By Deborah Constant, Margit Endler, Daniel Grossman, Gregory Petro and Malika Patel
Termed “forgettable contraception” as it only requires attention every 5-10 years, the intrauterine device (IUD) is a highly effective long-acting method and has potential to liberate women and girls from the hassle of frequent method administration required by short term methods. In high prevalence HIV settings, the copper IUD can also be a long-acting option of choice to avoid cross reactions with HIV medication. South Africa’s unmet need for modern contraception is 15%, however use of the IUD is low, at 2% of the method mix. As in many similar settings, healthcare services providing contraception are overburdened with short staff-patient interaction and rote provision of the injectable method.
The post-abortion period is a key time to reach women with better contraceptive choices. For women having a medical abortion in the later second trimester (17-20 gestational weeks) and wanting an IUD, the safety and effectiveness of having it inserted immediately after the abortion rather than delaying the insertion some weeks is unknown. Immediate or early insertion after surgical abortion and medical abortion up to 9 weeks is routinely done and consensus is that the benefits of actually getting the IUD outweigh the risks of expulsion. However, second trimester abortion requires repeated doses of the uterotonic misoprostol, which could theoretically increase the risk of expulsion.
New study provides robust evidence on the risk-benefit ratio of immediate insertion following medical abortion at 17-20 gestational weeks.
We performed a randomized control trial to compare safety, effectiveness and acceptability of immediate compared to delayed insertion of the copper IUD after medical abortion at 17-20 gestational weeks. Our main outcome was use of the IUD at 6 weeks, defined as an adequately placed IUD without clinical indication for removal. An IUD was considered to be adequately placed if it had an intrauterine location by ultrasound and did not cause symptoms warranting removal. At in-person follow-up, if the IUD was expulsed, removed or had not been placed, women were again offered the IUD for insertion by the study clinician at that visit. Thus, we were interested in 1) use of the original IUD as planned at 6 weeks and 2) use of any IUD at 6 weeks.
We randomized 112 women who wanted an IUD after their abortion to either immediate or delayed (after 3 weeks, at their local healthcare facility) IUD insertion. We asked women to return for a follow-up clinical examination at 6 weeks, or to complete a phone interview. We also checked the medical records for IUD insertion, removal or any IUD-related complications of all women not seen in person by the study clinician.
We showed that use of the original IUD at 6 weeks was 56% in the immediate group and 19% in the delayed group (p<0.001). At the end of the 6-week follow-up period, 42 women (76%) in the immediate group and 23 (40%) in the delayed group were using the original or replacement IUD (p<0.001). Significant differences in IUD use between groups were ongoing at 3 and 6 months and the majority of women in both groups said they would have preferred immediate insertion, given the choice.
What were the risks and how should they be managed?
Among women with immediate insertion not using the original IUD at 6 weeks (n=14), 6 had complete expulsion and 8 had the IUD removed because of intracervical location or symptomatic malposition. One woman with delayed insertion had the IUD removed because of symptomatic malposition. Two women had an unintended pregnancy in the 6 months following the abortion, both followed the delayed arm protocol. There were no significant differences between groups in frequency of localized infection and persistent cramping.
Thus, immediate IUD insertion results in higher rates of use at 6 weeks, 3 months and 6 months after abortion compared with delayed insertion, despite higher rates of expulsion or removal, and is safe. The risk of expulsion or removal of the IUD at 6 weeks following immediate insertion can be mitigated by offering a replacement IUD to women attending follow-up.
However, unnoticed expulsion leaves women vulnerable to unintended pregnancy if they are not followed up and have no additional contraception coverage. Hence, emphasizing the importance of the follow-up visit, advising use of barrier contraception up to that time and streamlining follow-up processes by providing continuity of care are important recommendations for program implementation.
Dr. Deborah Constant is the Director of the Women’s Health Research Unit at the University of Cape Town. Her research is primarily in the field of sexual and reproductive health, with a focus on strengthening abortion care.