Human Reproduction, Vol.30, No.11 pp.

2539– 2546, 2015

Advanced Access publication on September 14, 2015 doi:10.1093/humrep/dev233

ORIGINAL ARTICLE Fertility control

Provision of intrauterine contraception

in association with first trimester
induced abortion reduces the need of

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repeat abortion: first-year results of a
randomized controlled trial
Elina Pohjoranta 1,†, Maarit Mentula 1,†, Mika Gissler 2, Satu Suhonen3,
and Oskari Heikinheimo 1,*
1
Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Kätilöopisto Hospital, PO Box 610, Helsinki
00029-HUS, Finland 2National Institute for Health and Welfare, Helsinki, Finland 3Centralized Family Planning, Department of Social Services and
Health Care, City of Helsinki, Helsinki, Finland

*Correspondence address. E-mail: oskari.heikinheimo@helsinki.fi

Submitted on June 30, 2015; resubmitted on August 18, 2015; accepted on August 24, 2015

study question: Can the need of subsequent abortion be reduced by providing intrauterine contraception as a part of the abortion
service?
summary answer: Provision of intrauterine devices (IUDs) in association with first trimester abortion more than halved the incidence of
repeat abortion during the first year of follow-up.
what is known already: Following abortion, the incidence of subsequent abortion is high, up to 30 –40%. In cohort studies, intra-
uterine contraception has reduced the need of repeat abortion by 60– 70%.
study design, size, duration: A randomized controlled trial. The main outcome measure was the incidence of subsequent induced
abortions during the follow-up. Altogether 751 women seeking first trimester induced abortion were recruited and randomized into two groups.
Randomization was accomplished by computer-assisted permuted-block randomization with random block sizes of four to six. The investigators
did not participate in randomization, which was done before commencing the study. The participants were recruited between 18 October 2010
and 21 January 2013.
participants, settings, methods: The inclusion criteria were age ≥18 years, duration of pregnancy ≤12 weeks, accepting intra-
uterine contraception, residence in Helsinki and signing the informed consent form. Women with contraindications to intrauterine contraception,
such as uterine anomaly, acute genital infection or pap-smear change requiring surgical treatment were ineligible to participate.
This study was conducted in collaboration between the Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki Uni-
versity Hospital, and Centralized family planning of the City of Helsinki.
The intervention group (n ¼ 375) was provided with intrauterine contraception (either the levonorgestrel-releasing intrauterine system or
copper-releasing intrauterine device) immediately following surgical abortion (18.1%) or at a follow-up 2– 4 weeks after medical abortion
(81.9%). Women in the control group were prescribed oral contraceptives and advised to contact their primary healthcare unit for a follow-
up visit and further contraceptive services according to national guidelines. The women were followed-up to 28 February 2014 by using the
Finnish National Abortion Registry, Helsinki University Hospital electronic database and clinical follow-up visit at 1 year.
main results and the role of chance: The median age of the whole study group was 27 years and 44% had a history of induced
abortion(s). During the follow-up year the number of women requesting subsequent abortion was significantly lower in the intervention than in the
control group (9/375 [2.4%] versus 20/373 [5.4%], difference 23.0 [95% CI 26.0 to 20.2] percentage points, P ¼ 0.038, according to inten-
tion-to-treat analysis and 5/346 [1.4%] versus 20/357 [5.6%], difference 24.2(27.2 to 21.4) percentage points, P ¼ 0.003, according to

†
Equal first author contribution.

& The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
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2540 Pohjoranta et al.

per-protocol analysis, respectively). Provision of intrauterine contraception was safe with rate of infection and expulsion similar to those reported
previously.
limitations, reasons for caution: The power calculation was calculated for a 5-year follow-up. However, significant differences
between the two groups were already seen after 1 year. The present study was performed in a single clinic, where, 15% of all abortions in Finland
are performed.
wider implications of the findings: In order to decrease the need of subsequent abortions, IUDs should be provided at the time
of abortion.
study funding/competing interest(s): This study was supported by Helsinki University Central Hospital Research funds and
by research grants provided by the Antti and Jenny Wihuri Foundation and the Yrjö Jahnsson Foundation. O.H. has served on advisory boards for

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Bayer Healthcare, Gedeon Richter and MSD Finland (part of Merck & Co. Inc.), and designed and lectured at educational events of these com-
panies. S.S. has lectured at educational events of Bayer and MSD Finland (part of Merck & Co. Inc.). The other authors have no conflicts of interest
to declare.
trial registration: The study was registered at www.clinicaltrials.gov (NCT01223521).
trial registration date: 18 October 2010.
date of first patient’s enrolment: 18 October 2010.
Key words: induced abortion / intrauterine contraception / counselling / repeat abortion / abortion registry

that provision of IUD reduces the need of subsequent abortion by half

Introduction
The efficacy of long-acting reversible contraceptive (LARC) methods,
including intrauterine devices and systems (hereafter referred as IUDs)
in reducing the rate of unplanned pregnancies is widely recognized
(Blumenthal et al., 2011; Winner et al., 2012; Secura et al., 2014). In
light of these recent findings, LARC methods are increasingly being
promoted as first-line contraception also among young and nulliparous
women (Secura et al., 2014). Women requesting induced abortion are
typically 20–30 years of age, with high fertility and a high risk of
subsequent abortion(s) (Sedgh et al., 2013; UK government, 2013;
National Institute for Health and Welfare, 2015a). In countries with
reliable abortion statistics, the percentage of women requesting repeat
abortion varies from 30 to 40% (Gissler et al., 2012; UK government,
2013; ISD Scotland, 2013; National Institute of Health and Welfare,
2015a). It has been calculated that a 10% switch from oral contraceptives
to LARC methods among US women aged 20 –29 years would result in
an annual net saving of 288 million USD by effective prevention of
unplanned pregnancy (Trussel et al., 2013).
In several cohort studies, post-abortal intrauterine contraception has
been associated with a significantly reduced risk of repeat abortion
(Goodman et al., 2008; Heikinheimo et al., 2008; Roberts et al., 2010;
Rose and Lawton, 2012; Cameron et al., 2012a,b). In women using
IUDs, the rate of subsequent abortion has been 60– 70% lower than
among women using oral contraceptives (Heikinheimo et al., 2008;
Roberts et al., 2010; Rose and Lawton, 2012) or contraception other
than intrauterine (Goodman et al., 2008). However, the efficacy of post-
abortal IUD placement in preventing repeat abortions has not been
tested in a randomized clinical trial (RCT).
The purpose of the present RCT was to study the long-term effect(s)
of routine provision of intrauterine contraception, either with the
levonorgestrel-releasing intrauterine system (LNG-IUS) or a copper-
releasing intrauterine device (Cu-IUD) included in abortion services. In
the present analysis, we focused on the need of repeat abortion during
the first year following the index abortion. The study hypothesis was
during the planned 5-year duration of the study.
Materials and Methods
According to Finnish legislation (Ministry of Justice, Finland) induced abortion
can be performed following approval (either by one or two physicians, or by
the National Supervisory Authority for Welfare and Health) at up to
20 weeks of gestation, and in cases of confirmed fetal anomaly, at up to
24 + 0 weeks. In general, abortion requested for social indications (such
as stressful life situation) up to 12 weeks of gestation requires approval by
two physicians, the referring and the performing physician. The woman is re-
ferred from primary healthcare to the hospital performing the abortion. The
hospitals are required to report all abortions within 1 month of the procedure
to the National Abortion Registry, kept by the National Institute for Health
and Welfare (www.thl.fi) and covering all abortions performed in Finland
(National Institute for Health and Welfare, 2015b).
According to Finnish national guidelines on induced abortion (The Finnish
Medical Society Duodecim, 2013) contraceptive counselling is given before
the referral, at the hospital performing abortion, and also at the follow-up
visit taking place at the primary healthcare 2 – 3 weeks after abortion.
Trial design
This trial was designed to compare routine provision of intrauterine contra-
ception versus a standard procedure of woman-controlled follow-up visit
and further planning of contraception (including IUD provision) after an
early induced abortion.
This is a collaborative study between the Department of Obstetrics and
Gynaecology, Helsinki University Hospital, performing annually 1700
induced abortions for women resident in Helsinki, and the Department of
Social Welfare and Health, City of Helsinki.
Participants
The inclusion criteria were age ≥18 years, residence in the City of Helsinki,
seeking induced abortion for non-fetal indications during the first trimester of
pregnancy (≤84 days of gestation), accepting intrauterine contraception and
Intrauterine contraception after induced abortion
willingness to participate and to sign the informed consent form. Exclusion
criteria were contraindications to intrauterine contraception (i.e. acute
genital infection, Pap-smear change necessitating surgical intervention or
known uterine structural abnormality). In addition, acute liver disease and
breast cancer were contraindications for the LNG-IUS; and Wilson’s
disease, copper allergy, iron deficiency anaemia and history of ectopic preg-
nancy for Cu-IUD.
Randomization
Randomization was accomplished by computer-assisted permuted-block
randomization with random block sizes of four to six. The investigators did
not participate in randomization, which was done before commencing the
study. The group assignments were kept in sealed envelopes. The study
nurse opened the envelopes after informing and recruiting the women.
Study procedures
The method of induced abortion was decided individually on the basis of pos-
sible contraindications and the women’s preferences. Medical abortion was
performed by administration of mifepristone followed by misoprostol 2 – 4
days later vaginally either at the hospital (n ¼ 227, 37.5%) or at home
(n ¼ 378, 62.5%). Women choosing surgical abortion received misoprostol
prior to vacuum aspiration under general anaesthesia. All procedures were
performed according to national guidelines (The Finnish Medical Society
Duodecim, 2013).
The women in the intervention group choosing surgical abortion received
the cost-free IUD (Cu-IUD [Nova-Tw] or LNG-IUS [Mirenaw], both from
Bayer Ag, Turku, Finland) at the time of vacuum aspiration. Its correct place-
ment was confirmed by vaginal ultrasonography at the follow-up visit at 2 – 4
weeks afterwards. For women choosing medical abortion, the IUD was
inserted at the follow-up visit in cases with no complications.
The women in the control group were mainly prescribed oral contracep-
tives for 1 year and advised to contact their primary healthcare unit for the
follow-up visit, including planning further contraception (including IUD pro-
vision), which is the current practice in Finland (The Finnish Medical
Society Duodecim, 2013).
Follow-up
After 3 months, women in the intervention group had an appointment with
the study nurse to confirm acceptability of intrauterine contraception and the
proper placement of the IUD by direct visualization of the IUD strings. Ultra-
sonography was used if the strings were missing or appeared too long. In
cases of expulsion or dislocation (n ¼ 18), a new device was offered.
All women were provided with a questionnaire regarding physical, mental,
sexual and reproductive health, and quality of life at enrolment, at 3 months,
and at 1 year after the abortion. A reminder text message was sent twice if the
follow-up questionnaire had not been received.
The next follow-up visit was scheduled 1 year after abortion for all women
participating in the study. In cases of no-show, the women were contacted
twice by phone. If they could not be reached, a letter was sent to schedule
a new appointment.
Women in both study groups requesting another abortion up to 28 Feb-
ruary 2014 were identified in the National Abortion Registry and Helsinki
University Hospital electronic database. All women requesting subsequent
abortion either with a viable intrauterine pregnancy, spontaneous miscar-
riage or ectopic pregnancy diagnosed at the time of assessment for abortion
were included in the group.
Adverse events
All participants after the index abortion were advised to contact the hospital
should symptoms of possible complications arise. Information on all
2541
additional hospital visits was analysed to assess possible adverse events
related to the IUD insertion.
Study overseers
The trial received approval from the Ethics Committees of the City of Helsinki
(10-1138/054) and the Hospital District of Helsinki and Uusimaa (HUS 260/
13/03/03/2009). Approval to carry out the study was granted by the Hos-
pital District of Helsinki and Uusimaa (§12/30.03.2010). The trial was regis-
tered at the Clinical Trials website (www.clinicaltrials.gov [NCT01223521]).
Approval to use personal-level data was obtained from the National Insti-
tute for Health and Welfare as required for registry-based studies in Finland
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(THL/1479/5.05.00/2013). All personal-level data that could be used to
identify individuals were removed before the analyses.
Statistical analysis
Based on earlier studies, we assumed that the risk of subsequent induced
abortion is 15% during the 5-year follow-up time (Heikinheimo et al.,
2008) and that provision of intrauterine contraception reduces this risk by
50%. Using the log-rank test and with a 1-year accrual time, for a 5-year
total study time with 80% power and a 5% significance level, we needed at
least 350 women in each group. Subsequently, a total of 751 women were
recruited during the study period (18 October 2010– 21 January 2013; Fig. 1).
The planned duration of the study is 5 years. However, at the time of the
1-year follow-up visit it became apparent that there might be a difference in
the rate of repeat abortion between the study groups, we modified the
protocol, and applied for an approval to perform the registry-based analysis
already at 1 year. Thus, in the present analysis the primary outcome was the
rate of subsequent induced abortion during the first year following the index
abortion. Secondary outcomes were contraception prior to repeat abortion,
timing of repeat abortion and adverse events related to IUD insertion.
All analyses were performed with PASW statistics software, version 18
(SPSS Inc., IL, USA). Analyses were conducted on an intention-to-treat
(ITT) and a per-protocol (PP) basis. Statistical significance was defined as
P , 0.05. Differences in continuous variables were analysed by means of
the Mann– Whitney U-test for skewed data. The data are presented as
medians (with interquartile range [IQR]). x 2 or Fisher’s exact tests were
used as appropriate for independent nominal data. Differences of propor-
tions and their 95% confidence intervals (CIs) were calculated using New-
combe’s method. Kaplan –Meier survival analysis with the log-rank test
was used to analyse cumulative subsequent induced abortions.
Results
Study participants
Of the total of 2305 eligible women requesting induced abortion during
the study period, 1139 (49.4%) expressed an interest in intrauterine
contraception (Fig. 1). A majority of them (751, 65.9%) were randomized
into the study. After randomization, three women decided to continue the
pregnancy and were excluded from all analyses. The remaining 748
women were included in the ITT-analysis. Twenty-seven women rando-
mized to the intervention group did not receive an IUD (none in the
group of surgical abortion and 27 in the group of medical abortion, P ¼
0.011) and were excluded from the PP analysis as a result of this protocol
violation. Sixteen women in the control group who received an IUD at
the time of surgical abortion were also excluded from the PP analysis.
Table I summarizes the characteristics of the study participants. The
median (IQR) age of the whole study group was 27 (23 –33) years.
Nearly half (48.4%, 362/748) of the women were parous and 43.7%
2542
Figure 1 Study flow chart.
(327/748) had a history of induced abortion(s). Randomization did not
result in any statistically significant differences in clinically important back-
ground factors between the groups.
In the intervention group, 307 (81.3%) women chose medical abor-
tion, and 68 (18.7%) surgical (Fig. 1). For women choosing medical abor-
tion, 302 women received the IUD within 4 weeks after the abortion, and
the remaining 46 later. Median (quartiles) time from induced abortion to
insertion of IUD was 20 (17 –24) days.
Primary outcome
During the first year of follow-up 29 (3.9%) and 25 (3.5%) women were
referred to hospital with a request for an induced abortion according to
the ITT and PP analyses, respectively (Table II). Finally, 24 (3.2%) women
in the ITT-analysis group and 20 (2.8%) women in the PP analysis group
underwent subsequent induced abortion. The remaining five women
were diagnosed with miscarriage (n ¼ 3) or ectopic pregnancy (n ¼ 2).
Thus, study intervention decreased the request for subsequent abor-
tions by more than half. The number of induced abortions was
reduced to one-third (ITT-analysis) or one-fifth (PP analysis).
The cumulative proportion of women without subsequent induced
abortion at 1 year was 98.4% in the intervention group and 95.0% in
the control group (P ¼ 0.012; Fig. 2).
The rate of repeat abortion in the intervention group was 0% (0/68)
following surgical and 2.0% (6/307) following medical abortion
(P ¼ 0.25). The corresponding figures were 2.7% (2/74) and 5.4%
(16/299) in the control group (P ¼ 0.34).
Pohjoranta et al.
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Secondary outcomes
The median time (with IQR) to subsequent induced abortion was
8 (6–11) months. None of the unplanned pregnancies occurred during
the use of intrauterine contraception. Half of the women (12/24)
undergoing subsequent abortion used no contraception at the time of
conception (Table III).
Comparison of the data on subsequent induced abortions included in
the national registry and in the hospital registry showed a 95.8% match,
with one missing case in the national registry.
Altogether 380 (50.5%) women attended the follow-up visit at 1 year
(225 [59.7%] in the intervention group and 155 [41.2%] in the control
group). The response rate as regards the questionnaires at 1 year was
60.7% in the intervention group and 42.3% in the control group.
Among women requesting a new abortion, the response rate was as
low as 17.2%. Only 4 of the 24 women undergoing a subsequent abortion
self-reported it in the questionnaire, resulting in only 16.7% concordance
with the abortion registry (Table III).
Adverse events
There were no cases of uterine perforation after IUD insertion. Al-
together 18 (5.2%) total or partial expulsions were detected by the
time of the 3-month follow-up visit. The rate was 7.2% (5/70) after sur-
gical termination and 4.7% (13/307) after medical termination. All of
these women were offered a new IUD; four declined and initiated oral
contraceptives.
Intrauterine contraception after induced abortion 2543

Table I Characteristics of the women (n 5 748) Table II Subsequent induced abortions/unplanned

undergoing first trimester induced abortion and pregnancies during follow-up of 1 year after the index
participating in the study (ITT-basis). abortion.

Variable Intervention Control group Study Control Difference P-value

group (n 5 375) (n 5 373) group group (95% CI)
........................................................................................ ........................................................................................
Age (years); median (IQR) 27 (22 –33) 27 (23– 33) ITT-basis n ¼ 375 n ¼ 373
Days of amenorrhea; 57 (49 –66) 56 (49– 65) PP-basis n ¼ 346 n ¼ 357
median (IQR) Women with subsequent induced abortions
Type of induced abortion

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ITT-basis 6 (1.6) 18 (4.8) 23.2 (26.0 to 20.7) 0.012
Medical 307 (81.9) 299 (80.2) PP-basis 2 (0.6) 18 (5.0) 24.5 (27.3 to 22.1) ,0.001
Surgical 68 (18.1) 74 (19.8) Unplanned pregnanciesa
Type of planned contraception ITT-basis 9 (2.4) 20 (5.4) 23.0 (26.0 to 20.2) 0.038
Cu-IUD 26 (6.9) 24 (6.4) PP-basis 5 (1.4) 20 (5.6) 24.2 (27.2 to 21.4) 0.003
LNG-IUS 349 (93.1) 349 (93.6)
The data are shown as n (%).
Parous 187 (49.9) 175 (46.9) a
Includes miscarriages and extrauterine pregnancies diagnosed at the time of
History of induced 174 (46.4) 153 (41.0) assessment for induced abortion.
abortion(s)
Marital status
Married 71 (18.9) 52 (13.9)
Cohabiting 102 (27.2) 92 (24.7)
Single 202 (53.9) 229 (61.4)
Socioeconomic status
Upper white-collar 29 (7.7) 23 (6.2)
Lower white-collar 77 (20.5) 74 (19.8)
Blue-collar workers 153 (40.8) 137 (36.7)
Students 72 (19.2) 92 (24.4)
Other 44 (11.7) 48 (12.9)
Smoking 188 (50.1) 189 (51.4)
Body mass index (kg/m2); 23 (21 –26) 23 (21– 26)
median (IQR)
Contraception used at the time of conception
Combined hormonal 45 (12.0) 49 (13.1)
contraceptives
Progestin-only pill 12 (3.2) 9 (2.4)
Cu-IUD — 1 (0.3)
Condom 159 (42.4) 135 (36.2)
Other 8 (2.1) 14 (3.8)
None 151 (40.3) 165 (44.2)

The data are shown as n (%) unless stated otherwise.

Figure 2 Cumulative proportions of women without subsequent

In total 12 (3.4%) women in the intervention group received antibio-
tics following IUD insertion because of clinically diagnosed genital infec-
tion by the time of the 3-month follow-up visit.
Discussion
We found that provision of intrauterine contraception in association with
induced abortion more than halved the number of requests for subse-
quent abortions during the first year of follow-up. Moreover, the
policy of IUD provision was safe, with expulsion and infection rates com-
parable to those reported previously (Grimes et al., 2010; Bednarek
et al., 2011).
induced abortion during the first year of follow-up after the index abortion.
The present study was performed at only one (albeit large) clinic,
which is a weakness. However, as Helsinki is the largest city in Finland,
15% of all induced abortions in Finland are performed there (National
Institute for Health and Welfare, 2014). Moreover, at the time of the
study, Helsinki represented the only large community in Finland to
provide a first IUD to women free of charge through primary healthcare
services. Thus, a large proportion of women randomized to the control
group also had the option to obtain free intrauterine contraception.
However, there is no possibility to know the precise number of IUDs
inserted to the women belonging to the control group.
2544
Table III Characteristics of the women (n 5 24)
undergoing subsequent abortion during the first year of
follow-up after the index abortion. ITT-analysis.
Variable GROUP
........................................
Intervention Control
(n 5 6) (n 5 18)
........................................................................................
Age (years) 33 (31 –37) 23 (21 –26)
[median (range)]
Parousa 5 (83.3) 6 (33.3)
Previous induced 5 (83.3) 8 (44.4)
abortionsa
Time (months) to 10 (5– 11) 8 (6– 11)
subsequent abortion
[median (range)]
Contraception prior to subsequent abortiona
COC 0 2 (11.1)
POP 0 4 (22.2)
Condom 1 (16.7) 5 (27.8)
None 5 (83.3) 7 (38.9)
COC, combined oral contraceptive; POP, progestogen-only pill.
a
n (%).
The study was designed to reflect contemporary practice as regards
both the method of abortion and the type of IUD used. Thus, the
method of abortion and type of IUD was decided individually based on
the woman’s preferences and medical recommendations. This may
also be criticized as the time of insertion of IUD following medical and
surgical abortion differed; also both copper- and LNG-releasing
devices were used. However, in our previous nationwide study the
risk of subsequent abortion did not differ after medical or surgical
induced abortion (Niinimäki et al., 2009). Regarding the choice of IUD,
a previous randomized study has shown a lower rate of contraceptive
failure among women receiving the LNG-IUS at the time surgical abor-
tion compared with women receiving Cu-IUD (Pakarinen et al., 2003).
However, in our and other cohort studies the rate of repeat abortion
has been similar among women receiving either the copper- or
LNG-releasing IUD at the time of abortion with a high rate of IUD
removals among women requesting repeat termination later during
the follow-up (Goodman et al., 2008; Heikinheimo et al., 2008;
Roberts et al., 2010; Rose and Lawton, 2012).
The rate of protocol violations and subsequent study exclusions
among women choosing surgical abortion was quite high. Surgical abor-
tions were performed by the gynaecologist on duty potentially willing to
follow the individual woman’s wish to obtain an IUD despite her random-
ization into the control group. Also the loss to follow-up at the 1-year
clinical visit was high. This is likely to be due to the challenging study popu-
lation, young women undergoing an induced abortion.
The women participating in the study were in their late twenties. They
were also highly fertile—nearly half of them were parous and almost half
of them had a history of induced abortion. The highest incidences of
induced abortion in Finland, in England and Wales as well as in most
other countries are seen among women between 20 and 24 years of
age (Sedgh et al., 2013; UK government, 2013; National Institute for
Health and Welfare, 2015a). This may indicate that in the present
Pohjoranta et al.
study, younger women were hesitant when considering an IUD for post-
abortal contraception. Intrauterine contraception has been shown to be
effective and highly acceptable among young and nulliparous women
(Suhonen et al., 2004; Yen et al., 2010; Secura et al., 2014; Kaislasuo
P-value et al., 2015). Even though the overall use of intrauterine contraception
is high (up to 18%) in Finland this form of contraception should be
further encouraged among young women especially after an unwanted
pregnancy.
0.001 The women were followed-up by using the Finnish National Abortion
Registry as well as the hospital database. In previous studies the reliability
0.033 of the National Abortion Registry has been high, with 99% of all
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0.098 induced abortions being reported to it (Gissler et al., 1996; Heikinheimo
et al., 2008). Similarly, in the present study, concordance between the
0.42 abortions reported to the registry and those identified in the hospital
electronic database was high. In contrast, only half of all the women
returned the follow-up questionnaire at 1 year and only a few of those
who underwent a subsequent abortion reported it in the questionnaire.
ns
Thus, follow-up using the national registry was highly reliable and super-
ns ior to self-reporting.
ns According to international guidelines, insertion of an IUD at the time of
ns surgical abortion is safe and effective (Grimes et al., 2010; WHO, 2015).
This is highlighted in a recent study in which immediate versus delayed
IUD insertion in association with uterine aspiration was compared
with significantly greater use of IUDs among women receiving one imme-
diately (Bednarek et al., 2011).
The practice of induced abortion has changed dramatically over the
last 20 years. Currently, the uptake of medical abortion in the USA is
25% (Jones and Jerman, 2014), and it is 50% in England and Wales
(UK government, 2013). However, more than 80% of women choose
medical abortion in Finland, Scotland and Sweden (The National Board
of Health and Welfare, Sweden, 2012; ISD Scotland, 2013; National In-
stitute for Health and Welfare, 2015a), as was the case in the present
study. According to international guidelines, intrauterine contraception
may be initiated following medical abortion when the termination is
complete (UKMEC, 2009; WHO, 2012; WHO, 2015). In previous
studies insertion of an IUD has been performed between 1 and 4
weeks after medical abortion (Heikinheimo et al., 2008; Sääv et al.,
2012). However, the lost-to-follow-up rate after induced abortion is
high (up to 43%) (Pohjoranta et al., 2011), and even though a tailored ap-
pointment for a follow-up visit and IUD insertion is scheduled, attend-
ance is poor (Stanek et al., 2009; Cameron et al., 2012a,b). In the
present study, 91% of women undergoing medical abortion attended
the IUD insertion visit as scheduled. This likely reflects the investigational
nature of the study and a high motivation among the study participants,
and also the frequent reminders. According to an RCT performed in
Sweden this could be further improved by more rapid provision of
IUD after medical abortion (Sääv et al., 2012). In the present study,
however, the rate of repeat abortion did not differ significantly among
women undergoing medical or surgical abortion
The overall rate of subsequent abortion during the first year of follow-
up was nearly 4%. This figure is similar to that in one of our previous
studies (Heikinheimo et al., 2008) and somewhat lower than the
overall first-year rate of subsequent abortion of 5–6% seen in Helsinki
(National Institute for Health and Welfare, 2014). Importantly, accord-
ing to ITT-analysis, only 1.6% of the women in the intervention group—in
contrast to 4.8% in the control group—requested subsequent abor-
tion(s) during the follow-up period. In PP analysis, the difference was
Intrauterine contraception after induced abortion
even larger. It is also noteworthy that in the intervention group all women
requesting a repeat abortion had had the IUD removed prior to the new
unplanned pregnancy. None of the subsequent unwanted pregnancies
were conceived because of an unnoticed IUD expulsion. This is in line
with previous studies showing that an unwanted pregnancy is often pre-
ceded by a change from an effective contraceptive method to a method
of lower efficacy (Bajos et al., 2006).
The high contraceptive efficacy of intrauterine devices is widely recog-
nized. Besides assessing the efficacy of the IUDs in prevention of un-
planned pregnancy, we studied how to optimize the provision of
post-abortal contraception. A key finding of the study is that by integrat-
ing IUD provision into immediate post-abortal care we were able to
reduce the need of subsequent abortion significantly within the first
year. Future follow-up will reveal whether this intensified provision of
IUDs is also cost-beneficial, as suggested by the results of previous
cohort and cost-analysis studies (Ames and Norman, 2012; Salcedo
et al., 2013), and associated with an overall improvement in the quality
of life.
The present results have a significant public health impact—in order to
decrease the need of subsequent abortion, provision of IUDs should be a
part of high-quality abortion services.
Acknowledgements
Study nurse Pirjo Ikonen is gratefully thanked for her irreplaceable con-
tribution to this study, and adjunct Professor Pasi Korhonen of EPID re-
search for his advice and help with statistical analysis. The authors also
thank the City of Helsinki for providing the LNG-IUSs and Cu-IUDs
used in the present study.
Authors’ roles
All authors participated in the study design, analysis of the data, manu-
script drafting and critical discussion. Authors E.P., M.M., S.S. and O.H.
were responsible for the practical arrangements of the study as well as
patient care, M.G. performed the registry linkages.
Funding
This study was supported by Helsinki University Central Hospital Re-
search funds and by research grants provided by the Antti and Jenny
Wihuri Foundation and the Yrjö Jahnsson Foundation.
Conflict of interest
O.H. has served on advisory boards for Bayer Healthcare, Gedeon
Richter and MSD Finland (part of Merck & Co. Inc.), and designed and
lectured at educational events of these companies. S.S. has lectured at
educational events of Bayer and MSD Finland (part of Merck & Co.
Inc.). The other authors have no conflicts of interest to declare.
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