Meeting the needs of women : provision of long-acting reversible contraception at the time of abortion

Background and aim: Unintended pregnancies represent a notable public health challenge, imposing substantial social and financial burdens on a global scale. In Sweden, approximately 37,000 abortions are conducted annually, with half of these involving women who have had at least one previous abortion. Considering that ovulation may return as early as eight days after an abortion, and that resumption of sexual activity within the first few weeks post-abortion is common, timely access to effective contraception is crucial. Long-acting reversible contraception (LARC), such as intrauterine devices (IUDs) and implants effectively prevent unintended pregnancies, lead to high user satisfaction, and are often chosen by women having an abortion. Surgical abortion presents an opportunity for feasible placement of LARC. However, this practice has not been studied in a Swedish context. During medical abortion, IUDs are routinely placed at a later follow-up visit and women who miss this visit risk being left without contraception. This thesis aimed to study the provision of LARC at the time of abortion. Methods: We performed a nationwide register-based observational study on women having surgical abortion, where we explored women’s sociodemographic factors and psychiatric disorders and their association to provision of LARC at the time of abortion. Additionally, we conducted a randomized, controlled, multicentre, superiority trial of women having medical abortion and opting for post-abortion IUD use. Based on the hypothesis that immediate placement would lead to higher uptake rates compared to later placement, and thereby compensate for a possible increase in IUD expulsion, we randomly assigned women to two groups: the intervention group, with IUD placement within 48 hours after completed abortion, and the control group, with placement during a standard follow-up visit after two to four weeks. The primary outcome measure was the proportion of IUD use after six months in both groups. Results: During surgical abortion in Sweden, social vulnerability and characteristics such as younger age, lower level of education, or not being employed, were associated with LARC provision at the abortion. The overall rate of LARC provision during surgical abortion was 40.2%, and 42.0% of the women having surgical abortion had a history of psychiatric disorders. Women with any psychiatric disorder had a higher likelihood of being provided with LARC, compared with women with no such disorder (aOR 1.21; 95% CI 1.08-1.35). In particular, personality-, substance use-, and neurodevelopmental disorders were associated with LARC provision. In early medical abortion with gestation of ≤9 weeks, the proportions of women using an IUD after six months were 91/111 (82.0%) in the intervention group vs. 87/112 (77.7%) in the control group (p=0.51). Attendance to IUD placement was comparable between groups in early abortion (108/117, 92.3% in the intervention group vs. 103/118, 87.3% in the control group; p=0.28). Moreover, IUD expulsion rates were similar between the groups (intervention group 10/111, 9.0% vs. control group 4/112, 3.6%; p=0.11). Women in the intervention group more often preferred their allocated time of placement and rated pain at placement lower compared to the control group. After one year, IUD continuation and satisfaction rates were high with >94% of IUD users reporting satisfaction with their contraceptive and we found no difference in rates of subsequent pregnancies or abortions. In medical abortion beyond 12 weeks of gestation, the proportions of women using an IUD after six months were 34/67 (50.7%) in the intervention group compared to 48/67 (71.6%) in the control group (p=0.021). Attendance rates for IUD placement were higher in the intervention group compared to the control group (69/77, 89.6% vs. 56/78, 71.8%; p=0.008), but expulsion occurred among 16/48 (33.3%) women with IUD placement within 48 hours compared to 2/27 (4.3%) with later placement (p<0.001). Conclusion: Women with an elevated likelihood of a subsequent unintended pregnancy are more often provided with LARC during a surgical abortion in Sweden. However, the potential of LARC provision during surgical abortion is likely not fully utilized. Contraceptive counselling in connection to the abortion should be tailored to meet the requirements of women. In medical abortion, placement of an IUD within 48 hours was not superior compared to placement after two to four weeks in terms of IUD utilization after six months. After an early medical abortion, IUD placement within 48 hours is safe, preferred by women, and does not increase expulsion rates, compared with later placement. Uptake of IUD is high when IUDs are provided for free at the abortion clinic. After a medical abortion beyond 12 weeks of gestation, IUD placement within 48 hours is associated with an increased risk of expulsion. In this case, an IUD should be placed within 48 hours only in selected cases after counselling patients on the risk for expulsion compared with later placement

The asymmetrical friction mechanism that puts the curl in the curling stone

a b s t r a c t Curling is an Olympic winter sport in which two teams slide stones across a sheet of ice towards a target area, some 28 m away from the release line. The sport has its name from the fact that the trajectory of a rotating stone becomes slightly curled, a fact used to reach open spots or take out opponent stones behind hindering &apos;&apos;guarding&apos;&apos; stones, etc. By slowly turning the stone clockwise when it is released, it will curl to the right, and vice versa. The resulting sideward deviation is typically slightly more than a metre. This intriguing tribological phenomenon has so far lacked a satisfactory explanation, although many attempts have been presented. In many of them, the curling motion has been attributed to an asymmetrical distribution of the friction force acting on the sliding stone, such that the friction on the rear of the stone (as seen in the direction of motion) is higher than that on the front. In a recent paper, we could show that no such redistribution of the friction, no matter how extreme, can explain the magnitude of the observed motion of a real curling stone. The present work presents an alternative asymmetrical mechanism that actually is strong enough to account for the observed motion. Further, in contrast to previous models, it satisfies other observed phenomena, including the independence of rotational speed of the stone and the strong dependence of the roughness of the stone. The model is backed up by experimental evidence and is based on the specific tribological conditions presented by the contact between a scratched curling stone and a pebbled ice sheet

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 (&gt;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

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 intra-uterine 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 pa-tient 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 &lt;.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% confi-dence 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 &lt;.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 &lt; 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

Medical students’ knowledge, attitudes, and perceptions on contraceptive use and counselling : a cross-sectional survey in Maharashtra, India

Objectives. This study aimed to investigate the knowledge, attitudes and perceptionstowards contraceptive use and counselling among medical students in Maharashtra, India. Setting. Considerable global maternal mortality and morbidity could be avoided through theuse of effective contraception. In India, contraception services are frequently unavailable or there are obstacles to obtaining modern, reversible contraceptives. Participants. A cross-sectional descriptive study using a self-administered questionnaire was conducted among 1996 medical students in their fifth year of study at 27 medical colleges in the state of Maharashtra, India. Descriptive and analytical statistics interpreted the survey instrument and significant results were presented with 95% CI. Results. Respondents expressed a desire to provide contraceptive services. A few studentshad experienced training in abortion care. There were misconceptions about moderncontraceptive methods and the impact of sex education. Attitudes towards contraceptionwere mainly positive, premarital counselling was supported and the influence of traditional values and negative provider attitudes on services was recognised. Gender, area of upbringing and type of medical college did not change the results. Conclusions. Despite mostly positive attitudes towards modern contraceptives, sex education and family planning counselling, medical students in Maharashtra have misconceptions about modern methods of contraception. Preservice and in-service training in contraceptive counselling should be implemented in order to increase women's access to evidence-based maternal healthcare services.Förebyggande av oönskade graviditeter och osäkra aborter i Indien- Klinikbaserade studier i syfte att förbättr

Medical students’ knowledge, attitudes and perceptions towards contraceptive use and counselling: a cross-sectional survey

Medical students&apos; knowledge, attitudes, and perceptions on contraceptive use and counselling: a cross-sectional survey in Maharashtra, India. Setting: Considerable global maternal mortality and morbidity could be avoided through the use of effective contraception. In India, contraception services are frequently unavailable or there are obstacles to obtaining modern, reversible contraceptives. Participants: A cross-sectional descriptive study using a self-administered questionnaire was conducted among 1996 medical students in their fifth year of study at 27 medical colleges in the state of Maharashtra, India. Descriptive and analytical statistics interpreted the survey instrument and significant results were presented with 95% CI. Results: Respondents expressed a desire to provide contraceptive services. A few students had experienced training in abortion care. There were misconceptions about modern contraceptive methods and the impact of sex education. Attitudes towards contraception were mainly positive, premarital counselling was supported and the influence of traditional values and negative provider attitudes on services was recognised. Gender, area of upbringing and type of medical college did not change the results. Conclusions: Despite mostly positive attitudes towards modern contraceptives, sex education and family planning counselling, medical students in Maharashtra have misconceptions about modern methods of contraception. Preservice and in-service training in contraceptive counselling should be implemented in order to increase women&apos;s access to evidence-based maternal healthcare services

Provision of long-acting reversible contraception at surgical abortion-A cross-sectional nationwide register study

Introduction: Provision of long-acting reversible contraception (LARC) at surgical abortion is safe, practical, and leads to higher user rates than does delayed provision. The aim of this study was to explore whether provision of LARC at surgical abortion is associated with known risk factors for subsequent abortions and inconsistent use of contraception, including sociodemographic factors and psychiatric disorders. Material and methods: This was a register-based cross-sectional study of 6251 women having a surgical abortion in Sweden. Data were collected from National health and population registers. Women with procedure codes for surgical abortion were identified in the National Patient Register from October 2016 to December 2018. Information from Statistics Sweden, the National Patient Register, and the Swedish prescribed drug register on sociodemographic factors, psychiatric disorders, and dispensed LARC was added and linked on an individual level. Associations of sociodemographic factors and psychiatric disorders with LARC provision were explored with generalized logit mixed models and presented as crude and adjusted odds ratios with 95% confidence intervals (CIs). Results: The overall rate of LARC provision at the time of the abortion was 2515/6251 (40.2%). Younger age and lower level of education were associated with an increased likelihood of LARC provision. In the study population, 2624/6251 (42.0%) patients had a pre- or post-abortion psychiatric disorder, a factor associated with an increased likelihood of LARC provision compared with women with no such disorders (adjusted odds ratio 1.21; 95% CI 1.08-1.34). The highest rates and odds were seen among women with personality, substance use, and/or neurodevelopmental disorders and among women with multiple psychiatric disorders. Conclusions: Sociodemographic risk factors and psychiatric disorders were associated with increased LARC provision at surgical abortion, indicating that women at high risk of unwanted pregnancies are provided with effective contraception. Still, less than half of all women undergoing surgical abortion were provided with LARC, suggesting that contraceptive access and counseling prior to a surgical abortion can be improved

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: To study if placement of an intrauterine device within 48 hours of completed medical abortion up to 63 days' gestation leads to higher user rates at six months after the abortion compared with placement at two to four weeks after abortion. Furthermore, 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 up to 63 days' gestation and opting for intrauterine device were allocated to placement within 48 hours of complete medical abortion (intervention group) or at 2-4 weeks after abortion (control group). We defined the abortion as complete after bleeding of clots and cessation of heavy bleeding following use of misoprostol. Patients answered questionnaires at 3, 6 and 12 months. Primary outcome was use of intrauterine device at 6 months post abortion. Secondary outcomes included expulsion rate, pain at placement, adverse events and complications from the abortion, acceptability, and pregnancies and their outcomes. Differences in non-parametric continuous variables were analyzed by the Mann-Whitney U-test and differences in dichotomous variables were analyzed by Chi square test or Fisher's exact test. A p-value of &lt; 0.05 was considered statistically significant. RESULTS: In the intervention group, 91/111 (82%) used an intrauterine device at six months after the abortion, compared to 87/112 (77.7%) in the control group with a difference in proportion of 4.3% (95% CI -0.062, 0.148, p=0.51). Attendance rate and rate of successful intrauterine device placement were similar between groups. Patients in the intervention group had lower pain scores at placement of the intrauterine device (mean pain score VAS 32.3, SD 29) compared to the control group (mean pain score VAS 43.4, SD 27.9, p=0.002). Patients preferred their allocated time of placement significantly more often in the intervention group, (83/111, 74.8%) compared to the control group (70/114, 61.4%, p=0.03). Use of ultrasound at intrauterine device placement (because of doubts concerning complete abortion) was more common in the intervention group (43/108, 39.8%) compared to the control group (15/101, 14.9%, p&lt;0.001) and in one patient in the control group, a retained gestational sac was found. Three patients in the intervention group and two patients in the control group had a vacuum aspiration. No difference was found in intrauterine device expulsion rates between the groups. In the intervention group, 9/97 (9.3%) patients experienced expulsion during the first six months after abortion and 4/89 (4.5%, p=0.25) 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 six months after the abortion, compared with intrauterine device placement at 2-4 weeks after abortion. When compared with placement at a follow-up visit after 2-4 weeks, intrauterine device placement within 48 hours after early medical abortion appears safe, is preferred by patients and associated with lower pain scores

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: We aimed to investigate effectiveness, safety, and acceptability of intrauterine device placement within 48 hours, compared with placement at two to four weeks after second trimester medical abortion. We hypothesized that intrauterine device placement within 48 hours would be superior compared with placement at two to four weeks after the abortion, in terms of the proportion of intrauterine device use after six months, with maintained safety and acceptability. STUDY DESIGN: In this open-label, randomized, controlled, superiority trial, we recruited participants at eight abortion clinics in Sweden. Eligible participants were ≥18 years, requesting medical abortion with gestation ≥85 days and opting for use of a post abortion 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 non-normal continuous variables were analyzed with the Mann-Whitney U-test and differences in dichotomous variables with the chi square or Fisher's exact tests. A P value &lt;.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 intervention and 89 to control. Enrolment was prematurely stopped after an interim analysis exceeded a predefined intrauterine device expulsion rate of 20%. By modified intention-to-treat, use of intrauterine device after 6 months was 50.7% (34/67) in the intervention group compared to 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 versus 2.9% (2/70; P &lt;.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 non-superior 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 counselling on expulsion risk