Strengths and limitations
Immediate insertion of the IUD after medical abortion at 17-20 GW has
not to our knowledge been studied. Most women in our study represented a
group which is particularly vulnerable to infringements on their sexual
and reproductive health and rights, which makes this study of particular
relevance.
The study estimated sample size did not accurately predict how many
women would not receive an IUD in the immediate group or how many would
fail to follow-through for delayed insertion. Despite this, findings
were statistically significant and loss-to-follow-up lower than
predicted. Our sensitivity analysis used a conservative scenario that
minimized outcome differences between groups in order to adjust for the
uncertainty of missing and self-reported data and did not change the
direction or significance of our findings.
The study was embedded in clinical services which currently have
relatively little experience with IUD insertions which may make results
less generalizable to other contexts. To mitigate this both hospital
staff and CHC staff received structured mentoring sessions in IUD
insertion after medical abortion prior to the study start. It is however
unlikely that varying experience had a measurable impact on expulsion as
expulsion rates were low with interval placement and replacement of the
IUD.
Compared to a non-study situation, the study environment and other
interventions may have influenced women´s behaviours or opinions but
they should not affect relative results. The impact of study procedures
on results as well as the feasibility of the intervention is being
explored in a separate process evaluation.