Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion

Expulsion and continuation rates after postabortion insertion of framed IUDs versus frameless IUDs - review of the literature

BACKGROUND

Early intrauterine device (IUD) discontinuation after insertion immediately following aspiration abortion or after early medical abortion occurs as a consequence of expulsion of the IUD or removal due to side effects. These are often the consequence of the uterine forces impacting on the IUD due to spatial discrepancy with the uterine cavity causing pain, abnormal bleeding, and eventually, removal of the IUD. These women are candidates for repeat pregnancy as they often select less-effective methods or no contraception at all. Repeat abortion could be reduced by giving attention to these factors.

STUDY DESIGN

In order to have an indication on the magnitude of the problem of IUD expulsion or discontinuation, we searched the MEDLINE database for clinical trials, randomized controlled trials, and prospective observational studies related to immediate postaspiration termination of pregnancy (TOP) and early medical abortion IUD insertion studies that reported IUD expulsion and IUD continuation rates.

RESULTS

The search identified 17 clinical trials that were suitable based on the data they presented. The majority concerned T-shape IUDs, inserted immediately following surgical (aspiration) pregnancy termination. Two studies were conducted after medical TOP, and four studies were conducted with the frameless IUD inserted after surgical (vacuum aspiration) TOP. The results showed expulsion rates between 0.8% and 17.3% at 8 weeks, up to 5 years after insertion, respectively. In four studies with the frameless IUD, totaling 553 insertions, the expulsion rate was 0.0% in three of them. Follow-up in the latter studies varied between 5 weeks and 54 months. Reported continuation rates with conventional (framed) IUDs were between 33.8% and 80% at 1 year for studies providing 1 year rates and between 68% and 94.1% for studies reporting continuation rates at 6 months. Studies utilizing frameless IUDs reported 1 year continuation rate over 95%.

CONCLUSION

Frameless IUDs, due to their attachment to the uterine fundus, appear to be better retained by the postabortal uterus when compared with conventional framed IUDs. The absence of a frame ensures compatibility with uterine cavity anatomical dimensions, and may therefore result in improved acceptability and continuation rates in comparison with framed IUDs. Both these characteristics of the frameless IUD could help reduce the number of repeat unwanted pregnancies and subsequent abortions in some cases.

Motivational interviewing to improve postabortion contraceptive uptake by young women: development and feasibility of a counseling intervention

OBJECTIVE

The objective was to develop and test a postabortal contraception counseling intervention using motivational interviewing (MI) and to determine the feasibility, impact and patient acceptability of the intervention when integrated into an urban academic abortion clinic.

STUDY DESIGN

A single-session postabortal contraception counseling intervention for young women aged 15-24 years incorporating principles, skills and style of MI was developed. Medical and social work professionals were trained to deliver the intervention, their competency was assessed, and the intervention was integrated into the clinical setting. Feasibility was determined by assessing ability to approach and recruit participants, ability to complete the full intervention without interruption and participant satisfaction with the counseling.

RESULTS

We approached 90% of eligible patients and 71% agreed to participate (n=20). All participants received the full counseling intervention. The median duration of the intervention was 29 min. Immediately after the intervention and at the 1-month follow-up contact, 95% and 77% of participants reported that the session was helpful, respectively.

CONCLUSIONS

MI counseling can be tailored to the abortion setting. It is feasible to train professionals to use MI principles, skills and style and to implement an MI-based contraception counseling intervention in an urban academic abortion clinic. The sessions are acceptable to participants.

IMPLICATIONS

The use of motivational interviewing in contraception counseling may be an appropriate and effective strategy for increasing use of contraception after abortion. This study demonstrates that this patient-centered, directive and collaborative approach can be developed into a counseling intervention that can be integrated into an abortion clinic.

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

OBJECTIVE

Women 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 DESIGN

Women 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.

RESULTS

A 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.

CONCLUSION

A 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.

IMPLICATIONS

In 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.

Impact of a theory-based video on initiation of long-acting reversible contraception after abortion

OBJECTIVE

Adoption of long-acting reversible contraception (LARC) (ie, the intrauterine device or the contraceptive implant) immediately after abortion is associated with high contraceptive satisfaction and reduced rates of repeat abortion. Theory-based counseling interventions have been demonstrated to improve a variety of health behaviors; data on theory-based counseling interventions for postabortion contraception are lacking.

STUDY DESIGN

Informed by the transtheoretical model of behavioral change, a video intervention was developed to increase awareness of, and dispel misconceptions about, LARC methods. The intervention was evaluated in a randomized controlled trial among women aged 18-29 years undergoing surgical abortion at a clinic in Chicago, IL. Participants were randomized 1:1 to watch the intervention video or to watch a stress management video (control), both 7 minutes in duration. Contraceptive methods were supplied to all participants free of charge. Rates of LARC initiation immediately after abortion were compared.

RESULTS

Rates of LARC initiation immediately after abortion were not significantly different between the 2 study arms; 59.6% in the intervention and 51.6% in the control arm chose a LARC method (P = .27).

CONCLUSION

This study resulted in an unexpectedly high rate of LARC initiation immediately after abortion. High rates of LARC initiation could not be attributed to a theory-based counseling intervention.

Association of age and parity with intrauterine device expulsion

OBJECTIVE

To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs).

METHODS

This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan-Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion.

RESULTS

A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68-3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75-5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44-0.78).

CONCLUSION

IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type.

LEVEL OF EVIDENCE

: II.

Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Background

Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation.

Objective

This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD.

Proposed problem solving

The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best.

Conclusion

One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

Recent advances in contraception

Focusing on intrauterine contraceptives (IUC), contraceptive implants, and emergency contraceptives, we review recent advances in contraceptive development and discuss progress in policies to improve access to the most effective methods. We report on the shift in practice towards routinely providing IUCs and implants to young and nulliparous women, prompted in part by the reduced diameter of the insertion tube for the Mirena IUC and the development of a smaller IUC called Skyla. Additionally, we describe the new SCu300A intrauterine ball and the development of an implant called Nexplanon, which comes with a preloaded inserter. We also discuss the efficacy of ulipristal acetate versus levonorgestrel for emergency contraception, especially for women who weigh more than 75 kg. Finally, in light of the increasing interest in providing IUCs and implants to women in the immediate postpartum and post-abortion periods, we consider the rationale for this change in practice and review the progress that has been made so far in the United States.

Plan A: postabortion contraception

More than 1 million abortions are performed annually in the United States. Women presenting for abortion care are often motivated by the pregnancy to use effective contraception; they are also at high risk for repeat unintended pregnancy. For these reasons, abortion represents an optimal time to initiate effective contraception. There is strong evidence that most methods of contraception, including intrauterine devices and the contraceptive implant, should be initiated at the time of the abortion procedure. Most women ovulate within the first month after an abortion. If provision of contraception is delayed, women are less likely to use effective contraception and more likely to have a repeat unintended pregnancy. Although some methods of permanent contraception can be safely performed at the time of abortion, federal and state laws often restrict these procedures being performed concurrently. Contraceptive counseling and provision at the time of abortion are important strategies to decrease rates of unintended pregnancy.

Immediate postabortal insertion of intrauterine devices

Background The use of an effective contraceptive may be necessary after an abortion. Insertion of an intrauterine device (IUD) may be done the same day or later. Immediate IUD insertion is an option since the woman is not pregnant, pain of insertion is less because the cervical os is open, and her motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries risks, such as spontaneous expulsion.Objectives To assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion.Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov,and ICTRP in January 27, 2014. We also contacted investigators to identify other trials.Selection criteria We sought all randomised controlled trials (RCTs) with at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion.Data collection and analysis We evaluated the methodological quality of each report and abstracted the data. We focused on discontinuation rates for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease.We computed the weighted average of the rate ratios.We compute drisk ratios (RRs) with 95% Confidence Intervals (CIs).We performed an intention-to-treat (ITT) analysis by including all randomised participants in the analysis according to the Cochrane Handbook for Systematic Reviews of Interventions.Main results We identified 12 trials most of which are of moderate risk of bias involving 7,119 participants which described random assignment.Five trials randomised to either immediate or delayed insertion of IUD. One of them randomised to immediate versus delayed insertion of Copper 7 showed immediate insertion of the Copper 7 was associated with a higher risk of expulsion than was delayed insertion(RR 11.98, 95% CI 1.61 to 89.35,1 study, 259 participants); the quality of evidence was moderate. Moderate quality of evidence also suggests that use and expulsion of levonorgestrel-releasing intrauterine system or CuT380A was more likely for immediate compared to delayed insertion risk ratio (RR) 1.40 (95% CI 1.24 to 1.58; 3 studies; 878 participants) and RR 2.64 ( 95% CI 1.16 to 6.00; 3 studies; 878 participants) respectively. Another trial randomised to the levonorgestrel IUD or Nova T showed discontinuation rates due to pregnancy were likely to be higher for women in the Nova T group. (MD 8.70, 95% CI 3.92 to 13.48;1 study; 438 participants);moderate quality evidence.Seven trials examined immediate insertion of IUD only. From meta-analysis of two multicentre trials, pregnancy was less likely for the TCu 220C versus the Lippes Loop (RR 0.43, 95% CI 0.24 to 0.75; 2 studies; 2257 participants ) as was expulsion (RR 0.61, 95% CI0.46 to 0.81; 2 studies; 2257 participants). Estimates for the TCu 220 versus the Copper 7 were RR 0.42 ( 95% CI 0.23 to 0.77; 2 studies, 2,274 participants) and RR 0.68, (95% CI 0.51 to 0.91); 2 studies, 2,274 participants), respectively. In other work, adding copper sleeves to the Lippes Loop improved efficacy (RR 3.40, 95% CI 1.28 to 9.04, 1 study, 400 participants) and reduced expulsion(RR 3.00, 95% CI 1.51 to 5.97; 1 study, 400 participants).Authors' conclusions Moderate quality evidence shows that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher immediately after abortions compared to delayed insertions. However, at six months postabortion, IUD use is higher following immediate insertion compared to delayed insertion.

Roles of the pharmacist in the use of safe and highly effective long-acting reversible contraception: an opinion of the women's health practice and research network of the American College of Clinical Pharmacy

The U.S. population continues to experience an alarmingly high rate of unintended pregnancies that have an impact on individual families and society alike. Lack of effective contraception accounts for most unintended pregnancies, along with incorrect use of contraceptives. The most common reversible contraceptive method used in the United States is the oral contraceptive pill, which has significant failure and discontinuation rates. Use of long-acting reversible contraceptive (LARC) methods has been increasing in recent years after efforts to educate providers and patients. Women are more likely to use LARC methods when barriers such as access and cost are removed. An uptake in the use of LARC methods would allow for markedly reduced contraception failure rates and higher user satisfaction and thus higher continuation rates than those seen with current contraception use. Promoting the use of LARC methods is an important strategy in improving both individual and public health outcomes by reducing unintended pregnancies. The pharmacist's role in family planning is expanding and can contribute to these efforts. Although knowledge regarding LARC has not been studied among pharmacists, a knowledge deficit exists among health care professionals in general. Thus pharmacist education and training should include LARC methods along with other contraceptives. The American College of Clinical Pharmacy Women's Health Practice and Research Network advocates for the pharmacist's role in the use of safe and highly effective LARC methods. These roles include educating patients, informing providers, facilitating access by providing referrals, and modifying institutional procedures to encourage provision of LARC methods.

Acceptability and clinical outcomes of first- and second-trimester surgical abortion by suction aspiration in Colombia

OBJECTIVE(S)

Since partial decriminalization of abortion in Colombia, Oriéntame has provided legal abortion services through 15 weeks gestation in an outpatient primary care setting. We sought to document the safety and acceptability of the second trimester compared to the first-trimester surgical abortion in this setting.

STUDY DESIGN

This was a prospective cohort study using a consecutive sample of 100 women undergoing surgical first-trimester abortion (11 weeks 6 days gestational age or less) and 200 women undergoing second-trimester abortion (12 weeks 0 days-15 weeks 0 days) over a 5-month period in 2012. After obtaining informed consent, a trained interviewer collected demographic and clinical information from direct observation and the patient's clinical chart. The interviewer asked questions after the procedure regarding satisfaction with the procedure, physical pain and emotional discomfort. Fifteen days later, the interviewer assessed satisfaction with the procedure and any delayed complications.

RESULTS

There were no major complications and seven minor complications. Average measured blood loss was 37.87 mL in the first trimester and 109 mL in the second trimester (p<.001). Following the procedure, more second-trimester patients reported being very satisfied (81% vs. 94%, p=.006). Satisfaction was similar between groups at follow-up. There were no differences in reported emotional discomfort after the procedure or at follow-up, with the majority reporting no emotional discomfort. The majority of women (99%) stated that they would recommend the clinic to a friend or family member.

CONCLUSIONS

Second-trimester surgical abortion in an outpatient primary care setting in Colombia can be provided safely, and satisfaction with these services is high.

IMPLICATIONS

This is one of the first studies from Latin America, a region with a high proportion of maternal mortality due to unsafe abortion, which documents the safety and acceptability of surgical abortion in an outpatient primary care setting. Findings could support increased access to safe abortion services, particularly in the second trimester.

Postabortal and postpartum contraception

Healthcare providers often underestimate a woman' need for immediate effective contraception after an abortion or childbirth. Yet, these are times when women may be highly motivated to avoid or delay another pregnancy. In addition, starting the most effective long-acting reversible methods (i.e. the intrauterine device, intrauterine system or implants) at these times, is safe, with low risk of complications. Good evidence shows that women choosing long-acting reversible contraceptives at the time of an abortion are at significantly lower risk of another abortion, compared with counterparts choosing other methods. Uptake of long-acting reversible methods postpartum can also prevent short inter-pregnancy intervals, which have negative consequences for maternal and child health. It is important, therefore, that providers of abortion and maternity care are trained and funded to be able to provide these methods for women immediately after an abortion or childbirth.

Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States

Three intrauterine devices (IUDs), one copper and two containing the progestin levonorgestrel, are available for use in the United States. IUDs offer higher rates of contraceptive efficacy than nonlong-acting methods, and several studies have demonstrated higher satisfaction rates and continuation rates of any birth control method. This efficacy is not affected by age or parity. The safety of IUDs is well studied, and the risks of pelvic inflammatory disease, perforation, expulsion, and ectopic pregnancy are all of very low incidence. Noncontraceptive benefits include decreased menstrual blood loss, improved dysmenorrhea, improved pelvic pain associated with endometriosis, and protection of the endometrium from hyperplasia. The use of IUDs is accepted in patients with multiple medical problems who may have contraindications to other birth control methods. Yet despite well-published data, concerns and misperceptions still persist, especially among younger populations and nulliparous women. Medical governing bodies advocate for use of IUDs in these populations, as safety and efficacy is unchanged, and IUDs have been shown to decrease unintended pregnancies. Dispersion of accurate information among patients and practitioners is needed to further increase the acceptability and use of IUDs.

Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice

OBJECTIVE

The objective was to evaluate whether having intrauterine devices (IUDs), contraceptive implants and injections immediately available to women undergoing abortion, compared to requiring an additional visit for these methods, leads to fewer pregnancies and fewer abortions in the following 12 months.

METHODS

We conducted a historical cohort study using health records of Medicaid-insured women obtaining a first-trimester surgical abortion within a single practice in New York City. Women in Cohort 1 (2007-2008) needed an additional visit to initiate the IUD or injection. Women in Cohort 2 (2008-2009) were able to initiate these contraceptives and implants during the abortion visit. Women in both cohorts received these methods without additional cost, and all could receive a pill, patch or ring prescription. We compared the proportions of each cohort who experienced a pregnancy that began in the 12 months following the index abortion and also evaluated the outcomes of those pregnancies.

RESULTS

Cohorts 1 and 2 consisted of 407 and 405 women, respectively. The proportions with pregnancy beginning over the following 12 months were substantially greater in Cohort 1 than Cohort 2 (27.3% versus 15.3%, p<.001). Women in Cohort 1 then underwent both more additional abortions (17.2% versus 9.9%, p=.003) and more births (7.9% versus 3.7%, p=.02). The proportion of women in Cohort 1 who initiated IUDs and implants within 12 months was smaller than in Cohort 2 (11% versus 46%, p<.001).

CONCLUSIONS

Among women insured by Medicaid, offering immediate comprehensive contraceptive access--including IUDs and implants--on the same day as an induced abortion, compared to requiring an additional visit, increased uptake of IUDs and implants and decreased repeat pregnancies in the next 12 months and abortions.

Characteristics of women who have repeat abortions in the Netherlands

OBJECTIVES

To explore the demographic characteristics of women having multiple abortions, in order to identify abortion clients who might be at increased risk of repeat abortion.

METHODS

On the basis of the registration data of most Dutch abortion clinics, responsible for 64% of all such procedures, women who procured a first abortion were compared to those who had one or more previously. Results of bivariate analyses and a multivariate binary logistic regression analysis are presented.

RESULTS

Of all abortions, 36% were repeat abortions. Women aged over 20 were more likely to have repeat abortions, as were migrants, particularly those with a Caribbean background (from Surinam or the Netherlands Antilles) and women who had children. Effect sizes of other factors were very small. Surprisingly, women who had repeat abortions more often used contraception in the preceding six months than women who had a first abortion, but also this effect size was small as well. A multivariate logistic regression analysis led to similar results.

CONCLUSIONS

Abortion clients with a Caribbean background should be targeted for the prevention of more unwanted pregnancies. Not only should the use of reliable contraception be promoted, but also compliance and continuation.

Myths and misconceptions about intrauterine contraception among women seeking termination of pregnancy

BACKGROUND

Immediate initiation of an intrauterine device (IUD) or intrauterine system (IUS) following termination of pregnancy (TOP) is associated with a significant reduction in the risk of another TOP. In spite of its high efficacy, uptake of intrauterine contraception in the UK is low. Myths and misconceptions about the method may contribute to the low uptake.

STUDY DESIGN

Anonymous, self-administered questionnaire among women requesting a TOP in a hospital abortion service in Scotland, UK.

METHODS

Misconceptions about intrauterine contraception were extracted from an online social networking and micro-blogging service, and from existing research to develop a questionnaire containing 12 negative statements about intrauterine contraception. Respondents indicated their level of agreement with each statement.

RESULTS

A total of 106/125 (85%) women requesting a TOP completed the questionnaire. The two commonest negative statements that respondents agreed with were that the IUD/IUS 'Is painful to have inserted' (n=36; 34%) and that 'It can move around inside your body' (n=25; 23.6%). The range of women who neither agreed nor disagreed with negative statements was 26.4-56.0%. Twenty-seven (25%) women indicated that the IUD/IUS was their planned method of post-TOP contraception.

CONCLUSIONS

Although myths about intrauterine contraception persist among a small proportion of women requesting a TOP, lack of knowledge about the method is also evident. The consultation prior to TOP is an important opportunity to provide accurate and quality information to women about the IUD/IUS that may serve to increase uptake and prevent repeat abortions.

Precision intrauterine contraception may significantly increase continuation of use: a review of long-term clinical experience with frameless copper-releasing intrauterine contraception devices

Objective

The purpose of this paper is to review the experience with the frameless, anchored, GyneFix copper-releasing intrauterine contraceptive devices (IUCDs/IUDs) (Contrel Europe, Belgium), and to demonstrate their high acceptability and low rate of discontinuation of use, which could contribute to current efforts that aim to reduce radically the high number of unintended pregnancies and induced abortions, particularly in young women.

Materials and methods

This paper is based on studies that examined the differences in uterine volume and cavity size, related to age and parity, and on original clinical research data and practical experience with frameless copper IUDs, as well as on literature data on the IUD–endometrial cavity relationship of conventional IUDs, with special reference to side effects and user discontinuation.

Results

The mean transverse diameter in nulliparous and parous women is significantly less than the length of the transverse arm of the TCu380A IUD (ParaGard, Duramed, NY, USA) or the levonorgestrel intrauterine system (Mirena, Bayer, Germany). Small, frameless, flexible, and unidimensional copper IUDs appear to be well tolerated, with less impact on menstrual bleeding, resulting in low discontinuation rates when compared with standard-size conventional IUDs, which often result in increased expulsion rates, complaints of pain and erratic or increased menstrual bleeding, and subsequent high rates of discontinuation, particularly in young women.

Conclusion

The unidimensional GyneFix IUDs fit the majority of uterine cavities. An IUD that fits is likely to result in increased tolerance and continued use of the method. As this would appeal to women, the logical result should be greater use of the method and fewer unintended pregnancies and induced abortions. Recommending the standard TCu380A (ParaGard) IUD or the Mirena levonorgestrel intrauterine system, primarily developed for use in parous women, for general use in nulliparous and adolescent women should be done with caution in the light of current scientific evidence, except if 3-D sonography indicates that the uterine cavity is sufficiently large.

Women's reports on postabortion family-planning services provided by the public-sector legal abortion program in Mexico City

OBJECTIVE

To investigate patients' views of family-planning services provided in Mexico City during abortion care at public facilities and their acceptance of postabortion contraception.

METHODS

In total, 402 women seeking first-trimester abortion care in Mexico City were surveyed. Logistic regression was used to test whether postabortion contraception varied according to abortion visit characteristics or patient sociodemographics.

RESULTS

Most participants (328 [81.6%]) reported being offered contraception at their visit and 359/401 (89.5%) selected a contraceptive method for postabortion use, with 236/401 (58.9%) selecting an intrauterine device. Women who underwent surgical abortion were more likely than those who underwent medical abortion to report being offered contraception (P<0.001); women attended by a female physician were more likely than those attended by a male physician to report being offered contraception (P<0.05). Women who attended the general hospital were less likely to report being offered contraception (P<0.001).

CONCLUSION

Public-sector facilities in Mexico City provide a high level of postabortion family-planning care, and uptake of postabortion contraception is high.

Immediate post-abortion insertion of intrauterine contraceptives (IUC) in a diverse urban population

Ethnic minority women have a higher incidence of unintended pregnancy and abortion than Caucasian women, with significant individual and social implications. Post-abortion intrauterine contraceptive (IUC) use may reduce future unintended pregnancy. This was a retrospective review of 265 women undergoing abortion at a Los Angeles County Reproductive Options Clinic. Demographic factors, reproductive history, and post-abortion contraceptive choice were evaluated and analyzed. The population was predominantly Latina (73%) and single, with a mean age of 27. Immediate post-abortion IUC insertion was chosen by 48% overall and more frequently by Latinas (55%) than by African Americans (33%) or Asians (43%) (p = 0.02). IUC use increased with age, undesired future fertility, increasing gravidity, and history of previous abortion in univariate analysis. In multivariate analysis, IUC use increased with Latina ethnicity and increasing gravidity. In a clinic serving low-income urban women in Los Angeles, post-abortal IUC uptake is highest among Latinas and those with prior pregnancies. Future research should examine reasons for and barriers to IUC uptake in diverse communities and methods to improve post-abortion IUC uptake to prevent subsequent unintended pregnancies.

Early versus delayed insertion of intrauterine contraception after medical abortion - a randomized controlled trial

Background

Today, a large proportion of early abortions are medical terminations, in accordance to the woman's choice. Intrauterine contraceptives (IUC) provide highly effective, reversible, long-acting contraception. However, the effects of timing of IUC insertion after medical abortion are not known.

Methods

Women undergoing medical abortion with mifepristone and misoprostol up to 63 days gestation and opting for IUC were randomised to early insertion (day 5–9 after mifepristone) or delayed (routine) insertion (at 3–4 weeks after mifepristone). The primary outcome was the rate of IUC expulsion at six months after IUC insertion.

Results

A total of 129 women were randomized, and 116 women had a successful IUC insertion. There was no difference in expulsion rate between early (9.7%) vs. delayed (7.4%) IUC insertion (risk difference −9.2–13.4). Furthermore, 1.5% of women randomized to early and 11.5% to delayed insertion did not attend the follow up (proportion difference 10.0%, 95% CI: 1.8–20.6%, p = 0.015), and a higher proportion of women (41%) had had unprotected intercourse prior to returning for insertion in the delayed group compared with the early group (16%) (p = 0.015). Adverse events were rare and did not differ between the groups.

Conclusions

Early insertion of IUC after medical abortion was safe and well tolerated with no increased incidence for expulsions or complications. Women were more likely to return for the IUC insertion if scheduled early after the abortion, and less likely to have had an unprotected intercourse prior to the IUC insertion. Early insertion should be offered as a routine for women undergoing first trimester medical abortion.

Trial Registration

ClinicalTrials.gov NCT01537562

Comparing the effectiveness of copper intrauterine devices available in Canada. Is FlexiT non-inferior to NovaT when inserted immediately after first-trimester abortion? Study protocol for a randomized controlled trial

BACKGROUND

We describe the rationale and protocol for a randomized noninferiority controlled trial (RCT) to determine if the Flexi-T380(+) copper intrauterine contraceptive device (IUD) is comparable in terms of effectiveness and expulsion rates to the most common Canadian IUD currently in use, NovaT-200, when placed immediately after a first-trimester abortion.

METHODS/DESIGN

Consenting women choosing to use an IUD after an abortion for a pregnancy of less than 12 weeks of gestation will be randomized to device-type groups to receive immediate post-abortion placement of either a Flexi-T380(+) IUD, a device for which no current evidence on expulsion or effectiveness rates is available, or the Nova-T200 IUD, the only other brand of copper IUD available in Canada at the time of study initiation. The primary outcome measure is IUD expulsion rate at 1 year. Secondary outcomes include: pregnancy rate, method continuation rate, complication rates (infection, perforation), and satisfaction with contraceptive method. A non-intervention group of consenting women choosing a range of other post-abortion contraception methods, including no contraception, will be included for comparison of secondary outcomes. Web-based contraception satisfaction questionnaires, clinical records, and government-linked health administrative databases will be used to assess primary and secondary outcomes.

DISCUSSION

The RCT design, combined with access to clinical records at all provincial abortion clinics, and to information in provincial single-payer linked administrative health databases, birth registry, and hospital records, offers a unique opportunity to determine if a novel IUD has a comparable expulsion rate to that of the current standard IUD in Canada, in addition to the first opportunity to determine pregnancy rate and method satisfaction at 1 year post-abortion for women choosing a range of post-abortion contraceptive options. We highlight considerations of design, implementation, and evaluation of the first trial to provide rigorous evidence for the effectiveness of current Canadian IUDs when inserted after first-trimester abortion.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01174225.

Determinants of long-acting reversible contraceptive (LARC) use by adolescent girls and young women

OBJECTIVES

To identify factors relevant for adolescents and young women in their selection of a contraceptive method and reasons for acceptance or rejection of long-acting reversible contraceptives (LARCs).

METHOD

Questionnaire survey among 194 women attending an integrated young people service.

RESULTS

Compared to the number of those who had heard about all LARCs (71%), the number of respondents who had used a LARC was low (28%). Awareness of intrauterine methods was the lowest, compared to other LARCs. High efficacy, protection against sexually transmitted infections and non interference with sex were the three most important factors when choosing a contraceptive method, whereas the possibility of altering the menstrual pattern and reversibility were not considered important. Qualities of LARCs such as reliability and long duration of action would encourage young women to accept LARCs. Knowledge of peers' good experience with a LARC fosters, but fear of pain and needle (most obvious for intrauterine methods) restrains use of these methods.

CONCLUSIONS

Despite reliability and long-term use being important advantages, fear of pain and needles make LARCs less appealing to young people. Current LARCs meet some, but not all expectations of adolescents and young women.

Contraceptive paths of adolescent women undergoing an abortion in France

PURPOSE

Although more than 30,000 teenagers had an induced abortion in France in 2007 (14.3% of all abortions), little is known about their abortion experience. We explore young women's decisions related to their abortion and the patterns of abortion care among teenagers in France, and draw particular attention to the contraceptive circumstances surrounding the abortion.

METHODS

The data are drawn from the French National Survey of Abortion Patients conducted in 2007, comprising 1,525 women aged 13-19 years.

RESULTS

A majority of French teens (82%) reported their pregnancy was unplanned and took on the responsibility of having an abortion: 45% made the decision alone, 46% shared the decision with their family or partner, and 9% reported the decision was made on their family's or partner's request alone. Sixty-nine percent of teenagers were eligible for both medical and surgical abortions, but only 43% thought they were given a choice of methods. Two-thirds of pregnancies were caused by contraceptive misuse or failure, mostly due to condom slippage or breakage (26%) or inconsistent pill use (20%). In 68% of cases, teenagers were prescribed a more effective method than the one they were using before, although only 11% received a prescription for a long-acting method. One in five teenagers reported not receiving a prescription for contraception.

CONCLUSIONS

Our results reveal varying degrees of young women's autonomy in the decisions regarding their abortion. Although most teens switch to more effective methods of contraception after an abortion, only a minority receives a prescription for a long-acting method.

The New York City mayoral abortion training initiative at public hospitals

BACKGROUND

We set out to describe and understand the first-ever abortion training political initiative on the provision of abortion services and abortion residency training.

STUDY DESIGN

We completed in-depth interviews with 22 participants (response rate of 92%) who have knowledge of abortion training and services in the New York City (NYC) public hospital system before and/or after the initiative. We used grounded theory to describe the initiative's effects.

RESULTS

Respondents identified strategies that helped achieve renovation of abortion facilities, updating of abortion services and protocols, and training of abortion providers. Respondents also identified public health impacts including improvement of abortion services, empowerment of abortion providers, and legitimization of abortion training and services.

CONCLUSION

This NYC political initiative can be a model for other city governments to influence obstetrics and gynecology resident training and the provision of abortion services.

State-of-the-art of non-hormonal methods of contraception: III. Intrauterine devices

Since the 1959 revival of the IUD, non-hormonal devices have become the most widely used of all reversible contraceptives. Pregnancy rates of copper-releasing IUDs in current use range from approximately 0.5 to 1.5 per hundred continuing users in the first year, with somewhat lower annual pregnancy rates thereafter. Evidence-based research has been systematically conducted and translated into guidelines for eligibility criteria and problem management. Recent device research, beyond the T, Multiload and frameless devices has centred on improved designs such as U ,Y and Slimline shapes, or enhanced copper release, the latter through electrochemical effects or nanotechnology applications. Other IUD research foci concern devices that decrease bleeding and pain by releasing non-steroidal anti-inflammatory drugs. Yet other research lines indicate noncontraceptive benefits of copper intrauterine devices in protecting against endometrial cancer, and favourable risk-benefit analyses of IUD use by women at risk of or post HIV infection. IUD mechanisms of action and the relation of IUDs to pelvic infection and ectopic pregnancy are briefly reviewed. For our literature search we used Medline, Popline and Cochrane Library data bases, Google search, our personal files, and the references contained in articles in our files.

Impact of long-acting reversible contraception on return for repeat abortion

OBJECTIVE

The objective of the study was to determine the rate of return for repeat abortion in relation to postabortion contraceptive method choice 24 months onward from an intervention study.

STUDY DESIGN

This was a prospective cohort study involving a hospital note search for 510 women 24 months after an abortion.

RESULTS

Women using long-acting reversible contraceptive (LARC) methods (intrauterine device [IUD] and depot medroxyprogesterone acetate) had significantly lower return rates for repeat abortion (6.45%; 95% confidence interval [CI], 4.0-9.8) than non-LARC users, of whom 14.5% returned (95% CI, 9.9-20.2). A Cox proportional hazard analysis showed that the postabortion method choice was significantly related to the likelihood of returning for a repeat abortion (P = .002), controlling for major demographic factors and previous pregnancy history. Using the pill as a reference group for risk of repeat abortion, the IUD hazard ratio (HR) was 0.36 (95% CI, 0.17-0.77), the depot medroxyprogesterone acetate HR was 0.55 (95% CI, 0.21-1.45), and the HR for all other methods was 1.8 (95% CI, 0.83-3.92).

CONCLUSION

This study provides strong support for the promotion of immediate postabortion access to LARC methods (particularly intrauterine devices) to prevent repeat abortion.

The benefits and risks of using a levonorgestrel-releasing intrauterine system for contraception

The contraceptive profile of the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena®) is well established, with efficacy similar to that achieved with sterilization and rapid return to fertility after discontinuation of use. The LNG-IUS is typically associated with transient menstrual disturbance during the first few months of use, but this usually settles with continued use, with a concomitant decrease in menstrual blood loss. Overall, the safety profile of the LNG-IUS has been well established across a wide population of women, and the available data do not suggest that the LNG-IUS adversely affects bone health or increase the risk of adverse cardiovascular events or breast and uterine cancers. This article reviews the literature to provide updated information on the risks and benefits associated with the LNG-IUS, particularly focusing on its use in contraception.

Contraceptive discontinuation and repeat unintended pregnancy within 1 year after an abortion

BACKGROUND

We examined 12-month hormonal contraceptive continuation and pregnancy rates by abortion history.

STUDY DESIGN

Women who wanted to avoid pregnancy for at least 1 year were recruited at four San Francisco Bay area family planning clinics on regular service days and on abortion care days. Participants completed baseline and follow-up questionnaires. Multivariable Cox models assessed the factors associated with method discontinuation and pregnancy.

RESULTS

Women who were enrolled into the study on the day of their abortion were 20% more likely to discontinue their contraceptive method than women who never had an abortion [adjusted hazard ratio (AHR)=1.21, 95% confidence interval (CI)=1.03-1.42]. Women who had a recent abortion or previous abortion were 60% more likely to have a pregnancy during follow-up than women who never had an abortion (AHR=1.63, 95% CI =1.21-2.20, and AHR=1.66, 95% CI=1.18-2.33, respectively).

CONCLUSION

The experience of having an unintended pregnancy and abortion does not lead to behavioral changes that protect against another unintended pregnancy.

Immediate vs. delayed insertion of intrauterine contraception after second trimester abortion: study protocol for a randomized controlled trial

BACKGROUND

We describe the rationale and protocol for a randomized controlled trial (RCT) to assess whether intrauterine contraception placed immediately after a second trimester abortion will result in fewer pregnancies than current recommended practice of intended placement at 4 weeks post-abortion. Decision analysis suggests the novel strategy could substantially reduce subsequent unintended pregnancies and abortions. This paper highlights considerations of design, implementation and evaluation of a trial expected to provide rigorous evidence for appropriate insertion timing and health economics of intrauterine contraception after second trimester abortion.

METHODS/DESIGN

Consenting women choosing to use intrauterine contraception after abortion for a pregnancy of 12 to 24 weeks will be randomized to insertion timing groups either immediately (experimental intervention) or four weeks (recommended care) post abortion. Primary outcome measure is pregnancy rate at one year. Secondary outcomes include: cumulative pregnancy rates over five year follow-up period, comprehensive health economic analyses comparing immediate and delayed insertion groups, and device retention rates, complication rates (infection, expulsion) and, contraceptive method satisfaction. Web-based Contraception Satisfaction Questionnaires, clinical records and British Columbia linked health databases will be used to assess primary and secondary outcomes. Enrolment at all clinics in the province performing second trimester abortions began in May 2010 and is expected to complete in late 2011. Data on one year outcomes will be available for analysis in 2014.

DISCUSSION

The RCT design combined with access to clinical records at all provincial abortion clinics, and to information in provincial single-payer linked administrative health databases, birth registry and hospital records, offers a unique opportunity to evaluate such an approach by determining pregnancy rate at one through five years among enrolled women. We highlight considerations of design, implementation and evaluation of a trial expected to provide rigorous evidence for appropriate insertion timing and health economics of intrauterine contraception after second trimester abortion.

Immediate versus delayed IUD insertion after uterine aspiration

BACKGROUND

Intrauterine devices (IUDs) provide highly effective, reversible, long-term contraception that is appropriate for many women after first-trimester uterine aspiration. However, the effects of immediate versus delayed IUD insertion after uterine aspiration on rates of complications and IUD use are uncertain.

METHODS

We performed a randomized noninferiority trial involving women undergoing uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks of gestation who desired an IUD. Subjects were randomly assigned (in a 5:6 ratio) to IUD insertion immediately after the procedure or 2 to 6 weeks afterward (delayed insertion). The primary outcome was the rate of IUD expulsion 6 months after IUD insertion; an expulsion rate 8 percentage points higher in the immediate-insertion group was defined as inferior.

RESULTS

Among 575 women who underwent randomization, an IUD was inserted in 100% (258 of 258) of the women in the immediate-insertion group and in 71.3% (226 of 317) of those in the delayed-insertion group (difference, 28.7 percentage points; 95% confidence interval [CI], 23.7 to 33.7). The 6-month expulsion risk was 5.0% (13 of 258 women) after immediate insertion and 2.7% (6 of 226) after delayed insertion (difference, 2.3 percentage points; 95% CI, -1.0 to 5.8), which was consistent with the predefined criterion for noninferiority. Six-month rates of IUD use were higher in the immediate-insertion group (92.3%, vs. 76.6% after delayed insertion; P<0.001). Adverse events were rare and did not differ significantly between groups. No pregnancies occurred in the immediate-insertion group; five occurred in the delayed-insertion group (P=0.07), all in women who never received an IUD.

CONCLUSIONS

The 6-month rate of expulsion of an IUD after immediate insertion was higher than but not inferior to that after delayed insertion. Immediate insertion resulted in higher rates of IUD use at 6 months, without an increased risk of complications. (Funded by the Susan Thompson Buffett Foundation; ClinicalTrials.gov number, NCT00562276.).

Perceived and insurance-related barriers to the provision of contraceptive services in U.S. abortion care settings

BACKGROUND

Abortion facilities represent a potentially convenient setting for providing contraception to women experiencing unintended pregnancies. This analysis examines a range of factors that may act as barriers to integrating contraceptive and abortion services and documents abortion providers' perspectives on their role in their patients' contraceptive care.

METHODS

Administrators from 173 large, nonhospital facilities that provide abortions in the United States responded to a structured survey between May and September 2009. We used chi-square tests to assess differences in categorical outcomes.

RESULTS

Although the majority of U.S. abortion facilities offer a range of contraceptive methods on site, facility staff identified multiple barriers to full integration of the two services, in particular, insurance, patient, and cost barriers. Few of these perceived barriers, however, were associated with differences in the actual provision of most contraceptive methods. Specialized abortion clinics that do not accept health insurance were less likely to have highly effective methods, such as intrauterine devices and implants, on site. Facilities located in Medicaid states were more likely to accept both public and private health insurance for contraceptive services.

CONCLUSION

Increased access to contraceptive services during abortion care is one strategy for reducing repeat unintended pregnancy, and stakeholders at all levels--including abortion providers, insurance companies, and policy makers--have a role to play in achieving this goal.

Comparison of contraceptive method chosen by women with and without a recent history of induced abortion

BACKGROUND

Women undergoing induced abortion may be more motivated to choose long-acting reversible contraception (LARC), including the intrauterine device (IUD) and implant, than women without a history of abortion. Our objective was to determine whether the contraceptive method chosen is influenced by a recent history of induced abortion and access to immediate postabortion contraception.

STUDY DESIGN

This was a subanalysis of the Contraceptive CHOICE Project. We compared contraception chosen by women with a recent history of abortion to women without a recent history. Participants with a recent history of abortion were divided into immediate postabortion contraception and delayed-start contraception groups.

RESULTS

Data were available for 5083 women: 3410 women without a recent abortion history, 937 women who received immediate postabortion contraception and 736 women who received delayed-start postabortion contraception. Women offered immediate postabortion contraception were more than three times as likely to choose an IUD [adjusted relative risk (RR(adj)) 3.30, 95% confidence interval (CI) 2.67-4.85] and 50% more likely to choose the implant (RR(adj) 1.51, 95%CI 1.12-2.03) compared to women without a recent abortion. There was no difference in contraceptive method selected among women offered delayed-start postabortion contraception compared to women without a recent abortion.

CONCLUSION

Women offered immediate postabortion contraception are more likely to choose the IUD and implant than women without a recent abortion history. Increasing access to immediate postabortion LARC is essential to preventing repeat unintended pregnancies.