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