Choice of the levonorgestrel intrauterine device,etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion

ObjectiveWomen who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion.Study designWomen presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA.ResultsA total of 260 women, aged 18–45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users.ConclusionA variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling.ImplicationsIn contraceptive counseling, after screening for IPV, assessing patient’s stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient’s choice of method.     

Immediate Postabortion Intrauterine Device Insertion: Continuation and Satisfaction

BackgroundThe provision of intrauterine devices (IUDs) immediately postabortion has the potential to decrease unintended pregnancy in the United States. Studies have demonstrated safety and efficacy; however, there are limited data about continuation, satisfaction, and bleeding patterns among women receiving immediate postabortion IUDs.Study DesignWe performed a retrospective cohort study of women undergoing immediate postabortion IUD insertion. Demographics and clinical data were collected from intake forms and procedure notes. We attempted to contact women by telephone to administer a short questionnaire to assess continuation, satisfaction, and bleeding patterns.ResultsWe were able to contact 77 of 225 (34%). Women lost to follow-up were more likely to have higher parity or a pregnancy of greater gestational age at the time of abortion compared with women who were successfully contacted. Continuation and satisfaction rates were high (80.5% and 80.6%, respectively). Reported bleeding patterns with IUD use were similar to previously reported patterns.ConclusionFollow-up of women undergoing immediate postabortion IUD insertion is challenging. However, we found that women choosing immediate postabortion IUD had high rates of continuation and satisfaction.     

Preventing repeat abortion in Canada: is the immediate insertion of intrauterine devices postabortion a cost-effective option associated with fewer repeat abortions?

BackgroundIn 2005, 97,254 abortions were performed in Canada, of which 38% were repeat abortions. The objective of this research was to determine if provision of free intrauterine devices (IUDs) postabortion is associated with a reduction in health-care costs and repeat abortions in a Canadian population compared with provision of oral contraceptives (OCPs) or depo-medroxyprogesterone acetate (DMPA).Study DesignA retrospective cohort study was conducted by intention-to-treat chart review in a facility providing the majority of abortions in a Canadian health region. All (n=1782) residents of this region who underwent abortion in 2003, 2004 and 2008 were included. One- and 5-year rates of repeat abortion were calculated, and a cost-effectiveness analysis was conducted to compare health-care system costs of providing patients with IUDs, OCPs or DMPA and subsequent repeat abortions.ResultsIn 2003 and 2004, 1101 index abortions occurred. The main contraceptive cohorts were immediate IUD insertion (n=117, 10.6%), immediate OCP (n=413, 37.5%) and immediate DMPA administration (n=357, 32.4%). After 5 years repeat abortion rates in the respective cohorts were: IUD, 9.4%, OCP, 17.4%, DMPA, 16.2% (p=.05). One-year rates of repeat abortion were not significantly different. Costs of providing contraception and subsequent abortions over 5 years were $142.63 (IUD), $385.61 (OCP) and $384.81 (DMPA) per user.ConclusionThe immediate insertion of IUDs postabortion is associated with a lower 5-year rate of repeat abortion than provision of OCPs or DMPA. A cost reduction to the health-care system occurs when providing IUDs postabortion vs. alternate contraception of equivalent duration.     

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.     

Routine counseling about intrauterine contraception for women seeking emergency contraception

Objective

To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC.

Study design

For 8 months before and 21 months after this change in clinic policy, women aged 15–45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n= 328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data.

Results

Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months.

Conclusions

Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC.

Implications

Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.     

Availability,practices and acceptance of postabortion contraceptive services in health facilities: A study in six states of India

ObjectiveTo assess the availability of and practices around postabortion contraceptive services in health facilities, and document women’s acceptance of postabortion contraception in six Indian states.Study DesignWe conducted a survey of 4001 public and private health facilities that provide abortion-related care in six Indian states. In this analysis, we assess the availability and range of contraceptive methods offered, the protocols and practices around postabortion contraceptive counseling, the extent to which facilities require women to adopt contraception, and contraceptive uptake among women.ResultsAlthough some contraceptive methods and information were available at a majority of facilities (75–97%), the range of methods was lacking and the information provided to women varied considerably by state. 8–26% of facilities required women seeking induced abortions to accept a modern contraceptive method. Only half to two-thirds of postabortion patients adopted a modern method.ConclusionThe limited number of methods offered in facilities suggests that some women may not obtain the method they desire, or get information about the full range of methods that should be available. While contraceptive uptake should be voluntary, the requirement imposed by some facilities for women to adopt a modern contraceptive method in order to obtain an abortion must be addressed.ImplicationsSome 15.6 million Indian women had an induced abortion in 2015. Understanding the provision of postabortion contraceptive services in health facilities, including counseling, is necessary to inform policies and practices to better enable women and couples to make informed decisions to prevent future unintended pregnancies.     

Women's questions after postabortion insertion of intrauterine contraception

Background

Postabortion insertion of intrauterine contraception has the potential to decrease unintended pregnancy and repeat abortions, but little is known about how to ensure that women receive appropriate counseling about this method in this setting. The goal of this investigation was to document women's questions and to assess retention of information provided during contraceptive counseling after immediate postabortion intrauterine contraceptive placement.

Study Design

Women who received postabortion intrauterine contraceptives (IUCs) at an urban, hospital-based abortion clinic were surveyed 2–3 months postabortion to evaluate for expulsion, assess their concerns about IUC and evaluate retention of information provided during contraceptive counseling.

Results

Of 141 women contacted, 121 participated. Almost half of participants (46%) had responses to the question “Do you have any questions or concerns about your intrauterine device?” that fell into the following categories: spotting/bleeding (16%), cramping/pain (15%), string management (10%), expulsion concern (5%). Seventy percent reported less bleeding during menses than prior to IUC placement, and 37% had less cramping. Sixty-three percent were able to accurately report statistics regarding IUC efficacy, 56% recalled common side effects, and 42% remembered what to do if expulsion occurred.

Conclusion

Although IUCs are highly effective and their placement in the abortion setting is safe, women frequently have questions and do not recall critical counseling information about IUCs. In order to improve IUC continuation, techniques to improve both patient knowledge retention and anticipatory guidance should be studied further.     

Immediate postabortal contraception with the levonorgestrel intrauterine device, Norplant, and traditional methods

Women seeking legal first trimester abortion were counseled concerning contraception methods available for use immediately postabortion. Fifty women each accepted hormonal methods that were available only in the clinic and were novel to the country, the levonorgestrel IUD and Norplant implants, whereas another 50 chose either coitus interruptus or abstinence. All were experienced contraceptors, but larger percentages of women selecting the levonorgestrel IUD or implants had used the pill or IUDs previously, were under age 30, and weighed less than 60 kg compared to the other study participants. In the initial 2–6 weeks postabortion, women using the long-acting hormonal methods resumed sexual activity earlier and experienced more bleeding and spotting days than did other study participants, but their hematocrits were not adversely affected. No clinically significant side effects were noted in any group in the 6 weeks following the abortion. At the end of 1 year of follow-up, women using the hormonal methods had experienced no pregnancies and had high rates of continuation. IUD and implant participants had greater weight gain than did the other participants, but their mean weight remained below that of participants using traditional methods. No significant between-group differences in levels or changes in levels from admission were noted in hematocrit and blood pressure. The women found the levonorgestrel implants and IUDs easy and safe to use and highly effective. Bleeding disturbances, including amenorrhea, were the principal features the women disliked.     

Predictors of postabortion contraception use in Cambodia

Objective

To evaluate which characteristics collected at the point of abortion are associated with contraceptive use over the extended postabortion period for women in Cambodia.

Associations Between Abortion Services and Acceptance of Postabortion Contraception in Six Indian States

Women receiving induced abortions or postabortion care are at high risk of subsequent unintended pregnancy, and intervals of less than six months between abortion and subsequent pregnancy may be associated with adverse outcomes. This study highlights the prevalence and attributes of postabortion contraceptive acceptance from 2,456 health facilities in six major Indian states, among 292,508 women who received abortion care services from July 2011 through June 2014. Eighty‐one percent of the women accepted postabortion contraceptive methods: 53 percent short‐term, 11 percent intrauterine devices, and 16 percent sterilization. Postabortion contraceptive acceptance was highest among women who were aged 25 years and older, received first‐trimester services, received induced abortion, attended primary‐level health facilities, and had medical abortions. Doctors receiving post‐training support were more likely to offer contraceptives, but no association was observed between such support and acceptance of IUDs or sterilization. Comprehensive service‐delivery interventions, including ensuring availability of skilled providers and contraceptive commodities, offering clinical mentoring for providers, identifying and addressing provider bias, and improving provider counseling skills, can increase postabortion contraceptive acceptance and reduce unintended pregnancy.     

Implanon users are less likely to be satisfied with their contraception after 6 months than IUD users

Background

The study was conducted to perform a direct comparison of the satisfaction of intrauterine device (IUD) users and Implanon users after 6 months.

Study design

Women were recruited to this study in the contraception clinics of Southern Health and Family Planning Victoria. Each woman completed a questionnaire at the time of starting her contraception with either an IUD or Implanon. Women were sent a follow-up questionnaire after 6 months to assess their satisfaction with their chosen method of contraception.

Results

A total of 439 participants were recruited for this non randomized cohort study; 211 choosing an IUD and 228 choosing to use Implanon. The main reason patients in both groups chose their contraceptive method was recommendation by the doctor. Follow-up was achieved in over 84% in both groups. More than 50% of women in both groups reported at least one side effect. The most commonly reported side effect in both groups was abnormal bleeding and this was also the most common reason for having the contraceptive device removed. The IUD users reported a higher rate of satisfaction with their chosen method of contraception, although there was no difference between groups in the removal rate or whether the women would recommend the contraception to others.

Conclusions

IUD users reported a higher level of satisfaction than did Implanon users at 6 months. Side effects in women using IUDs and Implanon are common. The range of likely side effects should be included in counseling women about long-term reversible contraception.     

Determinants of Contraceptive Acceptance Among Cambodian Abortion Patients

Although Cambodia's total fertility rate is declining, limited access to and use of contraceptives has meant that some women rely upon induced abortion, legal since 1997, to achieve their fertility intentions. This study identifies factors that facilitate acceptance of postabortion contraception among women using Cambodia's public health facilities. Data were collected in all of Cambodia's hospitals with obstetric and delivery services (n = 71) and a representative sample of 115 of its 887 health-care centers, and from women seeking induced abortion or with abortion complications who presented to selected facilities during a three-week period (n = 933). Weighted data from 316 women who reported not wanting to become pregnant within the next few months and who presented to facilities that provide postabortion contraceptives were analyzed for bivariate and multivariate associations. Approximately 42 percent of women accepted contraceptives at the conclusion of care. After controlling for individual and facility characteristics, women who presented at facilities where a nurse/midwife managed abortion services, where contraceptives and abortions were provided in the same room, and where a larger range of methods were offered had significantly higher odds of contraceptive acceptance following abortion care. Improving contraceptive counseling and training for midwives and physicians, increasing contraceptive choices, and promoting access to contraceptives on site may reduce Cambodian women's risk of unwanted pregnancy and, potentially, unsafe abortion.     

Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand

Background

Many misconceptions still prevail about the appropriateness of use of the intrauterine device (IUD), particularly for younger women. This study examines the factors associated with post abortion IUD use as compared to the combined oral contraceptive pill (COC). It then examines the effect of type of post abortion contraception with the likelihood of seeking subsequent abortions.

Study design

This prospective cohort study followed, for a period of 3 years, 1422 women who had a first trimester surgical abortion between November 2004 and January 2005 in Auckland's public abortion clinic.

Results

Compared to women who left the clinic with COC, those leaving with an IUD (OR 0.3) at baseline were less likely to return for a subsequent abortion. Among women who had not had a previous termination, younger women were less likely than older women to have had an IUD inserted post abortion. With every additional live birth, women were three times as likely to have left the abortion clinic with an IUD. Among women who had had a previous termination, age was no longer significantly associated with post abortion IUD insertion. However, parity was still significantly associated, as was having a negative sexually transmitted infection test.

Conclusions

Young and nulliparous women are less likely to use an IUD as a method of contraception following an abortion. However, those women who have an IUD inserted following an abortion are much less likely to return for a subsequent abortion. IUDs are a safe and effective method of contraception that are currently still underused among the younger population.     

Experiences with Prenatal and Postpartum Contraceptive Services among Women with a Preterm Birth

BackgroundProviding postpartum contraception can help to achieve recommended interpregnancy intervals (≥18 months from birth to next pregnancy), decrease the risk of preterm birth, and thus improve maternal and infant health outcomes of future pregnancies. However, the experiences of women with preterm birth regarding contraceptive services have not been documented. We sought to better understand contraceptive counseling experiences and postpartum contraception of women with a preterm birth.MethodsWe interviewed 35 women, ages 18–42 years, with a recent preterm birth in California. The transcribed interviews were analyzed using ATLAS.ti v.8.ResultsWomen had public (n = 15), private (n = 16), or no insurance (n = 4) at the time of the interview. Women were mainly Latina (n = 14), Caucasian (n = 9), or African American (n = 6); 15 women were foreign born. Women's experiences ranged from spontaneous preterm births to births with severe medical complications. We identified five themes that were associated with women's engagement in the contraceptive method choice and understanding of birth spacing: 1) timing and frequency of contraceptive counseling; 2) quality of patient–provider interaction and ability to follow up on questions; 3) women's personal experiences with contraceptive use and experiences of other women; 4) context in which contraceptive counseling was framed; and 5) system barriers to contraceptive use.ConclusionsPostpartum contraceptive counseling should address women's preterm birth experience, medical conditions, age, contraceptive preference, and childbearing plans. Having a preterm birth intensifies gaps in hospital and outpatient clinic coordination and provider–patient communication that can lead to use of less effective or no contraceptive methods and risk of early subsequent unplanned pregnancies.     

Pregnancy outcomes with an IUD in situ: a systematic review

BackgroundWhile intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ.MethodsWe searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs.ResultsNine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions.ConclusionPregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks.     

'Without a plan' but 'keeping on track': views on contraception, pregnancy and abortion in Mexico City

Despite increased use of modern contraception among Mexican women, there has been a significant increase in abortions. Little is known about the experiences behind these trends. This study examines decision-making around contraception, pregnancy, childbearing and abortion. We carried out 26 in-depth interviews with 23- to 35-year-old females and males in Mexico City. Interviewees described reproductive planning 'without a plan' and sporadic contraceptive use. Linking of reproductive preferences and contraceptive use occurred only after raising a child for a few years or after experiencing an abortion. Interviewees described side effects of hormonal contraceptives and the intrauterine device (IUD) and problems with condoms. Only 8% of participants disagreed with abortion completely. Those with mixed views opposed abortion for pregnancies resulting from lack of responsibility or due to personal problems or concerns about one's future. However, these more controversial reasons were the primary motivations for terminating pregnancies. Females and males expressed that females made most decisions related to contraception, pregnancy and abortion. Further research could explore the reasons behind reproductive planning 'without a plan', 'on and off' contraceptive use and abortion beliefs and experiences that are somewhat contradictory.     

Contraceptive policies affect post-abortion provision of long-acting reversible contraception

Background

Placement of long-acting reversible contraceptives (LARC) — intrauterine devices (IUDs) and the implant — directly after an abortion provides immediate contraceptive protection and has been proven safe.

Study Design

We conducted a survey of National Abortion Federation member facilities (n=326; response rate 75%) to assess post-abortion contraceptive practices. Using multivariable logistic regression, we measured variations in provision of long-acting contraception by clinic factors and state contraceptive laws and policies.

Results

The majority (69%) of providers surveyed offered long-acting methods, but fewer offered immediate post-abortion placement of intrauterine devices (36%) or implants (17%). Most patients were provided with contraception; 6.6% chose LARC methods offering the highest level of protection. Post-abortion provision of these methods was lower in stand-alone abortion clinics (p≤.001), but higher with recent clinician training (p≤.001) and in the absence of clinic flow barriers (p≤.001). State policies had a significant impact on how women paid for contraception and the likelihood of LARC use. Patient use was higher in states with contraceptive coverage mandates (p≤.01) or Medicaid family planning expansion programs (p≤.05).

Conclusions

Use of the most effective contraceptives immediately post-abortion is rare in the United States. State policies, high cost to patients, and the ongoing need for clinician training in the methods hinder provision and patient uptake. Contraceptive policies are an important component of abortion patient access to the most effective methods.     

Women's reproductive decision making and abortion experiences in Cape Town,South Africa: A qualitative study

ABSTRACT

Unintended pregnancy is a significant public health issue in South Africa. Despite free services including contraception, women face structural and institutional barriers to accessing care. This qualitative study comprised interviews with 16 women aged 18 to 40 years and receiving post-abortion services at a public clinic in Cape Town. Data analysis revealed three main themes: personal journeys in seeking abortion, contraceptive experiences, and contrasting feelings of empowerment (in reproductive decision making) and disempowerment (in the health care system). Women perceived themselves as solely responsible for their reproductive health, but found it difficult to obtain adequate information or services.