Dr. Helen Roberts Senior Lecturer Women’s Health University of Auckland, New Zealand Research Manager Family Planning Sex and the Teenager LARCS

What am I going to talk about? Background abortion statistics for NZ Results of our study at EDU Review of some IUD/LARC information What do we need to do now?

ASC report 2009

The general abortion rate is the number of abortions per 1,000 of the mean estimated population of women aged years.

ASC report 2009 The abortion ratio is the number of abortions per 1,000 known pregnancies. Known pregnancies include live births, stillbirths and induced abortions combined, but do not include miscarriages

Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand Prospective cohort study at Epsom Day Unit (Auckland’s public abortion clinic) EDU is the largest abortion clinic in NZ providing approximately 30% of all abortions 1422 women who had a first trimester surgical abortion between November 2004 and January 2005 Followed for 3 years Roberts H, Silva M, Xu S. Contraception 2010;82:260-5

Descriptive variable%N Age < Ethnicity European Maori European/Maori Pacific European/Pacific Asian Asian Indian Other Previous abortions Yes No Sample description

Contraception at conception Barrier COC POP Depo Provera IUD ECP NFP Tubal ligation No contraception % N 1420 Reason for failure Method failure User failure No information available Post abortion contraception Barrier COC POP Depo Provera IUD GP / FP No contraception

Only 14.5% of young women 19 years of age or less left using IUD

Odds ratio (confidence interval) p-value Age < ( ) 3.1 ( ) 13.4 ( ) 2.8 ( ) 8.2 ( ) <.001 Relative odds of leaving the abortion clinic with IUD among women with no previous abortions (n=428) Relative odds of leaving the abortion clinic with IUD among women with one or more previous abortions (n=307) Odds ratio (confidence interval) p-value Age < ( ) 1.2 ( ) 1.7 ( ) 3.4 ( ) 9.4 ( ) 0.196

Conclusions Over the 3-year follow-up period, women using IUD were more than 70% less likely to return for a repeat abortion than those who left with a COC prescription (p<.001) All age groups were more likely than those 19 yrs or younger to leave the clinics with an IUD (p<.001) Nulliparous women were less likely to have an IUD inserted following abortion. With each added live birth, women were more than twice as likely to have left the clinic with an IUD versus COC

One year after study publication A recent 2011 EDU audit of 100 women who had an abortion showed an increase in IUD use. 49% left with an IUD insitu 45% of younger or nulliparous women had an IUD inserted An ongoing audit will determine whether this will translate into fewer repeat abortions for these women.

Why were young women not using IUD? Family Health International Underused Research Findings

IUDs: information lags behind the evidence British Survey (2006) reported that women lacked objective information about IUDs, not well informed by health professionals Asker 2006 Textbooks (both UK and US) lag behind the evidence Advantages under-reported and disadvantages exaggerated Several texts listed qualities of women considered by the authors, but unsupported by the evidence, to be contraindications to IUD use eg nulliparity Espey 2002

Results from a questionnaire sent to US family physicians Rubin S et al. Family Medicine Journal June 2010

What do we know about the risk of PID with IUDs? IUD in situ Don’t know No IUD get STI diff PID risk get STI Cx+STI Increased Cx+no STI IUD insert PID risk IUD insert So we know that if insert IUD with STI present small increase in PID compared to if no STI but do not know whether PID risk is any different when STI acquired with IUD in situ compared to women not using IUD

Risk of PID if insertion with STI No RCTs insertion with STI v without STI But 6 prospective studies Included women who had inadvertently had IUD inserted with lab documented STI Risk of PID 0-5% v 0-2% without STI Mohllagee. Contraception 2006;73:145-53

Risk of PID among IUD users Absolute rates of PID among IUD users are low. In a 5-year follow-up study in eight developing countries, the rate of acute PID among users of the copper IUD was 0.6 per 1000 woman years Mohllajee et al. Contraception 2006;73: 145–153

NICE Guidelines (UK) 2005 National Institute for Health+Clinical Excellence IUD may be used by adolescents but STI risk should be considered where relevant ie same advice as for other women IUD use is not contraindicated in nulliparous women of any age

Grimes D Contraception 2009

How can we improve the failure rate with pill use Although the practical failure rate of the combined pill is 5% –the adolescent failure rate is as high as 32% more “technical”problems Alan Guttemacher Institute 1994

Continuous hormones Much less likely to have escape ovulation with missed pills Would need to miss 9 pills in a row to get possibility of escape ovulation Similar episodes of breakthough bleeding If breakthrough bleeding- take 3 day break

Continuous versus cyclic use of combined oral contraceptives for contraception: systematic Cochrane review of randomized controlled trials A. Edelman et al Human Reproduction.Oxford:2006;21:573Human Reproduction2006 METHODS: The review aimed to compare contraceptive efficacy, compliance, continuation, satisfaction, bleeding profiles, and menstrual symptoms of combined oral contraceptives with continuous dosing (>28 days of active pills) versus traditional cyclic dosing (21 days of active pills and 7 days of placebo). We searched five computerized databases as well as reference lists of relevant articles for randomized controlled trials (RCT) using continuous or extended combined oral contraceptives for contraception. RESULTS: Six RCT met inclusion criteria and were of good quality. Discontinuation overall, and for bleeding problems, was not uniformly higher in either group. When studied, participants reported high satisfaction with both dosing regimens. Five out of the six studies found that bleeding patterns were either equivalent or improved with continuous-dosing regimens. The continuous-dosing group had greater improvement of menstrual- associated symptoms (headaches, genital irritation, tiredness, bloating, and menstrual pain).

Improving compliance with Depo Provera Counselling women on expected bleeding patterns has been shown to improve continuation rates with methods such as Depo Provera Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004317

Long Acting Reversible Contraception (LARC) IUDs and implants Potential to…. Decrease unintended pregnancy NICE guidelines on LARC LARC more cost effective (even at 1 year ) than coc or injectables

One rod implant- 3 years Implanon (etonorgestrel) Two rod implant –5 years Jadelle (levonorgestrel) Jadelle fully funded in NZ since 2010 Another LARC Contraceptive Implants

Bleeding and Continuation rates with Implants Review of 11 clinical trials Amenorrhea 22% Infrequent bleeding 34% Frequent bleeding 7% Prolonged bleeding 18% Discontinuation rate of 11% for bleeding irregularities Mansour 2008

Summary and what needs to happen next? LARCs have a real potential to decrease unintended pregnancies IUDs are an appropriate method for adolescent and nulliparous women Clinics may need to consider increasing staff trained in LARC insertion Abortion hospitals need to have trained staff to offer immediate implant insertion post abortion We now have 3 trained nurses at EDU

Improving continuation rates with Jadelle There is almost no research regarding the adverse event rate post abortion insertion of Jadelle. A single study suggests that, for at least some women post abortion, discontinuation rates for irregular bleeding are less than when insertion takes place at other times

Improving continuation rates with Jadelle Recent Grant Application Adverse events following immediate insertion of Jadelle contraceptive implant post abortion and the effect on continuation rates.