Frequency and Risk Factors for Repeat Abortions After Surgical Compared With Medical Termination of Pregnancy

Pregnancy outcomes following routine early provision of intrauterine device after first-trimester induced abortion-A secondary analysis of a randomized controlled trial with a 5-year follow up

INTRODUCTION

Women undergoing an induced abortion are highly fertile and at risk of subsequent unplanned pregnancy. We recently completed a randomized clinical trial showing that routine provision of intrauterine device (IUD) at the time of abortion significantly reduced the risk of subsequent abortion during a 5-year follow up. As the use of highly effective contraception may affect all subsequent pregnancies, we analyzed the rate and distribution of all subsequent pregnancies (deliveries, miscarriages, and abortions), and the risk factors for these various pregnancy outcomes in the above-mentioned randomized clinical trial.

MATERIAL AND METHODS

We enrolled adult women requesting first-trimester induced abortion and candidates for IUD for post-abortion contraception. Women (n = 751) were randomized to receive an IUD (either levonorgestrel-releasing IUD or copper IUD) by the clinic responsible for abortion care vs. routine care of IUD provision in primary health care with oral contraceptives for interval contraception. In the present secondary analysis, we identified all deliveries, miscarriages, and abortions in the intervention (n = 375) and control (n = 373) cohorts during the 5-year follow up using the Finnish national registries. The trial is registered at Clinical Trials (NTC01223521).

RESULTS

The overall delivery, miscarriage, and abortion rates were 42.0, 12.0 and 32.1/1000 years of follow up (yFU). Any new pregnancy occurred in 98 women in the intervention and in 129 women in the control cohort (hazard ratio 0.73, 95% confidence interval 0.56-0.95, p = 0.023). The effect of routine IUD provision in reducing pregnancies was limited to the first 2 yFU. The number of subsequent induced abortions and of women undergoing it were significantly reduced, and time to abortion was prolonged by the intervention. However, the overall number, the number of women with subsequent delivery or miscarriage, and the times to these events were not significantly affected. History of previous pregnancy (delivery or abortion) and smoking were risk factors for subsequent induced abortion, but not for delivery or miscarriage.

CONCLUSIONS

Routine provision of IUD as part of abortion care did not reduce the rates of delivery or miscarriage during the 5-year follow up. The rates of all pregnancies and the need of subsequent induced abortion were reduced by IUD provision during the first 2 yFU.

Factors influencing the risk of repeat termination of pregnancy: A register-based study in Finland

OBJECTIVE

This study aimed to assess how factors such as sociodemographic characteristics, termination of pregnancy (TOP) related factors and contraception affect the risk of repeat TOP.

MATERIALS AND METHOD

This is a nationwide register-based study of 193,741 women who had TOP(s) during 1987-2015, using the Finnish Register of Induced Abortions. The risk of various factors, such as age, marital status, residence, parity, TOP related factors and contraception, was assessed separately for each repeat TOP. Cox proportional hazard model was used to estimate risk of different factors for repeat TOPs.

RESULTS

21% of the women having TOP had repeat TOPs during the years 1987-2015. Among women with repeat TOPs, more than 70% had one repeat TOP and the rest had two or more. Older, married and rural or semi-urban women had reduced risk of repeat TOPs. Adjusted risk for one repeat TOP was higher among parous women (HR 1.67, 95% CI 1.61-1.72). No significant risk for repeat TOP was observed by method in sub-analysis for the recent period after 2006. Women using less reliable (HR 1.14, 95% CI 1.06-1.23) and unreliable (HR 1.33, 95% CI 1.23-1.43) contraception had increased risk of repeat TOP than women using reliable contraception.

CONCLUSION

Older age, being married, residing in rural or semi-urban areas and using reliable contraception were found to be protective factors for repeat TOPs whereas, parous women had higher risk for repeat TOPs. Proper counselling regarding contraception and use of reliable contraception immediately after TOP should be encouraged.

A 3-year retrospective study of unintended pregnancy in a developed multi-ethnic Asian community: A call for better healthcare system for family planning

Background

Women of childbearing age may face unintended pregnancy (UP). They are usually referred by primary care professionals (PCPs) to gynecologists to manage their UP in countries where abortion is legalized. The study aimed to determine the prevalence, demographic profiles, and associated factors of women in a developed community seeking referrals from PCPs for their UP.

Methods

The sociodemographic and clinical data were extracted from the electronic medical records of pregnant multi-ethnic Asian women at eight Singapore public primary care clinics from July 2017 to June 2020. Their demographic profiles were reviewed and compared among women of different age bands using appropriate statistical tests. Logistic regression was used to identify the factors associated with UP referrals.

Results

Among 9,794 gravid women, 974 of them requested gynecologist referrals to terminate UP over the 3-year period, constituting a prevalence of 9.94%. The mean age of women requesting such referrals was 29.7 ± 7 years. There were 10.7% with more than one prior unintended pregnancy and 15.7% were foreigners. The majority of these women were married, neither required social assistance nor had comorbidities. Only 2.9% of them were known to be prescribed contraceptives. A multivariable logistic regression analysis showed that women of Indian ethnicity, single, aged below 20 years and above 40 years, were more likely to request referrals for UP.

Conclusion

One in 10 gravid women had sought referrals for UP, especially adolescents and older women, and Indian ethnicity. An accessible community-based healthcare service to educate and counsel women on family planning is urgently needed to reduce the incidence of UP.

What are the social correlates of subsequent abortions in Flanders, Belgium?

OBJECTIVE

To study whether the social correlates of subsequent abortions vary depending on the order of the abortion. Methodology: Drawing upon the Flemish abortion centres' anonymized patient records (2010-2019), discrete-time hazard models were used to examine whether individual abortion experiences across women's reproductive life course have different social correlates.

RESULTS

Overall, women who were in their twenties, of foreign origin, single, had non-tertiary education, were not in paid employment, had children, did not (consistently and without errors) use contraception and had a previous abortion through medication, had an elevated probability to experience subsequent abortions. While single women and women with a vulnerable socioeconomic status were more likely to have a second or third abortion, this difference is no longer prevalent when considering higher-order abortions. The hazard for higher-order abortions was more pronounced in women with a migration background, regardless of the order considered. Contraceptive use was unrelated to fourth or higher-order abortions.

CONCLUSION

Using discrete-time hazard models, we unpack individual abortion experiences across women's reproductive life courses. By studying the transitions into different orders of subsequent abortions separately, we provide a more detailed understanding of risk factors compared to other European studies. The social correlates vary by the order considered: A certain profile emerges for women who have a second or third abortion, but disintegrates when considering higher-order abortions. This knowledge enables clinicians and policymakers to better understand women who experience subsequent abortions and to tailor services best suited to their needs.

Magnitude and associated factors of repeat induced abortion among reproductive age group women who seeks abortion Care Services at Marie Stopes International Ethiopia Clinics in Addis Ababa, Ethiopia

Background

Repeated induced abortion is important public health concern both in the developing and developed world that increases maternal morbidity and mortality. The aim of this study was to determine the magnitude and associated factors of repeated induced abortion among abortion care service seekers at Marie Stopes International Ethiopia clinics in Addis Ababa, Ethiopia.

Methods

A cross sectional study was conducted among 429 women seeking abortion care at Marie Stopes International Ethiopia clinics. Simple random sampling technique was used to select study participants. Data were collected by trained data collectors using pretested structured questionnaires. Data were checked for completeness, consistency, coded and entered and analyzed through SPSS version 20. Bivariate and multivariate logistic regression analysis was computed to test the strength of association and the p-value < 0.05 was considered as statistical significant.

Result

The magnitude of repeat induced abortion was 33.6%. Based on this study age groups 20–24 years (AOR = 1.2; CI: 1.1–2.3), 25–29 years (AOR = 5.4; CI: 3.1–6.2) and 30–34 years (AOR = 1.1; CI: 1.02–2.6); respondents with the educational level of primary (AOR = 0.2; CI: 0.070.6), secondary (AOR = 0.4; CI: 0.2–0.8) and college diploma and above (AOR = 0.4; CI: 0.2–0.6); those with the monthly income of 1001–2000 Ethiopian birr (AOR = 4.2; CI: 1.8–9.4) and 2001–3000 Ethiopian birr (AOR = 0.3; CI: 0.2–0.9); those with years in marriage with 1–2 years (AOR = 2.4; CI: 1.2–4.9) and those with last time of abortions of 1–2 years, 2–3 years and above 3 years, (AOR = 0.2; CI: 0.1–0.5), (AOR = 0.1; CI: 0.05–0.4), (AOR = 0.4; CI: 0.2–0.9), respectively were found to be significantly associated with repeat induced abortions.

Conclusion and recommendation

The magnitude of repeat induced abortion is similar with the reports from developing countries but it was lower than that of developed countries. Age group (20–24, 25–29 and 30–34 were positively associated with repeat induced abortion), educational level (primary, secondary and collage diploma and above were negatively associated with repeat induced abortion), monthly income (earn 1001–2000 Ethiopian birr were positively where as monthly income between 2001 and 3000 Ethiopian birr negatively associated), years in marriage (1–2 years was negatively associated) and time of last abortion (1–2 years, 2-3 years and above the three years were negatively associated) were the associated factors for repeat induced abortion. Health promotion messages are needed to focus to improve the knowledge of women about contraceptives as a primary prevention of repeated induced abortion.

Implementing medical abortion with mifepristone and misoprostol in Norway 1998-2013

Background: Medical abortion with mifepristone and misoprostol was introduced in Norway in 1998, and since then there has been an almost complete change from predominantly surgical to medical abortions. We aimed to describe the medical abortion implementation process, and to compare characteristics of women obtaining medical and surgical abortion.

Methods: Information from all departments of obstetrics and gynaecology in Norway on the time of implementation of medical abortion and abortion procedures in use up to 12 weeks of gestation was assessed by surveys in 2008 and 2012. We also analysed data from the National Abortion Registry comprising 223 692 women requesting abortion up to 12 weeks of gestation during 1998–2013.

Results: In 2012, all hospitals offered medical abortion, 84.4% offered medical abortion at 9–12 weeks of gestation and 92.1% offered home administration of misoprostol. The use of medical abortion increased from 5.9% of all abortions in 1998 to 82.1% in 2013. Compared with women having a surgical abortion, women obtaining medical abortion had higher odds for undergoing an abortion at 4–6 weeks (adjusted OR 2.33; 95% confidence interval 2.28-2.38). Waiting time between registered request for an abortion until termination was reduced from 11.3 days in 1998 to 7.3 days in 2013.

Conclusions: Norwegian women have gained access to more treatment modalities and simplified protocols for medical abortion. At the same time they obtained abortions at an earlier gestational age and the waiting time has been reduced.

[Repeat induced abortion: A multicenter study on medical abortions in France in 2014]

OBJECTIVES

To describe the social characteristics of women seeking a medical abortion, and the conditions of that abortion, according to whether they had one or more previous induced abortions.

METHODS

An observational study was carried out in 11 French units in 2013-2014, among women 18 years or older. A self-administered questionnaire on the abortion context and social situation was given to them, as well as a diary to record the pain level for each of five days following the mifepristone intake. The sample included 453 women.

RESULTS

Among the respondents, 22% had had one previous abortion and 8% had had two or more. Women having had a previous voluntary abortion were more often isolated and in a poorer social situation than women having their first abortion.

CONCLUSION

Better support for contraception after abortion could reduce the number of repeated abortions.

Mifepristone and misoprostol is safe and effective method in the second-trimester pregnancy termination

PURPOSE

The second-trimester medical abortions constitute 10-15 % of all induced abortions worldwide, but are responsible for two-thirds of major abortion related complications. During the last decade, medical methods for the second-trimester-induced abortion have been become safer and more accessible. The aim of this study is to evaluate factors affecting clinical effectiveness of the second-trimester medical terminations using mifepristone and misoprostol combination.

METHODS

In this retrospective observational study, 142 consecutive women underwent medical abortion on 12-24 weeks of gestation. Clinical data were collected from Oulu University Hospital patients' records for the period between January 2008 and June 2011. The associations between patient characteristics and different outcomes were evaluated using the standard statistical test for correlation.

RESULTS

The majority (92 %) of women aborted successfully within 24 h and were considered as day cases with small complication rate, as compared to hospitalized patients. In nulliparous patients, the time for complete abortion was longer than in other groups (P < 0.0019). Nulliparous women and women with gestation more than 16 weeks required opiate analgesia more often (P = 0.003 and <0.001, respectively).

CONCLUSION

Women with previous live births aborted more often within 8 h than women with no previous births. Mifepristone and misoprostol is safe and effective method for the second-trimester pregnancy termination. The second-trimester medical abortion can be provided by a nurse-midwife with the back-up of a gynecologist.

EDUCATIONAL INEQUALITIES IN REPEAT ABORTION: A LONGITUDINAL REGISTER STUDY IN FINLAND 1975-2010

The proportion of repeat abortions among all abortions has increased over the last decades in Finland. This study examined the association of education with the likelihood of repeat abortion, and the change in this association over time using reliable longitudinal data. A unique set of register data from three birth cohorts were followed from age 20 to 45, including about 22,000 cases of repeat abortion, and analysed using discrete-time event-history models. Low education was found to be associated with a higher likelihood of repeat abortion. Women with low education had abortions sooner after the preceding abortion, and were more often single, younger and had larger families at the time of abortion than more highly educated women. The educational differences were more significant for later than earlier cohorts. The results show a lack of appropriate contraceptive use, possibly due to lack of knowledge of, or access to, services. There is a need to improve access to family planning services, and contraceptives should be provided free of charge. Register data overcome the common problems of under-reporting of abortion and attrition ensuring the results are reliable, unique and of interest internationally.

The association between education and induced abortion for three cohorts of adults in Finland

This paper explores whether the likelihood of abortion by education changed over time in Finland, where comprehensive family planning services and sexuality education have been available since the early 1970s. This subject has not previously been studied longitudinally with comprehensive and reliable data. A unique longitudinal set of register data of more than 250,000 women aged 20–49 born in 1955–59, 1965–69, and 1975–79 was analysed, using descriptive statistics, concentration curves, and discrete-time event-history models. Women with basic education had a higher likelihood of abortion than others and the association grew stronger for later cohorts. Selection into education may explain this phenomenon: although it was fairly common to have only basic education in the 1955–59 cohort, it became increasingly unusual over time. Thus, even though family planning services were easily available, socio-economic differences in the likelihood of abortion remained.

Characteristics of women with repeat termination of pregnancy: a study of all requests for pregnancy termination in Norway during 2007-2011

INTRODUCTION

We studied the proportion of all pregnancy terminations requested by women with a history of pregnancy termination. We also studied risk factors for repeat pregnancy termination.

MATERIAL AND METHODS

We used data from the Norwegian Register of Pregnancy Termination during the period 2007-2011, a total of 80,346 requests for pregnancy termination before the end of the 12th gestational week. Odds ratios for repeat pregnancy termination were estimated according to age, parity, contraceptive use, marital status, education, employment status and region of residency by applying logistic regression analyses. Repeat pregnancy termination was defined as request for pregnancy termination for the second time or more.

RESULTS

Among the 80 346 requests for pregnancy termination, 36.7% were among women with a history of pregnancy termination. In total, 25.0% had one prior termination and 11.7% had two or more. Factors associated with repeat pregnancy termination were; age ≥25 years, having one or more children, and use of contraception at the time of conception. College/university education as compared with primary school only, was associated with reduced risk of repeat termination.

CONCLUSION

Among all requests for pregnancy termination in Norway, 36.7% were from women with a history of pregnancy termination. Many women with repeat pregnancy termination have children and/or used contraception at the time of conception. Our findings therefore suggest that high fecundity is an underlying risk factor for repeat pregnancy termination.

Repeat abortions in New York City, 2010

This study aims to describe factors associated with the number of past abortions obtained by New York City (NYC) abortion patients in 2010. We calculated rates of first and repeat abortion by age, race/ethnicity, and neighborhood-level poverty and the mean number of self-reported past abortions by age, race/ethnicity, neighborhood-level poverty, number of living children, education, payment method, marital status, and nativity. We used negative binomial regression to predict number of past abortions by patient characteristics. Of the 76,614 abortions reported for NYC residents in 2010, 57% were repeat abortions. Repeat abortions comprised >50% of total abortions among the majority of sociodemographic groups we examined. Overall, mean number of past abortions was 1.3. Mean number of past abortions was higher for women aged 30-34 years (1.77), women with ≥5 children (2.50), and black non-Hispanic women (1.52). After multivariable regression, age, race/ethnicity, and number of children were the strongest predictors of number of past abortions. This analysis demonstrates that, although socioeconomic disparities exist, all abortion patients are at high risk for repeat unintended pregnancy and abortion.

Time to second abortion or continued pregnancy following a first abortion: a retrospective cohort study

STUDY QUESTION

What proportions of women have a second abortion or continued pregnancy within 12-46 months of a first abortion?

SUMMARY ANSWER

Estimated return rates for a second abortion were 5, 10.9 and 19.8% at 12, 24 and 46-months, respectively, and rates of continued pregnancy were 5.6, 12.9 and 24.3% at the same intervals.

WHAT IS KNOWN ALREADY

Studies attempting to identify women at risk for 'repeat abortion' for intervention purposes have described a range of demographic and behavioural characteristics associated with presentation for more than one abortion, but few have taken timing of abortions into account.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study involving women presenting for a first abortion at a public hospital abortion clinic in New Zealand (2007-2010).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Electronically stored records were analysed for women discharged from a public hospital abortion clinic in New Zealand. Outcome measures were the proportion of women having a second abortion or continued pregnancy within 24 months of a first abortion, and characteristics associated with shorter time to subsequent pregnancy. Cox proportional hazards modelling was used to detect factors associated with time to a second abortion or continued pregnancy, and Kaplan-Meier survival analyses were used to estimate time to one of these two pregnancy outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 6767 women had a first abortion between 2007 and 2010. Some data were missing for 11 women so were excluded from the cohort and analyses. Return rates for a second abortion estimated from survival analyses were 5, 10.9 and 19.8% at 12, 24 and 46 months, respectively. Estimated rates of continued pregnancies were 5.6, 12.9 and 24.3% at 12, 24 and 46 months, respectively. Younger age, non-European ethnicity and greater parity were significantly associated with shorter time to a second abortion and to a subsequent continued pregnancy (P < 0.01 for all factor P-values). Hazard ratios (HR) for a second abortion were highest among those aged 16-19 years (HR 1.6, 95% confidence interval (CI) 1.3-1.9, Reference 20-24), of Pacific Island (HR 1.35, 95% CI 1.1-1.7) or Maori ethnicity (HR 1.26, 95% CI 1.1-1.5, Reference New Zealand European), and with 1 (HR 1.41, 95% CI 1.1-1.7) or 2 (HR 1.41, 95% CI 1.1-1.9, Reference nulliparous) children at the time of the first abortion. Both pregnancy outcomes were observed among 120 women (1.8%), with 60% of these women having a second abortion before the continued pregnancy.

LIMITATIONS, REASONS FOR CAUTION

This study was limited to analysis of routinely collected clinical and demographic data for women presenting for abortion over a 4-year period. Conclusions could not be drawn about a wider range of personal and situational factors influencing pregnancy and pregnancy outcomes. Data were drawn from only one clinic but characteristics of the study sample were broadly representative of those reported nationally. Loss to follow-up for women seeking a second abortion elsewhere in the country cannot be ruled out and would serve to underestimate return rates reported here.

WIDER IMPLICATIONS OF THE FINDINGS

To date, the most effective public health measure known to reduce abortion return rates within 24 months is the initiation of long-acting reversible contraception (LARC) at the time of an abortion. The high proportion of women seeking a second abortion <4 years after a first abortion (20%) could be significantly reduced by use of LARC, as could unintended pregnancies that are continued soon after a first abortion, particularly among teenaged and young women. Barrier-free access to a range of LARC methods should be prioritized to prevent unintended and mistimed pregnancies.

STUDY FUNDING/COMPETING INTERESTS

Funded by a Lottery Health Research Grant and a University of Otago Research Grant. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: population register based study

OBJECTIVE

To determine the risks of short term adverse events in adolescent and older women undergoing medical abortion.

DESIGN

Population based retrospective cohort study.

SETTING

Finnish abortion register 2000-6.

PARTICIPANTS

All women (n = 27,030) undergoing medical abortion during 2000-6, with only the first induced abortion analysed for each woman.

MAIN OUTCOME MEASURES

Incidence of adverse events (haemorrhage, infection, incomplete abortion, surgical evacuation, psychiatric morbidity, injury, thromboembolic disease, and death) among adolescent (<18 years) and older (≥ 18 years) women through record linkage of Finnish registries and genital Chlamydia trachomatis infections detected concomitantly with abortion and linked with data from the abortion register for 2004-6.

RESULTS

During 2000-6, 3024 adolescents and 24,006 adults underwent at least one medical abortion. The rate of chlamydia infections was higher in the adolescent cohort (5.7% v 3.7%, P < 0.001). The incidence of adverse events among adolescents was similar or lower than that among the adults. The risks of haemorrhage (adjusted odds ratio 0.87, 95% confidence interval 0.77 to 0.99), incomplete abortion (0.69, 0.59 to 0.82), and surgical evacuation (0.78, 0.67 to 0.90) were lower in the adolescent cohort. In subgroup analysis of primigravid women, the risks of incomplete abortion (0.68, 0.56 to 0.81) and surgical evacuation (0.75, 0.64 to 0.88) were lower in the adolescent cohort. In logistic regression, duration of gestation was the most important risk factor for infection, incomplete abortion, and surgical evacuation.

CONCLUSIONS

The incidence of adverse events after medical abortion was similar or lower among adolescents than among older women. Thus, medical abortion seems to be at least as safe in adolescents as it is in adults.

Attendance at post-abortal follow-up visits is low - can the risks of non-attendance be identified?

Post-abortal follow-up visits are recommended following induced abortion. To assess the rates of attendance and the factors affecting it, we performed a retrospective study of 500 women who had an induced abortion up to 20 weeks of gestation. Altogether, 285 (57%) women attended for the follow-up visit as scheduled. In univariable analysis a history of drug abuse (OR=0.22, 95%CI 0.06-0.81, p=0.02) was associated with non-attendance. Women who underwent medical abortion either at the hospital (OR=3.93, 95%CI 2.61-5.92, p<0.01) or partly at home (OR=3.30, 95%CI 1.86-5.84, p<0.01) and those with a history of human papilloma virus manifestation (OR=2.38, 95%CI 1.04-5.26, p=0.04) were more likely to attend the follow-up visit. The effects of medical abortion and a history of human papilloma virus manifestation persisted in multivariable analysis. We conclude that attendance at post-abortal follow-up visits is low, with only a few clinically significant risk factors predicting non-attendance.

Young age and termination of pregnancy during the second trimester are risk factors for repeat second-trimester abortion

OBJECTIVE

The objective of the study was to characterize women undergoing a termination of pregnancy (TOP) during the second trimester and to evaluate the risk factors and timing of repeat TOP.

STUDY DESIGN

This nationwide retrospective cohort study investigated 41,750 women who underwent TOP during the first (n = 39,850) or second (n = 1900) trimester in Finland in 2000-2005. The follow-up time was until repeat TOP or until Dec. 31, 2006.

RESULTS

TOP during the second trimester increases the risk of repeat TOP (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.3-1.6), repeat second-trimester TOP (HR, 3.8; 95% CI, 2.9-5.1), and repeat TOP after 16 weeks of gestation (HR, 5.0; 95% CI, 3.3-7.7). The other risk factor for these is young age (HR, 7.0, 95% CI, 5.3-9.3; and HR, 12.5; 95% CI, 3.1-50.4 for age <20 years).

CONCLUSION

Second-trimester TOP and young age are risk factors for repeat second-trimester TOP. Special focus on these women might be effective in decreasing repeat abortions.