Improving access to medical abortion and uptake of effective contraceptives

<p dir="ltr">Introduction: Contraceptive prevention is a key factor to avoid an unintended pregnancy. Several studies have shown that an increased uptake of Long-Acting Reversible Contraceptive methods (LARCs) reduce unintended pregnancies and abortions. LARCs are the most effective methods, as they are not user- dependent, compared to short-acting methods. Surveys show that women in Sweden consider effectiveness as the most important factor when choosing a contraceptive. However, use of less effective methods is often seen. In comparison to similar European countries, abortion rates in Sweden are among the highest and the unmet need of contraception in Sweden 17.2%.</p><p dir="ltr">Contraceptive counselling can facilitate prevention, although consistent and clear recommendations on how to provide counselling is lacking. Medical treatment with mifepristone and misoprostol for medical abortion is effective and safe. Treatment can be self-managed at home in the first trimester. However, clear evidence is lacking on very early medical abortion (VEMA) before a pregnancy is confirmed on ultrasound. Abortion providers may therefore delay care until a pregnancy is visualized. Telemedicine abortion provides a way to reduce barriers and expand access to safe abortion care, however there are no randomized trials from high income settings.</p><p dir="ltr">Aim: The overall aim of this thesis is to provide evidence on models that can contribute to expanded access to medical abortion in very early gestation (before confirmed intrauterine pregnancy) and following telemedicine consultation. In addition we aimed to evaluate if a structured contraceptive counselling model can increase women's use of highly effective contraceptive methods.</p><p dir="ltr">Method: We conducted one retrospective cohort study and two randomized trials. In study I the efficacy of abortion was retrospectively evaluated in patients seeking medical abortion with an unconfirmed intra-uterine pregnancy (IUP) compared to women with confirmed IUP. In study II women seeking care at abortion clinics, youth or maternal health clinics were randomized to structured contraceptive counselling (SCC) or contraceptive counselling according to routine (i.e no clear/specified structure) to evaluate the effect on LARC uptake and continuation. In study III patients seeking early medical abortion (<9weeks) were randomized at the phone booking to an online consultation or standard in- clinic care.</p><p dir="ltr">Results: Study I showed no significant difference in abortion efficacy after VEMA compared to standard care (efficacy 98.2 vs 97.1%) No difference was seen in ongoing pregnancies, and interventions (additional misoprostol and surgical aspiration) for incomplete abortion was significantly less after VEMA. In Study II LARC uptake increased after SCC and LARC use was higher at 12 months follow- up compared to those who received routine counselling. At abortion clinics, at 12 months, pregnancy rates were significantly lower after receiving SCC. Among women initiating a LARC method no effect on continuation rates could be seen between groups at the 12 month follow-up. In study III telemedicine consultation was non-inferior to standard medical abortion care (98.2 vs 98.2%). Conclusion:</p><p dir="ltr">Medical abortion treatment before confirmed IUP is effective and safe and should be offered to patients seeking abortion in very early gestation. The risk for ectopic pregnancy needs to be acknowledged, therefore a structured clinical protocol should be implemented if VEMA is offered. Structured contraceptive counselling provides a valuable tool in increasing the uptake of LARC methods and reduce unintended pregnancies. Telemedicine abortion is an effective and safe alternative to standard in-clinic care.</p><h3>List of scientific papers</h3><p dir="ltr">I. Efficacy and safety of very early medical termination of pregnancy: a cohort study <b>Bizjak I,</b> Fiala C, Berggren L, Hognert H, Sääv I, Bring J, Gemzell- Danielsson K. BJOG. 2017 Dec;124(13):1993-1999<br><a href="https://doi.org/10.1111/1471-0528.14904" rel="noreferrer" target="_blank">https://doi.org/10.1111/1471-0528.14904<br><br></a></p><p dir="ltr">II. Increasing uptake of long-acting reversible contraception with structured contraceptive counselling: cluster randomized controlled trial (the LOWE trial) Emtell Iwarsson K*, Envall N*, <b>Bizjak I,</b> Bring J, Kopp Kallner H, Gemzell-Danielsson K. BJOG. 2021 Aug;128(9):1546-1554<br><a href="https://doi.org/10.1111/1471-0528.16754" rel="noreferrer" target="_blank">https://doi.org/10.1111/1471-0528.16754<br><br></a></p><p dir="ltr">III. Contraceptive uptake and compliance after structured contraceptive counselling - secondary outcomes of the LOWE trial <b>Bizjak I,</b> Envall N, Emtell Iwarsson K, Kopp Kallner H, Gemzell- Danielsson K. Acta Obstet Gynecol Scand. 2024 May;103(5):873-883.<br><a href="https://doi.org/10.1111/aogs.14792" rel="noreferrer" target="_blank">https://doi.org/10.1111/aogs.14792<br><br></a></p><p dir="ltr">IV. A Randomized Trial on Efficacy of Telemedicine Abortion <b>Isabella Bizjak</b>*, Karin Brandell*, Ninni Mannerberg, Anette Aronsson, Amanda Cleeve & Kristina Gemzell Danielsson. [Manuscript]</p><p dir="ltr">*Shared first author</p>