7 research outputs found

    Long-acting reversible contraception (LARC) after pregnancy and childbirth

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    Background and aims: Unmet need of contraception is a global challenge. The need of additional visits to initiate contraception is found to be a barrier for postpartum and postabortion contraceptive care. The IUDs and the implant are called long-acting reversible contraception (LARC). The LARC-method can be used for years without having to remember a contraceptive during sexual intercourse or, in case of hormonal contraception, every day, week or month. The overall aim of this thesis was to add knowledge to the field of long-acting reversible contraception after pregnancy in Sweden in our effort to improve the quality of contraceptive care after pregnancy and childbirth. Methods and main results: Study 1 was a retrospective cohort study including 11,066 women. Data was extracted from medical records regarding attendance to the postpartum visit and choice of contraception, breastfeeding, and abortion during 12-24 months after delivery. The primary outcome was the proportion of induced abortions during follow-up, with the outcome measure of abortion being a surrogate for unintended pregnancy. Among attendees to the follow up 2.1 % had an abortion compared to 3.6 % among nonattendants. A decision to use LARC was associated with a lower risk of abortion (OR 0.74; 95% CI 0.60-0.91; p = .005), as was exclusive breastfeeding (p < .001). Smoking and having had an earlier abortion were associated with a higher risk of abortion during the follow-up. Study II and III were open-label, prospective, randomised, controlled, multicenter studies. In study II, 101 women were either allocated to early placement (52/101) of a hormonal IUD within 48 hours after vaginal delivery or to standard placement (49/101) at 6-8 weeks postpartum. Follow-up was one year after IUD placement. Inclusion was prematurely stopped after an interim analysis due to high expulsion rate in the early placement group, and instead of 600 women only 101 were included. In the early placement group 23/52 (44.2 %) of devices were expelled within a year and 10 women had the hormonal device replaced. In the standard placement group there were no expulsions. The IUD continuation rate for the early group was 37/52 (71.2%), compared to 41/49 (83.7%, p = .13) for the standard placement group at study closure. In study III, 240 women seeking medical abortion up to 63 days´ gestation were randomised to either IUD placement within 48 hours (120/240) after completed abortion or to IUD placement at 2-4 weeks (120/240) after abortion. Follow-up was one year after abortion. The primary outcome was IUD use at 6 months postabortion. In the early placement group (intervention), 91/111 (82%) women used IUD at 6 months compared to 87/112 (77.7%) in the later placement (control) group (p= .51) Pain scores at IUD placement (measured by the visual analogue scale) were lower in the intervention group (p= .002). Women in the intervention group preferred the allocated time significantly more often compared to the control group (p= .03). There was no difference regarding expulsion. In study II and III there were no differences regarding safety profile between groups. Study IV was a qualitative study where 20 women who had undergone elective caesarean section (CS) were interviewed within 6 weeks of CS, to enable deeper understanding of women´s preferences and needs regarding contraceptive services at the time of pregnancy. Ten of the interviewees had chosen IUD placement during the latest CS. Three themes were identified; Receptivity to contraceptive counseling during pregnancy; Communication and decision-making of postpartum contraception during pregnancy and Needs to navigate in the Maternal Health Care System to receive contraceptive services before and after caesarean section. Women were generally positive to contraceptive counseling from about 25 gestational weeks and expressed positive attitudes about the concept of antenatal counseling. Feeling involved and informed was important, but few women had been involved in antenatal counseling. Women who had chosen IUD placement during CS were usually satisfied with the decision. Some interviewees expressed a need to navigate in the contraceptive services by themselves. The communication and coordinating units that should integrate around the woman have not sufficiently adapted to new evidence, needs and conditions. Conclusions: The choice of LARC postpartum is associated with lower risk for unintended pregnancy compared to the choice of other contraceptives or no choice at all. Attendance to the postpartum visit is a prerequisite to initiate LARC when provision of early/immediate LARC initiation postpartum is not part of the established contraceptive health care. Placement of a hormonal IUD within 48 hours after vaginal delivery seems safe, accepted by patients but associated with much higher expulsion rates compared to placement 6- 12 weeks postpartum. Early placement of an IUD within 48 hours after completed medical abortion does not lead to higher continuation rates at one year after abortion compared to standard placement 2-4 weeks after abortion when devices are provided free of charge. Early placement seems safe, preferred by patients, and associated with lower pain scores compared to standard IUD placement postabortion. Antenatal counseling for contraceptive method to use postpartum seems acceptable to women from around 25 gestational weeks. To have the opportunity to discuss contraception antenatally and enable placement during planned CS is generally considered valuable

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

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    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 (R)) 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 &amp;gt;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.Funding Agencies|County Council of Ostergotland (ALF) [LIO-931995, LIO-794921]</p

    Risk of abortion within 1-2 years after childbirth in relation to contraceptive choice: a retrospective cohort study

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    Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period. Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum. Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age amp;lt;25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk. Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.Funding Agencies|county council of Ostergotland and county council of Stockholm</p

    Risk of abortion within 1-2 years after childbirth in relation to contraceptive choice: a retrospective cohort study

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    Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period. Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum. Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age amp;lt;25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk. Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.Funding Agencies|county council of Ostergotland and county council of Stockholm</p

    Risk of abortion within 1-2 years after childbirth in relation to contraceptive choice: a retrospective cohort study

    No full text
    Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period. Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum. Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age amp;lt;25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk. Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.Funding Agencies|county council of Ostergotland and county council of Stockholm</p

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

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    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

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

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    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
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