Contraception After an Induced Abortion and Childbirth

Publisher Copyright: © 2021, Springer Nature Switzerland AG.Even though the rate of unintended pregnancy has been declining globally during the last 20 years, unintended pregnancy remains a significant public health issue and burden throughout the world. In 2014, the rate of unintended pregnancy was globally 62/1000 15–44-year-old women, and varied from that of 41/1000 women in Europe to 96/1000 in Latin America. Also the proportion of unintended pregnancies resulting in an abortion varies markedly in different parts of the world. The highest proportion (70%) was seen in Europe and the lowest (36%) in North America (Bearak et al., Lancet Glob Health. 6(4):e380–e389, 2018]. In addition to the high need of induced abortion, unintended pregnancy is associated with an increased risk of adverse pregnancy outcomes, such as low birth weight. Similarly, recent studies from the US show that nearly 50% of all pregnancies are unintended. Approx. 40% of these result in an induced abortion, the risk being higher among older and highly educated women (Finer and Zolna, N Engl J Med. 374(9):843–852, 2016). Thus, unmet need of contraception remains a significant global public health challenge. Pregnancy and childbirth bring most women to the attention of medical professionals, and thus providing an opportunity for contraceptive counseling and initiation. Providing effective contraception—regardless of the pregnancy outcome—is highly justified and may even be life-saving in settings where abortion is illegal (Glasier et al., Acta Obstet Gynecol Scand 8(11):1378–1385, 2019; Morroni and Glasier, Lancet Glob Health. 8(3):e316–e317, 2020). The contraceptive effectiveness of a contraceptive method in a given woman depends on her capacity to conceive, frequency and timing of intercourse, degree of compliance and inherent contraceptive efficacy of the method (Steiner et al., Obstet Gynecol 88(3 Suppl):24S–30S, 1996). Thus, most women with a recent history of an induced abortion and/or childbirth are highly fertile and likely to resume sexual activity soon after the pregnancy. This is highlighted in studies analyzing the need of subsequent abortion in women with history of abortion. Previous pregnancies (both deliveries and induced abortions) and young age—indicators of high fertility and sexual activity—emerge as risk factors for a subsequent abortion. In contrast, the use of effective contraceptive methods requiring minimal daily compliance, such as contraceptive implants and/or intrauterine devices, significantly reduces this risk (Goodman et al., Contraception 78(2):143–148, 2008; Heikinheimo et al., Contraception. 78: 149–154, 2008; Niinimäki et al., Obstet Gynecol 113: 845–852, 2009; Rose and Lawton, Am J Obstet Gynecol 206(1):37.e1–6, 2012). Therefore, safe and effective contraception, preferably with minimal daily/regular remembering is important if another pregnancy is not desired soon. In this chapter, we focus on contraceptive choices after induced abortion and childbirth. The high efficacy of the long-acting reversible methods of contraception (i.e., contraceptive implants and intrauterine devices) and importance of rapid post-pregnancy initiation of contraception are highlighted.Peer reviewe

Kenelle kierukkaehkäisy sopii?

Kie­rukka on pitkä­vai­kut­teinen ehkäi­sy­muoto, jon­ka te­hoon käyt­täjän vir­heet tai unoh­dukset ei­vät vai­kuta. Ikä tai synnyt­tä­neisyys ei­vät vai­kuta kieruk­kaeh­käisyn sopi­vuuteen tai turval­li­suuteen. Kie­rukkaa käyt­tävät nai­set ovat yleensä tyyty­väisiä ehkäi­sy­me­ne­tel­määnsä. Varmis­ta­malla kie­rukan help­po saa­tavuus voi­daan merkit­tä­västi vä­hentää suunnit­te­le­mat­tomia ras­kauksia.Peer reviewe

Intrauterine contraception after medical abortion : factors affecting success of early insertion

Objective: To assess the success and factors affecting early intrauterine device (IUD) provision after first trimester medical termination of pregnancy (MTOP). Study design: Subgroup analysis of a randomized contraceptive trial assessing the long-term effects of early provision of intrauterine contraception following abortion. Altogether, 606 women undergoing MTOP were included and followed for 3 months. The intervention group (n=307) was offered an IUD (either the levonorgestrel-releasing intrauterine system or copper-IUD) at a follow-up visit 1-4 weeks after MTOP. The control group (n=299) contacted primary health care for follow-up and contraceptive provision. Adverse events (infections, bleeding, residual tissue and incomplete abortion) were analyzed on intention-to-treat basis and IUD expulsions on per-protocol (PP) basis. Results: In the intervention group, 234 women (76.2%) received the IUD as scheduled, 46 later (altogether 91.2%). In the control group, the corresponding figures were 8 (2.7%) and 64 [altogether 24.1%, Odds ratio (OR) (95% Confidence interval (Cl)) = 32.7 (20.3-52.6)]. Eighty-five (27.7%) women in the intervention group and 38 (12.7%) in the control group received treatment (administration of antibiotics, misoprostol or surgical evacuation) because of presumed adverse event [2.63 (1.72-4.01)], mainly residual tissue. In the control group, 23 (60.5%) of these occurred during the first 2 weeks. IUD expulsion occurred in 12 (5.4%) of the 222 women in the intervention group (PP basis). Conclusions: When provided as part of abortion service, most early insertions following MTOP were performed as planned. The main reason for postponement was overdiagnosis of adverse events suspected at follow-up. The rate of IUD expulsion was similar to that reported previously. Implications: Early insertion following MTOP is safe, and the rate of IUD expulsion is low. Most adverse events possibly delaying IUD insertion occur early. Based on timing of adverse events in the control group, IUD insertion at approximately 2 weeks after completed MTOP seems optimal. (C) 2017 Elsevier Inc. All rights reserved.Peer reviewe

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 fol low-up visit, whereas in the control group 67 (22.4%) women did not contact the PHC to schedule a follow-up (p Conclusions Factors predicting low compliance with post-MTOP fol low-up are few. Comprehensive provision of abortion care and post-abortion services seems beneficial for minimising the loss to fol low-up and delay in initiation of effective contraception.Peer reviewe

Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion : first-year results of a randomized controlled trial

Correction: Volume: 34 Issue: 3 Pages: 587-588 DOI: 10.1093/humrep/dey376 Published: MAR 2019 Accession Number: WOS:000461140700021STUDY QUESTION: Can the need of subsequent abortion be reduced by providing intrauterine contraception as a part of the abortion service? SUMMARY ANSWER: Provision of intrauterine devices (IUDs) in association with first trimester abortion more than halved the incidence of repeat abortion during the first year of follow-up. WHAT IS KNOWN ALREADY: Following abortion, the incidence of subsequent abortion is high, up to 30-40%. In cohort studies, intrauterine contraception has reduced the need of repeat abortion by 60-70%. STUDY DESIGN, SIZE, DURATION: A randomized controlled trial. The main outcome measure was the incidence of subsequent induced abortions during the follow-up. Altogether 751 women seeking first trimester induced abortion were recruited and randomized into two groups. Randomization was accomplished by computer-assisted permuted-block randomization with random block sizes of four to six. The investigators did not participate in randomization, which was done before commencing the study. The participants were recruited between 18 October 2010 and 21 January 2013. PARTICIPANTS, SETTINGS, METHODS: The inclusion criteria were age >= 18 years, duration of pregnancy This study was conducted in collaboration between the Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, and Centralized family planning of the City of Helsinki. The intervention group (n = 375) was provided with intrauterine contraception (either the levonorgestrel-releasing intrauterine system or copper-releasing intrauterine device) immediately following surgical abortion (18.1%) or at a follow-up 2-4 weeks after medical abortion (81.9%). Women in the control group were prescribed oral contraceptives and advised to contact their primary healthcare unit for a follow-up visit and further contraceptive services according to national guidelines. The women were followed-up to 28 February 2014 by using the Finnish National Abortion Registry, Helsinki University Hospital electronic database and clinical follow-up visit at 1 year. MAIN RESULTS AND THE ROLE OF CHANCE: The median age of the whole study group was 27 years and 44% had a history of induced abortion(s). During the follow-up year the number of women requesting subsequent abortion was significantly lower in the intervention than in the control group (9/375 [2.4%] versus 20/373 [5.4%], difference -3.0 [95% CI -6.0 to -0.2] percentage points, P = 0.038, according to intention-to-treat analysis and 5/346 [1.4%] versus 20/357 [5.6%], difference -4.2(-7.2 to -1.4) percentage points, P = 0.003, according toper-protocol analysis, respectively). Provision of intrauterine contraception was safe with rate of infection and expulsion similar to those reported previously. LIMITATIONS, REASONS FOR CAUTION: The powercalculation was calculated for a 5-year follow-up. However, significant differences between the two groups were already seen after 1 year. The present study was performed in a single clinic, where, similar to 15% of all abortions in Finland are performed. WIDER IMPLICATIONS OF THE FINDINGS: In order to decrease the need of subsequent abortions, IUDs should be provided at the time of abortion.Peer reviewe

Laki raskaudenkeskeytyksestä tarvitsee päivitystä

Laki edellyttää perustetta ennen 12. raskausviikkoa tehtävälle keskeytykselle, kahden lääkärin hyväksyntää naisen päätökselle sekä keskeytysten hoidon keskittämistä sairaaloihin. Nämä ¬vaatimukset ovat nykytilanteessa tarpeettomia ja ne pitäisi poistaa

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 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.Peer reviewe

Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: population register based study

Objective To determine the risks of short term adverse events in adolescent and older women undergoing medical abortion