Advertisement

Contraception after medication abortion in the United States: results from a cluster randomized trial

  • Corinne H. Rocca
    Correspondence
    Corresponding author: Corinne Rocca, PhD, MPH.
    Affiliations
    Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA

    Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA
    Search for articles by this author
  • Suzan Goodman
    Affiliations
    Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
    Search for articles by this author
  • Daniel Grossman
    Affiliations
    Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA

    Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA
    Search for articles by this author
  • Kara Cadwallader
    Affiliations
    Planned Parenthood of the Great Northwest and the Hawaiian Islands, Seattle, WA
    Search for articles by this author
  • Kirsten M.J. Thompson
    Affiliations
    Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
    Search for articles by this author
  • Elizabeth Talmont
    Affiliations
    Planned Parenthood of Northern, Central, and Southern New Jersey Inc, Morristown, NJ
    Search for articles by this author
  • J. Joseph Speidel
    Affiliations
    Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
    Search for articles by this author
  • Cynthia C. Harper
    Affiliations
    Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
    Search for articles by this author
Published:October 03, 2017DOI:https://doi.org/10.1016/j.ajog.2017.09.020

      Background

      Understanding how contraceptive choices and access differ for women having medication abortions compared to aspiration procedures can help to identify priorities for improved patient-centered postabortion contraceptive care.

      Objective

      The objective of this study was to investigate the differences in contraceptive counseling, method choices, and use between medication and aspiration abortion patients.

      Study Design

      This subanalysis examines data from 643 abortion patients from 17 reproductive health centers in a cluster, randomized trial across the United States. We recruited participants aged 18–25 years who did not desire pregnancy and followed them for 1 year. We measured the effect of a full-staff contraceptive training and abortion type on contraceptive counseling, choice, and use with multivariable regression models, using generalized estimating equations for clustering. We used survival analysis with shared frailty to model actual intrauterine device and subdermal implant initiation over 1 year.

      Results

      Overall, 26% of participants (n = 166) had a medication abortion and 74% (n = 477) had an aspiration abortion at the enrollment visit. Women obtaining medication abortions were as likely as those having aspiration abortions to receive counseling on intrauterine devices or the implant (55%) and on a short-acting hormonal method (79%). The proportions of women choosing to use these methods (29% intrauterine device or implant, 58% short-acting hormonal) were also similar by abortion type. The proportions of women who actually used short-acting hormonal methods (71% medication vs 57% aspiration) and condoms or no method (20% vs 22%) within 3 months were not significantly different by abortion type. However, intrauterine device initiation over a year was significantly lower after the medication than the aspiration abortion (11 per 100 person-years vs 20 per 100 person-years, adjusted hazard ratio, 0.50; 95% confidence interval, 0.28–0.89). Implant initiation rates were low and similar by abortion type (5 per 100 person-years vs 4 per 100 person-years, adjusted hazard ratio, 2.41; 95% confidence interval, 0.88–6.59). In contrast to women choosing short-acting methods, relatively few of those choosing a long-acting method at enrollment, 34% of medication abortion patients and 53% of aspiration abortion patients, had one placed within 3 months. Neither differences in health insurance nor pelvic examination preferences by abortion type accounted for lower intrauterine device use among medication abortion patients.

      Conclusion

      Despite similar contraceptive choices, fewer patients receiving medication abortion than aspiration abortion initiated intrauterine devices over 1 year of follow-up. Interventions to help patients receiving medication abortion to successfully return for intrauterine device placement are warranted. New protocols for same-day implant placement may also help patients receiving medication abortion and desiring a long-acting method to receive one.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2014. Perspect Sex Reprod Health 2017;49:17-27.

        • Cameron S.
        • Glasier A.
        • Dewart H.
        • Johnstone A.
        Women's experiences of the final stage of early medical abortion at home: results of a pilot survey.
        J Fam Plan Reprod Health Care. 2010; 36: 213-216
        • Finer L.B.
        • Wei J.
        Effect of mifepristone on abortion access in the United States.
        Obstet Gynecol. 2009; 114: 623-630
      2. Centers for Disease Control and Prevention, Department of Health and Human Services. US medical eligibility criteria for contraceptive use, 2010. MMWR Morb Mort Wkly Rep 2010;59:2.

        • Grimes D.
        • Schulz K.
        • Stanwood N.
        Immediate postabortal insertion of intrauterine devices.
        Cochrane Database Syst Rev. 2004; : CD001777
        • American College of Obstetricians and Gynecologists
        Medical management of first-trimester abortion. ACOG Practice bulletin no. 143.
        Obstet Gynecol. 2014; 123: 676-692
        • Langston A.M.
        • Joslin-Roher S.L.
        • Westhoff C.L.
        Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice.
        Contraception. 2014; 89: 103-108
        • Okusanya B.O.
        • Oduwole O.
        • Effa E.E.
        Immediate postabortal insertion of intrauterine devices.
        Cochrane Database Syst Rev. 2014; : CD001777
        • Bednarek P.H.
        • Creinin M.D.
        • Reeves M.F.
        • et al.
        Immediate versus delayed IUD insertion after uterine aspiration.
        N Engl J Med. 2011; 364: 2208-2217
        • Cremer M.
        • Bullard K.A.
        • Mosley R.M.
        • et al.
        Immediate vs. delayed post-abortal Copper T 380A IUD insertion in cases over 12 weeks of gestation.
        Contraception. 2011; 83: 522-527
        • Raymond E.G.
        • Weaver M.A.
        • Tan Y.-L.
        • et al.
        Effect of immediate compared with delayed insertion of etonogestrel implants on medical abortion efficacy and repeat pregnancy.
        Obstet Gynecol. 2016; 127: 306-312
        • Hognert H.
        • Kallner H.K.
        • Cameron S.
        • et al.
        Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion-a randomized controlled equivalence trial.
        Hum Reprod. 2016; 31: 2484-2490
        • Rocca C.H.
        • Thompson K.M.J.
        • Goodman S.
        • Westhoff C.L.
        • Harper C.C.
        Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial.
        Am J Obstet Gynecol. 2016; 214: 716.e1
        • Harper C.C.
        • Rocca C.H.
        • Thompson K.M.J.
        • et al.
        Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial.
        Lancet. 2015; 386: 562-568
        • World Health Organization, Department of Reproductive Health and Research, Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs
        Family planning: a global handbook for providers.
        World Health Organization and Center for Communication Programs, Geneva (Switzerland) and Baltimore (MD)2007
        • Johnson K.
        • Posner S.F.
        • Bierman J.
        • et al.
        Recommendations to improve preconception health and health care, United States: a report of the CEDC/ATSDR preconception care work group and the select panel on preconception care.
        MMWR Morb Mort Wkly Rep. 2006; 55: 1-23
        • Thompson K.M.J.
        • Rocca C.H.
        • Kohn J.E.
        • et al.
        Public funding for contraception, provider training, and use of highly effective contraceptives: a cluster randomized trial.
        Am J Public Health. 2016; 106: 541-546
        • Guttmacher Institute
        State policies in brief: Medicaid family planning eligibility expansions, insurance coverage of contraceptives, state family planning funding restrictions, state funding of abortion under Medicaid, and counseling and waiting periods for abortion.
        Guttmacher Institute, New York (NY)2011 (Available at:) (Accessed Oct. 23, 2014)
        • Rothman K.J.
        • Greenland S.
        • Lash T.L.
        Modern Epidemiology.
        3rd ed. Lippincott Williams & Wilkins, Philadelphia (PA)2008: 260-262
        • Azur M.J.
        • Stuart E.A.
        • Frangakis C.
        • Leaf P.J.
        Multiple imputation by chained equations: what is it and how does it work?.
        Int J Methods Psychiatr Res. 2011; 20: 40-49
        • Pohjoranta E.
        • Suhonen S.
        • Mentula M.
        • Heikinheimo O.
        Intrauterine contraception after medical abortion: factors affecting success of early insertion.
        Contraception. 2016; 95: 257-262
        • Douthwaite M.
        • Candelas J.A.
        • Reichwein B.
        • Eckhardt C.
        • Ngo T.D.
        • Dominguez A.
        Efficacy of early induced medical abortion with mifepristone when beginning progestin-only contraception on the same day.
        Int J Gynaecol Obstet. 2016; 133: 329-333
        • Park J.
        • Robinson N.
        • Wessels U.
        • Turner J.
        • Geller S.
        Progestin-based contraceptive on the same day as medical abortion.
        Int J Gynaecol Obstet. 2016; 133: 217-220
        • Raymond E.G.
        • Weaver M.A.
        • Louie K.S.
        • et al.
        Effects of depot medroxyprogesterone acetate injection timing on medical abortion efficacy and repeat pregnancy: a randomized controlled trial.
        Obstet Gynecol. 2016; 128: 739-745
        • Shimoni N.A.
        • Davis A.
        • Westhoff C.
        Can ultrasound predict IUD expulsion after medical abortion?.
        Contraception. 2014; 89: 434-439
        • Thompson K.M.J.
        • Speidel J.J.
        • Saporta V.
        • Waxman N.J.
        • Harper C.C.
        Contraceptive policies affect post-abortion provision of long-acting reversible contraception.
        Contraception. 2011; 83: 41-47
        • Purcell C.
        • Cameron S.
        • Lawton J.
        • Glasier A.
        • Harden J.
        Contraceptive care at the time of medical abortion: experiences of women and health professionals in a hospital or community sexual and reproductive health context.
        Contraception. 2016; 93: 170-177
        • Matulich M.
        • Cansino C.
        • Culwell K.R.
        • Creinin M.D.
        Understanding women's desires for contraceptive counseling at the time of first-trimester surgical abortion.
        Contraception. 2014; 89: 36-41
        • Gold R.B.
        Guarding against coercion while ensuring access: a delicate balance.
        Guttmacher Pol Rev. 2014; 17: 8-14
        • Higgins J.A.
        Celebration meets caution: LARC's boons, potential busts, and the benefits of a reproductive justice approach.
        Contraception. 2014; 89: 237-241