Elsevier

Contraception

Volume 78, Issue 2, August 2008, Pages 149-154
Contraception

Original research article
Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion

https://doi.org/10.1016/j.contraception.2008.03.013Get rights and content

Abstract

Background

The rate of repeat induced abortion varies from 30% to 38% in northern Europe. Thus, repeat abortion is an important public health issue. However, risk factors as regards repeat abortion are poorly understood. We characterized risk factors related to sociodemographic characteristics, history of abortion and post-abortal contraception.

Study design

A prospective cohort study of 1269 women undergoing medical abortion between August 2000 and December 2002 was conducted. The subjects were followed via the Finnish Registry of Induced Abortions until December 2005, the follow-up time (mean±SD) being 49.2±8.0 months.

Results

Altogether, 179 (14.1%) of the subjects requested repeat abortion within the follow-up time. In univariate analysis, a history of prior abortion, being parous, young age, smoking and failure to attend the follow-up visit were associated with repeat abortion. Immediate — in contrast to postponed — initiation of any contraceptive method was linked to a lower risk of repeat abortion. In comparison with combined oral contraceptives, use of intrauterine contraception was most efficacious in reducing the risk of another pregnancy termination. In multivariate analysis, the effects of young age, being parous, smoking, a history of prior abortion and type of contraception on the risk of another abortion persisted.

Conclusions

An increased focus on young women, parous women and those with a history of abortion may be efficacious in decreasing repeat abortion. Contraceptive choices made at the time of abortion have an important effect on the rate of repeat abortion. Use of intrauterine contraceptives for post-abortal contraception was associated with decreased risk of repeat abortion.

Introduction

The incidence of repeat induced abortion varies greatly from country to country. In 2005, the rate of repeat abortion was 32% in England and Wales [1], whereas corresponding figures were somewhat lower in Finland (30%) [2], but higher in Sweden (38%) [3] and in the USA (47%) [4]. However, many countries lack reliable statistics on abortion.

Apart from the personal trauma and cost to the woman or society, repeat abortion has been linked to increased risk of adverse outcome in future pregnancies. Namely, increased risks of ectopic pregnancy [5], fetal loss [6] and low birth weight and preterm delivery [7] have been reported. Thus, repeat abortion remains an important public health dilemma.

Risk factors of repeat abortion are poorly understood and are likely to vary in different societies. The rate of repeat abortion is likely to be related to the overall incidence of abortion. The current abortion rate in Finland is 9.0/1000 women aged 15–49 years [2], and it is 17.2 in Sweden [3] and 17.8 in England and Wales [1]. In previous cross-sectional studies performed in Canada, Scotland and USA, women seeking repeat abortion were older, more often parous, had a history of domestic violence and alcohol/drug abuse and were of lower socioeconomic status (SES) [8], [9], [10].

The influence of contraceptive use and counseling on the risk of repeat abortion is unclear [11], [12]. Oral contraceptive (OC) use has been reported to be more prevalent among Canadian women seeking repeat abortion(s) [9]. Similarly, in a recent study from California, the use of depot medroxyprogesterone acetate was more common among women requesting repeat abortion [10]. However, in a prospective study from Scotland, specialist counseling and provision of contraceptives did not have an effect on the rate of repeat abortion [13].

The objective of this study was to gain further insight into factors affecting the risk of repeat abortion by using prospective follow-up study material. A cohort of 1269 women established at the time of introduction of medical abortion in the Helsinki metropolitan area between 2000 and 2002 [14], [15] was followed until the end of 2005. The follow-up was performed by means of the Finnish Registry of Induced Abortions [2], to which all induced abortions performed in Finland are to be reported [16]. The effects of various demographic and abortion-related variables, as well as the contraceptive choices made at the time of abortion on the risk of repeat abortion, were assessed.

Section snippets

Materials and methods

Between August 2000 and December 2002, a total of 1269 women requested medical termination of first trimester pregnancy (up to 9 weeks of gestation) at Helsinki University Central Hospital, Helsinki, Finland. The detailed management and clinical outcomes of these women have been reported previously [14], [15]. The subjects received extensive contraceptive counseling both by nurses/midwives and by physicians at the time of abortion. Post-abortal contraception was planned and prescribed. The

Results

Of all index abortions (n=1269), 1258 (99%) were initially recognized in the Registry of Induced Abortions. The remaining 11 cases were added to the registry before further analysis. The follow-up time (mean±SD) was 49.2±8.0 months.

During the follow-up period of August 2000 to December 2005, a total of 179 women (14.1%) out of the cohort of 1269 requested repeat abortion(s). Of the 1238 subjects assessed at the control visit, 171 (13.8%) requested abortion(s) during the follow-up period. The

Discussion

In the present study, repeat abortion was fairly common, with 14% of the women having another abortion within the follow-up period (mean almost 50 months). Several demographic factors, namely, history of abortion, being parous, young age and smoking, were associated with increased risk of repeat abortion. In addition, contraceptive choices made at the time of termination had a significant impact on the risk of repeat abortion. Intrauterine contraception was associated with the lowest rate of

Acknowledgments

We wish to thank Dr Riikka Gunnar (née Leminen) and Ms Marjatta Tevilin for their help in data collection and analysis. We also thank Ms Nina Hedkrok for her expert secretarial assistance. Dr Pasi Korhonen of StatFinn Oy (Espoo, Finland) is to be thanked for expert help with the statistical analysis. Financial support from Helsinki University Central Hospital Research Funds is gratefully acknowledged.

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