1. Post Abortion Contraception
“Women have a human right to determine whether and when to get pregnant”
WHO

2. Some statistics
40% of pregnancies worldwide are unplanned (WHO)
39% of women who had an abortion in England and Wales in 2017 had >/=1 previous abortion
A woman can ovulate as early as D8 post abortion
90% of women ovulate within 1 month post abortion
Resumption of sexual intercourse often precedes 1st ovulation putting people at increased risk of another unintended pregnancy.
Therefore post abortion contraception is a vital part of abortion provision and aftercare to prevent another unplanned pregnancy

3. WHO
“Before leaving the healthcare facility following the surgical abortion procedure or administration of medical abortion pills, all women should receive contraceptive information, and if desired, the contraceptive method of their choice or referral to such services”

4. Contraceptive History
Ideally discuss visit 1
Determine current and past contraceptive history
Determine if a failure of method involved
Determine if any current barriers to contraceptive usage ( e.g. cost, working hours, lack of local LARC fitters etc)
Determine medical eligibility criteria ( MEC) & contraindications
Discuss benefits of immediate initiation of contraception
Discuss all contraceptive options
Try to initiate plan at 1st visit +/or give PILS to discuss at 2nd visit.
Patient centred approach & personal choice NB
If delayed initiation preferred – see whether amenable to bridging

5. Benefits of Immediate Initiation
Motivation likely to be high at this time
Known not to be pregnant
Currently accessing healthcare “captive audience”
Reduces chances of another unintended pregnancy
Studies have shown increased uptake at 6 months post abortion compared to delayed initiation

7. Contraceptive method Earliest time post medical
ICGP Interim Guideline P26. Table 4: Contraception Methods and post-termination initiation timeframes
Contraceptive method Earliest time
post medical
of initiation Earliest time of initiation
termination post surgical termination
Combined hormonal contraception (pills, patch or ring)
Progesterone only pill
Subdermal implant
DPMA ( Depo-provera)
Condoms & spermicide
IUD/IUS
Day of mifepristone
As soon as intercourse resumes
Once expulsion has occurred
Immediately

8. Medical Abortion
Encourage immediate initiation but mindful of individualised approach
Hormonal contraception DOES NOT interfere with efficacy of MA / bleeding pattern post MA
Consider providing EC if high risk (WHO)
CHC/POP/ Implant/ After mifepristone
Injectable At home after misoprostol
3. Within 1st 5 days with immediate effect
4. Bridging (apart from implant)
5. Quickstart if outside 1st 5 days with use of barrier contraception/
abstain until method effective
6. Start of next menses
Diaphragms/caps Immediate use T1. Delay x 6wks T2. High failure rate
Fertility-awareness Delay until return of menstrual cycle.
based methods
Female Sterilisation Referral with bridging contraception in interim

9. Intra-Uterine Method Copper IUD/ Progesterone IUS
Delay insertion until MA is successful
NB Delay insertion if symptomatic infection
Aim for visit 3 if successful MA, or sooner if possible
Delaying initiation/ waiting for next menses can increase risk of another unintended pregnancy
Determine potential barriers to insertion
Can use bridging contraception if immediate insertion not possible
CU-IUD immediately effective
Progesterone IUS :
immediately effective if inserted D1-5 / next menses
Barrier contraception/ abstain x 7 days if outside menses
Small increased risk of expulsion
Increased use at 6 months
No increased risk of infection/ perforation

10. Surgical Abortion
Immediate start possible for all types of contraceptives apart from diaphragm T2
IUD/IUS - Time of procedure :
Small increased risk of expulsion
Increased use at 6 months compared to delayed insertion
No increased risk of perforation or infection
Implanon/ Depo-provera – Day of procedure or within 1st 5 days with immediate effect
CHCs/ POP – Day of procedure or within 1st 5 days with immediate effect
Female sterilisation – Time of procedure or deferred

11. Conclusion
2-3 visits in abortion pathway – each consultation should be an opportunity to promote, discuss and plan for contraception provision
Knowledge of all contraceptive methods and when to initiate them after an abortion is essential
LARC needs to be promoted as the most effective method of contraception
Immediate initiation of contraception should be encouraged.
Individualised approach
Don’t forget CONDOMS to help prevent STIs
Maintain pressure on government to legislate for free contraception