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FIAPAC SeminarFIAPAC SeminarOctober 27-28, 2005, MoscowOctober 27-28, 2005, Moscow
Post-abortion Post-abortion contraception: Methods’ contraception: Methods’
choicechoice
Irina Savelieva, M. D., Ph.D., Irina Savelieva, M. D., Ph.D.,
Research Center Ob. & Gyn., Moscow, Research Center Ob. & Gyn., Moscow, RussiaRussia
Reproductive health intentions in postpartum and abortion clients
Postpartum
clients*
Postabortion clients
* *
Planned to have a child 59.3% 90.7%
Planned to use FP method 61.6% 70.0%
Planned to use modern CM 34,4% 67,3%
Planned to use CM immediately
10,3% 20,9%
The average waiting time for their (next) child is
3,7 years
BUT:BUT:
* E.Vikhlyaeva et al., Eur J Contr. And Repr. Health, 2001* * I.Savelieva, APHA, 2002
In 13 months: rate of repeat In 13 months: rate of repeat abortionsabortions
Postpartum clients
Postabortion clients
Repeat abortion after labour
10,3% 20,6%
Repeat abortion after previous abortion
18,5% 29,6%
* E.Vikhlyaeva et al., Eur J Contr. And Repr. Health, 2001* * I.Savelieva, APHA, 2002
Post-abortion contraception: wide Post-abortion contraception: wide range of methodsrange of methods Low-dose combined oral contraceptives Combined injectable contraceptives, patch & ring Progestogen-only contraceptives Emergence contraceptives pills Intrauterine devices (Cu-IUD and LNG-IUD) Barrier methods: condoms (Male latex, male
polyurethane, female condoms), spermicide (film, tablets, foam, gel), diaphragm (with spermicide), cervical cap
Fertility awareness-based methods (symptoms-based methods and calendar-based methods)
Surgical sterilization procedure (female and male)
Post-abortion contraception: Post-abortion contraception: counselingcounseling
Health-care providers and counselors have a responsibility to ensure that contraceptive services are available and offered to women who have abortions (WHO, 1997)
Providing family planning counseling can increase the proportion of women agreeing to use a contraceptive method before leaving the health facility which provided PAC (strong evidence) (Lema and Mpanga, 2000)
The availability of contraceptive commodities may increase the likelihood patients will report that they intend to use a contraceptive and will be discharged with a method (strong evidence)
Post-abortion contraception: Post-abortion contraception: counselingcounseling
Well-informed women will be more satisfied with their choices and more likely to use contraceptive method regularly and properly
Providing appropriate leaflets improves knowledge of contraception, in relation to oral contraceptive pill use (BMJ, 1998; 316:1948-52)
Linking family planning services with abortion services results in more effective family planning use and reduction of repeat abortions (SE) (Sentler et al., 2001)
Post-abortion contraception: Post-abortion contraception: counselingcounseling
She can become pregnant within a few days after the abortion (Cameron IT, Baird DT., 1988)
There are contraceptive methods that can help her prevent a future unwanted pregnancy
How and where various methods are available (either at time of treatment and/or after discharge
Clinic staff can provide referrals if she has other reproductive-health needs
What does “Informed Choice” What does “Informed Choice” means?means?
“Informed” means that: Clients have the clear, accurate, and specific
information that they need Clients understand their own needs
“Choice” means that: Clients have a range of FP methods to choose
from Clients make their own decisions
Post-abortion contraception: Post-abortion contraception: Decision making about a methodDecision making about a method
Each woman needs comprehensive information on her chosen contraceptive method, including:
Effectiveness Advantages and disadvantages How to use the method Which side effects are common and how to
manage them Complications STD prevention How to acquire additional supplies of the
method When to return
Medical Eligibility Checklist
Informed consent
Percentage of women experiencing an Percentage of women experiencing an unintended pregnancy within the first unintended pregnancy within the first year of use, USAyear of use, USA
Method % of women experiencing an unintended pregnancy within the first year of use
% of women continuing use at one
yearTypical use Perfect Use
No method 85 85
Spermicides 29 18 42
Withdrawal/Periodic abst. 27/ 25 4/ 1-9 43/ 51
Diaphragm/Cap 16/32 6/ 26 57/ 46
Condom Female Male
21 5 49
15 2 53
COC and minipill/ DMPA 8/ 3 0,3/ 0,3 68/ 56
CHP (Evra) / CH Ring 8/ 8 0,3/ 0,3 56/ 68
CIC (Lunelle) 3 0,05 56
IUD Cu/ Mirena 0,8/ 0,1 0,6/ 0,1 78/ 81
Sterilization Female/ Male 0,5/ 0,15 0,5/ 0,10 100
LNG implants 0,05 0,05 84
Trussel J. Contraceptive efficacy. In Hatcher RA, Trussel J.,et al., 2004
Conditions that expose a woman to Conditions that expose a woman to increase risk as a result of unintended increase risk as a result of unintended pregnancypregnancy
Breast cancer Complicated valvular heart diseases Diabetes: insulin-dependent; with
nephropathy/retinopathy/neuropathy or other vascular diseases; or of >20 years of duration
Endometrial or ovarian cancer High blood pressure (systolic > 160 mm Hg or diastolic >
100 mm Hg) STI / HIV / AIDS Ischemic heart disease Malignant gestational trophoblastic disease Malignant liver tumours (hepatoma); Schistomiasis with
fibrosis of the liver; Severe (decompensated) cirrhosis Sickle cell disease Stroke Thrombogenic mutations Tuberculosis WHO, 2004
Post- abortion contraception: when method should be started?
Most methods can be used without risk after a safe abortion
Surgical abortion Medical abortion
Just after abortion After confirmation of POC expulsion
Medical Eligibility Criteria for Medical Eligibility Criteria for Contraceptive UseContraceptive Use
Condition
COC CIC P/R POP DMPANet-En
LNG/ETGImplants
Cu-IUD
LNG-
IUD
First trimester
1 1 1 1 1 1 1 1
Second Trimester
1 1 1 1 1 1 2 2
Immediate post-septic abortion
1 1 1 1 1 1 4 4
Medical Eligibility Criteria for contraceptive use, 2004
Post-abortion contraception: Post-abortion contraception: surgical sterilization surgical sterilization
Sterilization can safely be performed at the time of induced abortion (Cheng MC, Cheong SC, Chew SC., 1979)
However combined procedures are associated with higher rates of failure and of regret on the part of the woman (Penny GC, et al, 1997)
Sterilization procedure has some medical restrictions in case of complications after abortion (postabortion sepsis or fever, severe haemorrhage, severe trauma to the genital tract, uterine perforation, acute haematometra)
Post-abortion contraception: Post-abortion contraception: COCCOC Use of oral contraceptives in the immediate post
abortion period is safe (strong evidence) (Niswonger et al., 1968)
Benefits of COC Very effective when used correctly Can be used as long as a woman wants to prevent
pregnancy. No rest period needed. Can be used from adolescence to menopause Monthly periods are more regular; lighter monthly
bleeding and fewer days of bleeding Help prevent: ectopic pregnancy, endometrial
cancer, ovarian cancer, ovarian cysts, pelvic inflammatory disease, benign breast disease
Can prevent or decrease iron deficiency anemia Fertility returns soon after stopping
see O. Serova
Post-abortion contraception: Post-abortion contraception: Intrauterine devicesIntrauterine devices
It is safe and effective to insert an IUD for contraceptive use immediately after first-trimester, spontaneous or induced abortion (Aral K, et al., 1993; Bitsch M, et al., 1990; WHO, 1983)
There was no differences in risk of complications for immediate versus delayed insertion of an IUD after abortion (WHO, 2004)
Expulsion was greater when an IUD was inserted following a second-trimester abortion versus following a first-trimester abortion (Stanwood et al., 2001)
There were no differences in safety or expulsions for post-abortion insertion of an LNG-IUD compared with Cu-IUD
see M - L Brival, S. Rogovskaya
Post-abortion contraception: emergency contraception
1,5 1,5 mgmg LNGLNG
Greater awareness and use of EC can reduce rates of unintended pregnancy and abortion
Use of EC may have prevented more than 50 000 US abortions in 2000 (Johnes et al., 2002)
If EC methods would be more available it would allowed to prevent 1,7 millions unwanted pregnancies and abortions would be decreased by twice (Boonstra, 2002)
ECPs containing LNG the most commonly used and most convenient form of EC
see Emergency contraception session
Post-abortion contraception: Barrier methods Women with conditions which make pregnancy an
unacceptable risk should be advised that BM for pregnancy prevention may not be appropriate for those who cannot use them consistently and correctly because of their relatively-higher typical-use failure rates
Male latex condoms are proven to protect against STI/HIV
Repeated and high-dose use of the spermicide nonoxynol-9 was associated with increased risk of genital lesions, which may increase the risk of acquiring HIV infection
Wilkinson D et al. Cochrane Database of Systematic Reviews, 2002, 4:CD003936
Partner’ Partner’ ««participatingparticipating» » in the in the abortion’ procedure, % (abortion’ procedure, % (WIN project, WIN project, Perm 1999-2002)Perm 1999-2002)
82,6
64,4
26
166
0
20
40
60
80
100
1 2 3 4 5
1. Have discussed pregnancy prevention with husband/ partner
2. Wish partner to participate in counseling 3. Partner come with woman 4. Partner participated in the talk about how to prevent
pregnancy 5. Partner have been invited to follow-up visit
Who do and who should makes the decision about contraceptionWho makes the decision to use a pregnancy prevention method
Who should make the decision to use a pregnancy prevention method
39,7% I myself/respondent
16,2%
5,3% My partner alone 4,4%
49,3% Both of us together 69,3%
5,7% Three of us together (me,
partner, doctor)
10,1%
Only 10% of all providers and 18% of providers who do CC have ever discussed FP with client’s partner
More than 90% thought that provision of RHS to men would improve women’s health
Implementing of Family planning counseling in all
levels of health care services
Access of using modern methods of contraception
Reducing of abortion rate, including repeat
abortion and abortion after delivery
Improvement women’s healthImprovement women’s health