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Hogmark S, Rydelius J, Envall N, Teleman P, Gemzell-Danielsson K, Kopp Kallner H. Placement of an intrauterine device within 48 hours after second-trimester medical abortion: a randomized controlled trial. Am J Obstet Gynecol 2024:S0002-9378(24)00627-6. [PMID: 38796039 DOI: 10.1016/j.ajog.2024.05.041] [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: 01/11/2024] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND International guidelines recommend placement of intrauterine devices immediately after second-trimester medical abortion, but evidence concerning the optimal time for intrauterine device placement is lacking from clinical trials. OBJECTIVE This study aimed to investigate effectiveness, safety, and acceptability of intrauterine device placement within 48 hours, compared with placement at 2 to 4 weeks after second-trimester medical abortion. We hypothesized that intrauterine device placement within 48 hours would be superior compared with placement at 2 to 4 weeks after the abortion, in terms of the proportion of intrauterine device use after 6 months, with maintained safety and acceptability. STUDY DESIGN In this open-label, randomized, controlled, superiority trial, we recruited participants at 8 abortion clinics in Sweden. Eligible participants were aged ≥18 years, requesting medical abortion with gestation ≥85 days, and opting for use of a postabortion intrauterine device. Participants were randomized (1:1) to intrauterine device placement either within 48 hours of complete abortion (intervention) or after 2 to 4 weeks (control). Our primary outcome was self-reported use of an intrauterine device after 6 months. Secondary outcomes included expulsion rates, pain at placement, adverse events and complications, acceptability, and subsequent pregnancies and abortions. Differences in nonnormal continuous variables were analyzed with the Mann-Whitney U test, and differences in dichotomous variables with the chi-square or Fisher exact tests. A P value <.05 was considered statistically significant. Group differences are presented by modified intention-to-treat and per-protocol analyses. RESULTS Between January 2019 and June 2022, we enrolled 179 participants, of whom 90 were assigned to the intervention and 89 to the control arm. Enrollment was prematurely stopped after an interim analysis exceeded a predefined intrauterine device expulsion rate of 20%. According to modified intention-to-treat analysis, use of intrauterine device after 6 months was 50.7% (34/67) in the intervention group vs 71.6% (48/67) in the control group (proportion difference, 20.9%; 95% confidence interval, 4.4%-35.9%; P=.02). The intrauterine device expulsion rate was 30.1% (22/73) in the intervention group vs 2.9% (2/70; P<.001) in the control group. Other adverse events were rare and patient acceptability was high in both groups. CONCLUSION Intrauterine device placement within 48 hours after second-trimester medical abortion was nonsuperior in terms of the proportion of intrauterine device use after 6 months when compared with placement after 2 to 4 weeks. Placement within 48 hours after second-trimester abortion can be used in selected individuals after counseling on expulsion risk.
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Affiliation(s)
- Sara Hogmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden; Department of Obstetrics and Gynecology, Falu Hospital, Falun, Sweden.
| | - Johanna Rydelius
- Department of Obstetrics and Gynecology, University of Gothenburg, Gothenburg, Sweden
| | - Niklas Envall
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; School of Health and Welfare, Dalarna University, Falun, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Pia Teleman
- Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Gynaecology and Obstetrics, Skåne University Hospital, Lund, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; World Health Organization Collaborating Centre for Research and Research Training in Human Reproduction, Karolinska University Hospital, Stockholm, Sweden, (j)Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology, University of Gothenburg, Gothenburg, Sweden
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Lou Y, Tang S, Sheng Z, Lian H, Yang J, Jin X. Immediate and delayed placement of the intrauterine device after abortion: a systematic review and meta-analysis. Sci Rep 2024; 14:11385. [PMID: 38762680 PMCID: PMC11102502 DOI: 10.1038/s41598-024-62327-1] [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: 08/28/2023] [Accepted: 05/15/2024] [Indexed: 05/20/2024] Open
Abstract
This article aims to report the comprehensive and up-to-date analysis and evidence of the insertion rate, expulsion rate, removal rate, and utilization rate of immediate placement of intrauterine devices (IUDs) versus delayed placement after artificial abortion. PubMed, Embase, Cochrane, Web of Science, CNKI, and Wanfang databases were comprehensively searched up to January 12, 2024 for studies that compared immediate versus delayed insertion of IUDs after abortion. The evaluation metrics included the number of IUD insertion after surgical or medical abortions, the frequency of expulsion and removal at 6 months or 1 year, the number of continued usage, pain intensity scores, the number of infections, the duration of bleeding, and instances of uterine perforation during or after IUD insertion. Ten randomized controlled articles were eligible, comprising 11 research projects, of which 3 projects involved the placement of an IUD after surgical abortion, and 8 projects involved the placement of an IUD after medical abortion. This included 2025 patients (977 in the immediate insertion group and 1,048 in the delayed insertion group). We summarized all the extracted evidence. The meta-analysis results indicated that for post-surgical abortions, the immediate insertion group exhibited a higher IUD placement rate than the delayed insertion group. After medical abortions, the immediate insertion group showed higher rates of IUD placement, utilization, and expulsion at 6 months or 1 year. The two groups showed no statistically significant differences in the removal rate, post-insertion infection rate, pain scores during insertion, and days of bleeding during the follow-up period. Compared to delayed placement, immediate insertion of IUDs can not only increase the usage rate at 6 months or 1 year but also enhance the placement rate.
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Affiliation(s)
- Ying Lou
- Women Healthcare Department, CiXi Maternity and Child Health Care Hospital, Cixi, 315300, Zhejiang, China
| | - Shanshan Tang
- Gynecology Department, Hangzhou Women's Hospital, Hangzhou, 310000, Zhejiang, China
| | - Zhumei Sheng
- Women Healthcare Department, Hangzhou Women's Hospital, Hangzhou, 310000, Zhejiang, China
| | - Hongqin Lian
- Gynecology Department, CiXi Maternity and Child Health Care Hospital, Cixi, 315300, Zhejiang, China
| | - Jingjing Yang
- Medical Department, CiXi Maternity and Child Health Care Hospital, Cixi, 315300, Zhejiang, China
| | - Xuejing Jin
- Reproductive Endocrinology Center, Hangzhou Women's Hospital, 369 Kunpeng Road, Shangcheng District, Hangzhou, 310000, Zhejiang, China.
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Hogmark S, Envall N, Gemzell‐Danielsson K, Kopp Kallner H. One-year follow up of contraceptive use and pregnancy rates after early medical abortion: Secondary outcomes from a randomized controlled trial of immediate post-abortion placement of intrauterine devices. Acta Obstet Gynecol Scand 2023; 102:1694-1702. [PMID: 37614066 PMCID: PMC10619601 DOI: 10.1111/aogs.14662] [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: 04/29/2023] [Revised: 06/22/2023] [Accepted: 07/27/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Intrauterine devices (IUDs) effectively prevent unwanted pregnancies. Little is known about long-term outcomes of women choosing an IUD after early medical abortion. MATERIAL AND METHODS We present secondary outcome data of continuation rates, factors associated with continuation and discontinuation, choice of IUD type, women's satisfaction with IUD, and IUD expulsions, subsequent pregnancies, and abortions within 1 year post-abortion in a randomized, controlled, multicenter trial on IUD placement within 48 hours compared with placement 2-4 weeks after medical abortion up to 63 days' gestation (ClinicalTrials.gov NCT03603145). RESULTS Of the 240 women studied, 112/120 (93.3%) in the intervention group vs 113/120 (94.2%) in the control group completed the 12-month follow-up. The rate of IUD use at 12 months was 84/112 (75%) in the intervention group vs 75/113 (66.4%) in the control group (P = 0.19). Attendance at the IUD placement visit was the only predictor of long-term IUD use (relative risk [RR] = 5.7, 95% confidence interval [CI] 2.03-16.0; P = 0.001). The main reason for choosing an IUD was high contraceptive effectiveness. The most common reasons for IUD discontinuation were bleeding problems and abdominal pain. IUD expulsion was rare and did not differ between groups. Satisfaction among IUD users at 1 year was high (>94%) and the majority of all participants would recommend IUD to a friend (65.8%). Use of no contraception and experience of unprotected intercourse were less common in the intervention group (11/112 [9.8%] vs 25/113 [22.1%], P = 0.02 and 17/112 [15.2%] vs 32/113 [28.3%], P = 0.02, respectively). There was no difference in the rate of subsequent pregnancies and abortions (pregnancies 14/112, 12.5% in the intervention group vs 8/113, 7.1% in the control group, P = 0.19; abortions 5/112, 4.5% vs 3/113, 2.7%, P = 0.5). CONCLUSIONS IUD placement after medical abortion led to high continuation and satisfaction rates with no difference between groups. We found no difference in IUD expulsions after immediate compared with later placement. Unprotected intercourse was significantly less common in the immediate group. In clinical practice, immediate placement of IUDs available free of charge at the abortion clinic is likely to increase attendance to the placement visit and continued use of IUDs after abortion.
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Affiliation(s)
- Sara Hogmark
- Department of Clinical SciencesDanderyd Hospital, Karolinska InstitutetStockholmSweden
- Center for Clinical Research DalarnaUppsala UniversityFalunSweden
| | - Niklas Envall
- Department of Clinical SciencesDanderyd Hospital, Karolinska InstitutetStockholmSweden
- School of Health and WelfareDalarna UniversityFalunSweden
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Kristina Gemzell‐Danielsson
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- World Health Organization Collaborating Center for Research and Research Training in Human ReproductionStockholmSweden
- Department of Gynecology and Reproductive medicineKarolinska University HospitalStockholmSweden
| | - Helena Kopp Kallner
- Department of Clinical SciencesDanderyd Hospital, Karolinska InstitutetStockholmSweden
- Department of Obstetrics and GynecologyDanderyd HospitalStockholmSweden
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Madison AM, Powers D, Maslowsky J, Goyal V. Association Between Publicly Funded Contraceptive Services and the Abortion Rate in Texas, 2010-2015. Obstet Gynecol 2023; 141:361-370. [PMID: 36649327 PMCID: PMC9858333 DOI: 10.1097/aog.0000000000005057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/20/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate how the availability of contraceptive services was associated with a change in the abortion rate before and after Texas' legislative changes to the family planning budget in 2011 and abortion access in 2013. METHODS In this cross-sectional study, we obtained 2010 and 2015 data on contraceptive provision (number of publicly funded clinics and number of contraceptive clients served per 1,000 reproductive-aged women) from the Guttmacher Institute and county-level abortion data from the Texas Department of State Health Services. We categorized counties as having an abortion rate that increased or declined less than the national rate between 2010 and 2015 ( low-decline counties ) compared with those having an abortion rate that declined equal to or greater than the national rate between 2010 and 2015 ( high-decline counties ). We evaluated differences in contraceptive provision between high-decline and low-decline counties and evaluated county characteristics (racial and ethnic composition, unemployment, poverty, uninsured, education, distance to an abortion clinic, deliveries covered by Medicaid, and Catholic hospital marketplace dominance) as potential confounders. RESULTS Of 157 counties that had at least one contraceptive clinic in either 2010 or 2015, 49 were low-decline counties and 108 were high-decline counties. Although the total number of publicly funded family planning clinics increased by 10.8%, there was a 4.7% decrease in the total number of contraceptive clients served statewide. Compared with low-decline counties, high-decline counties had a higher median number of contraceptive clients served per 1,000 women aged 18-44 years (31.9 vs 60.7, P <.05) in 2015. Between 2010 and 2015, the abortion rate decreased 19.7% for each 1.0% increase in contraceptive clients served. CONCLUSION Texas counties with higher abortion-rate declines had more publicly funded contraceptive clinics and served more contraceptive clients than counties with lower declines, which may indicate the importance of greater access to publicly funded contraceptive services.
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Affiliation(s)
- Anita M Madison
- Department of Obstetrics and Gynecology, Louisiana State University Health Science Center, Baton Rouge, Louisiana; the Population Research Center, University of Texas at Austin, Austin, Texas; and the School of Public Health, University of Illinois Chicago, Chicago, Illinois
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Hogmark S, Liljeblad KL, Envall N, Gemzell-Danielsson K, Kallner HK. Placement of an intrauterine device within 48 hours after early medical abortion-a randomized controlled trial. Am J Obstet Gynecol 2023; 228:53.e1-53.e9. [PMID: 35970199 DOI: 10.1016/j.ajog.2022.07.063] [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: 04/08/2022] [Revised: 07/29/2022] [Accepted: 07/31/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Intrauterine devices are safe, well-tolerated, and known to reduce the risk of unwanted pregnancies. At medical abortion, intrauterine devices are placed at a follow-up visit. Patients who miss this visit risk being left without contraception. OBJECTIVE This study aimed to investigate if placement of an intrauterine device within 48 hours of completed medical abortion at up to 63 days' gestation leads to higher user rates at 6 months after the abortion compared with placement at 2 to 4 weeks after abortion. Furthermore, we aimed to compare continued use of intrauterine devices, safety, and patient satisfaction between groups. STUDY DESIGN We performed an open-label, randomized, controlled, multicenter, superiority trial (phase 3). A total of 240 patients requesting medical abortion at up to 63 days' gestation and opting for an intrauterine device were allocated to placement within 48 hours of complete medical abortion (intervention group) or at 2 to 4 weeks after abortion (control group). We defined the abortion as complete after bleeding with clots and cessation of heavy bleeding following the use of misoprostol. Patients answered questionnaires at 3, 6, and 12 months. The primary outcome was use of intrauterine device at 6 months postabortion. Secondary outcomes included expulsion rate, pain at placement, adverse events and complications from the abortion, acceptability, and pregnancies and their outcomes. Differences in nonparametric continuous variables were analyzed with the Mann-Whitney U test and differences in dichotomous variables with the chi square or Fisher exact tests. A P value of <.05 was considered statistically significant. RESULTS In the intervention group, 91 of 111 (82%) participants used an intrauterine device at 6 months after the abortion vs 87 of 112 (77.7%) in the control group, with a difference in proportion of 4.3% (95% confidence interval, -0.062 to 0.148; P=.51). Attendance rate and rate of successful intrauterine device placement were similar between the groups. Patients in the intervention group had lower pain scores at placement of the intrauterine device (mean pain score [visual analogue scale], 32.3; standard deviation, 29) compared with the control group (mean pain score [visual analogue scale], 43.4; standard deviation, 27.9; P=.002). Patients preferred their allocated time of placement significantly more often in the intervention group (83/111, 74.8%) than in the control group (70/114, 61.4%; P=.03). Use of ultrasound at intrauterine device placement (because of doubts concerning complete abortion) was more common in the intervention group (43/108, 39.8%) than in the control group (15/101, 14.9%; P<.001), and in one patient in the control group a retained gestational sac was found. Three patients in the intervention group and 2 in the control group had a vacuum aspiration. No difference was found in intrauterine device expulsion rates between the groups. Expulsion during the first 6 months after abortion was experienced by 9 of 97 (9.3%) patients in the intervention group and 4 of 89 (4.5%; P=.25) in the control group. There were no perforations or infections requiring antibiotic treatment. CONCLUSION Placement of an intrauterine device within 48 hours after medical abortion at ≤63 days' gestation does not lead to higher user rates at 6 months after the abortion compared with intrauterine device placement at 2 to 4 weeks after abortion. When compared with placement at a follow-up visit after 2 to 4 weeks, intrauterine device placement within 48 hours after early medical abortion seems safe, is preferred by patients, and is associated with lower pain scores.
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Affiliation(s)
- Sara Hogmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden.
| | - Karin Lichtenstein Liljeblad
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden
| | - Niklas Envall
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; School of Health and Welfare, Dalarna University, Falun, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; World Health Organization Collaborating Centre for Research and Research Training in Human Reproduction, Department of Gynecology and Reproductive medicine, Karolinska University Hospital, Stockholm, Sweden
| | - 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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Costescu D, Chawla R, Hughes R, Teal S, Merz M. Discontinuation rates of intrauterine contraception due to unfavourable bleeding: a systematic review. BMC Womens Health 2022; 22:82. [PMID: 35313863 PMCID: PMC8939098 DOI: 10.1186/s12905-022-01657-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Levonorgestrel-releasing intrauterine devices (LNG-IUDs) and copper intrauterine devices (Cu-IUDs) offer long-acting contraception; however, some women may discontinue use within the first year due to bleeding pattern changes, limiting their potential. This systematic literature review investigated whether differences in bleeding profiles influence continuation rates in women in America, Europe and Australia. METHODS Searches performed in PubMed and Embase were screened to identify publications describing bleeding patterns and rates of early IUC removal/discontinuation or continuation, descriptions of bleeding patterns, reasons for discontinuation, and patient satisfaction, acceptability and tolerability for LNG-IUDs and Cu-IUDs published between January 2010 and December 2019. The results were further restricted to capture citations related to 'Humans' and 'Females'. The review was limited to studies published from 2010 onwards, as changing attitudes over time mean that results of studies performed before this date may not be generalizable to current practice. RESULTS Forty-eight publications describing 41 studies performed principally in the USA (n = 17) and Europe (n = 13) were identified. Publications describing bleeding patterns in LNG-IUD users (n = 11) consistently observed a reduction in bleeding in most women, whereas two of three studies in Cu-IUD users reported heavy bleeding in approximately 40% of patients. Rates of discontinuation for both devices ranged widely and may be as high as 50% but were lower for LNG-IUDs versus Cu-IUDs. Discontinuation rates due to bleeding were consistently higher for Cu-IUDs versus LNG-IUDs. CONCLUSIONS Bleeding is a common reason for discontinuation of Cu-IUDs and LNG-IUDs. The more favourable bleeding pattern observed in LNG-IUD users may be associated with a lower rate of early discontinuation of LNG-IUDs versus Cu-IUDs.
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Affiliation(s)
- Dustin Costescu
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON, Canada
| | | | | | - Stephanie Teal
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Martin Merz
- Medical Affairs and Pharmacovigilance, Pharmaceuticals MA TA Women's Health Care, Bayer AG, Building S101, 10/244, 13342, Berlin, Germany.
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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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Goyal V, Madison AM, Powers DA, Potter JE. Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception. Contraception 2021; 104:512-517. [PMID: 34077749 PMCID: PMC8502203 DOI: 10.1016/j.contraception.2021.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/10/2021] [Accepted: 05/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program. STUDY DESIGN In this prospective study conducted between October 2014 and March 2016, we evaluated participants' desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type. RESULTS Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use). CONCLUSIONS In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods. IMPLICATIONS State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients' ability to obtain their preferred method.
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Affiliation(s)
- Vinita Goyal
- Population Research Center, University of Texas at Austin, Austin, TX.
| | - Anita M Madison
- Department of Obstetrics and Gynecology, Louisiana State University Health Science Center, Baton Rouge, LA
| | - Daniel A Powers
- Population Research Center, University of Texas at Austin, Austin, TX
| | - Joseph E Potter
- Population Research Center, University of Texas at Austin, Austin, TX
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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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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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11
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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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12
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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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13
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Pohjoranta E, Mentula M, Suhonen SP, Heikinheimo O. Predicting poor compliance with follow-up and intrauterine contraception services after medical termination of pregnancy. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:bmjsrh-2018-200098. [PMID: 30219793 DOI: 10.1136/bmjsrh-2018-200098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Attendance at post-abortion follow-up visits is poor, but little is known about factors affecting it. OBJECTIVE To assess the factors associated with non-compliance with post-abortion services and to evaluate differences in rates of attendance and intrauterine device (IUD) insertion according to the type of service provision. METHODS 605 women undergoing a first trimester medical termination of pregnancy (MTOP) and planning to use intrauterine contraception were randomised into two groups. Women in the intervention group (n=306) were booked to have IUD insertion 1-4 weeks after the MTOP at the hospital providing the abortion, while women in the control group (n=299) were advised to contact their primary healthcare (PHC) centre for follow-up and IUD insertion. RESULTS In the intervention group, 21 (6.9%) women failed to attend the follow-up visit, whereas in the control group 67 (22.4%) women did not contact the PHC to schedule a follow-up (p<0.001). In both groups, non-attendance was associated with history of previous pregnancy and abortion. Not having an IUD inserted within 3 months was significantly more common in the control group (73.6% (n=220)) than in the intervention group (9.2% (n=28), p<0.001). In the intervention group, predictive factors for not having an IUD inserted were anxiety, history of pregnancy and abortion. However, we identified no significant predictive factors in the control group. CONCLUSIONS Factors predicting low compliance with post-MTOP follow-up are few. Comprehensive provision of abortion care and post-abortion services seems beneficial for minimising the loss to follow-up and delay in initiation of effective contraception. TRIAL REGISTRATION NUMBER NCT01223521;Results.
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Affiliation(s)
- Elina Pohjoranta
- 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
| | - Satu P Suhonen
- Centralised Family Planning, Department of Social Services and Health Care, Helsinki, Finland
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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14
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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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15
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Korjamo R, Mentula M, Heikinheimo O. Authors' reply re: 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; 125:93. [PMID: 29243361 DOI: 10.1111/1471-0528.14902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Riina Korjamo
- 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
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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