Early provision of intrauterine contraception after first trimester induced abortion - complications, adherence to post-abortion care, recovery and risk of subsequent abortion during the first year

In Finland more than every third abortion is performed to a woman with history of previous abortion, which indicates suboptimal contraceptive use and inadequacy of postabortion contraceptive services. Previous studies have shown that long-acting reversible contraceptive (LARC) methods, especially intrauterine devices (IUD) are most efficient in preventing repeat unwanted pregnancy. IUDs can usually be inserted at the time of surgical termination of pregnancy (TOP). After medical TOP (MTOP), an IUD can be inserted when the abortion is shown to be complete, commonly 1–4 weeks afterwards, according to various recommendations. However, attendance at post-abortion contraceptive visits is poor, and thus the planned IUD insertion often fails. We have conducted a randomized trial assessing early postabortal IUD insertion provided comprehensively as a part of abortion services. Altogether 748 women undergoing a first trimester TOP were recruited and randomized into two groups. Women in the intervention group received an IUD (either a LNG-IUS or a Cu-IUD, according to the woman’s choice), at the hospital providing the TOP, either at the time of surgical TOP or at a follow-up visit 1–4 weeks after MTOP. Women in the control group were prescribed oral contraceptives and advised to contact their primary health care (PHC) unit for IUD insertion, according to the current practice and the national guideline. All study participants were provided with a questionnaire assessing anxiety, quality of life (QoL) and sexual well-being at baseline, as well as three months and one year after the TOP. The primary outcome was to assess the effects of the intervention on the incidence of subsequent TOP, when compared to the normal practice. In this thesis, the results of the first year are described. In addition, incidence of complications related to early IUD insertion, as well as compliance to post-abortion care and IUD insertion were assessed in women choosing MTOP. As secondary outcomes, mental health and sexual well-being during the first year after TOP was assessed. During the first year of follow-up after TOP, a significant difference between the two study groups was seen in the attendance at follow-up, in receiving the planned IUD, and in the incidence of repeat unwanted pregnancy. The early insertion of IUD after MTOP was safe and did not increase the risk of severe complications or IUD expulsions. In the entire study population general reduction of anxiety was seen at three month and one year, compared to baseline. Concordantly, a better quality of life was generally reported after three months. Regarding overall sexual well-being, there was no significant change during the follow-up. Better rates in the sexuality questionnaire, i.e. better sexual well-being, were associated with having a relationship, and correlated positively with frequency of intercourse, quality of life, and negatively with anxiety. Contraceptive method appeared to have little effect on overall sexual well-being. However, at three months, IUD users had better scores of sexual well-being, compared to users of other methods. This study shows that providing TOP and IUD insertion comprehensively at the same unit with minimal delay results in higher attendance at follow-up, higher uptake of IUD and a reduced need of subsequent TOP during one-year of follow-up.