National Partnership for Women & Families

Monthly Women's Health Research Review

Study: Providing No-Cost Contraceptive Implants Post-Abortion Reduces Future Abortion, Pregnancy Rates for at Least Two Years

Summary of "Immediate Postabortion Initiation of Levonorgestrel Implants Reduces the Incidence of Births and Abortions at 2 Years and Beyond," Rose et al., Contraception, March 26, 2015.

Using long-acting reversible contraception (LARC) immediately after an abortion or after childbirth "is the most promising strategy to reduce rates of unintended pregnancy," but the availability and cost of such methods have been major barriers to their use, according to Sally Rose of the University of Otago's Department of Primary Health Care and General Practice and colleagues.

However, the researchers noted that New Zealand in August 2010 began to fully subsidize "the progesterone-only sub-dermal implant Jadelle," also known as the LNG implant, which "now incurs only consultation and insertion-related costs." Meanwhile, the multiload copper-bearing intrauterine device (CuIUD) was already a fully subsidized LARC method, while the "etonogestrel sub-dermal implant" (Implanon) and the "levonorgestrel-releasing intrauterine system" (LNG-IUS) were also available at the time of the study, although they both had device costs. According to the study, there are also several shorter-acting contraceptive methods that are partially or fully subsidized in New Zealand, including condoms, oral contraceptives and "depot medroxyprogesterone acetate/DMPA."

The researchers devised the study "to compare immediate postabortion uptake of the recently subsidized (no-cost) LNG-implant with already available intrauterine methods and with all other shorter-acting methods, and to describe the incidence of subsequent pregnancies within 2-years."

Methods

The researchers analyzed contraceptive, clinical and demographic data for individuals discharged from a public hospital abortion clinic between Aug. 1, 2010, when the LNG implant became fully subsidized, and July 31, 2012. The researchers linked records to determine subsequent abortions until July 2014 and subsequent births until December 2013.

According to the study, the clinic offered surgical abortion patients three LARC methods for immediate post-abortion insertion, including CuIUD, LNG-IUS and LNG-implants. Medication abortion patients who wanted a LARC method could opt for a surgical abortion.

Results

The study involved 4,698 women who initiated or selected a contraceptive method at the time of abortion. According to the researchers, 19.9% of the woman received a LNG implant, 19.6% received a CuIUD, 6.4% received a LNG-IUS and 54% selected "other shorter-acting methods."

Likelihood of Selecting LARC Method

The researchers found that younger women were significantly more likely to select the no-cost LNG implant or CuIUD LARC methods than shorter-acting contraceptive methods. In addition, women who had had more deliveries or more abortions were more likely to select LNG implants over shorter-acting methods. Researchers also said that an increasing number of past abortions or past deliveries was associated "to a lesser extent" with being more likely to select LNG implants or CuIUDs over more short-acting methods.

The researchers also found that ethnicity was significantly associated with women's contraceptive choice, with Maori women, relative to European women, being the most likely to select an LNG implant over a CuIUD. Meanwhile, Pacific women were the most likely to select an LNG implant over a shorter-acting method, while Asian women, compared with European women, were about 50% as likely to select an LNG implant instead of a shorter-acting method.

According to the study, low-income status was not significantly associated with women's contraceptive choices.

Subsequent Abortions

Rose and colleagues found that women who selected LNG implants or the LNG-IUS method were the least likely to have had a subsequent abortion at 12 or 24 months post-abortion. Specifically, they found that after adjusting for previous pregnancy, age and ethnicity, women who selected an LNG implant were about four times less likely to have an abortion than women who selected shorter-acting methods.

The researchers also found that women who selected LNG implants or LNG-IUS methods were the least likely to have a subsequent abortion at 24 months and 48 months. According to the study, the incidence of a subsequent abortion at 24 months was:

~ 3.0% for women who selected the LNG-IUS method;

~ 3.8% for women who selected a LNG implant;

~ 5.6% for women who selected a CuIUD; and

~ 11.6% for women who selected other shorter-acting contraceptive methods.

Meanwhile, women who opted for a LNG implant or for the LNG-IUS method also had the lowest rate of subsequent abortion at 48 months, at 6.6% and 8.2%, respectively.

Subsequent Pregnancies

The researchers found that "contraceptive method, age and previous births were significantly associated with subsequent continued pregnancy." Specifically, they found that "LARC methods were associated with at least a sixty-percent reduction in subsequent continued pregnancy, compared to shorter-acting methods."

According to the study, women who selected LNG implants or LNG-IUS methods were the least likely to have a continued pregnancy at 24 months or 34 months. The researchers found that the incidence of a continued pregnancy at 24 months was:

~ 6.0% for women who selected the LNG-IUS method;

~ 6.3% for women who selected a LNG implant;

~ 6.4% for women who selected a CuIUD; and

~ 15.7% for women who selected shorter-acting contraceptive methods.

Meanwhile, the researchers found that women who opted for a LNG implant or for the LNG-IUS method had the lowest rate of continued pregnancy by 34 months, at 7.2% and 8.3% respectively.

Discussion

Rose and colleagues wrote that the "[i]mmediate postabortion initiation of an implant significantly reduced the incidence of subsequent abortion and continued pregnancy within 24-months (and beyond) when compared with choice of other shorter-acting methods."

The researchers wrote that "[o]verall LARC uptake was 45% ... with similar proportions of women choosing implants and copper-IUDs." Specifically, they noted that 20% of the study cohort selected a LNG implant, including about 25% of women under age 20, "a group not historically accessing or [being] offered long-acting methods." According to the study, women under age 20 "had the highest uptake of implants in this study."

The researchers noted that the cost of the LNG-IUS in New Zealand is "significant" and "prohibitive to many women wishing to use it for contraceptive purposes," as reflected by the study results. However, the method was associated with women being less likely to have an abortion at follow-up. The researchers wrote, "Extending government funding in New Zealand to include the LNG-IUS would therefore have both personal and public health benefit[s]."

Rose and colleagues concluded, "This study demonstrates that receipt of no-cost contraceptive implants immediately postabortion reduces subsequent pregnancy rates for at least 2-years. Women wishing to prevent or delay pregnancy following an abortion should have access to, and be counselled to consider use of long-acting methods."