Elsevier

Contraception

Volume 89, Issue 2, February 2014, Pages 103-108
Contraception

Original research article
Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice,☆☆,,★★

https://doi.org/10.1016/j.contraception.2013.10.014Get rights and content

Abstract

Objective

The objective was to evaluate whether having intrauterine devices (IUDs), contraceptive implants and injections immediately available to women undergoing abortion, compared to requiring an additional visit for these methods, leads to fewer pregnancies and fewer abortions in the following 12 months.

Methods

We conducted a historical cohort study using health records of Medicaid-insured women obtaining a first-trimester surgical abortion within a single practice in New York City. Women in Cohort 1 (2007–2008) needed an additional visit to initiate the IUD or injection. Women in Cohort 2 (2008–2009) were able to initiate these contraceptives and implants during the abortion visit. Women in both cohorts received these methods without additional cost, and all could receive a pill, patch or ring prescription. We compared the proportions of each cohort who experienced a pregnancy that began in the 12 months following the index abortion and also evaluated the outcomes of those pregnancies.

Results

Cohorts 1 and 2 consisted of 407 and 405 women, respectively. The proportions with pregnancy beginning over the following 12 months were substantially greater in Cohort 1 than Cohort 2 (27.3% versus 15.3%, p<.001). Women in Cohort 1 then underwent both more additional abortions (17.2% versus 9.9%, p=.003) and more births (7.9% versus 3.7%, p=.02). The proportion of women in Cohort 1 who initiated IUDs and implants within 12 months was smaller than in Cohort 2 (11% versus 46%, p<.001).

Conclusions

Among women insured by Medicaid, offering immediate comprehensive contraceptive access — including IUDs and implants — on the same day as an induced abortion, compared to requiring an additional visit, increased uptake of IUDs and implants and decreased repeat pregnancies in the next 12 months and abortions.

Introduction

In the United States, 1.2 million induced abortions took place in 2008 [1], and approximately half were repeat abortions [2], [3], [4], [5], [6]. The visit for an induced abortion provides an opportunity to prevent future unwanted pregnancies by immediate postabortion initiation of highly effective contraception. Intrauterine devices (IUDs) and implants are highly effective, long-acting reversible contraceptives, sometimes referred to as “LARC” [7], [8], [9]. These methods are acceptable to both adolescents and adults [10], [11], [12] and are safe for immediate initiation after an induced abortion [7], [13], [14], [15], [16], [17], but underutilized partly due to financial barriers such as reimbursement policies that preclude billing for two procedures at a single visit [18], [19], [20], [21]. Throughout the course of this study, New York State (NYS) Medicaid covered the cost of induced abortion and also covered contraceptive procedures, but not both on the same day.

Studies have shown reductions in subsequent pregnancy and abortion among women who chose an immediate postabortion IUD compared to those who chose other contraceptive methods [22], [23], [24], [25], [26]. One randomized trial showed increased IUD uptake among women offered immediate insertion compared to delayed insertion after abortion [27].

The donation of a supply of highly effective reversible contraceptives for Medicaid and uninsured patients undergoing an abortion procedure in our practice beginning in 2008 allowed us to provide these methods on the same day as the abortion, in contrast to our previous usual practice of referring women to our neighboring clinic for an additional visit to initiate these methods. The study question is whether immediate, same-day availability of IUDs, implants and depot medroxyprogesterone acetate (DMPA) injections is associated with fewer repeat pregnancies compared to our usual practice.

Section snippets

Materials and methods

We conducted a historical cohort study of women seen in a single academic practice in New York City from October 2007 through June 2009. The Columbia University Medical Center Institutional Review Board approved this study. The study population consisted of Medicaid-insured women who underwent an office-based first-trimester (up to 13 6/7 weeks) vacuum aspiration with local anesthetic for induced abortion.

Usual care — including history, physical exam, ultrasound, counseling and the abortion

Results

We compared 407 women not offered immediate initiation of IUDs, implants and DMPA after induced abortion (Cohort 1) to 405 women offered immediate initiation of IUDs, implants and DMPA after induced abortion (Cohort 2). During the study enrollment periods, this service provided abortion-related care during 1326 visits (Table 1). To define Cohort 1, we reviewed 623 consecutive index visits; we found 407 women who met inclusion criteria and excluded 216 women. To define Cohort 2, we reviewed 703

Discussion

In this study, we compared how a specific change in practice policy affected 1-year pregnancy rates. That change was having highly effective contraceptive methods available for immediate postabortion initiation during the same visit rather than requiring an additional visit. For both cohorts, these highly effective methods were available at no extra cost; the only difference was eliminating an extra visit. After implementing this change, LARC uptake increased from 11% to 46%; 44% fewer women

Acknowledgments

Contraceptive devices donated by an anonymous foundation.

References (37)

Cited by (0)

Funding: grant from the Society of Family Planning.

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Potential financial and other conflicts of interest: Carolyn Westhoff receives support from Merck and Bayer as a DSMB member and from Agile as an advisory board member; she does not hold stocks and is not a speaker’s bureau member.

Presentations: oral presentation at Reproductive Health 2012, New Orleans, LA, September 20–22, 2012; poster presentation at North American Forum on Family Planning 2012, Denver, CO, October 27–29, 2012.

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Implications: Availability of intrauterine devices, implants and depot medroxyprogesterone acetate immediately postabortion during the same visit leads to fewer pregnancies in the next 12 months and fewer abortions.

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