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

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

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”

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

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

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

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/ 1. After mifepristone Injectable 2. 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

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

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

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 www.sexualwelllbeing.ie