Immediate postabortion initiation of levonorgestrel implants reduces the incidence of births and abortions at 2-years and beyond

Abstract

Objectives: To compare immediate postabortion uptake of recently subsidized (no-cost) levonorgestrel-releasing implants with already available intrauterine and shorter-acting methods; and to compare the incidence of subsequent pregnancies (ending in birth or abortion) within 2-years.

Study design: Retrospective chart review of 4698 women attending a New Zealand public hospital abortion clinic over 2-years (2010-2012) to describe postabortion contraceptive choice, with follow-up via clinic and national births records to assess subsequent pregnancies at 12, 24, 36 and 48-months.

Results: Twenty percent of the cohort (934/4698) received an implant, 26% an intrauterine method (927 copper IUD, 301 LNG-IUS) and 54% chose other shorter-acting methods (2536/4698). Method choice was significantly associated with age, ethnicity and pregnancy history (p<0.001). At 24 months, the unadjusted incidence of subsequent abortion for implant users was 3.8% (95% CI 2.5-5.0) and 11.6% (95% CI 10.3-12.8) for those choosing other short-acting methods. By 48 months, 6.6% of implant users had a subsequent abortion (compared with 18.3% for short-acting methods). The incidence of continued pregnancy at 24-months was 6.3% (95% CI 4.4-8.1) for implant users and 15.7% (95% CI 14-17.2) for those choosing other short-acting methods. Adjusted hazard ratios for subsequent abortion were lowest for women initiating an implant (HR 0.26, 95% CI 0.20-0.35) or LNG-IUS (HR 0.26, 0.16-0.44, reference group: short-acting methods).

Conclusions: Immediate postabortion insertion of an implant significantly reduced rates of subsequent pregnancy for at least 2-years. Abortion service providers should ensure women have barrier-free access to all LARCs [long acting reversible contraceptives] to delay or prevent pregnancy.

Implications: Initiation of an LNG-implant immediately postabortion was associated with a 74% reduction in subsequent abortion over the next 4-years compared with use of short-acting methods. Implants were popular among adolescents - a group at high risk of subsequent pregnancy, and who have not historically been considered appropriate candidates for intrauterine contraceptive methods.

Comment: In earlier overviews we talked about the advantages of offering long acting, reversible contraception when the woman comes for an abortion. This study again shows that we see a sharp reduction in later unplanned pregnancies. However, this study focuses also on adolescents: there is no reason not to offer an implant or a hormone-loaded IUS to adolescents. (HMV)