Plan A: postabortion contraception

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

OBJECTIVE

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.

INTENDED USERS

Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.

TARGET POPULATION

Women with an unintended or abnormal first or second trimester pregnancy.

EVIDENCE

PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.

VALUES

The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

Family Planning and Counseling Desires of Women Who Have Experienced Miscarriage

OBJECTIVE

To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling preferences of women experiencing spontaneous abortion.

METHODS

We conducted semistructured qualitative interviews with women who recently experienced spontaneous abortion to explore their feelings about conception, pregnancy, and miscarriage; their future family planning goals; and contraceptive counseling preferences. Two trained coders utilized an inductive, iterative approach to code transcripts and identify themes using Atlas.ti software to organize the analysis.

RESULTS

We interviewed 26 women reporting varied intentions in their recent pregnancies: 54% were trying to conceive, 27% were not trying but not preventing, and 19% were attempting to avoid pregnancy. Participants reported a range of feelings about the pregnancy diagnoses and eventual miscarriages with some relatively unemotional ("a little disappointed…suffering for two months for nothing") and others feeling devastated by their pregnancy losses ("in shock," "for it to be taken away was crushing"). Varying character and intensity of emotional reactions were seen across the range of initial pregnancy intentions. Some participants had consistent childbearing plans before and after miscarriage, whereas others experienced their pregnancies and losses as clarifying events leading to changed goals moving forward ("it was a wake-up call"). Although family planning needs were inconsistently addressed after spontaneous abortion, women were generally receptive to the idea of contraceptive counseling, though they had different preferences regarding timing, ranging from immediately to weeks later.

CONCLUSION

Women's reproductive goals after spontaneous abortion cannot be inferred based on initial pregnancy intention or emotional reactions to pregnancy loss. Health care providers should offer family planning counseling to all women after spontaneous abortion, remaining responsive to individual patient needs.

Contraception after Abortion and Risk of Repeated Unintended Pregnancy among Health Plan Members

CONTEXT

Optimizing access to effective contraception at the time of abortion can reduce repeated unintended pregnancies.

OBJECTIVE

To assess contraception initiation and repeated unintended pregnancies among women receiving abortions in Kaiser Permanente Northern California (KPNC) facilities and through outside contracted facilities.

DESIGN

A retrospective cohort study was conducted using a randomized proportional sample of women aged 15 to 44 years having abortions in KPNC, to determine contraception initiation within 90 days. Demographic and clinical characteristics (age, race/ethnicity, gravidity, parity, contraceptive method initiated, and pregnancies within 12 months) were collected from electronic health records. Descriptive statistics, χ² tests, t-tests, and logistic regression models assessed predictors of long-acting reversible contraception (LARC) initiation and having another unintended pregnancy within 12 months of abortion.

RESULTS

Women having abortions from contracted facilities were significantly less likely to initiate LARC within 90 days compared with those receiving abortions in KPNC facilities (11.99% vs 19.10%, p = 0.012). Significant factors associated with 90-day LARC initiation included abortions in KPNC facilities (adjusted odds ratio [aOR] = 1.87, p = 0.007) and gravidity of 3 or more. Women initiating short-acting or no contraception were significantly more likely to have an unintended pregnancy within 12 months of the abortion than those initiating LARC (aOR = 3.66, p = 0.005; no contraception vs LARC, aOR = 3.75, p = 0.005).

CONCLUSION

In response to this study, KPNC now provides reimbursement for LARC in all outside abortion contracts, internalized more abortions in KPNC facilities, and strengthened clinical recommendations for immediate, effective postabortion contraception, especially LARC.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.