Contraception After an Induced Abortion and Childbirth

Even though the rate of unintended pregnancy has been declining globally during the last 20 years, unintended pregnancy remains a significant public health issue and burden throughout the world. In 2014, the rate of unintended pregnancy was globally 62/1000 15–44-year-old women, and varied from that of 41/1000 women in Europe to 96/1000 in Latin America. Also the proportion of unintended pregnancies resulting in an abortion varies markedly in different parts of the world. The highest proportion (70%) was seen in Europe and the lowest (36%) in North America (Bearak et al., Lancet Glob Health. 6(4):e380–e389, 2018]. In addition to the high need of induced abortion, unintended pregnancy is associated with an increased risk of adverse pregnancy outcomes, such as low birth weight. Similarly, recent studies from the US show that nearly 50% of all pregnancies are unintended. Approx. 40% of these result in an induced abortion, the risk being higher among older and highly educated women (Finer and Zolna, N Engl J Med. 374(9):843–852, 2016). Thus, unmet need of contraception remains a significant global public health challenge. Pregnancy and childbirth bring most women to the attention of medical professionals, and thus providing an opportunity for contraceptive counseling and initiation. Providing effective contraception—regardless of the pregnancy outcome—is highly justified and may even be life-saving in settings where abortion is illegal (Glasier et al., Acta Obstet Gynecol Scand 8(11):1378–1385, 2019; Morroni and Glasier, Lancet Glob Health. 8(3):e316–e317, 2020). The contraceptive effectiveness of a contraceptive method in a given woman depends on her capacity to conceive, frequency and timing of intercourse, degree of compliance and inherent contraceptive efficacy of the method (Steiner et al., Obstet Gynecol 88(3 Suppl):24S–30S, 1996). Thus, most women with a recent history of an induced abortion and/or childbirth are highly fertile and likely to resume sexual activity soon after the pregnancy. This is highlighted in studies analyzing the need of subsequent abortion in women with history of abortion. Previous pregnancies (both deliveries and induced abortions) and young age—indicators of high fertility and sexual activity—emerge as risk factors for a subsequent abortion. In contrast, the use of effective contraceptive methods requiring minimal daily compliance, such as contraceptive implants and/or intrauterine devices, significantly reduces this risk (Goodman et al., Contraception 78(2):143–148, 2008; Heikinheimo et al., Contraception. 78: 149–154, 2008; Niinimäki et al., Obstet Gynecol 113: 845–852, 2009; Rose and Lawton, Am J Obstet Gynecol 206(1):37.e1–6, 2012). Therefore, safe and effective contraception, preferably with minimal daily/regular remembering is important if another pregnancy is not desired soon. In this chapter, we focus on contraceptive choices after induced abortion and childbirth. The high efficacy of the long-acting reversible methods of contraception (i.e., contraceptive implants and intrauterine devices) and importance of rapid post-pregnancy initiation of contraception are highlighted.