Factors associated with initiating long-acting reversible contraception immediately after first-trimester abortion

Contraceptive plans before preoperative assessment and at procedure in surgical abortion patients

OBJECTIVE

To describe changes in contraceptive method plans pre-appointment, after counseling, and post-procedure in patients having an abortion.

STUDY DESIGN

We reviewed electronic medical records of University of California, Davis Health patients who had an operating room abortion from January 2015 to December 2016. We excluded persons with procedures for fetal anomaly or demise. We extracted patient demographics and contraceptive plans reported at each encounter (telephone intake, pre-operative appointment, and day of abortion). We evaluated individual contraceptive plans across the encounters, identified patient characteristics that contributed to plan change, and created a multivariable logistic regression model for predictors of contraception method plan change from telephone intake to post-procedure.

RESULTS

The 747 patients had a mean gestational age of 16 4/7 ± 5 0/7 weeks with 244 (32.7%) <15 weeks and 235 (31.5%) ≥20 weeks. At telephone intake, 273 (36.4%) wanted a long-acting method (139 [50.9%] intrauterine device [IUD]; 99 [36.3%] implant; 35 [12.3%] unspecified), 11 (3.9%) permanent contraception, and 248 (33.2%) a less effective or no method; 215 (28.8%) stated they were undecided. Most (357/433 [82.4%]) patients who planned a reversible method based on the telephone intake obtained that or a similar method. Of the 273 patients planning a long-acting method, 258 (94.5%) received an IUD (158 [40.9%]) or implant (100 [36.6%]). Of the 215 undecided patients, 88 (40.9%) received an IUD and 55 (25.6%) an implant. No demographic factors predicted a change in method plan.

CONCLUSIONS

Most patients will receive the method they initially identified at the telephone intake after an abortion, especially those planning an IUD or implant. Undecided patients are commonly open to discussing options.

Access to Postabortion Contraception: ACOG Committee Opinion, Number 833

ABSTRACT

All contraceptive methods are safe and effective when provided immediately after abortion procedures and when otherwise medically appropriate for a patient. Providing a contraceptive method immediately after an induced or spontaneous abortion can help individuals achieve their desired reproductive outcomes and minimize the burden of multiple appointments. Contraceptive counseling and methods should be made available to all patients who experience induced or spontaneous abortion, and the patient's right to decline or postpone this care should be respected. Recognizing the individual barriers that may exist for each patient is important to providing patient-centered care. It also is important to understand the history of reproductive rights abuses, including contraceptive coercion and forced sterilization, in the United States. Ultimately, clinicians should focus on providing access to counseling and, ideally, providing all methods of contraception, while recognizing that each patient is unique.

Contraception Choice Among Those Seeking Abortion for Fetal Indication or Management of Pregnancy Loss

OBJECTIVE

To compare contraception choices of those who are undergoing abortion procedures for fetal indications or surgical management of pregnancy loss with those who are having abortions for another indication.

METHODS

We conducted a cross-sectional study at University of California, Irvine, from December 1, 2017, through December 31, 2018, and included gestational ages up to 24 0/7 weeks. We abstracted data from electronic medical records and analyzed them using descriptive statistics, χ2, Fisher exact tests, and a multivariate logistic regression model for primary outcome (whether a contraception method was chosen) and secondary outcome (whether a long-active reversible contraception was chosen).

RESULTS

Those with fetal indication were less likely to choose contraception than those with other indication (68/134, 50.7% vs 142/158, 89.9%, P<.001), and among those choosing contraception those with fetal indication were less likely to choose long-acting reversible contraception (LARC) (19/68, 27.9% vs 94/142, 66.2%, P<.001). Differences remained significant in multivariable analysis that controlled for age, gestational age in weeks, race, parity, procedure type, and comorbidities (among those with fetal indication for choosing any contraception: adjusted odds ratio [aOR] 0.11, 95% CI 0.05-0.23; choosing LARC: aOR 0.17, 95% CI 0.07-0.39).

CONCLUSION

Only half of those seeking abortion for a fetal indication or surgical management of pregnancy loss were interested in contraception.

The significant influence of history of induced abortion on the utilisation of long-acting reversible contraceptive methods in the immediate post abortion period, Northern Ethiopia

BACKGROUND

Rapid population growth, untended pregnancy, and related consequences remain the concern of Sub-Saharan African countries, including Ethiopia. Despite this, long-acting reversible contraceptives methods are still underutilised and no studies have sought the factors in this study setting. Therefore, this study conducted to assess the prevalence and determining factors of long-acting reversible contraceptives utilisation following an abortion in Northern Ethiopia.

METHOD

Facility-based cross-sectional study design was employed. A total of340 post aborted women selected by a systematic sampling method from August 1 to October 30, 2018. Data were entered into Epi-Info version 7 software and exported to SPSS version 20 for analysis. Both bivariate and multivariate logistic regression models were used to identify factors associated with the outcome variable.

RESULTS

The overall post-abortion long-acting reversible contraceptives utilisation was 57(16.76%) with 47(82.46%) implantand 10 (17.54%) intrauterine devices. Age range 20-29 years (AOR = 0.09, 95% CI 0.02-0.37), employed (AOR = 5.22, 95% CI 1.99-13.67), had ≥2 alive children (AOR = 7.02, 95% CI 1.58-31.23), induced abortion (AOR = 8.41, 95% CI 3.28-21.59), surgical abortion (AOR = 5.99, 95% CI 2.25-15.94), previous awareness (AOR = 3.18, 95% CI 1.14-8.82) and history of prior utilisation (AOR = 3.59, 95% CI 1.08-11.97) were the factors significantly associated with utilisation of post-abortion long-acting reversible contraceptives.

CONCLUSION

Long-acting reversible contraceptive methods level of utilisation following an abortion in this study was low. Advocating and raising awareness should always consider on benefits and effectiveness of long-acting reversible contraceptives for all type of abortion and methods of termination as an integral part of reproductive health care services.

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial

BACKGROUND

Unwanted pregnancies remain a burden for women living with HIV (WLWH). Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health. We evaluated the effect of a family planning voucher, inclusive of immediate postpartum counseling, on uptake, early initiation, and continuation of modern contraceptive methods among recently postpartum WLWH delivering at a publicly funded regional referral hospital in rural, southwestern Uganda.

METHODS AND FINDINGS

We performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis includes adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrollment and 6 months postpartum. Our primary outcome of interest for this analysis is initiation of a modern family planning method within 8 weeks postpartum. Secondary outcomes included family planning initiation at 12, 14, 16, and 20 weeks postpartum, family planning discontinuation and/or change, pregnancy incidence, and mean time without contraception. The trial was registered with clinicaltrials.gov (NCT02964169). At enrollment, half of the women in both the voucher (N = 87, 55%) and control (N = 86, 54%) groups wanted to have a child in 2 years postpartum. Over 80% of referent pregnancies in the voucher (N = 136, 86%) and control (N = 128, 81%) groups were planned. All women were accessing ART. The mean CD4 count was 396 cells/mm3 (SD = 61) for those enrolled in the control group versus 393 cells/mm3 (SD = 64) in the family planning voucher group. By 8 weeks postpartum, family planning was initiated in 144 (91%) participants in the voucher group and 83 (52%) participants in the control group (odds ratio [OR] 9.42; CI 4.67-13.97, P < 0.001). We also found high family planning uptake rates for both groups, with higher rates among the intervention group at 12 weeks (OR 5.66; CI 2.65-12.12, P < 0.001), 14 weeks (OR 2.51; CI 1.31-4.79, P < 0.001), 16 weeks (OR 4.02; CI 1.66-9.77, P = 0.001), and 20 weeks (OR 3.65; CI 1.40-9.47, P = 0.004) postpartum. The average time to family planning initiation was reduced to 5.9 weeks (SD = 2.4) for those in the voucher group compared to 9.3 weeks (SD = 5) in the control (P < 0.001). One pregnancy was recorded in the group receiving standard of care; none were reported in the voucher group. Method mix did not differ by group: injectables were selected by most women (N = 150, 50%), and 52% of this proportion were in the experimental arm, with <10% in each arm selecting condoms, oral contraception, or intrauterine devices (IUDs). Similar proportions of women changed contraceptive methods over the 6-month follow-up in the voucher and control groups (N = 8, 5% versus N = 5, 4%; P = 0.467). More women in the control group discontinued contraception for 1 to 2 weeks (N = 19, 13% versus N = 7, 5%; P = 0.008) or more than 4 weeks (N = 15, 10% versus N = 3, 2%; P = 0.002) compared to those given a family planning voucher. The main limitation of this study is that its findings may not be generalized to settings without improved availability of contraceptives in publicly funded facilities.

CONCLUSION

These findings indicate that a well-structured, time-bound family planning voucher program appeared to increase early postpartum contraceptive uptake and continuation in a setting in which users are faced with financial, knowledge, and structural barriers to contraceptive services. Further work should clarify the role of vouchers in empowering WLWH to avoid unintended pregnancies over time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02964169.

Prevalence and predictors of initiation of intrauterine devices and subdermal implants immediately after surgical abortion

OBJECTIVES

To estimate uptake of long-acting reversible contraception (LARC) methods immediately after surgical abortion in a system that makes these methods readily available, and to determine demographic, medical, social, and visit-specific predictors of immediate post-abortion intrauterine device (IUD) and implant initiation.

STUDY DESIGN

We performed a retrospective cohort study of LARC (levonorgestrel intrauterine system [IUS], copper IUD, and subdermal implant) initiation at the time of surgical abortion up to 21w0d gestation at Planned Parenthood League of Massachusetts from 2012 through 2017. We calculated proportions of IUD and implant initiation and used mixed effect logistic regression to estimate predictors of each outcome.

RESULTS

Among 26,858 surgical abortion patients, 25.4% received immediate post-abortion LARC: 14.2%, 4.2%, and 7.0% received a levonorgestrel IUS, copper IUD, and implant, respectively. Compared to White women, Black women had lower odds of initiating an IUD (aOR 0.81, 95% CI 0.74-0.89). Multiparous women had greater odds than nulliparous women of initiating an IUD (aOR 1.69, 95% CI 1.57-1.82) or implant (aOR 1.36, 95% 1.20-1.53). We found age was the strongest predictor of implant initiation (<18 versus≥35: aOR 3.26, 95% CI 2.26-4.71), but was not associated with IUD uptake. Gestational age was not associated with IUD or implant uptake. Implant uptake increased from 2.4% (2012) to 8.7% (2017) (aOR 3.65, 95% CI 2.36-5.65) while IUD uptake remained fairly constant.

CONCLUSION

About 25% of women chose to initiate intrauterine or implantable contraception immediately after surgical abortion when these methods are readily available. Implant uptake has increased significantly in recent years. Women who initiated IUDs and implants differed in their demographic and social profiles.

IMPLICATIONS

Women seeking surgical abortion should have same-day access to IUDs and implants. Clinicians and researchers should analyze IUD and implant initiation separately.