability for most women of reproductive age and in a variety of clinical contexts. This study examined obstetrician–gynecologists' practices and opinions about the use of IUDs in adolescents, nulliparous women and other patient groups, as well as for emergency contraception.

Design

A survey questionnaire was sent to a computer-generated sample of 3000 fellows who were reflective of the American College of Obstetricians and Gynecologists (College) membership.

Results

After exclusions from the 1552 returned surveys (51.7% response rate), 1150 eligible questionnaires were analyzed. Almost all obstetrician–gynecologists (95.8%) reported providing IUDs, but only 66.8% considered nulliparous women, and 43.0% considered adolescents appropriate candidates. Even among obstetrician–gynecologists who recalled reading a College publication about IUDs, only 78.0% and 45.0% considered nulliparous women and adolescents appropriate candidates, respectively. Few respondents (16.1%) had recommended the copper IUD as emergency contraception, and only 73.9% agreed that the copper IUD could be used as emergency contraception. A total of 67.3% of respondents agreed that an IUD can be inserted immediately after an abortion or miscarriage. Fewer (43.5%) agreed that an IUD can be inserted immediately postpartum, and very few provide these services (11.4% and 7.2%, respectively). Staying informed about practice recommendations for long-acting reversible contraception was associated with broader provision of IUDs.

Conclusions

Although most obstetrician–gynecologists offer IUDs, many exclude appropriate candidates for IUD use, both for emergency contraception and for long-term use, despite evidence-based recommendations.

Implications

This study shows that obstetrician–gynecologists still do not offer IUDs to appropriate candidates, such as nulliparous women and adolescents, and rarely provide the copper IUD as emergency contraception.     

A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device

BACKGROUND: Postplacental intrauterine device (IUD) insertion is a safe, convenient and effective option for postpartum contraception. Few studies involve ultrasound-guided insertion, and none involve the levonorgestrel IUD or take place in the United States. STUDY DESIGN: The study was conducted to assess the safety and feasibility of ultrasound-guided postplacental insertion of the levonorgestrel IUD following vaginal delivery in a U.S. residency program. Levonorgestrel IUDs were inserted under ultrasound guidance within 10 min of placental delivery by hand or using ring forceps. Subjects were examined at 4 and 10 weeks postpartum for evidence of expulsion or infection. RESULTS: Thirty-four subjects were enrolled and 20 received an IUD. Follow-up data are available for 19 subjects over the 10-week follow-up period; 16 subjects returned for the 4-week follow-up, and 14 returned at 10 weeks. Two additional subjects could be contacted by telephone only. At 4 and 10 weeks postpartum, no subjects had evidence of infection. There were two expulsions (2/19, 10.5%) by 10 weeks postpartum. None of the subjects examined had a partial expulsion (intracervical location of the IUD). CONCLUSIONS: In this pilot study, ultrasound-guided postplacental insertion of the levonorgestrel IUD was feasible and not associated with infection. The risk of expulsion was acceptable. Ultrasound-guided postplacental insertion of the levonorgestrel IUD may be an alternative to delayed insertion but warrants further study.