Early versus delayed insertion of intrauterine contraception after medical abortion - a randomized controlled trial

Adoption of contraception following a pregnancy loss in India

OBJECTIVE

The present study was carried out to describe contraceptive adoption following pregnancy terminations that resulted in outcomes other than live birth.

METHOD

Retrospective calendar data on 31486 women who had experienced a pregnancy loss within the last 60 months prior to the survey date were drawn from a nationally representative dataset. Logistic regression was employed to model the associated factors with contraceptive uptake.

RESULTS

Overall, 57.8% reported not adopting any method following the end of the recent pregnancy. There was a significant association between the choice of contraceptive method and timing of adoption. Women with living children were significantly more likely to adopt contraception as compared to women without any child.

CONCLUSION

Contraceptive uptake following a non-live birth is considerably low in India. Interventions in reproductive health should focus on provision of different contraceptive methods and counseling emphasizing on effectiveness and correct use of the methods at the end of any pregnancy.

Placement of an intrauterine device within 48 hours after second-trimester medical abortion: a randomized controlled trial

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.

Immediate and delayed placement of the intrauterine device after abortion: a systematic review and meta-analysis

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.

Contraception after abortion, miscarriage, ectopic and molar pregnancy

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.

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

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.

Knowledge, Attitude, and Practice of Brazilian Physicians about Immediate Postpartum and Postabortion Intrauterine Device Insertion

OBJECTIVE

 To assess the knowledge, attitude, and practice of Brazilian physicians about immediate postpartum and postabortion intrauterine device insertion.

METHODS

 Cross-sectional online survey involving physicians on duty in public Brazilian hospitals. Participants answered an anonymous questionnaire with close-ended questions to assess their knowledge, attitude, and experience on the immediate postpartum and postabortion insertion of copper intrauterine devices.

RESULTS

 One hundred twenty-seven physicians working in 23 hospitals in the 5 geographic regions of Brazil completed the questionnaire. Most were female (68.5%) and worked in teaching hospitals (95.3%). The mean (standard deviation) knowledge score (0-10 scale) was 5.3 (1.3); only 27.6% of the participants had overall scores ≥ 7.0. Most physicians (73.2%) would insert a postpartum intrauterine device in themselves/family members. About 42% of respondents stated that they had not received any training on postpartum or postabortion intrauterine device insertion. In the past 12 months, 19.7%, 22.8%, and 53.5% of respondents stated they had not inserted any intrauterine device during a cesarean section, immediately after a vaginal delivery, or after an abortion, respectively.

CONCLUSION

 Most study participants have a positive attitude toward the insertion of intrauterine devices in the immediate postpartum period, but they have limited knowledge about the use of this contraceptive method. A large percentage of respondents did not have previous training on postpartum and postabortion intrauterine device insertion and had not performed any such insertions in the last 12 months. Strategies are needed to improve the knowledge, training, and experience of Brazilian physicians on immediate postpartum and postabortion intrauterine device insertion.

Self-reported contraceptive use and satisfaction among women accessing telemedicine medical abortion at the onset of the COVID-19 pandemic at 3-6-month follow-up

BACKGROUND

Changes in legislation due to COVID-19 led to the introduction of telemedicine for early medical abortion (EMA) at home in Scotland. The opportunity to provide contraception at presentation may be more limited with this model of care. We compared contraceptive use immediately post-abortion with 3-6 months later to determine if contraceptive needs were being met.

METHODS

We contacted 579 women by telephone call or text message who agreed to be involved in a service evaluation of telemedicine EMA in NHS Lothian at 3-6 months post-abortion. A research nurse administered a questionnaire on the women's current contraception use. The research nurses also offered women support in switching or initiating contraception via the abortion service if desired.

RESULTS

The response rate to the contact was 57% (331/579). Under a third of the women (30%, 98/331) were using the progestogen-only pill (POP) at 3-6 month follow-up, a significant decrease (p<0.00) compared with 65% (215/331) who were provided with POP at the time of abortion. Thirty-nine women (12%) were provided with contraception through this telephone contact, leading to a significant increase in the proportion using subdermal implants, the progestogen injectable or intrauterine contraception.

CONCLUSIONS

This study shows that there was a decrease in the use of the POP 3-6 months after telemedicine EMA during the COVID-19 pandemic. Telephone contact at 3-6 months to facilitate obtaining contraception may be a promising strategy to improve access to effective methods with this model of abortion care.

Placement of an intrauterine device within 48 hours after early medical abortion-a randomized controlled trial

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.

Effectiveness, safety and overall satisfaction of early postpartum placement of hormonal IUD compared with standard procedure: An open-label, randomized, multicenter study

INTRODUCTION

In this open-label, randomized controlled, non-inferiority, multicenter study we aimed to study the risk of termination of pregnancy within 1 year postpartum, the safety profile and patient acceptability after early postpartum insertion of a hormonal intrauterine device (LNG-IUS, Mirena®) compared with standard placement 6-8 weeks postpartum.

MATERIAL AND METHODS

April 2018 to January 2020 women with uncomplicated vaginal delivery at four urban birth centers in Sweden, were randomized to either early placement within 48 h after delivery (early group) or standard placement 6-8 weeks postpartum (standard group) of a hormonal intrauterine device. The main outcome measure was the proportion of terminations of pregnancies in each group during the first year after placement of the intrauterine device. Registration EudraCT database no. 2017-001945-29.

RESULTS

The study was prematurely stopped according to the protocol due to an expulsion rate >20% in the early group. No pregnancies occurred. Fifty-two women were randomized to early and 49 women to standard insertion. In the early group, 23/52 (44.2%) of the intrauterine devices were expelled. After expulsion, 10 women chose to have another hormonal intrauterine device placed but still significantly fewer women (39/52, 75%, p = 0.22) in the early group used the hormonal intrauterine device method at study completion. No expulsions occurred in the standard group, but 5/49 (10.2%) requested removal and 41/49 (83.7%, p = 0.22) had used the hormonal intrauterine device method continuously for 1 year.

CONCLUSIONS

Early hormonal intrauterine device insertion after vaginal delivery is associated with high expulsion rates. Despite this, a high continuation rate of the hormonal intrauterine device method is seen among women once choosing the method. In the light of high continuation rates, the advantages of early insertion could balance the risk of expulsion for well-informed women.

Contraceptive Technology: Present and Future

Many sexually active, reproductive-aged persons capable of becoming pregnant use some method of contraception. To expand options for those desiring birth control, new choices include a vaginal ring, transdermal patch, progestin-only pill, and spermicide. Compared with currently available methods, additional technologies that are highly effective, easy to use, cost efficient, and well-tolerated lay on the horizon. During contraceptive counseling, patient choice, and reproductive autonomy should remain paramount.

Continuation of Contraception Following Termination of Pregnancy in a Canadian Urban Centre

OBJECTIVE

Minimal evidence exists on the continuation of contraception following termination of pregnancy. Continuation of effective contraception is important because it has been found to reduce unintended pregnancies. This study aims to determine the rate of continuation and choice of contraception following termination of pregnancy.

METHODS

A cross-sectional analytic study was undertaken of 400 patients undergoing termination of pregnancy over 2 years. Demographic information and contraception choice prior to, at time of, and 6 months following termination were collected. Data were analyzed to assess relationships between patient characteristics and contraceptive choice.

RESULTS

Prior to termination, 58.5% of patients were not using contraception and 22.4% used a less effective method (e.g., barrier or fertility awareness). Following termination, 99.7% of patients chose a method of contraception, and 95.2% chose a more effective method (e.g., long acting reversible contraception, permanent sterilization, combined hormonal contraceptives, progesterone-only contraceptive). Six months following termination, 85.8% of patients were using contraception. A more effective method was continued by 37.8%. There were no significant relationships between choice of contraception and age, previous pregnancies, or social determinants of health. Patients living with their sexual partner were significantly more likely to switch to a less effective method of contraception at 6 months.

CONCLUSIONS

Following termination of pregnancy, almost all patients chose a method of contraception and most continued using contraception 6 months following termination.

Early provision of intrauterine contraception as part of abortion care-5-year results of a randomised controlled trial

STUDY QUESTION

Can the incidence of subsequent termination of pregnancy (TOP) be reduced by providing intrauterine contraception as part of the abortion service?

SUMMARY ANSWER

Provision of an intrauterine device (IUD) as part of TOP services reduced the need for subsequent TOP but the effect was limited to the first 3 years of the 5-year follow-up.

WHAT IS KNOWN ALREADY

An IUD is highly effective in preventing subsequent TOP. Prompt initiation of IUD use leads to a higher usage rate during follow-up, as compliance with post-TOP IUD insertion visits is low.

STUDY DESIGN, SIZE, DURATION

The objective of this randomised controlled trial was to assess the effect of early comprehensive provision of intrauterine contraception after TOP, with primary outcome being the incidence of subsequent TOP during the 5 years of follow-up after the index abortion. This study was conducted at a tertiary care centre between 18 October 2010 and 21 January 2013. Altogether, 748 women undergoing a first trimester TOP were recruited and randomised into two groups. The intervention group (n = 375) was provided with an IUD during surgical TOP or 1-4 weeks following medical TOP at the hospital providing the abortion care. Women in the control group (n = 373) were advised to contact primary health care for follow-up and IUD insertion. Subsequent TOPs during the 5-year follow-up were identified from the Finnish Register on induced abortions.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The inclusion criteria were age ≥18 years, duration of gestation ≤12 weeks, residence in Helsinki and accepting intrauterine contraception. Women with contraindications to IUD were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

The overall numbers of subsequent TOPs were 50 in the intervention and 72 in the control group (26.7 versus 38.6/1000 years of follow-up, P = 0.027), and those of requested TOPs, including TOPs and early pregnancy failures, were 58 and 76, respectively (30.9 versus 40.8/1000, P = 0.080). Altogether 40 (10.7%) women in the intervention and 63 (16.9%) in the control group underwent one or several subsequent TOPs (hazard ratio 1.67 [95% CI 1.13 to 2.49], P = 0.011). The number of TOPs was reduced by the intervention during years 0-3 (22.2 versus 46.5/1000, P = 0.035), but not during years 4-5 (33.3 versus 26.8/1000, P = 0.631).

LIMITATIONS, REASONS FOR CAUTION

Both medical and surgical TOP were used. This may be seen as a limitation, but it also reflects the contemporary practice of abortion care. The immediate post-TOP care was provided by two different organizations, allowing us to compare two different ways of contraceptive service provision following TOP.

WIDER IMPLICATIONS OF THE FINDINGS

Providing TOP and IUD insertion comprehensively in the same heath care unit leads to significantly higher rates of attendance, IUD use and a significantly lower risk of subsequent TOP.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Helsinki University Central Hospital Research funds and by research grants provided by the Jenny and Antti Wihuri Foundation, the Yrjö Jahnsson Foundation and Finska Läkaresällskapet. E.P. has received a personal research grant from the Finnish Medical Society. The City of Helsinki supported the study by providing the IUDs. The funding organisations had no role in planning or execution of the study, or in analysing the study results.

TRIAL REGISTRATION NUMBER

The trial was registered at clinicaltrials.gov (NCT01223521).

TRIAL REGISTRATION DATE

18 October 2010.

DATE OF FIRST PATIENT’S ENROLMENT

18 October 2010.

Adherence to Swedish national recommendations for long acting reversible contraceptive provision at the time of medical abortion

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.

Management of Postabortion Complications for the Emergency Medicine Clinician

Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.

Medication Abortion Up to 70 Days of Gestation

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].

Long-acting reversible contraception immediately after medical abortion: systematic review with meta-analyses

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 &gt;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 (&gt;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.

Collaboratively seeking to improve contraceptive counselling at the time of an abortion: a case study of quality improvement efforts in Sweden

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.

Prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among young women (24 and below) in Nepal: Strategy in the search for improvements

Introduction

Postabortion contraceptive use differs across countries, suggesting the need for country-level research to identify barriers and suggest appropriate interventions. This study aimed to identify the prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among women aged 24 or younger in Nepal.

Methods

This is a cohort study using Health Management Information System (HMIS) data where individual case records of women seeking induced abortion or postabortion care were documented using structured HMIS 3.7 records. Analysis was performed on the individual case records of 20,307 women 24 years or younger who received induced abortion or postabortion care services in the three-year period from July 2014 to June 2017 at 433 public and private health facilities.

Findings

Overall, LARC uptake during the study period was 11% (IUD: 3% and implant: 8%). The odds of LARC acceptance was higher for young women (24 and below) who belonged to Brahmin/Chhetri (AOR = 1.23; 95% CI: 1.02–1.47) and Janajatis (AOR = 1.20; 95% CI: 1.01–1.43) as compared to Dalits; young women who had an induced abortion (AOR = 3.75; 95% CI: 1.75–8.06) compared with postabortion care; and those receiving service from public sector health facilities (AOR = 4.00; 95% CI: 2.06–7.75) compared with private sector health facilities.

Conclusion

The findings from this study indicate the need to focus on barriers to acceptance of LARC among several groups of young women (24 and below) receiving abortion care in Nepal: Dalits, Madhesis and Muslims; nulliparous women; and those receiving services at private sector health facilities.

Contraception after pregnancy

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.

Predicting poor compliance with follow-up and intrauterine contraception services after medical termination of pregnancy

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.

Bleeding pattern difference between levonorgestrel intrauterine system and copper intrauterine devices inserted immediately post-abortion: a multicenter, prospective, observational cohort study in Chinese women

BACKGROUND

To describe the bleeding pattern (primary outcome), side effects, treatment satisfaction and 6 month continuity rates associated with the 52 mg levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (Cu-IUD) inserted immediately after abortion.

METHODS

This multicenter, prospective, observational cohort study enrolled healthy women (aged ≥18 years) inserted with LNG-IUS or Cu-IUD immediately after first-trimester surgical abortion and followed up to 6 months. Bleeding pattern was obtained through daily patient bleeding diaries.

RESULTS

From 2013 to 2014, we enrolled 512 women (LNG-IUS = 312 [median age: 32.0 years] and Cu-IUD = 200 [median age: 30.0 years]) from nine Chinese centers. LNG-IUS resulted in a significantly lower number of bleeding/spotting days in the second 90 day reference period compared with Cu-IUD (median 14.5 vs. 18.0 days, p < .0001). Amenorrhea rate (no bleeding/spotting day in the second 90 day reference period) and no menstrual bleeding rate (absence of bleeding days in the second 90 day reference period) were significantly higher in LNG-IUS compared to Cu-IUD (13.9% vs. 0% and 39.5% vs. 0%; p < .001 for all). No dysmenorrhea was higher at the last follow-up in LNG-IUS users than Cu-IUD users (81.2% vs. 76%; p = .0047). Both treatments had a high satisfaction rate among women at both the follow-up visits, and the majority of them continued with the treatment. The rates of adverse events (e.g. oligomenorrhea, amenorrhea) in the LNG-IUS and Cu-IUD groups were 77.2% and 44.5% (p < .0001), respectively.

CONCLUSION

LNG-IUS post-abortion shows better bleeding patterns, and reduced dysmenorrhea and bleeding amount, but with a similar safety profile compared with Cu-IUD. ClinicalTrials.gov identifier: NCT01958684.

Induced abortion

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.

[Post-abortion contraception]

OBJECTIVE

To establish guidelines of the French National College of Gynecologists and Obstetricians about post-abortion contraception.

MATERIALS AND METHODS

A systematic review of the literature about post-abortion contraception was performed on Medline and Cochrane Database between 1978 and March 2016. The guidelines of the French and foreign scientific societies were also consulted.

RESULTS AND DISCUSSION

After an abortion, if the woman wishes to use a contraception, it should be started as soon as possible because of the very early ovulation resumption. The contraception choice must be done in accordance with the woman's expectations and lifestyle. The contraindications of each contraception must be respected. The long-acting reversible contraception, intra-uterine device (IUD) and implant, could be preferred (grade C) as the efficacy is not dependent on compliance. Thus, they could better prevent repeat abortion (LE3). In case of surgical abortion, IUD should be proposed and inserted immediately after the procedure (grade A), as well as the implant (grade B). In case of medical abortion, the implant can be inserted from the day of mifépristone, the IUD after an ultrasound examination confirming the success of the abortion (no continuing pregnancy or retained sac) (grade C).

Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial

Background

Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion.

Methods

A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114).

Results

There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use.

Conclusions

Simplified follow-up after early medical abortion will not change women’s opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women’s postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods.

Trial registration

Clinicaltrials.gov NCT01827995

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.

Post Abortion Contraception

A safe induced abortion has no impact on future fertility. Ovulation may resume as early as 8 days after the abortion. There is no difference in return to fertility after medical or surgical abortion. Most women resume sexual activity soon after an abortion. Contraceptive counseling and provision should therefore be an integrated part of the abortion services to help women avoid another unintended pregnancy and risk, in many cases an unsafe, abortion. Long-acting reversible contraceptive methods that includes implants and intrauterine contraception have been shown to be the most effective contraceptive methods to help women prevent unintended pregnancy following an abortion. However, starting any method is better than starting no method at all. This Special Report will give a short guide to available methods and when they can be started after an induced abortion.

Expulsion and continuation rates after postabortion insertion of framed IUDs versus frameless IUDs - review of the literature

BACKGROUND

Early intrauterine device (IUD) discontinuation after insertion immediately following aspiration abortion or after early medical abortion occurs as a consequence of expulsion of the IUD or removal due to side effects. These are often the consequence of the uterine forces impacting on the IUD due to spatial discrepancy with the uterine cavity causing pain, abnormal bleeding, and eventually, removal of the IUD. These women are candidates for repeat pregnancy as they often select less-effective methods or no contraception at all. Repeat abortion could be reduced by giving attention to these factors.

STUDY DESIGN

In order to have an indication on the magnitude of the problem of IUD expulsion or discontinuation, we searched the MEDLINE database for clinical trials, randomized controlled trials, and prospective observational studies related to immediate postaspiration termination of pregnancy (TOP) and early medical abortion IUD insertion studies that reported IUD expulsion and IUD continuation rates.

RESULTS

The search identified 17 clinical trials that were suitable based on the data they presented. The majority concerned T-shape IUDs, inserted immediately following surgical (aspiration) pregnancy termination. Two studies were conducted after medical TOP, and four studies were conducted with the frameless IUD inserted after surgical (vacuum aspiration) TOP. The results showed expulsion rates between 0.8% and 17.3% at 8 weeks, up to 5 years after insertion, respectively. In four studies with the frameless IUD, totaling 553 insertions, the expulsion rate was 0.0% in three of them. Follow-up in the latter studies varied between 5 weeks and 54 months. Reported continuation rates with conventional (framed) IUDs were between 33.8% and 80% at 1 year for studies providing 1 year rates and between 68% and 94.1% for studies reporting continuation rates at 6 months. Studies utilizing frameless IUDs reported 1 year continuation rate over 95%.

CONCLUSION

Frameless IUDs, due to their attachment to the uterine fundus, appear to be better retained by the postabortal uterus when compared with conventional framed IUDs. The absence of a frame ensures compatibility with uterine cavity anatomical dimensions, and may therefore result in improved acceptability and continuation rates in comparison with framed IUDs. Both these characteristics of the frameless IUD could help reduce the number of repeat unwanted pregnancies and subsequent abortions in some cases.

Recent advances in contraception

Focusing on intrauterine contraceptives (IUC), contraceptive implants, and emergency contraceptives, we review recent advances in contraceptive development and discuss progress in policies to improve access to the most effective methods. We report on the shift in practice towards routinely providing IUCs and implants to young and nulliparous women, prompted in part by the reduced diameter of the insertion tube for the Mirena IUC and the development of a smaller IUC called Skyla. Additionally, we describe the new SCu300A intrauterine ball and the development of an implant called Nexplanon, which comes with a preloaded inserter. We also discuss the efficacy of ulipristal acetate versus levonorgestrel for emergency contraception, especially for women who weigh more than 75 kg. Finally, in light of the increasing interest in providing IUCs and implants to women in the immediate postpartum and post-abortion periods, we consider the rationale for this change in practice and review the progress that has been made so far in the United States.

Immediate postabortal insertion of intrauterine devices

Background The use of an effective contraceptive may be necessary after an abortion. Insertion of an intrauterine device (IUD) may be done the same day or later. Immediate IUD insertion is an option since the woman is not pregnant, pain of insertion is less because the cervical os is open, and her motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries risks, such as spontaneous expulsion.Objectives To assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion.Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov,and ICTRP in January 27, 2014. We also contacted investigators to identify other trials.Selection criteria We sought all randomised controlled trials (RCTs) with at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion.Data collection and analysis We evaluated the methodological quality of each report and abstracted the data. We focused on discontinuation rates for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease.We computed the weighted average of the rate ratios.We compute drisk ratios (RRs) with 95% Confidence Intervals (CIs).We performed an intention-to-treat (ITT) analysis by including all randomised participants in the analysis according to the Cochrane Handbook for Systematic Reviews of Interventions.Main results We identified 12 trials most of which are of moderate risk of bias involving 7,119 participants which described random assignment.Five trials randomised to either immediate or delayed insertion of IUD. One of them randomised to immediate versus delayed insertion of Copper 7 showed immediate insertion of the Copper 7 was associated with a higher risk of expulsion than was delayed insertion(RR 11.98, 95% CI 1.61 to 89.35,1 study, 259 participants); the quality of evidence was moderate. Moderate quality of evidence also suggests that use and expulsion of levonorgestrel-releasing intrauterine system or CuT380A was more likely for immediate compared to delayed insertion risk ratio (RR) 1.40 (95% CI 1.24 to 1.58; 3 studies; 878 participants) and RR 2.64 ( 95% CI 1.16 to 6.00; 3 studies; 878 participants) respectively. Another trial randomised to the levonorgestrel IUD or Nova T showed discontinuation rates due to pregnancy were likely to be higher for women in the Nova T group. (MD 8.70, 95% CI 3.92 to 13.48;1 study; 438 participants);moderate quality evidence.Seven trials examined immediate insertion of IUD only. From meta-analysis of two multicentre trials, pregnancy was less likely for the TCu 220C versus the Lippes Loop (RR 0.43, 95% CI 0.24 to 0.75; 2 studies; 2257 participants ) as was expulsion (RR 0.61, 95% CI0.46 to 0.81; 2 studies; 2257 participants). Estimates for the TCu 220 versus the Copper 7 were RR 0.42 ( 95% CI 0.23 to 0.77; 2 studies, 2,274 participants) and RR 0.68, (95% CI 0.51 to 0.91); 2 studies, 2,274 participants), respectively. In other work, adding copper sleeves to the Lippes Loop improved efficacy (RR 3.40, 95% CI 1.28 to 9.04, 1 study, 400 participants) and reduced expulsion(RR 3.00, 95% CI 1.51 to 5.97; 1 study, 400 participants).Authors' conclusions Moderate quality evidence shows that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher immediately after abortions compared to delayed insertions. However, at six months postabortion, IUD use is higher following immediate insertion compared to delayed insertion.

Postabortal and postpartum contraception

Healthcare providers often underestimate a woman' need for immediate effective contraception after an abortion or childbirth. Yet, these are times when women may be highly motivated to avoid or delay another pregnancy. In addition, starting the most effective long-acting reversible methods (i.e. the intrauterine device, intrauterine system or implants) at these times, is safe, with low risk of complications. Good evidence shows that women choosing long-acting reversible contraceptives at the time of an abortion are at significantly lower risk of another abortion, compared with counterparts choosing other methods. Uptake of long-acting reversible methods postpartum can also prevent short inter-pregnancy intervals, which have negative consequences for maternal and child health. It is important, therefore, that providers of abortion and maternity care are trained and funded to be able to provide these methods for women immediately after an abortion or childbirth.

Postabortion contraception a decade after legalization of abortion in Nepal

OBJECTIVE

To assess the contraceptive information received and methods chosen, received, and used among women having abortions one decade after legalization of abortion in Nepal.

METHODS

We examined postabortion contraception with questionnaires at baseline and six months among women obtaining legal abortions (n=838) at four facilities in 2011. Multivariate regression analysis was used to measure factors associated with method information, choice, receipt, and use.

RESULTS

One-third of participants received no information on effective methods, and 56% left facilities without a method. The majority of women who chose to use injectables and pills were able to do so (88% and 75%, respectively). However, only 44% of women choosing long-acting reversible contraceptives and 5% choosing sterilization had initiated use of the method by six months. Levels of contraceptive use after medical abortion were on par with those after aspiration abortion. Nulliparous women were far less likely than parous women to receive information and use methods. Women living without husbands or partners were also less likely to receive information and supplies, or to use methods.

CONCLUSION

Improvements in postabortion counseling and provision are needed. Ensuring that women choosing long-acting and permanent contraceptive methods are able to obtain either them or interim methods is essential.

Contraception following abortion and the treatment of incomplete abortion

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