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Carroll AL, Strauss AM, Philipps NM, Kaczmarczik KD, Shakur Z, Ramirez G, Klc TR, Tessier KM, Boraas CM. Efficacy of medication abortion with concurrent initiation of progestin contraceptives: A retrospective cohort study. Contraception 2024:110536. [PMID: 38986862 DOI: 10.1016/j.contraception.2024.110536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
OBJECTIVES To evaluate medication abortion (MAB) outcomes for participants receiving intramuscular depot medroxyprogesterone acetate (DMPA) injections or subdermal etonogestrel implants concurrently with mifepristone compared to those who did not in a real-world setting. STUDY DESIGN This retrospective cohort study included MAB patients from one Planned Parenthood health center in St. Paul, MN, between 2017 and 2019. We abstracted electronic health records and compared sociodemographic variables, clinical information, and treatment failure rates (primary outcome) between study groups with logistic regression (generating odds ratios [OR] and 95% confidence intervals [CI]). RESULTS Among 7296 MAB participants, 224 (3.1%) received DMPA injections and 309 (4.2%) received etonogestrel implants concurrently with mifepristone; 141 (62.9%) and 200 (64.7%) completed follow-up respectively. From a random sample of 1000, 990 comparison participants met inclusion criteria; 704 (71.1%) completed follow-up. Fourteen (9.9%) DMPA participants (aOR 4.26, 95% CI 1.87-9.68, p < 0.001) and 6 (3.0%) etonogestrel implant participants (aOR 1.38, 95% CI 0.48-3.55, p = 0.522) required additional treatment to empty the uterus and/or had an ongoing pregnancy, each contrasted with 15 (2.1%) comparison patients (models adjusted for gestational duration, patient age, parity, and race). CONCLUSION Although our study is limited by high rates of loss to follow-up, our analysis suggests that concurrent administration of DMPA with mifepristone may decrease MAB efficacy, while etonogestrel implant placement does not appear to alter MAB outcomes. These findings are overall consistent with prior literature and inform post-MAB contraception counseling. IMPLICATIONS This retrospective cohort study reinforces prior randomized controlled trial findings that concurrent depot medroxyprogesterone acetate injection with mifepristone administration may decrease medication abortion efficacy. Conversely, concurrent etonogestrel contraceptive implant placement with mifepristone administration does not appear to decrease medication abortion efficacy. These findings inform post-abortion contraception counseling.
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Affiliation(s)
- Anna L Carroll
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, United States.
| | - Anna M Strauss
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Nicole M Philipps
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | | | - Zahrah Shakur
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Gerardo Ramirez
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Tenley R Klc
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, United States
| | - Katelyn M Tessier
- Masonic Cancer Center, Biostatistics Core, University of Minnesota, Minneapolis, MN, United States
| | - Christy M Boraas
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, United States; Research Division, Planned Parenthood North Central States, St. Paul, MN, United States
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2
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Cooper M, Cameron S. Contraception after abortion, miscarriage, ectopic and molar pregnancy. Best Pract Res Clin Obstet Gynaecol 2024; 92:102428. [PMID: 38142524 DOI: 10.1016/j.bpobgyn.2023.102428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/13/2023] [Indexed: 12/26/2023]
Abstract
Regardless of whether a pregnancy ends in abortion, miscarriage or ectopic pregnancy, fertility and sexual activity can resume quickly. For those who do not plan to become pregnant again immediately, effective contraception is therefore required. Although a contraceptive discussion and the offer to provide contraception is considered an integral part of abortion care, health care providers may not always offer this same standard of care to those whose pregnancy ends in miscarriage or ectopic due to sensitivities or assumptions around this and future fertility intentions. Yet, evidence-based recommendations support the safety of initiating contraception at these times. Provision of a chosen method of contraception may be convenient for women and valued by them. As part of holistic care, healthcare professionals who care for women around these reproductive events should therefore offer quality information on contraception and help them access their chosen method to better meet their ongoing reproductive health needs.
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Affiliation(s)
- Michelle Cooper
- Chalmers Sexual & Reproductive Health Centre, 2A Chalmers Street, Edinburgh, EH3 9ES, UK.
| | - Sharon Cameron
- Chalmers Sexual & Reproductive Health Centre, 2A Chalmers Street, Edinburgh, EH3 9ES, UK.
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3
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Stifani BM, Lavelanet AF. Reversal of medication abortion with progesterone: a systematic review. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:43-52. [PMID: 37863512 PMCID: PMC10850668 DOI: 10.1136/bmjsrh-2023-201875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/15/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND We sought to determine whether there is evidence to recommend progesterone for individuals not wishing to complete a medication abortion after taking mifepristone. METHODS We undertook an updated systematic review including a primary search for studies in which individuals received progesterone to reverse the effects of mifepristone, and a secondary search for studies in which individuals received mifepristone alone. We searched PubMed, Embase, Cochrane, CINAHL and grey literature up to December 2022. We used the Joanna Briggs Institute critical appraisal tools for risk of bias assessment. We compared ongoing pregnancy rates among individuals treated with progesterone to those managed expectantly. RESULTS We did not find new studies in our secondary search. For the main search, we included three case series and one randomised controlled trial. Data were available for 561 individuals who received progesterone after mifepristone, of whom 271 (48%) had ongoing pregnancies. The quality of the evidence in the case series was low due to methodological and ethical issues. Enrollment in the randomised trial stopped early due to bleeding events in both arms. The ongoing pregnancy rate for individuals ≤7 weeks who received progesterone was 42% (95% CI 37-48) compared with 22% (95% CI 11-39) for mifepristone alone. At 7-8 weeks, the ongoing pregnancy rate was 62% (95% CI 52-71) in the progesterone group and 50% (95% CI 15- 85) in the mifepristone alone group. CONCLUSION Based mostly on poor-quality data, it appears the ongoing pregnancy rate in individuals treated with progesterone after mifepristone is not significantly higher compared to that of individuals receiving mifepristone alone.
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Affiliation(s)
- Bianca Maria Stifani
- Department of Obstetrics & Gynecology, Westchester Medical Center / New York Medical College, Valhalla, New York, USA
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4
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Pearlman Shapiro M, Stowers P, Raidoo S. Contraception After Abortion. Clin Obstet Gynecol 2023; 66:749-758. [PMID: 37750667 DOI: 10.1097/grf.0000000000000809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
After a spontaneous or induced abortion, people may desire to delay or prevent a future pregnancy and many desire to use contraceptive methods to do so. Contraception counseling and provision at the time of abortion care are important components to improve contraceptive access and convenience for people undergoing abortion care. The majority of hormonal and barrier contraceptive methods may be safely initiated at the time of medication or procedural abortion or shortly thereafter, although delayed initiation may be necessary in certain circumstances. A patient-centered approach to contraceptive counseling can identify patients' priorities and mitigate provider coercion or pressure.
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Affiliation(s)
- Marit Pearlman Shapiro
- Department of Obstetrics and Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Paris Stowers
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii
| | - Shandhini Raidoo
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii
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Mazza D, Assifi AR, Hussainy SY, Bateson D, Johnston S, Tomnay J, Kasza J, Church J, Grzeskowiak LE, Nissen L, Cameron ST. Expanding community pharmacists' scope of practice in relation to contraceptive counselling and referral: a protocol for a pragmatic, stepped-wedge, cluster randomised trial (ALLIANCE). BMJ Open 2023; 13:e073154. [PMID: 37652588 PMCID: PMC10476139 DOI: 10.1136/bmjopen-2023-073154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Improving access to effective contraception has the potential to reduce unintended pregnancy and abortion rates. Community pharmacists could play an expanded role in contraceptive counselling and referral to contraceptive prescribers particularly when women are already attending community pharmacy to obtain emergency contraceptive pills (ECPs) or to have medical abortion (MA) medicines dispensed. The ALLIANCE trial aims to compare the subsequent uptake of effective contraception (hormonal or intrauterine) in women seeking ECP or MA medicines, who receive the ALLIANCE community pharmacy-based intervention with those who do not receive the intervention. METHODS AND ANALYSIS ALLIANCE is a stepped-wedge pragmatic cluster randomised trial in Australian community pharmacies. The ALLIANCE intervention involves community pharmacists delivering structured, patient-centred, effectiveness-based contraceptive counselling (and a referral to a contraceptive prescriber where appropriate) to women seeking either ECPs or to have MA medicines dispensed. Women participants will be recruited by participating pharmacists. A total of 37 pharmacies and 1554 participants will be recruited. Pharmacies commence in the control phase and are randomised to transition to the intervention phase at different time points (steps). The primary outcome is the self-reported use of effective contraception at 4 months; secondary outcomes include use of effective contraception and the rate of pregnancies or induced abortions at 12 months. A process and economic evaluation of the trial will also be undertaken. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Monash University Human Research Ethics Committee (#34563). An explanatory statement will be provided and written consent will be obtained from all participants (pharmacy owner, pharmacist and women) before their commencement in the trial. Dissemination will occur through a knowledge exchange workshop, peer-reviewed journal publications, presentations, social media and conferences. TRIAL REGISTRATION NUMBER ACTRN12622001024730.
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Affiliation(s)
- Danielle Mazza
- SPHERE NHMRC Centre of Research Excellence, Department General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anisa Rojanapenkul Assifi
- SPHERE NHMRC Centre of Research Excellence, Department General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Safeera Yasmeen Hussainy
- SPHERE NHMRC Centre of Research Excellence, Department General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah Bateson
- The Daffodil Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Jane Tomnay
- Centre for Excellence in Rural Sexual Health, University of Melbourne, Shepparton, Victoria, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jody Church
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Luke E Grzeskowiak
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute Limited, Adelaide, South Australia, Australia
| | - Lisa Nissen
- Centre for the Business & Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Sharon Tracey Cameron
- Obstetrics and Gynaecology, University of Edinburgh, Edinburgh, UK
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
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Dixon A, Reynolds-Wright JJ, Cameron ST. Uptake of long-acting reversible contraception after telemedicine delivered abortion during Covid-19. EUR J CONTRACEP REPR 2022; 27:284-288. [PMID: 35713651 DOI: 10.1080/13625187.2022.2085680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND During COVID-19, early medical abortion (EMA) at home in Scotland was largely delivered by telemedicine. Short-acting post-abortion contraception was provided with EMA medications, but long-acting reversible contraception (LARC) (implant, injectable and intrauterine device) required an in-person visit. We wished to assess LARC uptake following telemedicine abortion, and factors associated with method receipt. METHODS A prospective observational cohort study of patients accessing abortion via NHS Lothian (October 2020 to February 2021). Patients were offered contraception at telemedicine consultation and their choice was recorded in their clinical notes. Those wishing LARC were directed to the service's rapid-access LARC clinic. We reviewed electronic patient records six weeks post-abortion to determine whether patients received their chosen method. RESULTS 944 patients had an abortion; 768 (81.4%) had EMA, 131 (13.9%) had a medical or surgical abortion in hospital. The most popular contraceptive method was the progestogen-only pill (n = 324, 34%). 330 patients (35%) requested LARC but less than half (153/330; 46%) received this. Of patients choosing LARC, those who attended the clinic for a pre-abortion ultrasound, or had an abortion in hospital, were more likely to initiate LARC than those having full telemedicine EMA. Nulliparity, gestation over 7 weeks, and age under-26 years were also positively associated with initiating LARC. CONCLUSION During COVID-19 there was demand for post-abortion LARC but less than half of patients received this by six weeks. Provision was enhanced when in-person clinical interactions took place. Interventions are required to facilitate timely access and initiation of LARC with telemedicine delivered abortion care.
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Affiliation(s)
- Angharad Dixon
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - John J Reynolds-Wright
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Chalmers Centre, NHS Lothian, Edinburgh, UK
| | - Sharon T Cameron
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Chalmers Centre, NHS Lothian, Edinburgh, UK
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Sothornwit J, Eamudomkarn N, Lumbiganon P, Jampathong N, Festin MR, Salang L. Immediate versus delayed postabortal insertion of contraceptive implant. Cochrane Database Syst Rev 2022; 5:CD013565. [PMID: 35583092 PMCID: PMC9115762 DOI: 10.1002/14651858.cd013565.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Contraceptive implants are one of the most effective contraceptive methods, providing a long duration of pregnancy protection and a high safety profile. Hence this method is suitable for optimizing the interpregnancy interval, especially for women undergoing abortion. Women who have had abortions are at high risk of rapid repeat pregnancies. Provision of effective contraception at the time of an abortion visit can be a key strategy to increase access and uptake of contraception. A review of the evidence was needed to evaluate progestin-releasing implants for immediate use at the time of abortion, including whether immediate placement impacts the effectiveness of medical abortion, which relies on antiprogestogens. OBJECTIVES To compare contraceptive implant initiation rates, contraceptive effectiveness, and adverse outcomes associated with immediate versus delayed insertion of contraceptive implants following abortion. SEARCH METHODS We searched for all relevant studies regardless of language or publication status up to September 2019, with an update search in March 2021. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Ovid EBM Reviews), MEDLINE ALL (Ovid), Embase.com, CINAHL (EBSCOhost) (Cumulative Index to Nursing and Allied Health Literature), Global Health (Ovid), LILACS (Latin American and Caribbean Health Science Information database), Scopus, ClinicalTrials.gov, and the WHO ICTRP. We examined the reference lists of pertinent articles to identify other studies. SELECTION CRITERIA We sought randomized controlled trials (RCTs) comparing immediate versus delayed insertion of contraceptive implant for contraception following abortion. DATA COLLECTION AND ANALYSIS We followed the standard procedures recommended by Cochrane. To identify potentially relevant studies, two review authors (JS, LS) independently screened the titles, abstracts, and full texts of the search results, assessed trials for risk of bias, and extracted data. We computed the risk ratio (RR) with 95% confidence intervals (CIs) for binary outcomes, and the mean difference (MD) with 95% CIs for continuous variables. MAIN RESULTS We found three RCTs including a total of 1162 women. Our GRADE assessment of the overall certainty of the evidence ranged from moderate to very low, downgraded for risk of bias, inconsistency, and imprecision. Utilization rate at six months may be slightly higher for immediate compared with delayed insertion (RR 1.10, 95% CI 1.05 to 1.15; 3 RCTs; 1103 women; I2 = 62%; low certainty evidence). Unintended pregnancy within six months after abortion was probably lower with immediate insertion compared with delayed insertion (RR 0.25, 95% CI 0.08 to 0.77; 3 RCTs; 1029 women; I2 = 0%; moderate certainty evidence). Immediate insertion of contraceptive implants probably improves the initiation rate compared to delayed insertion following medical abortion (RR 1.26 for medical abortion, 95% CI 1.21 to 1.32; 2 RCTs; 1014 women; I2 = 89%; moderate certainty evidence) and may also improve initiation following surgical abortion (RR 2.32 for surgical abortion, 95% CI 1.79 to 3.01; 1 RCT; 148 women; I2 = not applicable; low certainty evidence). We did not pool results for the implant initiation outcome over both abortion types because of very high statistical heterogeneity. For medical termination of pregnancy, we found there is probably little or no difference between immediate and delayed insertion in overall failure of medical abortion (RR 1.18, 95% CI 0.58 to 2.40; 2 RCTs; 1001 women; I2 = 68%;moderate certainty evidence). There may be no difference between immediate and delayed insertion on rates of abnormal bleeding at one month after abortion (RR 1.00, 95% CI 0.88 to 1.14; 1 RCT; 462 women; I2 = not applicable; low certainty evidence). AUTHORS' CONCLUSIONS Provision of progestin-releasing implants concurrently with abortifacient agents likely has little or no negative impact on overall failure rate of medical abortion. Immediate insertion probably improves the initiation rate of contraceptive implant, as well as unintended pregnancy rate within six months after abortion, compared to delayed insertion. There may be no difference between immediate and delayed insertion approaches in bleeding adverse effects at one month after abortion.
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Affiliation(s)
- Jen Sothornwit
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nuntasiri Eamudomkarn
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | | | - Lingling Salang
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Constant D, Endler M, Grossman D, Petro G, Patel M. Immediate versus delayed insertion of the copper intrauterine device after medical abortion at 17-20 gestational weeks: a randomised controlled trial. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:28-34. [PMID: 33579718 DOI: 10.1136/bmjsrh-2020-200932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION This trial reports on use of the copper intrauterine device (IUD) after immediate compared with delayed insertion following medical abortion at 17-20 gestational weeks (GW). METHODS This randomised controlled trial was conducted at one tertiary hospital and five community healthcare centres in Cape Town, South Africa. Eligible consenting women were randomised to immediate (within 24 hours) or delayed (3 weeks post-abortion) insertion of the copper IUD. Follow-up was at 6 weeks, 3 months and 6 months. Main outcomes were use of the original IUD and use of any IUD, including replacement IUDs at 6 weeks post-abortion. Secondary outcomes included rates of expulsion and malposition at 6 weeks, use of any IUD at 3 and 6 months, and acceptability of the IUD. RESULTS We recruited and randomised 114 women admitted for elective medical abortion between August 2018 and June 2019. In the immediate and delayed study arms, respectively, 45/55 (82%) and 12/57 (21%) women received the IUD as planned. By intention-to-treat, 56% in the immediate and 19% in the delayed arms were using the original IUD at 6 weeks (p<0.001), and 76% in the immediate and 40% in the delayed arms were using any IUD (p<0.001). Complete expulsion or removal occurred in 32% in the immediate and 7% in the delayed arms (p=0.044). CONCLUSIONS Insertion of an IUD immediately after medical abortion at 17-20 GW results in increased use after 6 weeks compared with delayed insertion, however expulsion rates are higher than with interval insertion. CLINICAL TRIALS REGISTRATION NCT03505047), Pan African Trials Registry (www.pactr.org), 201804003324963.
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Affiliation(s)
- Deborah Constant
- Women's Health Research Unit, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Margit Endler
- Women's Health Research Unit, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Women and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Daniel Grossman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, California, USA
| | - Gregory Petro
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Malika Patel
- Reproductive Health & Fertility Regulation, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Rocca ML, Palumbo AR, Visconti F, Di Carlo C. Safety and Benefits of Contraceptives Implants: A Systematic Review. Pharmaceuticals (Basel) 2021; 14:548. [PMID: 34201123 PMCID: PMC8229462 DOI: 10.3390/ph14060548] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Morena Luigia Rocca
- Operative Unit of Obstetric and Gynaecology, Pugliese-Ciaccio Hospital, 88100 Catanzaro, Italy
| | - Anna Rita Palumbo
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
| | - Federica Visconti
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
| | - Costantino Di Carlo
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
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10
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Emtell Iwarsson K, Envall N, Bizjak I, Bring J, Kopp Kallner H, Gemzell-Danielsson K. Increasing uptake of long-acting reversible contraception with structured contraceptive counselling: cluster randomised controlled trial (the LOWE trial). BJOG 2021; 128:1546-1554. [PMID: 33988917 DOI: 10.1111/1471-0528.16754] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effect of structured contraceptive counselling on the uptake of long-acting reversible contraceptives (LARCs) and pregnancy rates. DESIGN Cluster randomised trial. SETTING Abortion, youth and maternal health clinics in Stockholm, Sweden. POPULATION Sexually active women aged ≥18 years without a wish for pregnancy seeking abortion and/or contraceptive counselling. METHODS For participants in clinics randomised to intervention, trained healthcare providers implemented a study-specific intervention package designed for structured contraceptive counselling. Participants in the control clinics received routine counselling. MAIN OUTCOME MEASURES The primary outcome was choice of LARCs at first visit. Secondary outcomes were LARC initiation at 3 months and pregnancy rates at 3 and 12 months. We used logistic mixed-effects models with random intercept for clinic to account for clustering. RESULTS From September 2017 to May 2019, 28 randomised clinics enrolled 1364 participants. Analyses including 1338 subjects showed that more participants in the intervention group compared with the control group chose LARCs: 267/658 (40.6%) versus 206/680 (30.3%) (OR 2.77, 95% CI 1.99-3.86). LARC initiation was higher in the intervention group compared with the control group: 213/528 (40.3%) versus 153/531 (28.8%) (OR 1.74, 95% CI 1.22-2.49). At the abortion clinics, the pregnancy rate was significantly lower at 12 months in the intervention group compared with the control group: 13/101 (12.9%) versus 28/103 (27.2%) (OR 0.39, 95% CI 0.18-0.88). CONCLUSIONS Structured contraceptive counselling increased LARC uptake in all clinics and significantly reduced unintended pregnancy rates in abortion clinics at the 12 months follow-up. TWEETABLE ABSTRACT Structured contraceptive counselling increased LARC uptake and reduced pregnancy rates at 12 months.
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Affiliation(s)
- K Emtell Iwarsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - N Envall
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,School of Health and Welfare, Dalarna University, Falun, Sweden
| | - I Bizjak
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - J Bring
- Statisticon Inc., Uppsala, Sweden
| | - H Kopp Kallner
- Division of Obstetrics and Gynaecology, Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Danderyd Hospital, Stockholm, Sweden
| | - K Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
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11
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Kim C, Nguyen AT, Berry-Bibee E, Ermias Y, Gaffield ME, Kapp N. Systemic hormonal contraception initiation after abortion: A systematic review and meta-analysis. Contraception 2021; 103:291-304. [PMID: 33548267 PMCID: PMC8040936 DOI: 10.1016/j.contraception.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 11/30/2022]
Abstract
Background Immediate contraceptive initiation, including start of a method before abortion completion, is a convenient option for women seeking abortion care. Objectives To evaluate the effect of systemic hormonal contraception initiation on medical abortion effectiveness and the safety of hormonal contraceptive methods following abortion. Data sources PubMed, Popline, Cochrane Library, and Clinicaltrials.gov. Study eligibility criteria Studies that assessed medical abortion effectiveness after systemic hormonal contraception initiation and the safety of hormonal contraception initiation after abortion. Participants Pregnant persons undergoing or who had recently undergone an abortion. Interventions Initiation of systemic hormonal contraception post abortion or on the day of the first pill of the medical abortion. Study appraisal and synthesis methods We assessed study quality using the US Preventive Services Task Force evidence grading system. We created narrative summaries and calculated pooled relative risks when appropriate. Results We identified 16 studies for inclusion, 7 randomized controlled trials, and 9 cohorts. Nine studies assessed medical abortion effectiveness with hormonal contraception initiation and generally found no decreased risk of abortion success or increased risk of additional treatment. One fair-quality study reported a small increase in ongoing pregnancy rate with immediate depot medroxyprogesterone (DMPA) compared with delayed DMPA initiation (3.6% vs 0.9%, risk difference 2.7%, 90% confidence interval 0.4–5.6). We identified no bleeding-related safety concerns following hormonal contraception initiation after medical or surgical abortion. Pooled results were too imprecise to draw firm conclusions. Limitations Included studies were poor or fair quality and primarily in high-income or upper-middle-income settings. Conclusions Abortion effectiveness did not differ between immediate vs delayed initiation of most systemic hormonal contraceptive methods after a first trimester medical abortion. However, immediate DMPA initiation did show increased ongoing pregnancy. Bleeding effects with hormonal contraception initiation postabortion appeared minimal. Implications Initiating a hormonal contraceptive method after an abortion and as early as the same day as the first pill of the medical abortion is an option if contraception is desired. The slight increase in ongoing pregnancy with immediate DMPA initiation highlights the importance of information provision during contraceptive counseling.
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Affiliation(s)
- Caron Kim
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland.
| | - Antoinette T Nguyen
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Erin Berry-Bibee
- Planned Parenthood of the Great Northwest and Hawaiian Islands, Seattle, Washington, USA
| | - Yokabed Ermias
- School of Medicine, University of California San Diego, San Diego, CA, United States
| | - Mary E Gaffield
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland
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Egardt A, Algovik M, Kopp Kallner H. Adherence to Swedish national recommendations for long acting reversible contraceptive provision at the time of medical abortion. Contraception 2020; 103:261-264. [PMID: 33373614 DOI: 10.1016/j.contraception.2020.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate if abortion clinics follow Swedish national guidelines regarding early insertion of long-acting reversible contraception (LARC) after medical abortions up to 9 weeks of gestation and, if not, the reasons for not doing so. STUDY DESIGN We attempted to survey representatives of all 60 known Swedish abortion clinics by telephone in November 2019, including public hospitals and private clinics. We asked questions about clinic characteristics, clinic routines concerning early insertion of IUDs and implants, adherence to guidelines and, when applicable, perceived reasons for nonadherence. Current guidelines include offering implant placement at the time of mifepristone administration and intrauterine device (IUD) insertion within 7 days of misoprostol treatment. RESULTS We obtained responses from 57 (95%) clinics of which 22 (40%) followed guidelines for both implants and IUDs. Slightly more than half (n = 33, 58%) follow implant guidelines and fewer (n = 25, 44%) follow IUD guidelines. Respondents most commonly cited lack of updated local guidelines at the clinic (7/24, 29%) and a perceived lack of time (6/25, 24%) as the most common reasons for nonadherence to guidelines for insertion of implants and insufficient number of nurse midwives for insertion of IUDs 8/32, 25%). CONCLUSIONS Less than half of Swedish abortion clinics fully adhere to national evidence-based guidelines regarding early LARC insertion at the time of abortion. IMPLICATIONS National guidelines alone are not always sufficient to effect change in practice; awareness of existing guidelines is needed in Swedish abortion clinics and work is needed to address barriers that limit LARC access after abortion.
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Affiliation(s)
| | | | - Helena Kopp Kallner
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden.
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Abstract
Medication abortion, also referred to as medical abortion, is a safe and effective method of providing abortion. Medication abortion involves the use of medicines rather than uterine aspiration to induce an abortion. The U.S. Food and Drug Administration (FDA)-approved medication abortion regimen includes mifepristone and misoprostol. The purpose of this document is to provide updated evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation. Information about medication abortion after 70 days of gestation is provided in other ACOG publications [1].
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Makins A, Cameron S. Post pregnancy contraception. Best Pract Res Clin Obstet Gynaecol 2020; 66:41-54. [DOI: 10.1016/j.bpobgyn.2020.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/10/2019] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
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Caruso S, Vitale SG, Fava V, Pasqua SD, Rapisarda AMC, Cianci S. Quality of life of women using the etonogestrel long-acting reversible contraceptive implant after abortion for unplanned pregnancy. EUR J CONTRACEP REPR 2020; 25:251-258. [PMID: 32436733 DOI: 10.1080/13625187.2020.1760240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aims of the study were to investigate the effect of a subcutaneous etonogestrel-containing contraceptive implant on the quality of life (QoL) and sexual function of women who had undergone termination of an unplanned pregnancy. METHODS At pregnancy termination 140 women received contraceptive counselling on the etonogestrel implant. The Short Form-36 questionnaire, the Female Sexual Function Index and the Female Sexual Distress Scale were used to investigate, respectively, the QoL, sexual function and sexual distress of the women at baseline and at 6, 12, 24 and 36 months of follow-up. RESULTS The study group comprised 86 (61.4%) women who chose to use the contraceptive implant. The control group comprised 28 (20.0%) women who chose to use short-acting reversible contraception (SARC) and 26 (18.6%) women who chose not to use hormonal contraception. In the women not using hormonal contraception there were 23 (88.5%) unintended pregnancies before the end of the 3 year study period. QoL, sexual function and sexual distress improved in the study group from the 6 months follow-up until the end of the study (p < 0.001). QoL (p < 0.02) and sexuality (p < 0.001) gradually improved in the control group after 24 and 12 months of follow-up, respectively. None of the women using the etonogestrel implant became pregnant during the study. Inter-group analysis showed better improvement in QoL, sexual function and sexual distress in the study group than in the control group from 6 months (p < 0.004) until the end of the study (p < 0.001). CONCLUSION Compared with SARC and non-hormonal contraception, the contraceptive implant promoted better QoL and sexuality in users and reduced the incidence of unplanned pregnancy. However, the women who opted for SARC or non-hormonal contraception did so because of the lower cost compared with that of the contraceptive implant.
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Affiliation(s)
- Salvatore Caruso
- Sexology Research Group, Gynaecology Clinic, Department of General Surgery and Medical Surgical Specialties, School of Medicine, University of Catania, Catania, Italy
| | - Salvatore Giovanni Vitale
- Sexology Research Group, Gynaecology Clinic, Department of General Surgery and Medical Surgical Specialties, School of Medicine, University of Catania, Catania, Italy
| | - Valentina Fava
- Sexology Research Group, Gynaecology Clinic, Department of General Surgery and Medical Surgical Specialties, School of Medicine, University of Catania, Catania, Italy
| | - Salvatore Di Pasqua
- Sexology Research Group, Gynaecology Clinic, Department of General Surgery and Medical Surgical Specialties, School of Medicine, University of Catania, Catania, Italy
| | - Agnese Maria Chiara Rapisarda
- Sexology Research Group, Gynaecology Clinic, Department of General Surgery and Medical Surgical Specialties, School of Medicine, University of Catania, Catania, Italy
| | - Stefano Cianci
- Department of Woman, Child and General and Specialised Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
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Schmidt-Hansen M, Hawkins JE, Lord J, Williams K, Lohr PA, Hasler E, Cameron S. Long-acting reversible contraception immediately after medical abortion: systematic review with meta-analyses. Hum Reprod Update 2020; 26:141-160. [DOI: 10.1093/humupd/dmz040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/21/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Long-acting reversible contraceptives (LARCs) are safe, effective and convenient post-abortal methods. However, there is concern that some LARCs may reduce the effectiveness of abortifacient drugs or result in other adverse outcomes.
OBJECTIVE AND RATIONALE
We undertook two systematic reviews to examine the early administration of LARCs in women undergoing medical abortion with mifepristone and misoprostol. (i) For women who are having a medical abortion and who plan to use a progestogen-only contraceptive implant or injectable, does administration of the contraception at the same time as mifepristone influence the efficacy of the abortion? (Implant/injectable review). (ii) For women who have had a medical abortion, how soon after expulsion of the products of conception is it safe to insert an intrauterine contraceptive device/system? (LNG-IUS/Cu-IUD review).
SEARCH METHODS
On 19 November 2018, we searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily and Epub Ahead-of-Print, In-Process and Other Non-Indexed Citations; the Cochrane Library; Cinahl Plus; and Web of Science Core Collection. Eligible studies were randomised controlled trials (RCTs), in English from 1985 (Implant/injectable review) or 2007 (LNG-IUS/Cu-IUD review) onwards, conducted in women undergoing medical abortion with mifepristone and misoprostol and studying either (i) simultaneous administration of mifepristone and a progestogen-only contraceptive implant or injectable compared to administration >24 h after mifepristone, or (ii) immediate insertion of intrauterine contraception after expulsion of the products of conception compared to early insertion (≤7 days) or to delayed insertion (>7 days) or early compared to delayed insertion. One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for RCTs. All the outcomes were analysed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel–Haenszel statistical method and a fixed-effect model. The overall quality of the evidence was assessed using GRADE.
OUTCOMES
Two RCTs (n = 1027) showed lower ‘subsequent unintended pregnancy’ rates and higher ‘patient satisfaction’ rates, and no other differences, after simultaneous administration of mifepristone and the implant compared to delayed administration. One RCT (n = 461) showed higher ‘patient satisfaction’ rates after simultaneous administration than after delayed administration of mifepristone and the injectable, but no other differences between these interventions. Three RCTs (n = 536) found no differences other than higher copper IUC uptake after early compared to delayed insertion at ≤9 weeks of gestation and higher rates of IUC expulsion, continuation and uptake after immediate compared to delayed insertion at 9+1–12+0 weeks of gestation and higher IUC continuation rates after immediate compared to delayed insertion at 12+1–20+0 weeks of gestation. The quality of this evidence ranged from very low to high and was mainly compromised by low event rates, high attrition and no blinding.
WIDER IMPLICATIONS
The contraceptive implant or injectable should be offered on the day of taking mifepristone. Intrauterine methods of contraception should be offered as soon as possible after expulsion of the pregnancy.
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Affiliation(s)
- Mia Schmidt-Hansen
- National Guideline Alliance, The Royal College of Obstetricians and Gynaecologists, London, SE1 1SZ, UK
| | - James E Hawkins
- National Guideline Alliance, The Royal College of Obstetricians and Gynaecologists, London, SE1 1SZ, UK
| | - Jonathan Lord
- Department of Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, TR1 3LQ, UK
| | - Kelly Williams
- National Guideline Alliance, The Royal College of Obstetricians and Gynaecologists, London, SE1 1SZ, UK
| | - Patricia A Lohr
- British Pregnancy Advisory Service, Stratford-upon-Avon, CV37 9BF, UK
| | - Elise Hasler
- National Guideline Alliance, The Royal College of Obstetricians and Gynaecologists, London, SE1 1SZ, UK
| | - Sharon Cameron
- Sexual and Reproductive Health Services, NHS Lothian, Edinburgh, EH3 9ES, Scotland
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Lichtenstein Liljeblad K, Kopp Kallner H, Brynhildsen J. Risk of abortion within 1-2 years after childbirth in relation to contraceptive choice: a retrospective cohort study. EUR J CONTRACEP REPR 2020; 25:141-146. [PMID: 32083501 DOI: 10.1080/13625187.2020.1718091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period.Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum.Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age <25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk.Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.
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Affiliation(s)
- Karin Lichtenstein Liljeblad
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Danderyd Hospital, Stockholm, Sweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Danderyd Hospital, Stockholm, Sweden
| | - Jan Brynhildsen
- Department of Obstetrics & Gynaecology, Department of Clinical & Experimental Medicine, Linköping University, Linköping, Sweden
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First trimester termination of pregnancy. Best Pract Res Clin Obstet Gynaecol 2020; 63:13-23. [DOI: 10.1016/j.bpobgyn.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/17/2019] [Indexed: 11/19/2022]
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Kilander H, Brynhildsen J, Alehagen S, Fagerkrantz A, Thor J. Collaboratively seeking to improve contraceptive counselling at the time of an abortion: a case study of quality improvement efforts in Sweden. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:190-199. [PMID: 31289100 DOI: 10.1136/bmjsrh-2018-200299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/15/2019] [Accepted: 05/16/2019] [Indexed: 05/21/2023]
Abstract
BACKGROUND Many women find it difficult to choose and initiate a contraceptive method at the time of an abortion. There is a gap between regular clinical practice and existing evidence on motivational and person-centred counselling, as well as on use of long-acting reversible contraception (LARC). This study aims to describe and evaluate a Quality Improvement Collaborative (QIC) designed to enhance contraceptive services, with regard to changes in healthcare professionals' (HCPs') counselling in clinical practice, and in women's subsequent choice of, and access to, contraception. METHODS Three multiprofessional teams working in abortion services from three hospitals in Sweden, and two women contributing with user experience, participated in a QIC during the period March-November 2017. Using a case study design, we collected and analysed both quantitative and qualitative data. RESULTS Teams agreed on QIC goals, including that ≥50% of women would start LARC within 30 days post-abortion, and tested multiple evidence-based changes, aided by the two women's feedback. During the QIC, participating HCPs reported that they gained new knowledge and developed skills in contraceptive counselling at the time of an abortion. The teams welcomed the development of a performance feedback system regarding women's post-abortion contraception. While the majority of women counselled during the QIC chose LARC, only 20%-40% received it within 30 days post-abortion. CONCLUSION The QIC, incorporating user feedback, helped HCPs to develop capability in providing contraceptive services at the time of an abortion. Timely access to LARC remains a challenge in the present setting.
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Affiliation(s)
- Helena Kilander
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Obstetrics and Gynaecology, Region Jönköping County, Eksjö, Sweden
| | - Jan Brynhildsen
- Obstetrics and Gynecology, Clinical and Experimental Medicine, Linköping, Sweden
| | - Siw Alehagen
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Amanda Fagerkrantz
- Department of Obstetrics and Gyneacology, Norrköping, Region Ostergotland, Linköping, Sweden
| | - Johan Thor
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden
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Cameron S, Rowlands S, Gemzell-Danielsson K. Self-assessment of success of early medical abortion using a self-performed urine pregnancy test. EUR J CONTRACEP REPR 2019; 24:319-321. [PMID: 31204845 DOI: 10.1080/13625187.2019.1618446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: The European Society of Contraception Expert Group on Abortion identified as one of its priorities the need to disseminate up-to-date evidence-based information on the use of urine pregnancy tests by women for the self assessment of the success of early medical abortion (EMA). Methods and materials: A concise communication was produced which summarises the latest research in an easy-to-read format suitable for busy clinicians. Information about individual urinary pregnancy tests is presented in boxes for ease of reference. Results: Urinary pregnancy tests (low sensitivity, high sensitivity and multilevel) can be used in combination with signs and symptoms of pregnancy to exclude an ongoing pregnancy after EMA. Conclusion: Women are able to determine the success of early medical abortion (EMA) themselves using a combination of signs, symptoms and a urine pregnancy test. This simplifies EMA, expands the range of professionals able to provide EMA and most importantly gives women greater control over their bodies and treatment.
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Affiliation(s)
- Sharon Cameron
- a Chalmers Sexual and Reproductive Healthcare Service , NHS Lothian and University of Edinburgh , Edinburgh , UK
| | - Sam Rowlands
- b Centre of Postgraduate Medical Research & Education , Bournemouth University , Bournemouth , UK
| | - Kristina Gemzell-Danielsson
- c Department of Women's and Children's Health , Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
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Glasier A, Bhattacharya S, Evers H, Gemzell-Danielsson K, Hardman S, Heikinheimo O, La Vecchia C, Somigliana E. Contraception after pregnancy. Acta Obstet Gynecol Scand 2019; 98:1378-1385. [PMID: 31001809 DOI: 10.1111/aogs.13627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/10/2019] [Indexed: 11/27/2022]
Abstract
Whatever the outcome, pregnancy provides the opportunity to offer effective contraception to couples motivated to avoid another pregnancy. This narrative review summarizes the evidence for health providers, drawing attention to current guidelines on which contraceptive methods can be used, and when they should be started after pregnancy, whatever its outcome. Fertility returns within 1 month of the end of pregnancy unless breastfeeding occurs. Breastfeeding, which itself suppresses fertility after childbirth, influences both when contraception should start and what methods can be used. Without breastfeeding, effective contraception should be started as soon as possible if another pregnancy is to be avoided. Interpregnancy intervals of at least 6 months after miscarriage and 1-2 years after childbirth have long been recommended by the World Health Organization in order to reduce the chance of adverse pregnancy outcome. Recent research suggests that this may not be necessary, at least for healthy women <35 years old. Most contraceptive methods can be used after pregnancy regardless of the outcome. Because of an increased risk of venous thromboembolism associated with estrogen-containing contraceptives, initiation of these methods should be delayed until 6 weeks after childbirth. More research is required to settle the questions over the use of combined hormonal contraception during breastfeeding, the use of injectable progestin-only contraceptives before 6 weeks after childbirth, and the use of both hormonal and intrauterine contraception after gestational trophoblastic disease. The potential impact on the risk of ectopic pregnancy of certain contraceptive methods often confuses healthcare providers. The challenges involved in providing effective, seamless service provision of contraception after pregnancy are numerous, even in industrialized countries. Nevertheless, the clear benefits demonstrate that it is worth the effort.
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Affiliation(s)
- Anna Glasier
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Hans Evers
- Maastricht University, Maastricht, the Netherlands
| | | | - Sarah Hardman
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Edgardo Somigliana
- University degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Abstract
When conducted in a legal setting and under safe conditions, abortion is an extremely effective and safe procedure. Tragically, almost half of all abortions that take place in the world are conducted under unsafe conditions, mostly in countries where abortion is illegal or highly restricted. These unsafe abortions are a major cause of maternal death and disability. Restricting a woman’s access to abortion does not prevent abortion but simply leads to more unsafe abortions. Barriers to safe abortion are many but include legal barriers, health policy barriers, shortages of trained healthcare workers, and stigma surrounding abortion. This commentary will consider some recent advances to improve access to safe abortion as well as refinements in abortion methods and service delivery in settings where safe abortion is available that further improve the care and wellbeing of women who seek abortion.
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Affiliation(s)
- Sharon Cameron
- Chalmers Centre, NHS Lothian & University of Edinburgh, 2a Chalmers Street, Edinburgh, EH3 9ES, UK
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Lang C, Chen ZE, Johnstone A, Cameron S. Initiating intramuscular depot medroxyprogesterone acetate 24-48 hours after mifepristone administration does not affect success of early medical abortion. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:bmjsrh-2017-101928. [PMID: 30049685 DOI: 10.1136/bmjsrh-2017-101928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 05/29/2018] [Accepted: 06/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The primary objective of this study was to determine whether intramuscular depot medroxyprogesterone acetate (IM DMPA) given at the time of misoprostol administration, 24-48 hours after mifepristone, affects the rate of continuing pregnancy. In addition, the study explored factors predictive of continuing pregnancy. DESIGN Case-control study based on database review of women who underwent early medical abortion (EMA) over a 4-year period. SETTING Single abortion service in Scotland. PARTICIPANTS 5122 women who underwent an EMA within the timeframe of this study. MAIN OUTCOME MEASURES Continuing pregnancies among women receiving IM DMPA were compared with those choosing other hormonal methods of contraception, non-hormonal contraception or no contraception at the time of misoprostol administration. Logistic regression was performed to assess the effects of demographic characteristics, gestation at presentation and method of contraception provided, on outcome of pregnancy. RESULTS A total of 4838 women with complete data were included, of which there were 20 continuing pregnancies (0.4%); 284 women were excluded due to missing data. There was no increased risk of a continuing pregnancy among women who initiated IM DMPA at the time of misoprostol administration (24-48 hours after mifepristone) compared with women who initiated no hormonal contraception at this time (RR 0.48; 95% CI 0.06 to 3.81). Gestation ≥8 weeks and previous terminations were factors associated with increased likelihood of continuing pregnancy. CONCLUSIONS Women choosing IM DMPA after EMA can be reassured that IM DMPA can be safely initiated at the time of misoprostol administration 24-48 hours after mifepristone without an increase in the risk of a continuing pregnancy. Both increasing gestation and previous termination were factors associated with an increased likelihood of continuing pregnancy following an EMA.
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Affiliation(s)
| | | | - Anne Johnstone
- Chalmers Sexual Health Clinic, Edinburgh, UK
- Obstetrics and Gynaecology, University of Edinburgh, Edinburgh, UK
| | - Sharon Cameron
- Chalmers Sexual Health Clinic, Edinburgh, UK
- Obstetrics and Gynaecology, University of Edinburgh, Edinburgh, UK
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Lohr PA, Aiken AR, Forsyth T, Trussell J. Telephone or integrated contraception counselling before abortion: impact on method choice and receipt. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:114-121. [PMID: 29921634 PMCID: PMC6034179 DOI: 10.1136/bmjsrh-2017-101818] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 01/12/2018] [Accepted: 01/15/2018] [Indexed: 05/05/2023]
Abstract
BACKGROUND Incorporating thorough contraception counselling into an abortion consultation is challenging. We compared contraceptive choices and methods received between two counselling models: (1) telephone counselling separate from the abortion consultation and (2) face-to-face counselling integrated into the consultation. METHODS We obtained de-identified data on demographic characteristics and contraceptive methods that had been chosen and received by women who had an abortion at British Pregnancy Advisory Service between 2011 and 2014 and had a choice of counselling models. We compared the characteristics of women who chose each model of counselling and the contraceptive methods they chose and received using Fisher's exact test, and used logistic regression to explore associations between counselling model and choice and receipt of Tier 1 contraceptive methods (intrauterine contraception, implant, sterilisation), controlling for covariates. RESULTS The sample included 18 573 women. Women choosing telephone counselling were more likely to be non-White (34% vs 22%, P<0.001), to report prior difficulty obtaining contraception (40% vs 3%, P<0.001), and to have not used contraception at conception (37.1% vs 33.8%, P<0.001). Overall, 93% of women chose a contraceptive method after counselling. Telephone counselling was significantly associated with both choosing and receiving a Tier 1 method (OR 1.80, 95% CI 1.66 to 1.96 and OR 1.60, 95% CI 1.42 to 1.71, respectively). Fewer women who had telephone counselling received a less effective method (eg, condom, diaphragm) compared with those who chose integrated counselling (6.0% vs 19.2%, P<0.001). DISCUSSION Telephone-based contraception counselling separate from the abortion consultation may serve some women better than integrated counselling, particularly those reporting past difficulty obtaining contraception.
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Affiliation(s)
- Patricia A. Lohr
- Clinical Department, British Pregnancy Advisory Service, Stratford upon Avon CV37 9BF, UK
| | - Abigail R.A. Aiken
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, 78713, USA
| | - Tracey Forsyth
- Clinical Department, British Pregnancy Advisory Service, Stratford upon Avon CV37 9BF, UK
| | - James Trussell
- Office of Population Research, Princeton University, Princeton NJ 08544, USA
- Clinical Effectiveness Unit, Chalmers Centre, University of Edinburgh, Edinburgh, EH3 9ES, UK
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Korjamo R, Heikinheimo O, Mentula M. Risk factors and the choice of long-acting reversible contraception following medical abortion: effect on subsequent induced abortion and unwanted pregnancy. EUR J CONTRACEP REPR 2018. [DOI: 10.1080/13625187.2018.1440385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Riina Korjamo
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Mentula
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Abstract
Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.
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MESH Headings
- Abortion, Criminal/adverse effects
- Abortion, Criminal/mortality
- Abortion, Criminal/prevention & control
- Abortion, Incomplete/diagnosis
- Abortion, Incomplete/mortality
- Abortion, Incomplete/therapy
- Abortion, Induced/adverse effects
- Abortion, Induced/legislation & jurisprudence
- Abortion, Induced/mortality
- Abortion, Induced/trends
- Abortion, Septic/diagnosis
- Abortion, Septic/mortality
- Abortion, Septic/prevention & control
- Abortion, Septic/therapy
- Adolescent
- Adult
- Congresses as Topic
- Female
- Global Health
- Harm Reduction
- Health Services Accessibility
- Humans
- International Agencies
- Maternal Mortality
- Pregnancy
- Pregnancy, Unplanned
- Reproductive Medicine/methods
- Reproductive Medicine/trends
- Young Adult
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Rocca CH, Goodman S, Grossman D, Cadwallader K, Thompson KMJ, Talmont E, Speidel JJ, Harper CC. Contraception after medication abortion in the United States: results from a cluster randomized trial. Am J Obstet Gynecol 2018; 218:107.e1-107.e8. [PMID: 28986072 DOI: 10.1016/j.ajog.2017.09.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/19/2017] [Accepted: 09/21/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Understanding how contraceptive choices and access differ for women having medication abortions compared to aspiration procedures can help to identify priorities for improved patient-centered postabortion contraceptive care. OBJECTIVE The objective of this study was to investigate the differences in contraceptive counseling, method choices, and use between medication and aspiration abortion patients. STUDY DESIGN This subanalysis examines data from 643 abortion patients from 17 reproductive health centers in a cluster, randomized trial across the United States. We recruited participants aged 18-25 years who did not desire pregnancy and followed them for 1 year. We measured the effect of a full-staff contraceptive training and abortion type on contraceptive counseling, choice, and use with multivariable regression models, using generalized estimating equations for clustering. We used survival analysis with shared frailty to model actual intrauterine device and subdermal implant initiation over 1 year. RESULTS Overall, 26% of participants (n = 166) had a medication abortion and 74% (n = 477) had an aspiration abortion at the enrollment visit. Women obtaining medication abortions were as likely as those having aspiration abortions to receive counseling on intrauterine devices or the implant (55%) and on a short-acting hormonal method (79%). The proportions of women choosing to use these methods (29% intrauterine device or implant, 58% short-acting hormonal) were also similar by abortion type. The proportions of women who actually used short-acting hormonal methods (71% medication vs 57% aspiration) and condoms or no method (20% vs 22%) within 3 months were not significantly different by abortion type. However, intrauterine device initiation over a year was significantly lower after the medication than the aspiration abortion (11 per 100 person-years vs 20 per 100 person-years, adjusted hazard ratio, 0.50; 95% confidence interval, 0.28-0.89). Implant initiation rates were low and similar by abortion type (5 per 100 person-years vs 4 per 100 person-years, adjusted hazard ratio, 2.41; 95% confidence interval, 0.88-6.59). In contrast to women choosing short-acting methods, relatively few of those choosing a long-acting method at enrollment, 34% of medication abortion patients and 53% of aspiration abortion patients, had one placed within 3 months. Neither differences in health insurance nor pelvic examination preferences by abortion type accounted for lower intrauterine device use among medication abortion patients. CONCLUSION Despite similar contraceptive choices, fewer patients receiving medication abortion than aspiration abortion initiated intrauterine devices over 1 year of follow-up. Interventions to help patients receiving medication abortion to successfully return for intrauterine device placement are warranted. New protocols for same-day implant placement may also help patients receiving medication abortion and desiring a long-acting method to receive one.
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Affiliation(s)
- Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA; Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA.
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Daniel Grossman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA; Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA
| | - Kara Cadwallader
- Planned Parenthood of the Great Northwest and the Hawaiian Islands, Seattle, WA
| | - Kirsten M J Thompson
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Elizabeth Talmont
- Planned Parenthood of Northern, Central, and Southern New Jersey Inc, Morristown, NJ
| | - J Joseph Speidel
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
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Fast-track vs. delayed insertion of the levonorgestrel-releasing intrauterine system after early medical abortion — a randomized trial. Contraception 2017; 96:344-351. [DOI: 10.1016/j.contraception.2017.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/18/2017] [Accepted: 07/23/2017] [Indexed: 11/23/2022]
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Korjamo R, Mentula M, Heikinheimo O. Immediate versus delayed initiation of the levonorgestrel-releasing intrauterine system following medical termination of pregnancy - 1 year continuation rates: a randomised controlled trial. BJOG 2017. [DOI: 10.1111/1471-0528.14802] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- R Korjamo
- Department of Obstetrics and Gynaecology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - M Mentula
- Department of Obstetrics and Gynaecology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - O Heikinheimo
- Department of Obstetrics and Gynaecology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Intrauterine Devices and Contraceptive Implants: Overview of Options and Updates on Method Use. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0200-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Affiliation(s)
- Sam Rowlands
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, Dorset, UK
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