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

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

Menstrual Pattern and Characteristics of One-Rod and Two-Rod Levonorgestrel Implant Users

Introduction

The maternal mortality ratio (MMR) in Indonesia reaches 359 per 100,000 live births. The long-acting reversible contraceptive (LARC) method is an effective contraceptive choice for reducing MMR. The contraceptive implant is one of the LARCs that has low usage due to lack of education about the side effects. This study aims to compare the menstrual pattern and characteristics between one-rod and two-rod levonorgestrel implant users.

Methods

A prospective cohort study was performed in patients at Cipto Mangunkusumo Hospital (RSCM) from March 2016 to May 2018. Subject recruitment was done by consecutive sampling. This study was conducted from March 2016 until May 2019. Statistical analysis was performed on the data using the chi-square test to determine the relationship between menstrual pattern and characteristics, and the use of one-rod or two-rod levonorgestrel implants.

Results

A total of 140 subjects participated in the study, comprising 70 (50%) one-rod users and 70 (50%) two-rod users. In the first month, 32.9% one-rod users experienced amenorrhea, 22.9% experienced shortened menstrual period, 30% experienced normal menstrual period, and 14,2 % experienced lengthened menstrual period. In comparison, in the first month, 41.4% two-rod users experienced amenorrhea, 15.7% experienced shortened menstrual period, 32.9% experienced normal menstrual period, and 10% experienced lengthened menstrual period. There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users.

Conclusion

There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users. Implications. Menstrual patterns and characteristics from levonorgestrel implants user can help clinicians to reduce discontinuation rate from the acceptors. Further research should be conducted to know other side effects aside from menstrual bleeding patterns.

Post-abortion contraception before hospital discharge after installation of a surveillance network in Brazil

OBJECTIVE

To evaluate the use of contraception soon after abortion, ectopic, or molar pregnancy following the establishment of a surveillance network (MUSA).

METHODS

A cross-sectional study of women admitted for abortion, or ectopic or molar pregnancy at UNICAMP Women's Hospital (part of the MUSA Network), Campinas, Brazil, between July 2017 and August 2019. Clinical and sociodemographic data were compared between women who initiated contraception before discharge and those who did not by using a Cochran-Armitage test and multiple logistic regression.

RESULTS

Overall, 382 women were enrolled (mean ± SD age, 29.6 ± 7.4 years). Most women (287, 75.2%) had abortions, and 146 (38.2%) initiated contraception before hospital discharge. The most common contraceptives were injectables (75, 51.4%) followed by pills (65, 44.5%). Use of contraception increased during the study period (Z=3.69, P<0.01), mostly due to injectables (Z=3.84, P<0.01). Factors independently associated with contraceptive initiation were admission in 2019 (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.36-5.17) and not having an abortion for legal reasons (OR, 3.54; 95% CI, 1.30-9.62).

CONCLUSION

Implementation of a surveillance network optimized the health service and quality of care. There was an increase in contraception use and a vulnerable population was identified.

Experiences of Reproductive Coercion Among Latina Women and Strategies for Minimizing Harm: "The Path Makes Us Strong"

INTRODUCTION

Latina women disproportionately report experiencing reproductive coercion (RC), a set of behaviors that interfere with autonomous reproductive decision making. Given RC's associations with intimate partner violence (IPV) and unintended pregnancy, it is critical to identify and address RC to assist women to achieve safety, autonomy, and reproductive life plans. The purpose of this study was to describe and understand the context of RC and the use of RC safety strategies among Latina women receiving services at an urban clinic, through listening to the experiences of the women in their own words.

METHODS

Qualitative descriptive methodology was used. Semistructured interviews were conducted with a purposive sample of 13 Latina women recruited from a Federally Qualified Health Center in the Washington, DC, area.

RESULTS

Data were organized into 3 a priori categories: (1) RC behaviors, (2) co-occurrence of RC and IPV, and (3) RC harm reduction strategies. New RC behaviors emerged, and immigration status was used as a method of coercive control. From these a priori categories emerged 4 themes: impact of immigrant and citizenship status, machismo, strength and bravery, and importance of family. Harm reduction strategies included less detectable contraception; some sought community services, but others resorted to deception and stalling as the only tools available to them.

DISCUSSION

Less detectable methods of contraception remained useful harm reduction strategies for women experiencing RC. Midwives should inquire about method fit and be mindful of honoring the request when patients ask to change methods. Women's strength and resilience emerged as a vital source of power and endurance. This diverse sample and the powerful voices of the women who participated make a significant contribution to the understanding of RC experienced by Latina women in the United States.

Intimate Partner Violence and Effectiveness Level of Contraceptive Selection Post-Abortion

Background: We examined whether experiencing more types of lifetime intimate partner violence (IPV) was independently associated with the effectiveness level of the contraceptive method women chose following an abortion. Materials and Methods: Using data on 245 women who were attending an urban hospital abortion clinic, we assessed whether women had ever experienced emotional, physical, or sexual IPV. Effectiveness of women's post-abortion contraceptive method selection was categorized into high (intrauterine device [IUD] and implant), moderate (pill, patch, ring, and shot), and low (condoms, emergency contraception, and none) effectiveness. Using multinomial logistic regression, we examined the relationship between number of types of IPV experienced and post-abortion contraceptive method effectiveness, adjusting for sociodemographics, prior abortion, having children, abortion trimester, importance of avoiding pregnancy in the next year, pre-abortion psychological distress, and effectiveness level of the contraceptive method women were planning to use before contraceptive counseling. Results: Twenty-seven percent (27%) of women experienced two or three types of IPV, 35% experienced one IPV type, and 38% experienced no IPV. Compared to women with no histories of IPV, women who experienced two or more types of IPV during their lifetimes were more likely to choose contraceptive methods with moderate effectiveness (adjusted odds ratio [AOR] = 5.23, 95% confidence interval [CI]: 1.13-24.23, p = 0.035) and high effectiveness (AOR = 5.01, 95% CI: 1.12-22.39, p = 0.035) than those with low effectiveness. Conclusion: Women who experienced two or more types of lifetime IPV selected more effective contraceptive methods post-abortion. Access to contraceptives that are not partner dependent, including long-acting reversible contraceptives (LARC), may be particularly important for women who have experienced multiple types of IPV.

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.

Post-abortion long-acting reversible contraception in a sample of Italian women: intrauterine device versus subdermal implant

Long-acting reversible contraceptives (LARC) represent an especially effective kind of post-abortion contraception. We aimed at assessing satisfaction, discontinuation, efficacy, and tolerability associated with either levonorgestrel intrauterine device (L-IUCD), the copper intrauterine device (C-IUCD) and implant (IMP) after termination of pregnancy (TOP). We recorded baseline data about the patients and performed phone surveys at 3, 6 and 12 months after insertion to assess the bleeding profile. Furthermore, women were inquired about possible adverse events, satisfaction, and discontinuation at 12 months after insertion. LARC continuers (>12 months after TOP) were divided into three groups: L-IUCD (n = 47), C-IUCD (n = 6) and IMP (n = 36). Satisfaction rates among L-IUCD users were higher than among IMP users (100% vs. 72.2%, p < .05). A higher, yet not significant, share of patients decided to withdraw contraception in IMP group (3.6% in IUCD group and 12.2% in IMP group). The bleeding profile was significantly more favorable among L-IUCD users than among IMP users. Finally, the reported rate of treatment-associated adverse events did not differ significantly among the groups. L-IUCD insertion after TOP is associated with higher satisfaction and lower discontinuation rates than IMP. Such pattern could be attributed to a more favorable bleeding profile.

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

OBJECTIVE

The objective was to identify predictors of postabortion long-acting reversible contraception (LARC) initiation to increase providers' understanding of motivators of contraceptive choices.

STUDY DESIGN

We prospectively enrolled a cohort of women having abortions at <13 weeks' gestational age who were eligible to receive no-cost contraceptive methods immediately postprocedure (N=1662) to evaluate the demographic and reproductive factors associated with choosing and receiving a long-acting contraceptive versus a short-acting method. We used stepwise logistic regression to identify independent predictors of LARC initiation.

RESULTS

During the study period, 1072 (64.5%) chose an immediate postabortion LARC method and 590 (35.5%) chose another method. Compared to the group of women who chose a non-LARC method, women who chose a LARC method were more likely to have a surgical abortion and were younger, more likely to be Hispanic, more likely to live greater than 70 miles from the clinic, more likely to have a nonurban address and less likely to have had a prior abortion.

CONCLUSIONS

We found that the differences in the demographic and reproductive factors of women choosing and receiving postabortion LARC were those which have been shown to be associated with difficulty in accessing contraception. Providers should offer a full range of contraceptive options to women immediately postabortion.

IMPLICATIONS

Postabortion LARC is more likely to be utilized by women from groups who have been shown to have difficulty accessing traditional family planning clinical care: those who are young, do not live in a city and are from groups with recognized health disparities. Offering postabortion LARC increases the options for these women.

Low Acceptability of Certain Contraceptive Methods among Young Women

STUDY OBJECTIVE

To examine what predicts low personal acceptability of 4 different contraceptive methods among young women.

DESIGN

Cross-sectional survey.

SETTING

Urban adolescent contraception clinic in Colorado.

PARTICIPANTS

Female clinic patients ages 13-24 initiating contraception from August 2011 to April 2012.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Survey participants reported their personal acceptability for oral contraceptive pills, depot medroxyprogesterone, contraceptive implants, and intrauterine devices on a scale from 0 (low) to 10 (high). Responses of 0-4 were categorized as low personal acceptability. Demographic characteristics, reproductive history, and perceived contraceptive satisfaction of friends and family members were incorporated into multivariable and hierarchical logistic regression models to determine distinct predictors of low personal acceptability for each method.

RESULTS

Surveys were completed by 1067 women. Participants' mean age was 20 (±2.6) years. Half (552/1067) were white, 26% (277/1067) Hispanic, and 8.5% (91/1067) black. Of participants who were aware of oral contraceptive pills 52% (535/1037) reported low acceptability of this method compared with 74% (645/876) of those aware of depot medroxyprogesterone. Fewer reported low acceptability of intrauterine devices (37% or 303/825) or implant (43% or 356/839), although fewer overall participants had heard of these methods. Each method had unique predictors of low personal acceptability, however, for all method models, significant predictors included knowing someone who had become pregnant while using that method or having a friend who dislikes that method.

CONCLUSION

Young women in this study with low personal acceptability of the 4 most common contraceptive methods had distinct demographic and reproductive health characteristics. Perceived negative experiences of friends and family members using contraception appeared most influential.

The effects of preabortion depressive symptoms on postabortion contraceptive effectiveness level chosen among women seeking abortions

OBJECTIVE

We examined whether preabortion depressive symptoms were associated with contraceptive method effectiveness level chosen among women seeking abortions.

STUDY DESIGN

Three-hundred and forty-seven young, low-income women 18 years or older who were seeking abortions at 3 community reproductive health clinics in Northern California were recruited to participate in a study on contraceptive decision making. We classified women into choosing low-, moderate- or high-effectiveness contraceptive methods based on typical-use failure rates. We used the Center for Epidemiologic Studies Depression scale to assess depressive symptoms as a continuous and dichotomous variable. Using the standard cutoff of 20, women who scored at or above this were considered depressed for the dichotomous measure. We used multinomial logistic regression to examine the association between preabortion depressive symptoms and contraceptive effectiveness level chosen to use after an abortion, adjusting for sociodemographics, abortion characteristics, pregnancy history, future pregnancy desires, relationship characteristics and adverse experiences.

RESULTS

After adjusting for covariates, we found that a one-unit increase in depressive symptoms was associated with a higher likelihood of choosing low- versus moderate- [adjusted odd ratio (aOR)=1.05, 95% confidence interval (CI): 1.01-1.10, p<.02] and high-effectiveness methods (aOR=1.05, 95% CI: 1.002-1.10, p<.05). Furthermore, women scoring above the cutoff for depression were more likely to choose low- versus moderate-effectiveness methods (aOR=4.56, 95% CI: 1.27-16.32, p=.02).

CONCLUSIONS

More preabortion depressive symptoms were independently associated with choosing low- versus moderate- and high-effectiveness contraceptives.

IMPLICATIONS

These findings together with other findings show that preabortion depressive symptoms do not uniformly influence effectiveness level of contraceptive method selected to use after an abortion. Reproductive health care providers should consider the impact of women's psychological symptoms on their contraceptive decision making.

High abortion rate in Martinique (F.W.I.) in spite of a large contraceptive availability. What are the determinants?

INTRODUCTION

Despite a similar health insurance coverage and access to contraception, Martinique F.W.I. has a higher rate of abortion than continental France (25.6 versus 15.3 per thousand respectively). The reasons are still largely unknown. A different contraceptive pattern, a lower use of emergency contraception in Martinique may be involved. We sought to explore the contraceptive pattern, to evaluate the use of emergency contraception and the reasons leading to an unwanted pregnancy among women seeking for an abortion.

MATERIAL AND METHODS

An anonymous cross-sectional survey about the contraceptive use in the year and in the month before abortion, the use of emergency contraception and the reasons why, to patients' point of view, they became pregnant albeit not willing it was proposed to women seeking for an abortion in the dedicated unit of the university hospital of Martinique.

RESULTS

Six hundred patients were included. A total of 83.7% of patients declared having a regular contraceptive use during the year preceding. Just before abortion, 61.1% of women had no contraception or a low reliable method (fertility awareness, withdrawal…). Lack of recognition of pregnancy risk was the main reason leading to abortion, accounting for 51.1% of cases, explaining a low use of emergency contraception (13.8%), whereas a difficult access to contraception was rarely quoted. Emergency contraception was used in 27.8% of relevant situations.

CONCLUSION

Insufficient estimation of pregnancy risk is the main reason leading to unwanted pregnancy. Availability of emergency contraception does not reduce the risk.

Correlates of contraceptive use 4 months postabortion: findings from a prospective study in Bangladesh

OBJECTIVES

Using the social determinants framework as a guide, this study sought to understand correlates of postabortion contraceptive use at the individual, family and abortion service delivery levels.

STUDY DESIGN

This prospective study assessed correlates of contraceptive use 4 months postabortion and timing of initiation using a facility-based sample of 398 abortion clients who selected pills, condoms, injectables or no method immediately following the procedure. We measured potential correlates immediately following abortion, inclusive of spontaneous or induced abortion, and assessed contraceptive use outcomes 4 months postabortion. Multivariable logistic regression models identified correlates at each level. Potential individual level correlates included contraceptive and abortion history and fertility intentions; family correlates included intimate partner violence (IPV), discordance in fertility intentions and household decision-making; and service delivery correlates included procedure type and postabortion contraceptive counseling.

RESULTS

Reported contraceptive use 4 months postabortion was high (85.4%). Contraceptive use at the index pregnancy (resulting in abortion) was the primary correlate of contraceptive use 4 months postabortion (adjusted odds ratio=2.9; 95% confidence interval: 1.5-5.9). Delayed contraceptive initiation was more common among women who reported past year IPV (36.8% vs. 19.5%; p=.03) particularly with spousal accompaniment for abortion, those in relationships with discordant fertility intentions (44.4% vs. 21.9%; p=.04) and those receiving medication abortion (56.7%) or dilation and curettage (57.1%), compared to manual vacuum aspiration (12.6%; p<.01).

CONCLUSIONS

Contraceptive use at the index pregnancy was the primary correlate of contraceptive use 4 months postabortion. Abortion procedure type and relationship dynamics were correlated with delayed postabortion contraceptive initiation. Women who reported IPV delayed initiation when accompanied by their spouse for abortion.

IMPLICATIONS

Postabortion contraceptive counseling should assess previous use patterns and provide information on using contraception effectively. Delayed initiation among women reporting IPV could be addressed through comprehensive, confidential counseling that includes violence screening, support for contraceptive initiation and offer of woman-controlled methods.