Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion

doi:10.1016/j.contraception.2008.03.003

Contraception

Volume 78, Issue 2, August 2008, Pages 143-148

https://doi.org/10.1016/j.contraception.2008.03.003 Get rights and content

Abstract

Background

Of the 1.3 million abortions performed annually in the United States, approximately half are repeat procedures. Immediate postabortal intrauterine device (IUD) insertion is a safe, effective, practical and underutilized intervention that we hypothesize will significantly decrease repeat unintended pregnancy and abortion.

Study design

All women receiving immediate postabortal IUD insertion in eight clinics of a Northern California Planned Parenthood agency during a 3-year period comprise the IUD cohort. We selected a cohort of controls receiving abortions but choosing other, non-IUD contraception on the day of the abortion visit in a 2:1 ratio matched by date of abortion. We obtained follow-up data on repeat abortions within the agency for both cohorts through 14 months after the 3-year period. We evaluated differences in repeat abortion between cohorts. All analyses were intent-to-treat.

Results

Women who received an immediate postabortal IUD had a lower rate of repeat abortions than controls (p<.001). Women who received a postabortal IUD had 34.6 abortions per 1000 woman-years of follow-up compared to 91.3 for the control group. The hazard ratio for repeat abortion was 0.38 [95% confidence interval (CI), 0.27–0.53] for women receiving a postabortal IUD compared to controls. When adjusted for age, race/ethnicity, marital status, and family size, the hazard ratio was 0.37 (95% CI, 0.26–0.52).

Conclusion

Immediate postabortal intrauterine contraception has the potential to significantly reduce repeat abortion.

Introduction

Among the 1.3 million women having abortions annually in the United States, approximately half are repeat procedures [1]. Studies conducted since the legalization of abortion have confirmed that women seeking a repeat abortion are equally [2] or more likely [1], [3], [4], [5], [6] to have been using a contraceptive method at the time of conception than women seeking a first abortion and that, among those who used contraception, they are more likely to have used a relatively effective method [1], [2], [3], [4], [6], [7]. With “typical” use, moderately effective hormonal methods such as the pill, the patch, and the vaginal ring have approximately 8% annual failure rates in the general population [5]. However, in the postabortal population, even much more effective methods, such as depot-medroxyprogesterone acetate, have been shown to have failure rates as high as 16% due to discontinuation [8]. To assist women in avoiding unintended pregnancy, more effective, convenient and long-acting contraception would be advantageous in women with a history of induced abortion.

Intrauterine contraception meets the desired criteria. Its contraceptive efficacy is similar to or better than tubal sterilization [9]. Intrauterine devices (IUDs) are rapidly effective, have high continuation rates (78–81%) compared to other methods [5] and have rapid return to fertility upon removal. They are discreet and do not require multiple repeat visits after insertion for continuation.

Given that up to 83% of abortion clients ovulate within the first cycle after the procedure [10], the risk of repeat pregnancy is high without good contraception. Delayed postabortal IUD insertion may not be adequate with one study showing that 40% of clients did not return for the insertion [11]. Women who have an IUD inserted immediately after an abortion may therefore have significantly fewer unintended pregnancies and repeat abortions than women scheduled for insertion at a follow-up visit. A recent decision analysis comparing immediate to delayed IUD insertion estimated a mean difference of 28 unintended pregnancies per 1000 women in the initial year following abortion [12].

Despite the need for immediate, highly effective contraception following abortion, lingering misperceptions regarding IUD safety exist in the United States among both health care providers and the public [13], [14], [15] and contribute to its low utilization in postabortal women in this country. Furthermore, among the small percentage of patients and their providers who do choose intrauterine contraception, delayed insertion is still the norm. We hypothesize that immediate postabortal IUD insertion will significantly decrease subsequent unintended pregnancy and repeat abortion in comparison to other forms of contraception.

Section snippets

Materials and methods

We conducted a multisite study of three interventions to minimize barriers to IUD use, including immediate postabortal IUD insertion, at a Northern California Planned Parenthood agency from November 2002–October 2005. Results of the original study, including impact on IUD utilization, have been described elsewhere [16]. In March 2004, national Planned Parenthood Standards and Guidelines were individualized for our agency to permit immediate postabortal IUD insertion in the absence of known or

Results

The IUD cohort consisted of 673 women who initiated intrauterine contraception (either copper-T380a or levonorgestrel-releasing intrauterine contraceptive) immediately following an abortion during the study. We selected 1346 matched controls (women who initiated other forms of contraception following an abortion) for a total study population of 2019. Cohorts differed on demographic factors as described in Table 1.

Forty-one women in the IUD cohort (6.1%) and 206 women in the control cohort

Discussion

Women who received immediate postabortal IUD insertion in this population had fewer repeat abortions than those who chose other contraceptive methods following an aspiration abortion during the same time period. The association was strong despite some removals and expulsions during the study, suggesting that immediate IUD insertion may have a powerful effect on prevention of repeat unintended pregnancy.

We also found in our Cox model that younger women have a higher risk for repeat abortion.

Acknowledgments

We would like to thank Madeline Pera-Floyd and Courtney Benedict, CNM, both from the Planned Parenthood Golden Gate, for their assistance with data extraction and review. We would also like to thank Kevin Grumbach, M.D., at the University of California San Francisco, for his methodological guidance and support.

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Postabortion and Postpartum Intrauterine Device Provision for Adolescents and Young Adults
2019, Journal of Pediatric and Adolescent Gynecology
Adolescents are at high risk for unintended pregnancy and rapid repeat pregnancy, both of which can be associated with negative health and social outcomes. Intrauterine device (IUD) use has been shown to decrease unintended pregnancy and rapid repeat pregnancy. Evidence supports IUD insertion postabortion and postpartum as safe and practical for nearly all women, including adolescent and young adult women. Providers of adolescent gynecology can play an important role in decreasing repeat and unintended pregnancy among adolescents by increasing access to IUDs, reducing barriers to care, and providing IUDs immediately postabortion and postpartum.
Trends and determinants of postabortion contraception use in a Canadian retrospective cohort
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We aim to describe demographic trends associated with postabortion contraceptive choice, characteristics of intrauterine device (IUD) users and relation to subsequent abortion.
Our retrospective chart review study included all patients obtaining an abortion from 2003 to 2010 at the primary service provider in the Interior Health Region of British Columbia, tracking each patient for 5 years to detect subsequent abortion. We used descriptive statistics to analyze demographic trends and logistic regression to examine determinants of choosing an IUD and likelihood of subsequent abortion per contraceptive method.
Our study cohort included 5206 patients, 1247 (24.0%) of whom chose an IUD. Patients increased IUD use from 10.14% to 45.74% of the cohort over the study period. Mean age of those choosing an IUD significantly decreased over the study period [30.9±7.3 years in 2003 to 26.2±6.5 years in 2010 (p<.001)]. In multivariable analysis, factors associated with choosing an IUD postabortion were prior delivery [aOR=2.77 (95% CI 2.40–3.20)] and being older than 20 years [20–29 years: AOR=1.87 (1.51–2.32); or 30+ years: AOR=1.96 (1.54–2.50)]. Patients choosing an IUD were less likely to have a subsequent abortion compared to those selecting oral contraceptives [aOR=1.96 (95% CI 1.54–2.52)] or depomedroxyprogesterone acetate [aOR=1.84 (95% CI 1.36–2.49)].
We found an increasing trend of choosing an IUD after an abortion in our population, especially among youth. Patients who chose an IUD postabortion were less likely to have a subsequent abortion over the next 5 years.
An important strategy for reducing subsequent abortion is to ensure that those seeking abortion have accurate information on the comparative effectiveness of postabortion contraception methods. Educational efforts, alongside removal of cost and other barriers, will contribute to the prevention of subsequent abortion and improve equitable access to IUDs among the population.
Prevalence and predictors of initiation of intrauterine devices and subdermal implants immediately after surgical abortion
2019, Contraception
To estimate uptake of long-acting reversible contraception (LARC) methods immediately after surgical abortion in a system that makes these methods readily available, and to determine demographic, medical, social, and visit-specific predictors of immediate post-abortion intrauterine device (IUD) and implant initiation.
We performed a retrospective cohort study of LARC (levonorgestrel intrauterine system [IUS], copper IUD, and subdermal implant) initiation at the time of surgical abortion up to 21w0d gestation at Planned Parenthood League of Massachusetts from 2012 through 2017. We calculated proportions of IUD and implant initiation and used mixed effect logistic regression to estimate predictors of each outcome.
Among 26,858 surgical abortion patients, 25.4% received immediate post-abortion LARC: 14.2%, 4.2%, and 7.0% received a levonorgestrel IUS, copper IUD, and implant, respectively. Compared to White women, Black women had lower odds of initiating an IUD (aOR 0.81, 95% CI 0.74–0.89). Multiparous women had greater odds than nulliparous women of initiating an IUD (aOR 1.69, 95% CI 1.57–1.82) or implant (aOR 1.36, 95% 1.20–1.53). We found age was the strongest predictor of implant initiation (<18 versus≥35: aOR 3.26, 95% CI 2.26–4.71), but was not associated with IUD uptake. Gestational age was not associated with IUD or implant uptake. Implant uptake increased from 2.4% (2012) to 8.7% (2017) (aOR 3.65, 95% CI 2.36–5.65) while IUD uptake remained fairly constant.
About 25% of women chose to initiate intrauterine or implantable contraception immediately after surgical abortion when these methods are readily available. Implant uptake has increased significantly in recent years. Women who initiated IUDs and implants differed in their demographic and social profiles.
Women seeking surgical abortion should have same-day access to IUDs and implants. Clinicians and researchers should analyze IUD and implant initiation separately.
Consensus canadien sur la contraception (partie 3 de 4): chapitre 7 - Contraception intra-utérine
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Fournir des lignes directrices aux fournisseurs de soins quant à l'utilisation de modes de contraception pour la prévention de la grossesse et quant à la promotion d'une sexualité saine.
Orientation des praticiens canadiens en ce qui concerne l'efficacité globale, le mécanisme d'action, les indications, les contre-indications, les avantages n’étant pas liés à la contraception, les effets indésirables, les risques et le protocole de mise en œuvre des modes de contraception abordés; planification familiale dans le contexte de la santé sexuelle et du bien-être général; méthodes de counseling en matière de contraception; et accessibilité et disponibilité des modes de contraception abordés au Canada.
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La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d’étude canadien sur les soins de santé préventifs (Tableau 1).
Déclarations sommaires
- 1
  Les contraceptifs intra-utérins sont aussi efficaces que les modes de contraception permanente. (II-2)
- 2
  L'utilisation du système intra-utérin à libération de lévonorgestrel 52 mg par des patientes prenant du tamoxifène n'est pas associée à la récurrence du cancer du sein. (I)
- 3
  Les contraceptifs intra-utérins comptent un certain nombre d'avantages n’étant pas liés à la contraception. L'utilisation du système intra-utérin à libération de lévonorgestrel 52 mg entraîne une atténuation significative de la perte sanguine menstruelle (I) et de la dysménorrhée. (II-2) Le dispositif intra-utérin au cuivre et le système intra-utérin à libération de lévonorgestrel entraînent tous deux une baisse significative du risque de cancer de l'endomètre. (II-2)
- 4
  Bien que le risque de perforation utérine soit inversement proportionnel à l'expérience du fournisseur de soins procédant à l'insertion, il est accru pendant la période postpartum et l'allaitement. (II-2)
- 5
  Bien que le risque de syndrome inflammatoire pelvien soit légèrement accru au cours du premier mois suivant l'insertion d'un contraceptif intra-utérin, le risque absolu est faible. La manifestation d'un syndrome inflammatoire pelvien après le premier mois d'utilisation est attribuable à une exposition à des infections transmissibles sexuellement et non à la présence même du contraceptif intra-utérin. (II-2)
- 6
  La nulliparité n'est pas associée à un risque accru d'expulsion du contraceptif intra-utérin. (II-2)
- 7
  Bien qu'il soit rare de constater une grossesse ectopique en présence d'un contraceptif intra-utérin in situ, de 15%à 50% des grossesses qui en viennent tout de même à se manifester sont de nature ectopique. (II-2)
- 8
  Chez les femmes qui en viennent à connaître une grossesse malgré la présence d'un contraceptif intra-utérin in situ, le retrait précoce de ce dernier entraîne une amélioration des issues de grossesse, mais ne mène pas à une élimination intégrale des risques. (II-2)
- 9
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- 10
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- 11
  L'insertion immédiate d'un contraceptif intra-utérin à la suite de la tenue de l'accouchement ou d'une césarienne (de 10 minutes à la suite de la délivrance du placenta à 48 heures) est associée à un risque accru d'expulsion. (I) Les avantages de l'insertion d'un contraceptif intra-utérin immédiatement à la suite de la tenue de l'accouchement ou d'une césarienne l'emportent sur les désavantages d'une telle pratique (soit des risques accrus de perforation et d'expulsion). (II-C)
- 12
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- 13
  L'insertion d'un contraceptif intra-utérin immédiatement à la suite d'un avortement entraîne une baisse significative du risque de devoir procéder à un autre avortement (II-2) et une hausse significative des taux de poursuite de l'utilisation d'un contraceptif intra-utérin à six mois. (I)
- 14
  La mise en œuvre d'une antibioprophylaxie au moment de l'insertion d'un contraceptif intra-utérin n'entraîne pas une atténuation significative de l'infection pelvienne postinsertion. (I)
- 1
  Les fournisseurs de soins devraient prendre soin d’éviter de restreindre l'accès aux modes de contraception intra-utérins en raison de risques théoriques ou non établis. (III-A) Les professionnels de la santé devraient considérer les contraceptifs intra-utérins comme étant des modes de contraception de première intention pour leurs patientes tant nullipares que multipares. (II-2A)
- 2
  Dans le cas des femmes qui cherchent à obtenir une contraception intra-utérine et qui connaissent des saignements menstruels abondants et/ou une dysménorrhée, les professionnels de la santé devraient envisager de privilégier l'utilisation du système intra- utérin à libération de lévonorgestrel 52 mg. (I-A)
- 3
  Les patientes atteintes du cancer du sein qui prennent du tamoxifène pourraient envisager l'utilisation d'un système intra- utérin à libération de lévonorgestrel 52 mg, à la suite d'une consultation auprès de leur oncologue. (I-A)
- 4
  Les femmes qui demandent la mise en place d'un système intra- utérin à libération de lévonorgestrel ou d'un dispositif intra-utérin au cuivre devraient bénéficier de services de counseling traitant du risque d'infection transmissible sexuellement, des modifications du cycle menstruel et de la durée d'utilisation. (III-A)
- 5
  Le professionnel de la santé devrait être raisonnablement sûr que sa patiente n'est pas enceinte avant de procéder à l'insertion d'un contraceptif intra-utérin. (III-A)
- 6
  Les fournisseurs de soins devraient envisager de procéder à l'insertion d'un contraceptif intra-utérin immédiatement à la suite d'un avortement provoqué, plutôt que d'attendre de procéder à une insertion d'intervalle. (I-B)
- 7
  Chez les femmes qui en viennent à connaître une grossesse en présence d'un contraceptif intra-utérin in situ, le diagnostic de grossesse ectopique devrait être écarté dès que possible. (II-A) Une fois la possibilité d'une grossesse ectopique écartée, le contraceptif intra-utérin devrait être retiré sans avoir recours à une intervention effractive. Le contraceptif intra-utérin pourrait être retiré au cours de la tenue d'une interruption de grossesse chirurgicale. (II-2B)
- 8
  En présence d'un syndrome inflammatoire pelvien, il n'est pas nécessaire de retirer le contraceptif intra-utérin pendant le traitement, sauf en l'absence d'une amélioration clinique de 48 à 72 heures à la suite de la mise en œuvre d'une antibiothérapie appropriée. (II-2B)
- 9
  La mise en œuvre systématique d'une antibioprophylaxie n'est pas indiquée pour l'insertion d'un contraceptif intra-utérin. (I-B) Chez les femmes qui sont exposées à des risques élevés d'infections transmissibles sexuellement, les fournisseurs de soins devraient procéder au dépistage de ces dernières au moment de l'insertion du contraceptif intra-utérin. Lorsque des résultats positifs sont obtenus en ce qui concerne la chlamydiose et/ou la gonorrhée, la patiente en question devrait faire l'objet d'un traitement post- insertion adéquat et son CIU peut demeurer in situ. (II-2B)
- 10
  Chez les utilisatrices de contraceptifs intra-utérins, les saignements imprévus, lorsqu'ils sont persistants ou associés à des douleurs pelviennes, devraient faire l'objet d'une exploration visant à écarter la possibilité d'une infection, d'une grossesse, d'une pathologie gynécologique, d'une expulsion ou d'un mauvais positionnement. (III-A)
Society of Family Planning clinical recommendations: contraception after surgical abortion
2019, Contraception
Citation Excerpt :
Up to half of women who have an abortion will not start or will discontinue short-acting methods, such as oral contraceptives, within the first two 2 months after their procedure [59]. The risk of subsequent unintended pregnancy with immediate postabortion initiation of IUDs and implants was lower than with interval initiation (GRADE 1A) [60–63] or with postabortion initiation of less-effective methods (GRADE 1A) [64–66]. In a large retrospective cohort study, 673 women who received an IUD immediately after surgical abortion were compared with 1346 date-matched controls who also had a surgical abortion but initiated another form of contraception (not including the implant); the rate of subsequent abortion over a 3-year follow-up period was more than twice as high in the control group as in the study group (15.3% vs. 6.1%, p<.001) [64].
These recommendations present an evidence-based assessment of provision of contraceptives at the time of surgical abortion. Most methods of contraception, including the intrauterine devices (IUD), implant, depot medroxyprogesterone injection, oral contraceptive pill, contraceptive patch, monthly vaginal ring, barrier methods and some permanent methods, can be safely initiated immediately after first- or second-trimester surgical abortion. Provision of postabortion contraceptives, particularly IUDs and implants, substantially reduces subsequent unintended pregnancy. IUD insertion immediately following uterine aspiration is safe. While this may be associated with a higher risk of device expulsion than with interval placement, expulsion rates remain low, and this risk must be weighed against the fact that patients often do not receive their desired IUD at an interval insertion and therefore experience higher rates of subsequent unintended pregnancy. Many patients experience barriers that prevent access to the full spectrum of postabortion contraceptive options, particularly IUDs and implants. Advancements in health-systems-based point-of-care provision and policies are needed to improve comprehensive contraceptive availability following surgical abortion. These recommendations will address clinical considerations for postabortion contraceptive provision and recommend interventions to improve contraceptive access following uterine evacuation.

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^☆: Financial support for this study was provided by FEI Women's Health (now DuraMed), producers of ParagardÒ T380A intrauterine copper contraceptive, who sponsored a Staff Training Pilot at Planned Parenthood Golden Gate (part of the intervention study). Ms. Hendlish is concurrently a research consultant for Berlex, Inc (now Bayer Health Care, Inc.), producers of Mirena® levonorgestrel-releasing intrauterine system.

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Original research articleImpact of immediate postabortal insertion of intrauterine contraception on repeat abortion☆

Abstract

Background

Study design

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgments

Contraception

Fert Steril

Obstet Gynecol

Meet Abstr Contracept

Contraception

Contraception

Contraception

Repeat abortions in New York City: 1970–1972

Fam Plann Perspect

Characteristics of women undergoing repeat induced abortion

CMAJ

Repeat abortions: blaming the victims

Am J Public Health

The repeat abortion patient

Fam Plann Perspect

Contraceptive efficacy

Repeat abortion and use of primary care health services

Fam Plann Perspect

Repeat abortion in the United States

Intrauterine devices (IUDs)

Return of ovarian function after abortion

Clin Endocrinol

Original research article
Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion☆