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.

List of scientific papers

I. Hogmark S, Envall N, Wikman A, Skoglund C, Kopp Kallner H, Hesselman S. Provision of long-acting reversible contraception at surgical abortion—A cross-sectional nationwide register study. Acta Obstet Gynecol Scand. 2022;101:77–83.
https://doi.org/10.1111/aogs.14289

II. Hogmark S, Lichtenstein Liljeblad K, Envall N, Gemzell-Danielsson K, Kopp Kallner H. Placement of an intrauterine device within 48 hours after early medical abortion—a randomized controlled trial. Am J Obstet Gynecol. 2023;228:53.e1-9.
https://doi.org/10.1016/j.ajog.2022.07.063

III. Hogmark S, Envall N, Gemzell-Danielsson K, Kopp Kallner H. 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. Acta Obstet Gynecol Scand. 2023;102:1694-1702.
https://doi.org/10.1111/aogs.14662

IV. Hogmark S, Rydelius J, Envall N, Teleman P, Gemzell-Danielsson K, Kopp Kallner H. Placement of an intrauterine device within 48 hours after second trimester medical abortion — a randomized controlled trial. [Submitted]