Safety and acceptability of post-abortal IUD insertion and the importance of counseling

Contraception following abortion and the treatment of incomplete abortion

Family planning counseling and the provision of postabortion contraception should be an integrated part of abortion and postabortion care to help women avoid another unplanned pregnancy and a repeat abortion. Postabortion contraception is significantly more effective in preventing repeat unintended pregnancy and abortion when it is provided before women leave the healthcare facility where they received abortion care, and when the chosen method is a long-acting reversible contraceptive (LARC) method. This article provides evidence supporting these two critical aspects of postabortion contraception. It suggests that gynecologists and obstetricians have an ethical obligation to do everything necessary to ensure that postabortion contraception, with a focus on LARC methods, becomes an integral part of abortion and postabortion care, in line with the recommendations of the International Federation of Gynecology and Obstetrics and of several other organizations.

Strategies for improving the acceptability and acceptance of the copper intrauterine device

BACKGROUND

Intrauterine devices (IUDs) are highly effective and are the most widely used reversible contraceptive method in the world. However, in developed countries IUDs are among the least common methods of contraception used. We evaluated the effect of interventions to increase uptake of the copper IUD, a long-acting, reversible contraceptive method.

OBJECTIVES

To determine effectiveness of interventions to improve uptake and continuation of the copper IUD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, PsycINFO, PubMed, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP) and OpenSIGLE. We also handsearched references of relevant reviews and included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled before and after studies of interventions which measured use and uptake of contraception including copper IUD as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search results for relevant studies and extracted data from included studies. We used RevMan 5.1 to calculate Peto odd ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes. We conducted meta-analysis by pooling data for similar types of intervention where possible. We used the GRADE system to evaluate the quality of evidence.

MAIN RESULTS

Nine studies representing 7960 women met our inclusion criteria, including seven randomised controlled trials and two controlled before and after studies that reported IUD uptake postintervention. We evaluated the quality of evidence as moderate to low. Three studies on contraceptive counselling and referrals by community workers showed an increase in uptake of the IUD among intervention groups (Peto OR 2.00; 95% CI 1.40 to 2.85). Two studies on antenatal contraceptive counselling also favoured the intervention groups (Peto OR 2.33; 95% CI 1.39 to 3.91). One study on postnatal couple contraceptive counselling also showed an increase in IUD uptake compared to control (Peto OR 5.73; 95% CI 3.59 to 9.15). The results of one study evaluating postnatal home visits and two studies on enhanced postabortion contraceptive counselling did not reach statistical significance.

AUTHORS' CONCLUSIONS

Community-based interventions and antenatal contraceptive counselling improved uptake of copper IUD contraception. Since the copper IUD is one of the most effective reversible contraceptive methods, primary care and family planning and practitioners could consider adopting these interventions. Although our review suggests these interventions are clinically effective, a cost-benefit analysis may be required to evaluate applicability.

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.).

Post abortion family planning counseling as a tool to increase contraception use

BACKGROUND

To describe the impact of the post-abortion family planning counseling in bringing about the contraceptive usage in women who had induced abortion in a family planning clinic.

METHOD

The Diyarbakir Office of Turkish Family Planning Association (DTFPA) is a nonprofit and nongovernmental organization which runs a family planning clinic to serve the lower socio-economic populations, in Diyarbakir-Turkey. Post abortion counseling is introduced by using proper communication skills and with using appropriate methods to women. In this study we introduced contraceptive usage of women who had induced abortion one year ago and followed by DTFPA's clinic.

RESULTS

55.3% of our clients were not using contraceptive methods before abortion. At the end of the one year, 75.9% of our followed-up clients revealed that they were using one of the modern contraceptive methods. There was no woman with IUD before induced abortion. At the end of one year 124 (52.3%) women had IUD. "A modern method was introduced immediately after abortion" was the most important factor increasing modern method usage.

CONCLUSION

Our results advocate that post-abortion counseling may be an effective tool to increase the usage of contraceptives. Improved and more qualified post-abortion family planning counseling should be an integral part of abortion services.

Review of the safety, efficacy and patient acceptability of the levonorgestrel-releasing intrauterine system

The levonorgestrel-containing intrauterine system is an extremely effective, reversible and safe form of long-term yet reversible birth control. In view of its efficacy, it is a safer alternative to permanent contraceptive methods such as sterilization. It is especially useful in situations where use of estrogen-containing contraceptives is contraindicated. While menstrual disturbances are a common side effect, proper counseling improves compliance. In addition to its contraceptive effect, the levonorgestrel intrauterine system offers potential therapeutic benefits in other clinical contexts, including menorrhagia, symptomatic fibroids, endometriosis, and endometrial protection.

Contraceptive Effectiveness of Immediate Compared With Delayed Insertion of Intrauterine Devices After Abortion

OBJECTIVE

To model rates of pregnancy and repeat abortion among women choosing intrauterine contraception after an abortion when the intrauterine device (IUD) is inserted immediately after the procedure or at a follow-up visit.

METHODS

We created an evidence-based decision model of women desiring to avoid pregnancy for the 12 months after an abortion. Base case assumptions were pregnancy rates of 0.5% with an IUD and 20% without an IUD, 1-year IUD continuation rate of 80%, an additional 5% risk of IUD expulsion with immediate insertion, and a 35% risk of not returning for a follow-up visit for IUD insertion. Sensitivity analyses and Monte Carlo simulation were performed.

RESULTS

Immediate IUD insertion after abortion prevented 52 pregnancies over the following year for every 1,000 women modeled by using base case assumptions. Sensitivity analyses show the model to be most dependent on the rate of expulsion in the immediate-insertion group and the proportion not returning in the delayed-insertion group. Monte Carlo analysis showed that immediate insertion resulted in fewer pregnancies than delayed insertion in 91% of scenarios, with an absolute mean difference of 28 pregnancies per 1,000 women in the initial year after abortion. If 20% of U.S. women undergoing abortion opted for immediate insertion, an estimated 20,000 repeat abortions would be prevented in the first year.

CONCLUSION

Women who have an IUD inserted immediately after an abortion are expected to have fewer pregnancies and repeat abortions than women scheduled for insertion of an IUD at a follow-up visit.

The effect of patient-centered contraceptive counseling in women who undergo a voluntary termination of pregnancy

OBJECTIVE

The aim of the study was to evaluate, by means of a randomized controlled trial, whether a patient-centered contraceptive counseling intervention increased the use of contraception, and the knowledge and positive attitudes towards contraception, in women who undergo a termination of pregnancy (TOP).

METHODS

The study was carried out at the San Paolo Hospital of Milan between the 1st of February and the 31st of May 2004. Participants (41 women; ages 20-44 years) were randomly divided into two groups: an experimental group (n = 20), who received patient-centered contraceptive counseling, and a control group (n = 21), who received the routine treatment in use at the San Paolo Hospital and were referred to the community health centers after the TOP. Both groups were administered a questionnaire at two points in time (before the counseling and 1 month later) which evaluated participants' knowledge, attitudes and use of contraception (the latter was also followed up 3 months later). The counseling intervention lasted 30 min and was carried out by a psychologist and a gynaecologist.

RESULTS

It was found that knowledge, favorable attitudes and use of effective contraception increased significantly for the experimental group, whereas there was no significant change for the control group.

CONCLUSION

The counseling intervention was therefore found to be efficacious in improving understanding and use of contraception in women who have undergone a TOP. The hope is that this will contribute to increased use of effective contraception in the future.

PRACTICE IMPLICATIONS

Following the principles of patient-centered medicine, this study provides evidence for the importance of exploring woman's feelings, beliefs, wishes and expectations regarding contraception within a contraceptive counseling intervention.

Contraception after medical abortion

OBJECTIVES

This study's objectives were to examine current evidence on contraception after abortion and to formulate guidelines for the use of different contraceptives after medical abortion based on current evidence.

METHODS

This study was based on review of published literature and guidelines on postabortion use of contraception.

RESULTS

Contraception needs to be initiated early following a first-trimester abortion. Postabortion family planning is an integral part of comprehensive abortion care. Concurrent contraception with surgical abortion has been found to be practical and effective, with high contraception usage following abortion. Most methods can be safely used following medical abortion and can be initiated either on the day of misoprostol administration (oral pills, condoms and injectable contraceptives) or after the next menstrual cycle (intrauterine device and sterilization).

CONCLUSION

With proper precautions, almost all contraceptive methods can be effectively used following medical abortion.