Society of Family Planning clinical recommendations: contraception after surgical abortion

Health services provided at the time of abortion in the US: a scoping review of the qualitative and quantitative evidence

Objectives

While it is well documented that abortion access is associated with improved health, pregnancy-related, and socioeconomic outcomes, the association between abortion access and other reproductive health outcomes is less well described. Abortion-providing clinics also offer preventative reproductive health services. We conducted a scoping review to ascertain the extent to which preventive reproductive healthcare services (contraception, sexually transmitted infection testing and treatment, cervical cancer screening) are affected by abortion access in the United States.

Methods

Researchers screened articles and extracted data from PubMed, Embase, Scopus and CINAHL. We excluded articles that did not link abortion to contraception, sexually transmitted infection testing and treatment and cervical cancer screening; or took place outside the US.

Results

5,359 papers were screened, 74 were included for full text review. Sixty-five were about contraception, seven on STIs, one on cervical cancer screening, and one on other services. The association between policies that restrict or protect abortion access and preventative health services has not been studied on a national scale. Drivers of variation were: insurance and billing policies; regulatory requirements of abortion-providing facilities, lack of staff training in clinics that did not specialize in abortion care; and limited follow up after abortion.

Conclusions

Abortion--providing clinics are a highly utilized access point for reproductive health services. More research is needed to determine the public health impact of constrained abortion access on contraceptive use, STI rates and cervical cancer in regions where many abortion-providing clinics have closed.

Implications

Attention should be paid to changing trends in contraceptive use, STI rates and cervical cancer as abortion-providing clinics close, this may reduce access to reproductive health services broadly.

Medication Abortion: A Comprehensive Review

This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.

Feasibility and acceptability of virtual group contraceptive counseling prior to abortion care

OBJECTIVES

This study aimed to evaluate the feasibility and acceptability of virtual group contraceptive counseling in the abortion care setting.

STUDY DESIGN

Patients seeking abortion care at an urban university hospital were invited to participate in this cohort study. Prior to their clinical appointments, groups of two to six patients participated in 45-minute virtual contraceptive counseling visits facilitated by study staff. Contraceptive method use, effectiveness, and side effects were reviewed according to group interest. Participant satisfaction scores were collected immediately following the sessions. After their appointments, providers estimated the time spent on contraceptive counseling during the clinical visit.

RESULTS

Of 195 patients approached, 86 (44%) were enrolled. Fifty-seven (66%) enrolled patients completed a session. The most common reason for declining enrollment was concern about the time commitment. Most (93%) participants reported being "satisfied" or "very satisfied" overall, and 96% would recommend group contraceptive counseling to a friend. Providers reported that compared to typical counseling, participants required a shorter amount of time during the clinical visit than nonparticipants (time spent <5 minutes: 74% vs 54%).

CONCLUSIONS

Virtual group contraceptive counseling for patients seeking abortion was feasible and acceptable in this study. Group virtual visits may reduce provider time burden, add value when virtual care delivery is desired or required, and deserve further study.

IMPLICATIONS

Family planning clinics can consider incorporating virtual group counseling as a person-centered and efficient approach to contraceptive counseling at the time of abortion care.

Knowledge, Attitude, and Practice of Brazilian Physicians about Immediate Postpartum and Postabortion Intrauterine Device Insertion

OBJECTIVE

 To assess the knowledge, attitude, and practice of Brazilian physicians about immediate postpartum and postabortion intrauterine device insertion.

METHODS

 Cross-sectional online survey involving physicians on duty in public Brazilian hospitals. Participants answered an anonymous questionnaire with close-ended questions to assess their knowledge, attitude, and experience on the immediate postpartum and postabortion insertion of copper intrauterine devices.

RESULTS

 One hundred twenty-seven physicians working in 23 hospitals in the 5 geographic regions of Brazil completed the questionnaire. Most were female (68.5%) and worked in teaching hospitals (95.3%). The mean (standard deviation) knowledge score (0-10 scale) was 5.3 (1.3); only 27.6% of the participants had overall scores ≥ 7.0. Most physicians (73.2%) would insert a postpartum intrauterine device in themselves/family members. About 42% of respondents stated that they had not received any training on postpartum or postabortion intrauterine device insertion. In the past 12 months, 19.7%, 22.8%, and 53.5% of respondents stated they had not inserted any intrauterine device during a cesarean section, immediately after a vaginal delivery, or after an abortion, respectively.

CONCLUSION

 Most study participants have a positive attitude toward the insertion of intrauterine devices in the immediate postpartum period, but they have limited knowledge about the use of this contraceptive method. A large percentage of respondents did not have previous training on postpartum and postabortion intrauterine device insertion and had not performed any such insertions in the last 12 months. Strategies are needed to improve the knowledge, training, and experience of Brazilian physicians on immediate postpartum and postabortion intrauterine device insertion.

Post-abortion contraception, an opportunity for male partners and male contraception

OBJECTIVES

Men who accompany their female partners at the time of an abortion represent a unique population who may be amenable to receiving postabortion contraceptive services. We sought to examine their interest in receiving both counseling and contraception when available.

STUDY DESIGN

We analyzed a subset of survey data on the experience of accompanying male partners at the time of an abortion at two urban family planning clinics. We examined their beliefs about shared contraceptive responsibility, attitudes towards participating in contraceptive counseling, and willingness to use novel male contraceptives. We conducted bivariate analyses and logistic regressions for sociodemographic and reproductive factors linked to these outcomes.

RESULTS

Of 210 male partners surveyed at the time of an abortion, nearly three-quarters characterized preventing unwanted pregnancy as a shared responsibility, believed in the importance of attending contraceptive counseling with their female partner, and reported willingness to use novel male contraceptives. Contraceptive method used when discovering the pregnancy was neither linked to men's attitudes towards counseling nor interest in using novel male contraceptives. Individuals between the ages of 25 to 34 (aOR: 2.69; 95%CI: 1.32-5.48), those with a college education (aOR: 5.49; 95%CI: 1.31-22.94), and those who had never experienced abortion (aOR: 2.21; 95%CI: 1.08-4.55) exhibited greater interest in using novel male contraceptives. Black respondents (aOR: 2.33; 95%CI: 1.01-5.38) exhibited greater interest in receiving contraceptive counseling with their partner and a counselor following the abortion.

CONCLUSION

For male partners, abortion may be an opportunity to engage men in contraceptive counseling and when available, offer new male contraceptives.

IMPLICATIONS

As few men receive comprehensive contraceptive counseling, engaging men when they accompany their female partners to family planning clinics may be an additional strategy to prevent unwanted pregnancy.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

First Trimester Miscarriage

First trimester miscarriage, or early pregnancy loss, is a common occurrence in the United States. Miscarriage management includes expectant, medical, or surgical approaches. Decisions about management options should be approached through shared decision making between the patient and provider and with consideration of patient's preferences, hemodynamic stability, cost, gestational age, and effectiveness. Emergencies requiring immediate interventions are rare. Newer developments in management, including a more effective medical regimen with the addition of mifepristone and cost-effective and convenient in-office surgical interventions, have expanded treatment options.

Contraceptive Technology: Present and Future

Many sexually active, reproductive-aged persons capable of becoming pregnant use some method of contraception. To expand options for those desiring birth control, new choices include a vaginal ring, transdermal patch, progestin-only pill, and spermicide. Compared with currently available methods, additional technologies that are highly effective, easy to use, cost efficient, and well-tolerated lay on the horizon. During contraceptive counseling, patient choice, and reproductive autonomy should remain paramount.

Committee Opinion No. 419: Coercion Free Contraceptive Care

OBJECTIVE

To provide guidance on culturally competent contraception counselling that is free of coercion and promotes shared decision-making and patient autonomy.

TARGET POPULATION

Individuals of reproductive age who seek contraception or counselling for family planning.

OPTIONS

Contraception counselling is provided within a rights-based family planning framework, where the individual's beliefs, culture, preferences, and ability to use the chosen method are respected.

OUTCOMES

To promote patient autonomy in decision-making surrounding family planning, including the right to access and use their contraceptive method of choice, to decline contraception or use less effective methods of contraception, and to freely choose to discontinue a method of contraception, as well as the right to unbiased, non-coercive contraception counselling and evidence-based information from their health care provider BENEFITS, HARMS, AND COSTS: Implementation of these recommendations would reduce real or perceived coercive contraceptive care, particularly among vulnerable populations, resulting in improved patient autonomy and a better patient experience in health care settings.

EVIDENCE

Databases searched: MEDLINE, Cochrane, PubMed, and CanLII. Medical terms used: contraception, family planning services, informed consent, coercion, decision making, sterilization, permanent contraception, counselling. Legal terms searched: forced sterilization, and aboriginal. Initial search conducted in 2020 and updated in 2021.

INTENDED AUDIENCE

This committee opinion is intended for health care providers (obstetricians, gynaecologists, family physicians, general surgeons, nurse practitioners, nurses, midwives, undergraduate/postgraduate medical trainees, and other health care providers) who provide sexual and reproductive health services.

Exploring the physician's role in contraceptive counseling at the time of abortion in the US

OBJECTIVE

We explored how physicians conceptualize their role in contraceptive counseling at the time of abortion, including identifying clinician attitudes that may lead to patients' perceptions of contraceptive coercion.

STUDY DESIGN

We conducted individual semi-structured interviews using questions based on components of the Theory of Planned Behavior. We recruited physician abortion providers using purposeful sampling to attain diversity in practice setting and geographic practice region. We analyzed transcribed interviews using initial and values coding methods.

RESULTS

We interviewed 39 participants across the United States, who primarily self-reported as White female obstetrician gynecologists (OB/GYNs) aged 25 to 44. Over half of participants practiced in an academic setting. Participants perceived providing patient education and taking a patient-centered approach as part of their role in contraceptive counseling. Participants also believed it was their responsibility to prevent unintended pregnancies and subsequent abortions among their patients. External motivations behind this belief included wanting patients to avoid the challenges of obtaining another abortion, particularly in states with multiple abortion restrictions. Internal motivations included valuing professional goal attainment, discomfort with abortion, and abortion stigma. When physicians counseled about contraception, many expressed preferences toward methods of long-acting reversible contraception (LARC) and an emphasis on contraception provision for adolescents and women with prior abortions.

CONCLUSIONS

Physicians providing abortions strive to use a patient-centered approach to contraceptive counseling. However, many continue to be motivated by the goal of avoiding a subsequent abortion which patients may perceive as coercion towards contraceptive uptake.

IMPLICATIONS

Considering contraceptive counseling as a means to prevent subsequent abortion may lead to coercive practices, especially with specific patient populations. Moral codes and abortion stigma influence physicians' counseling practices and physicians must examine their personal values and motivations behind recommending contraception after an abortion.

Tandem mass tag-based quantitative proteomic profiling of the serum of patients with abnormal uterine bleeding associated with copper intrauterine device

OBJECTIVE

To investigate changes in the level of protein in serum and uncover the underlying pathogenesis of abnormal uterine bleeding (AUB) associated with copper intrauterine devices (Cu IUD).

METHODS

Protein profiles were investigated via tandem mass tag (TMT)-based quantitative proteomics and bioinformatics technology. Quantification and characterization of candidate proteins were further performed in 33 controls and 45 cases by Luminex assay and enzyme-linked immunosorbent assay.

RESULTS

In total, 842 proteins were identified via TMT coupled with liquid chromatography-tandem mass spectrometry (LC-MS/MS) in the serum of individuals with IUDs. Among them, 25 differentially expressed proteins (p < 0.05) were observed, including eight upregulated proteins and 17 downregulated proteins. Ten proteins were verified, and Alpha-1-Antitrypsin (a1AT) had a significantly elevated expression in women with AUB associated with the Cu IUD compared with healthy controls (p = 0.026) and a high area under the curve value (0.656), as well as sensitivity (64.9%) and specificity (71.9%).

CONCLUSION

This is the first study to explore changes in serum protein and the underlying mechanisms of AUB associated with the Cu IUD via TMT technology. a1AT with biomarker potential was validated. These findings might provide an experimental basis for the early diagnosis or treatment of AUB associated with the Cu IUD.

Clinical Evaluation of Li Brush Endometrial Samplers for Diagnosing Endometrial Lesions in Women With Intrauterine Devices

Background: For women with intrauterine devices (IUDs), it is difficult to sample the endometrium when abnormal uterine bleeding occurs or when regular screening of endometrial cancer is proposed. The purpose of this study is to evaluate the validity of endometrial sampling using Li Brush in IUD users.

Methods: This study was a prospective cohort study and conducted in two parts. Part I was to assess the impact of Li Brush on the position of IUDs. Transvaginal ultrasound was used to locate IUDs before and after sampling. Part II was to explore the diagnostic accuracy of Li Brush in detecting endometrial lesions. IUD users with irregular uterine bleeding were recruited in the IUD group and IUD non-users who arranged for dilatation and curettage (D&C) were recruited in the control group. The endometrium was sampled by Li Brush for cells and by D&C for tissues in both groups. The satisfactoriness of sampling and validity of Li Brush were evaluated.

Results: Seventeen cases in part I confirmed no significant difference in the position of IUDs before and after sampling (p = 0.20). 112 IUD users and 139 IUD non-users were recruited in part II. Li Brush achieved 94.64 and 92.09% satisfactory sampling rates in the IUD group and control group, respectively, without statistically significant difference between the two groups (p = 0.42). The Sensitivity and specificity of Li Brush for detection of endometrial lesions in IUD group were 95.35 and 87.76% respectively.

Conclusions: Li Brush used for endometrial biopsy did not affect the position of IUDs and had high yield of satisfactory samples and good validity for endometrial diagnoses. It was feasible to screen endometrial lesions by Li Brush for women with IUDs.

Association between the use of free-of-charge intrauterine devices and a history of induced abortion: a retrospective study

Background

To determine whether use of intrauterine device (IUD) is influenced by a history of induced abortion and the type of contraceptives used until costs are covered.

Methods

We analyzed data from 301 female residents in Mecklenburg-West Pomerania, an economically challenged community. The women, aged between 20 and 35 years, were entitled to receive unemployment benefits, and had access to free-of-charge oral contraceptives, ring or IUD. Cross-sectional data were analyzed using logistic regression.

Results

There were 112 (37.2%) women with a history of induced abortion, and 46 (15.3%) reported exclusively using less effective contraceptives (e.g. condoms). In a univariate logistic regression, use of an IUD was associated with a history of having had an induced abortion. Furthermore, uptake of an IUD was associated with women who had, until costs were covered, exclusively choice to use less effective contraceptives (OR = 3.281, 95% CI: 1.717; 6.273). Both associations remained significant in a multivariate model.

Conclusions

Free contraceptives provided to women receiving unemployment benefits may increase the use of IUDs, especially among those with a history of an induced abortion and those using less effective contraceptives.

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.