Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first-year results of a randomized controlled trial

Human Reproduction, Oct 2015

STUDY QUESTION Can the need of subsequent abortion be reduced by providing intrauterine contraception as a part of the abortion service?

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

http://humrep.oxfordjournals.org/content/30/11/2539.full.pdf

Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first-year results of a randomized controlled trial

Advanced Access publication on September Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first-year results of a randomized controlled trial Elina Pohjoranta 2 Maarit Mentula 2 Mika Gissler 1 Satu Suhonen 0 Oskari Heikinheimo 2 0 Centralized Family Planning, Department of Social Services and Health Care, City of Helsinki , Helsinki , Finland 1 National Institute for Health and Welfare , Helsinki , Finland 2 Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Ka ̈tilo ̈ opisto Hospital , PO Box 610, Helsinki 00029-HUS , Finland *Correspondence address. E-mail: study question: Can the need of subsequent abortion be reduced by providing intrauterine contraception as a part of the abortion service? summary answer: Provision of intrauterine devices (IUDs) in association with first trimester abortion more than halved the incidence of repeat abortion during the first year of follow-up. what is known already: Following abortion, the incidence of subsequent abortion is high, up to 30 - 40%. In cohort studies, intrauterine contraception has reduced the need of repeat abortion by 60 - 70%. study design, size, duration: A randomized controlled trial. The main outcome measure was the incidence of subsequent induced abortions during the follow-up. Altogether 751 women seeking first trimester induced abortion were recruited and randomized into two groups. Randomization was accomplished by computer-assisted permuted-block randomization with random block sizes of four to six. The investigators did not participate in randomization, which was done before commencing the study. The participants were recruited between 18 October 2010 and 21 January 2013. - † Equal first author contribution. & The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: per-protocol analysis, respectively). Provision of intrauterine contraception was safe with rate of infection and expulsion similar to those reported previously. limitations, reasons for caution: The power calculation was calculated for a 5-year follow-up. However, significant differences between the two groups were already seen after 1 year. The present study was performed in a single clinic, where, 15% of all abortions in Finland are performed. wider implications of the findings: In order to decrease the need of subsequent abortions, IUDs should be provided at the time of abortion. study funding/competing interest(s): This study was supported by Helsinki University Central Hospital Research funds and by research grants provided by the Antti and Jenny Wihuri Foundation and the Yrjo¨ Jahnsson Foundation. O.H. has served on advisory boards for Bayer Healthcare, Gedeon Richter and MSD Finland (part of Merck & Co. Inc.), and designed and lectured at educational events of these companies. S.S. has lectured at educational events of Bayer and MSD Finland (part of Merck & Co. Inc.). The other authors have no conflicts of interest to declare. trial registration: The study was registered at www.clinicaltrials.gov (NCT01223521). trial registration date: 18 October 2010. date of first patient’s enrolment: 18 October 2010. Introduction The efficacy of long-acting reversible contraceptive (LARC) methods, including intrauterine devices and systems (hereafter referred as IUDs) in reducing the rate of unplanned pregnancies is widely recognized (Blumenthal et al., 2011; Winner et al., 2012; Secura et al., 2014). In light of these recent findings, LARC methods are increasingly being promoted as first-line contraception also among young and nulliparous women (Secura et al., 2014). Women requesting induced abortion are typically 20 – 30 years of age, with high fertility and a high risk of subsequent abortion(s) (Sedgh et al., 2013; UK government, 2013; National Institute for Health and Welfare, 2015a). In countries with reliable abortion statistics, the percentage of women requesting repeat abortion varies from 30 to 40% (Gissler et al., 2012; UK government, 2013; ISD Scotland, 2013; National Institute of Health and Welfare, 2015a). It has been calculated that a 10% switch from oral contraceptives to LARC methods among US women aged 20 – 29 years would result in an annual net saving of 288 million USD by effective prevention of unplanned pregnancy (Trussel et al., 2013). In several cohort studies, post-abortal intrauterine contraception has been associated with a significantly reduced risk of repeat abortion (Goodman et al., 2008; Heikinheimo et al., 2008; Roberts et al., 2010; Rose and Lawton, 2012; Cameron et al., 2012a,b). In women using IUDs, the rate of subsequent abortion has been 60 – 70% lower than among women using oral contraceptives (Heikinheimo et al., 2008; Roberts et al., 2010; Rose and Lawton, 2012) or contraception other than intrauterine (Goodman et al., 2008). However, the efficacy of postabortal IUD placement in preventing repeat abortions has not been tested in a randomized clinical trial (RCT). The purpose of the present RCT was to study the long-term effect(s) of routine provision of intrauterine contraception, either with the levonorgestrel-releasing intrauterine system (LNG-IUS) or a copperreleasing intrauterine device (Cu-IUD) included in abortion services. In the present analysis, we focused on the need of repeat abortion during the first year following the index abortion. The study hypothesis was that provision of IUD reduces the need of subsequent abortion by half during the planned 5-year duration of the study. Materials and Methods According to Finnish legislation (Ministry of Justice, Finland) induced abortion can be performed following approval (either by one or two physicians, or by the National Supervisory Authority for Welfare and Health) at up to 20 weeks of gestation, and in cases of confirmed fetal anomaly, at up to 24 + 0 weeks. In general, abortion requested for social indications (such as stressful life situation) up to 12 weeks of gestation requires approval by two physicians, the referring and the performing physician. The woman is referred from primary healthcare to the hospital performing the abortion. The hospitals are required to report all abortions within 1 month of the procedure to the National Abortion Registry, kept by the National Institute for Health and Welfare (www.thl.fi) and covering all abortions performed in Finland (National Institute for Health and Welfare, 2015b). According to Finnish national guidelines on induced abortion (The Finnish Medical Society Duodecim, 2013) contraceptive counselling is given before the referral, at the hospital performing abortion, and also at the follow-up visit taking place at the primary healthcare 2 – 3 weeks after abortion. Trial design This trial was designed to compare routine provision of intrauterine contraception versus a standard procedure of woman-controlled follow-up visit and further planning of contraception (including IUD provision) after an early induced abortion. This is a collaborative study between the Department of Obstetrics and Gynaecology, Helsinki University Hospital, performing annually 1700 induced abortions for women resident in Helsinki, and the Department of Social Welfare and Health, City of Helsinki. The inclusion criteria were age ≥18 years, residence in the City of Helsinki, seeking induced abortion for non-fetal indications during the first trimester of pregnancy (≤84 days of gestation), accepting intrauterine contraception and willingness to participate and to sign the informed consent form. Exclusion criteria were contraindications to intrauterine contraception (i.e. acute genital infection, Pap-smear change necessitating surgical intervention or known uterine structural abnormality). In addition, acute liver disease and breast cancer were contraindications for the LNG-IUS; and Wilson’s disease, copper allergy, iron deficiency anaemia and history of ectopic pregnancy for Cu-IUD. Randomization Randomization was accomplished by computer-assisted permuted-block randomization with random block sizes of four to six. The investigators did not participate in randomization, which was done before commencing the study. The group assignments were kept in sealed envelopes. The study nurse opened the envelopes after informing and recruiting the women. Study procedures The method of induced abortion was decided individually on the basis of possible contraindications and the women’s preferences. Medical abortion was performed by administration of mifepristone followed by misoprostol 2 – 4 days later vaginally either at the hospital (n ¼ 227, 37.5%) or at home (n ¼ 378, 62.5%). Women choosing surgical abortion received misoprostol prior to vacuum aspiration under general anaesthesia. All procedures were performed according to national guidelines (The Finnish Medical Society Duodecim, 2013). The women in the intervention group choosing surgical abortion received the cost-free IUD (Cu-IUD [Nova-Tw] or LNG-IUS [Mirenaw], both from Bayer Ag, Turku, Finland) at the time of vacuum aspiration. Its correct placement was confirmed by vaginal ultrasonography at the follow-up visit at 2 – 4 weeks afterwards. For women choosing medical abortion, the IUD was inserted at the follow-up visit in cases with no complications. The women in the control group were mainly prescribed oral contraceptives for 1 year and advised to contact their primary healthcare unit for the follow-up visit, including planning further contraception (including IUD provision), which is the current practice in Finland (The Finnish Medical Society Duodecim, 2013). After 3 months, women in the intervention group had an appointment with the study nurse to confirm acceptability of intrauterine contraception and the proper placement of the IUD by direct visualization of the IUD strings. Ultrasonography was used if the strings were missing or appeared too long. In cases of expulsion or dislocation (n ¼ 18), a new device was offered. All women were provided with a questionnaire regarding physical, mental, sexual and reproductive health, and quality of life at enrolment, at 3 months, and at 1 year after the abortion. A reminder text message was sent twice if the follow-up questionnaire had not been received. The next follow-up visit was scheduled 1 year after abortion for all women participating in the study. In cases of no-show, the women were contacted twice by phone. If they could not be reached, a letter was sent to schedule a new appointment. Women in both study groups requesting another abortion up to 28 February 2014 were identified in the National Abortion Registry and Helsinki University Hospital electronic database. All women requesting subsequent abortion either with a viable intrauterine pregnancy, spontaneous miscarriage or ectopic pregnancy diagnosed at the time of assessment for abortion were included in the group. Adverse events All participants after the index abortion were advised to contact the hospital should symptoms of possible complications arise. Information on all additional hospital visits was analysed to assess possible adverse events related to the IUD insertion. Study overseers The trial received approval from the Ethics Committees of the City of Helsinki (10-1138/054) and the Hospital District of Helsinki and Uusimaa (HUS 260/ 13/03/03/2009). Approval to carry out the study was granted by the Hospital District of Helsinki and Uusimaa (§12/30.03.2010). The trial was registered at the Clinical Trials website (www.clinicaltrials.gov [NCT01223521]). Approval to use personal-level data was obtained from the National Institute for Health and Welfare as required for registry-based studies in Finland (THL/1479/5.05.00/2013). All personal-level data that could be used to identify individuals were removed before the analyses. Statistical analysis Based on earlier studies, we assumed that the risk of subsequent induced abortion is 15% during the 5-year follow-up time (Heikinheimo et al., 2008) and that provision of intrauterine contraception reduces this risk by 50%. Using the log-rank test and with a 1-year accrual time, for a 5-year total study time with 80% power and a 5% significance level, we needed at least 350 women in each group. Subsequently, a total of 751 women were recruited during the study period (18 October 2010 – 21 January 2013; Fig. 1). The planned duration of the study is 5 years. However, at the time of the 1-year follow-up visit it became apparent that there might be a difference in the rate of repeat abortion between the study groups, we modified the protocol, and applied for an approval to perform the registry-based analysis already at 1 year. Thus, in the present analysis the primary outcome was the rate of subsequent induced abortion during the first year following the index abortion. Secondary outcomes were contraception prior to repeat abortion, timing of repeat abortion and adverse events related to IUD insertion. All analyses were performed with PASW statistics software, version 18 (SPSS Inc., IL, USA). Analyses were conducted on an intention-to-treat (ITT) and a per-protocol (PP) basis. Statistical significance was defined as P , 0.05. Differences in continuous variables were analysed by means of the Mann – Whitney U-test for skewed data. The data are presented as medians (with interquartile range [IQR]). x 2 or Fisher’s exact tests were used as appropriate for independent nominal data. Differences of proportions and their 95% confidence intervals (CIs) were calculated using Newcombe’s method. Kaplan – Meier survival analysis with the log-rank test was used to analyse cumulative subsequent induced abortions. Study participants Of the total of 2305 eligible women requesting induced abortion during the study period, 1139 (49.4%) expressed an interest in intrauterine contraception (Fig. 1). A majority of them (751, 65.9%) were randomized into the study. After randomization, three women decided to continue the pregnancy and were excluded from all analyses. The remaining 748 women were included in the ITT-analysis. Twenty-seven women randomized to the intervention group did not receive an IUD (none in the group of surgical abortion and 27 in the group of medical abortion, P ¼ 0.011) and were excluded from the PP analysis as a result of this protocol violation. Sixteen women in the control group who received an IUD at the time of surgical abortion were also excluded from the PP analysis. Table I summarizes the characteristics of the study participants. The median (IQR) age of the whole study group was 27 (23 – 33) years. Nearly half (48.4%, 362/748) of the women were parous and 43.7% Figure 1 Study flow chart. (327/748) had a history of induced abortion(s). Randomization did not result in any statistically significant differences in clinically important background factors between the groups. In the intervention group, 307 (81.3%) women chose medical abortion, and 68 (18.7%) surgical (Fig. 1). For women choosing medical abortion, 302 women received the IUD within 4 weeks after the abortion, and the remaining 46 later. Median (quartiles) time from induced abortion to insertion of IUD was 20 (17 – 24) days. Primary outcome During the first year of follow-up 29 (3.9%) and 25 (3.5%) women were referred to hospital with a request for an induced abortion according to the ITT and PP analyses, respectively (Table II). Finally, 24 (3.2%) women in the ITT-analysis group and 20 (2.8%) women in the PP analysis group underwent subsequent induced abortion. The remaining five women were diagnosed with miscarriage (n ¼ 3) or ectopic pregnancy (n ¼ 2). Thus, study intervention decreased the request for subsequent abortions by more than half. The number of induced abortions was reduced to one-third (ITT-analysis) or one-fifth (PP analysis). The cumulative proportion of women without subsequent induced abortion at 1 year was 98.4% in the intervention group and 95.0% in the control group (P ¼ 0.012; Fig. 2). The rate of repeat abortion in the intervention group was 0% (0/68) following surgical and 2.0% (6/307) following medical abortion (P ¼ 0.25). The corresponding figures were 2.7% (2/74) and 5.4% (16/299) in the control group (P ¼ 0.34). Secondary outcomes The median time (with IQR) to subsequent induced abortion was 8 (6 – 11) months. None of the unplanned pregnancies occurred during the use of intrauterine contraception. Half of the women (12/24) undergoing subsequent abortion used no contraception at the time of conception (Table III). Comparison of the data on subsequent induced abortions included in the national registry and in the hospital registry showed a 95.8% match, with one missing case in the national registry. Altogether 380 (50.5%) women attended the follow-up visit at 1 year (225 [59.7%] in the intervention group and 155 [41.2%] in the control group). The response rate as regards the questionnaires at 1 year was 60.7% in the intervention group and 42.3% in the control group. Among women requesting a new abortion, the response rate was as low as 17.2%. Only 4 of the 24 women undergoing a subsequent abortion self-reported it in the questionnaire, resulting in only 16.7% concordance with the abortion registry (Table III). Adverse events There were no cases of uterine perforation after IUD insertion. Altogether 18 (5.2%) total or partial expulsions were detected by the time of the 3-month follow-up visit. The rate was 7.2% (5/70) after surgical termination and 4.7% (13/307) after medical termination. All of these women were offered a new IUD; four declined and initiated oral contraceptives. Table I Characteristics of the women (n 5 748) undergoing first trimester induced abortion participating in the study (ITT-basis). Variable Intervention Control group group (n 5 375) (n 5 373) ........................................................................................ Age (years); median (IQR) 27 (22 – 33) 27 (23 – 33) Days of amenorrhea; 57 (49 – 66) 56 (49 – 65) median (IQR) Type of induced abortion Medical 307 (81.9) 299 (80.2) Surgical 68 (18.1) 74 (19.8) Type of planned contraception Cu-IUD 26 (6.9) 24 (6.4) LNG-IUS 349 (93.1) 349 (93.6) Parous 187 (49.9) 175 (46.9) History of induced 174 (46.4) 153 (41.0) abortion(s) Marital status Married 71 (18.9) 52 (13.9) Cohabiting 102 (27.2) 92 (24.7) Single 202 (53.9) 229 (61.4) Socioeconomic status Upper white-collar 29 (7.7) 23 (6.2) Lower white-collar 77 (20.5) 74 (19.8) Blue-collar workers 153 (40.8) 137 (36.7) Students 72 (19.2) 92 (24.4) Other 44 (11.7) 48 (12.9) Smoking 188 (50.1) 189 (51.4) Body mass index (kg/m2); 23 (21 – 26) 23 (21 – 26) median (IQR) Contraception used at the time of conception Combined hormonal 45 (12.0) 49 (13.1) contraceptives Progestin-only pill 12 (3.2) 9 (2.4) Cu-IUD — 1 (0.3) Condom 159 (42.4) 135 (36.2) Other 8 (2.1) 14 (3.8) None 151 (40.3) 165 (44.2) The data are shown as n (%) unless stated otherwise. In total 12 (3.4%) women in the intervention group received antibiotics following IUD insertion because of clinically diagnosed genital infection by the time of the 3-month follow-up visit. Discussion We found that provision of intrauterine contraception in association with induced abortion more than halved the number of requests for subsequent abortions during the first year of follow-up. Moreover, the policy of IUD provision was safe, with expulsion and infection rates comparable to those reported previously (Grimes et al., 2010; Bednarek et al., 2011). Table II Subsequent induced abortions/unplanned pregnancies during follow-up of 1 year after the index abortion. Study Control Difference P-value group group (95% CI) ........................................................................................ ITT-basis n ¼ 375 n ¼ 373 PP-basis n ¼ 346 n ¼ 357 Women with subsequent induced abortions ITT-basis 6 (1.6) 18 (4.8) 23.2 (26.0 to 20.7) 0.012 PP-basis 2 (0.6) 18 (5.0) 24.5 (27.3 to 22.1) ,0.001 Unplanned pregnanciesa ITT-basis 9 (2.4) 20 (5.4) 23.0 (26.0 to 20.2) 0.038 PP-basis 5 (1.4) 20 (5.6) 24.2 (27.2 to 21.4) 0.003 The data are shown as n (%). aIncludes miscarriages and extrauterine pregnancies diagnosed at the time of assessment for induced abortion. Figure 2 Cumulative proportions of women without subsequent induced abortion during the first year of follow-up after the index abortion. The present study was performed at only one (albeit large) clinic, which is a weakness. However, as Helsinki is the largest city in Finland, 15% of all induced abortions in Finland are performed there (National Institute for Health and Welfare, 2014). Moreover, at the time of the study, Helsinki represented the only large community in Finland to provide a first IUD to women free of charge through primary healthcare services. Thus, a large proportion of women randomized to the control group also had the option to obtain free intrauterine contraception. However, there is no possibility to know the precise number of IUDs inserted to the women belonging to the control group. Table III Characteristics of the women (n 5 24) undergoing subsequent abortion during the first year of follow-up after the index abortion. ITT-analysis. Previous induced abortionsa Time (months) to 10 (5 – 11) subsequent abortion [median (range)] Contraception prior to subsequent abortiona COC 0 POP 0 Condom 1 (16.7) None 5 (83.3) The study was designed to reflect contemporary practice as regards both the method of abortion and the type of IUD used. Thus, the method of abortion and type of IUD was decided individually based on the woman’s preferences and medical recommendations. This may also be criticized as the time of insertion of IUD following medical and surgical abortion differed; also both copper- and LNG-releasing devices were used. However, in our previous nationwide study the risk of subsequent abortion did not differ after medical or surgical induced abortion (Niinima¨ki et al., 2009). Regarding the choice of IUD, a previous randomized study has shown a lower rate of contraceptive failure among women receiving the LNG-IUS at the time surgical abortion compared with women receiving Cu-IUD (Pakarinen et al., 2003). However, in our and other cohort studies the rate of repeat abortion has been similar among women receiving either the copper- or LNG-releasing IUD at the time of abortion with a high rate of IUD removals among women requesting repeat termination later during the follow-up (Goodman et al., 2008; Heikinheimo et al., 2008; Roberts et al., 2010; Rose and Lawton, 2012). The rate of protocol violations and subsequent study exclusions among women choosing surgical abortion was quite high. Surgical abortions were performed by the gynaecologist on duty potentially willing to follow the individual woman’s wish to obtain an IUD despite her randomization into the control group. Also the loss to follow-up at the 1-year clinical visit was high. This is likely to be due to the challenging study population, young women undergoing an induced abortion. The women participating in the study were in their late twenties. They were also highly fertile—nearly half of them were parous and almost half of them had a history of induced abortion. The highest incidences of induced abortion in Finland, in England and Wales as well as in most other countries are seen among women between 20 and 24 years of age (Sedgh et al., 2013; UK government, 2013; National Institute for Health and Welfare, 2015a). This may indicate that in the present study, younger women were hesitant when considering an IUD for postabortal contraception. Intrauterine contraception has been shown to be effective and highly acceptable among young and nulliparous women (Suhonen et al., 2004; Yen et al., 2010; Secura et al., 2014; Kaislasuo et al., 2015). Even though the overall use of intrauterine contraception is high (up to 18%) in Finland this form of contraception should be further encouraged among young women especially after an unwanted pregnancy. The women were followed-up by using the Finnish National Abortion Registry as well as the hospital database. In previous studies the reliability of the National Abortion Registry has been high, with 99% of all induced abortions being reported to it (Gissler et al., 1996; Heikinheimo et al., 2008). Similarly, in the present study, concordance between the abortions reported to the registry and those identified in the hospital electronic database was high. In contrast, only half of all the women returned the follow-up questionnaire at 1 year and only a few of those who underwent a subsequent abortion reported it in the questionnaire. Thus, follow-up using the national registry was highly reliable and superior to self-reporting. According to international guidelines, insertion of an IUD at the time of surgical abortion is safe and effective (Grimes et al., 2010; WHO, 2015). This is highlighted in a recent study in which immediate versus delayed IUD insertion in association with uterine aspiration was compared with significantly greater use of IUDs among women receiving one immediately (Bednarek et al., 2011). The practice of induced abortion has changed dramatically over the last 20 years. Currently, the uptake of medical abortion in the USA is 25% (Jones and Jerman, 2014), and it is 50% in England and Wales (UK government, 2013). However, more than 80% of women choose medical abortion in Finland, Scotland and Sweden (The National Board of Health and Welfare, Sweden, 2012; ISD Scotland, 2013; National Institute for Health and Welfare, 2015a), as was the case in the present study. According to international guidelines, intrauterine contraception may be initiated following medical abortion when the termination is complete (UKMEC, 2009; WHO, 2012; WHO, 2015). In previous studies insertion of an IUD has been performed between 1 and 4 weeks after medical abortion (Heikinheimo et al., 2008; Sa¨a¨v et al., 2012). However, the lost-to-follow-up rate after induced abortion is high (up to 43%) (Pohjoranta et al., 2011), and even though a tailored appointment for a follow-up visit and IUD insertion is scheduled, attendance is poor (Stanek et al., 2009; Cameron et al., 2012a,b). In the present study, 91% of women undergoing medical abortion attended the IUD insertion visit as scheduled. This likely reflects the investigational nature of the study and a high motivation among the study participants, and also the frequent reminders. According to an RCT performed in Sweden this could be further improved by more rapid provision of IUD after medical abortion (Sa¨a¨v et al., 2012). In the present study, however, the rate of repeat abortion did not differ significantly among women undergoing medical or surgical abortion The overall rate of subsequent abortion during the first year of followup was nearly 4%. This figure is similar to that in one of our previous studies (Heikinheimo et al., 2008) and somewhat lower than the overall first-year rate of subsequent abortion of 5 – 6% seen in Helsinki (National Institute for Health and Welfare, 2014). Importantly, according to ITT-analysis, only 1.6% of the women in the intervention group—in contrast to 4.8% in the control group—requested subsequent abortion(s) during the follow-up period. In PP analysis, the difference was even larger. It is also noteworthy that in the intervention group all women requesting a repeat abortion had had the IUD removed prior to the new unplanned pregnancy. None of the subsequent unwanted pregnancies were conceived because of an unnoticed IUD expulsion. This is in line with previous studies showing that an unwanted pregnancy is often preceded by a change from an effective contraceptive method to a method of lower efficacy (Bajos et al., 2006). The high contraceptive efficacy of intrauterine devices is widely recognized. Besides assessing the efficacy of the IUDs in prevention of unplanned pregnancy, we studied how to optimize the provision of post-abortal contraception. A key finding of the study is that by integrating IUD provision into immediate post-abortal care we were able to reduce the need of subsequent abortion significantly within the first year. Future follow-up will reveal whether this intensified provision of IUDs is also cost-beneficial, as suggested by the results of previous cohort and cost-analysis studies (Ames and Norman, 2012; Salcedo et al., 2013), and associated with an overall improvement in the quality of life. The present results have a significant public health impact—in order to decrease the need of subsequent abortion, provision of IUDs should be a part of high-quality abortion services. Acknowledgements Study nurse Pirjo Ikonen is gratefully thanked for her irreplaceable contribution to this study, and adjunct Professor Pasi Korhonen of EPID research for his advice and help with statistical analysis. The authors also thank the City of Helsinki for providing the LNG-IUSs and Cu-IUDs used in the present study. Authors’ roles All authors participated in the study design, analysis of the data, manuscript drafting and critical discussion. Authors E.P., M.M., S.S. and O.H. were responsible for the practical arrangements of the study as well as patient care, M.G. performed the registry linkages. This study was supported by Helsinki University Central Hospital Research funds and by research grants provided by the Antti and Jenny Wihuri Foundation and the Yrjo¨ Jahnsson Foundation. Conflict of interest O.H. has served on advisory boards for Bayer Healthcare, Gedeon Richter and MSD Finland (part of Merck & Co. Inc.), and designed and lectured at educational events of these companies. S.S. has lectured at educational events of Bayer and MSD Finland (part of Merck & Co. Inc.). The other authors have no conflicts of interest to declare. Ames C , Norman W. Preventing repeat abortion in Canada: is the immediate insertion of intrauterine devices postabortion a cost-effective option associated with fewer repeat abortions? Contraception 2012 ; 85 : 51 - 55 . Bajos N , Lamarche-Vadel A , Gilbert F , Ferrand M ; COCON Group, Moreau C , Bouyer J , Ducot B , Hassoun D , Goulard H et al. Contraception at the time of abortion: high-risk time or high-risk women? Hum Reprod 2006 ; 21 : 2862 - 2867 . Bednarek PH , Creinin MD , Reeves MF , Cwiak C , Espey E , Jensen JT. Immediate versus delayed IUD insertion after uterine aspiration . N Engl J Med 2011 ; 364 : 2208 - 2217 . Blumenthal PD , Voedisch A , Gemzell-Danielsson K. Strategies to prevent unintended pregnancy: increasing use of long-acting reversible contraception . Hum Reprod Update 2011 ; 1 : 121 - 137 . Cameron ST , Berugoda N , Johnstone A , Glasier A. Assessment of a 'fast-track' referral service for intrauterine contraception following early medical abortion . J Fam Plann Reprod Health Care 2012a ; 38 : 175 - 178 . Cameron ST , Glasier A , Chen ZE , Johnstone A , Dunlop C , Heller R. Effect of contraception provided at termination of pregnancy and incidence of subsequent termination of pregnancy . BJOG 2012b ; 119 : 1074 - 1080 . Gissler M , Ulander VM , Hemminki E , Rasimus A. Declining induced abortion rate in Finland: data quality of the Finnish abortion register . Int J Epidemiol 1996 ; 25 : 376 - 380 . Gissler M , Fronteira I , Jahn A , Karro H , Moreau C , Oliveira da Silva M , Olsen J , Savona-Ventura C , Temmerman M , Hemminki E et al. Terminations of pregnancy in the European Union . BJOG 2012 ; 119 : 324 - 332 . Goodman S , Hendlish SK , Reeves MF , Foster-Rosales A. Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion . Contraception 2008 ; 78 : 143 - 148 . Grimes D , Lopez L , Schulz K , Stanwood N. Immediate postabortal insertion of intrauterine devices . Cochrane Database Syst Rev 2010 : CD001777 . doi: 10.1002/14651858.CD001777.pub3. Heikinheimo O , Gissler M , Suhonen S. Age , parity, history of abortion and contraceptive choices affect the risk of repeated abortion . Contraception 2008 ; 78 : 149 - 154 . ISD Scotland. Abortion statistics. 2013 . http://www.isdscotland. org/ Health-Topics/Sexual-Health/Publications/2013-05-28/2013-05-28- Abortions-Report.pdf (25 January 2015 , date last accessed) . Jones RK , Jerman J. Abortion incidence and service availability in the United States , 2011 . Guttmacher Institute 2011 . Perspect Sex Reprod Health 2014 ; 46 : 3 - 14 . Kaislasuo J , Heikinheimo O , La¨hteenma¨ki P , Suhonen S. Menstrual characteristics and ultrasonographic uterine measurements predict bleeding and pain in nulligravid women using intrauterine contraception . Hum Reprod 2015 ; 30 : 1580 - 1588 . Ministry of Justice, Finland. Finlex Data Bank. https://www.finlex.fi/fi/laki/ ajantasa/1970/19700359?search% 5Btype%5D=pika&search%5Bpika% 5D=keskeytta¨misesta¨ (25 January 2015 , date last accessed) . National Institute for Health and Welfare , Finland. 2014 . Induced abortions 2013 . http://urn.fi/URN: NBN:fi-fe2014101645230 (25 January 2015, date last accessed) . National Institute for Health and Welfare , Finland. 2015a. Induced abortions in the Nordic countries 2013 . http://urn.fi/URN: NBN:fi-fe2015032 62027 (26 June 2015, date last accessed) . National Institute for Health and Welfare , Finland, 2015b . https://www.thl. fi/en/web/thlfi-en/statistics/information-on-statistics/register-descriptions/ register-of-induced-abortions (26 June 2015 , date last accessed). Niinima¨ki M , Pouta A , Bloigu A , Gissler M , Hemminki E , Suhonen S , Heikinheimo O. Frequency and risk factors for repeat abortions after surgical compared with medical termination of pregnancy . Obstet Gynecol 2009 ; 113 : 845 - 852 . Pakarinen P , Toivonen J , Luukkainen T. Randomized comparison of levonorgestrel- and copper-releasing systems immediately after abortion, with 5 years' follow-up . Contraception 2003 ; 68 : 31 - 34 . Pohjoranta E , Suhonen S , Heikinheimo O. Attendance at post-abortal follow-up visits is low-can the risks of non-attendance be identified? Acta Obstet Gynecol Scand 2011 ; 90 : 543 - 546 . Roberts H , Silva M , Xu S. Post-abortion contraception and its effect on repeat abortions in Auckland, New Zealand . Contraception 2010 ; 82 : 260 - 265 . Rose SB , Lawton BA . Impact of long-acting reversible contraception on return for repeat abortion . Am J Obstet Gynecol 2012 ; 206 : e1 - e6 . Sa¨a ¨v I , Stephansson O , Gemzell-Danielsson K. Early versus delayed insertion of intrauterine contraception after medical abortion-a randomized controlled trial . Plos ONE 2012 ; 7 : e48948 . Salcedo J , Sorensen A , Rodriquez MI . Cost analysis of immediate postabortal IUD insertion compared to planned IUD insertion at the time of follow-up . Contraception 2013 ; 87 : 404 - 408 . Secura GM , Madden T , McNicholas C et al. Provision of no-cost, longacting contraception and teenage pregnancy . N Engl J Med 2014 ; 371 : 1316 - 1323 . Sedgh G , Bankole A , Singh S , Eilers M. Legal abortion levels and trends by woman's age at termination . Int Perspect Sex Reprod Health 2013 ; 45 : 13 - 22 . Stanek A , Bednarek P , Nichols M , Jensen J , Edelman A. Barriers associated with the failure to return to intrauterine device insertion following first-trimester abortion . Contraception 2009 ; 79 : 216 - 220 . Suhonen S , Haukkamaa M , Jakobsson T , Rauramo I. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study . Contraception 2004 ; 69 : 407 - 412 . The Finnish Medical Society Duodecim . Induced abortion, Current Care Guidelines . 2013 . www.kaypahoito. fi (25 January 2015 , date last accessed) . The National Board of Health and Welfare , Sweden. Abortion statistics 2012 . http://www.socialstyrelsen. se/SiteCollectionDocuments/statistikaborter-2012.pdf (25 January 2015 , date last accessed) . Trussel J , Henry N , Hassan F , Prezioso A , Law A , Filonenko A. Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception . Contraception 2013 ; 87 : 154 - 164 . UKMEC. Faculty of Sexual & Reproductive Health Care. UK Medical Eligibility Criteria for Contraceptive Use , 2nd edn. 2009 . http://www.fsrh. org/pdfs/ UKMEC2009.pdf (6 September 2015 , date last accessed) . UK government . Abortion statistics England and Wales 2013 . https:// www.gov.uk/government/uploads/system/uploads/attachment_data/ file/319460/Abortion_Statistics__ England_and_Wales_2013.pdf (25 January 2015 , date last accessed) . WHO. Medical Eligibility Criteria for Contraceptive Use , 5th edn. 2015 . http:// apps.who.int/iris/bitstream/10665/181468/1/9789241549158_eng. pdf?ua=1 (6 September 2015 , date last accessed) . WHO. Safe Abortion: Technical and Policy Guidance for Health Systems . 2012 . http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_ eng. pdf (6 September 2015 , date last accessed) . Winner B , Peipert JF , Zhao Q et al. Effectiveness of long-acting reversible contraception . N Engl J Med 2012 ; 366 : 1998 - 2007 . Yen S , Saah T , Hillard PJ . IUDs and adolescents-an under-utilized opportunity for pregnancy prevention . J Pediatr Adolesc Gynecol 2010 ; 23 : 123 - 128 .


This is a preview of a remote PDF: http://humrep.oxfordjournals.org/content/30/11/2539.full.pdf

Elina Pohjoranta, Maarit Mentula, Mika Gissler, Satu Suhonen, Oskari Heikinheimo. Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first-year results of a randomized controlled trial, Human Reproduction, 2015, 2539-2546, DOI: 10.1093/humrep/dev233