Postabortal contraception

Provision of effective contraception immediately after an abortion is important, as many women are highly motivated to use an effective method and avoid another unintended pregnancy at this time. Women’s need for effective contraception immediately after an abortion has been largely underestimated by healthcare professionals. Good evidence shows that more than one-half of women will have resumed sex within 2 weeks after an abortion . In one study, as many as 15% of women had resumed sexual intercourse within 1 week of taking mifepristone for early medical abortion; a time when they are still bleeding . Studies have shown that more than 80% of women ovulate in the first cycle after an abortion. Therefore, they are at risk of another pregnancy if they resume unprotected sexual intercourse .

Access to contraception at the time of an abortion may also be convenient for women, as it avoids another visit to a healthcare provider. Indeed, good evidence shows that up to 50% of women do not attend a scheduled follow-up appointment after an abortion . The need for an extra visit to have an intrauterine device (IUD) or intrauterine system (IUS) fitted has been shown to be a significant barrier to contraceptive uptake after an abortion . The World Health Organization (WHO) has issued recent guidance advising that all methods of contraception can be started immediately at surgical or medical abortion ( Table 1 ) .

Healthcare providers should, therefore, discuss future contraception with women before an abortion, so that a plan can be made for starting a suitable contraceptive method after the procedure. The abortion assessment visit, when the woman attends requesting an abortion, is an excellent opportunity to provide accurate information to women about contraceptive methods and dispel any misconceptions that they may have. Contrary to concerns that women may be too distressed or overloaded with information at this time, it has been show that women value the opportunity to discuss future contraception at this visit . In addition, provision of information on post-abortal contraception via an audiovisual DVD can help to educate women about their options and free up time during the consultation to discuss specific contraceptive concerns .

Use of long-acting reversible contraceptives after an abortion

It is increasingly being recognised that healthcare professionals should be promoting the most effective long-acting reversible methods of contraception (LARC); namely the IUD, IUS and implant. These methods have been shown to prevent more unintended pregnancies for women and further reduce unintended pregnancies in women who have already had an abortion . Global evidence shows that immediate insertion of an IUD or IUS after an abortion can reduce the risk of a woman having a further abortion . Evidence from the UK and USA also shows that immediate uptake of the contraceptive implant at medical or surgical abortion significantly reduces the risk of further abortion . The IUD and IUS can safely be inserted intra-operatively at surgical abortion or, for women undergoing a medical method of abortion, it can be inserted when it is reasonably certain that they are no longer pregnant . Healthcare professionals can be reassured that insertion immediately after an abortion is safe and associated with a low risk of complications .

A randomised-controlled trial (RCT) from the USA of more than 500 women (less than 9 weeks gestation) having either immediate insertion of an IUD or IUS after surgical abortion or delayed insertion (2–6 weeks later), showed that women in both groups had a similar low complication rate . In particular, no perforations occurred, rates of pelvic infection were low (2%), and expulsion rates in both groups were similar (about 5%) at 6 months. The only unintended pregnancies ( n = 5) that occurred were among women randomised to delayed insertion who failed to attend for this .

Studies have shown that IUD and IUS expulsion rates might be higher when inserted after surgical abortion in the mid-trimester or late first trimester compared with early first trimester insertion ; however, a cost analysis from the USA reported that immediate insertion remains cost-effective even with expulsion rates of up to 30% . The same study calculated considerable cost savings in the region of more than $4000 per woman (by 5 years) for immediate compared with delayed IUD insertion . This study also estimated that a switch to immediate IUD insertion could avert the equivalent of 180 births, and 160 subsequent abortions.

The WHO guidelines advise that an IUD and IUS can be inserted after medical abortion as soon as it is reasonably certain that the woman is no longer pregnant . With increasing numbers of women in Europe (France, Sweden, Porgugal, Denmark) and the USA opting for home medical abortion or choosing to go home soon after misoprostol administration to expel the pregnancy (UK), the opportunity to insert an IUD or IUS immediately after expulsion of the pregnancy is inevitably lost . Two RCTs and two observational studies have shown that insertion of an IUD or IUS in the first weeks after medical abortion is safe and has a similar low complication rate compared with insertion at a later date . In an RCT conducted in Sweden, over 100 women having early medical abortion (<9 weeks) were randomised to early insertion (5–9 days after mifepristone) or delayed insertion (2–3 weeks later) of an IUD or IUS. No perforations occurred in either group, and expulsion rates (10%) were similar in both groups .

Although existing data on risk of expulsion and thickness of the endometrium on ultrasound are conflicting, a cut-off measurement that predicts expulsion has not been determined. Therefore, ultrasound is not indicated except if required to confirm the success of an abortion . Women randomised to delayed insertion, however, are less likely to attend for insertion . As a consequence, they are more likely to experience another unintended pregnancy. In the RCT from the USA , four women randomised to delayed insertion of the IUD became pregnant. All of these women failed to attend compared with none in the immediate insertion group . Although insertion of the IUD does not adversely affect duration or heaviness of bleeding after an abortion , it has been shown that women who choose an IUS after medical or surgical abortion can benefit immediately with reduced bleeding . It is also possible that insertion of an IUD and IUS soon after medical abortion may be easier than at a later stage, as the cervix may be slightly dilated. Delayed insertion does, however, constitute a barrier to uptake of the IUD and IUS; uptake rates seem higher if this appointment for insertion is scheduled within 1 week of medical procedure rather than 2 . For women for whom insertion is delayed, it would also seem appropriate to offer a temporary ‘bridging’ method of contraception until they can have the IUD or IUS inserted, as many will recommence sexual activity within 1week of the abortion . No studies have been published comparing immediate with delayed IUD or IUS insertion after a mid-trimester medical abortion.

WHO advise that the contraceptive implant can be inserted at the time of surgical abortion or as early as the first pill prescribed for medical abortion (mifepristone) . In an observational study from the UK (where methods of contraception are available at no cost to women), it was shown that women choosing to have an implant inserted at the time of medical or surgical abortion were 16 times less likely to have another abortion within the next 2 years compared with counterparts choosing to the combined contraceptive pill (COC).This level of protection was comparable to that offered by the IUD or IUS. Although some health professionals may worry that women may feel pressurised to accept a contraceptive implant at abortion and be more likely to request subsequent removal, studies have shown that continuation rates with an implant are high when it is inserted immediately after abortion (81% at 1year), and comparable to continuation if inserted at other times . It has not been shown that insertion of an implant (or any other hormonal method) adversely affects the efficacy of medical abortion or vice versa , and it is unknown if insertion of an implant affects bleeding pattern after an abortion. This is being explored by several ongoing clinical studies.

Use of long-acting reversible contraceptives after an abortion

It is increasingly being recognised that healthcare professionals should be promoting the most effective long-acting reversible methods of contraception (LARC); namely the IUD, IUS and implant. These methods have been shown to prevent more unintended pregnancies for women and further reduce unintended pregnancies in women who have already had an abortion . Global evidence shows that immediate insertion of an IUD or IUS after an abortion can reduce the risk of a woman having a further abortion . Evidence from the UK and USA also shows that immediate uptake of the contraceptive implant at medical or surgical abortion significantly reduces the risk of further abortion . The IUD and IUS can safely be inserted intra-operatively at surgical abortion or, for women undergoing a medical method of abortion, it can be inserted when it is reasonably certain that they are no longer pregnant . Healthcare professionals can be reassured that insertion immediately after an abortion is safe and associated with a low risk of complications .

A randomised-controlled trial (RCT) from the USA of more than 500 women (less than 9 weeks gestation) having either immediate insertion of an IUD or IUS after surgical abortion or delayed insertion (2–6 weeks later), showed that women in both groups had a similar low complication rate . In particular, no perforations occurred, rates of pelvic infection were low (2%), and expulsion rates in both groups were similar (about 5%) at 6 months. The only unintended pregnancies ( n = 5) that occurred were among women randomised to delayed insertion who failed to attend for this .

Studies have shown that IUD and IUS expulsion rates might be higher when inserted after surgical abortion in the mid-trimester or late first trimester compared with early first trimester insertion ; however, a cost analysis from the USA reported that immediate insertion remains cost-effective even with expulsion rates of up to 30% . The same study calculated considerable cost savings in the region of more than $4000 per woman (by 5 years) for immediate compared with delayed IUD insertion . This study also estimated that a switch to immediate IUD insertion could avert the equivalent of 180 births, and 160 subsequent abortions.

The WHO guidelines advise that an IUD and IUS can be inserted after medical abortion as soon as it is reasonably certain that the woman is no longer pregnant . With increasing numbers of women in Europe (France, Sweden, Porgugal, Denmark) and the USA opting for home medical abortion or choosing to go home soon after misoprostol administration to expel the pregnancy (UK), the opportunity to insert an IUD or IUS immediately after expulsion of the pregnancy is inevitably lost . Two RCTs and two observational studies have shown that insertion of an IUD or IUS in the first weeks after medical abortion is safe and has a similar low complication rate compared with insertion at a later date . In an RCT conducted in Sweden, over 100 women having early medical abortion (<9 weeks) were randomised to early insertion (5–9 days after mifepristone) or delayed insertion (2–3 weeks later) of an IUD or IUS. No perforations occurred in either group, and expulsion rates (10%) were similar in both groups .

Although existing data on risk of expulsion and thickness of the endometrium on ultrasound are conflicting, a cut-off measurement that predicts expulsion has not been determined. Therefore, ultrasound is not indicated except if required to confirm the success of an abortion . Women randomised to delayed insertion, however, are less likely to attend for insertion . As a consequence, they are more likely to experience another unintended pregnancy. In the RCT from the USA , four women randomised to delayed insertion of the IUD became pregnant. All of these women failed to attend compared with none in the immediate insertion group . Although insertion of the IUD does not adversely affect duration or heaviness of bleeding after an abortion , it has been shown that women who choose an IUS after medical or surgical abortion can benefit immediately with reduced bleeding . It is also possible that insertion of an IUD and IUS soon after medical abortion may be easier than at a later stage, as the cervix may be slightly dilated. Delayed insertion does, however, constitute a barrier to uptake of the IUD and IUS; uptake rates seem higher if this appointment for insertion is scheduled within 1 week of medical procedure rather than 2 . For women for whom insertion is delayed, it would also seem appropriate to offer a temporary ‘bridging’ method of contraception until they can have the IUD or IUS inserted, as many will recommence sexual activity within 1week of the abortion . No studies have been published comparing immediate with delayed IUD or IUS insertion after a mid-trimester medical abortion.

WHO advise that the contraceptive implant can be inserted at the time of surgical abortion or as early as the first pill prescribed for medical abortion (mifepristone) . In an observational study from the UK (where methods of contraception are available at no cost to women), it was shown that women choosing to have an implant inserted at the time of medical or surgical abortion were 16 times less likely to have another abortion within the next 2 years compared with counterparts choosing to the combined contraceptive pill (COC).This level of protection was comparable to that offered by the IUD or IUS. Although some health professionals may worry that women may feel pressurised to accept a contraceptive implant at abortion and be more likely to request subsequent removal, studies have shown that continuation rates with an implant are high when it is inserted immediately after abortion (81% at 1year), and comparable to continuation if inserted at other times . It has not been shown that insertion of an implant (or any other hormonal method) adversely affects the efficacy of medical abortion or vice versa , and it is unknown if insertion of an implant affects bleeding pattern after an abortion. This is being explored by several ongoing clinical studies.

Non-long-acting reversible methods of contraception after abortion

Although the National Institute for Health and Care Excellence considers the injectable progestagens to be an LARC method, the injectable is not as effective as the IUD, IUS or implant, and is associated with higher discontinuation rates . In addition, some evidence shows that women who choose the injectable after medical or surgical abortion have a lower risk of another abortion within the next 2 years compared with women choosing the COC . WHO advises that the injectable can be started immediately after surgical or medical abortion .

Amenorrhoea commonly occurs with the use of injectables; however, women who start this method at the time of abortion should be advised that absence of bleeding should not be attributed to the contraceptive injection (or any other hormonal contraceptive method), and that confirmation of success of the procedure is necessary.

Women wishing to use an oral contraceptive pill can be advised to start this immediately after the abortion . Evidence shows that immediate initiation of the COC does not affect the duration of bleeding after a medical abortion , and some data suggest that this is also the case when starting the combined hormonal contraceptive patch .

Sterilisation can be safely carried out at the time of abortion, although may be more likely to be associated with regret and failure when performed at this time . The immediate and short-term complications of sterilisation when performed at abortion, are similar to the total morbidity with the two procedures when performed separately . No data are available on hysteroscopic sterilisation at the time of abortion.

If women opt to use a less effective method of contraception (e.g. condom) after an abortion, then it would be good practice to advise them about the availability of emergency contraception, should a condom burst or several pills be missed. In addition, women should be advised that natural family planning or ‘fertility awareness based’ methods cannot be used until normal cycles have resumed .

Strategies to increase long-acting reversible methods of contraception after abortion

To increase uptake of the most effective method of contraception after abortion, it is important that women are first provided with accurate, high-quality information in advance of the procedure. This should dispel any myths about LARC, and provide them with facts about the benefits associated with these methods . In a recent study from the UK, 100 women requesting an abortion were surveyed about intrauterine contraception. About one in three expressed an interest in using this method . This suggests that the pre-abortion visit is a good opportunity to provide contraceptive counselling about the IUD and IUS, so that women will be in a position to consider this method and opt for it immediately after abortion.

Abortion providers may also require training on LARC to reassure themselves that it is a safe and appropriate method for use immediately after medical or surgical abortion. Providers may also need to be trained to insert these methods, and funding will be given to provide these, given the evidence that providing LARC at no cost results in increased uptake after abortion . In one study from New Zealand , provision of the IUS at no cost resulted in a sixfold increase in uptake of this method after an abortion from 6–36%. Providers will also need sufficient clinical time to be able to offer these methods, as it is more time-consuming to insert an implant or IUD, than hand over a supply of pills. This has been identified as a challenge for services where women choose to have a home medical abortion rather than remain on clinic premises for this intervention .