Interpretation
This study explored both efficacy measures of immediate IUD insertion at 17-20 GW, such as expulsion and removal rates, and effectiveness measures such as how immediate insertion affects continued use. Our results show that planned immediate insertion of the IUD leads to significantly more women receiving an IUD compared to planned delayed insertion. We found that four out of ten women planned for immediate IUD insertion will either not have the IUD inserted, have the IUD removed, or expel the IUD. However, if a woman receives the IUD before she leaves the hospital, it is likely that she will continue to use the original, or a replacement IUD, if provided with continuity of care, as demonstrated by a 90% continuation rate at 6 weeks among women who received immediate insertion. Both groups showed a preference for immediate insertion despite many women in the immediate group needing removal and replacement of the original IUD.
Similarly, a systematic review of immediate vs delayed IUD insertion after abortion in the first- and early second trimester concluded that immediate insertion was associated with higher expulsion rates but also with higher rates of continued use.11
Immediate insertion was associated with higher rates of expulsion and removal due to malposition than delayed insertion. Interestingly, most women with intracervical IUD placement were asymptomatic which is concerning as they may be less likely to follow-up. Two Finnish studies found expulsion/removal rates of 12.5% after early medical abortion, 27.5% after later first trimester abortion and 18.5% after early second trimester abortion although the study was underpowered for the second trimester group.15,16 Expulsion and removal rates have been estimated at 5% and 8.5% after early and late surgical abortion respectively but these studies accepted self-report of IUD use which may underestimate malposition rates.17,18 Our study did not find lower rates of expulsion and removal among women who had the IUD inserted after vacuum aspiration. It is possible that the high cumulative doses of misoprostol needed for medical abortion in the latter part of the second trimester contributed to the relatively high expulsion/malposition rates. Studies on post-placental IUD insertion also indicate that insertion within the first 10 minutes of placental delivery is more effective than insertion at 10min-48 hours, which may also be true for post-abortion insertion and which this study cannot evaluate.13
Four out of the 6 women with complete expulsion did not notice the IUD falling out and thus would be unknowingly unprotected from a repeat pregnancy had they not come for a check-up. However, women in our immediate study arm were much more likely to follow-up in-person compared to women in the delayed arm. If women who receive an IUD before leaving the hospital are strongly motivated to return, the risk associated with unnoticed expulsion would be mitigated and they would be ensured of continued contraception. Pregnancy within the first 6-week period is not impossible, and in that case an advantage of the copper- over the levonorgestrel IUD is that a new pregnancy is likely to be detected early by the absence of a period. Scheduling the first follow-up visit at 3-4 weeks may be preferable as a replacement IUD would then act as emergency contraception in case of a pregnancy occurring within that period.
The low rates of use in the delayed arm were because only one in five women presented at CHCs for IUD insertion. This was despite several pre-emptive study measures to facilitate interval insertion at CHCs compared to standard care. Interval initiation of contraception post-abortion and postpartum is known to be complicated by low compliance, which is a main rationale for quick-start contraception post-abortion and postpartum.9,19 Finally, two women who followed the delayed protocol became pregnant during the study period. During the post-pregnancy period women are especially vulnerable to repeat pregnancy and this must be considered in the risk-benefit calculation of immediate and delayed IUD insertion post-abortion.20
Abortion care in South Africa suffers from a scarcity of willing providers, a high rate of second trimester abortion and an overall low use of LARC.5 In contrast to this, satisfaction rates with the IUD were high throughout the study period and most women predicted that they would use the IUD for the full five years of recommended use.