Initiation of long-acting reversible contraceptive methods (IUDs and implant) at pregnancy termination reduces repeat abortion
- Correspondence to: Jeffrey F Peipert
Department of OB/GYN, Washington University in St Louis School of Medicine, Campus Box 8219, 4533 Clayton Avenue, St Louis, MO 63110, USA;
Despite the availability of effective modern contraceptive methods, unplanned pregnancy continues to be a major problem worldwide. In 2008, the worldwide abortion rate was found to be 28/1000 women aged 15–44, unchanged from 2003 rates of 29/1000 women.1 Immediate initiation of long-acting reversible contraceptive (LARC) methods following pregnancy termination has been identified as an effective strategy to reduce repeat unintended pregnancy and abortion. Access to these LARC methods—intrauterine devices (IUDs) and implants—continues to be problematic, especially in the setting of pregnancy termination. Previous research has shown that delayed initiation of these methods often results in failure to obtain the method. Improving access to the most effective methods at the time of termination when women are particularly motivated to prevent subsequent pregnancy has the potential to positively impact unplanned pregnancy and abortion rates worldwide.
The study by Cameron and colleagues was a retrospective chart review of 1368 women requesting a termination at The Royal Infirmary of Edinburgh. Women presenting for services received comprehensive contraceptive counselling and were offered the reversible contraceptive method of their choice, free of charge, at the time of their procedure. Records were evaluated for the subsequent 24 months following the incident termination and were available for 72% of the cohort (N=986). An additional 101 women were excluded from the analysis for a variety of reasons. Sociodemographic characteristics and reproductive history were reported, and bivariate and multivariate logistic regression was used to evaluate the association of a post-termination method chosen with repeat termination while controlling for baseline differences.
The most common method chosen was combined oral contraceptive pills (COCPs) (30%), followed by implant and IUD. Younger women were more likely to choose COCP or implants; older women were more likely to choose an IUD. Parous women and those with a history of previous termination were more likely to choose the IUD.
Of the 986 women with complete records, 121 (12.3%) represented for subsequent termination within 24 months, and 10 (8%) presented more than once. The IUD and implant were associated with the lowest likelihood of having a repeat termination (OR=0.05, 95% CI 0.01 to 0.41 for IUD; OR=0.06, 95% CI 0.01 to 0.23 for implant). Young age and previous birth were associated with having a subsequent termination. Repeat requests for termination in women receiving COCPs and injectable progestin were similar to women receiving no method. Women receiving an IUD or implant were found to be 20 and 16 times less likely, respectively, to return for a subsequent termination.
The authors conclude that women who choose the IUD and implant at the time of pregnancy termination have a lower risk of a subsequent termination within the next 2 years. While other studies have shown that immediate IUD insertion is associated with a lower likelihood of repeat termination of pregnancy, the authors state that this is the first study to show comparable protection with the implant.
The authors comment that ‘the progestogen-only injectable is technically considered a long-acting reversible method (LARC)’. We beg to differ. The injectable lasts for only 12 weeks, and we (and others) do not consider this ‘long-acting’.
As a retrospective case review, the study has inherent limitations (eg, missing records in 28% of the women and 101 additional exclusions, underestimation of repeat terminations and inability to control for residual confounding). However, the findings further support the need to improve access to immediate provision of LARC methods following pregnancy termination. Despite the growing body of evidence confirming the safety and acceptability of LARC, few women have access to these methods. IUDs and implants have been shown not only to be the most effective methods of reversible contraception,2 they are also highly cost-effective. Although this study shows the potential to reduce risk of repeat unintended pregnancy by up to 20 times, implementation and translation of this evidence into practice faces many challenges. Developing nations, where more than 215 million women have unmet contraceptive needs,3 rarely have trained providers to disseminate these methods. Developed nations face different challenges. Often the cost of devices or inadequate clinician knowledge regarding insertion technique and appropriate candidates (adolescent and nulliparous women) limit more widespread use. The authors correctly identify that the ultimate solution is in public health policy reform. Regardless of the controversy surrounding abortion, if we are serious about reducing unintended pregnancy worldwide, we must find a way to reduce barriers to LARC methods through education, improved access and reducing financial barriers.